Preferred Drug List (PDL) Memorialcare Select Health Plan Applies To: Memorialcare Select Members Last Updated: February 2021

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Portfolio Medium – Preferred Drug List (PDL) MemorialCare Select Health Plan Applies to: MemorialCare Select Members Last Updated: February 2021

Please note the formulary is subject to change and all previous versions of the formulary will no longer be in effect.

To Access MemorialCare Select Pharmacy information: https://www.memorialcareselecthealthplan.org/access-information

To Access MemorialCare Select EOC: https://www.memorialcareselecthealthplan.org/seaside-select-member-services Table of Contents Informational Section...... 2 Alternative Therapy - Vitamins and Minerals...... 8 Analgesic, Anti-inflammatory or Antipyretic - Drugs for Pain and Fever...... 8 Anesthetics - Drugs for Pain and Fever...... 33 Anorectal Preparations - Rectal Preparations...... 34 Antidotes and other Reversal Agents - Drugs for Overdose or Poisoning...... 35 Anti-Infective Agents - Drugs for Infections...... 37 Antineoplastics - Drugs for Cancer...... 60 Antiseptics and Disinfectants - Antiseptics and Disinfectants...... 72 Biologicals - Biological Agents...... 72 Cardiovascular Therapy Agents...... 80 Cardiovascular Therapy Agents - Drugs for the Heart...... 81 Central Nervous System Agents - Drugs for the Nervous System...... 102 Chemical Dependency, Agents to Treat - Drugs for Addiction...... 146 Chemicals-Pharmaceutical Adjuvants...... 148 Cognitive Disorder Therapy - Drugs for the Nervous System...... 149 Contraceptives - Drugs for Women...... 151 Dermatological...... 165 Dermatological - Drugs for the Skin...... 165 Diagnostic Agents...... 217 Drugs to treat Erectile Dysfunction - Drugs for the Urinary System...... 217 Eating Disorder Therapy...... 218 Eating Disorder Therapy - Drugs for Eating Disorders...... 218 Electrolyte Balance-Nutritional Products - Drugs for Nutrition...... 220 Endocrine - Hormones...... 224 Enzymes - Vitamins and Minerals...... 258 FDB Class Obsolete-Not Used...... 258 Gastrointestinal Therapy Agents - Drugs for the Stomach...... 259 Genitourinary Therapy - Drugs for the Urinary System...... 276 Gout and Hyperuricemia Therapy - Drugs for Pain and Fever...... 282 Hematological Agents - Drugs for the Blood...... 283 Hepatobiliary System Treatment Agents - Drugs for the Liver...... 297 Immunosuppressive Agents - Drugs for Organ Transplants...... 297 Locomotor System - Drugs for Muscles, Ligaments, Tendons, and Bones...... 299 Medical Supplies and Durable Medical Equipment (DME) - Medical Supplies and Durable Medical Equipment...... 301 Medical Supply, FDB Superset...... 378 Metabolic Disease Enzyme Replacement Agents - Drugs for Metabolic Disease...... 423 Metabolic Modifiers...... 423 Metabolic Modifiers - Drugs that Alter Metabolism...... 423 Mouth-Throat-Dental - Preparations - Drugs for the Mouth and Throat...... 426 Multiple Sclerosis Agents - Drugs for the Nervous System...... 430 Ophthalmic Agents - Drugs for the Eye...... 432 Organ Preservation Solutions...... 446 Organ Preservation Solutions - Drugs for the Heart...... 446 Otic (Ear) - Drugs for the Ear...... 448 Respiratory Therapy Agents - Drugs for the Lungs...... 449 Vaginal Products - Drugs for Women...... 466 TOC-1 FORMULARY INFORMATION

What is a Formulary? The Formulary provides a list of covered generic and brand name drugs selected by physician and pharmacist subject matter experts who collaboratively support MedImpact’s Pharmacy and Therapeutics (P&T) Committee. This Formulary does not apply to drugs or devices that are obtained through the medical benefit portion of your coverage. The plan will cover drugs listed in the formulary as long as the drug is indicated for the clinical condition, is prescribed in the appropriate manner, the prescription is filled at a participating network pharmacy, and other plan rules are followed. The presence of a prescription drug on the formulary does not guarantee an enrollee will be prescribed that prescription drug by his or her prescribing provider for a particular medical condition. For more information regarding the Formulary or your prescription drug benefit, please contact your plan’s Member Services department at (855) 367- 7747, or for the hearing and speech impaired TTY: 711, Monday through Friday, between 8:00 am – 5:00 pm PST, or refer to your Plan Benefit Documents, available at https://www.memorialcareselecthealthplan.org.

Can the Formulary (drug list) change? Drugs may be added or deleted from the Formulary during the policy year, and the Formulary will be updated with any changes on a monthly basis. Changes will be effective on the first day of the month. If there is a change in drug or dosage form, if a drug is removed from the Formulary, if prior authorization, quantity limits and/or step therapy restrictions are added to a drug, or if a drug moves to a higher cost sharing tier, the plan will notify affected enrollees of the change before the change becomes effective. If the FDA deems a drug on the formulary to be unsafe or the drug’s manufacturer removes the drug from the market, the plan will immediately remove the drug from the formulary.

The Formulary is subject to change and all previous versions of this formulary are no longer in effect.

How does a member fill a prescription? To obtain drugs at a participating pharmacy, the enrollee must present his or her pharmacy benefit plan identification card. Except for covered emergencies, claims for drugs obtained without using the identification card will be denied. To locate a participating pharmacy (including specialty pharmacies), check the cost-sharing for a particular drug, or enroll in mail-order, visit https://www.memorialcareselecthealthplan.org . Your plan benefits may restrict coverage of specialty drugs only when obtained from a Network Specialty Pharmacy, except in case of an emergency.

What are generic drugs? The plan covers both brand name drugs and generic drugs provided they are prescribed per Food and Drug Administration (FDA) approved indications and in accordance with the plan pharmacy benefit coverage. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

How to Use this Formulary Document The categorical list of drugs in this document groups drugs into categories and classes based on the First National Databank (FDB), a widely-accepted independent drug classification system. A prescription drug may be located by looking up the therapeutic category and class to which the drug belongs or the brand or generic name of the drug in the alphabetical index. • A drug is listed alphabetically by the brand and generic name in the therapeutic category and class to which it belongs. • The generic name for a brand name drug is included after the brand name in parentheses and all bold and italicized lowercase letters. • If a generic equivalent for a brand name drug is both available and covered, the generic drug will be listed separately from the brand name drug in all bold and italicized lowercase letters. • If a generic drug is marketed under a proprietary, trademark protected brand name, the brand name will be listed in all CAPITAL letters after the generic name in parentheses and regular typeface with the first letter of each word capitalized. • If a generic equivalent for a brand name drug is not available on the market or is not covered, the drug will not be separately listed by its generic name.

For example, the brand name drug Riomet and its generic would be listed as follows: RIOMET ORAL SOLUTION 500 MG/5 ML (metformin) metformin oral solution 500 mg/5 ml (RIOMET)

Tier Benefit Design The Formulary applies to a tier benefit design, where the enrollee shares the cost of prescription drug therapy based on the drug’s tier and copay or coinsurance. Specialty drugs may be covered at a higher copay or coinsurance. Essential Health Benefit/Preventive Care medications, if available on the plan, will be covered without cost sharing (zero copay). To determine the cost-sharing for each drug tier, refer to your Plan Benefit Documents, available at https://www.memorialcareselecthealthplan.org .

Example of Formulary Tier Design: • Tier 1: Generic medications • Tier 2: Preferred brand medications (formulary agents) and for applicable plans, high cost generic medications • Tier 3: Non-preferred brand medications (non-formulary agents) • $0: Essential Health Benefit medications intended for preventive care under the Patient Protection and Affordable Care Act (ACA) covered at 100% with no deductible, copay or coinsurance required within coverage criteria

Are there any restrictions on coverage of drugs on the Formulary? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: • Prior Authorization: The plan requires enrollees or their prescribing providers to obtain prior authorization for certain drugs. This means that the enrollee will need to obtain approval before the prescription will be covered. • Quantity Limits: For certain drugs, the plan limits the amount of drug that is covered • Step Therapy: In some cases, the plan requires a trial of certain clinically appropriate alternative drug(s) before obtaining the prescribed drug. • Age Limit: For certain drugs, the plan limits coverage of the drug within a determined age limit.

For certain agents within the Formulary, a recommended prescribing guideline may apply. These are denoted throughout the Formulary listing using the following symbols (refer to table below).

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

drug. Prior authorization may be required. ST Step Therapy See “What is Step Therapy?” below for additional information. Coverage may require dispensing from a specialty pharmacy. Specialty copay/coinsurance may SP Specialty Drug apply depending on benefit. Prior authorization may be required.

DD Diabetes Drugs/Devices Drugs or devices used to treat or manage diabetes CT Contraceptives Drugs used to prevent pregnancy

OCH Oral Cancer Drugs Drugs taken by mouth to treat cancer

The enrollee can find out if the drug has any additional requirements or limits by looking within the Formulary.

Are there general exclusions on the formulary? Many enrollees have specific benefit inclusions, exclusions, copayments, out-of-pocket costs, or a lack of coverage, which are reflected in other Plan Benefit Documents.

The Formulary applies only to outpatient drugs provided to enrollees and does not apply to medications used in inpatient settings. If an enrollee has any specific questions regarding their coverage, they should contact their plan’s Member Services department at (855) 367-7747, or for the hearing and speech impaired TTY: 711, Monday through Friday, between 8:00 am – 5:00 pm PST, or refer to your Plan Benefit Documents, available at https://www.memorialcareselecthealthplan.org.

Examples of benefit exclusions: A. Over-the-Counter (OTC) medications or their equivalents, unless the plan offers coverage of the OTC medications B. Drugs specifically listed as not covered C. Any drug product used for cosmetic purposes D. Medical food/nutritional supplements E. Non-diabetic supplies/Diagnostic supplies/Ostomy supplies/Devices F. Disposable needles and syringes (non-insulin related) G. Any drug products used for cosmetic purposes H. Experiment drug products or any drug product used in an experimental manner I. Replacement of lost or stolen medication J. Repackaged drugs and institutional use drugs (e.g. hospital use) K. Lifestyle drugs (e.g. sexual dysfunction, infertility) L. Weight loss drugs M. Non self-administered injectable drug products unless otherwise specified in the Formulary listing N. Foreign sourced drugs or drugs not approved by the United States FDA, except in certain cases of drug shortage, when covered under the plan

What if a drug is not on the Formulary? How does an enrollee request an exception to the Formulary? Medically necessary non-formulary drugs are covered and subject to higher copayments. Enrollees and their prescribing providers may request an exception to any prior authorization or step therapy requirement by indicating the Request for Exception on the Pharmacy Prior Authorization form and submitting the form along with any supporting medical documentation to MedImpact by fax at 1-858-790-7100 or request by phone at 1-800-788-2949. Upon receipt of all required supporting information, MedImpact will review your request and make a decision to approve or deny your request. Decisions for routine requests are issued within 72 hours from the receipt of the complete information. If your provider believes your condition is life-threatening (exigent circumstance), your request will be expedited, and a decision will be issued within 24 hours from the receipt of the information. If a decision is not reached within these timeframes, your request is considered approved.

If your request is approved, your plan shall provide coverage for requests for the duration of the prescription, including refills. If your request is denied, your notice of denial will include information on how to file an appeal. Appeals are responded to within 5 days from the time of receipt, and within 72 hours for expedited appeals (for exigent circumstances). The notice will also include information on how to request an external appeal through the Department of Managed Health Care’s Independent Medical Review process.

What is a Prior Authorization? Many drugs have multiple indications, so prior authorizations are placed on those drugs to make sure the drug is safe and appropriate for the enrollee.

How does the program work? Drugs that require prior authorization will show PA in the Coverage Requirements and Limits column of the Formulary document. Before these drugs are covered, your prescribing provider must show that you have a medically necessary need for the drug. Drugs requiring prior authorization have specific clinical criteria that you must meet before the drug is covered. Your prescribing provider can work with MedImpact to obtain coverage approval for the drug in the same way as requesting coverage for a non-formulary drug, described above.

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

What is Step Therapy? Drugs that require step therapy will show ST in the Coverage Requirements and Limits column of the Formulary document. Step therapy encourages safe and competitively priced medication use through a stepwise approach. This means that before a drug requiring step therapy is covered, you must first try other preferred drugs that treat the same medical condition. After trying other preferred drugs first, then the step therapy drug will be covered. If you are unable to try other preferred drugs first, then your prescribing provider can work with MedImpact to obtain coverage approval for the drug in the same way as requesting coverage for a non-formulary drug, described above.

If you previously completed step therapy for a drug while covered under another plan, you may not be required to repeat step therapy for the drug under this plan. The plan may not limit or exclude coverage for a drug that was previously approved, if your provider continues to prescribe the drug for your medical condition, provided the drug is appropriately prescribed and is safe and effective for treating your medical condition.

Preventive Care Select over-the-counter (OTC) drugs with a United States Preventive Services Task Force (USPSTF) rating of A or B may be covered at a quantity greater than a 30-day supply. It is your plan’s intent to comply with federal law regarding preventive care benefits under the Patient Protection and Affordable Care Act. All prescriptions which qualify for the preventive care benefit, as defined by the appropriate federal regulatory agencies, and which are provided by a network-participating pharmacy, will be covered at 100% with no deductible, copay or coinsurance required. All such medications require a prescription from your doctor.

Members who are stable on their current FDA-approved, self-administered hormonal contraceptive, may receive up to a 12-month supply at one time. Select contraceptives are covered with a $0 copayment.

Diabetes Care Your outpatient prescription drug coverage includes the following prescription items for the management and treatment of diabetes: • Insulin • Needles and syringes for injecting insulin • Prescription medications for the treatment of diabetes • Glucagon • Diabetic testing supplies, including blood and urine testing strips and test tablets, lancets and lancet puncture devices and pen delivery systems for the administration of insulin

Other Pharmacy Items Some Durable Medical Equipment that is covered through your medical benefit is also available at the pharmacy for the management and treatment of diabetes when medically necessary and authorized: • Blood glucose monitors, including those designed to assist the visually impaired; • Insulin pumps and all related necessary supplies; • Continuous glucose monitors and all related necessary supplies; • Podiatric devices to prevent or treat diabetes-related complications, including extra-depth orthopedic shoes; • Visual aids, excluding eyewear and/or video-assisted devices, designed to assist the visually impaired with proper dosing of insulin;

Anti-Cancer Drugs If you are prescribed a covered, orally administered anti-cancer drug, the total amount of your cost-sharing shall not exceed $250 for an individual prescription for up to a 30-day supply.

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

“Brand name drug” is a drug that is marketed under a proprietary, trademark protected name. The brand name drug shall be listed in all CAPITAL letters. “Coinsurance” is a percentage of the cost of a covered health care benefit that an enrollee pays after the enrollee has paid the deductible, if a deductible applies to the health care benefit, such as the prescription drug benefit. “Copayment” is a fixed dollar amount that an enrollee pays for a covered health care benefit after the enrollee has paid the deductible, if a deductible applies to the health care benefit, such as the prescription drug benefit. “Deductible” is the amount an enrollee pays for covered health care benefits before the enrollee’s health plan begins payment for all or part of the cost of the health care benefit under the terms of the policy. “Drug Tier” is a group of prescription drugs that corresponds to a specified cost sharing tier in the health plan’s prescription drug coverage. The tier in which a prescription drug is placed determines the enrollee’s 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 prescription drug. If an enrollee, his or her designee, or prescribing health care provider submits an exception request for coverage of a prescription drug, the health plan must cover the prescription drug when the drug is determined to be medically necessary to treat the enrollee’s condition. “Exigent circumstances” are when an enrollee is suffering from a health condition that may seriously jeopardize the enrollee’s life, health, or ability to regain maximum function, or when an enrollee is undergoing a current course of treatment using a nonformulary drug. “Formulary” is the complete list of drugs preferred for use and eligible for coverage under a health plan product, and includes all drugs covered under the outpatient prescription drug benefit of the health plan product. Formulary is also known as a prescription drug list. “Generic drug” is the same drug as its brand name equivalent in dosage, safety, strength, how it is taken, quality, performance, and intended use. A generic drug is listed in bold and italicized lowercase letters. “Nonformulary drug” is a prescription drug that is not listed on the health plan’s formulary. “Out-of-pocket cost” are copayments, coinsurance, and the applicable deductible, plus all costs for health care services that are not covered by the health plan. “Prescribing provider” is a health care provider authorized to write a prescription to treat a medical condition for a health plan enrollee. “Prescription” is an oral, written, or electronic order by a prescribing provider for a specific enrollee that contains the name of the prescription drug, the quantity of the prescribed drug, the date of issue, the name and contact information of the prescribing provider, the signature of the prescribing provider if the prescription is in writing, and if requested by the enrollee, the medical condition or purpose for which the drug is being prescribed. “Prescription drug” is a drug that is prescribed by the enrollee’s prescribing provider and requires a prescription under applicable law. “Prior Authorization” is a health plan’s requirement that the enrollee or the enrollee’s prescribing provider obtain the health plan’s authorization for a prescription drug before the health plan will cover the drug. The health plan shall grant a prior authorization when it is medically necessary for the enrollee to obtain the drug. “Step therapy” is a process specifying the sequence in which different prescription drugs for a given medical condition and medically appropriate for a particular patient are prescribed. The health plan may require the enrollee to try one or more drugs to treat the enrollee’s medical condition before the health plan will cover a particular drug for the condition pursuant to a step therapy request. If the enrollee’s prescribing provider submits a request for step therapy exception, the health plans shall make exceptions to step therapy when the criteria is met. “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. Coverage Prescription Drug Name Drug Tier Requirements and Limits Alternative Therapy - Vitamins and Minerals Alternative Therapy - Unclassified - Vitamins and Minerals NUMOISYN MUCOUS MEMBRANE LIQUID (flaxseed) Tier 3 Analgesic, Anti-inflammatory or Antipyretic - Drugs for Pain and Fever Analgesic Opioid Agonists - Arthritis and Pain Drugs ST: Requires 7 consecutive days therapy of current ARYMO ER ORAL TABLET,ORAL ONLY,EXTND Tier 3 short-acting opioid RELEASE 15 MG, 30 MG, 60 MG (morphine sulfate) prescription; QL (3 EA per 1 day) QL (12 EA per 1 day); Age codeine sulfate oral tablet 15 mg, 30 mg Tier 1 (Min 12 Years) QL (6 EA per 1 day); Age codeine sulfate oral tablet 60 mg Tier 1 (Min 12 Years) DEMEROL (PF) INJECTION SYRINGE 100 MG/ML, 25 Tier 3 MG/ML, 50 MG/ML, 75 MG/ML (meperidine hcl/pf) DILAUDID (PF) INJECTION SYRINGE 0.5 MG/0.5 ML, 1 Tier 3 MG/ML, 2 MG/ML, 4 MG/ML (hydromorphone hcl/pf) fentanyl citrate (pf) intravenous patient Tier 1 control.analgesia soln 1,500 mcg/30 ml (50 mcg/ml) fentanyl citrate (pf)-0.9%nacl intravenous pt controlled Tier 1 analgesia syring 500 mcg/50 ml (10 mcg/ml) fentanyl citrate buccal lozenge on a handle 1,200 mcg, Tier 1 PA 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl citrate buccal tablet, effervescent 100 mcg, 200 Tier 1 PA mcg, 400 mcg, 600 mcg, 800 mcg PA; ST: Requires 7 consecutive days therapy fentanyl transdermal patch 72 hour 100 mcg/hr, 12 Tier 1 of current short-acting mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr opioid prescription; QL (1 EA per 3 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 8 Coverage Prescription Drug Name Drug Tier Requirements and Limits PA; ST: Requires 7 consecutive days therapy fentanyl transdermal patch 72 hour 37.5 mcg/hour, 62.5 Tier 1 of current short-acting mcg/hour, 87.5 mcg/hour opioid prescription; QL (1 EA per 3 days) FENTORA BUCCAL TABLET, EFFERVESCENT 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG (fentanyl Tier 3 PA citrate) ST: Requires 7 consecutive days therapy of current hydrocodone bitartrate oral capsule, oral only, er 12hr Tier 1 short-acting opioid 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg prescription; QL (2 EA per 1 day) hydromorphone (pf)-0.9 % nacl intravenous pt Tier 1 controlled analgesia syring 30 mg/30 ml (1 mg/ml) hydromorphone oral liquid 1 mg/ml Tier 1 hydromorphone oral tablet 2 mg, 4 mg, 8 mg Tier 1 PA; ST: Requires 7 consecutive days therapy hydromorphone oral tablet extended release 24 hr 12 Tier 1 of current short-acting mg, 16 mg, 8 mg opioid prescription; QL (1 EA per 1 day) PA; ST: Requires 7 consecutive days therapy hydromorphone oral tablet extended release 24 hr 32 Tier 1 of current short-acting mg opioid prescription; QL (2 EA per 1 day) hydromorphone rectal suppository 3 mg Tier 1 ST: Requires 7 consecutive HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.24 days therapy of current HR 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 Tier 2 short-acting opioid MG (hydrocodone bitartrate) prescription; QL (1 EA per 1 day) LAZANDA NASAL SPRAY,NON-AEROSOL 100 MCG/SPRAY, 300 MCG/SPRAY, 400 MCG/SPRAY Tier 3 PA (fentanyl citrate)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 9 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Requires 7 consecutive days therapy of current levorphanol tartrate oral tablet 2 mg Tier 1 short-acting opioid prescription ST: Requires 7 consecutive days therapy of current levorphanol tartrate oral tablet 3 mg Tier 1 short-acting opioid prescription meperidine (pf) injection solution 100 mg/ml, 50 mg/ml Tier 1 meperidine (pf) injection solution 25 mg/ml Tier 1 meperidine injection cartridge 10 mg/ml Tier 1 meperidine oral solution 50 mg/5 ml Tier 1 QL (30 ML per 1 day) meperidine oral tablet 50 mg Tier 1 QL (6 EA per 1 day) ST: Requires 7 consecutive days therapy of current methadone injection solution 10 mg/ml Tier 1 short-acting opioid prescription; QL (4 ML per 1 day) ST: Requires 7 consecutive days therapy of current methadone hcl (Methadone Intensol Oral Concentrate 10 Tier 1 short-acting opioid Mg/Ml) prescription; QL (4 ML per 1 day) ST: Requires 7 consecutive days therapy of current methadone oral concentrate 10 mg/ml Tier 1 short-acting opioid prescription; QL (4 ML per 1 day) ST: Requires 7 consecutive days therapy of current methadone oral solution 10 mg/5 ml Tier 1 short-acting opioid prescription; QL (20 ML per 1 day) ST: Requires 7 consecutive days therapy of current methadone oral solution 5 mg/5 ml Tier 1 short-acting opioid prescription; QL (40 ML per 1 day)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 10 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Requires 7 consecutive days therapy of current methadone oral tablet 10 mg Tier 1 short-acting opioid prescription; QL (4 EA per 1 day) ST: Requires 7 consecutive days therapy of current methadone oral tablet 5 mg Tier 1 short-acting opioid prescription; QL (8 EA per 1 day) ST: Requires 7 consecutive days therapy of current methadone oral tablet,soluble 40 mg Tier 1 short-acting opioid prescription; QL (1 EA per 1 day) ST: Requires 7 consecutive days therapy of current methadone hcl (Methadose Oral Tablet,Soluble 40 Mg) Tier 1 short-acting opioid prescription; QL (1 EA per 1 day) morphine (pf) intravenous syringe 1 mg/2 ml Tier 1 morphine concentrate oral solution 100 mg/5 ml (20 Tier 1 mg/ml) morphine in 0.9 % sodium chlor intravenous pt Tier 1 controlled analgesia syring 275 mg/55 ml (5 mg/ml) morphine in 0.9 % sodium chlor intravenous solution 1 Tier 1 mg/ml morphine in 0.9 % sodium chlor intravenous solution 5 Tier 1 mg/ml morphine intramuscular pen injector 10 mg/0.7 ml Tier 1 morphine intravenous pt controlled analgesia syring 30 Tier 1 mg/30 ml (1 mg/ml) ST: Requires 7 consecutive days therapy of current morphine oral capsule, er multiphase 24 hr 120 mg Tier 1 short-acting opioid prescription; QL (2 EA per 1 day)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 11 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Requires 7 consecutive days therapy of current morphine oral capsule, er multiphase 24 hr 30 mg, 45 Tier 1 short-acting opioid mg, 60 mg, 75 mg, 90 mg prescription; QL (1 EA per 1 day) ST: Requires 7 consecutive days therapy of current morphine oral capsule,extend.release pellets 10 mg, Tier 1 short-acting opioid 100 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 80 mg prescription; QL (2 EA per 1 day) morphine oral solution 10 mg/5 ml, 20 mg/5 ml (4 Tier 1 mg/ml) morphine oral tablet 15 mg, 30 mg Tier 1 ST: Requires 7 consecutive days therapy of current morphine oral tablet extended release 100 mg, 15 mg, Tier 1 short-acting opioid 200 mg, 30 mg, 60 mg prescription; QL (3 EA per 1 day) morphine rectal suppository 10 mg, 20 mg, 30 mg, 5 mg Tier 1 ST: Requires 7 consecutive NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 days therapy of current HR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG Tier 2 short-acting opioid (tapentadol hcl) prescription; QL (2 EA per 1 day) NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG Tier 2 QL (6 EA per 1 day) (tapentadol hcl) OXAYDO ORAL TABLET, ORAL ONLY 5 MG, 7.5 MG Tier 3 (oxycodone hcl) oxycodone oral capsule 5 mg Tier 1 oxycodone oral concentrate 20 mg/ml Tier 1 oxycodone oral solution 5 mg/5 ml Tier 1 oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 Tier 1 mg ST: Requires 7 consecutive days therapy of current oxycodone oral tablet,oral only,ext.rel.12 hr 10 mg, 15 Tier 1 short-acting opioid mg, 20 mg, 30 mg, 40 mg, 60 mg prescription; QL (2 EA per 1 day)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 12 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Requires 7 consecutive days therapy of current oxycodone oral tablet,oral only,ext.rel.12 hr 80 mg Tier 1 short-acting opioid prescription; QL (4 EA per 1 day) ST: Requires 7 consecutive OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR days therapy of current 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG Tier 2 short-acting opioid (oxycodone hcl) prescription; QL (2 EA per 1 day) ST: Requires 7 consecutive days therapy of current OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR Tier 2 short-acting opioid 80 MG (oxycodone hcl) prescription; QL (4 EA per 1 day) oxymorphone oral tablet 10 mg, 5 mg Tier 1 ST: Requires 7 consecutive days therapy of current oxymorphone oral tablet extended release 12 hr 10 mg, Tier 1 short-acting opioid 15 mg, 20 mg, 5 mg, 7.5 mg prescription; QL (2 EA per 1 day) ST: Requires 7 consecutive days therapy of current oxymorphone oral tablet extended release 12 hr 30 mg, Tier 1 short-acting opioid 40 mg prescription; QL (4 EA per 1 day) QDOLO ORAL SOLUTION 5 MG/ML (tramadol hcl) Tier 3 PA SUBSYS SUBLINGUAL SPRAY,NON-AEROSOL 1,200 MCG (600 MCG/SPRAY X 2), 1,600 MCG (800 MCG/SPRAY X 2), 100 MCG/SPRAY, 200 MCG/SPRAY, Tier 3 PA 400 MCG/SPRAY, 600 MCG/SPRAY, 800 MCG/SPRAY (fentanyl) ST: Requires 7 consecutive days therapy of current tramadol oral capsule,er biphase 24 hr 17-83 300 mg Tier 1 short-acting opioid prescription; QL (1 EA per 1 day); Age (Min 12 Years)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 13 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Requires 7 consecutive days therapy of current tramadol oral capsule,er biphase 24 hr 25-75 100 mg, Tier 1 short-acting opioid 200 mg prescription; QL (1 EA per 1 day); Age (Min 12 Years) QL (4 EA per 1 day); Age tramadol oral tablet 100 mg Tier 1 (Min 12 Years) QL (8 EA per 1 day); Age tramadol oral tablet 50 mg Tier 1 (Min 12 Years) ST: Requires 7 consecutive days therapy of current tramadol oral tablet extended release 24 hr 100 mg Tier 1 short-acting opioid prescription; QL (3 EA per 1 day); Age (Min 12 Years) ST: Requires 7 consecutive days therapy of current tramadol oral tablet extended release 24 hr 200 mg, 300 Tier 1 short-acting opioid mg prescription; QL (1 EA per 1 day); Age (Min 12 Years) ST: Requires 7 consecutive days therapy of current tramadol oral tablet, er multiphase 24 hr 100 mg Tier 1 short-acting opioid prescription; QL (3 EA per 1 day); Age (Min 12 Years) ST: Requires 7 consecutive days therapy of current tramadol oral tablet, er multiphase 24 hr 200 mg, 300 Tier 1 short-acting opioid mg prescription; QL (1 EA per 1 day); Age (Min 12 Years) ST: Requires 7 consecutive days therapy of current XTAMPZA ER ORAL CAP,SPRINKL,ER12HR(DONT Tier 3 short-acting opioid CRUSH) 13.5 MG, 18 MG, 9 MG (oxycodone myristate) prescription; QL (2 EA per 1 day) ST: Requires 7 consecutive days therapy of current XTAMPZA ER ORAL CAP,SPRINKL,ER12HR(DONT Tier 3 short-acting opioid CRUSH) 27 MG (oxycodone myristate) prescription; QL (4 EA per 1 day)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 14 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Requires 7 consecutive days therapy of current XTAMPZA ER ORAL CAP,SPRINKL,ER12HR(DONT Tier 3 short-acting opioid CRUSH) 36 MG (oxycodone myristate) prescription; QL (8 EA per 1 day) ST: Requires 7 consecutive days therapy of current ZOHYDRO ER ORAL CAPSULE, ORAL ONLY, ER 12HR Tier 3 short-acting opioid 20 MG, 40 MG (hydrocodone bitartrate) prescription; QL (2 EA per 1 day) Analgesic Opioid Codeine Combinations - Arthritis and Pain Drugs acetaminophen-codeine oral solution 120 mg-12 mg /5 QL (150 ML per 1 day); Tier 1 ml (5 ml), 120-12 mg/5 ml Age (Min 12 Years) acetaminophen-codeine oral solution 300 mg-30 mg Tier 1 Age (Min 12 Years) /12.5 ml acetaminophen-codeine oral tablet 300-15 mg, 300-30 QL (12 EA per 1 day); Age Tier 1 mg (Min 12 Years) QL (6 EA per 1 day); Age acetaminophen-codeine oral tablet 300-60 mg Tier 1 (Min 12 Years) codeine phosphate/butalbital/aspirin/caffeine (Ascomp QL (6 EA per 1 day); Age Tier 1 With Codeine Oral Capsule 30-50-325-40 Mg) (Min 12 Years) codeine phosphate/butalbital/aspirin/caffeine (Butalbital QL (6 EA per 1 day); Age Tier 1 Compound W/Codeine Oral Capsule 30-50-325-40 Mg) (Min 12 Years) butalbital-acetaminop-caf-cod oral capsule 50-300-40-30 QL (6 EA per 1 day); Age Tier 1 mg, 50-325-40-30 mg (Min 12 Years) codeine-butalbital-asa-caff oral capsule 30-50-325-40 QL (6 EA per 1 day); Age Tier 1 mg (Min 12 Years) Analgesic Opioid Dihydrocodeine Combinations - Arthritis and Pain Drugs ST: Requires prior prescription for Acetaminophen With acetaminophen-caff-dihydrocod oral capsule 320.5-30- Tier 1 Codeine tablets within the 16 mg past 120 days; QL (10 EA per 1 day); Age (Min 12 Years)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 15 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Requires prior prescription for Acetaminophen With acetaminophen-caff-dihydrocod oral tablet 325-30-16 Tier 1 Codeine tablets within the mg past 120 days; QL (10 EA per 1 day); Age (Min 12 Years) ST: Requires prior prescription for Acetaminophen With acetaminophen/caffeine/dihydrocodeine bitartrate Tier 1 Codeine tablets within the (Dvorah Oral Tablet 325-30-16 Mg) past 120 days; QL (10 EA per 1 day); Age (Min 12 Years) Analgesic Opioid Dihydrocodeine, Non- Salicylate Analgesic,Xanthine - Arthritis and Pain Drugs ST: Requires prior prescription for Acetaminophen With acetaminophen-caff-dihydrocod oral capsule 320.5-30- Tier 1 Codeine tablets within the 16 mg past 120 days; QL (10 EA per 1 day); Age (Min 12 Years) ST: Requires prior prescription for Acetaminophen With acetaminophen-caff-dihydrocod oral tablet 325-30-16 Tier 1 Codeine tablets within the mg past 120 days; QL (10 EA per 1 day); Age (Min 12 Years) ST: Requires prior prescription for Acetaminophen With acetaminophen/caffeine/dihydrocodeine bitartrate Tier 1 Codeine tablets within the (Dvorah Oral Tablet 325-30-16 Mg) past 120 days; QL (10 EA per 1 day); Age (Min 12 Years)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 16 Coverage Prescription Drug Name Drug Tier Requirements and Limits Analgesic Opioid Hydrocodone and Non- Salicylate Combinations - Arthritis and Pain Drugs ST: Requires prior prescription for APADAZ ORAL TABLET 4.08-325 MG, 6.12-325 MG, 8.16- Hydrocodone/acetaminoph Tier 3 325 MG (benzhydrocodone hcl/acetaminophen) en tablets within the past 120 days; QL (12 EA per 1 day) ST: Requires prior prescription for benzhydrocodone-acetaminophen oral tablet 4.08-325 Hydrocodone/acetaminoph Tier 1 mg, 6.12-325 mg, 8.16-325 mg en tablets within the past 120 days; QL (12 EA per 1 day) LORTAB ELIXIR ORAL SOLUTION 10-300 MG/15 ML Tier 3 QL (200 ML per 1 day) (hydrocodone bitartrate/acetaminophen) hydrocodone bitartrate/acetaminophen (Vicodin Hp Oral Tier 1 QL (13 EA per 1 day) Tablet 10-300 Mg) Analgesic Opioid Hydrocodone Combinations - Arthritis and Pain Drugs hydrocodone-acetaminophen oral solution 10-325 Tier 1 QL (184 ML per 1 day) mg/15 ml(15 ml) hydrocodone-acetaminophen oral solution 7.5-325 Tier 1 QL (184 ML per 1 day) mg/15 ml hydrocodone-acetaminophen oral tablet 10-300 mg, 5- Tier 1 QL (13 EA per 1 day) 300 mg, 7.5-300 mg hydrocodone-acetaminophen oral tablet 10-325 mg, 2.5- Tier 1 QL (12 EA per 1 day) 325 mg, 5-325 mg, 7.5-325 mg hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 Tier 1 mg, 7.5-200 mg LORTAB ELIXIR ORAL SOLUTION 10-300 MG/15 ML Tier 3 QL (200 ML per 1 day) (hydrocodone bitartrate/acetaminophen) hydrocodone bitartrate/acetaminophen (Vicodin Hp Oral Tier 1 QL (13 EA per 1 day) Tablet 10-300 Mg) hydrocodone/ibuprofen (Xylon 10 Oral Tablet 10-200 Mg) Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 17 Coverage Prescription Drug Name Drug Tier Requirements and Limits Analgesic Opioid Oxycodone and Non- Salicylate Combinations - Arthritis and Pain Drugs oxycodone hcl/acetaminophen (Endocet Oral Tablet 10- Tier 1 QL (12 EA per 1 day) 325 Mg, 2.5-325 Mg, 7.5-325 Mg) oxycodone-acetaminophen oral tablet 2.5-300 mg Tier 1 QL (12 EA per 1 day) PRIMLEV ORAL TABLET 10-300 MG (oxycodone Tier 1 QL (13 EA per 1 day) hcl/acetaminophen) PRIMLEV ORAL TABLET 5-300 MG, 7.5-300 MG Tier 3 QL (13 EA per 1 day) (oxycodone hcl/acetaminophen) Analgesic Opioid Oxycodone and NSAID Combinations - Arthritis and Pain Drugs ibuprofen-oxycodone oral tablet 400-5 mg Tier 1 Analgesic Opioid Oxycodone and Salicylate Combinations - Arthritis and Pain Drugs oxycodone-aspirin oral tablet 4.8355-325 mg Tier 1 Analgesic Opioid Oxycodone Combinations - Arthritis and Pain Drugs oxycodone hcl/acetaminophen (Endocet Oral Tablet 10- Tier 1 QL (12 EA per 1 day) 325 Mg, 2.5-325 Mg, 5-325 Mg, 7.5-325 Mg) ibuprofen-oxycodone oral tablet 400-5 mg Tier 1 oxycodone hcl/acetaminophen (Nalocet Oral Tablet 2.5- Tier 1 QL (12 EA per 1 day) 300 Mg) oxycodone-acetaminophen oral tablet 10-325 mg, 2.5- Tier 1 QL (12 EA per 1 day) 300 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg oxycodone-aspirin oral tablet 4.8355-325 mg Tier 1 PRIMLEV ORAL TABLET 10-300 MG (oxycodone Tier 1 QL (13 EA per 1 day) hcl/acetaminophen) PRIMLEV ORAL TABLET 5-300 MG, 7.5-300 MG Tier 3 QL (13 EA per 1 day) (oxycodone hcl/acetaminophen) oxycodone hcl/acetaminophen (Prolate Oral Tablet 10- Tier 1 QL (13 EA per 1 day) 300 Mg, 5-300 Mg, 7.5-300 Mg)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 20 Coverage Prescription Drug Name Drug Tier Requirements and Limits Anti-inflammatory - Interleukin-1 Receptor Antagonist - Arthritis and Pain Drugs ARCALYST SUBCUTANEOUS RECON SOLN 220 MG Tier 3 SP (rilonacept) Anti-inflammatory Tumor Necrosis Factor Inhibiting Agnts,TNF-alpha Sel - Arthritis and Pain Drugs CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT Tier 3 PA; SP 400 MG (200 MG X 2 VIALS) (certolizumab pegol) CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT Tier 3 PA; SP 400 MG/2 ML (200 MG/ML X 2) (certolizumab pegol) CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML Tier 3 PA; SP (200 MG/ML X 2) (certolizumab pegol) HUMIRA PEN CROHNS-UC-HS START SUBCUTANEOUS Tier 2 PA; SP PEN INJECTOR KIT 40 MG/0.8 ML (adalimumab) HUMIRA PEN PSOR-UVEITS-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML Tier 2 PA; SP (adalimumab) HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, Tier 2 PA; SP 20 MG/0.4 ML, 40 MG/0.8 ML (adalimumab) HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML, 80 Tier 2 PA; SP MG/0.8 ML-40 MG/0.4 ML (adalimumab) HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS Tier 2 PA; SP PEN INJECTOR KIT 80 MG/0.8 ML (adalimumab) HUMIRA(CF) PEN PSOR-UV-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML-40 MG/0.4 ML Tier 2 PA; SP (adalimumab) HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 Tier 2 PA; SP ML, 20 MG/0.2 ML, 40 MG/0.4 ML (adalimumab) SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MG/ML, Tier 3 PA; SP 50 MG/0.5 ML (golimumab) SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML, 50 Tier 3 PA; SP MG/0.5 ML (golimumab)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 24 Coverage Prescription Drug Name Drug Tier Requirements and Limits cyclosporine, modified (Gengraf Oral Solution 100 Mg/Ml) Tier 1 SP NEORAL ORAL SOLUTION 100 MG/ML (cyclosporine, Tier 2 SP modified) SANDIMMUNE ORAL SOLUTION 100 MG/ML Tier 2 SP (cyclosporine) DMARD - Interleukin-1 Receptor Antagonist (IL- 1Ra) - Arthritis and Pain Drugs KINERET SUBCUTANEOUS SYRINGE 100 MG/0.67 ML Tier 3 PA; SP (anakinra) DMARD - Interleukin-6 (IL-6) Receptor Inhibitors, Monoclonal Antibody - Arthritis and Pain Drugs ACTEMRA ACTPEN SUBCUTANEOUS PEN INJECTOR Tier 3 PA; SP 162 MG/0.9 ML (tocilizumab) ACTEMRA SUBCUTANEOUS SYRINGE 162 MG/0.9 ML Tier 3 PA; SP (tocilizumab) KEVZARA SUBCUTANEOUS PEN INJECTOR 150 Tier 3 PA; SP MG/1.14 ML, 200 MG/1.14 ML (sarilumab) KEVZARA SUBCUTANEOUS SYRINGE 150 MG/1.14 ML, Tier 3 PA; SP 200 MG/1.14 ML (sarilumab) DMARD - Janus Kinase (JAK) Inhibitors - Arthritis and Pain Drugs OLUMIANT ORAL TABLET 1 MG, 2 MG (baricitinib) Tier 3 PA; SP RINVOQ ORAL TABLET EXTENDED RELEASE 24 HR 15 Tier 2 PA; SP MG (upadacitinib) XELJANZ ORAL TABLET 5 MG (tofacitinib citrate) Tier 2 PA; SP XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 Tier 2 PA; SP HR 11 MG (tofacitinib citrate) DMARD - Other - Arthritis and Pain Drugs CUPRIMINE ORAL CAPSULE 250 MG (penicillamine) Tier 3 PA; SP D-PENAMINE ORAL TABLET 125 MG (penicillamine) Tier 1 PA; SP penicillamine oral tablet 250 mg Tier 1 PA; SP DMARD - Phosphodiesterase-4 (PDE4) Inhibitors - Arthritis and Pain Drugs OTEZLA ORAL TABLET 30 MG (apremilast) Tier 2 PA; SP PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 25 Coverage Prescription Drug Name Drug Tier Requirements and Limits OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG (47), 10 MG (4)-20 MG (4)-30 MG(19) Tier 2 PA; SP (apremilast) DMARD - Pyrimidine Synthesis Inhibitors - Arthritis and Pain Drugs leflunomide oral tablet 10 mg, 20 mg Tier 1 Immunomodulator B-Lymphocyte Stimulator (BLyS)-Specific Inhibitor MCAB - Arthritis and Pain Drugs BENLYSTA SUBCUTANEOUS AUTO-INJECTOR 200 Tier 3 PA; SP MG/ML (belimumab) BENLYSTA SUBCUTANEOUS SYRINGE 200 MG/ML Tier 3 PA; SP (belimumab) NSAID Analgesic and Histamine H2 Receptor Antagonist Combinations - Arthritis and Pain Drugs ST: Requires prior DUEXIS ORAL TABLET 800-26.6 MG prescription for Ibuprofen Tier 3 (ibuprofen/famotidine) within the past 120 days; QL (3 EA per 1 day) NSAID Analgesic and Prostaglandin Analog Combinations - Arthritis and Pain Drugs diclofenac-misoprostol oral tablet,ir,delayed Tier 1 rel,biphasic 50-200 mg-mcg, 75-200 mg-mcg NSAID Analgesic and Proton Pump Inhibitor Combinations - Arthritis and Pain Drugs ST: Requires prior prescription for Naprelan, naproxen-esomeprazole oral tablet,ir,delayed Tier 1 Naproxen Sodium, or rel,biphasic 375-20 mg, 500-20 mg Naproxen within the past 120 days NSAID Analgesic and Topical Irritant Counter- Irritant Combinations - Arthritis and Pain Drugs COMFORT PAC-IBUPROFEN KIT 800 MG Tier 3 (ibuprofen/irritants counter-irritants combination no.2)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 27 Coverage Prescription Drug Name Drug Tier Requirements and Limits NSAID Analgesic, Cyclooxygenase-2 (COX-2) Selective Inhibitors - Arthritis and Pain Drugs celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg Tier 1 NUDROXIPAK KIT, LIQUID AND CAPSULE 200 MG-0.025 %- 25 %-6 % (celecoxib/capsaicin/methyl Tier 3 salicylate/menthol) NSAID Analgesics (COX Non-Specific) - Anthranilic Acid Derivatives - Arthritis and Pain Drugs meclofenamate oral capsule 100 mg, 50 mg Tier 1 mefenamic acid oral capsule 250 mg Tier 1 NSAID Analgesics (COX Non-Specific) - Other - Arthritis and Pain Drugs ketorolac injection cartridge 15 mg/ml, 30 mg/ml Tier 1 ketorolac injection solution 15 mg/ml, 30 mg/ml (1 ml) Tier 1 ketorolac injection solution 30 mg/ml Tier 1 ketorolac injection syringe 15 mg/ml, 30 mg/ml Tier 1 ketorolac intramuscular cartridge 60 mg/2 ml Tier 1 ketorolac intramuscular solution 60 mg/2 ml Tier 1 ketorolac intramuscular syringe 60 mg/2 ml Tier 1 ST: Requires prior prescription for a generic Nonsteroidal Anti- ketorolac nasal spray,non-aerosol 15.75 mg/spray Tier 1 Inflammatory Drug (NSAID) within the past 120 days; QL (5 EA per 30 days) ketorolac oral tablet 10 mg Tier 1 QL (20 EA per 5 days) nabumetone oral tablet 500 mg, 750 mg Tier 1 ST: Requires prior prescription for generic Nabumetone tablets within RELAFEN DS ORAL TABLET 1,000 MG (nabumetone) Tier 3 the past 120 days; QL (2 EA per 1 day); Age (Min 18 Years)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 28 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Requires prior prescription for a generic SPRIX NASAL SPRAY,NON-AEROSOL 15.75 MG/SPRAY Nonsteroidal Anti- Tier 3 (ketorolac tromethamine) Inflammatory Drug (NSAID) within the past 120 days; QL (5 EA per 30 days) sulindac oral tablet 150 mg, 200 mg Tier 1 tolmetin oral capsule 400 mg Tier 1 tolmetin oral tablet 200 mg, 600 mg Tier 1 TORONOVA II SUIK KIT 30 MG/ML (ketorolac/norflurane Tier 3 and pentafluoropropane (hfc 245fa)) TORONOVA SUIK KIT 30 MG/ML (ketorolac/norflurane Tier 3 and pentafluoropropane (hfc 245fa)) NSAID Analgesics (COX Non-Specific) - Oxicam Derivatives - Arthritis and Pain Drugs meloxicam oral tablet 15 mg, 7.5 mg Tier 1 ST: At least 2 prior prescriptions for Diclofenac Potassium, Diclofenac meloxicam submicronized oral capsule 10 mg, 5 mg Tier 1 Sodium, or Meloxicam within the past 365 days; QL (1 EA per 1 day) piroxicam oral capsule 10 mg, 20 mg Tier 1 ST: At least 2 prior prescriptions for Diclofenac VIVLODEX ORAL CAPSULE 10 MG, 5 MG (meloxicam, Potassium, Diclofenac Tier 3 submicronized) Sodium, or Meloxicam within the past 365 days; QL (1 EA per 1 day) NSAID Analgesics (COX Non-Specific) - Phenylacetic Acid Derivatives - Arthritis and Pain Drugs CAMBIA ORAL POWDER IN PACKET 50 MG (diclofenac Tier 3 PA potassium) diclofenac potassium oral tablet 50 mg Tier 1 diclofenac sodium oral tablet extended release 24 hr Tier 1 100 mg

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 29 Coverage Prescription Drug Name Drug Tier Requirements and Limits diclofenac sodium oral tablet,delayed release (dr/ec) 25 Tier 1 mg, 50 mg, 75 mg ST: Requires prior prescription for Diclo Gel, Diclofenac Sodium, Diclofono, Diclozor, diclofenac submicronized oral capsule 35 mg Tier 1 Dyloject, Pennsaid, or Vopac Mds within the past 120 days; QL (3 EA per 1 day) ST: Requires prior prescription for Diclo Gel, Diclofenac Sodium, Diclofenac Sodium/misoprostol, ZIPSOR ORAL CAPSULE 25 MG (diclofenac potassium) Tier 3 Diclofono, Diclozor, Dyloject, Pennsaid, or Vopac Mds within the past 120 days; QL (4 EA per 1 day) ST: Requires prior prescription for Diclo Gel, Diclofenac Sodium, ZORVOLEX ORAL CAPSULE 18 MG, 35 MG (diclofenac Diclofono, Diclozor, Tier 3 submicronized) Dyloject, Pennsaid, or Vopac Mds within the past 120 days; QL (3 EA per 1 day) NSAID Analgesics (COX Non-Specific) - Propionic Acid Derivatives - Arthritis and Pain Drugs EC-NAPROXEN ORAL TABLET,DELAYED RELEASE Tier 1 (DR/EC) 375 MG, 500 MG (naproxen) fenoprofen oral capsule 200 mg, 400 mg Tier 1 fenoprofen oral tablet 600 mg Tier 1 flurbiprofen oral tablet 100 mg Tier 1 ibuprofen (Ibu Oral Tablet 400 Mg, 600 Mg, 800 Mg) Tier 1 IBUPAK ORAL KIT 600 MG (ibuprofen/glycerin) Tier 3 ibuprofen oral suspension 100 mg/5 ml Tier 1 PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 30 Coverage Prescription Drug Name Drug Tier Requirements and Limits ibuprofen oral tablet 400 mg, 600 mg, 800 mg Tier 1 ketoprofen oral capsule 25 mg, 50 mg, 75 mg Tier 1 ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg Tier 1 NAPRELAN CR ORAL TABLET, ER MULTIPHASE 24 HR Tier 3 750 MG (naproxen sodium) naproxen oral suspension 125 mg/5 ml Tier 1 naproxen oral tablet 250 mg, 375 mg, 500 mg Tier 1 naproxen oral tablet,delayed release (dr/ec) 375 mg, 500 Tier 1 mg naproxen sodium oral tablet 275 mg, 550 mg Tier 1 naproxen sodium oral tablet, er multiphase 24 hr 375 Tier 1 mg, 500 mg oxaprozin oral tablet 600 mg Tier 1 NSAID Analgesics, (COX Non-specific) - Indole Acetic Acid Derivatives - Arthritis and Pain Drugs etodolac oral capsule 200 mg, 300 mg Tier 1 etodolac oral tablet 400 mg, 500 mg Tier 1 etodolac oral tablet extended release 24 hr 400 mg, 500 Tier 1 mg, 600 mg INDOCIN ORAL SUSPENSION 25 MG/5 ML Tier 2 (indomethacin) INDOCIN RECTAL SUPPOSITORY 50 MG Tier 3 PA (indomethacin) indomethacin oral capsule 25 mg, 50 mg Tier 1 indomethacin oral capsule, extended release 75 mg Tier 1 ST: Requires prior prescription for indomethacin submicronized oral capsule 20 mg Tier 1 Indomethacin capsules within the past 120 days; QL (3 EA per 1 day) ST: Requires prior prescription for TIVORBEX ORAL CAPSULE 20 MG (indomethacin, Tier 3 Indomethacin capsules submicronized) within the past 120 days; QL (3 EA per 1 day)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 31 Coverage Prescription Drug Name Drug Tier Requirements and Limits Salicylate Analgesic and Sedative Combinations - Arthritis and Pain Drugs butalbital-aspirin-caffeine oral capsule 50-325-40 mg Tier 1 butalbital-aspirin-caffeine oral tablet 50-325-40 mg Tier 1 Salicylate Analgesic Combinations - Arthritis and Pain Drugs choline,magnesium salicylate oral liquid 500 mg/5 ml Tier 1 Salicylate Analgesics - Arthritis and Pain Drugs ADULT ASPIRIN REGIMEN ORAL TABLET,DELAYED $0 EHB RELEASE (DR/EC) 81 MG (aspirin) ADULT LOW DOSE ASPIRIN ORAL TABLET,DELAYED $0 EHB RELEASE (DR/EC) 81 MG (aspirin) ASPIRIN CHILDRENS ORAL TABLET,CHEWABLE 81 MG $0 EHB (aspirin) ASPIRIN LOW DOSE ORAL TABLET,DELAYED RELEASE $0 EHB (DR/EC) 81 MG (aspirin) aspirin oral tablet 325 mg $0 EHB aspirin oral tablet,chewable 81 mg $0 EHB aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg $0 EHB ASPIR-TRIN ORAL TABLET,DELAYED RELEASE (DR/EC) $0 EHB 325 MG (aspirin) CHILDREN'S ASPIRIN ORAL TABLET,CHEWABLE 81 MG $0 EHB (aspirin) diflunisal oral tablet 500 mg Tier 1 DURLAZA ORAL CAPSULE,EXTENDED RELEASE 24HR Tier 3 PA 162.5 MG (aspirin) ECOTRIN ORAL TABLET,DELAYED RELEASE (DR/EC) $0 EHB 325 MG (aspirin) LITE COAT ASPIRIN ORAL TABLET 325 MG (aspirin) $0 EHB LO-DOSE ASPIRIN ORAL TABLET,DELAYED RELEASE $0 EHB (DR/EC) 81 MG (aspirin) salsalate oral tablet 500 mg, 750 mg Tier 1 ST JOSEPH ASPIRIN ORAL TABLET,CHEWABLE 81 MG $0 EHB (aspirin)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 33 Coverage Prescription Drug Name Drug Tier Requirements and Limits Anorectal Preparations - Rectal Preparations Anal Fissure Pain/Treatment Agents - Nitrates - Rectal Preparations RECTIV RECTAL OINTMENT 0.4 % (W/W) (nitroglycerin) Tier 3 Anorectal - Glucocorticoids - Rectal Preparations ANUCORT-HC RECTAL SUPPOSITORY 25 MG Tier 1 (hydrocortisone acetate) hydrocortisone acetate rectal suppository 25 mg, 30 mg Tier 1 hydrocortisone topical cream with perineal applicator 1 Tier 1 %, 2.5 % hydrocortisone (Procto-Med Hc Topical Cream With Tier 1 Perineal Applicator 2.5 %) hydrocortisone (Procto-Pak Topical Cream With Perineal Tier 1 Applicator 1 %) hydrocortisone (Proctosol Hc Topical Cream With Perineal Tier 1 Applicator 2.5 %) hydrocortisone (Proctozone-Hc Topical Cream With Tier 1 Perineal Applicator 2.5 %) Anorectal - Hemorrhoidal Rectal Glucocorticoid-Local Anesthetic Comb - Rectal Preparations ANA-LEX KIT RECTAL KIT 2-2 % (hydrocortisone Tier 1 acetate/lidocaine hcl/aloe vera) hydrocortisone-pramoxine rectal cream 1-1 %, 2.5-1 %, Tier 1 2.5-1 % (4g) lidocaine hcl-hydrocortison ac rectal cream 3-0.5 % Tier 1 lidocaine hcl-hydrocortison ac rectal gel 3 %-2.5 % (7 Tier 1 gram) lidocaine hcl-hydrocortison ac rectal kit 2 %-2 % (7 Tier 1 gram) lidocaine hcl-hydrocortison ac rectal kit 3-0.5 %, 3-1 % Tier 1 (7 gram) lidocaine-hydrocortisone-aloe rectal gel 2.8-0.55 % Tier 1 lidocaine-hydrocortisone-aloe rectal kit 3-2.5 % (7 gram) Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 37 Coverage Prescription Drug Name Drug Tier Requirements and Limits amoxicillin-pot clavulanate oral tablet extended release Tier 1 12 hr 1,000-62.5 mg amoxicillin-pot clavulanate oral tablet,chewable 200- Tier 1 28.5 mg, 400-57 mg ST: Requires prior AUGMENTIN ORAL SUSPENSION FOR prescription for RECONSTITUTION 125-31.25 MG/5 ML Tier 3 Amoxicillin/potassium Clav (amoxicillin/potassium clavulanate) within the past 120 days; QL (150 ML per 30 days) Anthelmintic Agents - Benzimidazole Derivatives - Drugs for Parasites albendazole oral tablet 200 mg Tier 1 EGATEN ORAL TABLET 250 MG (triclabendazole) Tier 3 EMVERM ORAL TABLET,CHEWABLE 100 MG Tier 2 PA (mebendazole) Anthelmintic Agents - Macrocyclic Lactones - Drugs for Parasites ivermectin oral tablet 3 mg Tier 1 Anthelmintic Agents Other - Drugs for Parasites ivermectin oral tablet 3 mg Tier 1 praziquantel oral tablet 600 mg Tier 1 Antibacterial Folate Antagonist - Other Combinations - Antibiotics sulfamethoxazole-trimethoprim oral suspension 200-40 Tier 1 mg/5 ml sulfamethoxazole-trimethoprim oral tablet 400-80 mg, Tier 1 800-160 mg SULFATRIM ORAL SUSPENSION 200-40 MG/5 ML Tier 1 (sulfamethoxazole/trimethoprim) Antibacterial Folate Antagonist Others - Antibiotics PRIMSOL ORAL SOLUTION 50 MG/5 ML (trimethoprim) Tier 2 trimethoprim oral tablet 100 mg Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 38 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antibacterial Other - Antibiotics fosfomycin tromethamine oral packet 3 gram Tier 1 Antifungal - Allylamines - Drugs for Fungus terbinafine hcl oral tablet 250 mg Tier 1 Antifungal - Amphoteric Polyene Macrolides - Drugs for Fungus nystatin oral tablet 500,000 unit Tier 1 Antifungal - Imidazoles - Drugs for Fungus ketoconazole oral tablet 200 mg Tier 1 ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET Tier 3 50 MG (miconazole) Antifungal - Triazoles - Drugs for Fungus CRESEMBA ORAL CAPSULE 186 MG (isavuconazonium Tier 3 sulfate) fluconazole oral suspension for reconstitution 10 Tier 1 mg/ml, 40 mg/ml fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg Tier 1 itraconazole oral capsule 100 mg Tier 1 itraconazole oral solution 10 mg/ml Tier 1 NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML) Tier 3 (posaconazole) posaconazole oral tablet,delayed release (dr/ec) 100 mg Tier 1 TOLSURA ORAL CAPSULE, SOLID DISPERSION 65 MG Tier 3 PA (itraconazole) voriconazole oral suspension for reconstitution 200 Tier 1 mg/5 ml (40 mg/ml) voriconazole oral tablet 200 mg, 50 mg Tier 1 Antifungal other - Drugs for Fungus flucytosine oral capsule 250 mg, 500 mg Tier 1 griseofulvin microsize oral suspension 125 mg/5 ml Tier 1 griseofulvin microsize oral tablet 500 mg Tier 1 griseofulvin ultramicrosize oral tablet 125 mg, 250 mg Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 39 Coverage Prescription Drug Name Drug Tier Requirements and Limits Anti-Infective Immunologic Adjuvants - Interferons - Drugs for Infections ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG/0.5 Tier 3 PA; SP ML (interferon gamma-1b,recomb.) Antileprotic - Immunomodulators - Antibiotics THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, PA; SP; QL (2 EA per 1 Tier 2 50 MG (thalidomide) day) Antileprotic - Sulfone Agents - Antibiotics dapsone oral tablet 100 mg, 25 mg Tier 1 Antimalarial Combinations - Drugs for Parasites atovaquone-proguanil oral tablet 250-100 mg, 62.5-25 Tier 1 mg COARTEM ORAL TABLET 20-120 MG Tier 3 (artemether/lumefantrine) Antimalarials - Drugs for Parasites ARAKODA ORAL TABLET 100 MG (tafenoquine Tier 3 succinate) chloroquine phosphate oral tablet 250 mg Tier 1 QL (36 EA per 16 days) chloroquine phosphate oral tablet 500 mg Tier 1 QL (18 EA per 16 days) hydroxychloroquine oral tablet 200 mg Tier 1 QL (100 EA per 30 days) KRINTAFEL ORAL TABLET 150 MG (tafenoquine Tier 2 QL (2 EA per 1 FILL) succinate) mefloquine oral tablet 250 mg Tier 1 primaquine oral tablet 26.3 mg Tier 2 pyrimethamine oral tablet 25 mg Tier 1 PA; SP quinine sulfate oral capsule 324 mg Tier 1 Antiprotozoal Agents - Nitrofuran Derivatives - Drugs for Parasites LAMPIT ORAL TABLET 120 MG, 30 MG (nifurtimox) Tier 3 Antiprotozoal Agents - Nitroimidazole Derivatives - Drugs for Parasites benznidazole oral tablet 100 mg, 12.5 mg Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 40 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antiprotozoal Agents - Other - Drugs for Parasites ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 Tier 3 MG/5 ML (nitazoxanide) atovaquone oral suspension 750 mg/5 ml Tier 1 IMPAVIDO ORAL CAPSULE 50 MG (miltefosine) Tier 2 PA nitazoxanide oral tablet 500 mg Tier 1 Antiprotozoal Agents (antiparasitic) - 5- Nitrothiazolyl Derivatives - Drugs for Parasites ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 Tier 3 MG/5 ML (nitazoxanide) Antiprotozoal-Antibacterial 1st Generation 2- methyl-5-nitroimidazole - Drugs for Infections metronidazole oral capsule 375 mg Tier 1 metronidazole oral tablet 250 mg, 500 mg Tier 1 Antiprotozoal-Antibacterial 2nd Generation 2- methyl-5-nitroimidazole - Drugs for Infections ST: At least 2 prior prescriptions for Clindamycin HCL, Clindamycin Palmitate SOLOSEC ORAL GRANULES DEL RELEASE IN PACKET Tier 3 HCL, Clindamycin 2 GRAM (secnidazole) Phosphate, Metronidazole, Tinidazole, or Vandazole within the past 365 days; QL (1 EA per 30 days) tinidazole oral tablet 250 mg, 500 mg Tier 1 Antiretroviral - CCR5 Co-Receptor Antagonist - Drugs for Viral Infections SELZENTRY ORAL SOLUTION 20 MG/ML (maraviroc) Tier 2 SP; QL (31 ML per 1 day) SELZENTRY ORAL TABLET 150 MG, 75 MG (maraviroc) Tier 2 SP; QL (2 EA per 1 day) SELZENTRY ORAL TABLET 25 MG, 300 MG (maraviroc) Tier 2 SP; QL (4 EA per 1 day)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 41 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antiretroviral - CD4 Attachment Inhibitors - Drugs for Viral Infections RUKOBIA ORAL TABLET EXTENDED RELEASE 12 HR Tier 2 PA; SP 600 MG (fostemsavir tromethamine) Antiretroviral - HIV-1 Fusion Inhibitors - Drugs for Viral Infections FUZEON SUBCUTANEOUS RECON SOLN 90 MG Tier 2 SP; QL (2 EA per 1 day) (enfuvirtide) Antiretroviral - HIV-1 Integrase Strand Transfer Inhibitors - Drugs for Viral Infections ISENTRESS HD ORAL TABLET 600 MG (raltegravir Tier 2 SP; QL (2 EA per 1 day) potassium) ISENTRESS ORAL POWDER IN PACKET 100 MG Tier 2 SP; QL (2 EA per 1 day) (raltegravir potassium) ISENTRESS ORAL TABLET 400 MG (raltegravir Tier 2 SP; QL (2 EA per 1 day) potassium) ISENTRESS ORAL TABLET,CHEWABLE 100 MG, 25 MG Tier 2 SP; QL (6 EA per 1 day) (raltegravir potassium) TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG Tier 2 SP; QL (2 EA per 1 day) (dolutegravir sodium) TIVICAY PD ORAL TABLET FOR SUSPENSION 5 MG Tier 2 SP; QL (6 EA per 1 day) (dolutegravir sodium) Antiretroviral - Integrase Inhibitor and NNRTI Combinations - Drugs for Viral Infections JULUCA ORAL TABLET 50-25 MG (dolutegravir Tier 2 SP; QL (1 EA per 1 day) sodium/rilpivirine hcl) Antiretroviral - Integrase Inhibitor and NRTI Combinations - Drugs for Viral Infections DOVATO ORAL TABLET 50-300 MG (dolutegravir Tier 2 SP; QL (1 EA per 1 day) sodium/lamivudine) Antiretroviral - Non-Nucleoside Reverse Transcriptase Inhib (NNRTI) - Drugs for Viral Infections EDURANT ORAL TABLET 25 MG (rilpivirine hcl) Tier 2 SP; QL (1 EA per 1 day) efavirenz oral capsule 200 mg, 50 mg Tier 1 SP

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 46 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antitubercular Agents Other - Antibiotics ethambutol oral tablet 100 mg, 400 mg Tier 1 TRECATOR ORAL TABLET 250 MG (ethionamide) Tier 3 Antitubercular Combinations - Antibiotics RIFAMATE ORAL CAPSULE 300-150 MG Tier 2 (rifampin/isoniazid) RIFATER ORAL TABLET 50-120-300 MG Tier 3 (rifampin/isoniazid/pyrazinamide) Cephalosporin Antibiotics - 1st Generation - Antibiotics cefadroxil oral capsule 500 mg Tier 1 cefadroxil oral suspension for reconstitution 250 mg/5 Tier 1 ml, 500 mg/5 ml cefadroxil oral tablet 1 gram Tier 1 cephalexin oral capsule 250 mg, 500 mg, 750 mg Tier 1 cephalexin oral suspension for reconstitution 125 mg/5 Tier 1 ml, 250 mg/5 ml cephalexin oral tablet 250 mg, 500 mg Tier 1 Cephalosporin Antibiotics - 2nd Generation - Antibiotics cefaclor oral capsule 250 mg, 500 mg Tier 1 cefaclor oral suspension for reconstitution 125 mg/5 ml, Tier 1 250 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 12 hr 500 mg Tier 1 cefprozil oral suspension for reconstitution 125 mg/5 Tier 1 ml, 250 mg/5 ml cefprozil oral tablet 250 mg, 500 mg Tier 1 cefuroxime axetil oral tablet 250 mg, 500 mg Tier 1 Cephalosporin Antibiotics - 3rd Generation - Antibiotics cefdinir oral capsule 300 mg Tier 1 cefdinir oral suspension for reconstitution 125 mg/5 ml, Tier 1 250 mg/5 ml cefditoren pivoxil oral tablet 200 mg, 400 mg Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 47 Coverage Prescription Drug Name Drug Tier Requirements and Limits cefixime oral capsule 400 mg Tier 1 cefixime oral suspension for reconstitution 100 mg/5 Tier 1 ml, 200 mg/5 ml cefpodoxime oral suspension for reconstitution 100 Tier 1 mg/5 ml, 50 mg/5 ml cefpodoxime oral tablet 100 mg, 200 mg Tier 1 SUPRAX ORAL SUSPENSION FOR RECONSTITUTION Tier 2 500 MG/5 ML (cefixime) SUPRAX ORAL TABLET,CHEWABLE 100 MG, 200 MG Tier 2 (cefixime) CMV Antiviral Agent - Nucleoside Analogs - Drugs for Viral Infections valganciclovir oral recon soln 50 mg/ml Tier 1 valganciclovir oral tablet 450 mg Tier 1 CMV Antiviral Agent - Terminase Complex Inhibitors - Drugs for Viral Infections PREVYMIS ORAL TABLET 240 MG, 480 MG (letermovir) Tier 3 PA Fluoroquinolone Antibiotics - Antibiotics BAXDELA ORAL TABLET 450 MG (delafloxacin Tier 3 PA meglumine) CIPRO ORAL SUSPENSION,MICROCAPSULE RECON Tier 2 250 MG/5 ML, 500 MG/5 ML (ciprofloxacin) CIPRO XR ORAL TABLET, ER MULTIPHASE 24 HR 1,000 Tier 3 MG, 500 MG (ciprofloxacin/ciprofloxacin hcl) ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, Tier 1 750 mg ciprofloxacin oral suspension,microcapsule recon 250 Tier 1 mg/5 ml, 500 mg/5 ml FACTIVE ORAL TABLET 320 MG (gemifloxacin Tier 3 mesylate) levofloxacin oral solution 250 mg/10 ml Tier 1 levofloxacin oral tablet 250 mg, 500 mg, 750 mg Tier 1 moxifloxacin oral tablet 400 mg Tier 1 ofloxacin oral tablet 300 mg, 400 mg Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 51 Coverage Prescription Drug Name Drug Tier Requirements and Limits clindamycin palmitate hcl (Clindamycin Pediatric Oral Tier 1 Recon Soln 75 Mg/5 Ml) Macrolide Antibiotics - Antibiotics azithromycin oral packet 1 gram Tier 1 azithromycin oral suspension for reconstitution 100 Tier 1 mg/5 ml, 200 mg/5 ml azithromycin oral tablet 250 mg, 500 mg, 600 mg Tier 1 clarithromycin oral suspension for reconstitution 125 Tier 1 mg/5 ml, 250 mg/5 ml clarithromycin oral tablet 250 mg, 500 mg Tier 1 clarithromycin oral tablet extended release 24 hr 500 Tier 1 mg ST: Requires prior prescription for DIFICID ORAL SUSPENSION FOR RECONSTITUTION 40 Tier 2 Vancomycin oral capsules MG/ML (fidaxomicin) within the past 120 days; QL (5 ML per 1 day) ST: Requires prior prescription for DIFICID ORAL TABLET 200 MG (fidaxomicin) Tier 2 Vancomycin oral capsules within the past 120 days; QL (20 EA per 30 days) erythromycin ethylsuccinate (E.E.S. 400 Oral Tablet 400 Tier 1 Mg) erythromycin base (Ery-Tab Oral Tablet,Delayed Release Tier 1 (Dr/Ec) 250 Mg, 500 Mg) erythromycin stearate (Erythrocin (As Stearate) Oral Tier 1 Tablet 250 Mg) erythromycin ethylsuccinate oral suspension for Tier 1 reconstitution 200 mg/5 ml, 400 mg/5 ml erythromycin ethylsuccinate oral tablet 400 mg Tier 1 erythromycin oral capsule,delayed release(dr/ec) 250 Tier 1 mg erythromycin oral tablet 250 mg, 500 mg Tier 1 erythromycin oral tablet,delayed release (dr/ec) 250 mg, Tier 1 333 mg, 500 mg

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 52 Coverage Prescription Drug Name Drug Tier Requirements and Limits Misc Anti-Infective - Drugs for Infections methenamine hippurate oral tablet 1 gram Tier 1 methenamine mandelate oral tablet 0.5 g, 1 gram Tier 1 NEBUPENT INHALATION RECON SOLN 300 MG Tier 2 (pentamidine isethionate) pentamidine inhalation recon soln 300 mg Tier 1 UROQID-ACID NO.2 ORAL TABLET 500-500 MG (methenamine mandelate/sodium Tier 3 phosphate,monobasic) Misc Anti-Infective Combinations - Drugs for Infections HYOPHEN ORAL TABLET 81.6-0.12-10.8 MG (methenamine/methylene blue/benzoic Tier 1 acid/salicylat/hyoscyamin) methen-sod phos-meth blue-hyos oral tablet 81.6-40.8- Tier 1 0.12 mg PHOSPHASAL ORAL TABLET 81.6-10.8-40.8 MG (methenamine/methylene blue/sod Tier 2 phos/p.salicylate/hyoscyamine) URETRON D-S ORAL TABLET 81.6-10.8-40.8 MG (methenamine/methylene blue/sod Tier 2 phos/p.salicylate/hyoscyamine) URIMAR-T ORAL TABLET 120-0.12-10.8 MG (methenamine/methylene blue/salicylate/sodium Tier 1 phos/hyoscyamin) URIN DS ORAL TABLET 81.6-10.8-40.8 MG (methenamine/methylene blue/sod Tier 2 phos/p.salicylate/hyoscyamine) URO-458 ORAL TABLET 81-10.8-40.8 MG (methenamine/methylene blue/sod Tier 1 phos/p.salicylate/hyoscyamine) UROGESIC-BLUE ORAL TABLET 81.6-40.8-0.12 MG (methenamine/sod phosph,monobasic/methylene Tier 1 blue/hyoscyamine) URO-MP ORAL CAPSULE 118-10-40.8-36 MG (methenamine/methylene blue/sod Tier 1 phos/p.salicylate/hyoscyamine)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 58 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Requires prior prescription for generic MINOLIRA ER ORAL TABLET, IR - ER, BIPHASIC 24HR immediate-release Tier 3 105 MG, 135 MG (minocycline hcl) Minocycline within the past 120 days; QL (1 EA per 1 day); Age (Min 12 Years) doxycycline monohydrate (Mondoxyne Nl Oral Capsule Tier 1 QL (2 EA per 1 day) 100 Mg) ST: Requires prior prescription for generic doxycycline monohydrate (Mondoxyne Nl Oral Capsule Doxycycline Monohydrate Tier 1 75 Mg) 75mg tablets within the past 120 days; QL (2 EA per 1 day) ST: Requires prior prescription for generic MORGIDOX 1X 50 KIT 50 MG (doxycycline hyclate/skin Doxycycline Monohydrate Tier 3 cleanser combination no.19) 100mg capsules within the past 120 days; QL (1 EA per 30 days) ST: Requires prior prescription for generic MORGIDOX 1X100 KIT 100 MG (doxycycline Doxycycline Monohydrate Tier 3 hyclate/skin cleanser combination no.19) 100mg capsules within the past 120 days; QL (1 EA per 30 days) ST: Requires prior prescription for generic MORGIDOX 2X100 KIT 100 MG (doxycycline Doxycycline Monohydrate Tier 3 hyclate/skin cleanser combination no.19) 100mg capsules within the past 120 days; QL (1 EA per 30 days) NUZYRA ORAL TABLET 150 MG (omadacycline tosylate) Tier 3 PA ST: Requires prior prescription for Doryx Mpc, Doxycycline Hyclate, SEYSARA ORAL TABLET 100 MG, 150 MG, 60 MG Doxycycline Monohydrate, Tier 3 (sarecycline hcl) Minocycline HCL, or Vibramycin within the past 120 days; QL (1 EA per 1 day); Age (Min 9 Years) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 59 Coverage Prescription Drug Name Drug Tier Requirements and Limits tetracycline oral capsule 250 mg, 500 mg Tier 1 VIBRAMYCIN ORAL SYRUP 50 MG/5 ML (doxycycline Tier 2 calcium) Variola (Smallpox) Virus Antiviral Agents - Drugs for Viral Infections TPOXX (NATIONAL STOCKPILE) ORAL CAPSULE 200 Tier 3 MG (tecovirimat) Antineoplastics - Drugs for Cancer Antineoplasic-Epiderm.Growth Factor-EGFR (ErbB1),HER-2 (ErbB2)R.Inhib - Drugs for Cancer lapatinib oral tablet 250 mg Tier 1 PA; SP; OCH Antineoplastic - CYP17 (17 alpha- hydroxylase/C17,20-lyase) inhibitor - Drugs for Cancer abiraterone oral tablet 500 mg Tier 1 PA; SP; OCH YONSA ORAL TABLET 125 MG (abiraterone acetate, Tier 3 PA; SP; OCH submicronized) ZYTIGA ORAL TABLET 500 MG (abiraterone acetate) Tier 2 PA; SP; OCH Antineoplastic - 1st generation EGFR tyrosine kinase inhibitor - Drugs for Cancer erlotinib oral tablet 100 mg, 150 mg, 25 mg Tier 1 PA; SP; OCH IRESSA ORAL TABLET 250 MG (gefitinib) Tier 2 PA; SP; OCH Antineoplastic - 2nd generation EGFR tyrosine kinase inhibitor - Drugs for Cancer GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG (afatinib Tier 2 PA; SP; OCH dimaleate) NERLYNX ORAL TABLET 40 MG (neratinib maleate) Tier 2 PA; SP; OCH VIZIMPRO ORAL TABLET 15 MG, 30 MG, 45 MG Tier 2 PA; SP; OCH (dacomitinib) Antineoplastic - 3rd generation EGFR tyrosine kinase inhibitor - Drugs for Cancer TAGRISSO ORAL TABLET 40 MG, 80 MG (osimertinib Tier 2 PA; SP; OCH mesylate)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 60 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antineoplastic - Alkylating Agent - Alkyl Sulfonates - Drugs for Cancer MYLERAN ORAL TABLET 2 MG (busulfan) Tier 2 SP; OCH Antineoplastic - Alkylating Agent - Methylhydrazines - Drugs for Cancer MATULANE ORAL CAPSULE 50 MG (procarbazine hcl) Tier 2 SP; OCH Antineoplastic - Alkylating Agent - Nitrogen Mustards - Drugs for Cancer cyclophosphamide oral capsule 25 mg, 50 mg Tier 1 SP; OCH LEUKERAN ORAL TABLET 2 MG (chlorambucil) Tier 2 SP; OCH melphalan oral tablet 2 mg Tier 1 OCH Antineoplastic - Alkylating Agent - Nitrosoureas - Drugs for Cancer GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG Tier 3 PA; SP; OCH (lomustine) Antineoplastic - Alkylating Agent - Triazenes - Drugs for Cancer temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 Tier 1 PA; SP; OCH mg, 250 mg, 5 mg Antineoplastic - Anaplastic Lymphoma Kinase (ALK) Inhibitors - Drugs for Cancer ALECENSA ORAL CAPSULE 150 MG (alectinib hcl) Tier 2 PA; SP; OCH ALUNBRIG ORAL TABLET 180 MG, 30 MG, 90 MG Tier 3 PA; SP; OCH (brigatinib) ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 180 Tier 3 PA; SP; OCH MG (23) (brigatinib) LORBRENA ORAL TABLET 100 MG, 25 MG (lorlatinib) Tier 2 PA; SP; OCH XALKORI ORAL CAPSULE 200 MG, 250 MG (crizotinib) Tier 2 PA; SP; OCH ZYKADIA ORAL TABLET 150 MG (ceritinib) Tier 2 PA; SP; OCH Antineoplastic - Antiadrenals - Drugs for Cancer LYSODREN ORAL TABLET 500 MG (mitotane) Tier 2 SP; OCH

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 61 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antineoplastic - Antiandrogens - Drugs for Cancer abiraterone oral tablet 250 mg, 500 mg Tier 1 PA; SP; OCH bicalutamide oral tablet 50 mg Tier 1 OCH ERLEADA ORAL TABLET 60 MG (apalutamide) Tier 2 PA; SP; OCH flutamide oral capsule 125 mg Tier 1 OCH SP; OCH; QL (2 EA per 1 nilutamide oral tablet 150 mg Tier 1 day) NUBEQA ORAL TABLET 300 MG (darolutamide) Tier 2 PA; SP; OCH XTANDI ORAL CAPSULE 40 MG (enzalutamide) Tier 2 PA; SP; OCH YONSA ORAL TABLET 125 MG (abiraterone acetate, Tier 3 PA; SP; OCH submicronized) ZYTIGA ORAL TABLET 500 MG (abiraterone acetate) Tier 2 PA; SP; OCH Antineoplastic - Antimetabolite - Folic Acid Analogs - Drugs for Cancer methotrexate sodium (pf) injection recon soln 1 gram Tier 1 methotrexate sodium (pf) injection solution 25 mg/ml Tier 1 TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG Tier 2 OCH (methotrexate sodium) Antineoplastic - Antimetabolite - Purine Analogs - Drugs for Cancer mercaptopurine oral tablet 50 mg Tier 1 OCH SP; OCH; ST: Requires PURIXAN ORAL SUSPENSION 20 MG/ML prior prescription for Tier 2 (mercaptopurine) Mercaptopurine within the past 120 days TABLOID ORAL TABLET 40 MG (thioguanine) Tier 2 SP; OCH Antineoplastic - Antimetabolite - Pyrimidine Analogs - Drugs for Cancer capecitabine oral tablet 150 mg, 500 mg Tier 1 PA; SP; OCH ONUREG ORAL TABLET 200 MG, 300 MG (azacitidine) Tier 2 PA; SP; OCH Antineoplastic - Antimetabolite - Urea Derivatives - Drugs for Cancer hydroxyurea oral capsule 500 mg Tier 1 OCH

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 62 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antineoplastic - Antimetabolites - Pyrimidine Analog Combinations - Drugs for Cancer LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG Tier 2 PA; SP; OCH (trifluridine/tipiracil hcl) Antineoplastic - Aromatase Inhibitors - Drugs for Cancer $0 COPAY IF 40 YEARS OF AGE OR OLDER; anastrozole oral tablet 1 mg Tier 1 OCH; EHB; QL (1 EA per 1 day) $0 COPAY IF 35 YEARS exemestane oral tablet 25 mg Tier 1 OF AGE OR OLDER; OCH; QL (1 EA per 1 day) letrozole oral tablet 2.5 mg Tier 1 OCH Antineoplastic - B-cell lymphoma-2 (BCL-2) inhibitors - Drugs for Cancer VENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG Tier 2 PA; SP; OCH (venetoclax) VENCLEXTA STARTING PACK ORAL TABLETS,DOSE Tier 2 PA; SP; OCH PACK 10 MG-50 MG- 100 MG (venetoclax) Antineoplastic - BRAF Kinase Inhibitors - Drugs for Cancer BRAFTOVI ORAL CAPSULE 50 MG, 75 MG (encorafenib) Tier 2 PA; SP; OCH TAFINLAR ORAL CAPSULE 50 MG, 75 MG (dabrafenib Tier 2 PA; SP; OCH mesylate) PA; SP; OCH; QL (8 EA ZELBORAF ORAL TABLET 240 MG (vemurafenib) Tier 2 per 1 day) Antineoplastic - Bruton's tyrosine kinase (BTK) inhibitor - Drugs for Cancer BRUKINSA ORAL CAPSULE 80 MG (zanubrutinib) Tier 2 PA; SP; OCH CALQUENCE ORAL CAPSULE 100 MG (acalabrutinib) Tier 2 PA; SP; OCH IMBRUVICA ORAL CAPSULE 70 MG (ibrutinib) Tier 2 PA; SP; OCH IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, Tier 2 PA; SP; OCH 560 MG (ibrutinib)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 63 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antineoplastic - Cyclin-Dependent Kinase (CDK) 4/6 Inhibitors - Drugs for Cancer IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG Tier 2 PA; SP; OCH (palbociclib) IBRANCE ORAL TABLET 100 MG, 125 MG, 75 MG Tier 2 PA; SP; OCH (palbociclib) KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1), 400 MG/DAY (200 MG X 2), 600 MG/DAY (200 MG X 3) Tier 3 PA; SP; OCH (ribociclib succinate) VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 Tier 2 PA; SP; OCH MG (abemaciclib) Antineoplastic - Epidermal Growth Factor Receptor-2 (HER2) inhibitor - Drugs for Cancer TUKYSA ORAL TABLET 150 MG, 50 MG (tucatinib) Tier 2 PA; SP; OCH Antineoplastic - Epipodophyllotoxins - Drugs for Cancer etoposide oral capsule 50 mg Tier 1 OCH Antineoplastic - Estrogens - Drugs for Cancer EMCYT ORAL CAPSULE 140 MG (estramustine Tier 2 SP; OCH phosphate sodium) Antineoplastic - EZH2 Histone Methyltransferase (HMT) Inhibitor - Drugs for Cancer TAZVERIK ORAL TABLET 200 MG (tazemetostat Tier 2 PA; SP; OCH hydrobromide) Antineoplastic - Fibroblast Growth Factor Receptor (FGFR) Kinase Inhib - Drugs for Cancer BALVERSA ORAL TABLET 3 MG, 4 MG, 5 MG Tier 2 PA; SP; OCH (erdafitinib) PEMAZYRE ORAL TABLET 13.5 MG, 4.5 MG, 9 MG Tier 2 PA; SP; OCH (pemigatinib) Antineoplastic - FMS-Like Tyrosine Kinase 3 (FLT3) Inhibitors - Drugs for Cancer XOSPATA ORAL TABLET 40 MG (gilteritinib fumarate) Tier 2 PA; SP; OCH

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 64 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antineoplastic - Hedgehog Pathway Inhibitor - Drugs for Cancer DAURISMO ORAL TABLET 100 MG, 25 MG (glasdegib Tier 2 PA; SP; OCH maleate) PA; SP; OCH; QL (1 EA ERIVEDGE ORAL CAPSULE 150 MG (vismodegib) Tier 2 per 1 day) ODOMZO ORAL CAPSULE 200 MG (sonidegib Tier 2 PA; SP; OCH phosphate) Antineoplastic - Histone deacetylase (HDAC) inhibitors - Drugs for Cancer FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG Tier 2 PA; SP; OCH (panobinostat lactate) ZOLINZA ORAL CAPSULE 100 MG (vorinostat) Tier 2 SP; OCH Antineoplastic - Interferons - Drugs for Cancer INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML) Tier 2 PA; SP (interferon alfa-2b,recomb.) INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML, Tier 2 PA; SP 6 MILLION UNIT/ML (interferon alfa-2b,recomb.) SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG Tier 3 PA; SP (peginterferon alfa-2b) Antineoplastic - Janus Kinase (JAK) Inhibitors - Drugs for Cancer JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 Tier 2 PA; SP; OCH MG (ruxolitinib phosphate) Antineoplastic - Janus Kinase(JAK),FMS-like Tyrosine Kinase(FLT) Inhib - Drugs for Cancer INREBIC ORAL CAPSULE 100 MG (fedratinib Tier 2 PA; SP; OCH dihydrochloride) Antineoplastic - Kinase Inhibitor and Aromatase Inhibitor Combination - Drugs for Cancer KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X 1)-2.5 MG, 400 MG/DAY(200 MG X 2)- Tier 3 PA; SP; OCH 2.5 MG, 600 MG/DAY(200 MG X 3)-2.5 MG (ribociclib succinate/letrozole) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 65 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antineoplastic - LHRH (GnRH) Agonist Analog Pituitary Suppressants - Drugs for Cancer ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 22.5 Tier 2 PA; SP MG (leuprolide acetate) ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 MG Tier 2 PA; SP (leuprolide acetate) ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 MG Tier 2 PA; SP (leuprolide acetate) ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG (1 Tier 2 PA; SP MONTH) (leuprolide acetate) leuprolide subcutaneous kit 1 mg/0.2 ml Tier 1 PA; SP Antineoplastic - LHRH (GnRH) Antagonist Pituitary Suppressants - Drugs for Cancer FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS SP; QL (2 EA per 365 Tier 3 RECON SOLN 120 MG (degarelix acetate) days) FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS Tier 3 SP; QL (1 EA per 30 days) RECON SOLN 80 MG (degarelix acetate) FIRMAGON SUBCUTANEOUS RECON SOLN 120 MG SP; QL (2 EA per 365 Tier 3 (degarelix acetate) days) ORGOVYX ORAL TABLET 120 MG (relugolix) Tier 2 PA; SP; OCH Antineoplastic - Mast Cell Stabilizers - Drugs for Cancer cromolyn oral concentrate 100 mg/5 ml Tier 1 Antineoplastic - MEK1 and MEK2 Kinase Inhibitors - Drugs for Cancer PA; SP; OCH; QL (63 EA COTELLIC ORAL TABLET 20 MG (cobimetinib fumarate) Tier 2 per 28 days) KOSELUGO ORAL CAPSULE 10 MG, 25 MG (selumetinib Tier 2 PA; SP; OCH sulfate/vitamin e tpgs) MEKINIST ORAL TABLET 0.5 MG, 2 MG (trametinib Tier 2 PA; SP; OCH dimethyl sulfoxide) PA; SP; OCH; QL (6 EA MEKTOVI ORAL TABLET 15 MG (binimetinib) Tier 2 per 1 day)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 66 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antineoplastic - mTOR Kinase Inhibitors - Drugs for Cancer AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 Tier 2 PA; SP; OCH MG, 3 MG, 5 MG (everolimus) AFINITOR ORAL TABLET 10 MG (everolimus) Tier 2 PA; SP; OCH everolimus (antineoplastic) oral tablet 2.5 mg, 5 mg, 7.5 Tier 1 PA; SP; OCH mg Antineoplastic - Multikinase Inhibitors - Drugs for Cancer CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG Tier 2 PA; SP; OCH (cabozantinib s-malate) COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 PA; SP; OCH; QL (112 EA MG X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY Tier 2 per 28 days) (20 MG X 3/DAY) (cabozantinib s-malate) PA; SP; OCH; QL (2 EA ICLUSIG ORAL TABLET 15 MG (ponatinib hcl) Tier 2 per 1 day) PA; SP; OCH; QL (1 EA ICLUSIG ORAL TABLET 45 MG (ponatinib hcl) Tier 2 per 1 day) PA; SP; OCH; QL (4 EA NEXAVAR ORAL TABLET 200 MG (sorafenib tosylate) Tier 2 per 1 day) PA; SP; OCH; QL (3 EA STIVARGA ORAL TABLET 40 MG (regorafenib) Tier 2 per 1 day) Antineoplastic - Mutant Isocitrate Dehydrogenase 1 (mIDH1) Inhibitors - Drugs for Cancer TIBSOVO ORAL TABLET 250 MG (ivosidenib) Tier 2 PA; SP; OCH Antineoplastic - Mutant Isocitrate Dehydrogenase 2 (mIDH2) Inhibitors - Drugs for Cancer IDHIFA ORAL TABLET 100 MG, 50 MG (enasidenib Tier 3 PA; SP; OCH mesylate) Antineoplastic - Phosphatidylinositol 3-Kinase (PI3K) Inhibitors - Drugs for Cancer COPIKTRA ORAL CAPSULE 15 MG, 25 MG (duvelisib) Tier 3 PA; SP; OCH ZYDELIG ORAL TABLET 100 MG, 150 MG (idelalisib) Tier 2 PA; SP; OCH

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 67 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antineoplastic - PI3K-alpha Inhibitors - Drugs for Cancer PIQRAY ORAL TABLET 200 MG/DAY (200 MG X 1), 250 MG/DAY (200 MG X1-50 MG X1), 300 MG/DAY (150 MG X Tier 2 PA; SP; OCH 2) (alpelisib) Antineoplastic - PI3K-Delta and Gamma Inhibitors - Drugs for Cancer COPIKTRA ORAL CAPSULE 15 MG, 25 MG (duvelisib) Tier 3 PA; SP; OCH Antineoplastic - PI3K-delta Inhibitors - Drugs for Cancer ZYDELIG ORAL TABLET 100 MG, 150 MG (idelalisib) Tier 2 PA; SP; OCH Antineoplastic - Poly (ADP-ribose) polymerase (PARP) inhibitors - Drugs for Cancer LYNPARZA ORAL TABLET 100 MG, 150 MG (olaparib) Tier 2 PA; SP; OCH RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG Tier 3 PA; SP; OCH (rucaparib camsylate) TALZENNA ORAL CAPSULE 0.25 MG, 1 MG (talazoparib Tier 2 PA; SP; OCH tosylate) ZEJULA ORAL CAPSULE 100 MG (niraparib tosylate) Tier 2 PA; SP; OCH Antineoplastic - Progestins - Drugs for Cancer megestrol oral tablet 20 mg, 40 mg Tier 1 OCH Antineoplastic - Proteasome Enzyme Inhibitors - Drugs for Cancer NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG Tier 2 PA; SP; OCH (ixazomib citrate) Antineoplastic - Protein-Tyrosine Kinase Inhibitors - Drugs for Cancer AYVAKIT ORAL TABLET 100 MG, 200 MG, 300 MG Tier 2 PA; SP; OCH (avapritinib) PA; SP; OCH; QL (3 EA BOSULIF ORAL TABLET 100 MG (bosutinib) Tier 2 per 1 day) PA; SP; OCH; QL (1 EA BOSULIF ORAL TABLET 400 MG, 500 MG (bosutinib) Tier 2 per 1 day) BRUKINSA ORAL CAPSULE 80 MG (zanubrutinib) Tier 2 PA; SP; OCH

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 71 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antiseptics and Disinfectants - Antiseptics and Disinfectants Antiseptic - Chlorine Releasing - Antiseptics and Disinfectants ATRAPRO DERMAL SPRAY TOPICAL SPRAY,NON- AEROSOL 0.003-0.004 % (hypochlorous acid/sodium Tier 3 hypochlorite/sod chlorid/elec.water) DELUO TOPICAL SPRAY,NON-AEROSOL 0.018 %-0.004 % -0.06 % (hypochlorous acid/sodium hypochlorite/sod Tier 3 chlorid/elec.water) HYCLODEX TOPICAL SPRAY,NON-AEROSOL 0.012 %- 0.002 % -0.046 % (hypochlorous acid/sodium Tier 3 hypochlorite/sod chlorid/elec.water) MICROCYN TOPICAL SPRAY,NON-AEROSOL 0.003 %- 0.004 % -0.023 % (hypochlorous acid/sodium Tier 3 hypochlorite/sod chlorid/elec.water) Antiseptic - Iodine/Iodophores - Antiseptics and Disinfectants IODOFLEX TOPICAL PADS, MEDICATED 0.9 % Tier 3 (cadexomer iodine) IODOSORB TOPICAL GEL 0.9 % (cadexomer iodine) Tier 3 LUGOLS TOPICAL SOLUTION 5-10 % (iodine/potassium Tier 1 iodide) STRONG IODINE TOPICAL SOLUTION 5-10 % Tier 1 (iodine/potassium iodide) Antiseptic - Oxidizing Agents - Antiseptics and Disinfectants hydrogen peroxide solution 3 % Tier 1 Biologicals - Biological Agents Allergenic Extracts - Grass Pollen - Biological Agents GRASTEK SUBLINGUAL TABLET 2,800 BAU (allergenic Tier 2 PA extract,grass pollen-timothy,standard) ORALAIR SUBLINGUAL TABLET 100 INDX REACTIVITY, 300 INDX REACTIVITY (grass pollen-orchard/sweet Tier 2 PA vernal/rye/kentucky/timothy, std.)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 78 Coverage Prescription Drug Name Drug Tier Requirements and Limits Vaccine Viral - Influenza A and B - Vaccines AFLURIA QD 2020-21(3YR UP)(PF) INTRAMUSCULAR EHB; QL (0.5 ML per 180 SYRINGE 60 MCG (15 MCG X 4)/0.5 ML (influenza virus $0 days) vaccine quadrivalent 2020-21 (36 mos up)/pf) AFLURIA QD 2020-21(6-35MO)(PF) INTRAMUSCULAR EHB; QL (0.25 ML per 180 SYRINGE 30 MCG (7.5 MCG X 4)/0.25 ML (influenza $0 days) virus vaccine quadrival 2020-21 (6 mos-35 mos)/pf) AFLURIA QUAD 2020-2021(6MO UP) INTRAMUSCULAR EHB; QL (0.5 ML per 180 SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML (influenza $0 days) virus vaccine quadrivalent 2020-21 (6 mos and up)) FLUAD 2020-2021 (65 YR UP)(PF) INTRAMUSCULAR EHB; QL (0.5 ML per 180 SYRINGE 45 MCG (15 MCG X 3)/0.5 ML (influenza $0 days); Age (Min 65 Years) vaccine tvs 2020-21 (65 yr up)/adjuvant mf59c.1/pf) FLUAD QUAD 2020-21(65Y UP)(PF) INTRAMUSCULAR EHB; QL (0.5 ML per 180 SYRINGE 60 MCG (15 MCG X 4)/0.5 ML (influenza $0 days); Age (Min 65 Years) vaccine quadrivalent 2020-21 (65 yr up)/mf59c.1/pf) FLUARIX QUAD 2020-2021 (PF) INTRAMUSCULAR EHB; QL (0.5 ML per 180 SYRINGE 60 MCG (15 MCG X 4)/0.5 ML (influenza virus $0 days) vaccine quadrival 2020-2021(6 mos and up)/pf) FLUBLOK QUAD 2020-2021 (PF) INTRAMUSCULAR EHB; QL (0.5 ML per 180 SYRINGE 180 MCG (45 MCG X 4)/0.5 ML (influenza virus $0 days); Age (Min 18 Years) vaccine qv 2020-21(18 yrs and older)rcmb/pf) FLUCELVAX QUAD 2020-2021 (PF) INTRAMUSCULAR EHB; QL (0.5 ML per 180 SYRINGE 60 MCG (15 MCG X 4)/0.5 ML (flu vaccine $0 days) quad 2020-2021(4 years and older)cell derived/pf) FLUCELVAX QUAD 2020-2021 INTRAMUSCULAR EHB; QL (0.5 ML per 180 SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML (flu vaccine $0 days) quadriv 2020-2021(4 years and older)cell derived) FLULAVAL QUAD 2020-2021 (PF) INTRAMUSCULAR EHB; QL (0.5 ML per 180 SYRINGE 60 MCG (15 MCG X 4)/0.5 ML (influenza virus $0 days) vaccine quadrival 2020-2021(6 mos and up)/pf) FLUMIST QUAD 2020-2021 NASAL NASAL SPRAY EHB; QL (1 EA per 180 SYRINGE 10EXP6.5-7.5 FF UNIT/0.2 ML (influenza $0 days) vaccine quadrivalent live 2020-2021 (2 yrs-49 yrs)) FLUZONE HIGHDOSE QUAD 20-21 PF EHB; QL (0.7 ML per 180 INTRAMUSCULAR SYRINGE 240 MCG/0.7 ML (influenza $0 days); Age (Min 65 Years) virus vaccine quadrival split 2020-21(65 yr up)/pf)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 79 Coverage Prescription Drug Name Drug Tier Requirements and Limits FLUZONE QUAD 2020-2021 (PF) INTRAMUSCULAR EHB; QL (0.5 ML per 180 SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML (influenza $0 days) virus vaccine quadrival 2020-2021(6 mos and up)/pf) FLUZONE QUAD 2020-2021 (PF) INTRAMUSCULAR EHB; QL (0.5 ML per 180 SYRINGE 60 MCG (15 MCG X 4)/0.5 ML (influenza virus $0 days) vaccine quadrival 2020-2021(6 mos and up)/pf) FLUZONE QUAD 2020-2021 INTRAMUSCULAR EHB; QL (0.5 ML per 180 SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML (influenza $0 days) virus vaccine quadrivalent 2020-21 (6 mos and up)) Vaccine Viral - Varicella - Vaccines SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR EHB; QL (2 EA per 365 RECONSTITUTION 50 MCG/0.5 ML (varicella-zoster $0 days); Age (Min 50 Years) virus glycoprotein e,rec/as01b adjuvant/pf) SHINGRIX GE ANTIGEN COMPONENT INTRAMUSCULAR SUSPENSION FOR EHB; QL (2 EA per 365 $0 RECONSTITUTION 50 MCG (varicella-zoster virus days); Age (Min 50 Years) glycoprotein e,rec,component 2 of 2) VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR EHB; QL (2 EA per 365 RECONSTITUTION 1,350 UNIT/0.5 ML (varicella virus $0 days); Age (Min 18 Years) vaccine live/pf) ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR EHB; QL (1 EA per 365 RECONSTITUTION 19,400 UNIT/0.65 ML (zoster vaccine $0 days); Age (Min 60 Years) live/pf) Vaccine Viral Combinations - Vaccines M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1,000- EHB; QL (2 EA per 365 12,500 TCID50/0.5 ML (measles, mumps, and rubella $0 days); Age (Min 18 Years) vaccine live/pf) Cardiovascular Therapy Agents Plasma Kallikrein Inhibitor Agents, Small Molecule ORLADEYO ORAL CAPSULE 110 MG, 150 MG Tier 3 PA; SP (berotralstat hydrochloride)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 80 Coverage Prescription Drug Name Drug Tier Requirements and Limits Cardiovascular Therapy Agents - Drugs for the Heart ACE Inhibitor and Calcium Channel Blocker Combinations - Drugs for High Blood Pressure amlodipine-benazepril oral capsule 10-20 mg, 10-40 mg, Tier 1 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg ST: At least 2 prior prescriptions for Amlodipine Besylate, Amlodipine Besylate/benazepril, Benazepril HCL, Captopril, PRESTALIA ORAL TABLET 14-10 MG, 3.5-2.5 MG, 7-5 Enalapril Maleate, Epaned, Tier 3 MG (perindopril arginine/amlodipine besylate) Fosinopril Sodium, Lisinopril, Moexipril HCL, Perindopril Erbumine, Qbrelis, Quinapril HCL, Ramipril, or Trandolapril within the past 365 days; QL (1 EA per 1 day) trandolapril-verapamil oral tablet, ir - er, biphasic 24hr Tier 1 1-240 mg, 2-180 mg, 2-240 mg, 4-240 mg ACE Inhibitor and Diuretic Combinations - Drugs for High Blood Pressure benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, Tier 1 20-12.5 mg, 20-25 mg, 5-6.25 mg captopril-hydrochlorothiazide oral tablet 25-15 mg, 25- Tier 1 25 mg, 50-15 mg, 50-25 mg enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5- Tier 1 12.5 mg fosinopril-hydrochlorothiazide oral tablet 10-12.5 mg, Tier 1 20-12.5 mg lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20- Tier 1 12.5 mg, 20-25 mg quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20- Tier 1 12.5 mg, 20-25 mg ACE Inhibitors - Drugs for High Blood Pressure benazepril oral tablet 10 mg, 20 mg, 40 mg, 5 mg Tier 1 PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 81 Coverage Prescription Drug Name Drug Tier Requirements and Limits captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg Tier 1 enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg Tier 1 ST: Requires prior prescription for Enalapril tablets within the past 120 EPANED ORAL SOLUTION 1 MG/ML (enalapril maleate) Tier 3 days if 12 years of age and older; QL (1200 ML per 30 days) fosinopril oral tablet 10 mg, 20 mg, 40 mg Tier 1 lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 Tier 1 mg, 5 mg moexipril oral tablet 15 mg, 7.5 mg Tier 1 perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg Tier 1 ST: Requires prior prescription for Lisinopril tablets within the past 120 QBRELIS ORAL SOLUTION 1 MG/ML (lisinopril) Tier 3 days if 12 years of age and older; QL (1200 ML per 30 days) quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg Tier 1 ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg Tier 1 trandolapril oral tablet 1 mg, 2 mg, 4 mg Tier 1 Aldosterone Receptor Antagonists - Drugs for High Blood Pressure ST: Requires prior prescription for CAROSPIR ORAL SUSPENSION 25 MG/5 ML Tier 3 Spironolactone within the (spironolactone) past 120 days; QL (600 ML per 30 days) eplerenone oral tablet 25 mg, 50 mg Tier 1 spironolactone oral tablet 100 mg, 25 mg, 50 mg Tier 1 Alpha-Beta Blockers - Drugs for High Blood Pressure carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg Tier 1 carvedilol phosphate oral capsule, er multiphase 24 hr Tier 1 10 mg, 20 mg, 40 mg, 80 mg labetalol oral tablet 100 mg, 200 mg, 300 mg Tier 1 PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 82 Coverage Prescription Drug Name Drug Tier Requirements and Limits Angiotensin II Receptor Blocker (ARB)-Calcium Channel Blocker Comb. - Drugs for High Blood Pressure amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, Tier 1 5-20 mg, 5-40 mg amlodipine-valsartan oral tablet 10-160 mg, 10-320 mg, Tier 1 5-160 mg, 5-320 mg telmisartan-amlodipine oral tablet 40-10 mg, 40-5 mg, Tier 1 80-10 mg, 80-5 mg Angiotensin II Receptor Blocker (ARB)-Calcium Channel Blocker-Diuretic - Drugs for High Blood Pressure amlodipine-valsartan-hcthiazid oral tablet 10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160- Tier 1 25 mg olmesartan-amlodipin-hcthiazid oral tablet 20-5-12.5 mg, 40-10-12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 Tier 1 mg Angiotensin II Receptor Blocker (ARB)-Diuretic Combinations - Drugs for High Blood Pressure candesartan-hydrochlorothiazid oral tablet 16-12.5 mg, Tier 1 32-12.5 mg, 32-25 mg EDARBYCLOR ORAL TABLET 40-12.5 MG, 40-25 MG Tier 2 (azilsartan medoxomil/chlorthalidone) irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, Tier 1 300-12.5 mg losartan-hydrochlorothiazide oral tablet 100-12.5 mg, Tier 1 100-25 mg, 50-12.5 mg olmesartan-hydrochlorothiazide oral tablet 20-12.5 mg, Tier 1 40-12.5 mg, 40-25 mg telmisartan-hydrochlorothiazid oral tablet 40-12.5 mg, Tier 1 80-12.5 mg, 80-25 mg valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, Tier 1 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 83 Coverage Prescription Drug Name Drug Tier Requirements and Limits Angiotensin II Receptor Blocker-Neprilysin Inhibitor Comb. (ARNi) - Drugs for High Blood Pressure ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 Tier 2 QL (2 EA per 1 day) MG (sacubitril/valsartan) Angiotensin II Receptor Blockers (ARBs) - Drugs for High Blood Pressure candesartan oral tablet 16 mg, 32 mg, 4 mg, 8 mg Tier 1 EDARBI ORAL TABLET 40 MG, 80 MG (azilsartan Tier 2 medoxomil) eprosartan oral tablet 600 mg Tier 1 irbesartan oral tablet 150 mg, 300 mg, 75 mg Tier 1 losartan oral tablet 100 mg, 25 mg, 50 mg Tier 1 olmesartan oral tablet 20 mg, 40 mg, 5 mg Tier 1 telmisartan oral tablet 20 mg, 40 mg, 80 mg Tier 1 valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg Tier 1 Antianginal - Coronary Vasodilators (Nitrates) - Drugs for Angina amyl nitrite inhalation solution 0.3 ml Tier 1 DILATRATE-SR ORAL CAPSULE, EXTENDED RELEASE Tier 3 40 MG (isosorbide dinitrate) ST: At least 2 prior prescriptions for generic GONITRO SUBLINGUAL POWDER IN PACKET 400 MCG Tier 3 sublingual Nitroglycerin (nitroglycerin) products within the past 365 days isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 40 Tier 1 mg, 5 mg isosorbide dinitrate oral tablet extended release 40 mg Tier 1 isosorbide mononitrate oral tablet 10 mg, 20 mg Tier 1 isosorbide mononitrate oral tablet extended release 24 Tier 1 hr 120 mg, 30 mg, 60 mg nitroglycerin (Minitran Transdermal Patch 24 Hour 0.1 Tier 1 Mg/Hr, 0.2 Mg/Hr, 0.4 Mg/Hr, 0.6 Mg/Hr) nitroglycerin (Nitro-Bid Transdermal Ointment 2 %) Tier 2

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 90 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antihyperlipidemic - Selective Cholesterol Absorption Inhibitor - Drugs for Cholesterol ezetimibe oral tablet 10 mg Tier 1 QL (1 EA per 1 day) Antihyperlipidemic Agents - Dietary Source - Drugs for Cholesterol omega-3 acid ethyl esters oral capsule 1 gram Tier 1 QL (4 EA per 1 day) VASCEPA ORAL CAPSULE 0.5 GRAM (icosapent ethyl) Tier 2 QL (8 EA per 1 day) VASCEPA ORAL CAPSULE 1 GRAM (icosapent ethyl) Tier 2 QL (4 EA per 1 day) Antihyperlipidemic- ATP-Citrate Lyase and Cholesterol Absorption Inhib - Drugs for Cholesterol ST: Requires prior prescription for Atorvastatin Calcium, Flolipid, NEXLIZET ORAL TABLET 180-10 MG (bempedoic Fluvastatin Sodium, Tier 2 acid/ezetimibe) Lovastatin, Pravastatin Sodium, Rosuvastatin Calcium, or Simvastatin withn the past 120 days Antihyperlipidemic HMG CoA Reduct Inhib and Calcium Channel Blocker - Drugs for Cholesterol amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5- Tier 1 QL (1 EA per 1 day) 10 mg, 5-20 mg, 5-40 mg, 5-80 mg Antihyperlipidemic-HMG CoA Reduct Inhib and Cholesterol Absorp Inhibit - Drugs for Cholesterol ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 mg, Tier 1 QL (1 EA per 1 day) 10-40 mg ST: Requires prior prescription for Simvastatin ezetimibe-simvastatin oral tablet 10-80 mg Tier 1 within the past 365 days; QL (1 EA per 1 day)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 91 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antihyperlipidemic-Microsomal Triglyceride Transfer Protein (MTP)Inhib - Drugs for Cholesterol JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 Tier 2 PA; SP MG, 5 MG, 60 MG (lomitapide mesylate) Anti-PCSK9 Monoclonal Antibodies - Drugs for Cholesterol ST: Requires prior prescription for Atorvastatin Calcium, Flolipid, PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 150 Fluvastatin Sodium, Tier 2 MG/ML, 75 MG/ML (alirocumab) Lovastatin, Pravastatin Sodium, Rosuvastatin Calcium, or Simvastatin withn the past 120 days ST: Requires prior prescription for Atorvastatin Calcium, Flolipid, REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE Fluvastatin Sodium, Tier 2 INJECTOR 420 MG/3.5 ML (evolocumab) Lovastatin, Pravastatin Sodium, Rosuvastatin Calcium, or Simvastatin withn the past 120 days ST: Requires prior prescription for Atorvastatin Calcium, Flolipid, REPATHA SURECLICK SUBCUTANEOUS PEN Fluvastatin Sodium, Tier 2 INJECTOR 140 MG/ML (evolocumab) Lovastatin, Pravastatin Sodium, Rosuvastatin Calcium, or Simvastatin withn the past 120 days ST: Requires prior prescription for Atorvastatin Calcium, Flolipid, REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 Fluvastatin Sodium, Tier 2 MG/ML (evolocumab) Lovastatin, Pravastatin Sodium, Rosuvastatin Calcium, or Simvastatin withn the past 120 days

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 94 Coverage Prescription Drug Name Drug Tier Requirements and Limits diltiazem hcl oral tablet extended release 24 hr 180 mg, Tier 1 240 mg, 300 mg, 360 mg, 420 mg DILT-XR ORAL CAPSULE,EXT.REL 24H DEGRADABLE Tier 1 120 MG, 180 MG, 240 MG (diltiazem hcl) diltiazem hcl (Matzim La Oral Tablet Extended Release 24 Tier 1 Hr 180 Mg, 240 Mg, 300 Mg, 360 Mg, 420 Mg) diltiazem hcl (Taztia Xt Oral Capsule,Extended Release 24 Tier 1 Hr 120 Mg, 180 Mg, 240 Mg, 300 Mg, 360 Mg) diltiazem hcl (Tiadylt Er Oral Capsule,Extended Release Tier 1 24 Hr 120 Mg, 180 Mg, 240 Mg, 300 Mg, 360 Mg, 420 Mg) Calcium Channel Blockers - Dihydropyridines - Cerebrovascular Specific - Drugs for High Blood Pressure nimodipine oral capsule 30 mg Tier 1 NYMALIZE ORAL SYRINGE 30 MG/5 ML, 60 MG/10 ML Tier 3 PA; SP (nimodipine) Calcium Channel Blockers - Dihydropyridines - Drugs for High Blood Pressure amlodipine oral tablet 10 mg, 2.5 mg, 5 mg Tier 1 CONJUPRI ORAL TABLET 2.5 MG, 5 MG (levamlodipine Tier 3 PA maleate) felodipine oral tablet extended release 24 hr 10 mg, 2.5 Tier 1 mg, 5 mg isradipine oral capsule 2.5 mg, 5 mg Tier 1 KATERZIA ORAL SUSPENSION 1 MG/ML (amlodipine Tier 3 PA benzoate) nicardipine oral capsule 20 mg, 30 mg Tier 1 nifedipine oral capsule 10 mg, 20 mg Tier 1 nifedipine oral tablet extended release 24hr 30 mg, 60 Tier 1 mg, 90 mg nifedipine oral tablet extended release 30 mg, 60 mg, 90 Tier 1 mg nisoldipine oral tablet extended release 24 hr 17 mg, 20 Tier 1 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 97 Coverage Prescription Drug Name Drug Tier Requirements and Limits ethacrynic acid oral tablet 25 mg Tier 1 furosemide oral solution 10 mg/ml Tier 1 furosemide oral solution 40 mg/5 ml (8 mg/ml) Tier 1 furosemide oral tablet 20 mg, 40 mg, 80 mg Tier 1 torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg Tier 1 Diuretic - Potassium Sparing - Drugs for High Blood Pressure amiloride oral tablet 5 mg Tier 1 triamterene oral capsule 100 mg, 50 mg Tier 1 Diuretic - Potassium Sparing-Thiazide and Related Combinations - Drugs for High Blood Pressure ALDACTAZIDE ORAL TABLET 50-50 MG Tier 3 (spironolactone/hydrochlorothiazide) amiloride-hydrochlorothiazide oral tablet 5-50 mg Tier 1 spironolacton-hydrochlorothiaz oral tablet 25-25 mg Tier 1 triamterene-hydrochlorothiazid oral capsule 37.5-25 mg Tier 1 triamterene-hydrochlorothiazid oral tablet 37.5-25 mg, Tier 1 75-50 mg Diuretic - Selective Arginine Vasopressin V2 Receptor Antagonists - Drugs for High Blood Pressure JYNARQUE ORAL TABLET 15 MG, 30 MG (tolvaptan) Tier 2 PA; SP JYNARQUE ORAL TABLETS, SEQUENTIAL 15 MG (AM)/ 15 MG (PM), 30 MG (AM)/ 15 MG (PM), 45 MG (AM)/ 15 Tier 2 PA; SP MG (PM), 60 MG (AM)/ 30 MG (PM), 90 MG (AM)/ 30 MG (PM) (tolvaptan) SP; QL (30 EA per 365 tolvaptan oral tablet 15 mg Tier 1 days) SP; QL (60 EA per 365 tolvaptan oral tablet 30 mg Tier 1 days) Diuretic - Thiazides and Related - Drugs for High Blood Pressure chlorothiazide oral tablet 500 mg Tier 1 chlorthalidone oral tablet 25 mg, 50 mg Tier 1 PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 98 Coverage Prescription Drug Name Drug Tier Requirements and Limits DIURIL ORAL SUSPENSION 250 MG/5 ML Tier 3 (chlorothiazide) hydrochlorothiazide oral capsule 12.5 mg Tier 1 hydrochlorothiazide oral tablet 12.5 mg Tier 1 hydrochlorothiazide oral tablet 25 mg, 50 mg Tier 1 indapamide oral tablet 1.25 mg, 2.5 mg Tier 1 metolazone oral tablet 10 mg, 2.5 mg, 5 mg Tier 1 Ganglionic Blocking, Non-Depolarizing - Drugs for High Blood Pressure VECAMYL ORAL TABLET 2.5 MG (mecamylamine hcl) Tier 3 PA Hyperpolarization-Activated Cyclic Nucleotide- Gated Channel Inhibitors - Drugs for High Blood Pressure CORLANOR ORAL SOLUTION 5 MG/5 ML (ivabradine Tier 2 QL (20 ML per 1 day) hcl) CORLANOR ORAL TABLET 5 MG, 7.5 MG (ivabradine Tier 2 QL (2 EA per 1 day) hcl) Muscarinic Receptor Antagonists (Anticholinergic) - Drugs for Abnormal Heart Rhythms ATROPEN INTRAMUSCULAR PEN INJECTOR 0.5 MG/0.7 Tier 3 ML, 1 MG/0.7 ML (atropine sulfate) Non-Cardiac Selective Beta Blocker-Thiazide Diuretic and Related Comb. - Drugs for High Blood Pressure nadolol-bendroflumethiazide oral tablet 80-5 mg Tier 1 propranolol-hydrochlorothiazid oral tablet 40-25 mg, 80- Tier 1 25 mg PAH Agents - Selective Prostacyclin Receptor (IP) Agonists - Drugs for High Blood Pressure UPTRAVI ORAL TABLET 1,000 MCG, 1,200 MCG, 1,400 MCG, 1,600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 Tier 2 PA; SP MCG (selexipag) UPTRAVI ORAL TABLETS,DOSE PACK 200 MCG (140)- Tier 2 PA; SP 800 MCG (60) (selexipag)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 99 Coverage Prescription Drug Name Drug Tier Requirements and Limits Peripheral Alpha-1 Receptor Blockers - Drugs for High Blood Pressure CARDURA XL ORAL TABLET EXTENDED RELEASE Tier 3 24HR 4 MG, 8 MG (doxazosin mesylate) doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg Tier 1 phenoxybenzamine oral capsule 10 mg Tier 1 PA; SP prazosin oral capsule 1 mg, 2 mg, 5 mg Tier 1 terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg Tier 1 Peripheral Vasodilators, Single Agents - Drugs for High Blood Pressure isoxsuprine oral tablet 10 mg, 20 mg Tier 1 papaverine injection solution 30 mg/ml Tier 1 Pheochromocytoma, Agents to Treat - Drugs for High Blood Pressure DEMSER ORAL CAPSULE 250 MG (metyrosine) Tier 3 metyrosine oral capsule 250 mg Tier 1 Plasma Kallikrein Inhibitor Agents, Recombinant Monoclonal Antibody - Drugs for the Heart TAKHZYRO SUBCUTANEOUS SOLUTION 300 MG/2 ML Tier 3 PA; SP (150 MG/ML) (lanadelumab-flyo) Pulmonary Antihypertensive Agents - Prostacyclin-type - Drugs for High Blood Pressure ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG, 5 MG (treprostinil Tier 2 PA; SP diolamine) treprostinil sodium injection solution 1 mg/ml, 10 Tier 1 PA; SP mg/ml, 2.5 mg/ml, 5 mg/ml TYVASO INHALATION SOLUTION FOR NEBULIZATION Tier 3 PA; SP 1.74 MG/2.9 ML (0.6 MG/ML) (treprostinil) TYVASO INSTITUTIONAL START KIT INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML Tier 3 PA; SP (treprostinil/nebulizer and accessories)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 104 Coverage Prescription Drug Name Drug Tier Requirements and Limits DEPAKOTE SPRINKLES ORAL CAPSULE, DELAYED Tier 2 REL SPRINKLE 125 MG (divalproex sodium) divalproex oral capsule, delayed rel sprinkle 125 mg Tier 1 divalproex oral tablet extended release 24 hr 250 mg, Tier 1 500 mg divalproex oral tablet,delayed release (dr/ec) 125 mg, Tier 1 250 mg, 500 mg valproic acid (as sodium salt) oral solution 250 mg/5 ml Tier 1 valproic acid (as sodium salt) oral solution 500 mg/10 Tier 1 ml (10 ml) valproic acid oral capsule 250 mg Tier 1 Anticonvulsant - Functionalized Amino Acid - Drugs for Seizures /Personality Disorder/Nerve Pain VIMPAT ORAL SOLUTION 10 MG/ML (lacosamide) Tier 2 QL (1200 ML per 30 days) VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG Tier 2 QL (2 EA per 1 day) (lacosamide) VIMPAT ORAL TABLETS,DOSE PACK 50 MG (14)- 100 Tier 2 MG (14) (lacosamide) Anticonvulsant - GABA Analogs - Drugs for Seizures /Personality Disorder/Nerve Pain ACTIVE-PAC KIT,GEL AND CAPSULE 300-4-1 MG-%-% Tier 3 (gabapentin/lidocaine hcl/menthol) GABACAINE KIT 300 MG- 5 % (gabapentin/lidocaine) Tier 3 GABAPAL KIT, CREAM AND CAPSULE 100 MG-3.88 %- 4" X 4" (gabapentin/lidocaine hcl/gauze Tier 3 bandage/silicone adhesive) gabapentin oral capsule 100 mg, 300 mg, 400 mg Tier 1 gabapentin oral solution 250 mg/5 ml Tier 1 gabapentin oral solution 250 mg/5 ml (5 ml), 300 mg/6 Tier 1 ml (6 ml) gabapentin oral tablet 600 mg, 800 mg Tier 1 LIDOTIN KIT, CREAM AND CAPSULE 100 MG- 3.88 % Tier 3 (gabapentin/lidocaine hcl/silicone adhesive) LIPRITIN II KIT 100 MG-2.5 %- 2.5 %-6CM X 7CM Tier 3 (gabapentin/lidocaine/prilocaine/transparent dressing) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 105 Coverage Prescription Drug Name Drug Tier Requirements and Limits LIPRITIN KIT 100 MG-2.5 %- 2.5 %-6CM X 7CM Tier 3 (gabapentin/lidocaine/prilocaine/transparent dressing) LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 Tier 2 MG, 25 MG, 300 MG, 50 MG, 75 MG (pregabalin) LYRICA ORAL SOLUTION 20 MG/ML (pregabalin) Tier 2 NEURONTIN ORAL CAPSULE 100 MG, 300 MG, 400 MG Tier 2 (gabapentin) NEURONTIN ORAL SOLUTION 250 MG/5 ML Tier 2 (gabapentin) NEURONTIN ORAL TABLET 600 MG, 800 MG Tier 2 (gabapentin) PENTICAN KIT 100 MG- 5 % (gabapentin/lidocaine) Tier 3 pregabalin oral capsule 100 mg, 150 mg, 200 mg, 225 Tier 1 mg, 25 mg, 300 mg, 50 mg, 75 mg pregabalin oral solution 20 mg/ml Tier 1 Anticonvulsant - GABA Re-uptake Inhibitor, Nipecotic Acid Derivatives - Drugs for Seizures /Personality Disorder/Nerve Pain GABITRIL ORAL TABLET 12 MG, 2 MG, 4 MG (tiagabine Tier 2 QL (4 EA per 1 day) hcl) GABITRIL ORAL TABLET 16 MG (tiagabine hcl) Tier 2 QL (3 EA per 1 day) tiagabine oral tablet 12 mg, 2 mg, 4 mg Tier 1 QL (4 EA per 1 day) tiagabine oral tablet 16 mg Tier 1 QL (3 EA per 1 day) Anticonvulsant - GABA Transaminase (GABA- T) Inhibitor - Drugs for Seizures /Personality Disorder/Nerve Pain SABRIL ORAL TABLET 500 MG (vigabatrin) Tier 3 SP; QL (6 EA per 1 day) vigabatrin oral powder in packet 500 mg Tier 1 SP; QL (6 EA per 1 day) vigabatrin oral tablet 500 mg Tier 1 SP; QL (6 EA per 1 day) vigabatrin (Vigadrone Oral Powder In Packet 500 Mg) Tier 1 SP; QL (6 EA per 1 day) Anticonvulsant - Hydantoins - Drugs for Seizures /Personality Disorder/Nerve Pain phenytoin sodium extended (Dilantin Extended Oral Tier 2 Capsule 100 Mg) phenytoin (Dilantin Infatabs Oral Tablet,Chewable 50 Mg) Tier 2 PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 106 Coverage Prescription Drug Name Drug Tier Requirements and Limits DILANTIN ORAL CAPSULE 30 MG (phenytoin sodium Tier 2 extended) DILANTIN-125 ORAL SUSPENSION 125 MG/5 ML Tier 2 (phenytoin) phenytoin sodium extended (Phenytek Oral Capsule 200 Tier 2 Mg, 300 Mg) phenytoin oral suspension 100 mg/4 ml Tier 1 phenytoin oral suspension 125 mg/5 ml Tier 1 phenytoin oral tablet,chewable 50 mg Tier 1 phenytoin sodium extended oral capsule 100 mg, 200 Tier 1 mg, 300 mg Anticonvulsant - Iminostilbene Derivatives - Drugs for Seizures /Personality Disorder/Nerve Pain APTIOM ORAL TABLET 200 MG, 400 MG Tier 3 QL (1 EA per 1 day) (eslicarbazepine acetate) APTIOM ORAL TABLET 600 MG, 800 MG Tier 3 QL (2 EA per 1 day) (eslicarbazepine acetate) carbamazepine oral capsule, er multiphase 12 hr 100 Tier 1 mg, 200 mg, 300 mg carbamazepine oral suspension 100 mg/5 ml Tier 1 carbamazepine oral tablet 200 mg Tier 1 carbamazepine oral tablet extended release 12 hr 100 Tier 1 mg, 200 mg, 400 mg carbamazepine oral tablet,chewable 100 mg Tier 1 CARBATROL ORAL CAPSULE, ER MULTIPHASE 12 HR Tier 2 100 MG, 200 MG, 300 MG (carbamazepine) carbamazepine (Epitol Oral Tablet 200 Mg) Tier 1 EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 Tier 3 MG, 200 MG, 300 MG (carbamazepine) oxcarbazepine oral suspension 300 mg/5 ml (60 mg/ml) Tier 1 oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg Tier 1 OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 Tier 3 QL (1 EA per 1 day) HR 150 MG, 300 MG (oxcarbazepine) OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 Tier 3 QL (4 EA per 1 day) HR 600 MG (oxcarbazepine) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 107 Coverage Prescription Drug Name Drug Tier Requirements and Limits TEGRETOL ORAL SUSPENSION 100 MG/5 ML Tier 2 (carbamazepine) TEGRETOL ORAL TABLET 200 MG (carbamazepine) Tier 2 TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 Tier 2 HR 100 MG, 200 MG, 400 MG (carbamazepine) TRILEPTAL ORAL SUSPENSION 300 MG/5 ML (60 Tier 2 MG/ML) (oxcarbazepine) TRILEPTAL ORAL TABLET 150 MG, 300 MG, 600 MG Tier 2 (oxcarbazepine) Anticonvulsant - Monosaccharide Derivatives - Drugs for Seizures /Personality Disorder/Nerve Pain QUDEXY XR ORAL CAPSULE,SPRINKLE,ER 24HR 100 Tier 2 QL (1 EA per 1 day) MG, 25 MG, 50 MG (topiramate) QUDEXY XR ORAL CAPSULE,SPRINKLE,ER 24HR 150 Tier 2 QL (2 EA per 1 day) MG, 200 MG (topiramate) TOPAMAX ORAL CAPSULE, SPRINKLE 15 MG, 25 MG Tier 2 (topiramate) TOPAMAX ORAL TABLET 100 MG, 200 MG, 25 MG, 50 Tier 2 MG (topiramate) topiramate oral capsule, sprinkle 15 mg, 25 mg Tier 1 topiramate oral capsule,sprinkle,er 24hr 100 mg, 25 mg, Tier 1 QL (1 EA per 1 day) 50 mg topiramate oral capsule,sprinkle,er 24hr 150 mg, 200 Tier 1 QL (2 EA per 1 day) mg topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg Tier 1 TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE Tier 2 QL (2 EA per 1 day) 24HR 100 MG, 200 MG (topiramate) TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE Tier 2 QL (8 EA per 1 day) 24HR 25 MG (topiramate) TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE Tier 2 QL (4 EA per 1 day) 24HR 50 MG (topiramate)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 116 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antidepressant - Tricyclic and Antipsychotic, Phenothiazine Comb - Drugs for Depression perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, Tier 1 4-10 mg, 4-25 mg, 4-50 mg Antidepressant - Tricyclic-Benzodiazepine Combinations - Drugs for Depression amitriptyline-chlordiazepoxide oral tablet 12.5-5 mg, 25- Tier 1 10 mg Antidepressant-Norepinephrine and Dopamine Reuptake Inhibitors (NDRIs) - Drugs for Depression ST: Requires prior APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR prescription for Bupropion Tier 3 174 MG, 348 MG, 522 MG (bupropion hbr) HCL within the past 120 days; QL (1 EA per 1 day) bupropion hcl oral tablet 100 mg, 75 mg Tier 1 bupropion hcl oral tablet extended release 24 hr 150 Tier 1 mg, 300 mg ST: Requires prior prescription for Bupropion bupropion hcl oral tablet extended release 24 hr 450 mg Tier 1 HCL within the past 120 days; QL (1 EA per 1 day) bupropion hcl oral tablet sustained-release 12 hr 100 Tier 1 mg, 150 mg, 200 mg Antidepressant-Tricyclics and Related (Non- Select Reuptake Inhibitors) - Drugs for Depression amitriptyline oral tablet 10 mg, 100 mg, 150 mg, 25 mg, Tier 1 50 mg, 75 mg amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg Tier 1 clomipramine oral capsule 25 mg, 50 mg, 75 mg Tier 1 desipramine oral tablet 10 mg, 100 mg, 150 mg, 25 mg, Tier 1 50 mg, 75 mg doxepin oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 Tier 1 mg, 75 mg doxepin oral concentrate 10 mg/ml Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 123 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antipsychotic-Atypical,D2 Receptor Partial Agonist-5HT Serotonin Mixed - Drugs for Severe Mental Disorders ABILIFY MYCITE ORAL TABLET WITH SENSOR AND PATCH 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG Tier 3 PA; SP (aripiprazole) REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 Tier 2 QL (1 EA per 1 day) MG, 4 MG (brexpiprazole) Antipsychotic-Atypical,D3/D2 Receptor Partial Agonist-Serotonin Mixed - Drugs for Severe Mental Disorders VRAYLAR ORAL CAPSULE 4.5 MG, 6 MG (cariprazine Tier 2 QL (1 EA per 1 day) hcl) VRAYLAR ORAL CAPSULE,DOSE PACK 1.5 MG (1)- 3 Tier 2 QL (7 EA per 28 days) MG (6) (cariprazine hcl) Attention Deficit-Hyperact. Disorder (ADHD)- alpha-2 Receptor Agonist - Drugs for Attention Deficit Disorder clonidine hcl oral tablet extended release 12 hr 0.1 mg Tier 1 QL (120 EA per 30 days) guanfacine oral tablet extended release 24 hr 1 mg, 2 Tier 1 QL (1 EA per 1 day) mg, 3 mg, 4 mg Attention Deficit-Hyperactivity (ADHD) Therapy, Stimulant-Type - Drugs for Attention Deficit Disorder ADDERALL XR ORAL CAPSULE,EXTENDED RELEASE 24HR 10 MG, 15 MG, 5 MG (dextroamphetamine sulf- Tier 1 QL (1 EA per 1 day) saccharate/amphetamine sulf-aspartate) ADDERALL XR ORAL CAPSULE,EXTENDED RELEASE 24HR 20 MG, 25 MG, 30 MG (dextroamphetamine sulf- Tier 1 QL (2 EA per 1 day) saccharate/amphetamine sulf-aspartate) ST: Requires prior prescription for ADHANSIA XR ORAL CAPSULE, ER BIPHASIC 20-80 25 Methylphenidate HCL or MG, 35 MG, 45 MG, 55 MG, 70 MG, 85 MG Tier 3 Ritalin LA within the past (methylphenidate hcl) 120 days; QL (1 EA per 1 day)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 126 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Requires prior prescription for methylphenidate hcl oral tablet extended release 24hr Methylphenidate HCL or Tier 1 72 mg Ritalin LA within the past 120 days; QL (1 EA per 1 day) methylphenidate hcl oral tablet,chewable 10 mg, 2.5 Tier 1 QL (90 EA per 30 days) mg, 5 mg MYDAYIS ORAL CAPSULE, ER TRIPHASIC 24 HR 12.5 MG, 25 MG, 37.5 MG, 50 MG (dextroamphetamine sulf- Tier 2 QL (1 EA per 1 day) saccharate/amphetamine sulf-aspartate) QUILLICHEW ER ORAL TABLET,CHEW,IR- Tier 3 QL (1 EA per 1 day) ER.BIPHASIC24HR 20 MG, 40 MG (methylphenidate hcl) QUILLICHEW ER ORAL TABLET,CHEW,IR- Tier 3 QL (2 EA per 1 day) ER.BIPHASIC24HR 30 MG (methylphenidate hcl) QUILLIVANT XR ORAL SUSPENSION,EXT REL 60mL BOTTLE; QL (60 ML 24HR,RECON 5 MG/ML (25 MG/5 ML) (methylphenidate Tier 3 per 30 days) hcl) ST: Requires prior prescription for methylphenidate hcl (Relexxii Oral Tablet Extended Methylphenidate HCL or Tier 3 Release 24Hr 72 Mg) Ritalin LA within the past 120 days; QL (1 EA per 1 day) VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG (lisdexamfetamine Tier 2 QL (1 EA per 1 day) dimesylate) VYVANSE ORAL TABLET,CHEWABLE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG (lisdexamfetamine Tier 2 QL (1 EA per 1 day) dimesylate) dextroamphetamine sulfate (Zenzedi Oral Tablet 10 Mg) Tier 1 QL (180 EA per 30 days) ST: Requires prior prescription for ZENZEDI ORAL TABLET 15 MG (dextroamphetamine Tier 3 Dextroamphetamine sulfate) Sulfate within the past 120 days; QL (3 EA per 1 day)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 135 Coverage Prescription Drug Name Drug Tier Requirements and Limits Migraine Therapy - Calcitonin Gene-Related Peptide Inhibitors - Drugs for Migraine Headaches AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO- Tier 2 PA INJECTOR 140 MG/ML, 70 MG/ML (erenumab-aooe) AJOVY SYRINGE SUBCUTANEOUS SYRINGE 225 Tier 3 PA MG/1.5 ML (fremanezumab-vfrm) EMGALITY PEN SUBCUTANEOUS PEN INJECTOR 120 Tier 2 PA MG/ML (galcanezumab-gnlm) EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 120 Tier 2 PA MG/ML (galcanezumab-gnlm) Migraine Therapy - CGRP Ligand Blocker, Monoclonal Antibody - Drugs for Migraine Headaches AJOVY AUTOINJECTOR SUBCUTANEOUS AUTO- Tier 3 PA INJECTOR 225 MG/1.5 ML (fremanezumab-vfrm) Migraine Therapy - CGRP Receptor Blockers (gepants) - Drugs for Migraine Headaches NURTEC ODT ORAL TABLET,DISINTEGRATING 75 MG Tier 2 PA (rimegepant sulfate) UBRELVY ORAL TABLET 100 MG, 50 MG (ubrogepant) Tier 2 PA Migraine Therapy - CGRP Receptor Blockers, Monoclonal Antibody - Drugs for Migraine Headaches AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO- Tier 2 PA INJECTOR 140 MG/ML, 70 MG/ML (erenumab-aooe) Migraine Therapy - Ergot Alkaloids and Derivatives - Drugs for Migraine Headaches dihydroergotamine injection solution 1 mg/ml Tier 1 QL (15 ML per 14 days) ST: Requires prior prescription for Rizatriptan dihydroergotamine nasal spray,non-aerosol 0.5 Benzoate or Sumatriptan Tier 1 mg/pump act. (4 mg/ml) Succinate within the past 180 days; QL (8 ML per 28 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 137 Coverage Prescription Drug Name Drug Tier Requirements and Limits sumatriptan nasal spray,non-aerosol 20 mg/actuation, 5 Tier 1 QL (6 EA per 15 days) mg/actuation sumatriptan succinate oral tablet 100 mg Tier 1 QL (9 EA per 30 days) sumatriptan succinate oral tablet 25 mg, 50 mg Tier 1 QL (3 EA per 5 days) sumatriptan succinate subcutaneous cartridge 4 mg/0.5 Tier 1 QL (4 ML per 28 days) ml, 6 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 4 Tier 1 QL (4 ML per 28 days) mg/0.5 ml, 6 mg/0.5 ml sumatriptan succinate subcutaneous solution 6 mg/0.5 Tier 1 QL (5 ML per 28 days) ml sumatriptan succinate subcutaneous syringe 6 mg/0.5 Tier 1 QL (4 ML per 28 days) ml ST: Requires prior prescription for Rizatriptan TOSYMRA NASAL SPRAY,NON-AEROSOL 10 Benzoate or Sumatriptan Tier 3 MG/ACTUATION (sumatriptan) Succinate within the past 180 days; QL (12 EA per 30 days) ST: Requires prior prescription for generic ZEMBRACE SYMTOUCH SUBCUTANEOUS PEN Tier 3 Sumatriptan injection within INJECTOR 3 MG/0.5 ML (sumatriptan succinate) the past 120 days; QL (8 ML per 28 days) ST: Requires prior prescription for Rizatriptan Benzoate or Sumatriptan zolmitriptan oral tablet 2.5 mg, 5 mg Tier 1 Succinate within the past 180 days; QL (12 EA per 30 days) ST: Requires prior prescription for Rizatriptan Benzoate or Sumatriptan zolmitriptan oral tablet,disintegrating 2.5 mg, 5 mg Tier 1 Succinate within the past 180 days; QL (12 EA per 30 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 138 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Requires prior prescription for Rizatriptan ZOMIG NASAL SPRAY,NON-AEROSOL 2.5 MG Benzoate or Sumatriptan Tier 2 (zolmitriptan) Succinate within the past 180 days; QL (12 EA per 30 days) ST: Requires prior prescription for Rizatriptan ZOMIG NASAL SPRAY,NON-AEROSOL 5 MG Benzoate or Sumatriptan Tier 2 (zolmitriptan) Succinate within the past 180 days; QL (6 EA per 15 days) Migraine Therapy - Selective Serotonin Agonists 5-HT(1F) - Drugs for Migraine Headaches REYVOW ORAL TABLET 100 MG, 50 MG (lasmiditan Tier 2 PA succinate) Migraine Therapy - Serotonin Agonist 5-HT(1) and NSAID Comb. - Drugs for Migraine Headaches ST: Requires prior prescription for Almotriptan Malate, Eletriptan Hydrobromide, Frovatriptan Succinate, Naratriptan HCL, Onzetra Xsail, Rizatriptan Benzoate, Sumatriptan Succinate/naproxen sumatriptan-naproxen oral tablet 85-500 mg Tier 1 Sodium, Sumatriptan Succinate, Sumatriptan, Sumavel Dosepro, Tosymra, Treximet, Zecuity, Zembrace Symtouch, Zolmitriptan, or Zomig within the past 180 days; QL (9 EA per 30 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 139 Coverage Prescription Drug Name Drug Tier Requirements and Limits Movement Disorder Drug Therapy - Drugs for the Nervous System AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 MG Tier 3 PA; SP (deutetrabenazine) INGREZZA INITIATION PACK ORAL CAPSULE,DOSE Tier 3 PA; SP PACK 40 MG (7)- 80 MG (21) (valbenazine tosylate) INGREZZA ORAL CAPSULE 40 MG, 80 MG (valbenazine Tier 3 PA; SP tosylate) tetrabenazine oral tablet 12.5 mg, 25 mg Tier 1 PA; SP Movement Disorder Therapy - Huntington's Disease - Drugs for the Nervous System AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 MG Tier 3 PA; SP (deutetrabenazine) Movement Disorder Therapy - Restless Legs Syndrome - Drugs for the Nervous System ST: Requires prior prescription for Gabapentin, Gralise, HORIZANT ORAL TABLET EXTENDED RELEASE 300 MG Tier 3 Neuraptine, Pramipexole (gabapentin enacarbil) Di-HCL, or Ropinirole HCL within the past 120 days; QL (30 EA per 30 days) ST: Requires prior prescription for Gabapentin, Gralise, HORIZANT ORAL TABLET EXTENDED RELEASE 600 MG Tier 3 Neuraptine, Pramipexole (gabapentin enacarbil) Di-HCL, or Ropinirole HCL within the past 120 days; QL (2 EA per 1 day) Movement Disorder Therapy - Tardive Dyskinesia - Drugs for the Nervous System AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 MG Tier 3 PA; SP (deutetrabenazine) INGREZZA INITIATION PACK ORAL CAPSULE,DOSE Tier 3 PA; SP PACK 40 MG (7)- 80 MG (21) (valbenazine tosylate) INGREZZA ORAL CAPSULE 80 MG (valbenazine Tier 3 PA; SP tosylate)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 145 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Requires prior prescription for Zolpidem ZOLPIMIST ORAL SPRAY,NON-AEROSOL 5 MG/SPRAY Tier 3 Tartrate within the past 120 (0.1 ML) (zolpidem tartrate) days; QL (7.7 ML per 30 days) Sedative-Hypnotic - Orexin Receptor Antagonist - Drugs for Insomnia BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG Tier 2 QL (1 EA per 1 day) (suvorexant) DAYVIGO ORAL TABLET 10 MG, 5 MG (lemborexant) Tier 3 QL (1 EA per 1 day) Sedative-Hypnotic - Tricyclic Antidepressant Type - Drugs for Insomnia doxepin oral tablet 3 mg, 6 mg Tier 1 QL (1 EA per 1 day) Sedative-Hypnotic Combinations Other - Drugs for Insomnia MKO (MIDAZOLAM-KETAMINE-ONDAN) SUBLINGUAL TROCHE 3-25-2 MG (midazolam/ketamine Tier 1 hcl/ondansetron hcl) Chemical Dependency, Agents to Treat - Drugs for Addiction Agents for Opioid Withdrawal, Central Alpha-2 Adrenergic Agonist-Type - Drugs for Opioid Addiction LUCEMYRA ORAL TABLET 0.18 MG (lofexidine hcl) Tier 3 PA Agents for Opioid Withdrawal, Opioid-Type - Drugs for Opioid Addiction BUNAVAIL BUCCAL FILM 2.1-0.3 MG (buprenorphine Tier 3 QL (1 EA per 1 day) hcl/naloxone hcl) BUNAVAIL BUCCAL FILM 4.2-0.7 MG, 6.3-1 MG Tier 3 QL (2 EA per 1 day) (buprenorphine hcl/naloxone hcl) buprenorphine hcl sublingual tablet 2 mg, 8 mg Tier 1 QL (3 EA per 1 day) buprenorphine-naloxone sublingual film 12-3 mg, 8-2 Tier 1 QL (2 EA per 1 day) mg buprenorphine-naloxone sublingual film 2-0.5 mg, 4-1 Tier 1 QL (1 EA per 1 day) mg

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 146 Coverage Prescription Drug Name Drug Tier Requirements and Limits buprenorphine-naloxone sublingual tablet 2-0.5 mg, 8-2 Tier 1 QL (3 EA per 1 day) mg ZUBSOLV SUBLINGUAL TABLET 0.7-0.18 MG, 1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 MG Tier 2 QL (1 EA per 1 day) (buprenorphine hcl/naloxone hcl) ZUBSOLV SUBLINGUAL TABLET 8.6-2.1 MG Tier 2 QL (2 EA per 1 day) (buprenorphine hcl/naloxone hcl) Alcohol Abstinence Therapy - Glutamate and GABA System Type - Drugs for Alcohol Addiction acamprosate oral tablet,delayed release (dr/ec) 333 mg Tier 1 Alcohol Deterrents - Drugs for Alcohol Addiction disulfiram oral tablet 250 mg, 500 mg Tier 1 Smoking Deterrents - NE and Dopamine Reuptake Inhibitor (NDRI)-Type - Drugs for Smoking Addiction bupropion hcl (smoking deter) oral tablet extended EHB; QL (2 EA per 1 day); $0 release 12 hr 150 mg Age (Min 18 Years) Smoking Deterrents - Nicotine-Type - Drugs for Smoking Addiction EHB; QL (9 EA per 1 day); nicotine (polacrilex) buccal gum 2 mg, 4 mg $0 Age (Min 18 Years) EHB; QL (9 EA per 1 day); nicotine (polacrilex) buccal lozenge 2 mg, 4 mg $0 Age (Min 18 Years) EHB; QL (9 EA per 1 day); nicotine (polacrilex) buccal mini lozenge 2 mg, 4 mg $0 Age (Min 18 Years) nicotine transdermal patch 24 hour 14 mg/24 hr, 21 EHB; QL (1 EA per 1 day); $0 mg/24 hr, 7 mg/24 hr Age (Min 18 Years) nicotine transdermal patch, td daily, sequential 21-14-7 EHB; QL (1 EA per 1 day); $0 mg/24 hr Age (Min 18 Years)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 149 Coverage Prescription Drug Name Drug Tier Requirements and Limits galantamine oral solution 4 mg/ml Tier 1 QL (200 ML per 30 days) galantamine oral tablet 12 mg, 4 mg, 8 mg Tier 1 QL (60 EA per 30 days) rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, Tier 1 6 mg rivastigmine transdermal patch 24 hour 13.3 mg/24 Tier 1 QL (30 EA per 30 days) hour, 4.6 mg/24 hr, 9.5 mg/24 hr Alzheimer's Disease Therapy - NMDA Receptor Antagonists - Drugs for Alzheimer's Disease memantine oral capsule,sprinkle,er 24hr 14 mg, 21 mg, Tier 1 QL (30 EA per 30 days) 28 mg, 7 mg memantine oral solution 2 mg/ml Tier 1 QL (300 ML per 30 days) memantine oral tablet 10 mg, 5 mg Tier 1 QL (60 EA per 30 days) memantine oral tablets,dose pack 5-10 mg Tier 1 QL (49 EA per 28 days) NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE Tier 2 QL (28 EA per 28 days) PACK 7-14-21-28 MG (memantine hcl) Alzheimer's Thx - NMDA Receptor Antag. and Cholinesterase Inhib. Comb - Drugs for Alzheimer's Disease ST: At least 2 prior prescriptions for Donepezil NAMZARIC ORAL CAP,SPRINKLE,ER 24HR DOSE PACK HCL, Memantine HCL, or Tier 2 7/14/21/28 MG-10 MG (memantine hcl/donepezil hcl) Namenda XR within the past 365 days; QL (28 EA per 28 days) ST: At least 2 prior prescriptions for Donepezil NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR 14-10 HCL, Memantine HCL, or MG, 21-10 MG, 28-10 MG, 7-10 MG (memantine Tier 2 Namenda XR within the hcl/donepezil hcl) past 365 days; QL (1 EA per 1 day) Cognitive Disorder Therapy - Cerebral Vasodilators - Drugs for Alzheimer's Disease ergoloid oral tablet 1 mg Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 155 Coverage Prescription Drug Name Drug Tier Requirements and Limits levonorgestrel/ethinyl estradiol (Iclevia Oral Tablets,Dose CT; EHB; QL (91 EA per $0 Pack,3 Month 0.15 Mg-30 Mcg (91)) 84 days) levonorgestrel/ethinyl estradiol (Introvale Oral CT; EHB; QL (91 EA per $0 Tablets,Dose Pack,3 Month 0.15 Mg-30 Mcg (91)) 84 days) desogestrel-ethinyl estradiol (Isibloom Oral Tablet 0.15- $0 CT; EHB 0.03 Mg) ethinyl estradiol/drospirenone (Jasmiel (28) Oral Tablet $0 CT; EHB 3-0.02 Mg) JOLESSA ORAL TABLETS,DOSE PACK,3 MONTH 0.15 CT; EHB; QL (91 EA per $0 MG-30 MCG (91) (levonorgestrel/ethinyl estradiol) 84 days) desogestrel-ethinyl estradiol (Juleber Oral Tablet 0.15- $0 CT; EHB 0.03 Mg) norethindrone acetate-ethinyl estradiol (Junel 1.5/30 (21) $0 CT; EHB Oral Tablet 1.5-30 Mg-Mcg) norethindrone acetate-ethinyl estradiol (Junel 1/20 (21) $0 CT; EHB Oral Tablet 1-20 Mg-Mcg) norethindrone acetate-ethinyl estradiol/ferrous fumarate (Junel Fe 1.5/30 (28) Oral Tablet 1.5 Mg-30 Mcg $0 CT; EHB (21)/75 Mg (7)) norethindrone acetate-ethinyl estradiol/ferrous fumarate (Junel Fe 1/20 (28) Oral Tablet 1 Mg-20 Mcg $0 CT; EHB (21)/75 Mg (7)) norethindrone acetate-ethinyl estradiol/ferrous fumarate (Junel Fe 24 Oral Tablet 1 Mg-20 Mcg (24)/75 Mg $0 CT; EHB (4)) norethindrone-ethinyl estradiol/ferrous fumarate (Kaitlib $0 CT; EHB Fe Oral Tablet,Chewable 0.8Mg-25Mcg(24) And 75 Mg (4)) desogestrel-ethinyl estradiol (Kalliga Oral Tablet 0.15- $0 CT; EHB 0.03 Mg) ethynodiol diacetate-ethinyl estradiol (Kelnor 1/35 (28) $0 CT; EHB Oral Tablet 1-35 Mg-Mcg) ethynodiol diacetate-ethinyl estradiol (Kelnor 1-50 (28) $0 CT; EHB Oral Tablet 1-50 Mg-Mcg) levonorgestrel/ethinyl estradiol (Kurvelo (28) Oral Tablet $0 CT; EHB 0.15-0.03 Mg) norethindrone acetate-ethinyl estradiol (Larin 1.5/30 (21) $0 CT; EHB Oral Tablet 1.5-30 Mg-Mcg)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 160 Coverage Prescription Drug Name Drug Tier Requirements and Limits norethindrone (Deblitane Oral Tablet 0.35 Mg) $0 CT; EHB norethindrone (Errin Oral Tablet 0.35 Mg) $0 CT; EHB norethindrone (Heather Oral Tablet 0.35 Mg) $0 CT; EHB norethindrone (Incassia Oral Tablet 0.35 Mg) $0 CT; EHB norethindrone (Jencycla Oral Tablet 0.35 Mg) $0 CT; EHB norethindrone (Lyza Oral Tablet 0.35 Mg) $0 CT; EHB NORA-BE ORAL TABLET 0.35 MG (norethindrone) $0 CT; EHB norethindrone (contraceptive) oral tablet 0.35 mg $0 CT; EHB norethindrone (Norlyda Oral Tablet 0.35 Mg) $0 CT; EHB norethindrone (Sharobel Oral Tablet 0.35 Mg) $0 CT; EHB CT; EHB; ST: Requires prior prescription for a SLYND ORAL TABLET 4 MG (28) (drospirenone) $0 generic contraceptive within the past 120 days; QL (28 EA per 28 days) norethindrone (Tulana Oral Tablet 0.35 Mg) $0 CT; EHB Contraceptive Oral - Quadraphasic - Birth Control Pills levonorgestrel/ethinyl estradiol and ethinyl estradiol (Fayosim Oral Tablets,Dose Pack,3 Month 0.15 Mg-20 Mcg/ $0 CT; EHB 0.15 Mg-25 Mcg) l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 $0 CT; EHB month 0.15 mg-20 mcg/ 0.15 mg-25 mcg CT; EHB; ST: At least 2 NATAZIA ORAL TABLET 3 MG/2 MG-2 MG/ 2 MG-3 MG/1 prior prescriptions for $0 MG (estradiol valerate/dienogest) generic oral contraceptives within the past 365 days RIVELSA ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-20 MCG/ 0.15 MG-25 MCG (levonorgestrel/ethinyl $0 CT; EHB estradiol and ethinyl estradiol) Contraceptive Oral - Triphasic - Birth Control Pills norethindrone-ethinyl estradiol (Alyacen 7/7/7 (28) Oral $0 CT; EHB Tablet 0.5/0.75/1 Mg- 35 Mcg) norethindrone-ethinyl estradiol (Aranelle (28) Oral Tablet $0 CT; EHB 0.5/1/0.5-35 Mg-Mcg)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 161 Coverage Prescription Drug Name Drug Tier Requirements and Limits desogestrel-ethinyl estradiol (Caziant (28) Oral Tablet $0 CT; EHB 0.1/.125/.15-25 Mg-Mcg) norethindrone-ethinyl estradiol (Cyclafem 7/7/7 (28) Oral $0 CT; EHB Tablet 0.5/0.75/1 Mg- 35 Mcg) norethindrone-ethinyl estradiol (Dasetta 7/7/7 (28) Oral $0 CT; EHB Tablet 0.5/0.75/1 Mg- 35 Mcg) levonorgestrel/ethinyl estradiol (Enpresse Oral Tablet 50- $0 CT; EHB 30 (6)/75-40 (5)/125-30(10)) LEENA 28 ORAL TABLET 0.5/1/0.5-35 MG-MCG $0 CT; EHB (norethindrone-ethinyl estradiol) levonorgestrel/ethinyl estradiol (Levonest (28) Oral $0 CT; EHB Tablet 50-30 (6)/75-40 (5)/125-30(10)) levonorg-eth estrad triphasic oral tablet 50-30 (6)/75-40 $0 CT; EHB (5)/125-30(10) norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 $0 CT; EHB mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg (28) norethindrone-ethinyl estradiol (Nortrel 7/7/7 (28) Oral $0 CT; EHB Tablet 0.5/0.75/1 Mg- 35 Mcg) norethindrone-ethinyl estradiol (Pirmella Oral Tablet $0 CT; EHB 0.5/0.75/1 Mg- 35 Mcg) norethindrone acetate-ethinyl estradiol/ferrous fumarate (Tilia Fe Oral Tablet 1-20(5)/1-30(7) /1Mg-35Mcg $0 CT; EHB (9)) norgestimate-ethinyl estradiol (Tri Femynor Oral Tablet $0 CT; EHB 0.18/0.215/0.25 Mg-35 Mcg (28)) norgestimate-ethinyl estradiol (Tri-Estarylla Oral Tablet $0 CT; EHB 0.18/0.215/0.25 Mg-35 Mcg (28)) norethindrone acetate-ethinyl estradiol/ferrous fumarate (Tri-Legest Fe Oral Tablet 1-20(5)/1-30(7) /1Mg- $0 CT; EHB 35Mcg (9)) norgestimate-ethinyl estradiol (Tri-Linyah Oral Tablet $0 CT; EHB 0.18/0.215/0.25 Mg-35 Mcg (28)) norgestimate-ethinyl estradiol (Tri-Lo-Estarylla Oral $0 CT; EHB Tablet 0.18/0.215/0.25 Mg-25 Mcg) norgestimate-ethinyl estradiol (Tri-Lo-Marzia Oral Tablet $0 CT; EHB 0.18/0.215/0.25 Mg-25 Mcg) norgestimate-ethinyl estradiol (Tri-Lo-Mili Oral Tablet $0 CT; EHB 0.18/0.215/0.25 Mg-25 Mcg) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 162 Coverage Prescription Drug Name Drug Tier Requirements and Limits norgestimate-ethinyl estradiol (Tri-Lo-Sprintec Oral $0 CT; EHB Tablet 0.18/0.215/0.25 Mg-25 Mcg) norgestimate-ethinyl estradiol (Tri-Mili Oral Tablet $0 CT; EHB 0.18/0.215/0.25 Mg-35 Mcg (28)) norgestimate-ethinyl estradiol (Tri-Previfem (28) Oral $0 CT; EHB Tablet 0.18/0.215/0.25 Mg-35 Mcg (28)) norgestimate-ethinyl estradiol (Tri-Sprintec (28) Oral $0 CT; EHB Tablet 0.18/0.215/0.25 Mg-35 Mcg (28)) levonorgestrel/ethinyl estradiol (Trivora (28) Oral Tablet $0 CT; EHB 50-30 (6)/75-40 (5)/125-30(10)) norgestimate-ethinyl estradiol (Tri-Vylibra Lo Oral Tablet $0 CT; EHB 0.18/0.215/0.25 Mg-25 Mcg) norgestimate-ethinyl estradiol (Tri-Vylibra Oral Tablet $0 CT; EHB 0.18/0.215/0.25 Mg-35 Mcg (28)) desogestrel-ethinyl estradiol (Velivet Triphasic Regimen $0 CT; EHB (28) Oral Tablet 0.1/.125/.15-25 Mg-Mcg) Contraceptive Transdermal Combinations - Birth Control Pills XULANE TRANSDERMAL PATCH WEEKLY 150-35 CT; EHB; QL (3 EA per 28 $0 MCG/24 HR (norelgestromin/ethinyl estradiol) days) Contraceptive Transdermal Combinations - Estrogen and Progestin Comb. - Birth Control Pills TWIRLA TRANSDERMAL PATCH WEEKLY 120-30 Tier 3 CT; QL (3 EA per 28 days) MCG/24 HR (levonorgestrel/ethinyl estradiol) Contraceptives - Intravaginal, Systemic - Birth Control Pills etonogestrel-ethinyl estradiol vaginal ring 0.12-0.015 CT; EHB; QL (1 EA per 28 $0 mg/24 hr days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 172 Coverage Prescription Drug Name Drug Tier Requirements and Limits tretinoin microspheres topical gel with pump 0.04 %, Tier 1 Age (Max 25 Years) 0.1 % tretinoin topical cream 0.025 %, 0.05 %, 0.1 % Tier 1 Age (Max 25 Years) tretinoin topical gel 0.01 %, 0.025 %, 0.05 % Tier 1 Age (Max 25 Years) TRETIN-X CREAM KIT TOPICAL COMBO PACK 0.025 %, 0.05 %, 0.1 % (tretinoin/emollient combination no.9/skin Tier 3 Age (Max 25 Years) cleanser no.1) TRETIN-X TOPICAL CREAM 0.075 % (tretinoin) Tier 3 Age (Max 25 Years) Acne Therapy Topical Combinations Other - Drugs for the Skin DIMOXIA TOPICAL GEL 5-4 % Tier 3 (spironolactone/niacinamide) Antipsoriatic - Retinoid (Vitamin A Derivative) - Glucocorticoid - Drugs for the Skin ST: Requires prior prescription for Betamethasone augmented 0.05% (cream, gel, lotion, ointment), Clobetasol, DUOBRII TOPICAL LOTION 0.01-0.045 % (halobetasol Tier 3 Desoximetasone (cream, propionate/tazarotene) gel, ointment), Fluocinonide (cream, gel), or Halobetasol (cream, ointment) within the past 120 days; QL (200 GM per 28 days) Antipsoriatic - Vitamin D Analog - Glucocorticoid Combinations - Drugs for the Skin calcipotriene-betamethasone topical ointment 0.005- Tier 1 0.064 % calcipotriene-betamethasone topical suspension 0.005- Tier 1 0.064 % ENSTILAR TOPICAL FOAM 0.005-0.064 % Tier 3 (calcipotriene/betamethasone dipropionate) WYNZORA TOPICAL CREAM 0.005-0.064 % Tier 3 (calcipotriene/betamethasone dipropionate) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 173 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antipsoriatic Agents - Interleukin 12 and IL-23 Inhibitors,MC Antibody - Drugs for the Skin STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5 ML Tier 2 PA; SP (ustekinumab) STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML, 90 Tier 2 PA; SP MG/ML (ustekinumab) Antipsoriatic Agents - Interleukin-23 (IL-23) Antagonist, MC Antibody - Drugs for the Skin SKYRIZI SUBCUTANEOUS SYRINGE 75 MG/0.83 ML Tier 2 PA; SP (risankizumab-rzaa) SKYRIZI SUBCUTANEOUS SYRINGE KIT Tier 2 PA; SP 150MG/1.66ML(75 MG/0.83 ML X2) (risankizumab-rzaa) TREMFYA SUBCUTANEOUS AUTO-INJECTOR 100 Tier 2 PA; SP MG/ML (guselkumab) TREMFYA SUBCUTANEOUS SYRINGE 100 MG/ML Tier 2 PA; SP (guselkumab) Antipsoriatic Agents-Interleukin-17 (IL-17) Antagonist, MC Antibody - Drugs for the Skin COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE Tier 2 PA; SP 150 MG/ML (secukinumab) COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN Tier 2 PA; SP INJECTOR 150 MG/ML (secukinumab) COSENTYX PEN SUBCUTANEOUS PEN INJECTOR 150 Tier 2 PA; SP MG/ML (secukinumab) COSENTYX SUBCUTANEOUS SYRINGE 150 MG/ML Tier 2 PA; SP (secukinumab) SILIQ SUBCUTANEOUS SYRINGE 210 MG/1.5 ML Tier 3 PA; SP (brodalumab) TALTZ AUTOINJECTOR (2 PACK) SUBCUTANEOUS Tier 3 PA; SP AUTO-INJECTOR 80 MG/ML (ixekizumab) TALTZ AUTOINJECTOR (3 PACK) SUBCUTANEOUS Tier 3 PA; SP AUTO-INJECTOR 80 MG/ML (ixekizumab) TALTZ AUTOINJECTOR SUBCUTANEOUS AUTO- Tier 3 PA; SP INJECTOR 80 MG/ML (ixekizumab) TALTZ SYRINGE SUBCUTANEOUS SYRINGE 80 MG/ML Tier 3 PA; SP (ixekizumab)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 177 Coverage Prescription Drug Name Drug Tier Requirements and Limits Dermatological - Antifungal Combinations Other - Drugs for the Skin DIFMETIOXRIME TOPICAL SOLUTION 4-2-1-4 % Tier 3 (fluconazole/ibuprofen/itraconazole/terbinafine hcl) EXODERM TOPICAL LOTION 25-1 % (sodium Tier 1 thiosulfate/salicylic acid) IMIOXIA TOPICAL CREAM 1-4 % (econazole Tier 3 nitrate/niacinamide) ketoconazole-niacinamide topical cream 2-4 % Tier 1 Dermatological - Antifungal Hydroxypyridinone - Drugs for the Skin CICLODAN KIT TOPICAL COMBO PACK 0.77 % Tier 3 (ciclopirox olamine/skin cleanser combination no.28) ciclopirox topical cream 0.77 % Tier 1 QL (180 GM per 1 FILL) ciclopirox topical gel 0.77 % Tier 1 ciclopirox topical shampoo 1 % Tier 1 ciclopirox topical solution 8 % Tier 1 QL (19.8 ML per 1 FILL) ciclopirox topical suspension 0.77 % Tier 1 QL (180 ML per 1 FILL) ciclopirox-salicylic acid topical shampoo 0.77-2 % Tier 1 ciclopirox-ure-camph-menth-euc topical solution 8 % Tier 1 QL (19.8 ML per 1 FILL) LOPROX KIT TOPICAL COMBO PACK 0.77 % (ciclopirox Tier 3 olamine/skin cleanser combination no.40) LOPROX KIT TOPICAL KIT, SUSPENSION AND CLEANSER 0.77 % (ciclopirox olamine/skin cleanser Tier 3 combination no.40) Dermatological - Antifungal Imidazole and Related Agents - Drugs for the Skin clotrimazole topical cream 1 % Tier 1 clotrimazole topical solution 1 % Tier 1 ECONASIL TOPICAL KIT 1 %- 4" X 4" (econazole Tier 3 nitrate/gauze bandage/silicone, adhesive) econazole topical cream 1 % Tier 1 QL (170 GM per 1 FILL) ECOZA TOPICAL FOAM 1 % (econazole nitrate) Tier 3 ERTACZO TOPICAL CREAM 2 % (sertaconazole nitrate) Tier 3 EXELDERM TOPICAL CREAM 1 % (sulconazole nitrate) Tier 2 PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 178 Coverage Prescription Drug Name Drug Tier Requirements and Limits EXELDERM TOPICAL SOLUTION 1 % (sulconazole Tier 2 nitrate) ketoconazole topical cream 2 % Tier 1 QL (180 GM per 1 FILL) ketoconazole topical foam 2 % Tier 1 ketoconazole topical shampoo 2 % Tier 1 QL (360 ML per 1 FILL) KETODAN KIT TOPICAL COMBO PACK 2 % Tier 3 (ketoconazole/skin cleanser combination no.28) ketoconazole (Ketodan Topical Foam 2 %) Tier 1 ST: Requires prior prescriptions for Clotrimazole and luliconazole topical cream 1 % Tier 1 Ketoconazole within the past 365 days; QL (60 GM per 28 days) miconazole nitrate-zinc ox-pet topical ointment 0.25-15- Tier 1 81.35 % oxiconazole topical cream 1 % Tier 1 QL (180 GM per 1 FILL) OXISTAT TOPICAL LOTION 1 % (oxiconazole nitrate) Tier 3 PEDIZOL PAK TOPICAL KIT, CREAM AND SOLUTION 2-2 Tier 3 % (ketoconazole/miconazole nitrate) sulconazole topical cream 1 % Tier 1 sulconazole topical solution 1 % Tier 1 XOLEGEL TOPICAL GEL 2 % (ketoconazole) Tier 3 ZOLPAK TOPICAL KIT 1 %- 6 CM X 7 CM (econazole Tier 3 nitrate/transparent dressing) Dermatological - Antifungal Oxaborole - Drugs for the Skin KERYDIN TOPICAL SOLUTION WITH APPLICATOR 5 % Tier 3 PA (tavaborole) tavaborole topical solution with applicator 5 % Tier 1 PA Dermatological - Antifungal Triazole - Drugs for the Skin JUBLIA TOPICAL SOLUTION WITH APPLICATOR 10 % Tier 3 PA (efinaconazole)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 179 Coverage Prescription Drug Name Drug Tier Requirements and Limits Dermatological - Antifungal-Glucocorticoid Combinations - Drugs for the Skin ciclopirox-clobetasol topical shampoo 0.77-0.05 % Tier 1 ciclopirox-clobetasol-salicyl topical shampoo 0.77-0.05- Tier 1 3 % clotrimazole-betamethasone topical cream 1-0.05 % Tier 1 clotrimazole-betamethasone topical lotion 1-0.05 % Tier 1 DERMACINRX THERAZOLE PAK TOPICAL COMBO PACK 1-0.05-20 % (clotrimazole/betamethasone Tier 3 dipropionate/zinc oxide) DERMAZENE TOPICAL CREAM IN PACKET 1-1 % Tier 3 (hydrocortisone/iodoquinol) hydrocortisone-iodoquinol topical cream 1-1 % Tier 1 nystatin-triamcinolone topical cream 100,000-0.1 unit/g- Tier 1 % nystatin-triamcinolone topical ointment 100,000-0.1 Tier 1 unit/gram-% PHEYO TOPICAL CREAM 2-2.5 % Tier 3 (ketoconazole/hydrocortisone) Dermatological - Antineoplastic Alkylating Agents - Drugs for the Skin VALCHLOR TOPICAL GEL 0.016 % (mechlorethamine Tier 2 PA; SP hcl) Dermatological - Antineoplastic Antimetabolites - Drugs for the Skin FLUOROPLEX TOPICAL CREAM 1 % (fluorouracil) Tier 3 fluorouracil topical cream 0.5 % Tier 1 PA fluorouracil topical cream 5 % Tier 1 fluorouracil topical solution 2 %, 5 % Tier 1 TOLAK TOPICAL CREAM 4 % (fluorouracil) Tier 2 Dermatological - Antineoplastic or Premalig. Lesions -Diterpene Esters - Drugs for the Skin PICATO TOPICAL GEL 0.015 % (ingenol mebutate) Tier 2 QL (3 EA per 28 days) PICATO TOPICAL GEL 0.05 % (ingenol mebutate) Tier 2 QL (2 EA per 28 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 182 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Requires prior prescription for Betamethasone 0.05% (ointment, augmented IMPOYZ TOPICAL CREAM 0.025 % (clobetasol Tier 3 cream), Desoximetasone propionate) (cream, gel, ointment), Fluocinonide 0.05% (gel, ointment, solution, cream) within the past 120 days ST: Requires prior prescription for Clobetasol Propionate, Clobetasol LEXETTE TOPICAL FOAM 0.05 % (halobetasol Tier 3 Propionate/emoll, or propionate) Halobetasol Propionate within the past 120 days; QL (100 GM per 1 FILL) NUDERMRXPAK TOPICAL KIT 0.005-5 % Tier 3 (calcipotriene/dimethicone) ST: Requires prior prescription for a Topical SORILUX TOPICAL FOAM 0.005 % (calcipotriene) Tier 3 Anti-inflammatory Steroidal within the past 120 days tazarotene topical cream 0.1 % Tier 1 TAZORAC TOPICAL CREAM 0.05 % (tazarotene) Tier 2 TAZORAC TOPICAL GEL 0.05 %, 0.1 % (tazarotene) Tier 3 ST: Requires prior prescription for Betamethasone augmented (ointment, gel, lotion), Clobetasol (spray, ULTRAVATE TOPICAL LOTION 0.05 % (halobetasol lotion, gel, ointment, Tier 3 propionate) cream, solution), Fluocinonide 0.1% cream, or Halobetasol 0.05% (cream, ointment) within the past 120 days; QL (100 ML per 1 FILL)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 193 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Requires prior prescription for Betamethasone 0.05% ointment or augmented HALOG TOPICAL SOLUTION 0.1 % (halcinonide) Tier 3 cream, Desoximetasone (cram, gel, ointment), or Fluocinonide 0.05% (gel, ointment, solution, cream) withn the past 120 days hydrocortisone butyrate topical cream 0.1 % Tier 1 ST: Requires prior prescription for Betamethasone (0.05% lotion, 0.1% cream), Desonide 0.05% ointment, hydrocortisone butyrate topical lotion 0.1 % Tier 1 Fluticasone 0.05% cream, Hydrocortisone 0.2% cream, or Triamcinolone (0.1% lotion, 0.025% ointment) within the past 120 days ST: Requires prior prescription for Betamethasone (0.05% lotion, 0.1% cream), Desonide 0.05% ointment, hydrocortisone butyrate topical ointment 0.1 % Tier 1 Fluticasone 0.05% cream, Hydrocortisone 0.2% cream, or Triamcinolone (0.1% lotion, 0.025% ointment) within the past 120 days hydrocortisone butyrate topical solution 0.1 % Tier 1 hydrocortisone butyr-emollient topical cream 0.1 % Tier 1 hydrocortisone topical cream 1 %, 2.5 % Tier 1 hydrocortisone topical cream with perineal applicator 1 Tier 1 %, 2.5 % hydrocortisone topical lotion 2.5 % Tier 1 hydrocortisone topical ointment 1 %, 2.5 % Tier 1 hydrocortisone valerate topical cream 0.2 % Tier 1 PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 194 Coverage Prescription Drug Name Drug Tier Requirements and Limits hydrocortisone valerate topical ointment 0.2 % Tier 1 IMPEKLO TOPICAL LOTION IN METERED-DOSE PUMP Tier 3 0.05 % (clobetasol propionate) mometasone topical cream 0.1 % Tier 1 mometasone topical ointment 0.1 % Tier 1 mometasone topical solution 0.1 % Tier 1 ST: Requires prior prescription for Betamethasone (0.05% lotion, 0.1% cream), Desonide 0.05% ointment, PANDEL TOPICAL CREAM 0.1 % (hydrocortisone Tier 2 Fluticasone 0.05% cream, probutate) Hydrocortisone 0.2% cream, or Triamcinolone (0.1% lotion, 0.025% ointment) within the past 120 days prednicarbate topical cream 0.1 % Tier 1 prednicarbate topical ointment 0.1 % Tier 1 hydrocortisone (Procto-Pak Topical Cream With Perineal Tier 1 Applicator 1 %) hydrocortisone (Proctosol Hc Topical Cream With Perineal Tier 1 Applicator 2.5 %) SCALACORT DK TOPICAL COMBO PACK 2-2-2 % Tier 2 (hydrocortisone/salicylic acid/sulfur/shampoo no. 1) ST: Requires prior prescription for SERNIVO TOPICAL SPRAY WITH PUMP 0.05 % Tier 3 Triamcinolone Acetonide (betamethasone dipropionate) 0.147mg/g spray within the past 120 days SILA III TOPICAL KIT 0.1 %- 4" X 4" (triamcinolone Tier 3 acetonide/gauze bandage/silicone, adhesive) SILALITE PAK TOPICAL KIT,OINTMENT AND SHEET 0.1 Tier 3 % (triamcinolone acetonide/silicones) SILAZONE-II TOPICAL KIT 0.1 % (triamcinolone Tier 3 acetonide/silicones) TASOPROL TOPICAL KIT 0.05 %- 4" X 4" (clobetasol Tier 3 propionate/gauze bandage/silicone, adhesive)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 198 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Requires prior prescription for Diclofenac ZYCLARA TOPICAL CREAM IN METERED-DOSE PUMP 3%, generic Fluorouracil Tier 3 2.5 % (imiquimod) 5%, or Imiquimod 5% within the past 120 days; QL (7.5 GM per 28 days) ST: Requires prior prescription for Diclofenac ZYCLARA TOPICAL CREAM IN PACKET 3.75 % 3%, generic Fluorouracil Tier 3 (imiquimod) 5%, or Imiquimod 5% within the past 120 days; QL (1 EA per 1 day) Dermatological - Immunomodulator - Interferons - Drugs for the Skin ALFERON N INJECTION SOLUTION 5 MILLION UNIT/ML Tier 3 SP (interferon alfa-n3) Dermatological - Immunomodulator Combinations - Drugs for the Skin imiquimod-levocetirizin-niacin topical gel 5-1-2 % Tier 1 imiquimod-tretinoin-levocetir topical gel 5-0.05-1 % Tier 1 Dermatological - Keratolytic Combinations Other - Drugs for the Skin salicylic-cimetidine-lidocaine topical cream 40-10-5 % Tier 1 URAMAXIN GT TOPICAL KIT,CREAM AND GEL 45 % Tier 3 (urea/emollient combination no.65) Dermatological - Keratolytic-Antimitotic Combinations - Drugs for the Skin SALVAX DUO PLUS TOPICAL FOAM 6-35 % (salicylic Tier 3 acid/urea) silver nitrate applicators topical stick 75-25 % Tier 1 Dermatological - Keratolytic-Antimitotic Single Agents - Drugs for the Skin BENSAL HP TOPICAL OINTMENT 3 % (salicylic acid) Tier 3 cantharidin in acetone topical solution 0.7 % Tier 1 CEM-UREA TOPICAL GEL 45 % (urea) Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 210 Coverage Prescription Drug Name Drug Tier Requirements and Limits Dermatological Irritants-Counter-Irritant Single Agents - Drugs for the Skin methyl salicylate oil Tier 1 methyl salicylate topical liquid Tier 1 QUTENZA TOPICAL KIT 8 % (capsaicin/skin cleanser) Tier 3 PA WINTERGREEN OIL OIL (methyl salicylate) Tier 1 Human Cellular Regenerative Tissue Matrix - Drugs for the Skin EPIFIX AMNIOTIC MEMBRANE TOPICAL SHEET 14 MM, 2 X 3 CM, 4 X 4 CM, 5 X 6 CM, 7 X 7 CM (human Tier 3 regenerative tissue matrix) GRAFIX CORE TOPICAL SHEET 1.5 X 2 CM, 14 MM, 16 MM, 2 X 3 CM, 3 X 4 CM, 5 X 5 CM (human regenerative Tier 3 tissue matrix) GRAFIX PRIME TOPICAL SHEET 1.5 X 2 CM, 14 MM, 16 MM, 2 X 3 CM, 3 X 4 CM, 5 X 5 CM (human regenerative Tier 3 tissue matrix) GRAFIX XC TOPICAL SHEET 7.5 X 15 CM (human Tier 3 regenerative tissue matrix) STRAVIX TOPICAL SHEET 2 X 4 CM, 3 X 6 CM (human Tier 3 regenerative tissue matrix) TRUSKIN TOPICAL SHEET 2 X 4 CM, 4 X 8 CM (human Tier 3 regenerative tissue matrix) Nail Protectives - Drugs for the Skin GENADUR (WITH LEXINAL) KIT 2,500 MCG (biotin/carbitol/equisetum xt/ethanol/hydroxypropyl Tier 3 chito/msm) GENADUR TOPICAL LIQUID (carbitol/equisetum Tier 3 ext/ethanol/hydroxypropyl chitosan/msm) Ovine (sheep) Skin Dressings, Non-Living - Drugs for the Skin ENDOFORM FENESTRATED TOPICAL SHEET 2 X 2 ", 4 X 5 " (extracellular matrix (ecm), ovine derived Tier 3 fenestrated) ENDOFORM TOPICAL SHEET 2 X 2 ", 4 X 5 " Tier 3 (extracellular matrix (ecm), ovine derived)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 217 Coverage Prescription Drug Name Drug Tier Requirements and Limits Erectile Dysfunction (ED) Drugs-Sel.cGMP Phosphodiesterase Type5 Inhib - Drugs for Erectile Dysfunction sildenafil oral tablet 100 mg, 25 mg, 50 mg Tier 1 QL (1 EA per 5 days) ST: Requires prior STENDRA ORAL TABLET 100 MG, 200 MG, 50 MG prescription for Sildenafil Tier 3 (avanafil) Citrate within the past 365 days; QL (1 EA per 5 days) tadalafil oral tablet 10 mg, 20 mg Tier 1 QL (1 EA per 5 days) tadalafil oral tablet 2.5 mg, 5 mg Tier 1 PA; QL (1 EA per 1 day) ST: Requires prior prescription for Sildenafil vardenafil oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg Tier 1 Citrate within the past 365 days; QL (1 EA per 5 days) ST: Requires prior prescription for Sildenafil vardenafil oral tablet,disintegrating 10 mg Tier 1 Citrate within the past 365 days; QL (1 EA per 5 days) Eating Disorder Therapy Anti-Obesity - Melanocortin 4 (MC4) Receptor Agonist IMCIVREE SUBCUTANEOUS SOLUTION 10 MG/ML Tier 3 PA; SP (setmelanotide acetate) Eating Disorder Therapy - Drugs for Eating Disorders Anorexiant Combinations - Drugs for Eating Disorders QSYMIA ORAL CAPSULE, ER MULTIPHASE 24 HR 11.25-69 MG, 15-92 MG, 3.75-23 MG, 7.5-46 MG Tier 3 PA (phentermine hcl/topiramate) Anorexiants - Drugs for Eating Disorders benzphetamine oral tablet 50 mg Tier 1 diethylpropion oral tablet 25 mg Tier 1 diethylpropion oral tablet extended release 75 mg Tier 1 LOMAIRA ORAL TABLET 8 MG (phentermine hcl) Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 218 Coverage Prescription Drug Name Drug Tier Requirements and Limits phendimetrazine tartrate oral capsule, extended release Tier 1 105 mg phendimetrazine tartrate oral tablet 35 mg Tier 1 phentermine oral capsule 15 mg, 30 mg, 37.5 mg Tier 1 phentermine oral tablet 37.5 mg Tier 1 Anti-Obesity - Fat Absorption Decreasing Agents - Drugs for Eating Disorders XENICAL ORAL CAPSULE 120 MG (orlistat) Tier 3 PA Anti-Obesity - Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists - Drugs for Eating Disorders SAXENDA SUBCUTANEOUS PEN INJECTOR 3 MG/0.5 Tier 2 PA ML (18 MG/3 ML) (liraglutide) Anti-Obesity-Opioid Antag/Norepinephrine and Dopamine Reuptake Inhibit - Drugs for Eating Disorders CONTRAVE ORAL TABLET EXTENDED RELEASE 8-90 Tier 2 PA MG (naltrexone hcl/bupropion hcl) Appetite Stimulants - Cannabinoids - Drugs for Eating Disorders ST: Requires prior prescription for Dronabinol SYNDROS ORAL SOLUTION 5 MG/ML (dronabinol) Tier 3 or Megestrol Acetate within the past 120 days; QL (60 ML per 30 days) Appetite Stimulants - Progestin Hormone Type - Drugs for Eating Disorders megestrol oral suspension 400 mg/10 ml (10 ml) Tier 1 megestrol oral suspension 400 mg/10 ml (40 mg/ml) Tier 1 ST: Requires prior prescription for Megestrol megestrol oral suspension 625 mg/5 ml (125 mg/ml) Tier 1 Acetate within the past 120 days

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 222 Coverage Prescription Drug Name Drug Tier Requirements and Limits Sodium Chloride, Parenteral - Drugs for Nutrition BD POSIFLUSH NORMAL SALINE 0.9 INJECTION Tier 1 SYRINGE (sodium chloride 0.9 % (flush)) BD PRE-FILLED NORMAL SALINE INJECTION SYRINGE Tier 1 (sodium chloride 0.9 % (flush)) BD PRE-FILLED SALINE BLUNT CAN INJECTION Tier 1 SYRINGE (sodium chloride 0.9 % (flush)) NORMAL SALINE FLUSH INJECTION SYRINGE (sodium Tier 1 chloride 0.9 % (flush)) sodium chloride 0.45 % intravenous parenteral solution Tier 1 0.45 % sodium chloride 0.9 % (flush) injection syringe Tier 1 sodium chloride 0.9 % intravenous parenteral solution Tier 1 sodium chloride 0.9 % intravenous piggyback Tier 1 Vitamins - B-3, Niacin and Derivatives - Drugs for Nutrition niacin oral tablet 500 mg Tier 1 Vitamins - D Derivatives - Drugs for Nutrition calcitriol oral capsule 0.25 mcg, 0.5 mcg Tier 1 calcitriol oral solution 1 mcg/ml Tier 1 Vitamins - Folic Acid and Derivatives - Drugs for Nutrition folic acid injection solution 5 mg/ml Tier 1 folic acid oral tablet 1 mg Tier 1 folic acid oral tablet 400 mcg, 800 mcg $0 EHB Vitamins - K, Phytonadione and Derivatives - Drugs for Nutrition phytonadione (vitamin k1) injection solution 10 mg/ml Tier 1 phytonadione (vitamin k1) injection syringe 1 mg/0.5 ml Tier 1 phytonadione (vitamin k1) oral tablet 5 mg Tier 1 phytonadione (vit k1) (Vitamin K Injection Solution 1 Tier 1 Mg/0.5 Ml)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 225 Coverage Prescription Drug Name Drug Tier Requirements and Limits testosterone cypionate intramuscular oil 100 mg/ml, Tier 1 PA 200 mg/ml testosterone enanthate intramuscular oil 200 mg/ml Tier 1 PA testosterone transdermal gel 50 mg/5 gram (1 %) Tier 1 PA testosterone transdermal gel in metered-dose pump 10 mg/0.5 gram /actuation, 12.5 mg/ 1.25 gram (1 %), 20.25 Tier 1 PA mg/1.25 gram (1.62 %) testosterone transdermal gel in packet 1 % (25 mg/2.5gram), 1 % (50 mg/5 gram), 1.62 % (20.25 mg/1.25 Tier 1 PA gram), 1.62 % (40.5 mg/2.5 gram) testosterone transdermal solution in metered pump Tier 1 PA w/app 30 mg/actuation (1.5 ml) XYOSTED SUBCUTANEOUS AUTO-INJECTOR 100 MG/0.5 ML, 50 MG/0.5 ML, 75 MG/0.5 ML (testosterone Tier 3 PA enanthate) Antidiuretic and Vasopressor Hormones - Hormones DDAVP NASAL SOLUTION 0.1 MG/ML (REFRIGERATE) Tier 2 (desmopressin acetate) desmopressin injection solution 4 mcg/ml Tier 1 desmopressin nasal spray with pump 10 mcg/spray (0.1 Tier 1 ml) desmopressin nasal spray,non-aerosol 10 mcg/spray Tier 1 (0.1 ml) desmopressin oral tablet 0.1 mg, 0.2 mg Tier 1 NOCDURNA (MEN) SUBLINGUAL TABLET,DISINTEGRATING 55.3 MCG (desmopressin Tier 3 QL (1 EA per 1 day) acetate) NOCDURNA (WOMEN) SUBLINGUAL TABLET,DISINTEGRATING 27.7 MCG (desmopressin Tier 3 QL (1 EA per 1 day) acetate) NOCTIVA NASAL SPRAY,NON-AEROSOL 0.83 MCG/SPRAY (0.1 ML), 1.66 MCG/SPRAY (0.1 ML) Tier 3 QL (3.8 GM per 30 days) (desmopressin acetate) Antihyperglycemic - Alpha-Glucosidase Inhibitors - Drugs for Diabetes acarbose oral tablet 100 mg, 25 mg, 50 mg Tier 1 DD PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 226 Coverage Prescription Drug Name Drug Tier Requirements and Limits miglitol oral tablet 100 mg, 25 mg, 50 mg Tier 1 DD Antihyperglycemic - Dipeptidyl Peptidase-4 (DPP-4) Inhibitors - Drugs for Diabetes DD; ST: Requires prior prescription for Janumet alogliptin oral tablet 12.5 mg, 25 mg, 6.25 mg Tier 3 XR, Janumet, or Januvia within the past 120 days; QL (1 EA per 1 day) JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG Tier 2 DD; QL (1 EA per 1 day) (sitagliptin phosphate) DD; ST: Requires prior prescription for Janumet ONGLYZA ORAL TABLET 2.5 MG, 5 MG (saxagliptin hcl) Tier 3 XR, Janumet, or Januvia within the past 120 days; QL (1 EA per 1 day) DD; ST: Requires prior prescription for Janumet TRADJENTA ORAL TABLET 5 MG (linagliptin) Tier 3 XR, Janumet, or Januvia within the past 120 days; QL (1 EA per 1 day) Antihyperglycemic - Dopamine Receptor Agonists - Drugs for Diabetes DD; ST: Requires prior prescription for Glipizide/Metformin HCL, CYCLOSET ORAL TABLET 0.8 MG (bromocriptine Tier 3 Glyburide/Metformin HCL, mesylate) Metformin HCL, or Riomet ER within the past 180 days Antihyperglycemic - Glucocorticoid (Cortisol) Receptor Blocker (GR-II) - Drugs for Diabetes KORLYM ORAL TABLET 300 MG (mifepristone) Tier 2 PA; SP; DD Antihyperglycemic - Meglitinide Analog and Biguanide Combinations - Drugs for Diabetes repaglinide-metformin oral tablet 1-500 mg, 2-500 mg Tier 1 DD

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 227 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antihyperglycemic - Meglitinide Analogs - Drugs for Diabetes nateglinide oral tablet 120 mg, 60 mg Tier 1 DD repaglinide oral tablet 0.5 mg, 1 mg, 2 mg Tier 1 DD Antihyperglycemic - SGLT-2 Inhibitor and Biguanide Combinations - Drugs for Diabetes DD; ST: Requires prior prescription for Farxiga, INVOKAMET ORAL TABLET 150-1,000 MG, 150-500 MG, Jardiance, Synjardy XR, Tier 3 50-1,000 MG, 50-500 MG (canagliflozin/metformin hcl) Synjardy, or Xigduo XR within the past 120 DAYS; QL (2 EA per 1 day) DD; ST: Requires prior prescription for Farxiga, INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR Jardiance, Synjardy XR, 150-1,000 MG, 150-500 MG, 50-1,000 MG, 50-500 MG Tier 3 Synjardy, or Xigduo XR (canagliflozin/metformin hcl) within the past 120 DAYS; QL (2 EA per 1 day) DD; ST: Requires prior prescription for Farxiga, SEGLUROMET ORAL TABLET 2.5-1,000 MG, 2.5-500 MG, Jardiance, Synjardy XR, 7.5-1,000 MG, 7.5-500 MG (ertugliflozin Tier 3 Synjardy, or Xigduo XR pidolate/metformin hcl) within the past 120 DAYS; QL (2 EA per 1 day) SYNJARDY ORAL TABLET 12.5-1,000 MG, 12.5-500 MG, Tier 2 DD; QL (2 EA per 1 day) 5-1,000 MG, 5-500 MG (empagliflozin/metformin hcl) SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR Tier 2 DD; QL (1 EA per 1 day) 10-1,000 MG, 25-1,000 MG (empagliflozin/metformin hcl) SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 12.5-1,000 MG, 5-1,000 MG (empagliflozin/metformin Tier 2 DD; QL (2 EA per 1 day) hcl) XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10- 1,000 MG, 10-500 MG, 5-500 MG (dapagliflozin Tier 2 DD; QL (1 EA per 1 day) propanediol/metformin hcl) XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5- 1,000 MG, 5-1,000 MG (dapagliflozin Tier 2 DD; QL (2 EA per 1 day) propanediol/metformin hcl)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 230 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antihyperglycemic - Thiazolidinedione and Sulfonylurea Combinations - Drugs for Diabetes DD; ST: Requires prior prescription for Metformin, preferred Sulfonylurea, or pioglitazone-glimepiride oral tablet 30-2 mg, 30-4 mg Tier 1 preferred Metformin/Sulfonylurea combination within the past 120 days Antihyperglycemic, Amylin Analog-Type - Drugs for Diabetes SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR Tier 2 DD 2,700 MCG/2.7 ML (pramlintide acetate) SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1,500 Tier 2 DD MCG/1.5 ML (pramlintide acetate) Antihyperglycemic, Incretin Mimetic,GLP-1 Receptor Agonist Analog-Type - Drugs for Diabetes DD; ST: Requires prior prescription for Bydureon Bcise, Bydureon Pen, ADLYXIN SUBCUTANEOUS PEN INJECTOR 10 MCG/0.2 Bydureon, Byetta, Tier 3 ML- 20 MCG/0.2 ML, 20 MCG/0.2 ML (lixisenatide) Ozempic, Rybelsus, Trulicity, or Victoza within the past 120 days; QL (6 ML per 28 days) BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR DD; QL (0.85 ML per 7 Tier 2 2 MG/0.85 ML (exenatide microspheres) days) BYDUREON SUBCUTANEOUS PEN INJECTOR 2 Tier 2 DD; QL (1 EA per 7 days) MG/0.65 ML (exenatide microspheres) BYETTA SUBCUTANEOUS PEN INJECTOR 10 DD; QL (2.4 ML per 30 Tier 2 MCG/DOSE(250 MCG/ML) 2.4 ML (exenatide) days) BYETTA SUBCUTANEOUS PEN INJECTOR 5 DD; QL (1.2 ML per 30 Tier 2 MCG/DOSE (250 MCG/ML) 1.2 ML (exenatide) days) OZEMPIC SUBCUTANEOUS PEN INJECTOR 0.25 MG DD; QL (1.5 ML per 28 Tier 2 OR 0.5 MG(2 MG/1.5 ML) (semaglutide) days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 232 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Janumet JENTADUETO ORAL TABLET 2.5-1,000 MG, 2.5-500 MG, Tier 3 XR, Janumet, or Januvia 2.5-850 MG (linagliptin/metformin hcl) within the past 120 days; QL (2 EA per 1 day) DD; ST: Requires prior prescription for Janumet JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC Tier 3 XR, Janumet, or Januvia 24HR 2.5-1,000 MG (linagliptin/metformin hcl) within the past 120 days; QL (2 EA per 1 day) DD; ST: Requires prior prescription for Janumet JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC Tier 3 XR, Janumet, or Januvia 24HR 5-1,000 MG (linagliptin/metformin hcl) within the past 120 days; QL (1 EA per 1 day) DD; ST: Requires prior prescription for Janumet KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 Tier 3 XR, Janumet, or Januvia HR 2.5-1,000 MG (saxagliptin hcl/metformin hcl) within the past 120 days; QL (2 EA per 1 day) DD; ST: Requires prior KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 prescription for Janumet HR 5-1,000 MG, 5-500 MG (saxagliptin hcl/metformin Tier 3 XR, Janumet, or Januvia hcl) within the past 120 days; QL (1 EA per 1 day)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 233 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antihyperglycemic-Insulin, Long Acting and GLP-1 Receptor Agonist Comb - Drugs for Diabetes DD; ST: Requires prior prescriptions for Bydureon Bcise, Bydureon Pen, Bydureon, Byetta, Lantus Solostar, Lantus, Levemir Flextouch, Levemir, SOLIQUA 100/33 SUBCUTANEOUS INSULIN PEN 100 Ozempic, Rybelsus, Toujeo UNIT-33 MCG/ML (insulin glargine,human recombinant Tier 2 Max Solostar, Toujeo analog/lixisenatide) Solostar, Tresiba Flextouch U-100, Tresiba Flextouch U-200, Tresiba, Trulicity, or Victoza within the past 120 days; QL (30 ML per 28 days) DD; ST: Requires prior prescriptions for Bydureon Bcise, Bydureon Pen, Bydureon, Byetta, Lantus Solostar, Lantus, Levemir Flextouch, Levemir, XULTOPHY 100/3.6 SUBCUTANEOUS INSULIN PEN 100 Ozempic, Rybelsus, Toujeo Tier 2 UNIT-3.6 MG /ML (3 ML) (insulin degludec/liraglutide) Max Solostar, Toujeo Solostar, Tresiba Flextouch U-100, Tresiba Flextouch U-200, Tresiba, Trulicity, or Victoza within the past 120 days; QL (15 ML per 28 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 237 Coverage Prescription Drug Name Drug Tier Requirements and Limits estrogens-methyltestosterone oral tablet 0.625-1.25 mg, Tier 1 1.25-2.5 mg Estrogen-Progestin - Drugs for Women estradiol/norethindrone acetate (Amabelz Oral Tablet Tier 1 0.5-0.1 Mg, 1-0.5 Mg) BIJUVA ORAL CAPSULE 1-100 MG Tier 3 (estradiol/progesterone) CLIMARA PRO TRANSDERMAL PATCH WEEKLY 0.045- Tier 3 QL (1 EA per 7 days) 0.015 MG/24 HR (estradiol/levonorgestrel) COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY 0.05-0.14 MG/24 HR, 0.05-0.25 MG/24 HR Tier 2 QL (2 EA per 7 days) (estradiol/norethindrone acetate) estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 Tier 1 mg norethindrone acetate-ethinyl estradiol (Fyavolv Oral Tier 1 Tablet 0.5-2.5 Mg-Mcg, 1-5 Mg-Mcg) norethindrone acetate-ethinyl estradiol (Jinteli Oral Tier 1 Tablet 1-5 Mg-Mcg) estradiol/norethindrone acetate (Mimvey Oral Tablet 1- Tier 1 0.5 Mg) norethindrone ac-eth estradiol oral tablet 0.5-2.5 mg- Tier 1 mcg, 1-5 mg-mcg PREFEST ORAL TABLET 1 MG (15)/1 MG- 0.09 MG (15) Tier 3 (estradiol/norgestimate) PREMPHASE ORAL TABLET 0.625 MG (14)/ 0.625MG- 5MG(14) (estrogens, conjugated/medroxyprogesterone Tier 2 acetate) PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG (estrogens, Tier 2 conjugated/medroxyprogesterone acetate) Estrogens - Drugs for Women ALORA TRANSDERMAL PATCH SEMIWEEKLY 0.025 MG/24 HR, 0.05 MG/24 HR, 0.075 MG/24 HR, 0.1 MG/24 Tier 2 QL (2 EA per 7 days) HR (estradiol) DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML Tier 3 (estradiol valerate)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 238 Coverage Prescription Drug Name Drug Tier Requirements and Limits estradiol cypionate (Depo-Estradiol Intramuscular Oil 5 Tier 3 Mg/Ml) DIVIGEL TRANSDERMAL GEL IN PACKET 0.25 MG/0.25 GRAM (0.1 %), 0.5 MG/0.5 GRAM (0.1 %), 0.75 MG/0.75 Tier 2 GRAM (0.1%), 1 MG/GRAM (0.1 %), 1.25 MG/1.25 GRAM (0.1 %) (estradiol) estradiol (Dotti Transdermal Patch Semiweekly 0.025 Mg/24 Hr, 0.0375 Mg/24 Hr, 0.05 Mg/24 Hr, 0.075 Mg/24 Tier 1 QL (2 EA per 7 days) Hr, 0.1 Mg/24 Hr) ELESTRIN TRANSDERMAL GEL IN METERED-DOSE Tier 3 PUMP 0.87 GRAM/ACTUATION (estradiol) estradiol oral tablet 0.5 mg, 1 mg, 2 mg Tier 1 estradiol transdermal patch semiweekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1 Tier 1 QL (2 EA per 7 days) mg/24 hr estradiol transdermal patch weekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, 0.075 Tier 1 QL (1 EA per 7 days) mg/24 hr, 0.1 mg/24 hr estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml Tier 1 ESTROGEL TRANSDERMAL GEL IN METERED-DOSE Tier 3 PUMP 1.25 GRAM/ACTUATION (estradiol) ST: Requires prior EVAMIST TRANSDERMAL SPRAY,NON-AEROSOL 1.53 prescription for Alora or Tier 3 MG/SPRAY (1.7%) (estradiol) Estradiol within the past 120 days estradiol (Lyllana Transdermal Patch Semiweekly 0.025 Mg/24 Hr, 0.0375 Mg/24 Hr, 0.05 Mg/24 Hr, 0.075 Mg/24 Tier 1 QL (2 EA per 7 days) Hr, 0.1 Mg/24 Hr) estrogens,esterified (Menest Oral Tablet 0.3 Mg, 0.625 Tier 2 Mg, 1.25 Mg) MENEST ORAL TABLET 2.5 MG (estrogens,esterified) Tier 2 MENOSTAR TRANSDERMAL PATCH WEEKLY 14 Tier 3 QL (1 EA per 7 days) MCG/24 HR (estradiol) PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, Tier 2 0.9 MG, 1.25 MG (estrogens, conjugated)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 239 Coverage Prescription Drug Name Drug Tier Requirements and Limits Fertility Enhancer - Luteal Phase Supporting, Progesterone-type - Drugs for Women ST: Requires prior CRINONE VAGINAL GEL 8 % (progesterone, Tier 3 prescription for Endometrin micronized) within the past 120 days ENDOMETRIN VAGINAL INSERT 100 MG (progesterone, Tier 2 micronized) Fertility Enhancer - Ovulation Stimulant - Synthetic (Non-FSH) - Drugs for Women clomiphene citrate oral tablet 50 mg Tier 1 Follicle-Stimulating and Luteinizing Hormones - Drugs for Women MENOPUR SUBCUTANEOUS RECON SOLN 75 UNIT Tier 2 SP (menotropins) Follicle-Stimulating Hormone (FSH) - Drugs for Women BRAVELLE INJECTION RECON SOLN 75 UNIT Tier 3 SP (urofollitropin) SP; ST: Requires prior FOLLISTIM AQ SUBCUTANEOUS CARTRIDGE 300 prescription for Gonal-f Rff, UNIT/0.36 ML, 600 UNIT/0.72 ML, 900 UNIT/1.08 ML Tier 3 Gonal-f Rff Redi-ject, or (follitropin beta,recombinant) Gonal-f within the past 120 days GONAL-F RFF REDI-JECT SUBCUTANEOUS PEN INJECTOR 300/0.5 UNIT/ML, 450/0.75 UNIT/ML, 900/1.5 Tier 2 SP UNIT/ML (follitropin alfa, recombinant) GONAL-F RFF SUBCUTANEOUS RECON SOLN 75 UNIT Tier 2 SP (follitropin alfa, recombinant) GONAL-F SUBCUTANEOUS RECON SOLN 1,050 UNIT, Tier 2 SP 450 UNIT (follitropin alfa, recombinant) Glucocorticoid Salt Combinations - Drugs for Inflammation BETALOAN SUIK KIT 6 MG/ML (betamethasone acetate Tier 3 and sodium phosph/norflurane/hfc 245fa) POD-CARE 100CG KIT 6 MG/ML (betamethasone acetate Tier 3 and sodium phosph/norflurane/hfc 245fa)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 240 Coverage Prescription Drug Name Drug Tier Requirements and Limits Glucocorticoids - Drugs for Inflammation hydrocortisone sod succinate (A-Hydrocort Injection Tier 1 Recon Soln 100 Mg) ALKINDI SPRINKLE ORAL CAPSULE, SPRINKLE 0.5 MG, Tier 3 PA; SP 1 MG, 2 MG, 5 MG (hydrocortisone) cortisone oral tablet 25 mg Tier 1 dexamethasone (Decadron Oral Tablet 0.5 Mg, 0.75 Mg, 4 Tier 1 Mg, 6 Mg) ST: Requires prior prescription for generic dexamethasone (Dexabliss Oral Tablets,Dose Pack 1.5 Tier 1 Dexamethasone 1.5mg Mg (39 Tabs)) tablets within the past 120 days DEXAMETHASONE INTENSOL ORAL DROPS 1 MG/ML Tier 3 (dexamethasone) dexamethasone oral elixir 0.5 mg/5 ml Tier 1 dexamethasone oral solution 0.5 mg/5 ml Tier 1 dexamethasone oral tablet 0.5 mg, 0.75 mg, 1.5 mg, 4 Tier 1 mg, 6 mg dexamethasone oral tablet 1 mg, 2 mg Tier 1 ST: Requires prior prescription for generic dexamethasone oral tablets,dose pack 1.5 mg (21 tabs), Tier 1 Dexamethasone 1.5mg 1.5 mg (35 tabs), 1.5 mg (51 tabs) tablets within the past 120 days DEXONTO IONTOPHORETIC SOLUTION 0.4 % Tier 3 (dexamethasone sodium phosphate) DMT SUIK KIT 10 MG/ML (dexamethasone/pf/norflurane/pentafluoropropane (hfc Tier 3 245fa)) ST: Requires prior prescription for generic dexamethasone (Dxevo Oral Tablets,Dose Pack 1.5 Mg Tier 3 Dexamethasone 1.5mg (39 Tabs)) tablets within the past 120 days EMFLAZA ORAL SUSPENSION 22.75 MG/ML Tier 3 PA; SP (deflazacort)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 242 Coverage Prescription Drug Name Drug Tier Requirements and Limits prednisolone sodium phosphate oral Tier 1 tablet,disintegrating 10 mg, 15 mg, 30 mg PREDNISONE INTENSOL ORAL CONCENTRATE 5 Tier 2 MG/ML (prednisone) prednisone oral solution 5 mg/5 ml Tier 1 prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 Tier 1 mg, 50 mg prednisone oral tablets,dose pack 10 mg, 5 mg Tier 1 RAYOS ORAL TABLET,DELAYED RELEASE (DR/EC) 1 Tier 3 PA MG, 2 MG, 5 MG (prednisone) SOLU-CORTEF ACT-O-VIAL (PF) INJECTION RECON SOLN 100 MG/2 ML (hydrocortisone sodium Tier 3 succinate/pf) SOLU-CORTEF INJECTION RECON SOLN 100 MG Tier 3 (hydrocortisone sod succinate) ST: Requires prior prescription for generic dexamethasone (Taperdex Oral Tablets,Dose Pack 1.5 Mg Tier 1 Dexamethasone 1.5mg (21 Tabs), 1.5 Mg (49 Tabs)) tablets within the past 120 days ST: Requires prior prescription for generic TAPERDEX ORAL TABLETS,DOSE PACK 1.5 MG (27 Tier 1 Dexamethasone 1.5mg TABS) (dexamethasone) tablets within the past 120 days TRILOAN II SUIK KIT 40 MG/ML (triamcinolone/norflurane and pentafluoropropane (hfc Tier 3 245fa)) TRILOAN SUIK KIT 40 MG/ML (triamcinolone/norflurane Tier 3 and pentafluoropropane (hfc 245fa)) ST: Requires prior prescription for generic ZCORT ORAL TABLETS,DOSE PACK 1.5 MG (25 TABS) Tier 3 Dexamethasone 1.5mg (dexamethasone) tablets within the past 120 days Gonadotropin Inhibitor Pituitary Suppressants - Drugs for Women danazol oral capsule 100 mg, 200 mg, 50 mg Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 243 Coverage Prescription Drug Name Drug Tier Requirements and Limits Growth Hormone Receptor Antagonists - Drugs for Growth SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG, 15 Tier 2 SP MG, 20 MG, 25 MG, 30 MG (pegvisomant) Growth Hormone Releasing Hormones (GHRH) - Drugs for Growth EGRIFTA SV SUBCUTANEOUS RECON SOLN 2 MG Tier 3 PA; SP (tesamorelin acetate) Growth Hormones - Drugs for Growth GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML, 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 Tier 3 PA; SP ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML (somatropin) GENOTROPIN SUBCUTANEOUS CARTRIDGE 12 MG/ML Tier 3 PA; SP (36 UNIT/ML), 5 MG/ML (15 UNIT/ML) (somatropin) HUMATROPE INJECTION CARTRIDGE 12 MG (36 UNIT), Tier 3 PA; SP 24 MG (72 UNIT), 6 MG (18 UNIT) (somatropin) HUMATROPE INJECTION RECON SOLN 5 (15 UNIT) MG Tier 3 PA; SP (somatropin) NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 Tier 2 PA; SP MG/ML), 30 MG/3 ML (10 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) (somatropin) NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR 10 MG/2 ML (5 MG/ML), 20 MG/2 ML (10 Tier 3 PA; SP MG/ML), 5 MG/2 ML (2.5 MG/ML) (somatropin) OMNITROPE SUBCUTANEOUS CARTRIDGE 10 MG/1.5 Tier 3 PA; SP ML (6.7 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) (somatropin) OMNITROPE SUBCUTANEOUS RECON SOLN 5.8 MG Tier 3 PA; SP (somatropin) SAIZEN SAIZENPREP SUBCUTANEOUS CARTRIDGE Tier 3 PA; SP 8.8 MG/1.51 ML (FINAL CONC.) (somatropin) SAIZEN SUBCUTANEOUS RECON SOLN 5 MG, 8.8 MG Tier 3 PA; SP (somatropin) SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 Tier 3 PA; SP MG, 6 MG (somatropin)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 245 Coverage Prescription Drug Name Drug Tier Requirements and Limits Human Insulins - Intermediate Acting - Drugs for Diabetes HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS DD; QL (30 ML per 28 INSULIN PEN 100 UNIT/ML (3 ML) (insulin nph human Tier 2 days) isophane) HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS DD; QL (40 ML per 28 SUSPENSION 100 UNIT/ML (insulin nph human Tier 2 days) isophane) DD; ST: Requires prior NOVOLIN N FLEXPEN SUBCUTANEOUS INSULIN PEN prescription for Humulin N Tier 3 100 UNIT/ML (3 ML) (insulin nph human isophane) within the past 120 days; QL (30 ML per 28 days) DD; ST: Requires prior NOVOLIN N NPH U-100 INSULIN SUBCUTANEOUS prescription for Humulin N SUSPENSION 100 UNIT/ML (insulin nph human Tier 3 within the past 120 days; isophane) QL (40 ML per 28 days) Human Insulins - Rapid Acting - Drugs for Diabetes AFREZZA INHALATION CARTRIDGE WITH INHALER 12 UNIT, 4 UNIT, 4 UNIT (90)/ 8 UNIT (90), 4 UNIT/8 UNIT/ 12 Tier 3 PA; DD UNIT (60), 8 UNIT, 8 UNIT (90)/ 12 UNIT (90) (insulin regular, human) Human Insulins - Short Acting - Drugs for Diabetes AFREZZA INHALATION CARTRIDGE WITH INHALER 12 UNIT, 4 UNIT, 4 UNIT (90)/ 8 UNIT (90), 4 UNIT/8 UNIT/ 12 Tier 3 PA; DD UNIT (60), 8 UNIT (insulin regular, human) HUMULIN R REGULAR U-100 INSULN INJECTION DD; QL (40 ML per 28 Tier 2 SOLUTION 100 UNIT/ML (insulin regular, human) days) HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS DD; QL (40 ML per 28 Tier 2 SOLUTION 500 UNIT/ML (insulin regular, human) days) HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS DD; QL (24 ML per 28 INSULIN PEN 500 UNIT/ML (3 ML) (insulin regular, Tier 2 days) human) DD; ST: Requires prior NOVOLIN R FLEXPEN SUBCUTANEOUS INSULIN PEN prescription for Humulin R Tier 3 100 UNIT/ML (3 ML) (insulin regular, human) within the past 120 days; QL (30 ML per 28 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 247 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Humalog NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS Mix 75-25 or Humalog Mix INSULIN PEN 100 UNIT/ML (70-30) (insulin aspart Tier 3 75-25 Kwikpen within the protamine human/insulin aspart) past 120 days; QL (30 ML per 28 days) Insulin Analogs - Long Acting - Drugs for Diabetes DD; ST: Requires prior prescription for Lantus Solostar, Lantus, Levemir Flexpen, Levemir BASAGLAR KWIKPEN U-100 INSULIN SUBCUTANEOUS Flextouch, Levemir, Toujeo INSULIN PEN 100 UNIT/ML (3 ML) (insulin Tier 3 Max Solostar, Toujeo glargine,human recombinant analog) Solostar, Tresiba Flextouch U-100, or Tresiba Flextouch U-200 within the past 120 days; QL (30 ML per 28 days) LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS DD; QL (30 ML per 28 INSULIN PEN 100 UNIT/ML (3 ML) (insulin Tier 2 days) glargine,human recombinant analog) LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION DD; QL (40 ML per 28 100 UNIT/ML (insulin glargine,human recombinant Tier 2 days) analog) LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS DD; QL (30 ML per 28 Tier 2 INSULIN PEN 100 UNIT/ML (3 ML) (insulin detemir) days) LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION DD; QL (40 ML per 28 Tier 2 100 UNIT/ML (insulin detemir) days) DD; ST: Requires prior prescription for Lantus Solostar, Lantus, Levemir Flexpen, Levemir SEMGLEE PEN U-100 INSULIN SUBCUTANEOUS Flextouch, Levemir, Toujeo INSULIN PEN 100 UNIT/ML (3 ML) (insulin Tier 3 Max Solostar, Toujeo glargine,human recombinant analog) Solostar, Tresiba Flextouch U-100, or Tresiba Flextouch U-200 within the past 120 days; QL (30 ML per 28 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 249 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Humalog Junior Kwikpen, Humalog Kwikpen U-200, Humalog, ADMELOG U-100 INSULIN LISPRO SUBCUTANEOUS Tier 3 Insulin Lispro, Lyumjev SOLUTION 100 UNIT/ML (insulin lispro) Kwikpen U-100, Lyumjev Kwikpen U-200, or Lyumjev within the past 120 days; QL (40 ML per 28 days) DD; ST: Requires prior prescription for Humalog Junior Kwikpen, Humalog Kwikpen U-200, Humalog, APIDRA SOLOSTAR U-100 INSULIN SUBCUTANEOUS Tier 3 Insulin Lispro, Lyumjev INSULIN PEN 100 UNIT/ML (insulin glulisine) Kwikpen U-100, Lyumjev Kwikpen U-200, or Lyumjev within the past 120 days; QL (30 ML per 28 days) DD; ST: Requires prior prescription for Humalog Junior Kwikpen, Humalog Kwikpen U-200, Humalog, APIDRA U-100 INSULIN SUBCUTANEOUS SOLUTION Tier 3 Insulin Lispro, Lyumjev 100 UNIT/ML (insulin glulisine) Kwikpen U-100, Lyumjev Kwikpen U-200, or Lyumjev within the past 120 days; QL (40 ML per 28 days) DD; ST: Requires prior prescription for Humalog Junior Kwikpen, Humalog FIASP FLEXTOUCH U-100 INSULIN SUBCUTANEOUS Kwikpen U-200, Humalog, INSULIN PEN 100 UNIT/ML (3 ML) (insulin aspart Tier 3 Insulin Lispro, Lyumjev (niacinamide)) Kwikpen U-100, Lyumjev Kwikpen U-200, or Lyumjev within the past 120 days; QL (30 ML per 28 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 250 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Humalog Junior Kwikpen, Humalog FIASP PENFILL U-100 INSULIN SUBCUTANEOUS Kwikpen U-200, Humalog, CARTRIDGE 100 UNIT/ML (3 ML) (insulin aspart Tier 3 Insulin Lispro, Lyumjev (niacinamide)) Kwikpen U-100, Lyumjev Kwikpen U-200, or Lyumjev within the past 120 days; QL (30 ML per 28 days) DD; ST: Requires prior prescription for Humalog Junior Kwikpen, Humalog Kwikpen U-200, Humalog, FIASP U-100 INSULIN SUBCUTANEOUS SOLUTION 100 Tier 3 Insulin Lispro, Lyumjev UNIT/ML (insulin aspart (niacinamide)) Kwikpen U-100, Lyumjev Kwikpen U-200, or Lyumjev within the past 120 days; QL (40 ML per 28 days) HUMALOG JUNIOR KWIKPEN U-100 SUBCUTANEOUS DD; QL (30 ML per 28 Tier 2 INSULIN PEN, HALF-UNIT 100 UNIT/ML (insulin lispro) days) HUMALOG KWIKPEN INSULIN SUBCUTANEOUS DD; QL (30 ML per 28 Tier 1 INSULIN PEN 100 UNIT/ML (insulin lispro) days) HUMALOG KWIKPEN INSULIN SUBCUTANEOUS DD; QL (12 ML per 28 Tier 2 INSULIN PEN 200 UNIT/ML (3 ML) (insulin lispro) days) HUMALOG U-100 INSULIN SUBCUTANEOUS DD; QL (30 ML per 28 Tier 2 CARTRIDGE 100 UNIT/ML (insulin lispro) days) HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION DD; QL (40 ML per 28 Tier 1 100 UNIT/ML (insulin lispro) days) DD; ST: Requires prior prescription for Humalog Junior Kwikpen, Humalog Kwikpen U-200, Humalog, insulin aspart u-100 subcutaneous cartridge 100 unit/ml Tier 3 Insulin Lispro, Lyumjev Kwikpen U-100, Lyumjev Kwikpen U-200, or Lyumjev within the past 120 days; QL (30 ML per 28 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 251 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Humalog Junior Kwikpen, Humalog Kwikpen U-200, Humalog, insulin aspart u-100 subcutaneous insulin pen 100 Tier 3 Insulin Lispro, Lyumjev unit/ml (3 ml) Kwikpen U-100, Lyumjev Kwikpen U-200, or Lyumjev within the past 120 days; QL (30 ML per 28 days) DD; ST: Requires prior prescription for Humalog Junior Kwikpen, Humalog Kwikpen U-200, Humalog, insulin aspart u-100 subcutaneous solution 100 unit/ml Tier 3 Insulin Lispro, Lyumjev Kwikpen U-100, Lyumjev Kwikpen U-200, or Lyumjev within the past 120 days; QL (40 ML per 28 days) LYUMJEV KWIKPEN U-100 INSULIN SUBCUTANEOUS DD; QL (30 ML per 28 Tier 2 INSULIN PEN 100 UNIT/ML (insulin lispro-aabc) days) LYUMJEV KWIKPEN U-200 INSULIN SUBCUTANEOUS DD; QL (12 ML per 28 Tier 2 INSULIN PEN 200 UNIT/ML (3 ML) (insulin lispro-aabc) days) LYUMJEV U-100 INSULIN SUBCUTANEOUS SOLUTION DD; QL (40 ML per 28 Tier 2 100 UNIT/ML (insulin lispro-aabc) days) DD; ST: Requires prior prescription for Humalog Junior Kwikpen, Humalog Kwikpen U-200, Humalog, NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS Tier 3 Insulin Lispro, Lyumjev INSULIN PEN 100 UNIT/ML (3 ML) (insulin aspart) Kwikpen U-100, Lyumjev Kwikpen U-200, or Lyumjev within the past 120 days; QL (30 ML per 28 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 255 Coverage Prescription Drug Name Drug Tier Requirements and Limits Oxytocic - Ergot Alkaloids - Drugs for Women methylergonovine oral tablet 0.2 mg Tier 1 QL (28 EA per 30 days) Parathyroid Hormones - Drugs for Menopause and Bone Loss NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 Tier 3 PA; SP MCG/DOSE (parathyroid hormone) Progestins - Drugs for Women medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5 mg Tier 1 norethindrone acetate oral tablet 5 mg Tier 1 progesterone intramuscular oil 50 mg/ml Tier 1 progesterone micronized oral capsule 100 mg, 200 mg Tier 1 Prolactin Inhibitor - Ergot Derivative Dopamine Receptor Agonists - Drugs for Women cabergoline oral tablet 0.5 mg Tier 1 Selective Estrogen Receptor Modulators (SERMs) - Drugs for Menopause and Bone Loss raloxifene oral tablet 60 mg $0 EHB; QL (1 EA per 1 day) Somatostatic Agents - Drugs for Growth BYNFEZIA SUBCUTANEOUS PEN INJECTOR 2,500 Tier 3 PA; SP MCG/ML (octreotide acetate) MYCAPSSA ORAL CAPSULE,DELAYED Tier 3 PA; SP RELEASE(DR/EC) 20 MG (octreotide acetate) octreotide acetate injection solution 1,000 mcg/ml, 100 Tier 1 SP mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml octreotide acetate injection syringe 100 mcg/ml (1 ml), Tier 1 SP 50 mcg/ml (1 ml), 500 mcg/ml (1 ml) SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML) (pasireotide Tier 3 PA; SP diaspartate) Thyroid Hormone Combinations - Synthetic T3 and T4 - Drugs for Thyroid THYROLAR-1 ORAL TABLET 12.5-50 MCG (liotrix) Tier 3

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 262 Coverage Prescription Drug Name Drug Tier Requirements and Limits Colonic Acidifier (Ammonia Inhibitor) - Drugs for the Stomach lactulose (Enulose Oral Solution 10 Gram/15 Ml) Tier 1 lactulose (Generlac Oral Solution 10 Gram/15 Ml) Tier 1 lactulose oral solution 10 gram/15 ml (15 ml) Tier 1 Digestive Enzyme Mixtures - Drugs for the Stomach CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000 -60,000 UNIT, 24,000-76,000 -120,000 UNIT, 3,000-9,500- 15,000 UNIT, 36,000-114,000- 180,000 Tier 2 UNIT, 6,000-19,000 -30,000 UNIT (lipase/protease/amylase) PANCREAZE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,500-35,500- 61,500 UNIT, 16,800- 56,800- 98,400 UNIT, 2,600-6,200- 10,850 UNIT, 21,000- Tier 3 54,700- 83,900 UNIT, 4,200-14,200- 24,600 UNIT (lipase/protease/amylase) PERTZYE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 16,000-57,500- 60,500 UNIT, 24,000-86,250- 90,750 UNIT, Tier 3 4,000-14,375- 15,125 UNIT, 8,000-28,750- 30,250 UNIT (lipase/protease/amylase) VIOKACE ORAL TABLET 10,440-39,150- 39,150 UNIT, Tier 3 20,880-78,300- 78,300 UNIT (lipase/protease/amylase) ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT, 15,000-47,000 -63,000 UNIT, 20,000-63,000- 84,000 UNIT, 25,000-79,000- 105,000 Tier 2 UNIT, 3,000-10,000 -14,000-UNIT, 40,000-126,000- 168,000 UNIT, 5,000-17,000- 24,000 UNIT (lipase/protease/amylase) Digestive Enzymes - Drugs for the Stomach SUCRAID ORAL SOLUTION 8,500 UNIT/ML Tier 3 PA; SP (sacrosidase) Gallstone Solubilizing (Litholysis) Agents - Drugs for the Stomach chenodiol (Chenodal Oral Tablet 250 Mg) Tier 3 PA; SP ursodiol oral capsule 300 mg Tier 1 ursodiol oral tablet 250 mg, 500 mg Tier 1 PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 263 Coverage Prescription Drug Name Drug Tier Requirements and Limits Gastric Acid Secretion Reducers - Histamine H2-Receptor Antagonists - Drugs for Ulcers and Stomach Acid cimetidine hcl oral solution 300 mg/5 ml Tier 1 cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg Tier 1 famotidine oral suspension 40 mg/5 ml (8 mg/ml) Tier 1 famotidine oral tablet 20 mg, 40 mg Tier 1 nizatidine oral capsule 150 mg, 300 mg Tier 1 nizatidine oral solution 150 mg/10 ml Tier 1 Gastric Acid Secretion Reducing Agents - Proton Pump Inhibitors (PPIs) - Drugs for Ulcers and Stomach Acid ST: At least 2 prior prescriptions for Lansoprazole, ACIPHEX SPRINKLE ORAL CAPSULE, DELAYED REL Tier 3 Omeprazole, Pantoprazole SPRINKLE 10 MG, 5 MG (rabeprazole sodium) Sodium, or Protonix within the past 365 days; QL (1 EA per 1 day) ST: Requires prior prescription for Lansoprazole, DEXILANT ORAL CAPSULE,BIPHASE DELAYED RELEAS Omeprazole, Pantoprazole Tier 2 30 MG, 60 MG (dexlansoprazole) Sodium, Prilosec OTC, or Protonix within the past 120 days; QL (1 EA per 1 day) ESOMEP-EZS ORAL KIT, CAP DR AND SPRAY 20 MG Tier 3 (esomeprazole magnesium/glycerin) esomeprazole magnesium oral capsule,delayed Tier 1 QL (1 EA per 1 day) release(dr/ec) 20 mg esomeprazole magnesium oral capsule,delayed Tier 1 QL (2 EA per 1 day) release(dr/ec) 40 mg esomeprazole magnesium oral granules dr for susp in Tier 1 QL (1 EA per 1 day) packet 10 mg, 20 mg esomeprazole magnesium oral granules dr for susp in Tier 1 QL (2 EA per 1 day) packet 40 mg

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 266 Coverage Prescription Drug Name Drug Tier Requirements and Limits Gastrointestinal Prokinetic Agents - D2 Antagonist/5-HT4 Agonists - Drugs for the Stomach GIMOTI NASAL SPRAY WITH PUMP 15 MG/SPRAY Tier 3 PA; SP (metoclopramide hcl) metoclopramide hcl oral solution 5 mg/5 ml Tier 1 metoclopramide hcl oral tablet 10 mg, 5 mg Tier 1 metoclopramide hcl oral tablet,disintegrating 10 mg, 5 Tier 1 mg GI Antispasmodic - Belladonna Alkaloids - Drugs for Stomach Cramps ED-SPAZ ORAL TABLET,DISINTEGRATING 0.125 MG Tier 1 (hyoscyamine sulfate) hyoscyamine sulfate oral drops 0.125 mg/ml Tier 1 hyoscyamine sulfate oral elixir 0.125 mg/5 ml Tier 1 hyoscyamine sulfate oral tablet 0.125 mg Tier 1 hyoscyamine sulfate oral tablet extended release 12 hr Tier 1 0.375 mg hyoscyamine sulfate oral tablet,disintegrating 0.125 mg Tier 1 hyoscyamine sulfate sublingual tablet 0.125 mg Tier 1 HYOSYNE ORAL DROPS 0.125 MG/ML (hyoscyamine Tier 1 sulfate) HYOSYNE ORAL ELIXIR 0.125 MG/5 ML (hyoscyamine Tier 1 sulfate) methscopolamine oral tablet 2.5 mg, 5 mg Tier 1 OSCIMIN ORAL TABLET 0.125 MG (hyoscyamine Tier 1 sulfate) OSCIMIN SL SUBLINGUAL TABLET 0.125 MG Tier 1 (hyoscyamine sulfate) OSCIMIN SR ORAL TABLET EXTENDED RELEASE 12 Tier 1 HR 0.375 MG (hyoscyamine sulfate) SYMAX DUOTAB ORAL TABLET,EXT RELEASE MULTIPHASE 0.125 MG-0.25 MG (0.375 MG) Tier 3 (hyoscyamine sulfate)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 269 Coverage Prescription Drug Name Drug Tier Requirements and Limits IBS Agent - Gastrointestinal Chloride Channel Activator Agents - Drugs for Irritable Bowel Syndrome ST: Requires prior prescription for Linzess or AMITIZA ORAL CAPSULE 24 MCG, 8 MCG (lubiprostone) Tier 3 Movantik within the past 120 days; QL (2 EA per 1 day) IBS Agent - Guanylate Cyclase-C (GC-C) Agonists - Drugs for Irritable Bowel Syndrome ST: Requires prior prescription for Linzess TRULANCE ORAL TABLET 3 MG (plecanatide) Tier 3 within the past 120 days; QL (1 EA per 1 day) IBS Agent - Selective Partial 5-HT4 Receptor Agonists - Drugs for Irritable Bowel Syndrome ST: Requires prior prescription for Linzess ZELNORM ORAL TABLET 6 MG (tegaserod hydrogen Tier 3 within the past 120 days; maleate) QL (2 EA per 1 day); Age (Max 64 Years) Inflammatory Bowel Agent - Interleukin-12 and IL-23 Inhibitors, MC Ab - Drugs for Inflammatory Bowel Disease STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5 ML Tier 2 PA; SP (ustekinumab) STELARA SUBCUTANEOUS SYRINGE 90 MG/ML Tier 2 PA; SP (ustekinumab) Inflammatory Bowel Agent - Aminosalicylates and Related Agents - Drugs for Inflammatory Bowel Disease balsalazide oral capsule 750 mg Tier 1 ST: Requires prior prescription for Balsalazide DIPENTUM ORAL CAPSULE 250 MG (olsalazine sodium) Tier 3 Disodium, Mesalamine, or Pentasa within the past 120 days

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 271 Coverage Prescription Drug Name Drug Tier Requirements and Limits Inflammatory Bowel Agent - Janus Kinase (JAK) Inhibitors - Drugs for Inflammatory Bowel Disease XELJANZ ORAL TABLET 10 MG, 5 MG (tofacitinib Tier 2 PA; SP citrate) XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 Tier 2 PA; SP HR 22 MG (tofacitinib citrate) Inflammatory Bowel Agent - Tumor Necrosis Factor Alpha Blockers - Drugs for Inflammatory Bowel Disease CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT Tier 3 PA; SP 400 MG (200 MG X 2 VIALS) (certolizumab pegol) CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT Tier 3 PA; SP 400 MG/2 ML (200 MG/ML X 2) (certolizumab pegol) CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML Tier 3 PA; SP (200 MG/ML X 2) (certolizumab pegol) HUMIRA PEN CROHNS-UC-HS START SUBCUTANEOUS Tier 2 PA; SP PEN INJECTOR KIT 40 MG/0.8 ML (adalimumab) HUMIRA PEN PSOR-UVEITS-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML Tier 2 PA; SP (adalimumab) HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 Tier 2 PA; SP MG/0.8 ML (adalimumab) HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, Tier 2 PA; SP 20 MG/0.4 ML, 40 MG/0.8 ML (adalimumab) HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML, 80 Tier 2 PA; SP MG/0.8 ML-40 MG/0.4 ML (adalimumab) HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS Tier 2 PA; SP PEN INJECTOR KIT 80 MG/0.8 ML (adalimumab) HUMIRA(CF) PEN PSOR-UV-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML-40 MG/0.4 ML Tier 2 PA; SP (adalimumab) HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT Tier 2 PA; SP 40 MG/0.4 ML, 80 MG/0.8 ML (adalimumab) HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 Tier 2 PA; SP ML, 20 MG/0.2 ML, 40 MG/0.4 ML (adalimumab)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 274 Coverage Prescription Drug Name Drug Tier Requirements and Limits Laxative - Stimulant and Saline/Osmotic Combinations - Drugs to Prevent Constipation CLENPIQ ORAL SOLUTION 10 MG-3.5 GRAM -12 $0 COPAY IF AGE 50-75 GRAM/160 ML (sodium picosulfate/magnesium Tier 2 YEARS; EHB oxide/citric acid) PEG-PREP ORAL KIT 5-210 MG-GRAM $0 COPAY IF AGE 50-75 (bisacodyl/sodium chlor/sodium bicarb/potassium Tier 1 YEARS; EHB chl/peg 3350) Peptic Ulcer - Gastric Lumen Adherent Cytoprotectives - Drugs for Ulcers and Stomach Acid sucralfate oral suspension 100 mg/ml Tier 1 sucralfate oral tablet 1 gram Tier 1 Peptic Ulcer - Treatment of H. Pylori: Antibiotic- Bismuth Combinations - Drugs for Ulcers and Stomach Acid HELIDAC ORAL COMBO PACK 250-500-262.4 MG Tier 3 (bismuth subsalicylate/metronidazole/tetracycline hcl) PYLERA ORAL CAPSULE 140-125-125 MG (colloidal Tier 3 bismuth subcitrate/metronidazole/tetracycline hcl) Peptic Ulcer-Treatment H. Pylori-Proton Pump Inhibitor and Antibiotics - Drugs for Ulcers and Stomach Acid amoxicil-clarithromy-lansopraz oral combo pack 500- Tier 1 QL (112 EA per 10 days) 500-30 mg OMECLAMOX-PAK ORAL COMBO PACK 20 MG-500 MG- 500 MG (40) (omeprazole/clarithromycin/amoxicillin Tier 3 trihydrate) TALICIA ORAL CAPSULE,IR - DELAY REL,BIPHASE 10- QL (168 EA per 14 days); 250-12.5 MG (omeprazole magnesium/amoxicillin Tier 3 Age (Min 18 Years) trihydrate/rifabutin) Short Bowel Syndrome (SBS) - glucagon-like peptide-2 (GLP-2) Analog - Drugs for the Stomach GATTEX 30-VIAL SUBCUTANEOUS KIT 5 MG Tier 2 PA; SP (teduglutide)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 276 Coverage Prescription Drug Name Drug Tier Requirements and Limits glycine urologic solution irrigation solution 1.5 % Tier 1 RENACIDIN IRRIGATION SOLUTION 1980.6 MG-59.4 MG-980.4MG/30ML (citric Tier 3 acid/gluconolactone/magnesium carbonate) sorbitol irrigation solution 3 %, 3.3 % Tier 1 sorbitol-mannitol transurethral solution 2.7-0.54 Tier 1 gram/100 ml Interstitial Cystitis Agents - Drugs for the Urinary System ELMIRON ORAL CAPSULE 100 MG (pentosan Tier 2 PA polysulfate sodium) Kidney Stone Agents - Drugs for the Urinary System THIOLA EC ORAL TABLET,DELAYED RELEASE (DR/EC) Tier 2 SP 100 MG, 300 MG (tiopronin) THIOLA ORAL TABLET 100 MG (tiopronin) Tier 2 SP Overactive Bladder Agents - Beta -3 Adrenergic Receptor Agonist - Drugs for the Bladder MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 Tier 2 HR 25 MG, 50 MG (mirabegron) Phosphate Binders - Calcium-based - Drugs for the Urinary System PHOSLYRA ORAL SOLUTION 667 MG (169 MG Tier 3 CALCIUM)/5 ML (calcium acetate) Phosphate Binders - Drugs for the Urinary System AURYXIA ORAL TABLET 210 MG IRON (ferric citrate) Tier 3 QL (12 EA per 1 day) calcium acetate(phosphat bind) oral capsule 667 mg Tier 1 calcium acetate(phosphat bind) oral tablet 667 mg Tier 1 FOSRENOL ORAL POWDER IN PACKET 1,000 MG, 750 Tier 3 MG (lanthanum carbonate) lanthanum oral tablet,chewable 1,000 mg, 500 mg, 750 Tier 1 mg PHOSLYRA ORAL SOLUTION 667 MG (169 MG Tier 3 CALCIUM)/5 ML (calcium acetate)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 278 Coverage Prescription Drug Name Drug Tier Requirements and Limits Urinary Acidifier - Bacterial Urease Inhibitor - Drugs for Infections LITHOSTAT ORAL TABLET 250 MG (acetohydroxamic Tier 3 acid) Urinary Acidifier - Phosphates - Drugs for Infections K-PHOS NO 2 ORAL TABLET 305-700 MG (sodium phosphate,monobasic/potassium Tier 3 phosphate,monobasic) K-PHOS ORIGINAL ORAL TABLET,SOLUBLE 500 MG Tier 3 (potassium phosphate,monobasic) Urinary Alkalinizer - Citrates - Drugs for Infections ORACIT ORAL SOLUTION 490-640 MG/5 ML (citric Tier 3 acid/sodium citrate) potassium citrate oral tablet extended release 10 meq Tier 1 (1,080 mg), 15 meq, 5 meq (540 mg) SHOHL'S MODIFIED ORAL SOLUTION 500-300 MG/5 ML Tier 3 (citric acid/sodium citrate) Urinary Analgesics - Drugs for Infections phenazopyridine oral tablet 100 mg, 200 mg Tier 1 Urinary Antibacterial - Methenamine and Salts - Drugs for Infections UROQID-ACID NO.2 ORAL TABLET 500-500 MG (methenamine mandelate/sodium Tier 3 phosphate,monobasic) Urinary Antibacterial - Nitrofuran Derivatives - Drugs for Infections nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg Tier 1 nitrofurantoin macrocrystal oral capsule 25 mg Tier 1 QL (4 EA per 1 day) nitrofurantoin monohyd/m-cryst oral capsule 100 mg Tier 1 nitrofurantoin oral suspension 25 mg/5 ml Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 279 Coverage Prescription Drug Name Drug Tier Requirements and Limits Urinary Antibacterial - Quinolones - Drugs for Infections CIPRO XR ORAL TABLET, ER MULTIPHASE 24 HR 1,000 Tier 3 MG, 500 MG (ciprofloxacin/ciprofloxacin hcl) Urinary Anti-infective Methenamine-Antispas- Analg Combinations - Drugs for Infections URETRON D-S ORAL TABLET 81.6-10.8-40.8 MG (methenamine/methylene blue/sod Tier 2 phos/p.salicylate/hyoscyamine) URIMAR-T ORAL TABLET 120-0.12-10.8 MG (methenamine/methylene blue/salicylate/sodium Tier 1 phos/hyoscyamin) URIN DS ORAL TABLET 81.6-10.8-40.8 MG (methenamine/methylene blue/sod Tier 2 phos/p.salicylate/hyoscyamine) URO-458 ORAL TABLET 81-10.8-40.8 MG (methenamine/methylene blue/sod Tier 1 phos/p.salicylate/hyoscyamine) URO-MP ORAL CAPSULE 118-10-40.8-36 MG (methenamine/methylene blue/sod Tier 1 phos/p.salicylate/hyoscyamine) USTELL ORAL CAPSULE 120-0.12 MG (methenamine/methylene blue/salicylate/sodium Tier 1 phos/hyoscyamin) Urinary Anti-infective Methenamine- Antispasmodic Combinations - Drugs for Infections methen-sod phos-meth blue-hyos oral tablet 81.6-40.8- Tier 1 0.12 mg Urinary Antispasmodic - Antichol., M(3) Muscarinic Selective (Bladder) - Drugs for the Bladder darifenacin oral tablet extended release 24 hr 15 mg, 7.5 Tier 1 mg solifenacin oral tablet 10 mg, 5 mg Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 280 Coverage Prescription Drug Name Drug Tier Requirements and Limits Urinary Antispasmodic - Anticholinergics, Non- Selective - Drugs for the Bladder ED-SPAZ ORAL TABLET,DISINTEGRATING 0.125 MG Tier 1 (hyoscyamine sulfate) HYOSYNE ORAL DROPS 0.125 MG/ML (hyoscyamine Tier 1 sulfate) HYOSYNE ORAL ELIXIR 0.125 MG/5 ML (hyoscyamine Tier 1 sulfate) OSCIMIN ORAL TABLET 0.125 MG (hyoscyamine Tier 1 sulfate) OSCIMIN SL SUBLINGUAL TABLET 0.125 MG Tier 1 (hyoscyamine sulfate) OSCIMIN SR ORAL TABLET EXTENDED RELEASE 12 Tier 1 HR 0.375 MG (hyoscyamine sulfate) SYMAX DUOTAB ORAL TABLET,EXT RELEASE MULTIPHASE 0.125 MG-0.25 MG (0.375 MG) Tier 3 (hyoscyamine sulfate) Urinary Antispasmodic - Smooth Muscle Relaxants - Drugs for the Bladder flavoxate oral tablet 100 mg Tier 1 GELNIQUE TRANSDERMAL GEL IN PACKET 10 % (100 Tier 3 MG/GRAM) (oxybutynin chloride) oxybutynin chloride oral syrup 5 mg/5 ml Tier 1 oxybutynin chloride oral tablet 5 mg Tier 1 oxybutynin chloride oral tablet extended release 24hr Tier 1 10 mg, 15 mg, 5 mg OXYTROL TRANSDERMAL PATCH SEMIWEEKLY 3.9 Tier 3 MG/24 HR (oxybutynin) tolterodine oral capsule,extended release 24hr 2 mg, 4 Tier 1 mg tolterodine oral tablet 1 mg, 2 mg Tier 1 TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR 4 Tier 2 MG, 8 MG (fesoterodine fumarate) trospium oral capsule,extended release 24hr 60 mg Tier 1 trospium oral tablet 20 mg Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 283 Coverage Prescription Drug Name Drug Tier Requirements and Limits Blood Cell and Platelet Disorder Tx-Spleen Tyrosine Kinase Inhibitors - Drugs for the Blood TAVALISSE ORAL TABLET 100 MG, 150 MG Tier 3 PA; SP (fostamatinib disodium) C1 Esterase Inhibitor Agents - Drugs for the Blood BERINERT INTRAVENOUS KIT 500 UNIT (10 ML) (c1 Tier 3 PA; SP esterase inhibitor) BERINERT INTRAVENOUS RECON SOLN 500 UNIT (10 Tier 3 PA; SP ML) (c1 esterase inhibitor) CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML) Tier 3 PA; SP (c1 esterase inhibitor) HAEGARDA SUBCUTANEOUS RECON SOLN 2,000 Tier 3 PA; SP UNIT, 3,000 UNIT (c1 esterase inhibitor) RUCONEST INTRAVENOUS RECON SOLN 2,100 UNIT Tier 3 PA; SP (c1 esterase inhibitor, recombinant) Direct Factor Xa Inhibitors - Drugs to Prevent Blood Clots ELIQUIS DVT-PE TREAT 30D START ORAL Tier 2 QL (74 EA per 30 days) TABLETS,DOSE PACK 5 MG (74 TABS) (apixaban) ELIQUIS ORAL TABLET 2.5 MG (apixaban) Tier 2 QL (2 EA per 1 day) ELIQUIS ORAL TABLET 5 MG (apixaban) Tier 2 QL (74 EA per 30 days) ST: Requires prior prescriptions for Eliquis SAVAYSA ORAL TABLET 15 MG, 30 MG, 60 MG Tier 3 and Xarelto within the past (edoxaban tosylate) 365 days; QL (30 EA per 30 days) XARELTO DVT-PE TREAT 30D START ORAL TABLETS,DOSE PACK 15 MG (42)- 20 MG (9) Tier 2 QL (51 EA per 30 days) (rivaroxaban) XARELTO ORAL TABLET 10 MG, 20 MG (rivaroxaban) Tier 2 QL (1 EA per 1 day) XARELTO ORAL TABLET 15 MG, 2.5 MG (rivaroxaban) Tier 2 QL (2 EA per 1 day)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 288 Coverage Prescription Drug Name Drug Tier Requirements and Limits Factor X Preparations - Drugs to Prevent Bleeding COAGADEX INTRAVENOUS RECON SOLN 250 (+/-) UNIT RANGE, 500 (+/-) UNIT RANGE (coagulation factor Tier 3 SP x) Factor XIII Preparations - Drugs to Prevent Bleeding CORIFACT INTRAVENOUS RECON SOLN 1,000-1,600 Tier 3 SP UNIT (factor xiii) TRETTEN INTRAVENOUS RECON SOLN 2,500 UNIT Tier 3 SP (factor xiii a-subunit, recombinant) Granulocyte Colony-Stimulating Factor (G-CSF) - Drugs for the Blood FULPHILA SUBCUTANEOUS SYRINGE 6 MG/0.6 ML Tier 2 PA; SP (pegfilgrastim-jmdb) GRANIX SUBCUTANEOUS SOLUTION 300 MCG/ML, 480 Tier 2 PA; SP MCG/1.6 ML (tbo-filgrastim) GRANIX SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, Tier 2 PA; SP 480 MCG/0.8 ML (tbo-filgrastim) NEULASTA ONPRO SUBCUTANEOUS SYRINGE, W/ Tier 3 PA; SP WEARABLE INJECTOR 6 MG/0.6 ML (pegfilgrastim) NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6 ML Tier 2 PA; SP (pegfilgrastim) NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 Tier 3 PA; SP MCG/1.6 ML (filgrastim) NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 Tier 3 PA; SP MCG/0.8 ML (filgrastim) NIVESTYM INJECTION SOLUTION 300 MCG/ML, 480 Tier 3 PA; SP MCG/1.6 ML (filgrastim-aafi) NIVESTYM SUBCUTANEOUS SYRINGE 300 MCG/0.5 Tier 3 PA; SP ML, 480 MCG/0.8 ML (filgrastim-aafi) NYVEPRIA SUBCUTANEOUS SYRINGE 6 MG/0.6 ML Tier 3 PA; SP (pegfilgrastim-apgf) UDENYCA SUBCUTANEOUS SYRINGE 6 MG/0.6 ML Tier 3 PA; SP (pegfilgrastim-cbqv) ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 Tier 3 PA; SP MCG/0.8 ML (filgrastim-sndz) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 289 Coverage Prescription Drug Name Drug Tier Requirements and Limits ZIEXTENZO SUBCUTANEOUS SYRINGE 6 MG/0.6 ML Tier 3 PA; SP (pegfilgrastim-bmez) Granulocyte-Macrophage Colony-Stimulating Factor (GM-CSF) - Drugs for the Blood LEUKINE INJECTION RECON SOLN 250 MCG Tier 2 PA; SP (sargramostim) Hematorheologic Agents - Drugs for the Blood pentoxifylline oral tablet extended release 400 mg Tier 1 Hemostatic Systemic - Antifibrinolytic Agents - Drugs to Prevent Bleeding aminocaproic acid oral solution 250 mg/ml (25 %) Tier 1 aminocaproic acid oral tablet 1,000 mg, 500 mg Tier 1 tranexamic acid oral tablet 650 mg Tier 1 Hemostatic Systemic- von Willebrand factor (vWF) Preparations - Drugs to Prevent Bleeding VONVENDI INTRAVENOUS RECON SOLN 1,300 (+/-) UNIT RANGE, 650 (+/-) UNIT RANGE (von willebrand Tier 3 SP factor (recombinant)) Hemostatic Topical Agents - Drugs to Prevent Bleeding ASTRINGYN TOPICAL SOLUTION 259 MG/G (ferric Tier 3 subsulfate) AVITENE FLOUR TOPICAL POWDER (microfibrillar Tier 3 collagen) AVITENE TOPICAL POWDER IN PACKET (microfibrillar Tier 3 collagen) AVITENE TOPICAL SHEET 35 X 35 MM, 70 X 35 MM, 70 Tier 3 X 70 MM (microfibrillar collagen) ENDO AVITENE TOPICAL SHEET 10 MM, 5 MM Tier 3 (microfibrillar collagen) GELFILM IMPLANT FILM (gelatin) Tier 3 GELFOAM JMI POWDER TOPICAL KIT 5,000 UNIT Tier 3 (thrombin (bovine)/gelatin sponge,absorbable) GELFOAM JMI SPONGE TOPICAL COMBO PACK 5,000 Tier 3 UNIT (thrombin (bovine)/gelatin sponge,absorbable)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 292 Coverage Prescription Drug Name Drug Tier Requirements and Limits heparin lock flush (porcine) intravenous syringe 100 Tier 1 unit/ml HEPARIN LOCK FLUSH INTRAVENOUS SYRINGE 10 Tier 1 UNIT/ML (heparin sodium,porcine) HEPARIN LOCK INTRAVENOUS SOLUTION 100 UNIT/ML Tier 1 (heparin sodium,porcine) HEPARIN LOCKFLUSH(PORCINE)(PF) INTRAVENOUS SYRINGE 10 UNIT/ML, 100 UNIT/ML (heparin Tier 1 sodium,porcine/pf) heparin, porcine (pf) injection solution 1,000 unit/ml Tier 1 heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml, Tier 1 5,000 unit/ml heparin, porcine (pf) intravenous solution 100 unit/ml (1 Tier 1 ml) heparin, porcine (pf) intravenous syringe 1 unit/ml Tier 1 heparin, porcine (pf) intravenous syringe 10 unit/ml, 100 Tier 1 unit/ml heparin, porcine (pf) subcutaneous syringe 5,000 Tier 1 unit/0.5 ml Indirect Factor Xa Inhibitors - Drugs to Prevent Blood Clots SP; QL (24 ML per 30 fondaparinux subcutaneous syringe 10 mg/0.8 ml Tier 1 days) SP; QL (15 ML per 30 fondaparinux subcutaneous syringe 2.5 mg/0.5 ml Tier 1 days) SP; QL (12 ML per 30 fondaparinux subcutaneous syringe 5 mg/0.4 ml Tier 1 days) SP; QL (18 ML per 30 fondaparinux subcutaneous syringe 7.5 mg/0.6 ml Tier 1 days) Low Molecular Weight Heparins - Drugs to Prevent Blood Clots SP; QL (30 ML per 30 enoxaparin subcutaneous solution 300 mg/3 ml Tier 1 days) enoxaparin subcutaneous syringe 100 mg/ml, 120 mg/0.8 ml, 150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 Tier 1 SP mg/0.6 ml, 80 mg/0.8 ml

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 297 Coverage Prescription Drug Name Drug Tier Requirements and Limits Immunosuppressive - Inosine Monophosphate Dehydrogenase Inhibitors - Drugs for Organ Transplants mycophenolate mofetil oral capsule 250 mg Tier 1 SP mycophenolate mofetil oral suspension for Tier 1 SP reconstitution 200 mg/ml mycophenolate mofetil oral tablet 500 mg Tier 1 SP mycophenolate sodium oral tablet,delayed release Tier 1 SP (dr/ec) 180 mg, 360 mg Immunosuppressive - Interleukin-6 (IL-6) Receptor Inhibitors - Drugs for Organ Transplants ENSPRYNG SUBCUTANEOUS SYRINGE 120 MG/ML Tier 3 PA; SP (satralizumab-mwge) Immunosuppressive - Mammalian Target of Rapamycin (mTOR) Inhibitors - Drugs for Organ Transplants everolimus (immunosuppressive) oral tablet 0.25 mg, Tier 1 SP 0.5 mg, 0.75 mg RAPAMUNE ORAL SOLUTION 1 MG/ML (sirolimus) Tier 2 SP RAPAMUNE ORAL TABLET 0.5 MG, 1 MG, 2 MG Tier 2 SP (sirolimus) sirolimus oral solution 1 mg/ml Tier 1 SP sirolimus oral tablet 0.5 mg, 1 mg, 2 mg Tier 1 SP ZORTRESS ORAL TABLET 1 MG (everolimus) Tier 2 SP Immunosuppressive - Purine Analogs - Drugs for Organ Transplants AZASAN ORAL TABLET 100 MG, 75 MG (azathioprine) Tier 2 SP azathioprine oral tablet 50 mg Tier 1 SP

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 298 Coverage Prescription Drug Name Drug Tier Requirements and Limits Locomotor System - Drugs for Muscles, Ligaments, Tendons, and Bones Agents to Treat Periodic Paralysis - Carbonic Anhydrase Inhibitors - Drugs for Muscles, Ligaments, Tendons, and Bones KEVEYIS ORAL TABLET 50 MG (dichlorphenamide) Tier 2 PA; SP ALS Agents - Benzathiazoles - Drugs for Nerves and Muscles riluzole oral tablet 50 mg Tier 1 TIGLUTIK ORAL SUSPENSION 50 MG/10 ML (riluzole) Tier 3 PA; SP Antimyasthenic Agent - Reversible Cholinesterase Inhibitors - Drugs for Nerves and Muscles pyridostigmine bromide oral syrup 60 mg/5 ml Tier 1 pyridostigmine bromide oral tablet 30 mg Tier 1 pyridostigmine bromide oral tablet 60 mg Tier 1 pyridostigmine bromide oral tablet extended release Tier 1 180 mg Antimyasthenic Agents Other - Drugs for Nerves and Muscles guanidine oral tablet 125 mg Tier 1 Skeletal Muscle Relaxant - Analgesic Salicylate Combinations - Drugs for Muscles, Ligaments, Tendons, and Bones carisoprodol-aspirin oral tablet 200-325 mg Tier 1 orphenadrine citrate/aspirin/caffeine (Norgesic Forte Oral Tier 3 QL (4 EA per 1 day) Tablet 50-770-60 Mg) orphenadrine-asa-caffeine oral tablet 50-770-60 mg Tier 1 QL (4 EA per 1 day) orphenadrine citrate/aspirin/caffeine (Orphengesic Forte Tier 1 QL (4 EA per 1 day) Oral Tablet 50-770-60 Mg) Skeletal Muscle Relaxant - Central Muscle Relaxants - Drugs for Muscles, Ligaments, Tendons, and Bones baclofen oral tablet 10 mg, 20 mg Tier 1 PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 299 Coverage Prescription Drug Name Drug Tier Requirements and Limits baclofen oral tablet 5 mg Tier 1 carisoprodol oral tablet 250 mg, 350 mg Tier 1 QL (4 EA per 1 day) ST: Requires prior prescription for chlorzoxazone oral tablet 250 mg, 375 mg, 750 mg Tier 1 Chlorzoxazone 500mg within the past 120 days; QL (4 EA per 1 day) chlorzoxazone oral tablet 500 mg Tier 1 cyclobenzaprine oral capsule,extended release 24hr 15 Tier 1 mg, 30 mg cyclobenzaprine oral tablet 10 mg, 5 mg, 7.5 mg Tier 1 CYCLOTENS REFILL COMBO PACK 10 MG Tier 3 (cyclobenzaprine hcl/tens unit electrodes) CYCLOTENS STARTER COMBO PACK 10 MG Tier 3 (cyclobenzaprine hcl/tens unit/tens unit electrodes) metaxalone (Metaxall Oral Tablet 800 Mg) Tier 1 metaxalone oral tablet 400 mg, 800 mg Tier 1 methocarbamol oral tablet 500 mg, 750 mg Tier 1 orphenadrine citrate oral tablet extended release 100 Tier 1 mg OZOBAX ORAL SOLUTION 5 MG/5 ML (baclofen) Tier 3 PA tizanidine oral capsule 2 mg, 4 mg, 6 mg Tier 1 tizanidine oral tablet 2 mg, 4 mg Tier 1 Skeletal Muscle Relaxant - Direct Muscle Relaxants - Drugs for Muscles, Ligaments, Tendons, and Bones dantrolene oral capsule 100 mg, 25 mg, 50 mg Tier 1 Skeletal Muscle Relaxant - Opioid Analgesic Combinations - Drugs for Muscles, Ligaments, Tendons, and Bones QL (8 EA per 1 day); Age carisoprodol-aspirin-codeine oral tablet 200-325-16 mg Tier 1 (Min 12 Years)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 311 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle EASYMAX STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite ELEMENT COMPACT TEST STRIPS STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle ELEMENT TEST STRIPS STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite EMBRACE BLOOD GLUCOSE SYSTEM STRIP (blood Test Strips, Freestyle Tier 3 sugar diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 312 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite EMBRACE EVO TEST STRIPS STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite EMBRACE PRO TEST STRIPS STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite EMBRACE TALK TEST STRIPS STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle EVENCARE G2 STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 313 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle EVENCARE G3 TEST STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite EVENCARE MINI GLUCOSE TEST STR STRIP (blood Test Strips, Freestyle Tier 3 sugar diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite EVENCARE PROVIEW TEST STRIP STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle EVENCARE TEST STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 315 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite FORA 6 CONNECT GLUCOSE STRIP STRIP (blood Test Strips, Freestyle Tier 3 sugar diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle FORA D15G STRIPS STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle FORA D20 STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite FORA D40-G31 TEST STRIPS STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 316 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle FORA G20 STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite FORA G30-PREMIUM V10 TEST STRP STRIP (blood Test Strips, Freestyle Tier 3 sugar diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite FORA GD50 TEST STRIPS STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite FORA GTEL GLUCOSE TEST STRIP STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 317 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle FORA TEST STRIP STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite FORA TN'G VOICE TEST STRIPS STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle FORA V10 STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite FORA V10-V12-D10-D20 STRIPS STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 318 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle FORA V12 GLUCOSE STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle FORA V20 STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle FORA V30A STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle FORACARE GD20 STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 319 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite FORACARE GD40 TEST STRIPS STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite FORTISCARE GLUCOSE TEST STRIPS STRIP (blood Test Strips, Freestyle Tier 3 sugar diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; QL (200 EA per 30 FREESTYLE INSULINX STRIP (blood sugar diagnostic) Tier 2 days) FREESTYLE INSULINX TEST STRIPS STRIP (blood DD; QL (200 EA per 30 Tier 2 sugar diagnostic) days) FREESTYLE LITE STRIPS STRIP (blood sugar DD; QL (200 EA per 30 Tier 2 diagnostic) days) FREESTYLE PRECISION NEO STRIPS STRIP (blood DD; QL (200 EA per 30 Tier 2 sugar diagnostic) days) DD; QL (200 EA per 30 FREESTYLE TEST STRIP (blood sugar diagnostic) Tier 2 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite GE100 BLOOD GLUCOSE TEST STRIP STRIP (blood Test Strips, Freestyle Tier 3 sugar diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 320 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle GENSTRIP TEST STRIP STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite GENULTIMATE TEST STRIP STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite GLUCO NAVII TEST STRIP STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite GLUCOCARD 01 SENSOR PLUS STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 321 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite GLUCOCARD EXPRESSION STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite GLUCOCARD SHINE TEST STRIPS STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite GLUCOCARD VITAL SENSOR STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite GLUCOCARD VITAL TEST STRIPS STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 322 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle GLUCOCOM GLUCOSE STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle GM100 STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite GOJJI BLOOD GLUCOSE TEST STRIP STRIP (blood Test Strips, Freestyle Tier 3 sugar diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite GOODLIFE AC-302 TEST STRIP STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 323 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite HARMONY GLUCOSE TEST STRIP STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite HEALTHPRO TEST STRIPS STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle IGLUCOSE TEST STRIP STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle INFINITY TEST STRIPS STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 325 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle MYGLUCOHEALTH STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite NEUTEK 2TEK TEST STRIPS STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite NOVA MAX GLUCOSE TEST STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite ON CALL EXPRESS TEST STRIP STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 326 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite ON CALL PLUS TEST STRIP STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite ON CALL VIVID TEST STRIP STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite ONETOUCH ULTRA BLUE TEST STRIP STRIP (blood Test Strips, Freestyle Tier 3 sugar diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite ONETOUCH VERIO TEST STRIPS STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 327 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle OPTIUM EZ STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle OPTIUM TEST STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle OPTUMRX STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle PHARMACIST CHOICE STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 328 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite PRECISION PCX PLUS TEST STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle PRECISION PCX TEST STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite PRECISION POINT OF CARE TEST STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle PRECISION Q-I-D TEST STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; QL (200 EA per 30 PRECISION XTRA TEST STRIP (blood sugar diagnostic) Tier 2 days) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 329 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle PREMIER TEST STRIP STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle PREMIUM V10 STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite PRO VOICE V8-V9 TEST STRIP STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle PRODIGY NO CODING STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 330 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle QUINTET AC STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite QUINTET GLUCOSE TEST STRIPS STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle REFUAH PLUS STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite RELION CONFIRM-MICRO STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 331 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite RELION PRIME TEST STRIPS STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle RELION ULTIMA STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle REVEAL TEST STRIP STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite RIGHTEST GS250S TEST STRIPS STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 332 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite RIGHTEST GS260 TEST STRIPS STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite RIGHTEST GS550 TEST STRIPS STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite SMART SENSE TEST STRIPS STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle SMARTEST TEST STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 333 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite SOLUS V2 TEST STRIPS STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite SURE-TEST EASYPLUS MINI STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle TD GOLD TEST STRIP STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle TELCARE TEST STRIPS STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 335 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle TRUETRACK TEST STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle ULTIMA TEST STRIPS STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle ULTRATRAK STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle ULTRATRAK ULTIMATE STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 336 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle UNISTRIP1 TEST STRIP STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite VERASENS TEST STRIP STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite VIVAGUARD INO TEST STRIP STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle WAVESENSE JAZZ STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 337 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle WAVESENSE PRESTO STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) Medical Supplies and DME - Cervical Caps - Medical Supplies and Durable Medical Equipment FEMCAP VAGINAL DEVICE 22 MM, 26 MM, 30 MM $0 CT; EHB (cervical cap) Medical Supplies and DME - Compression Stockings - Medical Supplies and Durable Medical Equipment T.E.D. KNEE LENGTH-M-LONG (compression Tier 3 stocking,knee high,long length,small circumferen) T.E.D. KNEE LENGTH-S-REGULAR (compression Tier 3 stocking, knee high, regular length, small) Medical Supplies and DME - Dental Supplies Other - Medical Supplies and Durable Medical Equipment Q-CARE RX Q2 KIT 0.12 % (dental suction Tier 3 device/chlorhexidine/dental swab 1/mouthwash) Q-CARE RX Q4 KIT 0.12 % (dental suction Tier 3 device/chlorhexidine gl/dental swab comb no.1) Medical Supplies and DME - Diaphragms - Medical Supplies and Durable Medical Equipment CAYA CONTOURED VAGINAL DIAPHRAGM 65-80 MM $0 CT; EHB (diaphragms, contoured) WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 60 $0 CT; EHB MM (diaphragms, wide seal)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 347 Coverage Prescription Drug Name Drug Tier Requirements and Limits FLEXI-SEAL SIGNAL FMS RECTAL (fecal collector with Tier 3 charcoal filter/catheter/syringe) MONO-FLO DRAINAGE BAG 2,000 ML (drainage bag) Tier 3 Medical Supplies and DME - Insulin Needles- Syringes and Admin Supplies - Medical Supplies and Durable Medical Equipment ADVOCATE SYRINGES SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16" Tier 2 DD (syringe with needle,insulin,0.3 ml) ADVOCATE SYRINGES SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16" Tier 2 DD (syringe with needle,insulin,0.5 ml) ADVOCATE SYRINGES SYRINGE 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 Tier 2 DD (syringe with needle,disposable,insulin 1 ml) ASSURE ID INSULIN SAFETY SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 31 GAUGE X 15/64" (syringe with Tier 2 DD needle, insulin, safety, 0.5 ml) ASSURE ID INSULIN SAFETY SYRINGE 1 ML 29 GAUGE X 1/2", 1 ML 31 GAUGE X 15/64" (syringe with needle, Tier 2 DD insulin, safety, 1 ml) BD ECLIPSE LUER-LOK SYRINGE 1 ML 30 GAUGE X Tier 2 DD 1/2" (syringe with needle,disposable,insulin 1 ml) BD INSULIN SYRINGE HALF UNIT SYRINGE 0.3 ML 31 GAUGE X 5/16" (syringe with needle,insulin 0.3 ml (half Tier 2 DD unit mark)) BD INSULIN SYRINGE MICRO-FINE SYRINGE 1 ML 28 GAUGE X 1/2" (syringe with needle,disposable,insulin 1 Tier 2 DD ml) BD INSULIN SYRINGE SAFETY-LOK SYRINGE 1 ML 29 GAUGE X 1/2" (syringe with needle,disposable,insulin 1 Tier 2 DD ml) BD INSULIN SYRINGE SLIP TIP SYRINGE 1 ML (syringe Tier 2 DD without needle,insulin disposible, 1 ml) BD INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X Tier 2 DD 1/2" (syringe with needle,insulin,0.3 ml) BD INSULIN SYRINGE SYRINGE 0.5 ML 29 GAUGE X Tier 2 DD 1/2" (syringe with needle,insulin,0.5 ml) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 348 Coverage Prescription Drug Name Drug Tier Requirements and Limits BD INSULIN SYRINGE SYRINGE 1 ML 25 GAUGE X 5/8", 1 ML 25 X 1", 1 ML 26 X 1/2", 1 ML 27 GAUGE X 1/2", 1 Tier 2 DD ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2" (syringe with needle,disposable,insulin 1 ml) BD INSULIN SYRINGE U-500 SYRINGE 1/2 ML 31 GAUGE X 15/64" (syringe, insulin u-500 with needle, Tier 2 DD disposable, 0.5 ml) BD INSULIN SYRINGE ULTRA-FINE SYRINGE 0.3 ML 30 GAUGE X 1/2", 0.3 ML 31 GAUGE X 5/16" (syringe with Tier 2 DD needle,insulin,0.3 ml) BD INSULIN SYRINGE ULTRA-FINE SYRINGE 0.5 ML 30 GAUGE X 1/2", 0.5 ML 31 GAUGE X 5/16" (syringe with Tier 2 DD needle,insulin,0.5 ml) BD INSULIN SYRINGE ULTRA-FINE SYRINGE 1 ML 30 GAUGE X 1/2", 1 ML 31 GAUGE X 5/16 (syringe with Tier 2 DD needle,disposable,insulin 1 ml) BD LO-DOSE MICRO-FINE IV SYRINGE 1/2 ML 28 Tier 2 DD GAUGE X 1/2" (syringe with needle,insulin,0.5 ml) BD LO-DOSE ULTRA-FINE SYRINGE 0.5 ML 29 GAUGE Tier 2 DD X 1/2" (syringe with needle,insulin,0.5 ml) BD SAFETYGLIDE INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 31 GAUGE X 5/16" (syringe Tier 2 DD with needle,insulin,0.3 ml) BD SAFETYGLIDE INSULIN SYRINGE SYRINGE 0.3 ML 31 GAUGE X 15/64" (syringe with needle, insulin, safety, Tier 2 DD 0.3 ml) BD SAFETYGLIDE INSULIN SYRINGE SYRINGE 0.5 ML Tier 2 DD 30 GAUGE X 5/16" (syringe with needle,insulin,0.5 ml) BD SAFETYGLIDE INSULIN SYRINGE SYRINGE 0.5 ML 31 GAUGE X 15/64" (syringe with needle, insulin, safety, Tier 2 DD 0.5 ml) BD SAFETYGLIDE INSULIN SYRINGE SYRINGE 1 ML 29 GAUGE X 1/2" (syringe with needle,disposable,insulin 1 Tier 2 DD ml) BD SAFETYGLIDE INSULIN SYRINGE SYRINGE 1 ML 31 GAUGE X 15/64" (syringe with needle, insulin, safety, 1 Tier 2 DD ml) BD SAFETYGLIDE SYRINGE SYRINGE 1 ML 27 GAUGE Tier 2 DD X 5/8" (syringe with needle,disposable,insulin 1 ml) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 349 Coverage Prescription Drug Name Drug Tier Requirements and Limits BD VEO INSULIN SYR HALF UNIT SYRINGE 0.3 ML 31 GAUGE X 15/64" (syringe with needle,insulin 0.3 ml (half Tier 2 DD unit mark)) BD VEO INSULIN SYRINGE UF SYRINGE 0.3 ML 31 Tier 2 DD GAUGE X 15/64" (syringe with needle,insulin,0.3 ml) BD VEO INSULIN SYRINGE UF SYRINGE 1 ML 31 GAUGE X 15/64" (syringe with needle,disposable,insulin Tier 2 DD 1 ml) BD VEO INSULIN SYRINGE UF SYRINGE 1/2 ML 31 Tier 2 DD GAUGE X 15/64" (syringe with needle,insulin,0.5 ml) CARETOUCH INSULIN SYRINGE SYRINGE 0.3 ML 31 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin,0.3 ml) CARETOUCH INSULIN SYRINGE SYRINGE 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16" (syringe with Tier 2 DD needle,insulin,0.5 ml) CARETOUCH INSULIN SYRINGE SYRINGE 1 ML 28 X 5/16", 1 ML 29 GAUGE X 5/16, 1 ML 30 GAUGE X 5/16, 1 Tier 2 DD ML 31 GAUGE X 5/16 (syringe with needle,disposable,insulin 1 ml) COMFORT EZ INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 1/2", 0.3 ML 30 Tier 2 DD GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16" (syringe with needle,insulin,0.3 ml) COMFORT EZ INSULIN SYRINGE SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 Tier 2 DD GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1/2 ML 28 GAUGE X 1/2" (syringe with needle,insulin,0.5 ml) COMFORT EZ INSULIN SYRINGE SYRINGE 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X Tier 2 DD 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 (syringe with needle,disposable,insulin 1 ml) DROPLET INSULIN SYR HALF UNIT SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 15/64", 0.5 ML 31 Tier 2 DD GAUGE X 5/16", 0.5ML 30 GAUGE X 15/64" (syringe with needle,insulin 0.5 ml (half unit mark))

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 358 Coverage Prescription Drug Name Drug Tier Requirements and Limits ULTILET INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE, 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X Tier 2 DD 5/16", 0.3 ML 31 GAUGE X 5/16" (syringe with needle,insulin,0.3 ml) ULTILET INSULIN SYRINGE SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X Tier 2 DD 5/16", 1/2 ML 29 (syringe with needle,insulin,0.5 ml) ULTILET INSULIN SYRINGE SYRINGE 1 ML 29 GAUGE, 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 Tier 2 DD GAUGE X 5/16 (syringe with needle,disposable,insulin 1 ml) ULTRA CMFT INS SYR HALF UNIT SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin 0.3 ml (half unit mark)) ULTRA COMFORT INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30, 0.3 ML 30 GAUGE X 5/16", Tier 2 DD 0.3 ML 31 GAUGE X 5/16" (syringe with needle,insulin,0.3 ml) ULTRA COMFORT INSULIN SYRINGE SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1/2 ML 28 GAUGE, 1/2 ML 28 GAUGE X Tier 2 DD 1/2", 1/2 ML 29 , 1/2 ML 30 GAUGE (syringe with needle,insulin,0.5 ml) ULTRA COMFORT INSULIN SYRINGE SYRINGE 1 ML 28 GAUGE, 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE, 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 30 Tier 2 DD GAUGE X 7/16", 1 ML 31 GAUGE X 5/16 (syringe with needle,disposable,insulin 1 ml) ULTRA FLO INSULIN SYRINGE SYRINGE 0.3 ML 29 Tier 2 DD GAUGE X 1/2" (syringe with needle,insulin,0.3 ml) ULTRACARE INSULIN SYRINGE SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16" (syringe with Tier 2 DD needle,insulin,0.3 ml) ULTRACARE INSULIN SYRINGE SYRINGE 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin,0.5 ml) ULTRACARE INSULIN SYRINGE SYRINGE 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE Tier 2 DD X 5/16 (syringe with needle,disposable,insulin 1 ml) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 359 Coverage Prescription Drug Name Drug Tier Requirements and Limits ULTRA-THIN II (SHORT) INS SYR SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16" (syringe with Tier 2 DD needle,insulin,0.3 ml) ULTRA-THIN II (SHORT) INS SYR SYRINGE 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16" (syringe with Tier 2 DD needle,insulin,0.5 ml) ULTRA-THIN II (SHORT) INS SYR SYRINGE 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 (syringe with Tier 2 DD needle,disposable,insulin 1 ml) ULTRA-THIN II INSULIN SYRINGE SYRINGE 0.5 ML 29 Tier 2 DD GAUGE X 1/2" (syringe with needle,insulin,0.5 ml) ULTRA-THIN II INSULIN SYRINGE SYRINGE 1 ML 29 GAUGE X 1/2" (syringe with needle,disposable,insulin 1 Tier 2 DD ml) VANISHPOINT INSULIN SYRINGE SYRINGE 1 ML 30 GAUGE X 3/16" (syringe with needle, insulin, safety, 1 Tier 2 DD ml) VANISHPOINT SYRINGE SYRINGE 0.5 ML 30 GAUGE X Tier 2 DD 1/2" (syringe with needle,insulin,0.5 ml) VANISHPOINT SYRINGE SYRINGE 1 ML 29 GAUGE X Tier 2 DD 1/2" (syringe with needle,disposable,insulin 1 ml) Medical Supplies and DME - IV Sets-Tubing - Medical Supplies and Durable Medical Equipment BD INSYTE AUTOGUARD INFUSION SET 24 GAUGE X Tier 3 3/4" (intravenous catheter) BD SAF-T-INTIMA INFUSION SET 22 GAUGE X 3/4" Tier 3 (intravenous catheter kit) FILTERED EXTENSION SET INFUSION SET Tier 3 (intravenous administration extension set with filter) HI-VOLUME PUMPING CHAMBER SET (transfer sets) Tier 3 INSYTE IV CATHETER INFUSION SET 14 X 1.75 ", 20 X Tier 3 1.16 " (intravenous catheter) MICROBORE EXTENSION SET INFUSION SET Tier 3 (intravenous administration extension set) NEXIVA INFUSION SET 18 X 1 1/4 ", 18 X 1 3/4 ", 20 GAUGE X 1", 20 X 1 1/4 ", 20 X 1 3/4 ", 22 GAUGE X 1", 24 Tier 3 GAUGE X 3/4", 24 X 0.56 " (intravenous catheter) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 360 Coverage Prescription Drug Name Drug Tier Requirements and Limits PHASEAL SECONDARY SET INFUSION SET Tier 3 (intravenous piggyback administration set) PHASEAL Y-SITE (y-site line connector, closed system) Tier 3 RATE FLOW REGULATOR IV SET INFUSION SET Tier 3 (intravenous administration set) SILHOUETTE 23"-FULL SET INFUSION SET (infusion set Tier 3 DD for insulin pump) SILHOUETTE 43"-FULL SET INFUSION SET (infusion set Tier 3 DD for insulin pump) SILHOUETTE INFUSION SET (infusion set for insulin Tier 3 DD pump) Medical Supplies and DME - Male Erectile Dysfunction Aids - Medical Supplies and Durable Medical Equipment RAPPORT VACUUM THERAPY KIT (vacuum erection Tier 3 device system) Medical Supplies and DME - Miscellaneous Other - Medical Supplies and Durable Medical Equipment ACCU-CHEK SPIRIT CLIP CASE (subcutaneous infusion Tier 3 pump accessory) AMIELLE VAGINAL TRAINER KIT (medical supply, Tier 3 miscellaneous) ARGYLE TRACHEOSTOMY CARE TRAY (medical Tier 3 supply, miscellaneous) CEFALY COMBO PACK (transcutaneous electrical nerve Tier 3 stimulators(tens)/electrodes) OMNIPOD DASH 5 PACK POD SUBCUTANEOUS Tier 2 DD CARTRIDGE (insulin pump cartridge) OMNIPOD INSULIN REFILL SUBCUTANEOUS Tier 2 DD CARTRIDGE (insulin pump cartridge) PRO COMFORT TENS ELECTRODE PAD (tens unit Tier 3 electrodes) PRO COMFORT TENS UNIT COMBO PACK (transcutaneous electrical nerve Tier 3 stimulators(tens)/electrodes)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 371 Coverage Prescription Drug Name Drug Tier Requirements and Limits VORTEX HOLDING CHAMBER SPACER (inhaler, assist Tier 3 devices) VORTEX VHC FROG MASK-CHILD SPACER Tier 3 (inhaler,assist device with medium mask) VORTEX VHC LADYBUG MASK-TODDLR SPACER Tier 3 (inhaler,assist device with small mask) WILLIS THE WHALE COMPRESSR NEB DEVICE Tier 3 (nebulizer and compressor) Medical Supplies and DME - Scar Treatments - Medical Supplies and Durable Medical Equipment CELACYN TOPICAL GEL WITH PUMP (emollient Tier 3 combination no.60) CELLPAD TOPICAL PAD 2 X 5.5 " (gel-matrix pad Tier 3 dressing, silicone) CICASIL TOPICAL PAD 2 X 5.5 " (gel-matrix pad Tier 3 dressing, silicone) CICATRACE PAD TOPICAL PAD 4.7 X 5.7 " (gel-matrix Tier 3 pad dressing, silicone) DERM-SILK TOPICAL PAD 2.5 X 2 " (gel-matrix pad Tier 3 dressing, silicone) KELOTOP TOPICAL PAD 4.7 X 5.7 " (gel-matrix pad Tier 3 dressing, silicone) NUVAKAAN TOPICAL KIT 2.5-2.5 % Tier 1 (lidocaine/prilocaine/silicone, adhesive) POLYTOZA TOPICAL SHEET 5 CM X 14 CM (silicone Tier 3 adhesive) PROSILK TOPICAL PAD 2 X 5.5 " (gel-matrix pad Tier 3 dressing, silicone) SCARCARE TOPICAL KIT 2 X 5.5 " (gel-matrix Tier 3 pad,silicone-dimethicone-dime-decameoct-oct-vit e) SCARCINPAD TOPICAL PAD 1.57 X 5.12 " (gel-matrix Tier 3 pad dressing, silicone) SCARSILK TOPICAL PAD 2 X 5.5 " (gel-matrix pad Tier 3 dressing, silicone) SILIVEX TOPICAL PAD 2 X 5.5 " (gel-matrix pad Tier 3 dressing, silicone)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 390 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite EASY TRAK II TEST STRIP STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) EASY TWIST AND CAP LANCETS 28 GAUGE (lancets) Tier 2 DD DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle EASYGLUCO PLUS STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) EBASE CONTROLLER DEVICE (compressor, for Tier 3 nebulizer) ECLIPSE NEEDLE NEEDLE 23 GAUGE X 1", 25 X 5/8 ", Tier 3 27 GAUGE X 1/2" (needles, safety) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite ELEMENT COMPACT TEST STRIPS STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 391 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle ELEMENT TEST STRIPS STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite EMBRACE EVO TEST STRIPS STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) EMBRACE LANCETS 30 GAUGE (lancets) Tier 2 DD ENLITE GLUCOSE SENSOR DEVICE (blood-glucose Tier 3 DD sensor) ENLITE SERTER (diabetic supplies,miscell) Tier 3 DD ENLITE SYSTEM (blood-glucose transmitter/blood- Tier 3 DD glucose sensor) ENTERAL GRAVITY BAG SET-ENFIT (feeder container Tier 3 with gravity set, enfit) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite EVENCARE PROVIEW TEST STRIP STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 392 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle EVENCARE TEST STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) EVERSENSE SMART TRANSMITTER DEVICE (blood- Tier 3 PA; DD glucose transmitter) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite EVOLUTION TEST STRIPS STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) E-Z JECT LANCETS 26 GAUGE, 32 GAUGE (lancets) Tier 2 DD EZ SMART LANCETS 28 GAUGE (lancets) Tier 2 DD DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle EZ SMART PLUS TEST STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) EZ-LETS 26 GAUGE (lancets) Tier 2 DD CT; EHB; QL (30 EA per FC2 FEMALE CONDOM (condoms, female) $0 30 days) FEMALE CATHETER 14 FR (catheter) Tier 3 FEMCAP VAGINAL DEVICE 22 MM, 26 MM, 30 MM $0 CT; EHB (cervical cap)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 393 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle FIFTY50 TEST STRIP STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) filter needles needle 19 x 1 ", 19 x 1 1/2 " Tier 3 FINGERSTIX LANCETS (lancets) Tier 2 DD FLEXICHAMBER SPACER (inhaler, assist devices) Tier 3 FLEXICHAMBER-LG CHILD MASK DEVICE (inhaler, Tier 3 assist devices, accessories) FLEXICHAMBER-SM ADULT MASK DEVICE (inhaler, Tier 3 assist devices, accessories) FLEXICHAMBER-SM CHILD MASK DEVICE (inhaler, Tier 3 assist devices, accessories) FLEXI-SEAL SIGNAL FMS RECTAL (fecal collector with Tier 3 charcoal filter/catheter/syringe) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite FORA 6 CONNECT GLUCOSE STRIP STRIP (blood Test Strips, Freestyle Tier 3 sugar diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 395 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite FORA GD50 TEST STRIPS STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite FORA GTEL GLUCOSE TEST STRIP STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite FORA TN'G VOICE TEST STRIPS STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle FORA V20 STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 396 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle FORA V30A STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle FORACARE GD20 STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite FORACARE GD40 TEST STRIPS STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) FORACARE LANCETS 30 GAUGE (lancets) Tier 2 DD DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite FORTISCARE GLUCOSE TEST STRIPS STRIP (blood Test Strips, Freestyle Tier 3 sugar diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 398 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle GM100 STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite GOJJI BLOOD GLUCOSE TEST STRIP STRIP (blood Test Strips, Freestyle Tier 3 sugar diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) GOJJI LANCETS 30 GAUGE (lancets) Tier 2 DD DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite GOODLIFE AC-302 TEST STRIP STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) GUARDIAN RT CHARGER (diabetic supplies,miscell) Tier 3 DD GUARDIAN RT MONITOR SYSTEM (diabetic Tier 3 DD supplies,miscell)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 399 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite HARMONY GLUCOSE TEST STRIP STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) HEALTHWISE INSULIN SYRINGE SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16" (syringe with Tier 2 DD needle,insulin,0.3 ml) HEALTHWISE INSULIN SYRINGE SYRINGE 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16" (syringe with Tier 2 DD needle,insulin,0.5 ml) HEALTHWISE INSULIN SYRINGE SYRINGE 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 (syringe with Tier 2 DD needle,disposable,insulin 1 ml) HI-VOLUME PUMPING CHAMBER SET (transfer sets) Tier 3 HYDROFERA BLUE READY TOPICAL BANDAGE 2 1/2 X 2 1/2 ", 4 X 5 ", 8 X 8 " (methylene blue/gentian Tier 3 violet/foam bandage) HYDROFERA BLUE TOPICAL BANDAGE 2 X 2 ", 2 X 2 3/4 ", 2.25 X 8 ", 2.5 ", 9 MM (polyvinyl alcohol/gentian Tier 3 violet/methylene blue) HYPERSONIQ NEBULIZER CARTRIDGE (nebulizer Tier 3 accessories) INCONTROL SUPER THIN LANCETS 30 GAUGE Tier 2 DD (lancets) INCONTROL ULTRA THIN LANCETS 28 GAUGE (lancets) Tier 2 DD

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 401 Coverage Prescription Drug Name Drug Tier Requirements and Limits insulin syringe-needle u-100 syringe 0.3 ml 31 gauge x 1/4", 1 ml 28 gauge, 1 ml 29 gauge x 7/16", 1 ml 30 Tier 2 DD gauge x 3/8", 1 ml 31 gauge x 1/4", 1/2 ml 28 gauge, 1/2 ml 31 gauge x 1/4" INSYTE IV CATHETER INFUSION SET 14 X 1.75 ", 20 X Tier 3 1.16 " (intravenous catheter) INTERLINK LEVER LOCK CANNULA (syringe accessory) Tier 3 INVACARE LANCETS 30 GAUGE (lancets) Tier 2 DD I-PORT ADVANCE 6 MM INJEC PORT (injection ports) Tier 3 I-PORT ADVANCE 9 MM INJEC PORT (injection ports) Tier 3 KANGAROO 924 SAFETY SCREW (pump set) Tier 3 KANGAROO EPUMP SET (feeder container with pump Tier 3 set) KANGAROO GRAVITY SET (feeder container with Tier 3 gravity set) KELOTOP TOPICAL PAD 4.7 X 5.7 " (gel-matrix pad Tier 3 dressing, silicone) KENDALL DISINFECTANT CAP (alcohol swab cap) Tier 3 KENGUARD FOLEY CATHETER 18-16 FR-" (catheter) Tier 3 KENGUARD FOLEY CATHETER TRAY (catheterization Tier 3 tray) KERAGEL TOPICAL GEL (gel dressing) Tier 3 LANCETS, SUPER THIN (lancets) Tier 2 DD LANCETS,THIN 28 GAUGE (lancets) Tier 2 DD LANCETS,ULTRA THIN (lancets) Tier 2 DD LC PLUS NEBULIZER-PED MASK (nebulizer) Tier 3 LITE TOUCH INSULIN SYRINGE SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 1/2 ML 28 Tier 2 DD GAUGE, 1/2 ML 28 GAUGE X 1/2", 1/2 ML 29 , 1/2 ML 30 GAUGE (syringe with needle,insulin,0.5 ml) LITE TOUCH INSULIN SYRINGE SYRINGE 1 ML 28 GAUGE, 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE, 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 30 Tier 2 DD GAUGE X 7/16", 1 ML 31 GAUGE X 5/16 (syringe with needle,disposable,insulin 1 ml) LITE TOUCH LANCETS 28 GAUGE, 30 GAUGE, 33 Tier 2 DD GAUGE (lancets) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 402 Coverage Prescription Drug Name Drug Tier Requirements and Limits LITE TOUCH-MEDIUM MASK DEVICE (inhaler, assist Tier 3 devices, accessories) LITEAIRE MDI CHAMBER SPACER (inhaler, assist Tier 3 devices) LITETOUCH-LARGE MASK DEVICE (inhaler, assist Tier 3 devices, accessories) LITETOUCH-SMALL MASK DEVICE (inhaler, assist Tier 3 devices, accessories) LOFRIC 12-16 FR-", 14-16 FR-" (catheter) Tier 3 LOFRIC ORIGO 14-16 FR-" (catheter) Tier 3 MAGELLAN INSULIN SAFETY SYRNG SYRINGE 0.3 ML Tier 2 DD 29 X 1/2" (syringe with needle, insulin, safety, 0.3 ml) MAGELLAN INSULIN SAFETY SYRNG SYRINGE 0.5 ML 29 GAUGE X 1/2" (syringe with needle, insulin, safety, Tier 2 DD 0.5 ml) MAGELLAN INSULIN SAFETY SYRNG SYRINGE 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16" (syringe with Tier 2 DD needle, insulin, safety, 1 ml) MAGELLAN SAFETY NEEDLE NEEDLE 23 GAUGE X 5/8" Tier 3 (needles, safety) MAGELLAN SYRINGE SYRINGE 0.3 ML 30 X 5/16" Tier 2 DD (syringe with needle, insulin, safety, 0.3 ml) MAGELLAN SYRINGE SYRINGE 0.5 ML 30 GAUGE X Tier 2 DD 5/16" (syringe with needle, insulin, safety, 0.5 ml) MAGIC3 INTERMITTENT CATHETER 10-16 FR-", 12-16 Tier 3 FR-" (catheter) MAXICOMFORT INSULIN SYRINGE SYRINGE 1 ML 27 GAUGE X 1/2" (syringe with needle,disposable,insulin 1 Tier 2 DD ml) MAXI-COMFORT INSULIN SYRINGE SYRINGE 1 ML 28 GAUGE X 1/2" (syringe with needle,disposable,insulin 1 Tier 2 DD ml) MAXICOMFORT INSULIN SYRINGE SYRINGE 1/2 ML 27 Tier 2 DD GAUGE X 1/2" (syringe with needle,insulin,0.5 ml) MAXI-COMFORT INSULIN SYRINGE SYRINGE 1/2 ML 28 Tier 2 DD GAUGE X 1/2" (syringe with needle,insulin,0.5 ml)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 412 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle REFUAH PLUS STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) RELIAMED LANCET 23 GAUGE, 30 GAUGE (lancets) Tier 2 DD RELIAMED SAFETY SEAL LANCETS 28 GAUGE, 30 Tier 2 DD GAUGE (lancets) RELIAMED TWIST AND CAP LANCET 28 GAUGE Tier 2 DD (lancets) RELION THIN LANCETS 26 GAUGE (lancets) Tier 2 DD DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle RELION ULTIMA STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) RELION ULTRA THIN PLUS LANCETS (lancets) Tier 2 DD RELIZORB CARTRIDGE (enteral pump accessory for fat Tier 3 hydrolysis) REPLICARE DRESSING TOPICAL BANDAGE 1 1/2 X 2 Tier 3 1/2 ", 4 X 4 ", 6 X 6 ", 8 X 8 " (hydrocolloid dressing) REPLICARE THIN TOPICAL BANDAGE 2 X 2 3/4 ", 3 1/2 X Tier 3 5 1/2 ", 6 X 8 " (hydrocolloid dressing) REPLICARE ULTRA DRESSING TOPICAL BANDAGE 4 X Tier 3 4 ", 6 X 6 ", 7 X 8 " (hydrocolloid dressing) RESTORE TOPICAL BANDAGE 2 X 2 " (silver/calcium Tier 3 alginate) REVEL PEDIATRIC PROGRAM PUMP (subcutaneous Tier 3 DD insulin pump)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 415 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite SOLUS V2 TEST STRIPS STRIP (blood sugar Test Strips, Freestyle Tier 3 diagnostic) Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) SOOTHENEB COMPRESSOR NEBULIZER DEVICE Tier 3 (nebulizer and compressor) SOOTHENEB MESH NEBULIZER (nebulizer) Tier 3 SPACE CHAMBER PLUS SPACER (inhaler, assist Tier 3 devices) SPACE CHAMBER SPACER (inhaler, assist devices) Tier 3 SPACE CHAMBER WITH LARGE MASK SPACER Tier 3 (inhaler,assist device with large mask) SPACE CHAMBER WITH MEDIUM MASK SPACER Tier 3 (inhaler,assist device with medium mask) SPACE CHAMBER WITH SMALL MASK SPACER Tier 3 (inhaler,assist device with small mask) SPECTRAGEL TOPICAL GEL (gel dressing) Tier 3 SPEEDICATH (FEMALE) 16 FR (catheter) Tier 3 STERILANCE TL 30 GAUGE, 32 GAUGE (lancets) Tier 2 DD STRATACTX TOPICAL GEL (gel dressing) Tier 3 STRATAGRT TOPICAL GEL (gel dressing) Tier 3 STRATAXRT TOPICAL GEL (gel dressing) Tier 3 SUNRISE COMPRESSOR-NEBULIZER DEVICE Tier 3 (compressor, for nebulizer) SUPER THIN LANCETS (lancets) Tier 2 DD SURE COMFORT INS. SYR. U-100 SYRINGE 0.5 ML 29 Tier 2 DD GAUGE X 1/2" (syringe with needle,insulin,0.5 ml) SURE COMFORT INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 1/2", 0.3 ML 30 Tier 2 DD GAUGE X 5/16", 0.3 ML 31 GAUGE X 1/4" (syringe with needle,insulin,0.3 ml)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 418 Coverage Prescription Drug Name Drug Tier Requirements and Limits THINPRO INSULIN SYRINGE SYRINGE 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 3/8", 1 Tier 2 DD ML 31 X 3/8" (syringe with needle,disposable,insulin 1 ml) THRESHOLD IMT TRAINER DEVICE (spirometers and Tier 3 accessories) THRESHOLD PEP DEVICE DEVICE (spirometers and Tier 3 accessories) TOPCARE ULTRA COMFORT SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin,0.3 ml) TOPCARE ULTRA COMFORT SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin,0.5 ml) TOPCARE ULTRA COMFORT SYRINGE 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 Tier 2 DD (syringe with needle,disposable,insulin 1 ml) TOPCARE UNIVERSAL1 LANCET 33 GAUGE (lancets) Tier 2 DD TOUCH-TROL 10 FR (catheter) Tier 3 TRUE COMFORT INSULIN SYRINGE SYRINGE 0.5 ML 31 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin,0.5 ml) TRUE COMFORT INSULIN SYRINGE SYRINGE 1 ML 31 GAUGE X 5/16 (syringe with needle,disposable,insulin 1 Tier 2 DD ml) TRUE COMFORT LANCET 30 GAUGE (lancets) Tier 2 DD TRUEPLUS LANCETS 26 GAUGE, 33 GAUGE (lancets) Tier 2 DD TRUNEB NEBULIZER (nebulizer) Tier 3 TRUZONE PEAK FLOW METER DEVICE (peak flow Tier 3 meter) ULTILET BASIC LANCETS 30 GAUGE (lancets) Tier 2 DD ULTILET CLASSIC LANCETS 33 GAUGE (lancets) Tier 2 DD ULTILET INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE, 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X Tier 2 DD 5/16", 0.3 ML 31 GAUGE X 5/16" (syringe with needle,insulin,0.3 ml) ULTILET INSULIN SYRINGE SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X Tier 2 DD 5/16", 1/2 ML 29 (syringe with needle,insulin,0.5 ml) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 419 Coverage Prescription Drug Name Drug Tier Requirements and Limits ULTILET INSULIN SYRINGE SYRINGE 1 ML 29 GAUGE, 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 Tier 2 DD GAUGE X 5/16 (syringe with needle,disposable,insulin 1 ml) ULTILET LANCETS 30 GAUGE, 33 GAUGE (lancets) Tier 2 DD ULTILET SAFETY LANCETS 23 GAUGE (lancets) Tier 2 DD ULTRA CMFT INS SYR HALF UNIT SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16" (syringe with Tier 2 DD needle,insulin 0.3 ml (half unit mark)) ULTRA COMFORT INSULIN SYRINGE SYRINGE 0.3 ML Tier 2 DD 31 GAUGE X 5/16" (syringe with needle,insulin,0.3 ml) ULTRA COMFORT INSULIN SYRINGE SYRINGE 1 ML 31 GAUGE X 5/16 (syringe with needle,disposable,insulin 1 Tier 2 DD ml) ULTRA FINE LANCETS 30 GAUGE (lancets) Tier 2 DD ULTRA FLO INSULIN SYRINGE SYRINGE 0.3 ML 29 Tier 2 DD GAUGE X 1/2" (syringe with needle,insulin,0.3 ml) ULTRA THIN II LANCETS 30 GAUGE (lancets) Tier 2 DD ULTRA THIN LANCETS 33 GAUGE (lancets) Tier 2 DD ULTRA THIN PLUS LANCETS 33 GAUGE (lancets) Tier 2 DD ULTRACARE INSULIN SYRINGE SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16" (syringe with Tier 2 DD needle,insulin,0.3 ml) ULTRACARE INSULIN SYRINGE SYRINGE 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin,0.5 ml) ULTRACARE INSULIN SYRINGE SYRINGE 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE Tier 2 DD X 5/16 (syringe with needle,disposable,insulin 1 ml) ULTRA-CARE LANCETS 30 GAUGE (lancets) Tier 2 DD ULTRALANCE LANCETS 26 GAUGE, 28 GAUGE Tier 2 DD (lancets) ULTRA-THIN II (SHORT) INS SYR SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16" (syringe with Tier 2 DD needle,insulin,0.3 ml) ULTRA-THIN II (SHORT) INS SYR SYRINGE 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16" (syringe with Tier 2 DD needle,insulin,0.5 ml) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 420 Coverage Prescription Drug Name Drug Tier Requirements and Limits ULTRA-THIN II (SHORT) INS SYR SYRINGE 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 (syringe with Tier 2 DD needle,disposable,insulin 1 ml) ULTRA-THIN II INSULIN SYRINGE SYRINGE 0.5 ML 29 Tier 2 DD GAUGE X 1/2" (syringe with needle,insulin,0.5 ml) ULTRA-THIN II INSULIN SYRINGE SYRINGE 1 ML 29 GAUGE X 1/2" (syringe with needle,disposable,insulin 1 Tier 2 DD ml) ULTRA-THIN II LANCETS 28 GAUGE (lancets) Tier 2 DD DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle ULTRATRAK ULTIMATE STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days) UNISTIK 3 COMFORT LANCET (lancets) Tier 2 DD UNISTIK 3 LANCETS 21 GAUGE (lancets) Tier 2 DD UNISTIK 3 NORMAL LANCET 23 GAUGE (lancets) Tier 2 DD UNISTIK CZT LANCET 23 GAUGE, 28 GAUGE (lancets) Tier 2 DD UNISTIK PRO LANCET 21 GAUGE, 25 GAUGE, 28 Tier 2 DD GAUGE (lancets) UNISTIK SAFETY 28 GAUGE, 30 GAUGE (lancets) Tier 2 DD UNISTIK TOUCH LANCETS 28 GAUGE, 30 GAUGE Tier 2 DD (lancets) DD; ST: Requires prior prescription for Freestyle Insulinx, Freestyle Insulinx Test Strips, Freestyle Lite Test Strips, Freestyle UNISTRIP1 TEST STRIP STRIP (blood sugar diagnostic) Tier 3 Precision Neo, Freestyle Test Strips, or Precision Xtra within the past 120 days; QL (200 EA per 30 days)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 424 Coverage Prescription Drug Name Drug Tier Requirements and Limits Metabolic Modifier - Urea Cycle Disorder Agents-Conjugating agents - Drugs that Alter Metabolism RAVICTI ORAL LIQUID 1.1 GRAM/ML (glycerol Tier 3 PA; SP phenylbutyrate) sodium phenylbutyrate oral powder 0.94 gram/gram Tier 1 PA; SP sodium phenylbutyrate oral tablet 500 mg Tier 1 PA; SP Metabolic Modifier-Carbamoyl Phosphate Synthetase 1 (CPS 1) activator - Drugs that Alter Metabolism CARBAGLU ORAL TABLET, DISPERSIBLE 200 MG Tier 3 SP (carglumic acid) Pharmacoenhancer - Cytochrome P450 Inhibitors - Drugs that Alter Metabolism TYBOST ORAL TABLET 150 MG (cobicistat) Tier 2 QL (1 EA per 1 day) Pharmacological Chaperone Tx - alpha- galactosidase A enzyme stabilizer - Drugs that Alter Metabolism GALAFOLD ORAL CAPSULE 123 MG (migalastat hcl) Tier 3 PA; SP Phenylketonuria(PKU) Tx Agents - Cofactor of Phenylalanine Hydroxylase - Drugs that Alter Metabolism sapropterin oral powder in packet 100 mg, 500 mg Tier 1 PA; SP sapropterin oral tablet,soluble 100 mg Tier 1 PA; SP Phenylketonuria(PKU) Tx Agents - Phenylalanine Ammonia Lyase - Drugs that Alter Metabolism PALYNZIQ SUBCUTANEOUS SYRINGE 10 MG/0.5 ML, Tier 2 PA; SP 2.5 MG/0.5 ML, 20 MG/ML (pegvaliase-pqpz)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 427 Coverage Prescription Drug Name Drug Tier Requirements and Limits Mouth and Throat - Artificial Saliva - Drugs for the Mouth and Throat AQUORAL MUCOUS MEMBRANE AEROSOL,SPRAY Tier 3 (saliva substitute combo no.3) BOCASAL MUCOUS MEMBRANE POWDER IN PACKET Tier 3 538 MG (saliva substitute combo no.5) CAPHOSOL MUCOUS MEMBRANE SOLUTION (saliva Tier 3 substitute combo no.2) MUCOSITISRX MUCOUS MEMBRANE POWDER IN Tier 3 PACKET 351 MG (saliva substitute combination no.11) NEUTRASAL MUCOUS MEMBRANE POWDER IN Tier 3 PACKET (saliva substitution combination no.10) NUMOISYN MUCOUS MEMBRANE LIQUID (flaxseed) Tier 3 NUMOISYN MUCOUS MEMBRANE LOZENGE 0.3 GRAM (sorbitol/saliva stimulant comb no. 1/malic acid/calcium Tier 3 phos) SALIVAMAX MUCOUS MEMBRANE POWDER IN Tier 3 PACKET 351 MG (saliva substitute combination no.11) XEROSTOMIA RELIEF MUCOUS MEMBRANE Tier 3 AEROSOL,SPRAY (saliva substitute combo no.3) Mouth and Throat - Glucocorticoids - Drugs for the Mouth and Throat triamcinolone acetonide (Oralone Dental Paste 0.1 %) Tier 1 triamcinolone acetonide dental paste 0.1 % Tier 1 Mouth and Throat - Local Anesthetic Amides - Drugs for the Mouth and Throat lidocaine hcl mucous membrane solution 4 % (40 Tier 1 mg/ml) lidocaine hcl (Lidocaine Viscous Mucous Membrane Tier 1 Solution 2 %) Mouth and Throat - Mucositis-Stomatitis Agents - Drugs for the Mouth and Throat EPISIL MUCOUS MEMBRANE GEL FORMING SOLUTION (oral mucositis and stomatitis anti-inflammatory agent Tier 3 comb 2)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 429 Coverage Prescription Drug Name Drug Tier Requirements and Limits Therapy for Drooling- primary or secondary sialorrhea-Anticholinergic - Drugs for the Mouth and Throat CUVPOSA ORAL SOLUTION 1 MG/5 ML (0.2 MG/ML) Tier 3 (glycopyrrolate) Multiple Sclerosis Agents - Drugs for the Nervous System Multiple Sclerosis Agent - CD20 Specific Monoclonal Antibody - Drugs for Multiple Sclerosis KESIMPTA PEN SUBCUTANEOUS PEN INJECTOR 20 Tier 2 PA; SP MG/0.4 ML (ofatumumab) Multiple Sclerosis Agent - Interferons - Drugs for Multiple Sclerosis AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 Tier 2 PA; SP MCG/0.5 ML (interferon beta-1a) AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 Tier 2 PA; SP ML (interferon beta-1a) BETASERON SUBCUTANEOUS KIT 0.3 MG (interferon Tier 2 PA; SP beta-1b) BETASERON SUBCUTANEOUS RECON SOLN 0.3 MG Tier 2 PA; SP (interferon beta-1b) EXTAVIA SUBCUTANEOUS KIT 0.3 MG (interferon beta- Tier 3 PA; SP 1b) EXTAVIA SUBCUTANEOUS RECON SOLN 0.3 MG Tier 3 PA; SP (interferon beta-1b) PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML Tier 2 PA; SP (peginterferon beta-1a) PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG/0.5 ML, Tier 2 PA; SP 63 MCG/0.5 ML- 94 MCG/0.5 ML (peginterferon beta-1a) REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML (interferon beta-1a/albumin Tier 2 PA; SP human)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 432 Coverage Prescription Drug Name Drug Tier Requirements and Limits Miotics - Direct Acting - Drugs for Glaucoma pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 % Tier 1 Mydriatic and Cycloplegic Combinations - Drugs for the Eye CYCLOMYDRIL OPHTHALMIC (EYE) DROPS 0.2-1 % Tier 3 (cyclopentolate hcl/phenylephrine hcl) cyclopen-tropic-phenyleph-watr ophthalmic (eye) drops Tier 1 1-1-2.5 % cyclopent-tropic-phen-ketr-wat ophthalmic (eye) drops Tier 1 1 %-1 %-10 %- 0.5 %, 1 %-1 %-2.5 %- 0.5 % cyclop-trop-propa-phen-ket-wat ophthalmic (eye) drops Tier 1 1 %-1 %-0.1 %- 2.5 %-0.4 % PAREMYD OPHTHALMIC (EYE) DROPS 1-0.25 % Tier 3 (hydroxyamphetamine hbr/tropicamide) phenyleph-tropicamide in water ophthalmic (eye) drops Tier 1 2.5-1 % Ophth - Beta blocker-Adrenerg-Carbonic Anhyd Inhib-Prostagladin Analog - Drugs for Glaucoma timol-brimon-dorzo-latanop(pf) ophthalmic (eye) drops Tier 1 0.5 %-0.15 %- 2 %-0.005 % Ophthalmic - Adrenergic Receptor Agonist - Drugs for the Eye UPNEEQ (PF) OPHTHALMIC (EYE) DROPPERETTE 0.1 Tier 3 % (oxymetazoline hcl/pf) Ophthalmic - Adrenergic-Carbonic Anhydrase Inhibitor Combinations - Drugs for Glaucoma brimonidine-dorzolamide (pf) ophthalmic (eye) drops Tier 1 0.15-2 % SIMBRINZA OPHTHALMIC (EYE) DROPS,SUSPENSION Tier 2 1-0.2 % (brinzolamide/brimonidine tartrate) Ophthalmic - Agents for Corneal Collagen Cross-Linking - Drugs for the Eye PHOTREXA CROSS-LINKING KIT OPHTHALMIC (EYE) COMBO, DROPS AND DROPS VISCOUS 0.146 % -0.146 Tier 3 % (riboflavin 5-phosphate sodium in 20 % dextran) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 433 Coverage Prescription Drug Name Drug Tier Requirements and Limits PHOTREXA OPHTHALMIC (EYE) DROPS 0.146 % Tier 3 (riboflavin 5-phosphate sodium (b2)) PHOTREXA VISCOUS OPHTHALMIC (EYE) DROPS, VISCOUS 0.146 % (riboflavin 5-phosphate sodium in 20 Tier 3 % dextran) Ophthalmic - Antibacterial-Glucocorticoid Combinations - Anti-Infective/Anti- Inflammatories BLEPHAMIDE OPHTHALMIC (EYE) DROPS,SUSPENSION 10-0.2 % (sulfacetamide Tier 2 sodium/prednisolone acetate) sulfacetamide sodium/prednisolone acetate Tier 2 (Blephamide S.O.P. Ophthalmic (Eye) Ointment 10-0.2 %) neomycin-bacitracin-poly-hc ophthalmic (eye) ointment Tier 1 3.5-400-10,000 mg-unit/g-1% neomycin-polymyxin b-dexameth ophthalmic (eye) Tier 1 drops,suspension 3.5mg/ml-10,000 unit/ml-0.1 % neomycin-polymyxin b-dexameth ophthalmic (eye) Tier 1 ointment 3.5 mg/g-10,000 unit/g-0.1 % neomycin-polymyxin-hc ophthalmic (eye) Tier 1 drops,suspension 3.5-10,000-10 mg-unit-mg/ml neomycin sulfate/bacitracin zinc/polymyxin b/hydrocortisone (Neo-Polycin Hc Ophthalmic (Eye) Tier 1 Ointment 3.5-400-10,000 Mg-Unit/G-1%) PRED-G OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3- Tier 3 1 % (gentamicin sulfate/prednisolone acetate) PRED-G S.O.P. OPHTHALMIC (EYE) OINTMENT 0.3-0.6 Tier 3 % (gentamicin sulfate/prednisolone acetate) prednisolone acet-gatifloxacin ophthalmic (eye) Tier 1 drops,suspension 1-0.5 % prednisolone sod ph-moxiflox ophthalmic (eye) drops Tier 1 1-0.5 % prednisolone-moxifloxacin hcl ophthalmic (eye) Tier 1 drops,suspension 1-0.5 % sulfacetamide-prednisolone ophthalmic (eye) drops 10 Tier 1 %-0.23 % (0.25 %)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 435 Coverage Prescription Drug Name Drug Tier Requirements and Limits Ophthalmic - Antihistamines - Drugs for Itchy Eye azelastine ophthalmic (eye) drops 0.05 % Tier 1 ST: At least 2 prior prescriptions for Azelastine BEPREVE OPHTHALMIC (EYE) DROPS 1.5 % HCL, Epinastine HCL, or Tier 3 (bepotastine besilate) Olopatadine HCL within the past 120 days; QL (10 ML per 30 days) epinastine ophthalmic (eye) drops 0.05 % Tier 1 ST: At least 2 prior prescriptions for Azelastine LASTACAFT OPHTHALMIC (EYE) DROPS 0.25 % HCL, Epinastine HCL, or Tier 3 (alcaftadine) Olopatadine HCL within the past 120 days; QL (3 ML per 30 days) olopatadine ophthalmic (eye) drops 0.1 % Tier 1 olopatadine ophthalmic (eye) drops 0.2 % Tier 1 QL (3 ML per 30 days) ZERVIATE OPHTHALMIC (EYE) DROPPERETTE 0.24 % Tier 3 QL (60 EA per 30 days) (cetirizine hcl) Ophthalmic - Anti-Inflammatory, Glucocorticoids - Anti-Infective/Anti- Inflammatories ALREX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.2 % Tier 2 (loteprednol etabonate) dexamethasone sodium phosphate ophthalmic (eye) Tier 1 drops 0.1 % DEXTENZA INTRACANALICULAR INSERT 0.4 MG Tier 3 (dexamethasone) DUREZOL OPHTHALMIC (EYE) DROPS 0.05 % Tier 2 (difluprednate) EYSUVIS OPHTHALMIC (EYE) DROPS,SUSPENSION Tier 3 PA 0.25 % (loteprednol etabonate) FLAREX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 Tier 2 % (fluorometholone acetate) fluorometholone ophthalmic (eye) drops,suspension Tier 1 0.1 %

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 437 Coverage Prescription Drug Name Drug Tier Requirements and Limits Ophthalmic - Anti-Inflammatory, Immunomodulators - Anti-Infective/Anti- Inflammatories ST: Requires prior prescription for Restasis CEQUA OPHTHALMIC (EYE) DROPPERETTE 0.09 % Multidose, Restasis, or Tier 3 (cyclosporine) Xiidra within the past 120 days; QL (60 EA per 30 days) CYCLOSPORINE IN KLARITY OPHTHALMIC (EYE) DROPS 0.1-0.25 % (cyclosporine/chondroitin sulfate a Tier 1 sodium) RESTASIS MULTIDOSE OPHTHALMIC (EYE) DROPS Tier 2 QL (5.5 ML per 30 days) 0.05 % (cyclosporine) RESTASIS OPHTHALMIC (EYE) DROPPERETTE 0.05 % Tier 2 QL (60 EA per 30 days) (cyclosporine) XIIDRA OPHTHALMIC (EYE) DROPPERETTE 5 % Tier 2 QL (60 EA per 30 days) (lifitegrast) Ophthalmic - Anti-inflammatory, NSAIDs - Anti- Infective/Anti-Inflammatories ACUVAIL (PF) OPHTHALMIC (EYE) DROPPERETTE 0.45 Tier 3 % (ketorolac tromethamine/pf) bromfenac ophthalmic (eye) drops 0.09 % Tier 1 BROMSITE OPHTHALMIC (EYE) DROPS 0.075 % Tier 3 (bromfenac sodium) diclofenac sodium ophthalmic (eye) drops 0.1 % Tier 1 flurbiprofen sodium ophthalmic (eye) drops 0.03 % Tier 1 ILEVRO OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3 Tier 2 % (nepafenac) ketorolac ophthalmic (eye) drops 0.4 %, 0.5 % Tier 1 NEVANAC OPHTHALMIC (EYE) DROPS,SUSPENSION Tier 3 0.1 % (nepafenac) PROLENSA OPHTHALMIC (EYE) DROPS 0.07 % Tier 2 (bromfenac sodium)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 438 Coverage Prescription Drug Name Drug Tier Requirements and Limits Ophthalmic - Beta blocker-Adrenergic-Carbonic Anhydrase Inhibitor Comb - Drugs for Glaucoma timolol-brimonidi-dorzolam(pf) ophthalmic (eye) drops Tier 1 0.5-0.15-2 % Ophthalmic - Beta blocker-Carbonic Anhydrase Inhib-Prostagladin Analog - Drugs for Glaucoma timolol-dorzolamid-latanop(pf) ophthalmic (eye) drops Tier 1 0.5-2-0.005 % Ophthalmic - Beta blockers-Adrenergic Combinations - Drugs for Glaucoma COMBIGAN OPHTHALMIC (EYE) DROPS 0.2-0.5 % Tier 2 (brimonidine tartrate/timolol maleate) Ophthalmic - Beta blockers-Carbonic Anhydrase Inhibitor Combinations - Drugs for Glaucoma dorzolamide-timolol (pf) ophthalmic (eye) dropperette 2- Tier 1 QL (2 EA per 1 day) 0.5 % dorzolamide-timolol (pf) ophthalmic (eye) drops 2-0.5 % Tier 1 dorzolamide-timolol ophthalmic (eye) drops 22.3-6.8 Tier 1 mg/ml Ophthalmic - Beta blockers-Prostaglandin Analog Combinations - Drugs for Glaucoma timolol-latanoprost(pf) ophthalmic (eye) drops 0.5-0.005 Tier 1 % Ophthalmic - Carbonic Anhydrase Inhibitors - Drugs for Glaucoma AZOPT OPHTHALMIC (EYE) DROPS,SUSPENSION 1 % Tier 2 (brinzolamide) dorzolamide (pf) ophthalmic (eye) drops 2 % Tier 1 dorzolamide ophthalmic (eye) drops 2 % Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 439 Coverage Prescription Drug Name Drug Tier Requirements and Limits Ophthalmic - Cystine Depleting Agents - Drugs for the Eye CYSTADROPS OPHTHALMIC (EYE) DROPS 0.37 % Tier 2 PA; SP (cysteamine hcl) CYSTARAN OPHTHALMIC (EYE) DROPS 0.44 % Tier 2 PA; SP (cysteamine hcl) Ophthalmic - Decongestants - Drugs for Itchy Eye phenylephrine hcl ophthalmic (eye) drops 10 %, 2.5 % Tier 1 Ophthalmic - Diagnostic Agents - Drugs for the Eye fluorescein-proparacaine ophthalmic (eye) drops 0.25- Tier 1 0.5 % Ophthalmic - Glucocorticoid-NSAID Combinations - Anti-Infective/Anti- Inflammatories prednisolone acetate-bromfenac ophthalmic (eye) Tier 1 drops,suspension 1-0.075 % prednisolone acetate-nepafenac ophthalmic (eye) Tier 1 drops,suspension 1-0.1 % Ophthalmic - Human Nerve Growth Factor (hNGF) - Drugs for the Eye OXERVATE OPHTHALMIC (EYE) DROPS 0.002 % Tier 3 PA; SP (cenegermin-bkbj) Ophthalmic - Intraocular Pressure Reducing Agents, Beta-blockers - Drugs for Glaucoma betaxolol ophthalmic (eye) drops 0.5 % Tier 1 BETIMOL OPHTHALMIC (EYE) DROPS 0.25 %, 0.5 % Tier 3 (timolol) BETOPTIC S OPHTHALMIC (EYE) DROPS,SUSPENSION Tier 3 0.25 % (betaxolol hcl) carteolol ophthalmic (eye) drops 1 % Tier 1 levobunolol ophthalmic (eye) drops 0.5 % Tier 1 metipranolol ophthalmic (eye) drops 0.3 % Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 440 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Requires prior prescription for Timolol Maleate or Timoptic timolol maleate (pf) ophthalmic (eye) dropperette 0.5 % Tier 1 Ocudose within the past 120 days; QL (2 EA per 1 day) timolol maleate ophthalmic (eye) drops 0.25 %, 0.5 % Tier 1 timolol maleate ophthalmic (eye) drops, once daily 0.5 Tier 1 % timolol maleate ophthalmic (eye) gel forming solution Tier 1 0.25 %, 0.5 % ST: Requires prior prescription for Timolol TIMOPTIC OCUDOSE (PF) OPHTHALMIC (EYE) Maleate or Timoptic Tier 3 DROPPERETTE 0.25 %, 0.5 % (timolol maleate/pf) Ocudose within the past 120 days; QL (2 EA per 1 day) Ophthalmic - Local Anesthetic Combinations - Drugs for the Eye ALTAFLUOR BENOX OPHTHALMIC (EYE) DROPS 0.25- Tier 1 0.4 % (benoxinate hcl/fluorescein sodium) Ophthalmic - Local Anesthetic Esters - Drugs for the Eye proparacaine hcl (Alcaine Ophthalmic (Eye) Drops 0.5 %) Tier 1 ALTACAINE OPHTHALMIC (EYE) DROPS 0.5 % Tier 1 (tetracaine hcl) proparacaine ophthalmic (eye) drops 0.5 % Tier 1 tetracaine hcl (pf) ophthalmic (eye) drops 0.5 % Tier 1 tetracaine hcl ophthalmic (eye) drops 0.5 % Tier 1 Ophthalmic - Local Anesthetic, Amides - Drugs for the Eye AKTEN (PF) OPHTHALMIC (EYE) GEL 3.5 % (lidocaine Tier 3 hcl/pf)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 441 Coverage Prescription Drug Name Drug Tier Requirements and Limits Ophthalmic - Mast Cell Stabilizers - Drugs for Itchy Eye ALOCRIL OPHTHALMIC (EYE) DROPS 2 % (nedocromil Tier 2 sodium) ALOMIDE OPHTHALMIC (EYE) DROPS 0.1 % Tier 2 (lodoxamide tromethamine) cromolyn ophthalmic (eye) drops 4 % Tier 1 Ophthalmic - Mydriatic-NSAID Combinations - Anti-Infective/Anti-Inflammatories MYDRIATIC4(TROP-PROP-PE-KTRLC) OPHTHALMIC (EYE) DROPS 1-0.5-2.5-0.5 % Tier 1 (tropicamide/proparacaine/phenylephrine/ketorolac in water) tropic-proparacai-pe-ketor-wat ophthalmic (eye) drops Tier 1 1-0.5-2.5-0.5 % Ophthalmic - Rho Kinase Inhibitor and Prostaglandin Analog Combination - Drugs for Glaucoma ST: At least 2 prior prescriptions for Alphagan P, Azopt, Combigan, ROCKLATAN OPHTHALMIC (EYE) DROPS 0.02-0.005 % Tier 3 Latanoprost, Lumigan, (netarsudil mesylate/latanoprost) Simbrinza, or Travoprost within the past 365 days; QL (2.5 ML per 25 days) Ophthalmic - Surgical Aids Other - Drugs for the Eye GELFILM OPHTHALMIC (EYE) FILM (gelatin) Tier 3 Ophthalmic Antibacterial Mixtures - Anti- Infective/Anti-Inflammatories bacitracin/polymyxin b sulfate (Ak-Poly-Bac Ophthalmic Tier 1 (Eye) Ointment 500-10,000 Unit/Gram) bacitracin-polymyxin b ophthalmic (eye) ointment 500- Tier 1 10,000 unit/gram neomycin-bacitracin-polymyxin ophthalmic (eye) Tier 1 ointment 3.5-400-10,000 mg-unit-unit/g

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 442 Coverage Prescription Drug Name Drug Tier Requirements and Limits neomycin-polymyxin-gramicidin ophthalmic (eye) drops Tier 1 1.75 mg-10,000 unit-0.025mg/ml neomycin sulfate/bacitracin/polymyxin b (Neo-Polycin Tier 1 Ophthalmic (Eye) Ointment 3.5-400-10,000 Mg-Unit-Unit/G) bacitracin/polymyxin b sulfate (Polycin Ophthalmic (Eye) Tier 1 Ointment 500-10,000 Unit/Gram) polymyxin b sulf-trimethoprim ophthalmic (eye) drops Tier 1 10,000 unit- 1 mg/ml Ophthalmic Antibiotic - Aminoglycosides - Anti-Infective/Anti-Inflammatories gentamicin sulfate (Gentak Ophthalmic (Eye) Ointment 0.3 Tier 1 % (3 Mg/Gram)) gentamicin ophthalmic (eye) drops 0.3 % Tier 1 tobramycin ophthalmic (eye) drops 0.3 % Tier 1 TOBREX OPHTHALMIC (EYE) OINTMENT 0.3 % Tier 2 (tobramycin) Ophthalmic Antibiotic - Dehydropeptidase Inhibitors - Anti-Infective/Anti-Inflammatories bacitracin ophthalmic (eye) ointment 500 unit/gram Tier 1 Ophthalmic Antibiotic - Fluoroquinolones - Anti-Infective/Anti-Inflammatories BESIVANCE OPHTHALMIC (EYE) DROPS,SUSPENSION Tier 2 0.6 % (besifloxacin hcl) CILOXAN OPHTHALMIC (EYE) OINTMENT 0.3 % Tier 2 (ciprofloxacin hcl) ciprofloxacin hcl ophthalmic (eye) drops 0.3 % Tier 1 gatifloxacin ophthalmic (eye) drops 0.5 % Tier 1 levofloxacin ophthalmic (eye) drops 0.5 % Tier 1 moxifloxacin ophthalmic (eye) drops 0.5 % Tier 1 moxifloxacin ophthalmic (eye) drops, viscous 0.5 % Tier 1 ofloxacin ophthalmic (eye) drops 0.3 % Tier 1 Ophthalmic Antibiotic - Macrolides - Anti- Infective/Anti-Inflammatories AZASITE OPHTHALMIC (EYE) DROPS 1 % Tier 3 (azithromycin) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 443 Coverage Prescription Drug Name Drug Tier Requirements and Limits erythromycin ophthalmic (eye) ointment 5 mg/gram (0.5 Tier 1 %) KLARITY-A (AZITHRO-CHONDR)(PF) OPHTHALMIC (EYE) DROPS 1-0.25 % (azithromycin/chondroitin Tier 3 sulfate a sodium/pf) Ophthalmic Antibiotic - Sulfonamides - Anti- Infective/Anti-Inflammatories sulfacetamide sodium (Bleph-10 Ophthalmic (Eye) Drops Tier 1 10 %) sulfacetamide sodium ophthalmic (eye) drops 10 % Tier 1 sulfacetamide sodium ophthalmic (eye) ointment 10 % Tier 1 Ophthalmic Antifungals - Anti-Infective/Anti- Inflammatories NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION 5 Tier 3 % (natamycin) Ophthalmic Antifungals - Tetraene Polyene- type - Drugs for the Eye NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION 5 Tier 3 % (natamycin) Ophthalmic Antiseptics - Anti-Infective/Anti- Inflammatories BETADINE OPHTHALMIC PREP OPHTHALMIC (EYE) Tier 3 SOLUTION 5 % (povidone-iodine) Ophthalmic Antivirals - Anti-Infective/Anti- Inflammatories trifluridine ophthalmic (eye) drops 1 % Tier 1 ZIRGAN OPHTHALMIC (EYE) GEL 0.15 % (ganciclovir) Tier 2 Ophthalmic-Intraocular Press. Reducing, Sel. Alpha Adrenergic Agonists - Drugs for Glaucoma ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 % Tier 2 (brimonidine tartrate) apraclonidine ophthalmic (eye) drops 0.5 % Tier 1 brimonidine ophthalmic (eye) drops 0.15 %, 0.2 % Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 447 Coverage Prescription Drug Name Drug Tier Requirements and Limits cardioplegic solution no.25 perfusion solution 29 Tier 1 mmol/l (potassium) Otic (Ear) - Drugs for the Ear Otic (Ear) - Anti-infective-Glucocorticoid Combinations - Anti-Infective/Anti- Inflammatories CIPRO HC OTIC (EAR) DROPS,SUSPENSION 0.2-1 % Tier 3 (ciprofloxacin hcl/hydrocortisone) ciprofloxacin-dexamethasone otic (ear) Tier 1 drops,suspension 0.3-0.1 % ciprofloxacin-fluocinolone otic (ear) solution 0.3-0.025 Tier 1 % (0.25 ml) CORTISPORIN-TC OTIC (EAR) DROPS,SUSPENSION 3.3-3-10-0.5 MG/ML (neomycin sulf/colistin Tier 3 sul/hydrocortisone ac/thonzonium brom) neomycin-polymyxin-hc otic (ear) drops,suspension Tier 1 3.5-10,000-1 mg/ml-unit/ml-% neomycin-polymyxin-hc otic (ear) solution 3.5-10,000-1 Tier 1 mg/ml-unit/ml-% Otic (Ear) - Anti-infectives other - Antibiotics acetic acid otic (ear) solution 2 % Tier 1 Otic (Ear) - Fluoroquinolones - Antibiotics ciprofloxacin hcl otic (ear) dropperette 0.2 % Tier 1 ofloxacin otic (ear) drops 0.3 % Tier 1 OTIPRIO INTRATYMPANIC SUSPENSION 6 % (6 MG/0.1 Tier 3 ML) (ciprofloxacin) Otic (Ear) - Glucocorticoids - Anti- Infective/Anti-Inflammatories fluocinolone acetonide oil otic (ear) drops 0.01 % Tier 1 hydrocortisone-acetic acid otic (ear) drops 1-2 % Tier 1 Otic (Ear) - Pinna Combinations - Antibiotics CORTANE-B TOPICAL LOTION 1-1-0.1 % Tier 3 (hydrocortisone/pramoxine hcl/chloroxylenol)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 448 Coverage Prescription Drug Name Drug Tier Requirements and Limits Respiratory Therapy Agents - Drugs for the Lungs 1st Generation Antihistamine-Decongestant Combinations - Drugs for Cough and Cold promethazine-phenylephrine oral syrup 6.25-5 mg/5 ml Tier 1 1st Generation Antihistamine-Decongestant- Anticholinergic Combinations - Drugs for Cough and Cold RESPA-AR ORAL TABLET EXTENDED RELEASE 12 HR 8-90-0.24 MG (pseudoephedrine hcl/chlorpheniramine Tier 1 maleate/bellad alk) 2nd Generation Antihistamine-Decongestant Combinations - Drugs for Cough and Cold ST: Requires prior prescription for CLARINEX-D 12 HOUR ORAL TABLET, ER MULTIPHASE Desloratadine or 12 HR 2.5-120 MG (desloratadine/pseudoephedrine Tier 3 Levocetirizine tablets within sulfate) the past 120 days; QL (2 EA per 1 day) fexofenadine-pseudoephedrine oral tablet extended Tier 1 release 24 hr 180-240 mg SEMPREX-D ORAL CAPSULE 8-60 MG Tier 3 (pseudoephedrine hcl/acrivastine) Antihistamine - 1st Generation - Alkylamines - Drugs for Allergies dexchlorpheniramine maleate oral solution 2 mg/5 ml Tier 1 QL (236 ML per 1 FILL) Antihistamine - 1st Generation - Ethanolamines - Drugs for Allergies carbinoxamine maleate oral liquid 4 mg/5 ml Tier 1 Age (Min 2 Years) carbinoxamine maleate oral tablet 4 mg Tier 1 Age (Min 2 Years)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 449 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Requires prior prescriptions for Carbinoxamine tablet carbinoxamine maleate oral tablet 6 mg Tier 1 (4mg) and solution (4mg/5mL) within the past 365 days; QL (4 EA per 1 day); Age (Min 2 Years) clemastine oral tablet 2.68 mg Tier 1 diphenhydramine hcl (Diphen Oral Elixir 12.5 Mg/5 Ml) Tier 1 ST: Requires prior prescription for KARBINAL ER ORAL SUSPENSION,EXTENDED REL 12 Carbinoxamine Maleate Tier 3 HR 4 MG/5 ML (carbinoxamine maleate) within the past 120 days; QL (960 ML per 30 days); Age (Min 2 Years) Antihistamine - 1st Generation - Phenothiazines - Drugs for Allergies promethazine injection solution 25 mg/ml, 50 mg/ml Tier 1 promethazine injection syringe 25 mg/ml Tier 1 promethazine oral syrup 6.25 mg/5 ml Tier 1 promethazine oral tablet 12.5 mg, 25 mg, 50 mg Tier 1 promethazine rectal suppository 12.5 mg, 25 mg, 50 mg Tier 1 promethazine hcl (Promethegan Rectal Suppository 12.5 Tier 1 Mg, 25 Mg, 50 Mg) Antihistamine - 1st Generation - Piperidines - Drugs for Allergies cyproheptadine oral syrup 2 mg/5 ml Tier 1 cyproheptadine oral tablet 4 mg Tier 1 Antihistamines - 1st Generation - Drugs for Allergies carbinoxamine maleate oral liquid 4 mg/5 ml Tier 1 Age (Min 2 Years)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 450 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Requires prior prescriptions for Carbinoxamine tablet carbinoxamine maleate oral tablet 6 mg Tier 1 (4mg) and solution (4mg/5mL) within the past 365 days; QL (4 EA per 1 day); Age (Min 2 Years) clemastine oral tablet 2.68 mg Tier 1 dexchlorpheniramine maleate oral solution 2 mg/5 ml Tier 1 QL (236 ML per 1 FILL) ST: Requires prior prescription for KARBINAL ER ORAL SUSPENSION,EXTENDED REL 12 Carbinoxamine Maleate Tier 3 HR 4 MG/5 ML (carbinoxamine maleate) within the past 120 days; QL (960 ML per 30 days); Age (Min 2 Years) promethazine rectal suppository 50 mg Tier 1 promethazine hcl (Promethegan Rectal Suppository 25 Tier 1 Mg) Antihistamines - 2nd Generation - Drugs for Allergies cetirizine oral solution 1 mg/ml Tier 1 desloratadine oral tablet 5 mg Tier 1 QL (1 EA per 1 day) ST: Requires prior prescription for Desloratadine or desloratadine oral tablet,disintegrating 2.5 mg, 5 mg Tier 1 Levocetirizine tablets within the past 120 days; QL (1 EA per 1 day) ST: Requires prior prescription for Desloratadine or levocetirizine oral solution 2.5 mg/5 ml Tier 1 Levocetirizine tablets within the past 120 days; QL (10 ML per 1 day) levocetirizine oral tablet 5 mg Tier 1 Antitussives - Non-Opioid - Drugs for Allergies benzonatate oral capsule 100 mg, 150 mg, 200 mg Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 456 Coverage Prescription Drug Name Drug Tier Requirements and Limits albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 Tier 1 mg/ml albuterol sulfate inhalation solution for nebulization 2.5 Tier 1 mg/0.5 ml levalbuterol hcl inhalation solution for nebulization 0.31 Tier 1 mg/3 ml, 0.63 mg/3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml levalbuterol tartrate inhalation hfa aerosol inhaler 45 Tier 1 mcg/actuation PROAIR DIGIHALER INHALATION AERO POWDR BREATH ACT W/SENSOR 90 MCG/ACTUATION Tier 3 (albuterol sulfate) PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION (albuterol Tier 2 sulfate) Asthma/COPD Therapy - Beta Adrenergic Agents - Drugs for Asthma/COPD albuterol sulfate oral syrup 2 mg/5 ml Tier 1 albuterol sulfate oral tablet 2 mg, 4 mg Tier 1 albuterol sulfate oral tablet extended release 12 hr 4 Tier 1 mg, 8 mg metaproterenol oral syrup 10 mg/5 ml Tier 1 terbutaline oral tablet 2.5 mg, 5 mg Tier 1 Asthma/COPD Therapy - Beta Adrenergic- Anticholinergic Combinations - Drugs for Asthma/COPD ANORO ELLIPTA INHALATION BLISTER WITH DEVICE 62.5-25 MCG/ACTUATION (umeclidinium Tier 2 QL (60 EA per 30 days) bromide/vilanterol trifenatate) ST: Requires prior BEVESPI AEROSPHERE INHALATION HFA AEROSOL prescription for Anoro INHALER 9-4.8 MCG (glycopyrrolate/formoterol Tier 3 Ellipta and Stiolto Respimat fumarate) within the past 365 days; QL (10.7 GM per 30 days) COMBIVENT RESPIMAT INHALATION MIST 20-100 MCG/ACTUATION (ipratropium bromide/albuterol Tier 2 sulfate)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 458 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Requires prior prescription for Advair HFA, Breo Ellipta, DULERA INHALATION HFA AEROSOL INHALER 100-5 Budesonide/Formoterol MCG/ACTUATION, 200-5 MCG/ACTUATION Tier 3 Fumarate, or Fluticasone (mometasone furoate/formoterol fumarate) Propionate/Salmeterolor within the past 120 days; QL (13 GM per 30 days) ST: Requires prior prescription for Advair HFA, Breo Ellipta, DULERA INHALATION HFA AEROSOL INHALER 50-5 Budesonide/Formoterol MCG/ACTUATION (mometasone furoate/formoterol Tier 3 Fumarate, or Fluticasone fumarate) Propionate/Salmeterolor within the past 120 days; QL (39 GM per 25 days) ST: Requires prior prescription for Advair HFA, Breo Ellipta, fluticasone propion-salmeterol inhalation aerosol Budesonide/Formoterol powdr breath activated 113-14 mcg/actuation, 232-14 Tier 3 Fumarate, or Fluticasone mcg/actuation, 55-14 mcg/actuation Propionate/Salmeterolor within the past 120 days; QL (1 EA per 30 days) SYMBICORT INHALATION HFA AEROSOL INHALER 160- Tier 2 QL (10.2 GM per 30 days) 4.5 MCG/ACTUATION (budesonide/formoterol fumarate) SYMBICORT INHALATION HFA AEROSOL INHALER 80- Tier 2 QL (40.8 GM per 30 days) 4.5 MCG/ACTUATION (budesonide/formoterol fumarate) Asthma/COPD Tx - Beta-adrenergic- Anticholinergic-Glucocorticoid comb, - Drugs for Cystic Fibrosis BREZTRI AEROSPHERE INHALATION HFA AEROSOL INHALER 160-9-4.8 MCG/ACTUATION Tier 2 QL (10.7 GM per 30 days) (budesonide/glycopyrrolate/formoterol fumarate) TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-62.5-25 MCG (fluticasone furoate/umeclidinium Tier 2 QL (60 EA per 30 days) bromide/vilanterol trifenat) TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 200-62.5-25 MCG (fluticasone furoate/umeclidinium Tier 2 QL (2 EA per 1 day) bromide/vilanterol trifenat) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 459 Coverage Prescription Drug Name Drug Tier Requirements and Limits Cystic Fibrosis - Inhaled Aminoglycosides - Drugs for Cystic Fibrosis TOBI PODHALER INHALATION CAPSULE, Tier 2 PA; SP W/INHALATION DEVICE 28 MG (tobramycin) tobramycin in 0.225 % nacl inhalation solution for Tier 1 PA; SP nebulization 300 mg/5 ml tobramycin inhalation solution for nebulization 300 Tier 1 PA; SP mg/4 ml tobramycin with nebulizer inhalation solution for Tier 1 PA; SP nebulization 300 mg/5 ml Cystic Fibrosis - Inhaled Monobactams - Drugs for Cystic Fibrosis CAYSTON INHALATION SOLUTION FOR NEBULIZATION Tier 2 PA; SP 75 MG/ML (aztreonam lysine) Cystic Fibrosis-Transmembrane Conductance Regulator (CFTR) Potentiator - Drugs for Cystic Fibrosis KALYDECO ORAL GRANULES IN PACKET 25 MG, 50 Tier 2 PA; SP MG, 75 MG (ivacaftor) KALYDECO ORAL TABLET 150 MG (ivacaftor) Tier 2 PA; SP Cystic Fib-Transmemb Conduct. Reg.(CFTR) Potentiator and Corrector Cmb - Drugs for Cystic Fibrosis ORKAMBI ORAL GRANULES IN PACKET 100-125 MG, Tier 2 PA; SP 150-188 MG (lumacaftor/ivacaftor) ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG Tier 2 PA; SP (lumacaftor/ivacaftor) SYMDEKO ORAL TABLETS, SEQUENTIAL 100-150 MG (D)/ 150 MG (N), 50-75 MG (D)/ 75 MG (N) Tier 2 PA; SP (tezacaftor/ivacaftor) TRIKAFTA ORAL TABLETS, SEQUENTIAL 100-50-75 Tier 2 PA; SP MG(D) /150 MG (N) (elexacaftor/tezacaftor/ivacaftor) Elastase Inhibitors - Drugs for Asthma/COPD ARALAST NP INTRAVENOUS RECON SOLN 1,000 MG, Tier 3 SP 500 MG (alpha-1-proteinase inhibitor)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 462 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Requires prior prescription for Flunisolide, XHANCE NASAL AEROSOL BREATH ACTIVATED 93 Fluticasone Propionate, or Tier 2 MCG/ACTUATION (fluticasone propionate) Mometasone Furoate within the past 120 days; QL (32 ML per 30 days) ST: Requires prior prescription for Flunisolide ZETONNA NASAL HFA AEROSOL INHALER 37 Tier 3 or Fluticasone Propionate MCG/ACTUATION (ciclesonide) within the past 120 days; QL (6.1 GM per 30 days) Nasal Preparations Other - Drugs for the Nose ALZAIR NASAL SPRAY,NON-AEROSOL (hypromellose) Tier 3 Nasal Sympathomimetic Decongestants (Intranasal) - Allergy epinephrine hcl nasal solution 1 mg/ml Tier 1 TYZINE NASAL DROPS 0.1 % (tetrahydrozoline hcl) Tier 3 TYZINE NASAL SPRAY,NON-AEROSOL 0.1 % Tier 3 (tetrahydrozoline hcl) Non-Opioid Antitussive-1st Gen.Antihistamine- Decongestant Combinations - Drugs for Cough and Cold brompheniramine maleate/pseudoephedrine hcl/dextromethorphan (Bromfed Dm Oral Syrup 2-30-10 Tier 1 Mg/5 Ml) brompheniramine-pseudoeph-dm oral syrup 2-30-10 Tier 1 mg/5 ml Non-Opioid Antitussive-Antihistamine Combinations - Drugs for Cough and Cold promethazine-dm oral syrup 6.25-15 mg/5 ml Tier 1 Opioid Antitussive-1st Generation Antihistamine Combinations - Drugs for Cough and Cold hydrocodone-chlorpheniramine oral QL (10 ML per 1 day); Age Tier 1 suspension,extended rel 12 hr 10-8 mg/5 ml (Min 18 Years)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 467 Index of Drugs 1ST TIER UNILET acetaminophen-caff- ADMELOG SOLOSTAR U- COMFORTOUCH...... 340 dihydrocod...... 15, 16 100 INSULIN...... 249 abacavir...... 43 acetaminophen-codeine..... 15 ADMELOG U-100 INSULIN abacavir-lamivudine...... 45 acetazolamide...... 97 LISPRO...... 250 abacavir-lamivudine- acetic acid...... 276, 448 ADULT ASPIRIN REGIMEN..32 zidovudine...... 45 acetylcysteine...... 461 ADULT LOW DOSE ABILIFY MYCITE...... 124, 130 ACIPHEX SPRINKLE...... 264 ASPIRIN...... 32, 294 abiraterone...... 60, 62 acitretin...... 181 ADVAIR DISKUS...... 458 ABSORICA...... 165 ACTEMRA...... 25 ADVAIR HFA...... 458 ABSORICA LD...... 165 ACTEMRA ACTPEN...... 25 ADVANCE PLUS acamprosate...... 147 ACTHAR...... 224 INTERMITTENT...... 374, 379 acarbose...... 226 ACTICOAT 7 DRESSING....213 ADVANCED ALLERGY ACCUCAINE KIT...... 33, 202 ACTICOAT DRESSING...... 213 COLLECT KIT...... 189 ACCU-CHEK AVIVA PLUS ACTICOAT FLEX 3 ADVANCED GLUC METER TEST STRP...... 302 DRESSING...... 213 TEST STRIP...... 303 ACCU-CHEK COMBO ACTICOAT FLEX 7 ADVANCED TRAVEL SYSTEM...... 375, 378 DRESSING...... 213 LANCETS...... 341, 379 ACCU-CHEK FASTCLIX ACTICOAT SURGICAL ADVATE...... 286 LANCET DRUM...... 340, 378 DRESSING...... 214 ADVOCATE LANCET...... 341 ACCU-CHEK GUIDE TEST ACTI-LANCE LANCETS...... 341 ADVOCATE REDI-CODE....303 STRIPS...... 302 ACTIMMUNE...... 40 ADVOCATE REDI-CODE ACCU-CHEK LINKASSIST ACTIVE-PAC...... 105, 143 PLUS...... 303 INS DEV...... 364 ACUICYN...... 189 ADVOCATE SYRINGES ACCU-CHEK MULTICLIX ACUVAIL (PF)...... 438 ...... 348, 379 LANCET...... 340 acyclovir...... 51, 185 ADVOCATE TEST STRIPS ACCU-CHEK RAPID-D LINK ADACEL(TDAP ...... 304, 379 ...... 373, 378 ADOLESN/ADULT)(PF).. 76, 77 ADYNOVATE...... 286 ACCU-CHEK SAFE-T-PRO 340 adapalene...... 172 ADZENYS ER...... 125, 132 ACCU-CHEK SAFE-T-PRO adapalene-benzoyl ADZENYS XR-ODT.....125, 132 PLUS...... 340, 378 peroxide...... 171 AEMCOLO...... 55 ACCU-CHEK SMARTVIEW adapalene-benzoyl perox- AEROBIKA OSCILLATING TEST STRIP...... 302 niacin...... 171 PEP SYSTM...... 365, 379 ACCU-CHEK SOFTCLIX adapalene-benzoyl- AEROCHAMBER MINI 365, 379 LANCETS...... 340 clindamycin...... 170 AEROCHAMBER MV.. 365, 379 ACCU-CHEK SPIRIT ADASUVE...... 122 AEROCHAMBER PLUS ADAPTER...... 364, 378 ADAZIN...... 201 FLOW-VU...... 365 ACCU-CHEK SPIRIT ADDERALL XR....124, 131, 132 AEROCHAMBER PLUS CARTRIDGE SYS...... 364, 378 ADDYI...... 135 FLOW-VU,L MSK...... 365 ACCU-CHEK SPIRIT CLIP adefovir...... 49 AEROCHAMBER PLUS CASE...... 361, 364, 379 ADEMPAS...... 101 FLOW-VU,M MSK...... 365 ACCUTREND GLUCOSE adenovirus vac live type-4, AEROCHAMBER PLUS TEST STRIPS...... 303 7...... 75, 78 FLOW-VU,S MSK...... 365 ACD SOLUTION A...... 283 adenovirus vaccine live AEROCHAMBER PLUS Z ACD-A...... 283 type-4...... 75, 78 STAT...... 366, 380 ACE AEROSOL CLOUD adenovirus vaccine live AEROCHAMBER PLUS Z ENHANCER...... 365, 379 type-7...... 75, 78 STAT LG MSK...... 365, 379 acebutolol...... 93 ADHANSIA XR...... 124 AEROCHAMBER PLUS Z ACESO AG...... 213 ADLYXIN...... 231 STAT MD MSK...... 365, 379

468 AEROCHAMBER PLUS Z ALDACTAZIDE...... 98 ALTABAX...... 176 STAT SM MSK...... 365, 379 ALECENSA...... 61 ALTACAINE...... 441 AEROCHAMBER WITH alendronate...... 236 ALTAFLUOR BENOX...... 441 FLOWSIGNAL...... 366, 380 ALFERON N...... 199 Altavera (28)...... 153 AEROCHAMBER Z-STAT alfuzosin...... 278 ALTERA NEBULIZER. 362, 381 PLUS-FLW SG...... 366, 380 ALINIA...... 41 ALTERA NEBULIZER AEROECLIPSE II aliskiren...... 101 SYSTEM...... 362, 381 NEBULIZER...... 362, 380 ALKINDI SPRINKLE...... 241 ALTERNATE SITE LANCET AEROGEAR ACTION ALL FLOW 1000 KIT...... 366 ...... 341, 381 ASTHMA KIT...... 365, 380 ALL FLOW 1000 PFT ALTOPREV...... 88 AERONEB GO...... 366 FILTER...... 366 ALTRENO...... 172 AERONEB GO NEBULIZER ALL FLOW 3000 KIT...... 366 ALUNBRIG...... 61 ...... 362 ALL FLOW 3000 PFT ALVESCO...... 452 AEROTRACH PLUS....366, 380 FILTER...... 366 alvimopan...... 36 AEROVENT PLUS...... 366, 380 ALL FLOW 4000 KIT...... 366 Alyacen 1/35 (28)...... 153 AFINITOR...... 67 ALL FLOW 4000 PFT Alyacen 7/7/7 (28)...... 161 AFINITOR DISPERZ...... 67 FILTER...... 366 Alyq...... 101 Afirmelle...... 153 ALL FLOW 5000 KIT...... 366 ALZAIR...... 463 AFLURIA QD 2020-21(3YR ALL FLOW 5000 PFT Amabelz...... 238 UP)(PF)...... 79 FILTER...... 366 amantadine hcl...... 120 AFLURIA QD 2020-21(6- ALL FLOW 6000 PFT ambrisentan...... 101 35MO)(PF)...... 79 FILTER...... 366 amcinonide...... 189 AFLURIA QUAD 2020- ALLEVYN...... 214, 381 AMELUZ...... 205 2021(6MO UP)...... 79 ALLEVYN ADHESIVE Amethia...... 151 AFREZZA...... 246 DRESSING...... 214, 340, 380 Amethia Lo...... 151 AFSTYLA...... 286 ALLEVYN AG...... 214 Amethyst (28)...... 153 AFTERA...... 164 ALLEVYN AG ADHESIVE... 214 AMIELLE VAGINAL AGAMATRIX AMP TEST ALLEVYN AG GENTLE TRAINER...... 361 STRIPS...... 304, 380 DRESSING...... 214 amiloride...... 98 AGAMATRIX PRESTO ALLEVYN HEEL...... 214, 380 amiloride- TEST STRIPS...... 304, 380 ALLEVYN LIFE DRESSING hydrochlorothiazide...... 98 A-Hydrocort...... 241 ...... 214, 301, 380 aminocaproic acid...... 290 AIMOVIG AUTOINJECTOR 136 allopurinol...... 282 amiodarone...... 86 AIRDUO DIGIHALER...... 458 Allzital...... 20 AMITIZA...... 270, 273 AIRS DISPOSABLE almotriptan malate...... 137 amitriptyline...... 117 NEBULIZER...... 362, 380 ALOCRIL...... 442 amitriptyline- AJOVY AUTOINJECTOR....136 alogliptin...... 227 chlordiazepoxide...... 117 AJOVY SYRINGE...... 136 alogliptin-metformin...... 232 amlodipine...... 95 AKLIEF...... 172 alogliptin-pioglitazone...... 232 amlodipine-atorvastatin...... 91 Ak-Poly-Bac...... 442 ALOMIDE...... 442 amlodipine-benazepril...... 81 AKTEN (PF)...... 441 ALORA...... 238 amlodipine-olmesartan...... 83 AKYNZEO (NETUPITANT). 262 alosetron...... 273 amlodipine-valsartan...... 83 Ala-Cort...... 189 ALPHAGAN P...... 444 amlodipine-valsartan- ALA-QUIN...... 176 ALPHANATE...... 287 hcthiazid...... 83 Ala-Scalp...... 189 ALPHANINE SD...... 285 ammonium lactate...... 188 albendazole...... 38 alprazolam...... 102 Amnesteem...... 165 albuterol sulfate...... 456, 457 ALPRAZOLAM INTENSOL amoxapine...... 117 Alcaine...... 441 ...... 102, 128 amoxicil-clarithromy- alclometasone...... 189 ALPROLIX...... 285 lansopraz...... 275 ALCORTIN A...... 176 ALREX...... 436 amoxicillin...... 37 469 amoxicillin-pot clavulanate ARALAST NP...... 460 atorvastatin...... 88 ...... 37, 38 Aranelle (28)...... 161 atovaquone...... 41 amphetamine...... 125, 132 ARANESP (IN atovaquone-proguanil...... 40 amphetamine sulfate...... 132 POLYSORBATE)...... 285 ATRAPRO CP...... 186 ampicillin...... 37 ARAZLO...... 172 ATRAPRO DERMAL amyl nitrite...... 35, 84 ARCALYST...... 21 SPRAY...... 72, 213 AMZEEQ...... 167 ARCAPTA NEOHALER...... 456 ATRAPRO HYDROGEL...... 186 ANACAINE...... 210 ARESTIN...... 429 ATROPEN...... 99 ANADROL-50...... 225 ARGYLE TRACHEOSTOMY atropine...... 435 anagrelide...... 294 CARE TRAY...... 361, 381 ATROVENT HFA...... 456 ANA-LEX KIT...... 34 ARIKAYCE...... 37 AUBAGIO...... 432 ANALPRAM-HC...... 197 aripiprazole...... 130 Aubra...... 153 ANASCORP...... 73 armodafinil...... 141 Aubra Eq...... 153 ANASTIA...... 208 ARMONAIR DIGIHALER.....452 AUGMENTIN...... 38 anastrozole...... 63 ARMOUR THYROID...... 257 AURA PORTANEB...... 362, 381 ANDRODERM...... 225 ARNUITY ELLIPTA...... 452 Aurovela 1.5/30 (21)...... 153 ANGELIQ...... 237 ARTISS...... 208 Aurovela 1/20 (21)...... 153 ANNOVERA...... 164 ARYMO ER...... 8 Aurovela 24 Fe...... 153 ANODYNE LPT...... 201 Ascomp With Codeine...... 15 Aurovela Fe 1.5/30 (28)...... 153 ANORO ELLIPTA...... 457 asenapine maleate...... 130 Aurovela Fe 1-20 (28)...... 153 ANTARA...... 87 Ashlyna...... 152 AURUMHEEL...... 258 anticoag citrate phos ASMANEX HFA...... 453 AURYXIA...... 221, 277, 278 dextrose...... 283 ASMANEX TWISTHALER...453 AUSTEDO...... 140 ANUCORT-HC...... 34 aspirin...... 32 AUTOSOFT 30...... 375 APADAZ...... 17 ASPIRIN CHILDRENS.. 32, 294 AUTOSOFT 90...... 376 APEXICON E...... 189 ASPIRIN LOW DOSE...... 32 AUTOSOFT XC INFUSION APIDRA SOLOSTAR U-100 aspirin-dipyridamole...... 294 SET 23"...... 376 INSULIN...... 250 aspirin-omeprazole...... 295 AUTOSOFT XC INFUSION APIDRA U-100 INSULIN..... 250 ASPIR-TRIN...... 32, 295 SET 32"...... 376, 381 APLENZIN...... 117 ASSURE 4 STRIPS...... 304 AUTOSOFT XC INFUSION APLIGRAF...... 212 ASSURE HAEMOLANCE SET 43"...... 376 APOGEE HC INTERMIT PLUS...... 341 AUVI-Q...... 96 CATHETER...... 374 ASSURE ID INSULIN AVANDIA...... 254 APOGEE IC INTERMIT SAFETY...... 348, 381 AVAR...... 168 CATHETER...... 374, 381 ASSURE LANCE...... 341 AVAR LS...... 168 APOKYN...... 120 ASSURE LANCE PLUS...... 341 AVEIDAOXIA...... 207 apraclonidine...... 444 ASSURE PLATINUM TEST AVENOVA...... 189 aprepitant...... 262 STRIP...... 305 Aviane...... 154 Apri...... 153 ASSURE PRISM MULTI AVIDOXY DK...... 56 APTIOM...... 107 STRIP...... 305 AVITA...... 172 APTIVUS...... 54 ASTAGRAF XL...... 297 AVITENE...... 290 APTIVUS (WITH VITAMIN ASTERO...... 201 AVITENE FLOUR...... 290 E)...... 54 ASTHMAPACK AVO CREAM...... 186 AQUA CARE SODIUM CHILDREN'S...... 365, 381 AVONEX...... 430 CHLORIDE...... 221 ASTRINGYN...... 290 Ayuna...... 154 AQUA CARE STERILE atazanavir...... 55 AYVAKIT...... 68 WATER...... 221 atenolol...... 93 AZADROX...... 175 AQUA GLYCOLIC HC...... 198 atenolol-chlorthalidone...... 96 AZASAN...... 24, 298 AQUORAL...... 428 atomoxetine...... 128 AZASITE...... 443 ARAKODA...... 40 ATOPADERM...... 186 azathioprine...... 298 470 azelaic acid...... 167 BD POSIFLUSH NORMAL BETADINE OPHTHALMIC azelaic acid-niacinamide...167 SALINE 0.9...... 223 PREP...... 444 azelastine...... 436, 462 BD PRE-FILLED NORMAL BETALOAN SUIK...... 240 azelastine-fluticasone...... 461 SALINE...... 223 betamethasone AZELEX...... 167 BD PRE-FILLED SALINE dipropionate...... 189 azithromycin...... 52 BLUNT CAN...... 223 betamethasone valerate....189 AZOPT...... 439 BD SAFETYGLIDE INSULIN betamethasone, Azurette (28)...... 152 SYRINGE...... 349, 382 augmented...... 189, 190 bacitracin...... 443 BD SAFETYGLIDE BETASERON...... 430 bacitracin-polymyxin b..... 442 SYRINGE...... 349, 382 betaxolol...... 93, 440 baclofen...... 299, 300 BD SAF-T-INTIMA...... 360, 382 bethanechol chloride...... 282 BAFIERTAM...... 431 BD ULTRA FINE LANCETS BETIMOL...... 440 BALCOLTRA...... 154 ...... 341, 383 BETOPTIC S...... 440 balsalazide...... 270 BD ULTRA-FINE II BEVESPI AEROSPHERE... 457 balsam peru-castor oil...... 216 LANCETS...... 341 bexarotene...... 70 BALVERSA...... 64 BD VEO INSULIN SYR BEXSERO...... 78 Balziva (28)...... 154 HALF UNIT...... 350 bicalutamide...... 62 BANZEL...... 112 BD VEO INSULIN SYRINGE BIDIL...... 102 BAQSIMI...... 224 UF...... 350 BIJUVA...... 238 BARACLUDE...... 49 BEAU RX...... 205 BIKTARVY...... 45 BASADROX...... 175 BECONASE AQ...... 462 bimatoprost...... 445 BASAGLAR KWIKPEN U- Bekyree (28)...... 152 BINOSTO...... 236 100 INSULIN...... 248 BELBUCA...... 19 BIONECT...... 206 BAXDELA...... 48 belladonna alkaloids- BIONIME RIGHTEST TEST BD ECLIPSE LUER-LOK opium...... 268 STRIPS...... 305, 383 ...... 348, 381 BELSOMRA...... 146 BIOSTEP...... 214, 383 BD FILTER NEEDLE-5 benazepril...... 81 BIOSTEP AG...... 214 MICRON...... 363, 381 benazepril- bisoprolol fumarate...... 93 BD INSULIN SYRINGE hydrochlorothiazide...... 81 bisoprolol- ...... 348, 349, 381, 382 BENEFIX...... 285 hydrochlorothiazide...... 96 BD INSULIN SYRINGE BENLYSTA...... 26 Bleph-10...... 444 HALF UNIT...... 348 BENSAL HP...... 199 BLEPHAMIDE...... 434 BD INSULIN SYRINGE BENZEPRO...... 170 Blephamide S.O.P...... 434 MICRO-FINE...... 348, 381 BENZEPRO Blisovi 24 Fe...... 154 BD INSULIN SYRINGE (MICROSPHERES)...... 170 Blisovi Fe 1.5/30 (28)...... 154 SAFETY-LOK...... 348, 381 benzhydrocodone- Blisovi Fe 1/20 (28)...... 154 BD INSULIN SYRINGE SLIP acetaminophen...... 17 BLOOD GLUCOSE TEST... 305 TIP...... 348, 381 benznidazole...... 40 blunt needle, disposable BD INSULIN SYRINGE U- BENZODOX 30...... 56 ...... 363, 383 500...... 349, 382 BENZODOX 60...... 56 BOCASAL...... 428 BD INSULIN SYRINGE benzonatate...... 451 BONJESTA...... 260 ULTRA-FINE...... 349 benzoyl per-clindamycin- BOOSTRIX TDAP...... 77 BD INSYTE AUTOGUARD niacin...... 168 bosentan...... 101 ...... 360, 382 benzoyl peroxide...... 170 BOSULIF...... 68 BD LO-DOSE MICRO-FINE benzphetamine...... 218 BP 10-1...... 168 IV...... 349, 382 benztropine...... 119 BPCO...... 216 BD LO-DOSE ULTRA-FINE BEPREVE...... 436 BPO...... 170 ...... 349, 382 BERINERT...... 284 BRAFTOVI...... 63 BD MICROTAINER BESER KIT...... 196 BRAVELLE...... 240 LANCET...... 341, 382 BESIVANCE...... 443 471 BREATHERITE MDI Butalbital Compound CARBAGLU...... 425 SPACER...... 366 W/Codeine...... 15 carbamazepine...... 107 BREATHERITE SPACER- butalbital-acetaminop-caf- CARBATROL...... 107, 129 MASK, NEO...... 366 cod...... 15 carbidopa...... 119 BREATHERITE SPACER- butalbital-acetaminophen... 20 carbidopa-levodopa...... 118 MASK,ADULT...... 366 butalbital-acetaminophen- carbidopa-levodopa- BREATHERITE SPACER- caff...... 20 entacapone...... 118 MASK,CHILD...... 366 butalbital-aspirin-caffeine...32 carbinoxamine maleate BREATHERITE SPACER- butorphanol...... 19 ...... 449, 450, 451 MASK,INFANT...... 366 BUTTERFLY TOUCH CARDIOPLEGIA DEL NIDO BREATHERITE SPACER- LANCET...... 341, 383 FORMULA...... 446 MASK,S.CHLD...... 366 BYDUREON...... 231 CARDIOPLEGIA HIGH BREATHERITE VALVED BYDUREON BCISE...... 231 POTASSIUM...... 446 MDI CHAMBER...... 366 BYETTA...... 231 CARDIOPLEGIA IND 4:1 BREATHERITE VALVED BYNFEZIA...... 256, 276 PLASMALYT...... 446 MDI SPACER...... 366 BYSTOLIC...... 93 CARDIOPLEGIA IND 4:1 BREEZE 2 TEST STRIPS cabergoline...... 256 RINGER...... 446 ...... 306, 383 CABLIVI...... 283 CARDIOPLEGIA IND 8:1 BREO ELLIPTA...... 458 CABOMETYX...... 67 NON-ENRCH...... 446 BREZTRI AEROSPHERE... 459 CADIRA COMPLIANT CARDIOPLEGIA Briellyn...... 154 BLOOD STAT...... 375 INDUCTION 4:1...... 446, 447 BRILINTA...... 294 caffeine citrate...... 133 CARDIOPLEGIA brimonidine...... 444 calcipotriene...... 182 INDUCTION 8:1...... 447 brimonidine-dorzolamide calcipotriene- CARDIOPLEGIA MAIN 8:1 (pf)...... 433 betamethasone...... 173 NO-ENRCH...... 447 BRIVIACT...... 110, 111 calcitonin (salmon)...... 237 CARDIOPLEGIA MAINT 4:1 Bromfed Dm...... 463 calcitriol...... 182, 223 PLASMA...... 447 bromfenac...... 438 calcium acetate(phosphat CARDIOPLEGIA MAINT 4:1 bromocriptine...... 119 bind)...... 277 RINGER...... 447 brompheniramine- CALQUENCE...... 63, 69 CARDIOPLEGIA pseudoeph-dm...... 463 CAMBIA...... 29 MAINTENANCE 4:1...... 447 BROMSITE...... 438 Camila...... 160 CARDIOPLEGIA BROVANA...... 456 CAMRESE...... 152 MAINTENANCE 8:1...... 447 BRUKINSA...... 63, 68 CAMRESE LO...... 152 CARDIOPLEGIA BRYHALI...... 182 candesartan...... 84 REPERFUSATE 4:1...... 447 budesonide...... 271, 453 candesartan- cardioplegic no.17(induct BULLSEYE MINI SAFETY hydrochlorothiazid...... 83 4:1)...... 447 LANCETS...... 341 cantharidin in acetone...... 199 cardioplegic no.19 (maint bumetanide...... 97 CANTHARIS 4:1)...... 447 BUNAVAIL...... 146 COMPOSITUM...... 258 cardioplegic soln...... 447 BUPRENEX...... 19 capecitabine...... 62 cardioplegic solution buprenorphine...... 19 CAPEX...... 190 no.25...... 448 buprenorphine hcl...... 19, 146 CAPHOSOL...... 428 CARDIZEM LA...... 94 buprenorphine-naloxone CAPLYTA...... 122 CARDURA XL...... 100 ...... 146, 147 CAPRELSA...... 69 CAREONE THIN LANCET bupropion hcl...... 117 Capsfenac Pak...... 203 ...... 341, 383 bupropion hcl (smoking CAPSINAC...... 203 CAREONE ULTRA THIN deter)...... 147 captopril...... 82 LANCET...... 341 buspirone...... 103 captopril- hydrochlorothiazide...... 81 472 CARESENS LANCETS CERAMAX...... 186 cilostazol...... 294 ...... 341, 383 CERDELGA...... 424 CILOXAN...... 443 CARESENS N TEST CERVIDIL...... 224 CIMDUO...... 43 STRIPS...... 306 CESAMET...... 131, 260 cimetidine...... 264 CARETOUCH INSULIN CETACAINE...... 201 cimetidine hcl...... 264 SYRINGE...... 350, 383 CETACAINE ANESTHETIC 201 CIMZIA...... 21, 22, 272 CARETOUCH SAFETY cetirizine...... 451 CIMZIA POWDER FOR LANCETS...... 341, 383 CETROTIDE...... 255 RECONST...... 21, 22, 272 CARETOUCH TEST STRIP 306 cevimeline...... 429 CIMZIA STARTER KIT CARETOUCH TWIST CHANTIX...... 148 ...... 21, 22, 272 LANCET...... 341, 384 CHANTIX CONTINUING cinacalcet...... 237 carisoprodol...... 300 MONTH BOX...... 148 CINRYZE...... 284 carisoprodol-aspirin...... 299 CHANTIX STARTING CIPRO...... 48 carisoprodol-aspirin- MONTH BOX...... 148 CIPRO HC...... 448 codeine...... 300, 301 Charlotte 24 Fe...... 154 CIPRO XR...... 48, 280 CARNITOR (SUGAR-FREE) Chateal (28)...... 154 ciprofloxacin...... 48 ...... 424 Chateal Eq (28)...... 154 ciprofloxacin hcl.. 48, 443, 448 CAROSPIR...... 82 CHEMET...... 36 ciprofloxacin- CARRASYN HYDROGEL Chenodal...... 263 dexamethasone...... 448 WOUND DRESS...... 214 CHILDREN'S ASPIRIN...... 32 ciprofloxacin-fluocinolone448 carteolol...... 440 CHILDREN'S IRON...... 221 citalopram...... 114 Cartia Xt...... 94 CHLOOXIA...... 196 citric acid (bulk)...... 148 carvedilol...... 82 chlordiazepoxide hcl...... 102 citric acid anhydrous carvedilol phosphate...... 82 chlordiazepoxide- (bulk)...... 148, 149 CAVERJECT...... 217 clidinium...... 268 Claravis...... 165 CAVERJECT IMPULSE...... 217 chlorhexidine gluconate... 427 CLARINEX-D 12 HOUR...... 449 CAYA CONTOURED...338, 384 chloroquine phosphate...... 40 clarithromycin...... 52 CAYSTON...... 460 chlorothiazide...... 98 CLEANSING WASH.... 168, 207 Caziant (28)...... 162 chlorpromazine...... 123 CLEARSHIELD SODIUM cefaclor...... 47 chlorthalidone...... 98 CHLOR FLUSH...... 222 cefadroxil...... 47 chlorzoxazone...... 300 clemastine...... 450, 451 CEFALY...... 361, 384 CHOICEDM CLARUS. 306, 384 CLENPIQ...... 275 cefdinir...... 47 CHOLBAM...... 262 CLEO 90 INFUSION SET cefditoren pivoxil...... 47 cholestyramine (with 24"...... 376 cefixime...... 48 sugar)...... 86 CLEO 90 INFUSION SET cefpodoxime...... 48 Cholestyramine Light...... 86 31"...... 376 cefprozil...... 47 choline,magnesium CLEOCIN...... 466 cefuroxime axetil...... 47 salicylate...... 32 CLEVER CHEK LANCETS..341 CELACYN...... 186, 372 chorionic gonadotropin, CLEVER CHOICE celecoxib...... 28 human...... 245 CHAMBER-LRG MASK...... 366 CELLPAD...... 372, 384 CICASIL...... 372, 384 CLEVER CHOICE CELONTIN...... 111 CICATRACE PAD...... 372, 384 CHAMBER-MED MASK...... 367 CEM-UREA...... 199 CICLODAN KIT...... 178 CLEVER CHOICE CENTANY AT...... 175 ciclopirox...... 178 CHAMBER-SM MASK...... 367 cephalexin...... 47 ciclopirox-clobetasol...... 180 CLEVER CHOICE MICRO CEQUA...... 438 ciclopirox-clobetasol- TEST STRIP...... 307, 384 CEQUR SIMPLICITY...373, 384 salicyl...... 180 CLEVER CHOICE CEQUR SIMPLICITY ciclopirox-salicylic acid.... 178 NEBULIZER...... 367, 384 INSERTER...... 341, 384 ciclopirox-ure-camph- CERACADE...... 186 menth-euc...... 178 473 CLEVER CHOICE PRO codeine-butalbital-asa-caff. 15 Compro...... 261 ...... 307, 385 colchicine...... 282 CONCEPTION...... 386 CLEVER CHOICE TALK colesevelam...... 86, 87 CONCERTA...... 125 TEST...... 307, 385 COLESTID FLAVORED...... 87 CONDYLOX...... 200 CLEVER CHOICE TEST colestipol...... 87 CONJUPRI...... 95 STRIPS...... 307 COLLATYL...... 214 CONSENSI...... 94 CLEVER CHOICE VOICE+ COLOR LANCETS...... 341, 385 Constulose...... 273 TEST...... 308 COMBIGAN...... 439 CONTACT DETACH INFUS CLEVER CHOICE COMBIPATCH...... 238 SET 23"...... 376 WHISPER AIRE PED.. 367, 385 COMBIVENT RESPIMAT....457 CONTACT DETACH INFUS CLIMARA PRO...... 238 COMETRIQ...... 67 SET 32"...... 376 CLINDACIN ETZ...... 168 COMFORT EZ INSULIN CONTOUR NEXT TEST CLINDACIN PAC...... 168 SYRINGE...... 350, 385 STRIPS...... 308 clindamycin hcl...... 51 COMFORT EZ LANCETS... 341 CONTOUR TEST STRIPS.. 308 Clindamycin Pediatric...... 52 COMFORT INFUSION SET CONTRAVE...... 219 clindamycin phosphate 23"...... 376, 385 COOL GLUCOSE TEST ...... 167, 466 COMFORT INFUSION SET STRIP...... 308, 386 clindamycin-benzoyl 32"...... 376, 386 COPAXONE...... 431 peroxide...... 168 COMFORT INFUSION SET COPIKTRA...... 67, 68 clindamycin-tretinoin...... 170 43"...... 376, 386 CORDRAN...... 190 CLINDESSE...... 466 COMFORT LANCETS...... 342 CORDRAN TAPE LARGE CLINPRO 5000...... 426 COMFORT PAC- ROLL...... 190 clobazam...... 103, 104 CYCLOBENZAPRINE...... 301 Coremino...... 56, 166 clobetasol...... 190 COMFORT PAC- CORIFACT...... 289 clobetasol-calcipotriene... 196 IBUPROFEN...... 26 CORLANOR...... 99 clobetasol-emollient...... 190 COMFORT PAC- CORTANE-B...... 448 clobetasol-levocetirizine...196 MELOXICAM...... 27 CORTIFOAM...... 271 clobetasol-niacinamide.....196 COMFORT PAC- cortisone...... 241 CLOBETAVIX...... 190 NAPROXEN...... 27 CORTISPORIN...... 176 clocortolone pivalate...... 190 COMFORT PAC- CORTISPORIN-TC...... 448 CLODAN KIT...... 198 TIZANIDINE...... 301 COSENTYX...... 174 clomiphene citrate...... 240 COMFORT SHORT COSENTYX (2 SYRINGES) 174 clomipramine...... 117 INSULIN PUMP 23".....376, 386 COSENTYX PEN...... 174 clonazepam...... 102 COMFORT SHORT COSENTYX PEN (2 PENS) 174 clonidine...... 97 INSULIN PUMP 32".....376, 386 COTELLIC...... 66 clonidine hcl...... 97, 124 COMFORT SHORT COTEMPLA XR-ODT...... 125 clopidogrel...... 295 INSULIN PUMP 43".....376, 386 COVARYX...... 237 clorazepate dipotassium...103 COMPACT SPACE COVARYX H.S...... 237 clotrimazole...... 178, 427 CHAMBER...... 367, 386 CRALONIN...... 258 clotrimazole- COMPACT SPACE CREON...... 263 betamethasone...... 180 CHAMBER PLUS...... 367, 386 CRESEMBA...... 39 Clovique...... 35 COMPACT SPACE CRINONE...... 240, 467 clozapine...... 122 CHAMBER-LRG MASK...... 367 CRIXIVAN...... 55 COAGADEX...... 289 COMPACT SPACE cromolyn...... 66, 442, 454 COAGUCHEK LANCETS CHAMBER-MED MASK...... 367 Crotan...... 212 ...... 341, 385 COMPACT SPACE CRYOSERV...... 149 COAGUCHEK XS...... 301, 385 CHAMBER-SM MASK...... 367 Cryselle (28)...... 154 COARTEM...... 40 COMP-AIR NEBULIZER CUPRIMINE...... 25, 35 cocaine...... 461 COMPRESSOR...... 367, 386 codeine sulfate...... 8 COMPLERA...... 45 474 CURAFIL GEL WOUND Dasetta 7/7/7 (28)...... 162 desog- ...... 214, 386 DAURISMO...... 65 e.estradiol/e.estradiol...... 152 CURITY AMD...... 340, 386 Daysee...... 152 DESONATE...... 191 CURITY AMD (WITH DAYTRANA...... 125 desonide...... 191 POLYHEXAMETH)...... 214, 386 DAYVIGO...... 146 desoximetasone...... 191 CURITY DRAINAGE BAG DDAVP...... 226 desoximetasone- ...... 347, 386 DEBACTEROL...... 427 niacinamide...... 196 CURITY IODOFORM Deblitane...... 161 desvenlafaxine...... 115 PACKING STRIP...... 340, 387 Decadron...... 241 desvenlafaxine succinate. 115 CUROSURF...... 461 deferasirox...... 36 DEVILBISS DISPOSABLE CUTAQUIG...... 74 deferiprone...... 36 NEBULIZER...... 362, 387 CUVITRU...... 74 deferoxamine...... 36 DEVILBISS PULMO-AIDE CUVPOSA...... 430 DELESTROGEN...... 238 COMPRESSR...... 367, 387 Cyclafem 1/35 (28)...... 154 DELSTRIGO...... 46 DEVILBISS PULMOMATE Cyclafem 7/7/7 (28)...... 162 DELUO...... 72, 213 COMPRESSOR...... 367, 387 cyclobenzaprine...... 300 demeclocycline...... 56 DEVILBISS PULMONEB LT CYCLOMYDRIL...... 433 DEMEROL (PF)...... 8 COMP-NEB...... 367, 387 cyclopentolate...... 435 DEMSER...... 100 DEVILBISS TRAVELER cyclopen-tropic- DENAVIR...... 185 COMPRESSOR...... 367 phenyleph-watr...... 433 DENTA 5000 PLUS...... 426 Dexabliss...... 241 cyclopent-tropic-phen- DENTAGEL...... 426 dexamethasone...... 241 ketr-wat...... 433 DEOXIA...... 167, 168 DEXAMETHASONE cyclophosphamide...... 61 DEPAKOTE...... 104, 129 INTENSOL...... 241 cyclop-trop-propa-phen- DEPAKOTE ER...... 104 dexamethasone sodium ket-wat...... 433 DEPAKOTE SPRINKLES phosphate...... 436 cycloserine...... 46 ...... 105, 129 dexchlorpheniramine CYCLOSET...... 227 Depo-Estradiol...... 239 maleate...... 449, 451 cyclosporine...... 24, 297 DEPO-SUBQ PROVERA DEXCOM G4 RECEIVER....342 CYCLOSPORINE IN 104...... 151 DEXCOM G4 RECEIVER KLARITY...... 438 DERMACINRX PEDIATRIC...... 342 cyclosporine modified...... 297 CLORHEXACIN...... 216 DEXCOM G4 RECEIVER- CYCLOTENS REFILL...... 300 DERMACINRX LEXITRAL.. 203 SHARE (PED)...... 342 CYCLOTENS STARTER.....300 DERMACINRX PHN PAK....210 DEXCOM G4 RECEIVER- cyproheptadine...... 450 DERMACINRX SURGICAL SHARE KIT...... 342 Cyred...... 154 PHARMAPAK...... 216 DEXCOM G4 Cyred Eq...... 154 DERMACINRX TRANSMITTER...... 342, 387 CYSTADANE...... 424 THERAZOLE PAK...... 180 DEXCOM G5 RECEIVER....342 CYSTADROPS...... 440 DERMACINRX ZRM PAK... 210 DEXCOM G5 CYSTAGON...... 276 DERMAGRAFT...... 212 TRANSMITTER...... 342, 387 CYSTARAN...... 440 DERMAWERX SURGICAL DEXCOM G5-G4 SENSOR CYTOMEL...... 257 PLUS PAK...... 216 ...... 342, 387 dalfampridine...... 431 DERMAZENE...... 180 DEXCOM G6 RECEIVER DALIRESP...... 455 DERMAZYL KIT...... 210 ...... 342, 387 danazol...... 243 DERM-SILK...... 372, 387 DEXCOM G6 SENSOR dantrolene...... 300 DERMULCERA...... 216 ...... 342, 387 dapsone...... 40, 167 DESCOVY...... 43 DEXCOM G6 darifenacin...... 280 desflurane...... 33 TRANSMITTER...... 342, 387 DARIO BLOOD GLUCOSE desipramine...... 117 DEXCOM RECEIVER. 342, 387 TEST STRIP...... 309 desloratadine...... 451 DEXERYL...... 187 Dasetta 1/35 (28)...... 155 desmopressin...... 226 DEXILANT...... 264 475 dexmethylphenidate...... 126 digoxin...... 97 DOVER LATEX FOLEY DEXONTO...... 241 dihydroergotamine...... 136 CATHETER...... 374, 388 DEXTENZA...... 436 DILANTIN...... 107 DOVER RED RUBBER dextroamphetamine.. 132, 133 Dilantin Extended...... 106 ROBINSON CATH...... 374, 388 dextroamphetamine- Dilantin Infatabs...... 106 DOVER UNIVERSAL.. 374, 388 amphetamine...... 132 DILANTIN-125...... 107 doxazosin...... 100 DIACOMIT...... 112 DILATRATE-SR...... 84 doxepin...... 117, 146, 210 DIADIMAXIA...... 168 DILAUDID (PF)...... 8 doxercalciferol...... 423 DIAOXIA...... 168 diltiazem hcl...... 94, 95 doxycycline hyclate DIASDIMAXIA...... 168 DILT-XR...... 95 ...... 57, 58, 429 DIASOXIA...... 168 DILUENT FOR ROTARIX....220 doxycycline monohydrate DIASTAT...... 104, 128 DILUTING MEDIUM FOR ...... 58, 207 DIASTAT ACUDIAL.....104, 128 NOVOLOG...... 220 doxylamine-pyridoxine (vit DIATRUE PLUS TEST DIMENTHO...... 204 b6)...... 260 STRIP...... 309, 387 dimethyl fumarate...... 431 D-PENAMINE...... 25, 36 diazepam...... 103, 104, 128 DIMOXIA...... 173 DRAXACE...... 168 Diazepam Intensol...... 103, 128 DIPENTUM...... 270 DRITHOCREME HP...... 182 diazoxide...... 224 Diphen...... 450 DRIXECE...... 169 DICLO GEL...... 204 diphenoxylate-atropine..... 259 DRIZALMA SPRINKLE116, 135 DICLO GEL-XRYLIX SHEET dipyridamole...... 295 dronabinol...... 260 ...... 204 disopyramide phosphate.... 85 DROPLET INSULIN SYR diclofenac epolamine...... 204 disulfiram...... 147 HALF UNIT...... 350, 388 diclofenac potassium...... 29 DITHOL...... 204 DROPLET INSULIN diclofenac sodium DIURIL...... 99 SYRINGE...... 351, 388 ...... 29, 30, 181, 204, 438 divalproex...... 105 DROPLET LANCETS...... 342 diclofenac submicronized.. 30 DIVIGEL...... 239 drospirenone-e.estradiol- diclofenac-hyaluronate- DM2...... 253 lm.fa...... 155 niacin...... 203 DMT SUIK...... 241 drospirenone-ethinyl diclofenac-misoprostol...... 26 dofetilide...... 86 estradiol...... 155 DICLOFEX DC...... 203 DOJOLVI...... 222 DROXIA...... 295, 296 DICLOFONO...... 204 DOLOTRANZ...... 201 DRYSOL...... 181 DICLOPAK...... 203 donepezil...... 149 DRYSOL DAB-O-MATIC..... 181 DICLOPR...... 203 DONNATAL...... 268 DUAKLIR PRESSAIR...... 458 DICLOSAICIN...... 203 Donnatal...... 268, 269 DUAVEE...... 237 DICLOTRAL...... 203 DOPTELET (10 TAB PACK)296 DUEXIS...... 26 DICLOTREX...... 203 DOPTELET (15 TAB PACK)296 DULERA...... 459 DICLOVIX...... 203 DOPTELET (30 TAB PACK)296 duloxetine...... 116 DICLOVIX M...... 203 DORYX...... 57 DUOBRII...... 173 dicloxacillin...... 54 DORYX MPC...... 56 DUODOTE...... 35 DICLOZOR...... 204 dorzolamide...... 439 DUOPA...... 118 dicyclomine...... 268 dorzolamide (pf)...... 439 DUPIXENT PEN...... 175 didanosine...... 43 dorzolamide-timolol...... 439 DUPIXENT SYRINGE...... 175 diethylpropion...... 218 dorzolamide-timolol (pf)....439 DUREZOL...... 436 DIFFERIN...... 172 Dotti...... 239 DURLAZA...... 32, 295 DIFICID...... 52 DOVATO...... 42 dutasteride...... 278 diflorasone...... 192 DOVER COATED LATEX dutasteride-tamsulosin..... 276 diflunisal...... 32 FOLEY...... 374, 387 DUTOPROL...... 96 DIFMETIOXRIME...... 178 DOVER FOLEY CATHETER DUZALLO...... 282 Digitek...... 97 ...... 374, 387 Dvorah...... 16 Digox...... 97 Dxevo...... 241 476 DYANAVEL XR...... 126, 132 EASYMAX...... 312 Eluryng...... 164 E.E.S. 400...... 52 EASYMAX 15 TEST EMBRACE BLOOD EAR POPPER INFLATION STRIPS...... 311 GLUCOSE SYSTEM...... 312 DEVICE...... 375, 388 EBASE CONTROLLER EMBRACE EVO TEST EASIVENT HOLDING ...... 368, 391 STRIPS...... 313, 392 CHAMBER...... 367 ECEOXIA...... 167 EMBRACE LANCETS. 342, 392 EASIVENT MASK LARGE ECLIPSE NEEDLE...... 363, 391 EMBRACE PRO TEST ...... 367, 388 EC-NAPROXEN...... 30 STRIPS...... 313 EASIVENT MASK MEDIUM ECONASIL...... 178 EMBRACE TALK TEST ...... 367, 388 econazole...... 178 STRIPS...... 313 EASIVENT MASK SMALL ECONTRA EZ...... 164 EMCYT...... 64 ...... 367, 388 ECONTRA ONE-STEP...... 164 EMEND...... 262 EASY COMFORT INSULIN ECOTRIN...... 32 EMFLAZA...... 241, 242 SYRINGE...... 351, 388 ECOZA...... 178 EMGALITY PEN...... 136 EASY COMFORT EDARBI...... 84 EMGALITY SYRINGE. 102, 136 LANCETS...... 342 EDARBYCLOR...... 83 Emoquette...... 155 EASY GLIDE INSULIN EDEX...... 217 EMSAM...... 114 SYRINGE...... 351, 388, 389 EDLUAR...... 145 emtricitabine...... 44 EASY GLUCO G2...... 309, 389 ED-SPAZ...... 267, 281 emtricitabine-tenofovir EASY PLUS II TEST... 309, 389 EDURANT...... 42 (tdf)...... 43 EASY STEP...... 310, 389 EEMT...... 237 EMTRIVA...... 44 EASY TALK GLUCOSE EEMT HS...... 237 EMULSION SB...... 187 TEST...... 310, 389 efavirenz...... 42, 43 EMVERM...... 38 EASY TOUCH FLIPLOCK efavirenz-emtricitabin- enalapril maleate...... 82 INSULIN...... 351, 390 tenofov...... 46 enalapril- EASY TOUCH INSULIN efavirenz-lamivu-tenofov hydrochlorothiazide...... 81 SAFETY SYR...... 351, 390 disop...... 46 ENBREL...... 22 EASY TOUCH INSULIN EFFACLAR ADAPALENE... 172 ENBREL MINI...... 22 SYRINGE...... 352 EFFER-K...... 222 ENBREL SURECLICK...... 22 EASY TOUCH LANCETS EGATEN...... 38 ENDARI...... 295 ...... 342, 390 EGRIFTA SV...... 244 ENDO AVITENE...... 290 EASY TOUCH LUER LOCK ELEMENT COMPACT TEST Endocet...... 18 INSULIN...... 352, 390 STRIPS...... 312, 391 ENDOFORM...... 211 EASY TOUCH SAFETY ELEMENT TEST STRIPS ENDOFORM LANCETS...... 342, 390 ...... 312, 392 FENESTRATED...... 211 EASY TOUCH ELESTRIN...... 239 ENDOMETRIN...... 240 SHEATHLOCK INSULIN eletriptan...... 137 ENGERIX-B (PF)...... 73 ...... 352, 390 ELIGARD...... 66 ENLITE GLUCOSE EASY TOUCH TEST STRIP310 ELIGARD (3 MONTH)...... 66 SENSOR...... 342, 392 EASY TOUCH TWIST ELIGARD (4 MONTH)...... 66 ENLITE SERTER...... 343, 392 LANCETS...... 342, 390 ELIGARD (6 MONTH)...... 66 ENLITE SYSTEM...... 343, 392 EASY TOUCH UNI-SLIP..... 352 Elinest...... 155 enoxaparin...... 293 EASY TRAK GLUCOSE ELIQUIS...... 284 Enpresse...... 162 TEST...... 310, 390 ELIQUIS DVT-PE TREAT Enskyce...... 155 EASY TRAK II TEST STRIP 30D START...... 284 ENSPRYNG...... 298 ...... 311, 391 Elixophyllin...... 454 ENSTILAR...... 173 EASY TWIST AND CAP ELLA...... 164 entacapone...... 119 LANCETS...... 342, 391 ELLZIA PAK...... 196 entecavir...... 49 EASYGLUCO PLUS....311, 391 ELMIRON...... 277 ENTERAL GRAVITY BAG EASYGLUCO TEST...... 311 ELOCTATE...... 287 SET-ENFIT...... 339, 392 477 ENTEREG...... 36 estradiol...... 239, 467 EYE...... 258 ENTRESTO...... 84 estradiol valerate...... 239 EYSUVIS...... 436 ENTTY...... 187 estradiol-norethindrone E-Z JECT LANCETS... 343, 393 Enulose...... 263 acet...... 238 E-Z JECT THIN LANCETS..343 ENVARSUS XR...... 297 ESTRING...... 467 EZ SMART LANCETS.343, 393 EPANED...... 82 ESTROGEL...... 239 EZ SMART PLUS TEST EPCLUSA...... 50 estrogens- ...... 315, 393 EPICERAM...... 187 methyltestosterone...... 238 EZ SMART TEST...... 315 EPICYN...... 213 eszopiclone...... 145 EZALLOR SPRINKLE...... 88 EPIDIOLEX...... 104 ethacrynic acid...... 98 ezetimibe...... 91 EPIDUO FORTE...... 171 ethambutol...... 47 ezetimibe-simvastatin...... 91 EPIFIX AMNIOTIC ethosuximide...... 111 EZ-LETS...... 343, 393 MEMBRANE...... 211 ETHOXIA...... 172 FABIOR...... 172 EPIFOAM...... 197 ethyl chloride...... 202 FACTIVE...... 48 epinastine...... 436 ethynodiol diac-eth Falmina (28)...... 155 epinephrine...... 96, 452 estradiol...... 155 famciclovir...... 51 epinephrine hcl...... 463 etidronate disodium...... 236 famotidine...... 264 EPISIL...... 428 etodolac...... 31 FANAPT...... 121 Epitol...... 107, 129 etonogestrel-ethinyl FARXIGA...... 229 EPIVIR HBV...... 49 estradiol...... 163 FARYDAK...... 65 eplerenone...... 82 etoposide...... 64 FASENRA PEN...... 454 EPOGEN...... 285 EUCRISA...... 175 Fayosim...... 161 eprosartan...... 84 EURAX...... 212 FC2 FEMALE CONDOM EQUETRO...... 107, 129 EUTHYROX...... 257 ...... 339, 393 ergoloid...... 150 EVAMIST...... 239 febuxostat...... 282 ERGOMAR...... 137 EVARREST...... 291 FEIBA NF...... 283 ergotamine-caffeine...... 137 EVEKEO ODT...... 133 felbamate...... 104 ERIVEDGE...... 65 EVENCARE G2...... 313 FELBATOL...... 104 ERLEADA...... 62 EVENCARE G3 TEST...... 314 felodipine...... 95 erlotinib...... 60 EVENCARE MINI FEM PH...... 466 Errin...... 161 GLUCOSE TEST STR...... 314 FEMALE CATHETER..374, 393 ERTACZO...... 178 EVENCARE PROVIEW FEMCAP...... 338, 393 ERY PADS...... 167 TEST STRIP...... 314, 392 FEMRING...... 467 Ery-Tab...... 52 EVENCARE TEST...... 314, 393 Femynor...... 155 Erythrocin (As Stearate)...... 52 everolimus fenofibrate...... 87 erythromycin...... 52, 444 (antineoplastic)...... 67 fenofibrate micronized...... 87 erythromycin everolimus fenofibrate ethylsuccinate...... 52 (immunosuppressive)...... 298 nanocrystallized...... 87 erythromycin with ethanol 167 EVERSENSE SMART fenofibric acid...... 87 erythromycin-benzoyl TRANSMITTER...... 343, 393 fenofibric acid (choline)...... 87 peroxide...... 169 EVICEL...... 291 fenoprofen...... 30 ESBRIET...... 465 EVOLUTION TEST STRIPS fentanyl...... 8, 9 escitalopram oxalate...... 115 ...... 315, 393 fentanyl citrate...... 8 ESKATA...... 184 EVOTAZ...... 44, 55 fentanyl citrate (pf)...... 8, 33 ESOMEP-EZS...... 264 EVRYSDI...... 301 fentanyl citrate (pf)- esomeprazole magnesium264 EXEL INSULIN...... 352 0.9%nacl...... 8 esomeprazole strontium... 265 EXELDERM...... 178, 179 FENTORA...... 9 ESPEROCT...... 287 exemestane...... 63 FERRIPROX...... 36 Estarylla...... 155 EXODERM...... 178 FERRIPROX (2 TIMES A estazolam...... 145 EXTAVIA...... 430 DAY)...... 36 478 ferrous sulfate...... 221 FLUARIX QUAD 2020-2021 FLUZONE HIGHDOSE FETZIMA...... 116 (PF)...... 79 QUAD 20-21 PF...... 79 fexofenadine- FLUBLOK QUAD 2020-2021 FLUZONE QUAD 2020- pseudoephedrine...... 449 (PF)...... 79 2021...... 80 FIASP FLEXTOUCH U-100 FLUCELVAX QUAD 2020- FLUZONE QUAD 2020- INSULIN...... 250 2021...... 79 2021 (PF)...... 80 FIASP PENFILL U-100 FLUCELVAX QUAD 2020- FLYP NEBULIZER...... 362 INSULIN...... 251 2021 (PF)...... 79 FML FORTE...... 437 FIASP U-100 INSULIN...... 251 fluconazole...... 39 FML S.O.P...... 437 FIFTY50 SAFETY SEAL flucytosine...... 39 folic acid...... 223 LANCETS...... 343 fludrocortisone...... 255 FOLLISTIM AQ...... 240 FIFTY50 TEST STRIP.315, 394 FLULAVAL QUAD 2020- fondaparinux...... 293 filter needles...... 363, 394 2021 (PF)...... 79 FORA 6 CONNECT FILTERED EXTENSION FLUMIST QUAD 2020-2021..79 GLUCOSE STRIP...... 316, 394 SET...... 360 flunisolide...... 462 FORA D15G STRIPS.. 316, 395 FINACEA...... 167, 207 fluocinolone...... 192 FORA D20...... 316, 395 finasteride...... 278 fluocinolone acetonide oil 448 FORA D40-G31 TEST FINE 30 UNIVERSAL fluocinolone and shower STRIPS...... 316, 395 LANCETS...... 343 cap...... 192 FORA G20...... 317 FINGERSTIX LANCETS fluocinolone-niacinamide. 196 FORA G30-PREMIUM V10 ...... 343, 394 fluocinonide...... 192 TEST STRP...... 317, 395 FINTEPLA...... 112 Fluocinonide-E...... 192 FORA GD50 TEST STRIPS Fioricet...... 20 fluocinonide-emollient...... 192 ...... 317, 396 FIRDAPSE...... 431 FLUOPAR...... 196 FORA GTEL GLUCOSE FIRMAGON...... 66 fluorescein-proparacaine..440 TEST STRIP...... 317, 396 FIRMAGON KIT W fluoride (sodium)...... 426 FORA TEST STRIP...... 318 DILUENT SYRINGE...... 66 FLUORIDEX DAILY FORA TN'G VOICE TEST FIRVANQ...... 49 DEFENSE...... 426 STRIPS...... 318, 396 FLAREX...... 436 FLUORIDEX SENSITIVITY FORA V10...... 318 flavoxate...... 281 RELIEF...... 426 FORA V10-V12-D10-D20 flecainide...... 85 fluorometholone...... 436 STRIPS...... 318 FLEXICHAMBER...... 368, 394 FLUOROPLEX...... 180 FORA V12 GLUCOSE...... 319 FLEXICHAMBER-LG CHILD fluorouracil...... 180 FORA V20...... 319, 396 MASK...... 368, 394 FLUOVIX...... 192 FORA V30A...... 319, 397 FLEXICHAMBER-SM FLUOVIX PLUS...... 192 FORACARE GD20...... 319, 397 ADULT MASK...... 368, 394 fluoxetine...... 115 FORACARE GD40 TEST FLEXICHAMBER-SM fluphenazine hcl...... 123 STRIPS...... 320, 397 CHILD MASK...... 368, 394 FLURA-DROPS...... 426 FORACARE LANCETS FLEXIPAK...... 27 flurandrenolide...... 193 ...... 343, 397 FLEXI-SEAL SIGNAL FMS flurazepam...... 128, 145 FORAXA...... 208 ...... 348, 394 flurbiprofen...... 30 FORTEO...... 235 FLOLIPID...... 88 flurbiprofen sodium...... 438 FORTISCARE GLUCOSE FLORIVA (FLUORIDE- flutamide...... 62 TEST STRIPS...... 320, 397 VITAMIN D3)...... 222, 426 fluticasone propionate FOSAMAX PLUS D...... 236 FLOVENT DISKUS...... 453 ...... 193, 462 fosamprenavir...... 55 FLOVENT HFA...... 453 fluticasone propion- fosfomycin tromethamine...39 FLUAD 2020-2021 (65 YR salmeterol...... 459 fosinopril...... 82 UP)(PF)...... 79 fluvastatin...... 88, 89 fosinopril- FLUAD QUAD 2020-21(65Y fluvoxamine...... 115 hydrochlorothiazide...... 81 UP)(PF)...... 79 FOSRENOL...... 277 479 FRAGMIN...... 294 GAVRETO...... 70 GLUCOCARD VITAL FREESTYLE INSULINX GE100 BLOOD GLUCOSE SENSOR...... 322 ...... 320, 398 TEST STRIP...... 320 GLUCOCARD VITAL TEST FREESTYLE INSULINX GELCLAIR...... 429 STRIPS...... 322 TEST STRIPS...... 320, 398 GELFILM...... 290, 442 GLUCOCOM AUTOLINK FREESTYLE LANCETS GELFOAM...... 291 ...... 343, 398 ...... 343, 398 GELFOAM JMI POWDER... 290 GLUCOCOM GLUCOSE FREESTYLE LIBRE 14 DAY GELFOAM JMI SPONGE....290 ...... 323, 398 READER...... 343, 398 GELFOAM SPONGE SIZE GLUCOCOM LANCETS FREESTYLE LIBRE 14 DAY 200...... 291 ...... 343, 398 SENSOR...... 343, 398 GEL-KAM...... 426 glyburide...... 230 FREESTYLE LIBRE 2 GELNIQUE...... 281 glyburide micronized...... 230 READER...... 343, 398 GELX...... 429 glyburide-metformin...... 230 FREESTYLE LIBRE 2 gemfibrozil...... 87 glycine urologic solution.. 277 SENSOR...... 343, 398 Gemmily...... 155 glycopyrrolate...... 268 FREESTYLE LITE STRIPS. 320 GENADUR...... 211 Glydo...... 208 FREESTYLE NAVIGATOR GENADUR (WITH GLYXAMBI...... 229 GLUC SENS...... 343, 398 LEXINAL)...... 211 GM100...... 323, 399 FREESTYLE PRECISION Generlac...... 263 GOCOVRI...... 120 ...... 352, 398 Gengraf...... 24, 25, 297 GOJJI BLOOD GLUCOSE FREESTYLE PRECISION GENOTROPIN...... 244 TEST STRIP...... 323, 399 NEO STRIPS...... 320 GENOTROPIN MINIQUICK 244 GOJJI LANCETS...... 343, 399 FREESTYLE TEST...... 320 GENSTRIP TEST STRIP.... 321 GOLYTELY...... 274 FREESTYLE UNISTIK 2 Gentak...... 443 GONAL-F...... 240 ...... 343, 398 gentamicin...... 175, 443 GONAL-F RFF...... 240 FROTEK...... 204 GENULTIMATE TEST GONAL-F RFF REDI-JECT.240 frovatriptan...... 137 STRIP...... 321 GONITRO...... 84 FULPHILA...... 289 GENVOYA...... 45 GOODLIFE AC-302 TEST furosemide...... 98 GIANVI (28)...... 155 STRIP...... 323, 399 FUZEON...... 42 GILENYA...... 432 GRAFIX CORE...... 211 Fyavolv...... 238 GILOTRIF...... 60 GRAFIX PRIME...... 211 FYCOMPA...... 103 GIMOTI...... 267 GRAFIX XC...... 211 GABACAINE...... 105, 143 glatiramer...... 431 GRALISE...... 143 GABAPAL...... 105, 143 Glatopa...... 431 granisetron hcl...... 261 gabapentin...... 105 GLEOSTINE...... 61 GRANIX...... 289 GABITRIL...... 106 glimepiride...... 230 GRASTEK...... 72 GALAFOLD...... 425 glipizide...... 230 griseofulvin microsize...... 39 galantamine...... 149, 150 glipizide-metformin...... 230 griseofulvin ultramicrosize.39 GALZIN...... 35 GLOPERBA...... 282 guaiacol...... 148 GAMMAGARD LIQUID...... 74 GLUCAGEN HYPOKIT...... 224 guanfacine...... 97, 124 GAMMAKED...... 74 GLUCAGON EMERGENCY guanidine...... 299 GAMUNEX-C...... 74 KIT (HUMAN)...... 224 GUARDIAN CONNECT ganirelix...... 255 GLUCO NAVII TEST STRIP321 TRANSMITTER...... 343 GARDASIL 9 (PF)...... 78 GLUCOCARD 01 SENSOR GUARDIAN LINK 3 gatifloxacin...... 443 PLUS...... 321 TRANSMITTER...... 343 GATTEX 30-VIAL...... 275 GLUCOCARD GUARDIAN RT CHARGER GATTEX ONE-VIAL...... 276 EXPRESSION...... 322 ...... 343, 399 GAVILYTE-C...... 274 GLUCOCARD SHINE TEST GUARDIAN RT MONITOR Gavilyte-G...... 274 STRIPS...... 322 SYSTEM...... 344, 399 Gavilyte-N...... 274 480 GUARDIAN RT TEST PLUG heparin flush(porcine)- HUMIRA(CF) PEDI DEVICE...... 344 0.9nacl...... 292 CROHNS STARTER GUARDIAN SENSOR 3...... 344 HEPARIN LOCK...... 293 ...... 21, 22, 272 GVOKE HYPOPEN 1-PACK HEPARIN LOCK FLUSH..... 293 HUMIRA(CF) PEN...... 272 ...... 224 heparin lock flush HUMIRA(CF) PEN GVOKE HYPOPEN 2-PACK (porcine)...... 292, 293 CROHNS-UC-HS.... 21, 22, 272 ...... 225 HEPARIN HUMIRA(CF) PEN PSOR- GVOKE PFS 1-PACK LOCKFLUSH(PORCINE)(PF UV-ADOL HS...... 21, 22, 272 SYRINGE...... 225 )...... 293 HUMULIN 70/30 U-100 GVOKE PFS 2-PACK heparin, porcine (pf)..292, 293 INSULIN...... 245 SYRINGE...... 225 HEPLISAV-B (PF)...... 74 HUMULIN 70/30 U-100 GYNAZOLE-1...... 466 HETLIOZ...... 135 KWIKPEN...... 245 GYNOL II...... 164 HICON...... 69 HUMULIN N NPH INSULIN HAEGARDA...... 284 Hidex...... 242 KWIKPEN...... 246 Hailey...... 155 HI-VOLUME PUMPING HUMULIN N NPH U-100 Hailey 24 Fe...... 155 CHAMBER SET...... 360, 400 INSULIN...... 246 Hailey Fe 1.5/30 (28)...... 155 HIZENTRA...... 74 HUMULIN R REGULAR U- Hailey Fe 1/20 (28)...... 155 HOMATROPAIRE...... 435 100 INSULN...... 246 halcinonide...... 193 HOME NEBULIZER PLUS HUMULIN R U-500 (CONC) halobetasol propionate SIDESTREAM...... 368 INSULIN...... 246 ...... 182, 193 HORIZANT...... 140 HUMULIN R U-500 (CONC) HALOG...... 193, 194 HPR...... 187 KWIKPEN...... 246 haloperidol...... 122 HPR PLUS...... 187 HYCAMTIN...... 70 haloperidol lactate...... 122 HPR PLUS HYDROGEL..... 186 HYCLODEX...... 72 HALUCORT...... 187 HPR PLUS-MB HYDROGEL hydralazine...... 97 HARMONY GLUCOSE ...... 186 HYDRO 35...... 200 TEST STRIP...... 324, 400 HUMALOG JUNIOR hydrochlorothiazide...... 99 HARVONI...... 50 KWIKPEN U-100...... 251 hydrocodone bitartrate...... 9 HAVRIX (PF)...... 73 HUMALOG KWIKPEN hydrocodone- HEALTHPRO TEST STRIPS INSULIN...... 251 acetaminophen...... 17 ...... 324 HUMALOG MIX 50-50 hydrocodone- HEALTHWISE INSULIN INSULN U-100...... 247 chlorpheniramine...... 463 SYRINGE...... 352, 353, 400 HUMALOG MIX 50-50 hydrocodone-homatropine HEALTHY ACCENTS KWIKPEN...... 247 ...... 464 UNILET LANCET...... 344 HUMALOG MIX 75-25 hydrocodone-ibuprofen...... 17 Heather...... 161 KWIKPEN...... 247 hydrocortisone HELIDAC...... 275 HUMALOG MIX 75-25(U- ...... 34, 194, 242, 271 HEMADY...... 242 100)INSULN...... 247 hydrocortisone acetate...... 34 HEMANGEOL...... 93 HUMALOG U-100 INSULIN 251 hydrocortisone butyrate... 194 HEMLIBRA...... 288 HUMATE-P...... 287 hydrocortisone butyr- HEMOFIL M HIGH...... 287 HUMATROPE...... 244 emollient...... 194 HEMOFIL M LOW...... 287 HUMIRA...... 21, 22, 272 hydrocortisone valerate HEMOFIL M MID...... 287 HUMIRA PEN...... 272 ...... 194, 195 HEMOFIL M SUPER HIGH. 287 HUMIRA PEN CROHNS- hydrocortisone-acetic acid HEP FLUSH-10 (PF)...... 292 UC-HS START...... 21, 22, 272 ...... 448 heparin (porcine)...... 292 HUMIRA PEN PSOR- hydrocortisone-iodoquinl- heparin (porcine) in 0.9% UVEITS-ADOL HS...21, 22, 272 aloe2...... 176 nacl...... 292 HUMIRA(CF)...... 21, 22, 272 hydrocortisone-iodoquinol heparin (porcine) in 5 % ...... 180 dex...... 292 481 hydrocortisone- IMBRUVICA...... 63, 69 INNOSPIRE GO iodoquinol-aloe...... 176 IMCIVREE...... 218 NEBULIZER...... 362, 401 hydrocortisone-pramoxine IMIOXIA...... 178 INNOSPIRE MINI...... 368 ...... 34, 197 imipramine hcl...... 118 INNOSPIRE HYDROFERA BLUE....215, 400 imipramine pamoate...... 118 REPLACEMENT FILTER HYDROFERA BLUE imiquimod...... 198 ...... 368, 401 READY...... 215, 400 imiquimod-levocetirizin- INOVA...... 171 hydrogen peroxide...... 72 niacin...... 199 INOVA 4-1...... 171 Hydromet...... 464 imiquimod-tretinoin- INOVA 8-2...... 171 hydromorphone...... 9 levocetir...... 199 INPEN (FOR HUMALOG)... 353 hydromorphone (pf)-0.9 % IMPAVIDO...... 41 INPEN (FOR NOVOLOG nacl...... 9 IMPEKLO...... 195 OR FIASP)...... 353 hydroxychloroquine...... 40 IMPOYZ...... 183 INQOVI...... 71 hydroxypropyl cellulose... 149 IMVEXXY MAINTENANCE INREBIC...... 65 hydroxyurea...... 62 PACK...... 255 INSPIRACHAMBER.... 368, 401 hydroxyzine hcl...... 102 IMVEXXY STARTER PACK 255 INSPIRACHAMBER WITH hydroxyzine pamoate...... 102 INAVIX...... 27 MASK-LARGE...... 368, 401 HYGEL...... 205 INBRIJA...... 119 INSPIRACHAMBER WITH HYLAGUARD...... 187 Incassia...... 161 MASK-MED...... 368, 401 HYLATOPIC...... 187 INCONTROL SUPER THIN INSPIRACHAMBER WITH HYLATOPICPLUS...... 187 LANCETS...... 344, 400 MASK-SMALL...... 368, 401 HYOPHEN...... 53 INCONTROL ULTRA THIN INSPIRATION ELITE hyoscyamine sulfate...... 267 LANCETS...... 344, 400 FILTER...... 368, 401 HYOSYNE...... 267, 281 INCRELEX...... 254 INSUFLON...... 373, 401 HYPER-SAL...... 149 INCRUSE ELLIPTA...... 455 insulin asp prt-insulin HYPERSONIQ NEBULIZER indapamide...... 99 aspart...... 247 CARTRIDGE...... 368, 400 INDERAL XL...... 93 insulin aspart u-100...251, 252 HYPOCYN...... 189 INDOCIN...... 31 insulin syr/ndl u100 half hypromellose...... 149 indomethacin...... 31 mark...... 353, 401 HYQVIA...... 75 indomethacin INSULIN SYRINGE..... 353, 401 HYQVIA HY COMPONENT.258 submicronized...... 31 INSULIN SYRINGE HYQVIA IG COMPONENT....75 INFASURF...... 461 MICROFINE...... 353, 401 HYSINGLA ER...... 9 INFINITY TEST STRIPS..... 324 insulin syringe needleless ibandronate...... 236 INFINITY VOICE TEST ...... 353, 401 IBRANCE...... 64 STRIP...... 325, 401 insulin syringe-needle u- Ibu...... 30 INFLAMMACIN...... 27 100...... 353, 402 IBUPAK...... 30 INFLAMMA-K...... 204 INSYTE IV CATHETER ibuprofen...... 30, 31 INFLATHERM(DICLOFENA ...... 360, 402 ibuprofen-oxycodone...... 18 C-MENTHOL)...... 27 INTELENCE...... 43 icatibant...... 94 INGREZZA...... 140 INTERLINK LEVER LOCK Iclevia...... 156 INGREZZA INITIATION CANNULA...... 364, 402 ICLUSIG...... 67 PACK...... 140 INTRAROSA...... 255 IDELVION...... 285 INJECT EASE LANCETS INTRON A...... 65 IDHIFA...... 67 ...... 344, 401 Introvale...... 156 IFE-BIMIX 30/1...... 217 INLYTA...... 69 INVACARE LANCETS.344, 402 IFE-PG20...... 217 INNOPRAN XL...... 94 INVELTYS...... 437 IGLUCOSE TEST STRIP.... 324 INNOSPIRE DELUXE. 368, 401 INVIRASE...... 55 ILEVRO...... 438 INNOSPIRE ELEGANCE.... 368 INVOKAMET...... 228 ILIDERM...... 201 INNOSPIRE ESSENCE...... 368 INVOKAMET XR...... 228 imatinib...... 69 INVOKANA...... 229 482 IODOFLEX...... 72 Junel 1.5/30 (21)...... 156 KINERET...... 25 IODOSORB...... 72 Junel 1/20 (21)...... 156 KIONEX (WITH SORBITOL) IOPIDINE...... 445 Junel Fe 1.5/30 (28)...... 156 ...... 220 I-PORT...... 364 Junel Fe 1/20 (28)...... 156 KISQALI...... 64 I-PORT ADVANCE 6 MM Junel Fe 24...... 156 KISQALI FEMARA CO- INJEC PORT...... 364, 402 JUXTAPID...... 92 PACK...... 65 I-PORT ADVANCE 9 MM JYNARQUE...... 98, 259, 278 KIVIK...... 188 INJEC PORT...... 364, 402 Kaitlib Fe...... 156 KLARITY (CHONDROITIN) ipratropium bromide. 456, 461 KALETRA...... 44 (PF)...... 432 ipratropium-albuterol...... 458 Kalliga...... 156 KLARITY-A (AZITHRO- irbesartan...... 84 KALYDECO...... 460 CHONDR)(PF)...... 444 irbesartan- KAMDOY...... 201 KLARITY-B (BETAMETH- hydrochlorothiazide...... 83 KANGAROO 924 SAFETY CHOND)(PF)...... 437 IRESSA...... 60 SCREW...... 339, 402 KLARITY-L (LOTEPRED- ISENTRESS...... 42 KANGAROO EPUMP SET CHOND)(PF)...... 437 ISENTRESS HD...... 42 ...... 339, 402 KLONOPIN...... 103, 104, 128 Isibloom...... 156 KANGAROO GRAVITY SET Klor-Con M10...... 222 isoflurane...... 33 ...... 339, 402 Klor-Con M15...... 222 isoniazid...... 46 KAPSPARGO SPRINKLE..... 93 Klor-Con M20...... 222 isopropyl alcohol...... 149 KARBINAL ER...... 450, 451 KOATE...... 287 isosorbide dinitrate...... 84 Kariva (28)...... 152 KOGENATE FS...... 287 isosorbide mononitrate...... 84 KATERZIA...... 95 KOMBIGLYZE XR...... 233 isotretinoin...... 165 KELARX...... 205 KORLYM...... 227 isoxsuprine...... 100 Kelnor 1/35 (28)...... 156 KOSELUGO...... 66 isradipine...... 95 Kelnor 1-50 (28)...... 156 KOVALTRY...... 288 ISTURISA...... 224 KELOTOP...... 372, 402 KOVANAZE...... 427 ITHOXIA...... 172 KENDALL DISINFECTANT K-PHOS NO 2...... 279 itraconazole...... 39 CAP...... 364, 402 K-PHOS ORIGINAL...... 279 ivermectin...... 38, 212 KENGUARD FOLEY KRINTAFEL...... 40 IXINITY...... 286 CATHETER...... 375, 402 Kristalose...... 273 Jaimiess...... 152 KEPPRA...... 111 KRISTALOSE...... 273 JAKAFI...... 65 KEPPRA XR...... 111 Kurvelo (28)...... 156 Jantoven...... 283 KERAFOAM...... 200 KYLEENA...... 151 JANUMET...... 232 KERAGEL...... 215, 402 KYNMOBI...... 120 JANUMET XR...... 232 KERAGELT...... 215 l norgest/e.estradiol- JANUVIA...... 227 KERALYT SCALP e.estrad...... 152, 161 JARDIANCE...... 229 COMPLETE...... 200 L.E.T. (LIDO-EPINEPH- Jasmiel (28)...... 156 KERAMATRIX...... 212 TETRA)...... 208 JATENZO...... 225 KERLIX AMD...... 215 labetalol...... 82 JELMYTO...... 71 KERYDIN...... 179 LACRISERT...... 432 Jencycla...... 161 KESIMPTA PEN...... 430 lactated ringers...... 221 JENTADUETO...... 233 ketamine...... 33 lactulose...... 263, 273, 274 JENTADUETO XR...... 233 ketoconazole...... 39, 179 LAMICTAL...... 109 Jinteli...... 238 ketoconazole-niacinamide 178 LAMICTAL ODT...... 109, 129 JIVI...... 287 Ketodan...... 179 LAMICTAL ODT STARTER JOLESSA...... 156 KETODAN KIT...... 179 (BLUE)...... 109, 129 JORNAY PM...... 126 ketoprofen...... 31 LAMICTAL ODT STARTER JUBLIA...... 179 ketorolac...... 28, 438 (GREEN)...... 109, 129 Juleber...... 156 KEVEYIS...... 299 LAMICTAL ODT STARTER JULUCA...... 42 KEVZARA...... 25 (ORANGE)...... 109, 129 483 LAMICTAL STARTER Lessina...... 157 lidocaine-racepinep- (BLUE) KIT...... 109, 129 letrozole...... 63 tetracaine...... 209 LAMICTAL STARTER leucovorin calcium...... 71 lidocaine-tetracaine...... 209 (GREEN) KIT...... 109, 129 LEUKERAN...... 61 LIDOMARK 1-5...... 33 LAMICTAL STARTER LEUKINE...... 290 LIDOMARK 2-5...... 33 (ORANGE) KIT...... 109, 129 leuprolide...... 66 LIDOPAC...... 209 LAMICTAL XR...... 109 levalbuterol hcl...... 457 LIDOPIN...... 209 LAMICTAL XR STARTER levalbuterol tartrate...... 457 LIDOPURE PATCH...... 209 (BLUE)...... 110 LEVATOL...... 93 LIDORX...... 209 LAMICTAL XR STARTER LEVEMIR FLEXTOUCH U- LIDORXKIT...... 201 (GREEN)...... 110 100 INSULN...... 248 LIDOTIN...... 105, 143 LAMICTAL XR STARTER LEVEMIR U-100 INSULIN...248 LIDOTRANS 5 PAK...... 209 (ORANGE)...... 110 levetiracetam...... 111 LIDOTREX...... 209 LAMIOFLUR...... 258 LEVICYN ANTIPRURITIC LIDOTREX (WITH VITAMIN lamivudine...... 44, 49 ...... 210, 216 E)...... 209 lamivudine-zidovudine...... 45 LEVICYN ANTIPRURITIC LIDOVEX...... 209 lamotrigine...... 110, 129, 130 SG...... 187 LIDOVIX...... 27 LAMPIT...... 40 LEVICYN DERMAL...... 213 LIDTOPIC MAX...... 209 lancets...... 344 levobunolol...... 440 LILETTA...... 151 LANCETS, SUPER THIN levocarnitine...... 220, 424 Lillow (28)...... 157 ...... 344, 402 levocarnitine (with sugar). 424 lindane...... 212 LANCETS,THIN...... 344, 402 levocetirizine...... 451 linezolid...... 54 LANCETS,ULTRA THIN levofloxacin...... 48, 443 LINZESS...... 273 ...... 344, 402 Levonest (28)...... 162 liothyronine...... 257 LANOXIN...... 97 levonorgestrel...... 164 LIPRITIN...... 106, 143 lansoprazole...... 265 levonorgestrel-ethinyl LIPRITIN II...... 105, 143 lanthanum...... 277 estrad...... 157 lisinopril...... 82 LANTUS SOLOSTAR U-100 levonorg-eth estrad lisinopril- INSULIN...... 248 triphasic...... 162 hydrochlorothiazide...... 81 LANTUS U-100 INSULIN.... 248 Levora-28...... 157 LITE COAT ASPIRIN...... 32 lapatinib...... 60 levorphanol tartrate...... 10 LITE TOUCH INSULIN Larin 1.5/30 (21)...... 156 LEVO-T...... 257 SYRINGE...... 353, 354, 402 Larin 1/20 (21)...... 157 levothyroxine...... 257 LITE TOUCH LANCETS Larin 24 Fe...... 157 LEVOXYL...... 257 ...... 344, 402 Larin Fe 1.5/30 (28)...... 157 LEVULAN...... 205 LITE TOUCH-MEDIUM Larin Fe 1/20 (28)...... 157 LEXETTE...... 183 MASK...... 368, 403 Larissia...... 157 LEXIVA...... 55 LITEAIRE MDI CHAMBER LASTACAFT...... 436 LEXIXRYL...... 204 ...... 368, 403 latanoprost...... 445 LIALDA...... 271 LITETOUCH-LARGE MASK latanoprost (pf)...... 445 LICART...... 205 ...... 368, 403 LATUDA...... 121 LIDO BDK...... 375 LITETOUCH-SMALL MASK LAYOLIS FE...... 157 lidocaine...... 33, 209 ...... 369, 403 LAZANDA...... 9 lidocaine hcl.33, 208, 209, 428 lithium carbonate...... 131 LC PLUS...... 362 lidocaine hcl- lithium citrate...... 131 LC PLUS NEBULIZER-PED hydrocortison ac...... 34, 197 LITHOBID...... 131 MASK...... 362, 402 Lidocaine Viscous...... 428 LITHOSTAT...... 279 LDO PLUS...... 201, 206, 208 lidocaine-hydrocortisone- LIVALO...... 89 LEENA 28...... 162 aloe...... 34 LMR PLUS...... 201 leflunomide...... 26 lidocaine-prilocaine...... 201 LO LOESTRIN FE...... 152 LENVIMA...... 69 LO-DOSE ASPIRIN...... 32, 295 484 LOFRIC...... 375, 403 LYUMJEV KWIKPEN U-200 MEDIHONEY (CAL LOFRIC ORIGO...... 375, 403 INSULIN...... 252 ALGINATE-HONEY)....215, 404 LOFRIC PRIMO NELATON LYUMJEV U-100 INSULIN.. 252 MEDIHONEY (HONEY)...... 215 CATHETER...... 375 Lyza...... 161 MEDIHONEY Lojaimiess...... 152 mafenide acetate...... 185 (HYDROCOLLOID-HONEY) LOKELMA...... 220 MAGELLAN INSULIN ...... 215, 404 LOMAIRA...... 218 SAFETY SYRNG...... 354, 403 MEDISENSE THIN LONHALA MAGNAIR MAGELLAN SAFETY LANCETS...... 344 REFILL...... 455 NEEDLE...... 363, 403 MEDLANCE PLUS LONHALA MAGNAIR MAGELLAN SYRINGE 354, 403 LANCETS...... 344 STARTER...... 455 MAGIC3 INTERMITTENT MEDLANCE PLUS LONSURF...... 63 CATHETER...... 375, 403 SPECIAL BLADE...... 344 loperamide...... 259 malathion...... 212 MEDROL...... 242 lopinavir-ritonavir...... 44 maprotiline...... 118 MEDROLOAN II SUIK...... 242 LOPROX KIT...... 178 Marlissa (28)...... 157 MEDROLOAN SUIK...... 242 lorazepam...... 103 MARPLAN...... 114 medroxyprogesterone Lorazepam Intensol..... 103, 128 MARVONA SUIK (PF)...... 33 ...... 151, 256 LORBRENA...... 61 MATRISTEM...... 212 mefenamic acid...... 28 LORTAB ELIXIR...... 17 MATRISTEM mefloquine...... 40 Loryna (28)...... 157 MICROMATRIX...... 212 megestrol...... 68, 219 losartan...... 84 MATULANE...... 61 MEKINIST...... 66 losartan- Matzim La...... 95 MEKTOVI...... 66 hydrochlorothiazide...... 83 MAVENCLAD (10 TABLET Melodetta 24 Fe...... 158 LOTEMAX...... 437 PACK)...... 431 meloxicam...... 29 LOTEMAX SM...... 437 MAVENCLAD (4 TABLET meloxicam submicronized..29 loteprednol etabonate...... 437 PACK)...... 431 melphalan...... 61 LOUTREX...... 184, 187 MAVENCLAD (5 TABLET memantine...... 150 lovastatin...... 89 PACK)...... 431 MENACTRA (PF)...... 77 Low-Ogestrel (28)...... 157 MAVENCLAD (6 TABLET Menest...... 239 loxapine succinate...... 122 PACK)...... 431 MENEST...... 239 LOYON...... 187 MAVENCLAD (7 TABLET MENOPUR...... 240 Lo-Zumandimine (28)...... 157 PACK)...... 432 MENOSTAR...... 239 LUCEMYRA...... 146 MAVENCLAD (8 TABLET MENTAX...... 177 LUGOLS...... 72, 221 PACK)...... 432 MENTHO-CAINE...... 201 luliconazole...... 179 MAVENCLAD (9 TABLET MENVEO A-C-Y-W-135-DIP LUMIGAN...... 445 PACK)...... 432 (PF)...... 77 LUPANETA PACK (1 MAVYRET...... 50 meperidine...... 10 MONTH)...... 254 MAXICOMFORT INSULIN meperidine (pf)...... 10 LUPANETA PACK (3 SYRINGE...... 354, 403 meprobamate...... 103 MONTH)...... 254 MAXI-COMFORT INSULIN mercaptopurine...... 62 Lutera (28)...... 157 SYRINGE...... 354, 403 Merzee...... 158 LUXAMEND...... 187 MAXIDEX...... 437 mesalamine...... 271 Lyllana...... 239 MAYZENT...... 432 mesalamine with LYNPARZA...... 68 MAYZENT STARTER PACK cleansing wipe...... 271 LYRICA...... 106, 135 ...... 432 MESNEX...... 71 LYRICA CR. 134, 142, 143, 144 MB HYDROGEL...... 186 Metadate Er...... 126 LYSODREN...... 61 MB HYDROGEL metaproterenol...... 457 LYUMJEV KWIKPEN U-100 (CYCLOMETHICONE)...... 186 Metaxall...... 300 INSULIN...... 252 meclizine...... 260 metaxalone...... 300 meclofenamate...... 28 metformin...... 253 485 methadone...... 10, 11 MICRODOT BLOOD MINIMED INFUSION SET- Methadone Intensol...... 10 GLUCOSE SYSTEM...... 325 MMT 392...... 376, 405 Methadose...... 11 MICRODOT XTRA BLOOD MINIMED INFUSION SET- methamphetamine...... 133 GLUCOSE...... 325, 404 MMT 393...... 377, 405 methazolamide...... 97 Microgestin 1.5/30 (21)...... 158 MINIMED MIO 18"...... 377 methenamine hippurate...... 53 Microgestin 1/20 (21)...... 158 MINIMED MIO 23"...... 377 methenamine mandelate.....53 Microgestin 24 Fe...... 158 MINIMED MIO 32"...... 377 methen-sod phos-meth Microgestin Fe 1.5/30 (28)...158 MINIMED QUICK SET 18" blue-hyos...... 53, 280 Microgestin Fe 1/20 (28)...... 158 ...... 377, 405 methimazole...... 235 MICROLET LANCET...... 344 MINIMED QUICK SET 23".. 377 METHITEST...... 225 microplegic solution no.1. 446 MINIMED QUICK SET 32".. 377 methocarbamol...... 300 microplegic solution no.1- MINIMED QUICK SET 43".. 377 methotrexate sodium...... 23 cp2d...... 446 MINIMED SILHOUETTE 18" methotrexate sodium (pf)... 62 MICROSPACER...... 369 ...... 377, 405 methoxsalen...... 181 MICROVIX LP...... 201 MINIMED SILHOUETTE 23" methscopolamine...... 267 midazolam...... 33, 145 ...... 377 methyl salicylate...... 211 midazolam (pf)...... 33 MINIMED SILHOUETTE 32" methyldopa...... 97 midodrine...... 96 ...... 377 methyldopa- MIFEPREX...... 224 MINIMED SILHOUETTE 43" hydrochlorothiazide...... 97 mifepristone...... 224 ...... 377 methylergonovine...... 256 MIGERGOT...... 137 MINIMED SURE T 18".377, 405 methylphenidate hcl..126, 127 miglitol...... 227 MINIMED SURE T 23"...... 377 methylprednisolone...... 242 miglustat...... 424 MINIMED SURE T 32"...... 377 methyltestosterone...... 225 MIGRANOW...... 137 MINIMED SYRINGE metipranolol...... 440 Mili...... 158 RESERVOIR...... 354, 405 metoclopramide hcl...... 267 MILLIPRED...... 242 Minitran...... 84 metolazone...... 99 MILLIPRED DP...... 242 minocycline...... 58, 166 metoprolol succinate...... 93 Mimvey...... 238 MINOLIRA ER...... 59, 166 metoprolol ta- MINI PLUS NEBULIZER minoxidil...... 97 hydrochlorothiaz...... 96 ...... 362, 404 MIO INFUSION SET...... 377 metoprolol tartrate...... 93 MINI WRIGHT PEAK FLOW MIRCERA...... 285 metronidazole METER...... 365 MIRENA...... 151 ...... 41, 167, 207, 466 MINILINK REAL-TIME mirtazapine...... 114 metyrosine...... 100 TRANSMITTER...... 344, 404 MIRVASO...... 207 mexiletine...... 85 MINIMED 530G INSULIN misoprostol...... 266 MIACALCIN...... 237 PUMP...... 373 MISTASSIST...... 369, 405 Mibelas 24 Fe...... 158 MINIMED 630G GUARDIAN MISTASSIST KIT...... 369, 405 miconazole nitrate-zinc ox- START KT...... 344, 404 MITOSOL...... 435 pet...... 179 MINIMED 630G INSULIN MKO (MIDAZOLAM- MICONAZOLE-3...... 466 PUMP...... 373, 404 KETAMINE-ONDAN)...... 146 MICRO BLOOD GLUCOSE MINIMED 670G INSULIN M-M-R II (PF)...... 80 ...... 325, 404 PUMP...... 373 modafinil...... 141 MICRO THIN LANCETS...... 344 MINIMED 770G INSULIN moexipril...... 82 MICROAIR MESH PUMP...... 374 molindone...... 122 NEBULIZER...... 362 MINIMED INFUSION SET...376 mometasone...... 195, 462 MICROBORE EXTENSION MINIMED INFUSION SET- Mondoxyne Nl...... 59 SET...... 360, 404 MMT 390...... 376, 404 MONO-FLO DRAINAGE MICROCHAMBER...... 369 MINIMED INFUSION SET- BAG...... 348, 405 MICROCYN...... 72, 213 MMT 391...... 376, 404 MONOJECT BLOOD COLLECTION...... 302, 405 486 MONOJECT HYPODERMIC MYDRIATIC4(TROP-PROP- neomycin-polymyxin-hc NEEDLES...... 363, 405 PE-KTRLC)...... 442 ...... 434, 448 MONOJECT INSULIN myelogram tray...... 364, 406 Neo-Polycin...... 443 SAFETY SYRING 354, 355, 405 MYGLUCOHEALTH.... 326, 406 Neo-Polycin Hc...... 434 MONOJECT INSULIN MYGLUCOHEALTH NEORAL...... 25, 297 SYRINGE...... 355, 405, 406 LANCETS...... 344, 406 NEOSALUS...... 187, 188 MONOJECT LUER MYLERAN...... 61 NEO-SYNALAR...... 177 ADAPTER...... 364, 406 Myorisan...... 165 NEO-SYNALAR KIT...... 177 MONOJECT SYRINGE MYRBETRIQ...... 277 NERLYNX...... 60 ...... 355, 406 MYSOLINE...... 103 Neuac...... 169 MONOJECT ULTRA MYTESI...... 259 NEUAC KIT...... 169 COMFORT INSULIN... 355, 406 nabumetone...... 28 NEULASTA...... 289 MONOLET LANCETS...... 344 nadolol...... 94 NEULASTA ONPRO...... 289 MONOLET THIN LANCETS nadolol- NEUPOGEN...... 289 ...... 344, 406 bendroflumethiazide...... 99 NEUPRO...... 120 Mono-Linyah...... 158 naftifine...... 177 NEURAPTINE...... 202 MONONINE...... 286 NAFTIN...... 177 NEURCAINE...... 210 MONSEL'S...... 291 nalbuphine...... 19 NEURONTIN...... 106 montelukast...... 454 Nalocet...... 18 NEUTEK 2TEK TEST MORGIDOX 1X 50...... 59 naloxone...... 37 STRIPS...... 326 MORGIDOX 1X100...... 59 naltrexone...... 37 NEUTRASAL...... 428 MORGIDOX 2X100...... 59 NAMENDA XR...... 150 NEVANAC...... 438 morphine...... 11, 12 NAMZARIC...... 150 nevirapine...... 43 morphine (pf)...... 11 NAPRELAN CR...... 31 NEW DAY...... 164 morphine concentrate...... 11 naproxen...... 31 NEXAVAR...... 67 morphine in 0.9 % sodium naproxen sodium...... 31 NEXAVIR...... 201 chlor...... 11 naproxen-esomeprazole..... 26 NEXIUM PACKET...... 265 MOTEGRITY...... 266 naratriptan...... 137 NEXIVA...... 360, 406 MOTOFEN...... 260 NARCAN...... 37 NEXLETOL...... 86 MOVANTIK...... 36 NATACYN...... 444 NEXLIZET...... 91 MOXATAG...... 37 NATAZIA...... 161 NEXPLANON...... 151 moxifloxacin...... 48, 443 nateglinide...... 228 niacin...... 90, 223 MUCOSITISRX...... 428 NATESTO...... 225 Niacor...... 90 MUGARD...... 429 NATPARA...... 256 nicardipine...... 95 MULPLETA...... 296 NAYZILAM...... 104 nicotine...... 147 MULTAQ...... 86 NEBUPENT...... 53 nicotine (polacrilex)...... 147 mupirocin...... 175 NEBUSAL...... 149 NICOTROL...... 148 mupirocin calcium...... 175 Necon 0.5/35 (28)...... 158 NICOTROL NS...... 148 mupirocin-lidocaine...... 175 nefazodone...... 115 nifedipine...... 95 MURI-LUBE...... 149 NEOCERA...... 187 Nikki (28)...... 158 MUSE...... 217 neomycin...... 37 nilutamide...... 62 MY CHOICE...... 164 neomycin-bacitracin-poly- nimodipine...... 95 MY MDI PORTABLE hc...... 434 NINLARO...... 68 NEBULISER...... 369, 406 neomycin-bacitracin- nisoldipine...... 95 MY WAY...... 164 polymyxin...... 442 nitazoxanide...... 41 MYALEPT...... 254 neomycin-polymyxin b gu 276 nitisinone...... 424 MYCAPSSA...... 256 neomycin-polymyxin b- Nitro-Bid...... 84 mycophenolate mofetil..... 298 dexameth...... 434 NITRO-DUR...... 85 mycophenolate sodium.... 298 neomycin-polymyxin- nitrofurantoin...... 279 MYDAYIS...... 127, 132 gramicidin...... 443 487 nitrofurantoin NOVAREL...... 245 NUVAIL...... 206 macrocrystal...... 279 NOVOEIGHT...... 288 NUVAKAAN...... 202, 372 nitrofurantoin monohyd/m- NOVOLIN 70/30 U-100 NUVESSA...... 466 cryst...... 279 INSULIN...... 245 NUWIQ...... 288 nitroglycerin...... 85 NOVOLIN 70-30 FLEXPEN NUZYRA...... 59 NITROMIST...... 85 U-100...... 245 Nyamyc...... 177 Nitro-Time...... 85 NOVOLIN N FLEXPEN...... 246 NYMALIZE...... 95 NITYR...... 424 NOVOLIN N NPH U-100 Nymyo...... 159 NIVATOPIC PLUS...... 188 INSULIN...... 246 nystatin...... 39, 177, 427 NIVESTYM...... 289 NOVOLIN R FLEXPEN...... 246 nystatin-triamcinolone...... 180 nizatidine...... 264 NOVOLIN R REGULAR U- Nystop...... 177 NOCDURNA (MEN)...... 226 100 INSULN...... 247 NYVEPRIA...... 289 NOCDURNA (WOMEN)...... 226 NOVOLOG FLEXPEN U- OASIS ULTRA NOCTIVA...... 226 100 INSULIN...... 252 FENESTRATED...... 212, 406 NOPIOID-LMC KIT...... 301 NOVOLOG MIX 70-30 U- OASIS WOUND MATRIX NOPIOID-TC KIT...... 301 100 INSULN...... 247 FENESTRATED...... 212, 406 NORA-BE...... 161 NOVOLOG MIX 70- OASIS WOUND MATRIX NORDITROPIN FLEXPRO..244 30FLEXPEN U-100...... 248 MESHED...... 213, 407 noreth-ethinyl estradiol- NOVOPEN ECHO...... 355, 406 OBIZUR...... 288 iron...... 158 NOVOSEVEN RT...... 286 OBREDON...... 465 norethindrone NOXAFIL...... 39 OCALIVA...... 297 (contraceptive)...... 161 NOXIPAK...... 197 OCELLA...... 159 norethindrone acetate...... 256 NP THYROID...... 257 octreotide acetate...... 256 norethindrone ac-eth NUBEQA...... 62 ODACTRA...... 73 estradiol...... 158, 238 NUCALA...... 454, 455 ODEFSEY...... 46 norethindrone-e.estradiol- NUCARACLINPAK...... 167 ODOMZO...... 65 iron...... 159 NUCARARXPAK...... 169 OFEV...... 69, 465 Norgesic Forte...... 299 NUCORT...... 197 ofloxacin...... 48, 443, 448 norgestimate-ethinyl NUCYNTA...... 12 olanzapine...... 130 estradiol...... 159, 162 NUCYNTA ER...... 12 olanzapine-fluoxetine...... 130 NORITATE...... 167, 207 NUDERMRXPAK...... 183 olmesartan...... 84 Norlyda...... 161 NUDICLO SOLUPAK...... 204 olmesartan-amlodipin- NORMAL SALINE FLUSH...223 NUDICLO TABPAK...... 27 hcthiazid...... 83 NORMLGEL AG...... 175 NUDROXIPAK...... 28 olmesartan- NORPACE CR...... 85 NUDROXIPAK DSDR-50...... 27 hydrochlorothiazide...... 83 NORTHERA...... 96 NUDROXIPAK DSDR-75...... 27 olopatadine...... 436, 462 Nortrel 0.5/35 (28)...... 159 NUDROXIPAK E-400...... 27 OLUMIANT...... 25 NORTREL 1/35 (21)...... 159 NUDROXIPAK I-800...... 27 OMBRA COMPRESSOR Nortrel 1/35 (28)...... 159 NUDROXIPAK N-500...... 27 SYSTEM...... 369, 407 Nortrel 7/7/7 (28)...... 162 NUEDEXTA...... 145 OMECLAMOX-PAK...... 275 nortriptyline...... 118 NULYTELY LEMON-LIME...274 omega-3 acid ethyl esters...91 NORVIR...... 55 NUMBONEX...... 209 omeprazole...... 265 NOSE CLIP...... 369, 406 NUMBRINO...... 461 omeprazole-sodium NOURIANZ...... 118 NUMOISYN...... 8, 428 bicarbonate...... 266 NOVA MAX GLUCOSE NUPLAZID...... 123 OMNARIS...... 462 TEST...... 326 NURTEC ODT...... 136 OMNIPOD DASH 5 PACK NOVA SAFETY LANCETS..344 NUSURGEPAK SURGICAL POD...... 361, 407 NOVA SUREFLEX PREP...... 216 OMNIPOD DASH PDM KIT LANCETS...... 345, 406 NUTRASEB...... 188 ...... 355, 407 NOVACORT...... 198 NUTROPIN AQ NUSPIN..... 244 488 OMNIPOD INSULIN OPTUMRX...... 328, 408 oxycodone- MANAGEMENT...... 374, 407 ORACIT...... 279 acetaminophen...... 18 OMNIPOD INSULIN REFILL ORAFATE...... 429 oxycodone-aspirin...... 18 ...... 361, 407 ORALAIR...... 72, 73 OXYCONTIN...... 13 OMNITROPE...... 244 Oralone...... 428 oxymorphone...... 13 ON CALL EXPRESS TEST ORAMAGICRX...... 429 OXYTROL...... 281 STRIP...... 326, 407 ORAPEUTIC...... 429 OZEMPIC...... 231, 232 ON CALL LANCET...... 345, 407 ORAQIX...... 427 OZOBAX...... 300 ON CALL PLUS LANCET ORAVIG...... 39 Pacerone...... 86 ...... 345, 407 ORENCIA...... 24 PACNEX HP...... 171 ON CALL PLUS TEST ORENCIA CLICKJECT...... 24 PACNEX LP...... 171 STRIP...... 327, 407 ORENITRAM...... 100 PAIN EASE MEDIUM ON CALL VIVID TEST ORFADIN...... 424 STREAM SPRAY...... 202 STRIP...... 327 ORGOVYX...... 66 PAIN EASE MIST SPRAY...202 ondansetron...... 261 ORIAHNN...... 254 PAINGO KFT...... 202 ondansetron hcl...... 261 ORILISSA...... 255 PALFORZIA (LEVEL 1)...... 76 ONETOUCH DELICA ORKAMBI...... 460 PALFORZIA (LEVEL 2)...... 76 LANCETS...... 345, 407 ORLADEYO...... 80 PALFORZIA (LEVEL 3)...... 76 ONETOUCH DELICA PLUS orphenadrine citrate...... 300 PALFORZIA (LEVEL 4)...... 76 LANCET...... 345, 407 orphenadrine-asa-caffeine299 PALFORZIA (LEVEL 5)...... 76 ONETOUCH SURESOFT Orphengesic Forte...... 299 PALFORZIA (LEVEL 6)...... 76 LANCING DEV...... 345, 408 Orsythia...... 159 PALFORZIA (LEVEL 7)...... 76 ONETOUCH ULTRA BLUE ORTIKOS...... 271 PALFORZIA (LEVEL 8)...... 76 TEST STRIP...... 327 OSCIMIN...... 267, 281 PALFORZIA (LEVEL 9)...... 76 ONETOUCH ULTRASOFT OSCIMIN SL...... 267, 281 PALFORZIA (LEVEL 10)...... 76 LANCETS...... 345, 408 OSCIMIN SR...... 267, 281 PALFORZIA (LEVEL 11 UP- ONETOUCH VERIO TEST oseltamivir...... 51 DOSE)...... 76 STRIPS...... 327 OSMOLEX ER...... 120 PALFORZIA INITIAL DOSE.. 76 ONEXTON...... 169 OSMOPREP...... 274 PALFORZIA LEVEL 11 ONGENTYS...... 119 OSPHENA...... 255 MAINTENANCE...... 76 ONGLYZA...... 227 OTEZLA...... 25 paliperidone...... 121 ON-THE-GO LANCETS...... 345 OTEZLA STARTER...... 26, 184 PALYNZIQ...... 425 ONUREG...... 62 OTIPRIO...... 448 PANCREAZE...... 263 ONZETRA XSAIL...... 137 OTREXUP (PF)...... 23 PANDEL...... 195 OPCICON ONE-STEP...... 164 OVACE PLUS...... 184 PANRETIN...... 181 opium tincture...... 259 OVACE PLUS SHAMPOO.. 184 pantoprazole...... 265 OPSUMIT...... 101 OVIDREL...... 245 papaverine...... 100 OPTICHAMBER ADULT oxandrolone...... 225 PARADIGM RESERVOIR MASK-LARGE...... 369, 408 oxaprozin...... 31 ...... 355, 408 OPTICHAMBER DIAMOND OXAYDO...... 12 PARADIGM SILHOUETTE LG MASK...... 369, 408 oxazepam...... 103 INFUS SET...... 364 OPTICHAMBER DIAMOND OXBRYTA...... 296 PARAGARD T 380A...... 151 VHC...... 369, 408 oxcarbazepine...... 107 PAREMYD...... 433 OPTICHAMBER DIAMOND- OXERVATE...... 440 PARI BABY CONV KIT - MED MSK...... 369, 408 oxiconazole...... 179 SIZE 1...... 369, 408 OPTICHAMBER DIAMOND- OXISTAT...... 179 PARI BABY CONV KIT - SML MASK...... 369, 408 OXTELLAR XR...... 107 SIZE 2...... 369, 408 OPTION-2...... 164 oxybutynin chloride...... 281 PARI BABY CONV KIT - OPTIUM EZ...... 328 oxycodone...... 12, 13 SIZE 3...... 369, 408 OPTIUM TEST...... 328 489 PARI LC SPRINT PENTASA...... 271 phenytoin sodium NEBULIZER SET...... 362, 408 pentazocine-naloxone...... 19 extended...... 107 PARI LC SPRINT SINUS PENTICAN...... 106, 144 PHEODOYO...... 176 ...... 362, 408 pentoxifylline...... 290 PHEYO...... 180 PARI SINUS AEROSOL PERFOROMIST...... 456 Philith...... 159 SYSTEM...... 369, 408 perindopril erbumine...... 82 PHLAG SPRAY...... 188 PARI TREK S COMBO PERIO MED...... 426 PHOS-FLUR...... 426 PACK...... 369, 409 Periogard...... 427 PHOSLYRA...... 277 PARI TREK S COMPACT permethrin...... 212 PHOSPHASAL...... 53 COMPRESSOR...... 369, 409 perphenazine...... 123 PHOSPHOLINE IODIDE..... 432 PARI TREK S PORTABLE perphenazine-amitriptyline PHOTREXA...... 434 PWR KIT...... 369, 409 ...... 117 PHOTREXA CROSS- paricalcitol...... 424 PERTZYE...... 263 LINKING KIT...... 433 Paroex Oral Rinse...... 427 PEXEVA...... 115 PHOTREXA VISCOUS...... 434 paromomycin...... 37 PFLEX INSPIRATORY PHYSIOLYTE...... 221 paroxetine hcl...... 115 TRAINER...... 370, 409 PHYSIOSOL IRRIGATION..221 paroxetine PHARMABASE BARRIER...206 phytonadione (vitamin k1) 223 mesylate(menop.sym)...... 255 PHARMACIST CHOICE PICATO...... 180 PASER...... 46 ...... 328, 409 PIFELTRO...... 43 PAXIL...... 115 PHASEAL ASSEMBLY PILLOW MASK CHILD 370, 410 P-CARE D40G...... 242 FIXTURE...... 364, 409 pilocarpine hcl...... 429, 433 P-CARE D80G...... 242 PHASEAL CONNECTOR pimecrolimus...... 185 P-CARE K40G...... 242 LUER LOCK...... 364 pimozide...... 123 P-CARE K80G...... 242 PHASEAL INFUSION Pimtrea (28)...... 152 P-CARE MG (PF)...... 33 ADAPTER...... 364, 409 pindolol...... 93 PCCA ACCUPEN-15...339, 409 PHASEAL INFUSION pioglitazone...... 254 PEDIA IRON...... 222 CLAMP...... 364 pioglitazone-glimepiride... 231 PEDIATRIC COMP-AIR PHASEAL INJECTOR LUER pioglitazone-metformin.....230 COMPRES NEB...... 370, 409 ...... 364, 409 PIP LANCET...... 345, 410 PEDIATRIC DINOSAUR PHASEAL INJECTOR LUER PIQRAY...... 68 NEBULIZER...... 370, 409 LOCK...... 364 Pirmella...... 159, 162 PEDIATRIC DOG PHASEAL PROTECTOR piroxicam...... 29 NEBULIZER...... 370, 409 ...... 364, 409 PLANTAGO-HOMACCORD 258 PEDIATRIC FROG PHASEAL SECONDARY PLEGRIDY...... 430 NEBULIZER...... 370, 409 SET...... 361, 409 PLENVU...... 274 PEDIZOL PAK...... 179 PHASEAL Y-SITE...... 361, 410 PLEXION CLEANSING peg 3350-electrolytes...... 274 phenazopyridine...... 279 CLOTHS...... 169 peg3350-sod sul-nacl-kcl- phendimetrazine tartrate...219 PNEUMOVAX-23...... 77, 78 asb-c...... 274 phenelzine...... 114 POCKET CHAMBER...... 370 PEGASYS...... 49 phenobarb-hyoscy- POD-CARE 100CG...... 240 peg-electrolyte soln...... 274 atropine-scop...... 269 POD-CARE 100KG...... 242 PEGINTRON...... 49 phenobarbital...... 145 PODOCON...... 200 PEG-PREP...... 275 PHENOHYTRO...... 269 podofilox...... 200 PEMAZYRE...... 64 phenoxybenzamine...... 100 Polycin...... 443 PEN NEEDLE...... 355 phentermine...... 219 polymyxin b sulf- penicillamine...... 25, 36 phenylephrine hcl...... 440 trimethoprim...... 443 penicillin v potassium...... 54 phenyleph-tropicamide in POLYTOZA...... 372, 410 PENLEN...... 188 water...... 433 POMALYST...... 70 PENNSAID...... 205 Phenytek...... 107 PONTOCAINE...... 210 pentamidine...... 53 phenytoin...... 107 POPULUS COMPOSITUM..258 490 PORTABLE NEBULIZER prednisolone-moxifloxacin PRO COMFORT TENS SYSTEM...... 370, 410 hcl...... 434 ELECTRODE...... 361, 410 Portia 28...... 159 prednisolone-moxiflox- PRO COMFORT TENS posaconazole...... 39 bromfen...... 435 UNIT...... 361, 410 POTABA...... 224 prednisone...... 243 PRO VOICE V8-V9 TEST potassium chloride...... 222 PREDNISONE INTENSOL..243 STRIP...... 330, 411 potassium citrate...... 279 PREFEST...... 238 PROAIR DIGIHALER...... 457 PR BENZOYL PEROXIDE.. 171 pregabalin...... 106 PROAIR RESPICLICK...... 457 PR CREAM...... 205 PREGNYL...... 245 probenecid...... 282 PRADAXA...... 296 PREMARIN...... 239, 467 probenecid-colchicine...... 282 pralidoxime...... 35 PREMIER TEST STRIP...... 330 PROCARE COMPRESSOR PRALUENT PEN...... 92 PREMIUM V10...... 330, 410 NEBULIZER...... 370, 411 pramipexole...... 120, 121 PREMPHASE...... 238 PROCARE PEDIATRIC PRAMOSONE...... 198 PREMPRO...... 238 NEBULIZER...... 370 prasugrel...... 295 PREPIDIL...... 224 PROCARE SPACER WITH pravastatin...... 89 PRESERA...... 188 ADULT MASK...... 370, 411 praziquantel...... 38 PRESSURE ACTIVATED PROCARE SPACER WITH prazosin...... 100 LANCETS...... 345, 410 CHILD MASK...... 370, 411 PRECISION PCX PLUS PRESTALIA...... 81 PRO-CEPTION...... 362, 411 TEST...... 329 pretomanid...... 46 PROCHAMBER...... 370, 411 PRECISION PCX TEST...... 329 Prevalite...... 87 prochlorperazine...... 261 PRECISION POINT OF PREVIDENT...... 427 prochlorperazine maleate. 123 CARE TEST...... 329 PREVIDENT 5000 DRY PROCORT...... 35 PRECISION Q-I-D TEST.....329 MOUTH...... 426 PROCRIT...... 285 PRECISION XTRA TEST.... 329 PREVIDENT 5000 ENAMEL Proctofoam Hc...... 35 PRED MILD...... 437 PROTECT...... 426 Procto-Med Hc...... 34 PRED-G...... 434 PREVIDENT 5000 Procto-Pak...... 34, 195 PRED-G S.O.P...... 434 SENSITIVE...... 427 Proctosol Hc...... 34, 195 prednicarbate...... 195 Previfem...... 159 Proctozone-Hc...... 34 prednisol ace-gatiflox- PREVYMIS...... 48 PROCYSBI...... 276 bromfen...... 435 PREZCOBIX...... 45, 54 PRODIGY INSULIN prednisoln sp-gatiflox- PREZISTA...... 54 SYRINGE...... 356, 411 bromfen...... 435 PRIFTIN...... 46 PRODIGY LANCETS.. 345, 411 prednisoln sp-moxiflox- PRILO PATCH...... 210 PRODIGY MINI-MIST bromfen...... 435 PRILOSEC...... 265 NEBULIZER...... 362 prednisolone...... 242 primaquine...... 40 PRODIGY NO CODING...... 330 prednisolone acetate...... 437 PRIMEAIRE...... 370, 410 PRODIGY TWIST TOP prednisolone acetate (pf)..437 primidone...... 103 LANCET...... 345 prednisolone acetate- PRIMLEV...... 18 PROFILNINE...... 286 bromfenac...... 440 PRIMSOL...... 38 progesterone...... 256 prednisolone acetate- PRIZOTRAL...... 202 progesterone micronized..256 nepafenac...... 440 PRIZOTRAL-II...... 202 PROGRAF...... 297 prednisolone acet- PRO COMFORT INSULIN PROLASTIN-C...... 461 gatifloxacin...... 434 SYRINGE...... 355, 410 Prolate...... 18 prednisolone sod ph- PRO COMFORT LANCET PROLENSA...... 438 moxiflox...... 434 ...... 345, 410 PROMACTA...... 296 prednisolone sodium PRO COMFORT SPACER- promethazine..... 261, 450, 451 phosphate...... 242, 243, 437 ADULT MASK...... 370, 410 promethazine-codeine...... 464 prednisolone-moxiflo- PRO COMFORT SPACER- promethazine-dm...... 463 nepafenac...... 435 CHILD MASK...... 370, 410 491 promethazine-phenyleph- QINLOCK...... 69 REBIF (WITH ALBUMIN).... 430 codeine...... 464 QNASL...... 462 REBIF REBIDOSE...... 431 promethazine- QSYMIA...... 218 REBIF TITRATION PACK... 431 phenylephrine...... 449 QTERN...... 229 REBINYN...... 286 Promethegan...... 261, 450, 451 QUAKE VIBRATORY PEP RECEDO...... 206 PROMISEB...... 184 ...... 371, 412 Reclipsen (28)...... 159 PRONEB ULTRA II FILTER quazepam...... 145 RECOMBINATE...... 288 ASSEM...... 370, 411 QUDEXY XR...... 108 RECOMBIVAX HB (PF)...... 74 propafenone...... 85 quetiapine...... 130, 131 RECOTHROM...... 291 propantheline...... 268 QUICK-SET PARADIGM.....377 RECOTHROM SPRAY KIT. 291 proparacaine...... 441 QUICK-SET PARADIGM 43" RECTIV...... 34 propranolol...... 94 ...... 377, 412 REFUAH PLUS...... 331, 413 propranolol- QUILLICHEW ER...... 127 REGENECARE...... 209 hydrochlorothiazid...... 99 QUILLIVANT XR...... 127 REGENECARE WITH ALOE propylthiouracil...... 235 quinapril...... 82 ...... 209 PROSILK...... 372, 411 quinapril- REGIOCIT (EUA)...... 283 PROSILK GEL...... 205 hydrochlorothiazide...... 81 REGRANEX...... 216 PROSTIN E2...... 224 quinidine gluconate...... 85 RELAFEN DS...... 28 PROTHELIAL...... 429 quinidine sulfate...... 85 RELAGARD...... 467 PROTONIX...... 265 quinine sulfate...... 40 RELENZA DISKHALER...... 51 protriptyline...... 118 QUINIXIL...... 197 Relexxii...... 127 PROTYL AG...... 215 QUINJA...... 175 RELIAMED LANCET... 345, 413 PROVENT...... 370, 411 QUINTET AC...... 331, 412 RELIAMED SAFETY SEAL PROVENT STARTER. 370, 411 QUINTET GLUCOSE TEST LANCETS...... 345, 413 PRUCLAIR...... 188 STRIPS...... 331, 412 RELIAMED TWIST AND PRUMYX...... 188 QUIT 2...... 148 CAP LANCET...... 345, 413 PSORINOHEEL...... 258 QUIT 4...... 148 RELION CONFIRM-MICRO 331 PULMICORT FLEXHALER. 453 QUTENZA...... 211 RELION PRIME TEST PULMO-AIDE QVAR REDIHALER...... 453 STRIPS...... 332 COMPRESSOR...... 370 rabeprazole...... 266 RELION THIN LANCETS PULMONEB LT RADIAGEL...... 188 ...... 345, 413 COMPRESSOR NEBUL RADIAPLEXRX...... 205 RELION ULTIMA...... 332, 413 ...... 371, 411 RADIOGARDASE...... 35 RELION ULTRA THIN PLUS PULMOZYME...... 461 RAGWITEK...... 73 LANCETS...... 345, 413 PURE COMFORT raloxifene...... 256 RELISTOR...... 36 LANCETS...... 345, 411 ramelteon...... 135 RELIZORB...... 339, 413 PURE COMFORT SAFETY ramipril...... 82 RENACIDIN...... 277 LANCETS...... 345, 412 ranolazine...... 85 RENEEL...... 258 PURIXAN...... 62 RAPAMUNE...... 298 repaglinide...... 228 PUSH BUTTON SAFETY RAPPORT VACUUM repaglinide-metformin...... 227 LANCETS...... 345, 412 THERAPY...... 361, 412 REPATHA PUSHTRONEX....92 PYLERA...... 275 rasagiline...... 119 REPATHA SURECLICK...... 92 pyrazinamide...... 46 RASUVO (PF)...... 23, 24 REPATHA SYRINGE...... 92 pyridostigmine bromide....299 RATE FLOW REGULATOR REPLICARE DRESSING pyrimethamine...... 40 IV SET...... 361, 412 ...... 215, 413 QBRELIS...... 82 RAVICTI...... 425 REPLICARE THIN...... 215, 413 QBREXZA...... 177 RAYALDEE...... 424 REPLICARE ULTRA Q-CARE RX Q2...... 338 RAYOS...... 243 DRESSING...... 215, 413 Q-CARE RX Q4...... 338 READYLANCE SAFETY RESPA-AR...... 449 QDOLO...... 13 LANCETS...... 345, 412 RESTASIS...... 438 492 RESTASIS MULTIDOSE.....438 rivastigmine tartrate...... 150 SALIVAMAX...... 428 RESTORE...... 215, 340, 413 RIVELSA...... 161 salsalate...... 32 RESTORE CALCIUM RIXUBIS...... 286 SALVAX...... 200 ALGINATE...... 215 rizatriptan...... 137 SALVAX DUO PLUS...... 199 RESTORE CONTACT ROBINSON CLEAR VINYL SAMI THE SEAL...... 371, 414 LAYER SILVER...... 215 CATHETER...... 375, 414 SAMI THE SEAL MASK RESTORE FOAM ROCKLATAN...... 442 ...... 371, 415 DRESSING SILVER...... 215 ropinirole...... 121 SANADERMRX...... 197 RETACRIT...... 285 Rosadan...... 168, 207 SANCUSO...... 261 RETEVMO...... 70 ROSADAN...... 207 SANDIMMUNE...... 25, 297 RETIN-A MICRO PUMP...... 172 ROSANIL...... 169 SANTYL...... 188 REUSABLE NEBULIZER ROSULA...... 169 sapropterin...... 425 KIT...... 371 ROSULA CLEANSING SAVAYSA...... 284 REVCOVI...... 423 CLOTHS...... 169 SAVELLA...... 116, 135 REVEAL TEST STRIP...... 332 rosuvastatin...... 90 SAXENDA...... 219 REVEL PEDIATRIC ROTARIX...... 75 SCALACORT DK...... 195 PROGRAM PUMP...... 374, 413 ROTATEQ VACCINE...... 75 SCARCARE...... 206, 372 REVEL PROGRAMMABLE Roweepra...... 111 SCARCIN GEL...... 206 PUMP...... 374 Roweepra Xr...... 111 SCARCIN ROLL-ON...... 206 REVLIMID...... 70 ROZLYTREK...... 69 SCARCINPAD...... 372, 415 REXULTI...... 124 RUBBER MOUTHPIECE SCARSILK...... 372, 415 REYATAZ...... 55 ...... 371, 414 SCARSILK GEL...... 206 REYVOW...... 139 RUBRACA...... 68 SCLEROSOL RHOFADE...... 207 RUCONEST...... 284 INTRAPLEURAL...... 465 RHOPRESSA...... 446 rufinamide...... 112 scopolamine base...... 260 ribavirin...... 50, 55 RUKOBIA...... 42 SEBUDERM...... 188 RIDAURA...... 24 RUZURGI...... 431 SECONAL SODIUM...... 145 rifabutin...... 46, 55 RYBELSUS...... 232 SECUADO...... 121 RIFAMATE...... 47 RYDAPT...... 69 SEEBRI NEOHALER...... 455 rifampin...... 46 RYNODERM...... 200 SEGLUROMET...... 228 RIFATER...... 47 RYTARY...... 118 selegiline hcl...... 119 RIGHTEST GL300 SABAL-HOMACCORD...... 259 selenium sulfide...... 184 LANCETS...... 345, 414 SABRIL...... 106 SELF-CATHETER, FEMALE RIGHTEST GS250S TEST SAF-CLENS AF DERMAL ...... 375, 415 STRIPS...... 332, 414 WOUND...... 208 SELZENTRY...... 41 RIGHTEST GS260 TEST SAFESNAP INSULIN SEMGLEE PEN U-100 STRIPS...... 333, 414 SYRINGE...... 356 INSULIN...... 248 RIGHTEST GS550 TEST SAFETY LANCETS..... 345, 414 SEMGLEE U-100 INSULIN. 249 STRIPS...... 333, 414 safety needles...... 363, 414 SEMPREX-D...... 449 riluzole...... 299 SAFETY SEAL LANCETS...346 SEREVENT DISKUS...... 456 rimantadine...... 51 SAFETY-LET LANCETS SERNIVO...... 195 ringer's...... 221 ...... 346, 414 SEROQUEL XR...... 123 RINVOQ...... 25 SAIZEN...... 244, 276 SEROSTIM...... 244 RIOMET ER...... 253 SAIZEN SAIZENPREP...... 244 sertraline...... 115 risedronate...... 236, 237 salicylic acid...... 200 Setlakin...... 159 risperidone...... 122 salicylic acid-ceramides sevelamer carbonate...... 278 RITEFLO AEROCHAMBER no.1...... 200 sevelamer hcl...... 278 ...... 371, 414 salicylic-cimetidine- SEVENFACT...... 286 ritonavir...... 55 lidocaine...... 199 sevoflurane...... 33 rivastigmine...... 150 SALIMEZ FORTE...... 200 SEYSARA...... 59, 166 493 SF...... 427 SINUSTAR NEBULIZER SOLUPAK...... 202 SF 5000 PLUS...... 427 ...... 363, 415 SOLUS V2 LANCETS. 346, 415 Sharobel...... 161 sirolimus...... 298 SOLUS V2 TEST STRIPS SHINGRIX (PF)...... 80 SIRTURO...... 46 ...... 334, 416 SHINGRIX ADJUVANT SITAVIG...... 51 SOMAVERT...... 244 COMPONENT-PF...... 149 SIVEXTRO...... 54 SONAFINE...... 188 SHINGRIX GE ANTIGEN SKLICE...... 212 SOOLANTRA...... 207 COMPONENT...... 80 SKYLA...... 151 SOOTHENEB SHOHL'S MODIFIED...... 279 SKYRIZI...... 174 COMPRESSOR SIDESTREAM...... 363 SLYND...... 161 NEBULIZER...... 371, 416 SIDESTREAM MASK.. 371, 415 SMART SENSE LANCETS SOOTHENEB MESH SIDESTREAM NEBULIZER 363 ...... 346, 415 NEBULIZER...... 363, 416 SIDESTREAM PLUS...363, 415 SMART SENSE TEST sorbitol...... 277 SIGNIFOR...... 256 STRIPS...... 333 sorbitol-mannitol...... 277 SIKLOS...... 295, 296 SMARTEST LANCET..346, 415 SORILUX...... 183 SILA III...... 195 SMARTEST TEST...... 333, 415 Sorine...... 85 SILALITE PAK...... 195 sodium chlor 0.9% sotalol...... 86 SILASTIC FOLEY bacteriostat...... 220 Sotalol Af...... 86 CATHETER...... 375, 415 sodium chloride SOTYLIZE...... 86 SILAZONE-II...... 195 ...... 149, 202, 220, 221 SOVALDI...... 50 sildenafil...... 218 sodium chloride 0.45 %.....223 SPACE CHAMBER..... 371, 416 sildenafil sodium chloride 0.9 % SPACE CHAMBER PLUS (pulm.hypertension)...... 101 ...... 220, 223 ...... 371, 416 SILHOUETTE...... 361 sodium chloride 0.9 % SPACE CHAMBER WITH SILHOUETTE 23"-FULL (flush)...... 223 LARGE MASK...... 371, 416 SET...... 361, 378, 415 sodium citrate...... 283 SPACE CHAMBER WITH SILHOUETTE 43"-FULL sodium citrate in 0.9 % MEDIUM MASK...... 371, 416 SET...... 361, 378, 415 nacl...... 283 SPACE CHAMBER WITH SILICONE MASK...... 371 SODIUM FLUORIDE 5000 SMALL MASK...... 371, 416 SILICONE MASK - INFANT PLUS...... 427 SPECTRAGEL...... 215, 416 ...... 371, 415 sodium fluoride-pot nitrate SPEEDICATH (FEMALE) SILIPAC...... 206 ...... 427 ...... 375, 416 SILIQ...... 174 sodium iodide-123...... 217 spinosad...... 212 SILIVEX...... 372 sodium iodide-131...... 217 SPIRIVA RESPIMAT...... 455 SIL-K...... 373, 415 sodium phenylbutyrate..... 425 SPIRIVA WITH silodosin...... 278 SODIUM POLYSTYRENE HANDIHALER...... 455 SILTREX...... 373, 415 (SORB FREE)...... 220 spironolactone...... 82 silver nitrate...... 175 sodium polystyrene spironolacton- silver nitrate applicators... 199 sulfonate...... 220 hydrochlorothiaz...... 98 silver sulfadiazine...... 185 SOFT TOUCH LANCETS SPRAVATO...... 114 SILVRSTAT...... 175 ...... 346, 415 SPRAY AND STRETCH...... 202 SIMBRINZA...... 433 SOLARAVIX...... 181 Sprintec (28)...... 159 Simliya (28)...... 152 solifenacin...... 280 SPRITAM...... 111 Simpesse...... 153 SOLIQUA 100/33...... 234 SPRIX...... 29 SIMPONI...... 21, 23, 273 SOLOSEC...... 41 SPRYCEL...... 69 simvastatin...... 90 SOLOX GEL...... 175 Sps (With Sorbitol)...... 220 SINGLE-LET...... 346, 415 SOLTAMOX...... 70 SPS (WITH SORBITOL)...... 221 SINUSTAR AEROSOL...... 371 SOLU-CORTEF...... 243 Sronyx...... 159 SOLU-CORTEF ACT-O- SSD...... 185 VIAL (PF)...... 243 SSKI...... 221 494 SSS 10-5...... 169, 176 sulfadiazine...... 56 Syeda...... 160 ST JOSEPH ASPIRIN...... 32 sulfamethoxazole- SYLATRON...... 65 ST. JOSEPH ASPIRIN...... 33 trimethoprim...... 38 SYMAX DUOTAB...... 267, 281 stavudine...... 44 SULFAMYLON...... 185 SYMBICORT...... 459 STEGLATRO...... 230 sulfasalazine...... 271 SYMDEKO...... 460 STEGLUJAN...... 229 SULFATRIM...... 38 SYMJEPI...... 96 STELARA...... 174, 270 sulindac...... 29 SYMLINPEN 120...... 231 STENDRA...... 218 SUMADAN...... 170 SYMLINPEN 60...... 231 STERILANCE TL...... 346, 416 SUMADAN XLT...... 170, 208 SYMPAZAN...... 104 STERILE HYDROGEL FOR sumatriptan...... 138 SYMPROIC...... 37 JELMYTO...... 220 sumatriptan succinate...... 138 SYMTUZA...... 45 sterile talc...... 465 sumatriptan-naproxen...... 139 SYNALAR CREAM KIT...... 197 STERITALC...... 465 SUMAXIN CP...... 170 SYNALAR OINTMENT KIT. 197 STIOLTO RESPIMAT...... 458 SUNOSI...... 141 SYNALAR TS...... 198 STIVARGA...... 67 SUNRISE COMPRESSOR- SYNAREL...... 254 STOP SMOKING AID...... 148 NEBULIZER...... 371, 416 SYNDROS...... 131, 219, 261 STRATACTX...... 216, 416 SUPER THIN LANCETS SYNERA...... 209 STRATAGRT...... 216, 416 ...... 346, 416 SYNERDERM...... 188 STRATAMARK...... 206 SUPRANE...... 33 SYNJARDY...... 228 STRATATRIZ...... 206 SUPRAX...... 48 SYNJARDY XR...... 228 STRATAXRT...... 216, 416 SUPREP BOWEL PREP KIT SYNRIBO...... 71 STRAVIX...... 211 ...... 274 SYNTHROID...... 258 STRENSIQ...... 423 SURE COMFORT INS. syringe (reusable)...... 363, 417 STRIBILD...... 45 SYR. U-100...... 356, 416 SYRINGE AVITENE...... 291 STRIVERDI RESPIMAT...... 456 SURE COMFORT INSULIN SYZYGIUM COMPOSITUM 259 STRONG IODINE...... 72, 221 SYRINGE...... 356, 416, 417 SZOSIL...... 373 SUBSYS...... 13 SURE COMFORT T.E.D. ANTI-EMBOLISM Subvenite...... 110 LANCETS...... 346, 417 STOCKING...... 362 Subvenite Starter (Blue) Kit SURE RESULT DSS T.E.D. KNEE LENGTH-M- ...... 110, 130 PREMIUM PACK...... 204 LONG...... 338, 417 Subvenite Starter (Green) SURE-JECT INSULIN T.E.D. KNEE LENGTH-S- Kit...... 110, 130 SYRINGE...... 356, 357, 417 REGULAR...... 338, 417 Subvenite Starter (Orange) SURE-LANCE...... 346, 417 T:30 INFUSION SET...... 378 Kit...... 110, 130 SURE-LANCE ULTRA THIN T:90 INFUSION SET 23".....378 SUCRAID...... 263 ...... 346 T:90 INFUSION SET 43".....378 sucralfate...... 275 SURE-T INFUSION SET T:FLEX...... 362 sulconazole...... 179 ...... 364, 417 T:FLEX INSULIN DELIVERY sulfacetamide sodium SURE-T PARADIGM...... 378 PUMP...... 374, 417 ...... 184, 444 SURE-TEST EASYPLUS T:SLIM...... 362, 417 sulfacetamide sodium MINI...... 334 T:SLIM G4...... 362, 417 (acne)...... 168 SURE-TOUCH LANCET T:SLIM G4 INSULIN PUMP sulfacetamide sodium- ...... 346, 417 ...... 374, 417 sulfur...... 169, 170 SURFAXIN...... 461 T:SLIM INSULIN DELIVERY sulfacetamide sod-sulfur- SURGUARD2 SAFETY SYSTEM...... 374 urea...... 170, 207 ...... 363, 417 T:SLIM X2...... 362, 417 sulfacetamide- SURVANTA...... 461 T:SLIM X2 BASAL-IQ prednisolone...... 434 SUSTIVA...... 43 INSULIN PMP...... 374 sulfacetamide-sulfur- SUTAB...... 274 T:SLIM X2 CONTROL-IQ.... 374 cleansr23...... 170 SUTENT...... 69 T:SLIM X2 INSULIN PUMP. 374 SULFACLEANSE 8-4...... 170 SUVICORT...... 209 TABLOID...... 62 495 TABRECTA...... 69 TEGRETOL XR...... 108, 130 THRESHOLD IMT TRAINER TACHOSIL...... 292 TEGSEDI...... 225 ...... 371, 419 tacrolimus...... 185, 297 TEKTURNA HCT...... 102 THRESHOLD PEP DEVICE tacrolimus-hyaluronate- TELCARE LANCETS.. 346, 418 ...... 371, 419 niacin...... 185 TELCARE TEST STRIPS THROMBI-GEL...... 291 tacrolimus-niacinamide.... 185 ...... 334, 418 THROMBIN-JMI...... 291 tacrolimus-vehicle base telmisartan...... 84 THROMBI-PAD...... 291 no.238...... 186 telmisartan-amlodipine...... 83 THYROLAR-1...... 256 tadalafil...... 218 telmisartan- THYROLAR-1/2...... 257 tadalafil (pulm. hydrochlorothiazid...... 83 THYROLAR-1/4...... 257 hypertension)...... 101 temazepam...... 145 THYROLAR-2...... 257 TAFINLAR...... 63 TEMIXYS...... 43 THYROLAR-3...... 257 TAGRISSO...... 60 temozolomide...... 61 Tiadylt Er...... 95 TAKE ACTION...... 164 Tencon...... 20 tiagabine...... 106 TAKHZYRO...... 100 TENIVAC (PF)...... 77 TIBSOVO...... 67 TALICIA...... 275 tenofovir disoproxil TICALAST...... 462 TALTZ AUTOINJECTOR.....174 fumarate...... 44 TICANASE...... 462 TALTZ AUTOINJECTOR (2 TENS 502...... 362, 418 TICASPRAY...... 462 PACK)...... 174 TENS 504...... 362, 418 TIGLUTIK...... 299 TALTZ AUTOINJECTOR (3 terazosin...... 100 Tilia Fe...... 162 PACK)...... 174 terbinafine hcl...... 39 timol-brimon-dorzo- TALTZ SYRINGE...... 174 terbutaline...... 457 latanop(pf)...... 433 TALZENNA...... 68 terconazole...... 466 timolol maleate...... 94, 441 tamoxifen...... 70 teriparatide...... 235 timolol maleate (pf)...... 441 tamsulosin...... 278 Terrell...... 33 timolol-brimonidi- Taperdex...... 243 TERSI FOAM...... 184 dorzolam(pf)...... 439 TAPERDEX...... 243 TERUMO INSULIN timolol-dorzolamid- TARDEOXIA...... 170 SYRINGE...... 357, 418 latanop(pf)...... 439 TARDIMAXIA...... 171 TEST N'GO TEST...... 335, 418 timolol-latanoprost(pf)...... 439 TARGRETIN...... 181 testosterone...... 226 TIMOPTIC OCUDOSE (PF) 441 Tarina 24 Fe...... 160 testosterone cypionate..... 226 tinidazole...... 41 Tarina Fe 1/20 (28)...... 160 testosterone enanthate..... 226 TIROSINT...... 258 Tarina Fe 1-20 Eq (28)...... 160 tetrabenazine...... 140 TIROSINT-SOL...... 258 TAROXIA...... 171 tetracaine hcl...... 441 TISSEEL VHSD TASIGNA...... 69 tetracaine hcl (pf)...... 441 (APROTININ, SYN)...... 208 TASOPROL...... 195 tetracycline...... 60 TIS-U-SOL PENTALYTE.....221 tavaborole...... 179 TETRIX...... 206 TIVICAY...... 42 TAVALISSE...... 284 TEXACORT...... 196 TIVICAY PD...... 42 tazarotene...... 183 THALOMID...... 40 TIVORBEX...... 31 TAZORAC...... 183 THEO-24...... 454 tizanidine...... 300 Taztia Xt...... 95 Theochron...... 454 TOBI PODHALER...... 460 TAZVERIK...... 64 theophylline...... 454 TOBRADEX...... 435 TD GOLD TEST STRIP...... 334 THIN LANCETS...... 346 TOBRADEX ST...... 435 TDVAX...... 77 THINPRO INSULIN tobramycin...... 443, 460 TECHLITE INSULIN SYR SYRINGE...... 357, 418, 419 tobramycin in 0.225 % nacl HALF UNIT...... 357 THIOLA...... 277 ...... 460 TECHLITE INSULIN THIOLA EC...... 277 tobramycin with nebulizer 460 SYRINGE...... 357 thioridazine...... 123 tobramycin- TECHLITE LANCETS...... 346 thiothixene...... 123 dexamethasone...... 435 TEGRETOL...... 108, 130 TOBREX...... 443 496 TODAY CONTRACEPTIVE tretinoin microspheres TRIUMEQ...... 45 SPONGE...... 165 ...... 172, 173 Trivora (28)...... 163 TOLAK...... 180 tretinoin-benzoyl-clinda- Tri-Vylibra...... 163 tolcapone...... 119 niac...... 170 Tri-Vylibra Lo...... 163 tolmetin...... 29 tretinoin-clinda-spiron- TRIXYLITRAL...... 203 TOLSURA...... 39 niacin...... 170 TROKENDI XR...... 108 tolterodine...... 281 tretinoin-hyaluronate- tropicamide...... 435 tolvaptan...... 98 niacin...... 171 tropic-proparacai-pe-ketor- TOPAMAX...... 108 TRETIN-X...... 173 wat...... 442 TOPCARE ULTRA TRETIN-X CREAM KIT...... 173 trospium...... 281 COMFORT...... 357, 358, 419 TRETTEN...... 289 TRUE COMFORT INSULIN TOPCARE UNIVERSAL1 TREXALL...... 24, 62 SYRINGE...... 358, 419 LANCET...... 346, 419 Tri Femynor...... 162 TRUE COMFORT LANCET topiramate...... 108 triamcinolone acetonide ...... 346, 419 toremifene...... 70 ...... 196, 428 TRUE METRIX GLUCOSE TORONOVA II SUIK...... 29 triamcinolone-niacinamide TEST STRIP...... 335 TORONOVA SUIK...... 29 ...... 196 TRUE METRIX PRO TEST torsemide...... 98 triamterene...... 98 STRIP...... 335 TOSYMRA...... 138 triamterene- TRUEPLUS INSULIN...... 358 TOUCH-TROL...... 375, 419 hydrochlorothiazid...... 98 TRUEPLUS LANCETS 346, 419 TOUJEO MAX U-300 Trianex...... 196 TRUETEST TEST STRIPS. 335 SOLOSTAR...... 249 triazolam...... 145 TRUETRACK TEST...... 336 TOUJEO SOLOSTAR U-300 Triderm...... 196 TRULANCE...... 262, 270 INSULIN...... 249 trientine...... 36 TRULICITY...... 232 TOVET KIT...... 197 Tri-Estarylla...... 162 TRUMENBA...... 78 TOVIAZ...... 281 trifluoperazine...... 123 TRUNEB NEBULIZER.363, 419 TPOXX (NATIONAL trifluridine...... 444 TRUSKIN...... 211 STOCKPILE)...... 60 trihexyphenidyl...... 119 TRUSTEEL INFUSION SET TRACLEER...... 101 TRIJARDY XR...... 235 23"...... 378 TRADJENTA...... 227 TRIKAFTA...... 460 TRUSTEEL INFUSION SET tramadol...... 13, 14 Tri-Legest Fe...... 162 32"...... 378 tramadol-acetaminophen....19 TRILEPTAL...... 108 TRUVADA...... 43 trandolapril...... 82 Tri-Linyah...... 162 TRUZONE PEAK FLOW trandolapril-verapamil...... 81 TRILOAN II SUIK...... 243 METER...... 365, 419 tranexamic acid...... 290 TRILOAN SUIK...... 243 TUDORZA PRESSAIR...... 455 tranylcypromine...... 114 Tri-Lo-Estarylla...... 162 TUKYSA...... 64 TRANZAREL...... 209 Tri-Lo-Marzia...... 162 Tulana...... 161 travoprost...... 445 Tri-Lo-Mili...... 162 TURALIO...... 69 trazodone...... 115 Tri-Lo-Sprintec...... 163 TUSSICAPS...... 464 TRECATOR...... 47 Trilyte With Flavor Packets..274 TUXARIN ER...... 464 TRELEGY ELLIPTA...... 459 trimethobenzamide...... 261 TUZISTRA XR...... 464 TREMFYA...... 174 trimethoprim...... 38 TWINRIX (PF)...... 73 treprostinil sodium...... 100 Tri-Mili...... 163 TWIRLA...... 163 TRESIBA FLEXTOUCH U- trimipramine...... 118 TWIST LANCETS...... 346 100...... 249 TRI-MIX (PAPAVRN- TYBLUME...... 160 TRESIBA FLEXTOUCH U- PHNTLMN-PGE1)...... 217 TYBOST...... 425 200...... 249 TRIMO-SAN JELLY...... 467 Tydemy...... 160 TRESIBA U-100 INSULIN... 249 TRINTELLIX...... 116 TYMLOS...... 235 tretinoin...... 173 Tri-Previfem (28)...... 163 TYVASO...... 100 tretinoin (antineoplastic).....70 Tri-Sprintec (28)...... 163 497 TYVASO INSTITUTIONAL ULTRA-THIN II INSULIN UROGESIC-BLUE...... 53 START KIT...... 100 SYRINGE...... 360, 421 URO-MP...... 53, 280 TYVASO REFILL KIT...... 101 ULTRA-THIN II LANCETS UROQID-ACID NO.2..... 53, 279 TYVASO STARTER KIT...... 101 ...... 347, 421 ursodiol...... 263 TYZINE...... 463 ULTRATRAK...... 336 USTELL...... 54, 280 UBRELVY...... 136 ULTRATRAK ULTIMATE UTIBRON NEOHALER...... 458 UCERIS...... 271 ...... 336, 421 VAGINAL UDENYCA...... 289 ULTRAVATE...... 183 CONTRACEPTIVE FILM.....165 ULESFIA...... 212 UMECTA...... 200 VAGINAL ULTICARE...... 358 UNILET COMFORTOUCH CONTRACEPTIVE FOAM...165 ULTICARE INSULIN SYR LANCET...... 347 valacyclovir...... 51 HALF UNIT...... 358 UNILET EXCELITE II VALCHLOR...... 180 ULTICARE INSULIN LANCET...... 347 valganciclovir...... 48 SYRINGE...... 358 UNILET EXCELITE valproic acid...... 105 ULTILET BASIC LANCETS LANCET...... 347 valproic acid (as sodium ...... 346, 419 UNILET GP LANCET...... 347 salt)...... 105, 130 ULTILET CLASSIC UNILET LANCET...... 347 valsartan...... 84 LANCETS...... 346, 419 UNILET LANCETS...... 347 valsartan- ULTILET INSULIN UNILET SUPER THIN hydrochlorothiazide...... 83 SYRINGE...... 359, 419, 420 LANCETS...... 347 VALTOCO...... 104, 128 ULTILET LANCETS.....346, 420 UNISTIK 3 COMFORT Vanatol Lq...... 20 ULTILET SAFETY LANCET...... 347, 421 Vanatol S...... 20 LANCETS...... 346, 420 UNISTIK 3 EXTRA LANCET vancomycin...... 49 ULTIMA TEST STRIPS...... 336 ...... 347 VANDAZOLE...... 466 ULTRA CMFT INS SYR UNISTIK 3 GENTLE...... 347 VANISHPOINT INSULIN HALF UNIT...... 359, 420 UNISTIK 3 LANCETS..347, 421 SYRINGE...... 360, 422 ULTRA COMFORT INSULIN UNISTIK 3 NORMAL VANISHPOINT SYRINGE... 360 SYRINGE...... 359, 420 LANCET...... 347, 421 VANOXIDE-HC...... 171 ULTRA FINE LANCETS UNISTIK CZT LANCET VAPRO PLUS INTERMITT ...... 346, 420 ...... 347, 421 CATHETER...... 375, 422 ULTRA FLO INSULIN UNISTIK PRO LANCET VAQTA (PF)...... 73 SYRINGE...... 359, 420 ...... 347, 421 vardenafil...... 218 ULTRA THIN II LANCETS UNISTIK SAFETY...... 347, 421 VARDIMAXIA...... 171 ...... 346, 420 UNISTIK TOUCH LANCETS VARISOFT INFUSION SET ULTRA THIN LANCETS ...... 347, 421 23"...... 378 ...... 347, 420 UNISTRIP1 TEST STRIP VARISOFT INFUSION SET ULTRA THIN PLUS ...... 337, 421 32"...... 378 LANCETS...... 347, 420 UNITHROID...... 258 VARISOFT INFUSION SET ULTRA TLC LANCETS...... 347 UNIVERSAL 1 LANCETS....347 43"...... 378 ULTRACARE INSULIN UPNEEQ (PF)...... 433 VARITHENA SYRINGE...... 359, 420 UPTRAVI...... 99 ADMINISTRATION PACK ULTRA-CARE LANCETS URAMAXIN...... 200 ...... 365, 422 ...... 347, 420 URAMAXIN GT...... 199 VARIVAX (PF)...... 80 ULTRAFOAM...... 291 urea...... 200 VAROPHEN ULTRALANCE LANCETS UREA NAIL STICK...... 200 (DICLOFENAC)...... 204 ...... 347, 420 URETRON D-S...... 53, 280 VAROXIA...... 172 ULTRASAL-ER...... 200 UREVAZ...... 201 VARUBI...... 262 ULTRA-THIN II (SHORT) URIMAR-T...... 53, 280 VASCEPA...... 90, 91 INS SYR...... 360, 420, 421 URIN DS...... 53, 280 VASELINE WHITE URO-458...... 53, 280 PETROLEUM...... 206 498 VASHE WOUND THERAPY213 VISTASEAL-FIBRIN WIDE-SEAL DIAPHRAGM VAXCHORA ACTIVE SEALANT...... 292 60...... 338, 422 COMPONENT...... 75, 78 VISTOGARD...... 71 WIDE-SEAL DIAPHRAGM VAXCHORA BUFFER Vitamin K...... 223 65...... 339, 422 COMPONENT...... 149 Vitamin K1...... 224 WIDE-SEAL DIAPHRAGM VAXCHORA VACCINE... 75, 78 VITRAKVI...... 71 70...... 339, 422 VCF CONTRACEPTIVE VIVAGUARD INO TEST WIDE-SEAL DIAPHRAGM FILM...... 165 STRIP...... 337 75...... 339, 422 VCF CONTRACEPTIVE VIVAGUARD LANCET 347, 422 WIDE-SEAL DIAPHRAGM GEL...... 165 VIVLODEX...... 29 80...... 339, 422 VECAMYL...... 99 VIVOTIF...... 75, 77 WIDE-SEAL DIAPHRAGM Velivet Triphasic Regimen VIXONE NEBULIZER..363, 422 85...... 339, 422 (28)...... 163 VIXONE NEBULIZER- WIDE-SEAL DIAPHRAGM VELPHORO...... 278 ADULT MASK...... 363, 422 90...... 339, 422 VELTASSA...... 221 VIXONE NEBULIZER- WIDE-SEAL DIAPHRAGM VEMLIDY...... 49 PEDIATRIC MSK...... 363, 422 95...... 339, 423 VENCLEXTA...... 63 VIZIMPRO...... 60 WILATE...... 288 VENCLEXTA STARTING Volnea (28)...... 153 WILLIS THE WHALE PACK...... 63 VONVENDI...... 290 COMPRESSR NEB..... 372, 423 VENELEX...... 216 voriconazole...... 39 WINLEVI...... 165 venlafaxine...... 116 VORTEX HOLDING WINTERGREEN OIL...... 211 VENTAVIS...... 101 CHAMBER...... 372, 422 WPR PLUS...... 202 verapamil...... 86, 96 VORTEX VHC FROG Wymzya Fe...... 160 VERASENS TEST STRIP... 337 MASK-CHILD...... 372, 422 WYNZORA...... 173 VERDESO...... 196 VORTEX VHC LADYBUG XADAGO...... 120 VEREGEN...... 198 MASK-TODDLR...... 372, 422 XALIX...... 201 VERSACLOZ...... 122 VOSEVI...... 50 XALKORI...... 61 VERTIGOHEEL...... 259 VOTRIENT...... 69 XARELTO...... 284 VERZENIO...... 64 VRAYLAR...... 124, 131 XARELTO DVT-PE TREAT VEXASYN...... 209 Vtol Lq...... 20 30D START...... 284 V-GO 20...... 373, 422 VUMERITY...... 431 XATMEP...... 24 V-GO 30...... 373, 422 Vyfemla (28)...... 160 XCLAIR...... 188 V-GO 40...... 373, 422 VYLEESI...... 135 XCOPRI...... 113 VIBERZI...... 273 Vylibra...... 160 XCOPRI MAINTENANCE VIBRAMYCIN...... 60 VYNDAMAX...... 225 PACK...... 112 Vicodin Hp...... 17 VYNDAQEL...... 225 XCOPRI TITRATION PACK 114 VICTOZA 2-PAK...... 232 VYVANSE...... 127 XELITRAL...... 204 VICTOZA 3-PAK...... 232 VYZULTA...... 445 XELJANZ...... 25, 272 VIEKIRA PAK...... 51 WAKIX...... 141 XELJANZ XR...... 25, 272 Vienva...... 160 warfarin...... 283 XELPROS...... 445 vigabatrin...... 106 water for irrigation, sterile 221 XEMBIFY...... 75 Vigadrone...... 106 WAVESENSE JAZZ...... 337 XENAFLAMM...... 27 VIIBRYD...... 116 WAVESENSE PRESTO...... 338 XENICAL...... 219 VIMPAT...... 105 Wera (28)...... 160 XENLETA...... 54 VIOKACE...... 263 WESTHROID...... 257 XEPI...... 176 Viorele (28)...... 153 WHYTEDERM SURGIPAK. 216 XERESE...... 185 VIOS AEROSOL DELIVERY WHYTEDERM TDPAK...... 197 XERMELO...... 259 SYSTEM...... 371 WHYTEDERM TRILASIL XEROFORM...... 340, 423 VIRACEPT...... 55 PAK...... 197 XEROFORM NON- VIREAD...... 44, 49 OCCLUSIVE...... 340, 423 499 XEROFORM ZENPEP...... 263 ZYPRAM...... 35 PETROLATUM DRESSING Zenzedi 127, 128, 133, 141, 142 ZYTIGA...... 60, 62 ...... 340, 423 ZENZEDI XEROFORM ...... 127, 128, 133, 141, 142 PETROLATUM ZEPATIER...... 50 OVERWRAP...... 340, 423 ZEPOSIA...... 432 XEROSTOMIA RELIEF...... 428 ZEPOSIA STARTER KIT.....432 XHANCE...... 463 ZEPOSIA STARTER PACK 432 XIFAXAN...... 55, 56 ZERVIATE...... 436 XIGDUO XR...... 228 ZETONNA...... 463 XIIDRA...... 438 ZEYOCAINE...... 209 XILAPAK...... 198 zidovudine...... 44 XIMINO...... 166 ZIEXTENZO...... 290 XOFLUZA...... 51 ZILACAINE PATCH.....210, 373 XOLEGEL...... 179 zileuton...... 452 XOSPATA...... 64 ZILXI...... 208 XPOVIO...... 70 zinc oxide...... 206 XRYLIDERM...... 209 ZIOPTAN (PF)...... 445 XRYLIX (DICLOFENAC- ziprasidone hcl...... 131 KINES TAPE)...... 205 ZIPSOR...... 30 XTAMPZA ER...... 14, 15 ZIRGAN...... 444 XTANDI...... 62 ZITHRANOL...... 184 XULANE...... 163 ZOHYDRO ER...... 15 XULTOPHY 100/3.6...... 234 ZOKINVY...... 423 XURIDEN...... 424 ZOLINZA...... 65 Xylon 10...... 17 zolmitriptan...... 138 XYNTHA...... 288 ZOLPAK...... 179 XYNTHA SOLOFUSE...... 288 zolpidem...... 145 XYOSTED...... 226 ZOLPIMIST...... 146 XYREM...... 141 ZOMACTON...... 245 XYWAV...... 141 ZOMIG...... 139 YONSA...... 60, 62 ZONEGRAN...... 111 YOSPRALA...... 295 zonisamide...... 111 YUPELRI...... 456 ZONTIVITY...... 295 Yuvafem...... 467 ZORBTIVE...... 245, 276 zafirlukast...... 454 ZORTRESS...... 298 zaleplon...... 145 ZORVOLEX...... 30 Zarah...... 160 ZOSTAVAX (PF)...... 80 ZARONTIN...... 111 Zovia 1/35E (28)...... 160 Zarontin...... 111 Zovia 1-35 (28)...... 160 ZARXIO...... 289 ZTLIDO...... 210 ZCORT...... 243 ZUBSOLV...... 147 Zebutal...... 20 Zumandimine (28)...... 160 ZEJULA...... 68 ZUPLENZ...... 262 ZELAPAR...... 120 ZYCLARA...... 199 ZELBORAF...... 63 ZYDELIG...... 67, 68 ZELNORM...... 270, 273 ZYFLO...... 452 ZEMAIRA...... 461 ZYKADIA...... 61 ZEMBRACE SYMTOUCH... 138 ZYLET...... 435 Zenatane...... 165 ZYPITAMAG...... 90 500