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HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Amphetamine‐Dextroamphetamine Adderall Oral Tablet 10 MG Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets 1st Choice Lancets Super Thin Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets 1st Choice Lancets Thin Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets 1st Choice Lancets Ultra Thin Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle 1st Tier Unifine Pentips Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle 1st Tier Unifine Pentips Miscellaneous 31G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle 1st Tier Unifine Pentips Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle 1st Tier Unifine Pentips Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle 1st Tier Unifine Pentips Miscellaneous 32G X 4 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle 1st Tier Unifine Pentips Plus Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle 1st Tier Unifine Pentips Plus Miscellaneous 31G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle 1st Tier Unifine Pentips Plus Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle 1st Tier Unifine Pentips Plus Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle 1st Tier Unifine Pentips Plus Miscellaneous 32G X 4 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets 1st Tier Unilet ComforTouch Miscellaneous Tier 2 CHEMICALS 2‐Deoxy‐D‐ 2‐Deoxy‐D‐Glucose Powder Tier 3 CHEMICALS Hydroxytryptophan 5‐HTP Powder Tier 3 CHEMICALS Hydroxytryptophan 5‐Hydroxy‐L‐ Powder Tier 3 CHEMICALS 5‐Methyltetrahydrofolate 5‐Methyltetrahydrofolate Calc Powder Tier 3 CHEMICALS 7‐Ketodehydroepiandrosterone (7‐Keto DHEA) 7‐Keto DHEA Powder Tier 3 DERMATOLOGICALS Methoxsalen 8‐Mop Oral Capsule 10 MG Tier 3 DERMATOLOGICALS ‐Amitriptyline‐Gabapentin‐Cyclobenzaprine A.A.G.C. Kit in TeroDerm External Cream 8‐4‐10‐4 % Tier 3 ANTIVIRALS Abacavir Sulfate Abacavir Sulfate Oral Tablet 300 MG Tier 1 x ANTIVIRALS Abacavir Sulfate‐Lamivudine‐Zidovudine Abacavir‐Lamivudine‐Zidovudine Oral Tablet 300‐150‐300 MG Tier 1 x HEMATOPOIETIC AGENTS Cyanocobalamin‐Methylcobalamin Abaneu‐SL Sublingual Tablet Sublingual 600‐600 MCG Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Aripiprazole Abilify Maintena Intramuscular Suspension Reconstituted 300 MG Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Aripiprazole Abilify Maintena Intramuscular Suspension Reconstituted 400 MG Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Aripiprazole Abilify Oral Tablet 10 MG Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Aripiprazole Abilify Oral Tablet 15 MG Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Aripiprazole Abilify Oral Tablet 2 MG Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Aripiprazole Abilify Oral Tablet 20 MG Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Aripiprazole Abilify Oral Tablet 30 MG Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Aripiprazole Abilify Oral Tablet 5 MG Tier 3 xx DIAGNOSTIC PRODUCTS Gadofosveset Trisodium Ablavar Intravenous Solution 244 MG/ML Tier 3 x ANALGESICS ‐ Fentanyl Citrate Abstral Sublingual Tablet Sublingual 100 MCG Tier 3 x x ANALGESICS ‐ OPIOID Fentanyl Citrate Abstral Sublingual Tablet Sublingual 200 MCG Tier 3 x x ANALGESICS ‐ OPIOID Fentanyl Citrate Abstral Sublingual Tablet Sublingual 300 MCG Tier 3 x x ANALGESICS ‐ OPIOID Fentanyl Citrate Abstral Sublingual Tablet Sublingual 400 MCG Tier 3 x x ANALGESICS ‐ OPIOID Fentanyl Citrate Abstral Sublingual Tablet Sublingual 600 MCG Tier 3 x x ANALGESICS ‐ OPIOID Fentanyl Citrate Abstral Sublingual Tablet Sublingual 800 MCG Tier 3 x x CHEMICALS Extract AC Dermapeptide Liquid Tier 3 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Acamprosate Calcium Acamprosate Calcium Oral Tablet Delayed Release 333 MG Tier 1 x DERMATOLOGICALS Clindamycin Phosphate‐Benzoyl Peroxide Acanya External Gel 1.2‐2.5 % Tier 3 x ANTIDIABETICS Acarbose Acarbose Oral Tablet 100 MG Tier 1 ANTIDIABETICS Acarbose Acarbose Oral Tablet 25 MG Tier 1 ANTIDIABETICS Acarbose Acarbose Oral Tablet 50 MG Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Zafirlukast Accolate Oral Tablet 10 MG Tier 3 x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Zafirlukast Accolate Oral Tablet 20 MG Tier 3 x DIAGNOSTIC PRODUCTS Glucose Blood Accu‐Chek Active In Vitro Strip Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood Accu‐Chek Aviva In Vitro Strip Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood Accu‐Chek Aviva Plus In Vitro Strip Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood Accu‐Chek Compact Plus In Vitro Strip Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Accu‐Chek FastClix Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Accu‐Chek Multiclix Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies Accu‐Chek Nano SmartView Kit w/Device Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Accu‐Chek Safe‐T Pro Lancets Miscellaneous Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood Accu‐Chek SmartView In Vitro Strip Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Accu‐Chek Soft Touch Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Accu‐Chek Softclix Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies Accu‐Chek Voicemate Kit Tier 2 ANTIHYPERTENSIVES Quinapril HCl Accupril Oral Tablet 10 MG Tier 3 ANTIHYPERTENSIVES Quinapril HCl Accupril Oral Tablet 20 MG Tier 3 ANTIHYPERTENSIVES Quinapril HCl Accupril Oral Tablet 40 MG Tier 3 ANTIHYPERTENSIVES Quinapril HCl Accupril Oral Tablet 5 MG Tier 3 ANTIHYPERTENSIVES Quinapril‐ Accuretic Oral Tablet 10‐12.5 MG Tier 3 ANTIHYPERTENSIVES Quinapril‐Hydrochlorothiazide Accuretic Oral Tablet 20‐12.5 MG Tier 3 ANTIHYPERTENSIVES Quinapril‐Hydrochlorothiazide Accuretic Oral Tablet 20‐25 MG Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Accutrend Glucose In Vitro Strip Tier 2 BETA BLOCKERS Acebutolol HCl Acebutolol HCl Oral Capsule 200 MG Tier 1 BETA BLOCKERS Acebutolol HCl Acebutolol HCl Oral Capsule 400 MG Tier 1 ANTIHYPERTENSIVES Perindopril Erbumine Aceon Oral Tablet 4 MG Tier 3 ANTIHYPERTENSIVES Perindopril Erbumine Aceon Oral Tablet 8 MG Tier 3 ANTIDOTES (Antidote) Acetadote Intravenous Solution 200 MG/ML Tier 3 x ANALGESICS ‐ OPIOID Acetaminophen w/ Acetaminophen‐Codeine #2 Oral Tablet 300‐15 MG Tier 1 ANALGESICS ‐ OPIOID Acetaminophen w/ Codeine Acetaminophen‐Codeine #3 Oral Tablet 300‐30 MG Tier 1 ANALGESICS ‐ OPIOID Acetaminophen w/ Codeine Acetaminophen‐Codeine #4 Oral Tablet 300‐60 MG Tier 1 ANALGESICS ‐ OPIOID Acetaminophen w/ Codeine Acetaminophen‐Codeine Oral Solution 120‐12 MG/5ML Tier 1 ANALGESICS ‐ OPIOID Acetaminophen w/ Codeine Acetaminophen‐Codeine Oral Tablet 300‐15 MG Tier 1 ANALGESICS ‐ OPIOID Acetaminophen w/ Codeine Acetaminophen‐Codeine Oral Tablet 300‐30 MG Tier 1 ANALGESICS ‐ OPIOID Acetaminophen w/ Codeine Acetaminophen‐Codeine Oral Tablet 300‐60 MG Tier 1 OTIC AGENTS Hydrocortisone w/ Acetasol HC Otic Solution 2‐1 % Tier 1 DIURETICS Acetazolamide AcetaZOLAMIDE ER Oral Capsule Extended Release 12 Hour 500 MG Tier 1 DIURETICS Acetazolamide AcetaZOLAMIDE Oral Tablet 125 MG Tier 2 DIURETICS Acetazolamide AcetaZOLAMIDE Oral Tablet 250 MG Tier 1 DIURETICS Acetazolamide Sodium AcetaZOLAMIDE Sodium Injection Solution Reconstituted 500 MG Tier 1 x GENITOURINARY AGENTS ‐ MISCELLANEOUS Acetic Acid Acetic Acid Irrigation Solution 0.25 % Tier 1 OTIC AGENTS Acetic Acid (Otic) Acetic Acid Otic Solution 2 % Tier 1 OTIC AGENTS Acetic Acid‐Aluminum Acetate Acetic Acid‐Aluminum Acetate Otic Solution 2 % Tier 2 CHEMICALS Acetone Solution Tier 3 ANALGESICS ‐ NonNarcotic Aspirin Acetyl Salicylic Acid Powder Tier 3 COUGH//ALLERGY Acetylcysteine Acetylcysteine Inhalation Solution 10 % Tier 1 COUGH/COLD/ALLERGY Acetylcysteine Acetylcysteine Inhalation Solution 20 % Tier 1 ANTIDOTES Acetylcysteine (Antidote) Acetylcysteine Intravenous Solution 200 MG/ML Tier 1 x COUGH/COLD/ALLERGY Acetylcysteine Acetylcysteine Powder Tier 3 CHEMICALS Acetyl‐D‐Glucosamine Acetyl‐D‐Glucosamine Powder Tier 3 CHEMICALS Lactobacillus Acidophilus Acidophilus Lactobacillus Powder Tier 3 ULCER DRUGS Rabeprazole Sodium Aciphex Oral Tablet Delayed Release 20 MG Tier 3 x x ULCER DRUGS Rabeprazole Sodium AcipHex Sprinkle Oral Capsule Sprinkle 10 MG Tier 3 x x ULCER DRUGS Rabeprazole Sodium AcipHex Sprinkle Oral Capsule Sprinkle 5 MG Tier 3 x x DERMATOLOGICALS Acitretin Acitretin Oral Capsule 10 MG Tier 1 DERMATOLOGICALS Acitretin Acitretin Oral Capsule 17.5 MG Tier 1 DERMATOLOGICALS Acitretin Acitretin Oral Capsule 25 MG Tier 1 DERMATOLOGICALS Alclometasone Dipropionate Aclovate External Cream 0.05 % Tier 3 DERMATOLOGICALS Benzoyl Peroxide Acne 5 External Gel 5 % Tier 1 BIOLOGICALS MISC Acremonium Acremonium Subcutaneous Solution 20000 PNU/ML Tier 3 x ANALGESICS ‐ ANTI‐INFLAMMATORY Tocilizumab Actemra Subcutaneous Solution Prefilled Syringe 162 MG/0.9ML Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Corticotropin Acthar HP Injection Gel 80 UNIT/ML Tier 2 x Haemophilus B Polysac Conj Vac ActHIB Intramuscular Solution Reconstituted Tier 3 x DERMATOLOGICALS Acticin External Cream 5 % Tier 1 TETRACYCLINES Doxycycline Hyclate Acticlate Oral Tablet 150 MG Tier 3 x TETRACYCLINES Doxycycline Hyclate Acticlate Oral Tablet 75 MG Tier 3 x DERMATOLOGICALS Acticoat 7 External Sheet 6"X6" Tier 3 DERMATOLOGICALS Silver Acticoat Absorbent External Miscellaneous 3/4"X12" Tier 3 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

DERMATOLOGICALS Silver Acticoat External Sheet 16"X16" Tier 3 DERMATOLOGICALS Silver Acticoat External Sheet 4"X4" Tier 3 DERMATOLOGICALS Silver Acticoat External Sheet 4"X48" Tier 3 DERMATOLOGICALS Silver Acticoat External Sheet 4"X8" Tier 3 DERMATOLOGICALS Silver Acticoat External Sheet 5"X5" Tier 3 DERMATOLOGICALS Silver Acticoat External Sheet 8"X16" Tier 3 DERMATOLOGICALS Silver Acticoat Flex 3 External Sheet 16"X16" Tier 3 DERMATOLOGICALS Silver Acticoat Flex 3 External Sheet 2"X2" Tier 3 DERMATOLOGICALS Silver Acticoat Flex 3 External Sheet 4"X48" Tier 3 DERMATOLOGICALS Silver Acticoat Flex 3 External Sheet 4"X8" Tier 3 DERMATOLOGICALS Silver Acticoat Flex 3 External Sheet 8"X16" Tier 3 DERMATOLOGICALS Silver Acticoat Flex 7 External Sheet 1"X24" Tier 3 DERMATOLOGICALS Silver Acticoat Flex 7 External Sheet 16"X16" Tier 3 DERMATOLOGICALS Silver Acticoat Flex 7 External Sheet 2"X2" Tier 3 DERMATOLOGICALS Silver Acticoat Flex 7 External Sheet 4"X5" Tier 3 DERMATOLOGICALS Silver Acticoat Flex 7 External Sheet 6"X6" Tier 3 DERMATOLOGICALS Silver Acticoat Flex 7 External Sheet 8"X16" Tier 3 DERMATOLOGICALS Silver Acticoat Moisture Control External Pad 2"X2" Tier 3 DERMATOLOGICALS Silver Acticoat Moisture Control External Pad 4"X4" Tier 3 DERMATOLOGICALS Silver Acticoat Moisture Control External Pad 4"X8" Tier 3 DERMATOLOGICALS Silver Acticoat Site External Disk Tier 3 DERMATOLOGICALS Silver Acticoat Surgical External Pad 4"X10" Tier 3 DERMATOLOGICALS Silver Acticoat Surgical External Pad 4"X13‐3/4" Tier 3 DERMATOLOGICALS Silver Acticoat Surgical External Pad 4"X4‐3/4" Tier 3 DERMATOLOGICALS Silver Acticoat Surgical External Pad 4"X8" Tier 3 GASTROINTESTINAL AGENTS ‐ MISC. Ursodiol Actigall Oral Capsule 300 MG Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Acti‐Lance 28G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Acti‐Lance Lite Lancets 28G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Acti‐Lance Special Lancets 17G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Acti‐Lance Universal 23G Miscellaneous Tier 2 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Interferon Gamma‐1B Actimmune Subcutaneous Solution 2000000 UNIT/0.5ML Tier 2 x ANALGESICS ‐ OPIOID Fentanyl Citrate Actiq Buccal Lozenge on a Handle 1200 MCG Tier 3 x x ANALGESICS ‐ OPIOID Fentanyl Citrate Actiq Buccal Lozenge on a Handle 1600 MCG Tier 3 x x ANALGESICS ‐ OPIOID Fentanyl Citrate Actiq Buccal Lozenge on a Handle 200 MCG Tier 3 x x ANALGESICS ‐ OPIOID Fentanyl Citrate Actiq Buccal Lozenge on a Handle 400 MCG Tier 3 x x ANALGESICS ‐ OPIOID Fentanyl Citrate Actiq Buccal Lozenge on a Handle 600 MCG Tier 3 x x ANALGESICS ‐ OPIOID Fentanyl Citrate Actiq Buccal Lozenge on a Handle 800 MCG Tier 3 x x MEDICAL DEVICES AND SUPPLIES Lancets Active 1st Blood Lancets 30G Miscellaneous Tier 3 HEMATOPOIETIC AGENTS Fe Carbonyl‐FA‐B Complex‐A‐C‐D‐E‐Min Active FE Oral Tablet 75‐1.25 MG Tier 3 MULTIVITAMINS Prenatal w/o Vit A w/ Fe Carbonyl‐Folic Acid‐DHA Active OB Oral Capsule 20‐1‐320 MG Tier 3 MUSCULOSKELETAL THERAPY AGENTS Cyclobenzaprine HCl Active‐Cyclobenzaprine Transdermal Cream 5 % Tier 3 DERMATOLOGICALS Ketoprofen (Topical) Active‐Ketoprofen External Cream 5 % Tier 3 ESTROGENS & Norethindrone Acetate Activella Oral Tablet 0.5‐0.1 MG Tier 3 ESTROGENS Estradiol & Norethindrone Acetate Activella Oral Tablet 1‐0.5 MG Tier 3 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Gabapentin & Lidocaine‐ Active‐Pac/Gabapentin Combination Therapy Pack 300 & 4‐1 MG & % Tier 3 DERMATOLOGICALS Flurbiprofen‐Cyclobenzaprine Active‐Prep Kit I External Cream Tier 3 DERMATOLOGICALS Ketoprofen‐Baclofen‐Gabapentin Active‐Prep Kit II External Cream Tier 3 x DERMATOLOGICALS Ketoprofen‐Lidocaine HCl‐Gabapentin Active‐Prep Kit III External Cream Tier 3 x DERMATOLOGICALS ‐Gabapentin‐Menthol‐ Active‐Prep Kit IV External Cream Tier 3 DERMATOLOGICALS Itraconazole‐Phenytoin Sodium Active‐Prep Kit V External Cream Tier 3 DERMATOLOGICALS Tramadol HCl (Topical) Active‐Tramadol External Cream 8 % Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Risedronate Sodium Actonel Oral Tablet 150 MG Tier 3 xx ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Risedronate Sodium Actonel Oral Tablet 30 MG Tier 3 xx ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Risedronate Sodium Actonel Oral Tablet 35 MG Tier 3 xx ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Risedronate Sodium Actonel Oral Tablet 5 MG Tier 3 xx ANTIDIABETICS Pioglitazone HCl‐Metformin HCl Actoplus Met Oral Tablet 15‐500 MG Tier 3 ANTIDIABETICS Pioglitazone HCl‐Metformin HCl Actoplus Met Oral Tablet 15‐850 MG Tier 3 ANTIDIABETICS Pioglitazone HCl‐Metformin HCl Actoplus met XR Oral Tablet Extended Release 24 Hour 15‐1000 MG Tier 3 x ANTIDIABETICS Pioglitazone HCl‐Metformin HCl Actoplus met XR Oral Tablet Extended Release 24 Hour 30‐1000 MG Tier 3 x ANTIDIABETICS Pioglitazone HCl Actos Oral Tablet 15 MG Tier 3 ANTIDIABETICS Pioglitazone HCl Actos Oral Tablet 30 MG Tier 3 ANTIDIABETICS Pioglitazone HCl Actos Oral Tablet 45 MG Tier 3 OPHTHALMIC AGENTS Ketorolac Tromethamine (Ophth) Acular LS Ophthalmic Solution 0.4 % Tier 3 OPHTHALMIC AGENTS Ketorolac Tromethamine (Ophth) Acular Ophthalmic Solution 0.5 % Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Acura Blood Glucose Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies Acura Plus Blood Glucose Sys Kit w/Device Tier 3 OPHTHALMIC AGENTS Ketorolac Tromethamine (Ophth) Acuvail Ophthalmic Solution 0.45 % Tier 3 DERMATOLOGICALS Acyclovir Topical Acyclovir External Ointment 5 % Tier 1 ANTIVIRALS Acyclovir Acyclovir Oral Capsule 200 MG Tier 1 x ANTIVIRALS Acyclovir Acyclovir Oral Suspension 200 MG/5ML Tier 1 x ANTIVIRALS Acyclovir Acyclovir Oral Tablet 400 MG Tier 1 x ANTIVIRALS Acyclovir Acyclovir Oral Tablet 800 MG Tier 1 x ANTIVIRALS Acyclovir Sodium Acyclovir Sodium Intravenous Solution 50 MG/ML Tier 1 x ANTIVIRALS Acyclovir Sodium Acyclovir Sodium Intravenous Solution Reconstituted 500 MG Tier 1 x DERMATOLOGICALS Dapsone (Topical) Aczone External Gel 5 % Tier 3 TOXOIDS Tetanus Toxoid‐Diphtheria‐Acellular Pertussis Adsorb (Tdap) Adacel Intramuscular Suspension 5‐2‐15.5 LF‐MCG/0.5 Tier 3 x BIOLOGICALS MISC Pegademase Bovine Adagen Intramuscular Solution 250 UNIT/ML Tier 2 x CALCIUM CHANNEL BLOCKERS Adalat CC Oral Tablet Extended Release 24 Hour 30 MG Tier 3 CALCIUM CHANNEL BLOCKERS Nifedipine Adalat CC Oral Tablet Extended Release 24 Hour 60 MG Tier 3 CALCIUM CHANNEL BLOCKERS Nifedipine Adalat CC Oral Tablet Extended Release 24 Hour 90 MG Tier 3 DERMATOLOGICALS Adapalene Adapalene External Cream 0.1 % Tier 1 DERMATOLOGICALS Adapalene Adapalene External Gel 0.1 % Tier 1 DERMATOLOGICALS Adapalene Adapalene External Gel 0.3 % Tier 1 DERMATOLOGICALS Adapalene Adapalene External Lotion 0.1 % Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Loxapine Adasuve Inhalation Aerosol Powder Breath Activated 10 MG Tier 3 x DERMATOLOGICALS Benzocaine‐‐Lidocaine‐ Adazin External Cream 2‐0.035‐2‐10 % Tier 3 CARDIOVASCULAR AGENTS ‐ MISC. Tadalafil (Pulmonary Hypertension) Adcirca Oral Tablet 20 MG Tier 2 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Amphetamine‐Dextroamphetamine Adderall Oral Tablet 12.5 MG Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Amphetamine‐Dextroamphetamine Adderall Oral Tablet 15 MG Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Amphetamine‐Dextroamphetamine Adderall Oral Tablet 20 MG Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Amphetamine‐Dextroamphetamine Adderall Oral Tablet 30 MG Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Amphetamine‐Dextroamphetamine Adderall Oral Tablet 5 MG Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Amphetamine‐Dextroamphetamine Adderall Oral Tablet 7.5 MG Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Amphetamine‐Dextroamphetamine Adderall XR Oral Capsule Extended Release 24 Hour 10 MG Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Amphetamine‐Dextroamphetamine Adderall XR Oral Capsule Extended Release 24 Hour 15 MG Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Amphetamine‐Dextroamphetamine Adderall XR Oral Capsule Extended Release 24 Hour 20 MG Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Amphetamine‐Dextroamphetamine Adderall XR Oral Capsule Extended Release 24 Hour 25 MG Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Amphetamine‐Dextroamphetamine Adderall XR Oral Capsule Extended Release 24 Hour 30 MG Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Amphetamine‐Dextroamphetamine Adderall XR Oral Capsule Extended Release 24 Hour 5 MG Tier 3 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Flibanserin Addyi Oral Tablet 100 MG Tier 3 x x ANTIVIRALS Adefovir Dipivoxil Adefovir Dipivoxil Oral Tablet 10 MG Tier 1 x x CARDIOVASCULAR AGENTS ‐ MISC. Riociguat Adempas Oral Tablet 0.5 MG Tier 2 x x CARDIOVASCULAR AGENTS ‐ MISC. Riociguat Adempas Oral Tablet 1 MG Tier 2 x x CARDIOVASCULAR AGENTS ‐ MISC. Riociguat Adempas Oral Tablet 1.5 MG Tier 2 x x CARDIOVASCULAR AGENTS ‐ MISC. Riociguat Adempas Oral Tablet 2 MG Tier 2 x x CARDIOVASCULAR AGENTS ‐ MISC. Riociguat Adempas Oral Tablet 2.5 MG Tier 2 x x ANTIARRHYTHMICS Adenocard Intravenous Solution 6 MG/2ML Tier 3 x DIAGNOSTIC PRODUCTS Adenosine (Diagnostic) Adenoscan Intravenous Solution 3 MG/ML Tier 3 x DIAGNOSTIC PRODUCTS Adenosine (Diagnostic) Adenosine (Diagnostic) Intravenous Solution 3 MG/ML Tier 1 x ANTIARRHYTHMICS Adenosine Adenosine Intravenous Solution 12 MG/4ML Tier 1 x DIAGNOSTIC PRODUCTS Adenosine (Diagnostic) Adenosine Intravenous Solution 3 MG/ML Tier 1 x ANTIARRHYTHMICS Adenosine Adenosine Intravenous Solution 6 MG/2ML Tier 1 x HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Phentermine HCl Adipex‐P Oral Capsule 37.5 MG Tier 3 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Phentermine HCl Adipex‐P Oral Tablet 37.5 MG Tier 3 x MEDICAL DEVICES AND SUPPLIES Lancet Devices Adjustable Lancing Device Miscellaneous Tier 2 TETRACYCLINES Doxycycline (Monohydrate) Adoxa Oral Capsule 150 MG Tier 3 TETRACYCLINES Doxycycline (Monohydrate) Adoxa Oral Tablet 100 MG Tier 3 TETRACYCLINES Doxycycline (Monohydrate) Adoxa Oral Tablet 50 MG Tier 3 TETRACYCLINES Doxycycline (Monohydrate) Adoxa Oral Tablet 75 MG Tier 3 TETRACYCLINES Doxycycline (Monohydrate) Adoxa Pak 1/100 Oral Tablet 100 MG Tier 3 TETRACYCLINES Doxycycline (Monohydrate) Adoxa Pak 1/150 Oral Tablet 150 MG Tier 3 TETRACYCLINES Doxycycline (Monohydrate) Adoxa Pak 2/100 Oral Tablet 100 MG Tier 3 VASOPRESSORS Epinephrine Adrenaclick Injection Solution Auto‐injector 0.15 MG/0.15ML Tier 3 x VASOPRESSORS Epinephrine Adrenaclick Injection Solution Auto‐injector 0.3 MG/0.3ML Tier 3 x VASOPRESSORS Epinephrine Adrenalin Injection Solution 1 MG/ML Tier 3 x VASOPRESSORS Epinephrine Adrenalin Injection Solution 30 MG/30ML Tier 3 x NASAL AGENTS ‐ SYSTEMIC AND TOPICAL Epinephrine HCl (Nasal) Adrenalin Nasal Solution 0.1 % Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Fluorouracil Adrucil Intravenous Solution 2.5 GM/50ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Fluorouracil Adrucil Intravenous Solution 5 GM/100ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Fluorouracil Adrucil Intravenous Solution 500 MG/10ML Tier 1 x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Fluticasone‐Salmeterol Advair Diskus Inhalation Aerosol Powder Breath Activated 100‐50 MCG/DOSE Tier 2 xx ANTIASTHMATIC AND BRONCHODILATOR AGENTS Fluticasone‐Salmeterol Advair Diskus Inhalation Aerosol Powder Breath Activated 250‐50 MCG/DOSE Tier 2 xx ANTIASTHMATIC AND BRONCHODILATOR AGENTS Fluticasone‐Salmeterol Advair Diskus Inhalation Aerosol Powder Breath Activated 500‐50 MCG/DOSE Tier 2 xx ANTIASTHMATIC AND BRONCHODILATOR AGENTS Fluticasone‐Salmeterol Advair HFA Inhalation Aerosol 115‐21 MCG/ACT Tier 2 xx ANTIASTHMATIC AND BRONCHODILATOR AGENTS Fluticasone‐Salmeterol Advair HFA Inhalation Aerosol 230‐21 MCG/ACT Tier 2 xx ANTIASTHMATIC AND BRONCHODILATOR AGENTS Fluticasone‐Salmeterol Advair HFA Inhalation Aerosol 45‐21 MCG/ACT Tier 2 xx DIAGNOSTIC PRODUCTS Glucose Blood Advance Intuition Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies Advance Micro‐Draw Meter Device Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Advance Micro‐Draw Test In Vitro Strip Tier 3 DERMATOLOGICALS Hydrocortisone (Topical) Advanced Allergy Collection External Kit 2.5 % Tier 3 MULTIVITAMINS Multiple Vitamins w/ Calcium Advanced AM/PM Oral Miscellaneous Tier 3 HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor rAHF‐PFM Advate Intravenous Solution Reconstituted 1000 UNIT Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor rAHF‐PFM Advate Intravenous Solution Reconstituted 1500 UNIT Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor rAHF‐PFM Advate Intravenous Solution Reconstituted 2000 UNIT Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor rAHF‐PFM Advate Intravenous Solution Reconstituted 250 UNIT Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor rAHF‐PFM Advate Intravenous Solution Reconstituted 3000 UNIT Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor rAHF‐PFM Advate Intravenous Solution Reconstituted 4000 UNIT Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor rAHF‐PFM Advate Intravenous Solution Reconstituted 500 UNIT Tier 2 x ANTIHYPERLIPIDEMICS Niacin‐Lovastatin Advicor Oral Tablet Extended Release 24 Hour 1000‐20 MG Tier 3 x ANTIHYPERLIPIDEMICS Niacin‐Lovastatin Advicor Oral Tablet Extended Release 24 Hour 1000‐40 MG Tier 3 x ANTIHYPERLIPIDEMICS Niacin‐Lovastatin Advicor Oral Tablet Extended Release 24 Hour 500‐20 MG Tier 3 x ANTIHYPERLIPIDEMICS Niacin‐Lovastatin Advicor Oral Tablet Extended Release 24 Hour 750‐20 MG Tier 3 x MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies Advocate Blood Glucose System Kit w/Device Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Advocate Insulin Pen Needles Miscellaneous 29G X 12.7MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Advocate Insulin Pen Needles Miscellaneous 31G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Advocate Insulin Pen Needles Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Advocate Insulin Syringe Miscellaneous 29G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Advocate Insulin Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Advocate Insulin Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Advocate Insulin Syringe Miscellaneous 30G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Advocate Insulin Syringe Miscellaneous 30G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Advocate Insulin Syringe Miscellaneous 30G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Advocate Insulin Syringe Miscellaneous 31G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Advocate Insulin Syringe Miscellaneous 31G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Advocate Insulin Syringe Miscellaneous 31G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Advocate Lancets 30G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Advocate Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies Advocate Redi‐Code Device Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Advocate Redi‐Code In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies Advocate Redi‐Code+ Device Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Advocate Redi‐Code+ Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Advocate Safety Lancets 26G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Advocate Safety Lancets Miscellaneous Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood Advocate Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers AeroChamber Mini Chamber Device Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers AeroChamber MV Miscellaneous Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers AeroChamber Plus Flo‐Vu Large Miscellaneous Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers AeroChamber Plus Flo‐Vu Medium Miscellaneous Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers AeroChamber Plus Flo‐Vu Miscellaneous Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers AeroChamber Plus Flo‐Vu Small Miscellaneous Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers AeroChamber Plus Flo‐Vu w/Mask Miscellaneous Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers AeroChamber Plus Flow VU Miscellaneous Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers AeroChamber Plus Miscellaneous Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers AeroChamber Plus w/Mask Small Miscellaneous Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers AeroChamber w/FLOWSIGnal Miscellaneous Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers AeroChamber Z‐Stat Plus Chambr Miscellaneous Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers AeroChamber Z‐Stat Plus Miscellaneous Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers AeroChamber Z‐Stat Plus/Large Miscellaneous Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers AeroChamber Z‐Stat Plus/Medium Miscellaneous Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers AeroChamber Z‐Stat Plus/Small Miscellaneous Tier 2 x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Flunisolide HFA Aerospan Inhalation Aerosol Solution 80 MCG/ACT Tier 3 xx MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers AeroVent Plus Device Tier 2 x CALCIUM CHANNEL BLOCKERS Nifedipine Afeditab CR Oral Tablet Extended Release 24 Hour 30 MG Tier 1 CALCIUM CHANNEL BLOCKERS Nifedipine Afeditab CR Oral Tablet Extended Release 24 Hour 60 MG Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Everolimus Afinitor Disperz Oral Tablet Soluble 2 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Everolimus Afinitor Disperz Oral Tablet Soluble 3 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Everolimus Afinitor Disperz Oral Tablet Soluble 5 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Everolimus Afinitor Oral Tablet 10 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Everolimus Afinitor Oral Tablet 2.5 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Everolimus Afinitor Oral Tablet 5 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Everolimus Afinitor Oral Tablet 7.5 MG Tier 2 x x VACCINES Influenza Virus Split Afluria Intramuscular Suspension Tier 3 x VACCINES Influenza Virus Vaccine Split Free Afluria Preservative Free Intramuscular Suspension Prefilled Syringe 0.5 ML Tier 3 x ANTIDIABETICS Insulin Regular (Human) Afrezza Inhalation Powder 4 (30) & 8 (60) UNIT Tier 3 x ANTIDIABETICS Insulin Regular (Human) Afrezza Inhalation Powder 4 (60) & 8 (30) UNIT Tier 3 x ANTIDIABETICS Insulin Regular (Human) Afrezza Inhalation Powder 4 UNIT Tier 3 x ANTIDIABETICS Insulin Regular (Human) Afrezza Inhalation Powder 8 (60)& 12 (30) UNIT Tier 3 x DIAGNOSTIC PRODUCTS Glucose Blood AgaMatrix AMP Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood AgaMatrix Jazz Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood AgaMatrix KeyNote Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies AgaMatrix Presto Kit w/Device Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood AgaMatrix Presto Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets AgaMatrix Ultra‐Thin Lancets Miscellaneous Tier 2 CHEMICALS Agar Agar Powder Tier 3 HEMATOLOGICAL AGENTS ‐ MISC. Tirofiban HCl in Aggrastat Intravenous Solution 25‐0.9 MG/500ML‐% Tier 3 x HEMATOLOGICAL AGENTS ‐ MISC. Aspirin‐Dipyridamole Aggrenox Oral Capsule Extended Release 12 Hour 25‐200 MG Tier 3 x HEMATOLOGICAL AGENTS ‐ MISC. Anagrelide HCl Agrylin Oral Capsule 0.5 MG Tier 3 DERMATOLOGICALS Flurbiprofen‐Gabapentin‐Cyclobenzaprine‐Lido‐Dexamethasone AIF #2 Drug Preparation Kit External Cream Tier 3 DERMATOLOGICALS Flurbiprofen‐Baclofen‐Cyclobenzaprine‐Lidocaine AIF #3 Drug Preparation Kit External Cream Tier 3 HEMATOPOIETIC AGENTS Folic Acid‐Vitamin B6‐Vitamin B12 Airavite Oral Tablet 2.5‐25‐1 MG Tier 1 OPHTHALMIC AGENTS Bacitracin‐Polymyxin B (Ophth) AK‐Poly‐Bac Ophthalmic Ointment 500‐10000 UNIT/GM Tier 1 OPHTHALMIC AGENTS Lidocaine HCl (Ophth) Akten Ophthalmic Gel 3.5 % Tier 3 ANTIEMETICS Netupitant‐Palonosetron Akynzeo Oral Capsule 300‐0.5 MG Tier 3 x x DERMATOLOGICALS Hydrocortisone (Topical) Ala Cort External Cream 1 % Tier 1 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

DERMATOLOGICALS Hydrocortisone (Topical) Ala Scalp External Lotion 2 % Tier 3 ANTHELMINTICS Albendazole Albenza Oral Tablet 200 MG Tier 3 HEMATOLOGICAL AGENTS ‐ MISC. Albumin, Human Albuked 25 Intravenous Solution 25 % Tier 1 x HEMATOLOGICAL AGENTS ‐ MISC. Albumin, Human Albuked 5 Intravenous Solution 5 % Tier 1 x HEMATOLOGICAL AGENTS ‐ MISC. Albumin, Human Albumin Human Intravenous Solution 25 % Tier 1 x HEMATOLOGICAL AGENTS ‐ MISC. Albumin, Human Albumin Human Intravenous Solution 5 % Tier 1 x HEMATOLOGICAL AGENTS ‐ MISC. Albumin, Human Albuminar‐25 Intravenous Solution 25 % Tier 1 x HEMATOLOGICAL AGENTS ‐ MISC. Albumin, Human Albuminar‐5 Intravenous Solution 5 % Tier 1 x HEMATOLOGICAL AGENTS ‐ MISC. Albumin, Human Albumin‐ZLB Intravenous Solution 25 % Tier 1 x HEMATOLOGICAL AGENTS ‐ MISC. Albumin, Human Albumin‐ZLB Intravenous Solution 5 % Tier 1 x HEMATOLOGICAL AGENTS ‐ MISC. Albumin, Human AlbuRx Intravenous Solution 5 % Tier 1 x HEMATOLOGICAL AGENTS ‐ MISC. Albumin, Human Albutein Intravenous Solution 25 % Tier 1 x HEMATOLOGICAL AGENTS ‐ MISC. Albumin, Human Albutein Intravenous Solution 5 % Tier 1 x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Albuterol Sulfate Albuterol Sulfate ER Oral Tablet Extended Release 12 Hour 4 MG Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Albuterol Sulfate Albuterol Sulfate ER Oral Tablet Extended Release 12 Hour 8 MG Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Albuterol Sulfate Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083% Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Albuterol Sulfate Albuterol Sulfate Inhalation Nebulization Solution (5 MG/ML) 0.5% Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Albuterol Sulfate Albuterol Sulfate Inhalation Nebulization Solution 0.63 MG/3ML Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Albuterol Sulfate Albuterol Sulfate Inhalation Nebulization Solution 1.25 MG/3ML Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Albuterol Sulfate Albuterol Sulfate Oral Syrup 2 MG/5ML Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Albuterol Sulfate Albuterol Sulfate Oral Tablet 2 MG Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Albuterol Sulfate Albuterol Sulfate Oral Tablet 4 MG Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Albuterol Sulfate Albuterol Sulfate Powder Tier 3 OPHTHALMIC AGENTS Proparacaine HCl Alcaine Ophthalmic Solution 0.5 % Tier 3 DERMATOLOGICALS Alclometasone Dipropionate Alclometasone Dipropionate External Cream 0.05 % Tier 1 DERMATOLOGICALS Alclometasone Dipropionate Alclometasone Dipropionate External Ointment 0.05 % Tier 1 NUTRIENTS Alcohol Intravenous Solution 98 % Tier 1 x MEDICAL DEVICES AND SUPPLIES Alcohol Swabs Alcohol Prep Pad 70 % Tier 2 MEDICAL DEVICES AND SUPPLIES Alcohol Swabs Alcohol Swabs Pad Tier 2 MEDICAL DEVICES AND SUPPLIES Alcohol Swabs Alcohol Swabs Pad 70 % Tier 2 CHEMICALS Alcohol, USP Alcohol, USP Solution 95 % Tier 3 DIURETICS Spironolactone & Hydrochlorothiazide Aldactazide Oral Tablet 25‐25 MG Tier 3 DIURETICS Spironolactone & Hydrochlorothiazide Aldactazide Oral Tablet 50‐50 MG Tier 3 DIURETICS Spironolactone Aldactone Oral Tablet 100 MG Tier 3 DIURETICS Spironolactone Aldactone Oral Tablet 25 MG Tier 3 DIURETICS Spironolactone Aldactone Oral Tablet 50 MG Tier 3 DERMATOLOGICALS Imiquimod Aldara External Cream 5 % Tier 3 BIOLOGICALS MISC Alder Alder Subcutaneous Solution 1:20 Tier 3 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Alectinib HCl Alecensa Oral Capsule 150 MG Tier 3 DERMATOLOGICALS Capsaicin‐Menthol Alegenix External Disk 0.0375‐5 % Tier 1 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Alendronate Sodium Alendronate Sodium Oral Solution 70 MG/75ML Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Alendronate Sodium Alendronate Sodium Oral Tablet 10 MG Tier 1 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Alendronate Sodium Alendronate Sodium Oral Tablet 35 MG Tier 1 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Alendronate Sodium Alendronate Sodium Oral Tablet 40 MG Tier 2 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Alendronate Sodium Alendronate Sodium Oral Tablet 5 MG Tier 1 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Alendronate Sodium Alendronate Sodium Oral Tablet 70 MG Tier 1 x ANALGESICS ‐ OPIOID Alfentanil Alfenta Injection Injectable 500 MCG/ML Tier 3 x ANALGESICS ‐ OPIOID Alfentanil Alfentanil Injection Injectable 500 MCG/ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Interferon Alfa‐n3 Alferon N Injection Solution 5000000 UNIT/ML Tier 2 x GENITOURINARY AGENTS ‐ MISCELLANEOUS Alfuzosin HCl Alfuzosin HCl ER Oral Tablet Extended Release 24 Hour 10 MG Tier 1 CHEMICALS Alginic Acid Alginic Acid Powder Tier 3 ANTI‐INFECTIVE AGENTS ‐ MISC. Nitazoxanide Alinia Oral Suspension Reconstituted 100 MG/5ML Tier 2 x ANTI‐INFECTIVE AGENTS ‐ MISC. Nitazoxanide Alinia Oral Tablet 500 MG Tier 2 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Melphalan Alkeran Oral Tablet 2 MG Tier 2 DERMATOLOGICALS Silver Allevyn Ag Gentle External Pad 2"X2" Tier 3 DERMATOLOGICALS Silver Allevyn Ag Gentle External Pad 4"X4" Tier 3 DERMATOLOGICALS Silver Allevyn Ag Gentle External Pad 6"X6" Tier 3 DERMATOLOGICALS Silver Allevyn Ag Gentle External Pad 8"X8" Tier 3 DERMATOLOGICALS Levocetirizine‐Loratadine Allo‐PAX External Cream 5‐5 % Tier 3 GOUT AGENTS Allopurinol Allopurinol Oral Tablet 100 MG Tier 1 GOUT AGENTS Allopurinol Allopurinol Oral Tablet 300 MG Tier 1 MIGRAINE PRODUCTS Almotriptan Malate Almotriptan Malate Oral Tablet 12.5 MG Tier 1 x MIGRAINE PRODUCTS Almotriptan Malate Almotriptan Malate Oral Tablet 6.25 MG Tier 1 x OPHTHALMIC AGENTS Nedocromil Sodium (Ophth) Alocril Ophthalmic Solution 2 % Tier 3 OPHTHALMIC AGENTS Lodoxamide Tromethamine Alomide Ophthalmic Solution 0.1 % Tier 3 ESTROGENS Estradiol Alora Transdermal Patch Twice Weekly 0.025 MG/24HR Tier 2 xx ESTROGENS Estradiol Alora Transdermal Patch Twice Weekly 0.05 MG/24HR Tier 2 xx ESTROGENS Estradiol Alora Transdermal Patch Twice Weekly 0.075 MG/24HR Tier 2 xx ESTROGENS Estradiol Alora Transdermal Patch Twice Weekly 0.1 MG/24HR Tier 2 xx GASTROINTESTINAL AGENTS ‐ MISC. Alosetron HCl Alosetron HCl Oral Tablet 0.5 MG Tier 1 x GASTROINTESTINAL AGENTS ‐ MISC. Alosetron HCl Alosetron HCl Oral Tablet 1 MG Tier 1 x PHARMACEUTICAL ADJUVANTS Polyethylene Glycol AlpaWash External Ointment Tier 3 OPHTHALMIC AGENTS Brimonidine Tartrate Alphagan P Ophthalmic Solution 0.1 % Tier 2 OPHTHALMIC AGENTS Brimonidine Tartrate Alphagan P Ophthalmic Solution 0.15 % Tier 2 HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor/von Willebrand Factor Complex (Human) Alphanate/VWF Complex/Human Intravenous Solution Reconstituted 1000 UNIT Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor/von Willebrand Factor Complex (Human) Alphanate/VWF Complex/Human Intravenous Solution Reconstituted 1500 UNIT Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor/von Willebrand Factor Complex (Human) Alphanate/VWF Complex/Human Intravenous Solution Reconstituted 2000 UNIT Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor/von Willebrand Factor Complex (Human) Alphanate/VWF Complex/Human Intravenous Solution Reconstituted 250 UNIT Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor/von Willebrand Factor Complex (Human) Alphanate/VWF Complex/Human Intravenous Solution Reconstituted 500 UNIT Tier 2 x DERMATOLOGICALS Hydroquinone w/ Sunscreens Alphaquin HP External Cream 4 % Tier 1 DERMATOLOGICALS Betamethasone Dipropionate Augmented AlphaTrex External Gel 0.05 % Tier 1 ANTIANXIETY AGENTS ALPRAZolam ER Oral Tablet Extended Release 24 Hour 0.5 MG Tier 1 ANTIANXIETY AGENTS Alprazolam ALPRAZolam ER Oral Tablet Extended Release 24 Hour 1 MG Tier 1 ANTIANXIETY AGENTS Alprazolam ALPRAZolam ER Oral Tablet Extended Release 24 Hour 2 MG Tier 1 ANTIANXIETY AGENTS Alprazolam ALPRAZolam ER Oral Tablet Extended Release 24 Hour 3 MG Tier 1 ANTIANXIETY AGENTS Alprazolam ALPRAZolam Intensol Oral Concentrate 1 MG/ML Tier 3 ANTIANXIETY AGENTS Alprazolam ALPRAZolam Oral Tablet 0.25 MG Tier 1 ANTIANXIETY AGENTS Alprazolam ALPRAZolam Oral Tablet 0.5 MG Tier 1 ANTIANXIETY AGENTS Alprazolam ALPRAZolam Oral Tablet 1 MG Tier 1 ANTIANXIETY AGENTS Alprazolam ALPRAZolam Oral Tablet 2 MG Tier 1 ANTIANXIETY AGENTS Alprazolam ALPRAZolam Oral Tablet Dispersible 0.25 MG Tier 1 ANTIANXIETY AGENTS Alprazolam ALPRAZolam Oral Tablet Dispersible 0.5 MG Tier 1 ANTIANXIETY AGENTS Alprazolam ALPRAZolam Oral Tablet Dispersible 1 MG Tier 1 ANTIANXIETY AGENTS Alprazolam ALPRAZolam Oral Tablet Dispersible 2 MG Tier 1 ANTIANXIETY AGENTS Alprazolam ALPRAZolam XR Oral Tablet Extended Release 24 Hour 0.5 MG Tier 1 ANTIANXIETY AGENTS Alprazolam ALPRAZolam XR Oral Tablet Extended Release 24 Hour 1 MG Tier 1 ANTIANXIETY AGENTS Alprazolam ALPRAZolam XR Oral Tablet Extended Release 24 Hour 2 MG Tier 1 ANTIANXIETY AGENTS Alprazolam ALPRAZolam XR Oral Tablet Extended Release 24 Hour 3 MG Tier 1 ASSORTED CLASSES Alprostadil Alprostadil Injection Solution 500 MCG/ML Tier 1 x OPHTHALMIC AGENTS Loteprednol Etabonate Alrex Ophthalmic Suspension 0.2 % Tier 3 MIGRAINE PRODUCTS Sumatriptan Succinate Alsuma Subcutaneous Solution Auto‐injector 6 MG/0.5ML Tier 3 xx DERMATOLOGICALS Retapamulin Altabax External Ointment 1 % Tier 3 OPHTHALMIC AGENTS Tetracaine HCl (Ophth) Altacaine Ophthalmic Solution 0.5 % Tier 1 ANTIHYPERTENSIVES Ramipril Altace Oral Capsule 1.25 MG Tier 3 ANTIHYPERTENSIVES Ramipril Altace Oral Capsule 10 MG Tier 3 ANTIHYPERTENSIVES Ramipril Altace Oral Capsule 2.5 MG Tier 3 ANTIHYPERTENSIVES Ramipril Altace Oral Capsule 5 MG Tier 3 OPHTHALMIC AGENTS Fluorescein w/ Benoxinate Altafluor Ophthalmic Solution 0.25‐0.4 % Tier 1 OPHTHALMIC AGENTS Phenylephrine HCl (Ophth) Altafrin Ophthalmic Solution 10 % Tier 1 OPHTHALMIC AGENTS Phenylephrine HCl (Ophth) Altafrin Ophthalmic Solution 2.5 % Tier 1 CONTRACEPTIVES Levonorgestrel & Eth Estradiol Altavera Oral Tablet 0.15‐30 MG‐MCG Tier 1 BIOLOGICALS MISC Alternaria Alternaria Subcutaneous Solution 20000 PNU/ML Tier 3 x HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ANTIHYPERLIPIDEMICS Lovastatin Altoprev Oral Tablet Extended Release 24 Hour 20 MG Tier 3 x ANTIHYPERLIPIDEMICS Lovastatin Altoprev Oral Tablet Extended Release 24 Hour 40 MG Tier 3 x ANTIHYPERLIPIDEMICS Lovastatin Altoprev Oral Tablet Extended Release 24 Hour 60 MG Tier 3 x DERMATOLOGICALS Aluminum Chloride Aluminum Chloride Anhydrous Powder Tier 3 DERMATOLOGICALS Aluminum Chloride Aluminum Chloride Hexahydrate Powder Tier 3 CHEMICALS Alum (Potassium) Aluminum Potassium Sulfate Powder Tier 3 CHEMICALS Aluminum Sulfate Aluminum Sulfate Granules Tier 3 DERMATOLOGICALS Aluvea External Cream 39 % Tier 3 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Ciclesonide Alvesco Inhalation Aerosol Solution 160 MCG/ACT Tier 3 xx ANTIASTHMATIC AND BRONCHODILATOR AGENTS Ciclesonide Alvesco Inhalation Aerosol Solution 80 MCG/ACT Tier 3 xx CONTRACEPTIVES Norethindrone & Eth Estradiol Alyacen 1/35 Oral Tablet 1‐35 MG‐MCG Tier 1 CONTRACEPTIVES Norethindrone‐Eth Estradiol (Triphasic) Alyacen 7/7/7 Oral Tablet 0.5/0.75/1‐35 MG‐MCG Tier 1 ANTIPARKINSON AGENTS Amantadine HCl Amantadine HCl Oral Capsule 100 MG Tier 1 ANTIPARKINSON AGENTS Amantadine HCl Amantadine HCl Oral Syrup 50 MG/5ML Tier 1 ANTIPARKINSON AGENTS Amantadine HCl Amantadine HCl Oral Tablet 100 MG Tier 3 ANTIDIABETICS Glimepiride Amaryl Oral Tablet 1 MG Tier 3 ANTIDIABETICS Glimepiride Amaryl Oral Tablet 2 MG Tier 3 ANTIDIABETICS Glimepiride Amaryl Oral Tablet 4 MG Tier 3 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Zolpidem Tartrate Ambien CR Oral Tablet Extended Release 12.5 MG Tier 3 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Zolpidem Tartrate Ambien CR Oral Tablet Extended Release 6.25 MG Tier 3 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Zolpidem Tartrate Ambien Oral Tablet 10 MG Tier 3 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Zolpidem Tartrate Ambien Oral Tablet 5 MG Tier 3 DERMATOLOGICALS Amcinonide Amcinonide External Cream 0.1 % Tier 3 DERMATOLOGICALS Amcinonide Amcinonide External Lotion 0.1 % Tier 3 DERMATOLOGICALS Amcinonide Amcinonide External Ointment 0.1 % Tier 3 MIGRAINE PRODUCTS Naratriptan HCl Amerge Oral Tablet 1 MG Tier 3 x MIGRAINE PRODUCTS Naratriptan HCl Amerge Oral Tablet 2.5 MG Tier 3 x BIOLOGICALS MISC American Elm American Elm Subcutaneous Solution 1:20 Tier 3 x CONTRACEPTIVES Levonorgestrel‐Ethinyl Estradiol (91‐Day) Amethia Lo Oral Tablet 0.1‐0.02 & 0.01 MG Tier 1 CONTRACEPTIVES Levonorgestrel‐Ethinyl Estradiol (91‐Day) Amethia Oral Tablet 0.15‐0.03 &0.01 MG Tier 1 CONTRACEPTIVES Levonorgestrel‐Ethinyl Estradiol (Continuous) Amethyst Oral Tablet 90‐20 MCG Tier 1 HEMOSTATICS Aminocaproic Acid Amicar Oral Solution 0.25 GM/ML Tier 3 HEMOSTATICS Aminocaproic Acid Amicar Oral Syrup 25 % Tier 3 HEMOSTATICS Aminocaproic Acid Amicar Oral Tablet 1000 MG Tier 3 HEMOSTATICS Aminocaproic Acid Amicar Oral Tablet 500 MG Tier 3 GENERAL ANESTHETICS Amidate Intravenous Solution 2 MG/ML Tier 3 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Amifostine Crystalline Amifostine Intravenous Solution Reconstituted 500 MG Tier 1 x CHEMICALS Amikacin Amikacin Powder Tier 3 AMINOGLYCOSIDES Amikacin Sulfate Amikacin Sulfate Injection Solution 1 GM/4ML Tier 1 x AMINOGLYCOSIDES Amikacin Sulfate Amikacin Sulfate Injection Solution 500 MG/2ML Tier 1 x AMINOGLYCOSIDES Amikacin Sulfate Amikacin Sulfate Powder Tier 3 DIURETICS HCl AMILoride HCl Oral Tablet 5 MG Tier 1 DIURETICS Amiloride & Hydrochlorothiazide Amiloride‐Hydrochlorothiazide Oral Tablet 5‐50 MG Tier 1 GENITOURINARY AGENTS ‐ MISCELLANEOUS (GU Irrigant) Aminoacetic Acid Irrigation Solution 1.5 % Tier 1 VITAMINS Para‐Aminobenzoic Acid (PABA) Aminobenzoic Acid Powder Tier 3 HEMOSTATICS Aminocaproic Acid Aminocaproic Acid Intravenous Solution 250 MG/ML Tier 3 x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Aminophylline Aminophylline Anhydrous Powder Tier 3 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Aminophylline Aminophylline Intravenous Solution 25 MG/ML Tier 1 x GASTROINTESTINAL AGENTS ‐ MISC. Mesalamine Aminosalicylic Acid‐5 Powder Tier 3 NUTRIENTS Infusion Aminosyn II Intravenous Solution 10 % Tier 3 x NUTRIENTS Amino Acid Infusion Aminosyn II Intravenous Solution 15 % Tier 3 x NUTRIENTS Amino Acid Infusion Aminosyn II Intravenous Solution 8.5 % Tier 3 x NUTRIENTS Amino Acid Infusion Aminosyn Intravenous Solution 10 % Tier 3 x NUTRIENTS Amino Acid Infusion Aminosyn Intravenous Solution 8.5 % Tier 3 x NUTRIENTS Amino Acid Electrolyte Infusion Aminosyn/Electrolytes Intravenous Solution 8.5 % Tier 1 x ANTIARRHYTHMICS Amiodarone HCl Amiodarone HCl Intravenous Solution 150 MG/3ML Tier 1 x ANTIARRHYTHMICS Amiodarone HCl Amiodarone HCl Intravenous Solution 450 MG/9ML Tier 1 x ANTIARRHYTHMICS Amiodarone HCl Amiodarone HCl Oral Tablet 100 MG Tier 1 ANTIARRHYTHMICS Amiodarone HCl Amiodarone HCl Oral Tablet 200 MG Tier 1 ANTIARRHYTHMICS Amiodarone HCl Amiodarone HCl Oral Tablet 400 MG Tier 1 GASTROINTESTINAL AGENTS ‐ MISC. Lubiprostone Amitiza Oral Capsule 24 MCG Tier 2 x GASTROINTESTINAL AGENTS ‐ MISC. Lubiprostone Amitiza Oral Capsule 8 MCG Tier 2 x ANTIDEPRESSANTS Amitriptyline HCl Amitriptyline HCl Oral Tablet 10 MG Tier 1 ANTIDEPRESSANTS Amitriptyline HCl Amitriptyline HCl Oral Tablet 100 MG Tier 1 ANTIDEPRESSANTS Amitriptyline HCl Amitriptyline HCl Oral Tablet 150 MG Tier 1 ANTIDEPRESSANTS Amitriptyline HCl Amitriptyline HCl Oral Tablet 25 MG Tier 1 ANTIDEPRESSANTS Amitriptyline HCl Amitriptyline HCl Oral Tablet 50 MG Tier 1 ANTIDEPRESSANTS Amitriptyline HCl Amitriptyline HCl Oral Tablet 75 MG Tier 1 ANTIHYPERTENSIVES Amlodipine Besylate‐Benazepril HCl Amlodipine Besy‐Benazepril HCl Oral Capsule 10‐20 MG Tier 1 xx ANTIHYPERTENSIVES Amlodipine Besylate‐Benazepril HCl Amlodipine Besy‐Benazepril HCl Oral Capsule 10‐40 MG Tier 1 xx ANTIHYPERTENSIVES Amlodipine Besylate‐Benazepril HCl Amlodipine Besy‐Benazepril HCl Oral Capsule 2.5‐10 MG Tier 1 xx ANTIHYPERTENSIVES Amlodipine Besylate‐Benazepril HCl Amlodipine Besy‐Benazepril HCl Oral Capsule 5‐10 MG Tier 1 xx ANTIHYPERTENSIVES Amlodipine Besylate‐Benazepril HCl Amlodipine Besy‐Benazepril HCl Oral Capsule 5‐20 MG Tier 1 xx ANTIHYPERTENSIVES Amlodipine Besylate‐Benazepril HCl Amlodipine Besy‐Benazepril HCl Oral Capsule 5‐40 MG Tier 1 xx CALCIUM CHANNEL BLOCKERS Amlodipine Besylate AmLODIPine Besylate Oral Tablet 10 MG Tier 1 CALCIUM CHANNEL BLOCKERS Amlodipine Besylate AmLODIPine Besylate Oral Tablet 2.5 MG Tier 1 CALCIUM CHANNEL BLOCKERS Amlodipine Besylate AmLODIPine Besylate Oral Tablet 5 MG Tier 1 ANTIHYPERTENSIVES Amlodipine Besylate‐Valsartan Amlodipine Besylate‐Valsartan Oral Tablet 10‐160 MG Tier 1 x ANTIHYPERTENSIVES Amlodipine Besylate‐Valsartan Amlodipine Besylate‐Valsartan Oral Tablet 10‐320 MG Tier 1 x ANTIHYPERTENSIVES Amlodipine Besylate‐Valsartan Amlodipine Besylate‐Valsartan Oral Tablet 5‐160 MG Tier 1 x ANTIHYPERTENSIVES Amlodipine Besylate‐Valsartan Amlodipine Besylate‐Valsartan Oral Tablet 5‐320 MG Tier 1 x CARDIOVASCULAR AGENTS ‐ MISC. Amlodipine Besylate‐Atorvastatin Calcium Amlodipine‐Atorvastatin Oral Tablet 10‐10 MG Tier 1 CARDIOVASCULAR AGENTS ‐ MISC. Amlodipine Besylate‐Atorvastatin Calcium Amlodipine‐Atorvastatin Oral Tablet 10‐20 MG Tier 1 CARDIOVASCULAR AGENTS ‐ MISC. Amlodipine Besylate‐Atorvastatin Calcium Amlodipine‐Atorvastatin Oral Tablet 10‐40 MG Tier 1 CARDIOVASCULAR AGENTS ‐ MISC. Amlodipine Besylate‐Atorvastatin Calcium Amlodipine‐Atorvastatin Oral Tablet 10‐80 MG Tier 1 CARDIOVASCULAR AGENTS ‐ MISC. Amlodipine Besylate‐Atorvastatin Calcium Amlodipine‐Atorvastatin Oral Tablet 2.5‐10 MG Tier 1 CARDIOVASCULAR AGENTS ‐ MISC. Amlodipine Besylate‐Atorvastatin Calcium Amlodipine‐Atorvastatin Oral Tablet 2.5‐20 MG Tier 1 CARDIOVASCULAR AGENTS ‐ MISC. Amlodipine Besylate‐Atorvastatin Calcium Amlodipine‐Atorvastatin Oral Tablet 2.5‐40 MG Tier 1 CARDIOVASCULAR AGENTS ‐ MISC. Amlodipine Besylate‐Atorvastatin Calcium Amlodipine‐Atorvastatin Oral Tablet 5‐10 MG Tier 1 CARDIOVASCULAR AGENTS ‐ MISC. Amlodipine Besylate‐Atorvastatin Calcium Amlodipine‐Atorvastatin Oral Tablet 5‐20 MG Tier 1 CARDIOVASCULAR AGENTS ‐ MISC. Amlodipine Besylate‐Atorvastatin Calcium Amlodipine‐Atorvastatin Oral Tablet 5‐40 MG Tier 1 CARDIOVASCULAR AGENTS ‐ MISC. Amlodipine Besylate‐Atorvastatin Calcium Amlodipine‐Atorvastatin Oral Tablet 5‐80 MG Tier 1 ANTIHYPERTENSIVES Amlodipine‐Valsartan‐Hydrochlorothiazide Amlodipine‐Valsartan‐HCTZ Oral Tablet 10‐160‐12.5 MG Tier 1 x ANTIHYPERTENSIVES Amlodipine‐Valsartan‐Hydrochlorothiazide Amlodipine‐Valsartan‐HCTZ Oral Tablet 10‐160‐25 MG Tier 1 x ANTIHYPERTENSIVES Amlodipine‐Valsartan‐Hydrochlorothiazide Amlodipine‐Valsartan‐HCTZ Oral Tablet 10‐320‐25 MG Tier 1 x ANTIHYPERTENSIVES Amlodipine‐Valsartan‐Hydrochlorothiazide Amlodipine‐Valsartan‐HCTZ Oral Tablet 5‐160‐12.5 MG Tier 1 x ANTIHYPERTENSIVES Amlodipine‐Valsartan‐Hydrochlorothiazide Amlodipine‐Valsartan‐HCTZ Oral Tablet 5‐160‐25 MG Tier 1 x DERMATOLOGICALS Lactic Acid ( Lactate) Ammonium Lactate External Cream 12 % Tier 1 DERMATOLOGICALS Lactic Acid (Ammonium Lactate) Ammonium Lactate External Lotion 12 % Tier 1 CHEMICALS Ammonium Phosphate Ammonium Phosphate Dibasic Granules Tier 3 DERMATOLOGICALS Isotretinoin Amnesteem Oral Capsule 10 MG Tier 1 DERMATOLOGICALS Isotretinoin Amnesteem Oral Capsule 20 MG Tier 1 DERMATOLOGICALS Isotretinoin Amnesteem Oral Capsule 40 MG Tier 1 ANTIDEPRESSANTS Amoxapine Oral Tablet 100 MG Tier 3 ANTIDEPRESSANTS Amoxapine Amoxapine Oral Tablet 150 MG Tier 3 ANTIDEPRESSANTS Amoxapine Amoxapine Oral Tablet 25 MG Tier 3 ANTIDEPRESSANTS Amoxapine Amoxapine Oral Tablet 50 MG Tier 3 ULCER DRUGS Amoxicillin‐Clarithromycin w/ Lansoprazole Amoxicill‐Clarithro‐Lansopraz Oral Miscellaneous Tier 1 x x PENICILLINS Amoxicillin Amoxicillin ER Oral Tablet Extended Release 24 Hour 775 MG Tier 3 PENICILLINS Amoxicillin Amoxicillin Oral Capsule 250 MG Tier 1 PENICILLINS Amoxicillin Amoxicillin Oral Capsule 500 MG Tier 1 PENICILLINS Amoxicillin Amoxicillin Oral Suspension Reconstituted 125 MG/5ML Tier 1 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

PENICILLINS Amoxicillin Amoxicillin Oral Suspension Reconstituted 200 MG/5ML Tier 1 PENICILLINS Amoxicillin Amoxicillin Oral Suspension Reconstituted 250 MG/5ML Tier 1 PENICILLINS Amoxicillin Amoxicillin Oral Suspension Reconstituted 400 MG/5ML Tier 1 PENICILLINS Amoxicillin Amoxicillin Oral Tablet 500 MG Tier 1 PENICILLINS Amoxicillin Amoxicillin Oral Tablet 875 MG Tier 1 PENICILLINS Amoxicillin Amoxicillin Oral Tablet Chewable 125 MG Tier 2 PENICILLINS Amoxicillin Amoxicillin Oral Tablet Chewable 250 MG Tier 2 PENICILLINS Amoxicillin Amoxicillin Trihydrate Powder Tier 3 PENICILLINS Amoxicillin & Pot Clavulanate Amoxicillin‐Pot Clavulanate ER Oral Tablet Extended Release 12 Hour 1000‐62.5 MG Tier 1 PENICILLINS Amoxicillin & Pot Clavulanate Amoxicillin‐Pot Clavulanate Oral Suspension Reconstituted 200‐28.5 MG/5ML Tier 1 PENICILLINS Amoxicillin & Pot Clavulanate Amoxicillin‐Pot Clavulanate Oral Suspension Reconstituted 250‐62.5 MG/5ML Tier 1 PENICILLINS Amoxicillin & Pot Clavulanate Amoxicillin‐Pot Clavulanate Oral Suspension Reconstituted 400‐57 MG/5ML Tier 1 PENICILLINS Amoxicillin & Pot Clavulanate Amoxicillin‐Pot Clavulanate Oral Suspension Reconstituted 600‐42.9 MG/5ML Tier 1 PENICILLINS Amoxicillin & Pot Clavulanate Amoxicillin‐Pot Clavulanate Oral Tablet 250‐125 MG Tier 1 PENICILLINS Amoxicillin & Pot Clavulanate Amoxicillin‐Pot Clavulanate Oral Tablet 500‐125 MG Tier 1 PENICILLINS Amoxicillin & Pot Clavulanate Amoxicillin‐Pot Clavulanate Oral Tablet 875‐125 MG Tier 1 PENICILLINS Amoxicillin & Pot Clavulanate Amoxicillin‐Pot Clavulanate Oral Tablet Chewable 200‐28.5 MG Tier 2 PENICILLINS Amoxicillin & Pot Clavulanate Amoxicillin‐Pot Clavulanate Oral Tablet Chewable 400‐57 MG Tier 2 ASSORTED CLASSES Hyaluronidase Bovine Amphadase Injection Solution 150 UNIT/ML Tier 3 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Amphetamine‐Dextroamphetamine Amphetamine‐Dextroamphet ER Oral Capsule Extended Release 24 Hour 10 MG Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Amphetamine‐Dextroamphetamine Amphetamine‐Dextroamphet ER Oral Capsule Extended Release 24 Hour 15 MG Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Amphetamine‐Dextroamphetamine Amphetamine‐Dextroamphet ER Oral Capsule Extended Release 24 Hour 20 MG Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Amphetamine‐Dextroamphetamine Amphetamine‐Dextroamphet ER Oral Capsule Extended Release 24 Hour 25 MG Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Amphetamine‐Dextroamphetamine Amphetamine‐Dextroamphet ER Oral Capsule Extended Release 24 Hour 30 MG Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Amphetamine‐Dextroamphetamine Amphetamine‐Dextroamphet ER Oral Capsule Extended Release 24 Hour 5 MG Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Amphetamine‐Dextroamphetamine Amphetamine‐Dextroamphetamine Oral Tablet 10 MG Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Amphetamine‐Dextroamphetamine Amphetamine‐Dextroamphetamine Oral Tablet 12.5 MG Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Amphetamine‐Dextroamphetamine Amphetamine‐Dextroamphetamine Oral Tablet 15 MG Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Amphetamine‐Dextroamphetamine Amphetamine‐Dextroamphetamine Oral Tablet 20 MG Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Amphetamine‐Dextroamphetamine Amphetamine‐Dextroamphetamine Oral Tablet 30 MG Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Amphetamine‐Dextroamphetamine Amphetamine‐Dextroamphetamine Oral Tablet 5 MG Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Amphetamine‐Dextroamphetamine Amphetamine‐Dextroamphetamine Oral Tablet 7.5 MG Tier 1 MOUTH/THROAT/DENTAL AGENTS Amphotericin B (Mouth‐Throat) Amphotericin B Powder Tier 3 MOUTH/THROAT/DENTAL AGENTS Amphotericin B (Mouth‐Throat) Amphotericin B Powder 905 UNIT/MG Tier 3 PENICILLINS Ampicillin Ampicillin Oral Capsule 250 MG Tier 1 PENICILLINS Ampicillin Ampicillin Oral Capsule 500 MG Tier 1 PENICILLINS Ampicillin Ampicillin Oral Suspension Reconstituted 125 MG/5ML Tier 2 PENICILLINS Ampicillin Ampicillin Oral Suspension Reconstituted 250 MG/5ML Tier 2 PENICILLINS Ampicillin Sodium Ampicillin Sodium Injection Solution Reconstituted 1 GM Tier 1 x PENICILLINS Ampicillin Sodium Ampicillin Sodium Injection Solution Reconstituted 10 GM Tier 1 x PENICILLINS Ampicillin Sodium Ampicillin Sodium Injection Solution Reconstituted 125 MG Tier 3 x PENICILLINS Ampicillin Sodium Ampicillin Sodium Injection Solution Reconstituted 2 GM Tier 1 x PENICILLINS Ampicillin Sodium Ampicillin Sodium Injection Solution Reconstituted 250 MG Tier 1 x PENICILLINS Ampicillin Sodium Ampicillin Sodium Injection Solution Reconstituted 500 MG Tier 1 x PENICILLINS Ampicillin Sodium Ampicillin Sodium Intravenous Solution Reconstituted 1 GM Tier 3 x PENICILLINS Ampicillin Sodium Ampicillin Sodium Intravenous Solution Reconstituted 10 GM Tier 1 x PENICILLINS Ampicillin Sodium Ampicillin Sodium Intravenous Solution Reconstituted 2 GM Tier 3 x PENICILLINS Ampicillin & Sulbactam Sodium Ampicillin‐Sulbactam Injection Solution Reconstituted 3 (2‐1) GM Tier 1 x PENICILLINS Ampicillin & Sulbactam Sodium Ampicillin‐Sulbactam Sodium Injection Solution Reconstituted 1.5 (1‐0.5) GM Tier 1 x PENICILLINS Ampicillin & Sulbactam Sodium Ampicillin‐Sulbactam Sodium Injection Solution Reconstituted 3 (2‐1) GM Tier 1 x PENICILLINS Ampicillin & Sulbactam Sodium Ampicillin‐Sulbactam Sodium Intravenous Solution Reconstituted 1.5 (1‐0.5) GM Tier 1 x PENICILLINS Ampicillin & Sulbactam Sodium Ampicillin‐Sulbactam Sodium Intravenous Solution Reconstituted 15 (10‐5) GM Tier 1 x PENICILLINS Ampicillin & Sulbactam Sodium Ampicillin‐Sulbactam Sodium Intravenous Solution Reconstituted 3 (2‐1) GM Tier 3 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Dalfampridine Ampyra Oral Tablet Extended Release 12 Hour 10 MG Tier 2 x x OPHTHALMIC AGENTS Sodium Hyaluronate Amvisc Intraocular Solution 12 MG/ML Tier 3 OPHTHALMIC AGENTS Sodium Hyaluronate Amvisc Plus Intraocular Solution 16 MG/ML Tier 3 DERMATOLOGICALS Benzocaine (Topical) Anacaine External Ointment 10 % Tier 3 ANDROGENS‐ANABOLIC Oxymetholone Anadrol‐50 Oral Tablet 50 MG Tier 3 x ANTIDEPRESSANTS Clomipramine HCl Anafranil Oral Capsule 25 MG Tier 3 ANTIDEPRESSANTS Clomipramine HCl Anafranil Oral Capsule 50 MG Tier 3 ANTIDEPRESSANTS Clomipramine HCl Anafranil Oral Capsule 75 MG Tier 3 HEMATOLOGICAL AGENTS ‐ MISC. Anagrelide HCl Anagrelide HCl Oral Capsule 0.5 MG Tier 1 HEMATOLOGICAL AGENTS ‐ MISC. Anagrelide HCl Anagrelide HCl Oral Capsule 1 MG Tier 1 ANORECTAL AGENTS Lidocaine‐Hydrocortisone Acetate (Rectal) Ana‐Lex Rectal Kit 2‐2 % Tier 1 ANORECTAL AGENTS Hydrocortisone Ace‐Pramoxine‐Dietary Manage Prod‐Cleans Wipe Analpram Advanced Combination Kit 2.5‐1 % Tier 3 ANORECTAL AGENTS Hydrocortisone Acetate w/ Pramoxine Analpram‐HC Rectal Cream 1‐1 % Tier 3 ANORECTAL AGENTS Hydrocortisone Acetate w/ Pramoxine Analpram‐HC Rectal Lotion 1‐2.5 % Tier 3 ANORECTAL AGENTS Hydrocortisone Acetate w/ Pramoxine Analpram‐HC Rectal Lotion 2.5‐1 % Tier 3 ANORECTAL AGENTS Hydrocortisone Acetate w/ Pramoxine Analpram‐HC Singles Rectal Cream 1‐1 % Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Naproxen Sodium Anaprox DS Oral Tablet 550 MG Tier 3 & Sodium Hypochlorite Anasept External Liquid 0.057 % Tier 3 ULCER DRUGS Hyoscyamine Sulfate Anaspaz Oral Tablet Dispersible 0.125 MG Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Anastrozole Anastrozole Oral Tablet 1 MG Tier 1 ANTIFUNGALS Flucytosine Ancobon Oral Capsule 250 MG Tier 3 ANTIFUNGALS Flucytosine Ancobon Oral Capsule 500 MG Tier 3 ANDROGENS‐ANABOLIC Testosterone Androderm Transdermal Patch 24 Hour 2 MG/24HR Tier 2 x ANDROGENS‐ANABOLIC Testosterone Androderm Transdermal Patch 24 Hour 4 MG/24HR Tier 2 x ANDROGENS‐ANABOLIC Testosterone AndroGel Pump Transdermal Gel 12.5 MG/ACT (1%) Tier 3 x ANDROGENS‐ANABOLIC Testosterone AndroGel Pump Transdermal Gel 20.25 MG/ACT (1.62%) Tier 2 x ANDROGENS‐ANABOLIC Testosterone AndroGel Transdermal Gel 20.25 MG/1.25GM (1.62%) Tier 2 x ANDROGENS‐ANABOLIC Testosterone AndroGel Transdermal Gel 25 MG/2.5GM (1%) Tier 3 x ANDROGENS‐ANABOLIC Testosterone AndroGel Transdermal Gel 40.5 MG/2.5GM (1.62%) Tier 2 x ANDROGENS‐ANABOLIC Testosterone AndroGel Transdermal Gel 50 MG/5GM (1%) Tier 3 x ANDROGENS‐ANABOLIC Methyltestosterone Android Oral Capsule 10 MG Tier 3 ANDROGENS‐ANABOLIC Fluoxymesterone Androxy Oral Tablet 10 MG Tier 2 NEUROMUSCULAR AGENTS Succinylcholine Chloride Anectine Injection Solution 20 MG/ML Tier 3 x ESTROGENS Drospirenone‐Estradiol Angeliq Oral Tablet 0.25‐0.5 MG Tier 3 x ESTROGENS Drospirenone‐Estradiol Angeliq Oral Tablet 0.5‐1 MG Tier 3 x HEMATOPOIETIC AGENTS Folic Acid‐Vit B6‐Vit B12‐Vit D‐Omega 3 Acids‐Phytosterols Animi‐3 Oral Capsule 1 MG Tier 3 HEMATOPOIETIC AGENTS Folic Acid‐Vit B6‐Vit B12‐Vit D‐Omega 3 Acids‐Phytosterols Animi‐3/Vitamin D Oral Capsule 1 MG Tier 3 DERMATOLOGICALS Capsaicin‐Lidocaine‐Menthol AnodyneRx External Patch 0.05‐2.5‐5 % Tier 3 DERMATOLOGICALS Capsaicin‐Menthol Anodynz External Disk 0.0375‐5 % Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Umeclidinium‐Vilanterol Anoro Ellipta Inhalation Aerosol Powder Breath Activated 62.5‐25 MCG/INH Tier 2 xx PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Disulfiram Antabuse Oral Tablet 250 MG Tier 3 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Disulfiram Antabuse Oral Tablet 500 MG Tier 3 x ANTIHYPERLIPIDEMICS Fenofibrate Micronized Antara Oral Capsule 30 MG Tier 3 xx ANTIHYPERLIPIDEMICS Fenofibrate Micronized Antara Oral Capsule 90 MG Tier 3 xx DERMATOLOGICALS Anthralin Anthralin Powder Tier 3 OTIC AGENTS ‐Polymyxin‐HC (Otic) Antibiotic Ear Otic Solution 3.5‐10000‐1 Tier 1 ANTICOAGULANTS Anticoagulant Sodium Citrate Anticoagulant Sodium Citrate In Vitro Solution 4 GM/100ML Tier 3 CHEMICALS Antimony Potassium Tartrate Antimony Potassium Tartrate Powder Tier 3 OTIC AGENTS Antipyrine‐Benzocaine Antipyrine‐Benzocaine Otic Solution 5.4‐1.4 % Tier 1 OTIC AGENTS Antipyrine‐Benzocaine Antipyrine‐Benzocaine Otic Solution 54‐14 MG/ML Tier 1 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 1 ML Anti‐Stick Immun Syringe Miscellaneous 23G X 1" 1 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Anti‐Stick Insulin Syringe Miscellaneous 28G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Anti‐Stick Insulin Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Anti‐Stick Insulin Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 ANORECTAL AGENTS Hydrocortisone (Rectal) Anusol‐HC Rectal Cream 2.5 % Tier 3 ANTIEMETICS Dolasetron Mesylate Anzemet Intravenous Solution 20 MG/ML Tier 3 x ANTIEMETICS Dolasetron Mesylate Anzemet Oral Tablet 100 MG Tier 3 x ANTIEMETICS Dolasetron Mesylate Anzemet Oral Tablet 50 MG Tier 3 x ANALGESICS ‐ OPIOID Acetaminophen‐Caff‐Dihydrocod APAP‐Caff‐Dihydrocodeine Oral Capsule 320.5‐30‐16 MG Tier 1 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

DERMATOLOGICALS Diflorasone Diacetate Emollient ApexiCon E External Cream 0.05 % Tier 3 ANTIDIABETICS Insulin Glulisine Apidra Injection Solution 100 UNIT/ML Tier 3 x ANTIDIABETICS Insulin Glulisine Apidra SoloStar Subcutaneous Solution Pen‐injector 100 UNIT/ML Tier 3 x ANTIDEPRESSANTS Bupropion Hydrobromide Aplenzin Oral Tablet Extended Release 24 Hour 174 MG Tier 3 xx ANTIDEPRESSANTS Bupropion Hydrobromide Aplenzin Oral Tablet Extended Release 24 Hour 348 MG Tier 3 xx ANTIDEPRESSANTS Bupropion Hydrobromide Aplenzin Oral Tablet Extended Release 24 Hour 522 MG Tier 3 xx MEDICAL DEVICES AND SUPPLIES Catheters Apogee HC Catheter 12FR/16" Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Catheters Apogee HC Catheter 14FR/16" Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Catheters Apogee HC Catheter 16FR/16" Miscellaneous Tier 3 ANTIPARKINSON AGENTS Apomorphine Hydrochloride Apokyn Subcutaneous Solution 10 MG/ML Tier 2 x OPHTHALMIC AGENTS Apraclonidine HCl Apraclonidine HCl Ophthalmic Solution 0.5 % Tier 1 CONTRACEPTIVES Desogestrel & Ethinyl Estradiol Apri Oral Tablet 0.15‐30 MG‐MCG Tier 1 ANTICONVULSANTS Eslicarbazepine Acetate Aptiom Oral Tablet 200 MG Tier 3 x ANTICONVULSANTS Eslicarbazepine Acetate Aptiom Oral Tablet 400 MG Tier 3 x ANTICONVULSANTS Eslicarbazepine Acetate Aptiom Oral Tablet 600 MG Tier 3 x ANTICONVULSANTS Eslicarbazepine Acetate Aptiom Oral Tablet 800 MG Tier 3 x ANTIVIRALS Tipranavir Aptivus Oral Capsule 250 MG Tier 2 x ANTIVIRALS Tipranavir Aptivus Oral Solution 100 MG/ML Tier 2 x MULTIVITAMINS Multiple Vitamins w/ Minerals AP‐Zel Oral Tablet Tier 3 VITAMINS Vitamin A Aquasol A Intramuscular Solution 50000 UNIT/ML Tier 3 x ANTIMALARIALS Chloroquine Phosphate Aralen Oral Tablet 500 MG Tier 3 CONTRACEPTIVES Norethindrone‐Eth Estradiol (Triphasic) Aranelle Oral Tablet 0.5/1/0.5‐35 MG‐MCG Tier 1 HEMATOPOIETIC AGENTS Darbepoetin Alfa Aranesp (Albumin Free) Injection Solution 10 MCG/0.4ML Tier 3 x HEMATOPOIETIC AGENTS Darbepoetin Alfa Aranesp (Albumin Free) Injection Solution 100 MCG/ML Tier 2 x HEMATOPOIETIC AGENTS Darbepoetin Alfa Aranesp (Albumin Free) Injection Solution 150 MCG/0.75ML Tier 2 x HEMATOPOIETIC AGENTS Darbepoetin Alfa Aranesp (Albumin Free) Injection Solution 25 MCG/ML Tier 2 x HEMATOPOIETIC AGENTS Darbepoetin Alfa Aranesp (Albumin Free) Injection Solution 40 MCG/ML Tier 2 x HEMATOPOIETIC AGENTS Darbepoetin Alfa Aranesp (Albumin Free) Injection Solution 60 MCG/ML Tier 2 x HEMATOPOIETIC AGENTS Darbepoetin Alfa Aranesp (Albumin Free) Injection Solution Prefilled Syringe 100 MCG/0.5ML Tier 2 x HEMATOPOIETIC AGENTS Darbepoetin Alfa Aranesp (Albumin Free) Injection Solution Prefilled Syringe 150 MCG/0.3ML Tier 2 x HEMATOPOIETIC AGENTS Darbepoetin Alfa Aranesp (Albumin Free) Injection Solution Prefilled Syringe 200 MCG/0.4ML Tier 2 x HEMATOPOIETIC AGENTS Darbepoetin Alfa Aranesp (Albumin Free) Injection Solution Prefilled Syringe 25 MCG/0.42ML Tier 2 x HEMATOPOIETIC AGENTS Darbepoetin Alfa Aranesp (Albumin Free) Injection Solution Prefilled Syringe 300 MCG/0.6ML Tier 2 x HEMATOPOIETIC AGENTS Darbepoetin Alfa Aranesp (Albumin Free) Injection Solution Prefilled Syringe 40 MCG/0.4ML Tier 2 x HEMATOPOIETIC AGENTS Darbepoetin Alfa Aranesp (Albumin Free) Injection Solution Prefilled Syringe 500 MCG/ML Tier 2 x HEMATOPOIETIC AGENTS Darbepoetin Alfa Aranesp (Albumin Free) Injection Solution Prefilled Syringe 60 MCG/0.3ML Tier 2 x ANALGESICS ‐ ANTI‐INFLAMMATORY Leflunomide Arava Oral Tablet 10 MG Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Leflunomide Arava Oral Tablet 20 MG Tier 3 ANTIHISTAMINES Carbinoxamine Maleate Arbinoxa Oral Solution 4 MG/5ML Tier 1 ANTIHISTAMINES Carbinoxamine Maleate Arbinoxa Oral Tablet 4 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Rilonacept Arcalyst Subcutaneous Solution Reconstituted 220 MG Tier 2 x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Indacaterol Maleate Arcapta Neohaler Inhalation Capsule 75 MCG Tier 3 x ANTICOAGULANTS Argatroban in Sodium Chloride Argatroban in Sodium Chloride Intravenous Solution 250 MG/250ML Tier 3 x ANTICOAGULANTS Argatroban in Sodium Chloride Argatroban Intravenous Solution 125 MG/125ML Tier 3 x ANTICOAGULANTS Argatroban Argatroban Intravenous Solution 250 MG/2.5ML Tier 1 x ANTICOAGULANTS Argatroban Argatroban Intravenous Solution 50 MG/50ML Tier 3 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers Arial Chamber Device Tier 2 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Donepezil Hydrochloride Aricept Oral Tablet 10 MG Tier 3 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Donepezil Hydrochloride Aricept Oral Tablet 23 MG Tier 3 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Donepezil Hydrochloride Aricept Oral Tablet 5 MG Tier 3 x DERMATOLOGICALS Silver Arida External Gel Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Anastrozole Arimidex Oral Tablet 1 MG Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Aripiprazole ARIPiprazole Oral Solution 1 MG/ML Tier 1 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Aripiprazole ARIPiprazole Oral Tablet 10 MG Tier 1 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Aripiprazole ARIPiprazole Oral Tablet 15 MG Tier 1 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Aripiprazole ARIPiprazole Oral Tablet 2 MG Tier 1 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Aripiprazole ARIPiprazole Oral Tablet 20 MG Tier 1 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Aripiprazole ARIPiprazole Oral Tablet 30 MG Tier 1 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Aripiprazole ARIPiprazole Oral Tablet 5 MG Tier 1 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Aripiprazole ARIPiprazole Oral Tablet Dispersible 10 MG Tier 2 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Aripiprazole ARIPiprazole Oral Tablet Dispersible 15 MG Tier 2 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Aripiprazole Lauroxil Aristada Intramuscular Prefilled Syringe 441 MG/1.6ML Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Aripiprazole Lauroxil Aristada Intramuscular Prefilled Syringe 662 MG/2.4ML Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Aripiprazole Lauroxil Aristada Intramuscular Prefilled Syringe 882 MG/3.2ML Tier 3 xx CORTICOSTEROIDS Triamcinolone Hexacetonide Aristospan Intra‐Articular Injection Suspension 20 MG/ML Tier 3 x ANTICOAGULANTS Fondaparinux Sodium Arixtra Subcutaneous Solution 10 MG/0.8ML Tier 3 x ANTICOAGULANTS Fondaparinux Sodium Arixtra Subcutaneous Solution 2.5 MG/0.5ML Tier 3 x ANTICOAGULANTS Fondaparinux Sodium Arixtra Subcutaneous Solution 5 MG/0.4ML Tier 3 x ANTICOAGULANTS Fondaparinux Sodium Arixtra Subcutaneous Solution 7.5 MG/0.6ML Tier 3 x THYROID AGENTS Thyroid Armour Thyroid Oral Tablet 120 MG Tier 3 THYROID AGENTS Thyroid Armour Thyroid Oral Tablet 15 MG Tier 3 THYROID AGENTS Thyroid Armour Thyroid Oral Tablet 180 MG Tier 3 THYROID AGENTS Thyroid Armour Thyroid Oral Tablet 240 MG Tier 3 THYROID AGENTS Thyroid Armour Thyroid Oral Tablet 30 MG Tier 3 THYROID AGENTS Thyroid Armour Thyroid Oral Tablet 300 MG Tier 3 THYROID AGENTS Thyroid Armour Thyroid Oral Tablet 60 MG Tier 3 THYROID AGENTS Thyroid Armour Thyroid Oral Tablet 90 MG Tier 3 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Fluticasone Furoate (Inhalation) Arnuity Ellipta Inhalation Aerosol Powder Breath Activated 100 MCG/ACT Tier 2 xx ANTIASTHMATIC AND BRONCHODILATOR AGENTS Fluticasone Furoate (Inhalation) Arnuity Ellipta Inhalation Aerosol Powder Breath Activated 200 MCG/ACT Tier 2 xx ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Exemestane Aromasin Oral Tablet 25 MG Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Diclofenac w/ Misoprostol Arthrotec Oral Tablet Delayed Release 50‐0.2 MG Tier 3 x ANALGESICS ‐ ANTI‐INFLAMMATORY Diclofenac w/ Misoprostol Arthrotec Oral Tablet Delayed Release 75‐0.2 MG Tier 3 x HEMOSTATICS Fibrin Sealant Component Artiss External Solution Tier 3 DERMATOLOGICALS Silver ‐Potassium Nitrate Arzol Silver Nit Applicators External Miscellaneous 75‐25 % Tier 3 GASTROINTESTINAL AGENTS ‐ MISC. Mesalamine Asacol HD Oral Tablet Delayed Release 800 MG Tier 3 xx DIAGNOSTIC PRODUCTS Glucose Blood Ascensia Autodisc Test In Vitro Disk Tier 3 ANALGESICS ‐ OPIOID Butalbital‐Aspirin‐ w/Cod Ascomp‐Codeine Oral Capsule 50‐325‐40‐30 MG Tier 1 VITAMINS Ascorbic Acid Ascorbic Acid Injection Solution 500 MG/ML Tier 1 x CONTRACEPTIVES Levonorgestrel‐Ethinyl Estradiol (91‐Day) Ashlyna Oral Tablet 0.15‐0.03 &0.01 MG Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Mometasone Furoate (Inhalation) Asmanex 120 Metered Doses Inhalation Aerosol Powder Breath Activated 220 MCG/INH Tier 3 xx ANTIASTHMATIC AND BRONCHODILATOR AGENTS Mometasone Furoate (Inhalation) Asmanex 14 Metered Doses Inhalation Aerosol Powder Breath Activated 220 MCG/INH Tier 3 xx ANTIASTHMATIC AND BRONCHODILATOR AGENTS Mometasone Furoate (Inhalation) Asmanex 30 Metered Doses Inhalation Aerosol Powder Breath Activated 110 MCG/INH Tier 3 xx ANTIASTHMATIC AND BRONCHODILATOR AGENTS Mometasone Furoate (Inhalation) Asmanex 30 Metered Doses Inhalation Aerosol Powder Breath Activated 220 MCG/INH Tier 3 xx ANTIASTHMATIC AND BRONCHODILATOR AGENTS Mometasone Furoate (Inhalation) Asmanex 60 Metered Doses Inhalation Aerosol Powder Breath Activated 220 MCG/INH Tier 3 xx ANTIASTHMATIC AND BRONCHODILATOR AGENTS Mometasone Furoate (Inhalation) Asmanex 7 Metered Doses Inhalation Aerosol Powder Breath Activated 110 MCG/INH Tier 3 xx ANTIASTHMATIC AND BRONCHODILATOR AGENTS Mometasone Furoate (Inhalation) Asmanex HFA Inhalation Aerosol 100 MCG/ACT Tier 3 xx ANTIASTHMATIC AND BRONCHODILATOR AGENTS Mometasone Furoate (Inhalation) Asmanex HFA Inhalation Aerosol 200 MCG/ACT Tier 3 xx BIOLOGICALS MISC Aspergillus Fumigatis Aspergillus Fumigatis Subcutaneous Solution 10000 PNU/ML Tier 3 x BIOLOGICALS MISC Aspergillus Fumigatis Aspergillus Fumigatis Subcutaneous Solution 20000 PNU/ML Tier 3 x ANALGESICS ‐ NonNarcotic Aspirin Aspirin Powder Tier 3 ANALGESICS ‐ OPIOID Aspirin‐Caffeine‐Dihydrocodeine Bitartrate Aspirin‐Caff‐Dihydrocodeine Oral Capsule 356.4‐30‐16 MG Tier 3 x x HEMATOLOGICAL AGENTS ‐ MISC. Aspirin‐Dipyridamole Aspirin‐Dipyridamole ER Oral Capsule Extended Release 12 Hour 25‐200 MG Tier 3 x DIAGNOSTIC PRODUCTS Glucose Blood Assure 3 Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Assure 4 Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Assure Comfort Lancets 28G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Assure Comfort Lancets 30G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Assure Haemolance Plus High Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Assure Haemolance Plus Low Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Assure Haemolance Plus Micro Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Assure Haemolance Plus Normal Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Assure Haemolance Plus Ped Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Assure ID Insulin Safety Syr Miscellaneous 29G X 1/2" 0.5 ML Tier 2 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Assure ID Insulin Safety Syr Miscellaneous 29G X 1/2" 1 ML Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood Assure II Check In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Assure II In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Assure Lance Lancets 21G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Assure Lance Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Assure Lance Plus Safety 25G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Assure Lance Plus Safety 30G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Assure Lancets Miscellaneous Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood Assure Platinum In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Assure Prism multi Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Assure Pro Test In Vitro Strip Tier 3 ASSORTED CLASSES Tacrolimus Astagraf XL Oral Capsule Extended Release 24 Hour 0.5 MG Tier 2 ASSORTED CLASSES Tacrolimus Astagraf XL Oral Capsule Extended Release 24 Hour 1 MG Tier 2 ASSORTED CLASSES Tacrolimus Astagraf XL Oral Capsule Extended Release 24 Hour 5 MG Tier 2 NASAL AGENTS ‐ SYSTEMIC AND TOPICAL Azelastine HCl Astepro Nasal Solution 0.15 % Tier 3 x MEDICAL DEVICES AND SUPPLIES Lancets At Last Lancets Miscellaneous Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood At Last Test In Vitro Strip Tier 3 MULTIVITAMINS Prenatal Vit w/ Docusate‐Iron Carbonyl‐Folic Acid Atabex EC Oral Tablet Delayed Release 29‐1 MG Tier 3 ANTIHYPERTENSIVES Candesartan Cilexetil‐Hydrochlorothiazide Atacand HCT Oral Tablet 16‐12.5 MG Tier 3 x ANTIHYPERTENSIVES Candesartan Cilexetil‐Hydrochlorothiazide Atacand HCT Oral Tablet 32‐12.5 MG Tier 3 x ANTIHYPERTENSIVES Candesartan Cilexetil‐Hydrochlorothiazide Atacand HCT Oral Tablet 32‐25 MG Tier 3 x ANTIHYPERTENSIVES Candesartan Cilexetil Atacand Oral Tablet 16 MG Tier 3 x ANTIHYPERTENSIVES Candesartan Cilexetil Atacand Oral Tablet 32 MG Tier 3 x ANTIHYPERTENSIVES Candesartan Cilexetil Atacand Oral Tablet 4 MG Tier 3 x ANTIHYPERTENSIVES Candesartan Cilexetil Atacand Oral Tablet 8 MG Tier 3 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Risedronate Sodium Atelvia Oral Tablet Delayed Release 35 MG Tier 3 xx DERMATOLOGICALS Lidocaine‐Menthol Atendia External Patch 4‐3 % Tier 3 BETA BLOCKERS Atenolol Atenolol Oral Tablet 100 MG Tier 1 BETA BLOCKERS Atenolol Atenolol Oral Tablet 25 MG Tier 1 BETA BLOCKERS Atenolol Atenolol Oral Tablet 50 MG Tier 1 BETA BLOCKERS Atenolol Atenolol Powder Tier 3 ANTIHYPERTENSIVES Atenolol & Chlorthalidone Atenolol‐Chlorthalidone Oral Tablet 100‐25 MG Tier 1 ANTIHYPERTENSIVES Atenolol & Chlorthalidone Atenolol‐Chlorthalidone Oral Tablet 50‐25 MG Tier 1 ASSORTED CLASSES Lymphocyte Immune Globulin,Anti‐Thymocyte Globulin (Equine) Atgam Intravenous Injectable 50 MG/ML Tier 2 x ANTIANXIETY AGENTS Lorazepam Ativan Injection Solution 2 MG/ML Tier 3 x ANTIANXIETY AGENTS Lorazepam Ativan Injection Solution 4 MG/ML Tier 3 x ANTIANXIETY AGENTS Lorazepam Ativan Oral Tablet 0.5 MG Tier 3 ANTIANXIETY AGENTS Lorazepam Ativan Oral Tablet 1 MG Tier 3 ANTIANXIETY AGENTS Lorazepam Ativan Oral Tablet 2 MG Tier 3 ANTIHYPERLIPIDEMICS Atorvastatin Calcium Atorvastatin Calcium Oral Tablet 10 MG Tier 1 ANTIHYPERLIPIDEMICS Atorvastatin Calcium Atorvastatin Calcium Oral Tablet 20 MG Tier 1 ANTIHYPERLIPIDEMICS Atorvastatin Calcium Atorvastatin Calcium Oral Tablet 40 MG Tier 1 ANTIHYPERLIPIDEMICS Atorvastatin Calcium Atorvastatin Calcium Oral Tablet 80 MG Tier 1 ANTI‐INFECTIVE AGENTS ‐ MISC. Atovaquone Atovaquone Oral Suspension 750 MG/5ML Tier 1 ANTIMALARIALS Atovaquone‐Proguanil HCl Atovaquone‐Proguanil HCl Oral Tablet 250‐100 MG Tier 1 ANTIMALARIALS Atovaquone‐Proguanil HCl Atovaquone‐Proguanil HCl Oral Tablet 62.5‐25 MG Tier 1 NEUROMUSCULAR AGENTS Atracurium Besylate Atracurium Besylate Intravenous Solution 100 MG/10ML Tier 1 x NEUROMUSCULAR AGENTS Atracurium Besylate Atracurium Besylate Intravenous Solution 50 MG/5ML Tier 1 x DERMATOLOGICALS Tretinoin Atralin External Gel 0.05 % Tier 3 x ANTIVIRALS Efavirenz‐Emtricitabine‐Tenofovir Disoproxil Fumarate Atripla Oral Tablet 600‐200‐300 MG Tier 2 x ULCER DRUGS Sulfate AtroPen Intramuscular Device 0.25 MG/0.3ML Tier 3 x ULCER DRUGS Atropine Sulfate AtroPen Intramuscular Device 0.5 MG/0.7ML Tier 3 x ULCER DRUGS Atropine Sulfate AtroPen Intramuscular Device 1 MG/0.7ML Tier 3 x ULCER DRUGS Atropine Sulfate AtroPen Intramuscular Device 2 MG/0.7ML Tier 3 x ULCER DRUGS Atropine Sulfate Atropine Sulfate Injection Solution 0.1 MG/ML Tier 1 x ULCER DRUGS Atropine Sulfate Atropine Sulfate Injection Solution 0.4 MG/ML Tier 1 x ULCER DRUGS Atropine Sulfate Atropine Sulfate Injection Solution 1 MG/ML Tier 1 x ULCER DRUGS Atropine Sulfate Monohydrate Atropine Sulfate Monohydrate Powder Tier 3 OPHTHALMIC AGENTS Atropine Sulfate (Ophthalmic) Atropine Sulfate Ophthalmic Ointment 1 % Tier 2 OPHTHALMIC AGENTS Atropine Sulfate (Ophthalmic) Atropine Sulfate Ophthalmic Solution 1 % Tier 1 ULCER DRUGS Atropine Sulfate Atropine Sulfate Powder Tier 3 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Ipratropium Bromide HFA Atrovent HFA Inhalation Aerosol Solution 17 MCG/ACT Tier 3 x NASAL AGENTS ‐ SYSTEMIC AND TOPICAL Ipratropium Bromide (Nasal) Atrovent Nasal Solution 0.03 % Tier 3 NASAL AGENTS ‐ SYSTEMIC AND TOPICAL Ipratropium Bromide (Nasal) Atrovent Nasal Solution 0.06 % Tier 3 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Teriflunomide Aubagio Oral Tablet 14 MG Tier 2 x x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Teriflunomide Aubagio Oral Tablet 7 MG Tier 2 x x CONTRACEPTIVES Levonorgestrel & Eth Estradiol Aubra Oral Tablet 0.1‐20 MG‐MCG Tier 1 PENICILLINS Amoxicillin & Pot Clavulanate Augmentin ES‐600 Oral Suspension Reconstituted 600‐42.9 MG/5ML Tier 3 PENICILLINS Amoxicillin & Pot Clavulanate Augmentin Oral Suspension Reconstituted 125‐31.25 MG/5ML Tier 2 PENICILLINS Amoxicillin & Pot Clavulanate Augmentin Oral Suspension Reconstituted 250‐62.5 MG/5ML Tier 3 PENICILLINS Amoxicillin & Pot Clavulanate Augmentin Oral Tablet 500‐125 MG Tier 3 PENICILLINS Amoxicillin & Pot Clavulanate Augmentin Oral Tablet 875‐125 MG Tier 3 PENICILLINS Amoxicillin & Pot Clavulanate Augmentin XR Oral Tablet Extended Release 12 Hour 1000‐62.5 MG Tier 3 BIOLOGICALS MISC Aureobasidium Aureobasidium Subcutaneous Solution 10000 PNU/ML Tier 3 x BIOLOGICALS MISC Aureobasidium Aureobasidium Subcutaneous Solution 20000 PNU/ML Tier 3 x MEDICAL DEVICES AND SUPPLIES Lancets Aurora Lancet Super Thin 30G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Aurora Lancet Thin 23G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Aurora Pen Needles Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Aurora Pen Needles Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Aurora Pen Needles Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Aurora Unifine Pentips Miscellaneous 31G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Aurora Unifine Pentips Miscellaneous 32G X 4 MM Tier 2 GASTROINTESTINAL AGENTS ‐ MISC. Ferric Citrate Auryxia Oral Tablet 210 MG Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Misc. Autolet II Clinisafe Kit Tier 2 MEDICAL DEVICES AND SUPPLIES Lancet Devices Autolet Lancing Device Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Misc. Autolet Lite Clinisafe Kit Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Misc. Autolet Lite Starter Pack Kit Tier 2 MEDICAL DEVICES AND SUPPLIES Lancet Devices Autolet Mini Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Misc. Autolet Platforms Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Injection Device for Insulin Autopen Device Tier 3 ANTIHYPERTENSIVES Irbesartan‐Hydrochlorothiazide Avalide Oral Tablet 150‐12.5 MG Tier 3 ANTIHYPERTENSIVES Irbesartan‐Hydrochlorothiazide Avalide Oral Tablet 300‐12.5 MG Tier 3 DERMATOLOGICALS Lidocaine‐Menthol AvaLin‐Rx External Patch 4‐1 % Tier 1 ANTIDIABETICS Rosiglitazone Maleate Avandia Oral Tablet 2 MG Tier 3 x ANTIDIABETICS Rosiglitazone Maleate Avandia Oral Tablet 4 MG Tier 3 x ANTIDIABETICS Rosiglitazone Maleate Avandia Oral Tablet 8 MG Tier 3 x ANTIHYPERTENSIVES Irbesartan Avapro Oral Tablet 150 MG Tier 3 ANTIHYPERTENSIVES Irbesartan Avapro Oral Tablet 300 MG Tier 3 ANTIHYPERTENSIVES Irbesartan Avapro Oral Tablet 75 MG Tier 3 DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Avar Cleanser External Emulsion 10‐5 % Tier 1 x DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Avar External Foam 9.5‐5 % Tier 3 x DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Avar External Pad 9.5‐5 % Tier 3 x DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Avar LS Cleanser External Liquid 10‐2 % Tier 3 DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Avar LS External Foam 10‐2 % Tier 3 x DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Avar LS External Pad 10‐2 % Tier 3 x DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Avar‐e Emollient External Cream 10‐5 % Tier 1 x DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Avar‐e Green External Cream 10‐5 % Tier 1 x DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Avar‐e LS External Cream 10‐2 % Tier 3 x VAGINAL PRODUCTS Sulfanilamide Vaginal AVC Vaginal Vaginal Cream 15 % Tier 3 FLUOROQUINOLONES Moxifloxacin HCl Avelox ABC Pack Oral Tablet 400 MG Tier 3 FLUOROQUINOLONES Moxifloxacin HCl Avelox Oral Tablet 400 MG Tier 3 CONTRACEPTIVES Levonorgestrel & Eth Estradiol Aviane Oral Tablet 0.1‐20 MG‐MCG Tier 1 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

TETRACYCLINES Doxycycline (Monohydrate) Avidoxy Oral Tablet 100 MG Tier 1 DERMATOLOGICALS Tretinoin Avita External Cream 0.025 % Tier 1 x DERMATOLOGICALS Tretinoin Avita External Gel 0.025 % Tier 1 x GENITOURINARY AGENTS ‐ MISCELLANEOUS Dutasteride Avodart Oral Capsule 0.5 MG Tier 3 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Interferon Beta‐1a Avonex Intramuscular Kit 30 MCG Tier 2 x x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Interferon Beta‐1a Avonex Pen Intramuscular Auto‐injector Kit 30 MCG/0.5ML Tier 2 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Interferon Beta‐1a Avonex Prefilled Intramuscular Prefilled Syringe Kit 30 MCG/0.5ML Tier 2 x MINERALS & ELECTROLYTES Pot Phosphate Monobasic w/ Sod Phosphate Dibasic & Monobasic Av‐Phos 250 Neutral Oral Tablet 155‐852‐130 MG Tier 1 HEMATOPOIETIC AGENTS Folic Acid‐Vitamin B6‐Vitamin B12 Av‐VITE FB Oral Tablet 2.5‐25‐1 MG Tier 1 CEPHALOSPORINS Ceftazidime‐Avibactam Sodium Avycaz Intravenous Solution Reconstituted 2.5 (2‐0.5) GM Tier 3 x MIGRAINE PRODUCTS Almotriptan Malate Axert Oral Tablet 12.5 MG Tier 3 xx MIGRAINE PRODUCTS Almotriptan Malate Axert Oral Tablet 6.25 MG Tier 3 xx ULCER DRUGS Nizatidine Axid Oral Capsule 300 MG Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Disp) 22 G Axillary Block Needle Miscellaneous 22G X 1" Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Disp) 25 G Axillary Block Needle Miscellaneous 25G X 1" Tier 3 ANDROGENS‐ANABOLIC Testosterone Axiron Transdermal Solution 30 MG/ACT Tier 3 x PROGESTINS Norethindrone Acetate Aygestin Oral Tablet 5 MG Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Azacitidine AzaCITIDine Injection Suspension Reconstituted 100 MG Tier 1 x ASSORTED CLASSES Azathioprine Azasan Oral Tablet 100 MG Tier 3 ASSORTED CLASSES Azathioprine Azasan Oral Tablet 75 MG Tier 3 OPHTHALMIC AGENTS Azithromycin (Ophth) AzaSite Ophthalmic Solution 1 % Tier 3 ASSORTED CLASSES Azathioprine AzaTHIOprine Oral Tablet 50 MG Tier 1 ASSORTED CLASSES Azathioprine AzaTHIOprine Powder Tier 3 NASAL AGENTS ‐ SYSTEMIC AND TOPICAL Azelastine HCl Azelastine HCl Nasal Solution 0.1 % Tier 1 NASAL AGENTS ‐ SYSTEMIC AND TOPICAL Azelastine HCl Azelastine HCl Nasal Solution 0.15 % Tier 1 x OPHTHALMIC AGENTS Azelastine HCl (Ophth) Azelastine HCl Ophthalmic Solution 0.05 % Tier 1 DERMATOLOGICALS Azelaic Acid (Acne) Azelex External Cream 20 % Tier 3 ANTIPARKINSON AGENTS Rasagiline Mesylate Azilect Oral Tablet 0.5 MG Tier 3 x ANTIPARKINSON AGENTS Rasagiline Mesylate Azilect Oral Tablet 1 MG Tier 3 x MACROLIDES Azithromycin Azithromycin Intravenous Solution Reconstituted 500 MG Tier 1 x MACROLIDES Azithromycin Azithromycin Oral Packet 1 GM Tier 2 MACROLIDES Azithromycin Azithromycin Oral Suspension Reconstituted 100 MG/5ML Tier 1 MACROLIDES Azithromycin Azithromycin Oral Suspension Reconstituted 200 MG/5ML Tier 1 MACROLIDES Azithromycin Azithromycin Oral Tablet 250 MG Tier 1 MACROLIDES Azithromycin Azithromycin Oral Tablet 500 MG Tier 1 MACROLIDES Azithromycin Azithromycin Oral Tablet 600 MG Tier 1 OPHTHALMIC AGENTS Brinzolamide Azopt Ophthalmic Suspension 1 % Tier 2 ANTIHYPERTENSIVES Amlodipine Besylate‐Olmesartan Medoxomil Azor Oral Tablet 10‐20 MG Tier 2 xx ANTIHYPERTENSIVES Amlodipine Besylate‐Olmesartan Medoxomil Azor Oral Tablet 10‐40 MG Tier 2 xx ANTIHYPERTENSIVES Amlodipine Besylate‐Olmesartan Medoxomil Azor Oral Tablet 5‐20 MG Tier 2 xx ANTIHYPERTENSIVES Amlodipine Besylate‐Olmesartan Medoxomil Azor Oral Tablet 5‐40 MG Tier 2 xx ANTI‐INFECTIVE AGENTS ‐ MISC. Aztreonam Aztreonam Injection Solution Reconstituted 1 GM Tier 1 x x ANTI‐INFECTIVE AGENTS ‐ MISC. Aztreonam Aztreonam Injection Solution Reconstituted 2 GM Tier 1 x x GASTROINTESTINAL AGENTS ‐ MISC. Sulfasalazine Azulfidine EN‐tabs Oral Tablet Delayed Release 500 MG Tier 3 GASTROINTESTINAL AGENTS ‐ MISC. Sulfasalazine Azulfidine Oral Tablet 500 MG Tier 3 URINARY ANTI‐INFECTIVES Methenamine‐Hyosc‐ Blue‐Sod Phos‐Phenyl Sal Azuphen MB Oral Capsule 120 MG Tier 1 CONTRACEPTIVES Desogestrel‐Ethinyl Estradiol (Biphasic) Azurette Oral Tablet 0.15‐0.02/0.01 MG (21/5) Tier 1 MULTIVITAMINS B‐Complex Vitamins B Complex Vitamins Injection Solution Tier 1 x HEMATOPOIETIC AGENTS Cyanocobalamin B‐12 Compliance Injection Injection Kit 1000 MCG/ML Tier 3 x HEMATOPOIETIC AGENTS Cobalamine Combinations B‐6 Folic Acid Oral Capsule 400‐1000‐50 MCG‐MCG‐MG Tier 3 ANTI‐INFECTIVE AGENTS ‐ MISC. Bacitracin BACiiM Intramuscular Solution Reconstituted 50000 UNIT Tier 1 x ANTI‐INFECTIVE AGENTS ‐ MISC. Bacitracin Bacitracin Intramuscular Solution Reconstituted 50000 UNIT Tier 1 x ANTI‐INFECTIVE AGENTS ‐ MISC. Bacitracin Bacitracin Intramuscular Solution Reconstituted 50000 UNIT Tier 3 x OPHTHALMIC AGENTS Bacitracin (Ophthalmic) Bacitracin Ophthalmic Ointment 500 UNIT/GM Tier 2 DERMATOLOGICALS Bacitracin (Topical) Bacitracin Powder Tier 3 OPHTHALMIC AGENTS Bacitracin‐Polymyxin B (Ophth) Bacitracin‐Polymyxin B Ophthalmic Ointment 500‐10000 UNIT/GM Tier 1 OPHTHALMIC AGENTS Bacitracin‐Poly‐Neomycin‐HC Bacitra‐Neomycin‐Polymyxin‐HC Ophthalmic Ointment 1 % Tier 1 DERMATOLOGICALS Baclofen (Topical) Baclofen External Cream 2 % Tier 3 MUSCULOSKELETAL THERAPY AGENTS Baclofen Baclofen Oral Tablet 10 MG Tier 1 MUSCULOSKELETAL THERAPY AGENTS Baclofen Baclofen Oral Tablet 20 MG Tier 1 MUSCULOSKELETAL THERAPY AGENTS Baclofen Baclofen Powder Tier 3 MULTIVITAMINS Multiple Vitamins w/ Minerals Bacmin Oral Tablet Tier 3 ANTI‐INFECTIVE AGENTS ‐ MISC. Sulfamethoxazole‐Trimethoprim Bactrim DS Oral Tablet 800‐160 MG Tier 3 ANTI‐INFECTIVE AGENTS ‐ MISC. Sulfamethoxazole‐Trimethoprim Bactrim Oral Tablet 400‐80 MG Tier 3 DERMATOLOGICALS Mupirocin Calcium (Topical) Bactroban External Cream 2 % Tier 3 DERMATOLOGICALS Mupirocin Bactroban External Ointment 2 % Tier 3 NASAL AGENTS ‐ SYSTEMIC AND TOPICAL Mupirocin Calcium Bactroban Nasal Nasal Ointment 2 % Tier 3 ANTIDOTES Dimercaprol Bal in Oil Intramuscular Solution 100 MG/ML Tier 3 x OPHTHALMIC AGENTS Ophthalmic Irrigation Solution ‐ Intraocular Balanced Intraocular Solution Tier 1 MULTIVITAMINS Prenatal w/Fe Polysacch Cmplx‐Sod Feredetate‐FA‐Omega 3 Bal‐Care DHA Oral Miscellaneous 27‐1 & 430 MG Tier 2 GASTROINTESTINAL AGENTS ‐ MISC. Balsalazide Disodium Balsalazide Disodium Oral Capsule 750 MG Tier 1 CONTRACEPTIVES Norethindrone & Eth Estradiol Balziva Oral Tablet 0.4‐35 MG‐MCG Tier 1 ANTICONVULSANTS Rufinamide Banzel Oral Suspension 40 MG/ML Tier 3 x ANTICONVULSANTS Rufinamide Banzel Oral Tablet 200 MG Tier 2 x ANTICONVULSANTS Rufinamide Banzel Oral Tablet 400 MG Tier 2 x ANTIVIRALS Entecavir Baraclude Oral Solution 0.05 MG/ML Tier 2 x ANTIVIRALS Entecavir Baraclude Oral Tablet 0.5 MG Tier 2 x x ANTIVIRALS Entecavir Baraclude Oral Tablet 1 MG Tier 2 x x DIAGNOSTIC PRODUCTS Barium Sulfate Barium Sulfate Powder Tier 3 PHARMACEUTICAL ADJUVANTS Polyethylene Glycol 1450 Base A Polyethylene Glycol Powder Tier 3 PHARMACEUTICAL ADJUVANTS Polyethylene Glycol 300 Base C Polyethylene Glycol 300 Liquid Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Bayer Breeze 2 Test In Vitro Disk Tier 3 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies Bayer Contour Monitor Kit w/Device Tier 3 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies Bayer Contour Next EZ Kit w/Device Tier 3 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies Bayer Contour next Link Kit w/Device Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Bayer Contour Next Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Bayer Contour Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Bayer Microlet Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle BD AutoShield Duo Miscellaneous 30G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle BD AutoShield Miscellaneous 29G X 5MM Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle BD AutoShield Miscellaneous 29G X 8MM Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Disp) 25 GBD Disp Needle Miscellaneous 25G X 1" Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Disp) 20 GBD Disp Needles Miscellaneous 20G X 1" Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Disp) 20 GBD Disp Needles Miscellaneous 20G X 1‐1/2" Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Disp) 18 GBD Hypodermic Needle Miscellaneous 18G X 1‐1/2" Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Disp) 20 GBD Hypodermic Needle Miscellaneous 20G X 1‐1/2" Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Disp) 21 GBD Hypodermic Needle Miscellaneous 21G X 1‐1/2" Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Disp) 22 GBD Hypodermic Needle Miscellaneous 22G X 1‐1/2" Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Disp) 23 GBD Hypodermic Needle Miscellaneous 23G X 1" Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Disp) 25 GBD Hypodermic Needle Miscellaneous 25G X 5/8" Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD Insulin Syr Ultrafine II Miscellaneous 31G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD Insulin Syr Ultrafine II Miscellaneous 31G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD Insulin Syr Ultrafine II Miscellaneous 31G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD Insulin Syringe Half‐Unit Miscellaneous 31G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD Insulin Syringe MicroFine Miscellaneous 27G X 5/8" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD Insulin Syringe MicroFine Miscellaneous 28G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD Insulin Syringe MicroFine Miscellaneous 28G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD Insulin Syringe MicroFine Miscellaneous 28G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD Insulin Syringe Miscellaneous 25G X 1" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD Insulin Syringe Miscellaneous 25G X 5/8" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD Insulin Syringe Miscellaneous 26G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD Insulin Syringe Miscellaneous 27.5G X 5/8" 2 ML Tier 2 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD Insulin Syringe Miscellaneous 27G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD Insulin Syringe Miscellaneous 28G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD Insulin Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD Insulin Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD Insulin Syringe Miscellaneous 29G X 1/2" 2 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD Insulin Syringe Miscellaneous 30G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD Insulin Syringe Miscellaneous 31G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringes (Disposable) BD Insulin Syringe Miscellaneous U‐100 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐40 BD Insulin Syringe U‐40 Miscellaneous 25G X 5/8" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD Insulin Syringe Ultrafine Miscellaneous 29G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD Insulin Syringe Ultrafine Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD Insulin Syringe Ultrafine Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD Insulin Syringe Ultrafine Miscellaneous 30G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD Insulin Syringe Ultrafine Miscellaneous 30G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD Insulin Syringe Ultrafine Miscellaneous 30G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD Insulin Syringe Ultrafine Miscellaneous 31G X 15/64" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD Insulin Syringe Ultrafine Miscellaneous 31G X 15/64" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD Insulin Syringe Ultrafine Miscellaneous 31G X 15/64" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD Insulin Syringe Ultrafine Miscellaneous 31G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD Insulin Syringe Ultrafine Miscellaneous 31G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD Insulin Syringe Ultrafine Miscellaneous 31G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD Integra Insulin Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD Integra Syringe Miscellaneous 25G X 1" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets BD Lancet Ultrafine 30G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets BD Lancet Ultrafine 33G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 10 ML BD Luer‐Lok Syringe Miscellaneous 21G X 1" 10 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 3 ML BD Luer‐Lok Syringe Miscellaneous 21G X 1" 3 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 5 ML BD Luer‐Lok Syringe Miscellaneous 21G X 1" 5 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 10 ML BD Luer‐Lok Syringe Miscellaneous 21G X 1‐1/2" 10 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 3 ML BD Luer‐Lok Syringe Miscellaneous 21G X 1‐1/2" 3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 5 ML BD Luer‐Lok Syringe Miscellaneous 21G X 1‐1/2" 5 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 3 ML BD Luer‐Lok Syringe Miscellaneous 22G X 1‐1/2" 3 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 3 ML BD Luer‐Lok Syringe Miscellaneous 23G X 1" 3 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 3 ML BD Luer‐Lok Syringe Miscellaneous 25G X 5/8" 3 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets BD Microtainer Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Injection Device for Insulin BD Pen Mini Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Injection Device for Insulin BD Pen Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle BD Pen Needle Mini U/F Miscellaneous 31G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle BD Pen Needle Nano U/F Miscellaneous 32G X 4 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle BD Pen Needle Short U/F Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle BD Pen Needle Ultrafine Miscellaneous 29G X 12.7MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD SafetyGlide Insulin Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD SafetyGlide Insulin Syringe Miscellaneous 30G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 BD Safety‐Lok Insulin Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Syringe (Disposable) BD Syringe Cath Tip Miscellaneous 60 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Disposable) BD Syringe Luer‐Lok Miscellaneous 20 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Disposable) BD Syringe Luer‐Lok Miscellaneous 3 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Disposable) BD Syringe Luer‐Lok Miscellaneous 5 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Disposable) BD Syringe Slip Tip Miscellaneous 1 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Disposable) BD Syringe Slip Tip Miscellaneous 3 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Disposable) BD Syringe Slip Tip Miscellaneous 5 ML Tier 3 NASAL AGENTS ‐ SYSTEMIC AND TOPICAL Beclomethasone Diprop Monohyd Beconase AQ Nasal Suspension 42 MCG/SPRAY Tier 3 xx CONTRACEPTIVES Desogestrel‐Ethinyl Estradiol (Biphasic) Bekyree Oral Tablet 0.15‐0.02/0.01 MG (21/5) Tier 1 ANALGESICS ‐ OPIOID Buprenorphine HCl Belbuca Buccal Film 150 MCG Tier 3 ANALGESICS ‐ OPIOID Buprenorphine HCl Belbuca Buccal Film 300 MCG Tier 3 ANALGESICS ‐ OPIOID Buprenorphine HCl Belbuca Buccal Film 450 MCG Tier 3 ANALGESICS ‐ OPIOID Buprenorphine HCl Belbuca Buccal Film 600 MCG Tier 3 ANALGESICS ‐ OPIOID Buprenorphine HCl Belbuca Buccal Film 75 MCG Tier 3 ANALGESICS ‐ OPIOID Buprenorphine HCl Belbuca Buccal Film 750 MCG Tier 3 ANALGESICS ‐ OPIOID Buprenorphine HCl Belbuca Buccal Film 900 MCG Tier 3 ULCER DRUGS Belladonna & Opium Belladonna Alkaloids‐Opium Rectal Suppository 16.2‐60 MG Tier 3 ULCER DRUGS Belladonna Alkaloids & Opium Belladonna‐Opium Rectal Suppository 16.2‐30 MG Tier 3 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Suvorexant Belsomra Oral Tablet 10 MG Tier 3 xx HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Suvorexant Belsomra Oral Tablet 15 MG Tier 3 xx HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Suvorexant Belsomra Oral Tablet 20 MG Tier 3 xx HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Suvorexant Belsomra Oral Tablet 5 MG Tier 3 xx ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Lorcaserin HCl Belviq Oral Tablet 10 MG Tier 3 x x ANTIHYPERTENSIVES Benazepril HCl Benazepril HCl Oral Tablet 10 MG Tier 1 ANTIHYPERTENSIVES Benazepril HCl Benazepril HCl Oral Tablet 20 MG Tier 1 ANTIHYPERTENSIVES Benazepril HCl Benazepril HCl Oral Tablet 40 MG Tier 1 ANTIHYPERTENSIVES Benazepril HCl Benazepril HCl Oral Tablet 5 MG Tier 1 ANTIHYPERTENSIVES Benazepril & Hydrochlorothiazide Benazepril‐Hydrochlorothiazide Oral Tablet 10‐12.5 MG Tier 1 ANTIHYPERTENSIVES Benazepril & Hydrochlorothiazide Benazepril‐Hydrochlorothiazide Oral Tablet 20‐12.5 MG Tier 1 ANTIHYPERTENSIVES Benazepril & Hydrochlorothiazide Benazepril‐Hydrochlorothiazide Oral Tablet 20‐25 MG Tier 1 ANTIHYPERTENSIVES Benazepril & Hydrochlorothiazide Benazepril‐Hydrochlorothiazide Oral Tablet 5‐6.25 MG Tier 1 ANTIHYPERTENSIVES Olmesartan Medoxomil‐Hydrochlorothiazide Benicar HCT Oral Tablet 20‐12.5 MG Tier 2 ANTIHYPERTENSIVES Olmesartan Medoxomil‐Hydrochlorothiazide Benicar HCT Oral Tablet 40‐12.5 MG Tier 2 ANTIHYPERTENSIVES Olmesartan Medoxomil‐Hydrochlorothiazide Benicar HCT Oral Tablet 40‐25 MG Tier 2 ANTIHYPERTENSIVES Olmesartan Medoxomil Benicar Oral Tablet 20 MG Tier 2 ANTIHYPERTENSIVES Olmesartan Medoxomil Benicar Oral Tablet 40 MG Tier 2 ANTIHYPERTENSIVES Olmesartan Medoxomil Benicar Oral Tablet 5 MG Tier 2 DERMATOLOGICALS Salicylic Acid & Bensal HP External Ointment 3‐6 % Tier 3 ULCER DRUGS Dicyclomine HCl Bentyl Intramuscular Solution 10 MG/ML Tier 3 x ULCER DRUGS Dicyclomine HCl Bentyl Oral Capsule 10 MG Tier 3 ULCER DRUGS Dicyclomine HCl Bentyl Oral Tablet 20 MG Tier 3 DERMATOLOGICALS Benzoyl Peroxide Benzac AC Wash External Liquid 5 % Tier 3 DERMATOLOGICALS Benzoyl Peroxide Benzac W Wash External Liquid 5 % Tier 3 DERMATOLOGICALS Clindamycin Phosphate‐Benzoyl Peroxide BenzaClin External Gel 1‐5 % Tier 3 DERMATOLOGICALS Clindamycin Phosphate‐Benzoyl Peroxide BenzaClin with Pump External Gel 1‐5 % Tier 3 ANTISEPTICS & DISINFECTANTS Benzalkonium Chloride Benzalkonium Chloride External Solution Tier 3 ANTISEPTICS & DISINFECTANTS Benzalkonium Chloride Benzalkonium Chloride External Solution 50 % Tier 3 DERMATOLOGICALS Benzoyl Peroxide‐Erythromycin Benzamycin External Gel 5‐3 % Tier 3 DERMATOLOGICALS Benzoyl Peroxide‐Erythromycin BenzamycinPak External Packet 5‐3 % Tier 2 x DERMATOLOGICALS Benzoyl Peroxide BenzEFoam External Foam 5.3 % Tier 3 DERMATOLOGICALS Benzoyl Peroxide BenzEFoamUltra External Foam 9.8 % Tier 3 DERMATOLOGICALS Benzoyl Peroxide BenzePrO Creamy Wash External Liquid 7 % Tier 1 DERMATOLOGICALS Benzoyl Peroxide BenzePrO External Foam 5.3 % Tier 1 DERMATOLOGICALS Benzoyl Peroxide BenzePrO Foaming Cloths External Miscellaneous 6 % Tier 1 DERMATOLOGICALS Benzoyl Peroxide BenzePrO Short Contact External Foam 9.8 % Tier 1 DERMATOLOGICALS Benzoyl Peroxide Benziq External Gel 5.25 % Tier 3 DERMATOLOGICALS Benzoyl Peroxide Benziq LS External Gel 2.75 % Tier 3 DERMATOLOGICALS Benzoyl Peroxide Benziq Wash External Liquid 5.25 % Tier 1 DERMATOLOGICALS Benzocaine (Topical) Benzocaine Powder Tier 3 TETRACYCLINES Doxycycline Monohydrate‐Benzoyl Peroxide BenzoDox 30 Combination Therapy Pack 100 (30) & 4.4 MG & % Tier 3 TETRACYCLINES Doxycycline Monohydrate‐Benzoyl Peroxide BenzoDox 60 Combination Therapy Pack 100 (60) & 4.4 MG & % Tier 3 DERMATOLOGICALS Benzoic Acid Benzoic Acid Powder Tier 3 DERMATOLOGICALS Benzoin Compound Benzoin Compound External Tincture Tier 3 DERMATOLOGICALS Benzoin Benzoin External Tincture Tier 3 COUGH/COLD/ALLERGY Benzonatate Benzonatate Oral Capsule 100 MG Tier 1 COUGH/COLD/ALLERGY Benzonatate Benzonatate Oral Capsule 150 MG Tier 1 COUGH/COLD/ALLERGY Benzonatate Benzonatate Oral Capsule 200 MG Tier 1 DERMATOLOGICALS Benzoyl Peroxide Benzoyl Peroxide External Foam 5.3 % Tier 1 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

DERMATOLOGICALS Benzoyl Peroxide Benzoyl Peroxide External Foam 9.8 % Tier 1 DERMATOLOGICALS Benzoyl Peroxide Benzoyl Peroxide External Gel 10 % Tier 1 DERMATOLOGICALS Benzoyl Peroxide Benzoyl Peroxide Hydrous Powder Tier 3 DERMATOLOGICALS Benzoyl Peroxide Benzoyl Peroxide Short Contact External Foam 9.8 % Tier 1 DERMATOLOGICALS Benzoyl Peroxide Benzoyl Peroxide Wash External Liquid 10 % Tier 1 DERMATOLOGICALS Benzoyl Peroxide‐Erythromycin Benzoyl Peroxide‐Erythromycin External Gel 5‐3 % Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Benzphetamine HCl Benzphetamine HCl Oral Tablet 50 MG Tier 1 x ANTIPARKINSON AGENTS Benztropine Mesylate Benztropine Mesylate Injection Solution 1 MG/ML Tier 1 x ANTIPARKINSON AGENTS Benztropine Mesylate Benztropine Mesylate Oral Tablet 0.5 MG Tier 1 ANTIPARKINSON AGENTS Benztropine Mesylate Benztropine Mesylate Oral Tablet 1 MG Tier 1 ANTIPARKINSON AGENTS Benztropine Mesylate Benztropine Mesylate Oral Tablet 2 MG Tier 1 PHARMACEUTICAL ADJUVANTS Benzyl Alcohol Liquid Tier 3 OPHTHALMIC AGENTS Bepotastine Besilate Bepreve Ophthalmic Solution 1.5 % Tier 3 BIOLOGICALS MISC Bermuda Grass Bermuda Grass Subcutaneous Solution 10000 BAU/ML Tier 3 x OPHTHALMIC AGENTS Besifloxacin HCl Besivance Ophthalmic Suspension 0.6 % Tier 3 OPHTHALMIC AGENTS Povidone‐ (Ophth) Betadine Ophthalmic Prep Ophthalmic Solution 5 % Tier 3 OPHTHALMIC AGENTS Levobunolol HCl Betagan Ophthalmic Solution 0.5 % Tier 3 CHEMICALS Betaine HCl Betaine HCl Powder Tier 3 DERMATOLOGICALS Betamethasone Dipropionate Augmented Betamethasone Dipropionate Aug External Cream 0.05 % Tier 1 DERMATOLOGICALS Betamethasone Dipropionate Augmented Betamethasone Dipropionate Aug External Gel 0.05 % Tier 1 DERMATOLOGICALS Betamethasone Dipropionate Augmented Betamethasone Dipropionate Aug External Lotion 0.05 % Tier 1 DERMATOLOGICALS Betamethasone Dipropionate Augmented Betamethasone Dipropionate Aug External Ointment 0.05 % Tier 1 DERMATOLOGICALS Betamethasone Dipropionate (Topical) Betamethasone Dipropionate External Cream 0.05 % Tier 1 DERMATOLOGICALS Betamethasone Dipropionate (Topical) Betamethasone Dipropionate External Lotion 0.05 % Tier 1 DERMATOLOGICALS Betamethasone Dipropionate (Topical) Betamethasone Dipropionate External Ointment 0.05 % Tier 1 DERMATOLOGICALS Betamethasone Dipropionate (Topical) Betamethasone Dipropionate Powder Tier 3 CORTICOSTEROIDS Betamethasone Sodium Phosphate Betamethasone Sodium Phosphate Powder Tier 3 DERMATOLOGICALS Betamethasone Valerate Betamethasone Valerate External Cream 0.1 % Tier 1 DERMATOLOGICALS Betamethasone Valerate Betamethasone Valerate External Foam 0.12 % Tier 1 DERMATOLOGICALS Betamethasone Valerate Betamethasone Valerate External Lotion 0.1 % Tier 1 DERMATOLOGICALS Betamethasone Valerate Betamethasone Valerate External Ointment 0.1 % Tier 1 DERMATOLOGICALS Betamethasone Valerate Betamethasone Valerate Powder Tier 3 BETA BLOCKERS Sotalol HCl (AFIB/AFL) Betapace AF Oral Tablet 120 MG Tier 3 BETA BLOCKERS Sotalol HCl (AFIB/AFL) Betapace AF Oral Tablet 160 MG Tier 3 BETA BLOCKERS Sotalol HCl (AFIB/AFL) Betapace AF Oral Tablet 80 MG Tier 3 BETA BLOCKERS Sotalol HCl Betapace Oral Tablet 120 MG Tier 3 BETA BLOCKERS Sotalol HCl Betapace Oral Tablet 160 MG Tier 3 BETA BLOCKERS Sotalol HCl Betapace Oral Tablet 80 MG Tier 3 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Interferon Beta‐1b Betaseron Subcutaneous Kit 0.3 MG Tier 2 x x OPHTHALMIC AGENTS Betaxolol HCl (Ophth) Betaxolol HCl Ophthalmic Solution 0.5 % Tier 1 BETA BLOCKERS Betaxolol HCl Betaxolol HCl Oral Tablet 10 MG Tier 1 BETA BLOCKERS Betaxolol HCl Betaxolol HCl Oral Tablet 20 MG Tier 1 URINARY ANTISPASMODICS Bethanechol Chloride Bethanechol Chloride Oral Tablet 10 MG Tier 1 URINARY ANTISPASMODICS Bethanechol Chloride Bethanechol Chloride Oral Tablet 25 MG Tier 1 URINARY ANTISPASMODICS Bethanechol Chloride Bethanechol Chloride Oral Tablet 5 MG Tier 1 URINARY ANTISPASMODICS Bethanechol Chloride Bethanechol Chloride Oral Tablet 50 MG Tier 1 AMINOGLYCOSIDES Tobramycin Bethkis Inhalation Nebulization Solution 300 MG/4ML Tier 2 x OPHTHALMIC AGENTS Timolol Betimol Ophthalmic Solution 0.25 % Tier 3 OPHTHALMIC AGENTS Timolol Betimol Ophthalmic Solution 0.5 % Tier 3 OPHTHALMIC AGENTS Betaxolol HCl (Ophth) Betoptic‐S Ophthalmic Suspension 0.25 % Tier 2 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Bexarotene Bexarotene Oral Capsule 75 MG Tier 1 x VACCINES Meningococcal Vac Group B (Recomb Adsorbed) Multicomponent Bexsero Intramuscular Suspension Prefilled Syringe Tier 3 x CONTRACEPTIVES Drospirenone‐Ethinyl Estradiol‐Levomefolate Calcium Beyaz Oral Tablet 3‐0.02‐0.451 MG Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood BG Star Test In Vitro Strip Tier 3 CHEMICALS Butylated Hydroxytoluene BHT Granules Tier 3 MACROLIDES Clarithromycin Biaxin Oral Suspension Reconstituted 250 MG/5ML Tier 3 MACROLIDES Clarithromycin Biaxin Oral Tablet 250 MG Tier 3 MACROLIDES Clarithromycin Biaxin Oral Tablet 500 MG Tier 3 MACROLIDES Clarithromycin Biaxin XL Oral Tablet Extended Release 24 Hour 500 MG Tier 3 MACROLIDES Clarithromycin Biaxin XL Pac Oral Tablet Extended Release 24 Hour 500 MG Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Bicalutamide Bicalutamide Oral Tablet 50 MG Tier 1 PENICILLINS Penicillin G Benzathine & Procaine Bicillin C‐R 900/300 Intramuscular Suspension 900000‐300000 UNIT/2ML Tier 3 x PENICILLINS Penicillin G Benzathine & Procaine Bicillin C‐R Intramuscular Suspension 1200000 UNIT/2ML Tier 3 x PENICILLINS Penicillin G Benzathine Bicillin L‐A Intramuscular Suspension 1200000 UNIT/2ML Tier 3 x PENICILLINS Penicillin G Benzathine Bicillin L‐A Intramuscular Suspension 2400000 UNIT/4ML Tier 3 x PENICILLINS Penicillin G Benzathine Bicillin L‐A Intramuscular Suspension 600000 UNIT/ML Tier 3 x CARDIOVASCULAR AGENTS ‐ MISC. ‐Hydralazine HCl BiDil Oral Tablet 20‐37.5 MG Tier 3 ESTROGENS Estradiol‐Estriol‐ Micronized Biest/Progesterone Transdermal Cream Tier 3 x HEMATOPOIETIC AGENTS Polysaccharide Fe Complex‐Fe Polypeptide‐FA‐Vit B12 BiferaRx Oral Tablet 22‐6‐1‐0.025 MG Tier 3 ANTHELMINTICS Praziquantel Biltricide Oral Tablet 600 MG Tier 2 OPHTHALMIC AGENTS Bimatoprost Bimatoprost Ophthalmic Solution 0.03 % Tier 3 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Alendronate Sodium Binosto Oral Tablet Effervescent 70 MG Tier 3 xx OPHTHALMIC AGENTS Fluorescein Sodium Topical Bio Glo Ophthalmic Strip 1 MG Tier 1 MULTIVITAMINS Multiple Vitamins w/ Minerals Biocel Oral Tablet Tier 1 DERMATOLOGICALS Hyaluronate Sodium Bionect External Cream 0.2 % Tier 3 DERMATOLOGICALS Hyaluronate Sodium Bionect External Foam 0.2 % Tier 3 DERMATOLOGICALS Hyaluronate Sodium Bionect External Gel 0.2 % Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Bioscanner Glucose Test In Vitro Strip Tier 3 ANTIFUNGALS Nystatin Bio‐Statin Oral Capsule 1000000 UNIT Tier 3 ANTIFUNGALS Nystatin Bio‐Statin Oral Capsule 500000 UNIT Tier 3 ANTIFUNGALS Nystatin Bio‐Statin Oral Powder Tier 1 VACCINES Vaccine Adsorbed BioThrax Intramuscular Suspension Tier 3 x VITAMINS Biotin Biotin Powder Tier 3 COUGH/COLD/ALLERGY Phenylephrine w/ DM‐GG Biotuss Oral Liquid 10‐15‐300 MG/5ML Tier 1 COUGH/COLD/ALLERGY Phenylephrine w/ DM‐GG Biotuss Pediatric Oral Liquid 2.5‐5‐50 MG/ML Tier 1 ANTIDIARRHEALS Bismuth Subgallate Bismuth Subgallate Powder Tier 3 CHEMICALS Bismuth Subnitrate Bismuth Subnitrate Powder Tier 3 BETA BLOCKERS Bisoprolol Fumarate Bisoprolol Fumarate Oral Tablet 10 MG Tier 1 BETA BLOCKERS Bisoprolol Fumarate Bisoprolol Fumarate Oral Tablet 5 MG Tier 1 ANTIHYPERTENSIVES Bisoprolol & Hydrochlorothiazide Bisoprolol‐Hydrochlorothiazide Oral Tablet 10‐6.25 MG Tier 1 ANTIHYPERTENSIVES Bisoprolol & Hydrochlorothiazide Bisoprolol‐Hydrochlorothiazide Oral Tablet 2.5‐6.25 MG Tier 1 ANTIHYPERTENSIVES Bisoprolol & Hydrochlorothiazide Bisoprolol‐Hydrochlorothiazide Oral Tablet 5‐6.25 MG Tier 1 ANTICOAGULANTS Bivalirudin Bivalirudin Intravenous Solution Reconstituted 250 MG Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Bleomycin Sulfate Bleomycin Sulfate Injection Solution Reconstituted 15 UNIT Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Bleomycin Sulfate Bleomycin Sulfate Injection Solution Reconstituted 30 UNIT Tier 1 x OPHTHALMIC AGENTS Sulfacetamide Sodium (Ophth) Bleph‐10 Ophthalmic Solution 10 % Tier 3 OPHTHALMIC AGENTS Sulfacetamide Sod‐Prednisolone Blephamide Ophthalmic Suspension 10‐0.2 % Tier 3 OPHTHALMIC AGENTS Sulfacetamide Sod‐Prednisolone Blephamide S.O.P. Ophthalmic Ointment 10‐0.2 % Tier 3 CONTRACEPTIVES Norethin Acet & Estrad‐Fe Blisovi 24 Fe Oral Tablet 1‐20 MG‐MCG(24) Tier 1 CONTRACEPTIVES Norethin Acet & Estrad‐Fe Blisovi Fe 1.5/30 Oral Tablet 1.5‐30 MG‐MCG Tier 1 CONTRACEPTIVES Norethin Acet & Estrad‐Fe Blisovi FE 1/20 Oral Tablet 1‐20 MG‐MCG Tier 1 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies Blood Glucose Monitor System Kit w/Device Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Blood Glucose Test In Vitro Strip Tier 3 ANTIMYASTHENIC/CHOLINERGIC AGENTS Neostigmine Methylsulfate Bloxiverz Intravenous Solution 10 MG/10ML Tier 3 x ANTIMYASTHENIC/CHOLINERGIC AGENTS Neostigmine Methylsulfate Bloxiverz Intravenous Solution 5 MG/10ML Tier 3 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Ibandronate Sodium Boniva Oral Tablet 150 MG Tier 3 x TOXOIDS Tetanus Toxoid‐Diphtheria‐Acellular Pertussis Adsorb (Tdap) Boostrix Intramuscular Suspension 5‐2.5‐18.5 Tier 3 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Bosutinib Bosulif Oral Tablet 100 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Bosutinib Bosulif Oral Tablet 500 MG Tier 2 x x BIOLOGICALS MISC Botrytis Botrytis Subcutaneous Solution 20000 PNU/ML Tier 3 x DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur BP 10‐1 External Emulsion 10‐1 % Tier 1 DERMATOLOGICALS Sulfacetamide Sodium‐Sulfur in Urea Vehicle BP Cleansing Wash External Emulsion 10‐4 % Tier 3 x HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

DERMATOLOGICALS Benzoyl Peroxide BP Foam External Foam 5.3 % Tier 1 DERMATOLOGICALS Benzoyl Peroxide BP Foam External Foam 9.8 % Tier 1 DERMATOLOGICALS Benzoyl Peroxide BP Foaming Wash External Liquid 10 % Tier 1 MULTIVITAMINS Prenatal w/ Calcium Carbonate‐Vit B6‐Vit B12‐Folic Acid BP FoliNatal Plus B Oral Tablet 1 MG Tier 3 MULTIVITAMINS Prenatal without A Vit w/ Fe Fumarate‐Folic Acid BP MultiNatal Plus Oral Tablet 30‐1 MG Tier 3 MULTIVITAMINS Prenatal without A Vit w/ Fe Fumarate‐Folic Acid BP MultiNatal Plus Oral Tablet Chewable 40‐1 MG Tier 3 HEMATOPOIETIC AGENTS Folic Acid‐Vitamin B6‐Vitamin B12‐Omega 3 Acids‐Phytosterols BP Vit 3 Oral Capsule 1 MG Tier 3 DERMATOLOGICALS Benzoyl Peroxide BP Wash External Liquid 2.5 % Tier 1 DERMATOLOGICALS Benzoyl Peroxide BP Wash External Liquid 7 % Tier 1 MULTIVITAMINS B‐Complex w/ C & Folic Acid B‐Plex Oral Tablet Tier 1 MULTIVITAMINS Multiple Vitamins w/ Minerals B‐Plex Plus Oral Tablet Tier 1 DERMATOLOGICALS Benzoyl Peroxide BPO External Gel 4 % Tier 3 DERMATOLOGICALS Benzoyl Peroxide BPO External Gel 8 % Tier 3 DERMATOLOGICALS Benzoyl Peroxide BPO Foaming Cloths External Miscellaneous 6 % Tier 1 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Urofollitropin Purified Bravelle Injection Solution Reconstituted 75 UNIT Tier 3 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers BreatheRite Coll Spacer Adult Miscellaneous Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers BreatheRite Coll Spacer Child Miscellaneous Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers BreatheRite Coll Spacer Infant Miscellaneous Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers BreatheRite Miscellaneous Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers BreatheRite Rigid Spacer/Mask Miscellaneous Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers BreatheRite Spacer Neonate Miscellaneous Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers BreatheRite Spacer Small Child Miscellaneous Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers BreatheRite/Large Mask Miscellaneous Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers BreatheRite/Medium Mask Miscellaneous Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers BreatheRite/Small Mask Miscellaneous Tier 2 x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Fluticasone Furoate‐Vilanterol Breo Ellipta Inhalation Aerosol Powder Breath Activated 100‐25 MCG/INH Tier 2 xx ANTIASTHMATIC AND BRONCHODILATOR AGENTS Fluticasone Furoate‐Vilanterol Breo Ellipta Inhalation Aerosol Powder Breath Activated 200‐25 MCG/INH Tier 2 xx BETA BLOCKERS Esmolol HCl Brevibloc Intravenous Solution 10 MG/ML Tier 3 x CONTRACEPTIVES Norethindrone & Eth Estradiol Brevicon (28) Oral Tablet 0.5‐35 MG‐MCG Tier 3 GENERAL ANESTHETICS Methohexital Sodium Brevital Sodium Injection Solution Reconstituted 500 MG Tier 3 x ANTIDOTES Sugammadex Sodium Bridion Intravenous Solution 200 MG/2ML Tier 3 x ANTIDOTES Sugammadex Sodium Bridion Intravenous Solution 500 MG/5ML Tier 3 x CONTRACEPTIVES Norethindrone & Eth Estradiol Briellyn Oral Tablet 0.4‐35 MG‐MCG Tier 1 HEMATOLOGICAL AGENTS ‐ MISC. Ticagrelor Brilinta Oral Tablet 60 MG Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Ticagrelor Brilinta Oral Tablet 90 MG Tier 2 x OPHTHALMIC AGENTS Brimonidine Tartrate Brimonidine Tartrate Ophthalmic Solution 0.15 % Tier 1 OPHTHALMIC AGENTS Brimonidine Tartrate Brimonidine Tartrate Ophthalmic Solution 0.2 % Tier 1 ANTIDEPRESSANTS Vortioxetine HBr Brintellix Oral Tablet 10 MG Tier 3 xx ANTIDEPRESSANTS Vortioxetine HBr Brintellix Oral Tablet 20 MG Tier 3 xx ANTIDEPRESSANTS Vortioxetine HBr Brintellix Oral Tablet 5 MG Tier 3 xx PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Paroxetine Mesylate (Vasomotor) Brisdelle Oral Capsule 7.5 MG Tier 3 x ASSORTED CLASSES Bromelains Powder Tier 3 COUGH/COLD/ALLERGY Pseudoephed‐Bromphen‐DM Bromfed DM Oral Syrup 30‐2‐10 MG/5ML Tier 1 OPHTHALMIC AGENTS Bromfenac Sodium (Ophth) Bromfenac Sodium (Once‐Daily) Ophthalmic Solution 0.09 % Tier 1 OPHTHALMIC AGENTS Bromfenac Sodium (Ophth) Bromfenac Sodium Ophthalmic Solution 0.09 % Tier 3 ANTIPARKINSON AGENTS Bromocriptine Mesylate Bromocriptine Mesylate Oral Capsule 5 MG Tier 1 ANTIPARKINSON AGENTS Bromocriptine Mesylate Bromocriptine Mesylate Oral Tablet 2.5 MG Tier 1 ANTIHISTAMINES Brompheniramine Maleate Brompheniramine Maleate Powder Tier 3 ANTIHISTAMINES Brompheniramine Tannate Brompheniramine Tannate Oral Tablet Chewable 12 MG Tier 3 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Arformoterol Tartrate Brovana Inhalation Nebulization Solution 15 MCG/2ML Tier 3 x OPHTHALMIC AGENTS Ophthalmic Irrigation Solution ‐ Intraocular BSS Intraocular Solution Tier 1 OPHTHALMIC AGENTS Ophthalmic Irrigation Solution ‐ Intraocular BSS Plus Intraocular Solution Tier 3 CORTICOSTEROIDS Budesonide Budesonide ER Oral Capsule Extended Release 24 Hour 3 MG Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Budesonide (Inhalation) Budesonide Inhalation Suspension 0.25 MG/2ML Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Budesonide (Inhalation) Budesonide Inhalation Suspension 0.5 MG/2ML Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Budesonide (Inhalation) Budesonide Inhalation Suspension 1 MG/2ML Tier 1 NASAL AGENTS ‐ SYSTEMIC AND TOPICAL Budesonide (Nasal) Budesonide Nasal Suspension 32 MCG/ACT Tier 1 x MEDICAL DEVICES AND SUPPLIES Lancets Bullseye Mini Safety Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Bullseye Safety Lancets Miscellaneous Tier 2 DIURETICS Bumetanide Injection Solution 0.25 MG/ML Tier 1 x DIURETICS Bumetanide Bumetanide Oral Tablet 0.5 MG Tier 1 DIURETICS Bumetanide Bumetanide Oral Tablet 1 MG Tier 1 DIURETICS Bumetanide Bumetanide Oral Tablet 2 MG Tier 1 DIURETICS Bumetanide Bumex Oral Tablet 0.5 MG Tier 3 DIURETICS Bumetanide Bumex Oral Tablet 1 MG Tier 3 DIURETICS Bumetanide Bumex Oral Tablet 2 MG Tier 3 HEMATOLOGICAL AGENTS ‐ MISC. Albumin, Human Buminate Intravenous Solution 5 % Tier 1 x ANALGESICS ‐ NonNarcotic Butalbital‐Acetaminophen Bupap Oral Tablet 50‐300 MG Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Sodium Phenylbutyrate Buphenyl Oral Powder 3 GM/TSP Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Sodium Phenylbutyrate Buphenyl Oral Tablet 500 MG Tier 3 LOCAL ANESTHETICS‐Parenteral Bupivacaine HCl Bupivacaine HCl (PF) Injection Solution 0.25 % Tier 1 x LOCAL ANESTHETICS‐Parenteral Bupivacaine HCl Bupivacaine HCl (PF) Injection Solution 0.5 % Tier 1 x LOCAL ANESTHETICS‐Parenteral Bupivacaine HCl Bupivacaine HCl (PF) Injection Solution 0.75 % Tier 1 x LOCAL ANESTHETICS‐Parenteral Bupivacaine HCl Bupivacaine HCl Injection Solution 0.25 % Tier 1 x LOCAL ANESTHETICS‐Parenteral Bupivacaine HCl Bupivacaine HCl Injection Solution 0.5 % Tier 1 x LOCAL ANESTHETICS‐Parenteral Bupivacaine HCl Bupivacaine HCl Powder Tier 3 LOCAL ANESTHETICS‐Parenteral Bupivacaine w/ Epinephrine Bupivacaine‐Epinephrine (PF) Injection Solution 0.25% ‐1:200000 Tier 1 x LOCAL ANESTHETICS‐Parenteral Bupivacaine w/ Epinephrine Bupivacaine‐Epinephrine (PF) Injection Solution 0.5% ‐1:200000 Tier 1 x ANALGESICS ‐ OPIOID Buprenorphine HCl Buprenorphine HCl Injection Solution 0.3 MG/ML Tier 1 x ANALGESICS ‐ OPIOID Buprenorphine HCl Buprenorphine HCl Sublingual Tablet Sublingual 2 MG Tier 1 ANALGESICS ‐ OPIOID Buprenorphine HCl Buprenorphine HCl Sublingual Tablet Sublingual 8 MG Tier 1 ANALGESICS ‐ OPIOID Buprenorphine HCl‐Naloxone HCl Dihydrate Buprenorphine HCl‐Naloxone HCl Sublingual Tablet Sublingual 2‐0.5 MG Tier 1 x ANALGESICS ‐ OPIOID Buprenorphine HCl‐Naloxone HCl Dihydrate Buprenorphine HCl‐Naloxone HCl Sublingual Tablet Sublingual 8‐2 MG Tier 1 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Bupropion HCl ( Deterrent) Buproban Oral Tablet Extended Release 12 Hour 150 MG Tier 1 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Bupropion HCl (Smoking Deterrent) BuPROPion HCl ER (Smoking Det) Oral Tablet Extended Release 12 Hour 150 MG Tier 1 ANTIDEPRESSANTS Bupropion HCl BuPROPion HCl ER (SR) Oral Tablet Extended Release 12 Hour 100 MG Tier 1 ANTIDEPRESSANTS Bupropion HCl BuPROPion HCl ER (SR) Oral Tablet Extended Release 12 Hour 150 MG Tier 1 ANTIDEPRESSANTS Bupropion HCl BuPROPion HCl ER (SR) Oral Tablet Extended Release 12 Hour 200 MG Tier 1 ANTIDEPRESSANTS Bupropion HCl BuPROPion HCl ER (XL) Oral Tablet Extended Release 24 Hour 150 MG Tier 1 ANTIDEPRESSANTS Bupropion HCl BuPROPion HCl ER (XL) Oral Tablet Extended Release 24 Hour 300 MG Tier 1 ANTIDEPRESSANTS Bupropion HCl BuPROPion HCl Oral Tablet 100 MG Tier 1 ANTIDEPRESSANTS Bupropion HCl BuPROPion HCl Oral Tablet 75 MG Tier 1 ANTIANXIETY AGENTS Buspirone HCl BusPIRone HCl Oral Tablet 10 MG Tier 1 ANTIANXIETY AGENTS Buspirone HCl BusPIRone HCl Oral Tablet 15 MG Tier 1 ANTIANXIETY AGENTS Buspirone HCl BusPIRone HCl Oral Tablet 30 MG Tier 1 ANTIANXIETY AGENTS Buspirone HCl BusPIRone HCl Oral Tablet 5 MG Tier 1 ANTIANXIETY AGENTS Buspirone HCl BusPIRone HCl Oral Tablet 7.5 MG Tier 1 ANALGESICS ‐ NonNarcotic Butalbital‐Acetaminophen Butalbital‐Acetaminophen Oral Tablet 50‐325 MG Tier 1 ANALGESICS ‐ OPIOID Butalbital‐Acetaminophen‐Caffeine w/ Codeine Butalbital‐APAP‐Caff‐Cod Oral Capsule 50‐300‐40‐30 MG Tier 1 ANALGESICS ‐ OPIOID Butalbital‐Acetaminophen‐Caffeine w/ Codeine Butalbital‐APAP‐Caff‐Cod Oral Capsule 50‐325‐40‐30 MG Tier 1 ANALGESICS ‐ NonNarcotic Butalbital‐Acetaminophen‐Caffeine Butalbital‐APAP‐Caffeine Oral Capsule 50‐300‐40 MG Tier 1 ANALGESICS ‐ NonNarcotic Butalbital‐Acetaminophen‐Caffeine Butalbital‐APAP‐Caffeine Oral Capsule 50‐325‐40 MG Tier 1 ANALGESICS ‐ NonNarcotic Butalbital‐Acetaminophen‐Caffeine Butalbital‐APAP‐Caffeine Oral Tablet 50‐325‐40 MG Tier 1 ANALGESICS ‐ OPIOID Butalbital‐Aspirin‐Caffeine w/Cod Butalbital‐ASA‐Caff‐Codeine Oral Capsule 50‐325‐40‐30 MG Tier 1 ANALGESICS ‐ NonNarcotic Butalbital‐Aspirin‐Caffeine Butalbital‐ASA‐Caffeine Oral Capsule 50‐325‐40 MG Tier 1 ANALGESICS ‐ NonNarcotic Butalbital‐Aspirin‐Caffeine Butalbital‐Aspirin‐Caffeine Oral Capsule 50‐325‐40 MG Tier 1 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Butabarbital Sodium Butisol Sodium Oral Tablet 30 MG Tier 3 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Butabarbital Sodium Butisol Sodium Oral Tablet 50 MG Tier 3 ANALGESICS ‐ OPIOID Butorphanol Tartrate Butorphanol Tartrate Injection Solution 1 MG/ML Tier 1 x x ANALGESICS ‐ OPIOID Butorphanol Tartrate Butorphanol Tartrate Injection Solution 2 MG/ML Tier 1 x x ANALGESICS ‐ OPIOID Butorphanol Tartrate Butorphanol Tartrate Nasal Solution 10 MG/ML Tier 1 x x ANALGESICS ‐ OPIOID Buprenorphine Butrans Transdermal Patch Weekly 10 MCG/HR Tier 3 x x HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ANALGESICS ‐ OPIOID Buprenorphine Butrans Transdermal Patch Weekly 15 MCG/HR Tier 3 x x ANALGESICS ‐ OPIOID Buprenorphine Butrans Transdermal Patch Weekly 20 MCG/HR Tier 3 x x ANALGESICS ‐ OPIOID Buprenorphine Butrans Transdermal Patch Weekly 5 MCG/HR Tier 3 x x ANALGESICS ‐ OPIOID Buprenorphine Butrans Transdermal Patch Weekly 7.5 MCG/HR Tier 3 x x CHEMICALS Butylated Hydroxytoluene Butylated Hydroxytoluene Granules Tier 3 CHEMICALS Butylated Hydroxytoluene Butylated Hydroxytoluene Powder Tier 3 ANTIDIABETICS Exenatide Bydureon Subcutaneous Pen‐injector 2 MG Tier 2 x ANTIDIABETICS Exenatide Bydureon Subcutaneous Suspension Reconstituted 2 MG Tier 2 x ANTIDIABETICS Exenatide Byetta 10 MCG Pen Subcutaneous Solution Pen‐injector 10 MCG/0.04ML Tier 2 x ANTIDIABETICS Exenatide Byetta 5 MCG Pen Subcutaneous Solution Pen‐injector 5 MCG/0.02ML Tier 2 x BETA BLOCKERS Nebivolol HCl Bystolic Oral Tablet 10 MG Tier 2 x BETA BLOCKERS Nebivolol HCl Bystolic Oral Tablet 2.5 MG Tier 2 x BETA BLOCKERS Nebivolol HCl Bystolic Oral Tablet 20 MG Tier 2 x BETA BLOCKERS Nebivolol HCl Bystolic Oral Tablet 5 MG Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Cabergoline Cabergoline Oral Tablet 0.5 MG Tier 1 CARDIOVASCULAR AGENTS ‐ MISC. Amlodipine Besylate‐Atorvastatin Calcium Caduet Oral Tablet 10‐10 MG Tier 3 CARDIOVASCULAR AGENTS ‐ MISC. Amlodipine Besylate‐Atorvastatin Calcium Caduet Oral Tablet 10‐20 MG Tier 3 CARDIOVASCULAR AGENTS ‐ MISC. Amlodipine Besylate‐Atorvastatin Calcium Caduet Oral Tablet 10‐40 MG Tier 3 CARDIOVASCULAR AGENTS ‐ MISC. Amlodipine Besylate‐Atorvastatin Calcium Caduet Oral Tablet 10‐80 MG Tier 3 CARDIOVASCULAR AGENTS ‐ MISC. Amlodipine Besylate‐Atorvastatin Calcium Caduet Oral Tablet 2.5‐10 MG Tier 3 CARDIOVASCULAR AGENTS ‐ MISC. Amlodipine Besylate‐Atorvastatin Calcium Caduet Oral Tablet 2.5‐20 MG Tier 3 CARDIOVASCULAR AGENTS ‐ MISC. Amlodipine Besylate‐Atorvastatin Calcium Caduet Oral Tablet 2.5‐40 MG Tier 3 CARDIOVASCULAR AGENTS ‐ MISC. Amlodipine Besylate‐Atorvastatin Calcium Caduet Oral Tablet 5‐10 MG Tier 3 CARDIOVASCULAR AGENTS ‐ MISC. Amlodipine Besylate‐Atorvastatin Calcium Caduet Oral Tablet 5‐20 MG Tier 3 CARDIOVASCULAR AGENTS ‐ MISC. Amlodipine Besylate‐Atorvastatin Calcium Caduet Oral Tablet 5‐40 MG Tier 3 CARDIOVASCULAR AGENTS ‐ MISC. Amlodipine Besylate‐Atorvastatin Calcium Caduet Oral Tablet 5‐80 MG Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Caffeine Citrate Cafcit Intravenous Solution 60 MG/3ML Tier 3 x MIGRAINE PRODUCTS w/ Caffeine Cafergot Oral Tablet 1‐100 MG Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Caffeine Caffeine Anhydrous Powder Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Caffeine Citrate Caffeine Citrate Intravenous Solution 60 MG/3ML Tier 1 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Caffeine Citrate Caffeine Citrate Oral Solution 20 MG/ML Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Caffeine Citrate Caffeine Citrate Oral Solution 60 MG/3ML Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Caffeine Citrate Caffeine Citrated Powder Tier 3 DERMATOLOGICALS Calamine Calamine Powder Tier 3 CALCIUM CHANNEL BLOCKERS HCl Calan Oral Tablet 120 MG Tier 3 CALCIUM CHANNEL BLOCKERS Verapamil HCl Calan Oral Tablet 80 MG Tier 3 CALCIUM CHANNEL BLOCKERS Verapamil HCl Calan SR Oral Tablet Extended Release 120 MG Tier 3 CALCIUM CHANNEL BLOCKERS Verapamil HCl Calan SR Oral Tablet Extended Release 180 MG Tier 3 CALCIUM CHANNEL BLOCKERS Verapamil HCl Calan SR Oral Tablet Extended Release 240 MG Tier 3 MINERALS & ELECTROLYTES Calcium Carbonate‐Folic Acid‐Vit D‐B6‐B12‐Boron‐ CalciFol Oral Wafer 1342‐1.6 MG Tier 3 DERMATOLOGICALS Calcipotriene Calcipotriene External Cream 0.005 % Tier 1 DERMATOLOGICALS Calcipotriene Calcipotriene External Ointment 0.005 % Tier 1 DERMATOLOGICALS Calcipotriene Calcipotriene External Solution 0.005 % Tier 1 DERMATOLOGICALS Calcipotriene‐Betamethasone Dipropionate Calcipotriene‐Betameth Diprop External Ointment 0.005‐0.064 % Tier 1 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. (Salmon) Calcitonin (Salmon) Nasal Solution 200 UNIT/ACT Tier 1 DERMATOLOGICALS Calcipotriene Calcitrene External Ointment 0.005 % Tier 1 DERMATOLOGICALS Calcitriol (Topical) Calcitriol External Ointment 3 MCG/GM Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Calcitriol Calcitriol Intravenous Solution 1 MCG/ML Tier 1 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Calcitriol Calcitriol Oral Capsule 0.25 MCG Tier 1 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Calcitriol Calcitriol Oral Capsule 0.5 MCG Tier 1 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Calcitriol Calcitriol Oral Solution 1 MCG/ML Tier 1 GASTROINTESTINAL AGENTS ‐ MISC. Calcium Acetate (Phosphate Binder) Calcium Acetate (Phos Binder) Oral Capsule 667 MG Tier 1 GASTROINTESTINAL AGENTS ‐ MISC. Calcium Acetate (Phosphate Binder) Calcium Acetate (Phos Binder) Oral Tablet 667 MG Tier 1 MINERALS & ELECTROLYTES Calcium Carbonate Calcium Carbonate Powder Tier 3 MINERALS & ELECTROLYTES Calcium Chloride (Dihydrate) Calcium Chloride Anhydrous Granules Tier 3 MINERALS & ELECTROLYTES Calcium Chloride (Dihydrate) Calcium Chloride Dihydrate Granules Tier 3 MINERALS & ELECTROLYTES Calcium Chloride (Dihydrate) Calcium Chloride Dihydrate Powder Tier 3 MINERALS & ELECTROLYTES Calcium Chloride (Dihydrate) Calcium Chloride Intravenous Solution 10 % Tier 1 x MINERALS & ELECTROLYTES Calcium Gluconate Calcium Gluconate Anhydrous Powder Tier 3 MINERALS & ELECTROLYTES Calcium Gluconate Calcium Gluconate Intravenous Solution 10 % Tier 1 x MINERALS & ELECTROLYTES Calcium Gluconate Calcium Gluconate Monohydrate Powder Tier 3 MINERALS & ELECTROLYTES Calcium Lactate Pentahydrate Calcium Lactate Pentahydrate Powder Tier 3 VITAMINS Calcium Pantothenate Calcium Pantothenate Powder Tier 3 MINERALS & ELECTROLYTES Calcium Phosphate, Dibasic Calcium Phosphate Dibasic Powder Tier 3 MINERALS & ELECTROLYTES Calcium Phosphate, Tribasic Calcium Phosphate Tribasic Powder Tier 3 MULTIVITAMINS Prenatal without Vit A w/ Fe Fum‐FA‐Omega Fatty Acids Calcium PNV Oral Capsule 28‐1‐250 MG Tier 2 CHEMICALS Calcium Propionate Calcium Propionate Powder Tier 3 MINERALS & ELECTROLYTES Calcium Carbonate‐Folic Acid‐Vit D‐B6‐B12‐Boron‐Magnesium Calcium‐Folic Acid Plus D Oral Wafer 1342‐1 MG Tier 3 CONTRACEPTIVES Norethindrone (Contraceptive) Camila Oral Tablet 0.35 MG Tier 1 CONTRACEPTIVES Levonorgestrel‐Ethinyl Estradiol (91‐Day) Camrese Lo Oral Tablet 0.1‐0.02 & 0.01 MG Tier 1 CONTRACEPTIVES Levonorgestrel‐Ethinyl Estradiol (91‐Day) Camrese Oral Tablet 0.15‐0.03 &0.01 MG Tier 1 GASTROINTESTINAL AGENTS ‐ MISC. Mesalamine Canasa Rectal Suppository 1000 MG Tier 2 x ANTIHYPERTENSIVES Candesartan Cilexetil Candesartan Cilexetil Oral Tablet 16 MG Tier 1 x ANTIHYPERTENSIVES Candesartan Cilexetil Candesartan Cilexetil Oral Tablet 32 MG Tier 1 x ANTIHYPERTENSIVES Candesartan Cilexetil Candesartan Cilexetil Oral Tablet 4 MG Tier 1 x ANTIHYPERTENSIVES Candesartan Cilexetil Candesartan Cilexetil Oral Tablet 8 MG Tier 1 x ANTIHYPERTENSIVES Candesartan Cilexetil‐Hydrochlorothiazide Candesartan Cilexetil‐HCTZ Oral Tablet 16‐12.5 MG Tier 1 x ANTIHYPERTENSIVES Candesartan Cilexetil‐Hydrochlorothiazide Candesartan Cilexetil‐HCTZ Oral Tablet 32‐12.5 MG Tier 1 x ANTIHYPERTENSIVES Candesartan Cilexetil‐Hydrochlorothiazide Candesartan Cilexetil‐HCTZ Oral Tablet 32‐25 MG Tier 1 x DERMATOLOGICALS Cantharidin Cantharidin Powder Tier 3 ULCER DRUGS Mepenzolate Bromide Cantil Oral Tablet 25 MG Tier 3 ANALGESICS ‐ NonNarcotic Butalbital‐Acetaminophen‐Caffeine Capacet Oral Capsule 50‐325‐40 MG Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Capecitabine Capecitabine Oral Tablet 150 MG Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Capecitabine Capecitabine Oral Tablet 500 MG Tier 1 x DERMATOLOGICALS Fluocinolone Acetonide Capex External Shampoo 0.01 % Tier 3 ANALGESICS ‐ OPIOID Acetaminophen w/ Codeine Capital/Codeine Oral Suspension 120‐12 MG/5ML Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Vandetanib Caprelsa Oral Tablet 100 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Vandetanib Caprelsa Oral Tablet 300 MG Tier 2 x x DERMATOLOGICALS Capsaicin Capsaicin Powder Tier 3 x DERMATOLOGICALS Capsaicin Capsaicin Powder 95 % Tier 3 x PHARMACEUTICAL ADJUVANTS Non Capsules (Empty) Capsule 0 Clear Veggie Capsule Tier 3 PHARMACEUTICAL ADJUVANTS Non Gelatin Capsules (Empty) Capsule Coni‐Snap #0 Clear Capsule Tier 3 PHARMACEUTICAL ADJUVANTS Non Gelatin Capsules (Empty) Capsule Coni‐Snap #1 Veggie Capsule Tier 3 PHARMACEUTICAL ADJUVANTS Non Gelatin Capsules (Empty) Capsule Coni‐Snap #3 Clear Capsule Tier 3 ANTIHYPERTENSIVES Captopril Captopril Oral Tablet 100 MG Tier 1 ANTIHYPERTENSIVES Captopril Captopril Oral Tablet 12.5 MG Tier 1 ANTIHYPERTENSIVES Captopril Captopril Oral Tablet 25 MG Tier 1 ANTIHYPERTENSIVES Captopril Captopril Oral Tablet 50 MG Tier 1 ANTIHYPERTENSIVES Captopril & Hydrochlorothiazide Captopril‐Hydrochlorothiazide Oral Tablet 25‐15 MG Tier 2 ANTIHYPERTENSIVES Captopril & Hydrochlorothiazide Captopril‐Hydrochlorothiazide Oral Tablet 25‐25 MG Tier 2 ANTIHYPERTENSIVES Captopril & Hydrochlorothiazide Captopril‐Hydrochlorothiazide Oral Tablet 50‐15 MG Tier 2 ANTIHYPERTENSIVES Captopril & Hydrochlorothiazide Captopril‐Hydrochlorothiazide Oral Tablet 50‐25 MG Tier 2 DERMATOLOGICALS Fluorouracil (Topical) Carac External Cream 0.5 % Tier 3 ULCER DRUGS Sucralfate Carafate Oral Suspension 1 GM/10ML Tier 2 ULCER DRUGS Sucralfate Carafate Oral Tablet 1 GM Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Carglumic Acid Carbaglu Oral Tablet 200 MG Tier 2 x ANTICONVULSANTS Carbamazepine CarBAMazepine ER Oral Capsule Extended Release 12 Hour 100 MG Tier 1 ANTICONVULSANTS Carbamazepine CarBAMazepine ER Oral Capsule Extended Release 12 Hour 200 MG Tier 1 ANTICONVULSANTS Carbamazepine CarBAMazepine ER Oral Capsule Extended Release 12 Hour 300 MG Tier 1 ANTICONVULSANTS Carbamazepine CarBAMazepine ER Oral Tablet Extended Release 12 Hour 200 MG Tier 1 ANTICONVULSANTS Carbamazepine CarBAMazepine ER Oral Tablet Extended Release 12 Hour 400 MG Tier 1 ANTICONVULSANTS Carbamazepine CarBAMazepine Oral Suspension 100 MG/5ML Tier 1 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ANTICONVULSANTS Carbamazepine CarBAMazepine Oral Tablet 200 MG Tier 1 ANTICONVULSANTS Carbamazepine CarBAMazepine Oral Tablet Chewable 100 MG Tier 1 ANTICONVULSANTS Carbamazepine CarBAMazepine Powder Tier 3 COUGH/COLD/ALLERGY Phenylephrine‐Chlorpheniramine‐Carbetapentane Carbaphen 12 Oral Liquid 10‐4‐27.5 MG/5ML Tier 3 COUGH/COLD/ALLERGY Phenylephrine‐Chlorpheniramine‐Carbetapentane Carbaphen 12 Ped Oral Suspension 2.5‐1.25‐7.5 MG/ML Tier 3 ANTICONVULSANTS Carbamazepine Carbatrol Oral Capsule Extended Release 12 Hour 100 MG Tier 3 ANTICONVULSANTS Carbamazepine Carbatrol Oral Capsule Extended Release 12 Hour 200 MG Tier 3 ANTICONVULSANTS Carbamazepine Carbatrol Oral Capsule Extended Release 12 Hour 300 MG Tier 3 ANTIPARKINSON AGENTS Carbidopa Carbidopa Oral Tablet 25 MG Tier 1 ANTIPARKINSON AGENTS Carbidopa‐Levodopa Carbidopa‐Levodopa ER Oral Tablet Extended Release 25‐100 MG Tier 1 x ANTIPARKINSON AGENTS Carbidopa‐Levodopa Carbidopa‐Levodopa ER Oral Tablet Extended Release 50‐200 MG Tier 1 x ANTIPARKINSON AGENTS Carbidopa‐Levodopa Carbidopa‐Levodopa Oral Tablet 10‐100 MG Tier 1 x ANTIPARKINSON AGENTS Carbidopa‐Levodopa Carbidopa‐Levodopa Oral Tablet 25‐100 MG Tier 1 x ANTIPARKINSON AGENTS Carbidopa‐Levodopa Carbidopa‐Levodopa Oral Tablet 25‐250 MG Tier 1 x ANTIPARKINSON AGENTS Carbidopa‐Levodopa Carbidopa‐Levodopa Oral Tablet Dispersible 10‐100 MG Tier 1 x ANTIPARKINSON AGENTS Carbidopa‐Levodopa Carbidopa‐Levodopa Oral Tablet Dispersible 25‐100 MG Tier 1 x ANTIPARKINSON AGENTS Carbidopa‐Levodopa Carbidopa‐Levodopa Oral Tablet Dispersible 25‐250 MG Tier 1 x ANTIPARKINSON AGENTS Carbidopa‐Levodopa‐Entacapone Carbidopa‐Levodopa‐Entacapone Oral Tablet 12.5‐50‐200 MG Tier 3 x ANTIPARKINSON AGENTS Carbidopa‐Levodopa‐Entacapone Carbidopa‐Levodopa‐Entacapone Oral Tablet 18.75‐75‐200 MG Tier 3 x ANTIPARKINSON AGENTS Carbidopa‐Levodopa‐Entacapone Carbidopa‐Levodopa‐Entacapone Oral Tablet 25‐100‐200 MG Tier 3 x ANTIPARKINSON AGENTS Carbidopa‐Levodopa‐Entacapone Carbidopa‐Levodopa‐Entacapone Oral Tablet 31.25‐125‐200 MG Tier 3 x ANTIPARKINSON AGENTS Carbidopa‐Levodopa‐Entacapone Carbidopa‐Levodopa‐Entacapone Oral Tablet 37.5‐150‐200 MG Tier 3 x ANTIPARKINSON AGENTS Carbidopa‐Levodopa‐Entacapone Carbidopa‐Levodopa‐Entacapone Oral Tablet 50‐200‐200 MG Tier 3 x ANTIHISTAMINES Carbinoxamine Maleate Carbinoxamine Maleate Oral Solution 4 MG/5ML Tier 1 ANTIHISTAMINES Carbinoxamine Maleate Carbinoxamine Maleate Oral Tablet 4 MG Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Carboplatin CARBOplatin Intravenous Solution 150 MG/15ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Carboplatin CARBOplatin Intravenous Solution 450 MG/45ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Carboplatin CARBOplatin Intravenous Solution 50 MG/5ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Carboplatin CARBOplatin Intravenous Solution 600 MG/60ML Tier 1 x CHEMICALS Carbomer Carbopol 940 NF Powder Tier 3 CHEMICALS Carbomer Carbopol 940 Powder Tier 3 CALCIUM CHANNEL BLOCKERS HCl in Sodium Chloride Cardene IV Intravenous Solution 20‐0.86 MG/200ML‐% Tier 3 x CALCIUM CHANNEL BLOCKERS Nicardipine HCl in Sodium Chloride Cardene IV Intravenous Solution 40‐0.83 MG/200ML‐% Tier 3 x NUTRIENTS DHA‐EPA‐Vit B6‐Vit B12‐Folic Acid CardioVid Plus Oral Capsule Tier 3 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Coated Beads Cardizem CD Oral Capsule Extended Release 24 Hour 120 MG Tier 3 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Coated Beads Cardizem CD Oral Capsule Extended Release 24 Hour 180 MG Tier 3 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Coated Beads Cardizem CD Oral Capsule Extended Release 24 Hour 240 MG Tier 3 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Coated Beads Cardizem CD Oral Capsule Extended Release 24 Hour 300 MG Tier 3 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Coated Beads Cardizem CD Oral Capsule Extended Release 24 Hour 360 MG Tier 3 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Coated Beads Cardizem LA Oral Tablet Extended Release 24 Hour 120 MG Tier 3 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Coated Beads Cardizem LA Oral Tablet Extended Release 24 Hour 180 MG Tier 3 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Coated Beads Cardizem LA Oral Tablet Extended Release 24 Hour 240 MG Tier 3 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Coated Beads Cardizem LA Oral Tablet Extended Release 24 Hour 300 MG Tier 3 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Coated Beads Cardizem LA Oral Tablet Extended Release 24 Hour 360 MG Tier 3 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Coated Beads Cardizem LA Oral Tablet Extended Release 24 Hour 420 MG Tier 3 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Cardizem Oral Tablet 120 MG Tier 3 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Cardizem Oral Tablet 30 MG Tier 3 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Cardizem Oral Tablet 60 MG Tier 3 ANTIHYPERTENSIVES Doxazosin Mesylate Cardura Oral Tablet 1 MG Tier 3 ANTIHYPERTENSIVES Doxazosin Mesylate Cardura Oral Tablet 2 MG Tier 3 ANTIHYPERTENSIVES Doxazosin Mesylate Cardura Oral Tablet 4 MG Tier 3 ANTIHYPERTENSIVES Doxazosin Mesylate Cardura Oral Tablet 8 MG Tier 3 GENITOURINARY AGENTS ‐ MISCELLANEOUS Doxazosin Mesylate (BPH) Cardura XL Oral Tablet Extended Release 24 Hour 4 MG Tier 3 x GENITOURINARY AGENTS ‐ MISCELLANEOUS Doxazosin Mesylate (BPH) Cardura XL Oral Tablet Extended Release 24 Hour 8 MG Tier 3 x MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle CareFine Pen Needles Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle CareFine Pen Needles Miscellaneous 30G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle CareFine Pen Needles Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle CareFine Pen Needles Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle CareFine Pen Needles Miscellaneous 32G X 4 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle CareFine Pen Needles Miscellaneous 32G X 5 MM Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle CareFine Pen Needles Miscellaneous 32G X 6 MM Tier 3 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies CareOne Blood Glucose System Kit w/Device Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood CareOne Blood Glucose Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 CareOne Insulin Syringe Miscellaneous 30G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 CareOne Insulin Syringe Miscellaneous 30G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 CareOne Insulin Syringe Miscellaneous 30G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 CareOne Insulin Syringe Miscellaneous 31G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 CareOne Insulin Syringe Miscellaneous 31G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 CareOne Insulin Syringe Miscellaneous 31G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets CareOne Lancet Thin 23G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets CareOne Lancet Ultra Thin 28G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle CareOne Unifine Pentips Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle CareOne Unifine Pentips Miscellaneous 31G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle CareOne Unifine Pentips Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle CareOne Unifine Pentips Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle CareOne Unifine Pentips Miscellaneous 32G X 4 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle CareOne Unifine Pentips Plus Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle CareOne Unifine Pentips Plus Miscellaneous 31G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle CareOne Unifine Pentips Plus Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle CareOne Unifine Pentips Plus Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle CareOne Unifine Pentips Plus Miscellaneous 32G X 4 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Blood Glucose Calibration CareSens Control A In Vitro Solution Tier 3 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies CareSens N Glucose System Device Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood CareSens N Glucose Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies CareSens N Voice System Device Tier 3 MUSCULOSKELETAL THERAPY AGENTS Carisoprodol Oral Tablet 250 MG Tier 1 MUSCULOSKELETAL THERAPY AGENTS Carisoprodol Carisoprodol Oral Tablet 350 MG Tier 1 MUSCULOSKELETAL THERAPY AGENTS Carisoprodol Carisoprodol Powder Tier 3 MUSCULOSKELETAL THERAPY AGENTS Carisoprodol w/ Aspirin Carisoprodol‐Aspirin Oral Tablet 200‐325 MG Tier 1 MUSCULOSKELETAL THERAPY AGENTS Carisoprodol w/ Aspirin & Codeine Carisoprodol‐Aspirin‐Codeine Oral Tablet 200‐325‐16 MG Tier 1 CHEMICALS Carmine Carmine Powder Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Levocarnitine (Metabolic Modifiers) Carnitor Oral Solution 1 GM/10ML Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Levocarnitine (Metabolic Modifiers) Carnitor Oral Tablet 330 MG Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Levocarnitine (Metabolic Modifiers) Carnitor SF Oral Solution 1 GM/10ML Tier 3 OPHTHALMIC AGENTS Carteolol HCl (Ophth) Carteolol HCl Ophthalmic Solution 1 % Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Coated Beads Cartia XT Oral Capsule Extended Release 24 Hour 120 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Coated Beads Cartia XT Oral Capsule Extended Release 24 Hour 180 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Coated Beads Cartia XT Oral Capsule Extended Release 24 Hour 240 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Coated Beads Cartia XT Oral Capsule Extended Release 24 Hour 300 MG Tier 1 BETA BLOCKERS Carvedilol Carvedilol Oral Tablet 12.5 MG Tier 1 BETA BLOCKERS Carvedilol Carvedilol Oral Tablet 25 MG Tier 1 BETA BLOCKERS Carvedilol Carvedilol Oral Tablet 3.125 MG Tier 1 BETA BLOCKERS Carvedilol Carvedilol Oral Tablet 6.25 MG Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Bicalutamide Casodex Oral Tablet 50 MG Tier 3 BIOLOGICALS MISC Cat Hair Extract Cat Hair Extract Subcutaneous Solution 10000 BAU/ML Tier 3 x ANTIHYPERTENSIVES Clonidine HCl Catapres Oral Tablet 0.1 MG Tier 3 ANTIHYPERTENSIVES Clonidine HCl Catapres Oral Tablet 0.2 MG Tier 3 ANTIHYPERTENSIVES Clonidine HCl Catapres Oral Tablet 0.3 MG Tier 3 ANTIHYPERTENSIVES Clonidine HCl Catapres‐TTS‐1 Transdermal Patch Weekly 0.1 MG/24HR Tier 3 ANTIHYPERTENSIVES Clonidine HCl Catapres‐TTS‐2 Transdermal Patch Weekly 0.2 MG/24HR Tier 3 ANTIHYPERTENSIVES Clonidine HCl Catapres‐TTS‐3 Transdermal Patch Weekly 0.3 MG/24HR Tier 3 HEMATOLOGICAL AGENTS ‐ MISC. Alteplase Cathflo Activase Injection Solution Reconstituted 2 MG Tier 3 x HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

MOUTH/THROAT/DENTAL AGENTS Sodium Fluoride (Dental) Cavarest Dental Gel 1.1 % Tier 1 CARDIOVASCULAR AGENTS ‐ MISC. Alprostadil (Vasodilator) Caverject Impulse Intracavernosal Kit 10 MCG Tier 3 x x CARDIOVASCULAR AGENTS ‐ MISC. Alprostadil (Vasodilator) Caverject Impulse Intracavernosal Kit 20 MCG Tier 3 x x CARDIOVASCULAR AGENTS ‐ MISC. Alprostadil (Vasodilator) Caverject Intracavernosal Solution Reconstituted 20 MCG Tier 3 x x CARDIOVASCULAR AGENTS ‐ MISC. Alprostadil (Vasodilator) Caverject Intracavernosal Solution Reconstituted 40 MCG Tier 3 x x MOUTH/THROAT/DENTAL AGENTS Sodium Fluoride (Dental) CaviRinse Mouth/Throat Solution 0.2 % Tier 1 ANTI‐INFECTIVE AGENTS ‐ MISC. Aztreonam Cayston Inhalation Solution Reconstituted 75 MG Tier 2 x x CONTRACEPTIVES Desogestrel‐Ethinyl Estradiol (Triphasic) Caziant Oral Tablet 0.1/0.125/0.15 ‐0.025 MG Tier 1 CEPHALOSPORINS Ceftibuten Cedax Oral Capsule 400 MG Tier 3 CEPHALOSPORINS Ceftibuten Cedax Oral Suspension Reconstituted 180 MG/5ML Tier 3 CEPHALOSPORINS Ceftibuten Cedax Oral Suspension Reconstituted 90 MG/5ML Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Lomustine CeeNU Oral Capsule 10 MG Tier 2 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Lomustine CeeNU Oral Capsule 100 MG Tier 2 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Lomustine CeeNU Oral Capsule 40 MG Tier 2 x CEPHALOSPORINS Cefaclor Monohydrate Cefaclor ER Oral Tablet Extended Release 12 Hour 500 MG Tier 3 CEPHALOSPORINS Cefaclor Cefaclor Oral Capsule 250 MG Tier 1 CEPHALOSPORINS Cefaclor Cefaclor Oral Capsule 500 MG Tier 1 CEPHALOSPORINS Cefaclor Cefaclor Oral Suspension Reconstituted 125 MG/5ML Tier 3 CEPHALOSPORINS Cefaclor Cefaclor Oral Suspension Reconstituted 250 MG/5ML Tier 3 CEPHALOSPORINS Cefaclor Cefaclor Oral Suspension Reconstituted 375 MG/5ML Tier 3 CEPHALOSPORINS Cefadroxil Cefadroxil Oral Capsule 500 MG Tier 1 CEPHALOSPORINS Cefadroxil Cefadroxil Oral Suspension Reconstituted 250 MG/5ML Tier 1 CEPHALOSPORINS Cefadroxil Cefadroxil Oral Suspension Reconstituted 500 MG/5ML Tier 1 CEPHALOSPORINS Cefadroxil Cefadroxil Oral Tablet 1 GM Tier 1 CEPHALOSPORINS Cefazolin Sodium CeFAZolin Sodium Injection Solution Reconstituted 1 GM Tier 1 x CEPHALOSPORINS Cefazolin Sodium CeFAZolin Sodium Injection Solution Reconstituted 10 GM Tier 1 x CEPHALOSPORINS Cefazolin Sodium CeFAZolin Sodium Injection Solution Reconstituted 20 GM Tier 1 x CEPHALOSPORINS Cefazolin Sodium CeFAZolin Sodium Injection Solution Reconstituted 500 MG Tier 1 x CEPHALOSPORINS Cefdinir Cefdinir Oral Capsule 300 MG Tier 1 CEPHALOSPORINS Cefdinir Cefdinir Oral Suspension Reconstituted 125 MG/5ML Tier 1 CEPHALOSPORINS Cefdinir Cefdinir Oral Suspension Reconstituted 250 MG/5ML Tier 1 CEPHALOSPORINS Cefditoren Pivoxil Cefditoren Pivoxil Oral Tablet 200 MG Tier 3 CEPHALOSPORINS Cefditoren Pivoxil Cefditoren Pivoxil Oral Tablet 400 MG Tier 3 CEPHALOSPORINS Cefepime HCl Cefepime HCl Injection Solution Reconstituted 1 GM Tier 1 x CEPHALOSPORINS Cefepime HCl Cefepime HCl Injection Solution Reconstituted 2 GM Tier 1 x CEPHALOSPORINS Cefixime Cefixime Oral Suspension Reconstituted 100 MG/5ML Tier 1 CEPHALOSPORINS Cefixime Cefixime Oral Suspension Reconstituted 200 MG/5ML Tier 1 CEPHALOSPORINS Cefotaxime Sodium Cefotaxime Sodium Injection Solution Reconstituted 1 GM Tier 1 x CEPHALOSPORINS Cefotaxime Sodium Cefotaxime Sodium Injection Solution Reconstituted 2 GM Tier 1 x CEPHALOSPORINS Cefotaxime Sodium Cefotaxime Sodium Injection Solution Reconstituted 500 MG Tier 1 x CEPHALOSPORINS Cefoxitin Sodium CefOXitin Sodium Injection Solution Reconstituted 10 GM Tier 1 x CEPHALOSPORINS Cefoxitin Sodium CefOXitin Sodium Intravenous Solution Reconstituted 1 GM Tier 1 x CEPHALOSPORINS Cefoxitin Sodium CefOXitin Sodium Intravenous Solution Reconstituted 2 GM Tier 1 x CEPHALOSPORINS Cefpodoxime Proxetil Cefpodoxime Proxetil Oral Suspension Reconstituted 100 MG/5ML Tier 1 CEPHALOSPORINS Cefpodoxime Proxetil Cefpodoxime Proxetil Oral Suspension Reconstituted 50 MG/5ML Tier 1 CEPHALOSPORINS Cefpodoxime Proxetil Cefpodoxime Proxetil Oral Tablet 100 MG Tier 1 CEPHALOSPORINS Cefpodoxime Proxetil Cefpodoxime Proxetil Oral Tablet 200 MG Tier 1 CEPHALOSPORINS Cefprozil Cefprozil Oral Suspension Reconstituted 125 MG/5ML Tier 1 CEPHALOSPORINS Cefprozil Cefprozil Oral Suspension Reconstituted 250 MG/5ML Tier 1 CEPHALOSPORINS Cefprozil Cefprozil Oral Tablet 250 MG Tier 1 CEPHALOSPORINS Cefprozil Cefprozil Oral Tablet 500 MG Tier 1 CEPHALOSPORINS Ceftazidime CefTAZidime Injection Solution Reconstituted 1 GM Tier 1 x CEPHALOSPORINS Ceftazidime CefTAZidime Injection Solution Reconstituted 2 GM Tier 1 x CEPHALOSPORINS Ceftazidime CefTAZidime Injection Solution Reconstituted 6 GM Tier 1 x CHEMICALS Ceftazidime with Sodium Carbonate CefTAZidime with Sod Carbonate Powder Tier 3 CEPHALOSPORINS Ceftibuten Ceftibuten Oral Capsule 400 MG Tier 3 CEPHALOSPORINS Ceftibuten Ceftibuten Oral Suspension Reconstituted 180 MG/5ML Tier 3 CEPHALOSPORINS Cefuroxime Axetil Ceftin Oral Suspension Reconstituted 125 MG/5ML Tier 3 CEPHALOSPORINS Cefuroxime Axetil Ceftin Oral Suspension Reconstituted 250 MG/5ML Tier 3 CEPHALOSPORINS Cefuroxime Axetil Ceftin Oral Tablet 250 MG Tier 3 CEPHALOSPORINS Cefuroxime Axetil Ceftin Oral Tablet 500 MG Tier 3 CEPHALOSPORINS Ceftriaxone Sodium CefTRIAXone Sodium Injection Solution Reconstituted 1 GM Tier 1 x CEPHALOSPORINS Ceftriaxone Sodium CefTRIAXone Sodium Injection Solution Reconstituted 2 GM Tier 1 x CEPHALOSPORINS Ceftriaxone Sodium CefTRIAXone Sodium Injection Solution Reconstituted 250 MG Tier 1 x CEPHALOSPORINS Ceftriaxone Sodium CefTRIAXone Sodium Injection Solution Reconstituted 500 MG Tier 1 x CEPHALOSPORINS Ceftriaxone Sodium CefTRIAXone Sodium Intravenous Solution Reconstituted 1 GM Tier 1 x CEPHALOSPORINS Ceftriaxone Sodium CefTRIAXone Sodium Intravenous Solution Reconstituted 10 GM Tier 1 x CEPHALOSPORINS Ceftriaxone Sodium CefTRIAXone Sodium Intravenous Solution Reconstituted 2 GM Tier 1 x CEPHALOSPORINS Cefuroxime Axetil Cefuroxime Axetil Oral Tablet 250 MG Tier 1 CEPHALOSPORINS Cefuroxime Axetil Cefuroxime Axetil Oral Tablet 500 MG Tier 1 CEPHALOSPORINS Cefuroxime Sodium Cefuroxime Sodium Injection Solution Reconstituted 1.5 GM Tier 1 x CEPHALOSPORINS Cefuroxime Sodium Cefuroxime Sodium Injection Solution Reconstituted 7.5 GM Tier 1 x CEPHALOSPORINS Cefuroxime Sodium Cefuroxime Sodium Injection Solution Reconstituted 750 MG Tier 1 x ANALGESICS ‐ ANTI‐INFLAMMATORY Celecoxib CeleBREX Oral Capsule 100 MG Tier 3 x x ANALGESICS ‐ ANTI‐INFLAMMATORY Celecoxib CeleBREX Oral Capsule 200 MG Tier 3 x x ANALGESICS ‐ ANTI‐INFLAMMATORY Celecoxib CeleBREX Oral Capsule 400 MG Tier 3 x x ANALGESICS ‐ ANTI‐INFLAMMATORY Celecoxib CeleBREX Oral Capsule 50 MG Tier 3 x x ANALGESICS ‐ ANTI‐INFLAMMATORY Celecoxib Celecoxib Oral Capsule 100 MG Tier 1 x x ANALGESICS ‐ ANTI‐INFLAMMATORY Celecoxib Celecoxib Oral Capsule 200 MG Tier 1 x x ANALGESICS ‐ ANTI‐INFLAMMATORY Celecoxib Celecoxib Oral Capsule 400 MG Tier 1 x x ANALGESICS ‐ ANTI‐INFLAMMATORY Celecoxib Celecoxib Oral Capsule 50 MG Tier 1 x x CORTICOSTEROIDS Betamethasone Sod Phosphate & Acetate Celestone Soluspan Injection Suspension 6 (3‐3) MG/ML Tier 3 x ANTIDEPRESSANTS Citalopram Hydrobromide CeleXA Oral Tablet 10 MG Tier 3 x ANTIDEPRESSANTS Citalopram Hydrobromide CeleXA Oral Tablet 20 MG Tier 3 x ANTIDEPRESSANTS Citalopram Hydrobromide CeleXA Oral Tablet 40 MG Tier 3 x ASSORTED CLASSES Mycophenolate Mofetil CellCept Oral Capsule 250 MG Tier 2 x ASSORTED CLASSES Mycophenolate Mofetil CellCept Oral Suspension Reconstituted 200 MG/ML Tier 2 x ASSORTED CLASSES Mycophenolate Mofetil CellCept Oral Tablet 500 MG Tier 2 x ANTICONVULSANTS Methsuximide Celontin Oral Capsule 300 MG Tier 3 DERMATOLOGICALS Urea CEM‐Urea External Solution 45 % Tier 3 HEMATOPOIETIC AGENTS Folic Acid‐Vitamin B6‐Vitamin B12 CenFol Oral Tablet 2.3‐24.5‐2 MG Tier 3 DERMATOLOGICALS Mupirocin Centany AT External Kit 2 % Tier 3 DERMATOLOGICALS Mupirocin Centany External Ointment 2 % Tier 2 HEMATOPOIETIC AGENTS Ferrous Fumarate‐FA‐B Complex‐C‐Zn‐Mg‐Mn‐Cu Centratex Oral Capsule 106‐1 MG Tier 3 CEPHALOSPORINS Cephalexin Cephalexin Oral Capsule 250 MG Tier 1 CEPHALOSPORINS Cephalexin Cephalexin Oral Capsule 500 MG Tier 1 CEPHALOSPORINS Cephalexin Cephalexin Oral Capsule 750 MG Tier 1 CEPHALOSPORINS Cephalexin Cephalexin Oral Suspension Reconstituted 125 MG/5ML Tier 1 CEPHALOSPORINS Cephalexin Cephalexin Oral Suspension Reconstituted 250 MG/5ML Tier 1 CEPHALOSPORINS Cephalexin Cephalexin Oral Tablet 250 MG Tier 2 CEPHALOSPORINS Cephalexin Cephalexin Oral Tablet 500 MG Tier 2 HEMATOPOIETIC AGENTS Eliglustat Tartrate Cerdelga Oral Capsule 84 MG Tier 2 x x ANTICONVULSANTS Sodium Cerebyx Injection Solution 100 MG PE/2ML Tier 3 x ANTICONVULSANTS Fosphenytoin Sodium Cerebyx Injection Solution 500 MG PE/10ML Tier 3 x DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Cerisa Wash External Emulsion 10‐1 % Tier 1 DERMATOLOGICALS Urea Cerovel External Gel 40 % Tier 1 DERMATOLOGICALS Urea Cerovel External Lotion 40 % Tier 1 VACCINES Human Papillomavirus (HPV) Bivalent (Types 16, 18) Recmb Vac Cervarix Intramuscular Suspension Tier 3 x OXYTOCICS Dinoprostone Cervidil Vaginal Insert 10 MG Tier 3 ANTIEMETICS Nabilone Cesamet Oral Capsule 1 MG Tier 3 x x CONTRACEPTIVES Desogestrel‐Ethinyl Estradiol (Triphasic) Cesia Oral Tablet 0.1/0.125/0.15 ‐0.025 MG Tier 1 ANTIHISTAMINES Cetirizine HCl Cetirizine HCl Oral Solution 1 MG/ML Tier 1 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ANTIHISTAMINES Cetirizine HCl Cetirizine HCl Oral Syrup 1 MG/ML Tier 1 ANTIHISTAMINES Cetirizine HCl Cetirizine HCl Oral Syrup 5 MG/5ML Tier 1 OTIC AGENTS Ciprofloxacin HCl (Otic) Cetraxal Otic Solution 0.2 % Tier 3 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Cetrorelix Acetate Cetrotide Subcutaneous Kit 0.25 MG Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Cetrorelix Acetate Cetrotide Subcutaneous Kit 3 MG Tier 2 x PHARMACEUTICAL ADJUVANTS Cetyl Alcohol Cetyl Alcohol Flakes Tier 3 PHARMACEUTICAL ADJUVANTS Cetyl Alcohol Cetyl Alcohol Powder Tier 3 ANTISEPTICS & DISINFECTANTS Glutaral Cetylcide‐G Concentrate Tier 3 MOUTH/THROAT/DENTAL AGENTS Cevimeline HCl Cevimeline HCl Oral Capsule 30 MG Tier 1 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Varenicline Tartrate Chantix Continuing Month Pak Oral Tablet 1 MG Tier 3 x x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Varenicline Tartrate Chantix Oral Tablet 0.5 MG Tier 3 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Varenicline Tartrate Chantix Oral Tablet 1 MG Tier 3 x x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Varenicline Tartrate Chantix Starting Month Pak Oral Tablet 0.5 MG X 11 & 1 MG X 42 Tier 3 x x CONTRACEPTIVES Levonorgestrel & Eth Estradiol Chateal Oral Tablet 0.15‐30 MG‐MCG Tier 1 DIAGNOSTIC PRODUCTS Acetone (Urine) Test Chek‐Stix Control In Vitro Strip Tier 2 GASTROINTESTINAL AGENTS ‐ MISC. Chenodiol Chenodal Oral Tablet 250 MG Tier 2 x PHARMACEUTICAL ADJUVANTS Cherry Syrup Cherry Oral Syrup Tier 3 ANTI‐INFECTIVE AGENTS ‐ MISC. Chloramphenicol Chloramphenicol Powder Tier 3 ANTIANXIETY AGENTS Chlordiazepoxide HCl ChlordiazePOXIDE HCl Oral Capsule 10 MG Tier 1 ANTIANXIETY AGENTS Chlordiazepoxide HCl ChlordiazePOXIDE HCl Oral Capsule 25 MG Tier 1 ANTIANXIETY AGENTS Chlordiazepoxide HCl ChlordiazePOXIDE HCl Oral Capsule 5 MG Tier 1 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Chlordiazepoxide‐Amitriptyline Chlordiazepoxide‐Amitriptyline Oral Tablet 10‐25 MG Tier 3 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Chlordiazepoxide‐Amitriptyline Chlordiazepoxide‐Amitriptyline Oral Tablet 5‐12.5 MG Tier 2 MOUTH/THROAT/DENTAL AGENTS Gluconate (Mouth‐Throat) Chlorhexidine Gluconate Mouth/Throat Solution 0.12 % Tier 1 ANTISEPTICS & DISINFECTANTS Chlorhexidine Gluconate Chlorhexidine Gluconate Solution 20 % Tier 3 PHARMACEUTICAL ADJUVANTS Chlorobutanol Anhydrous Powder Tier 3 CHEMICALS Chloroform Solution Tier 3 ANTIMALARIALS Chloroquine Phosphate Chloroquine Phosphate Oral Tablet 250 MG Tier 1 ANTIMALARIALS Chloroquine Phosphate Chloroquine Phosphate Oral Tablet 500 MG Tier 1 ANTIMALARIALS Chloroquine Phosphate Chloroquine Phosphate Powder Tier 3 DIURETICS Chlorothiazide Chlorothiazide Oral Tablet 250 MG Tier 2 DIURETICS Chlorothiazide Chlorothiazide Oral Tablet 500 MG Tier 1 DIURETICS Chlorothiazide Sodium Chlorothiazide Sodium Intravenous Solution Reconstituted 500 MG Tier 1 x ANTIHISTAMINES Chlorpheniramine Maleate Chlorpheniramine Maleate Powder Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Chlorpromazine HCl ChlorproMAZINE HCl Injection Solution 25 MG/ML Tier 3 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Chlorpromazine HCl ChlorproMAZINE HCl Injection Solution 50 MG/2ML Tier 3 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Chlorpromazine HCl ChlorproMAZINE HCl Oral Tablet 10 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Chlorpromazine HCl ChlorproMAZINE HCl Oral Tablet 100 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Chlorpromazine HCl ChlorproMAZINE HCl Oral Tablet 200 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Chlorpromazine HCl ChlorproMAZINE HCl Oral Tablet 25 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Chlorpromazine HCl ChlorproMAZINE HCl Oral Tablet 50 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Chlorpromazine HCl ChlorproMAZINE HCl Powder Tier 3 ANTIDIABETICS Chlorpropamide ChlorproPAMIDE Oral Tablet 100 MG Tier 3 ANTIDIABETICS Chlorpropamide ChlorproPAMIDE Oral Tablet 250 MG Tier 3 DIURETICS Chlorthalidone Chlorthalidone Oral Tablet 25 MG Tier 2 DIURETICS Chlorthalidone Chlorthalidone Oral Tablet 50 MG Tier 2 MUSCULOSKELETAL THERAPY AGENTS Chlorzoxazone Chlorzoxazone Oral Tablet 500 MG Tier 1 GASTROINTESTINAL AGENTS ‐ MISC. Cholic Acid Cholbam Oral Capsule 250 MG Tier 2 x GASTROINTESTINAL AGENTS ‐ MISC. Cholic Acid Cholbam Oral Capsule 50 MG Tier 2 x CHEMICALS Cholesterol Cholesterol Flakes Tier 3 CHEMICALS Cholesterol Cholesterol Powder Tier 3 ANTIHYPERLIPIDEMICS Cholestyramine Light Cholestyramine Light Oral Packet 4 GM Tier 1 ANTIHYPERLIPIDEMICS Cholestyramine Light Cholestyramine Light Oral Powder 4 GM/DOSE Tier 1 ANTIHYPERLIPIDEMICS Cholestyramine Cholestyramine Oral Packet 4 GM Tier 1 ANTIHYPERLIPIDEMICS Cholestyramine Cholestyramine Oral Powder 4 GM/DOSE Tier 1 ANALGESICS ‐ NonNarcotic Choline & Mag Salicylate Choline & Mag Trisalicylate Oral Tablet 1000 MG Tier 3 NUTRIENTS Choline Bitartrate Choline Bitartrate Powder Tier 3 ANALGESICS ‐ NonNarcotic Choline & Mag Salicylate Choline‐Mag Trisalicylate Oral Liquid 500 MG/5ML Tier 1 CHEMICALS Chrysin Chrysin Powder Tier 3 CARDIOVASCULAR AGENTS ‐ MISC. Tadalafil Cialis Oral Tablet 10 MG Tier 2 x x CARDIOVASCULAR AGENTS ‐ MISC. Tadalafil Cialis Oral Tablet 2.5 MG Tier 2 x x CARDIOVASCULAR AGENTS ‐ MISC. Tadalafil Cialis Oral Tablet 20 MG Tier 2 x x CARDIOVASCULAR AGENTS ‐ MISC. Tadalafil Cialis Oral Tablet 5 MG Tier 2 x x DERMATOLOGICALS Ciclopirox Olamine & Cleanser Ciclodan Cream External Kit 0.77 % Tier 3 x DERMATOLOGICALS Ciclopirox Olamine Ciclodan External Cream 0.77 % Tier 1 DERMATOLOGICALS Ciclopirox Ciclodan External Solution 8 % Tier 1 DERMATOLOGICALS Ciclopirox Ciclodan Solution External Kit 8 % Tier 3 x DERMATOLOGICALS Ciclopirox Ciclopirox External Gel 0.77 % Tier 1 DERMATOLOGICALS Ciclopirox Ciclopirox External Shampoo 1 % Tier 1 DERMATOLOGICALS Ciclopirox Ciclopirox External Solution 8 % Tier 1 DERMATOLOGICALS Ciclopirox Olamine Ciclopirox Olamine External Cream 0.77 % Tier 1 DERMATOLOGICALS Ciclopirox Olamine Ciclopirox Olamine External Suspension 0.77 % Tier 1 DERMATOLOGICALS Ciclopirox Olamine Ciclopirox Olamine Powder Tier 3 x DERMATOLOGICALS Ciclopirox Ciclopirox Treatment External Kit 8 % Tier 1 DERMATOLOGICALS Ciclopirox & Vitamin E Ciclopirox‐Vitamin E External Kit 8 & 5 % Tier 3 x DERMATOLOGICALS Lidocaine HCl CidalEaze External Cream 3 % Tier 1 x ANTIVIRALS Cidofovir Cidofovir Intravenous Solution 75 MG/ML Tier 1 x HEMATOPOIETIC AGENTS Folic Acid‐Cholecalciferol Ciferex Oral Capsule 1‐3775 MG‐UNIT Tier 3 HEMATOLOGICAL AGENTS ‐ MISC. Cilostazol Cilostazol Oral Tablet 100 MG Tier 1 HEMATOLOGICAL AGENTS ‐ MISC. Cilostazol Cilostazol Oral Tablet 50 MG Tier 1 OPHTHALMIC AGENTS Ciprofloxacin HCl (Ophth) Ciloxan Ophthalmic Ointment 0.3 % Tier 3 OPHTHALMIC AGENTS Ciprofloxacin HCl (Ophth) Ciloxan Ophthalmic Solution 0.3 % Tier 3 ULCER DRUGS Cimetidine HCl Cimetidine HCl Oral Solution 300 MG/5ML Tier 1 ULCER DRUGS Cimetidine Cimetidine Oral Tablet 200 MG Tier 1 ULCER DRUGS Cimetidine Cimetidine Oral Tablet 300 MG Tier 1 ULCER DRUGS Cimetidine Cimetidine Oral Tablet 400 MG Tier 1 ULCER DRUGS Cimetidine Cimetidine Oral Tablet 800 MG Tier 1 ULCER DRUGS Cimetidine Cimetidine Powder Tier 3 GASTROINTESTINAL AGENTS ‐ MISC. Certolizumab Pegol Cimzia Prefilled Subcutaneous Kit 2 X 200 MG/ML Tier 2 x GASTROINTESTINAL AGENTS ‐ MISC. Certolizumab Pegol Cimzia Starter Kit Subcutaneous Kit 6 X 200 MG/ML Tier 2 x GASTROINTESTINAL AGENTS ‐ MISC. Certolizumab Pegol Cimzia Subcutaneous Kit 2 X 200 MG Tier 2 x x OTIC AGENTS Ciprofloxacin‐Hydrocortisone Cipro HC Otic Suspension 0.2‐1 % Tier 3 x FLUOROQUINOLONES Ciprofloxacin Cipro Oral Suspension Reconstituted 250 MG/5ML (5%) Tier 3 FLUOROQUINOLONES Ciprofloxacin Cipro Oral Suspension Reconstituted 500 MG/5ML (10%) Tier 3 FLUOROQUINOLONES Ciprofloxacin HCl Cipro Oral Tablet 250 MG Tier 3 FLUOROQUINOLONES Ciprofloxacin HCl Cipro Oral Tablet 500 MG Tier 3 FLUOROQUINOLONES Ciprofloxacin‐Ciprofloxacin HCl Cipro XR Oral Tablet Extended Release 24 Hour 1000 MG Tier 3 FLUOROQUINOLONES Ciprofloxacin‐Ciprofloxacin HCl Cipro XR Oral Tablet Extended Release 24 Hour 500 MG Tier 3 OTIC AGENTS Ciprofloxacin‐Dexamethasone Ciprodex Otic Suspension 0.3‐0.1 % Tier 3 OPHTHALMIC AGENTS Ciprofloxacin HCl (Ophth) Ciprofloxacin HCl Ophthalmic Solution 0.3 % Tier 1 FLUOROQUINOLONES Ciprofloxacin HCl Ciprofloxacin HCl Oral Tablet 100 MG Tier 3 FLUOROQUINOLONES Ciprofloxacin HCl Ciprofloxacin HCl Oral Tablet 250 MG Tier 1 FLUOROQUINOLONES Ciprofloxacin HCl Ciprofloxacin HCl Oral Tablet 500 MG Tier 1 FLUOROQUINOLONES Ciprofloxacin HCl Ciprofloxacin HCl Oral Tablet 750 MG Tier 1 OTIC AGENTS Ciprofloxacin HCl (Otic) Ciprofloxacin HCl Otic Solution 0.2 % Tier 3 FLUOROQUINOLONES Ciprofloxacin Ciprofloxacin Intravenous Solution 200 MG/20ML Tier 1 x FLUOROQUINOLONES Ciprofloxacin Ciprofloxacin Intravenous Solution 400 MG/40ML Tier 1 x FLUOROQUINOLONES Ciprofloxacin Ciprofloxacin Oral Suspension Reconstituted 250 MG/5ML (5%) Tier 1 FLUOROQUINOLONES Ciprofloxacin Ciprofloxacin Oral Suspension Reconstituted 500 MG/5ML (10%) Tier 1 FLUOROQUINOLONES Ciprofloxacin‐Ciprofloxacin HCl Ciprofloxacin‐Ciproflox HCl ER Oral Tablet Extended Release 24 Hour 1000 MG Tier 1 FLUOROQUINOLONES Ciprofloxacin‐Ciprofloxacin HCl Ciprofloxacin‐Ciproflox HCl ER Oral Tablet Extended Release 24 Hour 500 MG Tier 1 NEUROMUSCULAR AGENTS Cisatracurium Besylate Cisatracurium Besylate Intravenous Solution 10 MG/5ML Tier 1 x HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

NEUROMUSCULAR AGENTS Cisatracurium Besylate Cisatracurium Besylate Intravenous Solution 10 MG/ML Tier 1 x NEUROMUSCULAR AGENTS Cisatracurium Besylate Cisatracurium Besylate Intravenous Solution 20 MG/10ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Cisplatin CISplatin Intravenous Solution 100 MG/100ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Cisplatin CISplatin Intravenous Solution 50 MG/50ML Tier 1 x ANTIDEPRESSANTS Citalopram Hydrobromide Citalopram Hydrobromide Oral Solution 10 MG/5ML Tier 1 x ANTIDEPRESSANTS Citalopram Hydrobromide Citalopram Hydrobromide Oral Tablet 10 MG Tier 1 x ANTIDEPRESSANTS Citalopram Hydrobromide Citalopram Hydrobromide Oral Tablet 20 MG Tier 1 x ANTIDEPRESSANTS Citalopram Hydrobromide Citalopram Hydrobromide Oral Tablet 40 MG Tier 1 x MULTIVITAMINS Prenatal w/o Vit A w/ Fe Carbonyl‐Fe Gluconate‐DSS‐FA‐DHA CitraNatal 90 DHA Oral Miscellaneous 90‐1 & 300 MG Tier 3 MULTIVITAMINS Prenatal w/o Vit A w/ Fe Carbonyl‐Fe Gluconate‐DSS‐FA‐DHA CitraNatal Assure Oral Miscellaneous 35‐1 & 300 MG Tier 3 MULTIVITAMINS Prenatal w/o Vit A w/ Fe Carbonyl‐Fe Gluconate‐FA & Vit B6 CitraNatal B‐Calm Oral Miscellaneous 20‐1 & 25 (2) MG Tier 2 MULTIVITAMINS Prenatal w/o Vit A w/ Fe Carbonyl‐Fe Gluconate‐DSS‐FA‐DHA CitraNatal DHA Oral Miscellaneous 27‐1 & 250 MG Tier 3 MULTIVITAMINS Prenatal w/o Vit A w/ Fe Fumarate‐Fe Carbonyl‐DSS‐FA‐DHA CitraNatal Harmony Oral Capsule 27‐1‐260 MG Tier 3 MULTIVITAMINS Prenatal without Vit A w/ Fe Carbonyl‐Fe Gluc‐Docusate‐FA CitraNatal Rx Oral Tablet 27‐1 MG Tier 2 GENITOURINARY AGENTS ‐ MISCELLANEOUS Sodium Citrate & Citric Acid‐Sodium Citrate Oral Solution 334‐500 MG/5ML Tier 1 BIOLOGICALS MISC Cladosporium Cladosporioides Cladosporium Cladosporioides Subcutaneous Solution 10000 PNU/ML Tier 3 x BIOLOGICALS MISC Cladosporium Cladosporioides Cladosporium Cladosporioides Subcutaneous Solution 20000 PNU/ML Tier 3 x BIOLOGICALS MISC Cladosporium Sphaerospermum Cladosporium Sphaerospermum Subcutaneous Solution 20000 PNU/ML Tier 3 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Cladribine Cladribine Intravenous Solution 1 MG/ML Tier 1 x CEPHALOSPORINS Cefotaxime Sodium Claforan Injection Solution Reconstituted 1 GM Tier 3 x CEPHALOSPORINS Cefotaxime Sodium Claforan Injection Solution Reconstituted 2 GM Tier 3 x CEPHALOSPORINS Cefotaxime Sodium Claforan Injection Solution Reconstituted 500 MG Tier 3 x CEPHALOSPORINS Cefotaxime Sodium Claforan Intravenous Solution Reconstituted 1 GM Tier 3 x CEPHALOSPORINS Cefotaxime Sodium Claforan Intravenous Solution Reconstituted 2 GM Tier 3 x DERMATOLOGICALS Isotretinoin Claravis Oral Capsule 10 MG Tier 1 DERMATOLOGICALS Isotretinoin Claravis Oral Capsule 20 MG Tier 1 DERMATOLOGICALS Isotretinoin Claravis Oral Capsule 30 MG Tier 1 DERMATOLOGICALS Isotretinoin Claravis Oral Capsule 40 MG Tier 1 ANTIHISTAMINES Desloratadine Clarinex Oral Syrup 0.5 MG/ML Tier 3 ANTIHISTAMINES Desloratadine Clarinex Oral Tablet 5 MG Tier 3 ANTIHISTAMINES Desloratadine Clarinex Reditabs Oral Tablet Dispersible 2.5 MG Tier 3 ANTIHISTAMINES Desloratadine Clarinex Reditabs Oral Tablet Dispersible 5 MG Tier 3 MACROLIDES Clarithromycin Clarithromycin ER Oral Tablet Extended Release 24 Hour 500 MG Tier 1 MACROLIDES Clarithromycin Clarithromycin Oral Suspension Reconstituted 125 MG/5ML Tier 1 MACROLIDES Clarithromycin Clarithromycin Oral Suspension Reconstituted 250 MG/5ML Tier 1 MACROLIDES Clarithromycin Clarithromycin Oral Tablet 250 MG Tier 1 MACROLIDES Clarithromycin Clarithromycin Oral Tablet 500 MG Tier 1 MEDICAL DEVICES AND SUPPLIES Lancets Cleanlet Lancets 28G Miscellaneous Tier 2 DERMATOLOGICALS Benzoyl Peroxide Clearplex X External Gel 10 % Tier 1 ANTIHISTAMINES Clemastine Fumarate Clemastine Fumarate Oral Tablet 2.68 MG Tier 1 ANTI‐INFECTIVE AGENTS ‐ MISC. Clindamycin HCl Cleocin Oral Capsule 150 MG Tier 3 ANTI‐INFECTIVE AGENTS ‐ MISC. Clindamycin HCl Cleocin Oral Capsule 300 MG Tier 3 ANTI‐INFECTIVE AGENTS ‐ MISC. Clindamycin HCl Cleocin Oral Capsule 75 MG Tier 3 ANTI‐INFECTIVE AGENTS ‐ MISC. Clindamycin Palmitate Hydrochloride Cleocin Oral Solution Reconstituted 75 MG/5ML Tier 3 ANTI‐INFECTIVE AGENTS ‐ MISC. Clindamycin Phosphate Cleocin Phosphate Injection Solution 300 MG/2ML Tier 3 x ANTI‐INFECTIVE AGENTS ‐ MISC. Clindamycin Phosphate Cleocin Phosphate Injection Solution 600 MG/4ML Tier 3 x ANTI‐INFECTIVE AGENTS ‐ MISC. Clindamycin Phosphate Cleocin Phosphate Injection Solution 9 GM/60ML Tier 3 x ANTI‐INFECTIVE AGENTS ‐ MISC. Clindamycin Phosphate Cleocin Phosphate Injection Solution 900 MG/6ML Tier 3 x ANTI‐INFECTIVE AGENTS ‐ MISC. Clindamycin Phosphate Cleocin Phosphate Intravenous Solution 600 MG/4ML Tier 3 x ANTI‐INFECTIVE AGENTS ‐ MISC. Clindamycin Phosphate Cleocin Phosphate Intravenous Solution 900 MG/6ML Tier 3 x VAGINAL PRODUCTS Clindamycin Phosphate Vaginal Cleocin Vaginal Cream 2 % Tier 3 VAGINAL PRODUCTS Clindamycin Phosphate Vaginal Cleocin Vaginal Suppository 100 MG Tier 2 DERMATOLOGICALS Clindamycin Phosphate (Topical) Cleocin‐T External Gel 1 % Tier 3 DERMATOLOGICALS Clindamycin Phosphate (Topical) Cleocin‐T External Lotion 1 % Tier 3 DERMATOLOGICALS Clindamycin Phosphate (Topical) Cleocin‐T External Solution 1 % Tier 3 DERMATOLOGICALS Clindamycin Phosphate (Topical) Cleocin‐T External Swab 1 % Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Clever Chek Auto‐Code Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies Clever Chek Auto‐Code Voice Device Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Clever Chek Auto‐Code Voice In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Clever Chek Lancets Miscellaneous Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood Clever Chek Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Clever Choice Auto‐Code Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Clever Choice Comfort EZ Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Clever Choice Comfort EZ Miscellaneous 33G X 4 MM Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Clever Choice Micro Test In Vitro Strip Tier 3 CALCIUM CHANNEL BLOCKERS Clevidipine Butyrate Cleviprex Intravenous Emulsion 0.5 MG/ML Tier 3 x MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Clickfine Pen Needles Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Clickfine Pen Needles Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Clickfine Pen Needles Miscellaneous 32G X 4 MM Tier 2 ESTROGENS Estradiol‐Levonorgestrel Climara Pro Transdermal Patch Weekly 0.045‐0.015 MG/DAY Tier 2 x ESTROGENS Estradiol Climara Transdermal Patch Weekly 0.025 MG/24HR Tier 3 ESTROGENS Estradiol Climara Transdermal Patch Weekly 0.0375 MG/24HR Tier 3 ESTROGENS Estradiol Climara Transdermal Patch Weekly 0.05 MG/24HR Tier 3 ESTROGENS Estradiol Climara Transdermal Patch Weekly 0.06 MG/24HR Tier 3 ESTROGENS Estradiol Climara Transdermal Patch Weekly 0.075 MG/24HR Tier 3 ESTROGENS Estradiol Climara Transdermal Patch Weekly 0.1 MG/24HR Tier 3 DERMATOLOGICALS Clindamycin Phosphate & Cleanser Clindacin ETZ External Kit 1 % Tier 3 x DERMATOLOGICALS Clindamycin Phosphate (Topical) Clindacin ETZ External Swab 1 % Tier 1 DERMATOLOGICALS Clindamycin Phosphate & Cleanser Clindacin Pac External Kit 1 % Tier 3 x DERMATOLOGICALS Clindamycin Phosphate (Topical) Clindacin‐P External Swab 1 % Tier 1 DERMATOLOGICALS Clindamycin Phosphate (Topical) Clindagel External Gel 1 % Tier 2 x DERMATOLOGICALS Clindamycin Phosphate (Topical) ClindaMax External Gel 1 % Tier 1 ANTI‐INFECTIVE AGENTS ‐ MISC. Clindamycin HCl Clindamycin HCl Oral Capsule 150 MG Tier 1 ANTI‐INFECTIVE AGENTS ‐ MISC. Clindamycin HCl Clindamycin HCl Oral Capsule 300 MG Tier 1 ANTI‐INFECTIVE AGENTS ‐ MISC. Clindamycin HCl Clindamycin HCl Oral Capsule 75 MG Tier 1 ANTI‐INFECTIVE AGENTS ‐ MISC. Clindamycin Palmitate Hydrochloride Clindamycin Palmitate HCl Oral Solution Reconstituted 75 MG/5ML Tier 1 DERMATOLOGICALS Clindamycin Phosphate‐Benzoyl Peroxide (Refrigerate) Clindamycin Phos‐Benzoyl Perox External Gel 1.2‐5 % Tier 1 DERMATOLOGICALS Clindamycin Phosphate‐Benzoyl Peroxide Clindamycin Phos‐Benzoyl Perox External Gel 1‐5 % Tier 1 DERMATOLOGICALS Clindamycin Phosphate (Topical) Clindamycin Phosphate External Foam 1 % Tier 1 DERMATOLOGICALS Clindamycin Phosphate (Topical) Clindamycin Phosphate External Gel 1 % Tier 1 DERMATOLOGICALS Clindamycin Phosphate (Topical) Clindamycin Phosphate External Lotion 1 % Tier 1 DERMATOLOGICALS Clindamycin Phosphate (Topical) Clindamycin Phosphate External Solution 1 % Tier 1 DERMATOLOGICALS Clindamycin Phosphate (Topical) Clindamycin Phosphate External Swab 1 % Tier 1 ANTI‐INFECTIVE AGENTS ‐ MISC. Clindamycin Phosphate Clindamycin Phosphate Injection Solution 300 MG/2ML Tier 1 x ANTI‐INFECTIVE AGENTS ‐ MISC. Clindamycin Phosphate Clindamycin Phosphate Injection Solution 600 MG/4ML Tier 1 x ANTI‐INFECTIVE AGENTS ‐ MISC. Clindamycin Phosphate Clindamycin Phosphate Injection Solution 9 GM/60ML Tier 1 x ANTI‐INFECTIVE AGENTS ‐ MISC. Clindamycin Phosphate Clindamycin Phosphate Injection Solution 900 MG/6ML Tier 1 x ANTI‐INFECTIVE AGENTS ‐ MISC. Clindamycin Phosphate Clindamycin Phosphate Intravenous Solution 900 MG/6ML Tier 1 x VAGINAL PRODUCTS Clindamycin Phosphate Vaginal Clindamycin Phosphate Vaginal Cream 2 % Tier 1 DERMATOLOGICALS Adapalene‐Clindamycin Phosphate Clindap‐T External Cream 0.3‐1 % Tier 3 x VAGINAL PRODUCTS Clindamycin Phosphate (One Dose) Clindesse Vaginal Cream 2 % Tier 3 NUTRIENTS Amino Acid Infusion Clinisol SF Intravenous Solution 15 % Tier 1 x DERMATOLOGICALS Clindamycin‐Tretinoin‐Cholestyramine Clinoin External Cream 1.25‐0.025‐1 % Tier 3 x MOUTH/THROAT/DENTAL AGENTS Sodium Fluoride (Dental) Clinpro 5000 Dental Paste 1.1 % Tier 1 DERMATOLOGICALS Clioquinol Clioquinol Powder Tier 3 DERMATOLOGICALS Clobetasol Propionate Clobetasol 17 Propionate Powder Tier 3 DERMATOLOGICALS Clobetasol Propionate Emollient Base Clobetasol Propionate E External Cream 0.05 % Tier 1 DERMATOLOGICALS Clobetasol Propionate Emulsion Clobetasol Propionate Emulsion External Foam 0.05 % Tier 1 DERMATOLOGICALS Clobetasol Propionate Clobetasol Propionate External Cream 0.05 % Tier 1 DERMATOLOGICALS Clobetasol Propionate Clobetasol Propionate External Foam 0.05 % Tier 1 DERMATOLOGICALS Clobetasol Propionate Clobetasol Propionate External Gel 0.05 % Tier 1 DERMATOLOGICALS Clobetasol Propionate Clobetasol Propionate External Liquid 0.05 % Tier 1 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

DERMATOLOGICALS Clobetasol Propionate Clobetasol Propionate External Lotion 0.05 % Tier 1 DERMATOLOGICALS Clobetasol Propionate Clobetasol Propionate External Ointment 0.05 % Tier 1 DERMATOLOGICALS Clobetasol Propionate Clobetasol Propionate External Shampoo 0.05 % Tier 1 DERMATOLOGICALS Clobetasol Propionate Clobetasol Propionate External Solution 0.05 % Tier 1 DERMATOLOGICALS Clobetasol Propionate Clobetasol Propionate Powder Tier 3 DERMATOLOGICALS Clobetasol Propionate Clobex External Lotion 0.05 % Tier 3 DERMATOLOGICALS Clobetasol Propionate Clobex External Shampoo 0.05 % Tier 3 DERMATOLOGICALS Clobetasol Propionate Clobex Spray External Liquid 0.05 % Tier 3 DERMATOLOGICALS Clocortolone Pivalate Clocortolone Pivalate External Cream 0.1 % Tier 3 DERMATOLOGICALS Clocortolone Pivalate Clocortolone Pivalate Pump External Cream 0.1 % Tier 3 DERMATOLOGICALS Clobetasol Propionate & Cleanser Clodan External Kit 0.05 % Tier 3 DERMATOLOGICALS Clobetasol Propionate Clodan External Shampoo 0.05 % Tier 1 DERMATOLOGICALS Clocortolone Pivalate Cloderm External Cream 0.1 % Tier 3 DERMATOLOGICALS Clocortolone Pivalate Cloderm Pump External Cream 0.1 % Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Clomiphene Citrate ClomiPHENE Citrate Oral Tablet 50 MG Tier 1 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Clomiphene Citrate ClomiPHENE Citrate Powder Tier 3 ANTIDEPRESSANTS Clomipramine HCl ClomiPRAMINE HCl Oral Capsule 25 MG Tier 1 ANTIDEPRESSANTS Clomipramine HCl ClomiPRAMINE HCl Oral Capsule 50 MG Tier 1 ANTIDEPRESSANTS Clomipramine HCl ClomiPRAMINE HCl Oral Capsule 75 MG Tier 1 ANTICONVULSANTS ClonazePAM Oral Tablet 0.5 MG Tier 1 ANTICONVULSANTS Clonazepam ClonazePAM Oral Tablet 1 MG Tier 1 ANTICONVULSANTS Clonazepam ClonazePAM Oral Tablet 2 MG Tier 1 ANTICONVULSANTS Clonazepam ClonazePAM Oral Tablet Dispersible 0.125 MG Tier 1 ANTICONVULSANTS Clonazepam ClonazePAM Oral Tablet Dispersible 0.25 MG Tier 1 ANTICONVULSANTS Clonazepam ClonazePAM Oral Tablet Dispersible 0.5 MG Tier 1 ANTICONVULSANTS Clonazepam ClonazePAM Oral Tablet Dispersible 1 MG Tier 1 ANTICONVULSANTS Clonazepam ClonazePAM Oral Tablet Dispersible 2 MG Tier 1 ANALGESICS ‐ NonNarcotic Clonidine HCl (Analgesia) CloNIDine HCl (Analgesia) Epidural Solution 100 MCG/ML Tier 1 x ANALGESICS ‐ NonNarcotic Clonidine HCl (Analgesia) CloNIDine HCl (Analgesia) Epidural Solution 500 MCG/ML Tier 1 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Clonidine HCl (ADHD) CloNIDine HCl ER Oral Tablet Extended Release 12 Hour 0.1 MG Tier 1 x x ANTIHYPERTENSIVES Clonidine HCl CloNIDine HCl Oral Tablet 0.1 MG Tier 1 ANTIHYPERTENSIVES Clonidine HCl CloNIDine HCl Oral Tablet 0.2 MG Tier 1 ANTIHYPERTENSIVES Clonidine HCl CloNIDine HCl Oral Tablet 0.3 MG Tier 1 ANTIHYPERTENSIVES Clonidine HCl CloNIDine HCl Powder Tier 3 ANTIHYPERTENSIVES Clonidine HCl CloNIDine HCl Transdermal Patch Weekly 0.1 MG/24HR Tier 1 ANTIHYPERTENSIVES Clonidine HCl CloNIDine HCl Transdermal Patch Weekly 0.2 MG/24HR Tier 1 ANTIHYPERTENSIVES Clonidine HCl CloNIDine HCl Transdermal Patch Weekly 0.3 MG/24HR Tier 1 HEMATOLOGICAL AGENTS ‐ MISC. Clopidogrel Bisulfate Clopidogrel Bisulfate Oral Tablet 300 MG Tier 1 HEMATOLOGICAL AGENTS ‐ MISC. Clopidogrel Bisulfate Clopidogrel Bisulfate Oral Tablet 75 MG Tier 1 ANTIANXIETY AGENTS Clorazepate Dipotassium Clorazepate Dipotassium Oral Tablet 15 MG Tier 1 ANTIANXIETY AGENTS Clorazepate Dipotassium Clorazepate Dipotassium Oral Tablet 3.75 MG Tier 1 ANTIANXIETY AGENTS Clorazepate Dipotassium Clorazepate Dipotassium Oral Tablet 7.5 MG Tier 1 ANTIHYPERTENSIVES Clonidine & Chlorthalidone Clorpres Oral Tablet 0.1‐15 MG Tier 3 ANTIHYPERTENSIVES Clonidine & Chlorthalidone Clorpres Oral Tablet 0.2‐15 MG Tier 3 ANTIHYPERTENSIVES Clonidine & Chlorthalidone Clorpres Oral Tablet 0.3‐15 MG Tier 3 DERMATOLOGICALS (Topical) Clotrimazole Anti‐Fungal External Cream 1 % Tier 1 DERMATOLOGICALS Clotrimazole (Topical) Clotrimazole External Cream 1 % Tier 1 DERMATOLOGICALS Clotrimazole (Topical) Clotrimazole External Solution 1 % Tier 1 MOUTH/THROAT/DENTAL AGENTS Clotrimazole Clotrimazole Mouth/Throat Lozenge 10 MG Tier 1 MOUTH/THROAT/DENTAL AGENTS Clotrimazole Clotrimazole Mouth/Throat Troche 10 MG Tier 1 DERMATOLOGICALS Clotrimazole (Topical) Clotrimazole Powder Tier 3 VAGINAL PRODUCTS Clotrimazole Vaginal Clotrimazole Vaginal Cream 2 % Tier 1 DERMATOLOGICALS Clotrimazole w/ Betamethasone Clotrimazole‐Betamethasone External Cream 1‐0.05 % Tier 1 DERMATOLOGICALS Clotrimazole w/ Betamethasone Clotrimazole‐Betamethasone External Lotion 1‐0.05 % Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Clozapine CloZAPine Oral Tablet 100 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Clozapine CloZAPine Oral Tablet 200 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Clozapine CloZAPine Oral Tablet 25 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Clozapine CloZAPine Oral Tablet 50 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Clozapine CloZAPine Oral Tablet Dispersible 100 MG Tier 1 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Clozapine CloZAPine Oral Tablet Dispersible 12.5 MG Tier 3 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Clozapine CloZAPine Oral Tablet Dispersible 150 MG Tier 3 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Clozapine CloZAPine Oral Tablet Dispersible 200 MG Tier 3 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Clozapine CloZAPine Oral Tablet Dispersible 25 MG Tier 1 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Clozapine Clozaril Oral Tablet 100 MG Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Clozapine Clozaril Oral Tablet 25 MG Tier 3 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐FA‐Omega 3 Fatty Acids C‐Nate DHA Oral Capsule 28‐1‐200 MG Tier 2 DERMATOLOGICALS Ciclopirox CNL8 Nail External Kit 8 % Tier 3 x MEDICAL DEVICES AND SUPPLIES Lancets CoaguChek Lancets Miscellaneous Tier 2 DERMATOLOGICALS Tar Extract Coal Tar External Solution 20 % Tier 3 CHEMICALS Coal Tar (Crude) Coal Tar Solution Tier 3 CHEMICALS Coal Tar (Crude) Coal Tar Solution 20 % Tier 3 ANTIMALARIALS Artemether‐Lumefantrine Coartem Oral Tablet 20‐120 MG Tier 3 ALTERNATIVE MEDICINES Ubiquinol‐Vitamin B12‐Resveratrol‐Folic Acid Co‐Balamin Oral Capsule 200‐5‐400‐0.8 MG Tier 3 DERMATOLOGICALS HCl Cocaine HCl External Solution 4 % Tier 3 DERMATOLOGICALS Cocaine HCl Cocaine HCl Powder Tier 3 PHARMACEUTICAL ADJUVANTS Cocoa Butter Cocoa Butter Miscellaneous Tier 3 COUGH/COLD/ALLERGY Chlorpheniramine w/ Codeine Codar AR Oral Liquid 2‐8 MG/5ML Tier 3 ANALGESICS ‐ OPIOID Codeine Phosphate Codeine Phosphate Powder Tier 3 ANALGESICS ‐ OPIOID Codeine Sulfate Codeine Sulfate Oral Tablet 15 MG Tier 1 ANALGESICS ‐ OPIOID Codeine Sulfate Codeine Sulfate Oral Tablet 15 MG Tier 3 ANALGESICS ‐ OPIOID Codeine Sulfate Codeine Sulfate Oral Tablet 30 MG Tier 1 ANALGESICS ‐ OPIOID Codeine Sulfate Codeine Sulfate Oral Tablet 30 MG Tier 3 ANALGESICS ‐ OPIOID Codeine Sulfate Codeine Sulfate Oral Tablet 60 MG Tier 1 ANALGESICS ‐ OPIOID Codeine Sulfate Codeine Sulfate Oral Tablet 60 MG Tier 3 CHEMICALS Coenzyme Q10 Coenzyme Q10 Powder Tier 3 ANTIPARKINSON AGENTS Benztropine Mesylate Cogentin Injection Solution 1 MG/ML Tier 3 x GASTROINTESTINAL AGENTS ‐ MISC. Balsalazide Disodium Colazal Oral Capsule 750 MG Tier 3 GOUT AGENTS Colchicine Oral Tablet 0.6 MG Tier 3 x GOUT AGENTS Colchicine Colchicine Powder Tier 3 x GOUT AGENTS Colchicine w/ Colchicine‐Probenecid Oral Tablet 0.5‐500 MG Tier 1 GOUT AGENTS Colchicine Colcrys Oral Tablet 0.6 MG Tier 2 x ANTIHYPERLIPIDEMICS Colestipol HCl Colestid Flavored Oral Granules 5 GM Tier 3 ANTIHYPERLIPIDEMICS Colestipol HCl Colestid Flavored Oral Packet 5 GM Tier 3 ANTIHYPERLIPIDEMICS Colestipol HCl Colestid Oral Granules 5 GM Tier 3 ANTIHYPERLIPIDEMICS Colestipol HCl Colestid Oral Packet 5 GM Tier 3 ANTIHYPERLIPIDEMICS Colestipol HCl Colestid Oral Tablet 1 GM Tier 3 ANTIHYPERLIPIDEMICS Colestipol HCl Colestipol HCl Oral Granules 5 GM Tier 1 ANTIHYPERLIPIDEMICS Colestipol HCl Colestipol HCl Oral Packet 5 GM Tier 1 ANTIHYPERLIPIDEMICS Colestipol HCl Colestipol HCl Oral Tablet 1 GM Tier 1 CHEMICALS Colhibin Colhibin Solution Tier 3 ANTI‐INFECTIVE AGENTS ‐ MISC. Colistimethate Sodium Colistimethate Sodium Injection Solution Reconstituted 150 MG Tier 1 x DERMATOLOGICALS Collagenase Powder Tier 3 DERMATOLOGICALS Dimethicone‐ Colliginix External Miscellaneous 5‐2 % Tier 3 PHARMACEUTICAL ADJUVANTS Collodion Flexible Collodion Flexible External Liquid Tier 3 PHARMACEUTICAL ADJUVANTS Collodion Collodion Liquid Tier 3 ANORECTAL AGENTS Hydrocortisone (Intrarectal) Colocort Rectal Enema 100 MG/60ML Tier 1 ANTI‐INFECTIVE AGENTS ‐ MISC. Colistimethate Sodium Coly‐Mycin M Injection Solution Reconstituted 150 MG Tier 3 x OTIC AGENTS Neomycin‐Colistin‐HC‐Thonzonium Coly‐Mycin S Otic Suspension 3.3‐3‐10‐0.5 MG/ML Tier 3 LAXATIVES PEG 3350‐KCl‐Sod Bicarb‐Sod Chloride‐Sod Sulfate Colyte with Packs Oral Solution Reconstituted 240 GM Tier 3 OPHTHALMIC AGENTS Brimonidine Tartrate‐Timolol Maleate Combigan Ophthalmic Solution 0.2‐0.5 % Tier 2 ESTROGENS Estradiol & Norethindrone Acetate CombiPatch Transdermal Patch Twice Weekly 0.05‐0.14 MG/DAY Tier 3 ESTROGENS Estradiol & Norethindrone Acetate CombiPatch Transdermal Patch Twice Weekly 0.05‐0.25 MG/DAY Tier 3 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ANTIASTHMATIC AND BRONCHODILATOR AGENTS Ipratropium‐Albuterol Combivent Respimat Inhalation Aerosol Solution 20‐100 MCG/ACT Tier 2 x ANTIVIRALS Lamivudine‐Zidovudine Combivir Oral Tablet 150‐300 MG Tier 3 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Cabozantinib S‐Malate Cometriq (100 mg Daily Dose) Oral Kit 1 X 80 & 1 X 20 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Cabozantinib S‐Malate Cometriq (140 mg Daily Dose) Oral Kit 1 X 80 & 3 X 20 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Cabozantinib S‐Malate Cometriq (60 mg Daily Dose) Oral Kit 20 MG Tier 2 x x MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Comfort Assist Insulin Syringe Miscellaneous 29G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Comfort Assist Insulin Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Comfort Assist Insulin Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Comfort Assist Insulin Syringe Miscellaneous 30G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Comfort Assist Insulin Syringe Miscellaneous 30G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Comfort Assist Insulin Syringe Miscellaneous 30G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Comfort Assist Insulin Syringe Miscellaneous 31G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Comfort Assist Insulin Syringe Miscellaneous 31G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Comfort Assist Insulin Syringe Miscellaneous 31G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Comfort Assured Lancets 28G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Comfort Assured Lancets 33G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Comfort EZ Insulin Syringe Miscellaneous 28G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Comfort EZ Insulin Syringe Miscellaneous 28G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Comfort EZ Insulin Syringe Miscellaneous 29G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Comfort EZ Insulin Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Comfort EZ Insulin Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Comfort EZ Insulin Syringe Miscellaneous 30G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Comfort EZ Insulin Syringe Miscellaneous 30G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Comfort EZ Insulin Syringe Miscellaneous 30G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Comfort EZ Insulin Syringe Miscellaneous 30G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Comfort EZ Insulin Syringe Miscellaneous 30G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Comfort EZ Insulin Syringe Miscellaneous 30G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Comfort EZ Insulin Syringe Miscellaneous 31G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Comfort EZ Insulin Syringe Miscellaneous 31G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Comfort EZ Insulin Syringe Miscellaneous 31G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Comfort EZ Pen Needles Miscellaneous 31G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Comfort EZ Pen Needles Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Comfort EZ Pen Needles Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Comfort EZ Pen Needles Miscellaneous 32G X 4 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Comfort EZ Pen Needles Miscellaneous 32G X 5 MM Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Comfort EZ Pen Needles Miscellaneous 32G X 6 MM Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Comfort EZ Pen Needles Miscellaneous 32G X 8 MM Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Comfort EZ Pen Needles Miscellaneous 33G X 4 MM Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Comfort EZ Pen Needles Miscellaneous 33G X 5 MM Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Comfort EZ Pen Needles Miscellaneous 33G X 6 MM Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Comfort EZ Pen Needles Miscellaneous 33G X 8 MM Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Comfort Lancets Miscellaneous Tier 2 ANTIPSYCHOTICS/ANTIMANIC AGENTS Prochlorperazine Maleate Compazine Oral Tablet 10 MG Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Prochlorperazine Maleate Compazine Oral Tablet 5 MG Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Prochlorperazine Compazine Rectal Suppository 25 MG Tier 1 ANTIVIRALS Emtricitabine‐Rilpivirine‐Tenofovir Disoproxil Fumarate Complera Oral Tablet 200‐25‐300 MG Tier 2 x MULTIVITAMINS Prenatal MV & Min w/Fe Bisglyc‐Fe Prot Succ‐FA‐CA‐Omega 3 Complete Natal DHA Oral Miscellaneous 29‐1‐200 & 250 MG Tier 3 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐Folic Acid CompleteNate Oral Tablet Chewable 29‐1 MG Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Prochlorperazine Compro Rectal Suppository 25 MG Tier 1 ANTIPARKINSON AGENTS Entacapone Comtan Oral Tablet 200 MG Tier 3 VACCINES Haemophilus B Polysac Conj‐Hepatitis B (Recomb) Vaccines Comvax Intramuscular Suspension 7.5‐5 MCG/0.5ML Tier 2 x MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐Folic Acid Co‐Natal FA Oral Tablet Tier 3 MULTIVITAMINS Prenatal Vit w/ Fe Fum‐Iron Polysacch Complex ‐FA‐Omega 3 Concept DHA Oral Capsule 53.5‐38‐1 MG Tier 2 MULTIVITAMINS Prenatal without A Vit w/ Fe Fum‐Iron Polysacch Complex ‐FA Concept OB Oral Capsule 130‐92.4‐1 MG Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Concerta Oral Tablet Extended Release 18 MG Tier 3 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Concerta Oral Tablet Extended Release 27 MG Tier 3 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Concerta Oral Tablet Extended Release 36 MG Tier 3 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Concerta Oral Tablet Extended Release 54 MG Tier 3 x x DERMATOLOGICALS Podofilox Condylox External Gel 0.5 % Tier 3 DERMATOLOGICALS Podofilox Condylox External Solution 0.5 % Tier 3 DIAGNOSTIC PRODUCTS Iothalamate Meglumine Conray 43 Intravenous Solution 43 % Tier 3 x DIAGNOSTIC PRODUCTS Iothalamate Meglumine Conray Injection Solution 60 % Tier 3 x LAXATIVES Lactulose Constulose Oral Solution 10 GM/15ML Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Naltrexone HCl‐Bupropion HCl Contrave Oral Tablet Extended Release 12 Hour 8‐90 MG Tier 3 x x DIAGNOSTIC PRODUCTS Glucose Blood Control AST In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Control Test In Vitro Strip Tier 3 DERMATOLOGICALS Emollient CopaSil External Gel Tier 3 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Glatiramer Acetate Copaxone Subcutaneous Solution Prefilled Syringe 20 MG/ML Tier 2 x x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Glatiramer Acetate Copaxone Subcutaneous Solution Prefilled Syringe 40 MG/ML Tier 2 x x ANTIVIRALS Ribavirin (Hepatitis C) Copegus Oral Tablet 200 MG Tier 2 x x ANTIARRHYTHMICS Amiodarone HCl Cordarone Oral Tablet 200 MG Tier 3 DERMATOLOGICALS Flurandrenolide Cordran External Cream 0.05 % Tier 3 DERMATOLOGICALS Flurandrenolide Cordran External Lotion 0.05 % Tier 3 DERMATOLOGICALS Flurandrenolide Cordran External Ointment 0.05 % Tier 3 DERMATOLOGICALS Flurandrenolide Cordran External Tape 4 MCG/SQCM Tier 3 BETA BLOCKERS Carvedilol Phosphate Coreg CR Oral Capsule Extended Release 24 Hour 10 MG Tier 3 x BETA BLOCKERS Carvedilol Phosphate Coreg CR Oral Capsule Extended Release 24 Hour 20 MG Tier 3 x BETA BLOCKERS Carvedilol Phosphate Coreg CR Oral Capsule Extended Release 24 Hour 40 MG Tier 3 x BETA BLOCKERS Carvedilol Phosphate Coreg CR Oral Capsule Extended Release 24 Hour 80 MG Tier 3 x BETA BLOCKERS Carvedilol Coreg Oral Tablet 12.5 MG Tier 3 BETA BLOCKERS Carvedilol Coreg Oral Tablet 25 MG Tier 3 BETA BLOCKERS Carvedilol Coreg Oral Tablet 3.125 MG Tier 3 BETA BLOCKERS Carvedilol Coreg Oral Tablet 6.25 MG Tier 3 BETA BLOCKERS Nadolol Corgard Oral Tablet 20 MG Tier 3 BETA BLOCKERS Nadolol Corgard Oral Tablet 40 MG Tier 3 BETA BLOCKERS Nadolol Corgard Oral Tablet 80 MG Tier 3 CARDIOVASCULAR AGENTS ‐ MISC. Ivabradine HCl Corlanor Oral Tablet 5 MG Tier 3 x x CARDIOVASCULAR AGENTS ‐ MISC. Ivabradine HCl Corlanor Oral Tablet 7.5 MG Tier 3 x x ANTIHYPERTENSIVES Fenoldopam Mesylate Corlopam Intravenous Solution 10 MG/ML Tier 3 x ANTIHYPERTENSIVES Fenoldopam Mesylate Corlopam Intravenous Solution 20 MG/2ML Tier 3 x DERMATOLOGICALS Clobetasol Propionate Cormax Scalp Application External Solution 0.05 % Tier 1 CHEMICALS Starch Corn Starch Powder Tier 3 CORTICOSTEROIDS Hydrocortisone Cortef Oral Tablet 10 MG Tier 3 CORTICOSTEROIDS Hydrocortisone Cortef Oral Tablet 20 MG Tier 3 CORTICOSTEROIDS Hydrocortisone Cortef Oral Tablet 5 MG Tier 3 ANORECTAL AGENTS Hydrocortisone (Intrarectal) Cortenema Rectal Enema 100 MG/60ML Tier 3 ANORECTAL AGENTS Hydrocortisone Acetate (Intrarectal) Cortifoam Rectal Foam 10 % Tier 3 CORTICOSTEROIDS Cortisone Acetate Cortisone Acetate Oral Tablet 25 MG Tier 3 CORTICOSTEROIDS Cortisone Acetate Cortisone Acetate Powder Tier 3 DERMATOLOGICALS Neomycin‐Polymyxin‐HC Cortisporin External Cream 0.5‐0.5‐10000 Tier 3 DERMATOLOGICALS Bacitracin‐Polymyxin‐Neomycin HC Cortisporin External Ointment 1 % Tier 3 OTIC AGENTS Neomycin‐Polymyxin‐HC (Otic) Cortisporin Otic Solution 3.5‐10000‐1 Tier 3 OTIC AGENTS Neomycin‐Colistin‐HC‐Thonzonium Cortisporin‐TC Otic Suspension 3.3‐3‐10‐0.5 MG/ML Tier 3 DIAGNOSTIC PRODUCTS Cosyntropin Cortrosyn Injection Solution Reconstituted 0.25 MG Tier 3 x ANTIARRHYTHMICS Ibutilide Fumarate Corvert Intravenous Solution 1 MG/10ML Tier 3 x HEMATOPOIETIC AGENTS Iron‐Folic Acid‐‐Vitamin B6‐Vitamin B12‐ Corvita 150 Oral Tablet 150‐1.25 MG Tier 1 MULTIVITAMINS Multiple Vitamins w/ Minerals & Folic Acid Corvita Oral Tablet 1.25 MG Tier 1 HEMATOPOIETIC AGENTS Iron Combinations Corvite 150 Oral Tablet Tier 3 HEMATOPOIETIC AGENTS Iron‐Folic Acid‐Vitamin C‐Vitamin B6‐Vitamin B12‐Zinc Corvite 150 Oral Tablet 150‐1.25 MG Tier 3 HEMATOPOIETIC AGENTS Iron Combinations Corvite Fe Oral Tablet Tier 3 MULTIVITAMINS Multiple Vitamins w/ Minerals Corvite Free Oral Tablet Tier 1 MULTIVITAMINS Multiple Vitamins w/ Minerals & Folic Acid Corvite Oral Tablet 1.25 MG Tier 3 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ANTIHYPERTENSIVES Nadolol & Bendroflumethiazide Corzide Oral Tablet 40‐5 MG Tier 3 ANTIHYPERTENSIVES Nadolol & Bendroflumethiazide Corzide Oral Tablet 80‐5 MG Tier 3 DERMATOLOGICALS Secukinumab Cosentyx Sensoready Pen Subcutaneous Solution Auto‐injector 150 MG/ML Tier 2 x DERMATOLOGICALS Secukinumab Cosentyx Subcutaneous Solution Prefilled Syringe 150 MG/ML Tier 2 x OPHTHALMIC AGENTS Dorzolamide HCl‐Timolol Maleate Cosopt Ophthalmic Solution 22.3‐6.8 MG/ML Tier 3 OPHTHALMIC AGENTS Dorzolamide HCl‐Timolol Maleate Cosopt PF Ophthalmic Solution 22.3‐6.8 MG/ML Tier 3 DIAGNOSTIC PRODUCTS Cosyntropin Cosyntropin Injection Solution Reconstituted 0.25 MG Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Cobimetinib Fumarate Cotellic Oral Tablet 20 MG Tier 3 x x ANTICOAGULANTS Sodium Coumadin Oral Tablet 1 MG Tier 3 ANTICOAGULANTS Warfarin Sodium Coumadin Oral Tablet 10 MG Tier 3 ANTICOAGULANTS Warfarin Sodium Coumadin Oral Tablet 2 MG Tier 3 ANTICOAGULANTS Warfarin Sodium Coumadin Oral Tablet 2.5 MG Tier 3 ANTICOAGULANTS Warfarin Sodium Coumadin Oral Tablet 3 MG Tier 3 ANTICOAGULANTS Warfarin Sodium Coumadin Oral Tablet 4 MG Tier 3 ANTICOAGULANTS Warfarin Sodium Coumadin Oral Tablet 5 MG Tier 3 ANTICOAGULANTS Warfarin Sodium Coumadin Oral Tablet 6 MG Tier 3 ANTICOAGULANTS Warfarin Sodium Coumadin Oral Tablet 7.5 MG Tier 3 ALTERNATIVE MEDICINES Ubiquinol‐Vitamin B12‐Resveratrol‐Folic Acid Co‐Veratrol Oral Capsule 200‐5‐400‐0.8 MG Tier 3 ANTIHYPERTENSIVES Losartan Potassium Cozaar Oral Tablet 100 MG Tier 3 ANTIHYPERTENSIVES Losartan Potassium Cozaar Oral Tablet 25 MG Tier 3 ANTIHYPERTENSIVES Losartan Potassium Cozaar Oral Tablet 50 MG Tier 3 PHARMACEUTICAL ADJUVANTS Cream Base Liposomic Cream Base Liposomic External Cream Tier 2 DIGESTIVE AIDS Pancrelipase (Lipase‐Protease‐Amylase) Creon Oral Capsule Delayed Release Particles 12000 UNIT Tier 2 DIGESTIVE AIDS Pancrelipase (Lipase‐Protease‐Amylase) Creon Oral Capsule Delayed Release Particles 24000 UNIT Tier 2 DIGESTIVE AIDS Pancrelipase (Lipase‐Protease‐Amylase) Creon Oral Capsule Delayed Release Particles 3000‐9500 UNIT Tier 2 DIGESTIVE AIDS Pancrelipase (Lipase‐Protease‐Amylase) Creon Oral Capsule Delayed Release Particles 36000 UNIT Tier 2 DIGESTIVE AIDS Pancrelipase (Lipase‐Protease‐Amylase) Creon Oral Capsule Delayed Release Particles 6000 UNIT Tier 2 ANTIFUNGALS Isavuconazonium Sulfate Cresemba Oral Capsule 186 MG Tier 3 x ANTIHYPERLIPIDEMICS Rosuvastatin Calcium Crestor Oral Tablet 10 MG Tier 2 x ANTIHYPERLIPIDEMICS Rosuvastatin Calcium Crestor Oral Tablet 20 MG Tier 2 x ANTIHYPERLIPIDEMICS Rosuvastatin Calcium Crestor Oral Tablet 40 MG Tier 2 x ANTIHYPERLIPIDEMICS Rosuvastatin Calcium Crestor Oral Tablet 5 MG Tier 2 x VAGINAL PRODUCTS Progesterone (Vaginal) Crinone Vaginal Gel 4 % Tier 3 VAGINAL PRODUCTS Progesterone (Vaginal) Crinone Vaginal Gel 8 % Tier 3 ANTIVIRALS Indinavir Sulfate Crixivan Oral Capsule 200 MG Tier 2 x ANTIVIRALS Indinavir Sulfate Crixivan Oral Capsule 400 MG Tier 2 x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Cromolyn Sodium Cromolyn Sodium Inhalation Nebulization Solution 20 MG/2ML Tier 2 OPHTHALMIC AGENTS Cromolyn Sodium (Ophth) Cromolyn Sodium Ophthalmic Solution 4 % Tier 1 GASTROINTESTINAL AGENTS ‐ MISC. Cromolyn Sodium (Mastocytosis) Cromolyn Sodium Oral Concentrate 100 MG/5ML Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Cromolyn Sodium Cromolyn Sodium Powder Tier 3 CONTRACEPTIVES Norgestrel & Ethinyl Estradiol Cryselle‐28 Oral Tablet 0.3‐30 MG‐MCG Tier 1 MINERALS & ELECTROLYTES Cupric Sulfate Cupric Sulfate Granules Tier 3 ASSORTED CLASSES Penicillamine Cuprimine Oral Capsule 250 MG Tier 3 MEDICAL DEVICES AND SUPPLIES Alcohol Swabs Curity Alcohol Preps Pad 70 % Tier 2 RESPIRATORY AGENTS ‐ MISC. Poractant Alfa Curosurf Inhalation Suspension 80 MG/ML Tier 3 DERMATOLOGICALS Fluticasone Propionate Cutivate External Cream 0.05 % Tier 3 DERMATOLOGICALS Fluticasone Propionate Cutivate External Lotion 0.05 % Tier 3 ULCER DRUGS Glycopyrrolate Cuvposa Oral Solution 1 MG/5ML Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood CVS Advanced Glucose Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets CVS Lancets 21G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets CVS Lancets Micro Thin 33G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets CVS Lancets Original Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets CVS Lancets Thin 26G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets CVS Lancets Ultra Thin 30G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets CVS Ultra Thin Lancets Miscellaneous Tier 2 HEMATOPOIETIC AGENTS Cyanocobalamin Cyanocobalamin Injection Solution 1000 MCG/ML Tier 1 x HEMATOPOIETIC AGENTS Cyanocobalamin Cyanocobalamin Powder Tier 3 CONTRACEPTIVES Norethindrone & Eth Estradiol Cyclafem 1/35 Oral Tablet 1‐35 MG‐MCG Tier 1 CONTRACEPTIVES Norethindrone‐Eth Estradiol (Triphasic) Cyclafem 7/7/7 Oral Tablet 0.5/0.75/1‐35 MG‐MCG Tier 1 CONTRACEPTIVES Desogestrel‐Ethinyl Estradiol (Triphasic) Cyclessa Oral Tablet 0.1/0.125/0.15 ‐0.025 MG Tier 3 MUSCULOSKELETAL THERAPY AGENTS Cyclobenzaprine HCl w/ Liniment Cyclobenzaprine Comfort Pac Combination Kit 10 MG Tier 3 MUSCULOSKELETAL THERAPY AGENTS Cyclobenzaprine HCl Cyclobenzaprine HCl Oral Tablet 10 MG Tier 1 MUSCULOSKELETAL THERAPY AGENTS Cyclobenzaprine HCl Cyclobenzaprine HCl Oral Tablet 5 MG Tier 1 MUSCULOSKELETAL THERAPY AGENTS Cyclobenzaprine HCl Cyclobenzaprine HCl Oral Tablet 7.5 MG Tier 1 MUSCULOSKELETAL THERAPY AGENTS Cyclobenzaprine‐Capsaicin‐Menthol CyclobenzaprinePax Combination Therapy Pack 10 & 0.0375‐5 MG & % Tier 3 OPHTHALMIC AGENTS Cyclopentolate HCl Cyclogyl Ophthalmic Solution 0.5 % Tier 2 OPHTHALMIC AGENTS Cyclopentolate HCl Cyclogyl Ophthalmic Solution 1 % Tier 2 OPHTHALMIC AGENTS Cyclopentolate HCl Cyclogyl Ophthalmic Solution 2 % Tier 2 OPHTHALMIC AGENTS Cyclopentolate w/ Phenylephrine Cyclomydril Ophthalmic Solution 0.2‐1 % Tier 3 CHEMICALS Cyclopentasiloxane‐PEG/PPG‐18/18 Dimethicone Cyclopentasilox‐PEG/PPG Dimeth Liquid Tier 3 OPHTHALMIC AGENTS Cyclopentolate HCl Cyclopentolate HCl Ophthalmic Solution 1 % Tier 1 OPHTHALMIC AGENTS Cyclopentolate HCl Cyclopentolate HCl Ophthalmic Solution 2 % Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Cyclophosphamide Cyclophosphamide Injection Solution Reconstituted 1 GM Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Cyclophosphamide Cyclophosphamide Injection Solution Reconstituted 2 GM Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Cyclophosphamide Cyclophosphamide Injection Solution Reconstituted 500 MG Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Cyclophosphamide Cyclophosphamide Oral Capsule 25 MG Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Cyclophosphamide Cyclophosphamide Oral Capsule 50 MG Tier 3 ANTIMYCOBACTERIAL AGENTS CycloSERINE Oral Capsule 250 MG Tier 3 ANTIDIABETICS Bromocriptine Mesylate (Diabetes) Cycloset Oral Tablet 0.8 MG Tier 3 x ASSORTED CLASSES Cyclosporine Modified (For Microemulsion) CycloSPORINE Modified Oral Capsule 100 MG Tier 1 ASSORTED CLASSES Cyclosporine Modified (For Microemulsion) CycloSPORINE Modified Oral Capsule 25 MG Tier 1 ASSORTED CLASSES Cyclosporine Modified (For Microemulsion) CycloSPORINE Modified Oral Capsule 50 MG Tier 2 ASSORTED CLASSES Cyclosporine Modified (For Microemulsion) CycloSPORINE Modified Oral Solution 100 MG/ML Tier 1 ASSORTED CLASSES Cyclosporine CycloSPORINE Oral Capsule 100 MG Tier 1 ASSORTED CLASSES Cyclosporine CycloSPORINE Oral Capsule 25 MG Tier 1 HEMOSTATICS Tranexamic Acid Cyklokapron Intravenous Solution 100 MG/ML Tier 3 x ANTIDEPRESSANTS Duloxetine HCl Cymbalta Oral Capsule Delayed Release Particles 20 MG Tier 3 ANTIDEPRESSANTS Duloxetine HCl Cymbalta Oral Capsule Delayed Release Particles 30 MG Tier 3 ANTIDEPRESSANTS Duloxetine HCl Cymbalta Oral Capsule Delayed Release Particles 60 MG Tier 3 ANTIHISTAMINES Cyproheptadine HCl Cyproheptadine HCl Oral Syrup 2 MG/5ML Tier 1 ANTIHISTAMINES Cyproheptadine HCl Cyproheptadine HCl Oral Tablet 4 MG Tier 1 CONTRACEPTIVES Desogestrel & Ethinyl Estradiol Cyred Oral Tablet 0.15‐30 MG‐MCG Tier 1 GENITOURINARY AGENTS ‐ MISCELLANEOUS Cysteamine Bitartrate Cystagon Oral Capsule 150 MG Tier 2 x GENITOURINARY AGENTS ‐ MISCELLANEOUS Cysteamine Bitartrate Cystagon Oral Capsule 50 MG Tier 2 x OPHTHALMIC AGENTS Cysteamine HCl Cystaran Ophthalmic Solution 0.44 % Tier 2 x x DIAGNOSTIC PRODUCTS Iothalamate Meglumine Cysto‐Conray II Urethral Solution 17.2 % Tier 3 DIAGNOSTIC PRODUCTS Diatrizoate Meglumine Cystografin Urethral Solution 30 % Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Cytarabine Cytarabine (PF) Injection Solution 100 MG/ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Cytarabine Cytarabine (PF) Injection Solution 20 MG/ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Cytarabine Cytarabine Injection Solution 20 MG/ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Cytarabine Cytarabine Injection Solution Reconstituted 100 MG Tier 2 x THYROID AGENTS Liothyronine Sodium Cytomel Oral Tablet 25 MCG Tier 3 THYROID AGENTS Liothyronine Sodium Cytomel Oral Tablet 5 MCG Tier 3 THYROID AGENTS Liothyronine Sodium Cytomel Oral Tablet 50 MCG Tier 3 ULCER DRUGS Misoprostol Cytotec Oral Tablet 100 MCG Tier 3 ULCER DRUGS Misoprostol Cytotec Oral Tablet 200 MCG Tier 3 GENITOURINARY AGENTS ‐ MISCELLANEOUS Potassium Citrate‐Citric Acid Cytra K Crystals Oral Packet 3300‐1002 MG Tier 1 GENITOURINARY AGENTS ‐ MISCELLANEOUS Sodium Citrate & Citric Acid Cytra‐2 Oral Solution 500‐334 MG/5ML Tier 1 GENITOURINARY AGENTS ‐ MISCELLANEOUS Pot & Sod Citrates w/Citric Ac Cytra‐3 Oral Syrup 550‐500‐334 MG/5ML Tier 3 GENITOURINARY AGENTS ‐ MISCELLANEOUS Potassium Citrate‐Citric Acid Cytra‐K Oral Solution 1100‐334 MG/5ML Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Dacarbazine Dacarbazine Intravenous Solution Reconstituted 200 MG Tier 1 x ANTIVIRALS Dihydrochloride Daklinza Oral Tablet 30 MG Tier 2 x x HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ANTIVIRALS Daclatasvir Dihydrochloride Daklinza Oral Tablet 60 MG Tier 2 x x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Roflumilast Daliresp Oral Tablet 500 MCG Tier 3 x ANDROGENS‐ANABOLIC Danazol Danazol Oral Capsule 100 MG Tier 1 ANDROGENS‐ANABOLIC Danazol Danazol Oral Capsule 200 MG Tier 1 ANDROGENS‐ANABOLIC Danazol Danazol Oral Capsule 50 MG Tier 1 ANDROGENS‐ANABOLIC Danazol Danazol Powder Tier 3 MUSCULOSKELETAL THERAPY AGENTS Dantrolene Sodium Dantrium Oral Capsule 25 MG Tier 3 MUSCULOSKELETAL THERAPY AGENTS Dantrolene Sodium Dantrium Oral Capsule 50 MG Tier 3 MUSCULOSKELETAL THERAPY AGENTS Dantrolene Sodium Dantrolene Sodium Oral Capsule 100 MG Tier 3 MUSCULOSKELETAL THERAPY AGENTS Dantrolene Sodium Dantrolene Sodium Oral Capsule 25 MG Tier 1 MUSCULOSKELETAL THERAPY AGENTS Dantrolene Sodium Dantrolene Sodium Oral Capsule 50 MG Tier 1 ANTI‐INFECTIVE AGENTS ‐ MISC. Dapsone Dapsone Oral Tablet 100 MG Tier 2 ANTI‐INFECTIVE AGENTS ‐ MISC. Dapsone Dapsone Oral Tablet 25 MG Tier 2 TOXOIDS Diphtheria, Acellular Pertussis & Tetanus Toxoids Daptacel Intramuscular Suspension 10‐15‐5 Tier 3 x ANTIMALARIALS Pyrimethamine Daraprim Oral Tablet 25 MG Tier 2 x CONTRACEPTIVES Norethindrone & Eth Estradiol Dasetta 1/35 Oral Tablet 1‐35 MG‐MCG Tier 1 CONTRACEPTIVES Norethindrone‐Eth Estradiol (Triphasic) Dasetta 7/7/7 Oral Tablet 0.5/0.75/1‐35 MG‐MCG Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Daunorubicin HCl DAUNOrubicin HCl Intravenous Injectable 5 MG/ML Tier 1 x ANALGESICS ‐ ANTI‐INFLAMMATORY Oxaprozin Daypro Oral Tablet 600 MG Tier 3 CONTRACEPTIVES Levonorgestrel‐Ethinyl Estradiol (91‐Day) Daysee Oral Tablet 0.15‐0.03 &0.01 MG Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate Daytrana Transdermal Patch 10 MG/9HR Tier 3 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate Daytrana Transdermal Patch 15 MG/9HR Tier 3 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate Daytrana Transdermal Patch 20 MG/9HR Tier 3 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate Daytrana Transdermal Patch 30 MG/9HR Tier 3 x x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Desmopressin Acetate DDAVP Injection Solution 4 MCG/ML Tier 3 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Desmopressin Acetate Spray DDAVP Nasal Solution 0.01 % Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Desmopressin Acetate DDAVP Oral Tablet 0.1 MG Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Desmopressin Acetate DDAVP Oral Tablet 0.2 MG Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Desmopressin Acetate Refrigerated DDAVP Rhinal Tube Nasal Solution 0.01 % Tier 3 MOUTH/THROAT/DENTAL AGENTS ‐Sulfonated Phenolics Debacterol Mouth/Throat Solution 30‐50 % Tier 3 CONTRACEPTIVES Norethindrone (Contraceptive) Deblitane Oral Tablet 0.35 MG Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Decitabine Decitabine Intravenous Solution Reconstituted 50 MG Tier 1 x COUGH/COLD/ALLERGY Brompheniramine & Phenyleph Decon‐A Oral Elixir 2‐5 MG/5ML Tier 3 ANTIDOTES Deferoxamine Mesylate Deferoxamine Mesylate Injection Solution Reconstituted 2 GM Tier 1 x ANTIDOTES Deferoxamine Mesylate Deferoxamine Mesylate Injection Solution Reconstituted 500 MG Tier 1 x DIAGNOSTIC PRODUCTS Perflutren Lipid Microsphere Definity Intravenous Suspension 6.52 MG/ML Tier 3 x CHEMICALS Micronized Micro Powder Tier 3 CHEMICALS Prasterone Dehydroepiandrosterone Powder Tier 3 ESTROGENS Estradiol Valerate Delestrogen Intramuscular Oil 10 MG/ML Tier 3 x ESTROGENS Estradiol Valerate Delestrogen Intramuscular Oil 20 MG/ML Tier 3 x ESTROGENS Estradiol Valerate Delestrogen Intramuscular Oil 40 MG/ML Tier 3 x CORTICOSTEROIDS Prednisone Deltasone Oral Tablet 20 MG Tier 1 CONTRACEPTIVES Levonorgestrel & Eth Estradiol Delyla Oral Tablet 0.1‐20 MG‐MCG Tier 1 GASTROINTESTINAL AGENTS ‐ MISC. Mesalamine Delzicol Oral Capsule Delayed Release 400 MG Tier 3 xx DIURETICS Torsemide Demadex Oral Tablet 10 MG Tier 3 DIURETICS Torsemide Demadex Oral Tablet 20 MG Tier 3 DIURETICS Torsemide Demadex Oral Tablet 5 MG Tier 3 TETRACYCLINES Demeclocycline HCl Demeclocycline HCl Oral Tablet 150 MG Tier 1 TETRACYCLINES Demeclocycline HCl Demeclocycline HCl Oral Tablet 300 MG Tier 1 ANALGESICS ‐ OPIOID Meperidine HCl Demerol Injection Solution 100 MG/ML Tier 3 x ANALGESICS ‐ OPIOID Meperidine HCl Demerol Injection Solution 50 MG/ML Tier 3 x ANALGESICS ‐ OPIOID Meperidine HCl Demerol Oral Tablet 100 MG Tier 3 ANALGESICS ‐ OPIOID Meperidine HCl Demerol Oral Tablet 50 MG Tier 3 ANTIHYPERTENSIVES Metyrosine Demser Oral Capsule 250 MG Tier 3 DERMATOLOGICALS Penciclovir Denavir External Cream 1 % Tier 3 DERMATOLOGICALS Capsaicin‐Menthol‐Methyl Salicylate Dendracin Neurodendraxcin External Lotion 0.025‐10‐30 % Tier 3 MOUTH/THROAT/DENTAL AGENTS Sodium Fluoride (Dental) Denta 5000 Plus Dental Cream 1.1 % Tier 1 ANTICONVULSANTS Valproic Acid Depakene Oral Capsule 250 MG Tier 3 ANTICONVULSANTS Valproate Sodium Depakene Oral Syrup 250 MG/5ML Tier 3 ANTICONVULSANTS Divalproex Sodium Depakote ER Oral Tablet Extended Release 24 Hour 250 MG Tier 3 ANTICONVULSANTS Divalproex Sodium Depakote ER Oral Tablet Extended Release 24 Hour 500 MG Tier 3 ANTICONVULSANTS Divalproex Sodium Depakote Oral Tablet Delayed Release 125 MG Tier 3 ANTICONVULSANTS Divalproex Sodium Depakote Oral Tablet Delayed Release 250 MG Tier 3 ANTICONVULSANTS Divalproex Sodium Depakote Oral Tablet Delayed Release 500 MG Tier 3 ANTICONVULSANTS Divalproex Sodium Depakote Sprinkles Oral Capsule Sprinkle 125 MG Tier 3 ASSORTED CLASSES Penicillamine Depen Titratabs Oral Tablet 250 MG Tier 2 ESTROGENS Estradiol Cypionate Depo‐Estradiol Intramuscular Oil 5 MG/ML Tier 3 x CORTICOSTEROIDS Methylprednisolone Acetate Depo‐Medrol Injection Suspension 40 MG/ML Tier 3 x CORTICOSTEROIDS Methylprednisolone Acetate Depo‐Medrol Injection Suspension 80 MG/ML Tier 3 x CONTRACEPTIVES Medroxyprogesterone Acetate (Contraceptive) Depo‐Provera Intramuscular Suspension 150 MG/ML Tier 3 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Medroxyprogesterone Acetate (Antineoplastic) Depo‐Provera Intramuscular Suspension 400 MG/ML Tier 3 x CONTRACEPTIVES Medroxyprogesterone Acetate (Contraceptive) Depo‐SubQ Provera 104 Subcutaneous Suspension 104 MG/0.65ML Tier 3 x x ANDROGENS‐ANABOLIC Testosterone Cypionate Depo‐Testosterone Intramuscular Solution 100 MG/ML Tier 3 x ANDROGENS‐ANABOLIC Testosterone Cypionate Depo‐Testosterone Intramuscular Solution 200 MG/ML Tier 3 x ULCER DRUGS Ranitidine HCl Deprizine FusePaq Oral Suspension Reconstituted 22.4 MG/ML Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Diclofenac Sodium‐Ranitidine HCl‐Capsaicin Derma SilkRX Anodynexa Pak Combination Therapy Pack 75‐150‐0.025 MG‐MG‐% Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Diclofenac Sodium‐Capsaicin Derma SilkRX DicloPak Combination Therapy Pack 75 & 0.025 MG‐% Tier 3 x DERMATOLOGICALS Triamcinolone Acetonide‐Dimethicone‐Silicone Derma SilkRX SDS Pak External Kit 0.1 & 5 % Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Diclofenac Sodium & Lidocaine‐Menthol‐Methyl Salicylate DermacinRx Analgesic ComboPak Combination Kit 75 MG Tier 3 x NASAL AGENTS ‐ SYSTEMIC AND TOPICAL Azelastine HCl‐Fluticasone Propionate DermacinRx Azenase Pak Nasal Therapy Pack 137 & 50 MCG/ACT Tier 3 xx DERMATOLOGICALS Methyl Salicylate‐Lidocaine‐Menthol DermacinRx DuoPatch PharmaPak External Therapy Pack 5 & 3‐10 % Tier 3 x CHEMICALS Carbitol DermacinRx Ethoxy Diglycol Liquid Tier 3 x ANALGESICS ‐ ANTI‐INFLAMMATORY Diclofenac Sodium‐Ranitidine HCl‐Capsaicin DermacinRx Inflammatral Pak Combination Therapy Pack 75‐150‐0.025 MG‐MG‐% Tier 3 x DERMATOLOGICALS Diclofenac Sodium‐Capsaicin (Topical) DermacinRx Lexitral PharmaPak Combination Therapy Pack 1.5 & 0.025 % Tier 3 x DERMATOLOGICALS Lidocaine‐Capsaicin DermacinRx NeuroTral PharmaPak External Therapy Pack 5 & 0.025 % Tier 3 x HEMATOPOIETIC AGENTS Folic Acid‐Cholecalciferol DermacinRx PureFolix Oral Tablet 1‐5000 MG‐UNIT Tier 3 x DERMATOLOGICALS Triamcinolone Acetonide‐Dimethicone‐Silicone DermacinRx SilaPak External Kit 0.1 & 5 % Tier 3 x DERMATOLOGICALS Chlorhexidine Gluconate‐Mupirocin‐Dimethicone‐Silicone DermacinRx Surgical PharmaPak External Kit Tier 3 x NASAL AGENTS ‐ SYSTEMIC AND TOPICAL Fluticasone Propionate‐Sodium Chloride DermacinRx Ticanase Pak Nasal Therapy Pack 50‐2.7 MCG/ACT‐% Tier 3 xx DERMATOLOGICALS Fluocinolone Acetonide Derma‐Smoothe/FS Body External Oil 0.01 % Tier 3 DERMATOLOGICALS Fluocinolone Acetonide Derma‐Smoothe/FS Scalp External Oil 0.01 % Tier 3 DERMATOLOGICALS Hydrocortisone & Cleanser Dermasorb HC External Kit 2 % Tier 3 DERMATOLOGICALS Triamcinolone Acetonide & Emollient Dermasorb TA External Kit 0.1 % Tier 3 DERMATOLOGICALS Urea & Emollient Dermasorb XM External Kit 39 % Tier 3 DERMATOLOGICALS Prednicarbate Dermatop External Cream 0.1 % Tier 3 DERMATOLOGICALS Prednicarbate Dermatop External Ointment 0.1 % Tier 3 DERMATOLOGICALS Chlorhexidine Gluconate‐Mupirocin‐Dimethicone‐Silicone DermaWerx Surgical Plus Pak External Kit 4 & 2 & 5 % (Oint) Tier 3 OTIC AGENTS Fluocinolone Acetonide (Otic) DermOtic Otic Oil 0.01 % Tier 3 ANTIDOTES Deferoxamine Mesylate Desferal Injection Solution Reconstituted 500 MG Tier 3 x ANTIDEPRESSANTS Desipramine HCl Desipramine HCl Oral Tablet 10 MG Tier 1 ANTIDEPRESSANTS Desipramine HCl Desipramine HCl Oral Tablet 100 MG Tier 1 ANTIDEPRESSANTS Desipramine HCl Desipramine HCl Oral Tablet 150 MG Tier 1 ANTIDEPRESSANTS Desipramine HCl Desipramine HCl Oral Tablet 25 MG Tier 1 ANTIDEPRESSANTS Desipramine HCl Desipramine HCl Oral Tablet 50 MG Tier 1 ANTIDEPRESSANTS Desipramine HCl Desipramine HCl Oral Tablet 75 MG Tier 1 ANTIHISTAMINES Desloratadine Desloratadine Oral Tablet 5 MG Tier 1 ANTIHISTAMINES Desloratadine Desloratadine Oral Tablet Dispersible 2.5 MG Tier 1 ANTIHISTAMINES Desloratadine Desloratadine Oral Tablet Dispersible 5 MG Tier 1 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Desmopressin Acetate Refrigerated Desmopressin Ace Rhinal Tube Nasal Solution 0.01 % Tier 1 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Desmopressin Acetate Spray Refrigerated Desmopressin Ace Spray Refrig Nasal Solution 0.01 % Tier 1 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Desmopressin Acetate Desmopressin Acetate Injection Solution 4 MCG/ML Tier 1 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Desmopressin Acetate Desmopressin Acetate Oral Tablet 0.1 MG Tier 1 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Desmopressin Acetate Desmopressin Acetate Oral Tablet 0.2 MG Tier 1 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Desmopressin Acetate Spray Desmopressin Acetate Spray Nasal Solution 0.01 % Tier 1 CONTRACEPTIVES Desogestrel & Ethinyl Estradiol Desogen Oral Tablet 0.15‐30 MG‐MCG Tier 3 CONTRACEPTIVES Desogestrel‐Ethinyl Estradiol (Biphasic) Desogestrel‐Ethinyl Estradiol Oral Tablet 0.15‐0.02/0.01 MG (21/5) Tier 1 CONTRACEPTIVES Desogestrel & Ethinyl Estradiol Desogestrel‐Ethinyl Estradiol Oral Tablet 0.15‐30 MG‐MCG Tier 1 DERMATOLOGICALS Desonide Desonate External Gel 0.05 % Tier 3 DERMATOLOGICALS Desonide Desonide External Cream 0.05 % Tier 1 DERMATOLOGICALS Desonide Desonide External Lotion 0.05 % Tier 1 DERMATOLOGICALS Desonide Desonide External Ointment 0.05 % Tier 1 DERMATOLOGICALS Desonide Desonide Powder Tier 3 DERMATOLOGICALS Desonide DesOwen External Cream 0.05 % Tier 3 DERMATOLOGICALS Desonide DesOwen External Lotion 0.05 % Tier 3 DERMATOLOGICALS Desonide DesOwen External Ointment 0.05 % Tier 3 DERMATOLOGICALS Desoximetasone Desoximetasone External Cream 0.05 % Tier 2 DERMATOLOGICALS Desoximetasone Desoximetasone External Cream 0.25 % Tier 1 DERMATOLOGICALS Desoximetasone Desoximetasone External Gel 0.05 % Tier 1 DERMATOLOGICALS Desoximetasone Desoximetasone External Ointment 0.05 % Tier 3 DERMATOLOGICALS Desoximetasone Desoximetasone External Ointment 0.25 % Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methamphetamine HCl Desoxyn Oral Tablet 5 MG Tier 3 ANTIDEPRESSANTS Desvenlafaxine Desvenlafaxine ER Oral Tablet Extended Release 24 Hour 100 MG Tier 3 xx ANTIDEPRESSANTS Desvenlafaxine Desvenlafaxine ER Oral Tablet Extended Release 24 Hour 50 MG Tier 3 xx ANTIDEPRESSANTS Desvenlafaxine Fumarate Desvenlafaxine Fumarate ER Oral Tablet Extended Release 24 Hour 100 MG Tier 3 xx ANTIDEPRESSANTS Desvenlafaxine Fumarate Desvenlafaxine Fumarate ER Oral Tablet Extended Release 24 Hour 50 MG Tier 3 xx URINARY ANTISPASMODICS Tolterodine Tartrate Detrol LA Oral Capsule Extended Release 24 Hour 2 MG Tier 3 x URINARY ANTISPASMODICS Tolterodine Tartrate Detrol LA Oral Capsule Extended Release 24 Hour 4 MG Tier 3 URINARY ANTISPASMODICS Tolterodine Tartrate Detrol Oral Tablet 1 MG Tier 3 URINARY ANTISPASMODICS Tolterodine Tartrate Detrol Oral Tablet 2 MG Tier 3 CORTICOSTEROIDS Dexamethasone Acetate Dexamethasone Acetate Powder Tier 3 CORTICOSTEROIDS Dexamethasone Dexamethasone Base Powder Tier 3 CORTICOSTEROIDS Dexamethasone Dexamethasone Intensol Oral Concentrate 1 MG/ML Tier 3 CORTICOSTEROIDS Dexamethasone Dexamethasone Oral Elixir 0.5 MG/5ML Tier 1 CORTICOSTEROIDS Dexamethasone Dexamethasone Oral Solution 0.5 MG/5ML Tier 2 CORTICOSTEROIDS Dexamethasone Dexamethasone Oral Tablet 0.5 MG Tier 1 CORTICOSTEROIDS Dexamethasone Dexamethasone Oral Tablet 0.75 MG Tier 1 CORTICOSTEROIDS Dexamethasone Dexamethasone Oral Tablet 1 MG Tier 2 CORTICOSTEROIDS Dexamethasone Dexamethasone Oral Tablet 1.5 MG Tier 1 CORTICOSTEROIDS Dexamethasone Dexamethasone Oral Tablet 2 MG Tier 2 CORTICOSTEROIDS Dexamethasone Dexamethasone Oral Tablet 4 MG Tier 1 CORTICOSTEROIDS Dexamethasone Dexamethasone Oral Tablet 6 MG Tier 1 CORTICOSTEROIDS Dexamethasone Dexamethasone Powder Tier 3 CORTICOSTEROIDS Dexamethasone Sodium Phosphate Dexamethasone Sod Phosphate PF Injection Solution 10 MG/ML Tier 3 x CORTICOSTEROIDS Dexamethasone Sodium Phosphate Dexamethasone Sodium Phosphate Injection Solution 10 MG/ML Tier 3 x CORTICOSTEROIDS Dexamethasone Sodium Phosphate Dexamethasone Sodium Phosphate Injection Solution 100 MG/10ML Tier 1 x CORTICOSTEROIDS Dexamethasone Sodium Phosphate Dexamethasone Sodium Phosphate Injection Solution 120 MG/30ML Tier 1 x CORTICOSTEROIDS Dexamethasone Sodium Phosphate Dexamethasone Sodium Phosphate Injection Solution 20 MG/5ML Tier 1 x CORTICOSTEROIDS Dexamethasone Sodium Phosphate Dexamethasone Sodium Phosphate Injection Solution 4 MG/ML Tier 1 x OPHTHALMIC AGENTS Dexamethasone Sodium Phosphate (Ophth) Dexamethasone Sodium Phosphate Ophthalmic Solution 0.1 % Tier 3 CORTICOSTEROIDS Dexamethasone Sodium Phosphate Dexamethasone Sodium Phosphate Powder Tier 3 MEDICAL DEVICES AND SUPPLIES Continuous Blood Glucose Monitor Dexcom G4 Plat Ped Rcv/Share Kit Tier 3 MEDICAL DEVICES AND SUPPLIES Continuous Blood Glucose Monitor Dexcom G4 Platinum Pediatric Kit Tier 3 MEDICAL DEVICES AND SUPPLIES Continuous Blood Glucose Monitor Dexcom G4 Platinum Rcv/Share Kit Tier 3 MEDICAL DEVICES AND SUPPLIES Continuous Blood Glucose Monitor Dexcom G4 Platinum Receiver Kit Tier 3 MEDICAL DEVICES AND SUPPLIES Continuous Blood Glucose Monitor Dexcom G5 Mobile Receiver Kit Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dextroamphetamine Sulfate Dexedrine Oral Capsule Extended Release 24 Hour 10 MG Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dextroamphetamine Sulfate Dexedrine Oral Capsule Extended Release 24 Hour 15 MG Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dextroamphetamine Sulfate Dexedrine Oral Capsule Extended Release 24 Hour 5 MG Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dextroamphetamine Sulfate Dexedrine Oral Tablet 10 MG Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dextroamphetamine Sulfate Dexedrine Oral Tablet 5 MG Tier 1 ULCER DRUGS Dexlansoprazole Dexilant Oral Capsule Delayed Release 30 MG Tier 2 x x ULCER DRUGS Dexlansoprazole Dexilant Oral Capsule Delayed Release 60 MG Tier 2 x x CORTICOSTEROIDS Dexamethasone Sod Phos & Bupivacaine HCl & Lidocaine HCl Dexlido‐M Injection Kit 10 & 0.25 & 1 MG/ML‐%‐% Tier 3 x HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Dexmedetomidine HCl Dexmedetomidine HCl Intravenous Solution 200 MCG/2ML Tier 1 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dexmethylphenidate HCl Dexmethylphenidate HCl ER Oral Capsule Extended Release 24 Hour 10 MG Tier 1 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dexmethylphenidate HCl Dexmethylphenidate HCl ER Oral Capsule Extended Release 24 Hour 15 MG Tier 1 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dexmethylphenidate HCl Dexmethylphenidate HCl ER Oral Capsule Extended Release 24 Hour 20 MG Tier 1 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dexmethylphenidate HCl Dexmethylphenidate HCl ER Oral Capsule Extended Release 24 Hour 30 MG Tier 1 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dexmethylphenidate HCl Dexmethylphenidate HCl ER Oral Capsule Extended Release 24 Hour 40 MG Tier 1 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dexmethylphenidate HCl Dexmethylphenidate HCl ER Oral Capsule Extended Release 24 Hour 5 MG Tier 1 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dexmethylphenidate HCl Dexmethylphenidate HCl Oral Tablet 10 MG Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dexmethylphenidate HCl Dexmethylphenidate HCl Oral Tablet 2.5 MG Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dexmethylphenidate HCl Dexmethylphenidate HCl Oral Tablet 5 MG Tier 1 CORTICOSTEROIDS Dexamethasone DexPak 10 Day Oral Tablet 1.5 MG Tier 3 CORTICOSTEROIDS Dexamethasone DexPak 13 Day Oral Tablet 1.5 MG Tier 3 CORTICOSTEROIDS Dexamethasone DexPak 6 Day Oral Tablet 1.5 MG Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Dexrazoxane Dexrazoxane Intravenous Solution Reconstituted 250 MG Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Dexrazoxane Dexrazoxane Intravenous Solution Reconstituted 500 MG Tier 1 x CHEMICALS Dextran Dextran 40000 Powder Tier 3 CHEMICALS Dextran Dextran 75000 Powder Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dextroamphetamine Sulfate Dextroamphetamine Sulfate ER Oral Capsule Extended Release 24 Hour 10 MG Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dextroamphetamine Sulfate Dextroamphetamine Sulfate ER Oral Capsule Extended Release 24 Hour 15 MG Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dextroamphetamine Sulfate Dextroamphetamine Sulfate ER Oral Capsule Extended Release 24 Hour 5 MG Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dextroamphetamine Sulfate Dextroamphetamine Sulfate Oral Solution 5 MG/5ML Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dextroamphetamine Sulfate Dextroamphetamine Sulfate Oral Tablet 10 MG Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dextroamphetamine Sulfate Dextroamphetamine Sulfate Oral Tablet 5 MG Tier 1 COUGH/COLD/ALLERGY HBr Dextromethorphan HBr Monohyd Powder Tier 3 COUGH/COLD/ALLERGY Dextromethorphan HBr Dextromethorphan HBr Powder Tier 3 CHEMICALS Prasterone DHEA Powder Tier 3 ANTIDIABETICS Glyburide Diabeta Oral Tablet 1.25 MG Tier 2 ANTIDIABETICS Glyburide Diabeta Oral Tablet 2.5 MG Tier 2 ANTIDIABETICS Glyburide Diabeta Oral Tablet 5 MG Tier 2 MULTIVITAMINS B‐Complex w/ C‐Biotin‐E‐Minerals & Folic Acid Dialyvite 3000 Oral Tablet 3 MG Tier 3 MULTIVITAMINS B‐Complex w/ C‐Biotin‐E‐Minerals & Folic Acid Dialyvite 5000 Oral Tablet 5 MG Tier 3 MULTIVITAMINS B‐Complex w/ C & Folic Acid Dialyvite Oral Tablet Tier 1 MULTIVITAMINS Multiple Vitamins w/ Minerals & Folic Acid Dialyvite Supreme D Oral Tablet 3 MG Tier 3 MULTIVITAMINS B‐Complex w/ C‐Zn & Folic Acid Dialyvite/Zinc Oral Tablet Tier 3 DIURETICS Acetazolamide Diamox Sequels Oral Capsule Extended Release 12 Hour 500 MG Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Diastar Easy Test II Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Diastar Easy Test Lancets Miscellaneous Tier 2 ANTICONVULSANTS (Anticonvulsant) Diastat AcuDial Rectal Gel 10 MG Tier 2 ANTICONVULSANTS Diazepam (Anticonvulsant) Diastat AcuDial Rectal Gel 20 MG Tier 2 ANTICONVULSANTS Diazepam (Anticonvulsant) Diastat Pediatric Rectal Gel 2.5 MG Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood DiaTrue Plus Test In Vitro Strip Tier 3 MULTIVITAMINS B‐Complex w/ C‐Biotin‐Minerals & Folic Acid Diatx Zn Oral Tablet 5 MG Tier 3 ANTIANXIETY AGENTS Diazepam Diazepam Injection Solution 5 MG/ML Tier 3 x ANTIANXIETY AGENTS Diazepam Diazepam Intensol Oral Concentrate 5 MG/ML Tier 1 ANTIANXIETY AGENTS Diazepam Diazepam Intramuscular Device 10 MG/2ML Tier 3 x ANTIANXIETY AGENTS Diazepam Diazepam Oral Concentrate 5 MG/ML Tier 1 ANTIANXIETY AGENTS Diazepam Diazepam Oral Solution 1 MG/ML Tier 3 ANTIANXIETY AGENTS Diazepam Diazepam Oral Solution 5 MG/5ML Tier 3 ANTIANXIETY AGENTS Diazepam Diazepam Oral Tablet 10 MG Tier 1 ANTIANXIETY AGENTS Diazepam Diazepam Oral Tablet 2 MG Tier 1 ANTIANXIETY AGENTS Diazepam Diazepam Oral Tablet 5 MG Tier 1 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ANTICONVULSANTS Diazepam (Anticonvulsant) Diazepam Rectal Gel 10 MG Tier 2 ANTICONVULSANTS Diazepam (Anticonvulsant) Diazepam Rectal Gel 2.5 MG Tier 2 ANTICONVULSANTS Diazepam (Anticonvulsant) Diazepam Rectal Gel 20 MG Tier 2 ANTIHYPERTENSIVES Phenoxybenzamine HCl Dibenzyline Oral Capsule 10 MG Tier 2 CHEMICALS Squaric Acid Dibutylester Dibutyl Squarate Liquid Tier 3 ANTIEMETICS Doxylamine‐Pyridoxine Diclegis Oral Tablet Delayed Release 10‐10 MG Tier 3 x x ANALGESICS ‐ ANTI‐INFLAMMATORY Diclofenac Potassium Diclofenac Potassium Oral Tablet 50 MG Tier 1 x ANALGESICS ‐ ANTI‐INFLAMMATORY Diclofenac Sodium Diclofenac Sodium ER Oral Tablet Extended Release 24 Hour 100 MG Tier 1 x OPHTHALMIC AGENTS Diclofenac Sodium (Ophth) Diclofenac Sodium Ophthalmic Solution 0.1 % Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Diclofenac Sodium Diclofenac Sodium Oral Tablet Delayed Release 25 MG Tier 1 x ANALGESICS ‐ ANTI‐INFLAMMATORY Diclofenac Sodium Diclofenac Sodium Oral Tablet Delayed Release 50 MG Tier 1 x ANALGESICS ‐ ANTI‐INFLAMMATORY Diclofenac Sodium Diclofenac Sodium Oral Tablet Delayed Release 75 MG Tier 1 x DERMATOLOGICALS Diclofenac Sodium (Actinic Keratoses) Diclofenac Sodium Transdermal Gel 3 % Tier 1 DERMATOLOGICALS Diclofenac Sodium (Topical) Diclofenac Sodium Transdermal Solution 1.5 % Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Diclofenac w/ Misoprostol Diclofenac‐Misoprostol Oral Tablet Delayed Release 50‐0.2 MG Tier 1 x ANALGESICS ‐ ANTI‐INFLAMMATORY Diclofenac w/ Misoprostol Diclofenac‐Misoprostol Oral Tablet Delayed Release 75‐0.2 MG Tier 1 x PENICILLINS Dicloxacillin Sodium Dicloxacillin Sodium Oral Capsule 250 MG Tier 1 PENICILLINS Dicloxacillin Sodium Dicloxacillin Sodium Oral Capsule 500 MG Tier 1 ANTIHISTAMINES Diphenhydramine HCl Dicopanol FusePaq Oral Suspension Reconstituted 5 MG/ML Tier 3 ULCER DRUGS Dicyclomine HCl Dicyclomine HCl Oral Capsule 10 MG Tier 1 ULCER DRUGS Dicyclomine HCl Dicyclomine HCl Oral Solution 10 MG/5ML Tier 1 ULCER DRUGS Dicyclomine HCl Dicyclomine HCl Oral Tablet 20 MG Tier 1 ANTIVIRALS Didanosine Didanosine Oral Capsule Delayed Release 125 MG Tier 1 x ANTIVIRALS Didanosine Didanosine Oral Capsule Delayed Release 200 MG Tier 1 x ANTIVIRALS Didanosine Didanosine Oral Capsule Delayed Release 250 MG Tier 1 x ANTIVIRALS Didanosine Didanosine Oral Capsule Delayed Release 400 MG Tier 1 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Benzphetamine HCl Didrex Oral Tablet 50 MG Tier 3 x CHEMICALS Carbitol Diethylene Glycol Monoethyl Et Liquid Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Diethylpropion HCl Diethylpropion HCl ER Oral Tablet Extended Release 24 Hour 75 MG Tier 1 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Diethylpropion HCl Diethylpropion HCl Oral Tablet 25 MG Tier 1 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Diethylpropion HCl Diethylpropion HCl Oral Tablet 25 MG Tier 3 x DERMATOLOGICALS Adapalene Differin External Cream 0.1 % Tier 3 x DERMATOLOGICALS Adapalene Differin External Gel 0.1 % Tier 3 x DERMATOLOGICALS Adapalene Differin External Gel 0.3 % Tier 3 x DERMATOLOGICALS Adapalene Differin External Lotion 0.1 % Tier 3 x MACROLIDES Fidaxomicin Dificid Oral Tablet 200 MG Tier 3 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Dyphylline‐Guaifenesin Difil‐G Forte Oral Liquid 100‐100 MG/5ML Tier 1 DERMATOLOGICALS Diflorasone Diacetate Diflorasone Diacetate External Cream 0.05 % Tier 2 DERMATOLOGICALS Diflorasone Diacetate Diflorasone Diacetate External Ointment 0.05 % Tier 3 ANTIFUNGALS Fluconazole Diflucan Oral Suspension Reconstituted 10 MG/ML Tier 3 ANTIFUNGALS Fluconazole Diflucan Oral Suspension Reconstituted 40 MG/ML Tier 3 ANTIFUNGALS Fluconazole Diflucan Oral Tablet 100 MG Tier 3 ANTIFUNGALS Fluconazole Diflucan Oral Tablet 150 MG Tier 3 ANTIFUNGALS Fluconazole Diflucan Oral Tablet 200 MG Tier 3 ANTIFUNGALS Fluconazole Diflucan Oral Tablet 50 MG Tier 3 ANALGESICS ‐ NonNarcotic Diflunisal Diflunisal Oral Tablet 500 MG Tier 1 CARDIOTONICS Digoxin Digitek Oral Tablet 125 MCG Tier 1 CARDIOTONICS Digoxin Digitek Oral Tablet 250 MCG Tier 1 CARDIOTONICS Digoxin Digox Oral Tablet 125 MCG Tier 1 CARDIOTONICS Digoxin Digox Oral Tablet 250 MCG Tier 1 CARDIOTONICS Digoxin Digoxin Injection Solution 0.25 MG/ML Tier 1 x CARDIOTONICS Digoxin Digoxin Oral Solution 0.05 MG/ML Tier 3 CARDIOTONICS Digoxin Digoxin Oral Tablet 125 MCG Tier 1 CARDIOTONICS Digoxin Digoxin Oral Tablet 250 MCG Tier 1 MIGRAINE PRODUCTS Dihydroergotamine Mesylate Dihydroergotamine Mesylate Injection Solution 1 MG/ML Tier 1 x MIGRAINE PRODUCTS Dihydroergotamine Mesylate Dihydroergotamine Mesylate Nasal Solution 4 MG/ML Tier 3 x MIGRAINE PRODUCTS Dihydroergotamine Mesylate Dihydroergotamine Mesylate Powder Tier 3 ANTICONVULSANTS Phenytoin Dilantin Infatabs Oral Tablet Chewable 50 MG Tier 3 ANTICONVULSANTS Phenytoin Sodium Extended Dilantin Oral Capsule 100 MG Tier 3 ANTICONVULSANTS Phenytoin Sodium Extended Dilantin Oral Capsule 30 MG Tier 3 ANTICONVULSANTS Phenytoin Dilantin Oral Suspension 125 MG/5ML Tier 3 ANTIANGINAL AGENTS Isosorbide Dinitrate Dilatrate‐SR Oral Capsule Extended Release 40 MG Tier 2 ANALGESICS ‐ OPIOID Hydromorphone HCl Dilaudid Oral Liquid 1 MG/ML Tier 3 ANALGESICS ‐ OPIOID Hydromorphone HCl Dilaudid Oral Tablet 2 MG Tier 3 ANALGESICS ‐ OPIOID Hydromorphone HCl Dilaudid Oral Tablet 4 MG Tier 3 ANALGESICS ‐ OPIOID Hydromorphone HCl Dilaudid Oral Tablet 8 MG Tier 3 ANALGESICS ‐ OPIOID Hydromorphone HCl Dilaudid‐HP Injection Solution 10 MG/ML Tier 3 x CALCIUM CHANNEL BLOCKERS Diltiazem HCl Coated Beads Diltiazem CD Oral Capsule Extended Release 24 Hour 120 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Coated Beads Diltiazem CD Oral Capsule Extended Release 24 Hour 180 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Coated Beads Diltiazem CD Oral Capsule Extended Release 24 Hour 240 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Extended Release Beads Diltiazem HCl ER Beads Oral Capsule Extended Release 24 Hour 120 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Extended Release Beads Diltiazem HCl ER Beads Oral Capsule Extended Release 24 Hour 180 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Extended Release Beads Diltiazem HCl ER Beads Oral Capsule Extended Release 24 Hour 240 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Extended Release Beads Diltiazem HCl ER Beads Oral Capsule Extended Release 24 Hour 300 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Extended Release Beads Diltiazem HCl ER Beads Oral Capsule Extended Release 24 Hour 360 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Extended Release Beads Diltiazem HCl ER Beads Oral Capsule Extended Release 24 Hour 420 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Coated Beads Diltiazem HCl ER Coated Beads Oral Capsule Extended Release 24 Hour 120 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Coated Beads Diltiazem HCl ER Coated Beads Oral Capsule Extended Release 24 Hour 180 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Coated Beads Diltiazem HCl ER Coated Beads Oral Capsule Extended Release 24 Hour 240 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Coated Beads Diltiazem HCl ER Coated Beads Oral Capsule Extended Release 24 Hour 300 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Coated Beads Diltiazem HCl ER Coated Beads Oral Capsule Extended Release 24 Hour 360 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Coated Beads Diltiazem HCl ER Coated Beads Oral Tablet Extended Release 24 Hour 180 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Coated Beads Diltiazem HCl ER Coated Beads Oral Tablet Extended Release 24 Hour 240 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Coated Beads Diltiazem HCl ER Coated Beads Oral Tablet Extended Release 24 Hour 300 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Coated Beads Diltiazem HCl ER Coated Beads Oral Tablet Extended Release 24 Hour 360 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Coated Beads Diltiazem HCl ER Coated Beads Oral Tablet Extended Release 24 Hour 420 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Diltiazem HCl ER Oral Capsule Extended Release 12 Hour 120 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Diltiazem HCl ER Oral Capsule Extended Release 12 Hour 60 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Diltiazem HCl ER Oral Capsule Extended Release 12 Hour 90 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Diltiazem HCl ER Oral Capsule Extended Release 24 Hour 120 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Diltiazem HCl ER Oral Capsule Extended Release 24 Hour 180 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Diltiazem HCl ER Oral Capsule Extended Release 24 Hour 240 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Diltiazem HCl Intravenous Solution 125 MG/25ML Tier 1 x CALCIUM CHANNEL BLOCKERS Diltiazem HCl Diltiazem HCl Intravenous Solution 25 MG/5ML Tier 1 x CALCIUM CHANNEL BLOCKERS Diltiazem HCl Diltiazem HCl Intravenous Solution 50 MG/10ML Tier 1 x CALCIUM CHANNEL BLOCKERS Diltiazem HCl Diltiazem HCl Oral Tablet 120 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Diltiazem HCl Oral Tablet 30 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Diltiazem HCl Oral Tablet 60 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Diltiazem HCl Oral Tablet 90 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Dilt‐XR Oral Capsule Extended Release 24 Hour 120 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Dilt‐XR Oral Capsule Extended Release 24 Hour 180 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Dilt‐XR Oral Capsule Extended Release 24 Hour 240 MG Tier 1 ANTIEMETICS Dimenhydrinate DimenhyDRINATE Oral Tablet 50 MG Tier 1 CHEMICALS Dimethyl Siloxane Hydroxyalkyl‐Terminated Dimethyl Siloxane Hydroxyalkyl Liquid Tier 3 ANTIHYPERTENSIVES Valsartan‐Hydrochlorothiazide Diovan HCT Oral Tablet 160‐12.5 MG Tier 3 x ANTIHYPERTENSIVES Valsartan‐Hydrochlorothiazide Diovan HCT Oral Tablet 160‐25 MG Tier 3 x ANTIHYPERTENSIVES Valsartan‐Hydrochlorothiazide Diovan HCT Oral Tablet 320‐12.5 MG Tier 3 x ANTIHYPERTENSIVES Valsartan‐Hydrochlorothiazide Diovan HCT Oral Tablet 320‐25 MG Tier 3 x ANTIHYPERTENSIVES Valsartan‐Hydrochlorothiazide Diovan HCT Oral Tablet 80‐12.5 MG Tier 3 x ANTIHYPERTENSIVES Valsartan Diovan Oral Tablet 160 MG Tier 3 x ANTIHYPERTENSIVES Valsartan Diovan Oral Tablet 320 MG Tier 3 x ANTIHYPERTENSIVES Valsartan Diovan Oral Tablet 40 MG Tier 3 x HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ANTIHYPERTENSIVES Valsartan Diovan Oral Tablet 80 MG Tier 3 x DERMATOLOGICALS Diclofenac‐Gabapentin‐Lidocaine HCl Dipentocaine External Cream 5‐5‐2 % Tier 3 x GASTROINTESTINAL AGENTS ‐ MISC. Olsalazine Sodium Dipentum Oral Capsule 250 MG Tier 3 x ANTIDIARRHEALS Diphenoxylate w/ Atropine Diphenatol Oral Tablet 2.5‐0.025 MG Tier 1 ANTIHISTAMINES Diphenhydramine HCl DiphenhydrAMINE HCl Injection Solution 50 MG/ML Tier 1 x ANTIHISTAMINES Diphenhydramine HCl DiphenhydrAMINE HCl Oral Capsule 25 MG Tier 1 ANTIHISTAMINES Diphenhydramine HCl DiphenhydrAMINE HCl Oral Capsule 50 MG Tier 1 ANTIHISTAMINES Diphenhydramine HCl DiphenhydrAMINE HCl Oral Elixir 12.5 MG/5ML Tier 1 ANTIHISTAMINES Diphenhydramine HCl DiphenhydrAMINE HCl Powder Tier 3 ANTIDIARRHEALS Diphenoxylate w/ Atropine Diphenoxylate‐Atropine Oral Liquid 2.5‐0.025 MG/5ML Tier 2 ANTIDIARRHEALS Diphenoxylate w/ Atropine Diphenoxylate‐Atropine Oral Tablet 2.5‐0.025 MG Tier 1 TOXOIDS Diphtheria‐Tetanus Toxoids (DT) Diphtheria‐Tetanus Toxoids DT Intramuscular Suspension 25‐5 LFU/0.5ML Tier 2 x GENERAL ANESTHETICS Diprivan Intravenous Emulsion 10 MG/ML Tier 3 x DERMATOLOGICALS Betamethasone Dipropionate Augmented Diprolene AF External Cream 0.05 % Tier 3 DERMATOLOGICALS Betamethasone Dipropionate Augmented Diprolene External Lotion 0.05 % Tier 3 DERMATOLOGICALS Betamethasone Dipropionate Augmented Diprolene External Ointment 0.05 % Tier 3 DIAGNOSTIC PRODUCTS Dipyridamole (Diagnostic) Dipyridamole Intravenous Solution 5 MG/ML Tier 1 x HEMATOLOGICAL AGENTS ‐ MISC. Dipyridamole Dipyridamole Oral Tablet 25 MG Tier 1 HEMATOLOGICAL AGENTS ‐ MISC. Dipyridamole Dipyridamole Oral Tablet 50 MG Tier 1 HEMATOLOGICAL AGENTS ‐ MISC. Dipyridamole Dipyridamole Oral Tablet 75 MG Tier 1 ANALGESICS ‐ NonNarcotic Salsalate Disalcid Oral Tablet 500 MG Tier 3 ANALGESICS ‐ NonNarcotic Salsalate Disalcid Oral Tablet 750 MG Tier 3 ANTIARRHYTHMICS Disopyramide Phosphate Disopyramide Phosphate Oral Capsule 100 MG Tier 1 ANTIARRHYTHMICS Disopyramide Phosphate Disopyramide Phosphate Oral Capsule 150 MG Tier 1 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Disulfiram Disulfiram Oral Tablet 250 MG Tier 1 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Disulfiram Disulfiram Oral Tablet 500 MG Tier 1 x URINARY ANTISPASMODICS Oxybutynin Chloride Ditropan XL Oral Tablet Extended Release 24 Hour 10 MG Tier 3 URINARY ANTISPASMODICS Oxybutynin Chloride Ditropan XL Oral Tablet Extended Release 24 Hour 15 MG Tier 3 URINARY ANTISPASMODICS Oxybutynin Chloride Ditropan XL Oral Tablet Extended Release 24 Hour 5 MG Tier 3 DIURETICS Chlorothiazide Diuril Oral Suspension 250 MG/5ML Tier 3 ANTICONVULSANTS Divalproex Sodium Divalproex Sodium ER Oral Tablet Extended Release 24 Hour 250 MG Tier 1 ANTICONVULSANTS Divalproex Sodium Divalproex Sodium ER Oral Tablet Extended Release 24 Hour 500 MG Tier 1 ANTICONVULSANTS Divalproex Sodium Divalproex Sodium Oral Capsule Sprinkle 125 MG Tier 1 ANTICONVULSANTS Divalproex Sodium Divalproex Sodium Oral Tablet Delayed Release 125 MG Tier 1 ANTICONVULSANTS Divalproex Sodium Divalproex Sodium Oral Tablet Delayed Release 250 MG Tier 1 ANTICONVULSANTS Divalproex Sodium Divalproex Sodium Oral Tablet Delayed Release 500 MG Tier 1 HEMATOPOIETIC AGENTS Folic Acid‐Vitamin B6‐Vitamin B12‐Omega 3 Acids‐Biotin‐Cr Divista Oral Capsule 1 MG Tier 3 NUTRIENTS DL‐Methionine Powder Tier 3 MEDICAL DEVICES AND SUPPLIES Feeding Tubes ‐ Sets Dobbhoff Feeding Tube System Miscellaneous Tier 3 VASOPRESSORS Dobutamine HCl DOBUTamine HCl Intravenous Solution 250 MG/20ML Tier 1 x LAXATIVES Docusate Sodium Docusate Sodium Powder Tier 3 BIOLOGICALS MISC Dog Epithelium (Canis Familiaris) Dog Epithelium Subcutaneous Solution 1:10 Tier 3 x ANALGESICS ‐ OPIOID HCl Dolophine Oral Tablet 10 MG Tier 3 ANALGESICS ‐ OPIOID Methadone HCl Dolophine Oral Tablet 5 MG Tier 3 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Donepezil Hydrochloride Donepezil HCl Oral Tablet 10 MG Tier 1 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Donepezil Hydrochloride Donepezil HCl Oral Tablet 23 MG Tier 1 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Donepezil Hydrochloride Donepezil HCl Oral Tablet 5 MG Tier 1 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Donepezil Hydrochloride Donepezil HCl Oral Tablet Dispersible 10 MG Tier 1 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Donepezil Hydrochloride Donepezil HCl Oral Tablet Dispersible 5 MG Tier 1 x VASOPRESSORS HCl DOPamine HCl Intravenous Solution 40 MG/ML Tier 1 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Doxapram HCl Dopram Intravenous Solution 20 MG/ML Tier 3 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Quazepam Doral Oral Tablet 15 MG Tier 3 ANTI‐INFECTIVE AGENTS ‐ MISC. Doripenem Doribax Intravenous Solution Reconstituted 250 MG Tier 3 x ANTI‐INFECTIVE AGENTS ‐ MISC. Doripenem Doribax Intravenous Solution Reconstituted 500 MG Tier 3 x TETRACYCLINES Doxycycline Hyclate Doryx Oral Tablet Delayed Release 200 MG Tier 3 TETRACYCLINES Doxycycline Hyclate Doryx Oral Tablet Delayed Release 50 MG Tier 3 OPHTHALMIC AGENTS Dorzolamide HCl Dorzolamide HCl Ophthalmic Solution 2 % Tier 1 OPHTHALMIC AGENTS Dorzolamide HCl‐Timolol Maleate Dorzolamide HCl‐Timolol Mal Ophthalmic Solution 22.3‐6.8 MG/ML Tier 1 MULTIVITAMINS Prenatal Vit w/ Fe Fum‐Iron Polysacch Complex ‐FA‐Omega 3 Dothelle DHA Oral Capsule 53.5‐38‐1 MG Tier 2 MEDICAL DEVICES AND SUPPLIES Catheters Dover Closed Urethral Tray Kit Tier 3 MEDICAL DEVICES AND SUPPLIES Catheters Dover Foley Insertion Tray Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Catheters Dover Hydrogel Foley Cath 16FR Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Catheters Dover Hydrogel Foley Cath 18FR Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Catheters Dover Hydrogel Foley Cath 20FR Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Catheters Dover Hydrogel Foley Cath 22FR Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Catheters Dover Hydrogel Foley Cath 24FR Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Catheters Dover Hydrogel Foley Cath 26FR Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Catheters Dover Hydrogel Foley Cath 28FR Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Catheters Dover Hydrogel Foley Cath 30FR Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Catheters Dover Hydrogel Foley Cath Kit Kit Tier 3 MEDICAL DEVICES AND SUPPLIES Catheters Dover Hydrogel Foley Tray 16FR Kit Tier 3 MEDICAL DEVICES AND SUPPLIES Catheters Dover Hydrogel Foley Tray 18FR Kit Tier 3 MEDICAL DEVICES AND SUPPLIES Catheters Dover Open Urethral Tray 14FR Kit Tier 3 MEDICAL DEVICES AND SUPPLIES Catheters Dover Silicone Foley Cath 18FR Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Catheters Dover Silicone Foley Cath 20FR Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Catheters Dover Silicone Foley Cath 22FR Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Catheters Dover Silicone Foley Cath 24FR Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Catheters Dover Silicone Foley Cath 26FR Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Catheters Dover Silicone Foley Catheter Kit Tier 3 MEDICAL DEVICES AND SUPPLIES Catheters Dover Silicone Urine Meter Kit Tier 3 MEDICAL DEVICES AND SUPPLIES Catheters Dover Silicone/Latex Catheter Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Catheters Dover Silver Cath Tray Kit Tier 3 MEDICAL DEVICES AND SUPPLIES Catheters Dover Uni Catheterization Tray Kit Tier 3 MEDICAL DEVICES AND SUPPLIES Catheters Dover Universal Tray Kit Tier 3 MEDICAL DEVICES AND SUPPLIES Catheters Dover Urethral Catheter Miscellaneous Tier 3 DERMATOLOGICALS Calcipotriene Dovonex External Cream 0.005 % Tier 3 ANTIHYPERTENSIVES Doxazosin Mesylate Doxazosin Mesylate Oral Tablet 1 MG Tier 1 ANTIHYPERTENSIVES Doxazosin Mesylate Doxazosin Mesylate Oral Tablet 2 MG Tier 1 ANTIHYPERTENSIVES Doxazosin Mesylate Doxazosin Mesylate Oral Tablet 4 MG Tier 1 ANTIHYPERTENSIVES Doxazosin Mesylate Doxazosin Mesylate Oral Tablet 8 MG Tier 1 ANTIDEPRESSANTS Doxepin HCl Doxepin HCl Oral Capsule 10 MG Tier 1 ANTIDEPRESSANTS Doxepin HCl Doxepin HCl Oral Capsule 100 MG Tier 1 ANTIDEPRESSANTS Doxepin HCl Doxepin HCl Oral Capsule 150 MG Tier 1 ANTIDEPRESSANTS Doxepin HCl Doxepin HCl Oral Capsule 25 MG Tier 1 ANTIDEPRESSANTS Doxepin HCl Doxepin HCl Oral Capsule 50 MG Tier 1 ANTIDEPRESSANTS Doxepin HCl Doxepin HCl Oral Capsule 75 MG Tier 3 ANTIDEPRESSANTS Doxepin HCl Doxepin HCl Oral Concentrate 10 MG/ML Tier 1 ANTIDEPRESSANTS Doxepin HCl Doxepin HCl Powder Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Doxercalciferol Doxercalciferol Intravenous Solution 4 MCG/2ML Tier 1 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Doxercalciferol Doxercalciferol Oral Capsule 0.5 MCG Tier 1 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Doxercalciferol Doxercalciferol Oral Capsule 1 MCG Tier 1 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Doxercalciferol Doxercalciferol Oral Capsule 2.5 MCG Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Doxorubicin HCl DOXOrubicin HCl Intravenous Solution 2 MG/ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Doxorubicin HCl Liposomal DOXOrubicin HCl Liposomal Intravenous Injectable 2 MG/ML Tier 1 x TETRACYCLINES Doxycycline Hyclate Doxy 100 Intravenous Solution Reconstituted 100 MG Tier 1 x TETRACYCLINES Doxycycline Hyclate Doxycycline Hyclate Intravenous Solution Reconstituted 100 MG Tier 1 x TETRACYCLINES Doxycycline Hyclate Doxycycline Hyclate Oral Capsule 100 MG Tier 1 TETRACYCLINES Doxycycline Hyclate Doxycycline Hyclate Oral Capsule 50 MG Tier 1 TETRACYCLINES Doxycycline Hyclate Doxycycline Hyclate Oral Tablet 100 MG Tier 1 TETRACYCLINES Doxycycline Hyclate Doxycycline Hyclate Oral Tablet 20 MG Tier 1 TETRACYCLINES Doxycycline Hyclate Doxycycline Hyclate Oral Tablet Delayed Release 100 MG Tier 1 TETRACYCLINES Doxycycline Hyclate Doxycycline Hyclate Oral Tablet Delayed Release 150 MG Tier 1 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

TETRACYCLINES Doxycycline Hyclate Doxycycline Hyclate Oral Tablet Delayed Release 75 MG Tier 1 TETRACYCLINES Doxycycline Hyclate Doxycycline Hyclate Powder Tier 3 TETRACYCLINES Doxycycline (Monohydrate) Doxycycline Monohydrate Oral Capsule 100 MG Tier 1 TETRACYCLINES Doxycycline (Monohydrate) Doxycycline Monohydrate Oral Capsule 150 MG Tier 1 TETRACYCLINES Doxycycline (Monohydrate) Doxycycline Monohydrate Oral Capsule 50 MG Tier 1 TETRACYCLINES Doxycycline (Monohydrate) Doxycycline Monohydrate Oral Capsule 75 MG Tier 1 TETRACYCLINES Doxycycline (Monohydrate) Doxycycline Monohydrate Oral Suspension Reconstituted 25 MG/5ML Tier 1 TETRACYCLINES Doxycycline (Monohydrate) Doxycycline Monohydrate Oral Tablet 100 MG Tier 1 TETRACYCLINES Doxycycline (Monohydrate) Doxycycline Monohydrate Oral Tablet 150 MG Tier 1 TETRACYCLINES Doxycycline (Monohydrate) Doxycycline Monohydrate Oral Tablet 50 MG Tier 1 TETRACYCLINES Doxycycline (Monohydrate) Doxycycline Monohydrate Oral Tablet 75 MG Tier 1 DERMATOLOGICALS Doxycycline (Rosacea) Doxycycline Oral Capsule Delayed Release 40 MG Tier 3 x ANTIHISTAMINES Doxylamine Succinate Doxylamine Succinate Powder Tier 3 BIOLOGICALS MISC Drechslera Drechslera Subcutaneous Solution 10000 PNU/ML Tier 3 x BIOLOGICALS MISC Drechslera Drechslera Subcutaneous Solution 20000 PNU/ML Tier 3 x DIAGNOSTIC PRODUCTS Arterial Blood Kits Drihep Arterial Line Syringe Kit 100 UNIT Tier 3 DIAGNOSTIC PRODUCTS Arterial Blood Gas Kits Drihep Plus Prefilled Syringe Kit 100 UNIT Tier 3 VITAMINS Ergocalciferol Drisdol Oral Capsule 50000 UNIT Tier 3 DERMATOLOGICALS Anthralin Dritho‐Creme HP External Cream 1 % Tier 2 ANTIEMETICS Dronabinol Dronabinol Oral Capsule 10 MG Tier 1 x x ANTIEMETICS Dronabinol Dronabinol Oral Capsule 2.5 MG Tier 1 x x ANTIEMETICS Dronabinol Dronabinol Oral Capsule 5 MG Tier 1 x x ANTIANXIETY AGENTS Droperidol Droperidol Injection Solution 2.5 MG/ML Tier 1 x ANTIANXIETY AGENTS Droperidol Droperidol Powder Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Droplet Lancets Ultra Thin 30G Miscellaneous Tier 2 CONTRACEPTIVES Drospirenone‐Ethinyl Estradiol Drospirenone‐Ethinyl Estradiol Oral Tablet 3‐0.02 MG Tier 1 CONTRACEPTIVES Drospirenone‐Ethinyl Estradiol Drospirenone‐Ethinyl Estradiol Oral Tablet 3‐0.03 MG Tier 1 HEMATOPOIETIC AGENTS Hydroxyurea (Sickle Cell Anemia) Droxia Oral Capsule 200 MG Tier 3 HEMATOPOIETIC AGENTS Hydroxyurea (Sickle Cell Anemia) Droxia Oral Capsule 300 MG Tier 3 HEMATOPOIETIC AGENTS Hydroxyurea (Sickle Cell Anemia) Droxia Oral Capsule 400 MG Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Drug Mart Lancets Thin 26G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Drug Mart On‐The‐Go Lancet 30G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Drug Mart Unifine Pentips Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Drug Mart Unifine Pentips Miscellaneous 31G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Drug Mart Unifine Pentips Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Drug Mart Unifine Pentips Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Drug Mart Unifine Pentips Miscellaneous 32G X 4 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Drug Mart Unifine Pentips Plus Miscellaneous 32G X 4 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Drug Mart Unilet Lancets 28G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Drug Mart Unilet Lancets 30G Miscellaneous Tier 2 DERMATOLOGICALS Aluminum Chloride Drysol External Solution 20 % Tier 2 DERMATOLOGICALS Diclofenac Sodium‐Benzalkonium Chloride DS Prep Pak Combination Therapy Pack 1 & 0.13 % Tier 3 DERMATOLOGICALS Clindamycin Phosphate‐Benzoyl Peroxide (Refrigerate) Duac External Gel 1.2‐5 % Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Duane Reade Lancet Altern Site Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Duane Reade Lancet Super Thin Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Duane Reade Lancet Ultra Thin Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Duane Reade Unifine Pentips Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Duane Reade Unifine Pentips Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Duane Reade Unifine Pentips Miscellaneous 31G X 8 MM Tier 2 ESTROGENS Conjugated Estrogens‐Bazedoxifene Duavee Oral Tablet 0.45‐20 MG Tier 2 x MULTIVITAMINS Prenatal w/Fe Polysacch Cmplx‐Sod Feredetate‐FA‐Omega 3 Duet DHA 400 Oral Miscellaneous 25‐1 & 400 MG Tier 2 MULTIVITAMINS Prenatal w/Fe Polysacch Cmplx‐Sod Feredetate‐FA‐Omega 3 Duet DHA Balanced Oral Miscellaneous 25‐1 & 267 MG Tier 2 ANTIDIABETICS Pioglitazone HCl‐Glimepiride Duetact Oral Tablet 30‐2 MG Tier 3 x ANTIDIABETICS Pioglitazone HCl‐Glimepiride Duetact Oral Tablet 30‐4 MG Tier 3 x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Mometasone Furoate‐Formoterol Fumarate Dihydrate Dulera Inhalation Aerosol 100‐5 MCG/ACT Tier 3 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Mometasone Furoate‐Formoterol Fumarate Dihydrate Dulera Inhalation Aerosol 200‐5 MCG/ACT Tier 3 ANTIDEPRESSANTS Duloxetine HCl DULoxetine HCl Oral Capsule Delayed Release Particles 20 MG Tier 1 x ANTIDEPRESSANTS Duloxetine HCl DULoxetine HCl Oral Capsule Delayed Release Particles 30 MG Tier 1 x ANTIDEPRESSANTS Duloxetine HCl DULoxetine HCl Oral Capsule Delayed Release Particles 40 MG Tier 3 xx ANTIDEPRESSANTS Duloxetine HCl DULoxetine HCl Oral Capsule Delayed Release Particles 60 MG Tier 1 x DIAGNOSTIC PRODUCTS Glucose Blood Duo‐Care Test In Vitro Strip Tier 3 ANTIDOTES Atropine‐Pralidoxime Chloride DuoDote Intramuscular Solution Auto‐injector 2.1‐600 MG Tier 3 x ANTIPARKINSON AGENTS Carbidopa‐Levodopa Duopa Enteral Suspension 4.63‐20 MG/ML Tier 3 x HEMATOPOIETIC AGENTS Folic Acid‐Cholecalciferol Durachol Oral Capsule 1‐3775 MG‐UNIT Tier 3 ANALGESICS ‐ NonNarcotic Clonidine HCl (Analgesia) Duraclon Epidural Solution 100 MCG/ML Tier 3 x DERMATOLOGICALS Silver Durafiber Ag External Pad 2"X2" Tier 3 DERMATOLOGICALS Silver Durafiber Ag External Pad 3/4"X18" Tier 3 DERMATOLOGICALS Silver Durafiber Ag External Pad 4"X4" Tier 3 DERMATOLOGICALS Silver Durafiber Ag External Pad 4"X4‐3/4" Tier 3 DERMATOLOGICALS Silver Durafiber Ag External Pad 6"X6" Tier 3 DERMATOLOGICALS Silver Durafiber Ag External Pad 8"X11‐3/4" Tier 3 DERMATOLOGICALS Silver Durafiber External Pad 4"X4‐3/4" Tier 3 ANALGESICS ‐ OPIOID Fentanyl Duragesic‐100 Transdermal Patch 72 Hour 100 MCG/HR Tier 3 x ANALGESICS ‐ OPIOID Fentanyl Duragesic‐12 Transdermal Patch 72 Hour 12 MCG/HR Tier 3 x ANALGESICS ‐ OPIOID Fentanyl Duragesic‐25 Transdermal Patch 72 Hour 25 MCG/HR Tier 3 x ANALGESICS ‐ OPIOID Fentanyl Duragesic‐50 Transdermal Patch 72 Hour 50 MCG/HR Tier 3 x ANALGESICS ‐ OPIOID Fentanyl Duragesic‐75 Transdermal Patch 72 Hour 75 MCG/HR Tier 3 x ANALGESICS ‐ OPIOID Sulfate Duramorph Injection Solution 0.5 MG/ML Tier 1 x ANALGESICS ‐ OPIOID Morphine Sulfate Duramorph Injection Solution 1 MG/ML Tier 1 x LOCAL ANESTHETICS‐Parenteral Lidocaine HCl (Local Anesth.) Durasafe Spinal/Epidural Tray Injection Kit 1 % Tier 3 x ANALGESICS ‐ NonNarcotic Acetaminophen‐Salicylamide‐Phenyltoloxamine Duraxin Oral Capsule 300‐200‐20 MG Tier 1 OPHTHALMIC AGENTS Difluprednate Durezol Ophthalmic Emulsion 0.05 % Tier 3 HEMATOLOGICAL AGENTS ‐ MISC. Aspirin (Platelet Aggregation Inhibitor) Durlaza Oral Capsule Extended Release 24 Hour 162.5 MG Tier 3 GENITOURINARY AGENTS ‐ MISCELLANEOUS Dutasteride Dutasteride Oral Capsule 0.5 MG Tier 1 x GENITOURINARY AGENTS ‐ MISCELLANEOUS Dutasteride‐Tamsulosin HCl Dutasteride‐Tamsulosin HCl Oral Capsule 0.5‐0.4 MG Tier 1 x ANTIHYPERTENSIVES Metoprolol & Hydrochlorothiazide Dutoprol Oral Tablet Extended Release 24 Hour 100‐12.5 MG Tier 2 xx ANTIHYPERTENSIVES Metoprolol & Hydrochlorothiazide Dutoprol Oral Tablet Extended Release 24 Hour 25‐12.5 MG Tier 2 xx ANTIHYPERTENSIVES Metoprolol & Hydrochlorothiazide Dutoprol Oral Tablet Extended Release 24 Hour 50‐12.5 MG Tier 2 xx DIAGNOSTIC PRODUCTS D‐Xylose D‐Xylose Powder Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Amphetamine Dyanavel XR Oral Suspension Extended Release 2.5 MG/ML Tier 3 DIURETICS Triamterene & Hydrochlorothiazide Dyazide Oral Capsule 37.5‐25 MG Tier 3 NASAL AGENTS ‐ SYSTEMIC AND TOPICAL Azelastine HCl‐Fluticasone Propionate Dymista Nasal Suspension 137‐50 MCG/ACT Tier 3 x DIURETICS Triamterene Dyrenium Oral Capsule 100 MG Tier 3 DIURETICS Triamterene Dyrenium Oral Capsule 50 MG Tier 3 DERMATOLOGICALS AbobotulinumtoxinA (Glabellar Lines) Dysport (Glabellar Lines) Intramuscular Solution Reconstituted 300 UNIT Tier 3 x NEUROMUSCULAR AGENTS AbobotulinumtoxinA Dysport Intramuscular Solution Reconstituted 300 UNIT Tier 2 x NEUROMUSCULAR AGENTS AbobotulinumtoxinA Dysport Intramuscular Solution Reconstituted 500 UNIT Tier 2 x MACROLIDES Erythromycin Ethylsuccinate E.E.S. 400 Oral Tablet 400 MG Tier 2 MACROLIDES Erythromycin Ethylsuccinate E.E.S. Granules Oral Suspension Reconstituted 200 MG/5ML Tier 3 MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers EasiVent Mask Large Miscellaneous Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers EasiVent Mask Medium Miscellaneous Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers EasiVent Mask Small Miscellaneous Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers EasiVent Miscellaneous Tier 2 x BIOLOGICALS MISC Eastern Cottonwood Eastern Cottonwood Subcutaneous Solution 1:20 Tier 3 x MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Easy Comfort Insulin Syringe Miscellaneous 30G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Easy Comfort Insulin Syringe Miscellaneous 30G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Easy Comfort Insulin Syringe Miscellaneous 30G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Easy Comfort Insulin Syringe Miscellaneous 30G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Easy Comfort Insulin Syringe Miscellaneous 30G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Easy Comfort Insulin Syringe Miscellaneous 31G X 5/16" 0.5 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Easy Comfort Insulin Syringe Miscellaneous 31G X 5/16" 1 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Easy Comfort Lancets Miscellaneous Tier 2 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Easy Comfort Pen Needles Miscellaneous 31G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Easy Comfort Pen Needles Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Easy Comfort Pen Needles Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Easy Comfort Pen Needles Miscellaneous 32G X 4 MM Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood Easy Plus Blood Glucose Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Easy Plus II Glucose Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Easy Step Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Easy Talk Blood Glucose Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Alcohol Swabs Easy Touch Alcohol Prep Medium Pad 70 % Tier 2 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 1 ML Easy Touch Fluringe Miscellaneous 25G X 1" 1 ML Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Easy Touch HealthPro Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Easy Touch Insulin Safety Syr Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Easy Touch Insulin Safety Syr Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Easy Touch Insulin Safety Syr Miscellaneous 30G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Easy Touch Insulin Safety Syr Miscellaneous 30G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Easy Touch Insulin Syringe Miscellaneous 27G X 1/2" 0.5 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Easy Touch Insulin Syringe Miscellaneous 27G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Easy Touch Insulin Syringe Miscellaneous 28G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Easy Touch Insulin Syringe Miscellaneous 28G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Easy Touch Insulin Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Easy Touch Insulin Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Easy Touch Insulin Syringe Miscellaneous 30G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Easy Touch Insulin Syringe Miscellaneous 30G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Easy Touch Insulin Syringe Miscellaneous 30G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Easy Touch Insulin Syringe Miscellaneous 30G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Easy Touch Insulin Syringe Miscellaneous 30G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Easy Touch Insulin Syringe Miscellaneous 30G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Easy Touch Insulin Syringe Miscellaneous 31G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Easy Touch Insulin Syringe Miscellaneous 31G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Easy Touch Insulin Syringe Miscellaneous 31G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Easy Touch Lancets 21G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Easy Touch Lancets 23G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Easy Touch Lancets 26G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Easy Touch Lancets 26G/Twist Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Easy Touch Lancets 28G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Easy Touch Lancets 28G/Twist Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Easy Touch Lancets 30G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Easy Touch Lancets 30G/Twist Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Easy Touch Lancets 32G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Easy Touch Lancets 32G/Twist Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Easy Touch Lancets 33G/Twist Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Easy Touch Pen Needles Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Easy Touch Pen Needles Miscellaneous 31G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Easy Touch Pen Needles Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Easy Touch Pen Needles Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Easy Touch Pen Needles Miscellaneous 32G X 4 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Easy Touch Pen Needles Miscellaneous 32G X 5 MM Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Easy Touch Pen Needles Miscellaneous 32G X 6 MM Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Easy Touch Safety Lancets 21G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Easy Touch Safety Lancets 23G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Easy Touch Safety Lancets 26G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Easy Touch Safety Lancets 28G Miscellaneous Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood Easy Touch Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Easy Trak Blood Glucose Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Easy Twist & Cap Lancets Miscellaneous Tier 2 MOUTH/THROAT/DENTAL AGENTS Stannous Fluoride Easygel Dental Gel 0.4 % Tier 1 DIAGNOSTIC PRODUCTS Glucose Blood EasyGluco In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies EasyGluco Kit Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood EasyGluco Plus In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood EasyMax 15 Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood EasyMax Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood EasyPlus Blood Glucose Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood EasyPRO Blood Glucose Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood EasyPRO Plus In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets EasyTest II Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets EasyTest Lancets Miscellaneous Tier 2 ANALGESICS ‐ ANTI‐INFLAMMATORY Naproxen EC‐Naprosyn Oral Tablet Delayed Release 375 MG Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Naproxen EC‐Naprosyn Oral Tablet Delayed Release 500 MG Tier 3 DERMATOLOGICALS Econazole Nitrate Econazole Nitrate External Cream 1 % Tier 1 DERMATOLOGICALS Econazole Nitrate Ecoza External Foam 1 % Tier 3 HEMATOPOIETIC AGENTS Ferrous Fumarate‐Folic Acid‐Docusate Sodium ED Cyte F Oral Tablet 324‐1‐50 MG Tier 3 ANTIHYPERTENSIVES Azilsartan Medoxomil Edarbi Oral Tablet 40 MG Tier 3 xx ANTIHYPERTENSIVES Azilsartan Medoxomil Edarbi Oral Tablet 80 MG Tier 3 xx ANTIHYPERTENSIVES Azilsartan Medoxomil‐Chlorthalidone Edarbyclor Oral Tablet 40‐12.5 MG Tier 3 xx ANTIHYPERTENSIVES Azilsartan Medoxomil‐Chlorthalidone Edarbyclor Oral Tablet 40‐25 MG Tier 3 xx DIURETICS Ethacrynic Acid Edecrin Oral Tablet 25 MG Tier 3 ANTIDOTES Edetate Calcium Disodium Edetate Calcium Disodium Powder Tier 3 CARDIOVASCULAR AGENTS ‐ MISC. Alprostadil (Vasodilator) Edex Intracavernosal Kit 10 MCG Tier 3 x x CARDIOVASCULAR AGENTS ‐ MISC. Alprostadil (Vasodilator) Edex Intracavernosal Kit 20 MCG Tier 3 x x CARDIOVASCULAR AGENTS ‐ MISC. Alprostadil (Vasodilator) Edex Intracavernosal Kit 40 MCG Tier 3 x x ANALGESICS ‐ NonNarcotic Acetaminophen‐Salicylamide‐Phenyltoloxamine Ed‐Flex Oral Capsule 300‐200‐20 MG Tier 1 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Zolpidem Tartrate Edluar Sublingual Tablet Sublingual 10 MG Tier 3 x HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Zolpidem Tartrate Edluar Sublingual Tablet Sublingual 5 MG Tier 3 x ULCER DRUGS Hyoscyamine Sulfate Ed‐Spaz Oral Tablet Dispersible 0.125 MG Tier 1 ANTIVIRALS Rilpivirine HCl Edurant Oral Tablet 25 MG Tier 2 x MINERALS & ELECTROLYTES Potassium Bicarbonate‐Citric Acid Effer‐K Oral Tablet Effervescent 10 MEQ Tier 3 MINERALS & ELECTROLYTES Potassium Bicarbonate‐Citric Acid Effer‐K Oral Tablet Effervescent 20 MEQ Tier 3 MINERALS & ELECTROLYTES Potassium Bicarbonate Effer‐K Oral Tablet Effervescent 25 MEQ Tier 1 MINERALS & ELECTROLYTES Potassium Bicarb & Chloride Effervescent Pot Chloride Oral Tablet Effervescent 25 MEQ Tier 1 ANTIDEPRESSANTS Venlafaxine HCl Effexor XR Oral Capsule Extended Release 24 Hour 150 MG Tier 3 ANTIDEPRESSANTS Venlafaxine HCl Effexor XR Oral Capsule Extended Release 24 Hour 37.5 MG Tier 3 ANTIDEPRESSANTS Venlafaxine HCl Effexor XR Oral Capsule Extended Release 24 Hour 75 MG Tier 3 HEMATOLOGICAL AGENTS ‐ MISC. Prasugrel HCl Effient Oral Tablet 10 MG Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Prasugrel HCl Effient Oral Tablet 5 MG Tier 2 x DERMATOLOGICALS Fluorouracil (Topical) Efudex External Cream 5 % Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Tesamorelin Acetate Egrifta Subcutaneous Solution Reconstituted 1 MG Tier 2 x x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Tesamorelin Acetate Egrifta Subcutaneous Solution Reconstituted 2 MG Tier 2 x ANTIPARKINSON AGENTS Selegiline HCl Eldepryl Oral Capsule 5 MG Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Element Compact Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Element Test In Vitro Strip Tier 3 OPHTHALMIC AGENTS Epinastine HCl (Ophth) Elestat Ophthalmic Solution 0.05 % Tier 3 ESTROGENS Estradiol Elestrin Transdermal Gel 0.52 MG/0.87 GM (0.06%) Tier 3 x DERMATOLOGICALS Pimecrolimus Elidel External Cream 1 % Tier 2 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Leuprolide Acetate (3 Month) Eligard Subcutaneous Kit 22.5 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Leuprolide Acetate (4 Month) Eligard Subcutaneous Kit 30 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Leuprolide Acetate (6 Month) Eligard Subcutaneous Kit 45 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Leuprolide Acetate Eligard Subcutaneous Kit 7.5 MG Tier 2 x x DERMATOLOGICALS Permethrin Elimite External Cream 5 % Tier 3 CONTRACEPTIVES Norgestrel & Ethinyl Estradiol Elinest Oral Tablet 0.3‐30 MG‐MCG Tier 1 GASTROINTESTINAL AGENTS ‐ MISC. Calcium Acetate (Phosphate Binder) Eliphos Oral Tablet 667 MG Tier 3 ANTICOAGULANTS Apixaban Eliquis Oral Tablet 2.5 MG Tier 3 x ANTICOAGULANTS Apixaban Eliquis Oral Tablet 5 MG Tier 3 x HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

MULTIVITAMINS Prenatal Vit w/ Iron Carbonyl‐Folic Acid Elite‐OB Oral Tablet 50‐1.25 MG Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Elite‐Thin Insulin Syringe Miscellaneous 28G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Elite‐Thin Insulin Syringe Miscellaneous 28G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Elite‐Thin Insulin Syringe Miscellaneous 28G X 5/16" 0.5 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Elite‐Thin Insulin Syringe Miscellaneous 28G X 5/16" 1 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Elite‐Thin Insulin Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Elite‐Thin Insulin Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Elite‐Thin Insulin Syringe Miscellaneous 29G X 5/16" 0.5 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Elite‐Thin Insulin Syringe Miscellaneous 29G X 5/16" 1 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Elite‐Thin Insulin Syringe Miscellaneous 30G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Elite‐Thin Insulin Syringe Miscellaneous 30G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Elite‐Thin Insulin Syringe Miscellaneous 31G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Elite‐Thin Insulin Syringe Miscellaneous 31G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Elite‐Thin Insulin Syringe Miscellaneous 31G X 5/16" 1 ML Tier 2 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Theophylline Elixophyllin Oral Elixir 80 MG/15ML Tier 2 CONTRACEPTIVES Ulipristal Acetate Ella Oral Tablet 30 MG Tier 3 GENITOURINARY AGENTS ‐ MISCELLANEOUS Pentosan Polysulfate Sodium Elmiron Oral Capsule 100 MG Tier 2 DERMATOLOGICALS Mometasone Furoate Elocon External Cream 0.1 % Tier 3 DERMATOLOGICALS Mometasone Furoate Elocon External Lotion 0.1 % Tier 3 DERMATOLOGICALS Mometasone Furoate Elocon External Ointment 0.1 % Tier 3 HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor (Recomb) Fc Fusion (rFVIIIFc) Eloctate Intravenous Solution Reconstituted 1000 UNIT Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor (Recomb) Fc (rFVIIIFc) Eloctate Intravenous Solution Reconstituted 1500 UNIT Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor (Recomb) Fc Fusion Protein (rFVIIIFc) Eloctate Intravenous Solution Reconstituted 2000 UNIT Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor (Recomb) Fc Fusion Protein (rFVIIIFc) Eloctate Intravenous Solution Reconstituted 250 UNIT Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor (Recomb) Fc Fusion Protein (rFVIIIFc) Eloctate Intravenous Solution Reconstituted 3000 UNIT Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor (Recomb) Fc Fusion Protein (rFVIIIFc) Eloctate Intravenous Solution Reconstituted 500 UNIT Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor (Recomb) Fc Fusion Protein (rFVIIIFc) Eloctate Intravenous Solution Reconstituted 750 UNIT Tier 2 x OPHTHALMIC AGENTS Emedastine Difumarate Emadine Ophthalmic Solution 0.05 % Tier 3 ANALGESICS ‐ OPIOID Morphine‐Naltrexone Embeda Oral Capsule Extended Release 100‐4 MG Tier 3 x x ANALGESICS ‐ OPIOID Morphine‐Naltrexone Embeda Oral Capsule Extended Release 20‐0.8 MG Tier 3 x x ANALGESICS ‐ OPIOID Morphine‐Naltrexone Embeda Oral Capsule Extended Release 30‐1.2 MG Tier 3 x x ANALGESICS ‐ OPIOID Morphine‐Naltrexone Embeda Oral Capsule Extended Release 50‐2 MG Tier 3 x x ANALGESICS ‐ OPIOID Morphine‐Naltrexone Embeda Oral Capsule Extended Release 60‐2.4 MG Tier 3 x x ANALGESICS ‐ OPIOID Morphine‐Naltrexone Embeda Oral Capsule Extended Release 80‐3.2 MG Tier 3 x x DIAGNOSTIC PRODUCTS Glucose Blood Embrace Blood Glucose Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Embrace Evo Blood Glucose Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Embrace Lancets Ultra Thin 30G Miscellaneous Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood Embrace Pro Glucose Test In Vitro Strip Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Estramustine Phosphate Sodium Emcyt Oral Capsule 140 MG Tier 2 ANTIEMETICS Aprepitant Emend Oral Capsule 125 MG Tier 3 x ANTIEMETICS Aprepitant Emend Oral Capsule 40 MG Tier 3 x ANTIEMETICS Aprepitant Emend Oral Capsule 80 & 125 MG Tier 2 x ANTIEMETICS Aprepitant Emend Oral Capsule 80 MG Tier 3 x DERMATOLOGICALS Lidocaine‐Prilocaine EMLA External Cream 2.5‐2.5 % Tier 3 CONTRACEPTIVES Desogestrel & Ethinyl Estradiol Emoquette Oral Tablet 0.15‐30 MG‐MCG Tier 1 PHARMACEUTICAL ADJUVANTS Non Gelatin Capsules (Empty) Empty Capsule Size 1 Veg Clear Capsule Tier 3 ANTIDEPRESSANTS Selegiline Emsam Transdermal Patch 24 Hour 12 MG/24HR Tier 3 xx ANTIDEPRESSANTS Selegiline Emsam Transdermal Patch 24 Hour 6 MG/24HR Tier 3 xx ANTIDEPRESSANTS Selegiline Emsam Transdermal Patch 24 Hour 9 MG/24HR Tier 3 xx ANTIVIRALS Emtricitabine Emtriva Oral Capsule 200 MG Tier 2 x ANTIVIRALS Emtricitabine Emtriva Oral Solution 10 MG/ML Tier 2 x DERMATOLOGICALS Dermatological Products, Misc. Emulsion SB External Emulsion Tier 3 DERMATOLOGICALS Diclofenac Sodium‐Amitriptyline‐Prilocaine‐Lidocaine Emvoren External Cream Tier 3 URINARY ANTISPASMODICS Darifenacin Hydrobromide Enablex Oral Tablet Extended Release 24 Hour 15 MG Tier 3 xx URINARY ANTISPASMODICS Darifenacin Hydrobromide Enablex Oral Tablet Extended Release 24 Hour 7.5 MG Tier 3 xx ANTIHYPERTENSIVES Enalapril Maleate Enalapril Maleate Oral Tablet 10 MG Tier 1 ANTIHYPERTENSIVES Enalapril Maleate Enalapril Maleate Oral Tablet 2.5 MG Tier 1 ANTIHYPERTENSIVES Enalapril Maleate Enalapril Maleate Oral Tablet 20 MG Tier 1 ANTIHYPERTENSIVES Enalapril Maleate Enalapril Maleate Oral Tablet 5 MG Tier 1 ANTIHYPERTENSIVES Enalaprilat Enalaprilat Intravenous Injectable 1.25 MG/ML Tier 1 x ANTIHYPERTENSIVES Enalapril Maleate & Hydrochlorothiazide Enalapril‐Hydrochlorothiazide Oral Tablet 10‐25 MG Tier 1 ANTIHYPERTENSIVES Enalapril Maleate & Hydrochlorothiazide Enalapril‐Hydrochlorothiazide Oral Tablet 5‐12.5 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Etanercept Enbrel Subcutaneous Kit 25 MG Tier 2 x x ANALGESICS ‐ ANTI‐INFLAMMATORY Etanercept Enbrel Subcutaneous Solution Prefilled Syringe 25 MG/0.5ML Tier 2 x x ANALGESICS ‐ ANTI‐INFLAMMATORY Etanercept Enbrel Subcutaneous Solution Prefilled Syringe 50 MG/ML Tier 2 x x ANALGESICS ‐ ANTI‐INFLAMMATORY Etanercept Enbrel SureClick Subcutaneous Solution Auto‐injector 50 MG/ML Tier 2 x x ANALGESICS ‐ OPIOID Oxycodone w/ Acetaminophen Endocet Oral Tablet 10‐325 MG Tier 1 x ANALGESICS ‐ OPIOID Oxycodone w/ Acetaminophen Endocet Oral Tablet 2.5‐325 MG Tier 1 x ANALGESICS ‐ OPIOID Oxycodone w/ Acetaminophen Endocet Oral Tablet 5‐325 MG Tier 1 x ANALGESICS ‐ OPIOID Oxycodone w/ Acetaminophen Endocet Oral Tablet 7.5‐325 MG Tier 1 x ANALGESICS ‐ OPIOID Oxycodone‐Aspirin Endodan Oral Tablet 4.8355‐325 MG Tier 1 VAGINAL PRODUCTS Progesterone (Vaginal) Endometrin Vaginal Insert 100 MG Tier 3 VACCINES (Recomb) Engerix‐B Injection Suspension 10 MCG/0.5ML Tier 3 x VACCINES Hepatitis B Vaccine (Recomb) Engerix‐B Injection Suspension 20 MCG/ML Tier 3 x VACCINES Hepatitis B Vaccine (Recomb) Engerix‐B Intramuscular Injectable 10 MCG/0.5ML Tier 2 x VACCINES Hepatitis B Vaccine (Recomb) Engerix‐B Intramuscular Injectable 20 MCG/ML Tier 2 x ESTROGENS Estrogens, Conjugated Synthetic B Enjuvia Oral Tablet 0.3 MG Tier 3 ESTROGENS Estrogens, Conjugated Synthetic B Enjuvia Oral Tablet 0.45 MG Tier 3 ESTROGENS Estrogens, Conjugated Synthetic B Enjuvia Oral Tablet 0.625 MG Tier 3 ESTROGENS Estrogens, Conjugated Synthetic B Enjuvia Oral Tablet 0.9 MG Tier 3 ESTROGENS Estrogens, Conjugated Synthetic B Enjuvia Oral Tablet 1.25 MG Tier 3 DERMATOLOGICALS Baclofen (Topical) EnovaRX‐Baclofen External Cream 1 % Tier 3 MUSCULOSKELETAL THERAPY AGENTS Cyclobenzaprine HCl EnovaRX‐Cyclobenzaprine HCl Transdermal Cream 20 MG/GM Tier 3 DERMATOLOGICALS Ibuprofen (Topical) EnovaRX‐Ibuprofen External Cream 10 % Tier 3 DERMATOLOGICALS Lidocaine HCl EnovaRX‐Lidocaine HCl External Cream 10 % Tier 3 x DERMATOLOGICALS Lidocaine HCl EnovaRX‐Lidocaine HCl External Cream 5 % Tier 3 x DERMATOLOGICALS Naproxen (Topical) EnovaRX‐Naproxen External Cream 10 % Tier 3 DERMATOLOGICALS Tramadol HCl (Topical) EnovaRX‐Tramadol External Cream 5 % Tier 3 ANTICOAGULANTS Enoxaparin Sodium Enoxaparin Sodium Injection Solution 300 MG/3ML Tier 1 x ANTICOAGULANTS Enoxaparin Sodium Enoxaparin Sodium Subcutaneous Solution 100 MG/ML Tier 1 x ANTICOAGULANTS Enoxaparin Sodium Enoxaparin Sodium Subcutaneous Solution 120 MG/0.8ML Tier 1 x ANTICOAGULANTS Enoxaparin Sodium Enoxaparin Sodium Subcutaneous Solution 150 MG/ML Tier 1 x ANTICOAGULANTS Enoxaparin Sodium Enoxaparin Sodium Subcutaneous Solution 30 MG/0.3ML Tier 1 x ANTICOAGULANTS Enoxaparin Sodium Enoxaparin Sodium Subcutaneous Solution 40 MG/0.4ML Tier 1 x ANTICOAGULANTS Enoxaparin Sodium Enoxaparin Sodium Subcutaneous Solution 60 MG/0.6ML Tier 1 x ANTICOAGULANTS Enoxaparin Sodium Enoxaparin Sodium Subcutaneous Solution 80 MG/0.8ML Tier 1 x CONTRACEPTIVES Levonorgestrel‐Eth Estradiol (Triphasic) Enpresse‐28 Oral Tablet Tier 1 CONTRACEPTIVES Desogestrel & Ethinyl Estradiol Enskyce Oral Tablet 0.15‐30 MG‐MCG Tier 1 DERMATOLOGICALS Calcipotriene‐Betamethasone Dipropionate Enstilar External Foam 0.005‐0.064 % Tier 3 ANTIPARKINSON AGENTS Entacapone Entacapone Oral Tablet 200 MG Tier 1 ANTIVIRALS Entecavir Entecavir Oral Tablet 0.5 MG Tier 1 x ANTIVIRALS Entecavir Entecavir Oral Tablet 1 MG Tier 1 x GASTROINTESTINAL AGENTS ‐ MISC. Alvimopan Entereg Oral Capsule 12 MG Tier 3 CORTICOSTEROIDS Budesonide Entocort EC Oral Capsule Extended Release 24 Hour 3 MG Tier 3 CARDIOVASCULAR AGENTS ‐ MISC. Sacubitril‐Valsartan Entresto Oral Tablet 24‐26 MG Tier 3 x x CARDIOVASCULAR AGENTS ‐ MISC. Sacubitril‐Valsartan Entresto Oral Tablet 49‐51 MG Tier 3 x x CARDIOVASCULAR AGENTS ‐ MISC. Sacubitril‐Valsartan Entresto Oral Tablet 97‐103 MG Tier 3 x x MEDICAL DEVICES AND SUPPLIES Feeding Tubes ‐ Tubing EntriFlex Feeding Tb 10FR/43" Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Feeding Tubes ‐ Tubing EntriFlex Feeding Tb 12FR/43" Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Feeding Tubes ‐ Tubing EntriFlex Feeding Tube 8FR/36" Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Feeding Tubes ‐ Tubing EntriFlex Feeding Tube 8FR/43" Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Feeding Tubes EntriStar PEG Enteral Connect Miscellaneous Tier 3 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ASSORTED CLASSES Tacrolimus Envarsus XR Oral Tablet Extended Release 24 Hour 0.75 MG Tier 2 ASSORTED CLASSES Tacrolimus Envarsus XR Oral Tablet Extended Release 24 Hour 1 MG Tier 2 ASSORTED CLASSES Tacrolimus Envarsus XR Oral Tablet Extended Release 24 Hour 4 MG Tier 2 DIAGNOSTIC PRODUCTS Gadoxetate Disodium Eovist Intravenous Solution 0.25 MOL/L Tier 3 x ANTIHYPERTENSIVES Enalapril Maleate Epaned Oral Solution Reconstituted 1 MG/ML Tier 3 VASOPRESSORS Ephedrine Sulfate (Pressors) ePHEDrine Sulfate Injection Solution 50 MG/ML Tier 1 x DERMATOLOGICALS Dermatological Products, Misc. EpiCeram External Emulsion Tier 3 BIOLOGICALS MISC Epicoccum Epicoccum Subcutaneous Solution 10000 PNU/ML Tier 3 x BIOLOGICALS MISC Epicoccum Epicoccum Subcutaneous Solution 20000 PNU/ML Tier 3 x DERMATOLOGICALS Adapalene‐Benzoyl Peroxide Epiduo External Gel 0.1‐2.5 % Tier 3 x DERMATOLOGICALS Adapalene‐Benzoyl Peroxide Epiduo Forte External Gel 0.3‐2.5 % Tier 3 x MEDICAL DEVICES AND SUPPLIES Epidural Needle (Disp) 18 G Epidural Needle Miscellaneous 18G X 3‐1/2" Tier 3 MEDICAL DEVICES AND SUPPLIES Epidural Needle (Disp) 18 G Epidural Needle Miscellaneous 18G X 4" Tier 3 DERMATOLOGICALS Amniotic Membrane Allograft (Human) EpiFix External Sheet 4 CM X 4 CM Tier 3 DERMATOLOGICALS Pramoxine‐HC Epifoam External Foam 1‐1 % Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Disposable) EPILOR Syringe Miscellaneous 10 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Disposable) EPILOR Syringe Miscellaneous 5 ML Tier 3 OPHTHALMIC AGENTS Epinastine HCl (Ophth) Epinastine HCl Ophthalmic Solution 0.05 % Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Epinephrine HCl EPINEPHrine HCl Injection Solution 1 MG/ML Tier 1 x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Epinephrine HCl EPINEPHrine HCl Injection Solution Prefilled Syringe 0.1 MG/ML Tier 1 x VASOPRESSORS Epinephrine HCl (Pressors) EPINEPHrine HCl PF Intravenous Solution 1 MG/ML Tier 3 x VASOPRESSORS Epinephrine EPINEPHrine Injection Solution Auto‐injector 0.15 MG/0.15ML Tier 3 x VASOPRESSORS Epinephrine EPINEPHrine Injection Solution Auto‐injector 0.3 MG/0.3ML Tier 2 x VASOPRESSORS Epinephrine EpiPen 2‐Pak Injection Solution Auto‐injector 0.3 MG/0.3ML Tier 2 x VASOPRESSORS Epinephrine EpiPen Jr 2‐Pak Injection Solution Auto‐injector 0.15 MG/0.3ML Tier 2 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Epirubicin HCl Epirubicin HCl Intravenous Solution 200 MG/100ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Epirubicin HCl Epirubicin HCl Intravenous Solution 50 MG/25ML Tier 1 x MOUTH/THROAT/DENTAL AGENTS Oral Wound Care Products Episil Mouth/Throat Liquid Tier 3 VASOPRESSORS Epinephrine EPIsnap Injection Kit 1 MG/ML Tier 3 x ANTICONVULSANTS Carbamazepine Epitol Oral Tablet 200 MG Tier 1 ANTIVIRALS Lamivudine (HBV) Epivir HBV Oral Solution 5 MG/ML Tier 2 ANTIVIRALS Lamivudine (HBV) Epivir HBV Oral Tablet 100 MG Tier 3 ANTIVIRALS Lamivudine Epivir Oral Solution 10 MG/ML Tier 2 x ANTIVIRALS Lamivudine Epivir Oral Tablet 150 MG Tier 3 x ANTIVIRALS Lamivudine Epivir Oral Tablet 300 MG Tier 3 x ANTIHYPERTENSIVES Eplerenone Eplerenone Oral Tablet 25 MG Tier 1 ANTIHYPERTENSIVES Eplerenone Eplerenone Oral Tablet 50 MG Tier 1 HEMATOPOIETIC AGENTS Epoetin Alfa Epogen Injection Solution 10000 UNIT/ML Tier 2 x HEMATOPOIETIC AGENTS Epoetin Alfa Epogen Injection Solution 2000 UNIT/ML Tier 2 x HEMATOPOIETIC AGENTS Epoetin Alfa Epogen Injection Solution 20000 UNIT/ML Tier 2 x HEMATOPOIETIC AGENTS Epoetin Alfa Epogen Injection Solution 3000 UNIT/ML Tier 2 x HEMATOPOIETIC AGENTS Epoetin Alfa Epogen Injection Solution 4000 UNIT/ML Tier 2 x ANTIHYPERTENSIVES Eprosartan Mesylate Eprosartan Mesylate Oral Tablet 600 MG Tier 3 xx HEMATOLOGICAL AGENTS ‐ MISC. Eptifibatide Eptifibatide Intravenous Solution 0.75 MG/ML Tier 1 x HEMATOLOGICAL AGENTS ‐ MISC. Eptifibatide Eptifibatide Intravenous Solution 2 MG/ML Tier 1 x ANTIVIRALS Abacavir Sulfate‐Lamivudine Epzicom Oral Tablet 600‐300 MG Tier 2 x DIAGNOSTIC PRODUCTS Glucose Blood EQ Blood Glucose Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets EQL Color Lancets 21G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets EQL Color Lancets Micro 33G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 EQL Insulin Syringe Miscellaneous 29G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 EQL Insulin Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 EQL Insulin Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 EQL Insulin Syringe Miscellaneous 30G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 EQL Insulin Syringe Miscellaneous 30G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 EQL Insulin Syringe Miscellaneous 30G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 EQL Insulin Syringe Miscellaneous 31G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 EQL Insulin Syringe Miscellaneous 31G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 EQL Insulin Syringe Miscellaneous 31G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle EQL Short Pen Needle Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets EQL Super Thin Lancets 30G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets EQL Thin Lancets 26G Miscellaneous Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood EQL TRUEtest Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood EQL TrueTrack Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 EQL Ultra Comfort Insulin Syr Miscellaneous 30G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 EQL Ultra Comfort Insulin Syr Miscellaneous 31G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle EQL Ultra Short Pen Needle Miscellaneous 31G X 6 MM Tier 2 ANALGESICS ‐ NonNarcotic ‐Aspirin Equagesic Oral Tablet 200‐325 MG Tier 3 ANTIHYPERLIPIDEMICS Atorvastatin Calcium‐Coenzyme Q10 EquaPAX/Atorvastatin/CoQ10 Oral Therapy Pack 20 & 100 MG Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Ibuprofen & Multiple Minerals EquaPAX/Ibuprofen/Minrex Oral Therapy Pack 800 MG Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Carbamazepine (Antipsychotic) Equetro Oral Capsule Extended Release 12 Hour 100 MG Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Carbamazepine (Antipsychotic) Equetro Oral Capsule Extended Release 12 Hour 200 MG Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Carbamazepine (Antipsychotic) Equetro Oral Capsule Extended Release 12 Hour 300 MG Tier 3 DERMATOLOGICALS Baclofen (Topical) Equipto‐Baclofen External Cream 2 % Tier 3 DERMATOLOGICALS Naproxen (Topical) Equipto‐Naproxen External Cream 10 % Tier 3 MEDICAL DEVICES AND SUPPLIES Impotence Aid Device ErecAid Esteem Kit Tier 3 VITAMINS Ergocalciferol Ergocalciferol Oral Capsule 50000 UNIT Tier 1 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Ergoloid Mesylates Ergoloid Mesylates Oral Tablet 1 MG Tier 3 MIGRAINE PRODUCTS Ergotamine Tartrate Ergomar Sublingual Tablet Sublingual 2 MG Tier 3 MIGRAINE PRODUCTS Ergotamine Tartrate Ergotamine Tartrate Powder Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Vismodegib Erivedge Oral Capsule 150 MG Tier 2 x x CONTRACEPTIVES Norethindrone (Contraceptive) Errin Oral Tablet 0.35 MG Tier 1 DERMATOLOGICALS Sertaconazole Nitrate Ertaczo External Cream 2 % Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Erwinia Chrysanthemi Erwinaze Injection Solution Reconstituted 10000 UNIT Tier 2 x DERMATOLOGICALS Erythromycin (Acne Aid) Ery External Pad 2 % Tier 1 DERMATOLOGICALS Erythromycin (Acne Aid) Erygel External Gel 2 % Tier 3 MACROLIDES Erythromycin Ethylsuccinate EryPed 200 Oral Suspension Reconstituted 200 MG/5ML Tier 3 MACROLIDES Erythromycin Ethylsuccinate EryPed 400 Oral Suspension Reconstituted 400 MG/5ML Tier 3 MACROLIDES Erythromycin Base Ery‐Tab Oral Tablet Delayed Release 250 MG Tier 3 MACROLIDES Erythromycin Base Ery‐Tab Oral Tablet Delayed Release 333 MG Tier 3 MACROLIDES Erythromycin Base Ery‐Tab Oral Tablet Delayed Release 500 MG Tier 3 MACROLIDES Erythromycin Lactobionate Erythrocin Lactobionate Intravenous Solution Reconstituted 500 MG Tier 3 x MACROLIDES Erythromycin Stearate Erythrocin Stearate Oral Tablet 250 MG Tier 3 MACROLIDES Erythromycin Base Erythromycin Base Oral Capsule Delayed Release Particles 250 MG Tier 1 MACROLIDES Erythromycin Base Erythromycin Base Oral Tablet 250 MG Tier 2 MACROLIDES Erythromycin Base Erythromycin Base Oral Tablet 500 MG Tier 2 MACROLIDES Erythromycin Ethylsuccinate Erythromycin Ethylsuccinate Oral Tablet 400 MG Tier 2 MACROLIDES Erythromycin Ethylsuccinate Erythromycin Ethylsuccinate Powder Tier 3 DERMATOLOGICALS Erythromycin (Acne Aid) Erythromycin External Gel 2 % Tier 1 DERMATOLOGICALS Erythromycin (Acne Aid) Erythromycin External Pad 2 % Tier 1 DERMATOLOGICALS Erythromycin (Acne Aid) Erythromycin External Solution 2 % Tier 1 OPHTHALMIC AGENTS Erythromycin (Ophth) Erythromycin Ophthalmic Ointment 5 MG/GM Tier 1 MACROLIDES Erythromycin Stearate Erythromycin Stearate Oral Tablet 250 MG Tier 3 RESPIRATORY AGENTS ‐ MISC. Pirfenidone Esbriet Oral Capsule 267 MG Tier 2 x x MULTIVITAMINS Ped Multivitamins w/Fl & Iron Escavite D Oral Tablet Chewable 0.25‐6 MG Tier 2 MULTIVITAMINS Ped Multivitamins w/Fl & Iron Escavite LQ Oral Liquid 0.25‐6 MG/ML Tier 3 MULTIVITAMINS Ped Multivitamins w/Fl & Iron Escavite Oral Tablet Chewable 0.25‐7.5 MG Tier 2 ANTIDEPRESSANTS Escitalopram Oxalate Escitalopram Oxalate Oral Solution 5 MG/5ML Tier 1 ANTIDEPRESSANTS Escitalopram Oxalate Escitalopram Oxalate Oral Tablet 10 MG Tier 1 ANTIDEPRESSANTS Escitalopram Oxalate Escitalopram Oxalate Oral Tablet 20 MG Tier 1 ANTIDEPRESSANTS Escitalopram Oxalate Escitalopram Oxalate Oral Tablet 5 MG Tier 1 ANALGESICS ‐ NonNarcotic Butalbital‐Acetaminophen‐Caffeine Esgic Oral Capsule 50‐325‐40 MG Tier 1 ANALGESICS ‐ NonNarcotic Butalbital‐Acetaminophen‐Caffeine Esgic Oral Tablet 50‐325‐40 MG Tier 3 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

BETA BLOCKERS Esmolol HCl Esmolol HCl Intravenous Solution 100 MG/10ML Tier 1 x ULCER DRUGS Esomeprazole Magnesium Esomeprazole Magnesium Oral Capsule Delayed Release 20 MG Tier 1 x x ULCER DRUGS Esomeprazole Magnesium Esomeprazole Magnesium Oral Capsule Delayed Release 40 MG Tier 1 x x DERMATOLOGICALS (Skin Cleanser) Essentra Wipes 9x9" External Miscellaneous 70 % Tier 3 CONTRACEPTIVES Norgestimate‐Ethinyl Estradiol Estarylla Oral Tablet 0.25‐35 MG‐MCG Tier 1 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Estazolam Estazolam Oral Tablet 1 MG Tier 1 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Estazolam Estazolam Oral Tablet 2 MG Tier 1 ESTROGENS Estradiol Estrace Oral Tablet 0.5 MG Tier 3 ESTROGENS Estradiol Estrace Oral Tablet 1 MG Tier 3 ESTROGENS Estradiol Estrace Oral Tablet 2 MG Tier 3 VAGINAL PRODUCTS Estradiol Vaginal Estrace Vaginal Cream 0.1 MG/GM Tier 3 ESTROGENS Estradiol Estradiol Implant Pellet 10 MG Tier 3 ESTROGENS Estradiol Estradiol Implant Pellet 12.5 MG Tier 3 ESTROGENS Estradiol Estradiol Implant Pellet 18 MG Tier 3 ESTROGENS Estradiol Estradiol Implant Pellet 20 MG Tier 3 ESTROGENS Estradiol Estradiol Implant Pellet 25 MG Tier 3 ESTROGENS Estradiol Estradiol Implant Pellet 31 MG Tier 3 ESTROGENS Estradiol Estradiol Implant Pellet 37.5 MG Tier 3 ESTROGENS Estradiol Estradiol Implant Pellet 50 MG Tier 3 ESTROGENS Estradiol Estradiol Implant Pellet 6 MG Tier 3 ESTROGENS Estradiol Micronized Estradiol Micronized Powder Tier 3 ESTROGENS Estradiol Estradiol Oral Tablet 0.5 MG Tier 1 ESTROGENS Estradiol Estradiol Oral Tablet 1 MG Tier 1 ESTROGENS Estradiol Estradiol Oral Tablet 2 MG Tier 1 ESTROGENS Estradiol Estradiol Powder Tier 3 ESTROGENS Estradiol Estradiol Transdermal Patch Twice Weekly 0.025 MG/24HR Tier 1 x ESTROGENS Estradiol Estradiol Transdermal Patch Twice Weekly 0.0375 MG/24HR Tier 1 x ESTROGENS Estradiol Estradiol Transdermal Patch Twice Weekly 0.05 MG/24HR Tier 1 x ESTROGENS Estradiol Estradiol Transdermal Patch Twice Weekly 0.075 MG/24HR Tier 1 x ESTROGENS Estradiol Estradiol Transdermal Patch Twice Weekly 0.1 MG/24HR Tier 1 x ESTROGENS Estradiol Estradiol Transdermal Patch Weekly 0.025 MG/24HR Tier 1 ESTROGENS Estradiol Estradiol Transdermal Patch Weekly 0.0375 MG/24HR Tier 1 ESTROGENS Estradiol Estradiol Transdermal Patch Weekly 0.05 MG/24HR Tier 1 ESTROGENS Estradiol Estradiol Transdermal Patch Weekly 0.06 MG/24HR Tier 1 ESTROGENS Estradiol Estradiol Transdermal Patch Weekly 0.075 MG/24HR Tier 1 ESTROGENS Estradiol Estradiol Transdermal Patch Weekly 0.1 MG/24HR Tier 1 ESTROGENS Estradiol Valerate Estradiol Valerate Intramuscular Oil 20 MG/ML Tier 1 x ESTROGENS Estradiol Valerate Estradiol Valerate Intramuscular Oil 40 MG/ML Tier 1 x ESTROGENS Estradiol & Norethindrone Acetate Estradiol‐Norethindrone Acet Oral Tablet 0.5‐0.1 MG Tier 1 ESTROGENS Estradiol & Norethindrone Acetate Estradiol‐Norethindrone Acet Oral Tablet 1‐0.5 MG Tier 1 VAGINAL PRODUCTS Estradiol Vaginal Estring Vaginal Ring 2 MG Tier 3 x ESTROGENS Estriol Micronized Estriol Micronized Powder Tier 3 ESTROGENS Estriol Micronized Estriol Powder Tier 3 ESTROGENS Estradiol Estrogel Transdermal Gel 0.75 MG/1.25 GM (0.06%) Tier 3 x ESTROGENS Estrone Estrone Powder Tier 3 ESTROGENS Estropipate Estropipate Oral Tablet 0.75 MG Tier 1 ESTROGENS Estropipate Estropipate Oral Tablet 1.5 MG Tier 1 ESTROGENS Estropipate Estropipate Oral Tablet 3 MG Tier 3 CONTRACEPTIVES Norethindrone Acetate‐Ethinyl Estradiol‐Fe Estrostep Fe Oral Tablet 1‐20/1‐30/1‐35 MG‐MCG Tier 3 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Eszopiclone Eszopiclone Oral Tablet 1 MG Tier 1 x HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Eszopiclone Eszopiclone Oral Tablet 2 MG Tier 1 x HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Eszopiclone Eszopiclone Oral Tablet 3 MG Tier 1 x DIURETICS Ethacrynate Sodium Ethacrynate Sodium Intravenous Solution Reconstituted 50 MG Tier 1 x ANTIMYCOBACTERIAL AGENTS Ethambutol HCl Ethambutol HCl Oral Tablet 100 MG Tier 1 ANTIMYCOBACTERIAL AGENTS Ethambutol HCl Ethambutol HCl Oral Tablet 400 MG Tier 1 ASSORTED CLASSES Ethanolamine Oleate Ethamolin Intravenous Solution 5 % Tier 3 x ESTROGENS Ethinyl Estradiol Ethinyl Estradiol Powder Tier 3 ANTICONVULSANTS Ethosuximide Ethosuximide Oral Capsule 250 MG Tier 1 ANTICONVULSANTS Ethosuximide Ethosuximide Oral Solution 250 MG/5ML Tier 1 CHEMICALS Carbitol Ethoxy Diglycol Liquid Tier 3 CHEMICALS Carbitol Ethoxy Diglycol Reagent Liquid Tier 3 PHARMACEUTICAL ADJUVANTS Ethyl Acetate Ethyl Acetate Solution Tier 3 PHARMACEUTICAL ADJUVANTS Ethyl Alcohol (Vehicle) Ethyl Alcohol Solution 100 % Tier 3 CHEMICALS Alcohol, USP Ethyl Alcohol Solution 95 % Tier 3 DERMATOLOGICALS Ethyl Chloride Ethyl Chloride External Aerosol Tier 3 CHEMICALS Ethyl Ethyl Vanillin Flakes Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Etidronate Disodium Etidronate Disodium Oral Tablet 200 MG Tier 3 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Etidronate Disodium Etidronate Disodium Oral Tablet 400 MG Tier 3 x ANALGESICS ‐ ANTI‐INFLAMMATORY Etodolac Etodolac ER Oral Tablet Extended Release 24 Hour 400 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Etodolac Etodolac ER Oral Tablet Extended Release 24 Hour 500 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Etodolac Etodolac ER Oral Tablet Extended Release 24 Hour 600 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Etodolac Etodolac Oral Capsule 200 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Etodolac Etodolac Oral Capsule 300 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Etodolac Etodolac Oral Tablet 400 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Etodolac Etodolac Oral Tablet 500 MG Tier 1 GENERAL ANESTHETICS Etomidate Etomidate Intravenous Solution 2 MG/ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Etoposide Etoposide Intravenous Solution 1 GM/50ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Etoposide Etoposide Intravenous Solution 100 MG/5ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Etoposide Etoposide Intravenous Solution 500 MG/25ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Etoposide Etoposide Oral Capsule 50 MG Tier 2 x DERMATOLOGICALS Crotamiton Eurax External Cream 10 % Tier 2 DERMATOLOGICALS Crotamiton Eurax External Lotion 10 % Tier 2 ESTROGENS Estradiol Evamist Transdermal Solution 1.53 MG/SPRAY Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Amphetamine Sulfate Evekeo Oral Tablet 10 MG Tier 3 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Amphetamine Sulfate Evekeo Oral Tablet 5 MG Tier 3 x x DIAGNOSTIC PRODUCTS Glucose Blood EvenCare + Blood Glucose Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood EvenCare Blood Glucose Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood EvenCare G2 Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood EvenCare G3 Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood EvenCare Mini Glucose Test In Vitro Strip Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Raloxifene HCl Evista Oral Tablet 60 MG Tier 3 x HEMOSTATICS Thrombin (Human) Evithrom External Solution 800‐1200 UNIT/ML Tier 3 DERMATOLOGICALS Clindamycin Phosphate (Topical) Evoclin External Foam 1 % Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Evolution Autocode In Vitro Strip Tier 3 ANTIVIRALS Sulfate‐Cobicistat Evotaz Oral Tablet 300‐150 MG Tier 2 x MOUTH/THROAT/DENTAL AGENTS Cevimeline HCl Evoxac Oral Capsule 30 MG Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood ExacTech R‐S‐G Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood ExacTech Test In Vitro Strip Tier 3 COUGH/COLD/ALLERGY Phenylephrine w/ DM‐GG Exactuss Oral Liquid 10‐28‐388 MG/5ML Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Excel Comfort Point Pen Needle Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Excel Comfort Point Pen Needle Miscellaneous 31G X 4 MM Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Excel Comfort Point Pen Needle Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Excel Comfort Point Pen Needle Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Exel Comfort Point Insulin Syr Miscellaneous 28G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Exel Comfort Point Insulin Syr Miscellaneous 28G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Exel Comfort Point Insulin Syr Miscellaneous 29G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Exel Comfort Point Insulin Syr Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Exel Comfort Point Insulin Syr Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Exel Comfort Point Insulin Syr Miscellaneous 30G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Exel Comfort Point Insulin Syr Miscellaneous 30G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Exel Comfort Point Insulin Syr Miscellaneous 30G X 5/16" 1 ML Tier 2 DERMATOLOGICALS Sulconazole Nitrate Exelderm External Cream 1 % Tier 3 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

DERMATOLOGICALS Sulconazole Nitrate Exelderm External Solution 1 % Tier 3 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Rivastigmine Tartrate Exelon Oral Capsule 1.5 MG Tier 3 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Rivastigmine Tartrate Exelon Oral Capsule 3 MG Tier 3 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Rivastigmine Tartrate Exelon Oral Capsule 4.5 MG Tier 3 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Rivastigmine Tartrate Exelon Oral Capsule 6 MG Tier 3 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Rivastigmine Exelon Transdermal Patch 24 Hour 13.3 MG/24HR Tier 3 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Rivastigmine Exelon Transdermal Patch 24 Hour 4.6 MG/24HR Tier 3 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Rivastigmine Exelon Transdermal Patch 24 Hour 9.5 MG/24HR Tier 3 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Exemestane Exemestane Oral Tablet 25 MG Tier 1 ANTIHYPERTENSIVES Amlodipine‐Valsartan‐Hydrochlorothiazide Exforge HCT Oral Tablet 10‐160‐12.5 MG Tier 3 xx ANTIHYPERTENSIVES Amlodipine‐Valsartan‐Hydrochlorothiazide Exforge HCT Oral Tablet 10‐160‐25 MG Tier 3 xx ANTIHYPERTENSIVES Amlodipine‐Valsartan‐Hydrochlorothiazide Exforge HCT Oral Tablet 10‐320‐25 MG Tier 3 xx ANTIHYPERTENSIVES Amlodipine‐Valsartan‐Hydrochlorothiazide Exforge HCT Oral Tablet 5‐160‐12.5 MG Tier 3 xx ANTIHYPERTENSIVES Amlodipine‐Valsartan‐Hydrochlorothiazide Exforge HCT Oral Tablet 5‐160‐25 MG Tier 3 xx ANTIHYPERTENSIVES Amlodipine Besylate‐Valsartan Exforge Oral Tablet 10‐160 MG Tier 3 xx ANTIHYPERTENSIVES Amlodipine Besylate‐Valsartan Exforge Oral Tablet 10‐320 MG Tier 3 xx ANTIHYPERTENSIVES Amlodipine Besylate‐Valsartan Exforge Oral Tablet 5‐160 MG Tier 3 xx ANTIHYPERTENSIVES Amlodipine Besylate‐Valsartan Exforge Oral Tablet 5‐320 MG Tier 3 xx ANTIDOTES Deferasirox Exjade Oral Tablet Soluble 125 MG Tier 2 x ANTIDOTES Deferasirox Exjade Oral Tablet Soluble 250 MG Tier 2 x ANTIDOTES Deferasirox Exjade Oral Tablet Soluble 500 MG Tier 2 x DERMATOLOGICALS Sodium Thiosulfate‐Salicylic Acid Exoderm External Lotion 25‐1 % Tier 3 DERMATOLOGICALS Amantadine HCl‐Gabapentin‐Diclofenac Sod‐Baclofen‐Lidocaine Extardol External Cream Tier 3 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Interferon Beta‐1b Extavia Subcutaneous Kit 0.3 MG Tier 2 x x DERMATOLOGICALS Ketoconazole (Topical) Extina External Foam 2 % Tier 3 x ASSORTED CLASSES Icodextrin‐Electrolytes Extraneal Intraperitoneal Solution 7.5 % Tier 3 MULTIVITAMINS Prenatal w/o Vit A w/Fe Fumarate‐Docusate Ca‐Folic Acid‐DHA Extra‐Virt Plus DHA Oral Capsule 29‐1.25‐350 MG Tier 3 PHARMACEUTICAL ADJUVANTS Transdermal Patch Exyderm Patch Tier 3 VACCINES Influenza Virus Vaccine Tissue‐Cultured Subunit EZ Flu Shot‐Flucelvax Intramuscular Prefilled Syringe Kit 0.5 ML Tier 3 x VACCINES Influenza Virus Vaccine Types A & B Surface Antigen EZ Flu Shot‐Fluvirin Intramuscular Prefilled Syringe Kit 0.5 ML Tier 3 x MEDICAL DEVICES AND SUPPLIES Lancets E‐Z Ject Lancet Micro‐Thin 33G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets E‐Z Ject Lancet Super Thin 30G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets E‐Z Ject Lancets 21G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets E‐Z Ject Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets E‐Z Ject Lancets Thin 26G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Ez Smart Blood Glucose Lancets Miscellaneous Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood Ez Smart Blood Glucose Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Ez Smart Plus Glucose Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers E‐Z Spacer Device Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers E‐Z Spacer The Body Guards Pk Device Tier 2 x MEDICAL DEVICES AND SUPPLIES Lancets EZ‐Lets Lancets 21G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets EZ‐Lets Lancets 23G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets EZ‐Lets Lancets 26G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets EZ‐Lets Lancets 28G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets EZ‐Lets Lancets 30G Miscellaneous Tier 2 DIAGNOSTIC PRODUCTS Barium Sulfate E‐Z‐Paque Oral Suspension Reconstituted 96 % Tier 3 HEMATOPOIETIC AGENTS Folic Acid‐Vitamin B6‐Vitamin B12 FaBB Oral Tablet 2.2‐25‐1 MG Tier 1 DERMATOLOGICALS Tazarotene (Acne) Fabior External Foam 0.1 % Tier 3 x FLUOROQUINOLONES Gemifloxacin Mesylate Factive Oral Tablet 320 MG Tier 3 CONTRACEPTIVES Levonorgestrel‐Ethinyl Estradiol & Folic Acid FaLessa Oral Kit 20‐1‐0.1 MCG‐MG Tier 3 CONTRACEPTIVES Levonorgestrel & Eth Estradiol Falmina Oral Tablet 0.1‐20 MG‐MCG Tier 1 ANTIVIRALS Famciclovir Famciclovir Oral Tablet 125 MG Tier 1 x ANTIVIRALS Famciclovir Famciclovir Oral Tablet 250 MG Tier 1 x ANTIVIRALS Famciclovir Famciclovir Oral Tablet 500 MG Tier 1 x ULCER DRUGS Famotidine Famotidine Intravenous Solution 20 MG/2ML Tier 1 x ULCER DRUGS Famotidine Famotidine Intravenous Solution 200 MG/20ML Tier 1 x ULCER DRUGS Famotidine Famotidine Intravenous Solution 40 MG/4ML Tier 1 x ULCER DRUGS Famotidine Famotidine Oral Suspension Reconstituted 40 MG/5ML Tier 1 ULCER DRUGS Famotidine Famotidine Oral Tablet 20 MG Tier 1 ULCER DRUGS Famotidine Famotidine Oral Tablet 40 MG Tier 1 ANTIVIRALS Famciclovir Famvir Oral Tablet 125 MG Tier 3 x ANTIVIRALS Famciclovir Famvir Oral Tablet 250 MG Tier 3 x ANTIVIRALS Famciclovir Famvir Oral Tablet 500 MG Tier 3 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Iloperidone Fanapt Oral Tablet 1 MG Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Iloperidone Fanapt Oral Tablet 10 MG Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Iloperidone Fanapt Oral Tablet 12 MG Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Iloperidone Fanapt Oral Tablet 2 MG Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Iloperidone Fanapt Oral Tablet 4 MG Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Iloperidone Fanapt Oral Tablet 6 MG Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Iloperidone Fanapt Oral Tablet 8 MG Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Iloperidone Fanapt Titration Pack Oral Tablet 1 & 2 & 4 & 6 MG Tier 3 x ANTICONVULSANTS Gabapentin Fanatrex FusePaq Oral Suspension 25 MG/ML Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Toremifene Citrate Fareston Oral Tablet 60 MG Tier 2 ANTIDIABETICS Dapagliflozin Propanediol Farxiga Oral Tablet 10 MG Tier 3 x x ANTIDIABETICS Dapagliflozin Propanediol Farxiga Oral Tablet 5 MG Tier 3 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Panobinostat Lactate Farydak Oral Capsule 10 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Panobinostat Lactate Farydak Oral Capsule 15 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Panobinostat Lactate Farydak Oral Capsule 20 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Fulvestrant Faslodex Intramuscular Solution 250 MG/5ML Tier 2 x HEMATOPOIETIC AGENTS Folic Acid‐Vitamin B6‐Vitamin B12 FA‐Vitamin B‐6‐Vitamin B‐12 Oral Tablet 2.2‐25‐0.5 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Clozapine FazaClo Oral Tablet Dispersible 100 MG Tier 3 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Clozapine FazaClo Oral Tablet Dispersible 12.5 MG Tier 3 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Clozapine FazaClo Oral Tablet Dispersible 150 MG Tier 3 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Clozapine FazaClo Oral Tablet Dispersible 200 MG Tier 3 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Clozapine FazaClo Oral Tablet Dispersible 25 MG Tier 3 x DERMATOLOGICALS Flurbiprofen‐Baclofen‐Lidocaine HCl FBL Kit External Cream 15‐4‐5 % Tier 3 x HEMATOPOIETIC AGENTS Iron‐Vitamin C‐Vitamin B12‐Folic Acid FE C Plus Oral Tablet 100‐250‐0.025‐1 MG Tier 1 HEMATOLOGICAL AGENTS ‐ MISC. Antiinhibitor Coagulant Complex Feiba Intravenous Solution Reconstituted Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Antiinhibitor Coagulant Complex Feiba NF Intravenous Solution Reconstituted Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Antiinhibitor Coagulant Complex Feiba VH Immuno Intravenous Solution Reconstituted Tier 2 x ANTICONVULSANTS Felbamate Oral Suspension 600 MG/5ML Tier 1 ANTICONVULSANTS Felbamate Felbamate Oral Tablet 400 MG Tier 1 ANTICONVULSANTS Felbamate Felbamate Oral Tablet 600 MG Tier 1 ANTICONVULSANTS Felbamate Felbatol Oral Suspension 600 MG/5ML Tier 3 ANTICONVULSANTS Felbamate Felbatol Oral Tablet 400 MG Tier 3 ANTICONVULSANTS Felbamate Felbatol Oral Tablet 600 MG Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Piroxicam Feldene Oral Capsule 10 MG Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Piroxicam Feldene Oral Capsule 20 MG Tier 3 CALCIUM CHANNEL BLOCKERS Felodipine Felodipine ER Oral Tablet Extended Release 24 Hour 10 MG Tier 1 CALCIUM CHANNEL BLOCKERS Felodipine Felodipine ER Oral Tablet Extended Release 24 Hour 2.5 MG Tier 1 CALCIUM CHANNEL BLOCKERS Felodipine Felodipine ER Oral Tablet Extended Release 24 Hour 5 MG Tier 1 VAGINAL PRODUCTS Acetic Acid‐Oxyquinoline Vaginal Fem pH Vaginal Gel 0.9‐0.025 % Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Letrozole Femara Oral Tablet 2.5 MG Tier 3 CONTRACEPTIVES Norethindrone & Ethinyl Estradiol‐Fe Femcon Fe Oral Tablet Chewable 0.4‐35 MG‐MCG Tier 3 ESTROGENS Norethindrone Acetate‐Ethinyl Estradiol Femhrt Low Dose Oral Tablet 0.5‐2.5 MG‐MCG Tier 3 x VAGINAL PRODUCTS Estradiol Acetate Vaginal Femring Vaginal Ring 0.05 MG/24HR Tier 3 x VAGINAL PRODUCTS Estradiol Acetate Vaginal Femring Vaginal Ring 0.1 MG/24HR Tier 3 x ANTIHYPERLIPIDEMICS Fenofibrate Micronized Fenofibrate Micronized Oral Capsule 130 MG Tier 1 x ANTIHYPERLIPIDEMICS Fenofibrate Micronized Fenofibrate Micronized Oral Capsule 134 MG Tier 1 ANTIHYPERLIPIDEMICS Fenofibrate Micronized Fenofibrate Micronized Oral Capsule 200 MG Tier 1 ANTIHYPERLIPIDEMICS Fenofibrate Micronized Fenofibrate Micronized Oral Capsule 43 MG Tier 1 x ANTIHYPERLIPIDEMICS Fenofibrate Micronized Fenofibrate Micronized Oral Capsule 67 MG Tier 1 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ANTIHYPERLIPIDEMICS Fenofibrate Fenofibrate Oral Capsule 150 MG Tier 2 xx ANTIHYPERLIPIDEMICS Fenofibrate Fenofibrate Oral Capsule 50 MG Tier 2 xx ANTIHYPERLIPIDEMICS Fenofibrate Fenofibrate Oral Tablet 120 MG Tier 3 xx ANTIHYPERLIPIDEMICS Fenofibrate Fenofibrate Oral Tablet 145 MG Tier 1 x ANTIHYPERLIPIDEMICS Fenofibrate Fenofibrate Oral Tablet 160 MG Tier 1 x ANTIHYPERLIPIDEMICS Fenofibrate Fenofibrate Oral Tablet 40 MG Tier 3 xx ANTIHYPERLIPIDEMICS Fenofibrate Fenofibrate Oral Tablet 48 MG Tier 1 x ANTIHYPERLIPIDEMICS Fenofibrate Fenofibrate Oral Tablet 54 MG Tier 1 ANTIHYPERLIPIDEMICS Choline Fenofibrate Fenofibric Acid Oral Capsule Delayed Release 135 MG Tier 1 xx ANTIHYPERLIPIDEMICS Choline Fenofibrate Fenofibric Acid Oral Capsule Delayed Release 45 MG Tier 1 xx ANTIHYPERLIPIDEMICS Fenofibric Acid Fenofibric Acid Oral Tablet 105 MG Tier 2 xx ANTIHYPERLIPIDEMICS Fenofibric Acid Fenofibric Acid Oral Tablet 35 MG Tier 2 xx ANTIHYPERLIPIDEMICS Fenofibrate Fenoglide Oral Tablet 120 MG Tier 3 xx ANTIHYPERLIPIDEMICS Fenofibrate Fenoglide Oral Tablet 40 MG Tier 3 xx ANALGESICS ‐ ANTI‐INFLAMMATORY Fenoprofen Calcium Fenoprofen Calcium Oral Capsule 400 MG Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Fenoprofen Calcium Fenoprofen Calcium Oral Tablet 600 MG Tier 2 ANALGESICS ‐ OPIOID Fentanyl Citrate FentaNYL Citrate Buccal Lozenge on a Handle 1200 MCG Tier 1 x ANALGESICS ‐ OPIOID Fentanyl Citrate FentaNYL Citrate Buccal Lozenge on a Handle 1600 MCG Tier 1 x ANALGESICS ‐ OPIOID Fentanyl Citrate FentaNYL Citrate Buccal Lozenge on a Handle 200 MCG Tier 1 x ANALGESICS ‐ OPIOID Fentanyl Citrate FentaNYL Citrate Buccal Lozenge on a Handle 400 MCG Tier 1 x ANALGESICS ‐ OPIOID Fentanyl Citrate FentaNYL Citrate Buccal Lozenge on a Handle 600 MCG Tier 1 x ANALGESICS ‐ OPIOID Fentanyl Citrate FentaNYL Citrate Buccal Lozenge on a Handle 800 MCG Tier 1 x ANALGESICS ‐ OPIOID Fentanyl Citrate FentaNYL Citrate Injection Solution 0.05 MG/ML Tier 1 x x ANALGESICS ‐ OPIOID Fentanyl Citrate FentaNYL Citrate Powder Tier 3 ANALGESICS ‐ OPIOID Fentanyl FentaNYL Transdermal Patch 72 Hour 100 MCG/HR Tier 1 x ANALGESICS ‐ OPIOID Fentanyl FentaNYL Transdermal Patch 72 Hour 12 MCG/HR Tier 1 x ANALGESICS ‐ OPIOID Fentanyl FentaNYL Transdermal Patch 72 Hour 25 MCG/HR Tier 1 x ANALGESICS ‐ OPIOID Fentanyl FentaNYL Transdermal Patch 72 Hour 37.5 MCG/HR Tier 3 x ANALGESICS ‐ OPIOID Fentanyl FentaNYL Transdermal Patch 72 Hour 50 MCG/HR Tier 1 x ANALGESICS ‐ OPIOID Fentanyl FentaNYL Transdermal Patch 72 Hour 62.5 MCG/HR Tier 3 x x ANALGESICS ‐ OPIOID Fentanyl FentaNYL Transdermal Patch 72 Hour 75 MCG/HR Tier 1 x ANALGESICS ‐ OPIOID Fentanyl FentaNYL Transdermal Patch 72 Hour 87.5 MCG/HR Tier 3 x ANALGESICS ‐ OPIOID Fentanyl Citrate Fentora Buccal Tablet 100 MCG Tier 3 x x ANALGESICS ‐ OPIOID Fentanyl Citrate Fentora Buccal Tablet 200 MCG Tier 3 x x ANALGESICS ‐ OPIOID Fentanyl Citrate Fentora Buccal Tablet 400 MCG Tier 3 x x ANALGESICS ‐ OPIOID Fentanyl Citrate Fentora Buccal Tablet 600 MCG Tier 3 x x ANALGESICS ‐ OPIOID Fentanyl Citrate Fentora Buccal Tablet 800 MCG Tier 3 x x HEMATOPOIETIC AGENTS Ferumoxytol Feraheme Intravenous Solution 510 MG/17ML Tier 3 x HEMATOPOIETIC AGENTS Fe Asparto Gly‐Vit B12‐FA‐Vit C‐DSS‐Succinic Acid‐Zinc FeRiva 21/7 Oral Tablet 75‐1 MG Tier 3 HEMATOPOIETIC AGENTS Fe Bisglycinate‐Fe Carbonyl‐Vit C‐FA‐B12‐Biotin‐Docusate FeRiva Oral Capsule 75‐1 MG Tier 3 HEMATOPOIETIC AGENTS Iron‐Vit C‐FA‐B12‐Biotin‐Copper‐Docusate FeRivaFA Oral Capsule 110‐1 MG Tier 3 HEMATOPOIETIC AGENTS Ferrous Fumarate w/ B12‐Vit C‐FA‐IFC Ferocon Oral Capsule Tier 1 HEMATOPOIETIC AGENTS Ferrous Fumarate w/ B12‐Vit C‐FA‐IFC Ferotrinsic Oral Capsule Tier 1 HEMATOPOIETIC AGENTS Fe Carbonyl‐Fe Gluconate‐FA‐Vit B12‐Vit C‐Docusate Sodium Ferralet 90 Oral Tablet 90‐1 MG Tier 3 HEMATOPOIETIC AGENTS Iron‐Folic Acid‐Vitamin B12‐Vitamin C‐Docusate Sodium FerraPlus 90 Oral Tablet 90‐1 MG Tier 2 HEMATOPOIETIC AGENTS Fe Asp Gly‐Fe Polysaccharide‐Succ Acd‐C‐Threonic Acid‐B12‐FA Ferrex 150 Forte Plus Oral Capsule 50‐100 MG Tier 3 HEMATOPOIETIC AGENTS Fe Asparto Gly‐Fe Fum‐B12‐Folic Acid‐Vit C‐Succinic Acid Ferrex 28 Oral Tablet Tier 2 ANTIDOTES Deferiprone Ferriprox Oral Solution 100 MG/ML Tier 3 x ANTIDOTES Deferiprone Ferriprox Oral Tablet 500 MG Tier 2 x HEMATOPOIETIC AGENTS Ferrous Fumarate‐FA‐B Complex‐C‐Zn‐Mg‐Mn‐Cu Ferrocite Plus Oral Tablet 106‐1 MG Tier 1 HEMATOPOIETIC AGENTS Fe Fumarate‐Vitamin C‐Vitamin B12‐Folic Acid FerroGels Forte Oral Capsule 460‐60‐0.01‐1 MG Tier 1 HEMATOPOIETIC AGENTS Ferrous Fumarate‐Docusate Na‐C‐E‐B12‐IF‐Folic Acid FERRO‐plex Hematinic Oral Tablet 115‐1 MG Tier 3 HEMATOPOIETIC AGENTS Iron w/ B12‐Vit C‐FA‐IFC Ferrotrin Oral Capsule Tier 3 HEMATOPOIETIC AGENTS Ferrous Sulfate Ferrous Sulfate Granules Tier 3 ANTIDEPRESSANTS HCl Fetzima Oral Capsule Extended Release 24 Hour 120 MG Tier 3 xx ANTIDEPRESSANTS Levomilnacipran HCl Fetzima Oral Capsule Extended Release 24 Hour 20 MG Tier 3 xx ANTIDEPRESSANTS Levomilnacipran HCl Fetzima Oral Capsule Extended Release 24 Hour 40 MG Tier 3 xx ANTIDEPRESSANTS Levomilnacipran HCl Fetzima Oral Capsule Extended Release 24 Hour 80 MG Tier 3 xx ANTIDEPRESSANTS Levomilnacipran HCl Fetzima Titration Oral Capsule ER 24 Hour Therapy Pack 20 & 40 MG Tier 3 xx MUSCULOSKELETAL THERAPY AGENTS Cyclobenzaprine HCl Fexmid Oral Tablet 7.5 MG Tier 3 ANTIHYPERLIPIDEMICS Fenofibric Acid Fibricor Oral Tablet 105 MG Tier 2 xx ANTIHYPERLIPIDEMICS Fenofibric Acid Fibricor Oral Tablet 35 MG Tier 2 xx DIAGNOSTIC PRODUCTS Glucose Blood Fifty50 Glucose Test 2.0 In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Fifty50 Pen Needles Miscellaneous 31G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Fifty50 Pen Needles Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Fifty50 Safety Seal Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Fifty50 Superior Comfort Syr Miscellaneous 31G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Fifty50 Superior Comfort Syr Miscellaneous 31G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Fifty50 Superior Comfort Syr Miscellaneous 31G X 5/16" 1 ML Tier 2 DERMATOLOGICALS Azelaic Acid Finacea External Foam 15 % Tier 2 DERMATOLOGICALS Azelaic Acid Finacea External Gel 15 % Tier 2 DERMATOLOGICALS Finasteride (Alopecia) Finasteride Oral Tablet 1 MG Tier 1 GENITOURINARY AGENTS ‐ MISCELLANEOUS Finasteride Finasteride Oral Tablet 5 MG Tier 1 MEDICAL DEVICES AND SUPPLIES Lancets Fine 30 Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Fingerstix Lancets Miscellaneous Tier 2 ANALGESICS ‐ NonNarcotic Butalbital‐Acetaminophen‐Caffeine Fioricet Oral Capsule 50‐300‐40 MG Tier 3 ANALGESICS ‐ OPIOID Butalbital‐Acetaminophen‐Caffeine w/ Codeine Fioricet/Codeine Oral Capsule 50‐300‐40‐30 MG Tier 3 ANALGESICS ‐ NonNarcotic Butalbital‐Aspirin‐Caffeine Fiorinal Oral Capsule 50‐325‐40 MG Tier 3 ANALGESICS ‐ OPIOID Butalbital‐Aspirin‐Caffeine w/Cod Fiorinal/Codeine #3 Oral Capsule 50‐325‐40‐30 MG Tier 3 HEMATOLOGICAL AGENTS ‐ MISC. Icatibant Acetate Firazyr Subcutaneous Solution 30 MG/3ML Tier 2 x MOUTH/THROAT/DENTAL AGENTS Diphenhydramine‐Lidocaine‐Nystatin First‐BXN Mouthwash Mouth/Throat Suspension Tier 3 MOUTH/THROAT/DENTAL AGENTS Diphenhydramine‐Hydrocortisone‐Nystatin First‐Dukes Mouthwash Mouth/Throat Suspension Tier 3 DERMATOLOGICALS Hydrocortisone (Topical) First‐Hydrocortisone External Gel 10 % Tier 3 ULCER DRUGS Lansoprazole First‐Lansoprazole Oral Suspension 3 MG/ML Tier 3 x MOUTH/THROAT/DENTAL AGENTS Diphenhydramine‐Hydrocortisone‐Nystatin‐Tetracycline First‐Marys Mouthwash Mouth/Throat Suspension Tier 3 MOUTH/THROAT/DENTAL AGENTS Diphenhydramine‐Lidocaine‐Alum Hydroxide‐Mg Hydroxide‐Simeth First‐Mouthwash BLM Mouth/Throat Suspension Tier 3 ULCER DRUGS Omeprazole First‐Omeprazole Oral Suspension 2 MG/ML Tier 3 x VAGINAL PRODUCTS Progesterone (Vaginal) First‐Progesterone VGS 100 Vaginal Suppository 100 MG Tier 3 VAGINAL PRODUCTS Progesterone (Vaginal) First‐Progesterone VGS 200 Vaginal Suppository 200 MG Tier 3 VAGINAL PRODUCTS Progesterone (Vaginal) First‐Progesterone VGS 25 Vaginal Suppository 25 MG Tier 3 VAGINAL PRODUCTS Progesterone (Vaginal) First‐Progesterone VGS 400 Vaginal Suppository 400 MG Tier 3 VAGINAL PRODUCTS Progesterone (Vaginal) First‐Progesterone VGS 50 Vaginal Suppository 50 MG Tier 3 ANDROGENS‐ANABOLIC Testosterone Propionate First‐Testosterone MC Transdermal Cream 2 % Tier 3 x ANDROGENS‐ANABOLIC Testosterone Propionate First‐Testosterone Transdermal Ointment 2 % Tier 3 x ANTI‐INFECTIVE AGENTS ‐ MISC. Vancomycin HCl First‐Vancomycin 25 Oral Solution 25 MG/ML Tier 3 ANTI‐INFECTIVE AGENTS ‐ MISC. Vancomycin HCl First‐Vancomycin 50 Oral Solution 50 MG/ML Tier 3 ANTI‐INFECTIVE AGENTS ‐ MISC. Metronidazole Flagyl ER Oral Tablet Extended Release 24 Hour 750 MG Tier 3 ANTI‐INFECTIVE AGENTS ‐ MISC. Metronidazole Flagyl Oral Capsule 375 MG Tier 3 ANTI‐INFECTIVE AGENTS ‐ MISC. Metronidazole Flagyl Oral Tablet 250 MG Tier 3 ANTI‐INFECTIVE AGENTS ‐ MISC. Metronidazole Flagyl Oral Tablet 500 MG Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Naproxen w/ Liniment Flanax Pain Relief Combination Kit 500 MG Tier 3 OPHTHALMIC AGENTS Fluorometholone Acetate Flarex Ophthalmic Suspension 0.1 % Tier 3 URINARY ANTISPASMODICS Flavoxate HCl FlavoxATE HCl Oral Tablet 100 MG Tier 1 ANTIARRHYTHMICS Flecainide Acetate Flecainide Acetate Oral Tablet 100 MG Tier 1 ANTIARRHYTHMICS Flecainide Acetate Flecainide Acetate Oral Tablet 150 MG Tier 1 ANTIARRHYTHMICS Flecainide Acetate Flecainide Acetate Oral Tablet 50 MG Tier 1 DERMATOLOGICALS Diclofenac Epolamine Flector Transdermal Patch 1.3 % Tier 3 x HEMATOLOGICAL AGENTS ‐ MISC. Albumin, Human Flexbumin Intravenous Solution 25 % Tier 1 x MUSCULOSKELETAL THERAPY AGENTS Cyclobenzaprine‐Capsaicin‐Menthol FlexePax Combination Therapy Pack 10 & 0.0375‐5 MG & % Tier 3 MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers Flexichamber Device Tier 2 x DERMATOLOGICALS Capsaicin‐Menthol Flexin External Patch 0.0375‐5 % Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Diclofenac Sodium‐Ranitidine HCl‐Lidocaine Flexizol Combipak Combination Therapy Pack 75 & 150 & 3.75 MG‐MG‐% Tier 3 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

GENITOURINARY AGENTS ‐ MISCELLANEOUS Tamsulosin HCl Flomax Oral Capsule 0.4 MG Tier 3 CORTICOSTEROIDS Prednisolone Acetate Flo‐Pred Oral Suspension 16.7 (15 Base) MG/5ML Tier 3 MINERALS & ELECTROLYTES Sodium Fluoride‐Vitamin D Floriva Oral Liquid 0.25‐400 MG‐UNIT/ML Tier 2 MULTIVITAMINS Pediatric Multiple Vitamins & Minerals w/ Fluoride Floriva Oral Tablet Chewable 0.25 MG Tier 3 MULTIVITAMINS Pediatric Multiple Vitamins & Minerals w/ Fluoride Floriva Oral Tablet Chewable 0.5 MG Tier 3 MULTIVITAMINS Pediatric Multiple Vitamins & Minerals w/ Fluoride Floriva Oral Tablet Chewable 1 MG Tier 3 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Fluticasone Propionate (Inhalation) Flovent Diskus Inhalation Aerosol Powder Breath Activated 100 MCG/BLIST Tier 2 x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Fluticasone Propionate (Inhalation) Flovent Diskus Inhalation Aerosol Powder Breath Activated 250 MCG/BLIST Tier 2 x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Fluticasone Propionate (Inhalation) Flovent Diskus Inhalation Aerosol Powder Breath Activated 50 MCG/BLIST Tier 2 x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Fluticasone Propionate HFA Flovent HFA Inhalation Aerosol 110 MCG/ACT Tier 2 x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Fluticasone Propionate HFA Flovent HFA Inhalation Aerosol 220 MCG/ACT Tier 2 x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Fluticasone Propionate HFA Flovent HFA Inhalation Aerosol 44 MCG/ACT Tier 2 x COUGH/COLD/ALLERGY Hydrocodone‐Guaifenesin Flowtuss Oral Solution 2.5‐200 MG/5ML Tier 3 VACCINES Influenza Virus Vaccine Split Preservative Free Fluarix Intramuscular Suspension Prefilled Syringe 0.5 ML Tier 3 x VACCINES Influenza Virus Vaccine Split Quadrivalent Fluarix Quadrivalent Intramuscular Suspension Prefilled Syringe 0.5 ML Tier 3 x VACCINES Influenza Virus Vaccine Recombinant Hemagglutinin (HA) Flublok Intramuscular Solution Tier 3 x OPHTHALMIC AGENTS Fluorescein w/ Proparacaine Flucaine Ophthalmic Solution 0.25‐0.5 % Tier 1 VACCINES Influenza Virus Vaccine Tissue‐Cultured Subunit Flucelvax Intramuscular Suspension Prefilled Syringe 0.5 ML Tier 3 x ANTIFUNGALS Fluconazole in NaCl Fluconazole in Sodium Chloride Intravenous Solution 100‐0.9 MG/50ML‐% Tier 3 x ANTIFUNGALS Fluconazole in NaCl Fluconazole in Sodium Chloride Intravenous Solution 200‐0.9 MG/100ML‐% Tier 1 x ANTIFUNGALS Fluconazole in NaCl Fluconazole in Sodium Chloride Intravenous Solution 400‐0.9 MG/200ML‐% Tier 1 x ANTIFUNGALS Fluconazole Fluconazole Oral Suspension Reconstituted 10 MG/ML Tier 1 ANTIFUNGALS Fluconazole Fluconazole Oral Suspension Reconstituted 40 MG/ML Tier 1 ANTIFUNGALS Fluconazole Fluconazole Oral Tablet 100 MG Tier 1 ANTIFUNGALS Fluconazole Fluconazole Oral Tablet 150 MG Tier 1 ANTIFUNGALS Fluconazole Fluconazole Oral Tablet 200 MG Tier 1 ANTIFUNGALS Fluconazole Fluconazole Oral Tablet 50 MG Tier 1 ANTIFUNGALS Flucytosine Flucytosine Oral Capsule 250 MG Tier 1 ANTIFUNGALS Flucytosine Flucytosine Oral Capsule 500 MG Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Fludarabine Phosphate Fludarabine Phosphate Intravenous Solution 50 MG/2ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Fludarabine Phosphate Fludarabine Phosphate Intravenous Solution Reconstituted 50 MG Tier 1 x CORTICOSTEROIDS Fludrocortisone Acetate Fludrocortisone Acetate Oral Tablet 0.1 MG Tier 1 CORTICOSTEROIDS Fludrocortisone Acetate Fludrocortisone Acetate Powder Tier 3 VACCINES Influenza Virus Vaccine Split Quadrivalent Flulaval Quadrivalent Intramuscular Suspension Tier 3 x VACCINES Influenza Virus Vaccine Split Quadrivalent Flulaval Quadrivalent Intramuscular Suspension Prefilled Syringe 0.5 ML Tier 3 x ANTIVIRALS Hydrochloride Flumadine Oral Tablet 100 MG Tier 3 ANTIDOTES Flumazenil Flumazenil Intravenous Solution 0.5 MG/5ML Tier 1 x ANTIDOTES Flumazenil Flumazenil Intravenous Solution 1 MG/10ML Tier 1 x VACCINES Influenza Virus Vaccine Live Quadrivalent FluMist Quadrivalent Nasal Suspension Tier 3 NASAL AGENTS ‐ SYSTEMIC AND TOPICAL Flunisolide (Nasal) Flunisolide Nasal Solution 25 MCG/ACT (0.025%) Tier 1 DERMATOLOGICALS Fluocinolone Acetonide Fluocinolone Acetonide Body External Oil 0.01 % Tier 1 DERMATOLOGICALS Fluocinolone Acetonide Fluocinolone Acetonide External Cream 0.01 % Tier 1 DERMATOLOGICALS Fluocinolone Acetonide Fluocinolone Acetonide External Cream 0.025 % Tier 1 DERMATOLOGICALS Fluocinolone Acetonide Fluocinolone Acetonide External Ointment 0.025 % Tier 1 DERMATOLOGICALS Fluocinolone Acetonide Fluocinolone Acetonide External Solution 0.01 % Tier 1 OTIC AGENTS Fluocinolone Acetonide (Otic) Fluocinolone Acetonide Otic Oil 0.01 % Tier 1 DERMATOLOGICALS Fluocinolone Acetonide Fluocinolone Acetonide Powder Tier 3 DERMATOLOGICALS Fluocinolone Acetonide Fluocinolone Acetonide Scalp External Oil 0.01 % Tier 1 DERMATOLOGICALS Fluocinonide Fluocinonide External Cream 0.05 % Tier 1 DERMATOLOGICALS Fluocinonide Fluocinonide External Cream 0.1 % Tier 1 DERMATOLOGICALS Fluocinonide Fluocinonide External Gel 0.05 % Tier 1 DERMATOLOGICALS Fluocinonide Fluocinonide External Ointment 0.05 % Tier 1 DERMATOLOGICALS Fluocinonide Fluocinonide External Solution 0.05 % Tier 1 DERMATOLOGICALS Fluocinonide Fluocinonide Powder Tier 3 DERMATOLOGICALS Fluocinonide Emulsified Base Fluocinonide‐E External Cream 0.05 % Tier 1 MINERALS & ELECTROLYTES Sodium Fluoride Fluorabon Oral Solution 0.55 (0.25 F) MG/0.6ML Tier 2 OPHTHALMIC AGENTS Fluorescein w/ Proparacaine Fluoracaine Ophthalmic Solution 0.25‐0.5 % Tier 3 MINERALS & ELECTROLYTES Sodium Fluoride Fluor‐a‐day Oral Solution 0.275 (0.125 F) MG/DROP Tier 1 MINERALS & ELECTROLYTES Sodium Fluoride‐Xylitol Fluor‐a‐day Oral Tablet Chewable 0.25 (F)‐236.79 MG Tier 2 MINERALS & ELECTROLYTES Sodium Fluoride‐Xylitol Fluor‐a‐day Oral Tablet Chewable 0.5 (F)‐236.79 MG Tier 2 MINERALS & ELECTROLYTES Sodium Fluoride‐Xylitol Fluor‐a‐day Oral Tablet Chewable 1 (F)‐236.79 MG Tier 2 CHEMICALS Fluorescein Sodium Fluorescein Sodium Powder Tier 3 OPHTHALMIC AGENTS Fluorescein w/ Benoxinate Fluorescein‐Benoxinate Ophthalmic Solution 0.25‐0.4 % Tier 1 OPHTHALMIC AGENTS Fluorescein Sodium Topical Fluor‐I‐Strips A.T. Ophthalmic Strip 1 MG Tier 1 MINERALS & ELECTROLYTES Sodium Fluoride Fluoritab Oral Solution 0.275 (0.125 F) MG/DROP Tier 1 MINERALS & ELECTROLYTES Sodium Fluoride Fluoritab Oral Tablet Chewable 0.55 (0.25 F) MG Tier 1 MINERALS & ELECTROLYTES Sodium Fluoride Fluoritab Oral Tablet Chewable 1.1 (0.5 F) MG Tier 1 MINERALS & ELECTROLYTES Sodium Fluoride Fluoritab Oral Tablet Chewable 2.2 (1 F) MG Tier 1 OPHTHALMIC AGENTS Fluorometholone (Ophth) Fluorometholone Ophthalmic Suspension 0.1 % Tier 1 DERMATOLOGICALS Fluorouracil (Topical) Fluoroplex External Cream 1 % Tier 3 DERMATOLOGICALS Fluorouracil (Topical) Fluorouracil External Cream 0.5 % Tier 3 DERMATOLOGICALS Fluorouracil (Topical) Fluorouracil External Cream 5 % Tier 1 DERMATOLOGICALS Fluorouracil (Topical) Fluorouracil External Solution 2 % Tier 1 DERMATOLOGICALS Fluorouracil (Topical) Fluorouracil External Solution 5 % Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Fluorouracil Fluorouracil Intravenous Solution 1 GM/20ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Fluorouracil Fluorouracil Intravenous Solution 2.5 GM/50ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Fluorouracil Fluorouracil Intravenous Solution 5 GM/100ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Fluorouracil Fluorouracil Intravenous Solution 500 MG/10ML Tier 1 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Fluoxetine HCl (PMDD) FLUoxetine HCl (PMDD) Oral Capsule 10 MG Tier 1 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Fluoxetine HCl (PMDD) FLUoxetine HCl (PMDD) Oral Capsule 20 MG Tier 1 ANTIDEPRESSANTS Fluoxetine HCl FLUoxetine HCl Oral Capsule 10 MG Tier 1 ANTIDEPRESSANTS Fluoxetine HCl FLUoxetine HCl Oral Capsule 20 MG Tier 1 ANTIDEPRESSANTS Fluoxetine HCl FLUoxetine HCl Oral Capsule 40 MG Tier 1 ANTIDEPRESSANTS Fluoxetine HCl FLUoxetine HCl Oral Capsule Delayed Release 90 MG Tier 1 ANTIDEPRESSANTS Fluoxetine HCl FLUoxetine HCl Oral Solution 20 MG/5ML Tier 1 ANTIDEPRESSANTS Fluoxetine HCl FLUoxetine HCl Oral Tablet 10 MG Tier 1 ANTIDEPRESSANTS Fluoxetine HCl FLUoxetine HCl Oral Tablet 20 MG Tier 1 ANTIDEPRESSANTS Fluoxetine HCl FLUoxetine HCl Oral Tablet 60 MG Tier 2 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Fluphenazine Decanoate FluPHENAZine Decanoate Injection Solution 25 MG/ML Tier 1 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Fluphenazine HCl FluPHENAZine HCl Oral Concentrate 5 MG/ML Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Fluphenazine HCl FluPHENAZine HCl Oral Elixir 2.5 MG/5ML Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Fluphenazine HCl FluPHENAZine HCl Oral Tablet 1 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Fluphenazine HCl FluPHENAZine HCl Oral Tablet 10 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Fluphenazine HCl FluPHENAZine HCl Oral Tablet 2.5 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Fluphenazine HCl FluPHENAZine HCl Oral Tablet 5 MG Tier 1 MINERALS & ELECTROLYTES Sodium Fluoride Flura‐Drops Oral Solution 0.275 (0.125 F) MG/DROP Tier 1 MINERALS & ELECTROLYTES Sodium Fluoride Flura‐Drops Oral Solution 0.55 (0.25 F) MG/DROP Tier 2 OPHTHALMIC AGENTS Fluorexon‐Benoxinate Flura‐Safe Ophthalmic Solution 0.35‐0.4 % Tier 3 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS HCl Flurazepam HCl Oral Capsule 15 MG Tier 2 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Flurazepam HCl Flurazepam HCl Oral Capsule 30 MG Tier 2 ANALGESICS ‐ ANTI‐INFLAMMATORY Flurbiprofen Flurbiprofen Oral Tablet 100 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Flurbiprofen Flurbiprofen Oral Tablet 50 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Flurbiprofen Flurbiprofen Powder Tier 3 OPHTHALMIC AGENTS Flurbiprofen Sodium Flurbiprofen Sodium Ophthalmic Solution 0.03 % Tier 1 OPHTHALMIC AGENTS Fluorescein w/ Benoxinate Flurox Ophthalmic Solution 0.25‐0.4 % Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Flutamide Flutamide Oral Capsule 125 MG Tier 1 DERMATOLOGICALS Fluticasone Propionate Fluticasone Propionate External Cream 0.05 % Tier 1 DERMATOLOGICALS Fluticasone Propionate Fluticasone Propionate External Lotion 0.05 % Tier 1 DERMATOLOGICALS Fluticasone Propionate Fluticasone Propionate External Ointment 0.005 % Tier 1 NASAL AGENTS ‐ SYSTEMIC AND TOPICAL Fluticasone Propionate (Nasal) Fluticasone Propionate Nasal Suspension 50 MCG/ACT Tier 1 ANTIHYPERLIPIDEMICS Fluvastatin Sodium Fluvastatin Sodium ER Oral Tablet Extended Release 24 Hour 80 MG Tier 1 x ANTIHYPERLIPIDEMICS Fluvastatin Sodium Fluvastatin Sodium Oral Capsule 20 MG Tier 1 x HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ANTIHYPERLIPIDEMICS Fluvastatin Sodium Fluvastatin Sodium Oral Capsule 40 MG Tier 1 x VACCINES Influenza Virus Vaccine Types A & B Surface Antigen Fluvirin Intramuscular Suspension Tier 3 x VACCINES Influenza Virus Vaccine Types A & B Surface Antigen Fluvirin Intramuscular Suspension Prefilled Syringe 0.5 ML Tier 3 x VACCINES Influenza Virus Vaccine Types A & B Preservative Free Fluvirin Preservative Free Intramuscular Suspension Prefilled Syringe 0.5 ML Tier 3 x ANTIDEPRESSANTS Fluvoxamine Maleate FluvoxaMINE Maleate ER Oral Capsule Extended Release 24 Hour 100 MG Tier 1 x ANTIDEPRESSANTS Fluvoxamine Maleate FluvoxaMINE Maleate ER Oral Capsule Extended Release 24 Hour 150 MG Tier 1 x ANTIDEPRESSANTS Fluvoxamine Maleate FluvoxaMINE Maleate Oral Tablet 100 MG Tier 1 ANTIDEPRESSANTS Fluvoxamine Maleate FluvoxaMINE Maleate Oral Tablet 25 MG Tier 1 ANTIDEPRESSANTS Fluvoxamine Maleate FluvoxaMINE Maleate Oral Tablet 50 MG Tier 1 VACCINES Influenza Virus Vaccine Split High‐Dose Preservative Free Fluzone High‐Dose Intramuscular Suspension Prefilled Syringe 0.5 ML Tier 3 x VACCINES Influenza Virus Vaccine Split Fluzone Intramuscular Suspension Tier 3 x VACCINES Influenza Virus Vaccine Split Quadrivalent Fluzone Quadrivalent Intradermal Suspension Pen‐injector 9 MCG/STRAIN Tier 3 x VACCINES Influenza Virus Vaccine Split Quadrivalent Fluzone Quadrivalent Intramuscular Suspension Tier 3 x VACCINES Influenza Virus Vaccine Split Quadrivalent Fluzone Quadrivalent Intramuscular Suspension 0.5 ML Tier 3 x VACCINES Influenza Virus Vaccine Split Quadrivalent Fluzone Quadrivalent Intramuscular Suspension Prefilled Syringe 0.25 ML Tier 3 x VACCINES Influenza Virus Vaccine Split Quadrivalent Fluzone Quadrivalent Intramuscular Suspension Prefilled Syringe 0.5 ML Tier 3 x OPHTHALMIC AGENTS Fluorometholone (Ophth) FML Forte Ophthalmic Suspension 0.25 % Tier 2 OPHTHALMIC AGENTS Fluorometholone (Ophth) FML Liquifilm Ophthalmic Suspension 0.1 % Tier 2 OPHTHALMIC AGENTS Fluorometholone (Ophth) FML Ophthalmic Ointment 0.1 % Tier 2 MULTIVITAMINS Prenatal w/o Vit A w/ Fe Carbonyl‐Fe Gluconate‐DSS‐FA‐DHA Focalgin 90 DHA Oral Miscellaneous 90‐1 & 300 MG Tier 3 MULTIVITAMINS Prenatal w/o Vit A w/ Fe Carbonyl‐Fe Gluconate‐DSS‐FA‐DHA Focalgin CA Oral Miscellaneous 35‐1 & 300 MG Tier 3 HEMATOPOIETIC AGENTS Fe Carbonyl‐Fe Gluconate‐FA‐Vit B12‐Vit C‐Docusate Sodium Focalgin DSS Oral Tablet 90‐1 MG Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dexmethylphenidate HCl Focalin Oral Tablet 10 MG Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dexmethylphenidate HCl Focalin Oral Tablet 2.5 MG Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dexmethylphenidate HCl Focalin Oral Tablet 5 MG Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dexmethylphenidate HCl Focalin XR Oral Capsule Extended Release 24 Hour 10 MG Tier 3 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dexmethylphenidate HCl Focalin XR Oral Capsule Extended Release 24 Hour 15 MG Tier 3 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dexmethylphenidate HCl Focalin XR Oral Capsule Extended Release 24 Hour 20 MG Tier 3 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dexmethylphenidate HCl Focalin XR Oral Capsule Extended Release 24 Hour 25 MG Tier 3 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dexmethylphenidate HCl Focalin XR Oral Capsule Extended Release 24 Hour 30 MG Tier 3 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dexmethylphenidate HCl Focalin XR Oral Capsule Extended Release 24 Hour 35 MG Tier 3 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dexmethylphenidate HCl Focalin XR Oral Capsule Extended Release 24 Hour 40 MG Tier 3 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dexmethylphenidate HCl Focalin XR Oral Capsule Extended Release 24 Hour 5 MG Tier 3 x x HEMATOPOIETIC AGENTS Folic Acid‐Vitamin B6‐Vitamin B12 Folbee Oral Tablet 2.5‐25‐1 MG Tier 1 MULTIVITAMINS B‐Complex w/ C‐Biotin‐Minerals & Folic Acid Folbee Plus CZ Oral Tablet 5 MG Tier 1 MULTIVITAMINS B‐Complex w/ C & Folic Acid Folbee Plus Oral Tablet Tier 1 MULTIVITAMINS Prenatal w/o Vit A w/ Fe Fumarate‐DSS‐FA‐DHA Folcal DHA Oral Capsule 27‐1.25‐300 MG Tier 3 MULTIVITAMINS Prenatal Vit w/ Iron Carbonyl‐Fe Aspart Glyc‐FA‐Omega 3 Folcaps Omega 3 Oral Capsule 27‐1 MG Tier 3 MULTIVITAMINS Prenatal Vit w/Fe Carbonyl‐Fe Bisglyc‐Methylfol‐DSS & DHA Folet DHA Oral Therapy Pack 38‐1 & 350 MG Tier 3 MULTIVITAMINS Prenatal w/o A w/Fe Carbonyl‐Fe Bisglyc‐L Methylfol‐DSS‐DHA Folet One Oral Capsule 38‐1‐225 MG Tier 3 MULTIVITAMINS Multiple Vitamins w/ Minerals & Calcium‐Folic Acid Folgard OS Oral Tablet 500‐1.1 MG Tier 3 HEMATOPOIETIC AGENTS Folic Acid‐Vitamin B6‐Vitamin B12 Folgard RX Oral Tablet 2.2‐25‐1 MG Tier 3 HEMATOPOIETIC AGENTS Folic Acid Folic Acid Injection Solution 5 MG/ML Tier 3 x HEMATOPOIETIC AGENTS Folic Acid Folic Acid Oral Tablet 1 MG Tier 1 HEMATOPOIETIC AGENTS Folic Acid Folic Acid Powder Tier 3 HEMATOPOIETIC AGENTS Ferrous Fumarate‐Iron Polysaccharide Complex‐Folic Acid‐C‐B3 Folivane‐F Oral Capsule 125‐1 MG Tier 3 MULTIVITAMINS Prenatal without A Vit w/ Fe Fum‐Iron Polysacch Complex ‐FA Folivane‐OB Oral Capsule 130‐92.4‐1 MG Tier 3 HEMATOPOIETIC AGENTS Fe Fum‐Iron Polysacch Complex‐FA‐B Complex‐C‐Biotin Folivane‐Plus Oral Capsule Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Follitropin Beta Follistim AQ Subcutaneous Solution 300 UNT/0.36ML Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Follitropin Beta Follistim AQ Subcutaneous Solution 600 UNT/0.72ML Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Follitropin Beta Follistim AQ Subcutaneous Solution 900 UNT/1.08ML Tier 2 x HEMATOPOIETIC AGENTS Folic Acid‐Vitamin B6‐Vitamin B12 Folplex 2.2 Oral Tablet 2.2‐25‐0.5 MG Tier 1 HEMATOPOIETIC AGENTS Cobalamine Combinations Foltrate Oral Tablet 500‐1 MCG‐MG Tier 3 HEMATOPOIETIC AGENTS Ferrous Fumarate w/ B12‐Vit C‐FA‐IFC Foltrin Oral Capsule Tier 1 ANTIDOTES Fomepizole Intravenous Solution 1.5 GM/1.5ML Tier 1 x ANTICOAGULANTS Fondaparinux Sodium Fondaparinux Sodium Subcutaneous Solution 10 MG/0.8ML Tier 1 x ANTICOAGULANTS Fondaparinux Sodium Fondaparinux Sodium Subcutaneous Solution 2.5 MG/0.5ML Tier 1 x ANTICOAGULANTS Fondaparinux Sodium Fondaparinux Sodium Subcutaneous Solution 5 MG/0.4ML Tier 1 x ANTICOAGULANTS Fondaparinux Sodium Fondaparinux Sodium Subcutaneous Solution 7.5 MG/0.6ML Tier 1 x MEDICAL DEVICES AND SUPPLIES Blood Glucose Calibration FORA Control In Vitro Solution Normal Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood FORA D10 Blood Glucose Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood FORA D15g Blood Glucose Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood FORA D20 Blood Glucose Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Fora D40/G31 Blood Glucose In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood FORA G20 Blood Glucose Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood FORA G30a Blood Glucose Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Fora GD20 Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood FORA GD50 Blood Glucose Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets FORA Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancet Devices FORA Lancing Device Miscellaneous Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Fora TN'G/TN'G Voice In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood FORA V10 Blood Glucose Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies FORA V12 Blood Glucose System Device Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood FORA V12 Blood Glucose Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood FORA V20 Blood Glucose Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood FORA V30a Blood Glucose Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood ForaCare GD40 Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood ForaCare premium V10 Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood ForaCare Test N Go Test In Vitro Strip Tier 3 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Formoterol Fumarate Foradil Aerolizer Inhalation Capsule 12 MCG Tier 2 x GENERAL ANESTHETICS Forane Inhalation Solution Tier 3 ANTIDEPRESSANTS Bupropion HCl Forfivo XL Oral Tablet Extended Release 24 Hour 450 MG Tier 2 xx ANTISEPTICS & DISINFECTANTS Formadon External Solution 10 % Tier 1 ANTISEPTICS & DISINFECTANTS Formaldehyde Formaldehyde External Solution 10 % Tier 1 ANTISEPTICS & DISINFECTANTS Formaldehyde Formaldehyde External Solution 37 % Tier 3 ANTISEPTICS & DISINFECTANTS Formaldehyde Forma‐Ray External Solution 20 % Tier 3 ANTIDIABETICS Metformin HCl Fortamet Oral Tablet Extended Release 24 Hour 1000 MG Tier 3 x ANTIDIABETICS Metformin HCl Fortamet Oral Tablet Extended Release 24 Hour 500 MG Tier 3 x MULTIVITAMINS Multiple Vitamins w/ Minerals Fortavit Oral Capsule Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Teriparatide (Recombinant) Forteo Subcutaneous Solution 600 MCG/2.4ML Tier 2 x ANDROGENS‐ANABOLIC Testosterone Fortesta Transdermal Gel 10 MG/ACT (2%) Tier 3 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Calcitonin (Salmon) Fortical Nasal Solution 200 UNIT/ACT Tier 3 x MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies FortisCare Glucose System Kit w/Device Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Alendronate Sodium Fosamax Oral Tablet 70 MG Tier 3 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Alendronate Sodium‐Cholecalciferol Fosamax Plus D Oral Tablet 70‐2800 MG‐UNIT Tier 3 xx ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Alendronate Sodium‐Cholecalciferol Fosamax Plus D Oral Tablet 70‐5600 MG‐UNIT Tier 3 xx ANTIVIRALS Foscarnet Sodium Foscavir Intravenous Solution 24 MG/ML Tier 3 x ANTIHYPERTENSIVES Fosinopril Sodium Fosinopril Sodium Oral Tablet 10 MG Tier 1 ANTIHYPERTENSIVES Fosinopril Sodium Fosinopril Sodium Oral Tablet 20 MG Tier 1 ANTIHYPERTENSIVES Fosinopril Sodium Fosinopril Sodium Oral Tablet 40 MG Tier 1 ANTIHYPERTENSIVES Fosinopril Sodium & Hydrochlorothiazide Fosinopril Sodium‐HCTZ Oral Tablet 10‐12.5 MG Tier 1 ANTIHYPERTENSIVES Fosinopril Sodium & Hydrochlorothiazide Fosinopril Sodium‐HCTZ Oral Tablet 20‐12.5 MG Tier 1 ANTICONVULSANTS Fosphenytoin Sodium Fosphenytoin Sodium Injection Solution 100 MG PE/2ML Tier 1 x ANTICONVULSANTS Fosphenytoin Sodium Fosphenytoin Sodium Injection Solution 500 MG PE/10ML Tier 1 x GASTROINTESTINAL AGENTS ‐ MISC. Carbonate Fosrenol Oral Packet 1000 MG Tier 3 GASTROINTESTINAL AGENTS ‐ MISC. Lanthanum Carbonate Fosrenol Oral Packet 750 MG Tier 3 GASTROINTESTINAL AGENTS ‐ MISC. Lanthanum Carbonate Fosrenol Oral Tablet Chewable 1000 MG Tier 3 GASTROINTESTINAL AGENTS ‐ MISC. Lanthanum Carbonate Fosrenol Oral Tablet Chewable 500 MG Tier 3 GASTROINTESTINAL AGENTS ‐ MISC. Lanthanum Carbonate Fosrenol Oral Tablet Chewable 750 MG Tier 3 ANTICOAGULANTS Dalteparin Sodium Fragmin Subcutaneous Solution 10000 UNIT/ML Tier 3 x x ANTICOAGULANTS Dalteparin Sodium Fragmin Subcutaneous Solution 12500 UNIT/0.5ML Tier 3 x x ANTICOAGULANTS Dalteparin Sodium Fragmin Subcutaneous Solution 15000 UNIT/0.6ML Tier 3 x x HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ANTICOAGULANTS Dalteparin Sodium Fragmin Subcutaneous Solution 18000 UNT/0.72ML Tier 3 x x ANTICOAGULANTS Dalteparin Sodium Fragmin Subcutaneous Solution 2500 UNIT/0.2ML Tier 3 x x ANTICOAGULANTS Dalteparin Sodium Fragmin Subcutaneous Solution 5000 UNIT/0.2ML Tier 3 x x ANTICOAGULANTS Dalteparin Sodium Fragmin Subcutaneous Solution 7500 UNIT/0.3ML Tier 3 x x ANTICOAGULANTS Dalteparin Sodium Fragmin Subcutaneous Solution 95000 UNIT/3.8ML Tier 3 x MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Freds Pharmacy Unifine Pentip+ Miscellaneous 31G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Freds Pharmacy Unifine Pentip+ Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Freds Pharmacy Unifine Pentips Miscellaneous 32G X 4 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Freds Pharmacy Unilet Lanc 28G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Freds Pharmacy Unilet Lanc 30G Miscellaneous Tier 2 PHARMACEUTICAL ADJUVANTS Poloxamer‐Xylitol Freedom Poloxitol Powder Tier 3 MEDICAL DEVICES AND SUPPLIES Blood Glucose Calibration FreeStyle Control Solution In Vitro Liquid Tier 3 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies FreeStyle Freedom Lite Kit w/Device Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood FreeStyle InsuLinx Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets FreeStyle Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies FreeStyle Lite Device Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood FreeStyle Lite Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 FreeStyle Precision Ins Syr Miscellaneous 30G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 FreeStyle Precision Ins Syr Miscellaneous 30G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 FreeStyle Precision Ins Syr Miscellaneous 31G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 FreeStyle Precision Ins Syr Miscellaneous 31G X 5/16" 1 ML Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood FreeStyle Precision Neo Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies FreeStyle System Kit Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood FreeStyle Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets FreeStyle Unistick II Lancets Miscellaneous Tier 2 GENERAL ANESTHETICS Propofol Fresenius Propoven Intravenous Emulsion 10 MG/ML Tier 1 x MIGRAINE PRODUCTS Frovatriptan Succinate Frova Oral Tablet 2.5 MG Tier 3 xx NUTRIENTS Fructose Granules Tier 3 OPHTHALMIC AGENTS Fluorescein Sodium Topical Ful‐Glo Ophthalmic Strip 0.6 MG Tier 3 OPHTHALMIC AGENTS Fluorescein Sodium Topical Ful‐Glo Ophthalmic Strip 1 MG Tier 1 ANTIDIARRHEALS Crofelemer Fulyzaq Oral Tablet Delayed Release 125 MG Tier 3 x x URINARY ANTI‐INFECTIVES Nitrofurantoin Furadantin Oral Suspension 25 MG/5ML Tier 3 DIURETICS Furosemide Injection Solution 10 MG/ML Tier 1 x DIURETICS Furosemide Furosemide Oral Solution 10 MG/ML Tier 1 DIURETICS Furosemide Furosemide Oral Solution 40 MG/4ML Tier 1 DIURETICS Furosemide Furosemide Oral Solution 8 MG/ML Tier 3 DIURETICS Furosemide Furosemide Oral Tablet 20 MG Tier 1 DIURETICS Furosemide Furosemide Oral Tablet 40 MG Tier 1 DIURETICS Furosemide Furosemide Oral Tablet 80 MG Tier 1 DIURETICS Furosemide Furosemide Powder Tier 3 BIOLOGICALS MISC Fusarium Fusarium Subcutaneous Solution 10000 PNU/ML Tier 3 x BIOLOGICALS MISC Fusarium Fusarium Subcutaneous Solution 20000 PNU/ML Tier 3 x HEMATOPOIETIC AGENTS Ferrous Fumarate‐Iron Polysaccharide Complex‐FA‐C‐Probiotic Fusion Sprinkles Oral Packet 7‐0.25‐50‐5 MG Tier 3 ANTIVIRALS Enfuvirtide Fuzeon Subcutaneous Kit 90 MG Tier 2 x ANTIVIRALS Enfuvirtide Fuzeon Subcutaneous Solution Reconstituted 90 MG Tier 2 x ANTICONVULSANTS Fycompa Oral Tablet 10 MG Tier 3 x ANTICONVULSANTS Perampanel Fycompa Oral Tablet 12 MG Tier 3 x ANTICONVULSANTS Perampanel Fycompa Oral Tablet 2 MG Tier 3 x ANTICONVULSANTS Perampanel Fycompa Oral Tablet 4 MG Tier 3 x ANTICONVULSANTS Perampanel Fycompa Oral Tablet 6 MG Tier 3 x ANTICONVULSANTS Perampanel Fycompa Oral Tablet 8 MG Tier 3 x ANTICONVULSANTS Gabapentin Gabapentin Oral Capsule 100 MG Tier 1 ANTICONVULSANTS Gabapentin Gabapentin Oral Capsule 300 MG Tier 1 ANTICONVULSANTS Gabapentin Gabapentin Oral Capsule 400 MG Tier 1 ANTICONVULSANTS Gabapentin Gabapentin Oral Solution 250 MG/5ML Tier 1 ANTICONVULSANTS Gabapentin Gabapentin Oral Tablet 600 MG Tier 1 ANTICONVULSANTS Gabapentin Gabapentin Oral Tablet 800 MG Tier 1 ANTICONVULSANTS Tiagabine HCl Gabitril Oral Tablet 12 MG Tier 3 ANTICONVULSANTS Tiagabine HCl Gabitril Oral Tablet 16 MG Tier 3 ANTICONVULSANTS Tiagabine HCl Gabitril Oral Tablet 2 MG Tier 3 ANTICONVULSANTS Tiagabine HCl Gabitril Oral Tablet 4 MG Tier 3 MUSCULOSKELETAL THERAPY AGENTS Baclofen Gablofen Intrathecal Solution 10000 MCG/20ML Tier 2 x MUSCULOSKELETAL THERAPY AGENTS Baclofen Gablofen Intrathecal Solution 20000 MCG/20ML Tier 2 x MUSCULOSKELETAL THERAPY AGENTS Baclofen Gablofen Intrathecal Solution 40000 MCG/20ML Tier 2 x DIAGNOSTIC PRODUCTS Gadobutrol Gadavist Intravenous Solution 1 MMOL/ML Tier 3 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Galantamine Hydrobromide Galantamine Hydrobromide ER Oral Capsule Extended Release 24 Hour 16 MG Tier 1 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Galantamine Hydrobromide Galantamine Hydrobromide ER Oral Capsule Extended Release 24 Hour 24 MG Tier 1 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Galantamine Hydrobromide Galantamine Hydrobromide ER Oral Capsule Extended Release 24 Hour 8 MG Tier 1 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Galantamine Hydrobromide Galantamine Hydrobromide Oral Solution 4 MG/ML Tier 3 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Galantamine Hydrobromide Galantamine Hydrobromide Oral Tablet 12 MG Tier 1 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Galantamine Hydrobromide Galantamine Hydrobromide Oral Tablet 4 MG Tier 1 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Galantamine Hydrobromide Galantamine Hydrobromide Oral Tablet 8 MG Tier 1 MINERALS & ELECTROLYTES Zinc Acetate (Oral) Galzin Oral Capsule 25 MG Tier 3 MINERALS & ELECTROLYTES Zinc Acetate (Oral) Galzin Oral Capsule 50 MG Tier 3 PASSIVE IMMUNIZING AGENTS Immune Globulin (Human) IV or Subcutaneous Gammagard Injection Solution 1 GM/10ML Tier 2 x PASSIVE IMMUNIZING AGENTS Immune Globulin (Human) IV or Subcutaneous Gammagard Injection Solution 10 GM/100ML Tier 2 x PASSIVE IMMUNIZING AGENTS Immune Globulin (Human) IV or Subcutaneous Gammagard Injection Solution 2.5 GM/25ML Tier 2 x PASSIVE IMMUNIZING AGENTS Immune Globulin (Human) IV or Subcutaneous Gammagard Injection Solution 20 GM/200ML Tier 2 x PASSIVE IMMUNIZING AGENTS Immune Globulin (Human) IV or Subcutaneous Gammagard Injection Solution 30 GM/300ML Tier 2 x PASSIVE IMMUNIZING AGENTS Immune Globulin (Human) IV or Subcutaneous Gammagard Injection Solution 5 GM/50ML Tier 2 x PASSIVE IMMUNIZING AGENTS Immune Globulin (Human) IV or Subcutaneous Gammaked Injection Solution 1 GM/10ML Tier 2 x PASSIVE IMMUNIZING AGENTS Immune Globulin (Human) IV or Subcutaneous Gammaked Injection Solution 10 GM/100ML Tier 2 x PASSIVE IMMUNIZING AGENTS Immune Globulin (Human) IV or Subcutaneous Gammaked Injection Solution 2.5 GM/25ML Tier 2 x PASSIVE IMMUNIZING AGENTS Immune Globulin (Human) IV or Subcutaneous Gammaked Injection Solution 20 GM/200ML Tier 2 x PASSIVE IMMUNIZING AGENTS Immune Globulin (Human) IV or Subcutaneous Gammaked Injection Solution 5 GM/50ML Tier 2 x PASSIVE IMMUNIZING AGENTS Immune Globulin (Human) IV or Subcutaneous Gamunex‐C Injection Solution 1 GM/10ML Tier 2 x PASSIVE IMMUNIZING AGENTS Immune Globulin (Human) IV or Subcutaneous Gamunex‐C Injection Solution 10 GM/100ML Tier 2 x PASSIVE IMMUNIZING AGENTS Immune Globulin (Human) IV or Subcutaneous Gamunex‐C Injection Solution 2.5 GM/25ML Tier 2 x PASSIVE IMMUNIZING AGENTS Immune Globulin (Human) IV or Subcutaneous Gamunex‐C Injection Solution 20 GM/200ML Tier 2 x PASSIVE IMMUNIZING AGENTS Immune Globulin (Human) IV or Subcutaneous Gamunex‐C Injection Solution 40 GM/400ML Tier 2 x PASSIVE IMMUNIZING AGENTS Immune Globulin (Human) IV or Subcutaneous Gamunex‐C Injection Solution 5 GM/50ML Tier 2 x ANTIVIRALS Ganciclovir Sodium Ganciclovir Sodium Intravenous Solution Reconstituted 500 MG Tier 1 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Ganirelix Acetate Ganirelix Acetate Subcutaneous Solution 250 MCG/0.5ML Tier 2 x OPHTHALMIC AGENTS Gentamicin Sulfate (Ophth) Garamycin Ophthalmic Solution 0.3 % Tier 3 VACCINES Human Papillomavirus (HPV) 9‐Valent Recombinant Vaccine Gardasil 9 Intramuscular Suspension Tier 3 x VACCINES Human Papillomavirus (HPV) 9‐Valent Recombinant Vaccine Gardasil 9 Intramuscular Suspension Prefilled Syringe Tier 2 x VACCINES Human Papillomavirus (HPV) Quadrivalent Recombinant Vaccine Gardasil Intramuscular Suspension Tier 3 x ULCER DRUGS Hyoscyamine‐Phenyltoloxamine Gastrinex NF Oral Capsule 0.0625‐15 MG Tier 3 GASTROINTESTINAL AGENTS ‐ MISC. Cromolyn Sodium (Mastocytosis) Gastrocrom Oral Concentrate 100 MG/5ML Tier 3 DIAGNOSTIC PRODUCTS Diatrizoate Meglumine & Sodium Gastrografin Oral Solution 66‐10 % Tier 3 OPHTHALMIC AGENTS Gatifloxacin (Ophth) Gatifloxacin Ophthalmic Solution 0.5 % Tier 1 GASTROINTESTINAL AGENTS ‐ MISC. Teduglutide (rDNA) Gattex Subcutaneous Kit 5 MG Tier 2 x LAXATIVES PEG 3350‐KCl‐Sod Bicarb‐Sod Chloride‐Sod Sulfate GaviLyte‐C Oral Solution Reconstituted 240 GM Tier 1 LAXATIVES PEG 3350‐KCl‐Sod Bicarb‐Sod Chloride‐Sod Sulfate GaviLyte‐G Oral Solution Reconstituted 236 GM Tier 1 LAXATIVES Bisacodyl‐PEG 3350‐Pot Chloride‐Sod Bicarb‐Sod Chloride GaviLyte‐H Oral Kit 5‐210 MG‐GM Tier 1 LAXATIVES PEG 3350‐‐Sod Bicarbonate‐Sod Chloride GaviLyte‐N with Flavor Pack Oral Solution Reconstituted 420 GM Tier 1 DIAGNOSTIC PRODUCTS Glucose Blood GE100 Blood Glucose Test In Vitro Strip Tier 3 DERMATOLOGICALS Pentafluoropropane‐Tetrafluoroethane Gebauers Pain Ease External Aerosol Tier 3 DERMATOLOGICALS Pentafluoropropane‐Tetrafluoroethane Gebauers Spray and Stretch External Aerosol Tier 3 MOUTH/THROAT/DENTAL AGENTS Povidone‐Sodium Hyaluronate‐Glycyrrhetinic Acid Gelclair Mouth/Throat Gel Tier 3 URINARY ANTISPASMODICS Oxybutynin Chloride Gelnique Transdermal Gel 10 % Tier 2 URINARY ANTISPASMODICS Oxybutynin Gelnique Transdermal Gel 3 (28) % (MG/ACT) Tier 2 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

MOUTH/THROAT/DENTAL AGENTS Oral Wound Care Products GelX Mouth/Throat Gel Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Gemcitabine HCl Gemcitabine HCl Intravenous Solution 1 GM/26.3ML Tier 2 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Gemcitabine HCl Gemcitabine HCl Intravenous Solution 2 GM/52.6ML Tier 2 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Gemcitabine HCl Gemcitabine HCl Intravenous Solution 200 MG/5.26ML Tier 2 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Gemcitabine HCl Gemcitabine HCl Intravenous Solution Reconstituted 1 GM Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Gemcitabine HCl Gemcitabine HCl Intravenous Solution Reconstituted 2 GM Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Gemcitabine HCl Gemcitabine HCl Intravenous Solution Reconstituted 200 MG Tier 1 x ANTIHYPERLIPIDEMICS Gemfibrozil Gemfibrozil Oral Tablet 600 MG Tier 1 ANTIHYPERLIPIDEMICS Gemfibrozil Gemfibrozil Powder Tier 3 CONTRACEPTIVES Norethindrone & Ethinyl Estradiol‐Fe Generess FE Oral Tablet Chewable 0.8‐25 MG‐MCG Tier 3 GASTROINTESTINAL AGENTS ‐ MISC. Lactulose (Encephalopathy) Generlac Oral Solution 10 GM/15ML Tier 1 ASSORTED CLASSES Cyclosporine Modified (For Microemulsion) Gengraf Oral Capsule 100 MG Tier 1 ASSORTED CLASSES Cyclosporine Modified (For Microemulsion) Gengraf Oral Capsule 25 MG Tier 1 ASSORTED CLASSES Cyclosporine Modified (For Microemulsion) Gengraf Oral Solution 100 MG/ML Tier 1 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin Genotropin MiniQuick Subcutaneous Solution Reconstituted 0.2 MG Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin Genotropin MiniQuick Subcutaneous Solution Reconstituted 0.4 MG Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin Genotropin MiniQuick Subcutaneous Solution Reconstituted 0.6 MG Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin Genotropin MiniQuick Subcutaneous Solution Reconstituted 0.8 MG Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin Genotropin MiniQuick Subcutaneous Solution Reconstituted 1 MG Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin Genotropin MiniQuick Subcutaneous Solution Reconstituted 1.2 MG Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin Genotropin MiniQuick Subcutaneous Solution Reconstituted 1.4 MG Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin Genotropin MiniQuick Subcutaneous Solution Reconstituted 1.6 MG Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin Genotropin MiniQuick Subcutaneous Solution Reconstituted 1.8 MG Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin Genotropin MiniQuick Subcutaneous Solution Reconstituted 2 MG Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin Genotropin Subcutaneous Solution Reconstituted 12 MG Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin Genotropin Subcutaneous Solution Reconstituted 5 MG Tier 2 x DIAGNOSTIC PRODUCTS Glucose Blood GenStrip 50 In Vitro Strip Tier 3 OPHTHALMIC AGENTS Gentamicin Sulfate (Ophth) Gentak Ophthalmic Ointment 0.3 % Tier 1 AMINOGLYCOSIDES Gentamicin in Saline Gentamicin in Saline Intravenous Solution 0.8‐0.9 MG/ML‐% Tier 1 x AMINOGLYCOSIDES Gentamicin in Saline Gentamicin in Saline Intravenous Solution 1.2‐0.9 MG/ML‐% Tier 1 x AMINOGLYCOSIDES Gentamicin in Saline Gentamicin in Saline Intravenous Solution 1.6‐0.9 MG/ML‐% Tier 1 x AMINOGLYCOSIDES Gentamicin in Saline Gentamicin in Saline Intravenous Solution 1‐0.9 MG/ML‐% Tier 1 x DERMATOLOGICALS Gentamicin Sulfate (Topical) Gentamicin Sulfate External Cream 0.1 % Tier 2 DERMATOLOGICALS Gentamicin Sulfate (Topical) Gentamicin Sulfate External Ointment 0.1 % Tier 2 AMINOGLYCOSIDES Gentamicin Sulfate Gentamicin Sulfate Injection Solution 10 MG/ML Tier 1 x AMINOGLYCOSIDES Gentamicin Sulfate Gentamicin Sulfate Injection Solution 40 MG/ML Tier 1 x AMINOGLYCOSIDES Gentamicin Sulfate Gentamicin Sulfate Intravenous Solution 10 MG/ML Tier 1 x OPHTHALMIC AGENTS Gentamicin Sulfate (Ophth) Gentamicin Sulfate Ophthalmic Ointment 0.3 % Tier 1 OPHTHALMIC AGENTS Gentamicin Sulfate (Ophth) Gentamicin Sulfate Ophthalmic Solution 0.3 % Tier 1 DERMATOLOGICALS Gentamicin Sulfate (Topical) Gentamicin Sulfate Powder Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Gentle‐Let GP Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Gentle‐Let Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Misc. Gentle‐Let Platforms Miscellaneous Tier 2 ANTIVIRALS Elvitegravir‐Cobicistat‐Emtricitabine‐Tenofovir Alafenamide Genvoya Oral Tablet 150‐150‐200‐10 MG Tier 2 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Ziprasidone Mesylate Geodon Intramuscular Solution Reconstituted 20 MG Tier 3 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Ziprasidone HCl Geodon Oral Capsule 20 MG Tier 3 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Ziprasidone HCl Geodon Oral Capsule 40 MG Tier 3 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Ziprasidone HCl Geodon Oral Capsule 60 MG Tier 3 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Ziprasidone HCl Geodon Oral Capsule 80 MG Tier 3 x DIAGNOSTIC PRODUCTS Glucose Blood GHT Test In Vitro Strip Tier 3 CONTRACEPTIVES Drospirenone‐Ethinyl Estradiol Gianvi Oral Tablet 3‐0.02 MG Tier 1 CONTRACEPTIVES Norethindrone & Eth Estradiol Gildagia Oral Tablet 0.4‐35 MG‐MCG Tier 1 CONTRACEPTIVES Norethindrone Acet & Eth Estra Gildess 1.5/30 Oral Tablet 1.5‐30 MG‐MCG Tier 1 CONTRACEPTIVES Norethindrone Acet & Eth Estra Gildess 1/20 Oral Tablet 1‐20 MG‐MCG Tier 1 CONTRACEPTIVES Norethin Acet & Estrad‐Fe Gildess 24 FE Oral Tablet 1‐20 MG‐MCG(24) Tier 1 CONTRACEPTIVES Norethin Acet & Estrad‐Fe Gildess FE 1.5/30 Oral Tablet 1.5‐30 MG‐MCG Tier 1 CONTRACEPTIVES Norethin Acet & Estrad‐Fe Gildess FE 1/20 Oral Tablet 1‐20 MG‐MCG Tier 1 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Fingolimod HCl Gilenya Oral Capsule 0.5 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Afatinib Dimaleate Gilotrif Oral Tablet 20 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Afatinib Dimaleate Gilotrif Oral Tablet 30 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Afatinib Dimaleate Gilotrif Oral Tablet 40 MG Tier 2 x x COUGH/COLD/ALLERGY Phenylephrine‐Guaifenesin Gilphex TR Oral Tablet 10‐388 MG Tier 3 COUGH/COLD/ALLERGY Phenylephrine w/ DM‐GG Giltuss Oral Liquid 10‐28‐388 MG/5ML Tier 3 COUGH/COLD/ALLERGY Phenylephrine w/ Codeine‐GG Giltuss Ped‐C Oral Liquid 2.5‐3‐50 MG/ML Tier 3 COUGH/COLD/ALLERGY Phenylephrine w/ DM‐GG Giltuss Pediatric Oral Liquid 2.5‐7.5‐88 MG/ML Tier 1 COUGH/COLD/ALLERGY Phenylephrine w/ DM‐GG Giltuss TR Oral Tablet 10‐28‐388 MG Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Disposable) Glaspak Disp Syringe Miscellaneous 2.5 ML Tier 3 DIAGNOSTIC PRODUCTS Arterial Blood Gas Kits Glass Syringe 3 ML Kit Tier 3 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Glatiramer Acetate Glatopa Subcutaneous Solution Prefilled Syringe 20 MG/ML Tier 1 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Imatinib Mesylate Gleevec Oral Tablet 100 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Imatinib Mesylate Gleevec Oral Tablet 400 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Lomustine Gleostine Oral Capsule 10 MG Tier 2 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Lomustine Gleostine Oral Capsule 100 MG Tier 2 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Lomustine Gleostine Oral Capsule 40 MG Tier 2 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Lomustine Gleostine Oral Capsule 5 MG Tier 3 x ANTIDIABETICS Glimepiride Glimepiride Oral Tablet 1 MG Tier 1 ANTIDIABETICS Glimepiride Glimepiride Oral Tablet 2 MG Tier 1 ANTIDIABETICS Glimepiride Glimepiride Oral Tablet 4 MG Tier 1 ANTIDIABETICS Glipizide GlipiZIDE ER Oral Tablet Extended Release 24 Hour 10 MG Tier 1 ANTIDIABETICS Glipizide GlipiZIDE ER Oral Tablet Extended Release 24 Hour 2.5 MG Tier 1 ANTIDIABETICS Glipizide GlipiZIDE ER Oral Tablet Extended Release 24 Hour 5 MG Tier 1 ANTIDIABETICS Glipizide GlipiZIDE Oral Tablet 10 MG Tier 1 ANTIDIABETICS Glipizide GlipiZIDE Oral Tablet 5 MG Tier 1 ANTIDIABETICS Glipizide GlipiZIDE Powder Tier 3 ANTIDIABETICS Glipizide GlipiZIDE XL Oral Tablet Extended Release 24 Hour 10 MG Tier 1 ANTIDIABETICS Glipizide GlipiZIDE XL Oral Tablet Extended Release 24 Hour 2.5 MG Tier 1 ANTIDIABETICS Glipizide GlipiZIDE XL Oral Tablet Extended Release 24 Hour 5 MG Tier 1 ANTIDIABETICS Glipizide‐Metformin HCl GlipiZIDE‐MetFORMIN HCl Oral Tablet 2.5‐250 MG Tier 1 ANTIDIABETICS Glipizide‐Metformin HCl GlipiZIDE‐MetFORMIN HCl Oral Tablet 2.5‐500 MG Tier 1 ANTIDIABETICS Glipizide‐Metformin HCl GlipiZIDE‐MetFORMIN HCl Oral Tablet 5‐500 MG Tier 1 MEDICAL DEVICES AND SUPPLIES Alcohol Swabs Global Alcohol Prep Ease Pad 70 % Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Global Ease Inject Pen Needles Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Global Ease Inject Pen Needles Miscellaneous 31G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Global Ease Inject Pen Needles Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Global Ease Inject Pen Needles Miscellaneous 32G X 4 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Global Inject Ease Insulin Syr Miscellaneous 28G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Global Inject Ease Insulin Syr Miscellaneous 28G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Global Inject Ease Insulin Syr Miscellaneous 29G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Global Inject Ease Insulin Syr Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Global Inject Ease Insulin Syr Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Global Inject Ease Insulin Syr Miscellaneous 30G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Global Inject Ease Insulin Syr Miscellaneous 30G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Global Inject Ease Insulin Syr Miscellaneous 30G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Global Inject Ease Insulin Syr Miscellaneous 30G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Global Inject Ease Insulin Syr Miscellaneous 30G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Global Inject Ease Insulin Syr Miscellaneous 30G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Global Inject Ease Insulin Syr Miscellaneous 31G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Global Inject Ease Insulin Syr Miscellaneous 31G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Global Inject Ease Insulin Syr Miscellaneous 31G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Global Inject Ease Lancets 28G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Global Inject Ease Lancets 30G Miscellaneous Tier 2 DIAGNOSTIC PRODUCTS Glucagon HCl rDNA (Diagnostic) GlucaGen Diagnostic Injection Solution Reconstituted 1 MG Tier 2 x HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ANTIDIABETICS Glucagon (rDNA) Glucagon Emergency Injection Kit 1 MG Tier 2 x DIAGNOSTIC PRODUCTS Glucagon HCl (Diagnostic) Glucagon HCl (Diagnostic) Injection Solution Reconstituted 1 MG Tier 3 x MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies Gluco Perfect 3 Meter Device Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Gluco Perfect 3 Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies Glucocard 01 Blood Glucose Kit w/Device Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Glucocard 01 Sensor Plus In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies Glucocard Expression Monitor Kit w/Device Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Glucocard Expression Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Glucocard Shine Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies Glucocard Vital Monitor Kit w/Device Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Glucocard Vital Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Glucocard X‐Sensor In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets GlucoCom Lancets 28G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets GlucoCom Lancets 30G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets GlucoCom Lancets 33G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies GlucoCom Monitor Kit w/Device Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood GlucoCom Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Lancet Devices Glucolet 2 Automatic Lancing Miscellaneous Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood GlucoNavii Blood Glucose Test In Vitro Strip Tier 3 CHEMICALS Gluconolactone Gluconolactone Powder Tier 3 ANTIDIABETICS Metformin HCl Glucophage Oral Tablet 1000 MG Tier 3 ANTIDIABETICS Metformin HCl Glucophage Oral Tablet 500 MG Tier 3 ANTIDIABETICS Metformin HCl Glucophage Oral Tablet 850 MG Tier 3 ANTIDIABETICS Metformin HCl Glucophage XR Oral Tablet Extended Release 24 Hour 500 MG Tier 3 x ANTIDIABETICS Metformin HCl Glucophage XR Oral Tablet Extended Release 24 Hour 750 MG Tier 3 x MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 GlucoPro Insulin Syringe Miscellaneous 30G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 GlucoPro Insulin Syringe Miscellaneous 30G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 GlucoPro Insulin Syringe Miscellaneous 30G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 GlucoPro Insulin Syringe Miscellaneous 30G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 GlucoPro Insulin Syringe Miscellaneous 30G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 GlucoPro Insulin Syringe Miscellaneous 30G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 GlucoPro Insulin Syringe Miscellaneous 31G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 GlucoPro Insulin Syringe Miscellaneous 31G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 GlucoPro Insulin Syringe Miscellaneous 31G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Blood Glucose Calibration Glucose Control In Vitro Solution Normal Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Glucosource Lancets Miscellaneous Tier 2 ANTIDIABETICS Glipizide Glucotrol Oral Tablet 10 MG Tier 3 ANTIDIABETICS Glipizide Glucotrol Oral Tablet 5 MG Tier 3 ANTIDIABETICS Glipizide Glucotrol XL Oral Tablet Extended Release 24 Hour 10 MG Tier 3 ANTIDIABETICS Glipizide Glucotrol XL Oral Tablet Extended Release 24 Hour 2.5 MG Tier 3 ANTIDIABETICS Glipizide Glucotrol XL Oral Tablet Extended Release 24 Hour 5 MG Tier 3 ANTIDIABETICS Glyburide‐Metformin Glucovance Oral Tablet 1.25‐250 MG Tier 3 ANTIDIABETICS Glyburide‐Metformin Glucovance Oral Tablet 2.5‐500 MG Tier 3 ANTIDIABETICS Glyburide‐Metformin Glucovance Oral Tablet 5‐500 MG Tier 3 ANTISEPTICS & DISINFECTANTS Glutaral External Solution 25 % Tier 3 NUTRIENTS Glutathione‐L Powder Tier 3 NUTRIENTS Glutathione Glutathione‐L Reduced Powder Tier 3 ANTIDIABETICS Glyburide Micronized GlyBURIDE Micronized Oral Tablet 1.5 MG Tier 1 ANTIDIABETICS Glyburide Micronized GlyBURIDE Micronized Oral Tablet 3 MG Tier 1 ANTIDIABETICS Glyburide Micronized GlyBURIDE Micronized Oral Tablet 6 MG Tier 1 ANTIDIABETICS Glyburide GlyBURIDE Oral Tablet 1.25 MG Tier 1 ANTIDIABETICS Glyburide GlyBURIDE Oral Tablet 1.25 MG Tier 2 ANTIDIABETICS Glyburide GlyBURIDE Oral Tablet 2.5 MG Tier 1 ANTIDIABETICS Glyburide GlyBURIDE Oral Tablet 2.5 MG Tier 2 ANTIDIABETICS Glyburide GlyBURIDE Oral Tablet 5 MG Tier 1 ANTIDIABETICS Glyburide GlyBURIDE Oral Tablet 5 MG Tier 2 ANTIDIABETICS Glyburide‐Metformin GlyBURIDE‐MetFORMIN Oral Tablet 1.25‐250 MG Tier 1 ANTIDIABETICS Glyburide‐Metformin GlyBURIDE‐MetFORMIN Oral Tablet 2.5‐500 MG Tier 1 ANTIDIABETICS Glyburide‐Metformin GlyBURIDE‐MetFORMIN Oral Tablet 5‐500 MG Tier 1 CHEMICALS Glyceryl Monostearate Glyceryl Monostearate Flakes Tier 3 GENITOURINARY AGENTS ‐ MISCELLANEOUS Glycine (GU Irrigant) Glycine Irrigation Solution 1.5 % Tier 1 GENITOURINARY AGENTS ‐ MISCELLANEOUS Glycine (GU Irrigant) Glycine Powder Tier 3 GENITOURINARY AGENTS ‐ MISCELLANEOUS Glycine (GU Irrigant) Glycine Urologic Irrigation Solution 1.5 % Tier 1 DERMATOLOGICALS Glycolic Acid Solution 70 % Tier 3 ULCER DRUGS Glycopyrrolate Glycopyrrolate Injection Solution 0.2 MG/ML Tier 1 x ULCER DRUGS Glycopyrrolate Glycopyrrolate Injection Solution 0.4 MG/2ML Tier 1 x ULCER DRUGS Glycopyrrolate Glycopyrrolate Injection Solution 1 MG/5ML Tier 1 x ULCER DRUGS Glycopyrrolate Glycopyrrolate Injection Solution 4 MG/20ML Tier 1 x ULCER DRUGS Glycopyrrolate Glycopyrrolate Oral Tablet 1 MG Tier 1 ULCER DRUGS Glycopyrrolate Glycopyrrolate Oral Tablet 2 MG Tier 1 DERMATOLOGICALS Lidocaine HCl Glydo External Gel 2 % Tier 1 x ANTIDIABETICS Glyburide Micronized Glynase Oral Tablet 1.5 MG Tier 3 ANTIDIABETICS Glyburide Micronized Glynase Oral Tablet 3 MG Tier 3 ANTIDIABETICS Glyburide Micronized Glynase Oral Tablet 6 MG Tier 3 ANTIDIABETICS Miglitol Glyset Oral Tablet 100 MG Tier 3 x ANTIDIABETICS Miglitol Glyset Oral Tablet 25 MG Tier 3 x ANTIDIABETICS Miglitol Glyset Oral Tablet 50 MG Tier 3 x ANTIDIABETICS Empagliflozin‐Linagliptin Glyxambi Oral Tablet 10‐5 MG Tier 3 x x ANTIDIABETICS Empagliflozin‐Linagliptin Glyxambi Oral Tablet 25‐5 MG Tier 3 x x DIAGNOSTIC PRODUCTS Glucose Blood Gmate Blood Glucose Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Gmate Lancets 30G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies Gmate Voice Blood Glucose Sys Device Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle GNP Clickfine Pen Needles Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle GNP Clickfine Pen Needles Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 GNP Insulin Syringe Miscellaneous 28G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 GNP Insulin Syringe Miscellaneous 28G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 GNP Insulin Syringe Miscellaneous 29G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 GNP Insulin Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 GNP Insulin Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 GNP Insulin Syringe Miscellaneous 30G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 GNP Insulin Syringe Miscellaneous 30G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 GNP Insulin Syringe Miscellaneous 30G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 GNP Insulin Syringe Miscellaneous 31G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 GNP Insulin Syringe Miscellaneous 31G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 GNP Insulin Syringe Miscellaneous 31G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets GNP Lancets 21G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets GNP Lancets Micro Thin 33G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets GNP Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets GNP Lancets Super Thin 30G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets GNP Lancets Thin 26G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets GNP Lancets Thin Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets GNP Micro Thin Lancets 33G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets GNP Super Thin Lancets 30G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 GNP Ultra Com Insulin Syringe Miscellaneous 28G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 GNP Ultra Com Insulin Syringe Miscellaneous 28G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 GNP Ultra Com Insulin Syringe Miscellaneous 29G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 GNP Ultra Com Insulin Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 GNP Ultra Com Insulin Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 GNP Ultra Com Insulin Syringe Miscellaneous 30G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 GNP Ultra Com Insulin Syringe Miscellaneous 30G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 GNP Ultra Com Insulin Syringe Miscellaneous 30G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 GNP Ultra Com Insulin Syringe Miscellaneous 31G X 5/16" 0.3 ML Tier 2 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 GNP Ultra Com Insulin Syringe Miscellaneous 31G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 GNP Ultra Com Insulin Syringe Miscellaneous 31G X 5/16" 1 ML Tier 2 LAXATIVES PEG 3350‐KCl‐Sod Bicarb‐Sod Chloride‐Sod Sulfate Golytely Oral Solution Reconstituted 227.1 GM Tier 3 LAXATIVES PEG 3350‐KCl‐Sod Bicarb‐Sod Chloride‐Sod Sulfate Golytely Oral Solution Reconstituted 236 GM Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Follitropin Alfa Gonal‐f RFF Pen Subcutaneous Solution 300 UNIT/0.5ML Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Follitropin Alfa Gonal‐f RFF Pen Subcutaneous Solution 450 UNT/0.75ML Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Follitropin Alfa Gonal‐f RFF Pen Subcutaneous Solution 900 UNIT/1.5ML Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Follitropin Alfa Gonal‐f RFF Rediject Subcutaneous Solution 300 UNIT/0.5ML Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Follitropin Alfa Gonal‐f RFF Rediject Subcutaneous Solution 450 UNT/0.75ML Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Follitropin Alfa Gonal‐f RFF Rediject Subcutaneous Solution 900 UNIT/1.5ML Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Follitropin Alfa Gonal‐f RFF Subcutaneous Solution Reconstituted 75 UNIT Tier 2 x DERMATOLOGICALS Salicylic Acid & Lactic Acid Gordofilm External Solution 16.7‐16.7 % Tier 3 DERMATOLOGICALS Urea Gordons Urea External Ointment 40 % Tier 3 DERMATOLOGICALS Silver Nitrate‐Potassium Nitrate Grafco Silver Nit Applicator External Miscellaneous 75‐25 % Tier 1 DERMATOLOGICALS Multipotent Cellular Repair Matrix Grafix Core 2cm x 2cm External Miscellaneous Tier 3 DERMATOLOGICALS Multipotent Cellular Repair Matrix Grafix Core 5cm x 5cm External Miscellaneous Tier 3 DERMATOLOGICALS Multipotent Cellular Repair Matrix Grafix Prime 2cm x 2cm External Miscellaneous Tier 3 DERMATOLOGICALS Multipotent Cellular Repair Matrix Grafix Prime 5cm x 5cm External Miscellaneous Tier 3 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Gabapentin (Once‐Daily) Gralise Oral Tablet 300 MG Tier 3 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Gabapentin (Once‐Daily) Gralise Oral Tablet 600 MG Tier 3 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Gabapentin (Once‐Daily) Gralise Starter Oral Miscellaneous 300 & 600 MG Tier 3 x ANTIEMETICS Granisetron HCl Granisetron HCl Intravenous Solution 0.1 MG/ML Tier 1 ANTIEMETICS Granisetron HCl Granisetron HCl Intravenous Solution 1 MG/ML Tier 1 ANTIEMETICS Granisetron HCl Granisetron HCl Intravenous Solution 4 MG/4ML Tier 1 ANTIEMETICS Granisetron HCl Granisetron HCl Oral Tablet 1 MG Tier 1 x HEMATOPOIETIC AGENTS Tbo‐Filgrastim Granix Subcutaneous Solution Prefilled Syringe 300 MCG/0.5ML Tier 2 x HEMATOPOIETIC AGENTS Tbo‐Filgrastim Granix Subcutaneous Solution Prefilled Syringe 480 MCG/0.8ML Tier 2 x CHEMICALS Griseofulvin Micronized Griseofulvin Micronized Powder Tier 3 ANTIFUNGALS Griseofulvin Microsize Griseofulvin Microsize Oral Suspension 125 MG/5ML Tier 1 ANTIFUNGALS Griseofulvin Microsize Griseofulvin Microsize Oral Tablet 500 MG Tier 1 CHEMICALS Griseofulvin Micronized Griseofulvin Microsize Powder Tier 3 ANTIFUNGALS Griseofulvin Ultramicrosize Griseofulvin Ultramicrosize Oral Tablet 125 MG Tier 1 ANTIFUNGALS Griseofulvin Ultramicrosize Griseofulvin Ultramicrosize Oral Tablet 250 MG Tier 1 ANTIFUNGALS Griseofulvin Ultramicrosize Gris‐PEG Oral Tablet 125 MG Tier 3 ANTIFUNGALS Griseofulvin Ultramicrosize Gris‐PEG Oral Tablet 250 MG Tier 3 CHEMICALS Guaiacol Guaiacol Solution Tier 3 COUGH/COLD/ALLERGY Guaifenesin GuaiFENesin Powder Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Guanfacine HCl (ADHD) GuanFACINE HCl ER Oral Tablet Extended Release 24 Hour 1 MG Tier 1 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Guanfacine HCl (ADHD) GuanFACINE HCl ER Oral Tablet Extended Release 24 Hour 2 MG Tier 1 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Guanfacine HCl (ADHD) GuanFACINE HCl ER Oral Tablet Extended Release 24 Hour 3 MG Tier 1 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Guanfacine HCl (ADHD) GuanFACINE HCl ER Oral Tablet Extended Release 24 Hour 4 MG Tier 1 x x ANTIHYPERTENSIVES Guanfacine HCl GuanFACINE HCl Oral Tablet 1 MG Tier 1 ANTIHYPERTENSIVES Guanfacine HCl GuanFACINE HCl Oral Tablet 2 MG Tier 1 ANTIMYASTHENIC/CHOLINERGIC AGENTS Guanidine HCl Guanidine HCl Oral Tablet 125 MG Tier 2 VAGINAL PRODUCTS Butoconazole Nitrate (One Dose) Gynazole‐1 Vaginal Cream 2 % Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Haemolance Low Flow Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Haemolance Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Haemolance Plus High Flow Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Haemolance Plus Low Flow Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Haemolance Plus Max Flow Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Haemolance Plus Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Haemolance Plus Pediatric Flow Miscellaneous Tier 2 DERMATOLOGICALS Halobetasol Propionate & Ammonium Lactate Halac External Kit 0.05 & 12 % Tier 3 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Triazolam Halcion Oral Tablet 0.25 MG Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Decanoate Haldol Decanoate Intramuscular Solution 100 MG/ML Tier 3 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Haldol Decanoate Intramuscular Solution 50 MG/ML Tier 3 x DERMATOLOGICALS Halobetasol Propionate Halobetasol Propionate External Cream 0.05 % Tier 1 DERMATOLOGICALS Halobetasol Propionate Halobetasol Propionate External Ointment 0.05 % Tier 1 DERMATOLOGICALS Halcinonide Halog External Cream 0.1 % Tier 3 DERMATOLOGICALS Halcinonide Halog External Ointment 0.1 % Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Haloperidol Decanoate Haloperidol Decanoate Intramuscular Solution 100 MG/ML Tier 1 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Haloperidol Decanoate Haloperidol Decanoate Intramuscular Solution 50 MG/ML Tier 1 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Haloperidol Lactate Haloperidol Lactate Injection Solution 5 MG/ML Tier 1 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Haloperidol Lactate Haloperidol Lactate Oral Concentrate 2 MG/ML Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Haloperidol Haloperidol Oral Tablet 0.5 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Haloperidol Haloperidol Oral Tablet 1 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Haloperidol Haloperidol Oral Tablet 10 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Haloperidol Haloperidol Oral Tablet 2 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Haloperidol Haloperidol Oral Tablet 20 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Haloperidol Haloperidol Oral Tablet 5 MG Tier 1 DERMATOLOGICALS Haloprogin Halotin External Cream 1 % Tier 3 ANTIVIRALS Ledipasvir‐Sofosbuvir Harvoni Oral Tablet 90‐400 MG Tier 2 x x VACCINES Vaccine Havrix Intramuscular Suspension 1440 EL U/ML Tier 3 x VACCINES Hepatitis A Vaccine Havrix Intramuscular Suspension 720 EL U/0.5ML Tier 3 x OPHTHALMIC AGENTS Sodium Hyaluronate Healon GV Intraocular Solution 14 MG/ML Tier 3 OPHTHALMIC AGENTS Sodium Hyaluronate Healon Intraocular Solution 10 MG/ML Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets HealthWise Lancets 30G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle HealthWise Mini Pen Needles Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle HealthWise Pen Needles Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle HealthWise Short Pen Needles Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle HealthWise Unifine Pentips Miscellaneous 32G X 4 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Healthy Accents Unifine Pentip Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Healthy Accents Unifine Pentip Miscellaneous 31G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Healthy Accents Unifine Pentip Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Healthy Accents Unifine Pentip Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Healthy Accents Unifine Pentip Miscellaneous 32G X 4 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Healthy Accents Unilet Lancets Miscellaneous Tier 2 CONTRACEPTIVES Norethindrone (Contraceptive) Heather Oral Tablet 0.35 MG Tier 1 MEDICAL DEVICES AND SUPPLIES Lancets H‐E‐B inControl Lancets 28G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets H‐E‐B inControl Lancets 30G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets H‐E‐B inControl Lancets 33G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle H‐E‐B inControl Pen Needles Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle H‐E‐B inControl Pen Needles Miscellaneous 31G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle H‐E‐B inControl Pen Needles Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle H‐E‐B inControl Pen Needles Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle H‐E‐B inControl Pen Needles Miscellaneous 32G X 4 MM Tier 2 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Doxercalciferol Hectorol Intravenous Solution 4 MCG/2ML Tier 3 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Doxercalciferol Hectorol Oral Capsule 0.5 MCG Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Doxercalciferol Hectorol Oral Capsule 1 MCG Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Doxercalciferol Hectorol Oral Capsule 2.5 MCG Tier 3 HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor (Recombinant) Helixate FS Intravenous Kit 1000 UNIT Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor (Recombinant) Helixate FS Intravenous Kit 2000 UNIT Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor (Recombinant) Helixate FS Intravenous Kit 250 UNIT Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor (Recombinant) Helixate FS Intravenous Kit 500 UNIT Tier 2 x OXYTOCICS Carboprost Tromethamine Hemabate Intramuscular Solution 250 MCG/ML Tier 3 x BETA BLOCKERS Propranolol HCl Hemangeol Oral Solution 4.28 MG/ML Tier 3 HEMATOPOIETIC AGENTS Ferrous Fumarate‐FA‐B Complex‐C‐Zn‐Mg‐Mn‐Cu Hematinic Plus Vit/Minerals Oral Tablet 106‐1 MG Tier 1 HEMATOPOIETIC AGENTS Ferrous Fumarate‐Folic Acid Hematinic/Folic Acid Oral Tablet 324‐1 MG Tier 1 HEMATOPOIETIC AGENTS Fe Fumarate‐Vitamin C‐Vitamin B12‐Folic Acid Hematogen FA Oral Capsule 200‐250‐0.01‐1 MG Tier 3 HEMATOPOIETIC AGENTS Fe Fumarate‐Vitamin C‐Vitamin B12‐Folic Acid Hematogen Forte Oral Capsule 460‐60‐0.01‐1 MG Tier 1 HEMATOPOIETIC AGENTS Iron Combinations Hematogen Oral Capsule Tier 1 HEMATOPOIETIC AGENTS Iron‐Docusate‐B12‐Folic Acid‐Vit C‐Vit E‐Copper‐Biotin Hematron‐AF Oral Tablet 150‐1 MG Tier 3 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

MULTIVITAMINS Prenatal Vit w/ Fe Poly Cmplx‐Fe Heme Polypept‐FA & Omega 3 HemeNatal OB + DHA Oral Miscellaneous 28‐6‐1 & 203 MG Tier 2 MULTIVITAMINS Prenatal Vit w/ Fe Polysacch Complex‐Fe Heme Polypeptide‐FA HemeNatal OB Oral Tablet 28‐6‐1 MG Tier 2 HEMATOPOIETIC AGENTS Polysaccharide Fe Complex‐Fe Heme Polypeptide‐FA‐Vit B12 HemeTab Oral Tablet 22‐6‐1‐0.025 MG Tier 3 HEMATOPOIETIC AGENTS Ferrous Fumarate‐FA‐B Complex‐C‐Zn‐Mg‐Mn‐Cu Hemocyte Plus Oral Capsule 106‐1 MG Tier 3 HEMATOPOIETIC AGENTS Iron Combinations Hemocyte‐F Oral Elixir Tier 3 HEMATOPOIETIC AGENTS Ferrous Fumarate‐Folic Acid Hemocyte‐F Oral Tablet 324‐1 MG Tier 1 HEMATOPOIETIC AGENTS Ferrous Fumarate‐FA‐B Complex‐C‐Zn‐Mg‐Mn‐Cu Hemocyte‐Plus Oral Tablet 106‐1 MG Tier 1 ANTICOAGULANTS Heparin (Porcine) in Sodium Chloride Heparin (Porcine) in NaCl Injection Solution 100‐0.45 UNIT/ML‐% Tier 3 x ANTICOAGULANTS Heparin (Porcine) in Sodium Chloride Heparin (Porcine) in NaCl Injection Solution 2‐0.9 UNIT/ML‐% Tier 1 x ANTICOAGULANTS Heparin (Porcine) in Sodium Chloride Heparin (Porcine) in NaCl Injection Solution 2‐0.9 UNIT/ML‐% Tier 3 x ANTICOAGULANTS Heparin (Porcine) in Sodium Chloride Heparin (Porcine) in NaCl Injection Solution 50‐0.45 UNIT/ML‐% Tier 3 x ANTICOAGULANTS Heparin Sodium (Porcine) Lock Flush Heparin Lock Flush Intravenous Solution 1 UNIT/ML Tier 1 x ANTICOAGULANTS Heparin Sodium (Porcine) Lock Flush Heparin Lock Flush Intravenous Solution 1 UNIT/ML Tier 3 x ANTICOAGULANTS Heparin Sodium (Porcine) Lock Flush Heparin Lock Flush Intravenous Solution 10 UNIT/ML Tier 1 x ANTICOAGULANTS Heparin Sodium (Porcine) Lock Flush Heparin Lock Flush Intravenous Solution 100 UNIT/ML Tier 1 x ANTICOAGULANTS Heparin Sodium (Porcine) Lock Flush Heparin Lock Flush Intravenous Solution 2 UNIT/ML Tier 3 x ANTICOAGULANTS Heparin Sodium (Porcine) Heparin Sodium (Porcine) Injection Solution 1000 UNIT/ML Tier 1 x ANTICOAGULANTS Heparin Sodium (Porcine) Heparin Sodium (Porcine) Injection Solution 10000 UNIT/ML Tier 1 x ANTICOAGULANTS Heparin Sodium (Porcine) Heparin Sodium (Porcine) Injection Solution 20000 UNIT/ML Tier 1 x ANTICOAGULANTS Heparin Sodium (Porcine) Heparin Sodium (Porcine) Injection Solution 5000 UNIT/ML Tier 1 x ANTICOAGULANTS Heparin Sodium (Porcine) Heparin Sodium (Porcine) PF Injection Solution 5000 UNIT/0.5ML Tier 1 x ANTICOAGULANTS Heparin Sodium (Porcine) Lock Flush Heparin Sodium Lock Flush Intravenous Solution 10 UNIT/ML Tier 1 x ANTICOAGULANTS Heparin Sodium (Porcine) Lock Flush Heparin Sodium Lock Flush Intravenous Solution 100 UNIT/ML Tier 1 x ANTIVIRALS Adefovir Dipivoxil Hepsera Oral Tablet 10 MG Tier 2 x x HEMATOLOGICAL AGENTS ‐ MISC. Hetastarch in Sodium Chloride Hetastarch‐NaCl Intravenous Solution 6‐0.9 % Tier 1 x HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Tasimelteon Hetlioz Oral Capsule 20 MG Tier 2 x xx ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Hexalen Oral Capsule 50 MG Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Hetastarch in Lactated Electrolyte Hextend Intravenous Solution 6 % Tier 3 x URINARY ANTI‐INFECTIVES Methenamine Hippurate Hiprex Oral Tablet 1 GM Tier 3 OPHTHALMIC AGENTS Homatropine HBr Homatropaire Ophthalmic Solution 5 % Tier 1 OPHTHALMIC AGENTS Homatropine HBr Homatropine HBr Ophthalmic Solution 5 % Tier 1 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Gabapentin Enacarbil Horizant Oral Tablet Extended Release 300 MG Tier 3 x x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Gabapentin Enacarbil Horizant Oral Tablet Extended Release 600 MG Tier 3 x x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Corticotropin HP Acthar Injection Gel 80 UNIT/ML Tier 2 x DERMATOLOGICALS Dermatological Products, Misc. HPR Plus External Cream Tier 3 DERMATOLOGICALS Dermatological Products, Misc. HPR Plus External Foam Tier 3 PHARMACEUTICAL ADJUVANTS Human Serum Albumin Diluent HSA Sterile Diluent Injection Solution Tier 3 x MEDICAL DEVICES AND SUPPLIES Needle (Disp) 20 G Huber Needle Miscellaneous 20G X 1" Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Disp) 20 G Huber Needle Miscellaneous 20G X 1‐1/2" Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Disp) 22 G Huber Needle Miscellaneous 22G X 1" Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Disp) 22 G Huber Needle Miscellaneous 22G X 1‐1/2" Tier 3 ANTIDIABETICS (Human) HumaLOG KwikPen Subcutaneous Solution Pen‐injector 100 UNIT/ML Tier 2 x ANTIDIABETICS Insulin Lispro (Human) HumaLOG KwikPen Subcutaneous Solution Pen‐injector 200 UNIT/ML Tier 2 x ANTIDIABETICS Insulin Lispro Protamine & Lispro (Human) HumaLOG Mix 50/50 KwikPen Subcutaneous Suspension Pen‐injector (50‐50) 100 UNIT/ML Tier 2 x ANTIDIABETICS Insulin Lispro Protamine & Lispro (Human) HumaLOG Mix 50/50 Subcutaneous Suspension (50‐50) 100 UNIT/ML Tier 2 x ANTIDIABETICS Insulin Lispro Protamine & Lispro (Human) HumaLOG Mix 75/25 KwikPen Subcutaneous Suspension Pen‐injector (75‐25) 100 UNIT/ML Tier 2 x ANTIDIABETICS Insulin Lispro Protamine & Lispro (Human) HumaLOG Mix 75/25 Subcutaneous Suspension (75‐25) 100 UNIT/ML Tier 2 x ANTIDIABETICS Insulin Lispro (Human) HumaLOG Subcutaneous Solution 100 UNIT/ML Tier 2 x ANTIDIABETICS Insulin Lispro (Human) HumaLOG Subcutaneous Solution Cartridge 100 UNIT/ML Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Albumin, Human Human Albumin Grifols Intravenous Solution 25 % Tier 1 x MEDICAL DEVICES AND SUPPLIES Injection Device for Insulin HumaPen LUXURA HD Device Tier 3 HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor/von Willebrand Factor Complex (Human) Humate‐P Intravenous Solution Reconstituted 1000‐2400 UNIT Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin Humatrope Injection Solution Reconstituted 5 MG Tier 2 x ANALGESICS ‐ ANTI‐INFLAMMATORY Adalimumab Humira Pediatric Crohns Start Subcutaneous Prefilled Syringe Kit 40 MG/0.8ML Tier 2 x ANALGESICS ‐ ANTI‐INFLAMMATORY Adalimumab Humira Pen Subcutaneous Pen‐injector Kit 40 MG/0.8ML Tier 2 x ANALGESICS ‐ ANTI‐INFLAMMATORY Adalimumab Humira Pen‐Crohns Starter Subcutaneous Pen‐injector Kit 40 MG/0.8ML Tier 2 x ANALGESICS ‐ ANTI‐INFLAMMATORY Adalimumab Humira Pen‐Psoriasis Starter Subcutaneous Pen‐injector Kit 40 MG/0.8ML Tier 2 x ANALGESICS ‐ ANTI‐INFLAMMATORY Adalimumab Humira Subcutaneous Prefilled Syringe Kit 10 MG/0.2ML Tier 2 x ANALGESICS ‐ ANTI‐INFLAMMATORY Adalimumab Humira Subcutaneous Prefilled Syringe Kit 20 MG/0.4ML Tier 2 x ANALGESICS ‐ ANTI‐INFLAMMATORY Adalimumab Humira Subcutaneous Prefilled Syringe Kit 40 MG/0.8ML Tier 2 x ANTIDIABETICS Insulin NPH Isophane & Reg (Human) HumuLIN 70/30 KwikPen Subcutaneous Suspension Pen‐injector (70‐30) 100 UNIT/ML Tier 2 x ANTIDIABETICS Insulin NPH Isophane & Reg (Human) HumuLIN 70/30 Subcutaneous Suspension (70‐30) 100 UNIT/ML Tier 2 x ANTIDIABETICS Insulin NPH (Human) (Isophane) HumuLIN N KwikPen Subcutaneous Suspension Pen‐injector 100 UNIT/ML Tier 2 x ANTIDIABETICS Insulin NPH (Human) (Isophane) HumuLIN N Subcutaneous Suspension 100 UNIT/ML Tier 2 ANTIDIABETICS Insulin Regular (Human) HumuLIN R Injection Solution 100 UNIT/ML Tier 2 x ANTIDIABETICS Insulin Regular (Human) HumuLIN R U‐500 (CONCENTRATED) Subcutaneous Solution 500 UNIT/ML Tier 2 x DERMATOLOGICALS Sodium Hyaluronate‐Fluorouracil Hyalucil‐0.5 Transdermal Cream 2‐0.5 % Tier 3 DERMATOLOGICALS Sodium Hyaluronate‐Fluorouracil Hyalucil‐4 Transdermal Cream 2‐4 % Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Topotecan HCl Hycamtin Oral Capsule 0.25 MG Tier 2 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Topotecan HCl Hycamtin Oral Capsule 1 MG Tier 2 x ANALGESICS ‐ OPIOID Hydrocodone‐Acetaminophen Hycet Oral Solution 7.5‐325 MG/15ML Tier 3 COUGH/COLD/ALLERGY Pseudoeph w/Hydrocodone‐GG Hycofenix Oral Solution 30‐2.5‐200 MG/5ML Tier 3 ANTIHYPERTENSIVES Hydralazine HCl HydrALAZINE HCl Injection Solution 20 MG/ML Tier 1 x ANTIHYPERTENSIVES Hydralazine HCl HydrALAZINE HCl Oral Tablet 10 MG Tier 1 ANTIHYPERTENSIVES Hydralazine HCl HydrALAZINE HCl Oral Tablet 100 MG Tier 1 ANTIHYPERTENSIVES Hydralazine HCl HydrALAZINE HCl Oral Tablet 25 MG Tier 1 ANTIHYPERTENSIVES Hydralazine HCl HydrALAZINE HCl Oral Tablet 50 MG Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Hydroxyurea Hydrea Oral Capsule 500 MG Tier 3 DERMATOLOGICALS Urea in Lactic Acid Vehicle Hydro 35 External Foam 35 % Tier 3 DERMATOLOGICALS Urea Hydro 40 External Foam 40 % Tier 3 DIURETICS Hydrochlorothiazide Hydrochlorothiazide Oral Capsule 12.5 MG Tier 1 DIURETICS Hydrochlorothiazide Hydrochlorothiazide Oral Tablet 12.5 MG Tier 1 DIURETICS Hydrochlorothiazide Hydrochlorothiazide Oral Tablet 25 MG Tier 1 DIURETICS Hydrochlorothiazide Hydrochlorothiazide Oral Tablet 50 MG Tier 1 DIURETICS Hydrochlorothiazide Hydrochlorothiazide Powder Tier 3 COUGH/COLD/ALLERGY Hydrocodone Polistirex‐Chlorpheniramine Polistirex Hydrocod Polst‐CPM Polst ER Oral Liquid Extended Release 10‐8 MG/5ML Tier 1 ANALGESICS ‐ OPIOID Hydrocodone‐Acetaminophen Hydrocodone‐Acetaminophen Oral Solution 2.5‐108 MG/5ML Tier 1 ANALGESICS ‐ OPIOID Hydrocodone‐Acetaminophen Hydrocodone‐Acetaminophen Oral Solution 5‐217 MG/10ML Tier 1 ANALGESICS ‐ OPIOID Hydrocodone‐Acetaminophen Hydrocodone‐Acetaminophen Oral Solution 7.5‐325 MG/15ML Tier 1 ANALGESICS ‐ OPIOID Hydrocodone‐Acetaminophen Hydrocodone‐Acetaminophen Oral Tablet 10‐300 MG Tier 1 ANALGESICS ‐ OPIOID Hydrocodone‐Acetaminophen Hydrocodone‐Acetaminophen Oral Tablet 10‐325 MG Tier 1 ANALGESICS ‐ OPIOID Hydrocodone‐Acetaminophen Hydrocodone‐Acetaminophen Oral Tablet 2.5‐325 MG Tier 1 ANALGESICS ‐ OPIOID Hydrocodone‐Acetaminophen Hydrocodone‐Acetaminophen Oral Tablet 5‐300 MG Tier 1 ANALGESICS ‐ OPIOID Hydrocodone‐Acetaminophen Hydrocodone‐Acetaminophen Oral Tablet 5‐325 MG Tier 1 ANALGESICS ‐ OPIOID Hydrocodone‐Acetaminophen Hydrocodone‐Acetaminophen Oral Tablet 7.5‐300 MG Tier 1 ANALGESICS ‐ OPIOID Hydrocodone‐Acetaminophen Hydrocodone‐Acetaminophen Oral Tablet 7.5‐325 MG Tier 1 COUGH/COLD/ALLERGY Hydrocodone w/ Homatropine Hydrocodone‐Homatropine Oral Syrup 5‐1.5 MG/5ML Tier 1 COUGH/COLD/ALLERGY Hydrocodone w/ Homatropine Hydrocodone‐Homatropine Oral Tablet 5‐1.5 MG Tier 1 ANALGESICS ‐ OPIOID Hydrocodone‐Ibuprofen Hydrocodone‐Ibuprofen Oral Tablet 10‐200 MG Tier 1 ANALGESICS ‐ OPIOID Hydrocodone‐Ibuprofen Hydrocodone‐Ibuprofen Oral Tablet 5‐200 MG Tier 1 ANALGESICS ‐ OPIOID Hydrocodone‐Ibuprofen Hydrocodone‐Ibuprofen Oral Tablet 7.5‐200 MG Tier 1 ANORECTAL AGENTS Hydrocortisone Acetate w/ Pramoxine Hydrocortisone Ace‐Pramoxine Rectal Cream 1‐1 % Tier 1 DERMATOLOGICALS Hydrocortisone Acetate (Topical) Hydrocortisone Acetate Powder Tier 3 DERMATOLOGICALS Hydrocortisone Butyrate Hydrophilic Lipo Base Hydrocortisone Butyr Lipo Base External Cream 0.1 % Tier 1 DERMATOLOGICALS Hydrocortisone Butyrate Hydrocortisone Butyrate External Cream 0.1 % Tier 1 DERMATOLOGICALS Hydrocortisone Butyrate Hydrocortisone Butyrate External Ointment 0.1 % Tier 1 DERMATOLOGICALS Hydrocortisone Butyrate Hydrocortisone Butyrate External Solution 0.1 % Tier 1 DERMATOLOGICALS Hydrocortisone (Topical) Hydrocortisone External Cream 1 % Tier 1 DERMATOLOGICALS Hydrocortisone (Topical) Hydrocortisone External Cream 2.5 % Tier 1 DERMATOLOGICALS Hydrocortisone (Topical) Hydrocortisone External Lotion 2.5 % Tier 1 DERMATOLOGICALS Hydrocortisone (Topical) Hydrocortisone External Ointment 1 % Tier 1 DERMATOLOGICALS Hydrocortisone (Topical) Hydrocortisone External Ointment 2.5 % Tier 1 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

DERMATOLOGICALS Hydrocortisone Micronized Hydrocortisone Micronized Powder Tier 3 CORTICOSTEROIDS Hydrocortisone Hydrocortisone Oral Tablet 10 MG Tier 1 CORTICOSTEROIDS Hydrocortisone Hydrocortisone Oral Tablet 20 MG Tier 1 CORTICOSTEROIDS Hydrocortisone Hydrocortisone Oral Tablet 5 MG Tier 1 DERMATOLOGICALS Hydrocortisone (Topical) Hydrocortisone Powder Tier 3 ANORECTAL AGENTS Hydrocortisone (Rectal) Hydrocortisone Rectal Cream 1 % Tier 1 ANORECTAL AGENTS Hydrocortisone (Rectal) Hydrocortisone Rectal Cream 2.5 % Tier 1 ANORECTAL AGENTS Hydrocortisone (Intrarectal) Hydrocortisone Rectal Enema 100 MG/60ML Tier 1 DERMATOLOGICALS Hydrocortisone Valerate Hydrocortisone Valerate External Cream 0.2 % Tier 1 DERMATOLOGICALS Hydrocortisone Valerate Hydrocortisone Valerate External Ointment 0.2 % Tier 1 OTIC AGENTS Hydrocortisone w/Acetic Acid Hydrocortisone‐Acetic Acid Otic Solution 1‐2 % Tier 1 COUGH/COLD/ALLERGY Hydrocodone w/ Homatropine Hydromet Oral Syrup 5‐1.5 MG/5ML Tier 1 ANALGESICS ‐ OPIOID Hydromorphone HCl HYDROmorphone HCl ER Oral Tablet ER 24 Hour Abuse‐Deterrent 12 MG Tier 1 x ANALGESICS ‐ OPIOID Hydromorphone HCl HYDROmorphone HCl ER Oral Tablet ER 24 Hour Abuse‐Deterrent 16 MG Tier 1 x ANALGESICS ‐ OPIOID Hydromorphone HCl HYDROmorphone HCl ER Oral Tablet ER 24 Hour Abuse‐Deterrent 32 MG Tier 3 x ANALGESICS ‐ OPIOID Hydromorphone HCl HYDROmorphone HCl ER Oral Tablet ER 24 Hour Abuse‐Deterrent 8 MG Tier 1 x ANALGESICS ‐ OPIOID Hydromorphone HCl HYDROmorphone HCl Injection Solution 1 MG/ML Tier 1 x ANALGESICS ‐ OPIOID Hydromorphone HCl HYDROmorphone HCl Injection Solution 2 MG/ML Tier 1 x ANALGESICS ‐ OPIOID Hydromorphone HCl HYDROmorphone HCl Injection Solution 4 MG/ML Tier 1 x ANALGESICS ‐ OPIOID Hydromorphone HCl HYDROmorphone HCl Oral Liquid 1 MG/ML Tier 1 ANALGESICS ‐ OPIOID Hydromorphone HCl HYDROmorphone HCl Oral Tablet 2 MG Tier 1 ANALGESICS ‐ OPIOID Hydromorphone HCl HYDROmorphone HCl Oral Tablet 4 MG Tier 1 ANALGESICS ‐ OPIOID Hydromorphone HCl HYDROmorphone HCl Oral Tablet 8 MG Tier 1 ANALGESICS ‐ OPIOID Hydromorphone HCl HYDROmorphone HCl PF Injection Solution 10 MG/ML Tier 1 x ANALGESICS ‐ OPIOID Hydromorphone HCl HYDROmorphone HCl PF Injection Solution 50 MG/5ML Tier 1 x ANALGESICS ‐ OPIOID Hydromorphone HCl HYDROmorphone HCl PF Injection Solution 500 MG/50ML Tier 1 x ANALGESICS ‐ OPIOID Hydromorphone HCl HYDROmorphone HCl Powder Tier 3 ANALGESICS ‐ OPIOID Hydromorphone HCl HYDROmorphone HCl Rectal Suppository 3 MG Tier 3 ANALGESICS ‐ OPIOID Hydromorphone HCl‐Sodium Chloride HYDROmorphone HCl‐NaCl Intravenous Solution Prefilled Syringe 10‐0.9 MG/50ML‐% Tier 3 x DERMATOLOGICALS Hydroquinone Hydroquinone External Cream 4 % Tier 1 DERMATOLOGICALS Hydroquinone Hydroquinone Powder Tier 3 HEMATOPOIETIC AGENTS Hydroxocobalamin Hydroxocobalamin Intramuscular Solution 1000 MCG/ML Tier 3 x ANTIMALARIALS Hydroxychloroquine Sulfate Hydroxychloroquine Sulfate Oral Tablet 200 MG Tier 1 CHEMICALS Hydroxytryptophan Hydroxytryptophan L‐5 Powder Tier 3 CHEMICALS Hydroxytryptophan Hydroxytryptophan Powder Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Hydroxyurea Hydroxyurea Oral Capsule 500 MG Tier 1 ANTIANXIETY AGENTS Hydroxyzine HCl HydrOXYzine HCl Intramuscular Solution 25 MG/ML Tier 3 x ANTIANXIETY AGENTS Hydroxyzine HCl HydrOXYzine HCl Intramuscular Solution 50 MG/ML Tier 1 x ANTIANXIETY AGENTS Hydroxyzine HCl HydrOXYzine HCl Oral Syrup 10 MG/5ML Tier 1 ANTIANXIETY AGENTS Hydroxyzine HCl HydrOXYzine HCl Oral Tablet 10 MG Tier 1 ANTIANXIETY AGENTS Hydroxyzine HCl HydrOXYzine HCl Oral Tablet 25 MG Tier 1 ANTIANXIETY AGENTS Hydroxyzine HCl HydrOXYzine HCl Oral Tablet 50 MG Tier 1 ANTIANXIETY AGENTS Hydroxyzine Pamoate HydrOXYzine Pamoate Oral Capsule 100 MG Tier 2 ANTIANXIETY AGENTS Hydroxyzine Pamoate HydrOXYzine Pamoate Oral Capsule 25 MG Tier 1 ANTIANXIETY AGENTS Hydroxyzine Pamoate HydrOXYzine Pamoate Oral Capsule 50 MG Tier 1 ANTIANXIETY AGENTS Hydroxyzine Pamoate HydrOXYzine Pamoate Powder Tier 3 DERMATOLOGICALS Hyaluronate Sodium HyGel External Gel 2.5 % Tier 3 DERMATOLOGICALS Hyaluronate Sodium Hylase Wound External Gel Tier 3 DERMATOLOGICALS Dermatological Products, Misc. Hylatopic Plus External Cream Tier 3 DERMATOLOGICALS Dermatological Products, Misc. Hylatopic Plus External Foam Tier 3 ASSORTED CLASSES Hyaluronidase Human Hylenex Injection Solution 150 UNIT/ML Tier 3 x DERMATOLOGICALS Hyaluronate Sodium (Emollient) Hylira External Gel 0.2 % Tier 3 DERMATOLOGICALS Hyaluronate Sodium (Emollient) Hylira External Lotion 0.1 % Tier 3 URINARY ANTI‐INFECTIVES Methenamine‐Hyosc‐‐Sod Phos‐Phenyl Sal Hyolev MB Oral Tablet 81 MG Tier 1 ULCER DRUGS Hyoscyamine Sulfate HyoMax‐SL Sublingual Tablet Sublingual 0.125 MG Tier 1 URINARY ANTI‐INFECTIVES Methenamine‐Hyosc‐Methylene Blue‐Benzoic Acid‐Phenyl Sal Hyophen Oral Tablet 81.6 MG Tier 1 ULCER DRUGS Hyoscyamine Sulfate Hyoscyamine Sulfate ER Oral Tablet Extended Release 12 Hour 0.375 MG Tier 1 ULCER DRUGS Hyoscyamine Sulfate Hyoscyamine Sulfate Oral Elixir 0.125 MG/5ML Tier 1 ULCER DRUGS Hyoscyamine Sulfate Hyoscyamine Sulfate Oral Solution 0.125 MG/ML Tier 1 ULCER DRUGS Hyoscyamine Sulfate Hyoscyamine Sulfate Oral Tablet 0.125 MG Tier 1 ULCER DRUGS Hyoscyamine Sulfate Hyoscyamine Sulfate Oral Tablet Dispersible 0.125 MG Tier 1 ULCER DRUGS Hyoscyamine Sulfate Hyoscyamine Sulfate Sublingual Tablet Sublingual 0.125 MG Tier 1 ULCER DRUGS Hyoscyamine Sulfate Hyosyne Oral Elixir 0.125 MG/5ML Tier 1 ULCER DRUGS Hyoscyamine Sulfate Hyosyne Oral Solution 0.125 MG/ML Tier 1 PASSIVE IMMUNIZING AGENTS Rabies Immune Globulin (Human) HyperRAB S/D Intramuscular Injectable 150 UNIT/ML Tier 2 x COUGH/COLD/ALLERGY Sodium Chloride (Inhalant) HyperSal Inhalation Nebulization Solution 3.5 % Tier 3 COUGH/COLD/ALLERGY Sodium Chloride (Inhalant) HyperSal Inhalation Nebulization Solution 7 % Tier 3 PASSIVE IMMUNIZING AGENTS Tetanus Immune Globulin (Human) HyperTET S/D Intramuscular Injectable 250 UNIT/ML Tier 3 x ANALGESICS ‐ OPIOID Hydrocodone Bitartrate Hysingla ER Oral Tablet ER 24 Hour Abuse‐Deterrent 100 MG Tier 3 x x ANALGESICS ‐ OPIOID Hydrocodone Bitartrate Hysingla ER Oral Tablet ER 24 Hour Abuse‐Deterrent 120 MG Tier 3 x x ANALGESICS ‐ OPIOID Hydrocodone Bitartrate Hysingla ER Oral Tablet ER 24 Hour Abuse‐Deterrent 20 MG Tier 3 x x ANALGESICS ‐ OPIOID Hydrocodone Bitartrate Hysingla ER Oral Tablet ER 24 Hour Abuse‐Deterrent 30 MG Tier 3 x x ANALGESICS ‐ OPIOID Hydrocodone Bitartrate Hysingla ER Oral Tablet ER 24 Hour Abuse‐Deterrent 40 MG Tier 3 x x ANALGESICS ‐ OPIOID Hydrocodone Bitartrate Hysingla ER Oral Tablet ER 24 Hour Abuse‐Deterrent 60 MG Tier 3 x x ANALGESICS ‐ OPIOID Hydrocodone Bitartrate Hysingla ER Oral Tablet ER 24 Hour Abuse‐Deterrent 80 MG Tier 3 x x MEDICAL DEVICES AND SUPPLIES Lancets Hy‐Vee Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Hy‐Vee Thin Lancets Miscellaneous Tier 2 ANTIHYPERTENSIVES Losartan Potassium & Hydrochlorothiazide Hyzaar Oral Tablet 100‐12.5 MG Tier 3 ANTIHYPERTENSIVES Losartan Potassium & Hydrochlorothiazide Hyzaar Oral Tablet 100‐25 MG Tier 3 ANTIHYPERTENSIVES Losartan Potassium & Hydrochlorothiazide Hyzaar Oral Tablet 50‐12.5 MG Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Ibandronate Sodium Ibandronate Sodium Intravenous Solution 3 MG/3ML Tier 1 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Ibandronate Sodium Ibandronate Sodium Oral Tablet 150 MG Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Palbociclib Ibrance Oral Capsule 100 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Palbociclib Ibrance Oral Capsule 125 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Palbociclib Ibrance Oral Capsule 75 MG Tier 2 x x ANALGESICS ‐ OPIOID Hydrocodone‐Ibuprofen Ibudone Oral Tablet 10‐200 MG Tier 3 ANALGESICS ‐ OPIOID Hydrocodone‐Ibuprofen Ibudone Oral Tablet 5‐200 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Ibuprofen w/ Liniment Ibuprofen Comfort Pac Combination Kit 800 MG Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Ibuprofen Ibuprofen Oral Suspension 100 MG/5ML Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Ibuprofen Ibuprofen Oral Tablet 400 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Ibuprofen Ibuprofen Oral Tablet 600 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Ibuprofen Ibuprofen Oral Tablet 800 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Ibuprofen Ibuprofen Powder Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Ibuprofen w/ Caffeine & Vitamins IC 400 Oral Kit 400 MG Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Ibuprofen w/ Caffeine & Vitamins IC 800 Oral Kit 800 MG Tier 3 HEMATOPOIETIC AGENTS Iron‐Vitamin C‐Vitamin B12‐Folic Acid Icar‐C Plus Oral Tablet 100‐250‐0.025‐1 MG Tier 3 DERMATOLOGICALS Ichthammol Ichthammol Powder Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Ponatinib HCl Iclusig Oral Tablet 15 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Ponatinib HCl Iclusig Oral Tablet 45 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Idarubicin HCl IDArubicin HCl Intravenous Solution 10 MG/10ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Idarubicin HCl IDArubicin HCl Intravenous Solution 20 MG/20ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Idarubicin HCl IDArubicin HCl Intravenous Solution 5 MG/5ML Tier 1 x HEMATOPOIETIC AGENTS Iron Polysaccharide Complex‐Vit B12‐Folic Acid iFerex 150 Forte Oral Capsule 150‐25‐1 MG‐MCG‐MG Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Ifosfamide Ifosfamide Intravenous Solution 1 GM/20ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Ifosfamide Ifosfamide Intravenous Solution 3 GM/60ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Ifosfamide Ifosfamide Intravenous Solution Reconstituted 1 GM Tier 1 x OPHTHALMIC AGENTS Nepafenac Ilevro Ophthalmic Suspension 0.3 % Tier 3 OPHTHALMIC AGENTS Erythromycin (Ophth) Ilotycin Ophthalmic Ointment 5 MG/GM Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Imatinib Mesylate Imatinib Mesylate Oral Tablet 100 MG Tier 1 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Imatinib Mesylate Imatinib Mesylate Oral Tablet 400 MG Tier 1 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Ibrutinib Imbruvica Oral Capsule 140 MG Tier 2 x x ANTI‐INFECTIVE AGENTS ‐ MISC. Imipenem‐Cilastatin Imipenem‐Cilastatin Intravenous Solution Reconstituted 250 MG Tier 1 x HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ANTI‐INFECTIVE AGENTS ‐ MISC. Imipenem‐Cilastatin Imipenem‐Cilastatin Intravenous Solution Reconstituted 500 MG Tier 1 x ANTIDEPRESSANTS HCl Imipramine HCl Oral Tablet 10 MG Tier 1 ANTIDEPRESSANTS Imipramine HCl Imipramine HCl Oral Tablet 25 MG Tier 1 ANTIDEPRESSANTS Imipramine HCl Imipramine HCl Oral Tablet 50 MG Tier 1 ANTIDEPRESSANTS Imipramine HCl Imipramine HCl Powder Tier 3 ANTIDEPRESSANTS Imipramine Pamoate Imipramine Pamoate Oral Capsule 100 MG Tier 1 ANTIDEPRESSANTS Imipramine Pamoate Imipramine Pamoate Oral Capsule 125 MG Tier 1 ANTIDEPRESSANTS Imipramine Pamoate Imipramine Pamoate Oral Capsule 150 MG Tier 1 ANTIDEPRESSANTS Imipramine Pamoate Imipramine Pamoate Oral Capsule 75 MG Tier 1 DERMATOLOGICALS Imiquimod Imiquimod External Cream 5 % Tier 1 MIGRAINE PRODUCTS Sumatriptan Imitrex Nasal Solution 20 MG/ACT Tier 2 xx MIGRAINE PRODUCTS Sumatriptan Imitrex Nasal Solution 5 MG/ACT Tier 2 xx MIGRAINE PRODUCTS Sumatriptan Succinate Imitrex Oral Tablet 100 MG Tier 3 x MIGRAINE PRODUCTS Sumatriptan Succinate Imitrex Oral Tablet 25 MG Tier 3 x MIGRAINE PRODUCTS Sumatriptan Succinate Imitrex Oral Tablet 50 MG Tier 3 x MIGRAINE PRODUCTS Sumatriptan Succinate Imitrex STATdose Refill Subcutaneous Solution Cartridge 4 MG/0.5ML Tier 3 x x MIGRAINE PRODUCTS Sumatriptan Succinate Imitrex STATdose Refill Subcutaneous Solution Cartridge 6 MG/0.5ML Tier 3 x x MIGRAINE PRODUCTS Sumatriptan Succinate Imitrex STATdose System Subcutaneous Solution Auto‐injector 4 MG/0.5ML Tier 3 x x MIGRAINE PRODUCTS Sumatriptan Succinate Imitrex STATdose System Subcutaneous Solution Auto‐injector 6 MG/0.5ML Tier 3 x x MIGRAINE PRODUCTS Sumatriptan Succinate Imitrex Subcutaneous Solution 6 MG/0.5ML Tier 3 x PASSIVE IMMUNIZING AGENTS Rabies Immune Globulin (Human) Imogam Rabies‐HT Intramuscular Injectable 150 UNIT/ML Tier 2 x VACCINES Rabies Virus Vaccine, HDC Imovax Rabies Intramuscular Injectable 2.5 UNIT/ML Tier 3 x ASSORTED CLASSES Azathioprine Imuran Oral Tablet 50 MG Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood In Touch Blood Glucose Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets In Touch Sterile Lancets 30G Miscellaneous Tier 2 MULTIVITAMINS Prenatal Vit w/ Docusate‐Iron Carbonyl‐Folic Acid iNatal Advance Oral Tablet Tier 2 MULTIVITAMINS Prenatal Vit w/ Docusate‐Iron Carbonyl‐Folic Acid Inatal GT Oral Tablet Tier 2 MULTIVITAMINS Prenatal Vit w/ Docusate‐Iron Carbonyl‐Folic Acid iNatal Ultra Oral Tablet Tier 2 ANTIVIRALS Telaprevir Incivek Oral Tablet 375 MG Tier 2 x x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Mecasermin Increlex Subcutaneous Solution 40 MG/4ML Tier 2 x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Umeclidinium Bromide Incruse Ellipta Inhalation Aerosol Powder Breath Activated 62.5 MCG/INH Tier 2 x DIURETICS Indapamide Indapamide Oral Tablet 1.25 MG Tier 1 DIURETICS Indapamide Indapamide Oral Tablet 2.5 MG Tier 1 BETA BLOCKERS Propranolol HCl Inderal LA Oral Capsule Extended Release 24 Hour 120 MG Tier 3 BETA BLOCKERS Propranolol HCl Inderal LA Oral Capsule Extended Release 24 Hour 160 MG Tier 3 BETA BLOCKERS Propranolol HCl Inderal LA Oral Capsule Extended Release 24 Hour 60 MG Tier 3 BETA BLOCKERS Propranolol HCl Inderal LA Oral Capsule Extended Release 24 Hour 80 MG Tier 3 BETA BLOCKERS Propranolol HCl Sustained‐Release Beads Inderal XL Oral Capsule Extended Release 24 Hour 120 MG Tier 3 BETA BLOCKERS Propranolol HCl Sustained‐Release Beads Inderal XL Oral Capsule Extended Release 24 Hour 80 MG Tier 3 URINARY ANTI‐INFECTIVES Methenamine‐Hyoscamine‐Methylene Blue‐Sodium Phosphate Indiomin MB Oral Capsule 120 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Indomethacin Indocin Oral Suspension 25 MG/5ML Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Indomethacin Indocin Rectal Suppository 50 MG Tier 2 DIAGNOSTIC PRODUCTS Indocyanine Green Indocyanine Green Intravenous Solution Reconstituted 25 MG Tier 1 x CHEMICALS ‐3‐Carbinol Indole‐3‐Carbinol Powder Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Indomethacin Indomethacin ER Oral Capsule Extended Release 75 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Indomethacin Indomethacin Oral Capsule 25 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Indomethacin Indomethacin Oral Capsule 50 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Indomethacin Indomethacin Powder Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Indomethacin Sodium Indomethacin Sodium Intravenous Solution Reconstituted 1 MG Tier 3 x MULTIVITAMINS Prenatal w/o Vit A w/ Fe Carbonyl‐DSS‐FA‐DHA Infanate Balance Oral Capsule 29‐1‐265 MG Tier 3 TOXOIDS Diphtheria, Acellular Pertussis & Tetanus Toxoids Infanrix Intramuscular Suspension 25‐58‐10 Tier 3 x RESPIRATORY AGENTS ‐ MISC. Calfactant in NaCl Infasurf Inhalation Suspension 35‐0.9 MG/ML‐% Tier 3 HEMATOPOIETIC AGENTS Iron Dextran Infed Injection Solution 50 MG/ML Tier 3 x ANTIVIRALS Interferon alfacon‐1 Infergen Subcutaneous Injectable 15 MCG/0.5ML Tier 2 x x ANTIVIRALS Interferon alfacon‐1 Infergen Subcutaneous Injectable 9 MCG/0.3ML Tier 2 x x MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies Infinity Blood Glucose System Kit w/Device Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Infinity Blood Glucose Test In Vitro Strip Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Diclofenac Sodium‐Capsaicin Inflammacin Combination Therapy Pack 75 & 0.025 MG‐% Tier 1 x ANALGESICS ‐ ANTI‐INFLAMMATORY Diclofenac Sodium & Ranitidine HCl & Lidocaine‐Prilocaine Inflammation Reduction Pack Combination Therapy Pack 75‐150‐2.5‐2.5 MG‐MG‐%‐% Tier 3 MULTIVITAMINS Multiple Vitamin Infuvite Intravenous Injectable Tier 1 x MULTIVITAMINS Multiple Vitamin Infuvite Pediatric Intravenous Injectable Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Axitinib Inlyta Oral Tablet 1 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Axitinib Inlyta Oral Tablet 5 MG Tier 2 x x BETA BLOCKERS Propranolol HCl Sustained‐Release Beads InnoPran XL Oral Capsule Extended Release 24 Hour 120 MG Tier 3 BETA BLOCKERS Propranolol HCl Sustained‐Release Beads InnoPran XL Oral Capsule Extended Release 24 Hour 80 MG Tier 3 DERMATOLOGICALS Amantadine HCl‐Gabapentin‐Diclofenac Sod‐Baclofen‐Lidocaine Innoprax‐5 External Cream Tier 3 DERMATOLOGICALS Benzoyl Peroxide & Salicylic Acid & Vitamin E Inova 4/1 Acne Control Therapy External Kit 4 & 1 & 5 % Tier 3 x DERMATOLOGICALS Benzoyl Peroxide & Salicylic Acid & Vitamin E Inova 8/2 Acne Control Therapy External Kit 8 & 2 & 5 % Tier 3 x DERMATOLOGICALS Benzoyl Peroxide & Vitamin E Inova External Kit 4 & 5 % Tier 3 x DERMATOLOGICALS Benzoyl Peroxide & Vitamin E Inova External Kit 8 & 5 % Tier 3 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers InspiraChamber/Medium Device Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers InspiraChamber/Mouthpiece Device Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers InspiraChamber/Small Device Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers Inspirease Miscellaneous Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chamber Supplies ‐ Mouthpieces Inspirease Mouthpiece Miscellaneous Tier 2 x ANTIHYPERTENSIVES Eplerenone Inspra Oral Tablet 25 MG Tier 3 ANTIHYPERTENSIVES Eplerenone Inspra Oral Tablet 50 MG Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Insulin Syringe Miscellaneous 28G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Insulin Syringe Miscellaneous 28G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Insulin Syringe Miscellaneous 29G X 1" 0.3 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Insulin Syringe Miscellaneous 29G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Insulin Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Insulin Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Insulin Syringe Miscellaneous 30G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Insulin Syringe Miscellaneous 30G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Insulin Syringe Miscellaneous 30G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Insulin Syringe Miscellaneous 30G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Insulin Syringe Miscellaneous 31G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Insulin Syringe Miscellaneous 31G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Insulin Syringe Miscellaneous 31G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Insulin Syringe/Needle Miscellaneous 27G X 1/2" 0.5 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Insulin Syringe/Needle Miscellaneous 28G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Insulin Syringe/Needle Miscellaneous 28G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies Insul‐Tote Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Insupen Pen Needles Miscellaneous 32G X 4 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Insupen Pen Needles Miscellaneous 33G X 4 MM Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Insupen Sensitive Miscellaneous 32G X 6 MM Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Insupen Sensitive Miscellaneous 32G X 8 MM Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Insupen Ultrafin Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Insupen Ultrafin Miscellaneous 30G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Insupen Ultrafin Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Insupen Ultrafin Miscellaneous 31G X 8 MM Tier 2 HEMATOPOIETIC AGENTS Ferrous Fumarate‐Iron Polysaccharide Complex‐Folic Acid‐C‐B3 Integra F Oral Capsule 125‐1 MG Tier 3 HEMATOPOIETIC AGENTS Fe Fum‐Iron Polysacch Complex‐FA‐B Complex‐C‐Biotin Integra Plus Oral Capsule Tier 3 HEMATOLOGICAL AGENTS ‐ MISC. Eptifibatide Integrilin Intravenous Solution 0.75 MG/ML Tier 3 x HEMATOLOGICAL AGENTS ‐ MISC. Eptifibatide Integrilin Intravenous Solution 2 MG/ML Tier 3 x ANTIVIRALS Etravirine Intelence Oral Tablet 100 MG Tier 2 x ANTIVIRALS Etravirine Intelence Oral Tablet 200 MG Tier 2 x ANTIVIRALS Etravirine Intelence Oral Tablet 25 MG Tier 2 x CORTICOSTEROIDS Triamcinolone Acetonide & Lidocaine HCl & Interarticular Joint Combination Kit 40‐1 MG/ML‐% Tier 3 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Zolpidem Tartrate Intermezzo Sublingual Tablet Sublingual 1.75 MG Tier 3 xx HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Zolpidem Tartrate Intermezzo Sublingual Tablet Sublingual 3.5 MG Tier 3 xx HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Interferon Alfa‐2B Intron A Injection Solution 10000000 UNIT/ML Tier 2 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Interferon Alfa‐2B Intron A Injection Solution 6000000 UNIT/ML Tier 2 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Interferon Alfa‐2B Intron A Injection Solution Reconstituted 10000000 UNIT Tier 2 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Interferon Alfa‐2B Intron A Injection Solution Reconstituted 18000000 UNIT Tier 2 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Interferon Alfa‐2B Intron A Injection Solution Reconstituted 50000000 UNIT Tier 2 x CONTRACEPTIVES Levonorgestrel‐Ethinyl Estradiol (91‐Day) Introvale Oral Tablet 0.15‐0.03 MG Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Guanfacine HCl (ADHD) Intuniv Oral Tablet Extended Release 24 Hour 1 MG Tier 3 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Guanfacine HCl (ADHD) Intuniv Oral Tablet Extended Release 24 Hour 2 MG Tier 3 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Guanfacine HCl (ADHD) Intuniv Oral Tablet Extended Release 24 Hour 3 MG Tier 3 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Guanfacine HCl (ADHD) Intuniv Oral Tablet Extended Release 24 Hour 4 MG Tier 3 x x ANTIPSYCHOTICS/ANTIMANIC AGENTS Paliperidone Invega Oral Tablet Extended Release 24 Hour 1.5 MG Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Paliperidone Invega Oral Tablet Extended Release 24 Hour 3 MG Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Paliperidone Invega Oral Tablet Extended Release 24 Hour 6 MG Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Paliperidone Invega Oral Tablet Extended Release 24 Hour 9 MG Tier 3 xx ANTIVIRALS Saquinavir Mesylate Invirase Oral Capsule 200 MG Tier 2 x ANTIVIRALS Saquinavir Mesylate Invirase Oral Tablet 500 MG Tier 2 x ANTIDIABETICS Canagliflozin‐Metformin HCl Invokamet Oral Tablet 150‐1000 MG Tier 2 x x ANTIDIABETICS Canagliflozin‐Metformin HCl Invokamet Oral Tablet 150‐500 MG Tier 2 x x ANTIDIABETICS Canagliflozin‐Metformin HCl Invokamet Oral Tablet 50‐1000 MG Tier 2 x x ANTIDIABETICS Canagliflozin‐Metformin HCl Invokamet Oral Tablet 50‐500 MG Tier 2 x x ANTIDIABETICS Canagliflozin Invokana Oral Tablet 100 MG Tier 2 x x ANTIDIABETICS Canagliflozin Invokana Oral Tablet 300 MG Tier 2 x x MINERALS & ELECTROLYTES Iodine Strong (Lugol's) Iodine Strong Oral Solution 5 % Tier 3 ANTISEPTICS & DISINFECTANTS Iodine (Topical) Iodine Tincture External Tincture 2 % Tier 3 ANTISEPTICS & DISINFECTANTS Cadexomer Iodine Iodoflex External Pad 0.9 % Tier 3 CHEMICALS Iodoform Iodoform Powder Tier 3 AMEBICIDES Iodoquinol Iodoquinol Powder Tier 3 ANALGESICS ‐ OPIOID Fentanyl HCl Ionsys Transdermal Patch 40 MCG/ACT Tier 3 OPHTHALMIC AGENTS Apraclonidine HCl Iopidine Ophthalmic Solution 0.5 % Tier 3 x OPHTHALMIC AGENTS Apraclonidine HCl Iopidine Ophthalmic Solution 1 % Tier 3 x VACCINES Vaccine, IPV Ipol Injection Injectable Tier 3 x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Ipratropium Bromide Ipratropium Bromide Inhalation Solution 0.02 % Tier 1 x NASAL AGENTS ‐ SYSTEMIC AND TOPICAL Ipratropium Bromide (Nasal) Ipratropium Bromide Nasal Solution 0.03 % Tier 1 NASAL AGENTS ‐ SYSTEMIC AND TOPICAL Ipratropium Bromide (Nasal) Ipratropium Bromide Nasal Solution 0.06 % Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Ipratropium Bromide Ipratropium Bromide Powder Tier 3 x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Ipratropium‐Albuterol Ipratropium‐Albuterol Inhalation Solution 0.5‐2.5 (3) MG/3ML Tier 1 ANTIHYPERTENSIVES Irbesartan Irbesartan Oral Tablet 150 MG Tier 1 ANTIHYPERTENSIVES Irbesartan Irbesartan Oral Tablet 300 MG Tier 1 ANTIHYPERTENSIVES Irbesartan Irbesartan Oral Tablet 75 MG Tier 1 ANTIHYPERTENSIVES Irbesartan‐Hydrochlorothiazide Irbesartan‐Hydrochlorothiazide Oral Tablet 150‐12.5 MG Tier 1 ANTIHYPERTENSIVES Irbesartan‐Hydrochlorothiazide Irbesartan‐Hydrochlorothiazide Oral Tablet 300‐12.5 MG Tier 1 ANTIDEPRESSANTS Duloxetine HCl Irenka Oral Capsule Delayed Release Particles 40 MG Tier 3 xx ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Gefitinib Iressa Oral Tablet 250 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Irinotecan HCl Irinotecan HCl Intravenous Solution 100 MG/5ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Irinotecan HCl Irinotecan HCl Intravenous Solution 40 MG/2ML Tier 1 x HEMATOPOIETIC AGENTS Fe Bisglyc‐Fe Polysaccharide‐Succ Acd‐B Complex‐C‐Ca‐FA Irospan 24/6 Oral Miscellaneous Tier 3 HEMATOPOIETIC AGENTS Fe Bisglyc‐Fe Polysaccharide‐Succ Acd‐B Complex‐C‐Ca‐FA IS 24/6 Oral Miscellaneous Tier 3 ANTIVIRALS Raltegravir Potassium Isentress Oral Packet 100 MG Tier 2 x ANTIVIRALS Raltegravir Potassium Isentress Oral Tablet 400 MG Tier 2 x ANTIVIRALS Raltegravir Potassium Isentress Oral Tablet Chewable 100 MG Tier 2 x ANTIVIRALS Raltegravir Potassium Isentress Oral Tablet Chewable 25 MG Tier 2 x GENERAL ANESTHETICS Isoflurane Isoflurane Inhalation Solution Tier 1 MINERALS & ELECTROLYTES Electrolyte‐S (PH 7.4) Isolyte‐S pH 7.4 Intravenous Solution Tier 3 x ANTIMYCOBACTERIAL AGENTS Isoniazid Isoniazid Oral Syrup 50 MG/5ML Tier 2 ANTIMYCOBACTERIAL AGENTS Isoniazid Isoniazid Oral Tablet 100 MG Tier 1 ANTIMYCOBACTERIAL AGENTS Isoniazid Isoniazid Oral Tablet 300 MG Tier 1 ANTIMYCOBACTERIAL AGENTS Isoniazid Isoniazid Powder Tier 3 CHEMICALS Isopropyl Alcohol Isopropanol Solution 70 % Tier 3 CHEMICALS Isopropyl Alcohol Isopropyl Alcohol Solution Tier 3 CHEMICALS Isopropyl Alcohol Isopropyl Alcohol Solution 70 % Tier 3 CHEMICALS Isopropyl Alcohol Isopropyl Alcohol Solution 99 % Tier 3 CHEMICALS Isopropyl Palmitate Isopropyl Palmitate Liquid Tier 3 CALCIUM CHANNEL BLOCKERS Verapamil HCl Isoptin SR Oral Tablet Extended Release 240 MG Tier 3 OPHTHALMIC AGENTS Carbachol (Ophth) Isopto Carbachol Ophthalmic Solution 1.5 % Tier 2 OPHTHALMIC AGENTS Carbachol (Ophth) Isopto Carbachol Ophthalmic Solution 3 % Tier 2 OPHTHALMIC AGENTS Pilocarpine HCl Isopto Carpine Ophthalmic Solution 1 % Tier 3 OPHTHALMIC AGENTS Pilocarpine HCl Isopto Carpine Ophthalmic Solution 2 % Tier 3 OPHTHALMIC AGENTS Pilocarpine HCl Isopto Carpine Ophthalmic Solution 4 % Tier 3 OPHTHALMIC AGENTS Homatropine HBr Isopto Homatropine Ophthalmic Solution 2 % Tier 2 OPHTHALMIC AGENTS Homatropine HBr Isopto Homatropine Ophthalmic Solution 5 % Tier 3 OPHTHALMIC AGENTS Scopolamine HBr (Ophth) Isopto Hyoscine Ophthalmic Solution 0.25 % Tier 3 ANTIANGINAL AGENTS Isosorbide Dinitrate Isordil Titradose Oral Tablet 40 MG Tier 2 ANTIANGINAL AGENTS Isosorbide Dinitrate Isordil Titradose Oral Tablet 5 MG Tier 3 ANTIANGINAL AGENTS Isosorbide Dinitrate Isosorbide Dinitrate ER Oral Tablet Extended Release 40 MG Tier 3 ANTIANGINAL AGENTS Isosorbide Dinitrate Isosorbide Dinitrate Oral Tablet 10 MG Tier 1 ANTIANGINAL AGENTS Isosorbide Dinitrate Isosorbide Dinitrate Oral Tablet 20 MG Tier 1 ANTIANGINAL AGENTS Isosorbide Dinitrate Isosorbide Dinitrate Oral Tablet 30 MG Tier 2 ANTIANGINAL AGENTS Isosorbide Dinitrate Isosorbide Dinitrate Oral Tablet 5 MG Tier 1 ANTIANGINAL AGENTS Isosorbide Mononitrate Isosorbide Mononitrate ER Oral Tablet Extended Release 24 Hour 120 MG Tier 1 ANTIANGINAL AGENTS Isosorbide Mononitrate Isosorbide Mononitrate ER Oral Tablet Extended Release 24 Hour 30 MG Tier 1 ANTIANGINAL AGENTS Isosorbide Mononitrate Isosorbide Mononitrate ER Oral Tablet Extended Release 24 Hour 60 MG Tier 1 ANTIANGINAL AGENTS Isosorbide Mononitrate Isosorbide Mononitrate Oral Tablet 10 MG Tier 1 ANTIANGINAL AGENTS Isosorbide Mononitrate Isosorbide Mononitrate Oral Tablet 20 MG Tier 1 DIAGNOSTIC PRODUCTS Isosulfan Blue Isosulfan Blue Subcutaneous Solution 1 % Tier 3 x DIAGNOSTIC PRODUCTS Iopamidol Isovue‐200 Intravenous Solution 41 % Tier 3 x DIAGNOSTIC PRODUCTS Iopamidol Isovue‐250 Intravenous Solution 51 % Tier 3 x DIAGNOSTIC PRODUCTS Iopamidol Isovue‐300 Intravenous Solution 61 % Tier 3 x DIAGNOSTIC PRODUCTS Iopamidol Isovue‐370 Intravenous Solution 76 % Tier 3 x DIAGNOSTIC PRODUCTS Iopamidol Isovue‐M 200 Injection Solution 41 % Tier 3 x CALCIUM CHANNEL BLOCKERS Isradipine Isradipine Oral Capsule 2.5 MG Tier 1 CALCIUM CHANNEL BLOCKERS Isradipine Isradipine Oral Capsule 5 MG Tier 1 OPHTHALMIC AGENTS Timolol Maleate (Ophth) Istalol Ophthalmic Solution 0.5 % Tier 3 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Isoproterenol HCl Isuprel Injection Solution 0.2 MG/ML Tier 3 x ANTIFUNGALS Itraconazole Itraconazole Oral Capsule 100 MG Tier 1 x ANTHELMINTICS Ivermectin Oral Tablet 3 MG Tier 1 HEMATOLOGICAL AGENTS ‐ MISC. Coagulation Factor IX (Recombinant) Ixinity Intravenous Solution Reconstituted 1000 UNIT Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Coagulation Factor IX (Recombinant) Ixinity Intravenous Solution Reconstituted 1500 UNIT Tier 2 x ANTIDOTES Deferasirox Jadenu Oral Tablet 180 MG Tier 2 x ANTIDOTES Deferasirox Jadenu Oral Tablet 360 MG Tier 2 x ANTIDOTES Deferasirox Jadenu Oral Tablet 90 MG Tier 2 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Ruxolitinib Phosphate Jakafi Oral Tablet 10 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Ruxolitinib Phosphate Jakafi Oral Tablet 15 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Ruxolitinib Phosphate Jakafi Oral Tablet 20 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Ruxolitinib Phosphate Jakafi Oral Tablet 25 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Ruxolitinib Phosphate Jakafi Oral Tablet 5 MG Tier 2 x x GENITOURINARY AGENTS ‐ MISCELLANEOUS Dutasteride‐Tamsulosin HCl Jalyn Oral Capsule 0.5‐0.4 MG Tier 3 x ANTICOAGULANTS Warfarin Sodium Jantoven Oral Tablet 1 MG Tier 1 ANTICOAGULANTS Warfarin Sodium Jantoven Oral Tablet 10 MG Tier 1 ANTICOAGULANTS Warfarin Sodium Jantoven Oral Tablet 2 MG Tier 1 ANTICOAGULANTS Warfarin Sodium Jantoven Oral Tablet 2.5 MG Tier 1 ANTICOAGULANTS Warfarin Sodium Jantoven Oral Tablet 3 MG Tier 1 ANTICOAGULANTS Warfarin Sodium Jantoven Oral Tablet 4 MG Tier 1 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ANTICOAGULANTS Warfarin Sodium Jantoven Oral Tablet 5 MG Tier 1 ANTICOAGULANTS Warfarin Sodium Jantoven Oral Tablet 6 MG Tier 1 ANTICOAGULANTS Warfarin Sodium Jantoven Oral Tablet 7.5 MG Tier 1 ANTIDIABETICS Sitagliptin‐Metformin HCl Janumet Oral Tablet 50‐1000 MG Tier 2 x ANTIDIABETICS Sitagliptin‐Metformin HCl Janumet Oral Tablet 50‐500 MG Tier 2 ANTIDIABETICS Sitagliptin‐Metformin HCl Janumet XR Oral Tablet Extended Release 24 Hour 100‐1000 MG Tier 2 x ANTIDIABETICS Sitagliptin‐Metformin HCl Janumet XR Oral Tablet Extended Release 24 Hour 50‐1000 MG Tier 2 x ANTIDIABETICS Sitagliptin‐Metformin HCl Janumet XR Oral Tablet Extended Release 24 Hour 50‐500 MG Tier 2 x ANTIDIABETICS Sitagliptin Phosphate Januvia Oral Tablet 100 MG Tier 2 ANTIDIABETICS Sitagliptin Phosphate Januvia Oral Tablet 25 MG Tier 2 x ANTIDIABETICS Sitagliptin Phosphate Januvia Oral Tablet 50 MG Tier 2 x ANTIDIABETICS Empagliflozin Jardiance Oral Tablet 10 MG Tier 2 x x ANTIDIABETICS Empagliflozin Jardiance Oral Tablet 25 MG Tier 2 x x CONTRACEPTIVES Norethindrone (Contraceptive) Jencycla Oral Tablet 0.35 MG Tier 1 ANTIDIABETICS Linagliptin‐Metformin HCl Jentadueto Oral Tablet 2.5‐1000 MG Tier 3 x ANTIDIABETICS Linagliptin‐Metformin HCl Jentadueto Oral Tablet 2.5‐500 MG Tier 3 x ANTIDIABETICS Linagliptin‐Metformin HCl Jentadueto Oral Tablet 2.5‐850 MG Tier 3 x ESTROGENS Norethindrone Acetate‐Ethinyl Estradiol Jevantique Lo Oral Tablet 0.5‐2.5 MG‐MCG Tier 1 x ESTROGENS Norethindrone Acetate‐Ethinyl Estradiol Jinteli Oral Tablet 1‐5 MG‐MCG Tier 1 x BIOLOGICALS MISC Johnson Grass Johnson Grass Subcutaneous Solution 1:20 Tier 3 x CONTRACEPTIVES Levonorgestrel‐Ethinyl Estradiol (91‐Day) Jolessa Oral Tablet 0.15‐0.03 MG Tier 1 CONTRACEPTIVES Norethindrone (Contraceptive) Jolivette Oral Tablet 0.35 MG Tier 1 CORTICOSTEROIDS Triamcinolone Acetonide & Lidocaine HCl & Ammonia JTT Physicians Combination Kit 40‐1 MG/ML‐% Tier 3 DERMATOLOGICALS Efinaconazole Jublia External Solution 10 % Tier 3 x CONTRACEPTIVES Desogestrel & Ethinyl Estradiol Juleber Oral Tablet 0.15‐30 MG‐MCG Tier 1 CONTRACEPTIVES Norethindrone Acet & Eth Estra Junel 1.5/30 Oral Tablet 1.5‐30 MG‐MCG Tier 1 CONTRACEPTIVES Norethindrone Acet & Eth Estra Junel 1/20 Oral Tablet 1‐20 MG‐MCG Tier 1 CONTRACEPTIVES Norethin Acet & Estrad‐Fe Junel FE 1.5/30 Oral Tablet 1.5‐30 MG‐MCG Tier 1 CONTRACEPTIVES Norethin Acet & Estrad‐Fe Junel FE 1/20 Oral Tablet 1‐20 MG‐MCG Tier 1 CONTRACEPTIVES Norethin Acet & Estrad‐Fe Junel Fe 24 Oral Tablet 1‐20 MG‐MCG(24) Tier 1 CHEMICALS Juniper Tar Juniper Tar Oil Tier 3 ANTIHYPERLIPIDEMICS Lomitapide Mesylate Juxtapid Oral Capsule 10 MG Tier 2 x x ANTIHYPERLIPIDEMICS Lomitapide Mesylate Juxtapid Oral Capsule 20 MG Tier 2 x x ANTIHYPERLIPIDEMICS Lomitapide Mesylate Juxtapid Oral Capsule 30 MG Tier 2 x x ANTIHYPERLIPIDEMICS Lomitapide Mesylate Juxtapid Oral Capsule 40 MG Tier 2 x x ANTIHYPERLIPIDEMICS Lomitapide Mesylate Juxtapid Oral Capsule 5 MG Tier 2 x x ANTIHYPERLIPIDEMICS Lomitapide Mesylate Juxtapid Oral Capsule 60 MG Tier 2 x x DERMATOLOGICALS Ketoprofen‐Baclofen‐Gabapentin‐Lidocaine K.B.G.L in Teroderm External Cream 15‐4‐10‐2 % Tier 3 DERMATOLOGICALS Lidocaine‐Menthol K2K Pain Relieving External Patch 4‐4 % Tier 1 CONTRACEPTIVES Norethindrone & Ethinyl Estradiol‐Fe Kaitlib Fe Oral Tablet Chewable 0.8‐25 MG‐MCG Tier 1 ANTIVIRALS Lopinavir‐Ritonavir Kaletra Oral Solution 400‐100 MG/5ML Tier 2 x ANTIVIRALS Lopinavir‐Ritonavir Kaletra Oral Tablet 100‐25 MG Tier 2 x ANTIVIRALS Lopinavir‐Ritonavir Kaletra Oral Tablet 200‐50 MG Tier 2 x ASSORTED CLASSES Sodium Polystyrene Sulfonate Kalexate Oral Powder Tier 1 RESPIRATORY AGENTS ‐ MISC. Ivacaftor Kalydeco Oral Packet 50 MG Tier 2 x x RESPIRATORY AGENTS ‐ MISC. Ivacaftor Kalydeco Oral Packet 75 MG Tier 2 x x RESPIRATORY AGENTS ‐ MISC. Ivacaftor Kalydeco Oral Tablet 150 MG Tier 2 x x MEDICAL DEVICES AND SUPPLIES Feeding Tubes ‐ Sets Kangaroo 924 Safety Screw Set Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Feeding Tubes ‐ Sets Kangaroo Feed/Irrigation Kit Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Feeding Tubes ‐ Tubing Kangaroo Feeding Tube 12FR/43" Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Feeding Tubes ‐ Tubing Kangaroo Feeding Tube 6FR/20" Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Feeding Tubes ‐ Tubing Kangaroo Feeding Tube 6FR/36" Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Feeding Tubes ‐ Tubing Kangaroo Feeding Tube 8FR/42" Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Feeding Tubes ‐ Tubing Kangaroo Feeding Tube 8FR/43" Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Feeding Tubes ‐ Tubing Kangaroo Gastrostomy Tube Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Feeding Tubes ‐ Sets Kangaroo Proximal Spike Set Miscellaneous Tier 3 ANTIDIARRHEALS Kaolin Kaolin Powder Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Clonidine HCl (ADHD) Kapvay Oral Tablet Extended Release 12 Hour 0.1 MG Tier 3 x x ANTIHISTAMINES Carbinoxamine Maleate Karbinal ER Oral Liquid Extended Release 4 MG/5ML Tier 3 MINERALS & ELECTROLYTES Sodium Fluoride Karidium Oral Solution 0.275 (0.125 F) MG/DROP Tier 1 MOUTH/THROAT/DENTAL AGENTS Sodium Fluoride (Dental) Karigel Dental Gel 1.1 % Tier 1 MOUTH/THROAT/DENTAL AGENTS Sodium Fluoride (Dental) Karigel‐N Dental Gel 1.1 % Tier 1 CONTRACEPTIVES Desogestrel‐Ethinyl Estradiol (Biphasic) Kariva Oral Tablet 0.15‐0.02/0.01 MG (21/5) Tier 1 ASSORTED CLASSES Sodium Polystyrene Sulfonate Kayexalate Oral Powder Tier 3 ANTIDIABETICS Alogliptin‐Metformin HCl Kazano Oral Tablet 12.5‐1000 MG Tier 3 xx ANTIDIABETICS Alogliptin‐Metformin HCl Kazano Oral Tablet 12.5‐500 MG Tier 3 xx HEMATOLOGICAL AGENTS ‐ MISC. Albumin, Human Kedbumin Intravenous Solution 25 % Tier 1 x MINERALS & ELECTROLYTES Potassium Bicarbonate K‐Effervescent Oral Tablet Effervescent 25 MEQ Tier 1 CEPHALOSPORINS Cephalexin Keflex Oral Capsule 250 MG Tier 3 CEPHALOSPORINS Cephalexin Keflex Oral Capsule 500 MG Tier 3 CEPHALOSPORINS Cephalexin Keflex Oral Capsule 750 MG Tier 3 CONTRACEPTIVES Ethynodiol Diacet & Eth Estrad Kelnor 1/35 Oral Tablet 1‐35 MG‐MCG Tier 1 DERMATOLOGICALS Triamcinolone Acetonide (Topical) Kenalog External Aerosol Solution 0.147 MG/GM Tier 3 CORTICOSTEROIDS Triamcinolone Acetonide Kenalog Injection Suspension 10 MG/ML Tier 3 x CORTICOSTEROIDS Triamcinolone Acetonide Kenalog Injection Suspension 40 MG/ML Tier 3 x MINERALS & ELECTROLYTES Sodium Chloride Flush Kendall Sodium Chloride Flush Intravenous Solution 0.9 % Tier 1 x ANTISEPTICS & DISINFECTANTS Povidone‐Iodine & Chlorhexidine Gluconate Kendall Wet Skin Scrub Prep External Kit Tier 3 HEMATOLOGICAL AGENTS ‐ MISC. Cangrelor Tetrasodium Kengreal Intravenous Solution Reconstituted 50 MG Tier 3 x ANTICONVULSANTS Levetiracetam Keppra Oral Solution 100 MG/ML Tier 3 ANTICONVULSANTS Levetiracetam Keppra Oral Tablet 1000 MG Tier 3 ANTICONVULSANTS Levetiracetam Keppra Oral Tablet 250 MG Tier 3 ANTICONVULSANTS Levetiracetam Keppra Oral Tablet 500 MG Tier 3 ANTICONVULSANTS Levetiracetam Keppra Oral Tablet 750 MG Tier 3 ANTICONVULSANTS Levetiracetam Keppra XR Oral Tablet Extended Release 24 Hour 500 MG Tier 3 ANTICONVULSANTS Levetiracetam Keppra XR Oral Tablet Extended Release 24 Hour 750 MG Tier 3 DERMATOLOGICALS Urea Kerafoam 42 External Foam 42 % Tier 3 DERMATOLOGICALS Urea Kerafoam External Foam 30 % Tier 3 DERMATOLOGICALS Urea Keralac External Cream 47 % Tier 3 DERMATOLOGICALS Salicylic Acid Keralyt External Gel 6 % Tier 3 DERMATOLOGICALS Salicylic Acid Keralyt Scalp External Kit 6 % Tier 3 BETA BLOCKERS Betaxolol HCl Kerlone Oral Tablet 10 MG Tier 3 BETA BLOCKERS Betaxolol HCl Kerlone Oral Tablet 20 MG Tier 3 DERMATOLOGICALS Tavaborole Kerydin External Solution 5 % Tier 3 x GENERAL ANESTHETICS HCl Ketamine HCl Injection Solution 100 MG/ML Tier 1 x GENERAL ANESTHETICS Ketamine HCl Ketamine HCl Injection Solution 50 MG/ML Tier 1 x ANTI‐INFECTIVE AGENTS ‐ MISC. Telithromycin Ketek Oral Tablet 300 MG Tier 3 ANTI‐INFECTIVE AGENTS ‐ MISC. Telithromycin Ketek Oral Tablet 400 MG Tier 3 DIAGNOSTIC PRODUCTS Acetone (Urine) Test KetoCare In Vitro Strip Tier 2 DERMATOLOGICALS Ketoconazole (Topical) Ketoconazole External Cream 2 % Tier 1 DERMATOLOGICALS Ketoconazole (Topical) Ketoconazole External Foam 2 % Tier 1 DERMATOLOGICALS Ketoconazole (Topical) Ketoconazole External Shampoo 2 % Tier 1 ANTIFUNGALS Ketoconazole Ketoconazole Oral Tablet 200 MG Tier 1 DERMATOLOGICALS Ketoconazole (Topical) Ketodan External Foam 2 % Tier 1 x DERMATOLOGICALS Ketoconazole & Cleanser Ketodan External Kit 2 % Tier 3 x ANALGESICS ‐ ANTI‐INFLAMMATORY Ketoprofen Ketoprofen ER Oral Capsule Extended Release 24 Hour 200 MG Tier 2 ANALGESICS ‐ ANTI‐INFLAMMATORY Ketoprofen Ketoprofen Oral Capsule 50 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Ketoprofen Ketoprofen Oral Capsule 75 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Ketoprofen Ketoprofen Powder Tier 3 DERMATOLOGICALS Ketorolac Tromethamine (Topical) Ketorolac Tromethamine External Gel 2 % Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Ketorolac Tromethamine Ketorolac Tromethamine Injection Solution 15 MG/ML Tier 1 x ANALGESICS ‐ ANTI‐INFLAMMATORY Ketorolac Tromethamine Ketorolac Tromethamine Injection Solution 30 MG/ML Tier 1 x ANALGESICS ‐ ANTI‐INFLAMMATORY Ketorolac Tromethamine Ketorolac Tromethamine Injection Solution 60 MG/2ML Tier 1 x HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ANALGESICS ‐ ANTI‐INFLAMMATORY Ketorolac Tromethamine Ketorolac Tromethamine Intramuscular Solution 60 MG/2ML Tier 1 x OPHTHALMIC AGENTS Ketorolac Tromethamine (Ophth) Ketorolac Tromethamine Ophthalmic Solution 0.4 % Tier 1 OPHTHALMIC AGENTS Ketorolac Tromethamine (Ophth) Ketorolac Tromethamine Ophthalmic Solution 0.5 % Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Ketorolac Tromethamine Ketorolac Tromethamine Oral Tablet 10 MG Tier 1 x DIAGNOSTIC PRODUCTS Acetone (Urine) Test Ketostix In Vitro Strip Tier 2 OPHTHALMIC AGENTS Ketotifen Fumarate (Ophth) Ketotifen Fumarate Ophthalmic Solution 0.025 % Tier 1 DIURETICS Dichlorphenamide Keveyis Oral Tablet 50 MG Tier 3 ANTIDEPRESSANTS Desvenlafaxine Khedezla Oral Tablet Extended Release 24 Hour 100 MG Tier 3 xx ANTIDEPRESSANTS Desvenlafaxine Khedezla Oral Tablet Extended Release 24 Hour 50 MG Tier 3 xx CONTRACEPTIVES Desogestrel‐Ethinyl Estradiol (Biphasic) Kimidess Oral Tablet 0.15‐0.02/0.01 MG (21/5) Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Anakinra Kineret Subcutaneous Solution Prefilled Syringe 100 MG/0.67ML Tier 2 x MEDICAL DEVICES AND SUPPLIES Lancets Kinney Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Kinney Thin Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Kinray Insulin Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Kinray Insulin Syringe Miscellaneous 31G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Kinray Insulin Syringe Miscellaneous 31G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Kinray Insulin Syringe Miscellaneous 31G X 5/16" 1 ML Tier 2 TOXOIDS Diph‐Tetanus Tox Ad‐Acell Pertussis & Virus, IPV Vac Kinrix Intramuscular Suspension Tier 2 x ASSORTED CLASSES Sodium Polystyrene Sulfonate Kionex Oral Powder Tier 1 ASSORTED CLASSES Sodium Polystyrene Sulfonate Kionex Oral Suspension 15 GM/60ML Tier 1 AMINOGLYCOSIDES Tobramycin Kitabis Pak Inhalation Nebulization Solution 300 MG/5ML Tier 2 x DERMATOLOGICALS Sulfacetamide Sodium (Acne) Klaron External Lotion 10 % Tier 3 ANTICONVULSANTS Clonazepam KlonoPIN Oral Tablet 0.5 MG Tier 3 ANTICONVULSANTS Clonazepam KlonoPIN Oral Tablet 1 MG Tier 3 ANTICONVULSANTS Clonazepam KlonoPIN Oral Tablet 2 MG Tier 3 MINERALS & ELECTROLYTES Potassium Chloride Klor‐Con 10 Oral Tablet Extended Release 10 MEQ Tier 1 MINERALS & ELECTROLYTES Potassium Chloride Microencapsulated Crystals CR Klor‐Con M10 Oral Tablet Extended Release 10 MEQ Tier 1 MINERALS & ELECTROLYTES Potassium Chloride Microencapsulated Crystals CR Klor‐Con M15 Oral Tablet Extended Release 15 MEQ Tier 3 MINERALS & ELECTROLYTES Potassium Chloride Microencapsulated Crystals CR Klor‐Con M20 Oral Tablet Extended Release 20 MEQ Tier 1 MINERALS & ELECTROLYTES Potassium Chloride Klor‐Con Oral Packet 20 MEQ Tier 1 MINERALS & ELECTROLYTES Potassium Chloride Klor‐Con Oral Packet 25 MEQ Tier 2 MINERALS & ELECTROLYTES Potassium Chloride Klor‐Con Oral Tablet Extended Release 8 MEQ Tier 1 MINERALS & ELECTROLYTES Potassium Chloride Klor‐Con Sprinkle Oral Capsule Extended Release 10 MEQ Tier 1 MINERALS & ELECTROLYTES Potassium Chloride Klor‐Con Sprinkle Oral Capsule Extended Release 8 MEQ Tier 1 MINERALS & ELECTROLYTES Potassium Bicarbonate Klor‐Con/EF Oral Tablet Effervescent 25 MEQ Tier 1 MEDICAL DEVICES AND SUPPLIES Insulin Syringes (Disposable) Kmart Valu Insulin Syringe 29G Miscellaneous U‐100 0.5 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringes (Disposable) Kmart Valu Insulin Syringe 29G Miscellaneous U‐100 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringes (Disposable) Kmart Valu Insulin Syringe 30G Miscellaneous U‐100 0.3 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringes (Disposable) Kmart Valu Insulin Syringe 30G Miscellaneous U‐100 0.5 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringes (Disposable) Kmart Valu Insulin Syringe 30G Miscellaneous U‐100 1 ML Tier 2 HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor (Human) Koate‐DVI Intravenous Solution Reconstituted 1000 UNIT Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor (Human) Koate‐DVI Intravenous Solution Reconstituted 500 UNIT Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor (Recombinant) Kogenate FS Intravenous Kit 1000 UNIT Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor (Recombinant) Kogenate FS Intravenous Kit 2000 UNIT Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor (Recombinant) Kogenate FS Intravenous Kit 250 UNIT Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor (Recombinant) Kogenate FS Intravenous Kit 3000 UNIT Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor (Recombinant) Kogenate FS Intravenous Kit 500 UNIT Tier 2 x CHEMICALS Kojic Acid Kojic Acid Powder Tier 3 ANTIDIABETICS Saxagliptin‐Metformin HCl Kombiglyze XR Oral Tablet Extended Release 24 Hour 2.5‐1000 MG Tier 2 xx ANTIDIABETICS Saxagliptin‐Metformin HCl Kombiglyze XR Oral Tablet Extended Release 24 Hour 5‐1000 MG Tier 2 xx ANTIDIABETICS Saxagliptin‐Metformin HCl Kombiglyze XR Oral Tablet Extended Release 24 Hour 5‐500 MG Tier 2 xx ANTIDIABETICS Mifepristone (Hyperglycemia) Korlym Oral Tablet 300 MG Tier 2 x x GENITOURINARY AGENTS ‐ MISCELLANEOUS Potassium & Sodium Acid Phosphates K‐Phos No 2 Oral Tablet 305‐700 MG Tier 3 MINERALS & ELECTROLYTES Potassium Phosphate Monobasic K‐Phos Oral Tablet 500 MG Tier 3 MINERALS & ELECTROLYTES Pot Phosphate Monobasic w/ Sod Phosphate Dibasic & Monobasic K‐Phos‐Neutral Oral Tablet 155‐852‐130 MG Tier 3 MINERALS & ELECTROLYTES Potassium Bicarbonate K‐Prime Oral Tablet Effervescent 25 MEQ Tier 1 DIAGNOSTIC PRODUCTS Glucose Blood Kroger Blood Glucose Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Kroger Insulin Syringe Miscellaneous 29G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Kroger Insulin Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Kroger Insulin Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Kroger Insulin Syringe Miscellaneous 30G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Kroger Insulin Syringe Miscellaneous 30G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Kroger Insulin Syringe Miscellaneous 30G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Kroger Insulin Syringe Miscellaneous 31G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Kroger Insulin Syringe Miscellaneous 31G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Kroger Insulin Syringe Miscellaneous 31G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Kroger Lancets 21G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Kroger Lancets Micro Thin 33G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Kroger Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Kroger Lancets Super Thin Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Kroger Lancets Thin 26G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Kroger Lancets Thin Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Kroger Lancets UltraThin 30G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancet Devices Kroger Lancing Device Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Kroger Pen Needles Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Kroger Pen Needles Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Kroger Pen Needles Miscellaneous 31G X 8 MM Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood Kroger Premium Glucose Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Kroger Test In Vitro Strip Tier 3 MINERALS & ELECTROLYTES Potassium Chloride K‐Sol Oral Solution 20 MEQ/15ML (10%) Tier 1 MINERALS & ELECTROLYTES Potassium Chloride K‐Sol Oral Solution 40 MEQ/15ML (20%) Tier 1 MINERALS & ELECTROLYTES Potassium Chloride K‐Tab Oral Tablet Extended Release 10 MEQ Tier 3 MINERALS & ELECTROLYTES Potassium Chloride K‐Tab Oral Tablet Extended Release 20 MEQ Tier 2 MINERALS & ELECTROLYTES Potassium Chloride K‐Tab Oral Tablet Extended Release 8 MEQ Tier 3 HEMATOPOIETIC AGENTS Fe Fum‐Iron Polysacch Complex‐FA‐B Complex‐C‐Zn‐Mn‐Cu K‐Tan Plus Oral Capsule 162‐115.2‐1 MG Tier 1 CONTRACEPTIVES Levonorgestrel & Eth Estradiol Kurvelo Oral Tablet 0.15‐30 MG‐MCG Tier 1 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Sapropterin Dihydrochloride Kuvan Oral Packet 100 MG Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Sapropterin Dihydrochloride Kuvan Oral Packet 500 MG Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Sapropterin Dihydrochloride Kuvan Oral Tablet Soluble 100 MG Tier 2 x MINERALS & ELECTROLYTES Potassium Bicarbonate K‐Vescent Oral Tablet Effervescent 25 MEQ Tier 1 ANTIHYPERLIPIDEMICS Mipomersen Sodium Kynamro Subcutaneous Solution Prefilled Syringe 200 MG/ML Tier 2 x x BETA BLOCKERS Labetalol HCl Labetalol HCl Intravenous Solution 5 MG/ML Tier 1 x BETA BLOCKERS Labetalol HCl Labetalol HCl Oral Tablet 100 MG Tier 1 BETA BLOCKERS Labetalol HCl Labetalol HCl Oral Tablet 200 MG Tier 1 BETA BLOCKERS Labetalol HCl Labetalol HCl Oral Tablet 300 MG Tier 1 DERMATOLOGICALS Lactic Acid (Ammonium Lactate) Lac‐Hydrin External Cream 12 % Tier 3 DERMATOLOGICALS Lactic Acid (Ammonium Lactate) Lac‐Hydrin External Lotion 12 % Tier 3 OPHTHALMIC AGENTS Artificial Tear Insert Lacrisert Ophthalmic Insert 5 MG Tier 3 MINERALS & ELECTROLYTES Lactated Ringer's Lactated Ringers Intravenous Solution Tier 1 x ASSORTED CLASSES Lactated Ringer's (Irrigation) Lactated Ringers Irrigation Solution Tier 1 DERMATOLOGICALS Lactic Acid w/ Vitamin E Lactic Acid E External Cream 10‐3500 %‐UNT/30GM Tier 1 DERMATOLOGICALS Lactic Acid (Ammonium Lactate) Lactic Acid External Lotion 10 % Tier 1 PHARMACEUTICAL ADJUVANTS Lactose Lactose Anhydrous Powder Tier 3 PHARMACEUTICAL ADJUVANTS Lactose Monohydrate Lactose Monohydrate Powder Tier 3 LAXATIVES Lactulose Lactulose Oral Solution 10 GM/15ML Tier 1 LAXATIVES Lactulose Lactulose Oral Solution 20 GM/30ML Tier 1 NUTRIENTS L‐Alanine Powder Tier 3 ANTICONVULSANTS Lamotrigine LaMICtal ODT Oral Kit 25 & 50 & 100 MG Tier 2 x ANTICONVULSANTS Lamotrigine LaMICtal ODT Oral Kit 25 (21)‐50 (7) MG Tier 2 x ANTICONVULSANTS Lamotrigine LaMICtal ODT Oral Kit 50 (42)‐100(14) MG Tier 2 x ANTICONVULSANTS Lamotrigine LaMICtal ODT Oral Tablet Dispersible 100 MG Tier 3 x ANTICONVULSANTS Lamotrigine LaMICtal ODT Oral Tablet Dispersible 200 MG Tier 3 x HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ANTICONVULSANTS Lamotrigine LaMICtal ODT Oral Tablet Dispersible 25 MG Tier 3 x ANTICONVULSANTS Lamotrigine LaMICtal ODT Oral Tablet Dispersible 50 MG Tier 3 x ANTICONVULSANTS Lamotrigine LaMICtal Oral Tablet 100 MG Tier 2 x ANTICONVULSANTS Lamotrigine LaMICtal Oral Tablet 150 MG Tier 2 x ANTICONVULSANTS Lamotrigine LaMICtal Oral Tablet 200 MG Tier 2 x ANTICONVULSANTS Lamotrigine LaMICtal Oral Tablet 25 MG Tier 2 x ANTICONVULSANTS Lamotrigine LaMICtal Oral Tablet Chewable 25 MG Tier 2 x ANTICONVULSANTS Lamotrigine LaMICtal Oral Tablet Chewable 5 MG Tier 2 x ANTICONVULSANTS Lamotrigine LaMICtal Starter Oral Kit 25 (35) MG Tier 2 x ANTICONVULSANTS Lamotrigine LaMICtal Starter Oral Kit 25 (42)‐100 (7) MG Tier 2 x ANTICONVULSANTS Lamotrigine LaMICtal Starter Oral Kit 25 (84)‐100(14) MG Tier 2 x ANTICONVULSANTS Lamotrigine LaMICtal XR Oral Kit 25 & 50 & 100 MG Tier 2 x ANTICONVULSANTS Lamotrigine LaMICtal XR Oral Kit 25 (21)‐50 (7) MG Tier 2 x ANTICONVULSANTS Lamotrigine LaMICtal XR Oral Kit 50 & 100 & 200 MG Tier 2 x ANTICONVULSANTS Lamotrigine LaMICtal XR Oral Tablet Extended Release 24 Hour 100 MG Tier 3 x ANTICONVULSANTS Lamotrigine LaMICtal XR Oral Tablet Extended Release 24 Hour 200 MG Tier 3 x ANTICONVULSANTS Lamotrigine LaMICtal XR Oral Tablet Extended Release 24 Hour 25 MG Tier 3 x ANTICONVULSANTS Lamotrigine LaMICtal XR Oral Tablet Extended Release 24 Hour 250 MG Tier 3 x ANTICONVULSANTS Lamotrigine LaMICtal XR Oral Tablet Extended Release 24 Hour 300 MG Tier 3 x ANTICONVULSANTS Lamotrigine LaMICtal XR Oral Tablet Extended Release 24 Hour 50 MG Tier 3 x ANTIFUNGALS Terbinafine HCl LamISIL Oral Packet 125 MG Tier 3 ANTIFUNGALS Terbinafine HCl LamISIL Oral Packet 187.5 MG Tier 3 ANTIFUNGALS Terbinafine HCl LamISIL Oral Tablet 250 MG Tier 3 DERMATOLOGICALS Terbinafine HCl (Topical) LamISIL Spray External Solution 1 % Tier 3 ANTIVIRALS Lamivudine LamiVUDine Oral Solution 10 MG/ML Tier 1 x ANTIVIRALS Lamivudine (HBV) LamiVUDine Oral Tablet 100 MG Tier 1 ANTIVIRALS Lamivudine LamiVUDine Oral Tablet 150 MG Tier 1 x ANTIVIRALS Lamivudine LamiVUDine Oral Tablet 300 MG Tier 1 x ANTIVIRALS Lamivudine‐Zidovudine Lamivudine‐Zidovudine Oral Tablet 150‐300 MG Tier 1 x ANTICONVULSANTS Lamotrigine LamoTRIgine ER Oral Tablet Extended Release 24 Hour 100 MG Tier 1 x ANTICONVULSANTS Lamotrigine LamoTRIgine ER Oral Tablet Extended Release 24 Hour 200 MG Tier 1 x ANTICONVULSANTS Lamotrigine LamoTRIgine ER Oral Tablet Extended Release 24 Hour 25 MG Tier 1 x ANTICONVULSANTS Lamotrigine LamoTRIgine ER Oral Tablet Extended Release 24 Hour 250 MG Tier 1 x ANTICONVULSANTS Lamotrigine LamoTRIgine ER Oral Tablet Extended Release 24 Hour 300 MG Tier 1 x ANTICONVULSANTS Lamotrigine LamoTRIgine ER Oral Tablet Extended Release 24 Hour 50 MG Tier 1 x ANTICONVULSANTS Lamotrigine LamoTRIgine Oral Kit 25 & 50 & 100 MG Tier 1 x ANTICONVULSANTS Lamotrigine LamoTRIgine Oral Kit 25 (21)‐50 (7) MG Tier 1 x ANTICONVULSANTS Lamotrigine LamoTRIgine Oral Kit 50 (42)‐100(14) MG Tier 1 x ANTICONVULSANTS Lamotrigine LamoTRIgine Oral Tablet 100 MG Tier 1 x ANTICONVULSANTS Lamotrigine LamoTRIgine Oral Tablet 150 MG Tier 1 x ANTICONVULSANTS Lamotrigine LamoTRIgine Oral Tablet 200 MG Tier 1 x ANTICONVULSANTS Lamotrigine LamoTRIgine Oral Tablet 25 MG Tier 1 x ANTICONVULSANTS Lamotrigine LamoTRIgine Oral Tablet Chewable 25 MG Tier 1 x ANTICONVULSANTS Lamotrigine LamoTRIgine Oral Tablet Chewable 5 MG Tier 1 x ANTICONVULSANTS Lamotrigine LamoTRIgine Oral Tablet Dispersible 100 MG Tier 1 x ANTICONVULSANTS Lamotrigine LamoTRIgine Oral Tablet Dispersible 200 MG Tier 1 x ANTICONVULSANTS Lamotrigine LamoTRIgine Oral Tablet Dispersible 25 MG Tier 1 x ANTICONVULSANTS Lamotrigine LamoTRIgine Oral Tablet Dispersible 50 MG Tier 1 x MEDICAL DEVICES AND SUPPLIES Lancets Lancets 28G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Lancets 30G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Lancets Micro Thin 33G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Lancets Super Thin 28G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Lancets Thin Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Lancets Ultra Fine Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Lancets Ultra Thin 30G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Lancets Ultra Thin Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancet Devices Lancing Device Miscellaneous Tier 2 PHARMACEUTICAL ADJUVANTS Lanolin Anhydrous Lanolin Anhydrous External Ointment Tier 3 PHARMACEUTICAL ADJUVANTS Lanolin Lanolin External Ointment Tier 1 CARDIOTONICS Digoxin Lanoxin Oral Tablet 125 MCG Tier 2 CARDIOTONICS Digoxin Lanoxin Oral Tablet 187.5 MCG Tier 2 CARDIOTONICS Digoxin Lanoxin Oral Tablet 250 MCG Tier 2 CARDIOTONICS Digoxin Lanoxin Oral Tablet 62.5 MCG Tier 2 ULCER DRUGS Lansoprazole Lansoprazole Oral Capsule Delayed Release 15 MG Tier 1 x ULCER DRUGS Lansoprazole Lansoprazole Oral Capsule Delayed Release 30 MG Tier 1 x ANTIDIABETICS Insulin Glargine Lantus SoloStar Subcutaneous Solution Pen‐injector 100 UNIT/ML Tier 2 ANTIDIABETICS Insulin Glargine Lantus Subcutaneous Solution 100 UNIT/ML Tier 2 NUTRIENTS L‐Arginine Powder Tier 3 CONTRACEPTIVES Norethindrone Acet & Eth Estra Larin 1.5/30 Oral Tablet 1.5‐30 MG‐MCG Tier 1 CONTRACEPTIVES Norethindrone Acet & Eth Estra Larin 1/20 Oral Tablet 1‐20 MG‐MCG Tier 1 CONTRACEPTIVES Norethin Acet & Estrad‐Fe Larin 24 FE Oral Tablet 1‐20 MG‐MCG(24) Tier 1 CONTRACEPTIVES Norethin Acet & Estrad‐Fe Larin Fe 1.5/30 Oral Tablet 1.5‐30 MG‐MCG Tier 1 CONTRACEPTIVES Norethin Acet & Estrad‐Fe Larin Fe 1/20 Oral Tablet 1‐20 MG‐MCG Tier 1 DIURETICS Furosemide Lasix Oral Tablet 20 MG Tier 3 DIURETICS Furosemide Lasix Oral Tablet 40 MG Tier 3 DIURETICS Furosemide Lasix Oral Tablet 80 MG Tier 3 OPHTHALMIC AGENTS Alcaftadine Lastacaft Ophthalmic Solution 0.25 % Tier 3 OPHTHALMIC AGENTS Latanoprost Latanoprost Ophthalmic Solution 0.005 % Tier 1 DERMATOLOGICALS Bimatoprost (Topical) Latisse External Solution 0.03 % Tier 3 DERMATOLOGICALS Urea in Lactic Acid‐Salicylic Acid Vehicle Latrix External Suspension 50 % Tier 1 DERMATOLOGICALS Urea in Zinc Undecylenate‐Lactic Acid Vehicle Latrix XM External Emulsion 45 % Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Lurasidone HCl Latuda Oral Tablet 120 MG Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Lurasidone HCl Latuda Oral Tablet 20 MG Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Lurasidone HCl Latuda Oral Tablet 40 MG Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Lurasidone HCl Latuda Oral Tablet 60 MG Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Lurasidone HCl Latuda Oral Tablet 80 MG Tier 3 xx DERMATOLOGICALS Wound Cleansers Lavare Wound Wash External Gel Tier 3 CONTRACEPTIVES Norethindrone & Ethinyl Estradiol‐Fe Layolis FE Oral Tablet Chewable 0.8‐25 MG‐MCG Tier 1 ANALGESICS ‐ OPIOID Fentanyl Citrate Lazanda Nasal Solution 100 MCG/ACT Tier 3 x x ANALGESICS ‐ OPIOID Fentanyl Citrate Lazanda Nasal Solution 400 MCG/ACT Tier 3 x x NUTRIENTS HCl L‐Cysteine HCl Intravenous Solution 50 MG/ML Tier 1 x DERMATOLOGICALS Lidocaine HCl LDO Plus External Gel 4 % Tier 3 x MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Leader Insulin Syringe Miscellaneous 28G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Leader Insulin Syringe Miscellaneous 28G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Leader Insulin Syringe Miscellaneous 29G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Leader Insulin Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Leader Insulin Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Leader Insulin Syringe Miscellaneous 30G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Leader Insulin Syringe Miscellaneous 30G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Leader Insulin Syringe Miscellaneous 30G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Leader Insulin Syringe Miscellaneous 31G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Leader Insulin Syringe Miscellaneous 31G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Leader Insulin Syringe Miscellaneous 31G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Leader Unifine Pentips Miscellaneous 31G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Leader Unifine Pentips Miscellaneous 32G X 4 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Leader Unifine Pentips Plus Miscellaneous 31G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Leader Unifine Pentips Plus Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Leader Unifine Pentips Plus Miscellaneous 32G X 4 MM Tier 2 NUTRIENTS Lecithin Lecithin Granules Tier 3 NUTRIENTS Lecithin Lecithin Oral Granules Tier 3 CONTRACEPTIVES Norethindrone‐Eth Estradiol (Triphasic) Leena Oral Tablet 0.5/1/0.5‐35 MG‐MCG Tier 1 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ANALGESICS ‐ ANTI‐INFLAMMATORY Leflunomide Leflunomide Oral Tablet 10 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Leflunomide Leflunomide Oral Tablet 20 MG Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Lenvatinib Mesylate Lenvima 10 MG Daily Dose Oral Capsule Therapy Pack 10 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Lenvatinib Mesylate Lenvima 14 MG Daily Dose Oral Capsule Therapy Pack 10 & 4 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Lenvatinib Mesylate Lenvima 20 MG Daily Dose Oral Capsule Therapy Pack 10 (2) MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Lenvatinib Mesylate Lenvima 24 MG Daily Dose Oral Capsule Therapy Pack 10 (2) & 4 MG Tier 2 x x DERMATOLOGICALS Lidocaine‐Menthol LenzaPatch External Patch 4‐1 % Tier 3 ANTIHYPERLIPIDEMICS Fluvastatin Sodium Lescol Oral Capsule 20 MG Tier 3 x ANTIHYPERLIPIDEMICS Fluvastatin Sodium Lescol XL Oral Tablet Extended Release 24 Hour 80 MG Tier 3 x CONTRACEPTIVES Levonorgestrel & Eth Estradiol Lessina Oral Tablet 0.1‐20 MG‐MCG Tier 1 CARDIOVASCULAR AGENTS ‐ MISC. Ambrisentan Letairis Oral Tablet 10 MG Tier 2 x x CARDIOVASCULAR AGENTS ‐ MISC. Ambrisentan Letairis Oral Tablet 5 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Letrozole Letrozole Oral Tablet 2.5 MG Tier 1 LOCAL ANESTHETICS‐Parenteral Lidocaine & Tetracaine w/ Epinephrine LETS Kit Tier 3 NUTRIENTS Leucine Powder Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Leucovorin Calcium Leucovorin Calcium Injection Solution Reconstituted 100 MG Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Leucovorin Calcium Leucovorin Calcium Injection Solution Reconstituted 200 MG Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Leucovorin Calcium Leucovorin Calcium Injection Solution Reconstituted 350 MG Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Leucovorin Calcium Leucovorin Calcium Injection Solution Reconstituted 50 MG Tier 3 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Leucovorin Calcium Leucovorin Calcium Oral Tablet 10 MG Tier 2 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Leucovorin Calcium Leucovorin Calcium Oral Tablet 15 MG Tier 2 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Leucovorin Calcium Leucovorin Calcium Oral Tablet 25 MG Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Leucovorin Calcium Leucovorin Calcium Oral Tablet 5 MG Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Chlorambucil Leukeran Oral Tablet 2 MG Tier 2 x HEMATOPOIETIC AGENTS Sargramostim Leukine Injection Solution 500 MCG/ML Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Leuprolide Acetate Leuprolide Acetate Injection Kit 1 MG/0.2ML Tier 1 x ANALGESICS ‐ NonNarcotic Aspirin‐APAP‐Salicyl‐Caff Levacet Oral Tablet 500‐250‐150 MG Tier 3 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Levalbuterol HCl Levalbuterol HCl Inhalation Nebulization Solution 0.31 MG/3ML Tier 1 xx ANTIASTHMATIC AND BRONCHODILATOR AGENTS Levalbuterol HCl Levalbuterol HCl Inhalation Nebulization Solution 0.63 MG/3ML Tier 1 xx ANTIASTHMATIC AND BRONCHODILATOR AGENTS Levalbuterol HCl Levalbuterol HCl Inhalation Nebulization Solution 1.25 MG/0.5ML Tier 1 xx ANTIASTHMATIC AND BRONCHODILATOR AGENTS Levalbuterol HCl Levalbuterol HCl Inhalation Nebulization Solution 1.25 MG/3ML Tier 1 xx ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Levamisole HCl Levamisole HCl Powder Tier 3 FLUOROQUINOLONES Levofloxacin Levaquin Oral Tablet 250 MG Tier 3 FLUOROQUINOLONES Levofloxacin Levaquin Oral Tablet 500 MG Tier 3 FLUOROQUINOLONES Levofloxacin Levaquin Oral Tablet 750 MG Tier 3 DERMATOLOGICALS Capsaicin‐Menthol Levatio External Patch 0.03‐5 % Tier 3 BETA BLOCKERS Penbutolol Sulfate Levatol Oral Tablet 20 MG Tier 3 ULCER DRUGS Hyoscyamine Sulfate Levbid Oral Tablet Extended Release 12 Hour 0.375 MG Tier 3 ANTIDIABETICS Insulin Detemir Levemir FlexTouch Subcutaneous Solution Pen‐injector 100 UNIT/ML Tier 2 x ANTIDIABETICS Insulin Detemir Levemir Subcutaneous Solution 100 UNIT/ML Tier 2 x ANTICONVULSANTS Levetiracetam LevETIRAcetam ER Oral Tablet Extended Release 24 Hour 500 MG Tier 1 ANTICONVULSANTS Levetiracetam LevETIRAcetam ER Oral Tablet Extended Release 24 Hour 750 MG Tier 1 ANTICONVULSANTS Levetiracetam in Sodium Chloride Levetiracetam in NaCl Intravenous Solution 1000 MG/100ML Tier 3 x ANTICONVULSANTS Levetiracetam in Sodium Chloride Levetiracetam in NaCl Intravenous Solution 1500 MG/100ML Tier 3 x ANTICONVULSANTS Levetiracetam in Sodium Chloride Levetiracetam in NaCl Intravenous Solution 500 MG/100ML Tier 3 x ANTICONVULSANTS Levetiracetam LevETIRAcetam Intravenous Solution 500 MG/5ML Tier 1 x ANTICONVULSANTS Levetiracetam LevETIRAcetam Oral Solution 100 MG/ML Tier 1 ANTICONVULSANTS Levetiracetam LevETIRAcetam Oral Tablet 1000 MG Tier 1 ANTICONVULSANTS Levetiracetam LevETIRAcetam Oral Tablet 250 MG Tier 1 ANTICONVULSANTS Levetiracetam LevETIRAcetam Oral Tablet 500 MG Tier 1 ANTICONVULSANTS Levetiracetam LevETIRAcetam Oral Tablet 750 MG Tier 1 CARDIOVASCULAR AGENTS ‐ MISC. Vardenafil HCl Levitra Oral Tablet 10 MG Tier 3 x x CARDIOVASCULAR AGENTS ‐ MISC. Vardenafil HCl Levitra Oral Tablet 2.5 MG Tier 3 x x CARDIOVASCULAR AGENTS ‐ MISC. Vardenafil HCl Levitra Oral Tablet 20 MG Tier 3 x x CARDIOVASCULAR AGENTS ‐ MISC. Vardenafil HCl Levitra Oral Tablet 5 MG Tier 3 x x OPHTHALMIC AGENTS Levobunolol HCl Levobunolol HCl Ophthalmic Solution 0.25 % Tier 3 OPHTHALMIC AGENTS Levobunolol HCl Levobunolol HCl Ophthalmic Solution 0.5 % Tier 1 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Levocarnitine (Metabolic Modifiers) LevOCARNitine Intravenous Solution 200 MG/ML Tier 1 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Levocarnitine (Metabolic Modifiers) LevOCARNitine Oral Solution 1 GM/10ML Tier 1 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Levocarnitine (Metabolic Modifiers) LevOCARNitine Oral Tablet 330 MG Tier 1 ANTIHISTAMINES Levocetirizine Dihydrochloride Levocetirizine Dihydrochloride Oral Solution 2.5 MG/5ML Tier 1 ANTIHISTAMINES Levocetirizine Dihydrochloride Levocetirizine Dihydrochloride Oral Tablet 5 MG Tier 1 ANTIPARKINSON AGENTS Levodopa Levodopa Powder Tier 3 CHEMICALS Levofloxacin Hemihydrate Levofloxacin Hemihydrate Powder Tier 3 FLUOROQUINOLONES Levofloxacin Levofloxacin Intravenous Solution 25 MG/ML Tier 1 x OPHTHALMIC AGENTS Levofloxacin (Ophth) Levofloxacin Ophthalmic Solution 0.5 % Tier 1 FLUOROQUINOLONES Levofloxacin Levofloxacin Oral Solution 25 MG/ML Tier 1 FLUOROQUINOLONES Levofloxacin Levofloxacin Oral Tablet 250 MG Tier 1 FLUOROQUINOLONES Levofloxacin Levofloxacin Oral Tablet 500 MG Tier 1 FLUOROQUINOLONES Levofloxacin Levofloxacin Oral Tablet 750 MG Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Levoleucovorin Calcium Levoleucovorin Calcium Intravenous Solution 175 MG/17.5ML Tier 1 x MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐L Methylfolate‐FA‐DHA Levomefolate DHA Oral Capsule 27‐1.13‐0.4 MG Tier 3 CONTRACEPTIVES Levonorgestrel‐Eth Estradiol (Triphasic) Levonest Oral Tablet Tier 1 CONTRACEPTIVES Levonorgestrel‐Ethinyl Estradiol (91‐Day) Levonorgest‐Eth Estrad 91‐Day Oral Tablet 0.1‐0.02 & 0.01 MG Tier 1 CONTRACEPTIVES Levonorgestrel‐Ethinyl Estradiol (91‐Day) Levonorgest‐Eth Estrad 91‐Day Oral Tablet 0.15‐0.03 &0.01 MG Tier 1 CONTRACEPTIVES Levonorgestrel‐Ethinyl Estradiol (91‐Day) Levonorgest‐Eth Estrad 91‐Day Oral Tablet 0.15‐0.03 MG Tier 1 CONTRACEPTIVES Levonorgestrel (Emergency OC) Levonorgestrel Oral Tablet 1.5 MG Tier 1 CONTRACEPTIVES Levonorgestrel & Eth Estradiol Levonorgestrel‐Ethinyl Estrad Oral Tablet 0.1‐20 MG‐MCG Tier 1 CONTRACEPTIVES Levonorgestrel & Eth Estradiol Levonorgestrel‐Ethinyl Estrad Oral Tablet 0.15‐30 MG‐MCG Tier 1 CONTRACEPTIVES Levonorgestrel‐Ethinyl Estradiol (Continuous) Levonorgestrel‐Ethinyl Estrad Oral Tablet 90‐20 MCG Tier 1 CONTRACEPTIVES Levonorgestrel‐Eth Estradiol (Triphasic) Levonorg‐Eth Estrad Triphasic Oral Tablet Tier 1 VASOPRESSORS Bitartrate Levophed Intravenous Solution 1 MG/ML Tier 3 x CONTRACEPTIVES Levonorgestrel & Eth Estradiol Levora 0.15/30 (28) Oral Tablet 0.15‐30 MG‐MCG Tier 1 ANALGESICS ‐ OPIOID Tartrate Levorphanol Tartrate Oral Tablet 2 MG Tier 3 THYROID AGENTS Levothyroxine Sodium Levo‐T Oral Tablet 100 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Levo‐T Oral Tablet 112 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Levo‐T Oral Tablet 125 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Levo‐T Oral Tablet 137 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Levo‐T Oral Tablet 150 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Levo‐T Oral Tablet 175 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Levo‐T Oral Tablet 200 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Levo‐T Oral Tablet 25 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Levo‐T Oral Tablet 300 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Levo‐T Oral Tablet 50 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Levo‐T Oral Tablet 75 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Levo‐T Oral Tablet 88 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Levothyroxine Sodium Intravenous Solution Reconstituted 100 MCG Tier 3 x THYROID AGENTS Levothyroxine Sodium Levothyroxine Sodium Oral Tablet 100 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Levothyroxine Sodium Oral Tablet 112 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Levothyroxine Sodium Oral Tablet 125 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Levothyroxine Sodium Oral Tablet 137 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Levothyroxine Sodium Oral Tablet 150 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Levothyroxine Sodium Oral Tablet 175 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Levothyroxine Sodium Oral Tablet 200 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Levothyroxine Sodium Oral Tablet 25 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Levothyroxine Sodium Oral Tablet 300 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Levothyroxine Sodium Oral Tablet 50 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Levothyroxine Sodium Oral Tablet 75 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Levothyroxine Sodium Oral Tablet 88 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Levoxyl Oral Tablet 100 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Levoxyl Oral Tablet 112 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Levoxyl Oral Tablet 125 MCG Tier 1 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

THYROID AGENTS Levothyroxine Sodium Levoxyl Oral Tablet 137 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Levoxyl Oral Tablet 150 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Levoxyl Oral Tablet 175 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Levoxyl Oral Tablet 200 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Levoxyl Oral Tablet 25 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Levoxyl Oral Tablet 50 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Levoxyl Oral Tablet 75 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Levoxyl Oral Tablet 88 MCG Tier 1 ULCER DRUGS Hyoscyamine Sulfate Levsin Oral Tablet 0.125 MG Tier 3 ULCER DRUGS Hyoscyamine Sulfate Levsin/SL Sublingual Tablet Sublingual 0.125 MG Tier 3 DERMATOLOGICALS Aminolevulinic Acid HCl Levulan Kerastick External Solution Reconstituted 20 % Tier 3 ANTIDEPRESSANTS Escitalopram Oxalate Lexapro Oral Solution 5 MG/5ML Tier 3 x ANTIDEPRESSANTS Escitalopram Oxalate Lexapro Oral Tablet 10 MG Tier 3 x ANTIDEPRESSANTS Escitalopram Oxalate Lexapro Oral Tablet 20 MG Tier 3 x ANTIDEPRESSANTS Escitalopram Oxalate Lexapro Oral Tablet 5 MG Tier 3 x ANTIVIRALS Fosamprenavir Calcium Lexiva Oral Suspension 50 MG/ML Tier 2 x ANTIVIRALS Fosamprenavir Calcium Lexiva Oral Tablet 700 MG Tier 2 x COUGH/COLD/ALLERGY Chlorpheniramine w/ Codeine Lexuss 210 Oral Liquid 2‐10 MG/5ML Tier 3 NUTRIENTS L‐Glutamic Acid Powder Tier 3 NUTRIENTS L‐Glutamine Powder Tier 3 NUTRIENTS HCl L‐Histidine Monohydrochloride Powder Tier 3 NUTRIENTS Histidine L‐Histidine Powder Tier 3 GASTROINTESTINAL AGENTS ‐ MISC. Mesalamine Lialda Oral Tablet Delayed Release 1.2 GM Tier 2 MEDICAL DEVICES AND SUPPLIES Blood Glucose Calibration Liberty Glucose Control In Vitro Liquid Normal Tier 2 MEDICAL DEVICES AND SUPPLIES Blood Glucose Calibration Liberty Glucose Control In Vitro Solution Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Liberty Medical Lancets Miscellaneous Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood Liberty Next Generation Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Liberty Test In Vitro Strip Tier 2 ANORECTAL AGENTS Lidocaine‐Hydrocortisone Acetate (Rectal) LidaZone HC Rectal Cream 3‐0.5 % Tier 1 DERMATOLOGICALS Lidocaine‐Menthol Lidenza External Patch 4‐1 % Tier 1 DERMATOLOGICALS Lidocaine Lidocaine External Ointment 5 % Tier 1 x DERMATOLOGICALS Lidocaine Lidocaine External Patch 5 % Tier 1 x ANTIARRHYTHMICS Lidocaine HCl (Cardiac) Lidocaine HCl (Cardiac) Intravenous Solution 10 MG/ML Tier 3 x ANTIARRHYTHMICS Lidocaine HCl (Cardiac) Lidocaine HCl (Cardiac) Intravenous Solution 20 MG/ML Tier 1 x LOCAL ANESTHETICS‐Parenteral Lidocaine HCl (Local Anesth.) Lidocaine HCl (PF) Injection Solution 1 % Tier 1 x LOCAL ANESTHETICS‐Parenteral Lidocaine HCl (Local Anesth.) Lidocaine HCl (PF) Injection Solution 2 % Tier 1 x DERMATOLOGICALS Lidocaine HCl Lidocaine HCl External Cream 3 % Tier 1 x DERMATOLOGICALS Lidocaine HCl Lidocaine HCl External Gel 2 % Tier 1 x DERMATOLOGICALS Lidocaine HCl Lidocaine HCl External Lotion 3 % Tier 3 x DERMATOLOGICALS Lidocaine HCl Lidocaine HCl External Solution 4 % Tier 1 x LOCAL ANESTHETICS‐Parenteral Lidocaine HCl (Local Anesth.) Lidocaine HCl Injection Solution 1 % Tier 1 x LOCAL ANESTHETICS‐Parenteral Lidocaine HCl (Local Anesth.) Lidocaine HCl Injection Solution 1.5 % Tier 1 x LOCAL ANESTHETICS‐Parenteral Lidocaine HCl (Local Anesth.) Lidocaine HCl Injection Solution 2 % Tier 1 x MOUTH/THROAT/DENTAL AGENTS Lidocaine HCl (Mouth‐Throat) Lidocaine HCl Mouth/Throat Solution 4 % Tier 1 MOUTH/THROAT/DENTAL AGENTS Lidocaine HCl (Mouth‐Throat) Lidocaine Viscous Mouth/Throat Solution 2 % Tier 1 LOCAL ANESTHETICS‐Parenteral Lidocaine w/ Epinephrine Lidocaine‐Epinephrine Injection Solution 1 %‐1:100000 Tier 1 x LOCAL ANESTHETICS‐Parenteral Lidocaine w/ Epinephrine Lidocaine‐Epinephrine Injection Solution 1.5 %‐1:200000 Tier 1 x LOCAL ANESTHETICS‐Parenteral Lidocaine w/ Epinephrine Lidocaine‐Epinephrine Injection Solution 2 %‐1:100000 Tier 1 x LOCAL ANESTHETICS‐Parenteral Lidocaine w/ Epinephrine Lidocaine‐Epinephrine Injection Solution 2 %‐1:50000 Tier 1 x ANORECTAL AGENTS Lidocaine‐Hydrocortisone Acetate (Rectal) Lidocaine‐Hydrocortisone Ace Rectal Cream 3‐0.5 % Tier 1 ANORECTAL AGENTS Lidocaine‐Hydrocortisone Acetate (Rectal) Lidocaine‐Hydrocortisone Ace Rectal Gel 2.8‐0.55 % Tier 3 ANORECTAL AGENTS Lidocaine‐Hydrocortisone Acetate (Rectal) Lidocaine‐Hydrocortisone Ace Rectal Kit 2‐2 % Tier 1 ANORECTAL AGENTS Lidocaine‐Hydrocortisone Acetate (Rectal) Lidocaine‐Hydrocortisone Ace Rectal Kit 3‐0.5 % Tier 1 ANORECTAL AGENTS Lidocaine‐Hydrocortisone Acetate (Rectal) Lidocaine‐Hydrocortisone Ace Rectal Kit 3‐1 % Tier 1 ANORECTAL AGENTS Lidocaine‐Hydrocortisone Acetate (Rectal) Lidocaine‐Hydrocortisone Ace Rectal Kit 3‐2.5 % Tier 1 DERMATOLOGICALS Lidocaine‐Prilocaine Lidocaine‐Prilocaine External Cream 2.5‐2.5 % Tier 1 DERMATOLOGICALS Lidocaine‐Prilocaine Lidocaine‐Prilocaine External Kit 2.5‐2.5 % Tier 1 DERMATOLOGICALS Lidocaine‐Tetracaine Lidocaine‐Tetracaine External Cream 7‐7 % Tier 3 DERMATOLOGICALS Lidocaine HCl Lidocin External Gel 3 % Tier 3 x DERMATOLOGICALS Lidocaine Lidoderm External Patch 5 % Tier 3 x DERMATOLOGICALS Lidocaine‐Menthol Lidodextrapine External Patch 4‐1 % Tier 1 DERMATOLOGICALS Lidocaine HCl Lido‐K External Lotion 3 % Tier 3 x DERMATOLOGICALS Lidocaine HCl Lidopin External Cream 3 % Tier 1 x DERMATOLOGICALS Lidocaine HCl Lidopin External Cream 3.25 % Tier 3 x DERMATOLOGICALS Ketoprofen‐Ketamine‐Lidocaine LidoProfen External Cream 5‐5‐2 % Tier 3 x DERMATOLOGICALS Lidocaine HCl LidoRx External Gel 3 % Tier 3 x DERMATOLOGICALS Lidocaine‐Menthol Lidothol External Patch 4.5‐5 % Tier 3 DERMATOLOGICALS Lidocaine HCl Lidotral External Cream 3.88 % Tier 3 x MEDICAL DEVICES AND SUPPLIES Lancets LifeScan Unistik 2 Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets LifeScan Unistik II Lancets Miscellaneous Tier 2 DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS Flavocoxid Limbrel Oral Capsule 250 MG Tier 3 DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS Flavocoxid Limbrel Oral Capsule 500 MG Tier 3 ANTI‐INFECTIVE AGENTS ‐ MISC. Lincomycin HCl Lincocin Injection Solution 300 MG/ML Tier 3 x ANTI‐INFECTIVE AGENTS ‐ MISC. Lincomycin HCl Lincomycin HCl Injection Solution 300 MG/ML Tier 1 x DERMATOLOGICALS Lindane External Lotion 1 % Tier 1 DERMATOLOGICALS Lindane Lindane External Shampoo 1 % Tier 1 ANTI‐INFECTIVE AGENTS ‐ MISC. Linezolid Linezolid Intravenous Solution 2 MG/ML Tier 1 x ANTI‐INFECTIVE AGENTS ‐ MISC. Linezolid Linezolid Oral Suspension Reconstituted 100 MG/5ML Tier 1 ANTI‐INFECTIVE AGENTS ‐ MISC. Linezolid Linezolid Oral Tablet 600 MG Tier 1 GASTROINTESTINAL AGENTS ‐ MISC. Linzess Oral Capsule 145 MCG Tier 2 x GASTROINTESTINAL AGENTS ‐ MISC. Linaclotide Linzess Oral Capsule 290 MCG Tier 2 x MUSCULOSKELETAL THERAPY AGENTS Baclofen Lioresal Intrathecal Solution 10 MG/20ML Tier 2 x MUSCULOSKELETAL THERAPY AGENTS Baclofen Lioresal Intrathecal Solution 40 MG/20ML Tier 2 x THYROID AGENTS Liothyronine Sodium Liothyronine Sodium Oral Tablet 25 MCG Tier 1 THYROID AGENTS Liothyronine Sodium Liothyronine Sodium Oral Tablet 5 MCG Tier 1 THYROID AGENTS Liothyronine Sodium Liothyronine Sodium Oral Tablet 50 MCG Tier 1 THYROID AGENTS Liothyronine Sodium Liothyronine Sodium Powder Tier 3 ANTIHYPERLIPIDEMICS Atorvastatin Calcium Lipitor Oral Tablet 10 MG Tier 3 ANTIHYPERLIPIDEMICS Atorvastatin Calcium Lipitor Oral Tablet 20 MG Tier 3 ANTIHYPERLIPIDEMICS Atorvastatin Calcium Lipitor Oral Tablet 40 MG Tier 3 ANTIHYPERLIPIDEMICS Atorvastatin Calcium Lipitor Oral Tablet 80 MG Tier 3 PHARMACEUTICAL ADJUVANTS Lecithin‐Isopropyl Palmitate Lipmax Solution Tier 2 ANTIHYPERLIPIDEMICS Fenofibrate Lipofen Oral Capsule 150 MG Tier 2 x ANTIHYPERLIPIDEMICS Fenofibrate Lipofen Oral Capsule 50 MG Tier 2 x PHARMACEUTICAL ADJUVANTS Cream Base Liposomic Lipozyme External Cream Tier 3 DIAGNOSTIC PRODUCTS Barium Sulfate Liquid E‐Z‐Paque Oral Suspension 60 % Tier 3 DIAGNOSTIC PRODUCTS Arterial Blood Gas Kits Liquihep II Prefilled Syringe Kit 500 UNIT Tier 3 DIAGNOSTIC PRODUCTS Arterial Blood Gas Kits Liquihep Prefilled Syringe Kit 500 UNIT Tier 3 ANTIHYPERTENSIVES Lisinopril Lisinopril Oral Tablet 10 MG Tier 1 ANTIHYPERTENSIVES Lisinopril Lisinopril Oral Tablet 2.5 MG Tier 1 ANTIHYPERTENSIVES Lisinopril Lisinopril Oral Tablet 20 MG Tier 1 ANTIHYPERTENSIVES Lisinopril Lisinopril Oral Tablet 30 MG Tier 1 ANTIHYPERTENSIVES Lisinopril Lisinopril Oral Tablet 40 MG Tier 1 ANTIHYPERTENSIVES Lisinopril Lisinopril Oral Tablet 5 MG Tier 1 ANTIHYPERTENSIVES Lisinopril & Hydrochlorothiazide Lisinopril‐Hydrochlorothiazide Oral Tablet 10‐12.5 MG Tier 1 ANTIHYPERTENSIVES Lisinopril & Hydrochlorothiazide Lisinopril‐Hydrochlorothiazide Oral Tablet 20‐12.5 MG Tier 1 ANTIHYPERTENSIVES Lisinopril & Hydrochlorothiazide Lisinopril‐Hydrochlorothiazide Oral Tablet 20‐25 MG Tier 1 NUTRIENTS L‐Isoleucine Powder Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Lite Touch Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Lite Touch Pen Needles Miscellaneous 31G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers LiteAire Device Tier 2 x MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Litetouch Insulin Syringe Miscellaneous 28G X 1/2" 0.5 ML Tier 2 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Litetouch Insulin Syringe Miscellaneous 28G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Litetouch Insulin Syringe Miscellaneous 29G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Litetouch Insulin Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Litetouch Insulin Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Litetouch Insulin Syringe Miscellaneous 30G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Litetouch Insulin Syringe Miscellaneous 30G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Litetouch Insulin Syringe Miscellaneous 30G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Litetouch Insulin Syringe Miscellaneous 31G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Litetouch Insulin Syringe Miscellaneous 31G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Litetouch Insulin Syringe Miscellaneous 31G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Litetouch Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Litetouch Pen Needles Miscellaneous 29G X 12.7MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Litetouch Pen Needles Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Litetouch Pen Needles Miscellaneous 31G X 8 MM Tier 2 ANTIPSYCHOTICS/ANTIMANIC AGENTS Lithium Carbonate Lithium Carbonate ER Oral Tablet Extended Release 300 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Lithium Carbonate Lithium Carbonate ER Oral Tablet Extended Release 450 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Lithium Carbonate Lithium Carbonate Oral Capsule 150 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Lithium Carbonate Lithium Carbonate Oral Capsule 150 MG Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Lithium Carbonate Lithium Carbonate Oral Capsule 300 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Lithium Carbonate Lithium Carbonate Oral Capsule 600 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Lithium Carbonate Lithium Carbonate Oral Capsule 600 MG Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Lithium Carbonate Lithium Carbonate Oral Tablet 300 MG Tier 1 DIAGNOSTIC PRODUCTS Arterial Blood Gas Kits Lithium Heparin Prefilled Syr Kit 500 UNIT Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Lithium Lithium Oral Solution 8 MEQ/5ML Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Lithium Carbonate Lithobid Oral Tablet Extended Release 300 MG Tier 3 GENITOURINARY AGENTS ‐ MISCELLANEOUS Acetohydroxamic Acid Lithostat Oral Tablet 250 MG Tier 3 ANTIHYPERLIPIDEMICS Pitavastatin Calcium Livalo Oral Tablet 1 MG Tier 3 x ANTIHYPERLIPIDEMICS Pitavastatin Calcium Livalo Oral Tablet 2 MG Tier 3 x ANTIHYPERLIPIDEMICS Pitavastatin Calcium Livalo Oral Tablet 4 MG Tier 3 x MEDICAL DEVICES AND SUPPLIES Lancets Live Better Lancet Super Thin Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Live Better Lancet Ultra Thin Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Live Better Pen Needles Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Live Better Pen Needles Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Live Better Pen Needles Miscellaneous 31G X 8 MM Tier 2 DERMATOLOGICALS Lidocaine‐Prilocaine Livixil Pak External Kit 2.5‐2.5 % Tier 1 NUTRIENTS Leucine L‐Leucine Powder Tier 3 HEMATOLOGICAL AGENTS ‐ MISC. Dextran 40 in Saline LMD in NaCl Intravenous Solution 10‐0.9 % Tier 3 x NUTRIENTS Methionine L‐Methionine Powder Tier 3 CONTRACEPTIVES Norethindrone Acetate‐Ethinyl Estradiol‐Fe Fum (Biphasic) Lo Loestrin Fe Oral Tablet 1 MG‐10 MCG / 10 MCG Tier 3 DERMATOLOGICALS Hydrocortisone Butyrate Locoid External Cream 0.1 % Tier 3 DERMATOLOGICALS Hydrocortisone Butyrate Locoid External Lotion 0.1 % Tier 3 DERMATOLOGICALS Hydrocortisone Butyrate Locoid External Ointment 0.1 % Tier 3 DERMATOLOGICALS Hydrocortisone Butyrate Locoid External Solution 0.1 % Tier 3 DERMATOLOGICALS Hydrocortisone Butyrate Hydrophilic Lipo Base Locoid Lipocream External Cream 0.1 % Tier 3 ANTIPARKINSON AGENTS Carbidopa Lodosyn Oral Tablet 25 MG Tier 3 CONTRACEPTIVES Norethindrone Acet & Eth Estra Loestrin 1.5/30 (21) Oral Tablet 1.5‐30 MG‐MCG Tier 3 CONTRACEPTIVES Norethindrone Acet & Eth Estra Loestrin 1/20 (21) Oral Tablet 1‐20 MG‐MCG Tier 3 CONTRACEPTIVES Norethin Acet & Estrad‐Fe Loestrin Fe 1.5/30 Oral Tablet 1.5‐30 MG‐MCG Tier 3 CONTRACEPTIVES Norethin Acet & Estrad‐Fe Loestrin Fe 1/20 Oral Tablet 1‐20 MG‐MCG Tier 3 ANTIDIARRHEALS Diphenoxylate w/ Atropine Lofene Oral Tablet 2.5‐0.025 MG Tier 1 ANTIHYPERLIPIDEMICS Fenofibrate Micronized Lofibra Oral Capsule 134 MG Tier 3 ANTIHYPERLIPIDEMICS Fenofibrate Micronized Lofibra Oral Capsule 200 MG Tier 3 ANTIHYPERLIPIDEMICS Fenofibrate Micronized Lofibra Oral Capsule 67 MG Tier 3 ANTIHYPERLIPIDEMICS Fenofibrate Lofibra Oral Tablet 160 MG Tier 3 ANTIHYPERLIPIDEMICS Fenofibrate Lofibra Oral Tablet 54 MG Tier 3 DERMATOLOGICALS Desonide LoKara External Lotion 0.05 % Tier 1 CONTRACEPTIVES Norethin Acet & Estrad‐Fe Lomedia 24 FE Oral Tablet 1‐20 MG‐MCG(24) Tier 1 ANTIDIARRHEALS Diphenoxylate w/ Atropine Lomotil Oral Tablet 2.5‐0.025 MG Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Lomustine Lomustine Oral Capsule 10 MG Tier 2 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Lomustine Lomustine Oral Capsule 100 MG Tier 2 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Lomustine Lomustine Oral Capsule 40 MG Tier 2 x MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Longs Insulin Syringe Miscellaneous 31G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Longs Lancets Standard Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Longs Lancets Thin Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Longs Lancets Ultra Thin Miscellaneous Tier 2 ANTIDIARRHEALS Diphenoxylate w/ Atropine Lonox Oral Tablet 2.5‐0.025 MG Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Trifluridine‐Tipiracil Lonsurf Oral Tablet 15‐6.14 MG Tier 3 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Trifluridine‐Tipiracil Lonsurf Oral Tablet 20‐8.19 MG Tier 3 x ANTIDIARRHEALS HCl Loperamide HCl Oral Capsule 2 MG Tier 1 ANTIDIARRHEALS Loperamide HCl Loperamide HCl Oral Tablet 2 MG Tier 1 ANTIDIARRHEALS Loperamide HCl Loperamide HCl Powder Tier 3 ANTIHYPERLIPIDEMICS Gemfibrozil Lopid Oral Tablet 600 MG Tier 3 ESTROGENS Estradiol & Norethindrone Acetate Lopreeza Oral Tablet 0.5‐0.1 MG Tier 1 ESTROGENS Estradiol & Norethindrone Acetate Lopreeza Oral Tablet 1‐0.5 MG Tier 1 ANTIHYPERTENSIVES Metoprolol & Hydrochlorothiazide Lopressor HCT Oral Tablet 100‐25 MG Tier 3 ANTIHYPERTENSIVES Metoprolol & Hydrochlorothiazide Lopressor HCT Oral Tablet 50‐25 MG Tier 3 BETA BLOCKERS Metoprolol Tartrate Lopressor Oral Tablet 100 MG Tier 3 BETA BLOCKERS Metoprolol Tartrate Lopressor Oral Tablet 50 MG Tier 3 DERMATOLOGICALS Ciclopirox Loprox External Shampoo 1 % Tier 3 x ANTIANXIETY AGENTS Lorazepam LORazepam Injection Solution 2 MG/ML Tier 1 x ANTIANXIETY AGENTS Lorazepam LORazepam Injection Solution 4 MG/ML Tier 1 x ANTIANXIETY AGENTS Lorazepam LORazepam Intensol Oral Concentrate 2 MG/ML Tier 1 ANTIANXIETY AGENTS Lorazepam LORazepam Oral Concentrate 2 MG/ML Tier 1 ANTIANXIETY AGENTS Lorazepam LORazepam Oral Tablet 0.5 MG Tier 1 ANTIANXIETY AGENTS Lorazepam LORazepam Oral Tablet 1 MG Tier 1 ANTIANXIETY AGENTS Lorazepam LORazepam Oral Tablet 2 MG Tier 1 ANALGESICS ‐ OPIOID Hydrocodone‐Acetaminophen Lorcet HD Oral Tablet 10‐325 MG Tier 1 ANALGESICS ‐ OPIOID Hydrocodone‐Acetaminophen Lorcet Oral Tablet 5‐325 MG Tier 1 ANALGESICS ‐ OPIOID Hydrocodone‐Acetaminophen Lorcet Plus Oral Tablet 7.5‐325 MG Tier 1 DERMATOLOGICALS Lidocaine‐Menthol Lorenza External Patch 4‐1 % Tier 1 ANALGESICS ‐ OPIOID Hydrocodone‐Acetaminophen Lortab Oral Elixir 10‐300 MG/15ML Tier 3 ANALGESICS ‐ OPIOID Hydrocodone‐Acetaminophen Lortab Oral Tablet 10‐325 MG Tier 1 ANALGESICS ‐ OPIOID Hydrocodone‐Acetaminophen Lortab Oral Tablet 5‐325 MG Tier 1 ANALGESICS ‐ OPIOID Hydrocodone‐Acetaminophen Lortab Oral Tablet 7.5‐325 MG Tier 1 CONTRACEPTIVES Drospirenone‐Ethinyl Estradiol Loryna Oral Tablet 3‐0.02 MG Tier 1 MUSCULOSKELETAL THERAPY AGENTS Chlorzoxazone Lorzone Oral Tablet 375 MG Tier 3 MUSCULOSKELETAL THERAPY AGENTS Chlorzoxazone Lorzone Oral Tablet 750 MG Tier 3 ANTIHYPERTENSIVES Losartan Potassium Losartan Potassium Oral Tablet 100 MG Tier 1 ANTIHYPERTENSIVES Losartan Potassium Losartan Potassium Oral Tablet 25 MG Tier 1 ANTIHYPERTENSIVES Losartan Potassium Losartan Potassium Oral Tablet 50 MG Tier 1 ANTIHYPERTENSIVES Losartan Potassium & Hydrochlorothiazide Losartan Potassium‐HCTZ Oral Tablet 100‐12.5 MG Tier 1 ANTIHYPERTENSIVES Losartan Potassium & Hydrochlorothiazide Losartan Potassium‐HCTZ Oral Tablet 100‐25 MG Tier 1 ANTIHYPERTENSIVES Losartan Potassium & Hydrochlorothiazide Losartan Potassium‐HCTZ Oral Tablet 50‐12.5 MG Tier 1 CONTRACEPTIVES Levonorgestrel‐Ethinyl Estradiol (91‐Day) LoSeasonique Oral Tablet 0.1‐0.02 & 0.01 MG Tier 3 OPHTHALMIC AGENTS Loteprednol Etabonate Lotemax Ophthalmic Gel 0.5 % Tier 3 OPHTHALMIC AGENTS Loteprednol Etabonate Lotemax Ophthalmic Ointment 0.5 % Tier 2 OPHTHALMIC AGENTS Loteprednol Etabonate Lotemax Ophthalmic Suspension 0.5 % Tier 3 ANTIHYPERTENSIVES Benazepril & Hydrochlorothiazide Lotensin HCT Oral Tablet 10‐12.5 MG Tier 3 ANTIHYPERTENSIVES Benazepril & Hydrochlorothiazide Lotensin HCT Oral Tablet 20‐12.5 MG Tier 3 ANTIHYPERTENSIVES Benazepril & Hydrochlorothiazide Lotensin HCT Oral Tablet 20‐25 MG Tier 3 ANTIHYPERTENSIVES Benazepril HCl Lotensin Oral Tablet 10 MG Tier 3 ANTIHYPERTENSIVES Benazepril HCl Lotensin Oral Tablet 20 MG Tier 3 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ANTIHYPERTENSIVES Benazepril HCl Lotensin Oral Tablet 40 MG Tier 3 ANTIHYPERTENSIVES Amlodipine Besylate‐Benazepril HCl Lotrel Oral Capsule 10‐20 MG Tier 3 xx ANTIHYPERTENSIVES Amlodipine Besylate‐Benazepril HCl Lotrel Oral Capsule 10‐40 MG Tier 3 xx ANTIHYPERTENSIVES Amlodipine Besylate‐Benazepril HCl Lotrel Oral Capsule 2.5‐10 MG Tier 3 xx ANTIHYPERTENSIVES Amlodipine Besylate‐Benazepril HCl Lotrel Oral Capsule 5‐10 MG Tier 3 xx ANTIHYPERTENSIVES Amlodipine Besylate‐Benazepril HCl Lotrel Oral Capsule 5‐20 MG Tier 3 xx DERMATOLOGICALS Clotrimazole w/ Betamethasone Lotrisone External Cream 1‐0.05 % Tier 3 GASTROINTESTINAL AGENTS ‐ MISC. Alosetron HCl Lotronex Oral Tablet 0.5 MG Tier 2 x GASTROINTESTINAL AGENTS ‐ MISC. Alosetron HCl Lotronex Oral Tablet 1 MG Tier 2 x DERMATOLOGICALS Antiseborrheic Products, Misc. Loutrex External Cream Tier 3 ANTIHYPERLIPIDEMICS Lovastatin Lovastatin Oral Tablet 10 MG Tier 1 x ANTIHYPERLIPIDEMICS Lovastatin Lovastatin Oral Tablet 20 MG Tier 1 x ANTIHYPERLIPIDEMICS Lovastatin Lovastatin Oral Tablet 40 MG Tier 1 x ANTIHYPERLIPIDEMICS Omega‐3‐acid Ethyl Esters Lovaza Oral Capsule 1 GM Tier 3 x x ANTICOAGULANTS Enoxaparin Sodium Lovenox Injection Solution 300 MG/3ML Tier 2 x ANTICOAGULANTS Enoxaparin Sodium Lovenox Subcutaneous Solution 100 MG/ML Tier 2 x ANTICOAGULANTS Enoxaparin Sodium Lovenox Subcutaneous Solution 120 MG/0.8ML Tier 2 x ANTICOAGULANTS Enoxaparin Sodium Lovenox Subcutaneous Solution 150 MG/ML Tier 2 x ANTICOAGULANTS Enoxaparin Sodium Lovenox Subcutaneous Solution 30 MG/0.3ML Tier 2 x ANTICOAGULANTS Enoxaparin Sodium Lovenox Subcutaneous Solution 40 MG/0.4ML Tier 2 x ANTICOAGULANTS Enoxaparin Sodium Lovenox Subcutaneous Solution 60 MG/0.6ML Tier 2 x ANTICOAGULANTS Enoxaparin Sodium Lovenox Subcutaneous Solution 80 MG/0.8ML Tier 2 x CONTRACEPTIVES Norgestrel & Ethinyl Estradiol Low‐Ogestrel Oral Tablet 0.3‐30 MG‐MCG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Loxapine Succinate Loxapine Succinate Oral Capsule 10 MG Tier 1 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Loxapine Succinate Loxapine Succinate Oral Capsule 25 MG Tier 1 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Loxapine Succinate Loxapine Succinate Oral Capsule 5 MG Tier 1 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Loxapine Succinate Loxapine Succinate Oral Capsule 50 MG Tier 1 x MINERALS & ELECTROLYTES Sodium Fluoride Lozi‐Flur Mouth/Throat Lozenge 2.2 (1 F) MG Tier 2 DERMATOLOGICALS Lidocaine‐Prilocaine LP Lite Pak External Kit 2.5‐2.5 % Tier 1 NUTRIENTS L‐Phenylalanine Powder Tier 3 NUTRIENTS L‐Proline Powder Tier 3 MOUTH/THROAT/DENTAL AGENTS Lidocaine HCl (Mouth‐Throat) LTA 360 Kit Mouth/Throat Solution 4 % Tier 3 NUTRIENTS Tryptophan L‐Tryptophan Powder Tier 3 NUTRIENTS L‐Tyrosine Powder Tier 3 MINERALS & ELECTROLYTES Sodium Fluoride Ludent Oral Tablet Chewable 0.55 (0.25 F) MG Tier 1 MINERALS & ELECTROLYTES Sodium Fluoride Ludent Oral Tablet Chewable 1.1 (0.5 F) MG Tier 1 MINERALS & ELECTROLYTES Sodium Fluoride Ludent Oral Tablet Chewable 2.2 (1 F) MG Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Dyphylline Lufyllin Oral Tablet 400 MG Tier 3 ANTISEPTICS & DISINFECTANTS Iodine (Topical) Lugols External Solution Tier 3 OPHTHALMIC AGENTS Bimatoprost Lumigan Ophthalmic Solution 0.01 % Tier 2 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Eszopiclone Lunesta Oral Tablet 1 MG Tier 3 x HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Eszopiclone Lunesta Oral Tablet 2 MG Tier 3 x HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Eszopiclone Lunesta Oral Tablet 3 MG Tier 3 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Leuprolide Acetate & Norethindrone Acetate Lupaneta Pack Combination Kit 11.25 & 5 MG Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Leuprolide Acetate & Norethindrone Acetate Lupaneta Pack Combination Kit 3.75 & 5 MG Tier 2 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Leuprolide Acetate (3 Month) Lupron Depot Intramuscular Kit 11.25 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Leuprolide Acetate (3 Month) Lupron Depot Intramuscular Kit 22.5 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Leuprolide Acetate Lupron Depot Intramuscular Kit 3.75 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Leuprolide Acetate (4 Month) Lupron Depot Intramuscular Kit 30 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Leuprolide Acetate (6 Month) Lupron Depot Intramuscular Kit 45 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Leuprolide Acetate Lupron Depot Intramuscular Kit 7.5 MG Tier 2 x x MINERALS & ELECTROLYTES Sodium Fluoride Luride Oral Solution 1.1 (0.5 F) MG/ML Tier 3 MINERALS & ELECTROLYTES Sodium Fluoride Luride Oral Tablet Chewable 0.55 (0.25 F) MG Tier 3 MINERALS & ELECTROLYTES Sodium Fluoride Luride Oral Tablet Chewable 1.1 (0.5 F) MG Tier 3 MINERALS & ELECTROLYTES Sodium Fluoride Luride Oral Tablet Chewable 2.2 (1 F) MG Tier 3 CONTRACEPTIVES Levonorgestrel & Eth Estradiol Lutera Oral Tablet 0.1‐20 MG‐MCG Tier 1 DERMATOLOGICALS Betamethasone Valerate Luxiq External Foam 0.12 % Tier 3 DERMATOLOGICALS Luliconazole Luzu External Cream 1 % Tier 3 x NUTRIENTS L‐Valine Powder Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Olaparib Lynparza Oral Capsule 50 MG Tier 2 x x DIAGNOSTIC PRODUCTS Arterial Blood Gas Kits Lyophil Lith Hep Prefilled Syr Kit 100 UNIT Tier 3 DIAGNOSTIC PRODUCTS Arterial Blood Gas Kits Lyophil Lith Hep Prefilled Syr Kit 70 UNIT Tier 3 ANTICONVULSANTS Pregabalin Lyrica Oral Capsule 100 MG Tier 2 x ANTICONVULSANTS Pregabalin Lyrica Oral Capsule 150 MG Tier 2 x ANTICONVULSANTS Pregabalin Lyrica Oral Capsule 200 MG Tier 2 x ANTICONVULSANTS Pregabalin Lyrica Oral Capsule 225 MG Tier 2 x ANTICONVULSANTS Pregabalin Lyrica Oral Capsule 25 MG Tier 2 x ANTICONVULSANTS Pregabalin Lyrica Oral Capsule 300 MG Tier 2 x ANTICONVULSANTS Pregabalin Lyrica Oral Capsule 50 MG Tier 2 x ANTICONVULSANTS Pregabalin Lyrica Oral Capsule 75 MG Tier 2 x ANTICONVULSANTS Pregabalin Lyrica Oral Solution 20 MG/ML Tier 3 x MULTIVITAMINS Multiple Vitamins w/ Minerals Lysiplex Plus Oral Tablet Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Mitotane Lysodren Oral Tablet 500 MG Tier 2 x x HEMOSTATICS Tranexamic Acid Lysteda Oral Tablet 650 MG Tier 3 x CONTRACEPTIVES Norethindrone (Contraceptive) Lyza Oral Tablet 0.35 MG Tier 1 MULTIVITAMINS Multiple Vitamin M.V.I. Adult Intravenous Injectable Tier 3 x MULTIVITAMINS Multiple Vitamin M.V.I.‐12 (without Vitamin K) Intravenous Injectable Tier 3 x DERMATOLOGICALS Capsaicin‐Menthol MaC Patch External Patch 0.0375‐5 % Tier 3 MULTIVITAMINS Prenatal w/o Vit A w/ Fe Carbonyl‐DSS‐FA‐DHA Macnatal CN DHA Oral Capsule 28‐1‐250 MG Tier 3 URINARY ANTI‐INFECTIVES Nitrofurantoin Monohyd Macro Macrobid Oral Capsule 100 MG Tier 3 URINARY ANTI‐INFECTIVES Nitrofurantoin Macrocrystal Macrodantin Oral Capsule 100 MG Tier 2 URINARY ANTI‐INFECTIVES Nitrofurantoin Macrocrystal Macrodantin Oral Capsule 25 MG Tier 2 URINARY ANTI‐INFECTIVES Nitrofurantoin Macrocrystal Macrodantin Oral Capsule 50 MG Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Magellan Insulin Safety Syr Miscellaneous 29G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Magellan Insulin Safety Syr Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Magellan Insulin Safety Syr Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Magellan Insulin Safety Syr Miscellaneous 30G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Magellan Insulin Safety Syr Miscellaneous 30G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Magellan Insulin Safety Syr Miscellaneous 30G X 5/16" 1 ML Tier 2 MINERALS & ELECTROLYTES Magnesium‐Calcium‐Folic Acid MagneBind 400 Oral Tablet 400‐200‐1 MG Tier 3 MINERALS & ELECTROLYTES Magnesium Chloride Magnesium Chloride Injection Solution 200 MG/ML Tier 1 x MINERALS & ELECTROLYTES Magnesium Chloride Magnesium Chloride Powder Tier 3 ANTACIDS Magnesium Magnesium Oxide Powder Tier 3 PHARMACEUTICAL ADJUVANTS Magnesium Stearate Magnesium Stearate Powder Tier 3 MINERALS & ELECTROLYTES Magnesium Sulfate Magnesium Sulfate Injection Solution 50 % Tier 1 x LAXATIVES Magnesium Sulfate (Laxative) Magnesium Sulfate Powder Tier 3 ANTACIDS Magnesium Trisilicate Magnesium Trisilicate Powder Tier 3 DIAGNOSTIC PRODUCTS Gadopentetate Dimeglumine Magnevist Intravenous Solution 469.01 MG/ML Tier 3 x ANTIMALARIALS Atovaquone‐Proguanil HCl Malarone Oral Tablet 250‐100 MG Tier 3 ANTIMALARIALS Atovaquone‐Proguanil HCl Malarone Oral Tablet 62.5‐25 MG Tier 3 DERMATOLOGICALS Malathion External Lotion 0.5 % Tier 1 DIURETICS Mannitol Mannitol Intravenous Solution 20 % Tier 1 x DIURETICS Mannitol Mannitol Intravenous Solution 25 % Tier 1 x ANTIDEPRESSANTS Maprotiline HCl Maprotiline HCl Oral Tablet 25 MG Tier 3 x ANTIDEPRESSANTS Maprotiline HCl Maprotiline HCl Oral Tablet 50 MG Tier 3 x ANTIDEPRESSANTS Maprotiline HCl Maprotiline HCl Oral Tablet 75 MG Tier 3 x LOCAL ANESTHETICS‐Parenteral Bupivacaine HCl Marcaine Injection Solution 0.25 % Tier 3 x LOCAL ANESTHETICS‐Parenteral Bupivacaine HCl Marcaine Injection Solution 0.5 % Tier 3 x LOCAL ANESTHETICS‐Parenteral Bupivacaine HCl Marcaine Injection Solution 0.75 % Tier 3 x LOCAL ANESTHETICS‐Parenteral Bupivacaine HCl Marcaine Preservative Free Injection Solution 0.25 % Tier 3 x LOCAL ANESTHETICS‐Parenteral Bupivacaine HCl Marcaine Preservative Free Injection Solution 0.5 % Tier 3 x LOCAL ANESTHETICS‐Parenteral Bupivacaine w/ Epinephrine Marcaine/Epinephrine Injection Solution 0.25% ‐1:200000 Tier 3 x HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

LOCAL ANESTHETICS‐Parenteral Bupivacaine w/ Epinephrine Marcaine/Epinephrine Injection Solution 0.5% ‐1:200000 Tier 3 x LOCAL ANESTHETICS‐Parenteral Bupivacaine w/ Epinephrine Marcaine/Epinephrine PF Injection Solution 0.25% ‐1:200000 Tier 3 x LOCAL ANESTHETICS‐Parenteral Bupivacaine w/ Epinephrine Marcaine/Epinephrine PF Injection Solution 0.5% ‐1:200000 Tier 3 x ANALGESICS ‐ NonNarcotic Butalbital‐Acetaminophen‐Caffeine Margesic Oral Capsule 50‐325‐40 MG Tier 1 ANTIEMETICS Dronabinol Marinol Oral Capsule 10 MG Tier 3 x x ANTIEMETICS Dronabinol Marinol Oral Capsule 2.5 MG Tier 3 x x ANTIEMETICS Dronabinol Marinol Oral Capsule 5 MG Tier 3 x x CONTRACEPTIVES Levonorgestrel & Eth Estradiol Marlissa Oral Tablet 0.15‐30 MG‐MCG Tier 1 MULTIVITAMINS Prenatal without Vit A w/ Iron Polysaccharide Complex‐FA Marnatal‐F Oral Capsule 60‐1 MG Tier 2 ANTIDEPRESSANTS Isocarboxazid Marplan Oral Tablet 10 MG Tier 3 x ANALGESICS ‐ NonNarcotic Butalbital‐Acetaminophen Marten‐Tab Oral Tablet 50‐325 MG Tier 1 MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chamber Supplies ‐ Masks Mask Vortex Miscellaneous Tier 2 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Procarbazine HCl Matulane Oral Capsule 50 MG Tier 2 x CALCIUM CHANNEL BLOCKERS Diltiazem HCl Coated Beads Matzim LA Oral Tablet Extended Release 24 Hour 180 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Coated Beads Matzim LA Oral Tablet Extended Release 24 Hour 240 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Coated Beads Matzim LA Oral Tablet Extended Release 24 Hour 300 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Coated Beads Matzim LA Oral Tablet Extended Release 24 Hour 360 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Coated Beads Matzim LA Oral Tablet Extended Release 24 Hour 420 MG Tier 1 ANTIHYPERTENSIVES Trandolapril Mavik Oral Tablet 1 MG Tier 3 ANTIHYPERTENSIVES Trandolapril Mavik Oral Tablet 2 MG Tier 3 ANTIHYPERTENSIVES Trandolapril Mavik Oral Tablet 4 MG Tier 3 MIGRAINE PRODUCTS Rizatriptan Benzoate Maxalt Oral Tablet 10 MG Tier 3 MIGRAINE PRODUCTS Rizatriptan Benzoate Maxalt Oral Tablet 5 MG Tier 3 x MIGRAINE PRODUCTS Rizatriptan Benzoate Maxalt‐MLT Oral Tablet Dispersible 10 MG Tier 3 x MIGRAINE PRODUCTS Rizatriptan Benzoate Maxalt‐MLT Oral Tablet Dispersible 5 MG Tier 3 x HEMATOPOIETIC AGENTS Fe Glycinate‐Fe Fumarate‐Vit C‐Vit B12‐Methylfolate Maxaron Forte Oral Tablet Tier 3 HEMATOPOIETIC AGENTS Iron‐FA‐Vit B12‐Biotin‐Vit C‐Docusate‐Magnesium‐Zinc MaxFe Oral Tablet 160‐1 MG Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Maxi‐Comfort Insulin Syringe Miscellaneous 28G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Maxi‐Comfort Insulin Syringe Miscellaneous 28G X 1/2" 1 ML Tier 2 OPHTHALMIC AGENTS Dexamethasone (Ophth) Maxidex Ophthalmic Suspension 0.1 % Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Maxima Blood Glucose Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies Maxima Starter Kit w/Device Tier 3 OPHTHALMIC AGENTS Neomycin‐Polymy‐Dexameth Maxitrol Ophthalmic Ointment 3.5‐10000‐0.1 Tier 3 OPHTHALMIC AGENTS Neomycin‐Polymy‐Dexameth Maxitrol Ophthalmic Suspension 3.5‐10000‐0.1 Tier 3 DIURETICS Triamterene & Hydrochlorothiazide Maxzide Oral Tablet 75‐50 MG Tier 3 DIURETICS Triamterene & Hydrochlorothiazide Maxzide‐25 Oral Tablet 37.5‐25 MG Tier 3 DERMATOLOGICALS Dermatological Products, Misc. MB HydroGel External Kit Tier 3 DIAGNOSTIC PRODUCTS Diatrizoate Meglumine & Sodium MD‐76 R Injection Solution 66‐10 % Tier 3 x DIAGNOSTIC PRODUCTS Diatrizoate Meglumine & Sodium MD‐Gastroview Oral Solution 66‐10 % Tier 1 URINARY ANTI‐INFECTIVES Methenamine‐Hyoscamine‐Methylene Blue‐Sodium Phosphate ME/NaPhos/MB/Hyo1 Oral Tablet 81.6 MG Tier 1 ANTHELMINTICS Mebendazole Mebendazole Powder Tier 3 ANTIEMETICS Meclizine HCl Meclizine HCl Oral Tablet 12.5 MG Tier 1 ANTIEMETICS Meclizine HCl Meclizine HCl Oral Tablet 25 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Meclofenamate Sodium Meclofenamate Sodium Oral Capsule 100 MG Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Meclofenamate Sodium Meclofenamate Sodium Oral Capsule 50 MG Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Meclofenamate Sodium Meclofenamate Sodium Powder Tier 3 PHARMACEUTICAL ADJUVANTS Polyethylene Glycol 300 Medibase C Liquid Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Medic Insulin Syringe Miscellaneous 30G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Medic Insulin Syringe Miscellaneous 30G X 5/16" 0.5 ML Tier 2 VACCINES Influenza Virus Vaccine Tissue‐Cultured Subunit Medical Provider EZ Flu Intramuscular Prefilled Syringe Kit 0.5 ML Tier 2 x VACCINES Influenza Virus Vaccine Types A & B Preservative Free Medical Provider EZ Flu PF Intramuscular Prefilled Syringe Kit 0.5 ML Tier 2 x MEDICAL DEVICES AND SUPPLIES Lancets MediChoice Safety Lancet Extra Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets MediChoice Safety Lancet Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets MediChoice Safety Lancet Norm Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Medicine Shoppe Pen Needles Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Medicine Shoppe Pen Needles Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Medicine Shoppe Pen Needles Miscellaneous 31G X 8 MM Tier 2 DERMATOLOGICALS Lidocaine‐Capsaicin‐Menthol‐Methyl Salicylate Medi‐Derm/L‐Rx External Cream 2‐0.035‐5‐20 % Tier 3 DERMATOLOGICALS Capsaicin‐Menthol‐Methyl Salicylate Medi‐Derm‐Rx External Cream 0.035‐5‐20 % Tier 3 DERMATOLOGICALS Lidocaine‐Capsaicin‐Menthol‐Methyl Salicylate Medi‐Patch Rx External Patch 0.5‐0.035‐5‐20 % Tier 3 MEDICAL DEVICES AND SUPPLIES Blood Glucose Calibration MediSense Glucose Ketone Contr In Vitro Liquid Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets MediSense Thin Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Medlance Extra 21G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Medlance Lite 25G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Medlance Plus Extra 21G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Medlance Plus Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Medlance Plus Lite 25G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Medlance Plus Special 0.8mm Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Medlance Plus SuperLite 30G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Medlance Plus Universal 21G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Medlance Universal 21G Miscellaneous Tier 2 CORTICOSTEROIDS Methylprednisolone Medrol (Pak) Oral Tablet 4 MG Tier 3 CORTICOSTEROIDS Methylprednisolone Medrol Oral Tablet 16 MG Tier 2 CORTICOSTEROIDS Methylprednisolone Medrol Oral Tablet 2 MG Tier 2 CORTICOSTEROIDS Methylprednisolone Medrol Oral Tablet 32 MG Tier 2 CORTICOSTEROIDS Methylprednisolone Medrol Oral Tablet 4 MG Tier 2 CORTICOSTEROIDS Methylprednisolone Medrol Oral Tablet 8 MG Tier 2 DERMATOLOGICALS Capsaicin‐Menthol‐Methyl Salicylate Medrox‐Rx External Ointment 0.05‐7‐20 % Tier 3 CONTRACEPTIVES Medroxyprogesterone Acetate (Contraceptive) MedroxyPROGESTERone Acetate Intramuscular Suspension 150 MG/ML Tier 1 x x PROGESTINS Medroxyprogesterone Acetate MedroxyPROGESTERone Acetate Oral Tablet 10 MG Tier 1 PROGESTINS Medroxyprogesterone Acetate MedroxyPROGESTERone Acetate Oral Tablet 2.5 MG Tier 1 PROGESTINS Medroxyprogesterone Acetate MedroxyPROGESTERone Acetate Oral Tablet 5 MG Tier 1 CHEMICALS Medroxyprogesterone Micronized MedroxyPROGESTERone Micronized Powder Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 1 ML MedSaver Syringe Miscellaneous 25G X 5/8" 1 ML Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Mefenamic Acid Oral Capsule 250 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Mefenamic Acid Mefenamic Acid Powder Tier 3 ANTIMALARIALS Mefloquine HCl Mefloquine HCl Oral Tablet 250 MG Tier 1 PROGESTINS Megestrol Acetate (Appetite) Megace ES Oral Suspension 625 MG/5ML Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Megestrol Acetate Megace Oral Oral Suspension 40 MG/ML Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Megestrol Acetate Megestrol Acetate Oral Suspension 40 MG/ML Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Megestrol Acetate Megestrol Acetate Oral Suspension 400 MG/10ML Tier 1 PROGESTINS Megestrol Acetate (Appetite) Megestrol Acetate Oral Suspension 625 MG/5ML Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Megestrol Acetate Megestrol Acetate Oral Suspension 800 MG/20ML Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Megestrol Acetate Megestrol Acetate Oral Tablet 20 MG Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Megestrol Acetate Megestrol Acetate Oral Tablet 40 MG Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Megestrol Acetate Megestrol Acetate Powder Tier 2 MEDICAL DEVICES AND SUPPLIES Alcohol Swabs Meijer Alcohol Swabs Pad 70 % Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood Meijer Blood Glucose Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Meijer Essential Glucose Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Meijer Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Meijer Lancets Thin Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Meijer Lancets Universal 21G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Meijer Lancets Universal 30G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Meijer Lancets Universal 33G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Meijer Pen Needles Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Meijer Pen Needles Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Meijer Pen Needles Miscellaneous 31G X 8 MM Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood Meijer Premium Glucose Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Meijer Super Thin Lancets Miscellaneous Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood Meijer TRUEtest Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Meijer TRUEtrack Test In Vitro Strip Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Trametinib Dimethyl Sulfoxide Mekinist Oral Tablet 0.5 MG Tier 2 x x HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Trametinib Dimethyl Sulfoxide Mekinist Oral Tablet 2 MG Tier 2 x x ANALGESICS ‐ ANTI‐INFLAMMATORY Meloxicam w/ Liniment Meloxicam Comfort Pac Combination Kit 15 MG Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Meloxicam Meloxicam Oral Suspension 7.5 MG/5ML Tier 2 ANALGESICS ‐ ANTI‐INFLAMMATORY Meloxicam Meloxicam Oral Tablet 15 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Meloxicam Meloxicam Oral Tablet 7.5 MG Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Melphalan HCl Melphalan HCl Intravenous Solution Reconstituted 50 MG Tier 1 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. HCl Memantine HCl Oral Solution 2 MG/ML Tier 1 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Memantine HCl Memantine HCl Oral Tablet 10 MG Tier 1 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Memantine HCl Memantine HCl Oral Tablet 5 (28)‐10 (21) MG Tier 1 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Memantine HCl Memantine HCl Oral Tablet 5 MG Tier 1 x VACCINES Meningococcal (A,C,Y&W‐135) Polysaccharide Conjugate Vaccine Menactra Intramuscular Injectable Tier 3 x ESTROGENS Esterified Estrogens Menest Oral Tablet 0.3 MG Tier 2 x ESTROGENS Esterified Estrogens Menest Oral Tablet 0.625 MG Tier 2 x ESTROGENS Esterified Estrogens Menest Oral Tablet 1.25 MG Tier 2 x ESTROGENS Esterified Estrogens Menest Oral Tablet 2.5 MG Tier 2 x VACCINES Meningococcal (C & Y)‐Haemophilus B Tetanus Tox Conj Vaccine Menhibrix Intramuscular Solution Reconstituted 5‐5‐2.5 MCG Tier 3 x VACCINES Meningococcal Vac A,C,Y&W‐135 Menomune Subcutaneous Injectable Tier 3 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Menotropins Menopur Subcutaneous Solution Reconstituted 75 UNIT Tier 3 x ESTROGENS Estradiol Menostar Transdermal Patch Weekly 14 MCG/24HR Tier 3 x DERMATOLOGICALS Butenafine HCl Mentax External Cream 1 % Tier 3 DERMATOLOGICALS Lidocaine‐Menthol Mentholix External Liquid 4‐1 % Tier 3 VACCINES Meningococcal (A,C,Y&W‐135) Conjugate Vac Menveo Intramuscular Solution Reconstituted Tier 3 x ANALGESICS ‐ OPIOID Meperidine HCl Meperidine HCl Injection Solution 100 MG/ML Tier 1 x ANALGESICS ‐ OPIOID Meperidine HCl Meperidine HCl Injection Solution 25 MG/ML Tier 1 x ANALGESICS ‐ OPIOID Meperidine HCl Meperidine HCl Injection Solution 50 MG/ML Tier 1 x ANALGESICS ‐ OPIOID Meperidine HCl Meperidine HCl Oral Solution 50 MG/5ML Tier 3 ANALGESICS ‐ OPIOID Meperidine HCl Meperidine HCl Oral Tablet 100 MG Tier 1 ANALGESICS ‐ OPIOID Meperidine HCl Meperidine HCl Oral Tablet 50 MG Tier 1 ANALGESICS ‐ OPIOID Meperidine HCl Meperidine HCl Powder Tier 3 ANALGESICS ‐ OPIOID Meperidine HCl Meperitab Oral Tablet 100 MG Tier 1 ANALGESICS ‐ OPIOID Meperidine HCl Meperitab Oral Tablet 50 MG Tier 1 VITAMINS Phytonadione Mephyton Oral Tablet 5 MG Tier 2 ANTIANXIETY AGENTS Meprobamate Meprobamate Oral Tablet 200 MG Tier 1 ANTIANXIETY AGENTS Meprobamate Meprobamate Oral Tablet 400 MG Tier 1 ANTI‐INFECTIVE AGENTS ‐ MISC. Atovaquone Mepron Oral Suspension 750 MG/5ML Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Mercaptopurine Mercaptopurine Oral Tablet 50 MG Tier 1 x ANTI‐INFECTIVE AGENTS ‐ MISC. Meropenem Meropenem Intravenous Solution Reconstituted 1 GM Tier 1 x ANTI‐INFECTIVE AGENTS ‐ MISC. Meropenem Meropenem Intravenous Solution Reconstituted 500 MG Tier 1 x GASTROINTESTINAL AGENTS ‐ MISC. Mesalamine Mesalamine Powder Tier 3 GASTROINTESTINAL AGENTS ‐ MISC. Mesalamine Mesalamine Rectal Enema 4 GM Tier 1 GASTROINTESTINAL AGENTS ‐ MISC. Mesalamine w/ Cleanser Mesalamine‐Cleanser Rectal Kit 4 GM Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Mesna Mesna Intravenous Solution 100 MG/ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Mesna Mesnex Oral Tablet 400 MG Tier 2 x BIOLOGICALS MISC Mesquite (Prosopis) Mesquite Subcutaneous Solution 1:20 Tier 3 x ANTIMYASTHENIC/CHOLINERGIC AGENTS Pyridostigmine Bromide Mestinon Oral Syrup 60 MG/5ML Tier 2 ANTIMYASTHENIC/CHOLINERGIC AGENTS Pyridostigmine Bromide Mestinon Oral Tablet 60 MG Tier 3 ANTIMYASTHENIC/CHOLINERGIC AGENTS Pyridostigmine Bromide Mestinon Oral Tablet Extended Release 180 MG Tier 2 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Metadate CD Oral Capsule Extended Release 10 MG Tier 3 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Metadate CD Oral Capsule Extended Release 20 MG Tier 3 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Metadate CD Oral Capsule Extended Release 30 MG Tier 3 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Metadate CD Oral Capsule Extended Release 40 MG Tier 3 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Metadate CD Oral Capsule Extended Release 50 MG Tier 3 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Metadate CD Oral Capsule Extended Release 60 MG Tier 3 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Metadate ER Oral Tablet Extended Release 20 MG Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Metaproterenol Sulfate Metaproterenol Sulfate Oral Syrup 10 MG/5ML Tier 3 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Metaproterenol Sulfate Metaproterenol Sulfate Oral Tablet 10 MG Tier 3 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Metaproterenol Sulfate Metaproterenol Sulfate Oral Tablet 20 MG Tier 3 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Metaproterenol Sulfate Metaproterenol Sulfate Powder Tier 3 MUSCULOSKELETAL THERAPY AGENTS Metaxalone Metaxall Oral Tablet 800 MG Tier 1 MUSCULOSKELETAL THERAPY AGENTS Metaxalone Metaxalone Oral Tablet 400 MG Tier 3 MUSCULOSKELETAL THERAPY AGENTS Metaxalone Metaxalone Oral Tablet 800 MG Tier 1 ANTIDIABETICS Metformin HCl MetFORMIN HCl ER (MOD) Oral Tablet Extended Release 24 Hour 1000 MG Tier 1 ANTIDIABETICS Metformin HCl MetFORMIN HCl ER (MOD) Oral Tablet Extended Release 24 Hour 500 MG Tier 1 ANTIDIABETICS Metformin HCl MetFORMIN HCl ER (OSM) Oral Tablet Extended Release 24 Hour 1000 MG Tier 1 x ANTIDIABETICS Metformin HCl MetFORMIN HCl ER (OSM) Oral Tablet Extended Release 24 Hour 500 MG Tier 1 x ANTIDIABETICS Metformin HCl MetFORMIN HCl ER Oral Tablet Extended Release 24 Hour 500 MG Tier 1 x ANTIDIABETICS Metformin HCl MetFORMIN HCl ER Oral Tablet Extended Release 24 Hour 750 MG Tier 1 x ANTIDIABETICS Metformin HCl MetFORMIN HCl Oral Tablet 1000 MG Tier 1 ANTIDIABETICS Metformin HCl MetFORMIN HCl Oral Tablet 500 MG Tier 1 ANTIDIABETICS Metformin HCl MetFORMIN HCl Oral Tablet 850 MG Tier 1 DIAGNOSTIC PRODUCTS Methacholine Chloride Methacholine Chloride Powder Tier 3 ANALGESICS ‐ OPIOID Methadone HCl Methadone HCl Intensol Oral Concentrate 10 MG/ML Tier 1 ANALGESICS ‐ OPIOID Methadone HCl Methadone HCl Oral Concentrate 10 MG/ML Tier 1 ANALGESICS ‐ OPIOID Methadone HCl Methadone HCl Oral Solution 10 MG/5ML Tier 1 ANALGESICS ‐ OPIOID Methadone HCl Methadone HCl Oral Solution 10 MG/5ML Tier 3 ANALGESICS ‐ OPIOID Methadone HCl Methadone HCl Oral Solution 5 MG/5ML Tier 1 ANALGESICS ‐ OPIOID Methadone HCl Methadone HCl Oral Solution 5 MG/5ML Tier 3 ANALGESICS ‐ OPIOID Methadone HCl Methadone HCl Oral Tablet 10 MG Tier 1 ANALGESICS ‐ OPIOID Methadone HCl Methadone HCl Oral Tablet 5 MG Tier 1 ANALGESICS ‐ OPIOID Methadone HCl Methadone HCl Oral Tablet Soluble 40 MG Tier 1 ANALGESICS ‐ OPIOID Methadone HCl Methadone HCl Powder Tier 3 ANALGESICS ‐ OPIOID Methadone HCl Methadose Oral Concentrate 10 MG/ML Tier 3 ANALGESICS ‐ OPIOID Methadone HCl Methadose Oral Tablet Soluble 40 MG Tier 1 ANALGESICS ‐ OPIOID Methadone HCl Methadose ‐Free Oral Concentrate 10 MG/ML Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methamphetamine HCl Methamphetamine HCl Oral Tablet 5 MG Tier 1 DIURETICS Methazolamide Methazolamide Oral Tablet 25 MG Tier 1 DIURETICS Methazolamide Methazolamide Oral Tablet 50 MG Tier 1 URINARY ANTI‐INFECTIVES Methenamine Hippurate Methenamine Hippurate Oral Tablet 1 GM Tier 1 URINARY ANTI‐INFECTIVES Methenamine Mandelate Methenamine Mandelate Oral Tablet 0.5 GM Tier 3 URINARY ANTI‐INFECTIVES Methenamine Mandelate Methenamine Mandelate Oral Tablet 1 GM Tier 1 OXYTOCICS Methylergonovine Maleate Methergine Oral Tablet 0.2 MG Tier 3 THYROID AGENTS Methimazole Methimazole Oral Tablet 10 MG Tier 1 THYROID AGENTS Methimazole Methimazole Oral Tablet 5 MG Tier 1 THYROID AGENTS Methimazole Methimazole Powder Tier 3 NUTRIENTS Methionine Methionine Powder Tier 3 ANDROGENS‐ANABOLIC Methyltestosterone Methitest Oral Tablet 10 MG Tier 3 MUSCULOSKELETAL THERAPY AGENTS Methocarbamol Methocarbamol Injection Solution 1000 MG/10ML Tier 1 x MUSCULOSKELETAL THERAPY AGENTS Methocarbamol Methocarbamol Oral Tablet 500 MG Tier 1 MUSCULOSKELETAL THERAPY AGENTS Methocarbamol Methocarbamol Oral Tablet 750 MG Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Methotrexate Sodium Methotrexate Oral Tablet 2.5 MG Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Methotrexate Methotrexate Powder Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Methotrexate Sodium Methotrexate Sodium (PF) Injection Solution 1 GM/40ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Methotrexate Sodium Methotrexate Sodium (PF) Injection Solution 25 MG/ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Methotrexate Sodium Methotrexate Sodium (PF) Injection Solution 250 MG/10ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Methotrexate Sodium Methotrexate Sodium (PF) Injection Solution 50 MG/2ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Methotrexate Sodium Methotrexate Sodium Injection Solution 25 MG/ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Methotrexate Sodium Methotrexate Sodium Injection Solution Reconstituted 1 GM Tier 1 x DERMATOLOGICALS Methoxsalen (Topical) Methoxsalen Powder Tier 3 DERMATOLOGICALS Methoxsalen Rapid Methoxsalen Rapid Oral Capsule 10 MG Tier 1 ULCER DRUGS Methscopolamine Bromide Methscopolamine Bromide Oral Tablet 2.5 MG Tier 1 ULCER DRUGS Methscopolamine Bromide Methscopolamine Bromide Oral Tablet 5 MG Tier 1 DIURETICS Methyclothiazide Methyclothiazide Oral Tablet 5 MG Tier 3 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

DERMATOLOGICALS Methyl Salicylate Methyl Salicylate External Liquid Tier 3 ANTIHYPERTENSIVES Methyldopa Methyldopa Oral Tablet 250 MG Tier 1 ANTIHYPERTENSIVES Methyldopa Methyldopa Oral Tablet 500 MG Tier 1 ANTIHYPERTENSIVES Methyldopa & Hydrochlorothiazide Methyldopa‐Hydrochlorothiazide Oral Tablet 250‐15 MG Tier 2 ANTIHYPERTENSIVES Methyldopa & Hydrochlorothiazide Methyldopa‐Hydrochlorothiazide Oral Tablet 250‐25 MG Tier 2 ANTIDOTES Methylene Blue (Antidote) Methylene Blue Injection Solution 1 % Tier 3 x OXYTOCICS Methylergonovine Maleate Methylergonovine Maleate Injection Solution 0.2 MG/ML Tier 1 x OXYTOCICS Methylergonovine Maleate Methylergonovine Maleate Oral Tablet 0.2 MG Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Methylin Oral Solution 10 MG/5ML Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Methylin Oral Solution 5 MG/5ML Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Methylin Oral Tablet Chewable 10 MG Tier 3 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Methylin Oral Tablet Chewable 2.5 MG Tier 3 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Methylin Oral Tablet Chewable 5 MG Tier 3 x x PHARMACEUTICAL ADJUVANTS Methylparaben Methylparaben Powder Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Methylphenidate HCl ER (CD) Oral Capsule Extended Release 10 MG Tier 1 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Methylphenidate HCl ER (CD) Oral Capsule Extended Release 20 MG Tier 1 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Methylphenidate HCl ER (CD) Oral Capsule Extended Release 30 MG Tier 1 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Methylphenidate HCl ER (CD) Oral Capsule Extended Release 40 MG Tier 1 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Methylphenidate HCl ER (CD) Oral Capsule Extended Release 50 MG Tier 1 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Methylphenidate HCl ER (CD) Oral Capsule Extended Release 60 MG Tier 1 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Methylphenidate HCl ER (LA) Oral Capsule Extended Release 24 Hour 20 MG Tier 1 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Methylphenidate HCl ER (LA) Oral Capsule Extended Release 24 Hour 30 MG Tier 1 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Methylphenidate HCl ER (LA) Oral Capsule Extended Release 24 Hour 40 MG Tier 1 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Methylphenidate HCl ER Oral Tablet Extended Release 10 MG Tier 1 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Methylphenidate HCl ER Oral Tablet Extended Release 18 MG Tier 2 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Methylphenidate HCl ER Oral Tablet Extended Release 20 MG Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Methylphenidate HCl ER Oral Tablet Extended Release 24 Hour 18 MG Tier 2 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Methylphenidate HCl ER Oral Tablet Extended Release 24 Hour 27 MG Tier 2 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Methylphenidate HCl ER Oral Tablet Extended Release 24 Hour 36 MG Tier 2 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Methylphenidate HCl ER Oral Tablet Extended Release 24 Hour 54 MG Tier 2 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Methylphenidate HCl ER Oral Tablet Extended Release 27 MG Tier 2 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Methylphenidate HCl ER Oral Tablet Extended Release 36 MG Tier 2 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Methylphenidate HCl ER Oral Tablet Extended Release 54 MG Tier 2 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Methylphenidate HCl Oral Solution 10 MG/5ML Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Methylphenidate HCl Oral Solution 5 MG/5ML Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Methylphenidate HCl Oral Tablet 10 MG Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Methylphenidate HCl Oral Tablet 20 MG Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Methylphenidate HCl Oral Tablet 5 MG Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Methylphenidate HCl Oral Tablet Chewable 10 MG Tier 1 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Methylphenidate HCl Oral Tablet Chewable 2.5 MG Tier 1 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Methylphenidate HCl Oral Tablet Chewable 5 MG Tier 1 x CORTICOSTEROIDS Methylprednisolone MethylPREDNISolone (Pak) Oral Tablet 4 MG Tier 1 CORTICOSTEROIDS Methylprednisolone Acetate MethylPREDNISolone Acetate Injection Suspension 40 MG/ML Tier 1 x CORTICOSTEROIDS Methylprednisolone Acetate MethylPREDNISolone Acetate Injection Suspension 80 MG/ML Tier 1 x CORTICOSTEROIDS Methylprednisolone Acetate MethylPREDNISolone Acetate Powder Tier 3 CORTICOSTEROIDS Methylprednisolone MethylPREDNISolone Oral Tablet 16 MG Tier 1 CORTICOSTEROIDS Methylprednisolone MethylPREDNISolone Oral Tablet 32 MG Tier 1 CORTICOSTEROIDS Methylprednisolone MethylPREDNISolone Oral Tablet 4 MG Tier 1 CORTICOSTEROIDS Methylprednisolone MethylPREDNISolone Oral Tablet 8 MG Tier 1 CORTICOSTEROIDS Methylprednisolone MethylPREDNISolone Powder Tier 3 ANDROGENS‐ANABOLIC Methyltestosterone MethylTESTOSTERone Oral Capsule 10 MG Tier 1 ANDROGENS‐ANABOLIC Methyltestosterone MethylTESTOSTERone Powder Tier 3 OPHTHALMIC AGENTS Metipranolol Metipranolol Ophthalmic Solution 0.3 % Tier 3 GASTROINTESTINAL AGENTS ‐ MISC. Metoclopramide HCl Metoclopramide HCl Injection Solution 5 MG/ML Tier 1 x GASTROINTESTINAL AGENTS ‐ MISC. Metoclopramide HCl Monohydrate Metoclopramide HCl Monohydrate Powder Tier 3 GASTROINTESTINAL AGENTS ‐ MISC. Metoclopramide HCl Metoclopramide HCl Oral Solution 10 MG/10ML Tier 1 GASTROINTESTINAL AGENTS ‐ MISC. Metoclopramide HCl Metoclopramide HCl Oral Solution 5 MG/5ML Tier 1 GASTROINTESTINAL AGENTS ‐ MISC. Metoclopramide HCl Metoclopramide HCl Oral Tablet 10 MG Tier 1 GASTROINTESTINAL AGENTS ‐ MISC. Metoclopramide HCl Metoclopramide HCl Oral Tablet 5 MG Tier 1 GASTROINTESTINAL AGENTS ‐ MISC. Metoclopramide HCl Metoclopramide HCl Oral Tablet Dispersible 10 MG Tier 3 GASTROINTESTINAL AGENTS ‐ MISC. Metoclopramide HCl Metoclopramide HCl Oral Tablet Dispersible 5 MG Tier 1 GASTROINTESTINAL AGENTS ‐ MISC. Metoclopramide HCl Metoclopramide HCl Powder Tier 3 DIURETICS Metolazone Metolazone Oral Tablet 10 MG Tier 1 DIURETICS Metolazone Metolazone Oral Tablet 2.5 MG Tier 1 DIURETICS Metolazone Metolazone Oral Tablet 5 MG Tier 1 DIAGNOSTIC PRODUCTS Metyrapone Metopirone Oral Capsule 250 MG Tier 3 BETA BLOCKERS Metoprolol Succinate Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 100 MG Tier 1 BETA BLOCKERS Metoprolol Succinate Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 200 MG Tier 1 BETA BLOCKERS Metoprolol Succinate Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG Tier 1 BETA BLOCKERS Metoprolol Succinate Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 50 MG Tier 1 BETA BLOCKERS Metoprolol Tartrate Metoprolol Tartrate Intravenous Solution 1 MG/ML Tier 1 x BETA BLOCKERS Metoprolol Tartrate Metoprolol Tartrate Intravenous Solution 5 MG/5ML Tier 1 x BETA BLOCKERS Metoprolol Tartrate Metoprolol Tartrate Oral Tablet 100 MG Tier 1 BETA BLOCKERS Metoprolol Tartrate Metoprolol Tartrate Oral Tablet 25 MG Tier 1 BETA BLOCKERS Metoprolol Tartrate Metoprolol Tartrate Oral Tablet 50 MG Tier 1 BETA BLOCKERS Metoprolol Tartrate Metoprolol Tartrate Powder Tier 3 ANTIHYPERTENSIVES Metoprolol & Hydrochlorothiazide Metoprolol‐Hydrochlorothiazide Oral Tablet 100‐25 MG Tier 1 ANTIHYPERTENSIVES Metoprolol & Hydrochlorothiazide Metoprolol‐Hydrochlorothiazide Oral Tablet 100‐50 MG Tier 1 ANTIHYPERTENSIVES Metoprolol & Hydrochlorothiazide Metoprolol‐Hydrochlorothiazide Oral Tablet 50‐25 MG Tier 1 GASTROINTESTINAL AGENTS ‐ MISC. Metoclopramide HCl Metozolv ODT Oral Tablet Dispersible 5 MG Tier 3 DERMATOLOGICALS Metronidazole (Topical) MetroCream External Cream 0.75 % Tier 3 DERMATOLOGICALS Metronidazole (Topical) Metrogel External Gel 1 % Tier 3 VAGINAL PRODUCTS Metronidazole Vaginal MetroGel‐Vaginal Vaginal Gel 0.75 % Tier 3 DERMATOLOGICALS Metronidazole (Topical) MetroLotion External Lotion 0.75 % Tier 3 DERMATOLOGICALS Metronidazole Benzoate (Topical) MetroNIDAZOLE Benzoate Powder Tier 3 DERMATOLOGICALS Metronidazole (Topical) MetroNIDAZOLE External Cream 0.75 % Tier 1 DERMATOLOGICALS Metronidazole (Topical) MetroNIDAZOLE External Gel 0.75 % Tier 1 DERMATOLOGICALS Metronidazole (Topical) MetroNIDAZOLE External Gel 1 % Tier 1 DERMATOLOGICALS Metronidazole (Topical) MetroNIDAZOLE External Lotion 0.75 % Tier 1 ANTI‐INFECTIVE AGENTS ‐ MISC. Metronidazole in NaCl MetroNIDAZOLE in NaCl Intravenous Solution 5‐0.79 MG/ML‐% Tier 1 x ANTI‐INFECTIVE AGENTS ‐ MISC. Metronidazole in NaCl MetroNIDAZOLE in NaCl Intravenous Solution 500‐0.79 MG/100ML‐% Tier 1 x ANTI‐INFECTIVE AGENTS ‐ MISC. Metronidazole MetroNIDAZOLE Oral Capsule 375 MG Tier 1 ANTI‐INFECTIVE AGENTS ‐ MISC. Metronidazole MetroNIDAZOLE Oral Tablet 250 MG Tier 1 ANTI‐INFECTIVE AGENTS ‐ MISC. Metronidazole MetroNIDAZOLE Oral Tablet 500 MG Tier 1 VAGINAL PRODUCTS Metronidazole Vaginal MetroNIDAZOLE Vaginal Gel 0.75 % Tier 1 DERMATOLOGICALS Methyl Aminolevulinate HCl Metvixia External Cream 16.8 % Tier 3 ANTIHYPERLIPIDEMICS Lovastatin Mevacor Oral Tablet 40 MG Tier 3 x ANTIARRHYTHMICS Mexiletine HCl Mexiletine HCl Oral Capsule 150 MG Tier 1 ANTIARRHYTHMICS Mexiletine HCl Mexiletine HCl Oral Capsule 200 MG Tier 1 ANTIARRHYTHMICS Mexiletine HCl Mexiletine HCl Oral Capsule 250 MG Tier 1 MEDICAL DEVICES AND SUPPLIES Dentifrices MI Paste Plus Dental Paste Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Calcitonin (Salmon) Miacalcin Nasal Solution 200 UNIT/ACT Tier 3 ANTIHYPERTENSIVES Telmisartan‐Hydrochlorothiazide Micardis HCT Oral Tablet 40‐12.5 MG Tier 3 x ANTIHYPERTENSIVES Telmisartan‐Hydrochlorothiazide Micardis HCT Oral Tablet 80‐12.5 MG Tier 3 x ANTIHYPERTENSIVES Telmisartan‐Hydrochlorothiazide Micardis HCT Oral Tablet 80‐25 MG Tier 3 x ANTIHYPERTENSIVES Telmisartan Micardis Oral Tablet 20 MG Tier 3 x ANTIHYPERTENSIVES Telmisartan Micardis Oral Tablet 40 MG Tier 3 x ANTIHYPERTENSIVES Telmisartan Micardis Oral Tablet 80 MG Tier 3 x VAGINAL PRODUCTS Nitrate Vaginal Miconazole 3 Vaginal Suppository 200 MG Tier 3 DERMATOLOGICALS Miconazole Nitrate (Topical) Miconazole Nitrate Powder Tier 3 ANTIFUNGALS Miconazole Miconazole Powder Tier 3 MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers Microchamber Miscellaneous Tier 2 x HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

DIAGNOSTIC PRODUCTS Glucose Blood Microdot Test In Vitro Strip Tier 3 CONTRACEPTIVES Norethindrone Acet & Eth Estra Microgestin 1.5/30 Oral Tablet 1.5‐30 MG‐MCG Tier 1 CONTRACEPTIVES Norethindrone Acet & Eth Estra Microgestin 1/20 Oral Tablet 1‐20 MG‐MCG Tier 1 CONTRACEPTIVES Norethin Acet & Estrad‐Fe Microgestin 24 Fe Oral Tablet 1‐20 MG‐MCG Tier 1 CONTRACEPTIVES Norethin Acet & Estrad‐Fe Microgestin FE 1.5/30 Oral Tablet 1.5‐30 MG‐MCG Tier 1 CONTRACEPTIVES Norethin Acet & Estrad‐Fe Microgestin FE 1/20 Oral Tablet 1‐20 MG‐MCG Tier 1 MINERALS & ELECTROLYTES Potassium Chloride Micro‐K Oral Capsule Extended Release 10 MEQ Tier 3 MINERALS & ELECTROLYTES Potassium Chloride Micro‐K Oral Capsule Extended Release 8 MEQ Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Microlet Lancets Miscellaneous Tier 2 ANTIHYPERLIPIDEMICS Colestipol HCl Micronized Colestipol HCl Oral Tablet 1 GM Tier 1 MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers Microspacer Miscellaneous Tier 2 x MEDICAL DEVICES AND SUPPLIES Lancets Microtainer Safety Flow Lancet Miscellaneous Tier 2 DIURETICS Hydrochlorothiazide Microzide Oral Capsule 12.5 MG Tier 3 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Midazolam HCl Midazolam HCl Injection Solution 10 MG/10ML Tier 1 x HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Midazolam HCl Midazolam HCl Injection Solution 10 MG/2ML Tier 1 x HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Midazolam HCl Midazolam HCl Injection Solution 2 MG/2ML Tier 1 x HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Midazolam HCl Midazolam HCl Injection Solution 25 MG/5ML Tier 1 x HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Midazolam HCl Midazolam HCl Injection Solution 5 MG/5ML Tier 1 x HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Midazolam HCl Midazolam HCl Injection Solution 5 MG/ML Tier 1 x HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Midazolam HCl Midazolam HCl Injection Solution 50 MG/10ML Tier 1 x HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Midazolam HCl Midazolam HCl Oral Syrup 2 MG/ML Tier 1 VASOPRESSORS Midodrine HCl Midodrine HCl Oral Tablet 10 MG Tier 1 VASOPRESSORS Midodrine HCl Midodrine HCl Oral Tablet 2.5 MG Tier 1 VASOPRESSORS Midodrine HCl Midodrine HCl Oral Tablet 5 MG Tier 1 MIGRAINE PRODUCTS Ergotamine w/ Caffeine Migergot Rectal Suppository 2‐100 MG Tier 3 MIGRAINE PRODUCTS Dihydroergotamine Mesylate Migranal Nasal Solution 4 MG/ML Tier 3 x DERMATOLOGICALS Capsaicin‐Menthol Migryl External Disk 0.0375‐5 % Tier 1 CORTICOSTEROIDS Prednisolone Millipred DP 12‐Day Oral Tablet 5 MG Tier 3 CORTICOSTEROIDS Prednisolone Millipred DP Oral Tablet 5 MG Tier 3 CORTICOSTEROIDS Prednisolone Sodium Phosphate Millipred Oral Solution 10 MG/5ML Tier 3 CORTICOSTEROIDS Prednisolone Millipred Oral Tablet 5 MG Tier 2 CARDIOTONICS Milrinone Lactate Milrinone Lactate Intravenous Solution 10 MG/10ML Tier 1 x CARDIOTONICS Milrinone Lactate Milrinone Lactate Intravenous Solution 20 MG/20ML Tier 1 x CARDIOTONICS Milrinone Lactate Milrinone Lactate Intravenous Solution 50 MG/50ML Tier 1 x ESTROGENS Estradiol & Norethindrone Acetate Mimvey Lo Oral Tablet 0.5‐0.1 MG Tier 1 ESTROGENS Estradiol & Norethindrone Acetate Mimvey Oral Tablet 1‐0.5 MG Tier 1 CONTRACEPTIVES Norethin Acet & Estrad‐Fe Minastrin 24 Fe Oral Tablet Chewable 1‐20 MG‐MCG(24) Tier 3 MEDICAL DEVICES AND SUPPLIES Lancet Devices Mini Lancing Device Miscellaneous Tier 2 ANTIHYPERTENSIVES Prazosin HCl Minipress Oral Capsule 1 MG Tier 3 ANTIHYPERTENSIVES Prazosin HCl Minipress Oral Capsule 2 MG Tier 3 ANTIHYPERTENSIVES Prazosin HCl Minipress Oral Capsule 5 MG Tier 3 ANTIANGINAL AGENTS Nitroglycerin Minitran Transdermal Patch 24 Hour 0.1 MG/HR Tier 1 ANTIANGINAL AGENTS Nitroglycerin Minitran Transdermal Patch 24 Hour 0.2 MG/HR Tier 1 ANTIANGINAL AGENTS Nitroglycerin Minitran Transdermal Patch 24 Hour 0.4 MG/HR Tier 1 ANTIANGINAL AGENTS Nitroglycerin Minitran Transdermal Patch 24 Hour 0.6 MG/HR Tier 1 ESTROGENS Estradiol Minivelle Transdermal Patch Twice Weekly 0.025 MG/24HR Tier 3 xx ESTROGENS Estradiol Minivelle Transdermal Patch Twice Weekly 0.0375 MG/24HR Tier 3 xx ESTROGENS Estradiol Minivelle Transdermal Patch Twice Weekly 0.05 MG/24HR Tier 3 xx ESTROGENS Estradiol Minivelle Transdermal Patch Twice Weekly 0.075 MG/24HR Tier 3 xx ESTROGENS Estradiol Minivelle Transdermal Patch Twice Weekly 0.1 MG/24HR Tier 3 xx TETRACYCLINES HCl Minocin Intravenous Solution Reconstituted 100 MG Tier 3 x TETRACYCLINES Minocycline HCl Minocin Oral Capsule 100 MG Tier 3 x TETRACYCLINES Minocycline HCl Minocin Oral Capsule 50 MG Tier 3 x TETRACYCLINES Minocycline HCl Minocin Oral Capsule 75 MG Tier 3 x TETRACYCLINES Minocycline HCl Minocycline HCl ER Oral Tablet Extended Release 24 Hour 135 MG Tier 1 x TETRACYCLINES Minocycline HCl Minocycline HCl ER Oral Tablet Extended Release 24 Hour 45 MG Tier 1 x TETRACYCLINES Minocycline HCl Minocycline HCl ER Oral Tablet Extended Release 24 Hour 90 MG Tier 1 x TETRACYCLINES Minocycline HCl Minocycline HCl Oral Capsule 100 MG Tier 1 x TETRACYCLINES Minocycline HCl Minocycline HCl Oral Capsule 50 MG Tier 1 x TETRACYCLINES Minocycline HCl Minocycline HCl Oral Capsule 75 MG Tier 1 x TETRACYCLINES Minocycline HCl Minocycline HCl Oral Tablet 100 MG Tier 1 x TETRACYCLINES Minocycline HCl Minocycline HCl Oral Tablet 50 MG Tier 1 x TETRACYCLINES Minocycline HCl Minocycline HCl Oral Tablet 75 MG Tier 1 x TETRACYCLINES Minocycline HCl Minocycline HCl Powder Tier 3 x ANTIHYPERTENSIVES Minoxidil Minoxidil Oral Tablet 10 MG Tier 1 ANTIHYPERTENSIVES Minoxidil Minoxidil Oral Tablet 2.5 MG Tier 1 OPHTHALMIC AGENTS Chloride Miochol‐E Intraocular Solution Reconstituted 20 MG Tier 3 ANTIPARKINSON AGENTS Pramipexole Dihydrochloride Mirapex ER Oral Tablet Extended Release 24 Hour 0.375 MG Tier 3 x ANTIPARKINSON AGENTS Pramipexole Dihydrochloride Mirapex ER Oral Tablet Extended Release 24 Hour 0.75 MG Tier 3 x ANTIPARKINSON AGENTS Pramipexole Dihydrochloride Mirapex ER Oral Tablet Extended Release 24 Hour 1.5 MG Tier 3 x ANTIPARKINSON AGENTS Pramipexole Dihydrochloride Mirapex ER Oral Tablet Extended Release 24 Hour 2.25 MG Tier 3 x ANTIPARKINSON AGENTS Pramipexole Dihydrochloride Mirapex ER Oral Tablet Extended Release 24 Hour 3 MG Tier 3 x ANTIPARKINSON AGENTS Pramipexole Dihydrochloride Mirapex ER Oral Tablet Extended Release 24 Hour 3.75 MG Tier 3 x ANTIPARKINSON AGENTS Pramipexole Dihydrochloride Mirapex ER Oral Tablet Extended Release 24 Hour 4.5 MG Tier 3 x ANTIPARKINSON AGENTS Pramipexole Dihydrochloride Mirapex Oral Tablet 0.125 MG Tier 3 x ANTIPARKINSON AGENTS Pramipexole Dihydrochloride Mirapex Oral Tablet 0.25 MG Tier 3 x ANTIPARKINSON AGENTS Pramipexole Dihydrochloride Mirapex Oral Tablet 0.5 MG Tier 3 x ANTIPARKINSON AGENTS Pramipexole Dihydrochloride Mirapex Oral Tablet 0.75 MG Tier 3 x ANTIPARKINSON AGENTS Pramipexole Dihydrochloride Mirapex Oral Tablet 1 MG Tier 3 x ANTIPARKINSON AGENTS Pramipexole Dihydrochloride Mirapex Oral Tablet 1.5 MG Tier 3 x CONTRACEPTIVES Desogestrel‐Ethinyl Estradiol (Biphasic) Mircette Oral Tablet 0.15‐0.02/0.01 MG (21/5) Tier 3 CONTRACEPTIVES Levonorgestrel (IUD) Mirena Intrauterine Intrauterine Device 20 MCG/24HR Tier 2 x ANTIDEPRESSANTS Mirtazapine Mirtazapine Oral Tablet 15 MG Tier 1 ANTIDEPRESSANTS Mirtazapine Mirtazapine Oral Tablet 30 MG Tier 1 ANTIDEPRESSANTS Mirtazapine Mirtazapine Oral Tablet 45 MG Tier 1 ANTIDEPRESSANTS Mirtazapine Mirtazapine Oral Tablet 7.5 MG Tier 1 ANTIDEPRESSANTS Mirtazapine Mirtazapine Oral Tablet Dispersible 15 MG Tier 1 ANTIDEPRESSANTS Mirtazapine Mirtazapine Oral Tablet Dispersible 30 MG Tier 1 ANTIDEPRESSANTS Mirtazapine Mirtazapine Oral Tablet Dispersible 45 MG Tier 1 DERMATOLOGICALS Brimonidine Tartrate (Topical) Mirvaso External Gel 0.33 % Tier 3 ULCER DRUGS Misoprostol Misoprostol Oral Tablet 100 MCG Tier 1 ULCER DRUGS Misoprostol Misoprostol Oral Tablet 200 MCG Tier 1 BIOLOGICALS MISC Mite (D. farinae) Mite (D. farinae) Subcutaneous Solution 10000 AU/ML Tier 3 x BIOLOGICALS MISC Mite (D. pteronyssinus) Mite (D. pteronyssinus) Subcutaneous Solution 10000 AU/ML Tier 3 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Mitomycin Mitomycin Intravenous Solution Reconstituted 20 MG Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Mitomycin Mitomycin Intravenous Solution Reconstituted 40 MG Tier 1 x OPHTHALMIC AGENTS Mitomycin (Ophthalmic) Mitosol Ophthalmic Kit 0.2 MG Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Mitoxantrone HCl Mitoxantrone HCl Intravenous Concentrate 20 MG/10ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Mitoxantrone HCl Mitoxantrone HCl Intravenous Concentrate 25 MG/12.5ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Mitoxantrone HCl Mitoxantrone HCl Intravenous Concentrate 30 MG/15ML Tier 1 x BIOLOGICALS MISC Mixed Ragweed Mixed Ragweed Subcutaneous Solution 1:20 Tier 3 x VACCINES Measles, Mumps & Rubella Virus Vaccines M‐M‐R II Subcutaneous Injectable Tier 3 x ANALGESICS ‐ ANTI‐INFLAMMATORY Meloxicam Mobic Oral Suspension 7.5 MG/5ML Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Meloxicam Mobic Oral Tablet 15 MG Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Meloxicam Mobic Oral Tablet 7.5 MG Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Modafinil Modafinil Oral Tablet 100 MG Tier 1 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Modafinil Modafinil Oral Tablet 200 MG Tier 1 x x ANTIVIRALS Ribavirin (Hepatitis C) Moderiba 1200 Dose Pack Oral Tablet 600 MG Tier 2 x x ANTIVIRALS Ribavirin (Hepatitis C) Moderiba 800 Dose Pack Oral Tablet 400 MG Tier 2 x x ANTIVIRALS Ribavirin (Hepatitis C) Moderiba Oral Miscellaneous 200 & 400 MG Tier 2 x x ANTIVIRALS Ribavirin (Hepatitis C) Moderiba Oral Miscellaneous 400 & 600 MG Tier 2 x x ANTIVIRALS Ribavirin (Hepatitis C) Moderiba Oral Tablet 200 MG Tier 1 x x HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

CONTRACEPTIVES Norethindrone & Eth Estradiol Modicon (28) Oral Tablet 0.5‐35 MG‐MCG Tier 3 ANTIHYPERTENSIVES Moexipril HCl Moexipril HCl Oral Tablet 15 MG Tier 1 ANTIHYPERTENSIVES Moexipril HCl Moexipril HCl Oral Tablet 7.5 MG Tier 1 ANTIHYPERTENSIVES Moexipril‐Hydrochlorothiazide Moexipril‐Hydrochlorothiazide Oral Tablet 15‐12.5 MG Tier 1 ANTIHYPERTENSIVES Moexipril‐Hydrochlorothiazide Moexipril‐Hydrochlorothiazide Oral Tablet 15‐25 MG Tier 1 ANTIHYPERTENSIVES Moexipril‐Hydrochlorothiazide Moexipril‐Hydrochlorothiazide Oral Tablet 7.5‐12.5 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Molindone HCl Molindone HCl Oral Tablet 10 MG Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Molindone HCl Molindone HCl Oral Tablet 25 MG Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Molindone HCl Molindone HCl Oral Tablet 5 MG Tier 3 DERMATOLOGICALS Mometasone Furoate Mometasone Furoate External Cream 0.1 % Tier 1 DERMATOLOGICALS Mometasone Furoate Mometasone Furoate External Ointment 0.1 % Tier 1 DERMATOLOGICALS Mometasone Furoate Mometasone Furoate External Solution 0.1 % Tier 1 TETRACYCLINES Doxycycline (Monohydrate) Mondoxyne NL Oral Capsule 100 MG Tier 1 TETRACYCLINES Doxycycline (Monohydrate) Mondoxyne NL Oral Capsule 50 MG Tier 1 TETRACYCLINES Doxycycline (Monohydrate) Mondoxyne NL Oral Capsule 75 MG Tier 1 TETRACYCLINES Doxycycline (Monohydrate) Monodox Oral Capsule 100 MG Tier 3 TETRACYCLINES Doxycycline (Monohydrate) Monodox Oral Capsule 75 MG Tier 3 LOCAL ANESTHETICS‐Parenteral Lidocaine HCl (Local Anesth.) Monoject Bone Marrow Biopsy Injection Kit 1 % Tier 3 x ANTICOAGULANTS Heparin Sodium (Porcine) Lock Flush Monoject Flush Syr/Hep Lock Intravenous Solution 10 UNIT/ML Tier 1 x ANTICOAGULANTS Heparin Sodium (Porcine) Lock Flush Monoject Flush Syr/Hep Lock Intravenous Solution 100 UNIT/ML Tier 1 x MINERALS & ELECTROLYTES Sodium Chloride Flush Monoject Flush Syringe Intravenous Solution 0.9 % Tier 1 x MEDICAL DEVICES AND SUPPLIES Needle (Disp) 16 G Monoject Hypodermic Needle Miscellaneous 16G X 1‐1/2" Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Disp) 18 G Monoject Hypodermic Needle Miscellaneous 18G X 1" Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Disp) 18 G Monoject Hypodermic Needle Miscellaneous 18G X 1‐1/2" Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Disp) 19 G Monoject Hypodermic Needle Miscellaneous 19G X 1" Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Disp) 19 G Monoject Hypodermic Needle Miscellaneous 19G X 1‐1/2" Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Disp) 20 G Monoject Hypodermic Needle Miscellaneous 20G X 1" Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Disp) 20 G Monoject Hypodermic Needle Miscellaneous 20G X 1‐1/2" Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Disp) 21 G Monoject Hypodermic Needle Miscellaneous 21G X 1" Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Disp) 21 G Monoject Hypodermic Needle Miscellaneous 21G X 1‐1/2" Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Disp) 22 G Monoject Hypodermic Needle Miscellaneous 22G X 1" Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Disp) 22 G Monoject Hypodermic Needle Miscellaneous 22G X 1‐1/2" Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Disp) 23 G Monoject Hypodermic Needle Miscellaneous 23G X 1" Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Disp) 25 G Monoject Hypodermic Needle Miscellaneous 25G X 1" Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Disp) 25 G Monoject Hypodermic Needle Miscellaneous 25G X 1‐1/2" Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Disp) 25 G Monoject Hypodermic Needle Miscellaneous 25G X 5/8" Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Disp) 27 G Monoject Hypodermic Needle Miscellaneous 27G X 1/2" Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Disp) 30 G Monoject Hypodermic Needle Miscellaneous 30G X 3/4" Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Monoject Insulin Syringe Miscellaneous 25G X 5/8" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Monoject Insulin Syringe Miscellaneous 27G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Monoject Insulin Syringe Miscellaneous 28G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Monoject Insulin Syringe Miscellaneous 28G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Monoject Insulin Syringe Miscellaneous 29G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Monoject Insulin Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Monoject Insulin Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Monoject Insulin Syringe Miscellaneous 30G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Monoject Insulin Syringe Miscellaneous 30G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Monoject Insulin Syringe Miscellaneous 30G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Monoject Insulin Syringe Miscellaneous 31G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringes (Disposable) Monoject Insulin Syringe Miscellaneous U‐100 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Syringe (Disposable) Monoject Piston Syringe Miscellaneous 140 ML Tier 3 MINERALS & ELECTROLYTES Sodium Chloride Flush Monoject Sodium Chloride Flush Intravenous Solution 0.9 % Tier 1 x MEDICAL DEVICES AND SUPPLIES Syringe (Disposable) Monoject Syringe Cath Tip Miscellaneous 60 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Disposable) Monoject Syringe Ecc Luer Miscellaneous 35 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Disposable) Monoject Syringe Eccentric Tip Miscellaneous 12 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Disposable) Monoject Syringe Luer Lock Miscellaneous 6 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 12 ML Monoject Syringe Miscellaneous 18G X 1" 12 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 3 ML Monoject Syringe Miscellaneous 20G X 1" 3 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 12 ML Monoject Syringe Miscellaneous 20G X 1‐1/2" 12 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 3 ML Monoject Syringe Miscellaneous 20G X 1‐1/2" 3 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 6 ML Monoject Syringe Miscellaneous 20G X 1‐1/2" 6 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 12 ML Monoject Syringe Miscellaneous 21G X 1" 12 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 3 ML Monoject Syringe Miscellaneous 21G X 1" 3 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 6 ML Monoject Syringe Miscellaneous 21G X 1" 6 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 12 ML Monoject Syringe Miscellaneous 21G X 1‐1/2" 12 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 3 ML Monoject Syringe Miscellaneous 21G X 1‐1/2" 3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 6 ML Monoject Syringe Miscellaneous 21G X 1‐1/2" 6 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 3 ML Monoject Syringe Miscellaneous 22G X 1" 3 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 3 ML Monoject Syringe Miscellaneous 22G X 1‐1/2" 3 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 3 ML Monoject Syringe Miscellaneous 23G X 1" 3 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 3 ML Monoject Syringe Miscellaneous 25G X 1" 3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 3 ML Monoject Syringe Miscellaneous 25G X 5/8" 3 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 3 ML Monoject Syringe Miscellaneous 27G X 1‐1/4" 3 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Disposable) Monoject Syringe Miscellaneous 3 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Disposable) Monoject Syringe Reg Luer Miscellaneous 12 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Disposable) Monoject Syringe Regular Tip Miscellaneous 3 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Disposable) Monoject TB Syringe Miscellaneous 1 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Monoject Ultra Comfort Syringe Miscellaneous 28G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Monoject Ultra Comfort Syringe Miscellaneous 28G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Monoject Ultra Comfort Syringe Miscellaneous 29G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Monoject Ultra Comfort Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Monoject Ultra Comfort Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Monoject Ultra Comfort Syringe Miscellaneous 30G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Monoject Ultra Comfort Syringe Miscellaneous 30G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Monoject Ultra Comfort Syringe Miscellaneous 30G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Monoject Ultra Comfort Syringe Miscellaneous 31G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Monoject Ultra Comfort Syringe Miscellaneous 31G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Monolet Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Monolet OPD Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Monolettor Safety Lancets Miscellaneous Tier 2 CONTRACEPTIVES Norgestimate‐Ethinyl Estradiol Mono‐Linyah Oral Tablet 0.25‐35 MG‐MCG Tier 1 CONTRACEPTIVES Norgestimate‐Ethinyl Estradiol MonoNessa Oral Tablet 0.25‐35 MG‐MCG Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Montelukast Sodium Montelukast Sodium Oral Packet 4 MG Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Montelukast Sodium Montelukast Sodium Oral Tablet 10 MG Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Montelukast Sodium Montelukast Sodium Oral Tablet Chewable 4 MG Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Montelukast Sodium Montelukast Sodium Oral Tablet Chewable 5 MG Tier 1 URINARY ANTI‐INFECTIVES Fosfomycin Tromethamine Monurol Oral Packet 3 GM Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Moore Mono Insulin Syringe Miscellaneous 28G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Moore Mono Insulin Syringe Miscellaneous 28G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Moore Mono Insulin Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Moore Mono Insulin Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 TETRACYCLINES Doxycycline Hyclate w/ Cleanser Morgidox Combination Kit 1 x 100 MG Tier 3 TETRACYCLINES Doxycycline Hyclate w/ Cleanser Morgidox Combination Kit 2 x 100 MG Tier 3 TETRACYCLINES Doxycycline Hyclate Morgidox Oral Capsule 100 MG Tier 1 ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate (Concentrate) Oral Solution 10 MG/0.5ML Tier 1 x ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML Tier 1 x ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML Tier 1 x ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate (PF) Intravenous Solution 10 MG/ML Tier 1 x ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate (PF) Intravenous Solution 10 MG/ML Tier 3 x ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate (PF) Intravenous Solution 2 MG/ML Tier 3 x ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate (PF) Intravenous Solution 4 MG/ML Tier 1 x ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate (PF) Intravenous Solution 4 MG/ML Tier 3 x HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate (PF) Intravenous Solution 8 MG/ML Tier 1 x ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate (PF) Intravenous Solution 8 MG/ML Tier 3 x ANALGESICS ‐ OPIOID Morphine Sulfate Beads Morphine Sulfate ER Beads Oral Capsule Extended Release 24 Hour 120 MG Tier 3 x ANALGESICS ‐ OPIOID Morphine Sulfate Beads Morphine Sulfate ER Beads Oral Capsule Extended Release 24 Hour 30 MG Tier 3 x ANALGESICS ‐ OPIOID Morphine Sulfate Beads Morphine Sulfate ER Beads Oral Capsule Extended Release 24 Hour 45 MG Tier 3 x ANALGESICS ‐ OPIOID Morphine Sulfate Beads Morphine Sulfate ER Beads Oral Capsule Extended Release 24 Hour 60 MG Tier 3 x ANALGESICS ‐ OPIOID Morphine Sulfate Beads Morphine Sulfate ER Beads Oral Capsule Extended Release 24 Hour 75 MG Tier 3 x ANALGESICS ‐ OPIOID Morphine Sulfate Beads Morphine Sulfate ER Beads Oral Capsule Extended Release 24 Hour 90 MG Tier 3 x ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate ER Oral Capsule Extended Release 24 Hour 10 MG Tier 1 x ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate ER Oral Capsule Extended Release 24 Hour 100 MG Tier 1 x ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate ER Oral Capsule Extended Release 24 Hour 20 MG Tier 1 x ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate ER Oral Capsule Extended Release 24 Hour 30 MG Tier 1 x ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate ER Oral Capsule Extended Release 24 Hour 50 MG Tier 1 x ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate ER Oral Capsule Extended Release 24 Hour 60 MG Tier 1 x ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate ER Oral Capsule Extended Release 24 Hour 80 MG Tier 1 x ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate ER Oral Tablet Extended Release 100 MG Tier 1 x ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate ER Oral Tablet Extended Release 15 MG Tier 1 x ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate ER Oral Tablet Extended Release 200 MG Tier 1 x ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate ER Oral Tablet Extended Release 30 MG Tier 1 x ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate ER Oral Tablet Extended Release 60 MG Tier 1 x ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate Injection Solution 15 MG/ML Tier 3 x ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate Injection Solution 8 MG/ML Tier 1 x ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate Intramuscular Device 10 MG/0.7ML Tier 3 x ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate Intravenous Solution 1 MG/ML Tier 1 x ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate Intravenous Solution 25 MG/ML Tier 3 x ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate Intravenous Solution 50 MG/ML Tier 3 x ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate Oral Solution 10 MG/5ML Tier 1 x ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate Oral Solution 20 MG/5ML Tier 1 x ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate Oral Tablet 15 MG Tier 2 x ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate Oral Tablet 30 MG Tier 2 x ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate Powder Tier 3 x ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate Rectal Suppository 10 MG Tier 2 x ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate Rectal Suppository 20 MG Tier 2 x ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate Rectal Suppository 30 MG Tier 2 x ANALGESICS ‐ OPIOID Morphine Sulfate Morphine Sulfate Rectal Suppository 5 MG Tier 2 x ANTIDIARRHEALS Difenoxin w/ Atropine Motofen Oral Tablet 1‐0.025 MG Tier 3 GASTROINTESTINAL AGENTS ‐ MISC. Naloxegol Oxalate Movantik Oral Tablet 12.5 MG Tier 2 x x GASTROINTESTINAL AGENTS ‐ MISC. Naloxegol Oxalate Movantik Oral Tablet 25 MG Tier 2 x x LAXATIVES PEG 3350‐KCl‐NaCl‐Na Sulfate‐Na Ascorbate‐Ascorbic Acid MoviPrep Oral Solution Reconstituted 100 GM Tier 3 PENICILLINS Amoxicillin Moxatag Oral Tablet Extended Release 24 Hour 775 MG Tier 3 OPHTHALMIC AGENTS Moxifloxacin HCl (Ophth) Moxeza Ophthalmic Solution 0.5 % Tier 2 FLUOROQUINOLONES Moxifloxacin HCl Moxifloxacin HCl Oral Tablet 400 MG Tier 1 ANALGESICS ‐ OPIOID Morphine Sulfate MS Contin Oral Tablet Extended Release 100 MG Tier 3 x ANALGESICS ‐ OPIOID Morphine Sulfate MS Contin Oral Tablet Extended Release 15 MG Tier 3 x ANALGESICS ‐ OPIOID Morphine Sulfate MS Contin Oral Tablet Extended Release 200 MG Tier 3 x ANALGESICS ‐ OPIOID Morphine Sulfate MS Contin Oral Tablet Extended Release 30 MG Tier 3 x ANALGESICS ‐ OPIOID Morphine Sulfate MS Contin Oral Tablet Extended Release 60 MG Tier 3 x MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 MS Insulin Syringe Miscellaneous 31G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 MS Insulin Syringe Miscellaneous 31G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 MS Insulin Syringe Miscellaneous 31G X 5/16" 1 ML Tier 2 MOUTH/THROAT/DENTAL AGENTS Oral Wound Care Products Mucotrol Mouth/Throat Wafer Tier 3 MOUTH/THROAT/DENTAL AGENTS Oral Wound Care Products MuGard Mouth/Throat Liquid Tier 3 ANTIARRHYTHMICS Dronedarone HCl Multaq Oral Tablet 400 MG Tier 3 x MULTIVITAMINS Pediatric Multivitamins w/Fl Multi Vit/Fl Oral Tablet Chewable 0.25 MG Tier 1 MULTIVITAMINS Pediatric Multivitamins w/Fl Multi Vita‐Bets/Fluoride Oral Tablet Chewable 0.25 MG Tier 1 MULTIVITAMINS Pediatric Multivitamins w/Fl Multi Vitamin/Fluoride Oral Tablet Chewable 0.25 MG Tier 1 MULTIVITAMINS Pediatric Multivitamins w/Fl Multi Vitamin/Fluoride Oral Tablet Chewable 1 MG Tier 1 MEDICAL DEVICES AND SUPPLIES Syringe (Reusable) Multifit Reusable Syringe Miscellaneous 10 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Reusable) Multifit Reusable Syringe Miscellaneous 2 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Reusable) Multifit Reusable Syringe Miscellaneous 20 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Reusable) Multifit Reusable Syringe Miscellaneous 3 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Reusable) Multifit Reusable Syringe Miscellaneous 30 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Reusable) Multifit Reusable Syringe Miscellaneous 5 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Reusable) Multifit Reusable Syringe Miscellaneous 50 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Reusable) Multifit Reusable TB Syringe Miscellaneous 10 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Reusable) Multifit Reusable TB Syringe Miscellaneous 2 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Reusable) Multifit Reusable TB Syringe Miscellaneous 20 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Reusable) Multifit Reusable TB Syringe Miscellaneous 3 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Reusable) Multifit Reusable TB Syringe Miscellaneous 5 ML Tier 3 HEMATOPOIETIC AGENTS Fe Asparto Gly‐Succinic Acd‐Vit C‐Threonic Acd‐Vit B12‐FA Multigen Folic Oral Tablet 70‐150‐2‐1 MG Tier 3 HEMATOPOIETIC AGENTS Fe Asparto Gly‐Succin Ac‐C‐Threonic Ac‐B12‐Des Stom Subst Multigen Oral Tablet 70 MG Tier 3 HEMATOPOIETIC AGENTS Fe Asparto Gly‐Fe Fumarate‐Succ Acd‐C‐Threonic Acd‐B12‐FA Multigen Plus Oral Tablet 50‐101‐1 MG Tier 3 DIAGNOSTIC PRODUCTS Gadobenate Dimeglumine MultiHance Intravenous Solution 529 MG/ML Tier 3 x MULTIVITAMINS Pediatric Multivitamins w/Fl Multiple Vitamins/Fluoride Oral Tablet Chewable 1 MG Tier 1 CORTICOSTEROIDS Methylprednisolone Acetate w/ Lidocaine Multi‐Specialty Injection Kit 40 & 1 MG/ML‐% Tier 3 x MULTIVITAMINS Pediatric Multivitamins w/Fl Multi‐Vit/Fluoride Oral Solution 0.25 MG/ML Tier 1 MULTIVITAMINS Pediatric Multivitamins w/Fl Multi‐Vit/Fluoride Oral Solution 0.5 MG/ML Tier 1 MULTIVITAMINS Ped Multivitamins w/Fl & Iron Multi‐Vit/Fluoride/Iron Oral Solution 0.25‐10 MG/ML Tier 1 MULTIVITAMINS Pediatric Multivitamins w/Fl Multi‐Vitamin/Fluoride Oral Solution 0.25 MG/ML Tier 1 MULTIVITAMINS Pediatric Multivitamins w/Fl Multivitamin/Fluoride Oral Tablet Chewable 0.25 MG Tier 1 MULTIVITAMINS Pediatric Multivitamins w/Fl Multivitamin/Fluoride Oral Tablet Chewable 0.5 MG Tier 1 MULTIVITAMINS Pediatric Multivitamins w/Fl Multi‐Vitamin/Fluoride Oral Tablet Chewable 0.5 MG Tier 1 MULTIVITAMINS Pediatric Multivitamins w/Fl Multivitamin/Fluoride Oral Tablet Chewable 1 MG Tier 1 MULTIVITAMINS Ped Multivitamins w/Fl & Iron Multi‐Vitamin/Fluoride/Iron Oral Solution 0.25‐10 MG/ML Tier 1 MULTIVITAMINS Pediatric Multivitamins w/Fl Multi‐Vitamins/Fluoride Oral Solution 0.5 MG/ML Tier 1 MULTIVITAMINS Pediatric Multivitamins w/Fl Multivitamins/Fluoride Oral Tablet Chewable 0.25 MG Tier 1 MULTIVITAMINS Pediatric Multivitamins w/Fl Multivitamins/Fluoride Oral Tablet Chewable 0.5 MG Tier 1 MULTIVITAMINS Pediatric Multivitamins w/Fl Multivitamins/Fluoride Oral Tablet Chewable 1 MG Tier 1 MULTIVITAMINS Pediatric Multivitamins w/Fl Mult‐Vitamin/Fluoride Oral Tablet Chewable 0.5 MG Tier 1 DERMATOLOGICALS Mupirocin Calcium (Topical) Mupirocin Calcium External Cream 2 % Tier 1 DERMATOLOGICALS Mupirocin Mupirocin External Ointment 2 % Tier 1 CARDIOVASCULAR AGENTS ‐ MISC. Alprostadil (Vasodilator) Muse Urethral Pellet 1000 MCG Tier 3 x x CARDIOVASCULAR AGENTS ‐ MISC. Alprostadil (Vasodilator) Muse Urethral Pellet 125 MCG Tier 3 x x CARDIOVASCULAR AGENTS ‐ MISC. Alprostadil (Vasodilator) Muse Urethral Pellet 250 MCG Tier 3 x x CARDIOVASCULAR AGENTS ‐ MISC. Alprostadil (Vasodilator) Muse Urethral Pellet 500 MCG Tier 3 x x MULTIVITAMINS Pediatric Multivitamins w/Fl MVC‐Fluoride Oral Tablet Chewable 0.25 MG Tier 1 MULTIVITAMINS Pediatric Multivitamins w/Fl MVC‐Fluoride Oral Tablet Chewable 0.5 MG Tier 1 MULTIVITAMINS Pediatric Multivitamins w/Fl MVC‐Fluoride Oral Tablet Chewable 1 MG Tier 1 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐Folic Acid M‐Vit Oral Tablet Tier 3 CONTRACEPTIVES Levonorgestrel (Emergency OC) My Way Oral Tablet 1.5 MG Tier 1 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Metreleptin Myalept Subcutaneous Solution Reconstituted 11.3 MG Tier 2 x ANTIMYCOBACTERIAL AGENTS Ethambutol HCl Myambutol Oral Tablet 100 MG Tier 3 ANTIMYCOBACTERIAL AGENTS Ethambutol HCl Myambutol Oral Tablet 400 MG Tier 3 ANTIFUNGALS Micafungin Sodium Mycamine Intravenous Solution Reconstituted 100 MG Tier 3 x ANTIFUNGALS Micafungin Sodium Mycamine Intravenous Solution Reconstituted 50 MG Tier 3 x ANTIMYCOBACTERIAL AGENTS Rifabutin Mycobutin Oral Capsule 150 MG Tier 3 ASSORTED CLASSES Mycophenolate Mofetil Mycophenolate Mofetil Oral Capsule 250 MG Tier 1 ASSORTED CLASSES Mycophenolate Mofetil Mycophenolate Mofetil Oral Suspension Reconstituted 200 MG/ML Tier 1 ASSORTED CLASSES Mycophenolate Mofetil Mycophenolate Mofetil Oral Tablet 500 MG Tier 1 ASSORTED CLASSES Mycophenolate Sodium Mycophenolic Acid Oral Tablet Delayed Release 180 MG Tier 1 ASSORTED CLASSES Mycophenolate Sodium Mycophenolic Acid Oral Tablet Delayed Release 360 MG Tier 1 OPHTHALMIC AGENTS Tropicamide Mydriacyl Ophthalmic Solution 1 % Tier 3 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

HEMATOPOIETIC AGENTS Iron Polysaccharide Complex‐Vit B12‐Folic Acid Myferon 150 Forte Oral Capsule 150‐25‐1 MG‐MCG‐MG Tier 1 ASSORTED CLASSES Mycophenolate Sodium Myfortic Oral Tablet Delayed Release 180 MG Tier 2 x ASSORTED CLASSES Mycophenolate Sodium Myfortic Oral Tablet Delayed Release 360 MG Tier 2 x MEDICAL DEVICES AND SUPPLIES Lancets MyGlucoHealth Lancets 30G Miscellaneous Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood MyGlucoHealth Test In Vitro Strip Tier 3 MULTIVITAMINS Pediatric Vitamins ACD Fluoride & Iron MyKidz Iron FL Oral Suspension 0.25‐10 MG/2ML Tier 2 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Busulfan Myleran Oral Tablet 2 MG Tier 2 x MULTIVITAMINS Prenatal Vit w/ Docusate‐Iron Carbonyl‐Folic Acid Mynatal Advance Oral Tablet Tier 2 MULTIVITAMINS Prenatal Multivit‐Min w/Fe‐FA Mynatal Oral Capsule Tier 2 MULTIVITAMINS Prenatal Vit w/ Docusate‐Iron Carbonyl‐Folic Acid Mynatal Oral Tablet 90‐1 MG Tier 2 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐Folic Acid Mynatal Plus Oral Tablet Tier 3 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐Folic Acid Mynatal‐Z Oral Tablet Tier 3 MULTIVITAMINS Prenatal Vit w/ Docusate‐Fe Fumarate‐Folic Acid Mynate 90 Plus Oral Tablet Extended Release Tier 3 MULTIVITAMINS B‐Complex w/ C & Folic Acid Mynephrocaps Oral Capsule 1 MG Tier 1 DERMATOLOGICALS Isotretinoin Myorisan Oral Capsule 10 MG Tier 1 DERMATOLOGICALS Isotretinoin Myorisan Oral Capsule 20 MG Tier 1 DERMATOLOGICALS Isotretinoin Myorisan Oral Capsule 30 MG Tier 1 DERMATOLOGICALS Isotretinoin Myorisan Oral Capsule 40 MG Tier 1 OTIC AGENTS Benzocaine‐Chloroxylenol‐Hydrocortisone MyOxin Otic Suspension 15‐1‐10 MG/ML Tier 3 URINARY ANTISPASMODICS Mirabegron Myrbetriq Oral Tablet Extended Release 24 Hour 25 MG Tier 3 x URINARY ANTISPASMODICS Mirabegron Myrbetriq Oral Tablet Extended Release 24 Hour 50 MG Tier 3 PHARMACEUTICAL ADJUVANTS Polyoxyl 40 Stearate MYRJ 53 Powder Tier 3 ANTICONVULSANTS Primidone Mysoline Oral Tablet 250 MG Tier 3 ANTICONVULSANTS Primidone Mysoline Oral Tablet 50 MG Tier 3 CONTRACEPTIVES Levonorgestrel‐Eth Estradiol (Triphasic) Myzilra Oral Tablet Tier 1 HEMATOPOIETIC AGENTS Sodium Ferric Gluconate Complex in Na Ferric Gluc Cplx in Sucrose Intravenous Solution 12.5 MG/ML Tier 1 x ANALGESICS ‐ ANTI‐INFLAMMATORY Nabumetone Nabumetone Oral Tablet 500 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Nabumetone Nabumetone Oral Tablet 750 MG Tier 1 CHEMICALS Nicotinamide Adenine Dinucleotide (NADH), Disodium Trihydr NADH Disodium Powder Tier 3 CHEMICALS Nicotinamide Adenine Dinucleotide (NADH), Disodium Trihydr NADH Disodium Trihydrate Powder Tier 3 BETA BLOCKERS Nadolol Nadolol Oral Tablet 20 MG Tier 1 BETA BLOCKERS Nadolol Nadolol Oral Tablet 40 MG Tier 1 BETA BLOCKERS Nadolol Nadolol Oral Tablet 80 MG Tier 1 ANTIHYPERTENSIVES Nadolol & Bendroflumethiazide Nadolol‐Bendroflumethiazide Oral Tablet 40‐5 MG Tier 1 ANTIHYPERTENSIVES Nadolol & Bendroflumethiazide Nadolol‐Bendroflumethiazide Oral Tablet 80‐5 MG Tier 1 PENICILLINS Nafcillin Sodium Nafcillin Sodium Injection Solution Reconstituted 1 GM Tier 1 x PENICILLINS Nafcillin Sodium Nafcillin Sodium Injection Solution Reconstituted 10 GM Tier 1 x PENICILLINS Nafcillin Sodium Nafcillin Sodium Injection Solution Reconstituted 2 GM Tier 1 x PENICILLINS Nafcillin Sodium Nafcillin Sodium Intravenous Solution Reconstituted 1 GM Tier 3 x PENICILLINS Nafcillin Sodium Nafcillin Sodium Intravenous Solution Reconstituted 2 GM Tier 3 x MOUTH/THROAT/DENTAL AGENTS Sodium Fluoride‐Phosphoric Acid NaFrinse Daily Acidulated Mouth/Throat Solution Reconstituted 1 MG/5ML Tier 3 MOUTH/THROAT/DENTAL AGENTS Sodium Fluoride (Dental) NaFrinse Daily/Neutral Mouth/Throat Solution Reconstituted 0.05 % Tier 3 MINERALS & ELECTROLYTES Sodium Fluoride NaFrinse Drops Oral Solution 0.275 (0.125 F) MG/DROP Tier 1 MINERALS & ELECTROLYTES Sodium Fluoride NaFrinse Oral Tablet Chewable 2.2 (1 F) MG Tier 1 MOUTH/THROAT/DENTAL AGENTS Sodium Fluoride (Dental) NaFrinse Weekly Mouth/Throat Solution Reconstituted 0.2 % Tier 3 DERMATOLOGICALS Naftifine HCl Naftifine HCl External Cream 1 % Tier 3 DERMATOLOGICALS Naftifine HCl Naftifine HCl External Cream 2 % Tier 1 DERMATOLOGICALS Naftifine HCl Naftin External Cream 2 % Tier 3 DERMATOLOGICALS Naftifine HCl Naftin External Gel 1 % Tier 3 DERMATOLOGICALS Naftifine HCl Naftin External Gel 2 % Tier 3 ANALGESICS ‐ OPIOID Nalbuphine HCl Nalbuphine HCl Injection Solution 10 MG/ML Tier 1 x ANALGESICS ‐ OPIOID Nalbuphine HCl Nalbuphine HCl Injection Solution 20 MG/ML Tier 1 x ANALGESICS ‐ ANTI‐INFLAMMATORY Fenoprofen Calcium Nalfon Oral Capsule 400 MG Tier 3 ANTIDOTES Naloxone HCl Naloxone HCl Injection Solution 0.4 MG/ML Tier 1 x ANTIDOTES Naloxone HCl Naloxone HCl Injection Solution 1 MG/ML Tier 3 x ANTIDOTES Naltrexone HCl Naltrexone HCl Oral Tablet 50 MG Tier 1 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Memantine HCl Namenda Oral Solution 10 MG/5ML Tier 2 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Memantine HCl Namenda Oral Tablet 10 MG Tier 2 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Memantine HCl Namenda Oral Tablet 5 MG Tier 2 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Memantine HCl Namenda Titration Pak Oral Tablet 5 (28)‐10 (21) MG Tier 2 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Memantine HCl Namenda XR Oral Capsule Extended Release 24 Hour 14 MG Tier 2 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Memantine HCl Namenda XR Oral Capsule Extended Release 24 Hour 21 MG Tier 2 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Memantine HCl Namenda XR Oral Capsule Extended Release 24 Hour 28 MG Tier 2 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Memantine HCl Namenda XR Oral Capsule Extended Release 24 Hour 7 MG Tier 2 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Memantine HCl Namenda XR Titration Pack Oral Capsule Extended Release 24 Hour 7 & 14 & 21 &28 MG Tier 2 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Memantine HCl‐Donepezil HCl Namzaric Oral Capsule Extended Release 24 Hour 14‐10 MG Tier 3 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Memantine HCl‐Donepezil HCl Namzaric Oral Capsule Extended Release 24 Hour 28‐10 MG Tier 3 x OPHTHALMIC AGENTS Naphazoline HCl Naphazoline HCl Ophthalmic Solution 0.1 % Tier 2 ANALGESICS ‐ ANTI‐INFLAMMATORY Naproxen Sodium Naprelan Oral Tablet Extended Release 24 Hour 375 MG Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Naproxen Sodium Naprelan Oral Tablet Extended Release 24 Hour 500 MG Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Naproxen Sodium Naprelan Oral Tablet Extended Release 24 Hour 750 MG Tier 3 DERMATOLOGICALS Naproxen (Topical) NaPro External Cream 15 % Tier 3 DERMATOLOGICALS Naproxen‐Capsaicin‐Menthol NaproPax Combination Therapy Pack 500 & 0.0375‐5 MG & % Tier 3 x ANALGESICS ‐ ANTI‐INFLAMMATORY Naproxen Naprosyn Oral Tablet 250 MG Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Naproxen Naprosyn Oral Tablet 500 MG Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Naproxen w/ Liniment Naproxen Comfort Pac Combination Kit 500 MG Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Naproxen Naproxen DR Oral Tablet Delayed Release 375 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Naproxen Naproxen DR Oral Tablet Delayed Release 500 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Naproxen Naproxen Kit Oral Tablet 500 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Naproxen Naproxen Oral Suspension 125 MG/5ML Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Naproxen Naproxen Oral Tablet 250 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Naproxen Naproxen Oral Tablet 375 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Naproxen Naproxen Oral Tablet 500 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Naproxen Naproxen Powder Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Naproxen Sodium Naproxen Sodium ER Oral Tablet Extended Release 24 Hour 375 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Naproxen Sodium Naproxen Sodium ER Oral Tablet Extended Release 24 Hour 500 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Naproxen Sodium Naproxen Sodium Oral Tablet 220 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Naproxen Sodium Naproxen Sodium Oral Tablet 275 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Naproxen Sodium Naproxen Sodium Oral Tablet 550 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Naproxen Sodium Naproxen Sodium Powder Tier 3 DERMATOLOGICALS Naproxen‐Capsaicin‐Menthol NaproxenPAX Combination Therapy Pack 500 & 0.0375‐5 MG & % Tier 3 x MIGRAINE PRODUCTS Naratriptan HCl Naratriptan HCl Oral Tablet 1 MG Tier 1 x MIGRAINE PRODUCTS Naratriptan HCl Naratriptan HCl Oral Tablet 2.5 MG Tier 1 x ANTIDOTES Naloxone HCl Narcan Nasal Liquid 4 MG/0.1ML Tier 3 x ANTIDEPRESSANTS Phenelzine Sulfate Nardil Oral Tablet 15 MG Tier 3 LOCAL ANESTHETICS‐Parenteral Ropivacaine HCl Naropin Injection Solution 10 MG/ML Tier 3 x LOCAL ANESTHETICS‐Parenteral Ropivacaine HCl Naropin Injection Solution 2 MG/ML Tier 3 x LOCAL ANESTHETICS‐Parenteral Ropivacaine HCl Naropin Injection Solution 5 MG/ML Tier 3 x LOCAL ANESTHETICS‐Parenteral Ropivacaine HCl Naropin Injection Solution 7.5 MG/ML Tier 3 x HEMATOPOIETIC AGENTS Cyanocobalamin Nascobal Nasal Solution 500 MCG/0.1ML Tier 3 NASAL AGENTS ‐ SYSTEMIC AND TOPICAL Mometasone Furoate (Nasal) Nasonex Nasal Suspension 50 MCG/ACT Tier 2 MULTIVITAMINS Prenatal Vit w/ Fe Fum‐Fe Bisglycinate Chelate‐Folic Acid NataChew Oral Tablet Chewable 28‐1 MG Tier 2 OPHTHALMIC AGENTS Natamycin Natacyn Ophthalmic Suspension 5 % Tier 2 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐Folic Acid Natalvit Oral Tablet Tier 2 CONTRACEPTIVES Estradiol Valerate‐Dienogest Natazia Oral Tablet 3/2‐2/2‐3/1 MG Tier 2 ANTIDIABETICS Nateglinide Nateglinide Oral Tablet 120 MG Tier 1 ANTIDIABETICS Nateglinide Nateglinide Oral Tablet 60 MG Tier 1 MULTIVITAMINS Prenatal without Vit A w/ Fe Fum‐FA‐Omega Fatty Acids Natelle ONE Oral Capsule 28‐1‐250 MG Tier 2 ANDROGENS‐ANABOLIC Testosterone Natesto Nasal Gel 5.5 MG/ACT Tier 3 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Parathyroid Hormone (Recombinant) Natpara Subcutaneous Cartridge 100 MCG Tier 2 x x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Parathyroid Hormone (Recombinant) Natpara Subcutaneous Cartridge 25 MCG Tier 2 x x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Parathyroid Hormone (Recombinant) Natpara Subcutaneous Cartridge 50 MCG Tier 2 x x HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Parathyroid Hormone (Recombinant) Natpara Subcutaneous Cartridge 75 MCG Tier 2 x x THYROID AGENTS Thyroid Nature‐Throid Oral Tablet 113.75 MG Tier 3 THYROID AGENTS Thyroid Nature‐Throid Oral Tablet 130 MG Tier 3 THYROID AGENTS Thyroid Nature‐Throid Oral Tablet 146.25 MG Tier 3 THYROID AGENTS Thyroid Nature‐Throid Oral Tablet 16.25 MG Tier 3 THYROID AGENTS Thyroid Nature‐Throid Oral Tablet 162.5 MG Tier 3 THYROID AGENTS Thyroid Nature‐Throid Oral Tablet 195 MG Tier 3 THYROID AGENTS Thyroid Nature‐Throid Oral Tablet 260 MG Tier 3 THYROID AGENTS Thyroid Nature‐Throid Oral Tablet 32.5 MG Tier 3 THYROID AGENTS Thyroid Nature‐Throid Oral Tablet 325 MG Tier 3 THYROID AGENTS Thyroid Nature‐Throid Oral Tablet 48.75 MG Tier 3 THYROID AGENTS Thyroid Nature‐Throid Oral Tablet 65 MG Tier 3 THYROID AGENTS Thyroid Nature‐Throid Oral Tablet 81.25 MG Tier 3 THYROID AGENTS Thyroid Nature‐Throid Oral Tablet 97.5 MG Tier 3 DERMATOLOGICALS Levocetirizine‐Loratadine Nazirex External Cream Tier 3 ANTI‐INFECTIVE AGENTS ‐ MISC. Isethionate Nebupent Inhalation Solution Reconstituted 300 MG Tier 2 COUGH/COLD/ALLERGY Sodium Chloride (Inhalant) Nebusal Inhalation Nebulization Solution 3 % Tier 1 COUGH/COLD/ALLERGY Sodium Chloride (Inhalant) Nebusal Inhalation Nebulization Solution 6 % Tier 3 CONTRACEPTIVES Norethindrone & Eth Estradiol Necon 0.5/35 (28) Oral Tablet 0.5‐35 MG‐MCG Tier 1 CONTRACEPTIVES Norethindrone & Eth Estradiol Necon 1/35 (28) Oral Tablet 1‐35 MG‐MCG Tier 1 CONTRACEPTIVES Norethindrone & Mestranol Necon 1/50 (28) Oral Tablet 1‐50 MG‐MCG Tier 2 CONTRACEPTIVES Norethindrone‐Eth Estradiol (Biphasic) Necon 10/11 (28) Oral Tablet 35 MCG Tier 2 CONTRACEPTIVES Norethindrone‐Eth Estradiol (Triphasic) Necon 7/7/7 Oral Tablet 0.5/0.75/1‐35 MG‐MCG Tier 1 MULTIVITAMINS Prenatal without Vit A w/ Fe Fumarate‐L Methylfolate‐Omegas Neevo DHA Oral Capsule 27‐1.13 MG Tier 2 ANTIDEPRESSANTS Nefazodone HCl Nefazodone HCl Oral Tablet 100 MG Tier 3 x ANTIDEPRESSANTS Nefazodone HCl Nefazodone HCl Oral Tablet 150 MG Tier 3 x ANTIDEPRESSANTS Nefazodone HCl Nefazodone HCl Oral Tablet 200 MG Tier 3 x ANTIDEPRESSANTS Nefazodone HCl Nefazodone HCl Oral Tablet 250 MG Tier 1 x ANTIDEPRESSANTS Nefazodone HCl Nefazodone HCl Oral Tablet 50 MG Tier 1 x HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Sodium Nembutal Injection Solution 50 MG/ML Tier 3 x AMINOGLYCOSIDES Neomycin Sulfate Neomycin Sulfate Oral Tablet 500 MG Tier 1 DERMATOLOGICALS Neomycin Sulfate (Topical) Neomycin Sulfate Powder Tier 3 OPHTHALMIC AGENTS Neomycin‐Bacitracin Zn‐Polymyxin Neomycin‐Bacitracin Zn‐Polymyx Ophthalmic Ointment 5‐400‐10000 Tier 1 GENITOURINARY AGENTS ‐ MISCELLANEOUS Neomycin/Polymyxin B GU Neomycin‐Polymyxin B GU Irrigation Solution 40‐200000 Tier 1 OPHTHALMIC AGENTS Neomycin‐Polymy‐Dexameth Neomycin‐Polymyxin‐Dexameth Ophthalmic Ointment 3.5‐10000‐0.1 Tier 1 OPHTHALMIC AGENTS Neomycin‐Polymy‐Dexameth Neomycin‐Polymyxin‐Dexameth Ophthalmic Suspension 0.1 % Tier 1 OPHTHALMIC AGENTS Neomycin‐Polymy‐Dexameth Neomycin‐Polymyxin‐Dexameth Ophthalmic Suspension 3.5‐10000‐0.1 Tier 1 OPHTHALMIC AGENTS Neomycin‐Polymyxin‐Gramicidin Neomycin‐Polymyxin‐Gramicidin Ophthalmic Solution 1.75‐10000‐.025 Tier 1 OPHTHALMIC AGENTS Neomycin‐Polymyxin‐HC (Ophth) Neomycin‐Polymyxin‐HC Ophthalmic Suspension 3.5‐10000‐1 Tier 3 OTIC AGENTS Neomycin‐Polymyxin‐HC (Otic) Neomycin‐Polymyxin‐HC Otic Solution 1 % Tier 1 OTIC AGENTS Neomycin‐Polymyxin‐HC (Otic) Neomycin‐Polymyxin‐HC Otic Solution 3.5‐10000‐1 Tier 1 OTIC AGENTS Neomycin‐Polymyxin‐HC (Otic) Neomycin‐Polymyxin‐HC Otic Suspension 3.5‐10000‐1 Tier 1 OPHTHALMIC AGENTS Bacitracin‐Poly‐Neomycin‐HC Neo‐Polycin HC Ophthalmic Ointment 1 % Tier 1 OPHTHALMIC AGENTS Neomycin‐Bacitracin Zn‐Polymyxin Neo‐Polycin Ophthalmic Ointment 3.5‐400‐10000 Tier 1 ASSORTED CLASSES Cyclosporine Modified (For Microemulsion) Neoral Oral Capsule 100 MG Tier 3 ASSORTED CLASSES Cyclosporine Modified (For Microemulsion) Neoral Oral Capsule 25 MG Tier 3 ASSORTED CLASSES Cyclosporine Modified (For Microemulsion) Neoral Oral Solution 100 MG/ML Tier 3 DERMATOLOGICALS Dermatological Products, Misc. Neosalus External Cream Tier 3 DERMATOLOGICALS Dermatological Products, Misc. Neosalus External Foam Tier 3 GENITOURINARY AGENTS ‐ MISCELLANEOUS Neomycin/Polymyxin B GU Neosporin GU Irrigant Irrigation Solution 40‐200000 Tier 3 OPHTHALMIC AGENTS Neomycin‐Polymyxin‐Gramicidin Neosporin Ophthalmic Solution 1.75‐10000‐.025 Tier 3 ANTIMYASTHENIC/CHOLINERGIC AGENTS Neostigmine Methylsulfate Neostigmine Methylsulfate Injection Solution 0.5 MG/ML Tier 1 x ANTIMYASTHENIC/CHOLINERGIC AGENTS Neostigmine Methylsulfate Neostigmine Methylsulfate Injection Solution 1 MG/ML Tier 1 x ANTIMYASTHENIC/CHOLINERGIC AGENTS Neostigmine Methylsulfate Neostigmine Methylsulfate Intravenous Solution 10 MG/10ML Tier 1 x ANTIMYASTHENIC/CHOLINERGIC AGENTS Neostigmine Methylsulfate Neostigmine Methylsulfate Intravenous Solution 10 MG/10ML Tier 3 x ANTIMYASTHENIC/CHOLINERGIC AGENTS Neostigmine Methylsulfate Neostigmine Methylsulfate Intravenous Solution 5 MG/10ML Tier 1 x ANTIMYASTHENIC/CHOLINERGIC AGENTS Neostigmine Methylsulfate Neostigmine Methylsulfate Intravenous Solution 5 MG/10ML Tier 3 x DERMATOLOGICALS Neomycin‐Fluocinolone Neo‐Synalar External Cream 0.35‐0.025 % Tier 3 DERMATOLOGICALS Neomycin‐Fluocinolone & Emollient Neo‐Synalar External Kit 0.35‐0.025 % Tier 3 COUGH/COLD/ALLERGY Phenylephrine‐Chlorphen‐DM NeoTuss Plus Oral Liquid 7.5‐4‐30 MG/5ML Tier 3 MULTIVITAMINS B‐Complex w/ C‐Zn & Folic Acid Nephplex Rx Oral Tablet Tier 3 MULTIVITAMINS B‐Complex w/ C & Folic Acid Nephrocaps Oral Capsule 1 MG Tier 3 MULTIVITAMINS B‐Complex w/ C‐Biotin‐D & Folic Acid Nephrocaps QT Oral Tablet Dispersible 1 MG Tier 3 HEMATOPOIETIC AGENTS Ferrous Fumarate w/ FA‐DSS‐B Complex‐Vit C Nephron FA Oral Tablet Tier 3 MULTIVITAMINS B‐Complex w/ C & Folic Acid Nephronex Oral Tablet Tier 1 MULTIVITAMINS B‐Complex w/ C & Folic Acid Nephro‐Vite Rx Oral Tablet 1 MG Tier 3 DIURETICS Methazolamide Neptazane Oral Tablet 25 MG Tier 3 DIURETICS Methazolamide Neptazane Oral Tablet 50 MG Tier 3 LOCAL ANESTHETICS‐Parenteral Chloroprocaine HCl Nesacaine‐MPF Injection Solution 3 % Tier 3 x ANTIDIABETICS Alogliptin Benzoate Nesina Oral Tablet 12.5 MG Tier 3 xx ANTIDIABETICS Alogliptin Benzoate Nesina Oral Tablet 25 MG Tier 3 xx ANTIDIABETICS Alogliptin Benzoate Nesina Oral Tablet 6.25 MG Tier 3 xx MULTIVITAMINS Prenatal MV & Min w/o Vit A w/FE Polysac Cmplx‐FA‐CA‐Omega 3 Nestabs ABC Oral Miscellaneous 32‐1‐200 MG Tier 3 MULTIVITAMINS Prenatal Vit without Vit A w/ Fe Bisglycinate‐FA‐Omeg 3 Nestabs DHA Oral Miscellaneous 32‐1 MG Tier 2 MULTIVITAMINS Prenatal Vit without Vit A w/ Fe Bisglycinate‐Folic Acid Nestabs Oral Tablet 32‐1 MG Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets NetGroup Lancets Miscellaneous Tier 2 DERMATOLOGICALS Clindamycin Phosphate‐Benzoyl Peroxide (Refrigerate) Neuac External Gel 1.2‐5 % Tier 1 x DERMATOLOGICALS Clindamycin Phosphate‐Benzoyl Peroxide & Moisturizer Neuac External Kit 1.2‐5 % Tier 3 x HEMATOPOIETIC AGENTS Pegfilgrastim Neulasta Onpro Subcutaneous Prefilled Syringe Kit 6 MG/0.6ML Tier 2 x HEMATOPOIETIC AGENTS Pegfilgrastim Neulasta Subcutaneous Solution Prefilled Syringe 6 MG/0.6ML Tier 2 x HEMATOPOIETIC AGENTS Oprelvekin Neumega Subcutaneous Solution Reconstituted 5 MG Tier 2 x HEMATOPOIETIC AGENTS Filgrastim Neupogen Injection Solution 300 MCG/ML Tier 2 x x HEMATOPOIETIC AGENTS Filgrastim Neupogen Injection Solution 480 MCG/1.6ML Tier 2 x x HEMATOPOIETIC AGENTS Filgrastim Neupogen Injection Solution Prefilled Syringe 300 MCG/0.5ML Tier 2 x HEMATOPOIETIC AGENTS Filgrastim Neupogen Injection Solution Prefilled Syringe 480 MCG/0.8ML Tier 2 x HEMATOPOIETIC AGENTS Cyanocobalamin‐Methylcobalamin Neurin‐SL Sublingual Tablet Sublingual 600‐600 MCG Tier 3 ANTICONVULSANTS Gabapentin Neurontin Oral Capsule 100 MG Tier 3 ANTICONVULSANTS Gabapentin Neurontin Oral Capsule 300 MG Tier 3 ANTICONVULSANTS Gabapentin Neurontin Oral Capsule 400 MG Tier 3 ANTICONVULSANTS Gabapentin Neurontin Oral Solution 250 MG/5ML Tier 3 ANTICONVULSANTS Gabapentin Neurontin Oral Tablet 600 MG Tier 3 ANTICONVULSANTS Gabapentin Neurontin Oral Tablet 800 MG Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Neutek 2Tek Test In Vitro Strip Tier 3 MOUTH/THROAT/DENTAL AGENTS Sodium Fluoride (Dental) Neutral Sodium Fluoride Mouth/Throat Solution 0.2 % Tier 1 DERMATOLOGICALS Capsaicin‐Menthol Neuvaxin External Patch 0.0375‐5 % Tier 3 OPHTHALMIC AGENTS Nepafenac Nevanac Ophthalmic Suspension 0.1 % Tier 3 ANTIVIRALS Nevirapine Nevirapine ER Oral Tablet Extended Release 24 Hour 100 MG Tier 1 x ANTIVIRALS Nevirapine Nevirapine ER Oral Tablet Extended Release 24 Hour 400 MG Tier 1 x ANTIVIRALS Nevirapine Nevirapine Oral Suspension 50 MG/5ML Tier 3 x ANTIVIRALS Nevirapine Nevirapine Oral Tablet 200 MG Tier 1 x MULTIVITAMINS Prenatal Vit without Vit A w/ Fe Bisglycinate‐Folic Acid Newgen Oral Tablet 32‐1 MG Tier 2 MULTIVITAMINS Prenatal w/o Vit A w/Fe Fumarate‐Docusate Ca‐Folic Acid‐DHA Nexa Plus Oral Capsule 29‐1.25‐350 MG Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Sorafenib Tosylate NexAVAR Oral Tablet 200 MG Tier 2 x x DIAGNOSTIC PRODUCTS Glucose Blood NexGen Test In Vitro Strip Tier 3 ULCER DRUGS Esomeprazole Magnesium NexIUM Oral Capsule Delayed Release 20 MG Tier 3 x x ULCER DRUGS Esomeprazole Magnesium NexIUM Oral Capsule Delayed Release 40 MG Tier 3 x x ULCER DRUGS Esomeprazole Magnesium NexIUM Oral Packet 10 MG Tier 3 x x ULCER DRUGS Esomeprazole Magnesium NexIUM Oral Packet 2.5 MG Tier 3 x ULCER DRUGS Esomeprazole Magnesium NexIUM Oral Packet 20 MG Tier 3 x x ULCER DRUGS Esomeprazole Magnesium NexIUM Oral Packet 40 MG Tier 3 x x ULCER DRUGS Esomeprazole Magnesium NexIUM Oral Packet 5 MG Tier 3 x CONTRACEPTIVES Levonorgestrel (Emergency OC) Next Choice One Dose Oral Tablet 1.5 MG Tier 1 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ANTIHYPERLIPIDEMICS Niacin (Antihyperlipidemic) Niacin ER (Antihyperlipidemic) Oral Tablet Extended Release 1000 MG Tier 1 x ANTIHYPERLIPIDEMICS Niacin (Antihyperlipidemic) Niacin ER (Antihyperlipidemic) Oral Tablet Extended Release 500 MG Tier 1 x ANTIHYPERLIPIDEMICS Niacin (Antihyperlipidemic) Niacin ER (Antihyperlipidemic) Oral Tablet Extended Release 750 MG Tier 1 x ANTIHYPERLIPIDEMICS Niacin (Antihyperlipidemic) Niacin ER Oral Tablet Extended Release 750 MG Tier 1 x VITAMINS Niacin Niacin Oral Powder Tier 3 VITAMINS Niacin Niacin Powder Tier 3 VITAMINS Niacinamide Niacinamide Powder Tier 3 ANTIHYPERLIPIDEMICS Niacin (Antihyperlipidemic) Niacor Oral Tablet 500 MG Tier 2 x ANTIHYPERLIPIDEMICS Niacin (Antihyperlipidemic) Niaspan Oral Tablet Extended Release 1000 MG Tier 3 x ANTIHYPERLIPIDEMICS Niacin (Antihyperlipidemic) Niaspan Oral Tablet Extended Release 500 MG Tier 3 x ANTIHYPERLIPIDEMICS Niacin (Antihyperlipidemic) Niaspan Oral Tablet Extended Release 750 MG Tier 3 x MULTIVITAMINS Multiple Vitamins w/ Minerals Nicadan Oral Tablet Tier 3 CALCIUM CHANNEL BLOCKERS Nicardipine HCl NiCARdipine HCl Intravenous Solution 2.5 MG/ML Tier 1 x CALCIUM CHANNEL BLOCKERS Nicardipine HCl NiCARdipine HCl Oral Capsule 20 MG Tier 1 CALCIUM CHANNEL BLOCKERS Nicardipine HCl NiCARdipine HCl Oral Capsule 30 MG Tier 1 MULTIVITAMINS Multiple Vitamins w/ Minerals NicAzel Forte Oral Tablet Tier 3 MULTIVITAMINS Multiple Vitamins w/ Minerals Nicazel Oral Tablet Tier 3 MULTIVITAMINS Niacinamide w/ Zinc‐Copper & L‐Methylfolate Nicomide Oral Tablet 750‐25‐1.5‐0.5 MG Tier 3 MULTIVITAMINS Niacinamide w/ Zinc‐Copper‐Methylfolate‐Se‐Cr Nicomide Oral Tablet 750‐27‐2‐0.5 MG Tier 3 VITAMINS Niacinamide Nicotinamide Powder Tier 3 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Nicotrol Inhalation Inhaler 10 MG Tier 3 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Nicotine Nicotrol NS Nasal Solution 10 MG/ML Tier 3 CALCIUM CHANNEL BLOCKERS Nifedipine Nifediac CC Oral Tablet Extended Release 24 Hour 30 MG Tier 1 CALCIUM CHANNEL BLOCKERS Nifedipine Nifediac CC Oral Tablet Extended Release 24 Hour 60 MG Tier 1 CALCIUM CHANNEL BLOCKERS Nifedipine Nifedical XL Oral Tablet Extended Release 24 Hour 30 MG Tier 1 CALCIUM CHANNEL BLOCKERS Nifedipine Nifedical XL Oral Tablet Extended Release 24 Hour 60 MG Tier 1 CALCIUM CHANNEL BLOCKERS Nifedipine NIFEdipine ER Oral Tablet Extended Release 24 Hour 30 MG Tier 1 CALCIUM CHANNEL BLOCKERS Nifedipine NIFEdipine ER Oral Tablet Extended Release 24 Hour 60 MG Tier 1 CALCIUM CHANNEL BLOCKERS Nifedipine NIFEdipine ER Oral Tablet Extended Release 24 Hour 90 MG Tier 1 CALCIUM CHANNEL BLOCKERS Nifedipine NIFEdipine ER Osmotic Release Oral Tablet Extended Release 24 Hour 30 MG Tier 1 CALCIUM CHANNEL BLOCKERS Nifedipine NIFEdipine ER Osmotic Release Oral Tablet Extended Release 24 Hour 60 MG Tier 1 CALCIUM CHANNEL BLOCKERS Nifedipine NIFEdipine ER Osmotic Release Oral Tablet Extended Release 24 Hour 90 MG Tier 1 CALCIUM CHANNEL BLOCKERS Nifedipine NIFEdipine Oral Capsule 10 MG Tier 1 CALCIUM CHANNEL BLOCKERS Nifedipine NIFEdipine Oral Capsule 20 MG Tier 1 CALCIUM CHANNEL BLOCKERS Nifedipine NIFEdipine Powder Tier 3 CONTRACEPTIVES Drospirenone‐Ethinyl Estradiol Nikki Oral Tablet 3‐0.02 MG Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Nilutamide Nilandron Oral Tablet 150 MG Tier 2 NEUROMUSCULAR AGENTS Cisatracurium Besylate Nimbex Intravenous Solution 10 MG/5ML Tier 3 x NEUROMUSCULAR AGENTS Cisatracurium Besylate Nimbex Intravenous Solution 10 MG/ML Tier 3 x NEUROMUSCULAR AGENTS Cisatracurium Besylate Nimbex Intravenous Solution 20 MG/10ML Tier 3 x CALCIUM CHANNEL BLOCKERS Nimodipine NiMODipine Oral Capsule 30 MG Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Ixazomib Citrate Ninlaro Oral Capsule 2.3 MG Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Ixazomib Citrate Ninlaro Oral Capsule 3 MG Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Ixazomib Citrate Ninlaro Oral Capsule 4 MG Tier 3 ANTIANXIETY AGENTS Alprazolam Niravam Oral Tablet Dispersible 0.25 MG Tier 3 CALCIUM CHANNEL BLOCKERS Nisoldipine Nisoldipine ER Oral Tablet Extended Release 24 Hour 17 MG Tier 1 CALCIUM CHANNEL BLOCKERS Nisoldipine Nisoldipine ER Oral Tablet Extended Release 24 Hour 20 MG Tier 3 CALCIUM CHANNEL BLOCKERS Nisoldipine Nisoldipine ER Oral Tablet Extended Release 24 Hour 25.5 MG Tier 3 CALCIUM CHANNEL BLOCKERS Nisoldipine Nisoldipine ER Oral Tablet Extended Release 24 Hour 30 MG Tier 3 CALCIUM CHANNEL BLOCKERS Nisoldipine Nisoldipine ER Oral Tablet Extended Release 24 Hour 34 MG Tier 1 CALCIUM CHANNEL BLOCKERS Nisoldipine Nisoldipine ER Oral Tablet Extended Release 24 Hour 40 MG Tier 3 CALCIUM CHANNEL BLOCKERS Nisoldipine Nisoldipine ER Oral Tablet Extended Release 24 Hour 8.5 MG Tier 1 CHEMICALS Nitric Acid Nitric Acid Liquid Tier 3 MEDICAL DEVICES AND SUPPLIES Disposable Gloves Nitrile Gloves Medium Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Disposable Gloves Nitrile Gloves/Size 10 Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Disposable Gloves Nitrile Gloves/Size 6 Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Disposable Gloves Nitrile Gloves/Size 6.5 Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Disposable Gloves Nitrile Gloves/Size 7 Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Disposable Gloves Nitrile Gloves/Size 7.5 Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Disposable Gloves Nitrile Gloves/Size 8 Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Disposable Gloves Nitrile Gloves/Size 9 Miscellaneous Tier 3 ANTIANGINAL AGENTS Nitroglycerin Nitro‐Bid Transdermal Ointment 2 % Tier 2 ANTIANGINAL AGENTS Nitroglycerin Nitro‐Dur Transdermal Patch 24 Hour 0.1 MG/HR Tier 2 ANTIANGINAL AGENTS Nitroglycerin Nitro‐Dur Transdermal Patch 24 Hour 0.2 MG/HR Tier 2 ANTIANGINAL AGENTS Nitroglycerin Nitro‐Dur Transdermal Patch 24 Hour 0.3 MG/HR Tier 2 ANTIANGINAL AGENTS Nitroglycerin Nitro‐Dur Transdermal Patch 24 Hour 0.4 MG/HR Tier 2 ANTIANGINAL AGENTS Nitroglycerin Nitro‐Dur Transdermal Patch 24 Hour 0.6 MG/HR Tier 2 ANTIANGINAL AGENTS Nitroglycerin Nitro‐Dur Transdermal Patch 24 Hour 0.8 MG/HR Tier 2 URINARY ANTI‐INFECTIVES Nitrofurantoin Macrocrystal Nitrofurantoin Macrocrystal Oral Capsule 100 MG Tier 1 URINARY ANTI‐INFECTIVES Nitrofurantoin Macrocrystal Nitrofurantoin Macrocrystal Oral Capsule 25 MG Tier 1 URINARY ANTI‐INFECTIVES Nitrofurantoin Macrocrystal Nitrofurantoin Macrocrystal Oral Capsule 50 MG Tier 1 URINARY ANTI‐INFECTIVES Nitrofurantoin Monohyd Macro Nitrofurantoin Monohyd Macro Oral Capsule 100 MG Tier 1 URINARY ANTI‐INFECTIVES Nitrofurantoin Nitrofurantoin Oral Suspension 25 MG/5ML Tier 1 DERMATOLOGICALS Nitrofurazone Nitrofurazone Powder Tier 3 ANTIANGINAL AGENTS Nitroglycerin Nitroglycerin ER Oral Capsule Extended Release 2.5 MG Tier 1 ANTIANGINAL AGENTS Nitroglycerin Nitroglycerin ER Oral Capsule Extended Release 6.5 MG Tier 1 ANTIANGINAL AGENTS Nitroglycerin Nitroglycerin ER Oral Capsule Extended Release 9 MG Tier 1 ANTIANGINAL AGENTS Nitroglycerin Nitroglycerin Transdermal Patch 24 Hour 0.1 MG/HR Tier 1 ANTIANGINAL AGENTS Nitroglycerin Nitroglycerin Transdermal Patch 24 Hour 0.2 MG/HR Tier 1 ANTIANGINAL AGENTS Nitroglycerin Nitroglycerin Transdermal Patch 24 Hour 0.4 MG/HR Tier 1 ANTIANGINAL AGENTS Nitroglycerin Nitroglycerin Transdermal Patch 24 Hour 0.6 MG/HR Tier 1 ANTIANGINAL AGENTS Nitroglycerin Nitroglycerin Translingual Aerosol Solution 400 MCG/SPRAY Tier 3 ANTIANGINAL AGENTS Nitroglycerin Nitroglycerin Translingual Solution 0.4 MG/SPRAY Tier 1 ANTIANGINAL AGENTS Nitroglycerin Nitrolingual Translingual Solution 0.4 MG/SPRAY Tier 3 ANTIANGINAL AGENTS Nitroglycerin NitroMist Translingual Aerosol Solution 400 MCG/SPRAY Tier 3 ANTIANGINAL AGENTS Nitroglycerin Nitronal Intravenous Solution 1 MG/ML Tier 3 x ANTIANGINAL AGENTS Nitroglycerin Nitrostat Sublingual Tablet Sublingual 0.3 MG Tier 2 ANTIANGINAL AGENTS Nitroglycerin Nitrostat Sublingual Tablet Sublingual 0.4 MG Tier 2 ANTIANGINAL AGENTS Nitroglycerin Nitrostat Sublingual Tablet Sublingual 0.6 MG Tier 2 ANTIANGINAL AGENTS Nitroglycerin Nitro‐Time Oral Capsule Extended Release 2.5 MG Tier 1 ANTIANGINAL AGENTS Nitroglycerin Nitro‐Time Oral Capsule Extended Release 6.5 MG Tier 1 ANTIANGINAL AGENTS Nitroglycerin Nitro‐Time Oral Capsule Extended Release 9 MG Tier 1 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐Folic Acid Niva‐Plus Oral Tablet 27‐1 MG Tier 2 DERMATOLOGICALS Dermatological Products, Misc. Nivatopic Plus External Cream Tier 3 ULCER DRUGS Nizatidine Nizatidine Oral Capsule 150 MG Tier 1 ULCER DRUGS Nizatidine Nizatidine Oral Capsule 300 MG Tier 1 ULCER DRUGS Nizatidine Nizatidine Oral Solution 15 MG/ML Tier 1 DERMATOLOGICALS Ketoconazole (Topical) Nizoral External Shampoo 2 % Tier 3 x COUGH/COLD/ALLERGY Phenylephrine‐Chlorphen‐DM NoHist‐DM Oral Liquid 10‐4‐15 MG/5ML Tier 1 CONTRACEPTIVES Norethindrone (Contraceptive) Nora‐BE Oral Tablet 0.35 MG Tier 1 ANALGESICS ‐ OPIOID Hydrocodone‐Acetaminophen Norco Oral Tablet 10‐325 MG Tier 3 ANALGESICS ‐ OPIOID Hydrocodone‐Acetaminophen Norco Oral Tablet 5‐325 MG Tier 3 ANALGESICS ‐ OPIOID Hydrocodone‐Acetaminophen Norco Oral Tablet 7.5‐325 MG Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin Norditropin FlexPro Subcutaneous Solution 10 MG/1.5ML Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin Norditropin FlexPro Subcutaneous Solution 15 MG/1.5ML Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin Norditropin FlexPro Subcutaneous Solution 30 MG/3ML Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin Norditropin FlexPro Subcutaneous Solution 5 MG/1.5ML Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin Norditropin NordiFlex Pen Subcutaneous Solution 30 MG/3ML Tier 2 x VASOPRESSORS Norepinephrine Bitartrate Norepinephrine Bitartrate Intravenous Solution 1 MG/ML Tier 1 x CONTRACEPTIVES Norethin Acet & Estrad‐Fe Norethin Ace‐Eth Estrad‐FE Oral Tablet 1‐20 MG‐MCG Tier 1 CONTRACEPTIVES Norethin Acet & Estrad‐Fe Norethin Ace‐Eth Estrad‐FE Oral Tablet 1‐20 MG‐MCG(24) Tier 1 PROGESTINS Norethindrone Acetate Norethindrone Acetate Oral Tablet 5 MG Tier 1 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

PROGESTINS Norethindrone Acetate Norethindrone Acetate Powder Tier 3 CONTRACEPTIVES Norethindrone Acet & Eth Estra Norethindrone Acet‐Ethinyl Est Oral Tablet 1‐20 MG‐MCG Tier 1 CONTRACEPTIVES Norethindrone (Contraceptive) Norethindrone Oral Tablet 0.35 MG Tier 1 ESTROGENS Norethindrone Acetate‐Ethinyl Estradiol Norethindrone‐Eth Estradiol Oral Tablet 0.5‐2.5 MG‐MCG Tier 1 x ESTROGENS Norethindrone Acetate‐Ethinyl Estradiol Norethindrone‐Eth Estradiol Oral Tablet 1‐5 MG‐MCG Tier 1 x CONTRACEPTIVES Norethindrone & Ethinyl Estradiol‐Fe Norethin‐Eth Estradiol‐Fe Oral Tablet Chewable 0.8‐25 MG‐MCG Tier 1 CONTRACEPTIVES Norgestimate‐Ethinyl Estradiol Norgestimate‐Eth Estradiol Oral Tablet 0.25‐35 MG‐MCG Tier 1 CONTRACEPTIVES Norgestimate‐Ethinyl Estradiol (Triphasic) Norgestim‐Eth Estrad Triphasic Oral Tablet 0.18/0.215/0.25 MG‐25 MCG Tier 1 CONTRACEPTIVES Norgestimate‐Ethinyl Estradiol (Triphasic) Norgestim‐Eth Estrad Triphasic Oral Tablet 0.18/0.215/0.25 MG‐35 MCG Tier 1 CONTRACEPTIVES Norethindrone & Eth Estradiol Norinyl 1+35 (28) Oral Tablet 1‐35 MG‐MCG Tier 3 CONTRACEPTIVES Norethindrone & Mestranol Norinyl 1+50 (28) Oral Tablet 1‐50 MG‐MCG Tier 3 DERMATOLOGICALS Metronidazole (Topical) Noritate External Cream 1 % Tier 3 CONTRACEPTIVES Norethindrone (Contraceptive) Norlyroc Oral Tablet 0.35 MG Tier 1 MINERALS & ELECTROLYTES Sodium Chloride Flush Normal Saline Flush Intravenous Solution 0.9 % Tier 1 x MINERALS & ELECTROLYTES Electrolyte‐R Normosol‐R Intravenous Solution Tier 3 x MINERALS & ELECTROLYTES Electrolyte‐R (PH 7.4) Normosol‐R pH 7.4 Intravenous Solution Tier 3 x ANTIARRHYTHMICS Disopyramide Phosphate Norpace CR Oral Capsule Extended Release 12 Hour 100 MG Tier 2 ANTIARRHYTHMICS Disopyramide Phosphate Norpace CR Oral Capsule Extended Release 12 Hour 150 MG Tier 2 ANTIARRHYTHMICS Disopyramide Phosphate Norpace Oral Capsule 100 MG Tier 3 ANTIARRHYTHMICS Disopyramide Phosphate Norpace Oral Capsule 150 MG Tier 3 ANTIDEPRESSANTS Desipramine HCl Norpramin Oral Tablet 10 MG Tier 3 ANTIDEPRESSANTS Desipramine HCl Norpramin Oral Tablet 100 MG Tier 3 ANTIDEPRESSANTS Desipramine HCl Norpramin Oral Tablet 150 MG Tier 3 ANTIDEPRESSANTS Desipramine HCl Norpramin Oral Tablet 25 MG Tier 3 ANTIDEPRESSANTS Desipramine HCl Norpramin Oral Tablet 50 MG Tier 3 ANTIDEPRESSANTS Desipramine HCl Norpramin Oral Tablet 75 MG Tier 3 CONTRACEPTIVES Norethindrone (Contraceptive) Nor‐QD Oral Tablet 0.35 MG Tier 3 VASOPRESSORS Droxidopa Northera Oral Capsule 100 MG Tier 2 x x VASOPRESSORS Droxidopa Northera Oral Capsule 200 MG Tier 2 x x VASOPRESSORS Droxidopa Northera Oral Capsule 300 MG Tier 2 x x CONTRACEPTIVES Norethindrone & Eth Estradiol Nortrel 0.5/35 (28) Oral Tablet 0.5‐35 MG‐MCG Tier 1 CONTRACEPTIVES Norethindrone & Eth Estradiol Nortrel 1/35 (21) Oral Tablet 1‐35 MG‐MCG Tier 1 CONTRACEPTIVES Norethindrone & Eth Estradiol Nortrel 1/35 (28) Oral Tablet 1‐35 MG‐MCG Tier 1 CONTRACEPTIVES Norethindrone‐Eth Estradiol (Triphasic) Nortrel 7/7/7 Oral Tablet 0.5/0.75/1‐35 MG‐MCG Tier 1 ANTIDEPRESSANTS Nortriptyline HCl Nortriptyline HCl Oral Capsule 10 MG Tier 1 ANTIDEPRESSANTS Nortriptyline HCl Nortriptyline HCl Oral Capsule 25 MG Tier 1 ANTIDEPRESSANTS Nortriptyline HCl Nortriptyline HCl Oral Capsule 50 MG Tier 1 ANTIDEPRESSANTS Nortriptyline HCl Nortriptyline HCl Oral Capsule 75 MG Tier 1 ANTIDEPRESSANTS Nortriptyline HCl Nortriptyline HCl Oral Solution 10 MG/5ML Tier 3 ANTIDEPRESSANTS Nortriptyline HCl Nortriptyline HCl Powder Tier 3 COUGH/COLD/ALLERGY Phenylephrine w/ DM‐GG Nortuss‐DE Oral Liquid 2.5‐5‐50 MG/ML Tier 1 COUGH/COLD/ALLERGY Dextromethorphan‐Guaifenesin Nortuss‐Ex Oral Liquid 20‐200 MG/5ML Tier 3 CALCIUM CHANNEL BLOCKERS Amlodipine Besylate Norvasc Oral Tablet 10 MG Tier 3 CALCIUM CHANNEL BLOCKERS Amlodipine Besylate Norvasc Oral Tablet 2.5 MG Tier 3 CALCIUM CHANNEL BLOCKERS Amlodipine Besylate Norvasc Oral Tablet 5 MG Tier 3 ANTIVIRALS Ritonavir Norvir Oral Capsule 100 MG Tier 2 x ANTIVIRALS Ritonavir Norvir Oral Solution 80 MG/ML Tier 2 x ANTIVIRALS Ritonavir Norvir Oral Tablet 100 MG Tier 2 x MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies Nova Max Blood Glucose System Kit w/Device Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Nova Max Glucose Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Nova Safety Lancets 23G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Nova Safety Lancets 28G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Nova Sureflex Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancet Devices Nova Sureflex Lancing Device Miscellaneous Tier 2 DERMATOLOGICALS Citrate‐Adapalene‐Diclofenac Sodium Novoclair External Cream 0.2‐0.3‐2 % Tier 3 x MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle NovoFine Autocover Miscellaneous 30G X 8 MM Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle NovoFine Miscellaneous 30G X 8 MM Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle NovoFine Miscellaneous 32G X 6 MM Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle NovoFine Plus Miscellaneous 32G X 4 MM Tier 2 ANTIDIABETICS Insulin NPH Isophane & Reg (Human) NovoLIN 70/30 ReliOn Subcutaneous Suspension (70‐30) 100 UNIT/ML Tier 2 ANTIDIABETICS Insulin NPH Isophane & Reg (Human) NovoLIN 70/30 Subcutaneous Suspension (70‐30) 100 UNIT/ML Tier 2 ANTIDIABETICS Insulin NPH (Human) (Isophane) NovoLIN N ReliOn Subcutaneous Suspension 100 UNIT/ML Tier 2 ANTIDIABETICS Insulin NPH (Human) (Isophane) NovoLIN N Subcutaneous Suspension 100 UNIT/ML Tier 2 ANTIDIABETICS Insulin Regular (Human) NovoLIN R Injection Solution 100 UNIT/ML Tier 2 ANTIDIABETICS Insulin Regular (Human) NovoLIN R ReliOn Injection Solution 100 UNIT/ML Tier 2 ANTIDIABETICS NovoLOG FlexPen Subcutaneous Solution Pen‐injector 100 UNIT/ML Tier 2 ANTIDIABETICS Insulin Aspart Protamine & Aspart (Human) NovoLOG Mix 70/30 FlexPen Subcutaneous Suspension Pen‐injector (70‐30) 100 UNIT/ML Tier 2 ANTIDIABETICS Insulin Aspart Protamine & Aspart (Human) NovoLOG Mix 70/30 Subcutaneous Suspension (70‐30) 100 UNIT/ML Tier 2 ANTIDIABETICS Insulin Aspart NovoLOG PenFill Subcutaneous Solution Cartridge 100 UNIT/ML Tier 2 ANTIDIABETICS Insulin Aspart NovoLOG Subcutaneous Solution 100 UNIT/ML Tier 2 MEDICAL DEVICES AND SUPPLIES Injection Device for Insulin NovoPen Echo Device Tier 3 HEMATOLOGICAL AGENTS ‐ MISC. Coagulation Factor VIIa (Recombinant) NovoSeven RT Intravenous Solution Reconstituted 1 MG Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Coagulation Factor VIIa (Recombinant) NovoSeven RT Intravenous Solution Reconstituted 2 MG Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Coagulation Factor VIIa (Recombinant) NovoSeven RT Intravenous Solution Reconstituted 5 MG Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Coagulation Factor VIIa (Recombinant) NovoSeven RT Intravenous Solution Reconstituted 8 MG Tier 2 x MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle NovoTwist Miscellaneous 30G X 8 MM Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle NovoTwist Miscellaneous 32G X 5 MM Tier 3 ANTIFUNGALS Posaconazole Noxafil Oral Suspension 40 MG/ML Tier 3 ANTIFUNGALS Posaconazole Noxafil Oral Tablet Delayed Release 100 MG Tier 2 DERMATOLOGICALS Tramadol‐Flurbiprofen‐Amitriptylin‐Gabapentin‐Clonidine‐Lido NP #2 Drug Preparation Kit External Cream Tier 3 THYROID AGENTS Thyroid NP Thyroid Oral Tablet 30 MG Tier 1 THYROID AGENTS Thyroid NP Thyroid Oral Tablet 60 MG Tier 1 THYROID AGENTS Thyroid NP Thyroid Oral Tablet 90 MG Tier 1 DERMATOLOGICALS Hydrocortisone Acetate (Topical) NuCort External Lotion 2 % Tier 3 ANALGESICS ‐ OPIOID Tapentadol HCl Nucynta ER Oral Tablet Extended Release 12 Hour 100 MG Tier 3 x x ANALGESICS ‐ OPIOID Tapentadol HCl Nucynta ER Oral Tablet Extended Release 12 Hour 150 MG Tier 3 x x ANALGESICS ‐ OPIOID Tapentadol HCl Nucynta ER Oral Tablet Extended Release 12 Hour 200 MG Tier 3 x x ANALGESICS ‐ OPIOID Tapentadol HCl Nucynta ER Oral Tablet Extended Release 12 Hour 250 MG Tier 3 x x ANALGESICS ‐ OPIOID Tapentadol HCl Nucynta ER Oral Tablet Extended Release 12 Hour 50 MG Tier 3 x x ANALGESICS ‐ OPIOID Tapentadol HCl Nucynta Oral Tablet 100 MG Tier 3 x x ANALGESICS ‐ OPIOID Tapentadol HCl Nucynta Oral Tablet 50 MG Tier 3 x x ANALGESICS ‐ OPIOID Tapentadol HCl Nucynta Oral Tablet 75 MG Tier 3 x x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Dextromethorphan HBr‐Quinidine Sulfate Nuedexta Oral Capsule 20‐10 MG Tier 3 x HEMATOPOIETIC AGENTS Iron Combinations NuFera Oral Tablet Tier 3 HEMATOPOIETIC AGENTS Folic Acid‐Vitamin B6‐Vitamin B12 NuFol Oral Tablet 2.5‐25‐1 MG Tier 1 ULCER DRUGS Hyoscyamine Sulfate NuLev Oral Tablet Dispersible 0.125 MG Tier 1 LAXATIVES PEG 3350‐Potassium Chloride‐Sod Bicarbonate‐Sod Chloride Nulytely with Flavor Packs Oral Solution Reconstituted 420 GM Tier 3 DERMATOLOGICALS Benzoyl Peroxide‐Sulfur NuOx External Gel 6‐3 % Tier 3 NUTRIENTS Glutamine NutreStore Oral Packet 5 GM Tier 3 MULTIVITAMINS Multiple Vitamins w/ Minerals Nutricap Oral Tablet Tier 3 TETRACYCLINES Doxycycline Monohydrate w/ Omega 3‐Vit E NutriDox Oral Kit 75 MG Tier 3 MULTIVITAMINS Multiple Vitamins w/ Minerals Nutrifac ZX Oral Tablet Tier 1 MULTIVITAMINS B‐Complex w/ Lysine‐Min‐Fe & Folic Acid Nutrivit Oral Liquid Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin Nutropin AQ NuSpin 10 Subcutaneous Solution 10 MG/2ML Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin Nutropin AQ NuSpin 20 Subcutaneous Solution 20 MG/2ML Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin Nutropin AQ NuSpin 5 Subcutaneous Solution 5 MG/2ML Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin Nutropin AQ Pen Subcutaneous Solution 10 MG/2ML Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin Nutropin AQ Pen Subcutaneous Solution 20 MG/2ML Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin Nutropin AQ Subcutaneous Solution 10 MG/2ML Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin Nutropin Subcutaneous Solution Reconstituted 10 MG Tier 2 x CONTRACEPTIVES Etonogestrel‐Ethinyl Estradiol NuvaRing Vaginal Ring 0.12‐0.015 MG/24HR Tier 2 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Armodafinil Nuvigil Oral Tablet 150 MG Tier 3 x x HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Armodafinil Nuvigil Oral Tablet 200 MG Tier 3 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Armodafinil Nuvigil Oral Tablet 250 MG Tier 3 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Armodafinil Nuvigil Oral Tablet 50 MG Tier 3 x x DERMATOLOGICALS Tamoxifen Citrate‐Adapalene‐Diclofenac Sodium Nuvya External Cream 0.2‐0.3‐2 % Tier 3 x DERMATOLOGICALS Nystatin (Topical) Nyamyc External Powder 100000 UNIT/GM Tier 1 DERMATOLOGICALS Nystatin & Exfoliating Agent Nyata External Kit 100000 UNIT/GM Tier 3 CALCIUM CHANNEL BLOCKERS Nimodipine Nymalize Oral Solution 60 MG/20ML Tier 3 DERMATOLOGICALS Nystatin (Topical) Nystatin External Cream 100000 UNIT/GM Tier 1 DERMATOLOGICALS Nystatin (Topical) Nystatin External Ointment 100000 UNIT/GM Tier 1 DERMATOLOGICALS Nystatin (Topical) Nystatin External Powder Tier 1 DERMATOLOGICALS Nystatin (Topical) Nystatin External Powder 100000 UNIT/GM Tier 1 MOUTH/THROAT/DENTAL AGENTS Nystatin (Mouth‐Throat) Nystatin Mouth/Throat Suspension 100000 UNIT/ML Tier 1 ANTIFUNGALS Nystatin Nystatin Oral Powder Tier 1 ANTIFUNGALS Nystatin Nystatin Oral Tablet 500000 UNIT Tier 1 DERMATOLOGICALS Nystatin (Topical) Nystatin Powder Tier 2 DERMATOLOGICALS Nystatin‐Triamcinolone Nystatin‐Triamcinolone External Cream 100000‐0.1 UNIT/GM‐% Tier 1 DERMATOLOGICALS Nystatin‐Triamcinolone Nystatin‐Triamcinolone External Ointment 100000‐0.1 UNIT/GM‐% Tier 1 DERMATOLOGICALS Nystatin (Topical) Nystop External Powder 100000 UNIT/GM Tier 1 MULTIVITAMINS Prenatal without A w/ Fe Carbonyl‐L Methylfolate‐FA‐DHA OB Complete Gold Oral Capsule 27.5‐1‐200 MG Tier 3 MULTIVITAMINS Prenatal w/o Vit A w/ Fe Carbonyl‐Fe Aspart Glyc‐FA‐Fish Oil OB Complete One Oral Capsule 50‐1‐476 MG Tier 2 MULTIVITAMINS Prenatal Vit w/ Iron Carbonyl‐Folic Acid OB Complete Oral Tablet 50‐1.25 MG Tier 2 MULTIVITAMINS Prenatal w/o Vit A w/ Fe Carbonyl‐Fe Aspart Glyc‐FA‐Omega 3OB Complete Petite Oral Capsule 35‐5‐1‐200 MG Tier 2 MULTIVITAMINS Prenatal Vit w/ Iron Carbonyl‐Fe Aspart Glycinate‐FA OB Complete Premier Oral Tablet 30‐20‐1 MG Tier 2 MULTIVITAMINS Prenat Vit w/ Iron Carbonyl‐Fe Asp Glyc‐FA‐Omega Fatty Acid OB Complete/DHA Oral Capsule 30‐10‐1‐200 MG Tier 2 COUGH/COLD/ALLERGY Hydrocodone‐Guaifenesin Obredon Oral Solution 2.5‐200 MG/5ML Tier 3 MULTIVITAMINS Prenatal w/Fe Carbonyl‐FA‐DSS‐Omega 3 Fatty Acids Obstetrix DHA Oral Miscellaneous 29‐1 & 387 MG Tier 2 MULTIVITAMINS Prenatal Vit w/ Docusate‐Iron Carbonyl‐Folic Acid Obstetrix EC Oral Tablet 29‐1 MG Tier 3 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐Folic Acid O‐Cal FA Oral Tablet 27‐1 MG Tier 2 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐Folic Acid O‐Cal Prenatal Oral Tablet Tier 2 CONTRACEPTIVES Drospirenone‐Ethinyl Estradiol Ocella Oral Tablet 3‐0.03 MG Tier 1 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Octreotide Acetate Octreotide Acetate Injection Solution 100 MCG/ML Tier 1 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Octreotide Acetate Octreotide Acetate Injection Solution 1000 MCG/ML Tier 1 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Octreotide Acetate Octreotide Acetate Injection Solution 200 MCG/ML Tier 1 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Octreotide Acetate Octreotide Acetate Injection Solution 50 MCG/ML Tier 1 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Octreotide Acetate Octreotide Acetate Injection Solution 500 MCG/ML Tier 1 x OPHTHALMIC AGENTS Flurbiprofen Sodium Ocufen Ophthalmic Solution 0.03 % Tier 3 OPHTHALMIC AGENTS Ofloxacin (Ophth) Ocuflox Ophthalmic Solution 0.3 % Tier 3 MULTIVITAMINS Multiple Vitamins w/ Minerals & Folic Acid Ocuvel Oral Capsule 0.5 MG Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Sonidegib Phosphate Odomzo Oral Capsule 200 MG Tier 3 x x RESPIRATORY AGENTS ‐ MISC. Nintedanib Esylate Ofev Oral Capsule 100 MG Tier 2 x x RESPIRATORY AGENTS ‐ MISC. Nintedanib Esylate Ofev Oral Capsule 150 MG Tier 2 x x OPHTHALMIC AGENTS Ofloxacin (Ophth) Ofloxacin Ophthalmic Solution 0.3 % Tier 1 FLUOROQUINOLONES Ofloxacin Ofloxacin Oral Tablet 400 MG Tier 3 OTIC AGENTS Ofloxacin (Otic) Ofloxacin Otic Solution 0.3 % Tier 1 CONTRACEPTIVES Norgestrel & Ethinyl Estradiol Ogestrel Oral Tablet 0.5‐50 MG‐MCG Tier 2 PHARMACEUTICAL ADJUVANTS Emulsifying Ointment Ointment Base (Emulsifying) Ointment Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Olanzapine OLANZapine Intramuscular Solution Reconstituted 10 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Olanzapine OLANZapine Oral Tablet 10 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Olanzapine OLANZapine Oral Tablet 15 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Olanzapine OLANZapine Oral Tablet 2.5 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Olanzapine OLANZapine Oral Tablet 20 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Olanzapine OLANZapine Oral Tablet 5 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Olanzapine OLANZapine Oral Tablet 7.5 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Olanzapine OLANZapine Oral Tablet Dispersible 10 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Olanzapine OLANZapine Oral Tablet Dispersible 15 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Olanzapine OLANZapine Oral Tablet Dispersible 20 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Olanzapine OLANZapine Oral Tablet Dispersible 5 MG Tier 1 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Olanzapine‐Fluoxetine HCl OLANZapine‐FLUoxetine HCl Oral Capsule 12‐25 MG Tier 1 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Olanzapine‐Fluoxetine HCl OLANZapine‐FLUoxetine HCl Oral Capsule 12‐50 MG Tier 1 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Olanzapine‐Fluoxetine HCl OLANZapine‐FLUoxetine HCl Oral Capsule 3‐25 MG Tier 1 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Olanzapine‐Fluoxetine HCl OLANZapine‐FLUoxetine HCl Oral Capsule 6‐25 MG Tier 1 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Olanzapine‐Fluoxetine HCl OLANZapine‐FLUoxetine HCl Oral Capsule 6‐50 MG Tier 1 x ANTIDEPRESSANTS Trazodone HCl Oleptro Oral Tablet Extended Release 24 Hour 150 MG Tier 3 xx ANTIDEPRESSANTS Trazodone HCl Oleptro Oral Tablet Extended Release 24 Hour 300 MG Tier 3 xx NASAL AGENTS ‐ SYSTEMIC AND TOPICAL Olopatadine HCl (Nasal) Olopatadine HCl Nasal Solution 0.6 % Tier 1 x OPHTHALMIC AGENTS Olopatadine HCl Olopatadine HCl Ophthalmic Solution 0.1 % Tier 1 DERMATOLOGICALS Clobetasol Propionate Olux External Foam 0.05 % Tier 3 DERMATOLOGICALS Clobetasol Propionate Emulsion Olux‐E External Foam 0.05 % Tier 3 ANTIVIRALS Simeprevir Sodium Olysio Oral Capsule 150 MG Tier 2 x x ULCER DRUGS Amoxicillin‐Clarithromycin w/ Omeprazole Omeclamox‐Pak Oral Miscellaneous 500‐500‐20 MG Tier 2 ANTIHYPERLIPIDEMICS Omega‐3‐acid Ethyl Esters & Cholecalciferol Omega‐3/D‐3 Wellness Pack Oral Kit 1 & 1000 GM & UNIT Tier 3 ANTIHYPERLIPIDEMICS Omega‐3‐acid Ethyl Esters Omega‐3‐acid Ethyl Esters Oral Capsule 1 GM Tier 1 x x ULCER DRUGS Omeprazole Omeprazole Oral Capsule Delayed Release 10 MG Tier 1 x ULCER DRUGS Omeprazole Omeprazole Oral Capsule Delayed Release 20 MG Tier 1 x ULCER DRUGS Omeprazole Omeprazole Oral Capsule Delayed Release 40 MG Tier 1 x ULCER DRUGS Omeprazole Omeprazole+Syrspend SF Alka Oral Suspension 2 MG/ML Tier 3 x ULCER DRUGS Omeprazole‐Sodium Bicarbonate Omeprazole‐Sodium Bicarbonate Oral Capsule 20‐1100 MG Tier 1 x ULCER DRUGS Omeprazole‐Sodium Bicarbonate Omeprazole‐Sodium Bicarbonate Oral Capsule 40‐1100 MG Tier 1 x NASAL AGENTS ‐ SYSTEMIC AND TOPICAL Ciclesonide (Nasal) Omnaris Nasal Suspension 50 MCG/ACT Tier 3 xx DIAGNOSTIC PRODUCTS Iohexol Omnipaque Injection Solution 180 MG/ML Tier 3 x DIAGNOSTIC PRODUCTS Iohexol Omnipaque Injection Solution 240 MG/ML Tier 3 x DIAGNOSTIC PRODUCTS Iohexol Omnipaque Injection Solution 300 MG/ML Tier 3 x DIAGNOSTIC PRODUCTS Iohexol Omnipaque Intravenous Solution 350 MG/ML Tier 3 x OPHTHALMIC AGENTS Prednisolone Acetate (Ophth) Omnipred Ophthalmic Suspension 1 % Tier 3 DIAGNOSTIC PRODUCTS Gadodiamide Omniscan Injection Injectable 287 MG/ML Tier 3 x DIAGNOSTIC PRODUCTS Gadodiamide Omniscan Intravenous Solution 287 MG/ML Tier 3 x DIAGNOSTIC PRODUCTS Gadodiamide‐Sodium Chloride Omniscan/Sodium Chloride Intravenous Solution 287‐0.9 MG/ML‐% Tier 3 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin Omnitrope Subcutaneous Solution 10 MG/1.5ML Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin Omnitrope Subcutaneous Solution 5 MG/1.5ML Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin Omnitrope Subcutaneous Solution Reconstituted 5.8 MG Tier 2 x DIAGNOSTIC PRODUCTS Glucose Blood On Call Express Blood Glucose In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets On Call Lancets Miscellaneous Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood On Call Plus Blood Glucose In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets On Call Plus Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies On Call Plus Meter Kit w/Device Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood On Call Vivid Blood Glucose In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies On Call Vivid Meter Kit w/Device Tier 3 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies On Call Vivid Pal Meter Kit w/Device Tier 3 ANTIEMETICS Ondansetron HCl Ondansetron HCl Injection Solution 4 MG/2ML Tier 1 ANTIEMETICS Ondansetron HCl Ondansetron HCl Injection Solution 40 MG/20ML Tier 1 ANTIEMETICS Ondansetron HCl Ondansetron HCl Oral Solution 4 MG/5ML Tier 1 x ANTIEMETICS Ondansetron HCl Ondansetron HCl Oral Tablet 24 MG Tier 1 x ANTIEMETICS Ondansetron HCl Ondansetron HCl Oral Tablet 4 MG Tier 1 x ANTIEMETICS Ondansetron HCl Ondansetron HCl Oral Tablet 8 MG Tier 1 x ANTIEMETICS Ondansetron Ondansetron Oral Tablet Dispersible 4 MG Tier 1 x ANTIEMETICS Ondansetron Ondansetron Oral Tablet Dispersible 8 MG Tier 1 x MEDICAL DEVICES AND SUPPLIES Lancets OneTouch Club Lancets Fine Pt Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets OneTouch Combo Pack Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets OneTouch Delica Lancets 33G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets OneTouch Delica Lancets Fine Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets OneTouch FinePoint Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets OneTouch Lancets Miscellaneous Tier 2 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

MEDICAL DEVICES AND SUPPLIES Lancets Misc. OneTouch SureSoft Lancing Dev Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies OneTouch Ultra 2 Kit w/Device Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood OneTouch Ultra Blue In Vitro Strip Tier 2 MEDICAL DEVICES AND SUPPLIES Blood Glucose Calibration OneTouch Ultra Control In Vitro Solution Tier 3 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies OneTouch Ultra Mini Kit w/Device Tier 3 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies OneTouch UltraLink Kit w/Device Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets OneTouch UltraSoft Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies OneTouch Verio Flex System Kit w/Device Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood OneTouch Verio In Vitro Strip Tier 2 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies OneTouch Verio IQ System Kit w/Device Tier 3 ANTICONVULSANTS Clobazam Onfi Oral Suspension 2.5 MG/ML Tier 3 ANTICONVULSANTS Clobazam Onfi Oral Tablet 10 MG Tier 3 ANTICONVULSANTS Clobazam Onfi Oral Tablet 20 MG Tier 3 ANTIDIABETICS Saxagliptin HCl Onglyza Oral Tablet 2.5 MG Tier 2 xx ANTIDIABETICS Saxagliptin HCl Onglyza Oral Tablet 5 MG Tier 2 xx ANTIFUNGALS Itraconazole Onmel Oral Tablet 200 MG Tier 3 x x ANALGESICS ‐ OPIOID Oxymorphone HCl Opana ER Oral Tablet ER 12 Hour Abuse‐Deterrent 10 MG Tier 3 x x ANALGESICS ‐ OPIOID Oxymorphone HCl Opana ER Oral Tablet ER 12 Hour Abuse‐Deterrent 15 MG Tier 3 x x ANALGESICS ‐ OPIOID Oxymorphone HCl Opana ER Oral Tablet ER 12 Hour Abuse‐Deterrent 20 MG Tier 3 x x ANALGESICS ‐ OPIOID Oxymorphone HCl Opana ER Oral Tablet ER 12 Hour Abuse‐Deterrent 30 MG Tier 3 x x ANALGESICS ‐ OPIOID Oxymorphone HCl Opana ER Oral Tablet ER 12 Hour Abuse‐Deterrent 40 MG Tier 3 x x ANALGESICS ‐ OPIOID Oxymorphone HCl Opana ER Oral Tablet ER 12 Hour Abuse‐Deterrent 5 MG Tier 3 x x ANALGESICS ‐ OPIOID Oxymorphone HCl Opana ER Oral Tablet ER 12 Hour Abuse‐Deterrent 7.5 MG Tier 3 x x ANALGESICS ‐ OPIOID Oxymorphone HCl Opana Oral Tablet 10 MG Tier 3 x ANALGESICS ‐ OPIOID Oxymorphone HCl Opana Oral Tablet 5 MG Tier 3 x ANTIDIARRHEALS Paregoric Opium Tincture (Paregoric) Oral Tincture 2 MG/5ML Tier 3 CARDIOVASCULAR AGENTS ‐ MISC. Macitentan Opsumit Oral Tablet 10 MG Tier 2 x x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers OptiChamber Advantage Miscellaneous Tier 3 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers OptiChamber Advantage‐Lg Mask Miscellaneous Tier 3 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers OptiChamber Advantage‐Med Mask Miscellaneous Tier 3 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers OptiChamber Advantage‐Sm Mask Miscellaneous Tier 3 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers OptiChamber Diamond Device Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers OptiChamber Diamond Miscellaneous Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers OptiChamber Diamond‐Lg Mask Device Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers OptiChamber Diamond‐Md Mask Miscellaneous Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers OptiChamber Diamond‐Sm Mask Miscellaneous Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers OptiHaler Device Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers OptiHaler Miscellaneous Tier 2 x DIAGNOSTIC PRODUCTS Gadoversetamide OptiMARK Intravenous Solution 330.9 MG/ML Tier 3 x DIAGNOSTIC PRODUCTS Ioversol Optiray 240 Intravenous Solution 51 % Tier 3 x DIAGNOSTIC PRODUCTS Ioversol Optiray 300 Intravenous Solution 64 % Tier 3 x DIAGNOSTIC PRODUCTS Ioversol Optiray 320 Intravenous Solution 68 % Tier 3 x DIAGNOSTIC PRODUCTS Ioversol Optiray 350 Intravenous Solution 74 % Tier 3 x DIAGNOSTIC PRODUCTS Glucose Blood Optium Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood OptiumEZ Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood OptumRx Blood Glucose Test In Vitro Strip Tier 3 DERMATOLOGICALS Doxycycline (Rosacea) Oracea Oral Capsule Delayed Release 40 MG Tier 3 x GENITOURINARY AGENTS ‐ MISCELLANEOUS Sodium Citrate & Citric Acid Oracit Oral Solution 490‐640 MG/5ML Tier 3 MOUTH/THROAT/DENTAL AGENTS Sucralfate‐Malate Orafate Mouth/Throat Paste 10 % Tier 3 MOUTH/THROAT/DENTAL AGENTS Triamcinolone Acetonide (Mouth) Oralone Mouth/Throat Paste 0.1 % Tier 1 MOUTH/THROAT/DENTAL AGENTS Oral Wound Care Products OraMagicRx Mouth/Throat Suspension Reconstituted Tier 3 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Pimozide Orap Oral Tablet 1 MG Tier 3 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Pimozide Orap Oral Tablet 2 MG Tier 3 CORTICOSTEROIDS Prednisolone Sodium Phosphate Orapred ODT Oral Tablet Dispersible 10 MG Tier 3 CORTICOSTEROIDS Prednisolone Sodium Phosphate Orapred ODT Oral Tablet Dispersible 15 MG Tier 3 CORTICOSTEROIDS Prednisolone Sodium Phosphate Orapred ODT Oral Tablet Dispersible 30 MG Tier 3 ANTI‐INFECTIVE AGENTS ‐ MISC. Oritavancin Diphosphate Orbactiv Intravenous Solution Reconstituted 400 MG Tier 3 x ANALGESICS ‐ ANTI‐INFLAMMATORY Abatacept Orencia Subcutaneous Solution Prefilled Syringe 125 MG/ML Tier 2 x CARDIOVASCULAR AGENTS ‐ MISC. Treprostinil Diolamine Orenitram Oral Tablet Extended Release 0.125 MG Tier 2 x x CARDIOVASCULAR AGENTS ‐ MISC. Treprostinil Diolamine Orenitram Oral Tablet Extended Release 0.25 MG Tier 2 x x CARDIOVASCULAR AGENTS ‐ MISC. Treprostinil Diolamine Orenitram Oral Tablet Extended Release 1 MG Tier 2 x x CARDIOVASCULAR AGENTS ‐ MISC. Treprostinil Diolamine Orenitram Oral Tablet Extended Release 2.5 MG Tier 2 x x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Nitisinone Orfadin Oral Capsule 10 MG Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Nitisinone Orfadin Oral Capsule 2 MG Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Nitisinone Orfadin Oral Capsule 5 MG Tier 2 x RESPIRATORY AGENTS ‐ MISC. Lumacaftor‐Ivacaftor Orkambi Oral Tablet 200‐125 MG Tier 2 x x MUSCULOSKELETAL THERAPY AGENTS Citrate Orphenadrine Citrate ER Oral Tablet Extended Release 12 Hour 100 MG Tier 1 MUSCULOSKELETAL THERAPY AGENTS Orphenadrine Citrate Orphenadrine Citrate Injection Solution 30 MG/ML Tier 1 x MUSCULOSKELETAL THERAPY AGENTS Orphenadrine Citrate Orphenadrine Citrate Powder Tier 3 MUSCULOSKELETAL THERAPY AGENTS Orphenadrine w/ Aspirin & Caff Orphenadrine‐Aspirin‐Caffeine Oral Tablet 25‐385‐30 MG Tier 1 CONTRACEPTIVES Levonorgestrel & Eth Estradiol Orsythia Oral Tablet 0.1‐20 MG‐MCG Tier 1 HEMATOPOIETIC AGENTS Folic Acid‐Cholecalciferol Ortho D Oral Capsule 1‐3775 MG‐UNIT Tier 3 CONTRACEPTIVES Norethindrone (Contraceptive) Ortho Micronor Oral Tablet 0.35 MG Tier 3 CONTRACEPTIVES Norgestimate‐Ethinyl Estradiol (Triphasic) Ortho Tri‐Cyclen (28) Oral Tablet 0.18/0.215/0.25 MG‐35 MCG Tier 3 CONTRACEPTIVES Norgestimate‐Ethinyl Estradiol (Triphasic) Ortho Tri‐Cyclen Lo Oral Tablet 0.18/0.215/0.25 MG‐25 MCG Tier 3 CONTRACEPTIVES Norgestimate‐Ethinyl Estradiol Ortho‐Cyclen (28) Oral Tablet 0.25‐35 MG‐MCG Tier 3 CONTRACEPTIVES Norethindrone & Eth Estradiol Ortho‐Novum 1/35 (28) Oral Tablet 1‐35 MG‐MCG Tier 3 CONTRACEPTIVES Norethindrone‐Eth Estradiol (Triphasic) Ortho‐Novum 7/7/7 (28) Oral Tablet 0.5/0.75/1‐35 MG‐MCG Tier 3 ULCER DRUGS Hyoscyamine Sulfate Oscimin Oral Tablet 0.125 MG Tier 1 ULCER DRUGS Hyoscyamine Sulfate Oscimin Oral Tablet Dispersible 0.125 MG Tier 1 ULCER DRUGS Hyoscyamine Sulfate Oscimin SR Oral Tablet Extended Release 12 Hour 0.375 MG Tier 1 ULCER DRUGS Hyoscyamine Sulfate Oscimin Sublingual Tablet Sublingual 0.125 MG Tier 1 DERMATOLOGICALS Benzoyl Peroxide Oscion Cleanser External Lotion 6 % Tier 1 ANTIDIABETICS Alogliptin‐Pioglitazone Oseni Oral Tablet 12.5‐15 MG Tier 3 xx ANTIDIABETICS Alogliptin‐Pioglitazone Oseni Oral Tablet 12.5‐30 MG Tier 3 xx ANTIDIABETICS Alogliptin‐Pioglitazone Oseni Oral Tablet 12.5‐45 MG Tier 3 xx ANTIDIABETICS Alogliptin‐Pioglitazone Oseni Oral Tablet 25‐15 MG Tier 3 xx ANTIDIABETICS Alogliptin‐Pioglitazone Oseni Oral Tablet 25‐30 MG Tier 3 xx ANTIDIABETICS Alogliptin‐Pioglitazone Oseni Oral Tablet 25‐45 MG Tier 3 xx DIURETICS Mannitol Osmitrol Intravenous Solution 20 % Tier 1 x LAXATIVES Sodium Phosphate Monobasic‐Sodium Phosphate Dibasic OsmoPrep Oral Tablet 1.102‐0.398 GM Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Ospemifene Osphena Oral Tablet 60 MG Tier 3 x ANALGESICS ‐ ANTI‐INFLAMMATORY Apremilast Otezla Oral Tablet 30 MG Tier 2 x x ANALGESICS ‐ ANTI‐INFLAMMATORY Apremilast Otezla Oral Tablet Therapy Pack 10 & 20 & 30 MG Tier 2 x OTIC AGENTS Antipyrine‐Benzocaine‐Polycosanol Otic Care Otic Solution 5.4‐1.4‐0.0097 % Tier 1 OTIC AGENTS Pramoxine‐Chloroxylenol Oticin Otic Liquid 1‐0.1 % Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Methotrexate (Antirheumatic) Otrexup Subcutaneous Solution Auto‐injector 10 MG/0.4ML Tier 3 x x ANALGESICS ‐ ANTI‐INFLAMMATORY Methotrexate (Antirheumatic) Otrexup Subcutaneous Solution Auto‐injector 15 MG/0.4ML Tier 3 x x ANALGESICS ‐ ANTI‐INFLAMMATORY Methotrexate (Antirheumatic) Otrexup Subcutaneous Solution Auto‐injector 20 MG/0.4ML Tier 3 x x ANALGESICS ‐ ANTI‐INFLAMMATORY Methotrexate (Antirheumatic) Otrexup Subcutaneous Solution Auto‐injector 25 MG/0.4ML Tier 3 x x ANALGESICS ‐ ANTI‐INFLAMMATORY Methotrexate (Antirheumatic) Otrexup Subcutaneous Solution Auto‐injector 7.5 MG/0.4ML Tier 3 x x DERMATOLOGICALS Sulfacetamide Sodium Ovace Plus External Cream 10 % Tier 3 DERMATOLOGICALS Sulfacetamide Sodium Ovace Plus External Foam 9.8 % Tier 3 DERMATOLOGICALS Sulfacetamide Sodium Ovace Plus External Lotion 9.8 % Tier 3 DERMATOLOGICALS Sulfacetamide Sodium Ovace Plus External Shampoo 10 % Tier 3 DERMATOLOGICALS Sulfacetamide Sodium Ovace Plus Wash External Gel 10 % Tier 3 DERMATOLOGICALS Sulfacetamide Sodium Ovace Plus Wash External Liquid 10 % Tier 3 DERMATOLOGICALS Sulfacetamide Sodium Ovace Wash External Liquid 10 % Tier 3 CONTRACEPTIVES Norethindrone & Eth Estradiol Ovcon‐35 (28) Oral Tablet 0.4‐35 MG‐MCG Tier 3 DERMATOLOGICALS Malathion Ovide External Lotion 0.5 % Tier 3 PENICILLINS Oxacillin Sodium Oxacillin Sodium Injection Solution Reconstituted 1 GM Tier 1 x PENICILLINS Oxacillin Sodium Oxacillin Sodium Injection Solution Reconstituted 10 GM Tier 1 x HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

PENICILLINS Oxacillin Sodium Oxacillin Sodium Injection Solution Reconstituted 2 GM Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Oxaliplatin Oxaliplatin Intravenous Solution 100 MG/20ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Oxaliplatin Oxaliplatin Intravenous Solution 50 MG/10ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Oxaliplatin Oxaliplatin Intravenous Solution Reconstituted 100 MG Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Oxaliplatin Oxaliplatin Intravenous Solution Reconstituted 50 MG Tier 1 x ANDROGENS‐ANABOLIC Oxandrolone Oxandrin Oral Tablet 10 MG Tier 3 x ANDROGENS‐ANABOLIC Oxandrolone Oxandrin Oral Tablet 2.5 MG Tier 3 x ANDROGENS‐ANABOLIC Oxandrolone Oxandrolone Oral Tablet 10 MG Tier 1 x ANDROGENS‐ANABOLIC Oxandrolone Oxandrolone Oral Tablet 2.5 MG Tier 1 x ANALGESICS ‐ ANTI‐INFLAMMATORY Oxaprozin Oxaprozin Oral Tablet 600 MG Tier 1 ANALGESICS ‐ OPIOID Oxycodone HCl Oxaydo Oral Tablet Abuse‐Deterrent 5 MG Tier 3 x x ANALGESICS ‐ OPIOID Oxycodone HCl Oxaydo Oral Tablet Abuse‐Deterrent 7.5 MG Tier 3 x x ANTIANXIETY AGENTS Oxazepam Oxazepam Oral Capsule 10 MG Tier 1 ANTIANXIETY AGENTS Oxazepam Oxazepam Oral Capsule 15 MG Tier 1 ANTIANXIETY AGENTS Oxazepam Oxazepam Oral Capsule 30 MG Tier 1 ANTICONVULSANTS Oxcarbazepine OXcarbazepine Oral Suspension 300 MG/5ML Tier 1 ANTICONVULSANTS Oxcarbazepine OXcarbazepine Oral Tablet 150 MG Tier 1 ANTICONVULSANTS Oxcarbazepine OXcarbazepine Oral Tablet 300 MG Tier 1 ANTICONVULSANTS Oxcarbazepine OXcarbazepine Oral Tablet 600 MG Tier 1 DERMATOLOGICALS Oxiconazole Nitrate Oxistat External Cream 1 % Tier 3 DERMATOLOGICALS Oxiconazole Nitrate Oxistat External Lotion 1 % Tier 3 DERMATOLOGICALS Methoxsalen (Topical) Oxsoralen External Lotion 1 % Tier 3 DERMATOLOGICALS Methoxsalen Rapid Oxsoralen Ultra Oral Capsule 10 MG Tier 2 ANTICONVULSANTS Oxcarbazepine Oxtellar XR Oral Tablet Extended Release 24 Hour 150 MG Tier 3 ANTICONVULSANTS Oxcarbazepine Oxtellar XR Oral Tablet Extended Release 24 Hour 300 MG Tier 3 ANTICONVULSANTS Oxcarbazepine Oxtellar XR Oral Tablet Extended Release 24 Hour 600 MG Tier 3 URINARY ANTISPASMODICS Oxybutynin Chloride Oxybutynin Chloride ER Oral Tablet Extended Release 24 Hour 10 MG Tier 1 URINARY ANTISPASMODICS Oxybutynin Chloride Oxybutynin Chloride ER Oral Tablet Extended Release 24 Hour 15 MG Tier 1 URINARY ANTISPASMODICS Oxybutynin Chloride Oxybutynin Chloride ER Oral Tablet Extended Release 24 Hour 5 MG Tier 1 URINARY ANTISPASMODICS Oxybutynin Chloride Oxybutynin Chloride Oral Syrup 5 MG/5ML Tier 1 URINARY ANTISPASMODICS Oxybutynin Chloride Oxybutynin Chloride Oral Tablet 5 MG Tier 1 ANALGESICS ‐ OPIOID Oxycodone HCl OxyCODONE HCl ER Oral Tablet ER 12 Hour Abuse‐Deterrent 10 MG Tier 2 x x ANALGESICS ‐ OPIOID Oxycodone HCl OxyCODONE HCl ER Oral Tablet ER 12 Hour Abuse‐Deterrent 20 MG Tier 2 x x ANALGESICS ‐ OPIOID Oxycodone HCl OxyCODONE HCl ER Oral Tablet ER 12 Hour Abuse‐Deterrent 40 MG Tier 2 x x ANALGESICS ‐ OPIOID Oxycodone HCl OxyCODONE HCl ER Oral Tablet ER 12 Hour Abuse‐Deterrent 80 MG Tier 2 x x ANALGESICS ‐ OPIOID Oxycodone HCl OxyCODONE HCl Oral Capsule 5 MG Tier 1 x ANALGESICS ‐ OPIOID Oxycodone HCl OxyCODONE HCl Oral Concentrate 100 MG/5ML Tier 1 x ANALGESICS ‐ OPIOID Oxycodone HCl OxyCODONE HCl Oral Concentrate 100 MG/5ML Tier 3 x ANALGESICS ‐ OPIOID Oxycodone HCl OxyCODONE HCl Oral Concentrate 20 MG/ML Tier 1 x ANALGESICS ‐ OPIOID Oxycodone HCl OxyCODONE HCl Oral Solution 5 MG/5ML Tier 1 x ANALGESICS ‐ OPIOID Oxycodone HCl OxyCODONE HCl Oral Solution 5 MG/5ML Tier 3 x ANALGESICS ‐ OPIOID Oxycodone HCl OxyCODONE HCl Oral Tablet 10 MG Tier 1 x ANALGESICS ‐ OPIOID Oxycodone HCl OxyCODONE HCl Oral Tablet 15 MG Tier 1 x ANALGESICS ‐ OPIOID Oxycodone HCl OxyCODONE HCl Oral Tablet 20 MG Tier 1 x ANALGESICS ‐ OPIOID Oxycodone HCl OxyCODONE HCl Oral Tablet 30 MG Tier 1 x ANALGESICS ‐ OPIOID Oxycodone HCl OxyCODONE HCl Oral Tablet 5 MG Tier 1 x ANALGESICS ‐ OPIOID Oxycodone HCl OxyCODONE HCl Powder Tier 3 x x ANALGESICS ‐ OPIOID Oxycodone w/ Acetaminophen Oxycodone‐Acetaminophen Oral Tablet 10‐325 MG Tier 1 x ANALGESICS ‐ OPIOID Oxycodone w/ Acetaminophen Oxycodone‐Acetaminophen Oral Tablet 2.5‐325 MG Tier 1 x ANALGESICS ‐ OPIOID Oxycodone w/ Acetaminophen Oxycodone‐Acetaminophen Oral Tablet 5‐325 MG Tier 1 x ANALGESICS ‐ OPIOID Oxycodone w/ Acetaminophen Oxycodone‐Acetaminophen Oral Tablet 7.5‐325 MG Tier 1 x ANALGESICS ‐ OPIOID Oxycodone‐Aspirin Oxycodone‐Aspirin Oral Tablet 4.8355‐325 MG Tier 1 ANALGESICS ‐ OPIOID Oxycodone‐Ibuprofen Oxycodone‐Ibuprofen Oral Tablet 5‐400 MG Tier 1 x ANALGESICS ‐ OPIOID Oxycodone HCl OxyCONTIN Oral Tablet ER 12 Hour Abuse‐Deterrent 10 MG Tier 2 x x ANALGESICS ‐ OPIOID Oxycodone HCl OxyCONTIN Oral Tablet ER 12 Hour Abuse‐Deterrent 15 MG Tier 2 x x ANALGESICS ‐ OPIOID Oxycodone HCl OxyCONTIN Oral Tablet ER 12 Hour Abuse‐Deterrent 20 MG Tier 2 x x ANALGESICS ‐ OPIOID Oxycodone HCl OxyCONTIN Oral Tablet ER 12 Hour Abuse‐Deterrent 30 MG Tier 2 x x ANALGESICS ‐ OPIOID Oxycodone HCl OxyCONTIN Oral Tablet ER 12 Hour Abuse‐Deterrent 40 MG Tier 2 x x ANALGESICS ‐ OPIOID Oxycodone HCl OxyCONTIN Oral Tablet ER 12 Hour Abuse‐Deterrent 60 MG Tier 2 x x ANALGESICS ‐ OPIOID Oxycodone HCl OxyCONTIN Oral Tablet ER 12 Hour Abuse‐Deterrent 80 MG Tier 2 x x ANALGESICS ‐ OPIOID Oxymorphone HCl Oxymorphone HCl ER Oral Tablet Extended Release 12 Hour 10 MG Tier 1 x ANALGESICS ‐ OPIOID Oxymorphone HCl Oxymorphone HCl ER Oral Tablet Extended Release 12 Hour 15 MG Tier 1 x ANALGESICS ‐ OPIOID Oxymorphone HCl Oxymorphone HCl ER Oral Tablet Extended Release 12 Hour 20 MG Tier 1 x x ANALGESICS ‐ OPIOID Oxymorphone HCl Oxymorphone HCl ER Oral Tablet Extended Release 12 Hour 30 MG Tier 1 x ANALGESICS ‐ OPIOID Oxymorphone HCl Oxymorphone HCl ER Oral Tablet Extended Release 12 Hour 40 MG Tier 1 x ANALGESICS ‐ OPIOID Oxymorphone HCl Oxymorphone HCl ER Oral Tablet Extended Release 12 Hour 5 MG Tier 1 x ANALGESICS ‐ OPIOID Oxymorphone HCl Oxymorphone HCl ER Oral Tablet Extended Release 12 Hour 7.5 MG Tier 1 x ANALGESICS ‐ OPIOID Oxymorphone HCl Oxymorphone HCl Oral Tablet 10 MG Tier 1 x ANALGESICS ‐ OPIOID Oxymorphone HCl Oxymorphone HCl Oral Tablet 5 MG Tier 1 x TETRACYCLINES Oxytetracycline HCl Oxytetracycline HCl Powder Tier 3 URINARY ANTISPASMODICS Oxybutynin Oxytrol Transdermal Patch Twice Weekly 3.9 MG/24HR Tier 3 xx ANTIARRHYTHMICS Amiodarone HCl Pacerone Oral Tablet 100 MG Tier 1 ANTIARRHYTHMICS Amiodarone HCl Pacerone Oral Tablet 200 MG Tier 1 ANTIARRHYTHMICS Amiodarone HCl Pacerone Oral Tablet 400 MG Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES PACLitaxel Intravenous Concentrate 100 MG/16.7ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Paclitaxel PACLitaxel Intravenous Concentrate 30 MG/5ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Paclitaxel PACLitaxel Intravenous Concentrate 300 MG/50ML Tier 1 x MULTIVITAMINS Prenatal Vit w/ Fe Polysacch Cmplx‐Fe Asp‐Fe Glyc‐FA & DHA Paire OB Oral Miscellaneous 22‐6‐1 & 200 MG Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Paliperidone Paliperidone ER Oral Tablet Extended Release 24 Hour 1.5 MG Tier 1 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Paliperidone Paliperidone ER Oral Tablet Extended Release 24 Hour 3 MG Tier 1 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Paliperidone Paliperidone ER Oral Tablet Extended Release 24 Hour 6 MG Tier 1 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Paliperidone Paliperidone ER Oral Tablet Extended Release 24 Hour 9 MG Tier 1 x ANTIDEPRESSANTS Nortriptyline HCl Pamelor Oral Capsule 10 MG Tier 3 ANTIDEPRESSANTS Nortriptyline HCl Pamelor Oral Capsule 25 MG Tier 3 ANTIDEPRESSANTS Nortriptyline HCl Pamelor Oral Capsule 50 MG Tier 3 ANTIDEPRESSANTS Nortriptyline HCl Pamelor Oral Capsule 75 MG Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Pamidronate Disodium Pamidronate Disodium Intravenous Solution 30 MG/10ML Tier 1 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Pamidronate Disodium Pamidronate Disodium Intravenous Solution 90 MG/10ML Tier 1 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Pamidronate Disodium Pamidronate Disodium Intravenous Solution Reconstituted 30 MG Tier 1 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Pamidronate Disodium Pamidronate Disodium Intravenous Solution Reconstituted 90 MG Tier 1 x ULCER DRUGS Methscopolamine Bromide Pamine Forte Oral Tablet 5 MG Tier 3 ULCER DRUGS Methscopolamine & Misc. Intestinal Flora Regulator Pamine FQ Oral Kit 5 MG Tier 3 ULCER DRUGS Methscopolamine Bromide Pamine Oral Tablet 2.5 MG Tier 3 DIGESTIVE AIDS Pancrelipase (Lipase‐Protease‐Amylase) Pancreaze Oral Capsule Delayed Release Particles 10500 UNIT Tier 3 x DIGESTIVE AIDS Pancrelipase (Lipase‐Protease‐Amylase) Pancreaze Oral Capsule Delayed Release Particles 16800 UNIT Tier 3 x DIGESTIVE AIDS Pancrelipase (Lipase‐Protease‐Amylase) Pancreaze Oral Capsule Delayed Release Particles 21000 UNIT Tier 3 x DIGESTIVE AIDS Pancrelipase (Lipase‐Protease‐Amylase) Pancreaze Oral Capsule Delayed Release Particles 4200 UNIT Tier 3 x NEUROMUSCULAR AGENTS Pancuronium Bromide Pancuronium Bromide Intravenous Solution 1 MG/ML Tier 1 x NEUROMUSCULAR AGENTS Pancuronium Bromide Pancuronium Bromide Intravenous Solution 2 MG/ML Tier 1 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chamber Supplies ‐ Masks Panda Mask Large Miscellaneous Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chamber Supplies ‐ Masks Panda Mask Medium Miscellaneous Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chamber Supplies ‐ Masks Panda Mask Small Miscellaneous Tier 2 x DERMATOLOGICALS Hydrocortisone Probutate Pandel External Cream 0.1 % Tier 3 HEMATOLOGICAL AGENTS ‐ MISC. Hemin Panhematin Intravenous Solution Reconstituted 313 MG Tier 3 x DERMATOLOGICALS Alitretinoin Panretin External Gel 0.1 % Tier 3 ULCER DRUGS Pantoprazole Sodium Pantoprazole Sodium Oral Tablet Delayed Release 20 MG Tier 1 x ULCER DRUGS Pantoprazole Sodium Pantoprazole Sodium Oral Tablet Delayed Release 40 MG Tier 1 x CARDIOVASCULAR AGENTS ‐ MISC. Papaverine HCl Papaverine HCl Injection Solution 30 MG/ML Tier 1 x CARDIOVASCULAR AGENTS ‐ MISC. Papaverine HCl Papaverine HCl Powder Tier 3 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies Paradigm Link Glucose Monitor Kit w/Device Tier 3 MUSCULOSKELETAL THERAPY AGENTS Chlorzoxazone Parafon Forte DSC Oral Tablet 500 MG Tier 3 CONTRACEPTIVES Copper (IUD) Paragard Intrauterine Copper Intrauterine Intrauterine Device Tier 3 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

OPHTHALMIC AGENTS Hydroxyamphetamine‐Tropicamide Paremyd Ophthalmic Solution 1‐0.25 % Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Paricalcitol Paricalcitol Intravenous Solution 2 MCG/ML Tier 1 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Paricalcitol Paricalcitol Intravenous Solution 5 MCG/ML Tier 1 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Paricalcitol Paricalcitol Oral Capsule 1 MCG Tier 1 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Paricalcitol Paricalcitol Oral Capsule 2 MCG Tier 1 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Paricalcitol Paricalcitol Oral Capsule 4 MCG Tier 1 ANTIPARKINSON AGENTS Bromocriptine Mesylate Parlodel Oral Capsule 5 MG Tier 3 ANTIDEPRESSANTS Tranylcypromine Sulfate Parnate Oral Tablet 10 MG Tier 3 MOUTH/THROAT/DENTAL AGENTS Chlorhexidine Gluconate (Mouth‐Throat) Paroex Mouth/Throat Solution 0.12 % Tier 1 AMINOGLYCOSIDES Paromomycin Sulfate Paromomycin Sulfate Oral Capsule 250 MG Tier 1 ANTIDEPRESSANTS Paroxetine HCl PARoxetine HCl ER Oral Tablet Extended Release 24 Hour 12.5 MG Tier 1 ANTIDEPRESSANTS Paroxetine HCl PARoxetine HCl ER Oral Tablet Extended Release 24 Hour 25 MG Tier 1 ANTIDEPRESSANTS Paroxetine HCl PARoxetine HCl ER Oral Tablet Extended Release 24 Hour 37.5 MG Tier 1 ANTIDEPRESSANTS Paroxetine HCl PARoxetine HCl Oral Tablet 10 MG Tier 1 ANTIDEPRESSANTS Paroxetine HCl PARoxetine HCl Oral Tablet 20 MG Tier 1 ANTIDEPRESSANTS Paroxetine HCl PARoxetine HCl Oral Tablet 30 MG Tier 1 ANTIDEPRESSANTS Paroxetine HCl PARoxetine HCl Oral Tablet 40 MG Tier 1 ANTIMYCOBACTERIAL AGENTS Aminosalicylic Acid Paser Oral Packet 4 GM Tier 3 OPHTHALMIC AGENTS Olopatadine HCl Pataday Ophthalmic Solution 0.2 % Tier 2 NASAL AGENTS ‐ SYSTEMIC AND TOPICAL Olopatadine HCl (Nasal) Patanase Nasal Solution 0.6 % Tier 3 x OPHTHALMIC AGENTS Olopatadine HCl Patanol Ophthalmic Solution 0.1 % Tier 3 ANTIDEPRESSANTS Paroxetine HCl Paxil CR Oral Tablet Extended Release 24 Hour 12.5 MG Tier 3 x ANTIDEPRESSANTS Paroxetine HCl Paxil CR Oral Tablet Extended Release 24 Hour 25 MG Tier 3 x ANTIDEPRESSANTS Paroxetine HCl Paxil CR Oral Tablet Extended Release 24 Hour 37.5 MG Tier 3 x ANTIDEPRESSANTS Paroxetine HCl Paxil Oral Suspension 10 MG/5ML Tier 2 x ANTIDEPRESSANTS Paroxetine HCl Paxil Oral Tablet 10 MG Tier 3 x ANTIDEPRESSANTS Paroxetine HCl Paxil Oral Tablet 20 MG Tier 3 x ANTIDEPRESSANTS Paroxetine HCl Paxil Oral Tablet 30 MG Tier 3 x ANTIDEPRESSANTS Paroxetine HCl Paxil Oral Tablet 40 MG Tier 3 x OPHTHALMIC AGENTS Olopatadine HCl Pazeo Ophthalmic Solution 0.7 % Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets PC Lancets Super Thin 30G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle PC Unifine Pentips Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle PC Unifine Pentips Miscellaneous 31G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle PC Unifine Pentips Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle PC Unifine Pentips Miscellaneous 31G X 8 MM Tier 2 MACROLIDES Erythromycin Base (Coated) PCE Oral Tablet Delayed Release 333 MG Tier 3 MACROLIDES Erythromycin Base (Coated) PCE Oral Tablet Delayed Release 500 MG Tier 3 LAXATIVES Mag Cit‐Bisacodyl‐Petrolat‐PEG 3350‐Metoclopramide‐Electrol PCP 100 Combination Kit Tier 3 ANTIDIARRHEALS Pectin Pectin Powder Tier 3 DERMATOLOGICALS Hydrocortisone & Emollient Pediaderm HC External Kit 2 % Tier 3 DERMATOLOGICALS Triamcinolone Acetonide & Emollient Pediaderm TA External Kit 0.1 % Tier 3 CORTICOSTEROIDS Prednisolone Sodium Phosphate Pediapred Oral Solution 6.7 (5 Base) MG/5ML Tier 3 TOXOIDS Diph‐Tetanus Tox‐Acell Pert‐Hepatitis B Recomb‐Polio IPV Vac Pediarix Intramuscular Suspension Tier 2 x COUGH/COLD/ALLERGY Pseudoeph‐Triprolidine‐DM Pediatex TDM Oral Suspension 10‐0.938‐4 MG/ML Tier 3 MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chamber Supplies ‐ Masks Pediatric Panda Mask Miscellaneous Tier 2 x VACCINES Haemophilus B Polysac Conj Vac Pedvax HIB Intramuscular Suspension 7.5 MCG/0.5ML Tier 3 x PHARMACEUTICAL ADJUVANTS Polyethylene Glycol 300 Peg 300 Liquid Tier 3 LAXATIVES PEG 3350‐KCl‐Sod Bicarb‐Sod Chloride‐Sod Sulfate PEG 3350/Electrolytes Oral Solution Reconstituted 240 GM Tier 1 LAXATIVES PEG 3350‐Potassium Chloride‐Sod Bicarbonate‐Sod Chloride PEG 3350‐KCl‐Na Bicarb‐NaCl Oral Solution Reconstituted 420 GM Tier 1 LAXATIVES PEG 3350‐KCl‐Sod Bicarb‐Sod Chloride‐Sod Sulfate PEG‐3350/Electrolytes Oral Solution Reconstituted 236 GM Tier 1 ANTICONVULSANTS Ethotoin Peganone Oral Tablet 250 MG Tier 3 ANTIVIRALS Peginterferon alfa‐2a Pegasys ProClick Subcutaneous Solution 135 MCG/0.5ML Tier 2 x x ANTIVIRALS Peginterferon alfa‐2a Pegasys ProClick Subcutaneous Solution 180 MCG/0.5ML Tier 2 x x ANTIVIRALS Peginterferon alfa‐2a Pegasys Subcutaneous Kit 180 MCG/0.5ML Tier 2 x x ANTIVIRALS Peginterferon alfa‐2a Pegasys Subcutaneous Solution 180 MCG/0.5ML Tier 2 x x ANTIVIRALS Peginterferon alfa‐2a Pegasys Subcutaneous Solution 180 MCG/ML Tier 2 x x ANTIVIRALS Peginterferon alfa‐2b Peg‐Intron Redipen Pak 4 Subcutaneous Kit 120 MCG/0.5ML Tier 2 x x ANTIVIRALS Peginterferon alfa‐2b Peg‐Intron Redipen Pak 4 Subcutaneous Kit 150 MCG/0.5ML Tier 2 x x ANTIVIRALS Peginterferon alfa‐2b Peg‐Intron Redipen Pak 4 Subcutaneous Kit 50 MCG/0.5ML Tier 2 x x ANTIVIRALS Peginterferon alfa‐2b Peg‐Intron Redipen Pak 4 Subcutaneous Kit 80 MCG/0.5ML Tier 2 x x ANTIVIRALS Peginterferon alfa‐2b Peg‐Intron Redipen Subcutaneous Kit 120 MCG/0.5ML Tier 2 x x ANTIVIRALS Peginterferon alfa‐2b Peg‐Intron Redipen Subcutaneous Kit 150 MCG/0.5ML Tier 2 x x ANTIVIRALS Peginterferon alfa‐2b Peg‐Intron Redipen Subcutaneous Kit 50 MCG/0.5ML Tier 2 x x ANTIVIRALS Peginterferon alfa‐2b Peg‐Intron Redipen Subcutaneous Kit 80 MCG/0.5ML Tier 2 x x ANTIVIRALS Peginterferon alfa‐2b PegIntron Subcutaneous Kit 120 MCG/0.5ML Tier 2 x x ANTIVIRALS Peginterferon alfa‐2b Peg‐Intron Subcutaneous Kit 120 MCG/0.5ML Tier 2 x x ANTIVIRALS Peginterferon alfa‐2b PegIntron Subcutaneous Kit 150 MCG/0.5ML Tier 2 x x ANTIVIRALS Peginterferon alfa‐2b Peg‐Intron Subcutaneous Kit 150 MCG/0.5ML Tier 2 x x ANTIVIRALS Peginterferon alfa‐2b PegIntron Subcutaneous Kit 50 MCG/0.5ML Tier 2 x x ANTIVIRALS Peginterferon alfa‐2b Peg‐Intron Subcutaneous Kit 50 MCG/0.5ML Tier 2 x x ANTIVIRALS Peginterferon alfa‐2b PegIntron Subcutaneous Kit 80 MCG/0.5ML Tier 2 x x ANTIVIRALS Peginterferon alfa‐2b Peg‐Intron Subcutaneous Kit 80 MCG/0.5ML Tier 2 x x LAXATIVES Bisacodyl‐PEG 3350‐Pot Chloride‐Sod Bicarb‐Sod Chloride PEG‐Prep Oral Kit 5‐210 MG‐GM Tier 1 LAXATIVES Polyethylene Glycol 3350 PEGyLAX Oral Powder Tier 1 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Pen Needles 1/2" Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Pen Needles 3/16" Miscellaneous 31G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Pen Needles 5/16" Miscellaneous 30G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Pen Needles 5/16" Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Pen Needles Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Pen Needles Miscellaneous 31G X 6 MM Tier 2 ASSORTED CLASSES Penicillamine Penicillamine Powder Tier 3 PENICILLINS Penicillin G Potassium Penicillin G Potassium Injection Solution Reconstituted 20000000 UNIT Tier 1 x PENICILLINS Penicillin G Potassium Penicillin G Potassium Injection Solution Reconstituted 5000000 UNIT Tier 1 x PENICILLINS Penicillin G Procaine Penicillin G Procaine Intramuscular Suspension 600000 UNIT/ML Tier 3 x PENICILLINS Penicillin G Sodium Penicillin G Sodium Injection Solution Reconstituted 5000000 UNIT Tier 3 x PENICILLINS Penicillin V Potassium Penicillin V Potassium Oral Solution Reconstituted 125 MG/5ML Tier 1 PENICILLINS Penicillin V Potassium Penicillin V Potassium Oral Solution Reconstituted 250 MG/5ML Tier 1 PENICILLINS Penicillin V Potassium Penicillin V Potassium Oral Tablet 250 MG Tier 1 PENICILLINS Penicillin V Potassium Penicillin V Potassium Oral Tablet 500 MG Tier 1 BIOLOGICALS MISC Penicillium Notatum Penicillium Notatum Subcutaneous Solution 10000 PNU/ML Tier 3 x BIOLOGICALS MISC Penicillium Notatum Penicillium Notatum Subcutaneous Solution 20000 PNU/ML Tier 3 x DERMATOLOGICALS Ciclopirox Penlac External Solution 8 % Tier 3 x MEDICAL DEVICES AND SUPPLIES Lancets Misc. Penlet II Replacement Cap Miscellaneous Tier 2 DERMATOLOGICALS Diclofenac Sodium (Topical) Pennsaid Transdermal Solution 2 % Tier 3 x TOXOIDS Diph‐Ac Pert‐Tet Tox Ad‐Polio IPV‐Haemophil B Poly Vac Pentacel Intramuscular Suspension Reconstituted Tier 2 x GASTROINTESTINAL AGENTS ‐ MISC. Mesalamine Pentasa Oral Capsule Extended Release 250 MG Tier 3 GASTROINTESTINAL AGENTS ‐ MISC. Mesalamine Pentasa Oral Capsule Extended Release 500 MG Tier 3 ANALGESICS ‐ OPIOID Pentazocine w/ Naloxone Pentazocine‐Naloxone HCl Oral Tablet 50‐0.5 MG Tier 1 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle PenTips Miscellaneous 31G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle PenTips Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle PenTips Miscellaneous 32G X 4 MM Tier 2 HEMATOLOGICAL AGENTS ‐ MISC. Pentoxifylline Pentoxifylline ER Oral Tablet Extended Release 400 MG Tier 1 ULCER DRUGS Famotidine Pepcid Oral Suspension Reconstituted 40 MG/5ML Tier 3 ULCER DRUGS Famotidine Pepcid Oral Tablet 20 MG Tier 3 ULCER DRUGS Famotidine Pepcid Oral Tablet 40 MG Tier 3 ANALGESICS ‐ OPIOID Oxycodone w/ Acetaminophen Percocet Oral Tablet 10‐325 MG Tier 3 x ANALGESICS ‐ OPIOID Oxycodone w/ Acetaminophen Percocet Oral Tablet 2.5‐325 MG Tier 3 x ANALGESICS ‐ OPIOID Oxycodone w/ Acetaminophen Percocet Oral Tablet 5‐325 MG Tier 3 x ANALGESICS ‐ OPIOID Oxycodone w/ Acetaminophen Percocet Oral Tablet 7.5‐325 MG Tier 3 x ANALGESICS ‐ OPIOID Oxycodone‐Aspirin Percodan Oral Tablet 4.8355‐325 MG Tier 3 BIOLOGICALS MISC Perennial Rye Grass Standardized Perennial Rye Grass Pollen Subcutaneous Solution 100000 BAU/ML Tier 3 x MEDICAL DEVICES AND SUPPLIES Lancets Perfect Lancets 28G Miscellaneous Tier 2 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

MEDICAL DEVICES AND SUPPLIES Lancets Perfect Lancets 30G Miscellaneous Tier 2 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Formoterol Fumarate Perforomist Inhalation Nebulization Solution 20 MCG/2ML Tier 3 MOUTH/THROAT/DENTAL AGENTS Chlorhexidine Gluconate (Mouth‐Throat) Peridex Mouth/Throat Solution 0.12 % Tier 3 ANTIHYPERTENSIVES Perindopril Erbumine Perindopril Erbumine Oral Tablet 2 MG Tier 1 ANTIHYPERTENSIVES Perindopril Erbumine Perindopril Erbumine Oral Tablet 4 MG Tier 1 ANTIHYPERTENSIVES Perindopril Erbumine Perindopril Erbumine Oral Tablet 8 MG Tier 1 MOUTH/THROAT/DENTAL AGENTS Chlorhexidine Gluconate (Mouth‐Throat) Periogard Mouth/Throat Solution 0.12 % Tier 1 DERMATOLOGICALS Lidocaine‐Dextromethorphan‐Trolamine Salicylate Permavan External Patch 4‐4‐10 % Tier 3 DERMATOLOGICALS Permethrin Permethrin External Cream 5 % Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Perphenazine Perphenazine Oral Tablet 16 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Perphenazine Perphenazine Oral Tablet 2 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Perphenazine Perphenazine Oral Tablet 4 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Perphenazine Perphenazine Oral Tablet 8 MG Tier 1 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Perphenazine‐Amitriptyline Perphenazine‐Amitriptyline Oral Tablet 2‐10 MG Tier 2 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Perphenazine‐Amitriptyline Perphenazine‐Amitriptyline Oral Tablet 2‐25 MG Tier 2 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Perphenazine‐Amitriptyline Perphenazine‐Amitriptyline Oral Tablet 4‐10 MG Tier 2 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Perphenazine‐Amitriptyline Perphenazine‐Amitriptyline Oral Tablet 4‐25 MG Tier 2 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Perphenazine‐Amitriptyline Perphenazine‐Amitriptyline Oral Tablet 4‐50 MG Tier 2 HEMATOLOGICAL AGENTS ‐ MISC. Dipyridamole Persantine Oral Tablet 25 MG Tier 3 HEMATOLOGICAL AGENTS ‐ MISC. Dipyridamole Persantine Oral Tablet 50 MG Tier 3 HEMATOLOGICAL AGENTS ‐ MISC. Dipyridamole Persantine Oral Tablet 75 MG Tier 3 DIGESTIVE AIDS Pancrelipase (Lipase‐Protease‐Amylase) Pertzye Oral Capsule Delayed Release Particles 16000 UNIT Tier 3 x DIGESTIVE AIDS Pancrelipase (Lipase‐Protease‐Amylase) Pertzye Oral Capsule Delayed Release Particles 8000 UNIT Tier 3 x ANTIDEPRESSANTS Paroxetine Mesylate Pexeva Oral Tablet 10 MG Tier 3 xx ANTIDEPRESSANTS Paroxetine Mesylate Pexeva Oral Tablet 20 MG Tier 3 xx ANTIDEPRESSANTS Paroxetine Mesylate Pexeva Oral Tablet 30 MG Tier 3 xx ANTIDEPRESSANTS Paroxetine Mesylate Pexeva Oral Tablet 40 MG Tier 3 xx PENICILLINS Penicillin G Potassium Pfizerpen‐G Injection Solution Reconstituted 20000000 UNIT Tier 3 x PENICILLINS Penicillin G Potassium Pfizerpen‐G Injection Solution Reconstituted 5000000 UNIT Tier 3 x ANTIHISTAMINES Diphenhydramine HCl Pharbedryl Oral Capsule 50 MG Tier 1 DIAGNOSTIC PRODUCTS Glucose Blood Pharmacist Choice Autocode In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Pharmacist Choice Lancets Miscellaneous Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood Pharmacist Choice No Coding In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Pharmacy Counter Lancets Miscellaneous Tier 2 ANTIHISTAMINES Promethazine HCl Phenadoz Rectal Suppository 12.5 MG Tier 1 ANTIHISTAMINES Promethazine HCl Phenadoz Rectal Suppository 25 MG Tier 1 GENITOURINARY AGENTS ‐ MISCELLANEOUS Phenazopyridine HCl Phenazo Oral Tablet 200 MG Tier 1 GENITOURINARY AGENTS ‐ MISCELLANEOUS Phenazopyridine HCl Phenazopyridine HCl Oral Tablet 100 MG Tier 1 GENITOURINARY AGENTS ‐ MISCELLANEOUS Phenazopyridine HCl Phenazopyridine HCl Oral Tablet 200 MG Tier 1 GENITOURINARY AGENTS ‐ MISCELLANEOUS Phenazopyridine HCl Phenazopyridine HCl Powder Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Phendimetrazine Tartrate Phendimetrazine Tartrate ER Oral Capsule Extended Release 24 Hour 105 MG Tier 3 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Phendimetrazine Tartrate Phendimetrazine Tartrate Oral Tablet 35 MG Tier 1 x ANTIDEPRESSANTS Phenelzine Sulfate Phenelzine Sulfate Oral Tablet 15 MG Tier 1 ANTIHISTAMINES Promethazine HCl Phenergan Injection Solution 25 MG/ML Tier 3 x ANTIHISTAMINES Promethazine HCl Phenergan Injection Solution 50 MG/ML Tier 3 x ANTIHISTAMINES Promethazine HCl Phenergan Rectal Suppository 12.5 MG Tier 1 ANTIHISTAMINES Promethazine HCl Phenergan Rectal Suppository 25 MG Tier 1 ANTIHISTAMINES Promethazine HCl Phenergan Rectal Suppository 50 MG Tier 1 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS PHENobarbital Oral Elixir 20 MG/5ML Tier 1 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Phenobarbital PHENobarbital Oral Solution 20 MG/5ML Tier 1 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Phenobarbital PHENobarbital Oral Tablet 100 MG Tier 2 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Phenobarbital PHENobarbital Oral Tablet 15 MG Tier 2 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Phenobarbital PHENobarbital Oral Tablet 16.2 MG Tier 1 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Phenobarbital PHENobarbital Oral Tablet 30 MG Tier 2 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Phenobarbital PHENobarbital Oral Tablet 32.4 MG Tier 1 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Phenobarbital PHENobarbital Oral Tablet 60 MG Tier 2 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Phenobarbital PHENobarbital Oral Tablet 64.8 MG Tier 1 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Phenobarbital PHENobarbital Oral Tablet 97.2 MG Tier 1 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Phenobarbital PHENobarbital Powder Tier 3 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Phenobarbital Sodium PHENobarbital Sodium Injection Solution 130 MG/ML Tier 2 x HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Phenobarbital Sodium PHENobarbital Sodium Injection Solution 65 MG/ML Tier 3 x ANTIHYPERTENSIVES Phenoxybenzamine HCl Phenoxybenzamine HCl Oral Capsule 10 MG Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Phentermine HCl Phentermine HCl Oral Capsule 15 MG Tier 1 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Phentermine HCl Phentermine HCl Oral Capsule 30 MG Tier 1 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Phentermine HCl Phentermine HCl Oral Capsule 37.5 MG Tier 1 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Phentermine HCl Phentermine HCl Oral Tablet 37.5 MG Tier 1 x ANTIHYPERTENSIVES Phentolamine Mesylate Phentolamine Mesylate Injection Solution Reconstituted 5 MG Tier 3 x ANALGESICS ‐ ANTI‐INFLAMMATORY Phenylbutazone Phenylbutazone Powder Tier 3 COUGH/COLD/ALLERGY Phenyleph‐Promethazine w/ Cod Phenyleph‐Promethazine‐Cod Oral Syrup 5‐6.25‐10 MG/5ML Tier 1 VASOPRESSORS Phenylephrine HCl (Pressors) Phenylephrine HCl Injection Solution 10 MG/ML Tier 1 x VASOPRESSORS Phenylephrine HCl (Pressors) Phenylephrine HCl Injection Solution 10 MG/ML Tier 3 x OPHTHALMIC AGENTS Phenylephrine HCl (Ophth) Phenylephrine HCl Ophthalmic Solution 10 % Tier 1 OPHTHALMIC AGENTS Phenylephrine HCl (Ophth) Phenylephrine HCl Ophthalmic Solution 2.5 % Tier 1 NASAL AGENTS ‐ SYSTEMIC AND TOPICAL Phenylephrine HCl Phenylephrine HCl Powder Tier 3 COUGH/COLD/ALLERGY Phenylephrine‐Chlorphen‐DM Phenylephrine‐Chlorphen‐DM Oral Liquid 1.75‐0.75‐2.75 MG/ML Tier 3 COUGH/COLD/ALLERGY Phenylephrine‐Guaifenesin Phenylephrine‐Guaifenesin Oral Liquid 1.5‐20 MG/ML Tier 1 ANTICONVULSANTS Phenytoin Sodium Extended Phenytek Oral Capsule 200 MG Tier 3 ANTICONVULSANTS Phenytoin Sodium Extended Phenytek Oral Capsule 300 MG Tier 3 ANTICONVULSANTS Phenytoin Phenytoin Infatabs Oral Tablet Chewable 50 MG Tier 1 ANTICONVULSANTS Phenytoin Phenytoin Oral Suspension 125 MG/5ML Tier 1 ANTICONVULSANTS Phenytoin Phenytoin Oral Tablet Chewable 50 MG Tier 1 ANTICONVULSANTS Phenytoin Sodium Extended Phenytoin Sodium Extended Oral Capsule 100 MG Tier 1 ANTICONVULSANTS Phenytoin Sodium Extended Phenytoin Sodium Extended Oral Capsule 200 MG Tier 1 ANTICONVULSANTS Phenytoin Sodium Extended Phenytoin Sodium Extended Oral Capsule 300 MG Tier 1 ANTICONVULSANTS Phenytoin Sodium Phenytoin Sodium Injection Solution 50 MG/ML Tier 1 x ANTICONVULSANTS Phenytoin Sodium Phenytoin Sodium Powder Tier 3 CONTRACEPTIVES Norethindrone & Eth Estradiol Philith Oral Tablet 0.4‐35 MG‐MCG Tier 1 BIOLOGICALS MISC Phoma Exigua Phoma Exigua Subcutaneous Solution 20000 PNU/ML Tier 3 x GASTROINTESTINAL AGENTS ‐ MISC. Calcium Acetate (Phosphate Binder) PhosLo Oral Capsule 667 MG Tier 3 GASTROINTESTINAL AGENTS ‐ MISC. Calcium Acetate (Phosphate Binder) Phoslyra Oral Solution 667 MG/5ML Tier 3 MINERALS & ELECTROLYTES Pot Phosphate Monobasic w/ Sod Phosphate Dibasic & Monobasic Phospha 250 Neutral Oral Tablet 155‐852‐130 MG Tier 1 URINARY ANTI‐INFECTIVES Methenamine‐Hyosc‐Methylene Blue‐Sod Phos‐Phenyl Sal Phosphasal Oral Tablet 81.6 MG Tier 1 OPHTHALMIC AGENTS Echothiophate Iodide Phospholine Iodide Ophthalmic Solution Reconstituted 0.125 % Tier 2 CHEMICALS Phosphoric Acid Phosphoric Acid Solution 85 % Tier 3 HEMATOPOIETIC AGENTS Cyanocobalamin Physicians EZ Use B‐12 Injection Kit 1000 MCG/ML Tier 3 x CORTICOSTEROIDS Triamcinolone Acetonide & Lidocaine HCl & Ammonia Physicians EZ Use Joint/Tunnel Combination Kit 40‐1 MG/ML‐% Tier 3 CORTICOSTEROIDS Methylprednisolone Acetate & Bupivacaine HCl Physicians EZ Use M‐Pred Injection Kit 40‐0.5 MG/ML‐% Tier 3 x ASSORTED CLASSES Irrigation Solutions, Physiological Physiosol Irrigation Irrigation Solution Tier 1 ASSORTED CLASSES Irrigation Solutions, Physiological Physiosol Irrigation Irrigation Solution Tier 3 VITAMINS Phytonadione Phytonadione Injection Solution 1 MG/0.5ML Tier 1 x DERMATOLOGICALS Ingenol Mebutate Picato External Gel 0.015 % Tier 3 DERMATOLOGICALS Ingenol Mebutate Picato External Gel 0.05 % Tier 3 OPHTHALMIC AGENTS Pilocarpine HCl Pilocarpine HCl Ophthalmic Solution 1 % Tier 1 OPHTHALMIC AGENTS Pilocarpine HCl Pilocarpine HCl Ophthalmic Solution 2 % Tier 1 OPHTHALMIC AGENTS Pilocarpine HCl Pilocarpine HCl Ophthalmic Solution 4 % Tier 1 MOUTH/THROAT/DENTAL AGENTS Pilocarpine HCl (Oral) Pilocarpine HCl Oral Tablet 5 MG Tier 1 MOUTH/THROAT/DENTAL AGENTS Pilocarpine HCl (Oral) Pilocarpine HCl Oral Tablet 7.5 MG Tier 1 CHEMICALS Pilocarpine Hydrochloride Pilocarpine HCl Powder Tier 3 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Pimozide Pimozide Oral Tablet 1 MG Tier 1 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Pimozide Pimozide Oral Tablet 2 MG Tier 1 CONTRACEPTIVES Desogestrel‐Ethinyl Estradiol (Biphasic) Pimtrea Oral Tablet 0.15‐0.02/0.01 MG (21/5) Tier 1 BETA BLOCKERS Pindolol Pindolol Oral Tablet 10 MG Tier 1 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

BETA BLOCKERS Pindolol Pindolol Oral Tablet 5 MG Tier 1 ANTIDIABETICS Pioglitazone HCl Pioglitazone HCl Oral Tablet 15 MG Tier 1 ANTIDIABETICS Pioglitazone HCl Pioglitazone HCl Oral Tablet 30 MG Tier 1 ANTIDIABETICS Pioglitazone HCl Pioglitazone HCl Oral Tablet 45 MG Tier 1 ANTIDIABETICS Pioglitazone HCl‐Glimepiride Pioglitazone HCl‐Glimepiride Oral Tablet 30‐2 MG Tier 1 x ANTIDIABETICS Pioglitazone HCl‐Glimepiride Pioglitazone HCl‐Glimepiride Oral Tablet 30‐4 MG Tier 1 x ANTIDIABETICS Pioglitazone HCl‐Metformin HCl Pioglitazone HCl‐Metformin HCl Oral Tablet 15‐500 MG Tier 1 ANTIDIABETICS Pioglitazone HCl‐Metformin HCl Pioglitazone HCl‐Metformin HCl Oral Tablet 15‐850 MG Tier 1 PENICILLINS Piperacillin Sodium‐Tazobactam Sodium Piperacillin Sod‐Tazobactam So Intravenous Solution Reconstituted 2‐0.25 GM Tier 1 x PENICILLINS Piperacillin Sodium‐Tazobactam Sodium Piperacillin Sod‐Tazobactam So Intravenous Solution Reconstituted 3‐0.375 GM Tier 1 x PENICILLINS Piperacillin Sodium‐Tazobactam Sodium Piperacillin Sod‐Tazobactam So Intravenous Solution Reconstituted 36‐4.5 GM Tier 1 x PENICILLINS Piperacillin Sodium‐Tazobactam Sodium Piperacillin Sod‐Tazobactam So Intravenous Solution Reconstituted 4‐0.5 GM Tier 1 x CONTRACEPTIVES Norethindrone & Eth Estradiol Pirmella 1/35 Oral Tablet 1‐35 MG‐MCG Tier 1 CONTRACEPTIVES Norethindrone‐Eth Estradiol (Triphasic) Pirmella 7/7/7 Oral Tablet 0.5/0.75/1‐35 MG‐MCG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Piroxicam Piroxicam Oral Capsule 10 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Piroxicam Piroxicam Oral Capsule 20 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Piroxicam Piroxicam Powder Tier 3 OXYTOCICS Pitocin Injection Solution 10 UNIT/ML Tier 3 x CONTRACEPTIVES Levonorgestrel (Emergency OC) Plan B One‐Step Oral Tablet 1.5 MG Tier 3 ANTIMALARIALS Hydroxychloroquine Sulfate Plaquenil Oral Tablet 200 MG Tier 3 HEMATOLOGICAL AGENTS ‐ MISC. Albumin, Human Plasbumin‐25 Intravenous Solution 25 % Tier 1 x HEMATOLOGICAL AGENTS ‐ MISC. Albumin, Human Plasbumin‐5 Intravenous Solution 5 % Tier 1 x HEMATOLOGICAL AGENTS ‐ MISC. Clopidogrel Bisulfate Plavix Oral Tablet 300 MG Tier 3 HEMATOLOGICAL AGENTS ‐ MISC. Clopidogrel Bisulfate Plavix Oral Tablet 75 MG Tier 3 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Peginterferon Beta‐1a Plegridy Starter Pack Subcutaneous Solution Pen‐injector 63 & 94 MCG/0.5ML Tier 2 x x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Peginterferon Beta‐1a Plegridy Starter Pack Subcutaneous Solution Prefilled Syringe 63 & 94 MCG/0.5ML Tier 2 x x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Peginterferon Beta‐1a Plegridy Subcutaneous Solution Pen‐injector 125 MCG/0.5ML Tier 2 x x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Peginterferon Beta‐1a Plegridy Subcutaneous Solution Prefilled Syringe 125 MCG/0.5ML Tier 2 x x DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Plexion Cleanser External Liquid 9.8‐4.8 % Tier 3 x DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Plexion Cleansing Cloth External Pad 9.8‐4.8 % Tier 3 x DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Plexion External Cream 9.8‐4.8 % Tier 3 x DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Plexion External Lotion 9.8‐4.8 % Tier 3 x DERMATOLOGICALS Lidocaine‐Tetracaine Pliaglis External Cream 7‐7 % Tier 3 VACCINES Pneumococcal Vac Polyvalent Pneumovax 23 Injection Injectable 25 MCG/0.5ML Tier 3 x MULTIVITAMINS Prenatal Vit w/ Docusate‐Fe Fumarate‐Folic Acid PNV Fe Fum/Docusate/Folic Acid Oral Tablet 29‐1 MG Tier 2 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐Folic Acid PNV Folic Acid + Iron Oral Tablet 27‐1 MG Tier 2 MULTIVITAMINS Prenatal w/o Vit A w/ Fe Carbonyl‐Fe Gluconate‐DSS‐FA‐DHA PNV OB+DHA Oral Miscellaneous 27‐1 & 250 MG Tier 3 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐Folic Acid PNV Prenatal Plus Multivitamin Oral Tablet 27‐1 MG Tier 2 MULTIVITAMINS Prenatal Vit w/ Iron Carbonyl‐Folic Acid PNV Tabs 29‐1 Oral Tablet 29‐1 MG Tier 2 MULTIVITAMINS Prenatal without A w/ Fe Fumarate‐L Methylfolate‐FA‐DHA PNV‐DHA Oral Capsule 27‐0.6‐0.4‐300 MG Tier 2 MULTIVITAMINS Prenatal w/o Vit A w/ Fe Fumarate‐DSS‐FA‐DHA PNV‐DHA+Docusate Oral Capsule 27‐1.25‐300 MG Tier 3 MULTIVITAMINS Prenatal without A w/ Fe Fumarate‐L Methylfolate‐FA‐Omega 3 PNV‐Omega Oral Capsule 28‐0.6‐0.4‐340 MG Tier 2 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐L Methylfolate‐Folic Acid PNV‐Select Oral Tablet 27‐0.6‐0.4 MG Tier 2 MULTIVITAMINS Prenatal Vit w/ Fe Carbonyl‐Fe Bisglycinate‐FA‐Fish Oil PNV‐Total Oral Capsule 35‐5‐1.2 MG Tier 2 MULTIVITAMINS Prenatal without A Vit w/ Fe Fumarate‐Folic Acid PNV‐VP‐U Oral Capsule 106.5‐1 MG Tier 2 MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers Pocket Chamber Device Tier 2 x MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers Pocket Spacer Device Tier 2 x DIAGNOSTIC PRODUCTS Glucose Blood PocketChem EZ Test In Vitro Strip Tier 3 DERMATOLOGICALS Podofilox Podofilox External Solution 0.5 % Tier 1 OPHTHALMIC AGENTS Bacitracin‐Polymyxin B (Ophth) Polycin Ophthalmic Ointment 500‐10000 UNIT/GM Tier 1 PHARMACEUTICAL ADJUVANTS Polyethylene Glycol 1000 Polyethylene Glycol 1000 Powder Tier 3 PHARMACEUTICAL ADJUVANTS Polyethylene Glycol 1450 Polyethylene Glycol 1450 Flakes Tier 3 PHARMACEUTICAL ADJUVANTS Polyethylene Glycol 1450 Polyethylene Glycol 1450 Powder Tier 3 PHARMACEUTICAL ADJUVANTS Polyethylene Glycol 300 Polyethylene Glycol 300 Liquid Tier 3 LAXATIVES Polyethylene Glycol 3350 Polyethylene Glycol 3350 Oral Packet Tier 1 LAXATIVES Polyethylene Glycol 3350 Polyethylene Glycol 3350 Oral Powder Tier 1 PHARMACEUTICAL ADJUVANTS Polyethylene Glycol 400 Polyethylene Glycol 400 Liquid Tier 3 PHARMACEUTICAL ADJUVANTS Polyethylene Glycol 600 Polyethylene Glycol 600 Liquid Tier 3 PHARMACEUTICAL ADJUVANTS Polyethylene Glycol 8000 Polyethylene Glycol 8000 External Ointment Tier 3 PHARMACEUTICAL ADJUVANTS Polyethylene Glycol 8000 Polyethylene Glycol 8000 Granules Tier 3 PHARMACEUTICAL ADJUVANTS Polyethylene Glycol 8000 Polyethylene Glycol 8000 Powder Tier 3 PHARMACEUTICAL ADJUVANTS Polyethylene Glycol 1450 Polyethylene Glycol Powder Tier 3 HEMATOPOIETIC AGENTS Iron Polysaccharide Complex‐Vit B12‐Folic Acid Poly‐Iron 150 Forte Oral Capsule 150‐25‐1 MG‐MCG‐MG Tier 1 ANTI‐INFECTIVE AGENTS ‐ MISC. Polymyxin B Sulfate Polymyxin B Sulfate Injection Solution Reconstituted 500000 UNIT Tier 1 x ANTI‐INFECTIVE AGENTS ‐ MISC. Polymyxin B Sulfate Polymyxin B Sulfate Powder Tier 3 OPHTHALMIC AGENTS Polymyxin B‐Trimethoprim Polymyxin B‐Trimethoprim Ophthalmic Solution 10000‐0.1 UNIT/ML‐% Tier 1 PHARMACEUTICAL ADJUVANTS Polyoxyl 40 Stearate Polyoxyl 40 Stearate Pellet Tier 3 PHARMACEUTICAL ADJUVANTS Polyoxyl 40 Stearate Polyoxyl 40 Stearate Powder Tier 3 HEMATOPOIETIC AGENTS Iron Polysaccharide Complex‐Vit B12‐Folic Acid Polysaccharide Iron Forte Oral Capsule 150‐25‐1 MG‐MCG‐MG Tier 1 CHEMICALS Polysorbate 40 Polysorbate 40 Solution Tier 3 CHEMICALS Polysorbate 60 Polysorbate 60 Liquid Tier 3 CHEMICALS Polysorbate 80 Polysorbate 80 Oral Liquid Tier 3 OPHTHALMIC AGENTS Polymyxin B‐Trimethoprim Polytrim Ophthalmic Solution 10000‐0.1 UNIT/ML‐% Tier 3 MULTIVITAMINS Pediatric Multivitamins w/Fl Poly‐Vi‐Flor FS Oral Strip 0.25 MG Tier 3 MULTIVITAMINS Pediatric Multivitamins w/Fl Poly‐Vi‐Flor FS Oral Strip 0.5 MG Tier 3 MULTIVITAMINS Pediatric Multivitamins w/Fl Poly‐Vi‐Flor FS Oral Strip 1 MG Tier 3 MULTIVITAMINS Pediatric Multivitamins w/Fl Poly‐Vi‐Flor Oral Suspension 0.25 MG/ML Tier 2 MULTIVITAMINS Pediatric Multivitamins w/Fl Poly‐Vi‐Flor Oral Tablet Chewable 0.25 MG Tier 2 MULTIVITAMINS Pediatric Multivitamins w/Fl Poly‐Vi‐Flor Oral Tablet Chewable 0.5 MG Tier 2 MULTIVITAMINS Pediatric Multivitamins w/Fl Poly‐Vi‐Flor Oral Tablet Chewable 1 MG Tier 2 MULTIVITAMINS Ped Multivitamins w/Fl & Iron Poly‐Vi‐Flor/Iron Oral Suspension 0.25‐7 MG/ML Tier 2 MULTIVITAMINS Ped Multivitamins w/Fl & Iron Poly‐Vi‐Flor/Iron Oral Tablet Chewable 0.5‐10 MG Tier 2 OPHTHALMIC AGENTS Polyvinyl Alcohol Ophthalmic Solution 1.4 % Tier 1 MULTIVITAMINS Pediatric Multivitamins w/Fl Polyvitamin/Fluoride Oral Solution 0.25 MG/ML Tier 1 MULTIVITAMINS Pediatric Multivitamins w/Fl Poly‐Vitamin/Fluoride Oral Solution 0.5 MG/ML Tier 1 MULTIVITAMINS Pediatric Multivitamins w/Fl Polyvitamin/Fluoride Oral Tablet Chewable 0.5 MG Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Pomalidomide Pomalyst Oral Capsule 1 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Pomalidomide Pomalyst Oral Capsule 2 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Pomalidomide Pomalyst Oral Capsule 3 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Pomalidomide Pomalyst Oral Capsule 4 MG Tier 2 x x ANALGESICS ‐ ANTI‐INFLAMMATORY Mefenamic Acid Ponstel Oral Capsule 250 MG Tier 3 CONTRACEPTIVES Levonorgestrel & Eth Estradiol Portia‐28 Oral Tablet 0.15‐30 MG‐MCG Tier 1 GENITOURINARY AGENTS ‐ MISCELLANEOUS Pot & Sod Citrates w/Citric Ac Pot & Sod Cit‐Cit Ac Oral Solution 550‐500‐334 MG/5ML Tier 1 MINERALS & ELECTROLYTES Potassium Bicarb & Chloride Pot Bicarb‐Pot Chloride Oral Tablet Effervescent 25 MEQ Tier 1 MINERALS & ELECTROLYTES Potassium Acetate Intravenous Solution 2 MEQ/ML Tier 1 x MINERALS & ELECTROLYTES Potassium Acetate Potassium Acetate Intravenous Solution 2 MEQ/ML Tier 3 x MINERALS & ELECTROLYTES Potassium Bicarbonate Potassium Bicarbonate Granules Tier 3 MINERALS & ELECTROLYTES Potassium Bicarbonate Potassium Bicarbonate Oral Tablet Effervescent 25 MEQ Tier 1 MINERALS & ELECTROLYTES Potassium Bicarbonate Potassium Bicarbonate Powder Tier 3 CHEMICALS Potassium Bromide Potassium Bromide Granules Tier 3 CHEMICALS Potassium Bromide Potassium Bromide Powder Tier 3 MINERALS & ELECTROLYTES Potassium Chloride Microencapsulated Crystals CR Potassium Chloride Crys ER Oral Tablet Extended Release 10 MEQ Tier 1 MINERALS & ELECTROLYTES Potassium Chloride Microencapsulated Crystals CR Potassium Chloride Crys ER Oral Tablet Extended Release 20 MEQ Tier 1 MINERALS & ELECTROLYTES Potassium Chloride Potassium Chloride ER Oral Capsule Extended Release 10 MEQ Tier 1 MINERALS & ELECTROLYTES Potassium Chloride Potassium Chloride ER Oral Capsule Extended Release 8 MEQ Tier 1 MINERALS & ELECTROLYTES Potassium Chloride Microencapsulated Crystals CR Potassium Chloride ER Oral Tablet Extended Release 10 MEQ Tier 1 MINERALS & ELECTROLYTES Potassium Chloride Potassium Chloride ER Oral Tablet Extended Release 20 MEQ Tier 2 MINERALS & ELECTROLYTES Potassium Chloride Potassium Chloride ER Oral Tablet Extended Release 8 MEQ Tier 1 MINERALS & ELECTROLYTES Potassium Chloride Potassium Chloride ER Oral Tablet Extended Release 8 MEQ Tier 2 MINERALS & ELECTROLYTES Potassium Chloride Potassium Chloride Granules Tier 2 MINERALS & ELECTROLYTES Potassium Chloride in NaCl Potassium Chloride in NaCl Intravenous Solution 20‐0.45 MEQ/L‐% Tier 3 x MINERALS & ELECTROLYTES Potassium Chloride in NaCl Potassium Chloride in NaCl Intravenous Solution 20‐0.9 MEQ/L‐% Tier 1 x HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

MINERALS & ELECTROLYTES Potassium Chloride in NaCl Potassium Chloride in NaCl Intravenous Solution 20‐0.9 MEQ/L‐% Tier 3 x MINERALS & ELECTROLYTES Potassium Chloride in NaCl Potassium Chloride in NaCl Intravenous Solution 40‐0.9 MEQ/L‐% Tier 1 x MINERALS & ELECTROLYTES Potassium Chloride Potassium Chloride Intravenous Solution 10 MEQ/100ML Tier 1 x MINERALS & ELECTROLYTES Potassium Chloride Potassium Chloride Intravenous Solution 10 MEQ/50ML Tier 3 x MINERALS & ELECTROLYTES Potassium Chloride Potassium Chloride Intravenous Solution 2 MEQ/ML Tier 1 x MINERALS & ELECTROLYTES Potassium Chloride Potassium Chloride Intravenous Solution 20 MEQ/100ML Tier 3 x MINERALS & ELECTROLYTES Potassium Chloride Potassium Chloride Intravenous Solution 40 MEQ/100ML Tier 3 x MINERALS & ELECTROLYTES Potassium Chloride Potassium Chloride Oral Packet 20 MEQ Tier 1 MINERALS & ELECTROLYTES Potassium Chloride Potassium Chloride Oral Solution 20 MEQ/15ML (10%) Tier 1 MINERALS & ELECTROLYTES Potassium Chloride Potassium Chloride Oral Solution 40 MEQ/15ML (20%) Tier 1 MINERALS & ELECTROLYTES Potassium Chloride Potassium Chloride Powder Tier 3 GENITOURINARY AGENTS ‐ MISCELLANEOUS Potassium Citrate (Alkalinizer) Potassium Citrate ER Oral Tablet Extended Release 10 MEQ (1080 MG) Tier 1 GENITOURINARY AGENTS ‐ MISCELLANEOUS Potassium Citrate (Alkalinizer) Potassium Citrate ER Oral Tablet Extended Release 15 MEQ (1620 MG) Tier 1 GENITOURINARY AGENTS ‐ MISCELLANEOUS Potassium Citrate (Alkalinizer) Potassium Citrate ER Oral Tablet Extended Release 5 MEQ (540 MG) Tier 1 GENITOURINARY AGENTS ‐ MISCELLANEOUS Potassium Citrate (Alkalinizer) Potassium Citrate Monohydrate Granules Tier 3 GENITOURINARY AGENTS ‐ MISCELLANEOUS Potassium Citrate (Alkalinizer) Potassium Citrate Powder Tier 3 GENITOURINARY AGENTS ‐ MISCELLANEOUS Potassium Citrate‐Citric Acid Potassium Citrate‐Citric Acid Oral Packet 3300‐1002 MG Tier 1 GENITOURINARY AGENTS ‐ MISCELLANEOUS Potassium Citrate‐Citric Acid Potassium Citrate‐Citric Acid Oral Solution 1100‐334 MG/5ML Tier 1 CHEMICALS Potassium Hydroxide Potassium Hydroxide External Solution 5 % Tier 3 CHEMICALS Potassium Hydroxide Potassium Hydroxide Pellet Tier 3 CHEMICALS Potassium Hydroxide Potassium Hydroxide Solution 45 % Tier 3 MINERALS & ELECTROLYTES Potassium Phosphates Potassium Phosphates Intravenous Solution 45 MMOLE/15ML Tier 1 x CHEMICALS Potassium Sodium Tartrate Potassium Sodium Tartrate Granules Tier 3 PHARMACEUTICAL ADJUVANTS Potassium Sorbate Potassium Sorbate Powder Tier 3 ANTICONVULSANTS Ezogabine Potiga Oral Tablet 200 MG Tier 3 ANTICONVULSANTS Ezogabine Potiga Oral Tablet 300 MG Tier 3 ANTICONVULSANTS Ezogabine Potiga Oral Tablet 400 MG Tier 3 ANTICONVULSANTS Ezogabine Potiga Oral Tablet 50 MG Tier 3 DERMATOLOGICALS Benzoyl Peroxide PR Benzoyl Peroxide Wash External Liquid 7 % Tier 1 MULTIVITAMINS Prenatal MV & Min w/Fe Bisglyc‐Fe Prot Succ‐FA‐CA‐Omega 3PR Natal 400 ec Oral Miscellaneous 29‐1‐200 & 400 MG (DR) Tier 3 MULTIVITAMINS Prenatal MV & Min w/Fe Bisglyc‐Fe Prot Succ‐FA‐CA‐Omega 3PR Natal 400 Oral Miscellaneous 29‐1‐200 & 400 MG Tier 3 MULTIVITAMINS Prenatal MV & Min w/Fe Bisglyc‐Fe Prot Succ‐FA‐CA‐Omega 3PR Natal 430 ec Oral Miscellaneous 29‐1‐200 & 430 MG (DR) Tier 3 MULTIVITAMINS Prenatal MV & Min w/Fe Bisglyc‐Fe Prot Succ‐FA‐CA‐Omega 3PR Natal 430 Oral Miscellaneous 29‐1‐200 & 430 MG Tier 3 ANTICOAGULANTS Dabigatran Etexilate Mesylate Pradaxa Oral Capsule 110 MG Tier 3 x ANTICOAGULANTS Dabigatran Etexilate Mesylate Pradaxa Oral Capsule 150 MG Tier 2 x ANTICOAGULANTS Dabigatran Etexilate Mesylate Pradaxa Oral Capsule 75 MG Tier 2 x ANTIDOTES Pralidoxime Chloride Pralidoxime Chloride Intramuscular Solution Auto‐injector 600 MG/2ML Tier 3 x ANTIHYPERLIPIDEMICS Alirocumab Praluent Subcutaneous Solution Pen‐injector 150 MG/ML Tier 3 x x ANTIHYPERLIPIDEMICS Alirocumab Praluent Subcutaneous Solution Pen‐injector 75 MG/ML Tier 3 x x ANTIHYPERLIPIDEMICS Alirocumab Praluent Subcutaneous Solution Prefilled Syringe 150 MG/ML Tier 3 x x ANTIHYPERLIPIDEMICS Alirocumab Praluent Subcutaneous Solution Prefilled Syringe 75 MG/ML Tier 3 x x ANORECTAL AGENTS Hydrocortisone Acetate w/ Pramoxine PramCort Rectal Cream 1‐1 % Tier 1 ANTIPARKINSON AGENTS Pramipexole Dihydrochloride Pramipexole Dihydrochloride ER Oral Tablet Extended Release 24 Hour 0.375 MG Tier 1 x ANTIPARKINSON AGENTS Pramipexole Dihydrochloride Pramipexole Dihydrochloride ER Oral Tablet Extended Release 24 Hour 0.75 MG Tier 1 x ANTIPARKINSON AGENTS Pramipexole Dihydrochloride Pramipexole Dihydrochloride ER Oral Tablet Extended Release 24 Hour 1.5 MG Tier 1 x ANTIPARKINSON AGENTS Pramipexole Dihydrochloride Pramipexole Dihydrochloride ER Oral Tablet Extended Release 24 Hour 2.25 MG Tier 1 x ANTIPARKINSON AGENTS Pramipexole Dihydrochloride Pramipexole Dihydrochloride ER Oral Tablet Extended Release 24 Hour 3 MG Tier 1 x ANTIPARKINSON AGENTS Pramipexole Dihydrochloride Pramipexole Dihydrochloride ER Oral Tablet Extended Release 24 Hour 4.5 MG Tier 1 x ANTIPARKINSON AGENTS Pramipexole Dihydrochloride Pramipexole Dihydrochloride Oral Tablet 0.125 MG Tier 1 x ANTIPARKINSON AGENTS Pramipexole Dihydrochloride Pramipexole Dihydrochloride Oral Tablet 0.25 MG Tier 1 x ANTIPARKINSON AGENTS Pramipexole Dihydrochloride Pramipexole Dihydrochloride Oral Tablet 0.5 MG Tier 1 x ANTIPARKINSON AGENTS Pramipexole Dihydrochloride Pramipexole Dihydrochloride Oral Tablet 0.75 MG Tier 1 x ANTIPARKINSON AGENTS Pramipexole Dihydrochloride Pramipexole Dihydrochloride Oral Tablet 1 MG Tier 1 x ANTIPARKINSON AGENTS Pramipexole Dihydrochloride Pramipexole Dihydrochloride Oral Tablet 1.5 MG Tier 1 x ANTIDEPRESSANTS Escitalopram Oxalate & L‐Methylfolate‐Vit B6‐Vit B12‐Vit D PRAMLyte Oral Therapy Pack 10 MG Tier 3 DERMATOLOGICALS Pramoxine‐HC Pramosone External Cream 1‐1 % Tier 2 DERMATOLOGICALS Pramoxine‐HC Pramosone External Lotion 1‐1 % Tier 2 DERMATOLOGICALS Pramoxine‐HC Pramosone External Lotion 1‐2.5 % Tier 2 OTIC AGENTS Pramoxine‐Chloroxylenol PramOtic Otic Liquid 1‐0.1 % Tier 3 DERMATOLOGICALS Pramoxine HCl Pramox External Gel 1 % Tier 1 DERMATOLOGICALS Pramoxine HCl Pramoxine HCl Powder Tier 3 ANTIDIABETICS Repaglinide Prandin Oral Tablet 0.5 MG Tier 3 x ANTIDIABETICS Repaglinide Prandin Oral Tablet 1 MG Tier 3 x ANTIDIABETICS Repaglinide Prandin Oral Tablet 2 MG Tier 3 x DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Prascion External Emulsion 10‐5 % Tier 1 x DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Prascion FC External Pad 10‐5 % Tier 1 x DERMATOLOGICALS Sulfacetamide Sodium‐Sulfur‐Sunscreen Prascion RA External Cream 10‐5 % Tier 3 x ANALGESICS ‐ ANTI‐INFLAMMATORY Prasterone & Ibuprofen Prastera Oral Kit 200 & 400 MG Tier 3 ANTIHYPERLIPIDEMICS Pravastatin Sodium Pravachol Oral Tablet 20 MG Tier 3 ANTIHYPERLIPIDEMICS Pravastatin Sodium Pravachol Oral Tablet 40 MG Tier 3 ANTIHYPERLIPIDEMICS Pravastatin Sodium Pravachol Oral Tablet 80 MG Tier 3 ANTIHYPERLIPIDEMICS Pravastatin Sodium Pravastatin Sodium Oral Tablet 10 MG Tier 1 ANTIHYPERLIPIDEMICS Pravastatin Sodium Pravastatin Sodium Oral Tablet 20 MG Tier 1 ANTIHYPERLIPIDEMICS Pravastatin Sodium Pravastatin Sodium Oral Tablet 40 MG Tier 1 ANTIHYPERLIPIDEMICS Pravastatin Sodium Pravastatin Sodium Oral Tablet 80 MG Tier 1 ANTIHYPERTENSIVES Prazosin HCl Prazosin HCl Oral Capsule 1 MG Tier 1 ANTIHYPERTENSIVES Prazosin HCl Prazosin HCl Oral Capsule 2 MG Tier 1 ANTIHYPERTENSIVES Prazosin HCl Prazosin HCl Oral Capsule 5 MG Tier 1 MEDICAL DEVICES AND SUPPLIES Catheters Precision 200 Cath Tray Kit Tier 3 MEDICAL DEVICES AND SUPPLIES Catheters Precision 400 Cath Tray Kit Tier 3 MEDICAL DEVICES AND SUPPLIES Catheters Precision Foley Cath Tray Kit Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Precision PCx In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Precision PCX Plus Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Precision Point of Care Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Precision QID Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Precision Sof‐Tact Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Precision SureDose Plus Syr Miscellaneous 29G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Precision SureDose Plus Syr Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Precision Sure‐Dose Syringe Miscellaneous 28G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Precision Sure‐Dose Syringe Miscellaneous 28G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Precision Sure‐Dose Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Precision Sure‐Dose Syringe Miscellaneous 30G X 3/8" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Precision Sure‐Dose Syringe Miscellaneous 30G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Precision Thin Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Precision Thins GP Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Precision Ultra Lancet Miscellaneous Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood Precision Xtra Blood Glucose In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies Precision Xtra Device Tier 3 ANTIDIABETICS Acarbose Precose Oral Tablet 100 MG Tier 3 ANTIDIABETICS Acarbose Precose Oral Tablet 25 MG Tier 3 ANTIDIABETICS Acarbose Precose Oral Tablet 50 MG Tier 3 OPHTHALMIC AGENTS Prednisolone Acetate (Ophth) Pred Forte Ophthalmic Suspension 1 % Tier 3 OPHTHALMIC AGENTS Prednisolone Acetate (Ophth) Pred Mild Ophthalmic Suspension 0.12 % Tier 2 OPHTHALMIC AGENTS Gentamicin‐Prednisolone Acetate Pred‐G Ophthalmic Suspension 0.3‐1 % Tier 3 OPHTHALMIC AGENTS Gentamicin‐Prednisolone Acetate Pred‐G S.O.P. Ophthalmic Ointment 0.3‐0.6 % Tier 3 DERMATOLOGICALS Prednicarbate Prednicarbate External Cream 0.1 % Tier 1 DERMATOLOGICALS Prednicarbate Prednicarbate External Ointment 0.1 % Tier 1 OPHTHALMIC AGENTS Prednisolone Acetate (Ophth) PrednisoLONE Acetate Ophthalmic Suspension 1 % Tier 1 CORTICOSTEROIDS Prednisolone Acetate PrednisoLONE Acetate Powder Tier 3 CORTICOSTEROIDS Prednisolone PrednisoLONE Anhydrous Powder Tier 3 CORTICOSTEROIDS Prednisolone PrednisoLONE Oral Solution 15 MG/5ML Tier 1 CORTICOSTEROIDS Prednisolone PrednisoLONE Oral Syrup 15 MG/5ML Tier 1 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

CORTICOSTEROIDS Prednisolone PrednisoLONE Powder Tier 3 OPHTHALMIC AGENTS Prednisolone Sodium Phosphate (Ophth) PrednisoLONE Sodium Phosphate Ophthalmic Solution 1 % Tier 2 CORTICOSTEROIDS Prednisolone Sodium Phosphate PrednisoLONE Sodium Phosphate Oral Solution 15 MG/5ML Tier 1 CORTICOSTEROIDS Prednisolone Sodium Phosphate PrednisoLONE Sodium Phosphate Oral Solution 25 MG/5ML Tier 3 CORTICOSTEROIDS Prednisolone Sodium Phosphate PrednisoLONE Sodium Phosphate Oral Solution 6.7 (5 Base) MG/5ML Tier 1 CORTICOSTEROIDS Prednisolone Sodium Phosphate PrednisoLONE Sodium Phosphate Oral Tablet Dispersible 10 MG Tier 1 CORTICOSTEROIDS Prednisolone Sodium Phosphate PrednisoLONE Sodium Phosphate Oral Tablet Dispersible 15 MG Tier 1 CORTICOSTEROIDS Prednisolone Sodium Phosphate PrednisoLONE Sodium Phosphate Oral Tablet Dispersible 30 MG Tier 1 CORTICOSTEROIDS Prednisolone Sodium Phosphate PrednisoLONE Sodium Phosphate Powder Tier 3 CORTICOSTEROIDS Prednisone PredniSONE (Pak) Oral Tablet 10 MG Tier 2 CORTICOSTEROIDS Prednisone PredniSONE (Pak) Oral Tablet 5 MG Tier 2 CORTICOSTEROIDS Prednisone PredniSONE Intensol Oral Concentrate 5 MG/ML Tier 2 CORTICOSTEROIDS Prednisone PredniSONE Oral Solution 5 MG/5ML Tier 2 CORTICOSTEROIDS Prednisone PredniSONE Oral Tablet 1 MG Tier 1 CORTICOSTEROIDS Prednisone PredniSONE Oral Tablet 10 MG Tier 1 CORTICOSTEROIDS Prednisone PredniSONE Oral Tablet 2.5 MG Tier 1 CORTICOSTEROIDS Prednisone PredniSONE Oral Tablet 20 MG Tier 1 CORTICOSTEROIDS Prednisone PredniSONE Oral Tablet 5 MG Tier 1 CORTICOSTEROIDS Prednisone PredniSONE Oral Tablet 50 MG Tier 2 CORTICOSTEROIDS Prednisone PredniSONE Powder Tier 3 MULTIVITAMINS Prenatal Vit w/ Fe Polysacch Complex‐Fe Heme Polypeptide‐FA Prefera OB Oral Tablet 34‐1 MG Tier 3 MULTIVITAMINS Prenatal Vit w/ Fe Polysacch Cmplx‐Fe Heme Polypept‐FA & DHA PreferaOB +DHA Oral Miscellaneous 28‐6‐1 & 200 MG Tier 3 MULTIVITAMINS Prenatal Vit w/ Fe Polysacch Cmplx‐Fe Heme Polypept‐FA & DHA PreferaOB One Oral Capsule 22‐6‐1‐200 MG Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Preferred Plus Insulin Syringe Miscellaneous 28G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Preferred Plus Insulin Syringe Miscellaneous 28G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Preferred Plus Insulin Syringe Miscellaneous 29G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Preferred Plus Insulin Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Preferred Plus Insulin Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Preferred Plus Insulin Syringe Miscellaneous 30G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Preferred Plus Insulin Syringe Miscellaneous 30G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Preferred Plus Insulin Syringe Miscellaneous 30G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Preferred Plus Lancets Colored Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Preferred Plus Lancets Thin Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Preferred Plus Unifine Pentips Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Preferred Plus Unifine Pentips Miscellaneous 31G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Preferred Plus Unifine Pentips Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Preferred Plus Unifine Pentips Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Preferred Plus Unifine Pentips Miscellaneous 32G X 4 MM Tier 2 ESTROGENS Estradiol‐Norgestimate Prefest Oral Tablet 1/1‐0.09 MG (15/15) Tier 3 x HEMATOPOIETIC AGENTS Folic Acid‐Vitamin C Pre‐Folic Oral Tablet 1‐100 MG Tier 3 CHEMICALS (Micronized) Pregnenolone Micronized Powder Tier 3 CHEMICALS Pregnenolone Pregnenolone Powder Tier 3 ESTROGENS Estrogens, Conjugated Premarin Oral Tablet 0.3 MG Tier 2 x ESTROGENS Estrogens, Conjugated Premarin Oral Tablet 0.45 MG Tier 2 x ESTROGENS Estrogens, Conjugated Premarin Oral Tablet 0.625 MG Tier 2 x ESTROGENS Estrogens, Conjugated Premarin Oral Tablet 0.9 MG Tier 2 x ESTROGENS Estrogens, Conjugated Premarin Oral Tablet 1.25 MG Tier 2 x VAGINAL PRODUCTS Estrogens, Conjugated Vaginal Premarin Vaginal Cream 0.625 MG/GM Tier 2 NUTRIENTS Amino Acid Infusion Premasol Intravenous Solution 10 % Tier 3 x DERMATOLOGICALS Lidocaine Premium Lidocaine External Ointment 5 % Tier 1 x ESTROGENS Conjugated Estrogens‐Medroxyprogesterone Acetate Premphase Oral Tablet 0.625‐5 MG Tier 2 x ESTROGENS Conjugated Estrogens‐Medroxyprogesterone Acetate Prempro Oral Tablet 0.3‐1.5 MG Tier 2 x ESTROGENS Conjugated Estrogens‐Medroxyprogesterone Acetate Prempro Oral Tablet 0.45‐1.5 MG Tier 2 x ESTROGENS Conjugated Estrogens‐Medroxyprogesterone Acetate Prempro Oral Tablet 0.625‐2.5 MG Tier 2 x ESTROGENS Conjugated Estrogens‐Medroxyprogesterone Acetate Prempro Oral Tablet 0.625‐5 MG Tier 2 x MULTIVITAMINS Prenatal w/ Vit B2‐B6‐B12‐Cholecalciferol‐Folic Acid Prena1 Oral Tablet Chewable 1.4 MG Tier 2 MULTIVITAMINS Prenatal without A w/ Fe Fumarate‐Sod Feredetate‐FA‐DHA Prena1 Pearl Oral Capsule Extended Release 30‐1.4‐200 MG Tier 2 MULTIVITAMINS Prenatal w/o Vit A w/ Fe Carbonyl‐DSS‐FA‐DHA Prenaissance Balance Oral Capsule 30‐1‐260 MG Tier 3 MULTIVITAMINS Prenatal w/Fe Polysacch Cmplx‐Sod Feredetate‐FA‐Omega 3 Prenaissance Harmony DHA Oral Miscellaneous 27‐1 & 380 MG Tier 2 MULTIVITAMINS Prenatal w/o Vit A w/ Fe Fumarate‐DSS‐FA‐DHA Prenaissance Oral Capsule 29‐1.25‐325 MG Tier 3 MULTIVITAMINS Prenatal w/o Vit A w/ Fe Carbonyl‐DSS‐FA‐DHA Prenaissance Plus Oral Capsule 28‐1‐250 MG Tier 3 MULTIVITAMINS Prenatal without A Vit w/ Fe Fumarate‐Folic Acid PreNata Oral Tablet Chewable 29‐1 MG Tier 2 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐Folic Acid Prenatabs FA Oral Tablet Tier 3 MULTIVITAMINS Prenatal Vit w/ Iron Carbonyl‐Folic Acid Prenatabs Rx Oral Tablet 29‐1 MG Tier 2 MULTIVITAMINS Prenatal Vit w/ Docusate‐Fe Fumarate‐Folic Acid Prenatal 19 Oral Tablet Tier 2 MULTIVITAMINS Prenatal Vit w/ Docusate‐Fe Fumarate‐Folic Acid Prenatal 19 Oral Tablet 29‐1 MG Tier 2 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐Folic Acid Prenatal 19 Oral Tablet Chewable Tier 3 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐Folic Acid Prenatal 19 Oral Tablet Chewable 29‐1 MG Tier 3 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐Folic Acid Prenatal Formula Oral Tablet 27‐1 MG Tier 2 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐Folic Acid Prenatal Low Iron Oral Tablet 27‐1 MG Tier 2 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐Folic Acid Prenatal Oral Tablet 27‐0.8 MG Tier 3 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐Folic Acid Prenatal Oral Tablet 27‐1 MG Tier 2 MULTIVITAMINS Prenatal Vit w/ Iron Carbonyl‐Folic Acid Prenatal Plus Iron Oral Tablet 29‐1 MG Tier 2 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐Folic Acid Prenatal Plus Oral Tablet 27‐1 MG Tier 2 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐Folic Acid Prenatal Plus/Iron Oral Tablet 27‐1 MG Tier 2 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐Folic Acid Prenatal Vitamin Plus Low Iron Oral Tablet 27‐1 MG Tier 3 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐Folic Acid Prenatal/Folic Acid Oral Tablet Tier 2 MULTIVITAMINS Prenatal without A Vit w/ Fe Fumarate‐Folic Acid Prenatal‐U Oral Capsule 106.5‐1 MG Tier 2 MULTIVITAMINS Prenatal w/o A w/ Fe Asparto Glyc‐L Methylfolate‐FA‐DHA Prenate DHA Oral Capsule 18‐0.6‐0.4‐300 MG Tier 3 MULTIVITAMINS Prenatal without A w/ Fe Fumarate‐L Methylfolate‐FA‐DHA Prenate DHA Oral Capsule 28‐0.6‐0.4‐300 MG Tier 3 MULTIVITAMINS Prenatal w/ Fe Asparto Glycinate‐L Methylfolate‐Folic Acid Prenate Elite Oral Tablet 20‐0.6‐0.4 MG Tier 2 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐L Methylfolate‐Folic Acid Prenate Elite Oral Tablet 26‐0.6‐0.4 MG Tier 3 MULTIVITAMINS Prenatal without A w/ Fe Fumarate‐L Methylfolate‐FA‐DHA Prenate Enhance Oral Capsule 28‐0.6‐0.4‐400 MG Tier 3 MULTIVITAMINS Prenatal w/o A w/ Fe Asparto Glyc‐L Methylfolate‐FA‐DHA Prenate Essential Oral Capsule 18‐0.6‐0.4‐300 MG Tier 3 MULTIVITAMINS Prenatal without A w/ Fe Asp Glyc‐L Methylfolate‐FA‐Omega 3 Prenate Essential Oral Capsule 29‐0.6‐0.4‐340 MG Tier 2 MULTIVITAMINS Prenatal w/o Vit A w/ Fe Carbonyl‐Fe Asp Glyc‐Methfol‐FA‐DHA Prenate Mini Oral Capsule 18‐0.6‐0.4‐350 MG Tier 3 MULTIVITAMINS Prenatal without A w/ Fe Carbonyl‐L Methylfolate‐FA‐DHA Prenate Mini Oral Capsule 29‐0.6‐0.4‐350 MG Tier 3 MULTIVITAMINS Prenatal Multivitamins & Minerals w/ L‐Methylfolate‐FA Prenate Oral Tablet Chewable 0.6‐0.4 MG Tier 3 MULTIVITAMINS Prenatal w/o A w/ Fe Asparto Glyc‐L Methylfolate‐FA‐DHA Prenate Pixie Oral Capsule 10‐0.6‐0.4‐200 MG Tier 3 MULTIVITAMINS Prenatal without A w/ Fe Fumarate‐L Methylfolate‐FA‐DHA Prenate Restore Oral Capsule 27‐0.6‐0.4‐400 MG Tier 3 MULTIVITAMINS Prenatal Vitamins w/ Fe Asparto Glycinate‐Folic Acid Prenate Star Oral Tablet 20‐1 MG Tier 2 OXYTOCICS Dinoprostone Prepidil Vaginal Gel 0.5 MG/3GM Tier 3 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐Folic Acid PrePLUS Oral Tablet 27‐1 MG Tier 2 MULTIVITAMINS Prenatal MV & Min w/Fe Carbonyl‐Docusate‐Folic Acid‐DHA PreQue 10 Oral Tablet 15‐25‐0.5‐50 MG Tier 3 ANTIHYPERTENSIVES Perindopril Arginine‐Amlodipine Besylate Prestalia Oral Tablet 14‐10 MG Tier 3 xx ANTIHYPERTENSIVES Perindopril Arginine‐Amlodipine Besylate Prestalia Oral Tablet 3.5‐2.5 MG Tier 3 xx ANTIHYPERTENSIVES Perindopril Arginine‐Amlodipine Besylate Prestalia Oral Tablet 7‐5 MG Tier 3 xx MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐Folic Acid PreTAB Oral Tablet 29‐1 MG Tier 3 ULCER DRUGS Lansoprazole Prevacid Oral Capsule Delayed Release 15 MG Tier 3 x ULCER DRUGS Lansoprazole Prevacid Oral Capsule Delayed Release 30 MG Tier 3 x ULCER DRUGS Lansoprazole Prevacid SoluTab Oral Tablet Dispersible 15 MG Tier 3 x ULCER DRUGS Lansoprazole Prevacid SoluTab Oral Tablet Dispersible 30 MG Tier 3 x ANTIHYPERLIPIDEMICS Cholestyramine Light Prevalite Oral Packet 4 GM Tier 1 ANTIHYPERLIPIDEMICS Cholestyramine Light Prevalite Oral Powder 4 GM/DOSE Tier 1 MOUTH/THROAT/DENTAL AGENTS Sodium Fluoride (Dental) PreviDent 5000 Booster Dental Paste 1.1 % Tier 3 MOUTH/THROAT/DENTAL AGENTS Sodium Fluoride (Dental) PreviDent 5000 Booster Plus Dental Paste 1.1 % Tier 3 MOUTH/THROAT/DENTAL AGENTS Sodium Fluoride (Dental) PreviDent 5000 Plus Dental Cream 1.1 % Tier 3 MOUTH/THROAT/DENTAL AGENTS Sodium Fluoride (Dental) PreviDent Dental Gel 1.1 % Tier 3 MOUTH/THROAT/DENTAL AGENTS Sodium Fluoride (Dental) PreviDent Mouth/Throat Solution 0.2 % Tier 3 CONTRACEPTIVES Norgestimate‐Ethinyl Estradiol Previfem Oral Tablet 0.25‐35 MG‐MCG Tier 1 VACCINES Pneumococcal 13‐Valent Conjugate Vaccine Prevnar 13 Intramuscular Suspension Tier 3 x ULCER DRUGS Amoxicillin‐Clarithromycin w/ Lansoprazole Prevpac Oral Miscellaneous Tier 3 x x HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ANTIVIRALS Darunavir‐Cobicistat Prezcobix Oral Tablet 800‐150 MG Tier 2 x ANTIVIRALS Darunavir Ethanolate Prezista Oral Suspension 100 MG/ML Tier 2 x ANTIVIRALS Darunavir Ethanolate Prezista Oral Tablet 150 MG Tier 2 ANTIVIRALS Darunavir Ethanolate Prezista Oral Tablet 400 MG Tier 2 x ANTIVIRALS Darunavir Ethanolate Prezista Oral Tablet 600 MG Tier 2 x ANTIVIRALS Darunavir Ethanolate Prezista Oral Tablet 75 MG Tier 2 x ANTIVIRALS Darunavir Ethanolate Prezista Oral Tablet 800 MG Tier 2 x ANTIMYCOBACTERIAL AGENTS Rifapentine Priftin Oral Tablet 150 MG Tier 3 ULCER DRUGS Omeprazole PriLOSEC Oral Capsule Delayed Release 10 MG Tier 3 x ULCER DRUGS Omeprazole PriLOSEC Oral Capsule Delayed Release 20 MG Tier 3 x ULCER DRUGS Omeprazole PriLOSEC Oral Capsule Delayed Release 40 MG Tier 3 x ULCER DRUGS Omeprazole Magnesium PriLOSEC Oral Packet 10 MG Tier 3 x ULCER DRUGS Omeprazole Magnesium PriLOSEC Oral Packet 2.5 MG Tier 3 x ANTIMALARIALS Primaquine Phosphate Primaquine Phosphate Oral Tablet 26.3 MG Tier 2 ANTI‐INFECTIVE AGENTS ‐ MISC. Imipenem‐Cilastatin Primaxin IV Intravenous Solution Reconstituted 250‐250 MG Tier 3 x ANTI‐INFECTIVE AGENTS ‐ MISC. Imipenem‐Cilastatin Primaxin IV Intravenous Solution Reconstituted 500‐500 MG Tier 3 x ANTICONVULSANTS Primidone Primidone Oral Tablet 250 MG Tier 1 ANTICONVULSANTS Primidone Primidone Oral Tablet 50 MG Tier 1 ANALGESICS ‐ OPIOID Oxycodone w/ Acetaminophen Primlev Oral Tablet 10‐300 MG Tier 3 x x ANALGESICS ‐ OPIOID Oxycodone w/ Acetaminophen Primlev Oral Tablet 5‐300 MG Tier 3 x x ANALGESICS ‐ OPIOID Oxycodone w/ Acetaminophen Primlev Oral Tablet 7.5‐300 MG Tier 3 x x ANTI‐INFECTIVE AGENTS ‐ MISC. Trimethoprim HCl Primsol Oral Solution 50 MG/5ML Tier 3 ANTIHYPERTENSIVES Lisinopril Prinivil Oral Tablet 10 MG Tier 3 ANTIHYPERTENSIVES Lisinopril Prinivil Oral Tablet 20 MG Tier 3 ANTIHYPERTENSIVES Lisinopril Prinivil Oral Tablet 5 MG Tier 3 ANTIDEPRESSANTS Desvenlafaxine Succinate Pristiq Oral Tablet Extended Release 24 Hour 100 MG Tier 2 xx ANTIDEPRESSANTS Desvenlafaxine Succinate Pristiq Oral Tablet Extended Release 24 Hour 25 MG Tier 2 xx ANTIDEPRESSANTS Desvenlafaxine Succinate Pristiq Oral Tablet Extended Release 24 Hour 50 MG Tier 2 xx BIOLOGICALS MISC Privet (Ligustrum Vulgare) Privet Subcutaneous Solution 1:20 Tier 3 x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Albuterol Sulfate ProAir HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT Tier 2 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Albuterol Sulfate ProAir RespiClick Inhalation Aerosol Powder Breath Activated 108 (90 Base) MCG/ACT Tier 2 x GOUT AGENTS Probenecid Probenecid Oral Tablet 500 MG Tier 1 ANTIARRHYTHMICS Procainamide HCl Procainamide HCl Powder Tier 3 CALCIUM CHANNEL BLOCKERS Nifedipine Procardia Oral Capsule 10 MG Tier 3 CALCIUM CHANNEL BLOCKERS Nifedipine Procardia XL Oral Tablet Extended Release 24 Hour 30 MG Tier 3 CALCIUM CHANNEL BLOCKERS Nifedipine Procardia XL Oral Tablet Extended Release 24 Hour 60 MG Tier 3 CALCIUM CHANNEL BLOCKERS Nifedipine Procardia XL Oral Tablet Extended Release 24 Hour 90 MG Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dextroamphetamine Sulfate ProCentra Oral Solution 5 MG/5ML Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Prochlorperazine Edisylate Prochlorperazine Edisylate Injection Solution 5 MG/ML Tier 1 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Prochlorperazine Maleate Prochlorperazine Maleate Oral Tablet 10 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Prochlorperazine Maleate Prochlorperazine Maleate Oral Tablet 5 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Prochlorperazine Maleate Prochlorperazine Maleate Powder Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Prochlorperazine Prochlorperazine Rectal Suppository 25 MG Tier 1 ANORECTAL AGENTS Hydrocortisone Acetate w/ Pramoxine ProCort Rectal Cream 1.85‐1.15 % Tier 3 HEMATOPOIETIC AGENTS Epoetin Alfa Procrit Injection Solution 10000 UNIT/ML Tier 2 x HEMATOPOIETIC AGENTS Epoetin Alfa Procrit Injection Solution 2000 UNIT/ML Tier 2 x HEMATOPOIETIC AGENTS Epoetin Alfa Procrit Injection Solution 20000 UNIT/ML Tier 2 x HEMATOPOIETIC AGENTS Epoetin Alfa Procrit Injection Solution 3000 UNIT/ML Tier 2 x HEMATOPOIETIC AGENTS Epoetin Alfa Procrit Injection Solution 4000 UNIT/ML Tier 2 x HEMATOPOIETIC AGENTS Epoetin Alfa Procrit Injection Solution 40000 UNIT/ML Tier 2 x x ANORECTAL AGENTS Hydrocortisone (Rectal) ProctoCare‐HC Rectal Cream 2.5 % Tier 1 ANORECTAL AGENTS Hydrocortisone (Rectal) Proctocort Rectal Cream 1 % Tier 3 ANORECTAL AGENTS Hydrocortisone Acetate w/ Pramoxine Proctofoam HC Rectal Foam 1‐1 % Tier 2 ANORECTAL AGENTS Hydrocortisone (Rectal) Procto‐Pak Rectal Cream 1 % Tier 1 ANORECTAL AGENTS Hydrocortisone (Rectal) Proctosol HC Rectal Cream 2.5 % Tier 1 ANORECTAL AGENTS Hydrocortisone (Rectal) Proctozone‐HC Rectal Cream 2.5 % Tier 1 GENITOURINARY AGENTS ‐ MISCELLANEOUS Cysteamine Bitartrate Procysbi Oral Capsule Delayed Release 25 MG Tier 2 x GENITOURINARY AGENTS ‐ MISCELLANEOUS Cysteamine Bitartrate Procysbi Oral Capsule Delayed Release 75 MG Tier 2 x MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies Prodigy AutoCode Blood Glucose Device Tier 3 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies Prodigy AutoCode Blood Glucose Kit w/Device Tier 3 MEDICAL DEVICES AND SUPPLIES Blood Glucose Calibration Prodigy Control Solution In Vitro Solution Low Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Prodigy Insulin Syringe Miscellaneous 28G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Prodigy Insulin Syringe Miscellaneous 31G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Prodigy Insulin Syringe Miscellaneous 31G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Prodigy Lancets 28G Miscellaneous Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood Prodigy No Coding Blood Gluc In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies Prodigy Pocket Blood Glucose Kit w/Device Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Prodigy Safety Lancets 26G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Prodigy Twist Top Lancets 28G Miscellaneous Tier 2 HEMATOPOIETIC AGENTS Iron Heme Polypeptide‐Folic Acid Proferrin‐Forte Oral Tablet 12‐1 MG Tier 3 PROGESTINS Progesterone Progesterone Intramuscular Oil 50 MG/ML Tier 1 x PROGESTINS Progesterone Micronized Progesterone Micronized Oral Capsule 100 MG Tier 1 PROGESTINS Progesterone Micronized Progesterone Micronized Oral Capsule 200 MG Tier 1 PROGESTINS Progesterone Micronized Progesterone Micronized Powder Tier 3 PROGESTINS Progesterone Micronized Progesterone Micronized Transdermal Cream 10 % Tier 3 PROGESTINS Progesterone Progesterone Milled Powder Tier 3 PROGESTINS Progesterone Progesterone Powder Tier 3 PROGESTINS Progesterone Progesterone Wettable Powder Tier 3 ANTIDIABETICS Proglycem Oral Suspension 50 MG/ML Tier 2 ASSORTED CLASSES Tacrolimus Prograf Oral Capsule 0.5 MG Tier 2 ASSORTED CLASSES Tacrolimus Prograf Oral Capsule 1 MG Tier 2 ASSORTED CLASSES Tacrolimus Prograf Oral Capsule 5 MG Tier 2 DIAGNOSTIC PRODUCTS Gadoteridol Prohance Intravenous Solution 279.3 MG/ML Tier 3 x OPHTHALMIC AGENTS Bromfenac Sodium (Ophth) Prolensa Ophthalmic Solution 0.07 % Tier 3 HEMATOPOIETIC AGENTS Eltrombopag Olamine Promacta Oral Tablet 12.5 MG Tier 2 x x HEMATOPOIETIC AGENTS Eltrombopag Olamine Promacta Oral Tablet 25 MG Tier 2 x x HEMATOPOIETIC AGENTS Eltrombopag Olamine Promacta Oral Tablet 50 MG Tier 2 x x HEMATOPOIETIC AGENTS Eltrombopag Olamine Promacta Oral Tablet 75 MG Tier 2 x x ANTIHISTAMINES Promethazine HCl Promethazine HCl Injection Solution 25 MG/ML Tier 1 x ANTIHISTAMINES Promethazine HCl Promethazine HCl Injection Solution 50 MG/ML Tier 1 x ANTIHISTAMINES Promethazine HCl Promethazine HCl Oral Solution 6.25 MG/5ML Tier 1 ANTIHISTAMINES Promethazine HCl Promethazine HCl Oral Syrup 6.25 MG/5ML Tier 1 ANTIHISTAMINES Promethazine HCl Promethazine HCl Oral Tablet 12.5 MG Tier 1 ANTIHISTAMINES Promethazine HCl Promethazine HCl Oral Tablet 25 MG Tier 1 ANTIHISTAMINES Promethazine HCl Promethazine HCl Oral Tablet 50 MG Tier 1 ANTIHISTAMINES Promethazine HCl Promethazine HCl Rectal Suppository 12.5 MG Tier 1 ANTIHISTAMINES Promethazine HCl Promethazine HCl Rectal Suppository 25 MG Tier 1 ANTIHISTAMINES Promethazine HCl Promethazine HCl Rectal Suppository 50 MG Tier 1 COUGH/COLD/ALLERGY Promethazine & Phenylephrine Promethazine VC Oral Syrup 6.25‐5 MG/5ML Tier 1 COUGH/COLD/ALLERGY Phenyleph‐Promethazine w/ Cod Promethazine VC/Codeine Oral Syrup 6.25‐5‐10 MG/5ML Tier 1 COUGH/COLD/ALLERGY Promethazine w/Codeine Promethazine‐Codeine Oral Syrup 6.25‐10 MG/5ML Tier 1 COUGH/COLD/ALLERGY Promethazine‐DM Promethazine‐DM Oral Syrup 6.25‐15 MG/5ML Tier 1 COUGH/COLD/ALLERGY Promethazine & Phenylephrine Promethazine‐Phenylephrine Oral Syrup 6.25‐5 MG/5ML Tier 1 ANTIHISTAMINES Promethazine HCl Promethegan Rectal Suppository 12.5 MG Tier 1 ANTIHISTAMINES Promethazine HCl Promethegan Rectal Suppository 25 MG Tier 1 ANTIHISTAMINES Promethazine HCl Promethegan Rectal Suppository 50 MG Tier 1 PROGESTINS Progesterone Micronized Prometrium Oral Capsule 100 MG Tier 3 PROGESTINS Progesterone Micronized Prometrium Oral Capsule 200 MG Tier 3 DERMATOLOGICALS Antiseborrheic Products, Misc. Promiseb Complete External Kit Tier 3 DERMATOLOGICALS Antiseborrheic Products, Misc. Promiseb External Cream Tier 3 ANTIARRHYTHMICS Propafenone HCl Propafenone HCl ER Oral Capsule Extended Release 12 Hour 225 MG Tier 1 ANTIARRHYTHMICS Propafenone HCl Propafenone HCl ER Oral Capsule Extended Release 12 Hour 325 MG Tier 1 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ANTIARRHYTHMICS Propafenone HCl Propafenone HCl ER Oral Capsule Extended Release 12 Hour 425 MG Tier 1 ANTIARRHYTHMICS Propafenone HCl Propafenone HCl Oral Tablet 150 MG Tier 1 ANTIARRHYTHMICS Propafenone HCl Propafenone HCl Oral Tablet 225 MG Tier 1 ANTIARRHYTHMICS Propafenone HCl Propafenone HCl Oral Tablet 300 MG Tier 1 ULCER DRUGS Propantheline Bromide Propantheline Bromide Oral Tablet 15 MG Tier 2 ULCER DRUGS Propantheline Bromide Propantheline Bromide Powder Tier 3 OPHTHALMIC AGENTS Proparacaine HCl Proparacaine HCl Ophthalmic Solution 0.5 % Tier 1 OPHTHALMIC AGENTS Fluorescein w/ Proparacaine Proparacaine‐Fluorescein Ophthalmic Solution 0.5‐0.25 % Tier 1 DERMATOLOGICALS Finasteride (Alopecia) Propecia Oral Tablet 1 MG Tier 3 NASAL AGENTS ‐ SYSTEMIC AND TOPICAL Mometasone Furoate (Nasal) Propel Mini Nasal Implant 370 MCG Tier 3 x NASAL AGENTS ‐ SYSTEMIC AND TOPICAL Mometasone Furoate (Nasal) Propel Nasal Implant 370 MCG Tier 3 x GENERAL ANESTHETICS Propofol Propofol Intravenous Emulsion 10 MG/ML Tier 1 x BETA BLOCKERS Propranolol HCl Propranolol HCl ER Oral Capsule Extended Release 24 Hour 120 MG Tier 1 BETA BLOCKERS Propranolol HCl Propranolol HCl ER Oral Capsule Extended Release 24 Hour 160 MG Tier 1 BETA BLOCKERS Propranolol HCl Propranolol HCl ER Oral Capsule Extended Release 24 Hour 60 MG Tier 1 BETA BLOCKERS Propranolol HCl Propranolol HCl ER Oral Capsule Extended Release 24 Hour 80 MG Tier 1 BETA BLOCKERS Propranolol HCl Propranolol HCl Intravenous Solution 1 MG/ML Tier 1 x BETA BLOCKERS Propranolol HCl Propranolol HCl Oral Solution 20 MG/5ML Tier 2 BETA BLOCKERS Propranolol HCl Propranolol HCl Oral Solution 40 MG/5ML Tier 2 BETA BLOCKERS Propranolol HCl Propranolol HCl Oral Tablet 10 MG Tier 1 BETA BLOCKERS Propranolol HCl Propranolol HCl Oral Tablet 20 MG Tier 1 BETA BLOCKERS Propranolol HCl Propranolol HCl Oral Tablet 40 MG Tier 1 BETA BLOCKERS Propranolol HCl Propranolol HCl Oral Tablet 60 MG Tier 1 BETA BLOCKERS Propranolol HCl Propranolol HCl Oral Tablet 80 MG Tier 1 BETA BLOCKERS Propranolol HCl Propranolol HCl Powder Tier 3 ANTIHYPERTENSIVES Propranolol & Hydrochlorothiazide Propranolol‐HCTZ Oral Tablet 40‐25 MG Tier 3 ANTIHYPERTENSIVES Propranolol & Hydrochlorothiazide Propranolol‐HCTZ Oral Tablet 80‐25 MG Tier 3 PHARMACEUTICAL ADJUVANTS Propylene Glycol Propylene Glycol External Solution Tier 3 PHARMACEUTICAL ADJUVANTS Propylparaben Propylparaben Powder Tier 3 THYROID AGENTS Propylthiouracil Propylthiouracil Oral Tablet 50 MG Tier 1 VACCINES Measles‐Mumps‐Rubella‐Varicella Virus Vaccines ProQuad Subcutaneous Injectable Tier 2 x GENITOURINARY AGENTS ‐ MISCELLANEOUS Finasteride Proscar Oral Tablet 5 MG Tier 3 URINARY ANTI‐INFECTIVES Methenamine‐Hyosc‐Methylene Blue‐Benzoic Acid‐Phenyl Sal Prosed/DS Oral Tablet 81.6 MG Tier 3 OXYTOCICS Dinoprostone Prostin E2 Vaginal Suppository 20 MG Tier 3 ASSORTED CLASSES Alprostadil Prostin VR Injection Solution 500 MCG/ML Tier 3 x HEMATOLOGICAL AGENTS ‐ MISC. Protamine Sulfate Protamine Sulfate Intravenous Solution 10 MG/ML Tier 3 x MULTIVITAMINS Multiple Vitamins w/ Minerals Protect Plus Oral Capsule Tier 3 HEMATOPOIETIC AGENTS Iron Polysaccharide‐Folic Acid‐B Complex‐Vit C‐E & Minerals ProtectIron Oral Tablet 60‐1 MG Tier 3 MOUTH/THROAT/DENTAL AGENTS Sucralfate‐Malate ProThelial Mouth/Throat Paste 10 % Tier 3 ULCER DRUGS Pantoprazole Sodium Protonix Intravenous Solution Reconstituted 40 MG Tier 3 x ULCER DRUGS Pantoprazole Sodium Protonix Oral Packet 40 MG Tier 3 x ULCER DRUGS Pantoprazole Sodium Protonix Oral Tablet Delayed Release 20 MG Tier 3 x ULCER DRUGS Pantoprazole Sodium Protonix Oral Tablet Delayed Release 40 MG Tier 3 x ANTIDOTES Pralidoxime Chloride Protopam Chloride Intravenous Solution Reconstituted 1 GM Tier 3 x DERMATOLOGICALS Tacrolimus (Topical) Protopic External Ointment 0.03 % Tier 3 DERMATOLOGICALS Tacrolimus (Topical) Protopic External Ointment 0.1 % Tier 3 ANTIDEPRESSANTS Protriptyline HCl Protriptyline HCl Oral Tablet 10 MG Tier 1 ANTIDEPRESSANTS Protriptyline HCl Protriptyline HCl Oral Tablet 5 MG Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Albuterol Sulfate Proventil HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT Tier 3 PROGESTINS Medroxyprogesterone Acetate Provera Oral Tablet 10 MG Tier 3 PROGESTINS Medroxyprogesterone Acetate Provera Oral Tablet 2.5 MG Tier 3 PROGESTINS Medroxyprogesterone Acetate Provera Oral Tablet 5 MG Tier 3 MULTIVITAMINS Prenatal without A Vit w/ Fe Fum‐Iron Polysacch Complex ‐FA Provida OB Oral Capsule 20‐20‐1.25 MG Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Modafinil Provigil Oral Tablet 100 MG Tier 3 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Modafinil Provigil Oral Tablet 200 MG Tier 3 x x OPHTHALMIC AGENTS Sodium Hyaluronate Provisc Intraocular Solution 10 MG/ML Tier 3 DIAGNOSTIC PRODUCTS Methacholine Chloride Provocholine Inhalation Solution Reconstituted 100 MG Tier 3 ANTIDEPRESSANTS Fluoxetine HCl PROzac Oral Capsule 10 MG Tier 3 ANTIDEPRESSANTS Fluoxetine HCl PROzac Oral Capsule 20 MG Tier 3 ANTIDEPRESSANTS Fluoxetine HCl PROzac Oral Capsule 40 MG Tier 3 ANTIDEPRESSANTS Fluoxetine HCl PROzac Weekly Oral Capsule Delayed Release 90 MG Tier 3 DERMATOLOGICALS Doxepin HCl (Antipruritic) Prudoxin External Cream 5 % Tier 3 COUGH/COLD/ALLERGY Pseudoephed‐Bromphen‐DM Pseudoeph‐Bromphen‐DM Oral Syrup 30‐2‐10 MG/5ML Tier 1 COUGH/COLD/ALLERGY Pseudoephed‐CPM w/ Hydrocod Pseudoeph‐Chlorphen‐Hydrocod Oral Solution 60‐4‐5 MG/5ML Tier 1 NASAL AGENTS ‐ SYSTEMIC AND TOPICAL Pseudoephedrine HCl Pseudoephedrine HCl Oral Tablet 30 MG Tier 1 NASAL AGENTS ‐ SYSTEMIC AND TOPICAL Pseudoephedrine HCl Pseudoephedrine HCl Oral Tablet 60 MG Tier 1 DERMATOLOGICALS Diflorasone Diacetate Psorcon External Cream 0.05 % Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets PSS Select GP Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Misc. PSS Select Platforms Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets PSS Select Safety Lancets Miscellaneous Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood PTS Panels Glucose Test In Vitro Strip Tier 3 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Budesonide (Inhalation) Pulmicort Flexhaler Inhalation Aerosol Powder Breath Activated 180 MCG/ACT Tier 2 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Budesonide (Inhalation) Pulmicort Flexhaler Inhalation Aerosol Powder Breath Activated 90 MCG/ACT Tier 2 x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Budesonide (Inhalation) Pulmicort Inhalation Suspension 0.25 MG/2ML Tier 3 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Budesonide (Inhalation) Pulmicort Inhalation Suspension 0.5 MG/2ML Tier 3 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Budesonide (Inhalation) Pulmicort Inhalation Suspension 1 MG/2ML Tier 3 COUGH/COLD/ALLERGY Sodium Chloride (Inhalant) PulmoSal Inhalation Nebulization Solution 7 % Tier 1 RESPIRATORY AGENTS ‐ MISC. Dornase Alfa Pulmozyme Inhalation Solution 1 MG/ML Tier 2 x x MEDICAL DEVICES AND SUPPLIES Insulin Administration Supplies Pumping Insulin Book Volume 2 Miscellaneous Tier 3 MULTIVITAMINS Prenatal without A Vit w/ Fe Fum‐Iron Polysacch Complex ‐FA PureFe OB Plus Oral Capsule 162‐115.2‐1 MG Tier 2 HEMATOPOIETIC AGENTS Ferrous Fumarate‐FA‐B Complex‐C‐Zn‐Mg‐Mn‐Cu PureFe Plus Oral Capsule 106‐1 MG Tier 3 HEMATOPOIETIC AGENTS Fe Fum‐Iron Polysacch Complex‐FA‐B Complex‐C‐Zn‐Mn‐Cu PureVit DualFe Plus Oral Capsule 162‐115.2‐1 MG Tier 1 PHARMACEUTICAL ADJUVANTS Distilled Purified Water Oral Liquid Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Mercaptopurine Purinethol Oral Tablet 50 MG Tier 2 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Mercaptopurine Purixan Oral Suspension 2000 MG/100ML Tier 2 x MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle PX Extra Short Pen Needles Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 PX Insulin Syringe Miscellaneous 30G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 PX Insulin Syringe Miscellaneous 30G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 PX Insulin Syringe Miscellaneous 30G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 PX Insulin Syringe Miscellaneous 31G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 PX Insulin Syringe Miscellaneous 31G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 PX Insulin Syringe Miscellaneous 31G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets PX Lancets Ultra Thin Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle PX Mini Pen Needles Miscellaneous 31G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle PX Pen Needle Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle PX Pen Needle Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle PX Shortlength Pen Needles Miscellaneous 31G X 8 MM Tier 2 ULCER DRUGS Bismuth Subcitrate Potassium‐Metronidazole‐Tetracycline Pylera Oral Capsule 140‐125‐125 MG Tier 2 x x ANTIMYCOBACTERIAL AGENTS Pyrazinamide Pyrazinamide Oral Tablet 500 MG Tier 1 GENITOURINARY AGENTS ‐ MISCELLANEOUS Phenazopyridine HCl Pyridium Oral Tablet 100 MG Tier 3 GENITOURINARY AGENTS ‐ MISCELLANEOUS Phenazopyridine HCl Pyridium Oral Tablet 200 MG Tier 3 ANTIMYASTHENIC/CHOLINERGIC AGENTS Pyridostigmine Bromide Pyridostigmine Bromide ER Oral Tablet Extended Release 180 MG Tier 1 ANTIMYASTHENIC/CHOLINERGIC AGENTS Pyridostigmine Bromide Pyridostigmine Bromide Oral Tablet 60 MG Tier 1 VITAMINS Pyridoxine HCl Pyridoxine HCl Injection Solution 100 MG/ML Tier 3 x VITAMINS Pyridoxine HCl Pyridoxine HCl Powder Tier 3 DERMATOLOGICALS Pyrogallol‐Chlorobutanol Pyrogallic Acid External Ointment 25‐2 % Tier 3 CHEMICALS Pyruvic Acid Liquid Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets QC Lancets Super Thin 30G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets QC Lancets Ultra Thin Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle QC Pen Needles Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle QC Pen Needles Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle QC Pen Needles Miscellaneous 31G X 8 MM Tier 2 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle QC Unifine Pentips Miscellaneous 32G X 4 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets QC Unilet Lancets Micro Thin Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Oral Hygiene Products Q‐Care Q4 Oral Cleans/Suction Mouth/Throat Kit Tier 3 NASAL AGENTS ‐ SYSTEMIC AND TOPICAL Beclomethasone Dipropionate (Nasal) Qnasl Childrens Nasal Aerosol Solution 40 MCG/ACT Tier 3 x NASAL AGENTS ‐ SYSTEMIC AND TOPICAL Beclomethasone Dipropionate (Nasal) Qnasl Nasal Aerosol Solution 80 MCG/ACT Tier 3 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Phentermine HCl‐ Qsymia Oral Capsule Extended Release 24 Hour 11.25‐69 MG Tier 3 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Phentermine HCl‐Topiramate Qsymia Oral Capsule Extended Release 24 Hour 15‐92 MG Tier 3 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Phentermine HCl‐Topiramate Qsymia Oral Capsule Extended Release 24 Hour 3.75‐23 MG Tier 3 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Phentermine HCl‐Topiramate Qsymia Oral Capsule Extended Release 24 Hour 7.5‐46 MG Tier 3 x x TOXOIDS Diph‐Tetanus Tox Ad‐Acell Pertussis & Polio Virus, IPV Vac Quadracel Intramuscular Suspension Tier 3 x ANTIMALARIALS Quinine Sulfate Qualaquin Oral Capsule 324 MG Tier 3 x x CONTRACEPTIVES Levonorgestrel‐Ethinyl Estradiol (91‐Day) Quasense Oral Tablet 0.15‐0.03 MG Tier 1 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Quazepam Quazepam Oral Tablet 15 MG Tier 3 ANTICONVULSANTS Topiramate Qudexy XR Oral Capsule ER 24 Hour Sprinkle 100 MG Tier 3 x ANTICONVULSANTS Topiramate Qudexy XR Oral Capsule ER 24 Hour Sprinkle 150 MG Tier 3 x ANTICONVULSANTS Topiramate Qudexy XR Oral Capsule ER 24 Hour Sprinkle 200 MG Tier 3 x ANTICONVULSANTS Topiramate Qudexy XR Oral Capsule ER 24 Hour Sprinkle 25 MG Tier 3 x ANTICONVULSANTS Topiramate Qudexy XR Oral Capsule ER 24 Hour Sprinkle 50 MG Tier 3 x NEUROMUSCULAR AGENTS Succinylcholine Chloride Quelicin Injection Solution 20 MG/ML Tier 3 x ANTIHYPERLIPIDEMICS Cholestyramine Light Questran Light Oral Powder 4 GM/DOSE Tier 3 ANTIHYPERLIPIDEMICS Cholestyramine Questran Oral Packet 4 GM Tier 3 ANTIHYPERLIPIDEMICS Cholestyramine Questran Oral Powder 4 GM/DOSE Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Quetiapine Fumarate QUEtiapine Fumarate Oral Tablet 100 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Quetiapine Fumarate QUEtiapine Fumarate Oral Tablet 200 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Quetiapine Fumarate QUEtiapine Fumarate Oral Tablet 25 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Quetiapine Fumarate QUEtiapine Fumarate Oral Tablet 300 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Quetiapine Fumarate QUEtiapine Fumarate Oral Tablet 400 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Quetiapine Fumarate QUEtiapine Fumarate Oral Tablet 50 MG Tier 1 MULTIVITAMINS Pediatric Multivitamins w/Fl Quflora Pediatric Oral Solution 0.25 MG/ML Tier 3 MULTIVITAMINS Pediatric Multivitamins w/Fl Quflora Pediatric Oral Solution 0.5 MG/ML Tier 3 MULTIVITAMINS Pediatric Multivitamins w/Fl Quflora Pediatric Oral Tablet Chewable 0.25 MG Tier 3 MULTIVITAMINS Pediatric Multivitamins w/Fl Quflora Pediatric Oral Tablet Chewable 0.5 MG Tier 3 MULTIVITAMINS Pediatric Multivitamins w/Fl Quflora Pediatric Oral Tablet Chewable 1 MG Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood QuickTek Test In Vitro Strip Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl QuilliChew ER Oral Tablet Chewable Extended Release 20 MG Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl QuilliChew ER Oral Tablet Chewable Extended Release 30 MG Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl QuilliChew ER Oral Tablet Chewable Extended Release 40 MG Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Quillivant XR Oral Suspension Reconstituted 25 MG/5ML Tier 3 x ANTIMALARIALS Quinacrine HCl Quinacrine HCl Powder Tier 3 ANTIHYPERTENSIVES Quinapril HCl Quinapril HCl Oral Tablet 10 MG Tier 1 ANTIHYPERTENSIVES Quinapril HCl Quinapril HCl Oral Tablet 20 MG Tier 1 ANTIHYPERTENSIVES Quinapril HCl Quinapril HCl Oral Tablet 40 MG Tier 1 ANTIHYPERTENSIVES Quinapril HCl Quinapril HCl Oral Tablet 5 MG Tier 1 ANTIHYPERTENSIVES Quinapril‐Hydrochlorothiazide Quinapril‐Hydrochlorothiazide Oral Tablet 10‐12.5 MG Tier 1 ANTIHYPERTENSIVES Quinapril‐Hydrochlorothiazide Quinapril‐Hydrochlorothiazide Oral Tablet 20‐12.5 MG Tier 1 ANTIHYPERTENSIVES Quinapril‐Hydrochlorothiazide Quinapril‐Hydrochlorothiazide Oral Tablet 20‐25 MG Tier 1 ANTIARRHYTHMICS Quinidine Gluconate QuiNIDine Gluconate ER Oral Tablet Extended Release 324 MG Tier 1 ANTIARRHYTHMICS Quinidine Sulfate QuiNIDine Sulfate ER Oral Tablet Extended Release 300 MG Tier 3 ANTIARRHYTHMICS Quinidine Sulfate QuiNIDine Sulfate Oral Tablet 200 MG Tier 3 ANTIARRHYTHMICS Quinidine Sulfate QuiNIDine Sulfate Oral Tablet 300 MG Tier 3 ANTIMALARIALS Quinine Sulfate QuiNINE Sulfate Dihydrate Powder Tier 3 x x ANTIMALARIALS Quinine Sulfate QuiNINE Sulfate Oral Capsule 324 MG Tier 1 x x ANTIMALARIALS Quinine Sulfate QuiNINE Sulfate Powder Tier 3 x x DIAGNOSTIC PRODUCTS Glucose Blood Quintet AC Blood Glucose Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Quintet Blood Glucose Test In Vitro Strip Tier 3 DERMATOLOGICALS Capsaicin & Cleansing Gel Qutenza (2 Patch) External Kit 8 % Tier 3 x DERMATOLOGICALS Capsaicin & Cleansing Gel Qutenza External Kit 8 % Tier 3 x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Beclomethasone Dipropionate Qvar Inhalation Aerosol Solution 40 MCG/ACT Tier 2 x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Beclomethasone Dipropionate Qvar Inhalation Aerosol Solution 80 MCG/ACT Tier 2 MEDICAL DEVICES AND SUPPLIES Alcohol Swabs RA Alcohol Swabs Pad 70 % Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets RA E‐Zject Color Lancets 33G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets RA E‐Zject Lancets 28G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets RA E‐Zject Lancets Thin 26G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets RA E‐Zject Lancets Thin 28G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets RA E‐Zject Lancets Ultra Thin Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 RA Insulin Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 RA Insulin Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 RA Insulin Syringe Miscellaneous 30G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 RA Insulin Syringe Miscellaneous 30G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle RA Pen Needles Miscellaneous 31G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle RA Pen Needles Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies RA TRUE2go Blood Glucose Kit w/Device Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood RA TRUEtest Test In Vitro Strip Tier 3 VACCINES Rabies Vaccine, PCEC RabAvert Intramuscular Suspension Reconstituted Tier 3 x ULCER DRUGS Rabeprazole Sodium RABEprazole Sodium Oral Tablet Delayed Release 20 MG Tier 1 x x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Raloxifene HCl Raloxifene HCl Oral Tablet 60 MG Tier 1 x ANTIHYPERTENSIVES Ramipril Ramipril Oral Capsule 1.25 MG Tier 1 ANTIHYPERTENSIVES Ramipril Ramipril Oral Capsule 10 MG Tier 1 ANTIHYPERTENSIVES Ramipril Ramipril Oral Capsule 2.5 MG Tier 1 ANTIHYPERTENSIVES Ramipril Ramipril Oral Capsule 5 MG Tier 1 ANTIANGINAL AGENTS Ranolazine Ranexa Oral Tablet Extended Release 12 Hour 1000 MG Tier 2 x x ANTIANGINAL AGENTS Ranolazine Ranexa Oral Tablet Extended Release 12 Hour 500 MG Tier 2 x x ULCER DRUGS Ranitidine HCl Ranitidine HCl Oral Capsule 150 MG Tier 1 ULCER DRUGS Ranitidine HCl Ranitidine HCl Oral Capsule 300 MG Tier 1 ULCER DRUGS Ranitidine HCl Ranitidine HCl Oral Syrup 15 MG/ML Tier 1 ULCER DRUGS Ranitidine HCl Ranitidine HCl Oral Syrup 150 MG/10ML Tier 1 ULCER DRUGS Ranitidine HCl Ranitidine HCl Oral Syrup 75 MG/5ML Tier 1 ULCER DRUGS Ranitidine HCl Ranitidine HCl Oral Tablet 150 MG Tier 1 ULCER DRUGS Ranitidine HCl Ranitidine HCl Oral Tablet 300 MG Tier 1 GENITOURINARY AGENTS ‐ MISCELLANEOUS Silodosin Rapaflo Oral Capsule 4 MG Tier 2 x GENITOURINARY AGENTS ‐ MISCELLANEOUS Silodosin Rapaflo Oral Capsule 8 MG Tier 2 x ASSORTED CLASSES Sirolimus Rapamune Oral Solution 1 MG/ML Tier 2 x ASSORTED CLASSES Sirolimus Rapamune Oral Tablet 0.5 MG Tier 2 x ASSORTED CLASSES Sirolimus Rapamune Oral Tablet 1 MG Tier 2 x ASSORTED CLASSES Sirolimus Rapamune Oral Tablet 2 MG Tier 2 x ANTIVIRALS Peramivir Rapivab Intravenous Solution 200 MG/20ML Tier 3 x MEDICAL DEVICES AND SUPPLIES Impotence Aid Device Rapport RLS Kit Tier 3 MEDICAL DEVICES AND SUPPLIES Impotence Aid Device Rapport VTD Kit Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Methotrexate (Antirheumatic) Rasuvo Subcutaneous Solution Auto‐injector 10 MG/0.2ML Tier 2 x x ANALGESICS ‐ ANTI‐INFLAMMATORY Methotrexate (Antirheumatic) Rasuvo Subcutaneous Solution Auto‐injector 12.5 MG/0.25ML Tier 2 x x ANALGESICS ‐ ANTI‐INFLAMMATORY Methotrexate (Antirheumatic) Rasuvo Subcutaneous Solution Auto‐injector 15 MG/0.3ML Tier 2 x x ANALGESICS ‐ ANTI‐INFLAMMATORY Methotrexate (Antirheumatic) Rasuvo Subcutaneous Solution Auto‐injector 17.5 MG/0.35ML Tier 2 x x ANALGESICS ‐ ANTI‐INFLAMMATORY Methotrexate (Antirheumatic) Rasuvo Subcutaneous Solution Auto‐injector 20 MG/0.4ML Tier 2 x x ANALGESICS ‐ ANTI‐INFLAMMATORY Methotrexate (Antirheumatic) Rasuvo Subcutaneous Solution Auto‐injector 22.5 MG/0.45ML Tier 2 x x ANALGESICS ‐ ANTI‐INFLAMMATORY Methotrexate (Antirheumatic) Rasuvo Subcutaneous Solution Auto‐injector 25 MG/0.5ML Tier 2 x x ANALGESICS ‐ ANTI‐INFLAMMATORY Methotrexate (Antirheumatic) Rasuvo Subcutaneous Solution Auto‐injector 27.5 MG/0.55ML Tier 2 x x ANALGESICS ‐ ANTI‐INFLAMMATORY Methotrexate (Antirheumatic) Rasuvo Subcutaneous Solution Auto‐injector 30 MG/0.6ML Tier 2 x x ANALGESICS ‐ ANTI‐INFLAMMATORY Methotrexate (Antirheumatic) Rasuvo Subcutaneous Solution Auto‐injector 7.5 MG/0.15ML Tier 2 x x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Glycerol Phenylbutyrate Ravicti Oral Liquid 1.1 GM/ML Tier 2 x x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Galantamine Hydrobromide Razadyne ER Oral Capsule Extended Release 24 Hour 16 MG Tier 3 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Galantamine Hydrobromide Razadyne ER Oral Capsule Extended Release 24 Hour 24 MG Tier 3 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Galantamine Hydrobromide Razadyne ER Oral Capsule Extended Release 24 Hour 8 MG Tier 3 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Galantamine Hydrobromide Razadyne Oral Tablet 12 MG Tier 3 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Galantamine Hydrobromide Razadyne Oral Tablet 4 MG Tier 3 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Galantamine Hydrobromide Razadyne Oral Tablet 8 MG Tier 3 DERMATOLOGICALS Urea Rea Lo 39 External Cream 39 % Tier 1 DERMATOLOGICALS Urea Rea Lo 40 External Cream 40 % Tier 1 DERMATOLOGICALS Urea Rea Lo 40 External Lotion 40 % Tier 1 DIAGNOSTIC PRODUCTS Barium Sulfate Readi‐Cat 2 Oral Suspension 2.1 % Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Reality Insulin Syringe Miscellaneous 28G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Reality Insulin Syringe Miscellaneous 28G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Reality Insulin Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Reality Insulin Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Reality Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Reality Trigger Lancets Miscellaneous Tier 2 ANTIVIRALS Ribavirin (Hepatitis C) Rebetol Oral Capsule 200 MG Tier 2 x x ANTIVIRALS Ribavirin (Hepatitis C) Rebetol Oral Solution 40 MG/ML Tier 2 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Interferon Beta‐1a Rebif Rebidose Subcutaneous Solution Auto‐injector 22 MCG/0.5ML Tier 2 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Interferon Beta‐1a Rebif Rebidose Subcutaneous Solution Auto‐injector 44 MCG/0.5ML Tier 2 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Interferon Beta‐1a Rebif Rebidose Titration Pack Subcutaneous Solution Auto‐injector 6X8.8 & 6X22 MCG Tier 2 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Interferon Beta‐1a Rebif Subcutaneous Solution Prefilled Syringe 22 MCG/0.5ML Tier 2 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Interferon Beta‐1a Rebif Subcutaneous Solution Prefilled Syringe 44 MCG/0.5ML Tier 2 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Interferon Beta‐1a Rebif Titration Pack Subcutaneous Solution Prefilled Syringe 6X8.8 & 6X22 MCG Tier 2 x DERMATOLOGICALS Lidocaine‐Menthol Reciphexamine External Patch 4‐1 % Tier 1 CONTRACEPTIVES Desogestrel & Ethinyl Estradiol Reclipsen Oral Tablet 0.15‐30 MG‐MCG Tier 1 HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor (Recombinant) Recombinate Intravenous Solution Reconstituted 1241‐1800 UNIT Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor (Recombinant) Recombinate Intravenous Solution Reconstituted 1801‐2400 UNIT Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor (Recombinant) Recombinate Intravenous Solution Reconstituted 220‐400 UNIT Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor (Recombinant) Recombinate Intravenous Solution Reconstituted 401‐800 UNIT Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor (Recombinant) Recombinate Intravenous Solution Reconstituted 801‐1240 UNIT Tier 2 x VACCINES Hepatitis B Vaccine (Recomb) Recombivax HB Injection Suspension 10 MCG/ML Tier 3 x VACCINES Hepatitis B Vaccine (Recomb) Recombivax HB Injection Suspension 40 MCG/ML Tier 3 x VACCINES Hepatitis B Vaccine (Recomb) Recombivax HB Injection Suspension 5 MCG/0.5ML Tier 3 x HEMOSTATICS Thrombin (Recombinant) Recothrom External Solution Reconstituted 20000 UNIT Tier 3 HEMOSTATICS Thrombin (Recombinant) Recothrom External Solution Reconstituted 5000 UNIT Tier 3 HEMOSTATICS Thrombin (Recombinant) Recothrom Spray Kit External Solution Reconstituted 20000 UNIT Tier 3 ANORECTAL AGENTS Nitroglycerin (Intra‐Anal) Rectiv Rectal Ointment 0.4 % Tier 3 DERMATOLOGICALS Antifungal Combination Products, Misc. Recura External Cream Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood RefuAH Plus Blood Glucose Test In Vitro Strip Tier 3 DERMATOLOGICALS Lidocaine HCl‐‐Aloe Vera Regenecare External Gel 2 % Tier 3 PHARMACEUTICAL ADJUVANTS Ethyl Alcohol (Vehicle) Regent Alcohol Solution 100 % Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Benzphetamine HCl Regimex Oral Tablet 25 MG Tier 3 x x GASTROINTESTINAL AGENTS ‐ MISC. Metoclopramide HCl Reglan Oral Tablet 10 MG Tier 3 GASTROINTESTINAL AGENTS ‐ MISC. Metoclopramide HCl Reglan Oral Tablet 5 MG Tier 3 ANTIMYASTHENIC/CHOLINERGIC AGENTS Pyridostigmine Bromide Regonol Intravenous Solution 10 MG/2ML Tier 3 x DERMATOLOGICALS Regranex External Gel 0.01 % Tier 3 x DERMATOLOGICALS Lidocaine‐Prilocaine Relador Pak External Kit 2.5‐2.5 % Tier 1 DERMATOLOGICALS Lidocaine‐Prilocaine Relador Pak Plus External Kit 2.5‐2.5 % Tier 1 VAGINAL PRODUCTS Acetic Acid‐Oxyquinoline Vaginal Relagard Vaginal Gel 0.9‐0.025 % Tier 3 DERMATOLOGICALS Capsaicin‐Menthol Releevia External Patch 0.0375‐5 % Tier 3 DERMATOLOGICALS Capsaicin‐Menthol Releevia MC External Patch 0.0375‐5 % Tier 3 DERMATOLOGICALS Lidocaine‐Menthol Releevia ML External Patch 4‐1 % Tier 1 ANTIVIRALS Zanamivir Relenza Diskhaler Inhalation Aerosol Powder Breath Activated 5 MG/BLISTER Tier 3 x COUGH/COLD/ALLERGY Brompheniramine Tannate‐Phenylephrine Tannate Relhist Oral Tablet Chewable 6‐15 MG Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood ReliOn Blood Glucose Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies ReliOn Confirm Glucose Monitor Kit w/Device Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood ReliOn Confirm/micro Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Reli‐On Insulin Syringe Miscellaneous 29G 0.3 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Reli‐On Insulin Syringe Miscellaneous 29G 0.5 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 ReliOn Insulin Syringe Miscellaneous 29G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 ReliOn Insulin Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 ReliOn Insulin Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Reli‐On Insulin Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Reli‐On Insulin Syringe Miscellaneous 30G 0.3 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Reli‐On Insulin Syringe Miscellaneous 30G 0.5 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Reli‐On Insulin Syringe Miscellaneous 30G 1 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 ReliOn Insulin Syringe Miscellaneous 30G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 ReliOn Insulin Syringe Miscellaneous 30G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 ReliOn Insulin Syringe Miscellaneous 30G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 ReliOn Insulin Syringe Miscellaneous 31G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 ReliOn Insulin Syringe Miscellaneous 31G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 ReliOn Insulin Syringe Miscellaneous 31G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets ReliOn Lancets Micro‐Thin 33G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets ReliOn Lancets Standard 21G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets ReliOn Lancets Thin 26G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets ReliOn Lancets Ultra‐Thin 30G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancet Devices ReliOn Lancing Device Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies ReliOn Micro Kit w/Device Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle ReliOn Mini Pen Needles Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle ReliOn Pen Needles Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle ReliOn Pen Needles Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle ReliOn Pen Needles Miscellaneous 32G X 4 MM Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood ReliOn Prime Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle ReliOn Short Pen Needles Miscellaneous 31G X 8 MM Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood ReliOn Ultima Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets ReliOn Ultra Thin Lancets 30G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets ReliOn Ultra Thin Plus Lancets Miscellaneous Tier 2 GASTROINTESTINAL AGENTS ‐ MISC. Methylnaltrexone Bromide Relistor Subcutaneous Solution 12 MG/0.6ML Tier 2 x x GASTROINTESTINAL AGENTS ‐ MISC. Methylnaltrexone Bromide Relistor Subcutaneous Solution 8 MG/0.4ML Tier 2 x x MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐FA‐Omega 3 Fatty Acids Relnate DHA Oral Capsule 28‐1‐200 MG Tier 3 MIGRAINE PRODUCTS Eletriptan Hydrobromide Relpax Oral Tablet 20 MG Tier 3 x MIGRAINE PRODUCTS Eletriptan Hydrobromide Relpax Oral Tablet 40 MG Tier 3 x DERMATOLOGICALS Capsaicin‐Menthol‐Methyl Salicylate Rematex External Cream 0.035‐6‐30 % Tier 3 DERMATOLOGICALS Lidocaine‐Capsaicin‐Chondroitin‐Glucosamine Remaxazon External Patch 4‐0.0285‐3‐5 % Tier 3 ANTIDEPRESSANTS Mirtazapine Remeron Oral Tablet 15 MG Tier 3 ANTIDEPRESSANTS Mirtazapine Remeron Oral Tablet 30 MG Tier 3 ANTIDEPRESSANTS Mirtazapine Remeron Oral Tablet 45 MG Tier 3 ANTIDEPRESSANTS Mirtazapine Remeron SolTab Oral Tablet Dispersible 15 MG Tier 3 ANTIDEPRESSANTS Mirtazapine Remeron SolTab Oral Tablet Dispersible 30 MG Tier 3 ANTIDEPRESSANTS Mirtazapine Remeron SolTab Oral Tablet Dispersible 45 MG Tier 3 DERMATOLOGICALS Urea Remeven External Cream 50 % Tier 1 GASTROINTESTINAL AGENTS ‐ MISC. Sevelamer HCl Renagel Oral Tablet 400 MG Tier 3 GASTROINTESTINAL AGENTS ‐ MISC. Sevelamer HCl Renagel Oral Tablet 800 MG Tier 3 MULTIVITAMINS B‐Complex w/ C & Folic Acid Renal Oral Capsule 1 MG Tier 1 MULTIVITAMINS B‐Complex w/ C‐Biotin‐Vit E & Folic Acid Renatabs Oral Tablet 1 MG Tier 3 MULTIVITAMINS B Complex w/ C‐Biotin‐E‐Folic Acid & Iron Carbonyl Renatabs with Iron Oral Miscellaneous 1 & 100 MG Tier 3 MULTIVITAMINS B‐Complex w/ C & Folic Acid Rena‐Vite Rx Oral Tablet 1 MG Tier 1 MULTIVITAMINS B‐Complex w/ C & Folic Acid Reno Caps Oral Capsule 1 MG Tier 1 GASTROINTESTINAL AGENTS ‐ MISC. Sevelamer Carbonate Renvela Oral Packet 0.8 GM Tier 3 GASTROINTESTINAL AGENTS ‐ MISC. Sevelamer Carbonate Renvela Oral Packet 2.4 GM Tier 3 GASTROINTESTINAL AGENTS ‐ MISC. Sevelamer Carbonate Renvela Oral Tablet 800 MG Tier 2 ANTIDIABETICS Repaglinide Repaglinide Oral Tablet 0.5 MG Tier 1 x ANTIDIABETICS Repaglinide Repaglinide Oral Tablet 1 MG Tier 1 x ANTIDIABETICS Repaglinide Repaglinide Oral Tablet 2 MG Tier 1 x HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ANTIDIABETICS Repaglinide‐Metformin HCl Repaglinide‐Metformin HCl Oral Tablet 1‐500 MG Tier 3 x ANTIDIABETICS Repaglinide‐Metformin HCl Repaglinide‐Metformin HCl Oral Tablet 2‐500 MG Tier 3 x ANTIHYPERLIPIDEMICS Evolocumab Repatha Subcutaneous Solution Prefilled Syringe 140 MG/ML Tier 3 x x ANTIHYPERLIPIDEMICS Evolocumab Repatha SureClick Subcutaneous Solution Auto‐injector 140 MG/ML Tier 3 x x ANALGESICS ‐ OPIOID Hydrocodone‐Ibuprofen Reprexain Oral Tablet 10‐200 MG Tier 1 ANALGESICS ‐ OPIOID Hydrocodone‐Ibuprofen Reprexain Oral Tablet 5‐200 MG Tier 3 MULTIVITAMINS Multiple Vitamins w/ Minerals REQ 49+ Oral Tablet Tier 3 ANTIPARKINSON AGENTS Ropinirole Hydrochloride Requip Oral Tablet 0.25 MG Tier 3 ANTIPARKINSON AGENTS Ropinirole Hydrochloride Requip Oral Tablet 0.5 MG Tier 3 ANTIPARKINSON AGENTS Ropinirole Hydrochloride Requip Oral Tablet 1 MG Tier 3 ANTIPARKINSON AGENTS Ropinirole Hydrochloride Requip Oral Tablet 2 MG Tier 3 ANTIPARKINSON AGENTS Ropinirole Hydrochloride Requip Oral Tablet 3 MG Tier 3 ANTIPARKINSON AGENTS Ropinirole Hydrochloride Requip Oral Tablet 4 MG Tier 3 ANTIPARKINSON AGENTS Ropinirole Hydrochloride Requip Oral Tablet 5 MG Tier 3 ANTIPARKINSON AGENTS Ropinirole Hydrochloride Requip XL Oral Tablet Extended Release 24 Hour 12 MG Tier 3 x ANTIPARKINSON AGENTS Ropinirole Hydrochloride Requip XL Oral Tablet Extended Release 24 Hour 2 MG Tier 3 x ANTIPARKINSON AGENTS Ropinirole Hydrochloride Requip XL Oral Tablet Extended Release 24 Hour 4 MG Tier 3 x ANTIPARKINSON AGENTS Ropinirole Hydrochloride Requip XL Oral Tablet Extended Release 24 Hour 6 MG Tier 3 x ANTIPARKINSON AGENTS Ropinirole Hydrochloride Requip XL Oral Tablet Extended Release 24 Hour 8 MG Tier 3 x COUGH/COLD/ALLERGY Dexchlorpheniramine‐Phenylephrine Rescon‐MX Oral Tablet Extended Release 12 Hour 6‐40 MG Tier 3 ANTIVIRALS Delavirdine Mesylate Rescriptor Oral Tablet 100 MG Tier 2 x ANTIVIRALS Delavirdine Mesylate Rescriptor Oral Tablet 200 MG Tier 2 x OPHTHALMIC AGENTS Unoprostone Isopropyl Rescula Ophthalmic Solution 0.15 % Tier 3 x ANTIHYPERTENSIVES Reserpine Reserpine Oral Tablet 0.1 MG Tier 3 ANTIHYPERTENSIVES Reserpine Reserpine Oral Tablet 0.25 MG Tier 3 ANTIHYPERTENSIVES Reserpine Reserpine Powder Tier 3 CHEMICALS Resorcinol Powder Tier 3 ANTIHISTAMINES Brompheniramine Maleate Respa‐BR Oral Tablet Extended Release 12 Hour 11 MG Tier 3 OPHTHALMIC AGENTS Cyclosporine (Ophth) Restasis Ophthalmic Emulsion 0.05 % Tier 3 x x ANTIDIARRHEALS Lactobacillus Casei‐Folic Acid Restora RX Oral Capsule 60‐1.25 MG Tier 3 ANTIDIARRHEALS Lactobacillus Casei‐Folic Acid Restora Sprinkles Oral Packet 15‐0.25 MG Tier 3 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Temazepam Restoril Oral Capsule 15 MG Tier 3 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Temazepam Restoril Oral Capsule 22.5 MG Tier 3 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Temazepam Restoril Oral Capsule 30 MG Tier 3 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Temazepam Restoril Oral Capsule 7.5 MG Tier 3 DERMATOLOGICALS Tretinoin Retin‐A External Cream 0.025 % Tier 3 x DERMATOLOGICALS Tretinoin Retin‐A External Cream 0.05 % Tier 3 x DERMATOLOGICALS Tretinoin Retin‐A External Cream 0.1 % Tier 3 x DERMATOLOGICALS Tretinoin Retin‐A External Gel 0.01 % Tier 3 x DERMATOLOGICALS Tretinoin Retin‐A External Gel 0.025 % Tier 3 x DERMATOLOGICALS Tretinoin Microsphere Retin‐A Micro External Gel 0.04 % Tier 3 x DERMATOLOGICALS Tretinoin Microsphere Retin‐A Micro External Gel 0.1 % Tier 3 x DERMATOLOGICALS Tretinoin Microsphere Retin‐A Micro Pump External Gel 0.04 % Tier 3 x DERMATOLOGICALS Tretinoin Microsphere Retin‐A Micro Pump External Gel 0.08 % Tier 3 DERMATOLOGICALS Tretinoin Microsphere Retin‐A Micro Pump External Gel 0.1 % Tier 3 x DERMATOLOGICALS Tretinoin Retinoic Acid Powder Tier 3 ANTIVIRALS Zidovudine Retrovir Oral Capsule 100 MG Tier 3 x ANTIVIRALS Zidovudine Retrovir Oral Syrup 50 MG/5ML Tier 3 x CARDIOVASCULAR AGENTS ‐ MISC. Sildenafil Citrate (Pulmonary Hypertension) Revatio Oral Suspension Reconstituted 10 MG/ML Tier 2 x x CARDIOVASCULAR AGENTS ‐ MISC. Sildenafil Citrate (Pulmonary Hypertension) Revatio Oral Tablet 20 MG Tier 2 x x DIAGNOSTIC PRODUCTS Glucose Blood Reveal Blood Glucose Test In Vitro Strip Tier 3 HEMATOPOIETIC AGENTS Folic Acid‐Cholecalciferol Revesta Oral Capsule 1‐5750 MG‐UNIT Tier 3 ANTIDOTES Naltrexone HCl ReVia Oral Tablet 50 MG Tier 3 x ASSORTED CLASSES Lenalidomide Revlimid Oral Capsule 10 MG Tier 2 x ASSORTED CLASSES Lenalidomide Revlimid Oral Capsule 15 MG Tier 2 x ASSORTED CLASSES Lenalidomide Revlimid Oral Capsule 2.5 MG Tier 2 x ASSORTED CLASSES Lenalidomide Revlimid Oral Capsule 20 MG Tier 2 x ASSORTED CLASSES Lenalidomide Revlimid Oral Capsule 25 MG Tier 2 x ASSORTED CLASSES Lenalidomide Revlimid Oral Capsule 5 MG Tier 2 x MUSCULOSKELETAL THERAPY AGENTS Dantrolene Sodium Revonto Intravenous Solution Reconstituted 20 MG Tier 1 x DIAGNOSTIC PRODUCTS Glucose Blood Rexall Blood Glucose Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Rexall Lancets Ultra Thin 30G Miscellaneous Tier 2 ANTIPSYCHOTICS/ANTIMANIC AGENTS Brexpiprazole Rexulti Oral Tablet 0.25 MG Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Brexpiprazole Rexulti Oral Tablet 0.5 MG Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Brexpiprazole Rexulti Oral Tablet 1 MG Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Brexpiprazole Rexulti Oral Tablet 2 MG Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Brexpiprazole Rexulti Oral Tablet 3 MG Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Brexpiprazole Rexulti Oral Tablet 4 MG Tier 3 xx ANTIVIRALS Atazanavir Sulfate Reyataz Oral Capsule 100 MG Tier 2 x ANTIVIRALS Atazanavir Sulfate Reyataz Oral Capsule 150 MG Tier 2 x ANTIVIRALS Atazanavir Sulfate Reyataz Oral Capsule 200 MG Tier 2 x ANTIVIRALS Atazanavir Sulfate Reyataz Oral Capsule 300 MG Tier 2 x ANTIVIRALS Atazanavir Sulfate Reyataz Oral Packet 50 MG Tier 2 COUGH/COLD/ALLERGY Pseudoephedrine w/ Hydrocodone Rezira Oral Solution 60‐5 MG/5ML Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Methotrexate Sodium (Antirheumatic) Rheumatrex Oral Tablet 2.5 MG Tier 3 NASAL AGENTS ‐ SYSTEMIC AND TOPICAL Budesonide (Nasal) Rhinocort Aqua Nasal Suspension 32 MCG/ACT Tier 3 xx HEMATOLOGICAL AGENTS ‐ MISC. Fibrinogen Concentrate (Human) RiaSTAP Intravenous Solution Reconstituted Tier 2 x DERMATOLOGICALS Benzoyl Peroxide Riax External Foam 5.5 % Tier 3 DERMATOLOGICALS Benzoyl Peroxide Riax External Foam 9.5 % Tier 3 ANTIVIRALS Ribavirin (Hepatitis C) Ribasphere Oral Capsule 200 MG Tier 1 x ANTIVIRALS Ribavirin (Hepatitis C) Ribasphere Oral Tablet 200 MG Tier 1 x ANTIVIRALS Ribavirin (Hepatitis C) Ribasphere Oral Tablet 400 MG Tier 2 x x ANTIVIRALS Ribavirin (Hepatitis C) Ribasphere Oral Tablet 600 MG Tier 2 x x ANTIVIRALS Ribavirin (Hepatitis C) Ribasphere RibaPak Oral Tablet 200 & 400 MG Tier 2 x x ANTIVIRALS Ribavirin (Hepatitis C) Ribasphere RibaPak Oral Tablet 400 & 600 MG Tier 2 x x ANTIVIRALS Ribavirin (Hepatitis C) Ribasphere RibaPak Oral Tablet 400 MG Tier 2 x x ANTIVIRALS Ribavirin (Hepatitis C) Ribasphere RibaPak Oral Tablet 600 MG Tier 2 x x ANTIVIRALS Ribavirin (Hepatitis C) RibaTab Oral Miscellaneous 400 & 600 MG Tier 2 x x ANTIVIRALS Ribavirin (Hepatitis C) RibaTab Oral Tablet 400 MG Tier 2 x x ANTIVIRALS Ribavirin (Hepatitis C) RibaTab Oral Tablet 600 MG Tier 2 x x ANTIVIRALS Ribavirin (Hepatitis C) Ribavirin Oral Capsule 200 MG Tier 1 x ANTIVIRALS Ribavirin (Hepatitis C) Ribavirin Oral Tablet 200 MG Tier 1 x ANALGESICS ‐ ANTI‐INFLAMMATORY Auranofin Ridaura Oral Capsule 3 MG Tier 3 ANTIMYCOBACTERIAL AGENTS Rifabutin Rifabutin Oral Capsule 150 MG Tier 1 ANTIMYCOBACTERIAL AGENTS Rifampin Rifadin Oral Capsule 150 MG Tier 3 ANTIMYCOBACTERIAL AGENTS Rifampin Rifadin Oral Capsule 300 MG Tier 3 ANTIMYCOBACTERIAL AGENTS Isoniazid & Rifampin Rifamate Oral Capsule 150‐300 MG Tier 3 ANTIMYCOBACTERIAL AGENTS Rifampin Rifampin Intravenous Solution Reconstituted 600 MG Tier 1 x ANTIMYCOBACTERIAL AGENTS Rifampin Rifampin Oral Capsule 150 MG Tier 1 ANTIMYCOBACTERIAL AGENTS Rifampin Rifampin Oral Capsule 300 MG Tier 1 ANTIMYCOBACTERIAL AGENTS Rifampin Rifampin Powder Tier 3 ANTIMYCOBACTERIAL AGENTS Isoniazid‐Rifampin w/ Pyrazinamide Rifater Oral Tablet 50‐120‐300 MG Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Rightest GL300 Lancets Miscellaneous Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood Rightest GS100 Blood Glucose In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Rightest GS300 Blood Glucose In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Rightest GS550 Blood Glucose In Vitro Strip Tier 3 NEUROMUSCULAR AGENTS Rilutek Oral Tablet 50 MG Tier 3 x NEUROMUSCULAR AGENTS Riluzole Riluzole Oral Tablet 50 MG Tier 1 x ANTIVIRALS Rimantadine Hydrochloride Rimantadine HCl Oral Tablet 100 MG Tier 1 ANTIDIABETICS Metformin HCl Riomet Oral Solution 500 MG/5ML Tier 3 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Risedronate Sodium Risedronate Sodium Oral Tablet 150 MG Tier 1 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Risedronate Sodium Risedronate Sodium Oral Tablet 30 MG Tier 1 x HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Risedronate Sodium Risedronate Sodium Oral Tablet 35 MG Tier 1 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Risedronate Sodium Risedronate Sodium Oral Tablet 5 MG Tier 1 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Risedronate Sodium Risedronate Sodium Oral Tablet Delayed Release 35 MG Tier 1 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Risperidone Microspheres RisperDAL Consta Intramuscular Suspension Reconstituted 12.5 MG Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Risperidone Microspheres RisperDAL Consta Intramuscular Suspension Reconstituted 25 MG Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Risperidone Microspheres RisperDAL Consta Intramuscular Suspension Reconstituted 37.5 MG Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Risperidone Microspheres RisperDAL Consta Intramuscular Suspension Reconstituted 50 MG Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Risperidone RisperDAL M‐TAB Oral Tablet Dispersible 0.5 MG Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Risperidone RisperDAL M‐TAB Oral Tablet Dispersible 1 MG Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Risperidone RisperDAL M‐TAB Oral Tablet Dispersible 2 MG Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Risperidone RisperDAL M‐TAB Oral Tablet Dispersible 3 MG Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Risperidone RisperDAL M‐TAB Oral Tablet Dispersible 4 MG Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Risperidone RisperDAL Oral Solution 1 MG/ML Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Risperidone RisperDAL Oral Tablet 0.25 MG Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Risperidone RisperDAL Oral Tablet 0.5 MG Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Risperidone RisperDAL Oral Tablet 1 MG Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Risperidone RisperDAL Oral Tablet 2 MG Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Risperidone RisperDAL Oral Tablet 3 MG Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Risperidone RisperDAL Oral Tablet 4 MG Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Risperidone RisperiDONE M‐TAB Oral Tablet Dispersible 0.5 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Risperidone RisperiDONE M‐TAB Oral Tablet Dispersible 1 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Risperidone RisperiDONE M‐TAB Oral Tablet Dispersible 2 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Risperidone RisperiDONE M‐TAB Oral Tablet Dispersible 3 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Risperidone RisperiDONE M‐TAB Oral Tablet Dispersible 4 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Risperidone RisperiDONE Oral Solution 1 MG/ML Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Risperidone RisperiDONE Oral Tablet 0.25 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Risperidone RisperiDONE Oral Tablet 0.5 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Risperidone RisperiDONE Oral Tablet 1 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Risperidone RisperiDONE Oral Tablet 2 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Risperidone RisperiDONE Oral Tablet 3 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Risperidone RisperiDONE Oral Tablet 4 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Risperidone RisperiDONE Oral Tablet Dispersible 0.25 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Risperidone RisperiDONE Oral Tablet Dispersible 0.5 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Risperidone RisperiDONE Oral Tablet Dispersible 1 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Risperidone RisperiDONE Oral Tablet Dispersible 2 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Risperidone RisperiDONE Oral Tablet Dispersible 3 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Risperidone RisperiDONE Oral Tablet Dispersible 4 MG Tier 1 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Ritalin LA Oral Capsule Extended Release 24 Hour 10 MG Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Ritalin LA Oral Capsule Extended Release 24 Hour 20 MG Tier 3 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Ritalin LA Oral Capsule Extended Release 24 Hour 30 MG Tier 3 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Ritalin LA Oral Capsule Extended Release 24 Hour 40 MG Tier 3 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Ritalin LA Oral Capsule Extended Release 24 Hour 60 MG Tier 3 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Ritalin Oral Tablet 10 MG Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Ritalin Oral Tablet 20 MG Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Methylphenidate HCl Ritalin Oral Tablet 5 MG Tier 3 MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers RiteFlo Device Tier 2 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Rivastigmine Tartrate Rivastigmine Tartrate Oral Capsule 1.5 MG Tier 1 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Rivastigmine Tartrate Rivastigmine Tartrate Oral Capsule 3 MG Tier 1 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Rivastigmine Tartrate Rivastigmine Tartrate Oral Capsule 4.5 MG Tier 1 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Rivastigmine Tartrate Rivastigmine Tartrate Oral Capsule 6 MG Tier 1 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Rivastigmine Rivastigmine Transdermal Patch 24 Hour 13.3 MG/24HR Tier 1 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Rivastigmine Rivastigmine Transdermal Patch 24 Hour 4.6 MG/24HR Tier 1 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Rivastigmine Rivastigmine Transdermal Patch 24 Hour 9.5 MG/24HR Tier 1 x MIGRAINE PRODUCTS Rizatriptan Benzoate Rizatriptan Benzoate Oral Tablet 10 MG Tier 1 MIGRAINE PRODUCTS Rizatriptan Benzoate Rizatriptan Benzoate Oral Tablet 5 MG Tier 1 x MIGRAINE PRODUCTS Rizatriptan Benzoate Rizatriptan Benzoate Oral Tablet Dispersible 10 MG Tier 1 x MIGRAINE PRODUCTS Rizatriptan Benzoate Rizatriptan Benzoate Oral Tablet Dispersible 5 MG Tier 1 x MULTIVITAMINS Prenatal w/o Vit A w/ Fe Carbonyl‐Folic Acid‐DHA R‐Natal OB Oral Capsule 20‐1‐320 MG Tier 3 MUSCULOSKELETAL THERAPY AGENTS Methocarbamol Robaxin Injection Solution 1000 MG/10ML Tier 3 x MUSCULOSKELETAL THERAPY AGENTS Methocarbamol Robaxin Oral Tablet 500 MG Tier 3 MUSCULOSKELETAL THERAPY AGENTS Methocarbamol Robaxin‐750 Oral Tablet 750 MG Tier 3 ULCER DRUGS Glycopyrrolate Robinul Injection Solution 0.2 MG/ML Tier 3 x ULCER DRUGS Glycopyrrolate Robinul Injection Solution 0.4 MG/2ML Tier 3 x ULCER DRUGS Glycopyrrolate Robinul Injection Solution 1 MG/5ML Tier 3 x ULCER DRUGS Glycopyrrolate Robinul Injection Solution 4 MG/20ML Tier 3 x ULCER DRUGS Glycopyrrolate Robinul Oral Tablet 1 MG Tier 3 ULCER DRUGS Glycopyrrolate Robinul‐Forte Oral Tablet 2 MG Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Calcitriol Rocaltrol Oral Capsule 0.25 MCG Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Calcitriol Rocaltrol Oral Capsule 0.5 MCG Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Calcitriol Rocaltrol Oral Solution 1 MCG/ML Tier 3 CEPHALOSPORINS Ceftriaxone Sodium Rocephin Injection Solution Reconstituted 1 GM Tier 3 x CEPHALOSPORINS Ceftriaxone Sodium Rocephin Injection Solution Reconstituted 500 MG Tier 3 x NEUROMUSCULAR AGENTS Rocuronium Bromide Rocuronium Bromide Intravenous Solution 100 MG/10ML Tier 1 x NEUROMUSCULAR AGENTS Rocuronium Bromide Rocuronium Bromide Intravenous Solution 50 MG/5ML Tier 1 x ANTIPARKINSON AGENTS Ropinirole Hydrochloride ROPINIRole HCl ER Oral Tablet Extended Release 24 Hour 12 MG Tier 1 x ANTIPARKINSON AGENTS Ropinirole Hydrochloride ROPINIRole HCl ER Oral Tablet Extended Release 24 Hour 2 MG Tier 1 x ANTIPARKINSON AGENTS Ropinirole Hydrochloride ROPINIRole HCl ER Oral Tablet Extended Release 24 Hour 4 MG Tier 1 x ANTIPARKINSON AGENTS Ropinirole Hydrochloride ROPINIRole HCl ER Oral Tablet Extended Release 24 Hour 6 MG Tier 1 x ANTIPARKINSON AGENTS Ropinirole Hydrochloride ROPINIRole HCl ER Oral Tablet Extended Release 24 Hour 8 MG Tier 1 x ANTIPARKINSON AGENTS Ropinirole Hydrochloride ROPINIRole HCl Oral Tablet 0.25 MG Tier 1 ANTIPARKINSON AGENTS Ropinirole Hydrochloride ROPINIRole HCl Oral Tablet 0.5 MG Tier 1 ANTIPARKINSON AGENTS Ropinirole Hydrochloride ROPINIRole HCl Oral Tablet 1 MG Tier 1 ANTIPARKINSON AGENTS Ropinirole Hydrochloride ROPINIRole HCl Oral Tablet 2 MG Tier 1 ANTIPARKINSON AGENTS Ropinirole Hydrochloride ROPINIRole HCl Oral Tablet 3 MG Tier 1 ANTIPARKINSON AGENTS Ropinirole Hydrochloride ROPINIRole HCl Oral Tablet 4 MG Tier 1 ANTIPARKINSON AGENTS Ropinirole Hydrochloride ROPINIRole HCl Oral Tablet 5 MG Tier 1 LOCAL ANESTHETICS‐Parenteral Ropivacaine HCl Ropivacaine HCl Injection Solution 10 MG/ML Tier 1 x LOCAL ANESTHETICS‐Parenteral Ropivacaine HCl Ropivacaine HCl Injection Solution 2 MG/ML Tier 1 x LOCAL ANESTHETICS‐Parenteral Ropivacaine HCl Ropivacaine HCl Injection Solution 5 MG/ML Tier 1 x LOCAL ANESTHETICS‐Parenteral Ropivacaine HCl Ropivacaine HCl Injection Solution 7.5 MG/ML Tier 1 x DERMATOLOGICALS Metronidazole (Topical) Rosadan External Cream 0.75 % Tier 1 DERMATOLOGICALS Metronidazole (Topical) Rosadan External Gel 0.75 % Tier 1 DERMATOLOGICALS Metronidazole w/ Cleanser (Topical) Rosadan External Kit 0.75 % (Cream) Tier 3 DERMATOLOGICALS Metronidazole w/ Cleanser (Topical) Rosadan External Kit 0.75 % (Gel) Tier 3 DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Rosanil Cleanser External Emulsion 10‐5 % Tier 1 x DERMATOLOGICALS Sulfacetamide Sodium‐Sulfur w/ Skin Cleanser Rosanil External Kit 10‐5 % Tier 3 x DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Rosula External Pad 10‐5 % Tier 1 x DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Rosula Wash External Liquid 10‐4.5 % Tier 3 x VACCINES Vaccine, Live Oral Rotarix Oral Suspension Reconstituted Tier 3 VACCINES Rotavirus Vaccine, Live Oral Pentavalent RotaTeq Oral Solution Tier 3 GASTROINTESTINAL AGENTS ‐ MISC. Mesalamine w/ Cleanser Rowasa Rectal Kit 4 GM Tier 3 ANALGESICS ‐ OPIOID Oxycodone w/ Acetaminophen Roxicet Oral Solution 5‐325 MG/5ML Tier 3 x x ANALGESICS ‐ OPIOID Oxycodone w/ Acetaminophen Roxicet Oral Tablet 5‐325 MG Tier 1 x ANALGESICS ‐ OPIOID Oxycodone HCl Roxicodone Oral Tablet 15 MG Tier 3 x x ANALGESICS ‐ OPIOID Oxycodone HCl Roxicodone Oral Tablet 30 MG Tier 3 x x ANALGESICS ‐ OPIOID Oxycodone HCl Roxicodone Oral Tablet 5 MG Tier 3 x x HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Ramelteon Rozerem Oral Tablet 8 MG Tier 3 xx MULTIVITAMINS Prenatal without A w/ Fe Fumarate‐L Methylfolate‐FA‐DHA Rulavite DHA Oral Capsule 27‐0.6‐0.4‐300 MG Tier 2 ANTIARRHYTHMICS Propafenone HCl Rythmol Oral Tablet 150 MG Tier 3 ANTIARRHYTHMICS Propafenone HCl Rythmol Oral Tablet 225 MG Tier 3 ANTIARRHYTHMICS Propafenone HCl Rythmol SR Oral Capsule Extended Release 12 Hour 225 MG Tier 3 ANTIARRHYTHMICS Propafenone HCl Rythmol SR Oral Capsule Extended Release 12 Hour 325 MG Tier 3 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ANTIARRHYTHMICS Propafenone HCl Rythmol SR Oral Capsule Extended Release 12 Hour 425 MG Tier 3 ANTICONVULSANTS Vigabatrin Sabril Oral Packet 500 MG Tier 2 x ANTICONVULSANTS Vigabatrin Sabril Oral Tablet 500 MG Tier 2 x BIOLOGICALS MISC Saccharomyces Cerevisiae Saccharomyces Cerevisiae Subcutaneous Solution 20000 PNU/ML Tier 3 x MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 SafeSnap Insulin Syringe Miscellaneous 28G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 SafeSnap Insulin Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 SafeSnap Insulin Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 SafeSnap Insulin Syringe Miscellaneous 30G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 SafeSnap Insulin Syringe Miscellaneous 30G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Safe‐T‐Lance Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Safe‐T‐Lance Plus Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Safety Lancet 21G/Pressure Act Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Safety Lancet 28G/Pressure Act Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Safety Lancets 21G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Safety Lancets 28G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Safety Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Safety Let Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Safety Seal Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Safety‐Glide Syringe Miscellaneous 29G X 1/2" 0.3 ML Tier 2 CONTRACEPTIVES Drospirenone‐Ethinyl Estradiol‐Levomefolate Calcium Safyral Oral Tablet 3‐0.03‐0.451 MG Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin (Non‐Refrigerated) Saizen Injection Solution Reconstituted 5 MG Tier 2 x DERMATOLOGICALS Salicylic Acid Salacyn External Cream 6 % Tier 1 DERMATOLOGICALS Salicylic Acid Salacyn External Lotion 6 % Tier 1 MOUTH/THROAT/DENTAL AGENTS Pilocarpine HCl (Oral) Salagen Oral Tablet 5 MG Tier 3 MOUTH/THROAT/DENTAL AGENTS Pilocarpine HCl (Oral) Salagen Oral Tablet 7.5 MG Tier 3 MEDICAL DEVICES AND SUPPLIES Feeding Tubes ‐ Tubing Salem Sump Tube 10FR Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Feeding Tubes ‐ Tubing Salem Sump Tube 12FR Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Feeding Tubes ‐ Tubing Salem Sump Tube 14FR Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Feeding Tubes ‐ Tubing Salem Sump Tube 16FR Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Feeding Tubes ‐ Tubing Salem Sump Tube 18FR Miscellaneous Tier 3 DERMATOLOGICALS Salicylic Acid w/ Cleanser Salex External Kit 6 % (Cream) Tier 3 DERMATOLOGICALS Salicylic Acid w/ Cleanser Salex External Kit 6 % (Lotion) Tier 3 DERMATOLOGICALS Salicylic Acid Salex External Shampoo 6 % Tier 3 MOUTH/THROAT/DENTAL AGENTS Oral Wound Care Products SaliCept Mouth/Throat Suspension Reconstituted Tier 3 DERMATOLOGICALS Salicylic Acid Salicylic Acid External Cream 6 % Tier 1 DERMATOLOGICALS Salicylic Acid Salicylic Acid External Foam 6 % Tier 1 DERMATOLOGICALS Salicylic Acid Salicylic Acid External Gel 6 % Tier 1 DERMATOLOGICALS Salicylic Acid Salicylic Acid External Liquid 26 % Tier 3 DERMATOLOGICALS Salicylic Acid Salicylic Acid External Liquid 27.5 % Tier 1 DERMATOLOGICALS Salicylic Acid Salicylic Acid External Lotion 6 % Tier 1 DERMATOLOGICALS Salicylic Acid Salicylic Acid External Shampoo 6 % Tier 1 DERMATOLOGICALS Salicylic Acid Salicylic Acid External Solution 28.5 % Tier 1 DERMATOLOGICALS Salicylic Acid in Ammonium Lactate Vehicle Salicylic Acid in Ammon Lact External Foam 6 % Tier 3 DERMATOLOGICALS Salicylic Acid Salicylic Acid Powder Tier 3 DERMATOLOGICALS Salicylic Acid Salicylic Acid Remover External Liquid 27.5 % Tier 1 DERMATOLOGICALS Salicylic Acid w/ Cleanser Salicylic Acid‐Cleanser External Kit 6 % (Cream) Tier 1 DERMATOLOGICALS Salicylic Acid w/ Cleanser Salicylic Acid‐Cleanser External Kit 6 % (Lotion) Tier 1 MINERALS & ELECTROLYTES Sodium Chloride Flush Saline Flush Intravenous Solution 0.9 % Tier 1 x MINERALS & ELECTROLYTES Sodium Chloride Flush Saline Flush ZR Intravenous Solution 0.9 % Tier 1 x PHARMACEUTICAL ADJUVANTS Saline w/ Benzyl Alcohol Saline‐Benzyl Alcohol Injection Solution 0.9 % Tier 3 x DERMATOLOGICALS Salicylic Acid in Ammonium Lactate Vehicle Salkera External Foam 6 % Tier 3 ANALGESICS ‐ NonNarcotic Salsalate Salsalate Oral Tablet 500 MG Tier 1 ANALGESICS ‐ NonNarcotic Salsalate Salsalate Oral Tablet 750 MG Tier 1 DERMATOLOGICALS Salicylic Acid & Urea in Lactic Acid Vehicle Salvax Duo Plus External Kit 6 & 35 % Tier 3 DERMATOLOGICALS Salicylic Acid Salvax External Foam 6 % Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Tolvaptan Samsca Oral Tablet 15 MG Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Tolvaptan Samsca Oral Tablet 30 MG Tier 2 x DERMATOLOGICALS Triamcinolone Acetonide‐Dimethicone‐Silicone SanaDermRx Skin Repair External Kit 0.1 & 5 % Tier 3 ANTIEMETICS Granisetron Sancuso Transdermal Patch 3.1 MG/24HR Tier 3 x ASSORTED CLASSES Cyclosporine SandIMMUNE Intravenous Solution 50 MG/ML Tier 2 x ASSORTED CLASSES Cyclosporine SandIMMUNE Oral Capsule 100 MG Tier 3 ASSORTED CLASSES Cyclosporine SandIMMUNE Oral Capsule 25 MG Tier 3 ASSORTED CLASSES Cyclosporine SandIMMUNE Oral Solution 100 MG/ML Tier 2 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Octreotide Acetate SandoSTATIN Injection Solution 100 MCG/ML Tier 3 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Octreotide Acetate SandoSTATIN Injection Solution 1000 MCG/ML Tier 3 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Octreotide Acetate SandoSTATIN Injection Solution 200 MCG/ML Tier 3 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Octreotide Acetate SandoSTATIN Injection Solution 50 MCG/ML Tier 3 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Octreotide Acetate SandoSTATIN Injection Solution 500 MCG/ML Tier 3 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Octreotide Acetate SandoSTATIN LAR Depot Intramuscular Kit 10 MG Tier 3 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Octreotide Acetate SandoSTATIN LAR Depot Intramuscular Kit 20 MG Tier 3 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Octreotide Acetate SandoSTATIN LAR Depot Intramuscular Kit 30 MG Tier 3 x DERMATOLOGICALS Collagenase Santyl External Ointment 250 UNIT/GM Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Asenapine Maleate Saphris Sublingual Tablet Sublingual 10 MG Tier 2 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Asenapine Maleate Saphris Sublingual Tablet Sublingual 2.5 MG Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Asenapine Maleate Saphris Sublingual Tablet Sublingual 5 MG Tier 2 xx MEDICAL DEVICES AND SUPPLIES Lancets SAPScare Twist Top Lancets Miscellaneous Tier 2 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Fluoxetine HCl (PMDD) Sarafem Oral Tablet 10 MG Tier 3 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Fluoxetine HCl (PMDD) Sarafem Oral Tablet 20 MG Tier 3 ANTICOAGULANTS Heparin Sodium (Porcine) Lock Flush & NaCl Lock Flush Sash Kit Intravenous Kit 100‐0.9 UNIT/ML‐% Tier 1 x ANTICOAGULANTS Edoxaban Tosylate Savaysa Oral Tablet 15 MG Tier 3 x ANTICOAGULANTS Edoxaban Tosylate Savaysa Oral Tablet 30 MG Tier 3 x ANTICOAGULANTS Edoxaban Tosylate Savaysa Oral Tablet 60 MG Tier 3 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. HCl Savella Oral Tablet 100 MG Tier 3 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Milnacipran HCl Savella Oral Tablet 12.5 MG Tier 3 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Milnacipran HCl Savella Oral Tablet 25 MG Tier 3 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Milnacipran HCl Savella Oral Tablet 50 MG Tier 3 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Milnacipran HCl Savella Titration Pack Oral Miscellaneous 12.5 & 25 & 50 MG Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Liraglutide (Weight Management) Saxenda Subcutaneous Solution Pen‐injector 18 MG/3ML Tier 3 x x MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 SB Insulin Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 SB Insulin Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 SB Insulin Syringe Miscellaneous 30G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 SB Insulin Syringe Miscellaneous 30G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 SB Insulin Syringe Miscellaneous 31G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets SB Lancets Thin Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets SB Lancets Ultra Thin Miscellaneous Tier 2 DERMATOLOGICALS Hydrocortisone & Salicylic Acid‐Sulfur & Shampoo Scalacort DK External Kit 2 & 2‐2 % Tier 3 DERMATOLOGICALS Hydrocortisone (Topical) Scalacort External Lotion 2 % Tier 1 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Schnucks Insulin Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Schnucks Insulin Syringe Miscellaneous 30G X 5/16" 0.5 ML Tier 2 ULCER DRUGS Scopolamine HBr Scopolamine HBr Powder Tier 3 CONTRACEPTIVES Levonorgestrel‐Ethinyl Estradiol (91‐Day) Seasonique Oral Tablet 0.15‐0.03 &0.01 MG Tier 3 DERMATOLOGICALS Sulfacetamide Sodium Seb‐Prev Wash External Liquid 10 % Tier 1 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Secobarbital Sodium Seconal Oral Capsule 100 MG Tier 3 BETA BLOCKERS Acebutolol HCl Sectral Oral Capsule 200 MG Tier 3 BETA BLOCKERS Acebutolol HCl Sectral Oral Capsule 400 MG Tier 3 MULTIVITAMINS Prenatal Vit w/ Iron Polysaccharide Cmplx‐L Methylfolate‐FA Select‐OB Oral Tablet Chewable 29‐0.6‐0.4 MG Tier 3 MULTIVITAMINS Prenatal Vit w/ Iron Polysaccharide Complex‐Folic Acid Select‐OB Oral Tablet Chewable 29‐1 MG Tier 2 MULTIVITAMINS Prenatal MV & Min w/Fe Polysaccharide Complex‐FA‐DHA Select‐OB+DHA Oral Miscellaneous 29‐1 & 250 MG Tier 3 ANTIPARKINSON AGENTS Selegiline HCl Selegiline HCl Oral Capsule 5 MG Tier 1 ANTIPARKINSON AGENTS Selegiline HCl Selegiline HCl Oral Tablet 5 MG Tier 1 ANTIPARKINSON AGENTS Selegiline HCl Selegiline HCl Powder Tier 3 DERMATOLOGICALS Selenium Sulfide Selenium Sulfide External Lotion 2.5 % Tier 1 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

DERMATOLOGICALS Selenium Sulfide‐Pyrithione Zinc in Urea Vehicle Selenium Sulfide External Shampoo 2.25 % Tier 1 DERMATOLOGICALS Selenium Sulfide‐Pyrithione Zinc in Urea Vehicle Selenium Sulf‐Pyrithione‐Urea External Shampoo 2.25 % Tier 1 DERMATOLOGICALS Selenium Sulfide‐Pyrithione Zinc in Urea Vehicle SelRx External Shampoo 2.3 % Tier 3 ANTIVIRALS Maraviroc Selzentry Oral Tablet 150 MG Tier 2 x ANTIVIRALS Maraviroc Selzentry Oral Tablet 300 MG Tier 2 x MULTIVITAMINS Prenatal Vit w/ Docusate‐Fe Fumarate‐Folic Acid Se‐Natal 19 Oral Tablet 29‐1 MG Tier 2 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐Folic Acid Se‐Natal 19 Oral Tablet Chewable 29‐1 MG Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Cinacalcet HCl Sensipar Oral Tablet 30 MG Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Cinacalcet HCl Sensipar Oral Tablet 60 MG Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Cinacalcet HCl Sensipar Oral Tablet 90 MG Tier 3 LOCAL ANESTHETICS‐Parenteral Bupivacaine HCl Sensorcaine‐MPF Injection Solution 0.25 % Tier 1 x LOCAL ANESTHETICS‐Parenteral Bupivacaine HCl Sensorcaine‐MPF Injection Solution 0.5 % Tier 1 x LOCAL ANESTHETICS‐Parenteral Bupivacaine HCl Sensorcaine‐MPF Injection Solution 0.75 % Tier 1 x LOCAL ANESTHETICS‐Parenteral Bupivacaine w/ Epinephrine Sensorcaine‐MPF/Epinephrine Injection Solution 0.25% ‐1:200000 Tier 1 x LOCAL ANESTHETICS‐Parenteral Bupivacaine w/ Epinephrine Sensorcaine‐MPF/Epinephrine Injection Solution 0.5% ‐1:200000 Tier 1 x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Salmeterol Xinafoate Serevent Diskus Inhalation Aerosol Powder Breath Activated 50 MCG/DOSE Tier 2 x ANTIMYCOBACTERIAL AGENTS Cycloserine Seromycin Oral Capsule 250 MG Tier 2 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Clomiphene Citrate Serophene Oral Tablet 50 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Quetiapine Fumarate SEROquel Oral Tablet 100 MG Tier 3 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Quetiapine Fumarate SEROquel Oral Tablet 200 MG Tier 3 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Quetiapine Fumarate SEROquel Oral Tablet 25 MG Tier 3 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Quetiapine Fumarate SEROquel Oral Tablet 300 MG Tier 3 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Quetiapine Fumarate SEROquel Oral Tablet 400 MG Tier 3 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Quetiapine Fumarate SEROquel Oral Tablet 50 MG Tier 3 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Quetiapine Fumarate SEROquel XR Oral Tablet Extended Release 24 Hour 150 MG Tier 2 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Quetiapine Fumarate SEROquel XR Oral Tablet Extended Release 24 Hour 200 MG Tier 2 ANTIPSYCHOTICS/ANTIMANIC AGENTS Quetiapine Fumarate SEROquel XR Oral Tablet Extended Release 24 Hour 300 MG Tier 2 ANTIPSYCHOTICS/ANTIMANIC AGENTS Quetiapine Fumarate SEROquel XR Oral Tablet Extended Release 24 Hour 400 MG Tier 2 ANTIPSYCHOTICS/ANTIMANIC AGENTS Quetiapine Fumarate SEROquel XR Oral Tablet Extended Release 24 Hour 50 MG Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin (Non‐Refrigerated) Serostim Subcutaneous Solution Reconstituted 4 MG Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin (Non‐Refrigerated) Serostim Subcutaneous Solution Reconstituted 5 MG Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin (Non‐Refrigerated) Serostim Subcutaneous Solution Reconstituted 6 MG Tier 2 x ANTIDEPRESSANTS Sertraline HCl Sertraline HCl Oral Concentrate 20 MG/ML Tier 1 ANTIDEPRESSANTS Sertraline HCl Sertraline HCl Oral Tablet 100 MG Tier 1 ANTIDEPRESSANTS Sertraline HCl Sertraline HCl Oral Tablet 25 MG Tier 1 ANTIDEPRESSANTS Sertraline HCl Sertraline HCl Oral Tablet 50 MG Tier 1 MULTIVITAMINS Prenatal Vit w/ Fe Fum‐Iron Polysacch Complex ‐FA‐Omega 3Se‐Tan DHA Oral Capsule 15‐15‐1 MG Tier 2 HEMATOPOIETIC AGENTS Fe Fum‐Iron Polysacch Complex‐FA‐B Complex‐C‐Zn‐Mn‐Cu Se‐Tan PLUS Oral Capsule 162‐115.2‐1 MG Tier 1 CONTRACEPTIVES Levonorgestrel‐Ethinyl Estradiol (91‐Day) Setlakin Oral Tablet 0.15‐0.03 MG Tier 1 GENERAL ANESTHETICS Sevoflurane Inhalation Solution Tier 1 GASTROINTESTINAL AGENTS ‐ MISC. Mesalamine SfRowasa Rectal Enema 4 GM/60ML Tier 2 x CONTRACEPTIVES Norethindrone (Contraceptive) Sharobel Oral Tablet 0.35 MG Tier 1 GENITOURINARY AGENTS ‐ MISCELLANEOUS Sodium Citrate & Citric Acid Shohls Modified Oral Solution 500‐334 MG/5ML Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Shopko On‐the‐Go Lancets 30G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Shopko Unifine Pentips Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Shopko Unifine Pentips Miscellaneous 31G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Shopko Unifine Pentips Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Shopko Unifine Pentips Miscellaneous 32G X 4 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Shopko Unilet Lancets 28G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Shopko Unilet Lancets 30G Miscellaneous Tier 2 MULTIVITAMINS Multiple Vitamins w/ Minerals Siderol Oral Tablet Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Pasireotide Pamoate Signifor LAR Intramuscular Suspension Reconstituted 20 MG Tier 2 x x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Pasireotide Pamoate Signifor LAR Intramuscular Suspension Reconstituted 40 MG Tier 2 x x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Pasireotide Pamoate Signifor LAR Intramuscular Suspension Reconstituted 60 MG Tier 2 x x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Pasireotide Diaspartate Signifor Subcutaneous Solution 0.3 MG/ML Tier 2 x x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Pasireotide Diaspartate Signifor Subcutaneous Solution 0.6 MG/ML Tier 2 x x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Pasireotide Diaspartate Signifor Subcutaneous Solution 0.9 MG/ML Tier 2 x x DERMATOLOGICALS Triamcinolone Acetonide‐Silicone Silazone PharmaPak External Therapy Pack 0.1 % Tier 3 DERMATOLOGICALS Triamcinolone Acetonide‐Silicone Silazone‐II External Therapy Pack 0.1 % Tier 3 CARDIOVASCULAR AGENTS ‐ MISC. Sildenafil Citrate (Pulmonary Hypertension) Sildenafil Citrate Oral Tablet 20 MG Tier 1 x HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Doxepin HCl (Sleep) Silenor Oral Tablet 3 MG Tier 3 xx HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Doxepin HCl (Sleep) Silenor Oral Tablet 6 MG Tier 3 xx DERMATOLOGICALS Capsaicin‐Menthol‐ Silmanix Pain Relieiving External Cream 0.0375‐3‐0.035 % Tier 3 DERMATOLOGICALS Silver Sulfadiazine Silvadene External Cream 1 % Tier 3 DERMATOLOGICALS Silver Nitrate Silver Nitrate External Ointment 10 % Tier 3 DERMATOLOGICALS Silver Nitrate Silver Nitrate External Solution 0.5 % Tier 3 DERMATOLOGICALS Silver Nitrate Silver Nitrate External Solution 10 % Tier 3 DERMATOLOGICALS Silver Nitrate Silver Nitrate External Solution 25 % Tier 3 DERMATOLOGICALS Silver Nitrate Silver Nitrate External Solution 50 % Tier 3 ANTISEPTICS & DISINFECTANTS Silver Protein Mild Silver Protein Mild Powder Tier 3 DERMATOLOGICALS Silver Sulfadiazine Silver Sulfadiazine External Cream 1 % Tier 1 DERMATOLOGICALS Capsaicin‐Lidocaine‐Menthol Silvera Pain Relief External Patch 0.0375‐1‐5 % Tier 3 DERMATOLOGICALS Silver Silverseal Hydrogel Dressing External Pad 2"X3" Tier 3 DERMATOLOGICALS Silver Silverseal Hydrogel Dressing External Pad 4"X5" Tier 3 DERMATOLOGICALS Silver SilvrSTAT Wound Dressing External Gel Tier 3 OPHTHALMIC AGENTS Brinzolamide‐Brimonidine Tartrate Simbrinza Ophthalmic Suspension 1‐0.2 % Tier 3 x ANTIHYPERLIPIDEMICS Niacin‐Simvastatin Simcor Oral Tablet Extended Release 24 Hour 1000‐20 MG Tier 2 x ANTIHYPERLIPIDEMICS Niacin‐Simvastatin Simcor Oral Tablet Extended Release 24 Hour 1000‐40 MG Tier 2 x ANTIHYPERLIPIDEMICS Niacin‐Simvastatin Simcor Oral Tablet Extended Release 24 Hour 500‐20 MG Tier 2 x ANTIHYPERLIPIDEMICS Niacin‐Simvastatin Simcor Oral Tablet Extended Release 24 Hour 500‐40 MG Tier 2 x ANTIHYPERLIPIDEMICS Niacin‐Simvastatin Simcor Oral Tablet Extended Release 24 Hour 750‐20 MG Tier 2 x MEDICAL DEVICES AND SUPPLIES Lancet Devices Simple Diagnostics Lancing Dev Miscellaneous Tier 2 ANALGESICS ‐ ANTI‐INFLAMMATORY Golimumab Simponi Subcutaneous Solution Auto‐injector 100 MG/ML Tier 2 x ANALGESICS ‐ ANTI‐INFLAMMATORY Golimumab Simponi Subcutaneous Solution Auto‐injector 50 MG/0.5ML Tier 2 x ANALGESICS ‐ ANTI‐INFLAMMATORY Golimumab Simponi Subcutaneous Solution Prefilled Syringe 100 MG/ML Tier 2 x ANALGESICS ‐ ANTI‐INFLAMMATORY Golimumab Simponi Subcutaneous Solution Prefilled Syringe 50 MG/0.5ML Tier 2 x ANTIHYPERLIPIDEMICS Simvastatin Simvastatin Oral Tablet 10 MG Tier 1 ANTIHYPERLIPIDEMICS Simvastatin Simvastatin Oral Tablet 20 MG Tier 1 ANTIHYPERLIPIDEMICS Simvastatin Simvastatin Oral Tablet 40 MG Tier 1 ANTIHYPERLIPIDEMICS Simvastatin Simvastatin Oral Tablet 5 MG Tier 1 ANTIHYPERLIPIDEMICS Simvastatin Simvastatin Oral Tablet 80 MG Tier 1 x ANTIPARKINSON AGENTS Carbidopa‐Levodopa Sinemet CR Oral Tablet Extended Release 25‐100 MG Tier 3 x ANTIPARKINSON AGENTS Carbidopa‐Levodopa Sinemet CR Oral Tablet Extended Release 50‐200 MG Tier 3 x ANTIPARKINSON AGENTS Carbidopa‐Levodopa Sinemet Oral Tablet 10‐100 MG Tier 3 x ANTIPARKINSON AGENTS Carbidopa‐Levodopa Sinemet Oral Tablet 25‐100 MG Tier 3 x ANTIPARKINSON AGENTS Carbidopa‐Levodopa Sinemet Oral Tablet 25‐250 MG Tier 3 x MEDICAL DEVICES AND SUPPLIES Lancets Single‐Let Miscellaneous Tier 2 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Montelukast Sodium Singulair Oral Packet 4 MG Tier 3 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Montelukast Sodium Singulair Oral Tablet 10 MG Tier 3 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Montelukast Sodium Singulair Oral Tablet Chewable 4 MG Tier 3 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Montelukast Sodium Singulair Oral Tablet Chewable 5 MG Tier 3 ASSORTED CLASSES Sirolimus Sirolimus Oral Tablet 0.5 MG Tier 1 ASSORTED CLASSES Sirolimus Sirolimus Oral Tablet 1 MG Tier 1 ASSORTED CLASSES Sirolimus Sirolimus Oral Tablet 2 MG Tier 1 ANTIMYCOBACTERIAL AGENTS Bedaquiline Fumarate Sirturo Oral Tablet 100 MG Tier 3 ANTIVIRALS Acyclovir Sitavig Buccal Tablet 50 MG Tier 3 x ANTI‐INFECTIVE AGENTS ‐ MISC. Tedizolid Phosphate Sivextro Oral Tablet 200 MG Tier 3 MUSCULOSKELETAL THERAPY AGENTS Metaxalone Skelaxin Oral Tablet 800 MG Tier 3 DERMATOLOGICALS Ivermectin (Pediculicide) Sklice External Lotion 0.5 % Tier 3 MULTIVITAMINS B‐Complex w/ C & Folic Acid SM B‐Complex/Vitamin C Oral Tablet Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 SM Insulin Syringe Miscellaneous 31G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets SM Lancets 33G Miscellaneous Tier 2 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

MEDICAL DEVICES AND SUPPLIES Lancets Smart Sense Color Lancets 33G Miscellaneous Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood Smart Sense Premium Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Smart Sense Standard Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Smart Sense Super Thin Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Smart Sense Thin Lancets 26G Miscellaneous Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood Smart Sense Value Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Smartest Blood Glucose Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Smartest Lancets 28G Miscellaneous Tier 2 ANTI‐INFECTIVE AGENTS ‐ MISC. Sulfamethoxazole‐Trimethoprim SMZ‐TMP DS Oral Tablet 800‐160 MG Tier 1 GENITOURINARY AGENTS ‐ MISCELLANEOUS Sodium Citrate & Citric Acid Sod Citrate‐Citric Acid Oral Solution 500‐334 MG/5ML Tier 1 MINERALS & ELECTROLYTES Sodium Acetate Sodium Acetate Granules Tier 3 MINERALS & ELECTROLYTES Sodium Acetate Sodium Acetate Intravenous Solution 2 MEQ/ML Tier 1 x MINERALS & ELECTROLYTES Sodium Acetate Sodium Acetate Intravenous Solution 4 MEQ/ML Tier 1 x MINERALS & ELECTROLYTES Sodium Acetate Sodium Acetate Powder Tier 3 VITAMINS Sodium Ascorbate Sodium Ascorbate Granules Tier 3 VITAMINS Sodium Ascorbate Sodium Ascorbate Powder Tier 3 PHARMACEUTICAL ADJUVANTS Sodium Benzoate Powder Tier 3 MINERALS & ELECTROLYTES Sodium Bicarbonate Sodium Bicarbonate Intravenous Solution 4.2 % Tier 1 x MINERALS & ELECTROLYTES Sodium Bicarbonate Sodium Bicarbonate Intravenous Solution 7.5 % Tier 1 x MINERALS & ELECTROLYTES Sodium Bicarbonate Sodium Bicarbonate Intravenous Solution 8.4 % Tier 1 x ANTACIDS Sodium Bicarbonate (Antacid) Sodium Bicarbonate Oral Powder Tier 3 CHEMICALS Sodium Bisulfite Sodium Bisulfite Granules Tier 3 CHEMICALS Sodium Bromide Sodium Bromide Granules Tier 3 PHARMACEUTICAL ADJUVANTS Saline, Bacteriostatic Sodium Chloride Bacteriostatic Injection Solution 0.9 % Tier 1 x MINERALS & ELECTROLYTES Sodium Chloride Flush Sodium Chloride Flush Intravenous Solution 0.9 % Tier 1 x MINERALS & ELECTROLYTES Sodium Chloride Sodium Chloride Granules Tier 3 COUGH/COLD/ALLERGY Sodium Chloride (Inhalant) Sodium Chloride Inhalation Nebulization Solution 0.9 % Tier 1 COUGH/COLD/ALLERGY Sodium Chloride (Inhalant) Sodium Chloride Inhalation Nebulization Solution 10 % Tier 1 COUGH/COLD/ALLERGY Sodium Chloride (Inhalant) Sodium Chloride Inhalation Nebulization Solution 3 % Tier 1 COUGH/COLD/ALLERGY Sodium Chloride (Inhalant) Sodium Chloride Inhalation Nebulization Solution 7 % Tier 1 MINERALS & ELECTROLYTES Sodium Chloride Sodium Chloride Injection Solution 0.9 % Tier 1 x MINERALS & ELECTROLYTES Sodium Chloride Sodium Chloride Injection Solution 2.5 MEQ/ML Tier 1 x MINERALS & ELECTROLYTES Sodium Chloride Sodium Chloride Intravenous Solution 0.45 % Tier 1 x MINERALS & ELECTROLYTES Sodium Chloride Sodium Chloride Intravenous Solution 0.9 % Tier 1 x MINERALS & ELECTROLYTES Sodium Chloride Sodium Chloride Intravenous Solution 3 % Tier 1 x MINERALS & ELECTROLYTES Sodium Chloride Sodium Chloride Intravenous Solution 4 MEQ/ML Tier 1 x MINERALS & ELECTROLYTES Sodium Chloride Sodium Chloride Intravenous Solution 4 MEQ/ML Tier 3 x MINERALS & ELECTROLYTES Sodium Chloride Sodium Chloride Intravenous Solution 5 % Tier 1 x GENITOURINARY AGENTS ‐ MISCELLANEOUS Sodium Chloride (GU Irrigant) Sodium Chloride Irrigation Solution 0.9 % Tier 1 MINERALS & ELECTROLYTES Sodium Chloride Sodium Chloride Powder Tier 3 GENITOURINARY AGENTS ‐ MISCELLANEOUS Sodium Citrate Sodium Citrate Anhydrous Powder Tier 3 MINERALS & ELECTROLYTES Sodium Fluoride Sodium Fluoride Oral Solution 1.1 (0.5 F) MG/ML Tier 1 MINERALS & ELECTROLYTES Sodium Fluoride Sodium Fluoride Oral Tablet 1.1 (0.5 F) MG Tier 3 MINERALS & ELECTROLYTES Sodium Fluoride Sodium Fluoride Oral Tablet 2.2 (1 F) MG Tier 3 MINERALS & ELECTROLYTES Sodium Fluoride Sodium Fluoride Oral Tablet Chewable 0.55 (0.25 F) MG Tier 1 MINERALS & ELECTROLYTES Sodium Fluoride Sodium Fluoride Oral Tablet Chewable 1.1 (0.5 F) MG Tier 1 MINERALS & ELECTROLYTES Sodium Fluoride Sodium Fluoride Oral Tablet Chewable 2.2 (1 F) MG Tier 1 DERMATOLOGICALS Hyaluronate Sodium (Emollient) Sodium Hyaluronate External Gel 0.2 % Tier 1 CHEMICALS Sodium Hydroxide External Solution 10 % Tier 3 CHEMICALS Sodium Hydroxide Sodium Hydroxide Pellet Tier 3 PHARMACEUTICAL ADJUVANTS Sodium Lauryl Sulfate Sodium Lauryl Sulfate Powder Tier 3 CHEMICALS Sodium Metabisulfite Sodium Metabisulfite Granules Tier 3 CHEMICALS Sodium Metabisulfite Sodium Metabisulfite Powder Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Sodium Phenylbutyrate Sodium Phenylbutyrate Oral Powder 3 GM/TSP Tier 1 MINERALS & ELECTROLYTES Sodium Phosphate Sodium Phosphate Intravenous Solution 3 MMOLE/ML Tier 1 x ASSORTED CLASSES Sodium Polystyrene Sulfonate Sodium Polystyrene Sulfonate Oral Powder Tier 1 ASSORTED CLASSES Sodium Polystyrene Sulfonate Sodium Polystyrene Sulfonate Oral Suspension 15 GM/60ML Tier 1 ASSORTED CLASSES Sodium Polystyrene Sulfonate Sodium Polystyrene Sulfonate Rectal Suspension 30 GM/120ML Tier 1 ASSORTED CLASSES Sodium Polystyrene Sulfonate Sodium Polystyrene Sulfonate Rectal Suspension 50 GM/200ML Tier 1 ANALGESICS ‐ NonNarcotic Sodium Salicylate Sodium Salicylate Powder Tier 3 DERMATOLOGICALS Sulfacetamide Sodium Sodium Sulfacetamide External Shampoo 10 % Tier 1 DERMATOLOGICALS Sulfacetamide Sodium in Bakuchiol Vehicle Sodium Sulfacetamide Wash External Liquid 10 % Tier 3 MEDICAL DEVICES AND SUPPLIES Continuous Blood Glucose Monitor Supplies Sof‐Sensor Miscellaneous Tier 3 GENERAL ANESTHETICS Sevoflurane Sojourn Inhalation Solution Tier 1 DERMATOLOGICALS Capsaicin‐Menthol Solaice External Patch 0.05‐5 % Tier 3 DERMATOLOGICALS Diclofenac Sodium (Actinic Keratoses) Solaraze Transdermal Gel 3 % Tier 3 CONTRACEPTIVES Desogestrel & Ethinyl Estradiol Solia Oral Tablet 0.15‐30 MG‐MCG Tier 1 TETRACYCLINES Minocycline HCl Solodyn Oral Tablet Extended Release 24 Hour 105 MG Tier 3 x TETRACYCLINES Minocycline HCl Solodyn Oral Tablet Extended Release 24 Hour 115 MG Tier 3 x TETRACYCLINES Minocycline HCl Solodyn Oral Tablet Extended Release 24 Hour 55 MG Tier 3 x TETRACYCLINES Minocycline HCl Solodyn Oral Tablet Extended Release 24 Hour 65 MG Tier 3 x TETRACYCLINES Minocycline HCl Solodyn Oral Tablet Extended Release 24 Hour 80 MG Tier 3 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Tamoxifen Citrate Soltamox Oral Solution 10 MG/5ML Tier 3 CORTICOSTEROIDS Hydrocortisone Sod Succinate Solu‐CORTEF Injection Solution Reconstituted 100 MG Tier 3 x CORTICOSTEROIDS Hydrocortisone Sod Succinate Solu‐CORTEF Injection Solution Reconstituted 250 MG Tier 3 x CORTICOSTEROIDS Methylprednisolone Sod Succ Solu‐MEDROL Injection Solution Reconstituted 1000 MG Tier 3 x CORTICOSTEROIDS Methylprednisolone Sod Succ Solu‐MEDROL Injection Solution Reconstituted 125 MG Tier 3 x CORTICOSTEROIDS Methylprednisolone Sod Succ Solu‐MEDROL Injection Solution Reconstituted 40 MG Tier 3 x CORTICOSTEROIDS Methylprednisolone Sod Succ Solu‐MEDROL Injection Solution Reconstituted 500 MG Tier 3 x MEDICAL DEVICES AND SUPPLIES Lancets Solus V2 Lancets 28G Miscellaneous Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood Solus V2 Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Solus V2 Twist Lancets 30G Miscellaneous Tier 2 MUSCULOSKELETAL THERAPY AGENTS Carisoprodol Soma Oral Tablet 250 MG Tier 3 MUSCULOSKELETAL THERAPY AGENTS Carisoprodol Soma Oral Tablet 350 MG Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Lanreotide Acetate Somatuline Depot Subcutaneous Solution 120 MG/0.5ML Tier 2 x x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Lanreotide Acetate Somatuline Depot Subcutaneous Solution 60 MG/0.2ML Tier 2 x x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Lanreotide Acetate Somatuline Depot Subcutaneous Solution 90 MG/0.3ML Tier 2 x x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Pegvisomant Somavert Subcutaneous Solution Reconstituted 10 MG Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Pegvisomant Somavert Subcutaneous Solution Reconstituted 15 MG Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Pegvisomant Somavert Subcutaneous Solution Reconstituted 20 MG Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Pegvisomant Somavert Subcutaneous Solution Reconstituted 25 MG Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Pegvisomant Somavert Subcutaneous Solution Reconstituted 30 MG Tier 2 x HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Zaleplon Sonata Oral Capsule 10 MG Tier 3 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Zaleplon Sonata Oral Capsule 5 MG Tier 3 DERMATOLOGICALS Ivermectin (Rosacea) Soolantra External Cream 1 % Tier 3 DERMATOLOGICALS Lidocaine‐Capsaicin‐Menthol‐Methyl Salicylate Soothee External Patch 0.5‐0.0375‐5‐2 % Tier 3 PHARMACEUTICAL ADJUVANTS Sorbic Acid Sorbic Acid Powder Tier 3 DERMATOLOGICALS Acitretin Soriatane Oral Capsule 10 MG Tier 3 DERMATOLOGICALS Acitretin Soriatane Oral Capsule 17.5 MG Tier 3 DERMATOLOGICALS Acitretin Soriatane Oral Capsule 25 MG Tier 3 DERMATOLOGICALS Calcipotriene Sorilux External Foam 0.005 % Tier 3 BETA BLOCKERS Sotalol HCl Sorine Oral Tablet 120 MG Tier 1 BETA BLOCKERS Sotalol HCl Sorine Oral Tablet 160 MG Tier 1 BETA BLOCKERS Sotalol HCl Sorine Oral Tablet 240 MG Tier 1 BETA BLOCKERS Sotalol HCl Sorine Oral Tablet 80 MG Tier 1 BETA BLOCKERS Sotalol HCl (AFIB/AFL) Sotalol HCl (AF) Oral Tablet 120 MG Tier 1 BETA BLOCKERS Sotalol HCl (AFIB/AFL) Sotalol HCl (AF) Oral Tablet 160 MG Tier 1 BETA BLOCKERS Sotalol HCl (AFIB/AFL) Sotalol HCl (AF) Oral Tablet 80 MG Tier 1 BETA BLOCKERS Sotalol HCl Sotalol HCl Oral Tablet 120 MG Tier 1 BETA BLOCKERS Sotalol HCl Sotalol HCl Oral Tablet 160 MG Tier 1 BETA BLOCKERS Sotalol HCl Sotalol HCl Oral Tablet 240 MG Tier 1 BETA BLOCKERS Sotalol HCl Sotalol HCl Oral Tablet 80 MG Tier 1 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ASSORTED CLASSES Sodium Tetradecyl Sulfate Sotradecol Intravenous Solution 1 % Tier 3 x ASSORTED CLASSES Sodium Tetradecyl Sulfate Sotradecol Intravenous Solution 3 % Tier 3 x BETA BLOCKERS Sotalol HCl Sotylize Oral Solution 5 MG/ML Tier 3 ANTIVIRALS Sofosbuvir Sovaldi Oral Tablet 400 MG Tier 2 x x CHEMICALS Spearmint Oil Spearmint Oil Oil Tier 3 CEPHALOSPORINS Cefditoren Pivoxil Spectracef Oral Tablet 200 MG Tier 3 CEPHALOSPORINS Cefditoren Pivoxil Spectracef Oral Tablet 400 MG Tier 3 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Tiotropium Bromide Monohydrate Spiriva HandiHaler Inhalation Capsule 18 MCG Tier 2 x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Tiotropium Bromide Monohydrate Spiriva Respimat Inhalation Aerosol Solution 1.25 MCG/ACT Tier 2 x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Tiotropium Bromide Monohydrate Spiriva Respimat Inhalation Aerosol Solution 2.5 MCG/ACT Tier 2 x DIURETICS Spironolactone Spironolactone Oral Tablet 100 MG Tier 1 DIURETICS Spironolactone Spironolactone Oral Tablet 25 MG Tier 1 DIURETICS Spironolactone Spironolactone Oral Tablet 50 MG Tier 1 DIURETICS Spironolactone Spironolactone Powder Tier 3 DIURETICS Spironolactone & Hydrochlorothiazide Spironolactone‐HCTZ Oral Tablet 25‐25 MG Tier 1 ANTIFUNGALS Itraconazole Sporanox Oral Capsule 100 MG Tier 3 x ANTIFUNGALS Itraconazole Sporanox Oral Solution 10 MG/ML Tier 3 x ANTIFUNGALS Itraconazole Sporanox Pulsepak Oral Capsule 100 MG Tier 3 x CONTRACEPTIVES Norgestimate‐Ethinyl Estradiol Sprintec 28 Oral Tablet 0.25‐35 MG‐MCG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Ketorolac Tromethamine Sprix Nasal Solution 15.75 MG/SPRAY Tier 3 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Dasatinib Sprycel Oral Tablet 100 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Dasatinib Sprycel Oral Tablet 140 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Dasatinib Sprycel Oral Tablet 20 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Dasatinib Sprycel Oral Tablet 50 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Dasatinib Sprycel Oral Tablet 70 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Dasatinib Sprycel Oral Tablet 80 MG Tier 2 x x ASSORTED CLASSES Sodium Polystyrene Sulfonate SPS Oral Suspension 15 GM/60ML Tier 1 CONTRACEPTIVES Levonorgestrel & Eth Estradiol Sronyx Oral Tablet 0.1‐20 MG‐MCG Tier 1 DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur SS 10‐2 External Solution 10‐2 % Tier 1 DERMATOLOGICALS Silver Sulfadiazine SSD External Cream 1 % Tier 1 MINERALS & ELECTROLYTES Potassium Iodide SSKI Oral Solution 1 GM/ML Tier 2 DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur SSS 10‐5 External Cream 10‐5 % Tier 1 DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur SSS 10‐5 External Foam 10‐5 % Tier 1 ANTIPARKINSON AGENTS Carbidopa‐Levodopa‐Entacapone Stalevo 100 Oral Tablet 25‐100‐200 MG Tier 3 x ANTIPARKINSON AGENTS Carbidopa‐Levodopa‐Entacapone Stalevo 125 Oral Tablet 31.25‐125‐200 MG Tier 3 x ANTIPARKINSON AGENTS Carbidopa‐Levodopa‐Entacapone Stalevo 150 Oral Tablet 37.5‐150‐200 MG Tier 3 x ANTIPARKINSON AGENTS Carbidopa‐Levodopa‐Entacapone Stalevo 200 Oral Tablet 50‐200‐200 MG Tier 3 x ANTIPARKINSON AGENTS Carbidopa‐Levodopa‐Entacapone Stalevo 50 Oral Tablet 12.5‐50‐200 MG Tier 3 x ANTIPARKINSON AGENTS Carbidopa‐Levodopa‐Entacapone Stalevo 75 Oral Tablet 18.75‐75‐200 MG Tier 3 x ANTIDIABETICS Nateglinide Starlix Oral Tablet 120 MG Tier 3 ANTIDIABETICS Nateglinide Starlix Oral Tablet 60 MG Tier 3 ANTIVIRALS Stavudine Stavudine Oral Capsule 15 MG Tier 1 x ANTIVIRALS Stavudine Stavudine Oral Capsule 20 MG Tier 1 x ANTIVIRALS Stavudine Stavudine Oral Capsule 30 MG Tier 1 x ANTIVIRALS Stavudine Stavudine Oral Capsule 40 MG Tier 1 x ANTIVIRALS Stavudine Stavudine Oral Solution Reconstituted 1 MG/ML Tier 1 x ANTICONVULSANTS Valproic Acid Stavzor Oral Capsule Delayed Release 125 MG Tier 3 ANTICONVULSANTS Valproic Acid Stavzor Oral Capsule Delayed Release 250 MG Tier 3 ANTICONVULSANTS Valproic Acid Stavzor Oral Capsule Delayed Release 500 MG Tier 3 PHARMACEUTICAL ADJUVANTS Stearic Acid Stearic Acid Powder Tier 3 PHARMACEUTICAL ADJUVANTS Stearyl Alcohol Stearyl Alcohol Flakes Tier 3 PHARMACEUTICAL ADJUVANTS Stearyl Alcohol Stearyl Alcohol Powder Tier 3 DERMATOLOGICALS Ustekinumab Stelara Subcutaneous Solution Prefilled Syringe 45 MG/0.5ML Tier 2 x DERMATOLOGICALS Ustekinumab Stelara Subcutaneous Solution Prefilled Syringe 90 MG/ML Tier 2 x BIOLOGICALS MISC Stemphylium Stemphylium Subcutaneous Solution 20000 PNU/ML Tier 3 x CARDIOVASCULAR AGENTS ‐ MISC. Avanafil Stendra Oral Tablet 100 MG Tier 2 x x CARDIOVASCULAR AGENTS ‐ MISC. Avanafil Stendra Oral Tablet 200 MG Tier 2 x x CARDIOVASCULAR AGENTS ‐ MISC. Avanafil Stendra Oral Tablet 50 MG Tier 2 x x MEDICAL DEVICES AND SUPPLIES Lancets SteriLance TL Miscellaneous Tier 2 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Desmopressin Acetate Stimate Nasal Solution 1.5 MG/ML Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Disp) 22 G STIMEX Insulated Needle Miscellaneous 22G X 2‐1/8" Tier 3 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Tiotropium Bromide‐Olodaterol HCl Stiolto Respimat Inhalation Aerosol Solution 2.5‐2.5 MCG/ACT Tier 2 xx ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Regorafenib Stivarga Oral Tablet 40 MG Tier 2 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS HCl Strattera Oral Capsule 10 MG Tier 2 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Atomoxetine HCl Strattera Oral Capsule 100 MG Tier 2 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Atomoxetine HCl Strattera Oral Capsule 18 MG Tier 2 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Atomoxetine HCl Strattera Oral Capsule 25 MG Tier 2 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Atomoxetine HCl Strattera Oral Capsule 40 MG Tier 2 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Atomoxetine HCl Strattera Oral Capsule 60 MG Tier 2 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Atomoxetine HCl Strattera Oral Capsule 80 MG Tier 2 x x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Asfotase Alfa Strensiq Subcutaneous Solution 18 MG/0.45ML Tier 3 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Asfotase Alfa Strensiq Subcutaneous Solution 28 MG/0.7ML Tier 3 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Asfotase Alfa Strensiq Subcutaneous Solution 40 MG/ML Tier 3 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Asfotase Alfa Strensiq Subcutaneous Solution 80 MG/0.8ML Tier 3 x AMINOGLYCOSIDES Streptomycin Sulfate Streptomycin Sulfate Intramuscular Solution Reconstituted 1 GM Tier 3 x AMINOGLYCOSIDES Streptomycin Sulfate Streptomycin Sulfate Powder Tier 3 ANDROGENS‐ANABOLIC Testosterone Striant Buccal Miscellaneous 30 MG Tier 3 x ANTIVIRALS Elvitegravir‐Cobicistat‐Emtricitabine‐Tenofovir Stribild Oral Tablet 150‐150‐200‐300 MG Tier 2 x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Olodaterol HCl Striverdi Respimat Inhalation Aerosol Solution 2.5 MCG/ACT Tier 3 xx ANTHELMINTICS Ivermectin Stromectol Oral Tablet 3 MG Tier 3 MULTIVITAMINS Multiple Vitamins w/ Minerals & Folic Acid Strovite Forte Oral Syrup Tier 3 MULTIVITAMINS Multiple Vitamins w/ Minerals Strovite Forte Oral Tablet Tier 3 MULTIVITAMINS Multiple Vitamins w/ Minerals Strovite ONE Oral Tablet Tier 3 ANALGESICS ‐ OPIOID Fentanyl Citrate Sublimaze Injection Solution 0.05 MG/ML Tier 3 x x ANALGESICS ‐ OPIOID Buprenorphine HCl‐Naloxone HCl Dihydrate Suboxone Sublingual Film 12‐3 MG Tier 2 x ANALGESICS ‐ OPIOID Buprenorphine HCl‐Naloxone HCl Dihydrate Suboxone Sublingual Film 2‐0.5 MG Tier 2 x ANALGESICS ‐ OPIOID Buprenorphine HCl‐Naloxone HCl Dihydrate Suboxone Sublingual Film 4‐1 MG Tier 2 x ANALGESICS ‐ OPIOID Buprenorphine HCl‐Naloxone HCl Dihydrate Suboxone Sublingual Film 8‐2 MG Tier 2 x ANALGESICS ‐ OPIOID Fentanyl Subsys Sublingual Liquid 100 MCG Tier 3 x x ANALGESICS ‐ OPIOID Fentanyl Subsys Sublingual Liquid 1200 (600 X 2) MCG Tier 3 x x ANALGESICS ‐ OPIOID Fentanyl Subsys Sublingual Liquid 1600 (800 X 2) MCG Tier 3 x x ANALGESICS ‐ OPIOID Fentanyl Subsys Sublingual Liquid 200 MCG Tier 3 x x ANALGESICS ‐ OPIOID Fentanyl Subsys Sublingual Liquid 400 MCG Tier 3 x x ANALGESICS ‐ OPIOID Fentanyl Subsys Sublingual Liquid 600 MCG Tier 3 x x ANALGESICS ‐ OPIOID Fentanyl Subsys Sublingual Liquid 800 MCG Tier 3 x x DIGESTIVE AIDS Sacrosidase Sucraid Oral Solution 8500 UNIT/ML Tier 2 x x ULCER DRUGS Sucralfate Sucralfate Oral Suspension 1 GM/10ML Tier 2 ULCER DRUGS Sucralfate Sucralfate Oral Tablet 1 GM Tier 1 ULCER DRUGS Sucralfate Sucralfate Powder Tier 3 ANALGESICS ‐ OPIOID Sufentanil Citrate SUFentanil Citrate Intravenous Solution 100 MCG/2ML Tier 1 x ANALGESICS ‐ OPIOID Sufentanil Citrate SUFentanil Citrate Intravenous Solution 250 MCG/5ML Tier 1 x ANALGESICS ‐ OPIOID Sufentanil Citrate SUFentanil Citrate Intravenous Solution 50 MCG/ML Tier 1 x CALCIUM CHANNEL BLOCKERS Nisoldipine Sular Oral Tablet Extended Release 24 Hour 17 MG Tier 3 CALCIUM CHANNEL BLOCKERS Nisoldipine Sular Oral Tablet Extended Release 24 Hour 34 MG Tier 3 CALCIUM CHANNEL BLOCKERS Nisoldipine Sular Oral Tablet Extended Release 24 Hour 8.5 MG Tier 3 DERMATOLOGICALS Sulfacetamide Sodium (Acne) Sulfacetamide Sodium (Acne) External Lotion 10 % Tier 1 DERMATOLOGICALS Sulfacetamide Sodium Sulfacetamide Sodium External Gel 10 % (Cleans) Tier 1 DERMATOLOGICALS Sulfacetamide Sodium Sulfacetamide Sodium External Liquid 10 % Tier 1 DERMATOLOGICALS Sulfacetamide Sodium (Acne) Sulfacetamide Sodium External Suspension 10 % Tier 1 OPHTHALMIC AGENTS Sulfacetamide Sodium (Ophth) Sulfacetamide Sodium Ophthalmic Ointment 10 % Tier 2 OPHTHALMIC AGENTS Sulfacetamide Sodium (Ophth) Sulfacetamide Sodium Ophthalmic Solution 10 % Tier 1 DERMATOLOGICALS Sulfacetamide Sodium Sulfacetamide Sodium Powder Tier 3 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Sulfacetamide Sodium‐Sulfur External Cream 10‐2 % Tier 1 x DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Sulfacetamide Sodium‐Sulfur External Cream 10‐5 % Tier 1 DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Sulfacetamide Sodium‐Sulfur External Cream 9.8‐4.8 % Tier 1 DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Sulfacetamide Sodium‐Sulfur External Emulsion 10‐5 % Tier 1 x DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Sulfacetamide Sodium‐Sulfur External Foam 10‐5 % Tier 1 DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Sulfacetamide Sodium‐Sulfur External Liquid 10‐2 % Tier 1 DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Sulfacetamide Sodium‐Sulfur External Liquid 9.8‐4.8 % Tier 1 DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Sulfacetamide Sodium‐Sulfur External Liquid 9‐4 % Tier 1 DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Sulfacetamide Sodium‐Sulfur External Liquid 9‐4.5 % Tier 1 DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Sulfacetamide Sodium‐Sulfur External Lotion 10‐5 % Tier 1 DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Sulfacetamide Sodium‐Sulfur External Lotion 9.8‐4.8 % Tier 1 DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Sulfacetamide Sodium‐Sulfur External Pad 10‐4 % Tier 1 DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Sulfacetamide Sodium‐Sulfur External Suspension 10‐5 % Tier 3 DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Sulfacetamide Sodium‐Sulfur External Suspension 8‐4 % Tier 1 DERMATOLOGICALS Sulfacetamide Sodium‐Sulfur w/ Skin Cleanser Sulfacetamide Sod‐Sulfur Wash External Kit 9‐4.5 % Tier 1 OPHTHALMIC AGENTS Sulfacetamide Sod‐Prednisolone Sulfacetamide‐Prednisolone Ophthalmic Solution 10‐0.23 % Tier 1 OPHTHALMIC AGENTS Sulfacetamide Sod‐Prednisolone Sulfacetamide‐Prednisolone Ophthalmic Suspension 10‐0.2 % Tier 3 DERMATOLOGICALS Sulfacetamide Sodium‐Sulfur in Urea Vehicle Sulfacetamide‐Sulfur in Urea External Emulsion 10‐5 % Tier 3 DERMATOLOGICALS Sulfacetamide Sodium‐Sulfur in Urea Vehicle Sulfacetamide‐Sulfur in Urea External Gel 10‐5 % Tier 3 DERMATOLOGICALS Sulfacetamide Sodium‐Sulfur‐Sunscreen Sulfacetamide‐Sulfur‐Sunscreen External Kit 9‐4.5 % Tier 1 DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur SulfaCleanse 8/4 External Suspension 8‐4 % Tier 1 SULFONAMIDES Sulfadiazine SulfADIAZINE Oral Tablet 500 MG Tier 2 SULFONAMIDES Sulfadiazine SulfADIAZINE Powder Tier 3 SULFONAMIDES Sulfadiazine Sodium SulfADIAZINE Sodium Powder Tier 3 SULFONAMIDES Sulfamethoxazole Sulfamethoxazole Micro Powder Tier 3 SULFONAMIDES Sulfamethoxazole Sulfamethoxazole Powder Tier 3 ANTI‐INFECTIVE AGENTS ‐ MISC. Sulfamethoxazole‐Trimethoprim Sulfamethoxazole‐Trimethoprim Intravenous Solution 400‐80 MG/5ML Tier 3 x ANTI‐INFECTIVE AGENTS ‐ MISC. Sulfamethoxazole‐Trimethoprim Sulfamethoxazole‐Trimethoprim Oral Suspension 200‐40 MG/5ML Tier 1 ANTI‐INFECTIVE AGENTS ‐ MISC. Sulfamethoxazole‐Trimethoprim Sulfamethoxazole‐Trimethoprim Oral Tablet 400‐80 MG Tier 1 ANTI‐INFECTIVE AGENTS ‐ MISC. Sulfamethoxazole‐Trimethoprim Sulfamethoxazole‐Trimethoprim Oral Tablet 800‐160 MG Tier 1 DERMATOLOGICALS Mafenide Acetate Sulfamylon External Cream 85 MG/GM Tier 3 DERMATOLOGICALS Mafenide Acetate Sulfamylon External Packet 5 % Tier 3 CHEMICALS Sulfanilamide Sulfanilamide Powder Tier 3 SULFONAMIDES Sulfapyridine Sulfapyridine Powder Tier 3 GASTROINTESTINAL AGENTS ‐ MISC. Sulfasalazine SulfaSALAzine Oral Tablet 500 MG Tier 1 GASTROINTESTINAL AGENTS ‐ MISC. Sulfasalazine SulfaSALAzine Oral Tablet Delayed Release 500 MG Tier 1 GASTROINTESTINAL AGENTS ‐ MISC. Sulfasalazine SulfaSALAzine Powder Tier 3 ANTI‐INFECTIVE AGENTS ‐ MISC. Sulfamethoxazole‐Trimethoprim Sulfatrim Pediatric Oral Suspension 200‐40 MG/5ML Tier 1 GASTROINTESTINAL AGENTS ‐ MISC. Sulfasalazine Sulfazine EC Oral Tablet Delayed Release 500 MG Tier 1 GASTROINTESTINAL AGENTS ‐ MISC. Sulfasalazine Sulfazine Oral Tablet 500 MG Tier 1 DERMATOLOGICALS Sulfur Sulfoam External Shampoo 2 % Tier 3 DERMATOLOGICALS Sulfurated Lime (Scabacide) Sulfurated Lime External Solution Tier 3 CHEMICALS Sulfuric Acid Sulfuric Acid Solution Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Sulindac Sulindac Oral Tablet 150 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Sulindac Sulindac Oral Tablet 200 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Sulindac Sulindac Powder Tier 3 MIGRAINE PRODUCTS Sumatriptan Succinate & Capsaicin‐Menthol SumaChip Combination Therapy Pack 100 & 0.0375‐5 MG & % Tier 3 DERMATOLOGICALS Sulfacetamide Sodium‐Sulfur w/ Skin Cleanser Sumadan External Kit 9‐4.5 % Tier 3 DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Sumadan Wash External Liquid 9‐4.5 % Tier 3 DERMATOLOGICALS Sulfacetamide Sodium‐Sulfur‐Sunscreen Sumadan XLT External Kit 9‐4.5 % Tier 3 x MIGRAINE PRODUCTS Sumatriptan SUMAtriptan Nasal Solution 20 MG/ACT Tier 2 xx MIGRAINE PRODUCTS Sumatriptan SUMAtriptan Nasal Solution 5 MG/ACT Tier 2 xx MIGRAINE PRODUCTS Sumatriptan Succinate SUMAtriptan Succinate Oral Tablet 100 MG Tier 1 MIGRAINE PRODUCTS Sumatriptan Succinate SUMAtriptan Succinate Oral Tablet 25 MG Tier 1 MIGRAINE PRODUCTS Sumatriptan Succinate SUMAtriptan Succinate Oral Tablet 50 MG Tier 1 MIGRAINE PRODUCTS Sumatriptan Succinate SUMAtriptan Succinate Refill Subcutaneous Solution Cartridge 4 MG/0.5ML Tier 1 x MIGRAINE PRODUCTS Sumatriptan Succinate SUMAtriptan Succinate Refill Subcutaneous Solution Cartridge 6 MG/0.5ML Tier 1 x MIGRAINE PRODUCTS Sumatriptan Succinate SUMAtriptan Succinate Subcutaneous Solution 6 MG/0.5ML Tier 1 MIGRAINE PRODUCTS Sumatriptan Succinate SUMAtriptan Succinate Subcutaneous Solution Auto‐injector 4 MG/0.5ML Tier 1 x MIGRAINE PRODUCTS Sumatriptan Succinate SUMAtriptan Succinate Subcutaneous Solution Auto‐injector 6 MG/0.5ML Tier 1 x MIGRAINE PRODUCTS Sumatriptan Succinate SUMAtriptan Succinate Subcutaneous Solution Prefilled Syringe 6 MG/0.5ML Tier 3 x MIGRAINE PRODUCTS Sumatriptan Succinate Sumavel DosePro Subcutaneous Solution Jet‐injector 4 MG/0.5ML Tier 3 xx MIGRAINE PRODUCTS Sumatriptan Succinate Sumavel DosePro Subcutaneous Solution Jet‐injector 6 MG/0.5ML Tier 3 xx DERMATOLOGICALS Sulfacetamide Sodium‐Sulfur w/ Skin Cleanser Sumaxin CP External Kit 10‐4 % Tier 3 x DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Sumaxin External Pad 10‐4 % Tier 3 DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Sumaxin TS External Suspension 8‐4 % Tier 3 DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Sumaxin Wash External Liquid 9‐4 % Tier 3 x MEDICAL DEVICES AND SUPPLIES Lancets Super Thin Lancets Miscellaneous Tier 2 MULTIVITAMINS Multiple Vitamins w/ Minerals & Folic Acid Supervite EC Oral Tablet Delayed Release 1 MG Tier 3 MULTIVITAMINS B‐Complex w/ Lysine‐Zn & Folic Acid Supervite Oral Liquid Tier 3 MULTIVITAMINS Multiple Vitamins w/ Minerals Support Oral Liquid Tier 3 DERMATOLOGICALS Fluorouracil‐Salicylic Acid Supracil External Cream 5‐12 % Tier 3 GENERAL ANESTHETICS Suprane Inhalation Solution Tier 3 CEPHALOSPORINS Cefixime Suprax Oral Capsule 400 MG Tier 3 CEPHALOSPORINS Cefixime Suprax Oral Suspension Reconstituted 100 MG/5ML Tier 3 CEPHALOSPORINS Cefixime Suprax Oral Suspension Reconstituted 200 MG/5ML Tier 3 CEPHALOSPORINS Cefixime Suprax Oral Suspension Reconstituted 500 MG/5ML Tier 3 CEPHALOSPORINS Cefixime Suprax Oral Tablet Chewable 100 MG Tier 3 CEPHALOSPORINS Cefixime Suprax Oral Tablet Chewable 200 MG Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Supreme Test In Vitro Strip Tier 3 ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Phentermine HCl Suprenza Oral Tablet Dispersible 15 MG Tier 3 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Phentermine HCl Suprenza Oral Tablet Dispersible 30 MG Tier 3 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Phentermine HCl Suprenza Oral Tablet Dispersible 37.5 MG Tier 3 x x LAXATIVES Sodium Sulfate‐Potassium Sulfate‐Magnesium Sulfate Suprep Bowel Prep Oral Solution Tier 3 MEDICAL DEVICES AND SUPPLIES Alcohol Swabs Sure Comfort Alcohol Prep Pad 70 % Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Sure Comfort Insulin Syringe Miscellaneous 28G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Sure Comfort Insulin Syringe Miscellaneous 28G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Sure Comfort Insulin Syringe Miscellaneous 29G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Sure Comfort Insulin Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Sure Comfort Insulin Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Sure Comfort Insulin Syringe Miscellaneous 30G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Sure Comfort Insulin Syringe Miscellaneous 30G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Sure Comfort Insulin Syringe Miscellaneous 30G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Sure Comfort Insulin Syringe Miscellaneous 30G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Sure Comfort Insulin Syringe Miscellaneous 30G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Sure Comfort Insulin Syringe Miscellaneous 30G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Sure Comfort Insulin Syringe Miscellaneous 31G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Sure Comfort Insulin Syringe Miscellaneous 31G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Sure Comfort Insulin Syringe Miscellaneous 31G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Sure Comfort Lancets 28G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Sure Comfort Lancets 30G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Sure Comfort Pen Needles Miscellaneous 29G X 12.7MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Sure Comfort Pen Needles Miscellaneous 30G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Sure Comfort Pen Needles Miscellaneous 31G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Sure Comfort Pen Needles Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Sure Comfort Pen Needles Miscellaneous 32G X 4 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Sure Comfort Pen Needles Miscellaneous 32G X 6 MM Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Sure Edge Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood SureChek Blood Glucose Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Sure‐Fine Pen Needles Miscellaneous 29G X 12.7MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Sure‐Fine Pen Needles Miscellaneous 31G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Sure‐Fine Pen Needles Miscellaneous 31G X 8 MM Tier 2 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Sure‐Ject Insulin Syringe Miscellaneous 28G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Sure‐Ject Insulin Syringe Miscellaneous 28G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Sure‐Ject Insulin Syringe Miscellaneous 29G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Sure‐Ject Insulin Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Sure‐Ject Insulin Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Sure‐Ject Insulin Syringe Miscellaneous 30G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Sure‐Ject Insulin Syringe Miscellaneous 30G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Sure‐Ject Insulin Syringe Miscellaneous 30G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Sure‐Ject Insulin Syringe Miscellaneous 31G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Sure‐Ject Insulin Syringe Miscellaneous 31G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Sure‐Ject Insulin Syringe Miscellaneous 31G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Sure‐Lance Flat Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Sure‐Lance Lancets 26G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Sure‐Lance Thin Lancets 28G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Sure‐Lance Ultra Thin Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Surelite Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Alcohol Swabs Sure‐Prep Alcohol Prep Pad 70 % Tier 2 MEDICAL DEVICES AND SUPPLIES Blood Glucose Calibration SureStep Glucose Control In Vitro Solution Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Sure‐Test EasyPlus Mini Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Sure‐Touch Lancets Universal Miscellaneous Tier 2 RESPIRATORY AGENTS ‐ MISC. Lucinactant Surfaxin Inhalation Suspension 30 MG/ML Tier 3 ANTIDEPRESSANTS Trimipramine Maleate Surmontil Oral Capsule 100 MG Tier 3 ANTIDEPRESSANTS Trimipramine Maleate Surmontil Oral Capsule 25 MG Tier 3 ANTIDEPRESSANTS Trimipramine Maleate Surmontil Oral Capsule 50 MG Tier 3 RESPIRATORY AGENTS ‐ MISC. Beractant in NaCl Survanta Inhalation Suspension 25‐0.9 MG/ML‐% Tier 3 ANTIVIRALS Efavirenz Sustiva Oral Capsule 200 MG Tier 2 x ANTIVIRALS Efavirenz Sustiva Oral Capsule 50 MG Tier 2 x ANTIVIRALS Efavirenz Sustiva Oral Tablet 600 MG Tier 2 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Sunitinib Malate Sutent Oral Capsule 12.5 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Sunitinib Malate Sutent Oral Capsule 25 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Sunitinib Malate Sutent Oral Capsule 37.5 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Sunitinib Malate Sutent Oral Capsule 50 MG Tier 2 x x COUGH/COLD/ALLERGY Pseudoephedrine w/ Codeine‐GG Suttar‐2 Oral Syrup 30‐10‐100 MG/5ML Tier 3 COUGH/COLD/ALLERGY Pseudoephedrine w/ Codeine‐GG Suttar‐SF Oral Syrup 30‐10‐100 MG/5ML Tier 3 CONTRACEPTIVES Drospirenone‐Ethinyl Estradiol Syeda Oral Tablet 3‐0.03 MG Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Peginterferon alfa‐2b (Antineoplastic) Sylatron Subcutaneous Kit 200 MCG Tier 2 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Peginterferon alfa‐2b (Antineoplastic) Sylatron Subcutaneous Kit 300 MCG Tier 2 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Peginterferon alfa‐2b (Antineoplastic) Sylatron Subcutaneous Kit 4 X 200 MCG Tier 2 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Peginterferon alfa‐2b (Antineoplastic) Sylatron Subcutaneous Kit 4 X 300 MCG Tier 2 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Peginterferon alfa‐2b (Antineoplastic) Sylatron Subcutaneous Kit 4 X 600 MCG Tier 2 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Peginterferon alfa‐2b (Antineoplastic) Sylatron Subcutaneous Kit 600 MCG Tier 2 x ULCER DRUGS Hyoscyamine Sulfate Symax Duotab Oral Tablet Extended Release 0.375 MG Tier 2 ULCER DRUGS Hyoscyamine Sulfate Symax FasTabs Oral Tablet Dispersible 0.125 MG Tier 1 ULCER DRUGS Hyoscyamine Sulfate Symax‐SL Sublingual Tablet Sublingual 0.125 MG Tier 1 ULCER DRUGS Hyoscyamine Sulfate Symax‐SR Oral Tablet Extended Release 12 Hour 0.375 MG Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Budesonide‐Formoterol Fumarate Dihydrate Symbicort Inhalation Aerosol 160‐4.5 MCG/ACT Tier 2 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Budesonide‐Formoterol Fumarate Dihydrate Symbicort Inhalation Aerosol 80‐4.5 MCG/ACT Tier 2 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Olanzapine‐Fluoxetine HCl Symbyax Oral Capsule 12‐25 MG Tier 3 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Olanzapine‐Fluoxetine HCl Symbyax Oral Capsule 12‐50 MG Tier 3 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Olanzapine‐Fluoxetine HCl Symbyax Oral Capsule 3‐25 MG Tier 3 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Olanzapine‐Fluoxetine HCl Symbyax Oral Capsule 6‐25 MG Tier 3 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Olanzapine‐Fluoxetine HCl Symbyax Oral Capsule 6‐50 MG Tier 3 x ANTIDIABETICS Pramlintide Acetate SymlinPen 120 Subcutaneous Solution Pen‐injector 2700 MCG/2.7ML Tier 3 x ANTIDIABETICS Pramlintide Acetate SymlinPen 60 Subcutaneous Solution Pen‐injector 1500 MCG/1.5ML Tier 3 x MULTIVITAMINS Multiple Vitamins w/ Minerals & Folic Acid Synagex Oral Capsule 1.25 MG Tier 3 DERMATOLOGICALS Fluocinolone‐Emollient Synalar (Cream) External Kit 0.025 % Tier 3 DERMATOLOGICALS Fluocinolone‐Emollient Synalar (Ointment) External Kit 0.025 % Tier 3 DERMATOLOGICALS Fluocinolone Acetonide Synalar External Cream 0.025 % Tier 3 DERMATOLOGICALS Fluocinolone Acetonide Synalar External Ointment 0.025 % Tier 3 DERMATOLOGICALS Fluocinolone Acetonide Synalar External Solution 0.01 % Tier 3 DERMATOLOGICALS Fluocinolone Acetonide & Cleanser Synalar TS External Kit 0.01 % Tier 3 ANALGESICS ‐ OPIOID Aspirin‐Caffeine‐Dihydrocodeine Bitartrate Synalgos‐DC Oral Capsule 356.4‐30‐16 MG Tier 3 x ANALGESICS ‐ OPIOID Tramadol HCl Synapryn FusePaq Oral Suspension Reconstituted 10 MG/ML Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Nafarelin Acetate Synarel Nasal Solution 2 MG/ML Tier 2 x MULTIVITAMINS Multiple Vitamins w/ Minerals & Folic Acid SynaTek Oral Capsule 1.25 MG Tier 3 DERMATOLOGICALS Lidocaine‐Tetracaine Synera External Patch 70‐70 MG Tier 3 ANTI‐INFECTIVE AGENTS ‐ MISC. Quinupristin‐Dalfopristin Synercid Intravenous Solution Reconstituted 150‐350 MG Tier 3 x ANTIDIABETICS Empagliflozin‐Metformin HCl Synjardy Oral Tablet 12.5‐1000 MG Tier 3 ANTIDIABETICS Empagliflozin‐Metformin HCl Synjardy Oral Tablet 12.5‐500 MG Tier 3 ANTIDIABETICS Empagliflozin‐Metformin HCl Synjardy Oral Tablet 5‐1000 MG Tier 3 ANTIDIABETICS Empagliflozin‐Metformin HCl Synjardy Oral Tablet 5‐500 MG Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Omacetaxine Mepesuccinate Synribo Subcutaneous Solution Reconstituted 3.5 MG Tier 2 x THYROID AGENTS Levothyroxine Sodium Synthroid Oral Tablet 100 MCG Tier 2 THYROID AGENTS Levothyroxine Sodium Synthroid Oral Tablet 112 MCG Tier 2 THYROID AGENTS Levothyroxine Sodium Synthroid Oral Tablet 125 MCG Tier 2 THYROID AGENTS Levothyroxine Sodium Synthroid Oral Tablet 137 MCG Tier 2 THYROID AGENTS Levothyroxine Sodium Synthroid Oral Tablet 150 MCG Tier 2 THYROID AGENTS Levothyroxine Sodium Synthroid Oral Tablet 175 MCG Tier 2 THYROID AGENTS Levothyroxine Sodium Synthroid Oral Tablet 200 MCG Tier 2 THYROID AGENTS Levothyroxine Sodium Synthroid Oral Tablet 25 MCG Tier 2 THYROID AGENTS Levothyroxine Sodium Synthroid Oral Tablet 300 MCG Tier 2 THYROID AGENTS Levothyroxine Sodium Synthroid Oral Tablet 50 MCG Tier 2 THYROID AGENTS Levothyroxine Sodium Synthroid Oral Tablet 75 MCG Tier 2 THYROID AGENTS Levothyroxine Sodium Synthroid Oral Tablet 88 MCG Tier 2 DERMATOLOGICALS Lidocaine‐Menthol Synvexia TC External Cream 4‐1 % Tier 3 ASSORTED CLASSES Trientine HCl Syprine Oral Capsule 250 MG Tier 2 x x MEDICAL DEVICES AND SUPPLIES Syringe (Disposable) Syringe 10‐12 ML Miscellaneous 12 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Disposable) Syringe 20‐25 ML Miscellaneous 25 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Disposable) Syringe 2‐3 ML Miscellaneous 3 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Disposable) Syringe 30‐35 ML Miscellaneous 35 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Disposable) Syringe 50‐60 ML Miscellaneous 60 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Disposable) Syringe 5‐6 ML Miscellaneous 6 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Disposable) Syringe Disposable Miscellaneous 10 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Disposable) Syringe Disposable Miscellaneous 60 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Disposable) Syringe Luer Lock Miscellaneous 35 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Disposable) Syringe Luer Slip Miscellaneous 1 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 3 ML Syringe Miscellaneous 18G X 1‐1/2" 3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 3 ML Syringe Miscellaneous 20G X 1" 3 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 3 ML Syringe Miscellaneous 21G X 1" 3 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 3 ML Syringe Miscellaneous 22G X 1" 3 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 3 ML Syringe Miscellaneous 22G X 3/4" 3 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 3 ML Syringe Miscellaneous 23G X 1" 3 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Disposable) Syringe/Cannula Miscellaneous 10 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Disposable) Syringe/Cannula Miscellaneous 3 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Disposable) Syringe/Cannula Miscellaneous 5 ML Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Thioguanine Tabloid Oral Tablet 40 MG Tier 2 x MUSCULOSKELETAL THERAPY AGENTS Cyclobenzaprine HCl w/ MSM Tabradol FusePaq Oral Suspension 1 MG/ML Tier 3 DERMATOLOGICALS Calcipotriene‐Betamethasone Dipropionate Taclonex External Ointment 0.005‐0.064 % Tier 3 DERMATOLOGICALS Calcipotriene‐Betamethasone Dipropionate Taclonex External Suspension 0.005‐0.064 % Tier 3 x DERMATOLOGICALS Tacrolimus (Topical) Tacrolimus External Ointment 0.03 % Tier 1 DERMATOLOGICALS Tacrolimus (Topical) Tacrolimus External Ointment 0.1 % Tier 1 ASSORTED CLASSES Tacrolimus Tacrolimus Oral Capsule 0.5 MG Tier 1 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ASSORTED CLASSES Tacrolimus Tacrolimus Oral Capsule 1 MG Tier 1 ASSORTED CLASSES Tacrolimus Tacrolimus Oral Capsule 5 MG Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Dabrafenib Mesylate Tafinlar Oral Capsule 50 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Dabrafenib Mesylate Tafinlar Oral Capsule 75 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Osimertinib Mesylate Tagrisso Oral Tablet 40 MG Tier 3 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Osimertinib Mesylate Tagrisso Oral Tablet 80 MG Tier 3 x x ANALGESICS ‐ OPIOID Pentazocine Lactate Talwin Injection Solution 30 MG/ML Tier 3 x ANTIVIRALS Oseltamivir Phosphate Tamiflu Oral Capsule 30 MG Tier 3 x ANTIVIRALS Oseltamivir Phosphate Tamiflu Oral Capsule 45 MG Tier 3 x ANTIVIRALS Oseltamivir Phosphate Tamiflu Oral Capsule 75 MG Tier 3 x ANTIVIRALS Oseltamivir Phosphate Tamiflu Oral Suspension Reconstituted 6 MG/ML Tier 2 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Tamoxifen Citrate Tamoxifen Citrate Oral Tablet 10 MG Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Tamoxifen Citrate Tamoxifen Citrate Oral Tablet 20 MG Tier 1 GENITOURINARY AGENTS ‐ MISCELLANEOUS Tamsulosin HCl Tamsulosin HCl Oral Capsule 0.4 MG Tier 1 HEMATOPOIETIC AGENTS Ferrous Fumarate‐Iron Polysaccharide Complex‐Folic Acid Tandem F Oral Capsule 162‐115.2‐1 MG Tier 3 HEMATOPOIETIC AGENTS Fe Fum‐Iron Polysacch Complex‐FA‐B Complex‐C‐Zn‐Mn‐Cu Tandem Plus Oral Capsule 162‐115.2‐1 MG Tier 3 DERMATOLOGICALS Tannic Acid Tannic Acid Powder Tier 3 ANTIDIABETICS Albiglutide Tanzeum Subcutaneous Pen‐injector 30 MG Tier 3 xx ANTIDIABETICS Albiglutide Tanzeum Subcutaneous Pen‐injector 50 MG Tier 3 xx THYROID AGENTS Methimazole Tapazole Oral Tablet 10 MG Tier 3 THYROID AGENTS Methimazole Tapazole Oral Tablet 5 MG Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Erlotinib HCl Tarceva Oral Tablet 100 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Erlotinib HCl Tarceva Oral Tablet 150 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Erlotinib HCl Tarceva Oral Tablet 25 MG Tier 2 x x TETRACYCLINES Doxycycline Hyclate TargaDOX Oral Tablet 50 MG Tier 3 DERMATOLOGICALS Bexarotene (Topical) Targretin External Gel 1 % Tier 2 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Bexarotene Targretin Oral Capsule 75 MG Tier 2 x CONTRACEPTIVES Norethin Acet & Estrad‐Fe Tarina FE 1/20 Oral Tablet 1‐20 MG‐MCG Tier 1 ANTIHYPERTENSIVES Trandolapril‐Verapamil HCl Tarka Oral Tablet Extended Release 1‐240 MG Tier 2 xx ANTIHYPERTENSIVES Trandolapril‐Verapamil HCl Tarka Oral Tablet Extended Release 2‐180 MG Tier 2 xx ANTIHYPERTENSIVES Trandolapril‐Verapamil HCl Tarka Oral Tablet Extended Release 2‐240 MG Tier 2 xx ANTIHYPERTENSIVES Trandolapril‐Verapamil HCl Tarka Oral Tablet Extended Release 4‐240 MG Tier 2 xx HEMATOPOIETIC AGENTS Fe Bisglycinate‐Fe Polysaccharide‐Vit C‐Vit B12‐Folic Acid Taron Forte Oral Capsule Tier 3 MULTIVITAMINS Prenatal without Vit A w/ Iron Carbonyl‐Folic Acid & Vit B6 Taron‐Bc Oral Miscellaneous 20‐1 & 25 (2) MG Tier 2 MULTIVITAMINS Prenatal Vit w/ Fe Fum‐Iron Polysacch Complex ‐FA‐Omega 3 Taron‐C DHA Oral Capsule 53.5‐38‐1 MG Tier 2 GENITOURINARY AGENTS ‐ MISCELLANEOUS Potassium Citrate‐Citric Acid Taron‐Crystals Oral Packet 3300‐1002 MG Tier 1 MULTIVITAMINS Prenatal w/o Vit A w/ Fe Fumarate‐DSS‐FA‐DHA Taron‐Prex Oral Capsule 30‐1.2‐265 MG Tier 3 CHEMICALS Tartaric Acid Tartaric Acid Granules Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Nilotinib HCl Tasigna Oral Capsule 150 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Nilotinib HCl Tasigna Oral Capsule 200 MG Tier 2 x x ANTIPARKINSON AGENTS Tolcapone Tasmar Oral Tablet 100 MG Tier 3 NUTRIENTS Taurine Powder Tier 3 CEPHALOSPORINS Ceftazidime Tazicef Injection Solution Reconstituted 1 GM Tier 1 x CEPHALOSPORINS Ceftazidime Tazicef Injection Solution Reconstituted 2 GM Tier 1 x CEPHALOSPORINS Ceftazidime Tazicef Injection Solution Reconstituted 6 GM Tier 1 x CEPHALOSPORINS Ceftazidime Tazicef Intravenous Solution Reconstituted 1 GM Tier 1 x CEPHALOSPORINS Ceftazidime Tazicef Intravenous Solution Reconstituted 2 GM Tier 1 x DERMATOLOGICALS Tazarotene Tazorac External Cream 0.05 % Tier 3 x DERMATOLOGICALS Tazarotene Tazorac External Cream 0.1 % Tier 3 x DERMATOLOGICALS Tazarotene Tazorac External Gel 0.05 % Tier 2 x DERMATOLOGICALS Tazarotene Tazorac External Gel 0.1 % Tier 2 x CALCIUM CHANNEL BLOCKERS Diltiazem HCl Extended Release Beads Taztia XT Oral Capsule Extended Release 24 Hour 120 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Extended Release Beads Taztia XT Oral Capsule Extended Release 24 Hour 180 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Extended Release Beads Taztia XT Oral Capsule Extended Release 24 Hour 240 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Extended Release Beads Taztia XT Oral Capsule Extended Release 24 Hour 300 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Extended Release Beads Taztia XT Oral Capsule Extended Release 24 Hour 360 MG Tier 1 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Dimethyl Fumarate Tecfidera Oral Capsule Delayed Release 120 MG Tier 2 x x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Dimethyl Fumarate Tecfidera Oral Capsule Delayed Release 240 MG Tier 2 x x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Dimethyl Fumarate Tecfidera Oral Miscellaneous 120 & 240 MG Tier 2 x x MEDICAL DEVICES AND SUPPLIES Lancets TechLite AST Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets TechLite Lancets 30G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets TechLite Lancets Miscellaneous Tier 2 ANTIVIRALS Ombitasvir‐Paritaprevir‐Ritonavir Technivie Oral Tablet 12.5‐75‐50 MG Tier 3 x x CEPHALOSPORINS Ceftaroline Fosamil Teflaro Intravenous Solution Reconstituted 400 MG Tier 3 x CEPHALOSPORINS Ceftaroline Fosamil Teflaro Intravenous Solution Reconstituted 600 MG Tier 3 x ANTICONVULSANTS Carbamazepine TEGretol Oral Suspension 100 MG/5ML Tier 3 ANTICONVULSANTS Carbamazepine TEGretol Oral Tablet 200 MG Tier 3 ANTICONVULSANTS Carbamazepine TEGretol‐XR Oral Tablet Extended Release 12 Hour 100 MG Tier 3 ANTICONVULSANTS Carbamazepine TEGretol‐XR Oral Tablet Extended Release 12 Hour 200 MG Tier 3 ANTICONVULSANTS Carbamazepine TEGretol‐XR Oral Tablet Extended Release 12 Hour 400 MG Tier 3 ANTIHYPERTENSIVES Aliskiren‐Hydrochlorothiazide Tekturna HCT Oral Tablet 150‐12.5 MG Tier 2 xx ANTIHYPERTENSIVES Aliskiren‐Hydrochlorothiazide Tekturna HCT Oral Tablet 150‐25 MG Tier 2 xx ANTIHYPERTENSIVES Aliskiren‐Hydrochlorothiazide Tekturna HCT Oral Tablet 300‐12.5 MG Tier 2 xx ANTIHYPERTENSIVES Aliskiren‐Hydrochlorothiazide Tekturna HCT Oral Tablet 300‐25 MG Tier 2 xx ANTIHYPERTENSIVES Aliskiren Fumarate Tekturna Oral Tablet 150 MG Tier 2 x ANTIHYPERTENSIVES Aliskiren Fumarate Tekturna Oral Tablet 300 MG Tier 2 x MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies Telcare Blood Glucose System Kit w/Device Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Telcare Blood Glucose Test In Vitro Strip Tier 3 ANTIHYPERTENSIVES Telmisartan Telmisartan Oral Tablet 20 MG Tier 1 x ANTIHYPERTENSIVES Telmisartan Telmisartan Oral Tablet 40 MG Tier 1 x ANTIHYPERTENSIVES Telmisartan Telmisartan Oral Tablet 80 MG Tier 1 x ANTIHYPERTENSIVES Telmisartan‐Amlodipine Telmisartan‐Amlodipine Oral Tablet 40‐10 MG Tier 1 x ANTIHYPERTENSIVES Telmisartan‐Amlodipine Telmisartan‐Amlodipine Oral Tablet 40‐5 MG Tier 1 x ANTIHYPERTENSIVES Telmisartan‐Amlodipine Telmisartan‐Amlodipine Oral Tablet 80‐10 MG Tier 1 x ANTIHYPERTENSIVES Telmisartan‐Amlodipine Telmisartan‐Amlodipine Oral Tablet 80‐5 MG Tier 1 x ANTIHYPERTENSIVES Telmisartan‐Hydrochlorothiazide Telmisartan‐HCTZ Oral Tablet 40‐12.5 MG Tier 1 x ANTIHYPERTENSIVES Telmisartan‐Hydrochlorothiazide Telmisartan‐HCTZ Oral Tablet 80‐12.5 MG Tier 1 x ANTIHYPERTENSIVES Telmisartan‐Hydrochlorothiazide Telmisartan‐HCTZ Oral Tablet 80‐25 MG Tier 1 x HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Temazepam Temazepam Oral Capsule 15 MG Tier 1 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Temazepam Temazepam Oral Capsule 22.5 MG Tier 1 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Temazepam Temazepam Oral Capsule 30 MG Tier 1 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Temazepam Temazepam Oral Capsule 7.5 MG Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Temozolomide Temodar Oral Capsule 100 MG Tier 2 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Temozolomide Temodar Oral Capsule 140 MG Tier 2 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Temozolomide Temodar Oral Capsule 180 MG Tier 2 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Temozolomide Temodar Oral Capsule 20 MG Tier 2 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Temozolomide Temodar Oral Capsule 250 MG Tier 2 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Temozolomide Temodar Oral Capsule 5 MG Tier 2 x DERMATOLOGICALS Clobetasol Propionate Emollient Base Temovate E External Cream 0.05 % Tier 3 DERMATOLOGICALS Clobetasol Propionate Temovate External Cream 0.05 % Tier 3 DERMATOLOGICALS Clobetasol Propionate Temovate External Gel 0.05 % Tier 3 DERMATOLOGICALS Clobetasol Propionate Temovate External Ointment 0.05 % Tier 3 DERMATOLOGICALS Clobetasol Propionate Temovate External Solution 0.05 % Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Temozolomide Temozolomide Oral Capsule 100 MG Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Temozolomide Temozolomide Oral Capsule 140 MG Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Temozolomide Temozolomide Oral Capsule 180 MG Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Temozolomide Temozolomide Oral Capsule 20 MG Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Temozolomide Temozolomide Oral Capsule 250 MG Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Temozolomide Temozolomide Oral Capsule 5 MG Tier 1 x ANALGESICS ‐ NonNarcotic Butalbital‐Acetaminophen Tencon Oral Tablet 50‐325 MG Tier 1 ANTIHYPERTENSIVES Guanfacine HCl Tenex Oral Tablet 1 MG Tier 3 ANTIHYPERTENSIVES Guanfacine HCl Tenex Oral Tablet 2 MG Tier 3 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

TOXOIDS Tetanus‐Diphtheria Toxoids (Td) Tenivac Intramuscular Injectable 5‐2 LFU Tier 3 x ANTIHYPERTENSIVES Atenolol & Chlorthalidone Tenoretic 100 Oral Tablet 100‐25 MG Tier 3 ANTIHYPERTENSIVES Atenolol & Chlorthalidone Tenoretic 50 Oral Tablet 50‐25 MG Tier 3 BETA BLOCKERS Atenolol Tenormin Oral Tablet 100 MG Tier 3 BETA BLOCKERS Atenolol Tenormin Oral Tablet 25 MG Tier 3 BETA BLOCKERS Atenolol Tenormin Oral Tablet 50 MG Tier 3 VAGINAL PRODUCTS Terconazole Vaginal Terazol 3 Vaginal Cream 0.8 % Tier 3 VAGINAL PRODUCTS Terconazole Vaginal Terazol 7 Vaginal Cream 0.4 % Tier 3 ANTIHYPERTENSIVES Terazosin HCl Terazosin HCl Oral Capsule 1 MG Tier 1 ANTIHYPERTENSIVES Terazosin HCl Terazosin HCl Oral Capsule 10 MG Tier 1 ANTIHYPERTENSIVES Terazosin HCl Terazosin HCl Oral Capsule 2 MG Tier 1 ANTIHYPERTENSIVES Terazosin HCl Terazosin HCl Oral Capsule 5 MG Tier 1 ANTIFUNGALS Terbinafine HCl Terbinafine HCl Oral Tablet 250 MG Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Terbutaline Sulfate Terbutaline Sulfate Injection Solution 1 MG/ML Tier 1 x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Terbutaline Sulfate Terbutaline Sulfate Oral Tablet 2.5 MG Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Terbutaline Sulfate Terbutaline Sulfate Oral Tablet 5 MG Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Terbutaline Sulfate Terbutaline Sulfate Powder Tier 3 VAGINAL PRODUCTS Terconazole Vaginal Terconazole Vaginal Cream 0.4 % Tier 1 VAGINAL PRODUCTS Terconazole Vaginal Terconazole Vaginal Cream 0.8 % Tier 1 VAGINAL PRODUCTS Terconazole Vaginal Terconazole Vaginal Suppository 80 MG Tier 1 GENERAL ANESTHETICS Isoflurane Terrell Inhalation Solution Tier 1 DERMATOLOGICALS Selenium Sulfide Tersi External Foam 2.25 % Tier 3 COUGH/COLD/ALLERGY Benzonatate Tessalon Perles Oral Capsule 100 MG Tier 3 ANDROGENS‐ANABOLIC Testosterone Testim Transdermal Gel 50 MG/5GM (1%) Tier 3 x ANDROGENS‐ANABOLIC Testosterone Testopel Implant Pellet 75 MG Tier 3 x ANDROGENS‐ANABOLIC Testosterone Cypionate Testosterone Cypionate Intramuscular Solution 100 MG/ML Tier 1 x ANDROGENS‐ANABOLIC Testosterone Cypionate Testosterone Cypionate Intramuscular Solution 200 MG/ML Tier 1 x ANDROGENS‐ANABOLIC Testosterone Enanthate Testosterone Enanthate Intramuscular Solution 200 MG/ML Tier 1 x ANDROGENS‐ANABOLIC Testosterone Testosterone Implant Pellet 100 MG Tier 3 x ANDROGENS‐ANABOLIC Testosterone Testosterone Implant Pellet 12.5 MG Tier 3 x ANDROGENS‐ANABOLIC Testosterone Testosterone Implant Pellet 200 MG Tier 3 x ANDROGENS‐ANABOLIC Testosterone Testosterone Implant Pellet 25 MG Tier 3 x ANDROGENS‐ANABOLIC Testosterone Testosterone Implant Pellet 37.5 MG Tier 3 x ANDROGENS‐ANABOLIC Testosterone Testosterone Implant Pellet 50 MG Tier 3 x ANDROGENS‐ANABOLIC Testosterone Testosterone Implant Pellet 87.5 MG Tier 3 x ANDROGENS‐ANABOLIC Testosterone Testosterone Transdermal Gel 10 MG/ACT (2%) Tier 3 x ANDROGENS‐ANABOLIC Testosterone Testosterone Transdermal Gel 12.5 MG/ACT (1%) Tier 1 x ANDROGENS‐ANABOLIC Testosterone Testosterone Transdermal Gel 12.5 MG/ACT (1%) Tier 3 x ANDROGENS‐ANABOLIC Testosterone Testosterone Transdermal Gel 25 MG/2.5GM (1%) Tier 1 x ANDROGENS‐ANABOLIC Testosterone Testosterone Transdermal Gel 25 MG/2.5GM (1%) Tier 3 x ANDROGENS‐ANABOLIC Testosterone Testosterone Transdermal Gel 50 MG/5GM (1%) Tier 1 x ANDROGENS‐ANABOLIC Testosterone Testosterone Transdermal Gel 50 MG/5GM (1%) Tier 3 x ANDROGENS‐ANABOLIC Methyltestosterone Testred Oral Capsule 10 MG Tier 3 TOXOIDS Tetanus‐Diphtheria Toxoids (Td) Tetanus‐Diphtheria Toxoids Td Intramuscular Suspension 2‐2 LF/0.5ML Tier 2 x OPHTHALMIC AGENTS Tetracaine HCl (Ophth) Tetcaine Ophthalmic Solution 0.5 % Tier 1 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Tetrabenazine Tetrabenazine Oral Tablet 12.5 MG Tier 1 x x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Tetrabenazine Tetrabenazine Oral Tablet 25 MG Tier 1 x x OPHTHALMIC AGENTS Tetracaine HCl (Ophth) Tetracaine HCl Ophthalmic Solution 0.5 % Tier 1 LOCAL ANESTHETICS‐Parenteral Tetracaine HCl Tetracaine HCl Powder Tier 3 TETRACYCLINES Tetracycline HCl Tetracycline HCl Oral Capsule 250 MG Tier 2 TETRACYCLINES Tetracycline HCl Tetracycline HCl Oral Capsule 500 MG Tier 2 DERMATOLOGICALS Tetracycline HCl (Topical) Tetracycline HCl Powder Tier 3 OPHTHALMIC AGENTS Tetracaine HCl (Ophth) TetraVisc Forte Ophthalmic Solution 0.5 % Tier 1 OPHTHALMIC AGENTS Tetracaine HCl (Ophth) TetraVisc Ophthalmic Solution 0.5 % Tier 1 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin Tev‐Tropin Subcutaneous Solution Reconstituted 5 MG Tier 2 x DERMATOLOGICALS Hydrocortisone (Topical) Texacort External Solution 2.5 % Tier 3 MULTIVITAMINS Pediatric Multiple Vitamins w/Fluoride‐Iron‐Zinc TexaVite LQ Oral Liquid 0.25‐7‐3 MG/ML Tier 3 COUGH/COLD/ALLERGY Phenylephrine‐Chlorphen‐DM TGQ 15DM/5PEH/2CPM Oral Syrup 15‐5‐2 MG/5ML Tier 3 COUGH/COLD/ALLERGY Pseudoephedrine w/ DM‐GG TGQ 30PSE/150GFN/15DM Oral Syrup 30‐150‐15 MG/5ML Tier 3 COUGH/COLD/ALLERGY Pseudoephed‐Bromphen‐DM TGQ 30PSE/3BRM/15DM Oral Syrup 30‐3‐15 MG/5ML Tier 3 COUGH/COLD/ALLERGY Pseudoephed‐Bromphen‐DM TGQ 50PSE/3BRM/30DM Oral Syrup 50‐3‐30 MG/5ML Tier 3 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies TGT Blood Glucose Monitoring Kit w/Device Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood TGT Blood Glucose Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets TGT Lancet Alternate Site Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets TGT Lancet Micro Thin 33G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets TGT Lancet Super Thin 30G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets TGT Lancet Thin 23G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets TGT Lancet Thin 26G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets TGT Lancet Ultra Thin 28G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets TGT Lancet Ultra Thin 30G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancet Devices TGT Lancing Device Miscellaneous Tier 2 DIAGNOSTIC PRODUCTS Thallous Chloride TL 201 Thallous Chloride TL 201 Intravenous Solution 2 MCI/ML Tier 3 x ASSORTED CLASSES Thalidomide Thalomid Oral Capsule 100 MG Tier 2 x ASSORTED CLASSES Thalidomide Thalomid Oral Capsule 150 MG Tier 2 x ASSORTED CLASSES Thalidomide Thalomid Oral Capsule 200 MG Tier 2 x ASSORTED CLASSES Thalidomide Thalomid Oral Capsule 50 MG Tier 2 x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Theophylline Theo‐24 Oral Capsule Extended Release 24 Hour 100 MG Tier 3 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Theophylline Theo‐24 Oral Capsule Extended Release 24 Hour 200 MG Tier 3 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Theophylline Theo‐24 Oral Capsule Extended Release 24 Hour 300 MG Tier 3 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Theophylline Theo‐24 Oral Capsule Extended Release 24 Hour 400 MG Tier 3 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Theophylline Theochron Oral Tablet Extended Release 12 Hour 100 MG Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Theophylline Theochron Oral Tablet Extended Release 12 Hour 200 MG Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Theophylline Theochron Oral Tablet Extended Release 12 Hour 300 MG Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Theophylline Theophylline ER Oral Tablet Extended Release 12 Hour 100 MG Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Theophylline Theophylline ER Oral Tablet Extended Release 12 Hour 200 MG Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Theophylline Theophylline ER Oral Tablet Extended Release 12 Hour 300 MG Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Theophylline Theophylline ER Oral Tablet Extended Release 12 Hour 450 MG Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Theophylline Theophylline ER Oral Tablet Extended Release 24 Hour 400 MG Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Theophylline Theophylline ER Oral Tablet Extended Release 24 Hour 600 MG Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Theophylline Theophylline Oral Elixir 80 MG/15ML Tier 3 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Theophylline Theophylline Oral Solution 80 MG/15ML Tier 1 DERMATOLOGICALS Silver Sulfadiazine Thermazene External Cream 1 % Tier 1 ANTHELMINTICS Thiabendazole Thiabendazole Powder Tier 3 VITAMINS Thiamine HCl Thiamine HCl Injection Solution 100 MG/ML Tier 1 x VITAMINS Thiamine HCl Thiamine HCl Powder Tier 3 ANTISEPTICS & DISINFECTANTS Thimerosal Thimerosal Powder Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Thinlets GP Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Thinlets Lancet Miscellaneous Tier 2 GENITOURINARY AGENTS ‐ MISCELLANEOUS Tiopronin Thiola Oral Tablet 100 MG Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Thioridazine HCl Thioridazine HCl Oral Tablet 10 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Thioridazine HCl Thioridazine HCl Oral Tablet 100 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Thioridazine HCl Thioridazine HCl Oral Tablet 25 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Thioridazine HCl Thioridazine HCl Oral Tablet 50 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Thiothixene Thiothixene Oral Capsule 1 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Thiothixene Thiothixene Oral Capsule 10 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Thiothixene Thiothixene Oral Capsule 2 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Thiothixene Thiothixene Oral Capsule 5 MG Tier 1 NUTRIENTS Threonine Powder Tier 3 MULTIVITAMINS Prenatal Vit w/ Docusate‐Fe Fumarate‐Folic Acid Thrivite 19 Oral Tablet 29‐1 MG Tier 2 MULTIVITAMINS Prenatal Vit w/ Iron Carbonyl‐Folic Acid Thrivite Rx Oral Tablet 29‐1 MG Tier 2 HEMATOLOGICAL AGENTS ‐ MISC. Antithrombin III (Human) Thrombate III Intravenous Solution Reconstituted 500 UNIT Tier 3 x HEMOSTATICS Thrombin Thrombin‐JMI Epistaxis External Kit 5000 UNIT Tier 3 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

HEMOSTATICS Thrombin Thrombin‐JMI External Kit 20000 UNIT Tier 3 HEMOSTATICS Thrombin Thrombin‐JMI External Kit 5000 UNIT Tier 3 HEMOSTATICS Thrombin Thrombin‐JMI External Solution Reconstituted 20000 UNIT Tier 3 HEMOSTATICS Thrombin Thrombin‐JMI External Solution Reconstituted 5000 UNIT Tier 3 HEMOSTATICS Thrombin Thrombogen External Kit 10000 UNIT Tier 3 HEMOSTATICS Thrombin Thrombogen External Solution Reconstituted 1000 UNIT Tier 3 HEMOSTATICS Thrombin Thrombogen External Solution Reconstituted 10000 UNIT Tier 3 CHEMICALS Iodide Thymol Iodide Powder Tier 3 DIAGNOSTIC PRODUCTS Thyrotropin Alfa Thyrogen Intramuscular Solution Reconstituted 1.1 MG Tier 2 x THYROID AGENTS Thyroid Thyroid Powder Tier 3 THYROID AGENTS Thyroid Thyroid Powder 0.23 % Tier 3 THYROID AGENTS Liotrix (T3‐T4) Thyrolar‐1 Oral Tablet 60 (12.5‐50) MG (MCG) Tier 3 THYROID AGENTS Liotrix (T3‐T4) Thyrolar‐1/2 Oral Tablet 30 (6.25‐25) MG (MCG) Tier 3 THYROID AGENTS Liotrix (T3‐T4) Thyrolar‐1/4 Oral Tablet 15 (3.1‐12.5) MG (MCG) Tier 3 THYROID AGENTS Liotrix (T3‐T4) Thyrolar‐2 Oral Tablet 120 (25‐100) MG (MCG) Tier 3 THYROID AGENTS Liotrix (T3‐T4) Thyrolar‐3 Oral Tablet 180 (37.5‐150) MG (MCG) Tier 3 ANTICONVULSANTS Tiagabine HCl TiaGABine HCl Oral Tablet 2 MG Tier 1 ANTICONVULSANTS Tiagabine HCl TiaGABine HCl Oral Tablet 4 MG Tier 1 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Extended Release Beads Tiazac Oral Capsule Extended Release 24 Hour 120 MG Tier 3 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Extended Release Beads Tiazac Oral Capsule Extended Release 24 Hour 180 MG Tier 3 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Extended Release Beads Tiazac Oral Capsule Extended Release 24 Hour 240 MG Tier 3 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Extended Release Beads Tiazac Oral Capsule Extended Release 24 Hour 300 MG Tier 3 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Extended Release Beads Tiazac Oral Capsule Extended Release 24 Hour 360 MG Tier 3 CALCIUM CHANNEL BLOCKERS Diltiazem HCl Extended Release Beads Tiazac Oral Capsule Extended Release 24 Hour 420 MG Tier 3 ANTIEMETICS Trimethobenzamide HCl Tigan Intramuscular Solution 100 MG/ML Tier 3 x ANTIEMETICS Trimethobenzamide HCl Tigan Oral Capsule 300 MG Tier 3 ANTIARRHYTHMICS Dofetilide Tikosyn Oral Capsule 125 MCG Tier 3 ANTIARRHYTHMICS Dofetilide Tikosyn Oral Capsule 250 MCG Tier 3 ANTIARRHYTHMICS Dofetilide Tikosyn Oral Capsule 500 MCG Tier 3 CONTRACEPTIVES Norethindrone Acetate‐Ethinyl Estradiol‐Fe Tilia Fe Oral Tablet 1‐20/1‐30/1‐35 MG‐MCG Tier 1 OPHTHALMIC AGENTS Timolol Maleate (Ophth) Timolol Maleate Ophthalmic Gel Forming Solution 0.25 % Tier 1 OPHTHALMIC AGENTS Timolol Maleate (Ophth) Timolol Maleate Ophthalmic Gel Forming Solution 0.5 % Tier 1 OPHTHALMIC AGENTS Timolol Maleate (Ophth) Timolol Maleate Ophthalmic Solution 0.25 % Tier 1 OPHTHALMIC AGENTS Timolol Maleate (Ophth) Timolol Maleate Ophthalmic Solution 0.5 % Tier 1 BETA BLOCKERS Timolol Maleate Timolol Maleate Oral Tablet 10 MG Tier 2 BETA BLOCKERS Timolol Maleate Timolol Maleate Oral Tablet 20 MG Tier 2 BETA BLOCKERS Timolol Maleate Timolol Maleate Oral Tablet 5 MG Tier 2 BETA BLOCKERS Timolol Maleate Timolol Maleate Powder Tier 3 OPHTHALMIC AGENTS Timolol Maleate (Ophth) Timoptic Ocudose Ophthalmic Solution 0.25 % Tier 2 OPHTHALMIC AGENTS Timolol Maleate (Ophth) Timoptic Ocudose Ophthalmic Solution 0.5 % Tier 2 OPHTHALMIC AGENTS Timolol Maleate (Ophth) Timoptic Ophthalmic Solution 0.25 % Tier 2 OPHTHALMIC AGENTS Timolol Maleate (Ophth) Timoptic Ophthalmic Solution 0.5 % Tier 2 OPHTHALMIC AGENTS Timolol Maleate (Ophth) Timoptic‐XE Ophthalmic Gel Forming Solution 0.25 % Tier 3 OPHTHALMIC AGENTS Timolol Maleate (Ophth) Timoptic‐XE Ophthalmic Gel Forming Solution 0.5 % Tier 3 ANTI‐INFECTIVE AGENTS ‐ MISC. Tinidazole Tindamax Oral Tablet 250 MG Tier 3 ANTI‐INFECTIVE AGENTS ‐ MISC. Tinidazole Tindamax Oral Tablet 500 MG Tier 3 ANTI‐INFECTIVE AGENTS ‐ MISC. Tinidazole Tinidazole Oral Tablet 250 MG Tier 1 ANTI‐INFECTIVE AGENTS ‐ MISC. Tinidazole Tinidazole Oral Tablet 500 MG Tier 1 THYROID AGENTS Levothyroxine Sodium Tirosint Oral Capsule 100 MCG Tier 3 THYROID AGENTS Levothyroxine Sodium Tirosint Oral Capsule 112 MCG Tier 3 THYROID AGENTS Levothyroxine Sodium Tirosint Oral Capsule 125 MCG Tier 3 THYROID AGENTS Levothyroxine Sodium Tirosint Oral Capsule 13 MCG Tier 3 THYROID AGENTS Levothyroxine Sodium Tirosint Oral Capsule 137 MCG Tier 3 THYROID AGENTS Levothyroxine Sodium Tirosint Oral Capsule 150 MCG Tier 3 THYROID AGENTS Levothyroxine Sodium Tirosint Oral Capsule 25 MCG Tier 3 THYROID AGENTS Levothyroxine Sodium Tirosint Oral Capsule 50 MCG Tier 3 THYROID AGENTS Levothyroxine Sodium Tirosint Oral Capsule 75 MCG Tier 3 THYROID AGENTS Levothyroxine Sodium Tirosint Oral Capsule 88 MCG Tier 3 HEMOSTATICS Fibrin Sealant Component Tisseel VH External Kit 2 ML Tier 3 HEMOSTATICS Fibrin Sealant Component Tisseel VHSD External Solution Tier 3 CHEMICALS Titanium Dioxide Powder Tier 3 ANTIVIRALS Dolutegravir Sodium Tivicay Oral Tablet 50 MG Tier 2 x MUSCULOSKELETAL THERAPY AGENTS Tizanidine & Liniment Tizanidine Comfort Pac Combination Miscellaneous 4 MG Tier 3 MUSCULOSKELETAL THERAPY AGENTS Tizanidine HCl TiZANidine HCl Oral Capsule 2 MG Tier 1 x MUSCULOSKELETAL THERAPY AGENTS Tizanidine HCl TiZANidine HCl Oral Capsule 4 MG Tier 1 x MUSCULOSKELETAL THERAPY AGENTS Tizanidine HCl TiZANidine HCl Oral Capsule 6 MG Tier 1 x MUSCULOSKELETAL THERAPY AGENTS Tizanidine HCl TiZANidine HCl Oral Tablet 2 MG Tier 1 x MUSCULOSKELETAL THERAPY AGENTS Tizanidine HCl TiZANidine HCl Oral Tablet 4 MG Tier 1 x MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐L Methylfolate‐Folic Acid TL Folate Oral Tablet 27‐0.5‐0.5 MG Tier 3 HEMATOPOIETIC AGENTS Folic Acid‐Vitamin B6‐Vitamin B12 TL Gard Rx Oral Tablet 2.2‐25‐1 MG Tier 1 MULTIVITAMINS Multiple Vitamins w/ Minerals & Calcium‐Folic Acid TL G‐Fol OS Oral Tablet 500‐1.1 MG Tier 3 HEMATOPOIETIC AGENTS Ferrous Fumarate w/ B12‐Vit C‐FA‐IFC TL Icon Oral Capsule Tier 1 MULTIVITAMINS Prenatal w/Fe Fumarate‐FA‐DSS‐Fish Oil TL‐Care DHA Oral Capsule 27‐1‐500 MG Tier 2 MULTIVITAMINS Ped Multivitamins w/Fl & Iron TL‐Fluorivite Oral Tablet Chewable 0.25‐7.5 MG Tier 2 HEMATOPOIETIC AGENTS Iron‐Docusate‐B12‐Folic Acid‐Vit C‐Vit E‐Copper‐Biotin TL‐Hem 150 Oral Tablet 150‐1 MG Tier 1 MULTIVITAMINS Prenatal w/o Vit A w/ Fe Fumarate‐DSS‐FA‐DHA TL‐Select Oral Capsule 29‐1.25‐325 MG Tier 3 AMINOGLYCOSIDES Tobramycin Tobi Inhalation Nebulization Solution 300 MG/5ML Tier 2 x AMINOGLYCOSIDES Tobramycin Tobi Podhaler Inhalation Capsule 28 MG Tier 2 x OPHTHALMIC AGENTS Tobramycin‐Dexamethasone TobraDex Ophthalmic Ointment 0.3‐0.1 % Tier 3 OPHTHALMIC AGENTS Tobramycin‐Dexamethasone TobraDex Ophthalmic Suspension 0.3‐0.1 % Tier 3 OPHTHALMIC AGENTS Tobramycin‐Dexamethasone TobraDex ST Ophthalmic Suspension 0.3‐0.05 % Tier 3 AMINOGLYCOSIDES Tobramycin Tobramycin Inhalation Nebulization Solution 300 MG/5ML Tier 1 x OPHTHALMIC AGENTS Tobramycin (Ophth) Tobramycin Ophthalmic Solution 0.3 % Tier 1 AMINOGLYCOSIDES Tobramycin Tobramycin Pak Inhalation Nebulization Solution 300 MG/5ML Tier 1 x AMINOGLYCOSIDES Tobramycin Sulfate Tobramycin Sulfate Injection Solution 1.2 GM/30ML Tier 1 x AMINOGLYCOSIDES Tobramycin Sulfate Tobramycin Sulfate Injection Solution 10 MG/ML Tier 1 x AMINOGLYCOSIDES Tobramycin Sulfate Tobramycin Sulfate Injection Solution 2 GM/50ML Tier 1 x AMINOGLYCOSIDES Tobramycin Sulfate Tobramycin Sulfate Injection Solution 80 MG/2ML Tier 1 x AMINOGLYCOSIDES Tobramycin Sulfate Tobramycin Sulfate Injection Solution Reconstituted 1.2 GM Tier 1 x AMINOGLYCOSIDES Tobramycin Sulfate Tobramycin Sulfate Powder Tier 3 x OPHTHALMIC AGENTS Tobramycin‐Dexamethasone Tobramycin‐Dexamethasone Ophthalmic Suspension 0.3‐0.1 % Tier 1 OPHTHALMIC AGENTS Tobramycin (Ophth) Tobrex Ophthalmic Ointment 0.3 % Tier 3 OPHTHALMIC AGENTS Tobramycin (Ophth) Tobrex Ophthalmic Solution 0.3 % Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Todays Health Mini Pen Needles Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Todays Health Pen Needles Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Todays Health Short Pen Needle Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Todays Health Thin Lancets 28G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Todays Health Thin Lancets 30G Miscellaneous Tier 2 ANTIDEPRESSANTS Imipramine HCl Tofranil Oral Tablet 10 MG Tier 3 ANTIDEPRESSANTS Imipramine HCl Tofranil Oral Tablet 25 MG Tier 3 ANTIDEPRESSANTS Imipramine HCl Tofranil Oral Tablet 50 MG Tier 3 ANTIDEPRESSANTS Imipramine Pamoate Tofranil‐PM Oral Capsule 100 MG Tier 3 ANTIDEPRESSANTS Imipramine Pamoate Tofranil‐PM Oral Capsule 125 MG Tier 3 ANTIDEPRESSANTS Imipramine Pamoate Tofranil‐PM Oral Capsule 150 MG Tier 3 ANTIDEPRESSANTS Imipramine Pamoate Tofranil‐PM Oral Capsule 75 MG Tier 3 DERMATOLOGICALS Fluorouracil (Topical) Tolak External Cream 4 % Tier 3 ANTIDIABETICS Tolazamide TOLAZamide Oral Tablet 250 MG Tier 1 ANTIDIABETICS Tolazamide TOLAZamide Oral Tablet 500 MG Tier 3 ANTIDIABETICS Tolbutamide TOLBUTamide Oral Tablet 500 MG Tier 3 ANTIPARKINSON AGENTS Tolcapone Tolcapone Oral Tablet 100 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Tolmetin Sodium Tolmetin Sodium Oral Capsule 400 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Tolmetin Sodium Tolmetin Sodium Oral Tablet 200 MG Tier 3 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ANALGESICS ‐ ANTI‐INFLAMMATORY Tolmetin Sodium Tolmetin Sodium Oral Tablet 600 MG Tier 3 URINARY ANTISPASMODICS Tolterodine Tartrate Tolterodine Tartrate ER Oral Capsule Extended Release 24 Hour 2 MG Tier 1 x URINARY ANTISPASMODICS Tolterodine Tartrate Tolterodine Tartrate ER Oral Capsule Extended Release 24 Hour 4 MG Tier 1 URINARY ANTISPASMODICS Tolterodine Tartrate Tolterodine Tartrate Oral Tablet 1 MG Tier 1 URINARY ANTISPASMODICS Tolterodine Tartrate Tolterodine Tartrate Oral Tablet 2 MG Tier 1 CHEMICALS Tolonium Chloride Blue O Powder Tier 3 ANTICONVULSANTS Topiramate Topamax Oral Tablet 100 MG Tier 3 x ANTICONVULSANTS Topiramate Topamax Oral Tablet 200 MG Tier 3 x ANTICONVULSANTS Topiramate Topamax Oral Tablet 25 MG Tier 3 x ANTICONVULSANTS Topiramate Topamax Oral Tablet 50 MG Tier 3 x ANTICONVULSANTS Topiramate Topamax Sprinkle Oral Capsule Sprinkle 15 MG Tier 3 x ANTICONVULSANTS Topiramate Topamax Sprinkle Oral Capsule Sprinkle 25 MG Tier 3 x MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle TopCare Clickfine Pen Needles Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle TopCare Clickfine Pen Needles Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 TopCare Ultra Comfort Ins Syr Miscellaneous 29G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 TopCare Ultra Comfort Ins Syr Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 TopCare Ultra Comfort Ins Syr Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 TopCare Ultra Comfort Ins Syr Miscellaneous 30G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 TopCare Ultra Comfort Ins Syr Miscellaneous 30G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 TopCare Ultra Comfort Ins Syr Miscellaneous 30G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 TopCare Ultra Comfort Ins Syr Miscellaneous 31G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 TopCare Ultra Comfort Ins Syr Miscellaneous 31G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 TopCare Ultra Comfort Ins Syr Miscellaneous 31G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Topco Insulin Syringe Miscellaneous 28G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Topco Insulin Syringe Miscellaneous 28G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Topco Insulin Syringe Miscellaneous 29G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Topco Insulin Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Topco Insulin Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 MOUTH/THROAT/DENTAL AGENTS Benzocaine (Dental) Topex Topical Anesthetic Mouth/Throat Solution 20 % Tier 1 DERMATOLOGICALS Desoximetasone Topicort External Cream 0.05 % Tier 3 DERMATOLOGICALS Desoximetasone Topicort External Cream 0.25 % Tier 3 DERMATOLOGICALS Desoximetasone Topicort External Gel 0.05 % Tier 3 DERMATOLOGICALS Desoximetasone Topicort External Ointment 0.05 % Tier 3 DERMATOLOGICALS Desoximetasone Topicort External Ointment 0.25 % Tier 3 DERMATOLOGICALS Desoximetasone Topicort Spray External Liquid 0.25 % Tier 3 ANTICONVULSANTS Topiramate Topiramate ER Oral Capsule ER 24 Hour Sprinkle 100 MG Tier 3 x ANTICONVULSANTS Topiramate Topiramate ER Oral Capsule ER 24 Hour Sprinkle 150 MG Tier 3 x ANTICONVULSANTS Topiramate Topiramate ER Oral Capsule ER 24 Hour Sprinkle 200 MG Tier 3 x ANTICONVULSANTS Topiramate Topiramate ER Oral Capsule ER 24 Hour Sprinkle 25 MG Tier 3 x ANTICONVULSANTS Topiramate Topiramate ER Oral Capsule ER 24 Hour Sprinkle 50 MG Tier 3 x ANTICONVULSANTS Topiramate Topiramate Oral Capsule Sprinkle 15 MG Tier 1 x ANTICONVULSANTS Topiramate Topiramate Oral Capsule Sprinkle 25 MG Tier 1 x ANTICONVULSANTS Topiramate Topiramate Oral Tablet 100 MG Tier 1 x ANTICONVULSANTS Topiramate Topiramate Oral Tablet 200 MG Tier 1 x ANTICONVULSANTS Topiramate Topiramate Oral Tablet 25 MG Tier 1 x ANTICONVULSANTS Topiramate Topiramate Oral Tablet 50 MG Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Etoposide Toposar Intravenous Solution 1 GM/50ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Etoposide Toposar Intravenous Solution 500 MG/25ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Topotecan HCl Topotecan HCl Intravenous Solution Reconstituted 4 MG Tier 1 x BETA BLOCKERS Metoprolol Succinate Toprol XL Oral Tablet Extended Release 24 Hour 100 MG Tier 3 BETA BLOCKERS Metoprolol Succinate Toprol XL Oral Tablet Extended Release 24 Hour 200 MG Tier 3 BETA BLOCKERS Metoprolol Succinate Toprol XL Oral Tablet Extended Release 24 Hour 25 MG Tier 3 BETA BLOCKERS Metoprolol Succinate Toprol XL Oral Tablet Extended Release 24 Hour 50 MG Tier 3 DIURETICS Torsemide Torsemide Oral Tablet 10 MG Tier 1 DIURETICS Torsemide Torsemide Oral Tablet 100 MG Tier 1 DIURETICS Torsemide Torsemide Oral Tablet 20 MG Tier 1 DIURETICS Torsemide Torsemide Oral Tablet 5 MG Tier 1 ANTIDIABETICS Insulin Glargine Toujeo SoloStar Subcutaneous Solution Pen‐injector 300 UNIT/ML Tier 3 x URINARY ANTISPASMODICS Fesoterodine Fumarate Toviaz Oral Tablet Extended Release 24 Hour 4 MG Tier 3 x URINARY ANTISPASMODICS Fesoterodine Fumarate Toviaz Oral Tablet Extended Release 24 Hour 8 MG Tier 3 x CARDIOVASCULAR AGENTS ‐ MISC. Bosentan Tracleer Oral Tablet 125 MG Tier 2 x x CARDIOVASCULAR AGENTS ‐ MISC. Bosentan Tracleer Oral Tablet 62.5 MG Tier 2 x x ANTIDIABETICS Linagliptin Tradjenta Oral Tablet 5 MG Tier 3 x ANALGESICS ‐ OPIOID Tramadol HCl TraMADol HCl ER (Biphasic) Oral Tablet Extended Release 24 Hour 100 MG Tier 1 x ANALGESICS ‐ OPIOID Tramadol HCl TraMADol HCl ER (Biphasic) Oral Tablet Extended Release 24 Hour 200 MG Tier 1 x ANALGESICS ‐ OPIOID Tramadol HCl TraMADol HCl ER (Biphasic) Oral Tablet Extended Release 24 Hour 300 MG Tier 1 x ANALGESICS ‐ OPIOID Tramadol HCl TraMADol HCl ER Oral Capsule Extended Release 24 Hour 100 MG Tier 3 x ANALGESICS ‐ OPIOID Tramadol HCl TraMADol HCl ER Oral Capsule Extended Release 24 Hour 150 MG Tier 3 x ANALGESICS ‐ OPIOID Tramadol HCl TraMADol HCl ER Oral Capsule Extended Release 24 Hour 200 MG Tier 3 x ANALGESICS ‐ OPIOID Tramadol HCl TraMADol HCl ER Oral Capsule Extended Release 24 Hour 300 MG Tier 3 x ANALGESICS ‐ OPIOID Tramadol HCl TraMADol HCl ER Oral Tablet Extended Release 24 Hour 100 MG Tier 1 x ANALGESICS ‐ OPIOID Tramadol HCl TraMADol HCl ER Oral Tablet Extended Release 24 Hour 200 MG Tier 1 x ANALGESICS ‐ OPIOID Tramadol HCl TraMADol HCl ER Oral Tablet Extended Release 24 Hour 300 MG Tier 1 x ANALGESICS ‐ OPIOID Tramadol HCl TraMADol HCl Oral Tablet 50 MG Tier 1 ANALGESICS ‐ OPIOID Tramadol‐Acetaminophen Tramadol‐Acetaminophen Oral Tablet 37.5‐325 MG Tier 1 ANTIHYPERTENSIVES Trandolapril Trandolapril Oral Tablet 1 MG Tier 1 ANTIHYPERTENSIVES Trandolapril Trandolapril Oral Tablet 2 MG Tier 1 ANTIHYPERTENSIVES Trandolapril Trandolapril Oral Tablet 4 MG Tier 1 ANTIHYPERTENSIVES Trandolapril‐Verapamil HCl Trandolapril‐Verapamil HCl ER Oral Tablet Extended Release 1‐240 MG Tier 1 xx ANTIHYPERTENSIVES Trandolapril‐Verapamil HCl Trandolapril‐Verapamil HCl ER Oral Tablet Extended Release 2‐180 MG Tier 1 xx ANTIHYPERTENSIVES Trandolapril‐Verapamil HCl Trandolapril‐Verapamil HCl ER Oral Tablet Extended Release 2‐240 MG Tier 1 xx ANTIHYPERTENSIVES Trandolapril‐Verapamil HCl Trandolapril‐Verapamil HCl ER Oral Tablet Extended Release 4‐240 MG Tier 1 xx HEMOSTATICS Tranexamic Acid Tranexamic Acid Intravenous Solution 100 MG/ML Tier 1 x HEMOSTATICS Tranexamic Acid Tranexamic Acid Oral Tablet 650 MG Tier 1 x ANTIEMETICS Scopolamine Transderm‐Scop Transdermal Patch 72 Hour 1 MG/3DAYS Tier 3 x ANTIANXIETY AGENTS Clorazepate Dipotassium Tranxene‐T Oral Tablet 15 MG Tier 3 ANTIANXIETY AGENTS Clorazepate Dipotassium Tranxene‐T Oral Tablet 3.75 MG Tier 3 ANTIANXIETY AGENTS Clorazepate Dipotassium Tranxene‐T Oral Tablet 7.5 MG Tier 3 ANTIDEPRESSANTS Tranylcypromine Sulfate Tranylcypromine Sulfate Oral Tablet 10 MG Tier 1 NUTRIENTS Amino Acid Infusion Travasol Intravenous Solution 10 % Tier 3 x OPHTHALMIC AGENTS Travoprost Travatan Z Ophthalmic Solution 0.004 % Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Travel Lancets Miscellaneous Tier 2 OPHTHALMIC AGENTS Travoprost Travoprost Ophthalmic Solution 0.004 % Tier 2 ANTIDEPRESSANTS Trazodone HCl TraZODone HCl Oral Tablet 100 MG Tier 1 ANTIDEPRESSANTS Trazodone HCl TraZODone HCl Oral Tablet 150 MG Tier 1 ANTIDEPRESSANTS Trazodone HCl TraZODone HCl Oral Tablet 300 MG Tier 1 ANTIDEPRESSANTS Trazodone HCl TraZODone HCl Oral Tablet 50 MG Tier 1 ANTIDEPRESSANTS Trazodone HCl TraZODone HCl Powder Tier 3 xx OTIC AGENTS Antipyrine‐Benzocaine‐Polycosanol Treagan Otic Solution 5.4‐1.4‐0.0097 % Tier 3 ANTIMYCOBACTERIAL AGENTS Ethionamide Trecator Oral Tablet 250 MG Tier 3 ANTIDIABETICS Insulin Degludec Tresiba FlexTouch Subcutaneous Solution Pen‐injector 100 UNIT/ML Tier 3 x ANTIDIABETICS Insulin Degludec Tresiba FlexTouch Subcutaneous Solution Pen‐injector 200 UNIT/ML Tier 3 x DERMATOLOGICALS Tretinoin Tretinoin External Cream 0.025 % Tier 1 x DERMATOLOGICALS Tretinoin Tretinoin External Cream 0.05 % Tier 1 x DERMATOLOGICALS Tretinoin Tretinoin External Cream 0.1 % Tier 1 x DERMATOLOGICALS Tretinoin Tretinoin External Gel 0.01 % Tier 1 x DERMATOLOGICALS Tretinoin Tretinoin External Gel 0.025 % Tier 1 x DERMATOLOGICALS Tretinoin Tretinoin External Gel 0.05 % Tier 1 x DERMATOLOGICALS Tretinoin Microsphere Tretinoin Microsphere External Gel 0.04 % Tier 1 x DERMATOLOGICALS Tretinoin Microsphere Tretinoin Microsphere External Gel 0.1 % Tier 1 x DERMATOLOGICALS Tretinoin Microsphere Tretinoin Microsphere Pump External Gel 0.04 % Tier 1 x DERMATOLOGICALS Tretinoin Microsphere Tretinoin Microsphere Pump External Gel 0.1 % Tier 1 x HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Tretinoin (Chemotherapy) Tretinoin Oral Capsule 10 MG Tier 1 DERMATOLOGICALS Tretinoin Tretinoin Powder Tier 2 DERMATOLOGICALS Tretinoin Tretin‐X External Cream 0.0375 % Tier 3 DERMATOLOGICALS Tretinoin Tretin‐X External Cream 0.075 % Tier 3 DERMATOLOGICALS Tretinoin w/ Cleanser & Moisturizer Tretin‐X External Kit 0.025 % CREAM Tier 3 DERMATOLOGICALS Tretinoin w/ Cleanser & Moisturizer Tretin‐X External Kit 0.05 % CREAM Tier 3 DERMATOLOGICALS Tretinoin w/ Cleanser & Moisturizer Tretin‐X External Kit 0.1 % CREAM Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Methotrexate Sodium Trexall Oral Tablet 10 MG Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Methotrexate Sodium Trexall Oral Tablet 15 MG Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Methotrexate Sodium Trexall Oral Tablet 5 MG Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Methotrexate Sodium Trexall Oral Tablet 7.5 MG Tier 3 MIGRAINE PRODUCTS Sumatriptan‐Naproxen Sodium Treximet Oral Tablet 85‐500 MG Tier 3 xx ANALGESICS ‐ OPIOID Acetaminophen‐Caff‐Dihydrocod Trezix Oral Capsule 320.5‐30‐16 MG Tier 3 MULTIVITAMINS Prenatal Vit w/ Docusate‐Iron Carbonyl‐Folic Acid TriAdvance Oral Tablet 90‐1 MG Tier 3 DERMATOLOGICALS Triamcinolone Acetonide (Topical) Triamcinolone Acetonide External Aerosol Solution 0.147 MG/GM Tier 1 DERMATOLOGICALS Triamcinolone Acetonide (Topical) Triamcinolone Acetonide External Cream 0.025 % Tier 1 DERMATOLOGICALS Triamcinolone Acetonide (Topical) Triamcinolone Acetonide External Cream 0.1 % Tier 1 DERMATOLOGICALS Triamcinolone Acetonide (Topical) Triamcinolone Acetonide External Cream 0.5 % Tier 1 DERMATOLOGICALS Triamcinolone Acetonide (Topical) Triamcinolone Acetonide External Lotion 0.025 % Tier 1 DERMATOLOGICALS Triamcinolone Acetonide (Topical) Triamcinolone Acetonide External Lotion 0.1 % Tier 1 DERMATOLOGICALS Triamcinolone Acetonide (Topical) Triamcinolone Acetonide External Ointment 0.025 % Tier 1 DERMATOLOGICALS Triamcinolone Acetonide (Topical) Triamcinolone Acetonide External Ointment 0.1 % Tier 1 DERMATOLOGICALS Triamcinolone Acetonide (Topical) Triamcinolone Acetonide External Ointment 0.5 % Tier 2 MOUTH/THROAT/DENTAL AGENTS Triamcinolone Acetonide (Mouth) Triamcinolone Acetonide Mouth/Throat Paste 0.1 % Tier 1 NASAL AGENTS ‐ SYSTEMIC AND TOPICAL Triamcinolone Acetonide (Nasal) Triamcinolone Acetonide Nasal Aerosol 55 MCG/ACT Tier 1 DERMATOLOGICALS Triamcinolone Acetonide (Topical) Triamcinolone Acetonide Powder Tier 3 CORTICOSTEROIDS Triamcinolone Diacetate Micronized Triamcinolone Diacet Micronize Powder Tier 3 CORTICOSTEROIDS Triamcinolone Diacetate Micronized Triamcinolone Diacetate Powder Tier 3 DERMATOLOGICALS Triamcinolone Acetonide‐Silicone Triamsil Combipak External Therapy Pack 0.1 & 5 % Tier 3 DERMATOLOGICALS Triamcinolone Acetonide‐Silicone Triamsil Multipak External Therapy Pack 0.1 & 5 % Tier 3 DIURETICS Triamterene & Hydrochlorothiazide Triamterene‐HCTZ Oral Capsule 37.5‐25 MG Tier 1 DIURETICS Triamterene & Hydrochlorothiazide Triamterene‐HCTZ Oral Capsule 50‐25 MG Tier 3 DIURETICS Triamterene & Hydrochlorothiazide Triamterene‐HCTZ Oral Tablet 37.5‐25 MG Tier 1 DIURETICS Triamterene & Hydrochlorothiazide Triamterene‐HCTZ Oral Tablet 75‐50 MG Tier 1 DERMATOLOGICALS Triamcinolone Acetonide (Topical) Trianex External Ointment 0.05 % Tier 3 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Triazolam Triazolam Oral Tablet 0.125 MG Tier 1 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Triazolam Triazolam Oral Tablet 0.25 MG Tier 1 ANTIHYPERTENSIVES Olmesartan Medoxomil‐Amlodipine‐Hydrochlorothiazide Tribenzor Oral Tablet 20‐5‐12.5 MG Tier 2 x ANTIHYPERTENSIVES Olmesartan Medoxomil‐Amlodipine‐Hydrochlorothiazide Tribenzor Oral Tablet 40‐10‐12.5 MG Tier 2 x ANTIHYPERTENSIVES Olmesartan Medoxomil‐Amlodipine‐Hydrochlorothiazide Tribenzor Oral Tablet 40‐10‐25 MG Tier 2 x ANTIHYPERTENSIVES Olmesartan Medoxomil‐Amlodipine‐Hydrochlorothiazide Tribenzor Oral Tablet 40‐5‐12.5 MG Tier 2 x ANTIHYPERTENSIVES Olmesartan Medoxomil‐Amlodipine‐Hydrochlorothiazide Tribenzor Oral Tablet 40‐5‐25 MG Tier 2 x MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐Folic Acid TriCare Oral Tablet Tier 3 MULTIVITAMINS Prenatal without Vit A w/ Fe Fumarate‐FA‐Fish Oil TriCare Prenatal Compleat Oral Miscellaneous 27‐1 MG Tier 2 MULTIVITAMINS Prenatal w/Fe Fumarate‐FA‐DSS‐Fish Oil TriCare Prenatal DHA ONE Oral Capsule 27‐1‐500 MG Tier 2 DERMATOLOGICALS Trichloroacetic Acid Tri‐Chlor External Liquid 80 % Tier 3 DERMATOLOGICALS Trichloroacetic Acid Trichloroacetic Acid Powder Tier 3 BIOLOGICALS MISC Trichophyton Trichophyton Subcutaneous Solution 20000 PNU/ML Tier 3 x ANTICOAGULANTS Anticoagulant Sodium Citrate TriCitrasol In Vitro Concentrate 46.7 % Tier 3 GENITOURINARY AGENTS ‐ MISCELLANEOUS Pot & Sod Citrates w/Citric Ac Tricitrates Oral Solution 550‐500‐334 MG/5ML Tier 1 HEMATOPOIETIC AGENTS Ferrous Fumarate w/ B12‐Vit C‐FA‐IFC Tricon Oral Capsule Tier 1 ANTIHYPERLIPIDEMICS Fenofibrate Tricor Oral Tablet 145 MG Tier 3 x ANTIHYPERLIPIDEMICS Fenofibrate Tricor Oral Tablet 48 MG Tier 3 x DERMATOLOGICALS Triamcinolone Acetonide (Topical) Triderm External Cream 0.1 % Tier 1 DERMATOLOGICALS Calcitriol‐Fluticasone Propionate‐Tacrolimus Triderma Forte External Cream Tier 3 CONTRACEPTIVES Norgestimate‐Ethinyl Estradiol (Triphasic) Tri‐Estarylla Oral Tablet 0.18/0.215/0.25 MG‐35 MCG Tier 1 HEMATOPOIETIC AGENTS Ferric Pyrophosphate Citrate Triferic Hemodialysis Solution 27.2 MG/5ML Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Trifluoperazine HCl Trifluoperazine HCl Oral Tablet 1 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Trifluoperazine HCl Trifluoperazine HCl Oral Tablet 10 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Trifluoperazine HCl Trifluoperazine HCl Oral Tablet 2 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Trifluoperazine HCl Trifluoperazine HCl Oral Tablet 5 MG Tier 1 OPHTHALMIC AGENTS Trifluridine Trifluridine Ophthalmic Solution 1 % Tier 1 HEMATOPOIETIC AGENTS Fe Fumarate‐Vitamin C‐Vitamin B12‐Folic Acid Trigels‐F Forte Oral Capsule 460‐60‐0.01‐1 MG Tier 1 ANTIHYPERLIPIDEMICS Fenofibrate Triglide Oral Tablet 160 MG Tier 3 xx ANTIPARKINSON AGENTS Trihexyphenidyl HCl Trihexyphenidyl HCl Oral Elixir 0.4 MG/ML Tier 1 ANTIPARKINSON AGENTS Trihexyphenidyl HCl Trihexyphenidyl HCl Oral Tablet 2 MG Tier 1 ANTIPARKINSON AGENTS Trihexyphenidyl HCl Trihexyphenidyl HCl Oral Tablet 5 MG Tier 1 CONTRACEPTIVES Norethindrone Acetate‐Ethinyl Estradiol‐Fe Tri‐Legest Fe Oral Tablet 1‐20/1‐30/1‐35 MG‐MCG Tier 1 ANTICONVULSANTS Oxcarbazepine Trileptal Oral Suspension 300 MG/5ML Tier 3 ANTICONVULSANTS Oxcarbazepine Trileptal Oral Tablet 150 MG Tier 3 ANTICONVULSANTS Oxcarbazepine Trileptal Oral Tablet 300 MG Tier 3 ANTICONVULSANTS Oxcarbazepine Trileptal Oral Tablet 600 MG Tier 3 CONTRACEPTIVES Norgestimate‐Ethinyl Estradiol (Triphasic) Tri‐Linyah Oral Tablet 0.18/0.215/0.25 MG‐35 MCG Tier 1 ANTIHYPERLIPIDEMICS Choline Fenofibrate Trilipix Oral Capsule Delayed Release 135 MG Tier 3 x ANTIHYPERLIPIDEMICS Choline Fenofibrate Trilipix Oral Capsule Delayed Release 45 MG Tier 3 x CONTRACEPTIVES Norgestimate‐Ethinyl Estradiol (Triphasic) Tri‐Lo‐Estarylla Oral Tablet 0.18/0.215/0.25 MG‐25 MCG Tier 1 CONTRACEPTIVES Norgestimate‐Ethinyl Estradiol (Triphasic) Tri‐Lo‐Marzia Oral Tablet 0.18/0.215/0.25 MG‐25 MCG Tier 1 CONTRACEPTIVES Norgestimate‐Ethinyl Estradiol (Triphasic) Tri‐Lo‐Sprintec Oral Tablet 0.18/0.215/0.25 MG‐25 MCG Tier 1 DERMATOLOGICALS Fluocinolone‐Hydroquinone‐Tretinoin Tri‐Luma External Cream 0.01‐4‐0.05 % Tier 3 LAXATIVES PEG 3350‐Potassium Chloride‐Sod Bicarbonate‐Sod Chloride TriLyte Oral Solution Reconstituted 420 GM Tier 1 ANTIEMETICS Trimethobenzamide HCl Trimethobenzamide HCl Oral Capsule 300 MG Tier 1 ANTI‐INFECTIVE AGENTS ‐ MISC. Trimethoprim Trimethoprim Oral Tablet 100 MG Tier 1 ANTI‐INFECTIVE AGENTS ‐ MISC. Trimethoprim Trimethoprim Powder Tier 3 ANTIDEPRESSANTS Trimipramine Maleate Trimipramine Maleate Oral Capsule 100 MG Tier 1 ANTIDEPRESSANTS Trimipramine Maleate Trimipramine Maleate Oral Capsule 25 MG Tier 1 ANTIDEPRESSANTS Trimipramine Maleate Trimipramine Maleate Oral Capsule 50 MG Tier 1 MULTIVITAMINS Prenatal Vit w/ Docusate‐Iron Carbonyl‐Folic Acid Trinatal GT Oral Tablet 90‐1 MG Tier 2 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐Folic Acid Trinatal Rx 1 Oral Tablet 60‐1 MG Tier 3 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐Folic Acid Trinate Oral Tablet Tier 3 CONTRACEPTIVES Norgestimate‐Ethinyl Estradiol (Triphasic) TriNessa (28) Oral Tablet 0.18/0.215/0.25 MG‐35 MCG Tier 1 CONTRACEPTIVES Norgestimate‐Ethinyl Estradiol (Triphasic) TriNessa Lo Oral Tablet 0.18/0.215/0.25 MG‐25 MCG Tier 1 CONTRACEPTIVES Norethindrone‐Eth Estradiol (Triphasic) Tri‐Norinyl (28) Oral Tablet 0.5/1/0.5‐35 MG‐MCG Tier 3 THYROID AGENTS Liothyronine Sodium Triostat Intravenous Solution 10 MCG/ML Tier 3 x ANTIHISTAMINES Tripelennamine HCl Tripelennamine HCl Powder Tier 3 MULTIVITAMINS B‐Complex w/ C & Folic Acid Triphrocaps Oral Capsule 1 MG Tier 1 OPHTHALMIC AGENTS Neomycin‐Bacitracin Zn‐Polymyxin Triple Antibiotic Ophthalmic Ointment 5‐400‐10000 Tier 1 MULTIVITAMINS Pediatric Vitamins ACD w/ Fluoride Triple‐Vitamin/Fluoride Oral Solution 0.25 MG/ML Tier 1 CONTRACEPTIVES Norgestimate‐Ethinyl Estradiol (Triphasic) Tri‐Previfem Oral Tablet 0.18/0.215/0.25 MG‐35 MCG Tier 1 DERMATOLOGICALS Adapalene‐Clindamycin Phosphate Triseon External Cream 0.3‐1 % Tier 3 x CONTRACEPTIVES Norgestimate‐Ethinyl Estradiol (Triphasic) Tri‐Sprintec Oral Tablet 0.18/0.215/0.25 MG‐35 MCG Tier 1 MULTIVITAMINS Prenatal Vit without Vit A w/ Fe Bisglycinate‐FA‐Omeg 3 Tri‐Tabs DHA Oral Miscellaneous 32‐1 MG Tier 2 ANTIVIRALS Abacavir‐Dolutegravir‐Lamivudine Triumeq Oral Tablet 600‐50‐300 MG Tier 2 x MULTIVITAMINS Prenatal MV & Min w/Fe Bisglyc‐Fe Prot Succ‐FA‐CA‐Omega 3 Triveen‐Duo DHA Oral Miscellaneous 29‐1‐200 & 400 MG Tier 3 MULTIVITAMINS Prenatal w/o Vit A w/ Fe Fumarate‐DSS‐FA‐DHA Triveen‐PRx RNF Oral Capsule 26‐1.2‐300 MG Tier 3 MULTIVITAMINS Pediatric Vitamins ACD & L‐Methylfolate w/ Fluoride Tri‐Vi‐Flor Oral Suspension 0.25 MG/ML Tier 2 MULTIVITAMINS Pediatric Vitamins ACD & L‐Methylfolate w/ Fluoride Tri‐Vi‐Flor Oral Suspension 0.5 MG/ML Tier 2 MULTIVITAMINS Pediatric Vitamins ACD & L‐Methylfolate w/ Fluoride Tri‐Vi‐Floro Oral Suspension 0.25 MG/ML Tier 2 MULTIVITAMINS Pediatric Vitamins ACD & L‐Methylfolate w/ Fluoride Tri‐Vi‐Floro Oral Suspension 0.5 MG/ML Tier 2 MULTIVITAMINS Pediatric Vitamins ACD w/ Fluoride Tri‐Vit/Fluoride Oral Solution 0.25 MG/ML Tier 1 MULTIVITAMINS Pediatric Vitamins ACD w/ Fluoride Tri‐Vit/Fluoride Oral Solution 0.5 MG/ML Tier 1 MULTIVITAMINS Pediatric Vitamins ACD Fluoride & Iron Tri‐Vit/Fluoride/Iron Oral Solution 0.25‐10 MG/ML Tier 2 MULTIVITAMINS Pediatric Vitamins ACD w/ Fluoride Tri‐Vitamin/Fluoride Oral Solution 0.25 MG/ML Tier 1 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

MULTIVITAMINS Pediatric Vitamins ACD w/ Fluoride Tri‐Vitamin/Fluoride Oral Solution 0.5 MG/ML Tier 1 CONTRACEPTIVES Levonorgestrel‐Eth Estradiol (Triphasic) Trivora (28) Oral Tablet Tier 1 ANTIVIRALS Abacavir Sulfate‐Lamivudine‐Zidovudine Trizivir Oral Tablet 300‐150‐300 MG Tier 2 x ANTICONVULSANTS Topiramate Trokendi XR Oral Capsule Extended Release 24 Hour 100 MG Tier 3 x ANTICONVULSANTS Topiramate Trokendi XR Oral Capsule Extended Release 24 Hour 200 MG Tier 3 x ANTICONVULSANTS Topiramate Trokendi XR Oral Capsule Extended Release 24 Hour 25 MG Tier 3 x ANTICONVULSANTS Topiramate Trokendi XR Oral Capsule Extended Release 24 Hour 50 MG Tier 3 x PHARMACEUTICAL ADJUVANTS Trolamine (Triethanolamine) Trolamine Liquid Tier 3 PHARMACEUTICAL ADJUVANTS Trolamine (Triethanolamine) Trolamine Liquid 99 % Tier 3 OPHTHALMIC AGENTS Tropicamide Tropicamide Ophthalmic Solution 0.5 % Tier 1 OPHTHALMIC AGENTS Tropicamide Tropicamide Ophthalmic Solution 1 % Tier 1 OPHTHALMIC AGENTS Tropicamide Tropicamide Powder Tier 3 URINARY ANTISPASMODICS Trospium Chloride Trospium Chloride ER Oral Capsule Extended Release 24 Hour 60 MG Tier 1 URINARY ANTISPASMODICS Trospium Chloride Trospium Chloride Oral Tablet 20 MG Tier 1 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies True Metrix Air Glucose Meter Kit w/Device Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood True Metrix Blood Glucose Test In Vitro Strip Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood True Metrix Blood Glucose Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies True Metrix Meter Kit w/Device Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 TRUEplus Insulin Syringe Miscellaneous 28G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 TRUEplus Insulin Syringe Miscellaneous 28G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 TRUEplus Insulin Syringe Miscellaneous 29G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 TRUEplus Insulin Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 TRUEplus Insulin Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 TRUEplus Insulin Syringe Miscellaneous 30G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 TRUEplus Insulin Syringe Miscellaneous 30G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 TRUEplus Insulin Syringe Miscellaneous 30G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 TRUEplus Insulin Syringe Miscellaneous 31G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 TRUEplus Insulin Syringe Miscellaneous 31G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 TRUEplus Insulin Syringe Miscellaneous 31G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets TRUEplus Lancets 26G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets TRUEplus Lancets 28G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets TRUEplus Lancets 30G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets TRUEplus Lancets 33G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets TRUEplus Safety Lancets 28G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies TRUEresult Blood Glucose Kit w/Device Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood TRUEtest Test In Vitro Strip Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood TRUEtest Test In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies TrueTrack Blood Glucose Kit w/Device Tier 3 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies TrueTrack Smart System Kit Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood TrueTrack Test In Vitro Strip Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood TrueTrack Test In Vitro Strip Tier 3 ANTIDIABETICS Dulaglutide Trulicity Subcutaneous Solution Pen‐injector 0.75 MG/0.5ML Tier 3 xx ANTIDIABETICS Dulaglutide Trulicity Subcutaneous Solution Pen‐injector 1.5 MG/0.5ML Tier 3 xx VACCINES Meningococcal Group B Vaccine Trumenba Intramuscular Suspension Prefilled Syringe Tier 3 x OPHTHALMIC AGENTS Dorzolamide HCl Trusopt Ophthalmic Solution 2 % Tier 3 ANTIVIRALS Emtricitabine‐Tenofovir Disoproxil Fumarate Truvada Oral Tablet 200‐300 MG Tier 2 x NUTRIENTS Tryptophan Tryptophan Oral Capsule 500 MG Tier 3 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Aclidinium Bromide Tudorza Pressair Inhalation Aerosol Powder Breath Activated 400 MCG/ACT Tier 2 COUGH/COLD/ALLERGY Hydrocodone Polistirex‐Chlorpheniramine Polistirex TussiCaps Oral Capsule Extended Release 12 Hour 10‐8 MG Tier 3 COUGH/COLD/ALLERGY Hydrocodone Polistirex‐Chlorpheniramine Polistirex TussiCaps Oral Capsule Extended Release 12 Hour 5‐4 MG Tier 3 COUGH/COLD/ALLERGY Hydrocodone w/ Homatropine Tussigon Oral Tablet 5‐1.5 MG Tier 1 COUGH/COLD/ALLERGY Hydrocodone Polistirex‐Chlorpheniramine Polistirex Tussionex Pennkinetic ER Oral Liquid Extended Release 10‐8 MG/5ML Tier 3 COUGH/COLD/ALLERGY Codeine Polistirex‐Chlorpheniramine Polistirex Tuzistra XR Oral Liquid Extended Release 14.7‐2.8 MG/5ML Tier 3 VACCINES Hepatitis A (Inactivated)‐Hepatitis B (Recombinant) Vaccines Twinrix Intramuscular Suspension 720‐20 Tier 3 x ANTIHYPERTENSIVES Telmisartan‐Amlodipine Twynsta Oral Tablet 40‐10 MG Tier 3 x ANTIHYPERTENSIVES Telmisartan‐Amlodipine Twynsta Oral Tablet 40‐5 MG Tier 3 x ANTIHYPERTENSIVES Telmisartan‐Amlodipine Twynsta Oral Tablet 80‐10 MG Tier 3 x ANTIHYPERTENSIVES Telmisartan‐Amlodipine Twynsta Oral Tablet 80‐5 MG Tier 3 x ANTIVIRALS Cobicistat Tybost Oral Tablet 150 MG Tier 3 x ANTI‐INFECTIVE AGENTS ‐ MISC. Tigecycline Tygacil Intravenous Solution Reconstituted 50 MG Tier 3 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Lapatinib Ditosylate Tykerb Oral Tablet 250 MG Tier 2 x ANALGESICS ‐ OPIOID Acetaminophen w/ Codeine Tylenol with Codeine #3 Oral Tablet 300‐30 MG Tier 3 ANALGESICS ‐ OPIOID Acetaminophen w/ Codeine Tylenol with Codeine #4 Oral Tablet 300‐60 MG Tier 3 VACCINES Typhoid VI Polysaccharide Vaccine Typhim VI Intramuscular Solution 25 MCG/0.5ML Tier 3 x CARDIOVASCULAR AGENTS ‐ MISC. Treprostinil Tyvaso Inhalation Solution 0.6 MG/ML Tier 2 x CARDIOVASCULAR AGENTS ‐ MISC. Treprostinil Tyvaso Refill Inhalation Solution 0.6 MG/ML Tier 2 x CARDIOVASCULAR AGENTS ‐ MISC. Treprostinil Tyvaso Starter Inhalation Solution 0.6 MG/ML Tier 2 x ANTIVIRALS Telbivudine Tyzeka Oral Tablet 600 MG Tier 2 x x NASAL AGENTS ‐ SYSTEMIC AND TOPICAL Tetrahydrozoline HCl Tyzine Nasal Solution 0.05 % Tier 3 NASAL AGENTS ‐ SYSTEMIC AND TOPICAL Tetrahydrozoline HCl Tyzine Nasal Solution 0.1 % Tier 3 CHEMICALS Coenzyme Q10 Ubidecarenone Powder Tier 3 CORTICOSTEROIDS Budesonide Uceris Oral Tablet Extended Release 24 Hour 9 MG Tier 3 ANORECTAL AGENTS Budesonide (Intrarectal) Uceris Rectal Foam 2 MG/ACT Tier 3 MULTIVITAMINS Multiple Vitamins w/ Minerals & Folic Acid Udamin SP Oral Tablet 1 MG Tier 3 DERMATOLOGICALS Urea U‐Kera E External Cream 40 % Tier 1 DERMATOLOGICALS Benzyl Alcohol (Pediculicide) Ulesfia External Lotion 5 % Tier 3 GOUT AGENTS Febuxostat Uloric Oral Tablet 40 MG Tier 2 x GOUT AGENTS Febuxostat Uloric Oral Tablet 80 MG Tier 2 x GENERAL ANESTHETICS Sevoflurane Ultane Inhalation Solution Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 UltiCare Insulin Safety Syr Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 UltiCare Insulin Safety Syr Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 UltiCare Insulin Syringe Miscellaneous 28G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 UltiCare Insulin Syringe Miscellaneous 28G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 UltiCare Insulin Syringe Miscellaneous 29G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 UltiCare Insulin Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 UltiCare Insulin Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 UltiCare Insulin Syringe Miscellaneous 30G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 UltiCare Insulin Syringe Miscellaneous 30G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 UltiCare Insulin Syringe Miscellaneous 30G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 UltiCare Insulin Syringe Miscellaneous 30G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 UltiCare Insulin Syringe Miscellaneous 30G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 UltiCare Insulin Syringe Miscellaneous 30G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 UltiCare Insulin Syringe Miscellaneous 31G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 UltiCare Insulin Syringe Miscellaneous 31G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 UltiCare Insulin Syringe Miscellaneous 31G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle UltiCare Micro Pen Needles Miscellaneous 32G X 4 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle UltiCare Mini Pen Needles Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle UltiCare Pen Needles Miscellaneous 29G X 12.7MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle UltiCare Pen Needles Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 1.5 ML UltiCare Safety Syringe Miscellaneous 22G X 1‐1/2" 1.5 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle UltiCare Short Pen Needles Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 1 ML UltiCare Syringe Miscellaneous 22G X 1‐1/2" 1 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 1.5 ML UltiCare Syringe Miscellaneous 22G X 1‐1/2" 1.5 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 3 ML UltiCare Syringe Miscellaneous 22G X 1‐1/2" 3 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets UltiCare Thin Lancets 30G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Ultilet Classic Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Ultilet Insulin Syringe Short Miscellaneous 30G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Ultilet Insulin Syringe Short Miscellaneous 30G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Ultilet Insulin Syringe Short Miscellaneous 30G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Ultilet Insulin Syringe Short Miscellaneous 31G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Ultilet Insulin Syringe Short Miscellaneous 31G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Ultilet Insulin Syringe Short Miscellaneous 31G X 5/16" 1 ML Tier 2 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

MEDICAL DEVICES AND SUPPLIES Lancets Ultilet Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Ultilet Pen Needle Miscellaneous 31G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Ultilet Pen Needle Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Ultilet Pen Needle Miscellaneous 32G X 4 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Ultilet Safety Lancets 23G Miscellaneous Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood Ultima Test In Vitro Strip Tier 3 MULTIVITAMINS Prenatal w/Fe Cbnyl‐Fe Asparto Glyc‐FA‐DSS‐Omega 3 UltimateCare ONE NF Oral Capsule 20‐7‐1 MG Tier 3 MULTIVITAMINS Prenatal Vit w/ Iron Carbonyl‐Fe Aspart Glyc‐FA‐Omega 3 UltimateCare ONE Oral Capsule 27‐1 MG Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Ultra Comfort Insulin Syringe Miscellaneous 30G X 5/16" 0.3 ML Tier 2 MULTIVITAMINS Prenatal Vit w/ Docusate‐Iron Carbonyl‐Folic Acid Ultra Tabs Oral Tablet Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Ultra Thin Lancets 28G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Ultra Thin Lancets 30G Miscellaneous Tier 2 ANALGESICS ‐ OPIOID Tramadol‐Acetaminophen Ultracet Oral Tablet 37.5‐325 MG Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Ultra‐Comfort Insulin Syringe Miscellaneous 28G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Ultra‐Comfort Insulin Syringe Miscellaneous 28G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Ultra‐Comfort Insulin Syringe Miscellaneous 29G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Ultra‐Comfort Insulin Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Ultra‐Comfort Insulin Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Ultra‐Comfort Insulin Syringe Miscellaneous 30G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Ultra‐Comfort Insulin Syringe Miscellaneous 30G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Ultra‐Comfort Insulin Syringe Miscellaneous 30G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Ultra‐Comfort Insulin Syringe Miscellaneous 31G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Ultra‐Comfort Insulin Syringe Miscellaneous 31G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Ultra‐Comfort Insulin Syringe Miscellaneous 31G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Misc. UltraLance Miscellaneous Tier 2 ANALGESICS ‐ OPIOID Tramadol HCl Ultram ER Oral Tablet Extended Release 24 Hour 100 MG Tier 3 x ANALGESICS ‐ OPIOID Tramadol HCl Ultram ER Oral Tablet Extended Release 24 Hour 200 MG Tier 3 x ANALGESICS ‐ OPIOID Tramadol HCl Ultram ER Oral Tablet Extended Release 24 Hour 300 MG Tier 3 x ANALGESICS ‐ OPIOID Tramadol HCl Ultram Oral Tablet 50 MG Tier 3 DERMATOLOGICALS Salicylic Acid UltraSal‐ER External Solution 28.5 % Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Ultra‐Thin II Auto Lancet Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Ultra‐Thin II Ins Syr Short Miscellaneous 30G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Ultra‐Thin II Ins Syr Short Miscellaneous 30G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Ultra‐Thin II Ins Syr Short Miscellaneous 30G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Ultra‐Thin II Ins Syr Short Miscellaneous 31G X 5/16" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Ultra‐Thin II Ins Syr Short Miscellaneous 31G X 5/16" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Ultra‐Thin II Ins Syr Short Miscellaneous 31G X 5/16" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Ultra‐Thin II Insulin Syringe Miscellaneous 29G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Ultra‐Thin II Insulin Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Ultra‐Thin II Insulin Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Ultra‐Thin II Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Ultra‐Thin II Mini Pen Needle Miscellaneous 31G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Ultra‐Thin II Pen Needle Short Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Ultra‐Thin II Pen Needles Miscellaneous 29G X 12.7MM Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood UltraTRAK PRO Test In Vitro Strip Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood UltraTRAK Ultimate Test In Vitro Strip Tier 3 DERMATOLOGICALS Halobetasol Propionate Ultravate External Cream 0.05 % Tier 3 DERMATOLOGICALS Halobetasol Propionate Ultravate External Ointment 0.05 % Tier 3 DERMATOLOGICALS Halobetasol Propionate & Lactic Acid Ultravate X (Cream) External Kit 0.05 & 10 % Tier 3 DERMATOLOGICALS Halobetasol Propionate & Lactic Acid Ultravate X (Ointment) External Kit 0.05 & 10 % Tier 3 DIAGNOSTIC PRODUCTS Iopromide Ultravist Injection Solution 50 % Tier 3 x DIAGNOSTIC PRODUCTS Iopromide Ultravist Injection Solution 62 % Tier 3 x DIAGNOSTIC PRODUCTS Iopromide Ultravist Injection Solution 77 % Tier 3 x DERMATOLOGICALS Urea Umecta External Emulsion 40 % Tier 3 DERMATOLOGICALS Urea Umecta Mousse External Foam 40 % Tier 1 DERMATOLOGICALS Urea Umecta Nail Film External Suspension 40 % Tier 3 DERMATOLOGICALS Urea & Hyaluronate Sodium Umecta PD External Emulsion 40‐0.3 % Tier 3 DERMATOLOGICALS Urea & Hyaluronate Sodium Umecta PD External Suspension 40‐0.3 % Tier 3 PENICILLINS Ampicillin & Sulbactam Sodium Unasyn Injection Solution Reconstituted 3 (2‐1) GM Tier 3 x MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Unifine Pentips Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Unifine Pentips Miscellaneous 31G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Unifine Pentips Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Unifine Pentips Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Unifine Pentips Miscellaneous 32G X 4 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Unifine Pentips Plus Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Unifine Pentips Plus Miscellaneous 31G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Unifine Pentips Plus Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Unifine Pentips Plus Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Unifine Pentips Plus Miscellaneous 32G X 4 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Unilet ComforTouch Lancet Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Unilet ExceLite II Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Unilet ExceLite Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Unilet G.P. Lancet Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Unilet G.P. Superlite Lancet Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Unilet GP 28 Ultra Thin Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Unilet Lancet Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Unilet Micro‐Thin 33G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Unilet Superlite Lancet Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Unilet Super‐Thin 30G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Unilet Ultra‐Thin 28G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Misc. Unistik 1 Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Misc. Unistik 2 Comfort Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Misc. Unistik 2 Extra Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Misc. Unistik 2 Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Misc. Unistik 2 Normal Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Misc. Unistik 2 Super Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Misc. Unistik 3 Comfort Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Misc. Unistik 3 Extra Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Unistik 3 Gentle Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Misc. Unistik 3 Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Misc. Unistik 3 Neonatal Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Misc. Unistik 3 Normal Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Unistik Safety Lancets 28G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Unistik Safety Lancets 30G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Unistik Touch Safety Lanc 21G Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Unistik Touch Safety Lanc 23G Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Unistik Touch Safety Lanc 28G Miscellaneous Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Unistik Touch Safety Lanc 30G Miscellaneous Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Unistrip1 Generic In Vitro Strip Tier 3 THYROID AGENTS Levothyroxine Sodium Unithroid Direct Oral Tablet 100 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Unithroid Direct Oral Tablet 112 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Unithroid Direct Oral Tablet 125 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Unithroid Direct Oral Tablet 150 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Unithroid Direct Oral Tablet 175 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Unithroid Direct Oral Tablet 200 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Unithroid Direct Oral Tablet 25 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Unithroid Direct Oral Tablet 300 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Unithroid Direct Oral Tablet 50 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Unithroid Direct Oral Tablet 75 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Unithroid Direct Oral Tablet 88 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Unithroid Oral Tablet 100 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Unithroid Oral Tablet 112 MCG Tier 1 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

THYROID AGENTS Levothyroxine Sodium Unithroid Oral Tablet 125 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Unithroid Oral Tablet 137 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Unithroid Oral Tablet 150 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Unithroid Oral Tablet 175 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Unithroid Oral Tablet 200 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Unithroid Oral Tablet 25 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Unithroid Oral Tablet 300 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Unithroid Oral Tablet 50 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Unithroid Oral Tablet 75 MCG Tier 1 THYROID AGENTS Levothyroxine Sodium Unithroid Oral Tablet 88 MCG Tier 1 MEDICAL DEVICES AND SUPPLIES Lancets Universal 1 Lancets Thin 26G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Universal 1 Lancets Ultra Thin Miscellaneous Tier 2 CARDIOVASCULAR AGENTS ‐ MISC. Selexipag Uptravi Oral Tablet 1000 MCG Tier 3 CARDIOVASCULAR AGENTS ‐ MISC. Selexipag Uptravi Oral Tablet 1200 MCG Tier 3 CARDIOVASCULAR AGENTS ‐ MISC. Selexipag Uptravi Oral Tablet 1400 MCG Tier 3 CARDIOVASCULAR AGENTS ‐ MISC. Selexipag Uptravi Oral Tablet 1600 MCG Tier 3 CARDIOVASCULAR AGENTS ‐ MISC. Selexipag Uptravi Oral Tablet 200 MCG Tier 3 CARDIOVASCULAR AGENTS ‐ MISC. Selexipag Uptravi Oral Tablet 400 MCG Tier 3 CARDIOVASCULAR AGENTS ‐ MISC. Selexipag Uptravi Oral Tablet 600 MCG Tier 3 CARDIOVASCULAR AGENTS ‐ MISC. Selexipag Uptravi Oral Tablet 800 MCG Tier 3 CARDIOVASCULAR AGENTS ‐ MISC. Selexipag Uptravi Oral Tablet Therapy Pack 200 & 800 MCG Tier 3 URINARY ANTI‐INFECTIVES Methenamine‐Hyosc‐Methylene Blue‐Sod Phos‐Phenyl Sal Ur N‐C Oral Tablet 81.6 MG Tier 1 DERMATOLOGICALS Urea Uramaxin External Cream 45 % Tier 3 DERMATOLOGICALS Urea in Ammonium Lactate Vehicle Uramaxin External Foam 20 % Tier 3 DERMATOLOGICALS Urea Uramaxin External Gel 45 % Tier 3 DERMATOLOGICALS Urea Uramaxin External Lotion 45 % Tier 3 DERMATOLOGICALS Urea Uramaxin GT External Gel 45 % Tier 3 DERMATOLOGICALS Urea & Emollient Uramaxin GT External Kit 45 % Tier 3 URINARY ANTI‐INFECTIVES Methenamine‐Hyosc‐Methylene Blue‐Sod Phos‐Phenyl Sal Uramit MB Oral Capsule 118 MG Tier 1 DERMATOLOGICALS Urea Urea External Cream 39 % Tier 1 DERMATOLOGICALS Urea Urea External Cream 40 % Tier 1 DERMATOLOGICALS Urea Urea External Cream 45 % Tier 1 DERMATOLOGICALS Urea Urea External Cream 47 % Tier 1 DERMATOLOGICALS Urea Urea External Cream 50 % Tier 1 DERMATOLOGICALS Urea in Zinc Undecylenate‐Lactic Acid Vehicle Urea External Emulsion 50 % Tier 1 DERMATOLOGICALS Urea Urea External Gel 40 % Tier 1 DERMATOLOGICALS Urea Urea External Lotion 40 % Tier 1 DERMATOLOGICALS Urea Urea External Lotion 45 % Tier 1 DERMATOLOGICALS Urea Urea External Suspension 40 % Tier 1 DERMATOLOGICALS Urea in Lactic Acid‐Salicylic Acid Vehicle Urea External Suspension 50 % Tier 1 DERMATOLOGICALS Urea in Lactic Acid Vehicle Urea Hydrating External Foam 35 % Tier 1 DERMATOLOGICALS Urea in Zinc Undecylenate‐Lactic Acid Vehicle Urea in Zn Undecyl‐Lactic Acid External Emulsion 50 % Tier 1 DERMATOLOGICALS Urea Urea Nail External Gel 45 % Tier 1 DERMATOLOGICALS Urea & Hyaluronate Sodium Urea Nail External Kit 40 & 0.2 % Tier 3 DERMATOLOGICALS Urea in Zinc Undecylenate‐Lactic Acid Vehicle Urea Nail External Stick 50 % Tier 3 DERMATOLOGICALS Urea Urea Nail Film External Suspension 40 % Tier 1 DERMATOLOGICALS Urea Urea‐C40 External Lotion 40 % Tier 1 URINARY ANTISPASMODICS Bethanechol Chloride Urecholine Oral Tablet 10 MG Tier 3 URINARY ANTISPASMODICS Bethanechol Chloride Urecholine Oral Tablet 25 MG Tier 3 URINARY ANTISPASMODICS Bethanechol Chloride Urecholine Oral Tablet 5 MG Tier 3 URINARY ANTISPASMODICS Bethanechol Chloride Urecholine Oral Tablet 50 MG Tier 3 URINARY ANTI‐INFECTIVES Methenamine‐Hyosc‐Methylene Blue‐Sod Phos‐Phenyl Sal Urelle Oral Tablet 81 MG Tier 1 URINARY ANTI‐INFECTIVES Methenamine‐Hyosc‐Methylene Blue‐Sod Phos‐Phenyl Sal Uretron D/S Oral Tablet Tier 1 URINARY ANTI‐INFECTIVES Methenamine‐Hyosc‐Methylene Blue‐Sod Phos‐Phenyl Sal Uribel Oral Capsule 118 MG Tier 1 URINARY ANTI‐INFECTIVES Methenamine‐Hyosc‐Methylene Blue‐Sod Phos‐Phenyl Sal Urimar‐T Oral Tablet 120 MG Tier 3 URINARY ANTI‐INFECTIVES Methenamine‐Hyosc‐Methylene Blue‐Sod Phos‐Phenyl Sal Urin DS Oral Tablet Tier 1 GENITOURINARY AGENTS ‐ MISCELLANEOUS Potassium Citrate (Alkalinizer) Urocit‐K 10 Oral Tablet Extended Release 10 MEQ (1080 MG) Tier 3 GENITOURINARY AGENTS ‐ MISCELLANEOUS Potassium Citrate (Alkalinizer) Urocit‐K 15 Oral Tablet Extended Release 15 MEQ (1620 MG) Tier 3 GENITOURINARY AGENTS ‐ MISCELLANEOUS Potassium Citrate (Alkalinizer) Urocit‐K 5 Oral Tablet Extended Release 5 MEQ (540 MG) Tier 3 URINARY ANTI‐INFECTIVES Methenamine‐Hyoscamine‐Methylene Blue‐Sodium Phosphate Urogesic‐Blue Oral Tablet 81.6 MG Tier 3 URINARY ANTI‐INFECTIVES Methenamine‐Hyosc‐Methylene Blue‐Sod Phos‐Phenyl Sal Uro‐L Oral Tablet 81 MG Tier 1 URINARY ANTI‐INFECTIVES Methenamine‐Hyoscamine‐Methylene Blue‐Sodium Phosphate Urolet MB Oral Tablet 81.6 MG Tier 1 URINARY ANTI‐INFECTIVES Methenamine‐Hyosc‐Methylene Blue‐Sod Phos‐Phenyl Sal Uro‐MP Oral Capsule 118 MG Tier 1 URINARY ANTI‐INFECTIVES Methenamine‐Hyosc‐Methylene Blue‐Benzoic Acid‐Phenyl Sal Urophen MB Oral Tablet 81.6 MG Tier 1 URINARY ANTI‐INFECTIVES Methenamine Mandelate‐Sodium Phosphate Monobasic Uroqid #2 Oral Tablet 500‐500 MG Tier 3 GENITOURINARY AGENTS ‐ MISCELLANEOUS Alfuzosin HCl Uroxatral Oral Tablet Extended Release 24 Hour 10 MG Tier 3 GASTROINTESTINAL AGENTS ‐ MISC. Ursodiol Urso 250 Oral Tablet 250 MG Tier 3 GASTROINTESTINAL AGENTS ‐ MISC. Ursodiol Urso Forte Oral Tablet 500 MG Tier 3 GASTROINTESTINAL AGENTS ‐ MISC. Ursodiol Ursodiol Oral Capsule 300 MG Tier 1 GASTROINTESTINAL AGENTS ‐ MISC. Ursodiol Ursodiol Oral Tablet 250 MG Tier 1 GASTROINTESTINAL AGENTS ‐ MISC. Ursodiol Ursodiol Oral Tablet 500 MG Tier 1 URINARY ANTI‐INFECTIVES Methenamine‐Hyoscamine‐Methylene Blue‐Sodium Phosphate Uryl Oral Tablet 81.6 MG Tier 1 URINARY ANTI‐INFECTIVES Methenamine‐Hyosc‐Methylene Blue‐Sod Phos‐Phenyl Sal Ustell Oral Capsule 120 MG Tier 1 URINARY ANTI‐INFECTIVES Methenamine‐Hyoscamine‐Methylene Blue‐Sodium Phosphate UTA Oral Capsule 120 MG Tier 1 URINARY ANTI‐INFECTIVES Methenamine‐Hyosc‐Methylene Blue‐Sod Phos‐Phenyl Sal Uticap Oral Capsule 120 MG Tier 1 URINARY ANTI‐INFECTIVES Methenamine‐Hyosc‐Methylene Blue‐Sod Phos‐Phenyl Sal Utira‐C Oral Tablet 81.6 MG Tier 1 DERMATOLOGICALS Urea Utopic External Cream 41 % Tier 3 URINARY ANTI‐INFECTIVES Methenamine‐Hyosc‐Methylene Blue‐Sod Phos‐Phenyl Sal Utrona‐C Oral Tablet 81.6 MG Tier 1 VAGINAL PRODUCTS Estradiol Vaginal Vagifem Vaginal Tablet 10 MCG Tier 3 ANTIVIRALS Valacyclovir HCl ValACYclovir HCl Oral Tablet 1 GM Tier 1 x ANTIVIRALS Valacyclovir HCl ValACYclovir HCl Oral Tablet 500 MG Tier 1 x DERMATOLOGICALS Mechlorethamine HCl (Topical) Valchlor External Gel 0.016 % Tier 2 x ANTIVIRALS Valganciclovir HCl Valcyte Oral Solution Reconstituted 50 MG/ML Tier 2 x ANTIVIRALS Valganciclovir HCl Valcyte Oral Tablet 450 MG Tier 2 x ANTIVIRALS Valganciclovir HCl ValGANciclovir HCl Oral Tablet 450 MG Tier 1 x DERMATOLOGICALS Calcitriol‐Fluticasone Propionate‐Tacrolimus Validerm External Cream Tier 3 NUTRIENTS Valine Valine Powder Tier 3 ANTIANXIETY AGENTS Diazepam Valium Oral Tablet 10 MG Tier 3 ANTIANXIETY AGENTS Diazepam Valium Oral Tablet 2 MG Tier 3 ANTIANXIETY AGENTS Diazepam Valium Oral Tablet 5 MG Tier 3 ANTICONVULSANTS Valproate Sodium Valproate Sodium Intravenous Solution 100 MG/ML Tier 1 x ANTICONVULSANTS Valproate Sodium Valproate Sodium Intravenous Solution 500 MG/5ML Tier 1 x ANTICONVULSANTS Valproic Acid Valproic Acid Oral Capsule 250 MG Tier 1 ANTICONVULSANTS Valproate Sodium Valproic Acid Oral Solution 250 MG/5ML Tier 1 ANTICONVULSANTS Valproate Sodium Valproic Acid Oral Syrup 250 MG/5ML Tier 1 ANTIHYPERTENSIVES Valsartan Valsartan Oral Tablet 160 MG Tier 1 ANTIHYPERTENSIVES Valsartan Valsartan Oral Tablet 320 MG Tier 1 ANTIHYPERTENSIVES Valsartan Valsartan Oral Tablet 40 MG Tier 1 ANTIHYPERTENSIVES Valsartan Valsartan Oral Tablet 80 MG Tier 1 ANTIHYPERTENSIVES Valsartan‐Hydrochlorothiazide Valsartan‐Hydrochlorothiazide Oral Tablet 160‐12.5 MG Tier 1 ANTIHYPERTENSIVES Valsartan‐Hydrochlorothiazide Valsartan‐Hydrochlorothiazide Oral Tablet 160‐25 MG Tier 1 ANTIHYPERTENSIVES Valsartan‐Hydrochlorothiazide Valsartan‐Hydrochlorothiazide Oral Tablet 320‐12.5 MG Tier 1 ANTIHYPERTENSIVES Valsartan‐Hydrochlorothiazide Valsartan‐Hydrochlorothiazide Oral Tablet 320‐25 MG Tier 1 ANTIHYPERTENSIVES Valsartan‐Hydrochlorothiazide Valsartan‐Hydrochlorothiazide Oral Tablet 80‐12.5 MG Tier 1 ANTIVIRALS Valacyclovir HCl Valtrex Oral Tablet 1 GM Tier 3 x ANTIVIRALS Valacyclovir HCl Valtrex Oral Tablet 500 MG Tier 3 x MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Value Health Insulin Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 Value Health Insulin Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Value Plus Lancet Standard 21G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Value Plus Lancets Super Thin Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Value Plus Lancets Thin 26G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets ValuMark Lancet Super Thin 30G Miscellaneous Tier 2 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

MEDICAL DEVICES AND SUPPLIES Lancets ValuMark Lancet Ultra Thin 28G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle ValuMark Pen Needles Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle ValuMark Pen Needles Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle ValuMark Pen Needles Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers Valved Holding Chamber Device Tier 2 x ANALGESICS ‐ NonNarcotic Butalbital‐Acetaminophen‐Caffeine Vanatol LQ Oral Solution 50‐325‐40 MG/15ML Tier 3 ANTI‐INFECTIVE AGENTS ‐ MISC. Vancomycin HCl Vancocin HCl Oral Capsule 125 MG Tier 3 ANTI‐INFECTIVE AGENTS ‐ MISC. Vancomycin HCl Vancocin HCl Oral Capsule 250 MG Tier 3 ANTI‐INFECTIVE AGENTS ‐ MISC. Vancomycin HCl Vancomycin HCl Intravenous Solution Reconstituted 10 GM Tier 1 x ANTI‐INFECTIVE AGENTS ‐ MISC. Vancomycin HCl Vancomycin HCl Intravenous Solution Reconstituted 1000 MG Tier 1 x ANTI‐INFECTIVE AGENTS ‐ MISC. Vancomycin HCl Vancomycin HCl Intravenous Solution Reconstituted 500 MG Tier 1 x ANTI‐INFECTIVE AGENTS ‐ MISC. Vancomycin HCl Vancomycin HCl Intravenous Solution Reconstituted 5000 MG Tier 1 x ANTI‐INFECTIVE AGENTS ‐ MISC. Vancomycin HCl Vancomycin HCl Intravenous Solution Reconstituted 750 MG Tier 3 x ANTI‐INFECTIVE AGENTS ‐ MISC. Vancomycin HCl Vancomycin HCl Oral Capsule 125 MG Tier 1 ANTI‐INFECTIVE AGENTS ‐ MISC. Vancomycin HCl Vancomycin HCl Oral Capsule 250 MG Tier 1 ANTI‐INFECTIVE AGENTS ‐ MISC. Vancomycin HCl Vancomycin HCl Powder Tier 3 ANTI‐INFECTIVE AGENTS ‐ MISC. Vancomycin HCl Vancomycin+SyrSpend SF PH4 Oral Suspension 50 MG/ML Tier 3 VAGINAL PRODUCTS Metronidazole Vaginal Vandazole Vaginal Gel 0.75 % Tier 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Vandetanib Vandetanib Oral Tablet 100 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Vandetanib Vandetanib Oral Tablet 300 MG Tier 2 x x CHEMICALS Vanillin Vanillin Powder Tier 3 DERMATOLOGICALS Eflornithine HCl Vaniqa External Cream 13.9 % Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 VanishPoint Insulin Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 VanishPoint Insulin Syringe Miscellaneous 30G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Syringe/Needle (Disp) 1 ML VanishPoint Syringe Miscellaneous 25G X 1" 1 ML Tier 3 DERMATOLOGICALS Fluocinonide Vanos External Cream 0.1 % Tier 3 DERMATOLOGICALS Benzoyl Peroxide‐HC Vanoxide‐HC External Lotion 5‐0.5 % Tier 3 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Histrelin Acetate Vantas Subcutaneous Kit 50 MG Tier 2 x VACCINES Hepatitis A Vaccine Vaqta Intramuscular Suspension 25 UNIT/0.5ML Tier 3 x VACCINES Hepatitis A Vaccine Vaqta Intramuscular Suspension 50 UNIT/ML Tier 3 x VACCINES Varicella Virus Vaccine Live Varivax Subcutaneous Injectable 1350 PFU/0.5ML Tier 3 x ANTIEMETICS Rolapitant HCl Varubi Oral Tablet 90 MG Tier 3 x ANTIHYPERLIPIDEMICS Icosapent Ethyl Vascepa Oral Capsule 1 GM Tier 2 x x ANTIHYPERTENSIVES Enalapril Maleate & Hydrochlorothiazide Vaseretic Oral Tablet 10‐25 MG Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Vasopressin Injection Solution 20 UNIT/ML Tier 1 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Vasopressin Vasostrict Intravenous Solution 20 UNIT/ML Tier 3 x ANTIHYPERTENSIVES Enalapril Maleate Vasotec Oral Tablet 10 MG Tier 3 ANTIHYPERTENSIVES Enalapril Maleate Vasotec Oral Tablet 2.5 MG Tier 3 ANTIHYPERTENSIVES Enalapril Maleate Vasotec Oral Tablet 20 MG Tier 3 ANTIHYPERTENSIVES Enalapril Maleate Vasotec Oral Tablet 5 MG Tier 3 VASOPRESSORS Phenylephrine HCl (Pressors) Vazculep Intravenous Solution 10 MG/ML Tier 3 x MULTIVITAMINS Multiple Vitamins w/ Minerals V‐C Forte Oral Capsule Tier 1 ANTIHYPERTENSIVES Mecamylamine HCl Vecamyl Oral Tablet 2.5 MG Tier 3 DERMATOLOGICALS Calcitriol (Topical) Vectical External Ointment 3 MCG/GM Tier 2 NEUROMUSCULAR AGENTS Vecuronium Bromide Vecuronium Bromide Intravenous Solution Reconstituted 10 MG Tier 1 x NEUROMUSCULAR AGENTS Vecuronium Bromide Vecuronium Bromide Intravenous Solution Reconstituted 20 MG Tier 1 x PHARMACEUTICAL ADJUVANTS Non Gelatin Capsules (Empty) Vegetable Capsule #0 Green Capsule Tier 3 PHARMACEUTICAL ADJUVANTS Non Gelatin Capsules (Empty) Vegetable Capsule #0 White Capsule Tier 3 PHARMACEUTICAL ADJUVANTS Non Gelatin Capsules (Empty) Vegetable Capsule #00 White Capsule Tier 3 PHARMACEUTICAL ADJUVANTS Non Gelatin Capsules (Empty) Vegetable Capsule #1 White Capsule Tier 3 PHARMACEUTICAL ADJUVANTS Non Gelatin Capsules (Empty) Vegetable Capsule #2 White Capsule Tier 3 PHARMACEUTICAL ADJUVANTS Non Gelatin Capsules (Empty) Vegetable Capsule #3 White Capsule Tier 3 PHARMACEUTICAL ADJUVANTS Non Gelatin Capsules (Empty) Vegetable Capsule #4 White Capsule Tier 3 CONTRACEPTIVES Desogestrel‐Ethinyl Estradiol (Triphasic) Velivet Oral Tablet 0.1/0.125/0.15 ‐0.025 MG Tier 1 GASTROINTESTINAL AGENTS ‐ MISC. Sucroferric Oxyhydroxide Velphoro Oral Tablet Chewable 500 MG Tier 3 ASSORTED CLASSES Patiromer Sorbitex Calcium Veltassa Oral Packet 16.8 GM Tier 3 ASSORTED CLASSES Patiromer Sorbitex Calcium Veltassa Oral Packet 25.2 GM Tier 3 ASSORTED CLASSES Patiromer Sorbitex Calcium Veltassa Oral Packet 8.4 GM Tier 3 DERMATOLOGICALS Clindamycin Phosphate‐Tretinoin Veltin External Gel 1.2‐0.025 % Tier 3 x DERMATOLOGICALS Lidocaine‐Menthol Veltrix External Cream 4‐1 % Tier 3 MULTIVITAMINS Prenatal w/o Vit A w/ Fe Fumarate‐DSS‐FA‐DHA VemaVite‐PRx 2 Oral Capsule 27‐1.25‐300 MG Tier 3 MULTIVITAMINS Prenatal w/Fe Polysacch Cmplx‐Sod Feredetate‐FA‐Omega 3 Vena‐Bal DHA Oral Miscellaneous 27‐1 & 430 MG Tier 2 ANTIDEPRESSANTS Venlafaxine HCl Venlafaxine HCl ER Oral Capsule Extended Release 24 Hour 150 MG Tier 1 ANTIDEPRESSANTS Venlafaxine HCl Venlafaxine HCl ER Oral Capsule Extended Release 24 Hour 37.5 MG Tier 1 ANTIDEPRESSANTS Venlafaxine HCl Venlafaxine HCl ER Oral Capsule Extended Release 24 Hour 75 MG Tier 1 ANTIDEPRESSANTS Venlafaxine HCl Venlafaxine HCl ER Oral Tablet Extended Release 24 Hour 150 MG Tier 1 ANTIDEPRESSANTS Venlafaxine HCl Venlafaxine HCl ER Oral Tablet Extended Release 24 Hour 150 MG Tier 3 ANTIDEPRESSANTS Venlafaxine HCl Venlafaxine HCl ER Oral Tablet Extended Release 24 Hour 225 MG Tier 2 x ANTIDEPRESSANTS Venlafaxine HCl Venlafaxine HCl ER Oral Tablet Extended Release 24 Hour 37.5 MG Tier 1 ANTIDEPRESSANTS Venlafaxine HCl Venlafaxine HCl ER Oral Tablet Extended Release 24 Hour 37.5 MG Tier 3 ANTIDEPRESSANTS Venlafaxine HCl Venlafaxine HCl ER Oral Tablet Extended Release 24 Hour 75 MG Tier 1 ANTIDEPRESSANTS Venlafaxine HCl Venlafaxine HCl ER Oral Tablet Extended Release 24 Hour 75 MG Tier 3 ANTIDEPRESSANTS Venlafaxine HCl Venlafaxine HCl Oral Tablet 100 MG Tier 1 ANTIDEPRESSANTS Venlafaxine HCl Venlafaxine HCl Oral Tablet 25 MG Tier 1 ANTIDEPRESSANTS Venlafaxine HCl Venlafaxine HCl Oral Tablet 37.5 MG Tier 1 ANTIDEPRESSANTS Venlafaxine HCl Venlafaxine HCl Oral Tablet 50 MG Tier 1 ANTIDEPRESSANTS Venlafaxine HCl Venlafaxine HCl Oral Tablet 75 MG Tier 1 HEMATOPOIETIC AGENTS Iron Sucrose Venofer Intravenous Solution 20 MG/ML Tier 3 x CARDIOVASCULAR AGENTS ‐ MISC. Iloprost Ventavis Inhalation Solution 10 MCG/ML Tier 2 x x CARDIOVASCULAR AGENTS ‐ MISC. Iloprost Ventavis Inhalation Solution 20 MCG/ML Tier 2 x x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Albuterol Sulfate Ventolin HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT Tier 2 NASAL AGENTS ‐ SYSTEMIC AND TOPICAL Fluticasone Furoate Veramyst Nasal Suspension 27.5 MCG/SPRAY Tier 2 xx CALCIUM CHANNEL BLOCKERS Verapamil HCl Verapamil HCl ER Oral Capsule Extended Release 24 Hour 100 MG Tier 1 CALCIUM CHANNEL BLOCKERS Verapamil HCl Verapamil HCl ER Oral Capsule Extended Release 24 Hour 120 MG Tier 1 CALCIUM CHANNEL BLOCKERS Verapamil HCl Verapamil HCl ER Oral Capsule Extended Release 24 Hour 180 MG Tier 1 CALCIUM CHANNEL BLOCKERS Verapamil HCl Verapamil HCl ER Oral Capsule Extended Release 24 Hour 200 MG Tier 1 CALCIUM CHANNEL BLOCKERS Verapamil HCl Verapamil HCl ER Oral Capsule Extended Release 24 Hour 240 MG Tier 1 CALCIUM CHANNEL BLOCKERS Verapamil HCl Verapamil HCl ER Oral Capsule Extended Release 24 Hour 300 MG Tier 1 CALCIUM CHANNEL BLOCKERS Verapamil HCl Verapamil HCl ER Oral Capsule Extended Release 24 Hour 360 MG Tier 1 CALCIUM CHANNEL BLOCKERS Verapamil HCl Verapamil HCl ER Oral Tablet Extended Release 120 MG Tier 1 CALCIUM CHANNEL BLOCKERS Verapamil HCl Verapamil HCl ER Oral Tablet Extended Release 180 MG Tier 1 CALCIUM CHANNEL BLOCKERS Verapamil HCl Verapamil HCl ER Oral Tablet Extended Release 240 MG Tier 1 CALCIUM CHANNEL BLOCKERS Verapamil HCl Verapamil HCl Intravenous Solution 2.5 MG/ML Tier 1 x CALCIUM CHANNEL BLOCKERS Verapamil HCl Verapamil HCl Oral Tablet 120 MG Tier 1 CALCIUM CHANNEL BLOCKERS Verapamil HCl Verapamil HCl Oral Tablet 40 MG Tier 1 CALCIUM CHANNEL BLOCKERS Verapamil HCl Verapamil HCl Oral Tablet 80 MG Tier 1 CALCIUM CHANNEL BLOCKERS Verapamil HCl Verapamil HCl Powder Tier 3 DERMATOLOGICALS Desonide Verdeso External Foam 0.05 % Tier 3 ANALGESICS ‐ OPIOID Hydrocodone‐Acetaminophen Verdrocet Oral Tablet 2.5‐325 MG Tier 1 DERMATOLOGICALS Sinecatechins Veregen External Ointment 15 % Tier 3 CALCIUM CHANNEL BLOCKERS Verapamil HCl Verelan Oral Capsule Extended Release 24 Hour 120 MG Tier 3 CALCIUM CHANNEL BLOCKERS Verapamil HCl Verelan Oral Capsule Extended Release 24 Hour 180 MG Tier 3 CALCIUM CHANNEL BLOCKERS Verapamil HCl Verelan Oral Capsule Extended Release 24 Hour 240 MG Tier 3 CALCIUM CHANNEL BLOCKERS Verapamil HCl Verelan Oral Capsule Extended Release 24 Hour 360 MG Tier 3 CALCIUM CHANNEL BLOCKERS Verapamil HCl Verelan PM Oral Capsule Extended Release 24 Hour 100 MG Tier 3 CALCIUM CHANNEL BLOCKERS Verapamil HCl Verelan PM Oral Capsule Extended Release 24 Hour 200 MG Tier 3 CALCIUM CHANNEL BLOCKERS Verapamil HCl Verelan PM Oral Capsule Extended Release 24 Hour 300 MG Tier 3 CORTICOSTEROIDS Prednisolone Sodium Phosphate Veripred 20 Oral Solution 20 MG/5ML Tier 3 DERMATOLOGICALS Fluorouracil‐Salicylic Acid Verrunex External Cream 5‐12 % Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Clozapine Versacloz Oral Suspension 50 MG/ML Tier 3 x URINARY ANTISPASMODICS Solifenacin Succinate VESIcare Oral Tablet 10 MG Tier 2 URINARY ANTISPASMODICS Solifenacin Succinate VESIcare Oral Tablet 5 MG Tier 2 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

CONTRACEPTIVES Drospirenone‐Ethinyl Estradiol Vestura Oral Tablet 3‐0.02 MG Tier 1 OPHTHALMIC AGENTS Rimexolone Vexol Ophthalmic Suspension 1 % Tier 3 ANTIFUNGALS Voriconazole Vfend IV Intravenous Solution Reconstituted 200 MG Tier 3 x ANTIFUNGALS Voriconazole Vfend Oral Suspension Reconstituted 40 MG/ML Tier 3 ANTIFUNGALS Voriconazole Vfend Oral Tablet 200 MG Tier 3 ANTIFUNGALS Voriconazole Vfend Oral Tablet 50 MG Tier 3 CARDIOVASCULAR AGENTS ‐ MISC. Sildenafil Citrate Viagra Oral Tablet 100 MG Tier 3 x x CARDIOVASCULAR AGENTS ‐ MISC. Sildenafil Citrate Viagra Oral Tablet 25 MG Tier 3 x x CARDIOVASCULAR AGENTS ‐ MISC. Sildenafil Citrate Viagra Oral Tablet 50 MG Tier 3 x x GASTROINTESTINAL AGENTS ‐ MISC. Eluxadoline Viberzi Oral Tablet 100 MG Tier 3 x GASTROINTESTINAL AGENTS ‐ MISC. Eluxadoline Viberzi Oral Tablet 75 MG Tier 3 x TETRACYCLINES Doxycycline Hyclate Vibramycin Oral Capsule 100 MG Tier 3 TETRACYCLINES Doxycycline (Monohydrate) Vibramycin Oral Suspension Reconstituted 25 MG/5ML Tier 3 TETRACYCLINES Doxycycline Calcium Vibramycin Oral Syrup 50 MG/5ML Tier 3 MULTIVITAMINS Multiple Vitamins w/ Minerals Vicap Forte Oral Capsule Tier 1 MULTIVITAMINS Multiple Vitamins w/ Minerals VIC‐Forte Oral Capsule Tier 1 ANALGESICS ‐ OPIOID Hydrocodone‐Acetaminophen Vicodin ES Oral Tablet 7.5‐300 MG Tier 1 ANALGESICS ‐ OPIOID Hydrocodone‐Acetaminophen Vicodin HP Oral Tablet 10‐300 MG Tier 1 ANALGESICS ‐ OPIOID Hydrocodone‐Acetaminophen Vicodin Oral Tablet 5‐300 MG Tier 1 ANALGESICS ‐ OPIOID Hydrocodone‐Ibuprofen Vicoprofen Oral Tablet 7.5‐200 MG Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Victory AGM‐4000 Test In Vitro Strip Tier 3 ANTIDIABETICS Liraglutide Victoza Subcutaneous Solution Pen‐injector 18 MG/3ML Tier 2 xx ANTIVIRALS Boceprevir Victrelis Oral Capsule 200 MG Tier 2 x x MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Vida Mia Unifine Pentips Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Vida Mia Unifine Pentips Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Vida Mia Unifine Pentips Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Vida Mia Unifine Pentips Miscellaneous 32G X 4 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Vida Mia Unilet Lancets 28G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Vida Mia Unilet Lancets 30G Miscellaneous Tier 2 ANTIVIRALS Didanosine Videx EC Oral Capsule Delayed Release 125 MG Tier 3 x ANTIVIRALS Didanosine Videx EC Oral Capsule Delayed Release 200 MG Tier 3 x ANTIVIRALS Didanosine Videx EC Oral Capsule Delayed Release 250 MG Tier 3 x ANTIVIRALS Didanosine Videx EC Oral Capsule Delayed Release 400 MG Tier 3 x ANTIVIRALS Didanosine Videx Oral Solution Reconstituted 2 GM Tier 2 x ANTIVIRALS Didanosine Videx Oral Solution Reconstituted 4 GM Tier 2 x ANTIVIRALS Ombitasvir‐Paritaprevir‐Ritonavir & Dasabuvir Viekira Pak Oral Tablet Therapy Pack 12.5‐75‐50 &250 MG Tier 2 x x CONTRACEPTIVES Levonorgestrel & Eth Estradiol Vienva Oral Tablet 0.1‐20 MG‐MCG Tier 1 OPHTHALMIC AGENTS Moxifloxacin HCl (Ophth) Vigamox Ophthalmic Solution 0.5 % Tier 2 ANTIDEPRESSANTS Vilazodone HCl Viibryd Oral Tablet 10 MG Tier 3 xx ANTIDEPRESSANTS Vilazodone HCl Viibryd Oral Tablet 20 MG Tier 3 xx ANTIDEPRESSANTS Vilazodone HCl Viibryd Oral Tablet 40 MG Tier 3 xx ANTIDEPRESSANTS Vilazodone HCl Viibryd Starter Pack Oral Kit 10 & 20 MG Tier 3 x ANTICONVULSANTS Lacosamide Vimpat Oral Solution 10 MG/ML Tier 3 x ANTICONVULSANTS Lacosamide Vimpat Oral Tablet 100 MG Tier 2 x ANTICONVULSANTS Lacosamide Vimpat Oral Tablet 150 MG Tier 2 x ANTICONVULSANTS Lacosamide Vimpat Oral Tablet 200 MG Tier 2 x ANTICONVULSANTS Lacosamide Vimpat Oral Tablet 50 MG Tier 2 x MULTIVITAMINS Prenatal w/o Vit A w/ Fe Carbonyl‐Fe Gluconate‐FA & Vit B6 Vinacal B Oral Miscellaneous 20‐1 & 25 (2) MG Tier 2 MULTIVITAMINS Prenatal Vit w/ Fe Bisglycinate Chelate‐Folic Acid Vinate AZ Extra Oral Tablet 29‐1 MG Tier 3 MULTIVITAMINS Prenatal without A Vit w/ Fe Fumarate‐Folic Acid Vinate C Oral Tablet 30‐1 MG Tier 3 MULTIVITAMINS Prenatal Vit w/ Iron Carbonyl‐Fe Gluconate‐Folic Acid Vinate Calcium Oral Tablet 27‐1 MG Tier 2 MULTIVITAMINS Prenatal without A Vit w/ Fe Fumarate‐Folic Acid Vinate Care Oral Tablet Chewable 40‐1 MG Tier 3 MULTIVITAMINS Prenatal without Vit A w/ Fe Fumarate‐L Methylfolate‐Omegas Vinate DHA RF Oral Capsule 27‐1.13 MG Tier 2 MULTIVITAMINS Prenatal without A Vit w/ Fe Fum‐Iron Polysacch Complex ‐FA Vinate IC Oral Capsule 162‐115.2‐1 MG Tier 3 MULTIVITAMINS Prenatal Vit w/ Fe Bisglycinate Chelate‐Folic Acid Vinate II Oral Tablet 29‐1 MG Tier 3 MULTIVITAMINS Prenatal Vit w/ Selenium‐Fe Fumarate‐Folic Acid Vinate M Oral Tablet 27‐1 MG Tier 2 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐Folic Acid Vinate One Oral Tablet 60‐1 MG Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Vincristine Sulfate Vincasar PFS Intravenous Solution 1 MG/ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Vincristine Sulfate VinCRIStine Sulfate Intravenous Solution 1 MG/ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Vinorelbine Tartrate Vinorelbine Tartrate Intravenous Solution 10 MG/ML Tier 1 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Vinorelbine Tartrate Vinorelbine Tartrate Intravenous Solution 50 MG/5ML Tier 1 x DIGESTIVE AIDS Pancrelipase (Lipase‐Protease‐Amylase) Viokace Oral Tablet 10440 UNIT Tier 3 x DIGESTIVE AIDS Pancrelipase (Lipase‐Protease‐Amylase) Viokace Oral Tablet 20880 UNIT Tier 3 x CONTRACEPTIVES Desogestrel‐Ethinyl Estradiol (Biphasic) Viorele Oral Tablet 0.15‐0.02/0.01 MG (21/5) Tier 1 ANTIVIRALS Nelfinavir Mesylate Viracept Oral Tablet 250 MG Tier 2 x ANTIVIRALS Nelfinavir Mesylate Viracept Oral Tablet 625 MG Tier 2 x ANTIVIRALS Nevirapine Viramune Oral Suspension 50 MG/5ML Tier 3 x ANTIVIRALS Nevirapine Viramune Oral Tablet 200 MG Tier 3 x ANTIVIRALS Nevirapine Viramune XR Oral Tablet Extended Release 24 Hour 100 MG Tier 3 x ANTIVIRALS Nevirapine Viramune XR Oral Tablet Extended Release 24 Hour 400 MG Tier 3 x DERMATOLOGICALS Salicylic Acid Virasal External Liquid 27.5 % Tier 3 ANTIVIRALS Ribavirin Virazole Inhalation Solution Reconstituted 6 GM Tier 2 x ANTIVIRALS Tenofovir Disoproxil Fumarate Viread Oral Powder 40 MG/GM Tier 2 x ANTIVIRALS Tenofovir Disoproxil Fumarate Viread Oral Tablet 150 MG Tier 2 x ANTIVIRALS Tenofovir Disoproxil Fumarate Viread Oral Tablet 200 MG Tier 2 x ANTIVIRALS Tenofovir Disoproxil Fumarate Viread Oral Tablet 250 MG Tier 2 x ANTIVIRALS Tenofovir Disoproxil Fumarate Viread Oral Tablet 300 MG Tier 2 x OPHTHALMIC AGENTS Trifluridine Viroptic Ophthalmic Solution 1 % Tier 3 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐Folic Acid Virt Nate Oral Tablet 28‐1 MG Tier 3 MULTIVITAMINS Prenatal Vit w/ Docusate‐Iron Carbonyl‐Folic Acid Virt‐Advance Oral Tablet 90‐1 MG Tier 2 MULTIVITAMINS Prenatal Vit w/ Fe Fum‐Iron Polysacch Complex ‐FA‐Omega 3 Virt‐C DHA Oral Capsule 53.5‐38‐1 MG Tier 2 MULTIVITAMINS B‐Complex w/ C & Folic Acid Virt‐Caps Oral Capsule 1 MG Tier 1 MULTIVITAMINS Prenatal Vit w/ Iron Carbonyl‐Fe Aspart Glyc‐FA‐Omega 3 Virt‐Care One Oral Capsule 27‐1 MG Tier 2 HEMATOPOIETIC AGENTS Folic Acid‐Vitamin B6‐Vitamin B12 Virt‐Gard Oral Tablet 2.2‐25‐1 MG Tier 1 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐FA‐Omega 3 Fatty Acids Virt‐Nate DHA Oral Capsule 28‐1‐200 MG Tier 3 MINERALS & ELECTROLYTES Pot Phosphate Monobasic w/ Sod Phosphate Dibasic & Monobasic Virt‐Phos 250 Neutral Oral Tablet 155‐852‐130 MG Tier 1 MULTIVITAMINS Prenatal without A w/ Fe Fumarate‐L Methylfolate‐FA‐DHA Virt‐PN DHA Oral Capsule 27‐0.6‐0.4‐300 MG Tier 3 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐L Methylfolate‐Folic Acid Virt‐PN Oral Tablet 27‐0.6‐0.4 MG Tier 2 MULTIVITAMINS Prenatal without A w/ Fe Fumarate‐L Methylfolate‐FA‐Omega 3 Virt‐PN Plus Oral Capsule 28‐0.6‐0.4‐340 MG Tier 2 MULTIVITAMINS Prenatal w/o Vit A w/ Fe Fumarate‐DSS‐FA‐DHA VirtPrex Oral Capsule 26‐1.2‐300 MG Tier 3 GENITOURINARY AGENTS ‐ MISCELLANEOUS Sodium Citrate & Citric Acid Virtrate‐2 Oral Solution 500‐334 MG/5ML Tier 1 GENITOURINARY AGENTS ‐ MISCELLANEOUS Pot & Sod Citrates w/Citric Ac Virtrate‐3 Oral Solution 550‐500‐334 MG/5ML Tier 1 GENITOURINARY AGENTS ‐ MISCELLANEOUS Potassium Citrate‐Citric Acid Virtrate‐K Oral Solution 1100‐334 MG/5ML Tier 1 MULTIVITAMINS Prenatal w/o Vit A w/ Fe Fumarate‐DSS‐FA‐DHA Virt‐Select Oral Capsule 29‐1.25‐325 MG Tier 3 MULTIVITAMINS Prenatal Vit w/ Docusate‐Iron Carbonyl‐Folic Acid Virt‐Vite GT Oral Tablet 90‐1 MG Tier 2 HEMATOPOIETIC AGENTS Folic Acid‐Vitamin B6‐Vitamin B12 Virt‐Vite Oral Tablet 2.5‐25‐1 MG Tier 1 MULTIVITAMINS B‐Complex w/ C & Folic Acid Virt‐Vite Plus Oral Tablet 5 MG Tier 1 OPHTHALMIC AGENTS Na Chondroitin Sulfate‐Na Hyaluronate Viscoat Intraocular Solution 40‐30 MG/ML Tier 3 DIAGNOSTIC PRODUCTS Iodixanol Visipaque Intravenous Solution 270 MG/ML Tier 3 x DIAGNOSTIC PRODUCTS Iodixanol Visipaque Intravenous Solution 320 MG/ML Tier 3 x ANTIANXIETY AGENTS Hydroxyzine Pamoate Vistaril Oral Capsule 25 MG Tier 3 ANTIANXIETY AGENTS Hydroxyzine Pamoate Vistaril Oral Capsule 50 MG Tier 3 MULTIVITAMINS Multiple Vitamins w/ Minerals Vit B3‐AzelAc‐Turm‐FA‐B6‐Zn‐CU Oral Tablet Tier 1 MULTIVITAMINS Multiple Vitamins w/ Minerals Vita S Forte Oral Tablet Tier 1 MULTIVITAMINS Multiple Vitamins w/ Minerals Vitacel Oral Tablet Tier 1 MULTIVITAMINS Prenatal Vit w/ Fe Polysacch Complex‐L Methylfol‐FA‐DHA‐DSS Vitafol FE+ Oral Capsule Therapy Pack 90‐1‐200 & 50 MG Tier 3 MULTIVITAMINS Iron w/ Vitamins Vitafol Oral Tablet Tier 3 MULTIVITAMINS Prenatal Vit w/ Fe Polysacch Complex‐L Methylfolate‐FA‐DHA Vitafol Ultra Oral Capsule 29‐0.6‐0.4‐200 MG Tier 3 MULTIVITAMINS Prenatal w/o A Vit w/ Fe Fumarate‐L Methylfolate‐Folic Acid Vitafol‐Nano Oral Tablet 18‐0.6‐0.4 MG Tier 2 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐Folic Acid Vitafol‐OB Oral Tablet Tier 3 MULTIVITAMINS Prenatal MV & Min w/Fe Fumarate‐FA‐DHA Vitafol‐OB+DHA Oral Miscellaneous 65‐1 & 250 MG Tier 3 MULTIVITAMINS Prenatal MV & Min w/Fe Polysaccharide Complex‐FA‐DHA Vitafol‐One Oral Capsule 29‐1‐200 MG Tier 3 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

MULTIVITAMINS B‐Complex w/ C‐Biotin‐D‐Zinc & Folic Acid Vital‐D Rx Oral Tablet 1 MG Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets Vitalet Pro Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Vitalet Pro Plus Lancets Miscellaneous Tier 2 MULTIVITAMINS Pediatric Multiple Vitamin w/ Minerals & C Vitamax Pediatric Oral Solution Tier 1 MULTIVITAMINS Prenatal without A w/ Fe Fumarate‐L Methylfolate‐FA‐DHA VitaMedMD One Rx/Quatrefolic Oral Capsule 30‐0.6‐0.4‐200 MG Tier 3 MULTIVITAMINS Prenatal without A w/ Fe Chelate‐L Methylfolate‐FA‐DHA VitaMedMD Plus Rx/Quatrefolic Oral Miscellaneous 30‐0.6‐0.4 &300 MG Tier 3 MULTIVITAMINS Prenatal w/ Vit B2‐B6‐B12‐Cholecalciferol‐Folic Acid VitaMedMD RediChew Rx Oral Tablet Chewable 1.4 MG Tier 2 CHEMICALS Vitamin A Palmitate Vitamin A Palmitate Liquid Tier 3 MULTIVITAMINS B‐Complex Vitamins Vitamin B‐Complex 100 Injection Injectable Tier 1 x VITAMINS Ergocalciferol Vitamin D (Ergocalciferol) Oral Capsule 50000 UNIT Tier 1 VITAMINS Phytonadione Vitamin K1 Injection Solution 1 MG/0.5ML Tier 1 x VITAMINS Phytonadione Vitamin K1 Injection Solution 10 MG/ML Tier 3 x MULTIVITAMINS Multiple Vitamins w/ Minerals Vita‐Min Oral Capsule Tier 1 MULTIVITAMINS Pediatric Vitamins ACD w/ Fluoride Vitamins ACD‐Fluoride Oral Solution 0.25 MG/ML Tier 1 MULTIVITAMINS Prenatal without A w/ Fe Fumarate‐Sod Feredetate‐FA‐DHA VitaPearl Oral Capsule Extended Release 30‐1.4‐200 MG Tier 2 MULTIVITAMINS Prenatal Vit w/ Docusate‐Iron‐Folic Acid Vita‐Pren Oral Tablet Tier 2 MULTIVITAMINS Multiple Vitamins w/ Minerals Vitaroca Plus Oral Tablet Tier 3 MULTIVITAMINS Prenatal without A w/ Fe Amino Acid Chelate‐FA‐DHA VitaTrue Oral Miscellaneous 30‐1.4 & 300 MG Tier 3 ANTIVIRALS Elvitegravir Vitekta Oral Tablet 150 MG Tier 3 x ANTIVIRALS Elvitegravir Vitekta Oral Tablet 85 MG Tier 3 x COUGH/COLD/ALLERGY Hydrocodone‐Chlorpheniramine Vituz Oral Solution 5‐4 MG/5ML Tier 3 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐FA‐Omega 3 Fatty Acids Viva DHA Oral Capsule 28‐1‐200 MG Tier 2 ESTROGENS Estradiol Vivelle‐Dot Transdermal Patch Twice Weekly 0.025 MG/24HR Tier 3 xx ESTROGENS Estradiol Vivelle‐Dot Transdermal Patch Twice Weekly 0.0375 MG/24HR Tier 3 xx ESTROGENS Estradiol Vivelle‐Dot Transdermal Patch Twice Weekly 0.05 MG/24HR Tier 3 xx ESTROGENS Estradiol Vivelle‐Dot Transdermal Patch Twice Weekly 0.075 MG/24HR Tier 3 xx ESTROGENS Estradiol Vivelle‐Dot Transdermal Patch Twice Weekly 0.1 MG/24HR Tier 3 xx ANTIDOTES Naltrexone Vivitrol Intramuscular Suspension Reconstituted 380 MG Tier 2 x ANALGESICS ‐ ANTI‐INFLAMMATORY Meloxicam Vivlodex Oral Capsule 10 MG Tier 3 ANALGESICS ‐ ANTI‐INFLAMMATORY Meloxicam Vivlodex Oral Capsule 5 MG Tier 3 VACCINES Typhoid Vaccine Vivotif Berna Vaccine Oral Capsule Delayed Release Tier 3 VACCINES Typhoid Vaccine Vivotif Oral Capsule Delayed Release Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Vocal Point Blood Glucose Test In Vitro Strip Tier 3 ANDROGENS‐ANABOLIC Testosterone Vogelxo Pump Transdermal Gel 12.5 MG/ACT (1%) Tier 3 x ANDROGENS‐ANABOLIC Testosterone Vogelxo Transdermal Gel 50 MG/5GM (1%) Tier 3 x MULTIVITAMINS B‐Complex w/ C & Folic Acid Vol‐Care Rx Oral Tablet 1 MG Tier 1 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐Folic Acid Vol‐Nate Oral Tablet 28‐1 MG Tier 2 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐Folic Acid Vol‐Plus Oral Tablet 27‐1 MG Tier 2 MULTIVITAMINS Prenatal Vit w/ Iron Carbonyl‐Folic Acid Vol‐Tab Rx Oral Tablet 29‐1 MG Tier 2 DERMATOLOGICALS Diclofenac Sodium (Topical) Voltaren Transdermal Gel 1 % Tier 2 HEMATOLOGICAL AGENTS ‐ MISC. Hydroxyethyl Starch in Sodium Chloride Voluven Intravenous Solution 6‐0.9 % Tier 3 x DERMATOLOGICALS Ketoprofen‐Lidocaine HCl Vopac External Cream 10‐2 % Tier 3 DERMATOLOGICALS Ketoprofen‐Lidocaine HCl‐Gabapentin Vopac GB External Cream 5‐2‐5 % Tier 3 x DERMATOLOGICALS Ketoprofen‐Ketamine‐Lidocaine Vopac KT External Cream 5‐5‐2 % Tier 3 x ANTIFUNGALS Voriconazole Voriconazole Oral Suspension Reconstituted 40 MG/ML Tier 1 ANTIFUNGALS Voriconazole Voriconazole Oral Tablet 200 MG Tier 1 ANTIFUNGALS Voriconazole Voriconazole Oral Tablet 50 MG Tier 1 MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers Vortex Valved Holding Chamber Device Tier 2 x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Albuterol Sulfate VoSpire ER Oral Tablet Extended Release 12 Hour 4 MG Tier 3 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Albuterol Sulfate VoSpire ER Oral Tablet Extended Release 12 Hour 8 MG Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Pazopanib HCl Votrient Oral Tablet 200 MG Tier 2 x x MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 VP Insulin Syringe Miscellaneous 29G X 1/2" 0.3 ML Tier 2 MULTIVITAMINS Prenatal w/o Vit A w/ Fe Carbonyl‐DSS‐FA‐DHA VP‐CH Plus Oral Capsule 29‐1‐265 MG Tier 3 MULTIVITAMINS Prenatal w/o Vit A w/ Fe Carbonyl‐DSS‐FA‐DHA VP‐CH‐PNV Oral Capsule 30‐1‐260 MG Tier 3 MULTIVITAMINS Prenatal Vit w/ Fe Poly Cmplx‐Fe Heme Polypept‐FA & Omega 3VP‐Heme OB + DHA Oral Miscellaneous 28‐6‐1 & 203 MG Tier 2 MULTIVITAMINS Prenatal Vit w/ Fe Polysacch Complex‐Fe Heme Polypeptide‐FA VP‐Heme OB Oral Tablet 28‐6‐1 MG Tier 2 MULTIVITAMINS Prenatal Vit w/ Fe Polysacch Cmplx‐Fe Heme Polypept‐FA & DHA VP‐HEME One Oral Capsule 22‐6‐1‐200 MG Tier 3 MULTIVITAMINS Prenatal Vit w/ Ferrous Fumarate‐FA‐Omega 3 Fatty Acids VP‐PNV‐DHA Oral Capsule 28‐1‐215.8 MG Tier 2 MULTIVITAMINS B‐Complex w/ C & Folic Acid VP‐Vite Rx Oral Tablet 1 MG Tier 1 MULTIVITAMINS Multiple Vitamins w/ Minerals VP‐ZEL Oral Tablet Tier 3 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 V‐R Mono Insulin Syringe Miscellaneous 28G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 V‐R Mono Insulin Syringe Miscellaneous 28G X 1/2" 1 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 V‐R Mono Insulin Syringe Miscellaneous 29G X 1/2" 0.3 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 V‐R Mono Insulin Syringe Miscellaneous 29G X 1/2" 0.5 ML Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Syringe/Needle U‐100 V‐R Mono Insulin Syringe Miscellaneous 29G X 1/2" 1 ML Tier 2 CONTRACEPTIVES Norethindrone & Eth Estradiol Vyfemla Oral Tablet 0.4‐35 MG‐MCG Tier 1 ANTIHYPERLIPIDEMICS Ezetimibe‐Simvastatin Vytorin Oral Tablet 10‐10 MG Tier 2 x ANTIHYPERLIPIDEMICS Ezetimibe‐Simvastatin Vytorin Oral Tablet 10‐20 MG Tier 2 x ANTIHYPERLIPIDEMICS Ezetimibe‐Simvastatin Vytorin Oral Tablet 10‐40 MG Tier 2 x ANTIHYPERLIPIDEMICS Ezetimibe‐Simvastatin Vytorin Oral Tablet 10‐80 MG Tier 2 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Lisdexamfetamine Dimesylate Vyvanse Oral Capsule 10 MG Tier 2 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Lisdexamfetamine Dimesylate Vyvanse Oral Capsule 20 MG Tier 2 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Lisdexamfetamine Dimesylate Vyvanse Oral Capsule 30 MG Tier 2 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Lisdexamfetamine Dimesylate Vyvanse Oral Capsule 40 MG Tier 2 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Lisdexamfetamine Dimesylate Vyvanse Oral Capsule 50 MG Tier 2 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Lisdexamfetamine Dimesylate Vyvanse Oral Capsule 60 MG Tier 2 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Lisdexamfetamine Dimesylate Vyvanse Oral Capsule 70 MG Tier 2 x x MEDICAL DEVICES AND SUPPLIES Lancets W&F Lancets 26G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets W&F Lancets Colored 21G Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Walgreens Adv Travel Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Walgreens Lancets Micro Thin Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Walgreens Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Walgreens Lancets Super Thin Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Walgreens Thin Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Walgreens Ultra Thin Lancets Miscellaneous Tier 2 ANTICOAGULANTS Warfarin Sodium Warfarin Sodium Oral Tablet 1 MG Tier 1 ANTICOAGULANTS Warfarin Sodium Warfarin Sodium Oral Tablet 10 MG Tier 1 ANTICOAGULANTS Warfarin Sodium Warfarin Sodium Oral Tablet 2 MG Tier 1 ANTICOAGULANTS Warfarin Sodium Warfarin Sodium Oral Tablet 2.5 MG Tier 1 ANTICOAGULANTS Warfarin Sodium Warfarin Sodium Oral Tablet 3 MG Tier 1 ANTICOAGULANTS Warfarin Sodium Warfarin Sodium Oral Tablet 4 MG Tier 1 ANTICOAGULANTS Warfarin Sodium Warfarin Sodium Oral Tablet 5 MG Tier 1 ANTICOAGULANTS Warfarin Sodium Warfarin Sodium Oral Tablet 6 MG Tier 1 ANTICOAGULANTS Warfarin Sodium Warfarin Sodium Oral Tablet 7.5 MG Tier 1 MEDICAL DEVICES AND SUPPLIES Spacer/Aerosol‐Holding Chambers Watchhaler Device Tier 2 x DIAGNOSTIC PRODUCTS Glucose Blood WaveSense Presto In Vitro Strip Tier 3 MEDICAL DEVICES AND SUPPLIES Alcohol Swabs Webcol Alcohol Prep Large Pad 70 % Tier 2 MEDICAL DEVICES AND SUPPLIES Alcohol Swabs Webcol Alcohol Prep Medium Pad 70 % Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Wegmans Unifine Pentips Plus Miscellaneous 31G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Wegmans Unifine Pentips Plus Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Wegmans Unifine Pentips Plus Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle Wegmans Unifine Pentips Plus Miscellaneous 32G X 4 MM Tier 2 ANTIHYPERLIPIDEMICS Colesevelam HCl Welchol Oral Packet 3.75 GM Tier 2 x ANTIHYPERLIPIDEMICS Colesevelam HCl Welchol Oral Tablet 625 MG Tier 2 x ANTIDEPRESSANTS Bupropion HCl Wellbutrin Oral Tablet 100 MG Tier 3 ANTIDEPRESSANTS Bupropion HCl Wellbutrin Oral Tablet 75 MG Tier 3 ANTIDEPRESSANTS Bupropion HCl Wellbutrin SR Oral Tablet Extended Release 12 Hour 100 MG Tier 3 ANTIDEPRESSANTS Bupropion HCl Wellbutrin SR Oral Tablet Extended Release 12 Hour 150 MG Tier 3 ANTIDEPRESSANTS Bupropion HCl Wellbutrin SR Oral Tablet Extended Release 12 Hour 200 MG Tier 3 ANTIDEPRESSANTS Bupropion HCl Wellbutrin XL Oral Tablet Extended Release 24 Hour 150 MG Tier 3 ANTIDEPRESSANTS Bupropion HCl Wellbutrin XL Oral Tablet Extended Release 24 Hour 300 MG Tier 3 CONTRACEPTIVES Norethindrone & Eth Estradiol Wera Oral Tablet 0.5‐35 MG‐MCG Tier 1 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

DERMATOLOGICALS Hydrocortisone Valerate Westcort External Ointment 0.2 % Tier 3 THYROID AGENTS Thyroid Westhroid Oral Tablet 130 MG Tier 3 THYROID AGENTS Thyroid Westhroid Oral Tablet 195 MG Tier 3 THYROID AGENTS Thyroid Westhroid Oral Tablet 32.5 MG Tier 3 THYROID AGENTS Thyroid Westhroid Oral Tablet 65 MG Tier 3 THYROID AGENTS Thyroid Westhroid Oral Tablet 97.5 MG Tier 3 DERMATOLOGICALS Chlorhexidine Gluconate‐Mupirocin‐Dimethicone‐Silicone Whytederm SurgiPak External Kit 4 & 2 & 2 % Tier 3 DERMATOLOGICALS Triamcinolone Acetonide‐Dimethicone‐Silicone Whytederm TDPak External Kit 0.1‐2 % Tier 3 DERMATOLOGICALS Triamcinolone Acetonide‐Dimethicone‐Silicone Whytederm Trilasil Pak External Kit 0.1‐2 % Tier 3 THYROID AGENTS Thyroid WP Thyroid Oral Tablet 113.75 MG Tier 3 THYROID AGENTS Thyroid WP Thyroid Oral Tablet 130 MG Tier 3 THYROID AGENTS Thyroid WP Thyroid Oral Tablet 16.25 MG Tier 3 THYROID AGENTS Thyroid WP Thyroid Oral Tablet 32.5 MG Tier 3 THYROID AGENTS Thyroid WP Thyroid Oral Tablet 48.75 MG Tier 3 THYROID AGENTS Thyroid WP Thyroid Oral Tablet 65 MG Tier 3 THYROID AGENTS Thyroid WP Thyroid Oral Tablet 81.25 MG Tier 3 THYROID AGENTS Thyroid WP Thyroid Oral Tablet 97.5 MG Tier 3 CONTRACEPTIVES Norethindrone & Ethinyl Estradiol‐Fe Wymzya Fe Oral Tablet Chewable 0.4‐35 MG‐MCG Tier 1 OPHTHALMIC AGENTS Latanoprost Xalatan Ophthalmic Solution 0.005 % Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Crizotinib Xalkori Oral Capsule 200 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Crizotinib Xalkori Oral Capsule 250 MG Tier 2 x x ANTIANXIETY AGENTS Alprazolam Xanax Oral Tablet 0.25 MG Tier 3 ANTIANXIETY AGENTS Alprazolam Xanax Oral Tablet 0.5 MG Tier 3 ANTIANXIETY AGENTS Alprazolam Xanax Oral Tablet 1 MG Tier 3 ANTIANXIETY AGENTS Alprazolam Xanax Oral Tablet 2 MG Tier 3 ANTIANXIETY AGENTS Alprazolam Xanax XR Oral Tablet Extended Release 24 Hour 0.5 MG Tier 3 ANTIANXIETY AGENTS Alprazolam Xanax XR Oral Tablet Extended Release 24 Hour 1 MG Tier 3 ANTIANXIETY AGENTS Alprazolam Xanax XR Oral Tablet Extended Release 24 Hour 2 MG Tier 3 ANTIANXIETY AGENTS Alprazolam Xanax XR Oral Tablet Extended Release 24 Hour 3 MG Tier 3 ANTICOAGULANTS Rivaroxaban Xarelto Oral Tablet 10 MG Tier 2 x ANTICOAGULANTS Rivaroxaban Xarelto Oral Tablet 15 MG Tier 2 x ANTICOAGULANTS Rivaroxaban Xarelto Oral Tablet 20 MG Tier 2 x ANTICOAGULANTS Rivaroxaban Xarelto Starter Pack Oral Tablet Therapy Pack 15 & 20 MG Tier 2 x ANALGESICS ‐ OPIOID Oxycodone w/ Acetaminophen Xartemis XR Oral Tablet Extended Release 7.5‐325 MG Tier 3 x x ANALGESICS ‐ ANTI‐INFLAMMATORY Tofacitinib Citrate Xeljanz Oral Tablet 5 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Capecitabine Xeloda Oral Tablet 150 MG Tier 2 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Capecitabine Xeloda Oral Tablet 500 MG Tier 2 x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Tetrabenazine Xenazine Oral Tablet 12.5 MG Tier 2 x x PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Tetrabenazine Xenazine Oral Tablet 25 MG Tier 2 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Orlistat Xenical Oral Capsule 120 MG Tier 3 x x DERMATOLOGICALS Aluminum Chloride in Alcohol Xerac AC External Solution 6.25 % Tier 3 DERMATOLOGICALS Acyclovir‐Hydrocortisone Xerese External Cream 5‐1 % Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Denosumab Xgeva Subcutaneous Solution 120 MG/1.7ML Tier 2 x ANTI‐INFECTIVE AGENTS ‐ MISC. Rifaximin Xifaxan Oral Tablet 200 MG Tier 3 x x ANTI‐INFECTIVE AGENTS ‐ MISC. Rifaximin Xifaxan Oral Tablet 550 MG Tier 3 x ANTIDIABETICS Dapagliflozin‐Metformin HCl Xigduo XR Oral Tablet Extended Release 24 Hour 10‐1000 MG Tier 3 x ANTIDIABETICS Dapagliflozin‐Metformin HCl Xigduo XR Oral Tablet Extended Release 24 Hour 10‐500 MG Tier 3 x x ANTIDIABETICS Dapagliflozin‐Metformin HCl Xigduo XR Oral Tablet Extended Release 24 Hour 5‐1000 MG Tier 3 x x ANTIDIABETICS Dapagliflozin‐Metformin HCl Xigduo XR Oral Tablet Extended Release 24 Hour 5‐500 MG Tier 3 x x ANALGESICS ‐ OPIOID Hydrocodone‐Acetaminophen Xodol Oral Tablet 10‐300 MG Tier 3 ANALGESICS ‐ OPIOID Hydrocodone‐Acetaminophen Xodol Oral Tablet 5‐300 MG Tier 3 ANALGESICS ‐ OPIOID Hydrocodone‐Acetaminophen Xodol Oral Tablet 7.5‐300 MG Tier 3 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Omalizumab Xolair Subcutaneous Solution Reconstituted 150 MG Tier 2 x DERMATOLOGICALS Ketoconazole‐Hydrocortisone Xolegel CorePak External Kit 2 & 1 % Tier 3 DERMATOLOGICALS Ketoconazole & Pyrithione Zinc Xolegel Duo/Head & Shoulders External Kit 2 & 1 % Tier 3 DERMATOLOGICALS Ketoconazole & Pyrithione Zinc Xolegel Duo/Xolex External Kit 2 & 1 % Tier 3 DERMATOLOGICALS Ketoconazole (Topical) Xolegel External Gel 2 % Tier 3 x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Levalbuterol HCl Xopenex Concentrate Inhalation Nebulization Solution 1.25 MG/0.5ML Tier 3 xx ANTIASTHMATIC AND BRONCHODILATOR AGENTS Levalbuterol Tartrate Xopenex HFA Inhalation Aerosol 45 MCG/ACT Tier 3 xx ANTIASTHMATIC AND BRONCHODILATOR AGENTS Levalbuterol HCl Xopenex Inhalation Nebulization Solution 0.31 MG/3ML Tier 3 xx ANTIASTHMATIC AND BRONCHODILATOR AGENTS Levalbuterol HCl Xopenex Inhalation Nebulization Solution 0.63 MG/3ML Tier 3 xx ANTIASTHMATIC AND BRONCHODILATOR AGENTS Levalbuterol HCl Xopenex Inhalation Nebulization Solution 1.25 MG/3ML Tier 3 xx ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Enzalutamide Xtandi Oral Capsule 40 MG Tier 2 x x CONTRACEPTIVES Norelgestromin‐Ethinyl Estradiol Xulane Transdermal Patch Weekly 150‐35 MCG/24HR Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Uridine Triacetate Xuriden Oral Packet 2 GM Tier 3 ANTIARRHYTHMICS Lidocaine HCl (Cardiac) Xylocaine (Cardiac) Intravenous Solution 20 MG/ML Tier 3 x DERMATOLOGICALS Lidocaine HCl Xylocaine External Solution 4 % Tier 3 x LOCAL ANESTHETICS‐Parenteral Lidocaine HCl (Local Anesth.) Xylocaine Injection Solution 1 % Tier 3 x LOCAL ANESTHETICS‐Parenteral Lidocaine HCl (Local Anesth.) Xylocaine Injection Solution 2 % Tier 3 x LOCAL ANESTHETICS‐Parenteral Lidocaine w/ Epinephrine Xylocaine/Epinephrine Injection Solution 1 %‐1:100000 Tier 3 x LOCAL ANESTHETICS‐Parenteral Lidocaine w/ Epinephrine Xylocaine/Epinephrine Injection Solution 2 %‐1:100000 Tier 3 x LOCAL ANESTHETICS‐Parenteral Lidocaine HCl (Local Anesth.) Xylocaine‐MPF Injection Solution 1 % Tier 3 x LOCAL ANESTHETICS‐Parenteral Lidocaine HCl (Local Anesth.) Xylocaine‐MPF Injection Solution 1.5 % Tier 3 x LOCAL ANESTHETICS‐Parenteral Lidocaine HCl (Local Anesth.) Xylocaine‐MPF Injection Solution 2 % Tier 3 x LOCAL ANESTHETICS‐Parenteral Lidocaine w/ Epinephrine Xylocaine‐MPF/Epinephrine Injection Solution 1 %‐1:200000 Tier 3 x LOCAL ANESTHETICS‐Parenteral Lidocaine w/ Epinephrine Xylocaine‐MPF/Epinephrine Injection Solution 1.5 %‐1:200000 Tier 3 x LOCAL ANESTHETICS‐Parenteral Lidocaine w/ Epinephrine Xylocaine‐MPF/Epinephrine Injection Solution 2 %‐1:200000 Tier 3 x ANALGESICS ‐ OPIOID Hydrocodone‐Ibuprofen Xylon Oral Tablet 10‐200 MG Tier 1 HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor (Recombinant) Plasma/Albumin Free Xyntha Intravenous Kit 1000 UNIT Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor (Recombinant) Plasma/Albumin Free Xyntha Intravenous Kit 2000 UNIT Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor (Recombinant) Plasma/Albumin Free Xyntha Intravenous Kit 250 UNIT Tier 2 x HEMATOLOGICAL AGENTS ‐ MISC. Antihemophilic Factor (Recombinant) Plasma/Albumin Free Xyntha Intravenous Kit 500 UNIT Tier 2 x DERMATOLOGICALS Capsaicin‐Menthol Xyphex External Disk 0.0375‐5 % Tier 1 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Sodium Oxybate Xyrem Oral Solution 500 MG/ML Tier 2 x x ANTIHISTAMINES Levocetirizine Dihydrochloride Xyzal Oral Solution 2.5 MG/5ML Tier 3 ANTIHISTAMINES Levocetirizine Dihydrochloride Xyzal Oral Tablet 5 MG Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Disp) 19 G Yale Disp Needles Miscellaneous 19G X 1‐1/2" Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Disp) 21 G Yale Disp Needles Miscellaneous 21G X 1" Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Disp) 22 G Yale Disp Needles Miscellaneous 22G X 1" Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Reusable) 26 G Yale Reusable Needle Miscellaneous 26G X 3/8" Tier 3 MEDICAL DEVICES AND SUPPLIES Needle (Reusable) 27 G Yale Reusable Needle Miscellaneous 27G X 1" Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Reusable) Yale Reusable Syringe Miscellaneous 10 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Reusable) Yale Reusable Syringe Miscellaneous 2 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Reusable) Yale Reusable Syringe Miscellaneous 20 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Reusable) Yale Reusable Syringe Miscellaneous 3 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Reusable) Yale Reusable Syringe Miscellaneous 30 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Reusable) Yale Reusable Syringe Miscellaneous 5 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Reusable) Yale Reusable Syringe Miscellaneous 50 ML Tier 3 MEDICAL DEVICES AND SUPPLIES Syringe (Reusable) Yale Reusable TB Syringe Miscellaneous 1 ML Tier 3 CONTRACEPTIVES Drospirenone‐Ethinyl Estradiol Yasmin 28 Oral Tablet 3‐0.03 MG Tier 3 CONTRACEPTIVES Drospirenone‐Ethinyl Estradiol YAZ Oral Tablet 3‐0.02 MG Tier 3 VACCINES Yellow Fever Vaccine YF‐VAX Subcutaneous Injectable Tier 3 x AMEBICIDES Iodoquinol Yodoxin Oral Tablet 210 MG Tier 3 AMEBICIDES Iodoquinol Yodoxin Oral Tablet 650 MG Tier 3 DERMATOLOGICALS Benzoyl Peroxide & Hyaluronate Sodium Zacare External Kit 4 & 0.2 % Tier 3 x DERMATOLOGICALS Benzoyl Peroxide & Hyaluronate Sodium Zacare External Kit 8 & 0.2 % Tier 3 x DERMATOLOGICALS Benzoyl Peroxide Zaclir Cleansing External Lotion 8 % Tier 3 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Zafirlukast Zafirlukast Oral Tablet 10 MG Tier 1 x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Zafirlukast Zafirlukast Oral Tablet 20 MG Tier 1 x HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Zaleplon Zaleplon Oral Capsule 10 MG Tier 1 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Zaleplon Zaleplon Oral Capsule 5 MG Tier 1 ANALGESICS ‐ OPIOID Hydrocodone‐Acetaminophen Zamicet Oral Solution 10‐325 MG/15ML Tier 3 HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

MUSCULOSKELETAL THERAPY AGENTS Tizanidine HCl Zanaflex Oral Capsule 2 MG Tier 3 x MUSCULOSKELETAL THERAPY AGENTS Tizanidine HCl Zanaflex Oral Capsule 4 MG Tier 3 x MUSCULOSKELETAL THERAPY AGENTS Tizanidine HCl Zanaflex Oral Capsule 6 MG Tier 3 x MUSCULOSKELETAL THERAPY AGENTS Tizanidine HCl Zanaflex Oral Tablet 4 MG Tier 3 x ULCER DRUGS Ranitidine HCl Zantac Oral Tablet 150 MG Tier 3 ULCER DRUGS Ranitidine HCl Zantac Oral Tablet 300 MG Tier 3 CONTRACEPTIVES Drospirenone‐Ethinyl Estradiol Zarah Oral Tablet 3‐0.03 MG Tier 1 ANTICONVULSANTS Ethosuximide Zarontin Oral Capsule 250 MG Tier 3 ANTICONVULSANTS Ethosuximide Zarontin Oral Solution 250 MG/5ML Tier 3 HEMATOPOIETIC AGENTS Filgrastim‐sndz Zarxio Injection Solution Prefilled Syringe 300 MCG/0.5ML Tier 3 x HEMATOPOIETIC AGENTS Filgrastim‐sndz Zarxio Injection Solution Prefilled Syringe 480 MCG/0.8ML Tier 3 x MULTIVITAMINS Prenatal w/o Vit A w/ Fe Carbonyl‐DSS‐FA‐DHA Zatean‐CH Oral Capsule 27‐1‐250 MG Tier 3 MULTIVITAMINS Prenatal without A w/ Fe Fumarate‐L Methylfolate‐FA‐DHA Zatean‐Pn DHA Oral Capsule 27‐0.6‐0.4‐300 MG Tier 2 MULTIVITAMINS Prenatal without A w/ Fe Fumarate‐L Methylfolate‐FA‐Omega 3 Zatean‐Pn Plus Oral Capsule 28‐0.6‐0.4‐340 MG Tier 2 HEMATOPOIETIC AGENTS Folic Acid‐Cholecalciferol Zavara Oral Capsule 1‐5750 MG‐UNIT Tier 3 HEMATOPOIETIC AGENTS Miglustat Zavesca Oral Capsule 100 MG Tier 2 x x VAGINAL PRODUCTS Terconazole Vaginal Zazole Vaginal Cream 0.8 % Tier 1 VAGINAL PRODUCTS Terconazole Vaginal Zazole Vaginal Suppository 80 MG Tier 1 BETA BLOCKERS Bisoprolol Fumarate Zebeta Oral Tablet 10 MG Tier 3 BETA BLOCKERS Bisoprolol Fumarate Zebeta Oral Tablet 5 MG Tier 3 ANALGESICS ‐ NonNarcotic Butalbital‐Acetaminophen‐Caffeine Zebutal Oral Capsule 50‐325‐40 MG Tier 1 MIGRAINE PRODUCTS Sumatriptan Succinate Zecuity Transdermal Patch 6.5 MG/4HR Tier 3 x x ULCER DRUGS Omeprazole‐Sodium Bicarbonate Zegerid Oral Capsule 20‐1100 MG Tier 3 x ULCER DRUGS Omeprazole‐Sodium Bicarbonate Zegerid Oral Capsule 40‐1100 MG Tier 3 x ULCER DRUGS Omeprazole‐Sodium Bicarbonate Zegerid Oral Packet 20‐1680 MG Tier 3 x x ULCER DRUGS Omeprazole‐Sodium Bicarbonate Zegerid Oral Packet 40‐1680 MG Tier 3 x x ANTIPARKINSON AGENTS Selegiline HCl Zelapar Oral Tablet Dispersible 1.25 MG Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Vemurafenib Zelboraf Oral Tablet 240 MG Tier 2 x x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Paricalcitol Zemplar Intravenous Solution 5 MCG/ML Tier 3 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Paricalcitol Zemplar Oral Capsule 1 MCG Tier 3 ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Paricalcitol Zemplar Oral Capsule 2 MCG Tier 3 NEUROMUSCULAR AGENTS Rocuronium Bromide Zemuron Intravenous Solution 100 MG/10ML Tier 3 x NEUROMUSCULAR AGENTS Rocuronium Bromide Zemuron Intravenous Solution 50 MG/5ML Tier 3 x DERMATOLOGICALS Isotretinoin Zenatane Oral Capsule 10 MG Tier 1 DERMATOLOGICALS Isotretinoin Zenatane Oral Capsule 20 MG Tier 1 DERMATOLOGICALS Isotretinoin Zenatane Oral Capsule 30 MG Tier 1 DERMATOLOGICALS Isotretinoin Zenatane Oral Capsule 40 MG Tier 1 CONTRACEPTIVES Norethindrone & Ethinyl Estradiol‐Fe Zenchent FE Oral Tablet Chewable 0.4‐35 MG‐MCG Tier 1 CONTRACEPTIVES Norethindrone & Eth Estradiol Zenchent Oral Tablet 0.4‐35 MG‐MCG Tier 1 DERMATOLOGICALS Sulfacetamide Sodium w/ Sulfur Zencia External Liquid 9‐4 % Tier 1 x DIGESTIVE AIDS Pancrelipase (Lipase‐Protease‐Amylase) Zenpep Oral Capsule Delayed Release Particles 10000 UNIT Tier 2 x DIGESTIVE AIDS Pancrelipase (Lipase‐Protease‐Amylase) Zenpep Oral Capsule Delayed Release Particles 15000 UNIT Tier 2 x DIGESTIVE AIDS Pancrelipase (Lipase‐Protease‐Amylase) Zenpep Oral Capsule Delayed Release Particles 20000 UNIT Tier 2 x DIGESTIVE AIDS Pancrelipase (Lipase‐Protease‐Amylase) Zenpep Oral Capsule Delayed Release Particles 25000 UNIT Tier 2 x DIGESTIVE AIDS Pancrelipase (Lipase‐Protease‐Amylase) Zenpep Oral Capsule Delayed Release Particles 3000‐10000 UNIT Tier 2 x DIGESTIVE AIDS Pancrelipase (Lipase‐Protease‐Amylase) Zenpep Oral Capsule Delayed Release Particles 40000 UNIT Tier 2 x DIGESTIVE AIDS Pancrelipase (Lipase‐Protease‐Amylase) Zenpep Oral Capsule Delayed Release Particles 5000 UNIT Tier 2 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dextroamphetamine Sulfate Zenzedi Oral Tablet 10 MG Tier 1 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dextroamphetamine Sulfate Zenzedi Oral Tablet 15 MG Tier 3 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dextroamphetamine Sulfate Zenzedi Oral Tablet 2.5 MG Tier 3 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dextroamphetamine Sulfate Zenzedi Oral Tablet 20 MG Tier 3 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dextroamphetamine Sulfate Zenzedi Oral Tablet 30 MG Tier 3 x x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dextroamphetamine Sulfate Zenzedi Oral Tablet 5 MG Tier 1 x ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Dextroamphetamine Sulfate Zenzedi Oral Tablet 7.5 MG Tier 3 x x ANTIVIRALS Elbasvir‐Grazoprevir Zepatier Oral Tablet 50‐100 MG Tier 3 x x ANTIVIRALS Stavudine Zerit Oral Capsule 15 MG Tier 3 x ANTIVIRALS Stavudine Zerit Oral Capsule 20 MG Tier 3 x ANTIVIRALS Stavudine Zerit Oral Capsule 30 MG Tier 3 x ANTIVIRALS Stavudine Zerit Oral Capsule 40 MG Tier 3 x ANTIVIRALS Stavudine Zerit Oral Solution Reconstituted 1 MG/ML Tier 3 x DERMATOLOGICALS Lidocaine‐Menthol Zeruvia External Patch 4‐1 % Tier 1 ANTIHYPERTENSIVES Lisinopril & Hydrochlorothiazide Zestoretic Oral Tablet 10‐12.5 MG Tier 3 ANTIHYPERTENSIVES Lisinopril & Hydrochlorothiazide Zestoretic Oral Tablet 20‐12.5 MG Tier 3 ANTIHYPERTENSIVES Lisinopril & Hydrochlorothiazide Zestoretic Oral Tablet 20‐25 MG Tier 3 ANTIHYPERTENSIVES Lisinopril Zestril Oral Tablet 10 MG Tier 3 ANTIHYPERTENSIVES Lisinopril Zestril Oral Tablet 2.5 MG Tier 3 ANTIHYPERTENSIVES Lisinopril Zestril Oral Tablet 20 MG Tier 3 ANTIHYPERTENSIVES Lisinopril Zestril Oral Tablet 30 MG Tier 3 ANTIHYPERTENSIVES Lisinopril Zestril Oral Tablet 40 MG Tier 3 ANTIHYPERTENSIVES Lisinopril Zestril Oral Tablet 5 MG Tier 3 ANTIHYPERLIPIDEMICS Ezetimibe Zetia Oral Tablet 10 MG Tier 3 x NASAL AGENTS ‐ SYSTEMIC AND TOPICAL Ciclesonide (Nasal) Zetonna Nasal Aerosol Solution 37 MCG/ACT Tier 3 xx ANTIHYPERTENSIVES Bisoprolol & Hydrochlorothiazide Ziac Oral Tablet 10‐6.25 MG Tier 3 ANTIHYPERTENSIVES Bisoprolol & Hydrochlorothiazide Ziac Oral Tablet 2.5‐6.25 MG Tier 3 ANTIHYPERTENSIVES Bisoprolol & Hydrochlorothiazide Ziac Oral Tablet 5‐6.25 MG Tier 3 ANTIVIRALS Abacavir Sulfate Ziagen Oral Solution 20 MG/ML Tier 2 x ANTIVIRALS Abacavir Sulfate Ziagen Oral Tablet 300 MG Tier 3 x DERMATOLOGICALS Clindamycin Phosphate‐Tretinoin Ziana External Gel 1.2‐0.025 % Tier 3 x ANTIVIRALS Zidovudine Zidovudine Oral Capsule 100 MG Tier 1 x ANTIVIRALS Zidovudine Zidovudine Oral Syrup 50 MG/5ML Tier 1 x ANTIVIRALS Zidovudine Zidovudine Oral Tablet 300 MG Tier 1 x MINERALS & ELECTROLYTES Zinc Sulfate Zinc Sulfate Granules Tier 3 MINERALS & ELECTROLYTES Zinc Sulfate Zinc Sulfate Heptahydrate Powder Tier 3 CHEMICALS Zinc Undecylenate Zinc Undecylenate Powder Tier 3 OPHTHALMIC AGENTS Tafluprost Zioptan Ophthalmic Solution 0.0015 % Tier 3 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Ziprasidone HCl Ziprasidone HCl Oral Capsule 20 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Ziprasidone HCl Ziprasidone HCl Oral Capsule 40 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Ziprasidone HCl Ziprasidone HCl Oral Capsule 60 MG Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Ziprasidone HCl Ziprasidone HCl Oral Capsule 80 MG Tier 1 ANALGESICS ‐ ANTI‐INFLAMMATORY Diclofenac Potassium Zipsor Oral Capsule 25 MG Tier 3 x OPHTHALMIC AGENTS Ganciclovir Ophthalmic Zirgan Ophthalmic Gel 0.15 % Tier 3 DERMATOLOGICALS Anthralin Zithranol External Shampoo 1 % Tier 3 DERMATOLOGICALS Anthralin Zithranol‐RR External Cream 1.2 % Tier 3 MACROLIDES Azithromycin Zithromax Intravenous Solution Reconstituted 500 MG Tier 3 x MACROLIDES Azithromycin Zithromax Oral Packet 1 GM Tier 2 MACROLIDES Azithromycin Zithromax Oral Suspension Reconstituted 100 MG/5ML Tier 3 MACROLIDES Azithromycin Zithromax Oral Suspension Reconstituted 200 MG/5ML Tier 3 MACROLIDES Azithromycin Zithromax Oral Tablet 250 MG Tier 3 MACROLIDES Azithromycin Zithromax Oral Tablet 500 MG Tier 3 MACROLIDES Azithromycin Zithromax Oral Tablet 600 MG Tier 3 MACROLIDES Azithromycin Zithromax Tri‐Pak Oral Tablet 500 MG Tier 3 MACROLIDES Azithromycin Zithromax Z‐Pak Oral Tablet 250 MG Tier 3 MACROLIDES Azithromycin Zmax Oral Suspension Reconstituted 2 GM Tier 3 ANTIHYPERLIPIDEMICS Simvastatin Zocor Oral Tablet 10 MG Tier 3 ANTIHYPERLIPIDEMICS Simvastatin Zocor Oral Tablet 20 MG Tier 3 ANTIHYPERLIPIDEMICS Simvastatin Zocor Oral Tablet 40 MG Tier 3 ANTIHYPERLIPIDEMICS Simvastatin Zocor Oral Tablet 5 MG Tier 3 ANTIHYPERLIPIDEMICS Simvastatin Zocor Oral Tablet 80 MG Tier 3 x ANTIEMETICS Ondansetron HCl Zofran Injection Solution 40 MG/20ML Tier 3 ANTIEMETICS Ondansetron Zofran ODT Oral Tablet Dispersible 4 MG Tier 3 x ANTIEMETICS Ondansetron Zofran ODT Oral Tablet Dispersible 8 MG Tier 3 x ANTIEMETICS Ondansetron HCl Zofran Oral Solution 4 MG/5ML Tier 3 x HOSPITALITY RX OPEN FORMULARY

Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy

ANTIEMETICS Ondansetron HCl Zofran Oral Tablet 4 MG Tier 3 x ANTIEMETICS Ondansetron HCl Zofran Oral Tablet 8 MG Tier 3 x ANALGESICS ‐ OPIOID Hydrocodone Bitartrate Zohydro ER Oral Capsule ER 12 Hour Abuse‐Deterrent 10 MG Tier 3 x x ANALGESICS ‐ OPIOID Hydrocodone Bitartrate Zohydro ER Oral Capsule ER 12 Hour Abuse‐Deterrent 15 MG Tier 3 x x ANALGESICS ‐ OPIOID Hydrocodone Bitartrate Zohydro ER Oral Capsule ER 12 Hour Abuse‐Deterrent 20 MG Tier 3 x x ANALGESICS ‐ OPIOID Hydrocodone Bitartrate Zohydro ER Oral Capsule ER 12 Hour Abuse‐Deterrent 30 MG Tier 3 x x ANALGESICS ‐ OPIOID Hydrocodone Bitartrate Zohydro ER Oral Capsule ER 12 Hour Abuse‐Deterrent 40 MG Tier 3 x x ANALGESICS ‐ OPIOID Hydrocodone Bitartrate Zohydro ER Oral Capsule ER 12 Hour Abuse‐Deterrent 50 MG Tier 3 x x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Zoledronic Acid Zoledronic Acid Intravenous Concentrate 4 MG/5ML Tier 1 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Zoledronic Acid Zoledronic Acid Intravenous Solution 5 MG/100ML Tier 1 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Vorinostat Zolinza Oral Capsule 100 MG Tier 2 x x MIGRAINE PRODUCTS Zolmitriptan ZOLMitriptan Oral Tablet 2.5 MG Tier 1 x MIGRAINE PRODUCTS Zolmitriptan ZOLMitriptan Oral Tablet 5 MG Tier 1 x MIGRAINE PRODUCTS Zolmitriptan ZOLMitriptan Oral Tablet Dispersible 2.5 MG Tier 1 x MIGRAINE PRODUCTS Zolmitriptan ZOLMitriptan Oral Tablet Dispersible 5 MG Tier 1 x ANTIDEPRESSANTS Sertraline HCl Zoloft Oral Concentrate 20 MG/ML Tier 3 ANTIDEPRESSANTS Sertraline HCl Zoloft Oral Tablet 100 MG Tier 3 ANTIDEPRESSANTS Sertraline HCl Zoloft Oral Tablet 25 MG Tier 3 ANTIDEPRESSANTS Sertraline HCl Zoloft Oral Tablet 50 MG Tier 3 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Zolpidem Tartrate Zolpidem Tartrate ER Oral Tablet Extended Release 12.5 MG Tier 1 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Zolpidem Tartrate Zolpidem Tartrate ER Oral Tablet Extended Release 6.25 MG Tier 1 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Zolpidem Tartrate Zolpidem Tartrate Oral Tablet 10 MG Tier 1 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Zolpidem Tartrate Zolpidem Tartrate Oral Tablet 5 MG Tier 1 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Zolpidem Tartrate Zolpimist Oral Solution 5 MG/ACT Tier 3 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin Zomacton Subcutaneous Solution Reconstituted 10 MG Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin Zomacton Subcutaneous Solution Reconstituted 5 MG Tier 2 x MIGRAINE PRODUCTS Zolmitriptan Zomig Nasal Solution 2.5 MG Tier 2 xx MIGRAINE PRODUCTS Zolmitriptan Zomig Nasal Solution 5 MG Tier 2 xx MIGRAINE PRODUCTS Zolmitriptan Zomig Oral Tablet 2.5 MG Tier 3 xx MIGRAINE PRODUCTS Zolmitriptan Zomig Oral Tablet 5 MG Tier 3 xx MIGRAINE PRODUCTS Zolmitriptan Zomig ZMT Oral Tablet Dispersible 2.5 MG Tier 3 xx MIGRAINE PRODUCTS Zolmitriptan Zomig ZMT Oral Tablet Dispersible 5 MG Tier 3 xx DERMATOLOGICALS Doxepin HCl (Antipruritic) Zonalon External Cream 5 % Tier 3 COUGH/COLD/ALLERGY Benzonatate Zonatuss Oral Capsule 150 MG Tier 3 ANTICONVULSANTS Zonisamide Zonegran Oral Capsule 100 MG Tier 3 ANTICONVULSANTS Zonisamide Zonegran Oral Capsule 25 MG Tier 3 ANTICONVULSANTS Zonisamide Zonisamide Oral Capsule 100 MG Tier 1 ANTICONVULSANTS Zonisamide Zonisamide Oral Capsule 25 MG Tier 1 ANTICONVULSANTS Zonisamide Zonisamide Oral Capsule 50 MG Tier 1 HEMATOLOGICAL AGENTS ‐ MISC. Vorapaxar Sulfate Zontivity Oral Tablet 2.08 MG Tier 3 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Somatropin (Non‐Refrigerated) Zorbtive Subcutaneous Solution Reconstituted 8.8 MG Tier 2 x ASSORTED CLASSES Everolimus (Immunosuppressant) Zortress Oral Tablet 0.25 MG Tier 2 ASSORTED CLASSES Everolimus (Immunosuppressant) Zortress Oral Tablet 0.5 MG Tier 2 ASSORTED CLASSES Everolimus (Immunosuppressant) Zortress Oral Tablet 0.75 MG Tier 2 ANALGESICS ‐ ANTI‐INFLAMMATORY Diclofenac Zorvolex Oral Capsule 18 MG Tier 3 x ANALGESICS ‐ ANTI‐INFLAMMATORY Diclofenac Zorvolex Oral Capsule 35 MG Tier 3 x VACCINES Zoster Vaccine Live Zostavax Subcutaneous Solution Reconstituted 19400 UNT/0.65ML Tier 3 x PENICILLINS Piperacillin Sodium‐Tazobactam Sodium Zosyn Intravenous Solution Reconstituted 2‐0.25 GM Tier 3 x PENICILLINS Piperacillin Sodium‐Tazobactam Sodium Zosyn Intravenous Solution Reconstituted 3‐0.375 GM Tier 3 x PENICILLINS Piperacillin Sodium‐Tazobactam Sodium Zosyn Intravenous Solution Reconstituted 4‐0.5 GM Tier 3 x CONTRACEPTIVES Ethynodiol Diacet & Eth Estrad Zovia 1/35E (28) Oral Tablet 1‐35 MG‐MCG Tier 1 CONTRACEPTIVES Ethynodiol Diacet & Eth Estrad Zovia 1/50E (28) Oral Tablet 1‐50 MG‐MCG Tier 3 DERMATOLOGICALS Acyclovir Topical Zovirax External Cream 5 % Tier 2 DERMATOLOGICALS Acyclovir Topical Zovirax External Ointment 5 % Tier 3 ANTIVIRALS Acyclovir Zovirax Oral Capsule 200 MG Tier 3 x ANTIVIRALS Acyclovir Zovirax Oral Suspension 200 MG/5ML Tier 3 x ANTIVIRALS Acyclovir Zovirax Oral Tablet 400 MG Tier 3 x ANTIVIRALS Acyclovir Zovirax Oral Tablet 800 MG Tier 3 x ANALGESICS ‐ OPIOID Buprenorphine HCl‐Naloxone HCl Dihydrate Zubsolv Sublingual Tablet Sublingual 1.4‐0.36 MG Tier 2 x x ANALGESICS ‐ OPIOID Buprenorphine HCl‐Naloxone HCl Dihydrate Zubsolv Sublingual Tablet Sublingual 11.4‐2.9 MG Tier 2 x x ANALGESICS ‐ OPIOID Buprenorphine HCl‐Naloxone HCl Dihydrate Zubsolv Sublingual Tablet Sublingual 2.9‐0.71 MG Tier 2 x x ANALGESICS ‐ OPIOID Buprenorphine HCl‐Naloxone HCl Dihydrate Zubsolv Sublingual Tablet Sublingual 5.7‐1.4 MG Tier 2 x x ANALGESICS ‐ OPIOID Buprenorphine HCl‐Naloxone HCl Dihydrate Zubsolv Sublingual Tablet Sublingual 8.6‐2.1 MG Tier 2 x x COUGH/COLD/ALLERGY Pseudoephed‐CPM w/ Hydrocod Zutripro Oral Solution 60‐4‐5 MG/5ML Tier 3 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Bupropion HCl (Smoking Deterrent) Zyban Oral Tablet Extended Release 12 Hour 150 MG Tier 3 DERMATOLOGICALS Imiquimod Zyclara External Cream 3.75 % Tier 3 DERMATOLOGICALS Imiquimod Zyclara Pump External Cream 2.5 % Tier 3 DERMATOLOGICALS Imiquimod Zyclara Pump External Cream 3.75 % Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Idelalisib Zydelig Oral Tablet 100 MG Tier 2 x x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Idelalisib Zydelig Oral Tablet 150 MG Tier 2 x x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Zileuton Zyflo CR Oral Tablet Extended Release 12 Hour 600 MG Tier 3 x x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Zileuton Zyflo Oral Tablet 600 MG Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Ceritinib Zykadia Oral Capsule 150 MG Tier 2 x x OPHTHALMIC AGENTS Loteprednol Etabonate‐Tobramycin Zylet Ophthalmic Suspension 0.5‐0.3 % Tier 3 GOUT AGENTS Allopurinol Zyloprim Oral Tablet 100 MG Tier 3 GOUT AGENTS Allopurinol Zyloprim Oral Tablet 300 MG Tier 3 OPHTHALMIC AGENTS Gatifloxacin (Ophth) Zymaxid Ophthalmic Solution 0.5 % Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Olanzapine ZyPREXA Intramuscular Solution Reconstituted 10 MG Tier 3 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Olanzapine ZyPREXA Oral Tablet 10 MG Tier 3 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Olanzapine ZyPREXA Oral Tablet 15 MG Tier 3 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Olanzapine ZyPREXA Oral Tablet 2.5 MG Tier 3 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Olanzapine ZyPREXA Oral Tablet 20 MG Tier 3 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Olanzapine ZyPREXA Oral Tablet 5 MG Tier 3 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Olanzapine ZyPREXA Oral Tablet 7.5 MG Tier 3 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Olanzapine Pamoate ZyPREXA Relprevv Intramuscular Suspension Reconstituted 210 MG Tier 3 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Olanzapine Pamoate ZyPREXA Relprevv Intramuscular Suspension Reconstituted 300 MG Tier 3 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Olanzapine Pamoate ZyPREXA Relprevv Intramuscular Suspension Reconstituted 405 MG Tier 3 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Olanzapine ZyPREXA Zydis Oral Tablet Dispersible 10 MG Tier 3 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Olanzapine ZyPREXA Zydis Oral Tablet Dispersible 15 MG Tier 3 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Olanzapine ZyPREXA Zydis Oral Tablet Dispersible 20 MG Tier 3 x ANTIPSYCHOTICS/ANTIMANIC AGENTS Olanzapine ZyPREXA Zydis Oral Tablet Dispersible 5 MG Tier 3 x ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Abiraterone Acetate Zytiga Oral Tablet 250 MG Tier 2 x x DERMATOLOGICALS Diclofenac Sodium‐Amitriptyline‐Prilocaine‐Lidocaine Zyvodol External Cream Tier 3 ANTI‐INFECTIVE AGENTS ‐ MISC. Linezolid Zyvox Intravenous Solution 2 MG/ML Tier 3 x ANTI‐INFECTIVE AGENTS ‐ MISC. Linezolid Zyvox Oral Suspension Reconstituted 100 MG/5ML Tier 3 ANTI‐INFECTIVE AGENTS ‐ MISC. Linezolid Zyvox Oral Tablet 600 MG Tier 3