Pharmacy | PDL | California

2021 California Student Resources Traditional 3-Tier List

Please note: This Prescription Drug List (PDL) is accurate as of September 1, 2021 and is subject to change after this date. All previous versions of this PDL are no longer in effect. Your estimated coverage and copay/coinsurance may vary based on the benefit plan you choose and the effective date of the plan.

This PDL can also be accessed online at uhcsr.com > Search for School Name > Helpful Links > RX Drug List. Plan-specific coverage documents may be accessed online atuhcsr.com > Search for School Name > Choose a Plan Description. If you are a UnitedHealthcare Student Resources member, please register or log on to uhcsr.com, or call 1-855-828-7716 to find pharmacy information specific to your benefit plan. This PDL is applicable to the following health insurance products offered by UnitedHealthcare Student Resources: • Choice Plus • Options PPO

Updated 7/13/2021

7/21 © 2021 United HealthCare Services, Inc. All Rights Reserved. WF4335930-D Contents

At UnitedHealthcare, we want to help you better understand your options...... 3

How do I use my PDL? ...... 4

What are tiers? ...... 5

When does the PDL change? ...... 5

Utilization Management Programs ...... 6

Your Right to Request Access to a Non-formulary Drug ...... 6

Requesting a Prior Authorization ...... 7

How do I locate and fill a prescription through a retail network pharmacy? ...... 7

How do I locate and fill a prescription through the mail order pharmacy? ...... 7

How do I locate and fill a prescription at a specialty pharmacy? ...... 8

How do I get updated information about my pharmacy benefit? ...... 8

Nondiscrimination notice and access to communication services ...... 9

Prescription Drug List ...... 12

2 At UnitedHealthcare, we want to help you better understand your medication options. Your pharmacy benefit offers flexibility and choice in determining the right medication for you. To help you get the most out of your pharmacy benefit, we’ve included some of the most commonly used terms and their definitions as well as frequently asked questions: Brand-name drug means a Prescription Drug Product (1) which is manufactured and marketed under a trademark or name by a specific drug manufacturer; or (2) that we identify as a brand-name product, based on available data resources. This includes data sources such as Medi-Span, that classify drugs as either brand or generic based on a number of factors. Not all products identified as a “brand-name” by the manufacturer, pharmacy, or your Physician will be classified as brand-name by us. A brand- name drug is listed in this PDL in all CAPITAL letters. Coinsurance means a percentage of the cost of a covered health care benefit that you pay after you have paid the deductible, if a deductible applies to the health care benefit. Copayment means a fixed dollar amount that you pay for a covered health care benefit after you have paid the deductible, if a deductible applies to the health care benefit. Deductible means the amount you pay for covered health care benefits that are subject to the deductible before your health insurer begins to pay. If your health insurance policy has a deductible, it may have either 1 deductible or separate deductibles for medical benefits and prescription drug benefits. After you pay your deductible, you usually pay only a copayment or coinsurance for covered health care benefits. Your insurance company pays the rest. Drug Tier means a group of Prescription Drug Products that correspond to a specified cost sharing tier in your health insurance policy. The drug tier in which a Prescription Drug Product is placed determines your portion of the cost for the drug. Exception request means a request for coverage of a non-formulary drug. If you, your designee, or your prescribing health care provider submits a request for coverage of a non-formulary drug, your insurer must cover the non-formulary drug when it is medically necessary for you to take the drug. Exigent circumstances means when you are suffering from a medical condition that may seriously jeopardize your life, health, or ability to regain maximum function, or when you are undergoing a current course of treatment using a non-formulary drug. Formulary or Prescription Drug List (PDL) means a list that categorizes into tiers or products that have been approved by the U.S. Food and Drug Administration (FDA). This list is subject to our periodic review and modification (generally quarterly, but no more than 6 times per calendar year). means a Prescription Drug Product: (1) that is chemically equivalent to a brand-name drug; or (2) that we identify as a generic product based on available data resources. This includes data sources such as Medi-Span, that classify drugs as either brand or generic based on a number of factors. Not all products identified as a “generic” by the manufacturer, pharmacy or your Physician will be classified as a generic by us. A generic drug is listed in this PDL in italicized lowercase letters. Medically Necessary means health care benefits needed to diagnose, treat, or prevent a medical condition or its symptoms and that meet accepted standards of medicine. Health insurance usually does not cover health care benefits that are not medically necessary. Non-formulary drug means a Prescription Drug Product that is not listed on this PDL. Out-of-pocket costs means your expenses for health care benefits that aren’t reimbursed by your health insurance. Out-of- pocket costs include deductibles, copayments, and coinsurance for covered health care benefits, plus all costs for health care benefits that are not covered. Prescribing provider means a health care provider who can write a prescription for a drug to diagnose, treat, or prevent a medical condition. Prescription means an oral, written, or electronic order from a prescribing provider authorizing a Prescription Drug Product to be provided to a specific individual. Prescription Drug Product means a medication or product that has been approved by the U.S. Food and Drug Administration (FDA) and that can, under federal or state law, be dispensed only according to a Prescription Order or Refill. A Prescription Drug Product includes a medication that, due to its characteristics, is appropriate for self-administration or administration by a non-skilled caregiver.

3 We will provide coverage for a Prescription Drug Product which includes a medication that, due to its characteristics, is appropriate for self-administration or administration by a non-skilled caregiver. This definition includes: Inhalers (with spacers); ; the following diabetic supplies: standard insulin syringes with needles; blood-testing strips - glucose; urine-testing strips - glucose; ketone-testing strips and tablets; lancets and lancet devices; and glucose meters (including continuous glucose monitors); disposable devices which are medically necessary for the administration of a covered outpatient Prescription Drug Product. Benefits also include FDA-approved contraceptive drugs, devices, and products available over-the-counter when prescribed by a Network provider. Prior Authorization means a process by your health insurer to determine that a health care benefit is medically necessary for you. If a Prescription Drug Product is subject to prior authorization in this PDL, your prescribing provider must request approval from your health insurer to cover the drug. Your health insurer must grant a prior authorization request when it is medically necessary for you to take the drug. Step therapy means a specific sequence in which Prescription Drug Products for a particular medical condition must be tried. If a drug is subject to step therapy in this PDL, you may have to try 1 or more other drugs before your health insurance policy will cover that drug for your medical condition. If your prescribing provider submits a request for an exception to the step therapy requirement, your health insurer must grant the request when it is medically necessary for you to take the drug.

How do I use my PDL? When choosing a medication, you and your doctor should consult the PDL. It will help you and your doctor choose the most cost-effective prescription drugs. This guide tells you if special programs apply. Bring this list with you when you see your doctor. It is organized by therapeutic category and class. The therapeutic category and class are based on the American Hospital Formulary Service (AHFS) Pharmacologic-Therapeutic Classification. You may also find a drug by its brand or generic name in the alphabetical index. If a generic equivalent for a brand-name drug is not available on the market or is not covered, the drug will not be separately listed by its generic name. This is the way Prescription Drug Products appear in the PDL: 1. A drug is listed alphabetically by its brand and generic names in the therapeutic category and class to which it belongs; 2. The generic name for a brand-name drug is included after the brand-name in parentheses and all lowercase italicized letters; 3. If a generic equivalent for a brand-name drug is both available and covered, the generic drug will be listed separately from the brand-name drug in all lowercase italicized letters; and 4. If a generic drug is marketed under a proprietary, trademark-protected brand-name, the brand-name will be listed after the generic name in parentheses and regular typeface with the first letter of each word capitalized. Example:

Prescription Drug Name Drug Tier Coverage Requirements & Limits AVAPRO ORAL TABLET 150 MG, 300 MG, 75 MG () 3 irbesartan oral tablet 150 mg, 300 mg, 75 mg 1

If your medication is not listed in this document, please call 1-855-828-7716. Below is a list of drug tier numbers, abbreviations and designations used in the PDL as well as an explanation for each.

Drug Tier 1 Your lowest cost medications H May be part of health care reform preventive Drug Tier 2 Your mid-range cost medications H-N May be part of health care reform preventive when used for appropriate Drug Tier 3 Your highest cost medications preventive purposes PA Prior authorization required SP Specialty medication SL Supply Limit CM Orally administered anti-cancer medication ST Step Therapy

4 What are tiers? Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which is determined by your employer or health plan. This is how much you will pay when you fill a prescription. Tier 1 medications are your lowest-cost options. If your medication is placed in Tier 2 or 3, look to see if there is a Tier 1 option available. Discuss these options with your doctor. For orally administered anti-cancer medications on any Tier, the total amount of copayments and/or coinsurance shall not exceed $250 for an individual prescription of up to a 30-day supply. For high deductible health plans, the $250 maximum only applies once the deductible has been met. Check your benefit plan documents to find out your specific pharmacy plan costs, including any maximum dollar amount of cost sharing that may apply to a drug. Preferred medications are found in Tier 1 or Tier 2 and may vary depending on the medication and the condition it treats.

$ Drug Tier Includes Helpful Tips Tier 1 Medications that provide the highest Use Tier 1 drugs for the lowest out-of- $ Your lowest cost overall value. Mostly generic drugs. Some pocket costs. brand-name drugs may also be included.

Tier 2 Medications that provide good overall Use Tier 2 drugs instead of Tier 3 to $$ Your mid-range cost value. A mix of brand-name and help reduce your out-of-pocket costs. generic drugs.

Tier 3 Medications that provide the lowest Many Tier 3 drugs have lower-cost $$$ Your highest cost overall value. Mostly brand-name drugs, options in Tier 1 or 2. Ask your doctor if as well as some generics. they could work for you.

When does the PDL change? This PDL is required to be updated on a monthly basis. • Medications may move to a lower tier at any time. • Medications may move to a higher tier when a generic becomes available. • Medications may move to a higher tier or become non-formulary most often on Jan. 1. • Medications may become subject to new or revised utilization management procedures, such as prior authorization or supply limits, at any time but most often upon FDA approval of the medication or its generic, Jan. 1. When a medication changes tiers, you may have to pay a different amount for that medication. The presence of a Prescription Drug Product on the PDL does not guarantee that you will be prescribed that Prescription Drug Product by your provider for a particular medical condition.

5 Utilization Management Programs

Prior authorization required—Your doctor is required to provide additional information to us to determine coverage. For specific prior authorization requirements, please refer to your Evidence of Coverage.

Supply limit—Amount of medication covered per copayment or in a specific time period.

Step therapy — Requires you to try one or more other medications before the medication you are requesting may be covered. For specific step therapy requirements, please refer to your Evidence of Coverage.

Health Care Reform Preventive when used for appropriate preventive purposes—This medication is part of a health care reform preventive benefit and may be available at no cost to you when used for appropriate preventive purposes. For more information, please refer to the California Traditional, Access, and Enhanced HMO and PPO Prescription Drug List (PDL) PPACA $0 Cost-Share Preventive Care Medications list.

Designated specialty program—For certain Specialty Prescription Drug Products, we may direct you to a Designated Pharmacy with whom we have an arrangement to provide those Prescription Drug Products, which are identified in the Coverage Requirements and Limits column of the Prescription Drug List (PDL). If you choose not to obtain your Prescription Drug Product from the Designated Pharmacy, you may opt-out of the Designated Pharmacy program by calling 1-855-828-7716.

To learn more about a pharmacy program or to find out if it applies to you, please visit uhcsr.com or call the toll-free member phone number on your health plan ID card. If you are a pre-enrollee and you would like to learn more about your specific pharmacy benefit, please contact your school. Drugs administered by a health care professional are generally covered under the medical benefit while drugs that are self- administered are covered under the pharmacy benefit. In order to obtain medical benefits for drugs that are administered by a health care professional, your provider may also be required to obtain a prior authorization. The provider may contact UnitedHealthcare for more information or uhcprovider.com.

Your Right to Request Access to a Non-formulary Drug This plan must cover all Medically Necessary Prescription Drug Products. When a Prescription Drug Product is not on our PDL, you or your representative may request an exception to gain access to that Prescription Drug Product. To make a request, contact us in writing or call the toll-free number on your ID card. We will notify you of our determination within 72 hours. If approved, we will cover the Prescription Drug Product for the duration of the prescription, including refills.

Urgent Requests If your request requires immediate action and a delay could significantly increase the risk to your health, or the ability to regain maximum function, call us as soon as possible. We will provide a written or electronic determination within 24 hours. If approved, we will cover the Prescription Drug Product for the duration of the exigency.

External Review If you are not satisfied with our determination of your exception request, you may be entitled to request an external review. You or your representative may request an external review by sending a written request to us to the address set out in the determination letter or by calling the toll-free number on your ID card. The Independent Review Organization (IRO) will notify you of its determination within 72 hours.

Expedited External Review If you are not satisfied with our determination of your exception request and it involves an urgent situation, you or your representative may request an expedited external review by calling the toll-free number on your ID card or by sending a written request to the address set out in the determination letter. The IRO will notify you of our determination within 24 hours. If we deny your exception request, you may appeal. Please refer to your Evidence of Coverage for details. The complaint and appeals process, including independent review, is described under Section 6: Questions, Complaints and Appeals. You may also call the telephone number listed on your identification (ID) card.

6 Requesting Prior Authorization Before certain Prescription Drug Products are dispensed to you, your prescribing provider or your pharmacist is required to obtain prior authorization from us. Your prescribing provider can submit a request by phone to OptumRx or electronically by contacting us at uhcprovider.com. The Prior Authorization staff of qualified pharmacists and technicians is available Monday – Friday from 5 a.m. – 10 p.m. PST and Saturday from 6 a.m. – 3 p.m. PST to assist licensed physicians. Most authorizations are completed within 24 hours. The most common reason for delay in the authorization process is insufficient information. Your licensed physician may need to provide information on diagnosis and medication history and/or evidence in the form of documents, records or lab tests which establish that the use of the requested Prescription Drug Product meets plan criteria. You may determine whether a particular Prescription Drug Product is subject to prior authorization by going online at uhcsr. com or by calling 1-855-828-7716. If you are currently taking a Prescription Drug Product which was approved by UnitedHealthcare for a specific medical condition and that drug is removed from the Prescription Drug List (PDL) and the prescribing provider continues to prescribe the Prescription Drug Product for your medical condition, we will continue to cover the Prescription Drug Product provided that the drug is appropriately prescribed and is considered safe and effective for treating your medical condition. In the case of a standard prior authorization request, we will notify you, your designee, or your prescribing provider of the Benefit determination no later than 72 hours following receipt of the request. In the case of an expedited prior authorization request based on exigent circumstances, we will notify you, your designee, or your prescribing provider of the Benefit determination no later than 24 hours following receipt of the request. If we fail to respond to you, your designee, or your prescribing provider within the prescribed time limits, the request is deemed approved and we may not deny the request thereafter. If you disagree with a determination, you can request an appeal. The complaint and appeals process, including independent medical review, is described in the Evidence of Coverage under the Notice of Appeal Rights section. You may also call at the telephone number on your ID card.

How do I locate and fill a prescription through a retail network pharmacy? UnitedHealthcare has a well-established network of pharmacies including most major pharmacy and supermarket chains as well as many independent pharmacies. For a listing of network pharmacies, call the toll-free phone number on your health plan ID card to help locate a network pharmacy near you or visit our website at uhcsr.com for an up-to-date list.

How do I locate and fill a prescription through the mail order pharmacy? UnitedHealthcare offers a Mail Order Pharmacy Program through OptumRx®. If your health plan includes a mail order prescription benefit, here’s how to fill prescriptions through the Mail Order Pharmacy Program. 1. Call your prescribing provider to obtain a new prescription for each medication. When you call, ask the Physician to write the prescription for a 90-day supply which represents 3 prescription units with up to 3 additional refills. The doctor will tell you when to pick up the written prescription. (Note: OptumRx must have a new prescription to process any new Mail Order request.) 2. After picking up the prescription, complete the Mail Order Form. (To obtain forms or for assistance in completing the form, contact the Customer Service Department by calling the telephone number on the back of your ID card. You can also find the form at optumrx.com.) 3. Enclose the prescription and appropriate copayment via check, money order, or credit card. Your Pharmacy Schedule of Benefits will have the applicable copayment for the Mail Order Pharmacy Program. Make the check or money order payable to OptumRx. No cash please. Important Tip: If you are starting a new Prescription Drug Product, please request 2 prescriptions from your physician. Have 1 filled immediately at a network pharmacy while mailing the second prescription to UnitedHealthcare’s Mail Order Pharmacy. Once you receive your medication through the Mail Order Pharmacy Program, you should stop filling the prescription at the network pharmacy.

7 How do I locate and fill a prescription at a specialty pharmacy? Call 1-855-828-7716 or visit specialty.optumrx.com to locate a designated specialty pharmacy for your medication.

Designated Pharmacies If you require certain Specialty Prescription Drug Products, we may direct you to a Designated Pharmacy with whom we have an arrangement to provide those Specialty Prescription Drug Products. There are both retail and mail pharmacies in the Designated Pharmacy network. Note that not all contracted retail pharmacies are in the Designated Pharmacy network. Only retail pharmacies that are in the Designated Pharmacy network will provide access to these Specialty Prescription Drug Products. If you choose not to obtain your Specialty Prescription Drug Product from the Designated Pharmacy, you may opt-out of the Designated Pharmacy program by calling 1-855-828-7716. If you want to opt-out of the program and fill your Specialty Prescription Drug Product at a non-Designated Pharmacy but do not inform us, you will be responsible for the entire cost of the Specialty Prescription Drug Product and no Benefits will be paid. In urgent or emergent circumstances, you may contact Customer Service by calling the telephone number on the back of your ID card. This will allow you access to the retail network override process and allow the urgent or emergent prescription claim to pay at your local pharmacy for same day access if they have the Prescription Drug Product available.

How do I get updated information about my pharmacy benefit? Since the PDL may change during your plan year, we encourage you to visit uhcsr.com or call the toll-free member phone number on your health plan ID card for more current information.

Call 1-855-828-7716 for the following pharmacy information and tools: • Pharmacy benefit and coverage information • Possible lower-cost medication options • Medication interactions and side effects • Participating retail pharmacies by ZIP code • Your prescription history

And, if mail order services are included in your pharmacy benefit, you can also: • Refill prescriptions • Check the status of your order • Set up reminders for refills • Manage your account

Learn more Call the toll-free member phone number on your health plan ID card, or visit myuhc.com.

8 Nondiscrimination notice and access to communication services UnitedHealthcare Services, Inc. on behalf of itself and its affiliates does not discriminate on the basis of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability. If you think you were treated unfairly for any of these reasons, you can send a complaint to: Online: [email protected] Mail: Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, UT 84130 You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the toll- free phone number listed on your ID card. If you think you were treated unfairly because of your race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability, you can also send a complaint to the California Department of Insurance: California Department of Insurance Consumer Communications Bureau 300 South Spring Street, South Tower Los Angeles, CA 90013 1-800-927-HELP (1-800-927-4357) 1-800-482-4833 (TTY) Internet Website: www.insurance.ca.gov If you think you were treated unfairly because of your sex, age, race, color, national origin, or disability, you can also file a complaint with the U.S. Dept. of Health and Human Services: Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Phone: Toll-free 1-800-368-1019, 1-800-537-7697 (TDD) Mail: U.S. Dept. of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C. 20201

9 English IMPORTANT: You can get an interpreter at no cost to talk to your doctor or health insurance company. To get an interpreter or to ask about written information in your language, first call your insurance company’s phone number at 1-800-842-2656. Someone who speaks your language can help you. If you need more help, call the Department of Insurance Hotline at 1-800-927-4357.

Español IMPORTANTE: Puede obtener la ayuda de un intérprete sin costo alguno para hablar con su médico o con su compañía de seguros. Para obtener la ayuda de un intérprete o preguntar sobre información escrita en español, primero llame al número de teléfono de su compañía de seguros al 1-800-842-2656. Alguien que habla español puede ayudarle. Si necesita ayuda adicional, llame a la línea directa del Departamento de seguros al 1-800-927-4357. (Spanish)

中文

重要事項﹕您與您的醫生或醫療保險公司交談時,可獲得免費口譯服務。如欲請翻譯員提供口譯, 或欲查詢中文書面資料,請先致電您的保險公司,電話號碼1-800-842-2656

說中文人士將為您提供協助。如需更多協助,請致電保險部熱線 1-800-927-4357 (Chinese)

10 11 Table of Contents of Prescription Drug List Informational Section...... 1 ANTIHISTAMINE DRUGS - Drugs for Allergy...... 12 ANTI-INFECTIVE AGENTS - Drugs for Infections...... 14 ANTINEOPLASTIC AGENTS - Drugs for Cancer ...... 32 ANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINES - DRUGS FOR THE IMMUNE SYSTEM...... 41 AUTONOMIC DRUGS - Drugs for the Nervous System ...... 44 BLOOD FORMATION, COAGULATION, THROMBOSIS - Drugs for the Blood ...... 53 CARDIOVASCULAR DRUGS - Drugs for the Heart...... 62 CENTRAL NERVOUS SYSTEM AGENTS - Drugs for the Nervous System ...... 80 DENTAL AGENTS - Oral Care ...... 115 DEVICES - Medical Supplies and Durable Medical Equipment...... 115 DIAGNOSTIC AGENTS...... 118 DISINFECTANTS (FOR NON-DERMATOLOGIC USE) - Disinfectants ...... 119 ELECTROLYTIC, CALORIC, AND WATER BALANCE ...... 119 ENZYMES...... 126 EYE, EAR, NOSE AND THROAT (EENT) PREPS...... 127 GASTROINTESTINAL DRUGS ...... 135 GASTROINTESTINAL DRUGS - Drugs for the Stomach ...... 135 GOLD COMPOUNDS...... 142 HEAVY METAL ANTAGONISTS - Drugs to Reduce Iron ...... 142 HORMONES AND SYNTHETIC SUBSTITUTES - Hormones ...... 143 MISCELLANEOUS THERAPEUTIC AGENTS ...... 178 NONHORMONAL CONTRACEPTIVES - Drugs for Women ...... 196 OXYTOCICS - Drugs for Women...... 197 PHARMACEUTICAL AIDS...... 197 RESPIRATORY TRACT AGENTS - Drugs for the Lungs ...... 197 SKIN AND MUCOUS MEMBRANE AGENTS - Drugs for the Skin ...... 204 SMOOTH MUSCLE RELAXANTS - Drugs to Relax Muscles ...... 222 VITAMINS...... 223

TOC-1 Coverage Requirements & Prescription Drug Name Drug Tier Limits ANTIHISTAMINE DRUGS - Drugs for Allergy ANTIHISTAMINE DRUGS - Drugs for Allergy promethazine hcl oral tablet 25 mg 1 ETHANOLAMINE DERIVATIVES - Drugs for Allergy carbinoxamine maleate oral solution 4 mg/5ml 1 carbinoxamine maleate oral tablet 4 mg 1 clemastine fumarate oral tablet 2.68 mg 1 diphen oral elixir 12.5 mg/5ml 1 di-phen oral elixir 12.5 mg/5ml 3 diphenhydramine hcl oral elixir 12.5 mg/5ml 1 FIRST GEN. ANTIHIST. DERIVATIVES, MISC. - Drugs for Allergy cyproheptadine hcl oral syrup 2 mg/5ml 1 cyproheptadine hcl oral tablet 4 mg 1 FIRST GENERATION ANTIHISTAMINES - Drugs for Allergy ANTIVERT ORAL TABLET 50 MG ( meclizine hcl) 2 carbinoxamine maleate oral solution 4 mg/5ml 1 carbinoxamine maleate oral tablet 4 mg 1 clemastine fumarate oral tablet 2.68 mg 1 cyproheptadine hcl oral syrup 2 mg/5ml 1 cyproheptadine hcl oral tablet 4 mg 1 diphen oral elixir 12.5 mg/5ml 1 di-phen oral elixir 12.5 mg/5ml 3 diphenhydramine hcl oral elixir 12.5 mg/5ml 1 hydroxyzine hcl oral syrup 10 mg/5ml 1 hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 1 hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg 1 promethazine hcl oral solution 6.25 mg/5ml 1 promethazine hcl oral syrup 6.25 mg/5ml 1 promethazine hcl oral tablet 12.5 mg, 50 mg 1 promethazine hcl rectal suppository 12.5 mg, 25 mg 1 promethegan rectal suppository 12.5 mg, 25 mg, 50 mg 1 VISTARIL ORAL CAPSULE 25 MG, 50 MG (hydroxyzine 3 pamoate) OTHER ANTIHISTAMINES - Drugs for Allergy cimetidine hcl oral solution 300 mg/5ml, 400 mg/6.67ml 1 Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 12 Coverage Requirements & Prescription Drug Name Drug Tier Limits cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg 1 famotidine oral suspension reconstituted 40 mg/5ml 1 hydroxyzine hcl oral syrup 10 mg/5ml 1 hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 1 hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg 1 LASTACAFT OPHTHALMIC SOLUTION 0.25 % (alcaftadine) 3 SL (3 ml per prescription) nizatidine oral solution 15 mg/ml 1 SL (30.5 grams (1 box) per olopatadine hcl nasal solution 0.6 % 1 prescription.) olopatadine hcl solution 0.1 % ophthalmic (rx) 0.1 % 1 SL (30.5 grams (1 box) per PATANASE NASAL SOLUTION 0.6 % (olopatadine hcl) 3 prescription.) VISTARIL ORAL CAPSULE 25 MG, 50 MG (hydroxyzine 3 pamoate) PHENOTHIAZINE DERIVATIVES - Drugs for Allergy promethazine hcl oral solution 6.25 mg/5ml 1 promethazine hcl oral syrup 6.25 mg/5ml 1 promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg 1 promethazine hcl rectal suppository 12.5 mg, 25 mg 1 promethazine vc oral syrup 6.25-5 mg/5ml 1 promethazine vc/codeine oral syrup 6.25-5-10 mg/5ml 1 PA; SL (360 ml per month.) promethazine-codeine oral solution 6.25-10 mg/5ml 1 PA; SL (360 ml per month.) promethazine-codeine oral syrup 6.25-10 mg/5ml 1 PA; SL (360 ml per month.) promethazine-dm oral syrup 6.25-15 mg/5ml 1 promethazine-phenyleph-codeine oral syrup 6.25-5-10 mg/5ml 1 PA; SL (360 ml per month.) promethazine-phenylephrine oral syrup 6.25-5 mg/5ml 1 promethegan rectal suppository 12.5 mg, 25 mg, 50 mg 1 PROPYLAMINE DERIVATIVES - Drugs for Allergy hydrocodone polst-chlorphen polst er susp oral suspension 1 PA; SL (360 ml per month.) extended release 10-8 mg/5ml pseudoephedrine-bromphen-dm oral syrup 30-2-10 mg/5ml 1 PA; SL (10 capsules per TUSSICAPS ORAL CAPSULE EXTENDED RELEASE 12 3 prescription and 30 capsules HOUR 10-8 MG (hydrocod polst-chlorphen polst) per month.) PA; SL (10 tablets per TUXARIN ER ORAL TABLET EXTENDED RELEASE 12 HOUR 3 prescription and 30 tablets 54.3-8 MG (chlorpheniramine-codeine) per month.)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 13 Coverage Requirements & Prescription Drug Name Drug Tier Limits SECOND GENERATION ANTIHISTAMINES - Drugs for Allergy ALOMIDE OPHTHALMIC SOLUTION 0.1 % (lodoxamide 3 tromethamine) levocetirizine dihydrochloride oral solution 2.5 mg/5ml 1 levocetirizine dihydrochloride oral tablet 5 mg 1 ANTI-INFECTIVE AGENTS - Drugs for Infections 1ST GENERATION CEPHALOSPORIN ANTIBIOTICS - Antibiotics cefadroxil oral capsule 500 mg 1 cefadroxil oral suspension reconstituted 250 mg/5ml, 500 1 mg/5ml cefadroxil oral tablet 1 gm 1 cephalexin oral capsule 250 mg, 500 mg, 750 mg 1 cephalexin oral suspension reconstituted 125 mg/5ml, 250 1 mg/5ml cephalexin oral tablet 250 mg, 500 mg 1 KEFLEX ORAL CAPSULE 750 MG (cephalexin) 3 2ND GENERATION CEPHALOSPORIN ANTIBIOTICS - Antibiotics cefaclor er oral tablet extended release 12 hour 500 mg 1 cefaclor oral capsule 250 mg, 500 mg 1 cefaclor oral suspension reconstituted 125 mg/5ml, 250 mg/5ml, 1 375 mg/5ml cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml 1 cefprozil oral tablet 250 mg, 500 mg 1 cefuroxime axetil oral tablet 250 mg, 500 mg 1 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS - Antibiotics cefdinir oral capsule 300 mg 1 cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml 1 cefixime oral capsule 400 mg 1 cefixime oral suspension reconstituted 100 mg/5ml, 200 mg/5ml 1 cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, 1 50 mg/5ml cefpodoxime proxetil oral tablet 100 mg, 200 mg 1 SUPRAX ORAL CAPSULE 400 MG (cefixime) 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 14 Coverage Requirements & Prescription Drug Name Drug Tier Limits SUPRAX ORAL SUSPENSION RECONSTITUTED 100 3 MG/5ML, 200 MG/5ML, 500 MG/5ML (cefixime) SUPRAX ORAL TABLET CHEWABLE 100 MG, 200 MG 3 (cefixime) ADAMANTANE ANTIVIRALS - Drugs for Viral Infections amantadine hcl oral capsule 100 mg 1 amantadine hcl oral syrup 50 mg/5ml 1 amantadine hcl oral tablet 100 mg 1 OSMOLEX ER ORAL TABLET ER 24 HOUR THERAPY PACK 3 129 & 193 MG (amantadine hcl) rimantadine hcl oral tablet 100 mg 1 ALLYLAMINE ANTIFUNGALS - Drugs for Fungus terbinafine hcl oral tablet 250 mg 1 SL (90 tablets per 365 days) AMEBICIDES - Drugs for the Mouth and Throat FLAGYL ORAL CAPSULE 375 MG (metronidazole) 3 FLAGYL ORAL TABLET 500 MG (metronidazole) 3 metronidazole oral capsule 375 mg 1 metronidazole oral tablet 250 mg, 500 mg 1 metronidazole vaginal gel 0.75 % 1 paromomycin sulfate oral capsule 250 mg 1 vandazole vaginal gel 0.75 % 1 AMINOGLYCOSIDE ANTIBIOTICS - Antibiotics ARIKAYCE INHALATION SUSPENSION 590 MG/8.4ML 3 PA; SL (8.4 ml per day.); SP (amikacin sulfate liposome) neomycin sulfate oral tablet 500 mg 1 paromomycin sulfate oral capsule 250 mg 1 TOBI PODHALER INHALATION CAPSULE 28 MG PA; SL (224 capsules per 56 3 (tobramycin) days.); SP PA; SL (224 ml per 56 tobramycin inhalation nebulization solution 300 mg/4ml 1 days.); SP PA; SL (56 ampules (1 TOBRAMYCIN NEBULIZATION SOLUTION 300 MG/5ML 3 carton, 280 ml) per 56 days.); INHALATION 300 MG/5ML SP AMINOMETHYLCYCLINES - Antibiotics SL (30 tablets per NUZYRA ORAL TABLET 150 MG (omadacycline tosylate) 3 prescription.)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 15 Coverage Requirements & Prescription Drug Name Drug Tier Limits AMINOPENICILLIN ANTIBIOTICS - Antibiotics amoxicillin oral capsule 250 mg, 500 mg 1 amoxicillin oral suspension reconstituted 125 mg/5ml, 200 1 mg/5ml, 250 mg/5ml, 400 mg/5ml amoxicillin oral tablet 500 mg, 875 mg 1 amoxicillin oral tablet chewable 125 mg, 250 mg 1 amoxicillin-potassium clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml, 600-42.9 1 mg/5ml amoxicillin-potassium clavulanate oral tablet 250-125 mg, 500- 1 125 mg, 875-125 mg amoxicillin-potassium clavulanate oral tablet chewable 200-28.5 1 mg, 400-57 mg ampicillin oral capsule 500 mg 1 SL (1 carton (10 OMECLAMOX-PAK ORAL 500-500-20 MG (amoxicill-clarithro- 3 administrative cards, 80 omeprazole) tablets) per 6 months.) ANTHELMINTICS - Drugs for Parasites PA; SL (124 tablets per albendazole oral tablet 200 mg 1 month.) PA; SL (124 tablets per ALBENZA ORAL TABLET 200 MG ( albendazole) 3 month.) BILTRICIDE ORAL TABLET 600 MG (praziquantel) 3 EGATEN ORAL TABLET 250 MG (triclabendazole) 3 EMVERM ORAL TABLET CHEWABLE 100 MG ( mebendazole) 3 PA; SL (6 tablets per 3 days.) ivermectin oral tablet 3 mg 1 praziquantel oral tablet 600 mg 1 STROMECTOL ORAL TABLET 3 MG ( ivermectin) 3 ANTIFUNGALS, MISCELLANEOUS - Drugs for Fungus griseofulvin microsize oral suspension 125 mg/5ml 1 griseofulvin microsize oral tablet 500 mg 1 griseofulvin ultramicrosize oral tablet 125 mg, 250 mg 1 ANTI-INFECTIVES (SYSTEMIC), MISC. - Drugs for Infections PYLERA ORAL CAPSULE 140-125-125 MG (bis subcit- SL (120 capsules per 180 3 metronid-tetracyc) days.) ANTIMALARIALS - Drugs for the Mouth and Throat ARAKODA ORAL TABLET 100 MG (tafenoquine succinate) 3 SL (16 tablets per month.)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 16 Coverage Requirements & Prescription Drug Name Drug Tier Limits atovaquone-proguanil hcl oral tablet 250-100 mg, 62.5-25 mg 1 avidoxy oral tablet 100 mg 1 chloroquine phosphate oral tablet 250 mg, 500 mg 1 COARTEM ORAL TABLET 20-120 MG (artemether- 2 lumefantrine) DARAPRIM ORAL TABLET 25 MG (pyrimethamine) 3 PA; SP doxycycline hyclate oral capsule 100 mg, 50 mg 1 doxycycline hyclate oral tablet 100 mg 1 doxycycline monohydrate oral capsule 100 mg, 50 mg 1 doxycycline monohydrate oral suspension reconstituted 25 1 mg/5ml doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 mg, 1 75 mg hydroxychloroquine sulfate oral tablet 200 mg 1 SL (2 tablets per KRINTAFEL ORAL TABLET 150 MG ( tafenoquine succinate) 1 prescription.) MALARONE ORAL TABLET 250-100 MG, 62.5-25 MG 3 (atovaquone-proguanil hcl) mefloquine hcl oral tablet 250 mg 1 minocycline hcl oral capsule 100 mg, 50 mg, 75 mg 1 mondoxyne nl oral capsule 100 mg 1 morgidox oral capsule 100 mg 1 primaquine phosphate oral tablet 26.3 (15 base) mg 1 pyrimethamine oral tablet 25 mg 1 PA; SP QUALAQUIN ORAL CAPSULE 324 MG (quinine sulfate) 3 quinidine gluconate er oral tablet extended release 324 mg 1 quinidine sulfate oral tablet 200 mg, 300 mg 1 quinine sulfate oral capsule 324 mg 1 tetracycline hcl oral capsule 250 mg, 500 mg 1 VIBRAMYCIN ORAL CAPSULE 100 MG (doxycycline hyclate) 3 VIBRAMYCIN ORAL SUSPENSION RECONSTITUTED 25 3 MG/5ML (doxycycline monohydrate) VIBRAMYCIN ORAL SYRUP 50 MG/5ML (doxycycline calcium) 3 ANTIMYCOBACTERIALS, MISCELLANEOUS - Antibiotics dapsone oral tablet 100 mg, 25 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 17 Coverage Requirements & Prescription Drug Name Drug Tier Limits ANTIPROTOZOALS, MISCELLANEOUS - Drugs for the Mouth and Throat ALINIA ORAL SUSPENSION RECONSTITUTED 100 MG/5ML 2 SL (60 ml per prescription.) (nitazoxanide) SL (6 tablets per ALINIA ORAL TABLET 500 MG (nitazoxanide) 3 prescription.) atovaquone oral suspension 750 mg/5ml 1 BACTRIM DS ORAL TABLET 800-160 MG (sulfamethoxazole- 3 trimethoprim) BACTRIM ORAL TABLET 400-80 MG (sulfamethoxazole- 3 trimethoprim) PA; SL (248 tablets per 720 BENZNIDAZOLE ORAL TABLET 100 MG 2 days.) PA; SL (720 tablets per 720 BENZNIDAZOLE ORAL TABLET 12.5 MG 2 days.) dapsone oral tablet 100 mg, 25 mg 1 FLAGYL ORAL CAPSULE 375 MG (metronidazole) 3 FLAGYL ORAL TABLET 500 MG (metronidazole) 3 IMPAVIDO ORAL CAPSULE 50 MG (miltefosine) 2 PA; SL (3 capsules per day.) LAMPIT ORAL TABLET 120 MG (nifurtimox) 3 PA; SL (7.5 tablets per day.) LAMPIT ORAL TABLET 30 MG (nifurtimox) 3 PA; SL (9 tablets per day.) metronidazole oral capsule 375 mg 1 metronidazole oral tablet 250 mg, 500 mg 1 NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 3 MG (pentamidine isethionate) SL (6 tablets per nitazoxanide oral tablet 500 mg 1 prescription.) pentamidine isethionate inhalation solution reconstituted 300 1 mg PYLERA ORAL CAPSULE 140-125-125 MG (bis subcit- SL (120 capsules per 180 3 metronid-tetracyc) days.) ST; SL (1 packet per SOLOSEC ORAL PACKET 2 GM (secnidazole) 3 prescription.) sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml 1 sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 1 mg sulfatrim pediatric oral suspension 200-40 mg/5ml 1 tinidazole oral tablet 250 mg, 500 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 18 Coverage Requirements & Prescription Drug Name Drug Tier Limits ANTITUBERCULOSIS AGENTS - Antibiotics CIPRO ORAL SUSPENSION RECONSTITUTED 250 MG/5ML 3 (5%), 500 MG/5ML (10%) (ciprofloxacin) CIPRO ORAL TABLET 250 MG, 500 MG (ciprofloxacin hcl) 3 ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg 1 clarithromycin er oral tablet extended release 24 hour 500 mg 1 clarithromycin oral suspension reconstituted 125 mg/5ml, 250 1 mg/5ml clarithromycin oral tablet 250 mg, 500 mg 1 cycloserine oral capsule 250 mg 1 ethambutol hcl oral tablet 100 mg, 400 mg 1 isoniazid oral syrup 50 mg/5ml 1 isoniazid oral tablet 100 mg, 300 mg 1 levofloxacin oral solution 25 mg/ml 1 levofloxacin oral tablet 250 mg, 500 mg, 750 mg 1 moxifloxacin hcl oral tablet 400 mg 1 MYAMBUTOL ORAL TABLET 400 MG ( ethambutol hcl) 3 MYCOBUTIN ORAL CAPSULE 150 MG (rifabutin) 3 PASER ORAL PACKET 4 GM (aminosalicylic acid) 3 PRETOMANID ORAL TABLET 200 MG 3 PRIFTIN ORAL TABLET 150 MG (rifapentine) 2 pyrazinamide oral tablet 500 mg 1 rifabutin oral capsule 150 mg 1 rifampin oral capsule 150 mg, 300 mg 1 SIRTURO ORAL TABLET 100 MG, 20 MG (bedaquiline 2 fumarate) TRECATOR ORAL TABLET 250 MG ( ethionamide) 2 ANTIVIRALS, MISCELLANEOUS - Drugs for Viral Infections PREVYMIS ORAL TABLET 240 MG, 480 MG (letermovir) 2 PA XOFLUZA (40 MG DOSE) ORAL TABLET THERAPY PACK 2 3 SL (2 tablets per month.) X 20 MG (baloxavir marboxil) XOFLUZA (80 MG DOSE) ORAL TABLET THERAPY PACK 2 3 SL (2 tablets per month.) X 40 MG (baloxavir marboxil) AZOLE ANTIFUNGALS - Drugs for Fungus CRESEMBA ORAL CAPSULE 186 MG (isavuconazonium 3 sulfate)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 19 Coverage Requirements & Prescription Drug Name Drug Tier Limits DIFLUCAN ORAL SUSPENSION RECONSTITUTED 10 3 MG/ML, 40 MG/ML (fluconazole) DIFLUCAN ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG 3 (fluconazole) fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml 1 fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg 1 SL (180 capsules per 365 itraconazole oral capsule 100 mg 1 days) itraconazole oral solution 10 mg/ml 1 SL (1800 ml per 365 days) oral tablet 200 mg 1 NOXAFIL ORAL SUSPENSION 40 MG/ML (posaconazole) 2 SL (20 ml per day.) posaconazole oral tablet delayed release 100 mg 1 SL (180 capsules per 365 SPORANOX ORAL CAPSULE 100 MG (itraconazole) 3 days) SPORANOX ORAL SOLUTION 10 MG/ML (itraconazole) 3 SL (1800 ml per 365 days) SPORANOX PULSEPAK ORAL CAPSULE 100 MG SL (180 capsules per 365 3 (itraconazole) days) VFEND ORAL SUSPENSION RECONSTITUTED 40 MG/ML 3 SL (300 mL per prescription.) (voriconazole) SL (62 tablets per VFEND ORAL TABLET 200 MG (voriconazole) 3 prescription.) SL (124 tablets per VFEND ORAL TABLET 50 MG (voriconazole) 3 prescription) voriconazole oral suspension reconstituted 40 mg/ml 1 SL (62 tablets per voriconazole oral tablet 200 mg 1 prescription.) SL (124 tablets per voriconazole oral tablet 50 mg 1 prescription) ERYTHROMYCIN ANTIBIOTICS - Antibiotics E.E.S. GRANULES ORAL SUSPENSION RECONSTITUTED 3 200 MG/5ML (erythromycin ethylsuccinate) ERYPED 200 ORAL SUSPENSION RECONSTITUTED 200 3 MG/5ML (erythromycin ethylsuccinate) ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400 3 MG/5ML (erythromycin ethylsuccinate) ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 3 MG, 500 MG (erythromycin base) ERYTHROCIN STEARATE ORAL TABLET 250 MG 2 (erythromycin stearate)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 20 Coverage Requirements & Prescription Drug Name Drug Tier Limits erythromycin base oral capsule delayed release particles 250 1 mg erythromycin base oral tablet 250 mg, 500 mg 1 erythromycin base oral tablet delayed release 250 mg, 333 mg, 1 500 mg erythromycin ethylsuccinate oral suspension reconstituted 200 1 mg/5ml, 400 mg/5ml erythromycin ethylsuccinate oral tablet 400 mg 1 erythromycin oral tablet delayed release 250 mg, 333 mg, 500 1 mg GLYCOPEPTIDE ANTIBIOTICS - Antibiotics FIRVANQ ORAL SOLUTION RECONSTITUTED 25 MG/ML, 50 1 MG/ML (vancomycin hcl) VANCOCIN HCL ORAL CAPSULE 125 MG (vancomycin hcl) 3 SL (56 capsules per 11 days) SL (112 capsules per 11 VANCOCIN ORAL CAPSULE 250 MG (vancomycin hcl) 3 days) vancomycin hcl oral capsule 125 mg 1 SL (56 capsules per 11 days) SL (112 capsules per 11 vancomycin hcl oral capsule 250 mg 1 days) vancomycin hcl oral solution reconstituted 250 mg/5ml 1 HCV POLYMERASE INHIBITOR ANTIVIRALS - Drugs for Viral Infections EPCLUSA ORAL TABLET 200-50 MG (sofosbuvir-velpatasvir) 2 PA; SL (1 tablet per day.) PA; SL (84 tablets per 720 EPCLUSA ORAL TABLET 400-100 MG (sofosbuvir-velpatasvir) 2 days.) HARVONI ORAL PACKET 33.75-150 MG, 45-200 MG SL (1 pellet per day and 84 2 (ledipasvir-sofosbuvir) pellets per 720 days.) PA; ST; SL (84 tablets per HARVONI ORAL TABLET 45-200 MG (ledipasvir-sofosbuvir) 2 720 days.) PA; ST; SL (56 tablets per HARVONI ORAL TABLET 90-400 MG (ledipasvir-sofosbuvir) 2 720 days.) PA; ST; SL (56 tablets per LEDIPASVIR-SOFOSBUVIR ORAL TABLET 90-400 MG 2 720 days.) PA; SL (84 tablets per 720 SOFOSBUVIR-VELPATASVIR ORAL TABLET 400-100 MG 2 days.) PA; ST; SL (1 pellet per day SOVALDI ORAL PACKET 150 MG, 200 MG (sofosbuvir) 3 and 84 pellets per 720 days.) PA; ST; SL (84 tablets per SOVALDI ORAL TABLET 200 MG (sofosbuvir) 3 720 days.)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 21 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; ST; SL (84 tablets per SOVALDI ORAL TABLET 400 MG (sofosbuvir) 3 720 days.); SP VIEKIRA PAK ORAL TABLET THERAPY PACK 12.5-75-50 PA; ST; SL (336 tablets per 3 &250 MG (ombitas-paritapre-ritona-dasab) 720 days.); SP VOSEVI ORAL TABLET 400-100-100 MG (sofosbuv-velpatasv- PA; SL (84 tablets per 720 2 voxilaprev) days.); SP HCV PROTEASE INHIBITOR ANTIVIRALS - Drugs for Viral Infections MAVYRET ORAL TABLET 100-40 MG (glecaprevir- PA; SL (168 tablets per 720 2 pibrentasvir) days.); SP VIEKIRA PAK ORAL TABLET THERAPY PACK 12.5-75-50 PA; ST; SL (336 tablets per 3 &250 MG (ombitas-paritapre-ritona-dasab) 720 days.); SP VOSEVI ORAL TABLET 400-100-100 MG (sofosbuv-velpatasv- PA; SL (84 tablets per 720 2 voxilaprev) days.); SP PA; SL (84 tablets per 720 ZEPATIER ORAL TABLET 50-100 MG (elbasvir-grazoprevir) 2 days (12 weeks).); SP HCV REPLICATION COMPLEX INHIBITORS - Drugs for Viral Infections EPCLUSA ORAL TABLET 200-50 MG (sofosbuvir-velpatasvir) 2 PA; SL (1 tablet per day.) PA; SL (84 tablets per 720 EPCLUSA ORAL TABLET 400-100 MG (sofosbuvir-velpatasvir) 2 days.) HARVONI ORAL PACKET 33.75-150 MG, 45-200 MG SL (1 pellet per day and 84 2 (ledipasvir-sofosbuvir) pellets per 720 days.) PA; ST; SL (84 tablets per HARVONI ORAL TABLET 45-200 MG (ledipasvir-sofosbuvir) 2 720 days.) PA; ST; SL (56 tablets per HARVONI ORAL TABLET 90-400 MG (ledipasvir-sofosbuvir) 2 720 days.) PA; ST; SL (56 tablets per LEDIPASVIR-SOFOSBUVIR ORAL TABLET 90-400 MG 2 720 days.) MAVYRET ORAL TABLET 100-40 MG (glecaprevir- PA; SL (168 tablets per 720 2 pibrentasvir) days.); SP PA; SL (84 tablets per 720 SOFOSBUVIR-VELPATASVIR ORAL TABLET 400-100 MG 2 days.) VIEKIRA PAK ORAL TABLET THERAPY PACK 12.5-75-50 PA; ST; SL (336 tablets per 3 &250 MG (ombitas-paritapre-ritona-dasab) 720 days.); SP VOSEVI ORAL TABLET 400-100-100 MG (sofosbuv-velpatasv- PA; SL (84 tablets per 720 2 voxilaprev) days.); SP PA; SL (84 tablets per 720 ZEPATIER ORAL TABLET 50-100 MG (elbasvir-grazoprevir) 2 days (12 weeks).); SP

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 22 Coverage Requirements & Prescription Drug Name Drug Tier Limits HIV ENTRY AND FUSION INHIBITORS - Drugs for Viral Infections FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 2 MG (enfuvirtide) RUKOBIA ORAL TABLET EXTENDED RELEASE 12 HOUR 3 PA 600 MG (fostemsavir tromethamine) SELZENTRY ORAL SOLUTION 20 MG/ML (maraviroc) 2 PA SELZENTRY ORAL TABLET 150 MG, 25 MG, 300 MG, 75 MG 2 PA (maraviroc) HIV INTEGRASE INHIBITOR ANTIRETROVIRALS - Drugs for Viral Infections BIKTARVY ORAL TABLET 50-200-25 MG (bictegravir- 2 SL (1 tablet per day.) emtricitab-tenofov) DOVATO ORAL TABLET 50-300 MG (dolutegravir-lamivudine) 2 SL (1 tablet per day.) GENVOYA ORAL TABLET 150-150-200-10 MG (elviteg-cobic- 2 SL (1 tablet per day.) emtricit-tenofaf) ISENTRESS HD ORAL TABLET 600 MG (raltegravir 2 potassium) ISENTRESS ORAL PACKET 100 MG (raltegravir potassium) 2 ISENTRESS ORAL TABLET 400 MG (raltegravir potassium) 2 ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG 2 (raltegravir potassium) JULUCA ORAL TABLET 50-25 MG (dolutegravir-rilpivirine) 2 SL (1 tablet per day.) STRIBILD ORAL TABLET 150-150-200-300 MG (elviteg-cobic- 2 SL (1 tablet per day.) emtricit-tenofdf) TIVICAY ORAL TABLET 50 MG (dolutegravir sodium) 3 TIVICAY PD ORAL TABLET SOLUBLE 5 MG (dolutegravir 3 sodium) TRIUMEQ ORAL TABLET 600-50-300 MG (abacavir- 2 SL (1 tablet per day.) dolutegravir-lamivud) HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB. - Drugs for Viral Infections BIKTARVY ORAL TABLET 50-200-25 MG (bictegravir- 2 SL (1 tablet per day.) emtricitab-tenofov) COMPLERA ORAL TABLET 200-25-300 MG (emtricitab-rilpivir- 2 SL (1 tablet per day.) tenofovir) DELSTRIGO ORAL TABLET 100-300-300 MG (doravirin- 2 SL (1 tablet per day.) lamivudin-tenofov df) EDURANT ORAL TABLET 25 MG (rilpivirine hcl) 2

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 23 Coverage Requirements & Prescription Drug Name Drug Tier Limits efavirenz oral capsule 200 mg, 50 mg 1 efavirenz oral tablet 600 mg 1 efavirenz-emtricitab-tenofovir oral tablet 600-200-300 mg 1 SL (1 tablet per day.) efavirenz-lamivudine-tenofovir oral tablet 400-300-300 mg, 600- 1 SL (1 tablet per day.) 300-300 mg etravirine oral tablet 100 mg, 200 mg 1 INTELENCE ORAL TABLET 100 MG, 200 MG ( etravirine) 3 INTELENCE ORAL TABLET 25 MG ( etravirine) 2 JULUCA ORAL TABLET 50-25 MG (dolutegravir-rilpivirine) 2 SL (1 tablet per day.) nevirapine oral suspension 50 mg/5ml 1 nevirapine oral tablet 200 mg 1 ODEFSEY ORAL TABLET 200-25-25 MG (emtricitab-rilpivir- 2 SL (1 tablet per day.) tenofov af) PIFELTRO ORAL TABLET 100 MG (doravirine) 3 SUSTIVA ORAL TABLET 600 MG (efavirenz) 3 SYMFI LO ORAL TABLET 400-300-300 MG (efavirenz- 2 SL (1 tablet per day.) lamivudine-tenofovir) SYMFI ORAL TABLET 600-300-300 MG (efavirenz-lamivudine- 2 SL (1 tablet per day.) tenofovir) VIRAMUNE ORAL SUSPENSION 50 MG/5ML (nevirapine) 3 HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS - Drugs for Viral Infections abacavir sulfate oral solution 20 mg/ml 1 abacavir sulfate oral tablet 300 mg 1 abacavir sulfate-lamivudine oral tablet 600-300 mg 1 SL (1 tablet per day.) abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg 1 BIKTARVY ORAL TABLET 50-200-25 MG (bictegravir- 2 SL (1 tablet per day.) emtricitab-tenofov) CIMDUO ORAL TABLET 300-300 MG (lamivudine-tenofovir) 2 SL (1 tablet per day.) COMBIVIR ORAL TABLET 150-300 MG (lamivudine- 3 zidovudine) COMPLERA ORAL TABLET 200-25-300 MG (emtricitab-rilpivir- 2 SL (1 tablet per day.) tenofovir) DELSTRIGO ORAL TABLET 100-300-300 MG (doravirin- 2 SL (1 tablet per day.) lamivudin-tenofov df) DESCOVY ORAL TABLET 200-25 MG (emtricitabine-tenofovir 2 SL (1 tablet per day.); H-N af) DOVATO ORAL TABLET 50-300 MG (dolutegravir-lamivudine) 2 SL (1 tablet per day.) Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 24 Coverage Requirements & Prescription Drug Name Drug Tier Limits efavirenz-emtricitab-tenofovir oral tablet 600-200-300 mg 1 SL (1 tablet per day.) efavirenz-lamivudine-tenofovir oral tablet 400-300-300 mg, 600- 1 SL (1 tablet per day.) 300-300 mg emtricitabine oral capsule 200 mg 1 emtricitabine-tenofovir df oral tablet 100-150 mg, 133-200 mg, 1 SL (1 tablet per day.) 167-250 mg emtricitabine-tenofovir df oral tablet 200-300 mg 1 SL (1 tablet per day.); H EMTRIVA ORAL CAPSULE 200 MG (emtricitabine) 3 EMTRIVA ORAL SOLUTION 10 MG/ML (emtricitabine) 2 EPIVIR HBV ORAL SOLUTION 5 MG/ML (lamivudine) 2 EPIVIR HBV ORAL TABLET 100 MG (lamivudine) 3 EPIVIR ORAL SOLUTION 10 MG/ML (lamivudine) 3 EPIVIR ORAL TABLET 150 MG, 300 MG (lamivudine) 3 GENVOYA ORAL TABLET 150-150-200-10 MG (elviteg-cobic- 2 SL (1 tablet per day.) emtricit-tenofaf) lamivudine oral solution 10 mg/ml 1 lamivudine oral tablet 100 mg, 150 mg, 300 mg 1 lamivudine-zidovudine oral tablet 150-300 mg 1 ODEFSEY ORAL TABLET 200-25-25 MG (emtricitab-rilpivir- 2 SL (1 tablet per day.) tenofov af) RETROVIR ORAL CAPSULE 100 MG (zidovudine) 3 RETROVIR ORAL SYRUP 50 MG/5ML (zidovudine) 3 stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg 1 STRIBILD ORAL TABLET 150-150-200-300 MG (elviteg-cobic- 2 SL (1 tablet per day.) emtricit-tenofdf) SYMFI LO ORAL TABLET 400-300-300 MG (efavirenz- 2 SL (1 tablet per day.) lamivudine-tenofovir) SYMFI ORAL TABLET 600-300-300 MG (efavirenz-lamivudine- 2 SL (1 tablet per day.) tenofovir) SYMTUZA ORAL TABLET 800-150-200-10 MG (darun-cobic- 2 SL (1 tablet per day.) emtricit-tenofaf) tenofovir disoproxil fumarate oral tablet 300 mg 1 H-N TRIUMEQ ORAL TABLET 600-50-300 MG (abacavir- 2 SL (1 tablet per day.) dolutegravir-lamivud) TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 3 SL (1 tablet per day.) MG (emtricitabine-tenofovir df) VIREAD ORAL POWDER 40 MG/GM (tenofovir disoproxil 3 fumarate)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 25 Coverage Requirements & Prescription Drug Name Drug Tier Limits VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG (tenofovir 2 disoproxil fumarate) ZIAGEN ORAL SOLUTION 20 MG/ML (abacavir sulfate) 3 ZIAGEN ORAL TABLET 300 MG (abacavir sulfate) 3 zidovudine oral capsule 100 mg 1 zidovudine oral syrup 50 mg/5ml 1 zidovudine oral tablet 300 mg 1 HIV PROTEASE INHIBITOR ANTIRETROVIRALS - Drugs for Viral Infections APTIVUS ORAL CAPSULE 250 MG (tipranavir) 2 atazanavir sulfate oral capsule 150 mg, 200 mg, 300 mg 1 CRIXIVAN ORAL CAPSULE 400 MG (indinavir sulfate) 2 EVOTAZ ORAL TABLET 300-150 MG (atazanavir-cobicistat) 2 fosamprenavir calcium oral tablet 700 mg 1 INVIRASE ORAL TABLET 500 MG (saquinavir mesylate) 2 KALETRA ORAL SOLUTION 400-100 MG/5ML (lopinavir- 3 ritonavir) KALETRA ORAL TABLET 100-25 MG, 200-50 MG (lopinavir- 3 ritonavir) LEXIVA ORAL SUSPENSION 50 MG/ML (fosamprenavir 2 calcium) lopinavir-ritonavir oral solution 400-100 mg/5ml 1 lopinavir-ritonavir oral tablet 100-25 mg, 200-50 mg 1 NORVIR ORAL PACKET 100 MG (ritonavir) 2 NORVIR ORAL SOLUTION 80 MG/ML (ritonavir) 2 PREZCOBIX ORAL TABLET 800-150 MG (darunavir-cobicistat) 2 PREZISTA ORAL SUSPENSION 100 MG/ML (darunavir 2 ethanolate) PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG 2 (darunavir ethanolate) REYATAZ ORAL PACKET 50 MG (atazanavir sulfate) 2 ritonavir oral tablet 100 mg 1 SYMTUZA ORAL TABLET 800-150-200-10 MG (darun-cobic- 2 SL (1 tablet per day.) emtricit-tenofaf) VIRACEPT ORAL TABLET 250 MG, 625 MG (nelfinavir 2 mesylate)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 26 Coverage Requirements & Prescription Drug Name Drug Tier Limits INTERFERON ANTIVIRALS - Drugs for Viral Infections ALFERON N INJECTION SOLUTION 5000000 UNIT/ML 2 (interferon alfa-n3) INTRON A INJECTION SOLUTION 10000000 UNIT/ML, 3 PA; SP 6000000 UNIT/ML (interferon alfa-2b) INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT (interferon 3 PA; SP alfa-2b) PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/0.5ML PA; SL (4 prefilled syringes 2 (peginterferon alfa-2a) per month.); SP PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML PA; SL (4 auto-injectors per 2 (peginterferon alfa-2a) month); SP LINCOMYCIN ANTIBIOTICS - Antibiotics CLEOCIN ORAL CAPSULE 150 MG, 300 MG (clindamycin hcl) 3 CLEOCIN ORAL CAPSULE 75 MG (clindamycin hcl) 2 CLEOCIN ORAL SOLUTION RECONSTITUTED 75 MG/5ML 3 (clindamycin palmitate hcl) clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg 1 clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml 1 MONOBACTAM ANTIBIOTICS - Antibiotics CAYSTON INHALATION SOLUTION RECONSTITUTED 75 PA; ST; SL (84 vials per 56 2 MG (aztreonam lysine) days.); SP NATURAL PENICILLIN ANTIBIOTICS - Antibiotics penicillin v potassium oral solution reconstituted 125 mg/5ml, 1 250 mg/5ml penicillin v potassium oral tablet 250 mg, 500 mg 1 NEURAMINIDASE INHIBITOR ANTIVIRALS - Drugs for Viral Infections oseltamivir phosphate oral capsule 30 mg, 45 mg, 75 mg 1 oseltamivir phosphate oral suspension reconstituted 6 mg/ml 1 SL (180 ml per month.) RELENZA DISKHALER INHALATION AEROSOL POWDER 3 BREATH ACTIVATED 5 MG/BLISTER (zanamivir) NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS - Drugs for Viral Infections acyclovir oral capsule 200 mg 1 acyclovir oral suspension 200 mg/5ml 1 acyclovir oral tablet 400 mg, 800 mg 1 adefovir dipivoxil oral tablet 10 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 27 Coverage Requirements & Prescription Drug Name Drug Tier Limits BARACLUDE ORAL SOLUTION 0.05 MG/ML (entecavir) 2 entecavir oral tablet 0.5 mg, 1 mg 1 famciclovir oral tablet 125 mg, 500 mg 1 SL (62 tablets per famciclovir oral tablet 250 mg 1 prescription.) ribavirin inhalation solution reconstituted 6 gm 1 ribavirin oral capsule 200 mg 1 ribavirin oral tablet 200 mg 1 SL (31 tablets per valacyclovir hcl oral tablet 1 gm 1 prescription) SL (62 tablets per valacyclovir hcl oral tablet 500 mg 1 prescription.) valganciclovir hcl oral solution reconstituted 50 mg/ml 1 valganciclovir hcl oral tablet 450 mg 1 SL (2 tablets per day) VEMLIDY ORAL TABLET 25 MG (tenofovir alafenamide 3 ST fumarate) VIRAZOLE INHALATION SOLUTION RECONSTITUTED 6 GM 3 (ribavirin) ZOVIRAX ORAL SUSPENSION 200 MG/5ML (acyclovir) 3 OTHER MACROLIDE ANTIBIOTICS - Antibiotics azithromycin oral packet 1 gm 1 azithromycin oral suspension reconstituted 100 mg/5ml, 200 1 mg/5ml azithromycin oral tablet 250 mg, 500 mg, 600 mg 1 clarithromycin er oral tablet extended release 24 hour 500 mg 1 clarithromycin oral suspension reconstituted 125 mg/5ml, 250 1 mg/5ml clarithromycin oral tablet 250 mg, 500 mg 1 DIFICID ORAL SUSPENSION RECONSTITUTED 40 MG/ML 3 SL (136 mL per 10 days.) (fidaxomicin) DIFICID ORAL TABLET 200 MG (fidaxomicin) 3 SL (20 tablets per 7 days) SL (1 carton (10 OMECLAMOX-PAK ORAL 500-500-20 MG (amoxicill-clarithro- 3 administrative cards, 80 omeprazole) tablets) per 6 months.) ZITHROMAX ORAL PACKET 1 GM (azithromycin) 3 ZITHROMAX ORAL SUSPENSION RECONSTITUTED 100 3 MG/5ML, 200 MG/5ML (azithromycin) ZITHROMAX ORAL TABLET 250 MG, 500 MG (azithromycin) 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 28 Coverage Requirements & Prescription Drug Name Drug Tier Limits ZITHROMAX TRI-PAK ORAL TABLET 500 MG (azithromycin) 3 ZITHROMAX Z-PAK ORAL TABLET 250 MG (azithromycin) 3 OXAZOLIDINONE ANTIBIOTICS - Antibiotics linezolid oral suspension reconstituted 100 mg/5ml 1 SL (900 ml per 11 days) linezolid oral tablet 600 mg 1 SL (28 tablets per 11 days) SL (6 tablets per SIVEXTRO ORAL TABLET 200 MG (tedizolid phosphate) 3 prescription.) ZYVOX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML 3 SL (900 ml per 11 days) (linezolid) PENICILLINASE-RESISTANT PENICILLINS - Antibiotics dicloxacillin sodium oral capsule 250 mg, 500 mg 1 PLEUROMUTILINS - Antibiotics XENLETA ORAL TABLET 600 MG ( lefamulin acetate) 3 POLYENE ANTIFUNGALS - Drugs for Fungus nystatin mouth/throat suspension 100000 unit/ml 1 nystatin oral tablet 500000 unit 1 POLYMYXIN ANTIBIOTICS - Antibiotics colistimethate sodium (cba) injection solution reconstituted 150 1 mg COLY-MYCIN M INJECTION SOLUTION RECONSTITUTED 3 150 MG (colistimethate sodium) PYRIMIDINE ANTIFUNGALS - Drugs for Fungus ANCOBON ORAL CAPSULE 250 MG, 500 MG (flucytosine) 3 flucytosine oral capsule 250 mg, 500 mg 1 QUINOLONE ANTIBIOTICS - Antibiotics BAXDELA ORAL TABLET 450 MG (delafloxacin meglumine) 3 CIPRO ORAL SUSPENSION RECONSTITUTED 250 MG/5ML 3 (5%), 500 MG/5ML (10%) (ciprofloxacin) CIPRO ORAL TABLET 250 MG, 500 MG (ciprofloxacin hcl) 3 ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg 1 levofloxacin oral solution 25 mg/ml 1 levofloxacin oral tablet 250 mg, 500 mg, 750 mg 1 moxifloxacin hcl oral tablet 400 mg 1 ofloxacin oral tablet 300 mg, 400 mg 1 RIFAMYCIN ANTIBIOTICS - Antibiotics AEMCOLO ORAL TABLET DELAYED RELEASE 194 MG SL (12 tablets per 3 (rifamycin sodium) prescription.) Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 29 Coverage Requirements & Prescription Drug Name Drug Tier Limits MYCOBUTIN ORAL CAPSULE 150 MG (rifabutin) 3 PRIFTIN ORAL TABLET 150 MG (rifapentine) 2 rifabutin oral capsule 150 mg 1 rifampin oral capsule 150 mg, 300 mg 1 PA; SL (9 tablets per XIFAXAN ORAL TABLET 200 MG (rifaximin) 3 prescription) PA; SL (62 tablets per XIFAXAN ORAL TABLET 550 MG (rifaximin) 3 month.) SULFONAMIDE ANTIBIOTICS (SYSTEMIC) - Antibiotics AZULFIDINE EN-TABS ORAL TABLET DELAYED RELEASE 3 500 MG (sulfasalazine) AZULFIDINE ORAL TABLET 500 MG (sulfasalazine) 3 BACTRIM DS ORAL TABLET 800-160 MG (sulfamethoxazole- 3 trimethoprim) BACTRIM ORAL TABLET 400-80 MG (sulfamethoxazole- 3 trimethoprim) sulfadiazine oral tablet 500 mg 1 sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml 1 sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 1 mg sulfasalazine oral tablet 500 mg 1 sulfasalazine oral tablet delayed release 500 mg 1 sulfatrim pediatric oral suspension 200-40 mg/5ml 1 TETRACYCLINE ANTIBIOTICS - Antibiotics AVIDOXY DK COMBINATION KIT 100 MG (doxycycline- 3 suncreen-sal acid) avidoxy oral tablet 100 mg 1 demeclocycline hcl oral tablet 150 mg, 300 mg 1 doxycycline hyclate oral capsule 100 mg, 50 mg 1 doxycycline hyclate oral tablet 100 mg, 20 mg 1 doxycycline monohydrate oral capsule 100 mg, 50 mg 1 doxycycline monohydrate oral suspension reconstituted 25 1 mg/5ml doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 mg, 1 75 mg minocycline hcl oral capsule 100 mg, 50 mg, 75 mg 1 mondoxyne nl oral capsule 100 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 30 Coverage Requirements & Prescription Drug Name Drug Tier Limits morgidox oral capsule 100 mg 1 NUTRIDOX ORAL KIT 75 MG (doxycycline monohyd-omega 3- 3 e) PYLERA ORAL CAPSULE 140-125-125 MG (bis subcit- SL (120 capsules per 180 3 metronid-tetracyc) days.) tetracycline hcl oral capsule 250 mg, 500 mg 1 VIBRAMYCIN ORAL CAPSULE 100 MG (doxycycline hyclate) 3 VIBRAMYCIN ORAL SUSPENSION RECONSTITUTED 25 3 MG/5ML (doxycycline monohydrate) VIBRAMYCIN ORAL SYRUP 50 MG/5ML (doxycycline calcium) 3 URINARY ANTI-INFECTIVES - Drugs for the Urinary System BACTRIM DS ORAL TABLET 800-160 MG (sulfamethoxazole- 3 trimethoprim) BACTRIM ORAL TABLET 400-80 MG (sulfamethoxazole- 3 trimethoprim) fosfomycin tromethamine oral packet 3 gm 1 HIPREX ORAL TABLET 1 GM (methenamine hippurate) 3 HYOPHEN ORAL TABLET 81.6 MG (meth-hyo-m bl-benz acd- 3 ph sal) MACROBID ORAL CAPSULE 100 MG (nitrofurantoin monohyd 3 macro) MACRODANTIN ORAL CAPSULE 100 MG, 25 MG, 50 MG 3 (nitrofurantoin macrocrystal) me/naphos/mb/hyo1 oral tablet 81.6 mg 1 methenamine hippurate oral tablet 1 gm 1 methenamine mandelate oral tablet 0.5 gm, 1 gm 1 MONUROL ORAL PACKET 3 GM (fosfomycin tromethamine) 3 nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg 1 nitrofurantoin monohydrate macrocrystals oral capsule 100 mg 1 nitrofurantoin oral suspension 25 mg/5ml 1 PHOSPHASAL ORAL TABLET 81.6 MG (meth-hyo-m bl-na 2 phos-ph sal) PRIMSOL ORAL SOLUTION 50 MG/5ML (trimethoprim hcl) 3 sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml 1 sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 1 mg sulfatrim pediatric oral suspension 200-40 mg/5ml 1 trimethoprim oral tablet 100 mg 1 Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 31 Coverage Requirements & Prescription Drug Name Drug Tier Limits URELLE ORAL TABLET 81 MG (meth-hyo-m bl-na phos-ph 3 sal) URIBEL ORAL CAPSULE 118 MG (meth-hyo-m bl-na phos-ph 3 sal) urin ds oral tablet 81.6 mg 1 URO-458 ORAL TABLET 81 MG 3 UROGESIC-BLUE ORAL TABLET 81.6 MG (methen-hyosc- 2 meth blue-na phos) uro-mp oral capsule 118 mg 1 USTELL ORAL CAPSULE 120 MG (meth-hyo-m bl-na phos-ph 3 sal) UTIRA-C ORAL TABLET 81.6 MG (meth-hyo-m bl-na phos-ph 2 sal) VILAMIT MB ORAL CAPSULE 118 MG (meth-hyo-m bl-na 3 phos-ph sal) VILEVEV MB ORAL TABLET 81 MG (meth-hyo-m bl-na phos- 3 ph sal) ANTINEOPLASTIC AGENTS - Drugs for Cancer ANTINEOPLASTIC AGENTS - Drugs for Cancer PA; SL (4 tablets per day.); abiraterone acetate oral tablet 250 mg 1 SP; CM AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG, 5 PA; SL (1 tablet per day.); 2 MG () SP; CM PA; SL (1 tablet per day.); AFINITOR ORAL TABLET 10 MG (everolimus) 2 SP; CM PA; SL (8 capsules per day.); ALECENSA ORAL CAPSULE 150 MG (alectinib hcl) 2 SP; CM ALFERON N INJECTION SOLUTION 5000000 UNIT/ML 2 (interferon alfa-n3) ALKERAN ORAL TABLET 2 MG (melphalan) 3 CM PA; SL (1 tablet per day.); ALUNBRIG ORAL TABLET 180 MG, 90 MG (brigatinib) 2 SP; CM PA; SL (4 tablets per day.); ALUNBRIG ORAL TABLET 30 MG (brigatinib) 2 SP; CM ALUNBRIG ORAL TABLET THERAPY PACK 90 & 180 MG PA; SL (30 packs per year.); 2 (brigatinib) SP; CM anastrozole oral tablet 1 mg 1 AYVAKIT ORAL TABLET 100 MG, 200 MG, 300 MG PA; SL (1 tablet per day.); 3 (avapritinib) SP; CM

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 32 Coverage Requirements & Prescription Drug Name Drug Tier Limits AYVAKIT ORAL TABLET 25 MG, 50 MG (avapritinib) 3 PA; SP; CM PA; SL (3 tablets per day.); BALVERSA ORAL TABLET 3 MG (erdafitinib) 2 SP; CM PA; SL (2 tablets per day.); BALVERSA ORAL TABLET 4 MG (erdafitinib) 2 SP; CM PA; SL (1 tablet per day.); BALVERSA ORAL TABLET 5 MG (erdafitinib) 2 SP; CM bicalutamide oral tablet 50 mg 1 PA; ST; SL (4 tablets per BOSULIF ORAL TABLET 100 MG (bosutinib) 2 day.); SP; CM PA; ST; SL (1 tablet per BOSULIF ORAL TABLET 400 MG, 500 MG (bosutinib) 2 day.); SP; CM PA; ST; SL (6 capsules per BRAFTOVI ORAL CAPSULE 75 MG (encorafenib) 3 day.); SP; CM PA; SL (4 capsules per day.); BRUKINSA ORAL CAPSULE 80 MG (zanubrutinib) 2 SP; CM CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG PA; SL (1 tablet per day.); 2 (cabozantinib s-malate) SP; CM PA; SL (2 capsules per day.); CALQUENCE ORAL CAPSULE 100 MG (acalabrutinib) 2 SP; CM SL (84 tablets per capecitabine oral tablet 150 mg 1 prescription.); SP; CM SL (140 tablets per capecitabine oral tablet 500 mg 1 prescription.); SP; CM PA; SL (2 tablets per day.); CAPRELSA ORAL TABLET 100 MG (vandetanib) 2 SP; CM PA; SL (1 tablet per day.); CAPRELSA ORAL TABLET 300 MG (vandetanib) 2 SP; CM CASODEX ORAL TABLET 50 MG (bicalutamide) 3 PA; SL (93 capsules per COMETRIQ ORAL KIT 20 MG (cabozantinib s-malate) 2 month.); SP; CM COMETRIQ ORAL KIT 3 X 20 MG & 80 MG (cabozantinib s- PA; SL (124 capsules per 2 malate) month.); SP; CM PA; SL (62 capsules per COMETRIQ ORAL KIT 80 & 20 MG (cabozantinib s-malate) 2 month.); SP; CM PA; SL (2 capsules per day.); COPIKTRA ORAL CAPSULE 15 MG, 25 MG (duvelisib) 3 SP; CM cyclophosphamide oral capsule 25 mg, 50 mg 1 CYCLOPHOSPHAMIDE ORAL TABLET 25 MG, 50 MG 2 CM

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 33 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; SL (1 tablet per day.); DAURISMO ORAL TABLET 100 MG (glasdegib maleate) 2 SP; CM PA; SL (2 tablets per day.); DAURISMO ORAL TABLET 25 MG (glasdegib maleate) 2 SP; CM DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG 2 (hydroxyurea) ELIGARD SUBCUTANEOUS KIT 22.5 MG (leuprolide acetate 3 PA (3 month)) ELIGARD SUBCUTANEOUS KIT 30 MG (leuprolide acetate (4 3 PA month)) ELIGARD SUBCUTANEOUS KIT 45 MG (leuprolide acetate (6 3 PA month)) ELIGARD SUBCUTANEOUS KIT 7.5 MG (leuprolide acetate) 3 PA EMCYT ORAL CAPSULE 140 MG (estramustine phosphate 2 sodium) PA; SL (1 capsule per day.); ERIVEDGE ORAL CAPSULE 150 MG (vismodegib) 2 SP; CM PA; SL (4 tablets per day.); ERLEADA ORAL TABLET 60 MG (apalutamide) 2 SP; CM PA; SL (1 tablet per day.); erlotinib hcl oral tablet 100 mg, 150 mg, 25 mg 1 SP; CM etoposide oral capsule 50 mg 1 SP; CM PA; SL (1 tablet per day.); everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg 1 SP; CM exemestane oral tablet 25 mg 1 FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG PA; SL (6 capsules per 2 (panobinostat lactate) prescription.); SP; CM FIRMAGON (240 MG DOSE) SUBCUTANEOUS SOLUTION 3 SP RECONSTITUTED 120 MG/VIAL (degarelix acetate) FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 3 SP 80 MG (degarelix acetate) flutamide oral capsule 125 mg 1 PA; SL (4 capsules per day.); GAVRETO ORAL CAPSULE 100 MG (pralsetinib) 3 SP; CM GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG (afatinib PA; SL (1 tablet per day.); 3 dimaleate) SP; CM GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG 2 SP (lomustine) PA; SL (180 capsules per HYCAMTIN ORAL CAPSULE 0.25 MG (topotecan hcl) 2 prescription.); SP; CM Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 34 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; SL (40 capsules per HYCAMTIN ORAL CAPSULE 1 MG (topotecan hcl) 2 prescription.); SP; CM HYDREA ORAL CAPSULE 500 MG (hydroxyurea) 3 hydroxyurea oral capsule 500 mg 1 IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG PA; SL (21 capsules per 2 (palbociclib) month.); SP; CM IBRANCE ORAL TABLET 100 MG, 125 MG, 75 MG PA; SL (0.75 tablets per 2 (palbociclib) day.); SP; CM PA; SL (2 tablets per day.); ICLUSIG ORAL TABLET 15 MG (ponatinib hcl) 3 SP; CM PA; SL (1 tablet per day.); ICLUSIG ORAL TABLET 45 MG (ponatinib hcl) 3 SP; CM PA; SL (1 tablet per day.); IDHIFA ORAL TABLET 100 MG, 50 MG (enasidenib mesylate) 2 SP; CM PA; SL (6 tablets per day.); imatinib mesylate oral tablet 100 mg 1 SP; CM PA; SL (1 tablet per day.); imatinib mesylate oral tablet 400 mg 1 SP; CM PA; SL (3 capsules per day.); IMBRUVICA ORAL CAPSULE 140 MG (ibrutinib) 2 SP; CM PA; SL (1 capsule per day.); IMBRUVICA ORAL CAPSULE 70 MG (ibrutinib) 2 SP; CM IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, 560 PA; SL (1 tablet per day.); 2 MG (ibrutinib) SP; CM PA; SL (4 tablets per day.); INLYTA ORAL TABLET 1 MG (axitinib) 3 SP; CM PA; SL (124 tablets per 30 INLYTA ORAL TABLET 5 MG (axitinib) 3 days.); SP; CM PA; SL (5 tablets per INQOVI ORAL TABLET 35-100 MG (decitabine-cedazuridine) 3 month.); SP; CM PA; ST; SL (4 capsules per INREBIC ORAL CAPSULE 100 MG (fedratinib hcl) 3 day.); SP INTRON A INJECTION SOLUTION 10000000 UNIT/ML, 3 PA; SP 6000000 UNIT/ML (interferon alfa-2b) INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT (interferon 3 PA; SP alfa-2b) PA; SL (1 tablet per day.); IRESSA ORAL TABLET 250 MG (gefitinib) 3 SP; CM

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 35 Coverage Requirements & Prescription Drug Name Drug Tier Limits JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG PA; SL (2 tablets per day.); 2 (ruxolitinib phosphate) SP; CM KISQALI (400 MG DOSE) TABLET THERAPY PACK 200 MG 3 PA; ST; SP; CM ORAL 200 MG (ribociclib succinate) KISQALI (400 MG DOSE) TABLET THERAPY PACK 200 MG PA; ST; SL (42 tablets per 3 ORAL 200 MG (ribociclib succinate) month.); SP; CM KISQALI (600 MG DOSE) TABLET THERAPY PACK 200 MG 3 PA; ST; SP; CM ORAL 200 MG (ribociclib succinate) KISQALI (600 MG DOSE) TABLET THERAPY PACK 200 MG PA; ST; SL (63 tablets per 3 ORAL 200 MG (ribociclib succinate) month.); SP; CM KISQALI FEMARA ORAL TABLET THERAPY PACK 200 & 2.5 3 PA; ST; CM MG (ribociclib-letrozole) KISQALI ORAL TABLET THERAPY PACK 200 MG (ribociclib PA; ST; SL (21 tablets per 3 succinate) month.); SP; CM PA; SL (8 capsules per day.); KOSELUGO ORAL CAPSULE 10 MG (selumetinib sulfate) 3 SP; CM PA; SL (4 capsules per day.); KOSELUGO ORAL CAPSULE 25 MG (selumetinib sulfate) 3 SP; CM PA; SL (186 tablets per lapatinib ditosylate oral tablet 250 mg 1 prescription); SP; CM LENVIMA ORAL CAPSULE THERAPY PACK 10 & 4 MG, 2 X PA; SL (2 capsules per day.); 3 10 MG, 2 X 4 MG (lenvatinib mesylate) SP; CM LENVIMA ORAL CAPSULE THERAPY PACK 10 MG & 2 X 4 PA; SL (3 capsules per day.); 3 MG, 2 X 10 MG & 4 MG, 3 X 4 MG (lenvatinib mesylate) SP; CM LENVIMA ORAL CAPSULE THERAPY PACK 10 MG, 4 MG PA; SL (1 capsule per day.); 3 (lenvatinib mesylate) SP; CM letrozole oral tablet 2.5 mg 1 leuprolide acetate injection kit 1 mg/0.2ml 1 PA LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG PA; SL (100 tablets per 2 (trifluridine-tipiracil) month.); SP; CM LORBRENA ORAL TABLET 100 MG, 25 MG ( lorlatinib) 3 PA; SP; CM LUMAKRAS ORAL TABLET 120 MG (sotorasib) 3 PA; SP; CM PA; SL (4 tablets per day.); LYNPARZA ORAL TABLET 100 MG, 150 MG (olaparib) 2 SP; CM MATULANE ORAL CAPSULE 50 MG (procarbazine hcl) 2 SP; CM megestrol acetate oral suspension 40 mg/ml, 625 mg/5ml 1 megestrol acetate oral tablet 20 mg, 40 mg 1 MEKINIST ORAL TABLET 0.5 MG (trametinib dimethyl PA; SL (2 tablets per day.); 3 sulfoxide) SP; CM

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 36 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; SL (1 tablet per day.); MEKINIST ORAL TABLET 2 MG (trametinib ) 3 SP; CM PA; ST; SL (6 tablets per MEKTOVI ORAL TABLET 15 MG (binimetinib) 3 day.); SP; CM melphalan oral tablet 2 mg 1 CM mercaptopurine oral tablet 50 mg 1 methotrexate oral tablet 2.5 mg 1 methotrexate sodium (pf) injection solution 1 gm/40ml, 250 1 mg/10ml, 50 mg/2ml methotrexate sodium injection solution 250 mg/10ml, 50 mg/2ml 1 methotrexate sodium injection solution reconstituted 1 gm 1 methotrexate sodium oral tablet 2.5 mg 1 PA; SL (6 tablets per day.); NERLYNX ORAL TABLET 40 MG ( neratinib maleate) 2 SP; CM PA; SL (4 tablets per day.); NEXAVAR ORAL TABLET 200 MG (sorafenib tosylate) 2 SP; CM NILANDRON ORAL TABLET 150 MG ( nilutamide) 3 SP nilutamide oral tablet 150 mg 1 SP NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG (ixazomib PA; SL (3 capsules per 2 citrate) prescription.); SP; CM PA; SL (4 tablets per day.); NUBEQA ORAL TABLET 300 MG (darolutamide) 2 SP; CM PA; SL (1 capsule per day.); ODOMZO ORAL CAPSULE 200 MG (sonidegib phosphate) 2 SP; CM PA; SL (1 tablet per day.); ONUREG ORAL TABLET 200 MG, 300 MG (azacitidine) 2 SP; CM PA; SL (1 tablet per day); ORGOVYX ORAL TABLET 120 MG (relugolix) 3 SP; CM PEMAZYRE ORAL TABLET 13.5 MG, 4.5 MG, 9 MG PA; SL (14 tablets per 21 3 (pemigatinib) days.); SP; CM PIQRAY ORAL TABLET THERAPY PACK 2 X 150 MG, 200 & PA; SL (2 tablets per day.); 2 50 MG (alpelisib) SP; CM PA; SL (1 tablet per day.); PIQRAY ORAL TABLET THERAPY PACK 200 MG (alpelisib) 2 SP; CM POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG PA; SL (21 capsules per 3 (pomalidomide) prescription.); SP; CM PURIXAN ORAL SUSPENSION 2000 MG/100ML 3 PA; SP (mercaptopurine)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 37 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; SL (3 tablets per day.); QINLOCK ORAL TABLET 50 MG (ripretinib) 3 SP; CM PA; SL (6 capsules per day.); RETEVMO ORAL CAPSULE 40 MG (selpercatinib) 3 SP; CM RETEVMO ORAL CAPSULE 80 MG (selpercatinib) 3 PA; SP; CM REVLIMID ORAL CAPSULE 10 MG, 2.5 MG, 5 MG PA; SL (28 capsules per 2 (lenalidomide) prescription.); SP; CM REVLIMID ORAL CAPSULE 15 MG, 20 MG, 25 MG PA; SL (21 capsules per 2 (lenalidomide) prescription.); SP; CM PA; SL (1 capsule per day.); ROZLYTREK ORAL CAPSULE 100 MG (entrectinib) 2 SP; CM PA; SL (3 capsules per day.); ROZLYTREK ORAL CAPSULE 200 MG (entrectinib) 2 SP; CM PA; ST; SL (2 tablets per RUBRACA ORAL TABLET 200 MG (rucaparib camsylate) 3 day.); SP; CM RUBRACA ORAL TABLET 250 MG, 300 MG (rucaparib PA; ST; SL (4 tablets per 3 camsylate) day.); SP; CM PA; SL (8 capsules per day.); RYDAPT ORAL CAPSULE 25 MG (midostaurin) 2 SP; CM SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, PA; ST; SL (1 tablet per 3 80 MG (dasatinib) day.); SP; CM PA; ST; SL (2 tablets per SPRYCEL ORAL TABLET 20 MG (dasatinib) 3 day.); SP; CM PA; SL (84 tablets per STIVARGA ORAL TABLET 40 MG (regorafenib) 2 prescription.); SP; CM SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG PA; SL (1 capsule per day.); 2 (sunitinib malate) SP; CM SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED PA; SL (28 vials per month.); 2 3.5 MG (omacetaxine mepesuccinate) SP PA; SL (4 tablets per day.); TABRECTA ORAL TABLET 150 MG, 200 MG ( capmatinib hcl) 3 SP; CM TAFINLAR ORAL CAPSULE 50 MG, 75 MG (dabrafenib PA; SL (4 capsules per day.); 3 mesylate) SP; CM TAGRISSO ORAL TABLET 40 MG, 80 MG (osimertinib PA; SL (1 tablet per day.); 3 mesylate) SP; CM PA; ST; SL (3 capsules per TALZENNA ORAL CAPSULE 0.25 MG (talazoparib tosylate) 3 day.); SP; CM PA; ST; SL (1 capsule per TALZENNA ORAL CAPSULE 1 MG (talazoparib tosylate) 3 day.); SP; CM tamoxifen citrate oral tablet 10 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 38 Coverage Requirements & Prescription Drug Name Drug Tier Limits tamoxifen citrate oral tablet 20 mg 1 H-N TARGRETIN ORAL CAPSULE 75 MG (bexarotene) 1 CM TASIGNA ORAL CAPSULE 150 MG, 200 MG, 50 MG (nilotinib PA; ST; SL (4 capsules per 2 hcl) day.); SP; CM PA; SL (8 tablets per day.); TAZVERIK ORAL TABLET 200 MG (tazemetostat hbr) 3 SP; CM temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 1 PA; SP; CM 250 mg, 5 mg PA; SL (2 tablets per day.); TEPMETKO ORAL TABLET 225 MG ( tepotinib hcl) 3 SP; CM PA; SL (2 tablets per day.); TIBSOVO ORAL TABLET 250 MG (ivosidenib) 2 SP; CM toremifene citrate oral tablet 60 mg 1 SL (279 capsules per tretinoin oral capsule 10 mg 1 prescription.); SP; CM TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG 2 (methotrexate sodium) PA; SL (4 tablets per day.); TUKYSA ORAL TABLET 150 MG (tucatinib) 2 SP; CM PA; SL (10 tablets per day.); TUKYSA ORAL TABLET 50 MG (tucatinib) 2 SP; CM PA; SL (4 capsules per day.); TURALIO ORAL CAPSULE 200 MG (pexidartinib hcl) 2 SP; CM PA; SL (186 tablets per TYKERB ORAL TABLET 250 MG (lapatinib ditosylate) 3 prescription); SP; CM PA; SL (4 tablets per day.); UKONIQ ORAL TABLET 200 MG (umbralisib tosylate) 3 SP; CM PA; SL (4 tablets per day.); VENCLEXTA ORAL TABLET 10 MG, 100 MG (venetoclax) 2 SP; CM PA; SL (1 tablet per day.); VENCLEXTA ORAL TABLET 50 MG ( venetoclax) 2 SP; CM VENCLEXTA STARTING PACK ORAL TABLET THERAPY PA; SL (42 tablets per year.); 2 PACK 10 & 50 & 100 MG (venetoclax) SP; CM VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG PA; SL (2 tablets per day.); 2 (abemaciclib) SP; CM PA; SL (2 capsules per day.); VITRAKVI ORAL CAPSULE 100 MG (larotrectinib sulfate) 2 SP; CM PA; SL (6 capsules per day.); VITRAKVI ORAL CAPSULE 25 MG (larotrectinib sulfate) 2 SP; CM

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 39 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; SL (10 mL per day.); SP; VITRAKVI ORAL SOLUTION 20 MG/ML (larotrectinib sulfate) 2 CM PA; SL (1 tablet per day.); VIZIMPRO ORAL TABLET 15 MG, 30 MG, 45 MG (dacomitinib) 3 SP; CM PA; SL (4 tablets per day.); VOTRIENT ORAL TABLET 200 MG (pazopanib hcl) 2 SP; CM PA; SL (2 capsules per day.); XALKORI ORAL CAPSULE 200 MG, 250 MG (crizotinib) 2 SP; CM XATMEP ORAL SOLUTION 2.5 MG/ML (methotrexate) 3 PA; SL (4 ml per day.) PA; SL (3 tablets per day.); XOSPATA ORAL TABLET 40 MG (gilteritinib fumarate) 3 SP; CM XPOVIO (100 MG ONCE WEEKLY) ORAL TABLET THERAPY PA; SL (0.26 tablet per day.); 3 PACK 50 MG (selinexor) SP; CM XPOVIO (40 MG ONCE WEEKLY) ORAL TABLET THERAPY PA; SL (0.26 tablet per day.); 3 PACK 40 MG (selinexor) SP; CM XPOVIO (40 MG TWICE WEEKLY) ORAL TABLET THERAPY PA; SL (0.5 tablet per day.); 3 PACK 40 MG (selinexor) SP; CM XPOVIO (60 MG ONCE WEEKLY) ORAL TABLET THERAPY PA; SL (0.5 tablet per day.); 3 PACK 60 MG (selinexor) SP; CM XPOVIO (60 MG TWICE WEEKLY) ORAL TABLET THERAPY PA; SL (0.86 tablets per 3 PACK 20 MG (selinexor) day.); SP; CM XPOVIO (80 MG ONCE WEEKLY) ORAL TABLET THERAPY PA; SL (0.5 tablet per day.); 3 PACK 40 MG (selinexor) SP; CM XPOVIO (80 MG TWICE WEEKLY) ORAL TABLET THERAPY PA; SL (1.15 tablets per 3 PACK 20 MG (selinexor) day.); SP; CM PA; ST; SL (4 capsules per XTANDI ORAL CAPSULE 40 MG (enzalutamide) 3 day.); SP; CM PA; ST; SL (4 tablets per XTANDI ORAL TABLET 40 MG (enzalutamide) 3 day.); CM PA; ST; SL (2 tablets per XTANDI ORAL TABLET 80 MG (enzalutamide) 3 day.); CM PA; SL (3 capsules per day.); ZEJULA ORAL CAPSULE 100 MG (niraparib tosylate) 2 SP; CM PA; SL (8 tablets per day.); ZELBORAF ORAL TABLET 240 MG (vemurafenib) 2 SP; CM PA; SL (124 capsules per ZOLINZA ORAL CAPSULE 100 MG (vorinostat) 2 prescription); SP; CM PA; SL (60 tablets per ZYDELIG ORAL TABLET 100 MG, 150 MG (idelalisib) 3 month.); SP; CM

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 40 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; SL (3 tablets per day.); ZYKADIA ORAL TABLET 150 MG (ceritinib) 2 SP; CM ANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINES - DRUGS FOR THE IMMUNE SYSTEM ALLERGENIC EXTRACTS (THERAPEUTIC) - DRUGS FOR THE IMMUNE SYSTEM GRASTEK SUBLINGUAL TABLET SUBLINGUAL 2800 BAU 3 PA; SL (1 tablet per day.) (timothy grass pollen allergen) ODACTRA SUBLINGUAL TABLET SUBLINGUAL 12 SQ-HDM 3 PA; SL (1 tablet per day.) (dust mite mixed allergen ext) ORALAIR ADULT STARTER PACK SUBLINGUAL TABLET 3 PA; SL (1 tablet per day.) SUBLINGUAL 300 IR (grass mix pollens allergen ext) ORALAIR CHILDRENS STARTER PACK SUBLINGUAL 3 PA; SL (3 tablets per year.) TABLET SUBLINGUAL 100 IR (grass mix pollens allergen ext) ORALAIR SUBLINGUAL TABLET SUBLINGUAL 300 IR (grass 3 PA; SL (1 tablet per day.) mix pollens allergen ext) PALFORZIA ORAL 0.5 & 1 & 1.5 & 3 & 6 MG (peanut powder- PA; SL (13 capsules per 3 dnfp) year.); SP PALFORZIA ORAL 2 X 1 MG & 10 MG, 3 X 1 MG (peanut PA; SL (45 capsules per 13 3 powder-dnfp) days.); SP PALFORZIA ORAL 2 X 100 MG, 2 X 20 MG, 20 MG & 100 MG PA; SL (30 capsules per 13 3 (peanut powder-dnfp) days.); SP PALFORZIA ORAL 2 X 20 MG & 2 X 100 MG, 4 X 20 MG PA; SL (60 capsules per 13 3 (peanut powder-dnfp) days.); SP PA; SL (15 capsules per 13 PALFORZIA ORAL 20 MG (peanut powder-dnfp) 3 days.); SP PA; SL (60 capsule per 13 PALFORZIA ORAL 3 X 20 MG & 100 MG (peanut powder-dnfp) 3 days.); SP PA; SL (90 capsules per 13 PALFORZIA ORAL 6 X 1 MG (peanut powder-dnfp) 3 days.); SP PA; SL (1 capsule per day.); PALFORZIA ORAL PACKET 300 MG (peanut powder-dnfp) 3 SP PA; SL (15 capsules per 13 PALFORZIA ORAL PACKET 300 MG (peanut powder-dnfp) 3 days.); SP RAGWITEK SUBLINGUAL TABLET SUBLINGUAL 12 AMB A 3 PA; SL (1 tablet per day.) 1-U (short ragweed pollen ext) TOXOIDS - Vaccines ADACEL INTRAMUSCULAR SUSPENSION 5-2-15.5 LF- 3 H MCG/0.5 (tetanus-diphth-acell pertussis)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 41 Coverage Requirements & Prescription Drug Name Drug Tier Limits BOOSTRIX INTRAMUSCULAR SUSPENSION 5-2.5-18.5 LF- 2 H MCG/0.5 (tetanus-diphth-acell pertussis) DAPTACEL INTRAMUSCULAR SUSPENSION 23-15-5 (diphth- 2 H acell pertussis-tetanus) INFANRIX SUSPENSION 25-58-10 INTRAMUSCULAR 25-58- 2 H 10 (diphth-acell pertussis-tetanus) INFANRIX SUSPENSION 25-58-10 INTRAMUSCULAR 25-58- 3 H 10 (diphth-acell pertussis-tetanus) TENIVAC INTRAMUSCULAR INJECTABLE 5-2 LFU (tetanus- 3 H diphtheria toxoids td) VACCINES - Vaccines ACTHIB INTRAMUSCULAR SOLUTION RECONSTITUTED 2 H (haemophilus b polysac conj vac) ADACEL INTRAMUSCULAR SUSPENSION 5-2-15.5 LF- 3 H MCG/0.5 (tetanus-diphth-acell pertussis) AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION 3 H (influenza vac split quad) AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.25 ML, 0.5 ML (influenza vac split 3 H quad) ASTRAZENECA COVID-19 VACCINE INTRAMUSCULAR 3 H SUSPENSION 0.5 ML BEXSERO INTRAMUSCULAR SUSPENSION PREFILLED 3 H SYRINGE (meningococcal b recomb omv adj) BOOSTRIX INTRAMUSCULAR SUSPENSION 5-2.5-18.5 LF- 2 H MCG/0.5 (tetanus-diphth-acell pertussis) DAPTACEL INTRAMUSCULAR SUSPENSION 23-15-5 (diphth- 2 H acell pertussis-tetanus) ENGERIX-B INJECTION SUSPENSION 10 MCG/0.5ML, 20 2 H MCG/ML (hepatitis b vac recombinant) FLUAD QUADRIVALENT INTRAMUSCULAR PREFILLED 3 H SYRINGE 0.5 ML (influenza vac a&b sa adj quad) FLUARIX QUADRIVALENT INTRAMUSCULAR SUSPENSION 3 H PREFILLED SYRINGE 0.5 ML (influenza vac split quad) FLUCELVAX QUADRIVALENT INTRAMUSCULAR 3 H SUSPENSION (influenza vac subunit quad) FLUCELVAX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML (influenza vac 3 H subunit quad)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 42 Coverage Requirements & Prescription Drug Name Drug Tier Limits FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML (influenza vac 3 H split quad) FLUZONE HIGH-DOSE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.7 ML (influenza vac 3 H high-dose quad) FLUZONE QUADRIVALENT INTRAMUSCULAR 3 H SUSPENSION , 0.5 ML (influenza vac split quad) FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML (influenza vac 3 H split quad) GARDASIL 9 INTRAMUSCULAR SUSPENSION (hpv 9-valent 3 H recomb vaccine) GARDASIL 9 INTRAMUSCULAR SUSPENSION PREFILLED 3 H SYRINGE (hpv 9-valent recomb vaccine) HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL U/ML, 720 3 H EL U/0.5ML (hepatitis a vaccine) HEPLISAV-B INTRAMUSCULAR SOLUTION PREFILLED 3 H SYRINGE 20 MCG/0.5ML (hepatitis b vac recomb adj) HIBERIX INJECTION SOLUTION RECONSTITUTED 10 MCG 3 H (haemophilus b polysac conj vac) INFANRIX SUSPENSION 25-58-10 INTRAMUSCULAR 25-58- 2 H 10 (diphth-acell pertussis-tetanus) INFANRIX SUSPENSION 25-58-10 INTRAMUSCULAR 25-58- 3 H 10 (diphth-acell pertussis-tetanus) IPOL INJECTION INJECTABLE (poliovirus vaccine inactivated) 2 H JANSSEN COVID-19 VACCINE INTRAMUSCULAR 3 H SUSPENSION 0.5 ML MENACTRA INTRAMUSCULAR INJECTABLE (meningococcal 3 H a c y&w-135 conj) MENQUADFI INTRAMUSCULAR INJECTABLE 3 H (meningococcal a c y&w-135 conj) MENVEO INTRAMUSCULAR SOLUTION RECONSTITUTED 3 H (meningococcal a c y&w-135 olig) M-M-R II INJECTION SOLUTION RECONSTITUTED (measles, 2 H mumps & rubella vac) PEDVAX HIB INTRAMUSCULAR SUSPENSION 7.5 2 H MCG/0.5ML (haemophilus b polysac conj vac) PFIZER-BIONTECH COVID-19 VACC INTRAMUSCULAR 3 H SUSPENSION 30 MCG/0.3ML

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 43 Coverage Requirements & Prescription Drug Name Drug Tier Limits PNEUMOVAX 23 INJECTION INJECTABLE 25 MCG/0.5ML 2 H (pneumococcal vac polyvalent) PREVNAR 13 INTRAMUSCULAR SUSPENSION 3 H (pneumococcal 13-val conj vacc) RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML, 40 2 H MCG/ML, 5 MCG/0.5ML (hepatitis b vac recombinant) SHINGRIX INTRAMUSCULAR SUSPENSION RECONSTITUTED 50 MCG/0.5ML (zoster vac recomb 3 H adjuvanted) TRUMENBA INTRAMUSCULAR SUSPENSION PREFILLED 3 H SYRINGE (meningococcal b vac (recomb)) TWINRIX INTRAMUSCULAR SUSPENSION PREFILLED 3 H SYRINGE 720-20 ELU-MCG/ML (hepatitis a-hep b recomb vac) VAQTA INTRAMUSCULAR SUSPENSION 25 UNIT/0.5ML, 50 2 H UNIT/ML (hepatitis a vaccine) VARIVAX SUBCUTANEOUS INJECTABLE 1350 PFU/0.5ML 3 H (varicella virus vaccine live) AUTONOMIC DRUGS - Drugs for the Nervous System ALPHA- AND BETA-ADRENERGIC - Drugs for Heart and Lungs ADRENALIN NASAL SOLUTION 0.1 % (epinephrine hcl 2 (nasal)) PA; SL (90 tablets per droxidopa oral capsule 100 mg 1 month.); SP PA; SL (180 tablets per droxidopa oral capsule 200 mg, 300 mg 1 month.); SP epinephrine solution auto-injector 0.15 mg/0.3ml injection 0.15 SL (4 injections per 1 mg/0.3ml prescription.) epinephrine solution auto-injector 0.3 mg/0.3ml injection 0.3 SL (2 injections per 1 mg/0.3ml prescription.) pseudoephedrine-bromphen-dm oral syrup 30-2-10 mg/5ml 1 ALPHA-ADRENERGIC AGONISTS - Drugs for Heart and Lungs hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg 1 clonidine transdermal patch weekly 0.1 mg/24hr, 0.2 mg/24hr, 1 0.3 mg/24hr GILPHEX TR ORAL TABLET 10-388 MG (phenylephrine- 3 guaifenesin) oral tablet 250 mg, 500 mg 1 midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg 1 Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 44 Coverage Requirements & Prescription Drug Name Drug Tier Limits promethazine vc oral syrup 6.25-5 mg/5ml 1 promethazine vc/codeine oral syrup 6.25-5-10 mg/5ml 1 PA; SL (360 ml per month.) promethazine-phenyleph-codeine oral syrup 6.25-5-10 mg/5ml 1 PA; SL (360 ml per month.) promethazine-phenylephrine oral syrup 6.25-5 mg/5ml 1 ANTIMUSCARINICS/ - Drugs for Parkinson ANASPAZ ORAL TABLET DISPERSIBLE 0.125 MG 2 (hyoscyamine sulfate) ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/INH (umeclidinium- 3 SL (2 blisters per day.) vilanterol) ATROVENT HFA INHALATION AEROSOL SOLUTION 17 3 SL (0.87 grams per day.) MCG/ACT (ipratropium bromide hfa) belladonna alkaloids-opium rectal suppository 16.2-30 mg 1 belladonna alkaloids-opium rectal suppository 16.2-60 mg 2 BEVESPI AEROSPHERE INHALATION AEROSOL 9-4.8 2 SL (0.36 grams per day.) MCG/ACT (glycopyrrolate-formoterol) BREZTRI AEROSPHERE INHALATION AEROSOL 160-9-4.8 3 SL (0.36 grams per day.) MCG/ACT (budeson-glycopyrrol-formoterol) chlordiazepoxide-clidinium oral capsule 5-2.5 mg 1 COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 3 SL (0.28 grams per day.) 20-100 MCG/ACT (ipratropium-albuterol) CUVPOSA ORAL SOLUTION 1 MG/5ML (glycopyrrolate) 3 dicyclomine hcl oral capsule 10 mg 1 dicyclomine hcl oral solution 10 mg/5ml 1 dicyclomine hcl oral tablet 20 mg 1 diphenoxylate-atropine oral liquid 2.5-0.025 mg/5ml 1 diphenoxylate-atropine oral tablet 2.5-0.025 mg 1 DUAKLIR PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED 400-12 MCG/ACT (aclidinium br- 3 SL (0.04 mcg per day.) formoterol fum) ED-SPAZ ORAL TABLET DISPERSIBLE 0.125 MG 3 glycopyrrolate oral tablet 1 mg, 2 mg 1 PA; SL (120 mL per hydrocodone-homatropine oral syrup 5-1.5 mg/5ml 1 prescription and 360 ml per month.) hydrocodone-homatropine oral tablet 5-1.5 mg 1 PA

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 45 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; SL (120 mL per hydromet oral syrup 5-1.5 mg/5ml 1 prescription and 360 ml per month.) HYOPHEN ORAL TABLET 81.6 MG (meth-hyo-m bl-benz acd- 3 ph sal) hyoscyamine sulfate er oral tablet extended release 12 hour 1 0.375 mg hyoscyamine sulfate oral elixir 0.125 mg/5ml 1 hyoscyamine sulfate oral solution 0.125 mg/ml 1 hyoscyamine sulfate oral tablet 0.125 mg 1 hyoscyamine sulfate oral tablet dispersible 0.125 mg 1 hyoscyamine sulfate sl sublingual tablet sublingual 0.125 mg 1 hyoscyamine sulfate sublingual tablet sublingual 0.125 mg 1 hyosyne oral elixir 0.125 mg/5ml 1 hyosyne oral solution 0.125 mg/ml 1 ipratropium bromide inhalation solution 0.02 % 1 ipratropium bromide nasal solution 0.03 %, 0.06 % 1 ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml 1 LEVBID ORAL TABLET EXTENDED RELEASE 12 HOUR 3 0.375 MG (hyoscyamine sulfate) LEVSIN ORAL TABLET 0.125 MG (hyoscyamine sulfate) 3 LEVSIN/SL SUBLINGUAL TABLET SUBLINGUAL 0.125 MG 3 (hyoscyamine sulfate) LOMOTIL ORAL TABLET 2.5-0.025 MG (diphenoxylate- 3 atropine) me/naphos/mb/hyo1 oral tablet 81.6 mg 1 methscopolamine bromide oral tablet 2.5 mg, 5 mg 1 NULEV ORAL TABLET DISPERSIBLE 0.125 MG (hyoscyamine 3 sulfate) oscimin oral tablet 0.125 mg 1 oscimin sr oral tablet extended release 12 hour 0.375 mg 1 oscimin sublingual tablet sublingual 0.125 mg 1 PHOSPHASAL ORAL TABLET 81.6 MG (meth-hyo-m bl-na 2 phos-ph sal) scopolamine transdermal patch 72 hour 1 mg/3days 1 SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG 2 SL (1 capsule per day) (tiotropium bromide monohydrate)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 46 Coverage Requirements & Prescription Drug Name Drug Tier Limits SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 2 SL (0.15 grams per day.) MCG/ACT, 2.5 MCG/ACT (tiotropium bromide monohydrate) SYMAX DUOTAB ORAL TABLET EXTENDED RELEASE 0.375 3 MG (hyoscyamine sulfate) SYMAX-SL SUBLINGUAL TABLET SUBLINGUAL 0.125 MG 3 (hyoscyamine sulfate) SYMAX-SR ORAL TABLET EXTENDED RELEASE 12 HOUR 3 0.375 MG (hyoscyamine sulfate) TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-62.5-25 MCG/INH, 200-62.5-25 3 SL (2 blisters per day.) MCG/INH (fluticasone-umeclidin-vilant) URELLE ORAL TABLET 81 MG (meth-hyo-m bl-na phos-ph 3 sal) URIBEL ORAL CAPSULE 118 MG (meth-hyo-m bl-na phos-ph 3 sal) urin ds oral tablet 81.6 mg 1 URO-458 ORAL TABLET 81 MG 3 UROGESIC-BLUE ORAL TABLET 81.6 MG (methen-hyosc- 2 meth blue-na phos) uro-mp oral capsule 118 mg 1 USTELL ORAL CAPSULE 120 MG (meth-hyo-m bl-na phos-ph 3 sal) UTIRA-C ORAL TABLET 81.6 MG (meth-hyo-m bl-na phos-ph 2 sal) VILAMIT MB ORAL CAPSULE 118 MG (meth-hyo-m bl-na 3 phos-ph sal) VILEVEV MB ORAL TABLET 81 MG (meth-hyo-m bl-na phos- 3 ph sal) YUPELRI INHALATION SOLUTION 175 MCG/3ML 3 PA; SL (3 ml per day.) (revefenacin) ANTIPARKINSONIAN AGENTS - Drugs for Parkinson benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg 1 diphen oral elixir 12.5 mg/5ml 1 di-phen oral elixir 12.5 mg/5ml 3 diphenhydramine hcl oral elixir 12.5 mg/5ml 1 trihexyphenidyl hcl oral solution 0.4 mg/ml 1 trihexyphenidyl hcl oral tablet 2 mg, 5 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 47 Coverage Requirements & Prescription Drug Name Drug Tier Limits AUTONOMIC DRUGS, MISCELLANEOUS - Drugs for the Nervous System CHANTIX CONTINUING MONTH PAK ORAL TABLET 1 MG 3 H (varenicline tartrate) CHANTIX ORAL TABLET 0.5 MG, 1 MG (varenicline tartrate) 3 H CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X 3 H 11 & 1 MG X 42 (varenicline tartrate) goodsense nicotine mouth/throat lozenge 4 mg 1 H habitrol transdermal patch 24 hour 21 mg/24hr 1 H MOUTH/THROAT GUM 2 MG (nicotine polacrilex) 3 H nicotine polacrilex mini mouth/throat lozenge 2 mg 1 H nicotine polacrilex mouth/throat gum 2 mg, 4 mg 1 H nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg 1 H nicotine step 1 transdermal patch 24 hour 21 mg/24hr 1 H nicotine step 2 transdermal patch 24 hour 14 mg/24hr 1 H nicotine step 3 transdermal patch 24 hour 7 mg/24hr 1 H NICOTROL INHALATION INHALER 10 MG (nicotine) 3 H NICOTROL NS NASAL SOLUTION 10 MG/ML (nicotine) 3 H CENTRALLY ACTING SKELETAL MUSCLE RELAXNT - Drugs for Relaxing Muscles carisoprodol oral tablet 350 mg 1 carisoprodol-aspirin-codeine oral tablet 200-325-16 mg 1 chlorzoxazone oral tablet 500 mg 1 cyclobenzaprine hcl oral tablet 10 mg, 5 mg 1 metaxalone oral tablet 400 mg, 800 mg 1 methocarbamol oral tablet 500 mg, 750 mg 1 tizanidine hcl oral capsule 2 mg, 4 mg, 6 mg 1 tizanidine hcl oral tablet 2 mg, 4 mg 1 ZANAFLEX ORAL CAPSULE 2 MG, 4 MG, 6 MG (tizanidine 3 hcl) ZANAFLEX ORAL TABLET 4 MG (tizanidine hcl) 3 DIRECT-ACTING SKELETAL MUSCLE RELAXANTS - Drugs for Relaxing Muscles DANTRIUM ORAL CAPSULE 25 MG, 50 MG (dantrolene 3 sodium) dantrolene sodium oral capsule 100 mg, 25 mg, 50 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 48 Coverage Requirements & Prescription Drug Name Drug Tier Limits GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT - Drugs for Relaxing Muscles baclofen oral tablet 10 mg, 20 mg, 5 mg 1 OZOBAX ORAL SOLUTION 5 MG/5ML (baclofen) 3 PA NON-SEL. BETA-ADRENERGIC BLOCKING AGENTS - Drugs for the Heart BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG 3 (sotalol hcl af) carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1 CORGARD ORAL TABLET 20 MG, 40 MG, 80 MG () 3 labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 nadolol oral tablet 20 mg, 40 mg, 80 mg 1 pindolol oral tablet 10 mg, 5 mg 1 hcl er oral capsule extended release 24 hour 120 1 mg, 160 mg, 60 mg, 80 mg propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml 1 propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg 1 sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg 1 sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 SOTYLIZE ORAL SOLUTION 5 MG/ML (sotalol hcl) 3 PA maleate oral tablet 10 mg, 20 mg, 5 mg 1 NON-SEL.ALPHA-1-ADRENERGIC BLOCKING AGTS - Drugs for the Heart CARDURA ORAL TABLET 1 MG, 2 MG, 4 MG, 8 MG 3 ( mesylate) CARDURA XL ORAL TABLET EXTENDED RELEASE 24 3 HOUR 4 MG, 8 MG (doxazosin mesylate) doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg 1 MINIPRESS ORAL CAPSULE 1 MG, 2 MG, 5 MG ( 3 hcl) prazosin hcl oral capsule 1 mg, 2 mg, 5 mg 1 terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTS - Drugs for the Heart CAFERGOT ORAL TABLET 1-100 MG (-caffeine) 3 mesylate injection solution 1 mg/ml 1 PA; SL (8 mL per dihydroergotamine mesylate nasal solution 4 mg/ml 1 prescription.) Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 49 Coverage Requirements & Prescription Drug Name Drug Tier Limits ergoloid mesylates oral tablet 1 mg 1 ERGOMAR SUBLINGUAL TABLET SUBLINGUAL 2 MG PA; SL (5 tablets per 3 (ergotamine tartrate) prescription.) ergotamine-caffeine oral tablet 1-100 mg 1 MIGERGOT RECTAL SUPPOSITORY 2-100 MG (ergotamine- 3 caffeine) phenoxybenzamine hcl oral capsule 10 mg 1 PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) - Drugs for Bladder Incontinence chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg 1 cevimeline hcl oral capsule 30 mg 1 donepezil hcl oral tablet 10 mg, 5 mg 1 donepezil hcl oral tablet dispersible 10 mg, 5 mg 1 galantamine hydrobromide er oral capsule extended release 24 1 hour 16 mg, 24 mg, 8 mg galantamine hydrobromide oral solution 4 mg/ml 1 galantamine hydrobromide oral tablet 12 mg, 4 mg, 8 mg 1 MESTINON ORAL SOLUTION 60 MG/5ML (pyridostigmine 3 bromide) NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PACK 7 3 & 14 & 21 &28 -10 MG (memantine hcl-donepezil hcl) NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG (memantine hcl- 3 donepezil hcl) pilocarpine hcl oral tablet 5 mg, 7.5 mg 1 pyridostigmine bromide er oral tablet extended release 180 mg 1 pyridostigmine bromide oral solution 60 mg/5ml 1 pyridostigmine bromide oral tablet 60 mg 1 RAZADYNE ER ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 16 MG, 24 MG, 8 MG (galantamine hydrobromide) rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg 1 rivastigmine transdermal patch 24 hour 13.3 mg/24hr, 4.6 1 mg/24hr, 9.5 mg/24hr SALAGEN ORAL TABLET 5 MG, 7.5 MG (pilocarpine hcl) 3 SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENT - Drugs for the Heart alfuzosin hcl er oral tablet extended release 24 hour 10 mg 1 carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 50 Coverage Requirements & Prescription Drug Name Drug Tier Limits labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 silodosin oral capsule 4 mg, 8 mg 1 tamsulosin hcl oral capsule 0.4 mg 1 SELECTIVE BETA-2-ADRENERGIC AGONISTS - Drugs for Heart and Lungs ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 1 SL (2 blisters per day) MCG/DOSE (fluticasone-salmeterol) ADVAIR HFA INHALATION AEROSOL 115-21 MCG/ACT, 230- 3 SL (0.4 grams per day.) 21 MCG/ACT, 45-21 MCG/ACT (fluticasone-salmeterol) albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act SL (1 inhaler per 1 inhalation 108 (90 base) mcg/act prescription.) albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act SL (6.7 grams per 1 inhalation 108 (90 base) mcg/act prescription.) albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act SL (8.5 grams per 1 inhalation 108 (90 base) mcg/act prescription.) albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 1 0.083%, 0.63 mg/3ml, 1.25 mg/3ml, 2.5 mg/0.5ml albuterol sulfate inhalation nebulization solution (5 mg/ml) 0.5% 1 albuterol sulfate oral syrup 2 mg/5ml 1 albuterol sulfate oral tablet 2 mg, 4 mg 1 PA ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/INH (umeclidinium- 3 SL (2 blisters per day.) vilanterol) arformoterol tartrate inhalation nebulization solution 15 mcg/2ml 1 SL (2 nebules per day) BEVESPI AEROSPHERE INHALATION AEROSOL 9-4.8 2 SL (0.36 grams per day.) MCG/ACT (glycopyrrolate-formoterol) BREO ELLIPTA INHALATION AEROSOL POWDER BREATH 3 SL (2 inhalers per day.) ACTIVATED 100-25 MCG/INH (fluticasone furoate-vilanterol) BREO ELLIPTA INHALATION AEROSOL POWDER BREATH 3 SL (2 blisters per day.) ACTIVATED 200-25 MCG/INH (fluticasone furoate-vilanterol) BREZTRI AEROSPHERE INHALATION AEROSOL 160-9-4.8 3 SL (0.36 grams per day.) MCG/ACT (budeson-glycopyrrol-formoterol) BROVANA INHALATION NEBULIZATION SOLUTION 15 3 SL (2 nebules per day) MCG/2ML (arformoterol tartrate) COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 3 SL (0.28 grams per day.) 20-100 MCG/ACT (ipratropium-albuterol) DUAKLIR PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED 400-12 MCG/ACT (aclidinium br- 3 SL (0.04 mcg per day.) formoterol fum) Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 51 Coverage Requirements & Prescription Drug Name Drug Tier Limits FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 1 SL (0.04 mcg per day.) MCG/ACT, 55-14 MCG/ACT ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml 1 levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 1 SL (90 ml per prescription.) 0.63 mg/3ml, 1.25 mg/3ml levalbuterol hcl inhalation nebulization solution 1.25 mg/0.5ml 1 SL (30 vials per prescription) SL (15 grams per LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT 3 prescription.) PERFOROMIST INHALATION NEBULIZATION SOLUTION 20 3 SL (2 vials per day) MCG/2ML (formoterol fumarate) SEREVENT DISKUS INHALATION AEROSOL POWDER 2 SL (2 blisters per day.) BREATH ACTIVATED 50 MCG/DOSE (salmeterol xinafoate) STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 2 SL (0.14 grams per day.) 2.5 MCG/ACT (olodaterol hcl) SYMBICORT INHALATION AEROSOL 160-4.5 MCG/ACT, 80- 3 SL (0.34 grams per day.) 4.5 MCG/ACT (budesonide-formoterol fumarate) terbutaline sulfate oral tablet 2.5 mg, 5 mg 1 TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-62.5-25 MCG/INH, 200-62.5-25 3 SL (2 blisters per day.) MCG/INH (fluticasone-umeclidin-vilant) XOPENEX HFA INHALATION AEROSOL 45 MCG/ACT SL (15 grams per 3 (levalbuterol tartrate) prescription.) SELECTIVE BETA-ADRENERGIC BLOCKING AGENT - Drugs for the Heart acebutolol hcl oral capsule 200 mg, 400 mg 1 atenolol oral tablet 100 mg, 25 mg, 50 mg 1 betaxolol hcl oral tablet 10 mg, 20 mg 1 bisoprolol fumarate oral tablet 10 mg, 5 mg 1 KAPSPARGO SPRINKLE ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 200 MG, 25 MG, 50 MG (metoprolol 3 succinate) LOPRESSOR ORAL TABLET 100 MG, 50 MG (metoprolol 3 tartrate) metoprolol succinate er oral tablet extended release 24 hour 1 100 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg 1 TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 25 MG, 50 MG (metoprolol succinate)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 52 Coverage Requirements & Prescription Drug Name Drug Tier Limits SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS - Drugs for Relaxing Muscles orphenadrine citrate er oral tablet extended release 12 hour 100 1 mg orphenadrine-asa-caffeine oral tablet 50-770-60 mg 1 BLOOD FORMATION, COAGULATION, THROMBOSIS - Drugs for the Blood ANTIANEMIA DRUGS - Vitamins and Minerals ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 SL (2 syringes per month); 2 MCG/ML, 300 MCG/ML (darbepoetin alfa) SP ARANESP (ALBUMIN FREE) INJECTION SOLUTION 200 SL (4 syringes per month); MCG/ML, 25 MCG/ML, 40 MCG/ML, 60 MCG/ML ( darbepoetin 2 SP alfa) ARANESP (ALBUMIN FREE) INJECTION SOLUTION 2 SL (1.6 ml per month.); SP PREFILLED SYRINGE 10 MCG/0.4ML (darbepoetin alfa) ARANESP (ALBUMIN FREE) INJECTION SOLUTION SL (1 prefill syringe per 2 PREFILLED SYRINGE 100 MCG/0.5ML (darbepoetin alfa) month); SP ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 150 MCG/0.3ML, 60 MCG/0.3ML 2 SL (2 vials per month); SP (darbepoetin alfa) ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 200 MCG/0.4ML, 25 MCG/0.42ML, 40 2 SL (4 vials per month); SP MCG/0.4ML (darbepoetin alfa) ARANESP (ALBUMIN FREE) INJECTION SOLUTION SL (2 vials per prescription); 2 PREFILLED SYRINGE 300 MCG/0.6ML (darbepoetin alfa) SP ARANESP (ALBUMIN FREE) INJECTION SOLUTION SL (2 syringes per month); 2 PREFILLED SYRINGE 500 MCG/ML (darbepoetin alfa) SP RETACRIT INJECTION SOLUTION 10000 UNIT/ML (epoetin 2 SL (8 ml per 21 days.); SP alfa-epbx) RETACRIT INJECTION SOLUTION 2000 UNIT/ML, 3000 2 SL (12 ml per 21 days.); SP UNIT/ML, 4000 UNIT/ML (epoetin alfa-epbx) RETACRIT INJECTION SOLUTION 20000 UNIT/ML (epoetin 2 alfa-epbx) RETACRIT INJECTION SOLUTION 40000 UNIT/ML (epoetin 2 SL (4 ml per 21 days.); SP alfa-epbx) ANTICOAGULANTS, MISCELLANEOUS - Drugs to Prevent Blood Clots ACD-A NOCLOT-50 IN VITRO SOLUTION 0.73-2.45-2.2 3 GM/100ML (anticoagulant cit dext soln a)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 53 Coverage Requirements & Prescription Drug Name Drug Tier Limits ANTICOAGULANT SODIUM CITRATE IN VITRO SOLUTION 4 3 %, 4 GM/100ML SL (24 ml (30 syringes) per fondaparinux sodium subcutaneous solution 10 mg/0.8ml 1 prescription) SL (15 ml (30 syringes) per fondaparinux sodium subcutaneous solution 2.5 mg/0.5ml 1 prescription) SL (12 ml (30 syringes) per fondaparinux sodium subcutaneous solution 5 mg/0.4ml 1 prescription) SL (18 ml (30 syringes) per fondaparinux sodium subcutaneous solution 7.5 mg/0.6ml 1 prescription) TRICITRASOL IN VITRO CONCENTRATE 46.7 % 3 (anticoagulant sodium citrate) ANTITHROMBOTIC AGENTS, MISCELLANEOUS - Drugs to Prevent Blood Clots PA; SL (1 vial per day and 58 CABLIVI INJECTION KIT 11 MG (caplacizumab-yhdp) 2 vials per 120 days.); SP BLOOD FORM.,COAG,THROMBOSIS AGENTS MISC. - Drugs to Prevent Bleeding PA; SL (3 tablets per day.); OXBRYTA ORAL TABLET 500 MG (voxelotor) 3 SP TAVALISSE ORAL TABLET 100 MG, 150 MG (fostamatinib PA; ST; SL (2 tablets per 3 disodium) day.); SP COUMARIN DERIVATIVES - Drugs to Prevent Blood Clots jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 1 mg, 6 mg, 7.5 mg sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 1 mg, 5 mg, 6 mg, 7.5 mg DIRECT FACTOR XA INHIBITORS - Drugs to Prevent Blood Clots ELIQUIS DVT/PE STARTER PACK ORAL TABLET THERAPY 2 SL (2.5 tablets per day.) PACK 5 MG (apixaban) ELIQUIS ORAL TABLET 2.5 MG (apixaban) 2 SL (2 tablets per day.) ELIQUIS ORAL TABLET 5 MG (apixaban) 2 SL (2.5 tablets per day.) SAVAYSA ORAL TABLET 15 MG, 30 MG, 60 MG (edoxaban 3 SL (1 tablet per day.) tosylate) XARELTO ORAL TABLET 10 MG (rivaroxaban) 2 SL (1 tablet per day.) SL (52 tablets per month XARELTO ORAL TABLET 15 MG (rivaroxaban) 2 initial 1 tablet per day for maintenance.) XARELTO ORAL TABLET 2.5 MG (rivaroxaban) 2 SL (2 tablets per day.) Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 54 Coverage Requirements & Prescription Drug Name Drug Tier Limits XARELTO ORAL TABLET 20 MG (rivaroxaban) 2 SL (31 tablets per 31 days.) XARELTO STARTER PACK ORAL TABLET THERAPY PACK 2 SL (51 tablets per year.) 15 & 20 MG (rivaroxaban) DIRECT THROMBIN INHIBITORS - Drugs to Prevent Blood Clots PRADAXA ORAL CAPSULE 110 MG (dabigatran etexilate 2 SL (2 tablets per day.) mesylate) PRADAXA ORAL CAPSULE 150 MG, 75 MG (dabigatran SL (62 capsules per 31 2 etexilate mesylate) days.) HEMATOPOIETIC AGENTS - Drugs for Anemia ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 SL (2 syringes per month); 2 MCG/ML, 300 MCG/ML (darbepoetin alfa) SP ARANESP (ALBUMIN FREE) INJECTION SOLUTION 200 SL (4 syringes per month); MCG/ML, 25 MCG/ML, 40 MCG/ML, 60 MCG/ML ( darbepoetin 2 SP alfa) ARANESP (ALBUMIN FREE) INJECTION SOLUTION 2 SL (1.6 ml per month.); SP PREFILLED SYRINGE 10 MCG/0.4ML (darbepoetin alfa) ARANESP (ALBUMIN FREE) INJECTION SOLUTION SL (1 prefill syringe per 2 PREFILLED SYRINGE 100 MCG/0.5ML (darbepoetin alfa) month); SP ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 150 MCG/0.3ML, 60 MCG/0.3ML 2 SL (2 vials per month); SP (darbepoetin alfa) ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 200 MCG/0.4ML, 25 MCG/0.42ML, 40 2 SL (4 vials per month); SP MCG/0.4ML (darbepoetin alfa) ARANESP (ALBUMIN FREE) INJECTION SOLUTION SL (2 vials per prescription); 2 PREFILLED SYRINGE 300 MCG/0.6ML (darbepoetin alfa) SP ARANESP (ALBUMIN FREE) INJECTION SOLUTION SL (2 syringes per month); 2 PREFILLED SYRINGE 500 MCG/ML (darbepoetin alfa) SP PA; ST; SL (15 tablets per DOPTELET ORAL TABLET 20 MG ( avatrombopag maleate) 3 month.); SP LEUKINE INJECTION SOLUTION RECONSTITUTED 250 2 MCG (sargramostim) MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/1.2ML 2 SP (plerixafor) PA; SL (7 tablets per MULPLETA ORAL TABLET 3 MG ( lusutrombopag) 2 prescription.); SP NEULASTA SUBCUTANEOUS SOLUTION PREFILLED 3 SYRINGE 6 MG/0.6ML (pegfilgrastim) PROMACTA ORAL PACKET 12.5 MG (eltrombopag olamine) 3 PA; SP

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 55 Coverage Requirements & Prescription Drug Name Drug Tier Limits PROMACTA ORAL PACKET 25 MG (eltrombopag olamine) 3 PA PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG 3 PA; SP (eltrombopag olamine) RETACRIT INJECTION SOLUTION 10000 UNIT/ML (epoetin 2 SL (8 ml per 21 days.); SP alfa-epbx) RETACRIT INJECTION SOLUTION 2000 UNIT/ML, 3000 2 SL (12 ml per 21 days.); SP UNIT/ML, 4000 UNIT/ML (epoetin alfa-epbx) RETACRIT INJECTION SOLUTION 20000 UNIT/ML (epoetin 2 alfa-epbx) RETACRIT INJECTION SOLUTION 40000 UNIT/ML (epoetin 2 SL (4 ml per 21 days.); SP alfa-epbx) ZARXIO INJECTION SOLUTION PREFILLED SYRINGE 300 2 SP MCG/0.5ML, 480 MCG/0.8ML (filgrastim-sndz) ZIEXTENZO SUBCUTANEOUS SOLUTION PREFILLED 3 SP SYRINGE 6 MG/0.6ML (pegfilgrastim-bmez) HEMORRHEOLOGIC AGENTS - Drugs for Blood Flow pentoxifylline er oral tablet extended release 400 mg 1 HEMOSTATICS - Drugs to Prevent Bleeding ADVATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 4000 2 UNIT, 500 UNIT (antihemophil factor (rahf-pfm)) ADYNOVATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 3 PA UNIT, 750 UNIT AFSTYLA INTRAVENOUS KIT 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 500 UNIT 3 PA (antihemophil fact single chain) ALPHANATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT 2 (antihemophilic factor-vwf) ALPHANINE SD INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 500 UNIT 2 (coagulation factor ix) ALPROLIX INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 4000 UNIT, 500 3 UNIT (coagulation factor ix (rfixfc)) aminocaproic acid oral solution 0.25 gm/ml 1 aminocaproic acid oral tablet 1000 mg, 500 mg 1 ASTRINGYN EXTERNAL SOLUTION 259 MG/GM (ferric 3 subsulfate)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 56 Coverage Requirements & Prescription Drug Name Drug Tier Limits BENEFIX INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 2 UNIT, 3000 UNIT, 500 UNIT (coagulation factor ix (recomb)) COAGADEX INTRAVENOUS SOLUTION RECONSTITUTED 2 250 UNIT, 500 UNIT (coagulation factor x (human)) CORIFACT INTRAVENOUS KIT 1000-1600 UNIT (factor xiii 2 concentrate human) desmopressin ace spray refrig nasal solution 0.01 % 1 desmopressin acetate injection solution 4 mcg/ml 1 desmopressin acetate oral tablet 0.1 mg, 0.2 mg 1 desmopressin acetate pf injection solution 4 mcg/ml 1 desmopressin acetate spray nasal solution 0.01 % 1 ELOCTATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 3 PA 4000 UNIT, 500 UNIT, 5000 UNIT, 6000 UNIT, 750 UNIT (antihem fact (bdd-rfviiifc)) FEIBA INTRAVENOUS SOLUTION RECONSTITUTED 1000 2 UNIT, 2500 UNIT, 500 UNIT (antiinhibitor coagulant cmplx) GELFILM OPHTHALMIC FILM (gelatin adsorbable) 2 HEMLIBRA SUBCUTANEOUS SOLUTION 105 MG/0.7ML, 150 2 PA MG/ML, 30 MG/ML, 60 MG/0.4ML (emicizumab-kxwh) HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1700 UNIT, 250 UNIT, 500 UNIT (antihemophilic 2 factor) HUMATE-P INTRAVENOUS SOLUTION RECONSTITUTED 1000-2400 UNIT, 250-600 UNIT, 500-1200 UNIT 2 (antihemophilic factor-vwf) IDELVION INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3500 UNIT, 500 UNIT 3 (coagulation factor ix (rix-fp)) JIVI INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 3000 UNIT, 500 UNIT (ahf (bdd-rfviii peg- 3 PA aucl)) KOATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 2 UNIT, 250 UNIT, 500 UNIT (antihemophilic factor) KOATE-DVI INTRAVENOUS SOLUTION RECONSTITUTED 2 1000 UNIT, 500 UNIT (antihemophilic factor) KOGENATE FS INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 2 250 UNIT, 3000 UNIT, 500 UNIT (antihem factor recomb (rfviii))

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 57 Coverage Requirements & Prescription Drug Name Drug Tier Limits KOVALTRY INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT 2 (antihemophil factor (rahf-pfm)) LYSTEDA ORAL TABLET 650 MG (tranexamic acid) 3 SL (30 tablets per 5 days.) MONONINE INTRAVENOUS SOLUTION RECONSTITUTED 2 1000 UNIT (coagulation factor ix) monsels ferric subsulfate external solution 1 NOCDURNA SUBLINGUAL TABLET SUBLINGUAL 27.7 MCG, 3 PA; SL (1 tablet per day.) 55.3 MCG (desmopressin acetate) NOVOEIGHT INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 2 UNIT (antihemophil fact bd truncated) NOVOSEVEN RT INTRAVENOUS SOLUTION RECONSTITUTED 1 MG, 2 MG, 5 MG, 8 MG (coagulation 2 factor viia recomb) NUWIQ INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT (antihem fact 2 (bdd-rfviii,sim)) NUWIQ INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 4000 2 UNIT, 500 UNIT (antihem fact (bdd-rfviii,sim)) PROFILNINE INTRAVENOUS SOLUTION RECONSTITUTED 2 1000 UNIT, 1500 UNIT, 500 UNIT (factor ix complex) RECOMBINATE INTRAVENOUS SOLUTION RECONSTITUTED 1241-1800 UNIT, 1801-2400 UNIT, 220-400 2 UNIT, 401-800 UNIT, 801-1240 UNIT (antihem factor recomb (rfviii)) RECOTHROM EXTERNAL SOLUTION RECONSTITUTED 3 20000 UNIT, 5000 UNIT (thrombin (recombinant)) RECOTHROM SPRAY KIT EXTERNAL SOLUTION 3 RECONSTITUTED 20000 UNIT (thrombin (recombinant)) RIXUBIS INTRAVENOUS SOLUTION RECONSTITUTED 1000 2 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT STIMATE NASAL SOLUTION 1.5 MG/ML (desmopressin 3 acetate) THROMBIN-JMI EPISTAXIS EXTERNAL KIT 5000 UNIT 3 (thrombin) THROMBIN-JMI EXTERNAL KIT 20000 UNIT, 5000 UNIT 3 (thrombin) THROMBOGEN EXTERNAL KIT 10000 UNIT (thrombin) 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 58 Coverage Requirements & Prescription Drug Name Drug Tier Limits THROMBOGEN EXTERNAL SOLUTION RECONSTITUTED 3 1000 UNIT, 10000 UNIT (thrombin) tranexamic acid oral tablet 650 mg 1 SL (30 tablets per 5 days.) TRETTEN INTRAVENOUS SOLUTION RECONSTITUTED 3 2000-3125 UNIT (coagulation factor xiii a-sub) VONVENDI INTRAVENOUS SOLUTION RECONSTITUTED 2 1300 UNIT, 650 UNIT (von willebrand factor (recomb)) WILATE INTRAVENOUS KIT 1000-1000 UNIT, 500-500 UNIT 2 (antihemophilic factor-vwf) XYNTHA INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 3 PA; ST UNIT, 500 UNIT (antihem fact (bdd-rfviii,mor)) XYNTHA SOLOFUSE INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT (antihem fact (bdd- 3 PA; ST rfviii,mor)) HEPARINS - Drugs to Prevent Blood Clots SL (42 ml (14 vials) per enoxaparin sodium injection solution 300 mg/3ml 1 prescription) enoxaparin sodium subcutaneous solution 100 mg/ml, 150 SL (30 syringes per 1 mg/ml prescription) enoxaparin sodium subcutaneous solution 120 mg/0.8ml, 80 SL (24 ml (30 syringes) per 1 mg/0.8ml prescription) SL (9 ml (30 syringes) per enoxaparin sodium subcutaneous solution 30 mg/0.3ml 1 prescription) SL (12 ml (30 syringes) per enoxaparin sodium subcutaneous solution 40 mg/0.4ml 1 prescription) SL (18 ml (30 syringes) per enoxaparin sodium subcutaneous solution 60 mg/0.6ml 1 prescription) FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML SL (10 ml (10 syringes) per 3 (dalteparin sodium) prescription.) FRAGMIN SUBCUTANEOUS SOLUTION 12500 UNIT/0.5ML SL (5 ml (10 syringes) per 3 (dalteparin sodium) prescription.) FRAGMIN SUBCUTANEOUS SOLUTION 15000 UNIT/0.6ML SL (6 ml (10 syringes) per 3 (dalteparin sodium) prescription.) FRAGMIN SUBCUTANEOUS SOLUTION 18000 UNT/0.72ML SL (8 ml (10 syringes) per 3 (dalteparin sodium) prescription) FRAGMIN SUBCUTANEOUS SOLUTION 2500 UNIT/0.2ML, SL (2 ml (10 syringes) per 3 5000 UNIT/0.2ML (dalteparin sodium) prescription.) FRAGMIN SUBCUTANEOUS SOLUTION 7500 UNIT/0.3ML SL (3 ml (10 syringes) per 3 (dalteparin sodium) prescription.)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 59 Coverage Requirements & Prescription Drug Name Drug Tier Limits FRAGMIN SUBCUTANEOUS SOLUTION 95000 UNIT/3.8ML 3 (dalteparin sodium) heparin lock flush intravenous solution 10 unit/ml 1 heparin sodium (porcine) injection solution 1000 unit/ml, 10000 1 unit/ml, 20000 unit/ml, 5000 unit/ml heparin sodium (porcine) injection solution prefilled syringe 1 5000 unit/0.5ml heparin sodium (porcine) pf injection solution 5000 unit/0.5ml, 1 5000 unit/ml heparin sodium lock flush intravenous solution 100 unit/ml 1 IRON PREPARATIONS - Vitamins and Minerals ATABEX OB ORAL TABLET 29-1 MG (prenatal vit w/ fe bisg-fa) 3 CITRANATAL BLOOM ORAL TABLET 90-1 MG ( prenatal-dss- 3 fecb-fegl-fa) CITRANATAL ESSENCE ORAL THERAPY PACK 35-1 & 300 3 MG (prenat w/o a-fecbgl-fa-dha) CITRANATAL MEDLEY ORAL CAPSULE 27-1-200 MG 3 (prenat-fecb-fefum-fa-dha w/o a) ELITE-OB ORAL TABLET 50-1.25 MG (prenatal vit-iron 3 carbonyl-fa) ENBRACE HR ORAL CAPSULE (prenat vit-fe gly cys-fa- 3 omega) hematinic/folic acid oral tablet 324-1 mg 1 hemocyte-f oral tablet 324-1 mg 1 M-NATAL PLUS ORAL TABLET 27-1 MG 3 multi-vit/iron/fluoride oral solution 0.25-10 mg/ml 1 multi-vitamin/fluoride/iron oral solution 0.25-10 mg/ml 1 NEONATAL + DHA ORAL 29-1 & 200 MG 3 NEONATAL COMPLETE ORAL TABLET 27-1 MG, 29-1 MG 3 NEONATAL FE ORAL TABLET 90-1 MG 3 NEONATAL PLUS ORAL TABLET 27-1 MG ( prenatal vit-fe 3 fumarate-fa) NESTABS ORAL TABLET 32-1 MG (prenat-fe bisgly-fa-w/o vit 3 a) ONE VITE WOMENS PLUS ORAL TABLET 27-1 MG 3 POLY-VI-FLOR/IRON ORAL SUSPENSION 0.25-7 MG/ML 3 (ped multivitamins-fl-iron)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 60 Coverage Requirements & Prescription Drug Name Drug Tier Limits POLY-VI-FLOR/IRON ORAL TABLET CHEWABLE 0.5-10 MG 3 (ped multivitamins-fl-iron) PRENAISSANCE ORAL CAPSULE 29-1.25-325 MG 2 prenatal oral tablet 27-1 mg 1 prenatal plus iron oral tablet 29-1 mg 1 prenatal vitamin plus low iron oral tablet 27-1 mg 1 PRENATE DHA ORAL CAPSULE 18-0.6-0.4-300 MG (prenat- 3 feasp-meth-fa-dha w/o a) PRENATE ELITE ORAL TABLET 20-0.6-0.4 MG (prenatal- 3 feaspgly-methylfol-fa) PRENATE ENHANCE ORAL CAPSULE 28-0.6-0.4-400 MG 3 (prenat w/o a-fe-methfol-fa-dha) PRENATE ESSENTIAL ORAL CAPSULE 18-0.6-0.4-300 MG 3 (prenat-feasp-meth-fa-dha w/o a) PRENATE MINI ORAL CAPSULE 18-0.6-0.4-350 MG (prenat- 3 fecbn-feasp-meth-fa-dha) PRENATE PIXIE ORAL CAPSULE 10-0.6-0.4-200 MG (prenat- 3 feasp-meth-fa-dha w/o a) PRENATE RESTORE ORAL CAPSULE 27-0.6-0.4-400 MG 3 (prenat w/o a-fe-methfol-fa-dha) PRENATVITE COMPLETE ORAL TABLET 1 MG 3 PRENATVITE PLUS ORAL TABLET 1 MG 3 PRENATVITE RX ORAL TABLET 0.8 MG 3 preplus oral tablet 27-1 mg 1 PRETAB ORAL TABLET 29-1 MG 3 PRIMACARE ORAL CAPSULE 30-1-470 MG (pren-fe-meth-fa- 3 omeg w/o a) RELNATE DHA ORAL CAPSULE 28-1-200 MG 3 SELECT-OB ORAL TABLET CHEWABLE 29-1 MG (prenatal 3 vit-fe psac cmplx-fa) TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1-500 3 MG (prenatal-fefum-fa-dss-fish oil) TRINATE ORAL TABLET ( prenatal vit-fe fumarate-fa) 3 TRISTART DHA ORAL CAPSULE 31-0.6-0.4-200 MG 3 TRISTART FREE ORAL CAPSULE 33-1 MG (prenat w/o a- 3 fecbn-meth-fa-dha) TRISTART ONE ORAL CAPSULE 35-1-215 MG (prenat w/o a- 3 fecbn-meth-fa-dha)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 61 Coverage Requirements & Prescription Drug Name Drug Tier Limits VINATE ONE ORAL TABLET 60-1 MG (prenatal vit-fe 3 fumarate-fa) VITAFOL FE+ ORAL CAPSULE 90-0.6-0.4-200 MG (prenat-fe 3 poly-methfol-fa-dha) VITAFOL-NANO ORAL TABLET 18-0.6-0.4 MG (prenatal-fe 3 fum-methf-fa w/o a) VITAFOL-OB+DHA ORAL 65-1 & 250 MG (prenatal mv-min-fe 3 fum-fa-dha) VITATHELY WITH GINGER ORAL TABLET 27-1 MG (prenatal 3 vit-fe fumarate-fa) vp-pnv-dha oral capsule 28-1-215.8 mg 1 WESTGEL DHA ORAL CAPSULE 31-0.6-0.4-200 MG 3 LIVER AND STOMACH PREPARATIONS - Vitamins and Minerals cyanocobalamin injection solution 1000 mcg/ml 1 CYANOCOBALAMIN INJECTION SOLUTION 2000 MCG/ML 3 NASCOBAL NASAL SOLUTION 500 MCG/0.1ML 3 (cyanocobalamin) PLATELET-AGGREGATION INHIBITORS - Drugs to Prevent Blood Clots aspirin-dipyridamole er oral capsule extended release 12 hour 1 25-200 mg BRILINTA ORAL TABLET 60 MG, 90 MG ( ticagrelor) 3 SL (2 tablets per day.) cilostazol oral tablet 100 mg, 50 mg 1 clopidogrel bisulfate oral tablet 300 mg, 75 mg 1 dipyridamole oral tablet 25 mg, 50 mg, 75 mg 1 prasugrel hcl oral tablet 10 mg, 5 mg 1 SL (31 tablets per 31 days.) ZONTIVITY ORAL TABLET 2.08 MG (vorapaxar sulfate) 3 SL (1 tablet per day.) PLATELET-REDUCING AGENTS - Drugs to Prevent Blood Clots AGRYLIN ORAL CAPSULE 0.5 MG (anagrelide hcl) 3 anagrelide hcl oral capsule 0.5 mg, 1 mg 1 CARDIOVASCULAR DRUGS - Drugs for the Heart ALPHA-ADRENERGIC BLOCKING AGENTS - Drugs for High Blood Pressure CARDURA ORAL TABLET 1 MG, 2 MG, 4 MG, 8 MG 3 (doxazosin mesylate)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 62 Coverage Requirements & Prescription Drug Name Drug Tier Limits CARDURA XL ORAL TABLET EXTENDED RELEASE 24 3 HOUR 4 MG, 8 MG (doxazosin mesylate) carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1 doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg 1 labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 MINIPRESS ORAL CAPSULE 1 MG, 2 MG, 5 MG (prazosin 3 hcl) prazosin hcl oral capsule 1 mg, 2 mg, 5 mg 1 terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 ALPHA-ADRENERGIC BLOCKING AGT.(HYPOTEN) - Drugs for High Blood Pressure & Angina CARDURA ORAL TABLET 1 MG, 2 MG, 4 MG, 8 MG 3 (doxazosin mesylate) CARDURA XL ORAL TABLET EXTENDED RELEASE 24 3 HOUR 4 MG, 8 MG (doxazosin mesylate) carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1 doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg 1 labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 MINIPRESS ORAL CAPSULE 1 MG, 2 MG, 5 MG (prazosin 3 hcl) prazosin hcl oral capsule 1 mg, 2 mg, 5 mg 1 terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 ANGIOTENSIN II RECEPTOR ANTAGON.(HYPOTN) - Drugs for High Blood Pressure & Angina cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 mg 1 EDARBI ORAL TABLET 40 MG, 80 MG ( medoxomil) 3 irbesartan oral tablet 150 mg, 300 mg, 75 mg 1 potassium oral tablet 100 mg, 25 mg, 50 mg 1 medoxomil oral tablet 20 mg, 40 mg, 5 mg 1 oral tablet 20 mg, 40 mg, 80 mg 1 oral tablet 160 mg, 320 mg, 40 mg, 80 mg 1 ANGIOTENSIN II RECEPTOR ANTAGONISTS - Drugs for the Heart amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 1 mg, 5-160 mg, 5-320 mg candesartan cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 mg 1 candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 mg, 1 32-25 mg Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 63 Coverage Requirements & Prescription Drug Name Drug Tier Limits EDARBI ORAL TABLET 40 MG, 80 MG (azilsartan medoxomil) 3 EDARBYCLOR ORAL TABLET 40-12.5 MG, 40-25 MG 3 (azilsartan-chlorthalidone) ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG 3 PA; SL (2 tablets per day.) (-valsartan) irbesartan oral tablet 150 mg, 300 mg, 75 mg 1 irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300- 1 12.5 mg losartan potassium oral tablet 100 mg, 25 mg, 50 mg 1 losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 1 50-12.5 mg olmesartan medoxomil oral tablet 20 mg, 40 mg, 5 mg 1 olmesartan medoxomil-hctz oral tablet 20-12.5 mg, 40-12.5 mg, 1 40-25 mg telmisartan oral tablet 20 mg, 40 mg, 80 mg 1 telmisartan-hctz oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg 1 valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg 1 valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 1 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg ANGIOTENSIN-CONVERT.ENZYME INHIB(HYPOTN) - Drugs for High Blood Pressure & Angina ACCUPRIL ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG 3 ( hcl) hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg 1 maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg 1 EPANED ORAL SOLUTION 1 MG/ML (enalapril maleate) 3 PA sodium oral tablet 10 mg, 20 mg, 40 mg 1 oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 5 mg 1 lisinopril oral tablet 40 mg 1 LOTENSIN ORAL TABLET 10 MG, 20 MG, 40 MG ( benazepril 3 hcl) hcl oral tablet 15 mg, 7.5 mg 1 erbumine oral tablet 2 mg, 4 mg, 8 mg 1 PRINIVIL ORAL TABLET 20 MG (lisinopril) 3 quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 64 Coverage Requirements & Prescription Drug Name Drug Tier Limits oral tablet 1 mg, 2 mg, 4 mg 1 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS - Drugs for the Heart ACCUPRIL ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG 3 (quinapril hcl) ACCURETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 3 MG (quinapril-hydrochlorothiazide) amlodipine besylate-benazepril hcl oral capsule 10-20 mg, 10- 1 40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 1 mg, 20-25 mg, 5-6.25 mg captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg 1 enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg 1 enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg 1 EPANED ORAL SOLUTION 1 MG/ML (enalapril maleate) 3 PA fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg 1 fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg 1 lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 5 mg 1 lisinopril oral tablet 40 mg 1 lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 1 mg, 20-25 mg LOTENSIN HCT ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20- 3 25 MG (benazepril-hydrochlorothiazide) LOTENSIN ORAL TABLET 10 MG, 20 MG, 40 MG ( benazepril 3 hcl) moexipril hcl oral tablet 15 mg, 7.5 mg 1 perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg 1 PRINIVIL ORAL TABLET 20 MG (lisinopril) 3 QBRELIS ORAL SOLUTION 1 MG/ML (lisinopril) 3 PA quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 1 mg, 20-25 mg ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg 1 TARKA ORAL TABLET EXTENDED RELEASE 2-180 MG, 2- 3 240 MG, 4-240 MG (trandolapril- hcl) trandolapril oral tablet 1 mg, 2 mg, 4 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 65 Coverage Requirements & Prescription Drug Name Drug Tier Limits trandolapril-verapamil hcl er oral tablet extended release 1-240 1 mg, 2-180 mg, 2-240 mg, 4-240 mg ANTIARRHYTHMICS, MISCELLANEOUS - Drugs for Angina digitek oral tablet 125 mcg, 250 mcg 1 digox oral tablet 125 mcg, 250 mcg 1 oral solution 0.05 mg/ml 1 digoxin oral tablet 125 mcg, 250 mcg 1 LANOXIN ORAL TABLET 125 MCG, 250 MCG, 62.5 MCG 3 (digoxin) ANTILIPEMIC AGENTS, MISCELLANEOUS - Drugs for Cholesterol NEXLETOL ORAL TABLET 180 MG ( bempedoic acid) 2 PA; ST; SL (1 tablet per day.) NEXLIZET ORAL TABLET 180-10 MG (bempedoic acid- 2 PA; ST; SL (1 tablet per day.) ezetimibe) niacin er (antihyperlipidemic) oral tablet extended release 1000 1 mg, 500 mg, 750 mg NIASPAN ORAL TABLET EXTENDED RELEASE 1000 MG, 3 500 MG, 750 MG (niacin (antihyperlipidemic)) omega-3-acid ethyl esters oral capsule 1 gm 1 BETA-ADRENERGIC BLOCKING AGENTS - Drugs for Abnormal Heart Rhythms acebutolol hcl oral capsule 200 mg, 400 mg 1 atenolol oral tablet 100 mg, 25 mg, 50 mg 1 atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg 1 BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG 3 (sotalol hcl af) betaxolol hcl oral tablet 10 mg, 20 mg 1 bisoprolol fumarate oral tablet 10 mg, 5 mg 1 bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 1 mg, 5-6.25 mg carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1 CORGARD ORAL TABLET 20 MG, 40 MG, 80 MG (nadolol) 3 KAPSPARGO SPRINKLE ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 200 MG, 25 MG, 50 MG (metoprolol 3 succinate) labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 LOPRESSOR ORAL TABLET 100 MG, 50 MG (metoprolol 3 tartrate)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 66 Coverage Requirements & Prescription Drug Name Drug Tier Limits metoprolol succinate er oral tablet extended release 24 hour 1 100 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg 1 metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100-50 1 mg, 50-25 mg nadolol oral tablet 20 mg, 40 mg, 80 mg 1 pindolol oral tablet 10 mg, 5 mg 1 propranolol hcl er oral capsule extended release 24 hour 120 1 mg, 160 mg, 60 mg, 80 mg propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml 1 propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg 1 sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg 1 sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 SOTYLIZE ORAL SOLUTION 5 MG/ML (sotalol hcl) 3 PA timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1 TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 25 MG, 50 MG (metoprolol succinate) ZIAC ORAL TABLET 10-6.25 MG, 2.5-6.25 MG, 5-6.25 MG 3 (bisoprolol-hydrochlorothiazide) BETA-ADRENERGIC BLOCKING AGT.(HYPOTEN) - Drugs for High Blood Pressure & Angina acebutolol hcl oral capsule 200 mg, 400 mg 1 atenolol oral tablet 100 mg, 25 mg, 50 mg 1 BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG 3 (sotalol hcl af) betaxolol hcl oral tablet 10 mg, 20 mg 1 bisoprolol fumarate oral tablet 10 mg, 5 mg 1 carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1 CORGARD ORAL TABLET 20 MG, 40 MG, 80 MG (nadolol) 3 KAPSPARGO SPRINKLE ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 200 MG, 25 MG, 50 MG (metoprolol 3 succinate) labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 LOPRESSOR ORAL TABLET 100 MG, 50 MG (metoprolol 3 tartrate) metoprolol succinate er oral tablet extended release 24 hour 1 100 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 67 Coverage Requirements & Prescription Drug Name Drug Tier Limits nadolol oral tablet 20 mg, 40 mg, 80 mg 1 pindolol oral tablet 10 mg, 5 mg 1 propranolol hcl er oral capsule extended release 24 hour 120 1 mg, 160 mg, 60 mg, 80 mg propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml 1 propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg 1 sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg 1 sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 SOTYLIZE ORAL SOLUTION 5 MG/ML (sotalol hcl) 3 PA timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1 TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 25 MG, 50 MG (metoprolol succinate) BILE ACID SEQUESTRANTS - Drugs for Cholesterol cholestyramine light oral packet 4 gm 1 cholestyramine light oral powder 4 gm/dose 1 cholestyramine oral packet 4 gm 1 cholestyramine oral powder 4 gm/dose 1 COLESTID FLAVORED ORAL GRANULES 5 GM (colestipol 3 hcl) COLESTID FLAVORED ORAL PACKET 5 GM (colestipol hcl) 3 COLESTID ORAL GRANULES 5 GM (colestipol hcl) 3 COLESTID ORAL PACKET 5 GM (colestipol hcl) 3 COLESTID ORAL TABLET 1 GM (colestipol hcl) 3 colestipol hcl oral granules 5 gm 1 colestipol hcl oral packet 5 gm 1 colestipol hcl oral tablet 1 gm 1 prevalite oral packet 4 gm 1 prevalite oral powder 4 gm/dose 1 QUESTRAN LIGHT ORAL POWDER 4 GM/DOSE 3 (cholestyramine light) QUESTRAN ORAL PACKET 4 GM (cholestyramine) 3 QUESTRAN ORAL POWDER 4 GM/DOSE (cholestyramine) 3 WELCHOL ORAL PACKET 3.75 GM (colesevelam hcl) 1 WELCHOL ORAL TABLET 625 MG (colesevelam hcl) 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 68 Coverage Requirements & Prescription Drug Name Drug Tier Limits CALCIUM-CHANNEL BLOCK.AGT,MISC(HYPOTEN) - Drugs for High Blood Pressure & Angina CALAN SR ORAL TABLET EXTENDED RELEASE 120 MG, 3 180 MG, 240 MG (verapamil hcl) cartia xt oral capsule extended release 24 hour 120 mg, 180 1 mg, 240 mg, 300 mg diltiazem hcl er beads oral capsule extended release 24 hour 1 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er coated beads oral capsule extended release 24 1 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl er coated beads oral tablet extended release 24 1 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er oral capsule extended release 12 hour 120 mg, 1 60 mg, 90 mg diltiazem hcl er oral capsule extended release 24 hour 120 mg, 1 180 mg, 240 mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg 1 dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, 1 240 mg matzim la oral tablet extended release 24 hour 180 mg, 240 mg, 1 300 mg, 360 mg, 420 mg taztia xt oral capsule extended release 24 hour 120 mg, 180 1 mg, 240 mg, 300 mg, 360 mg tiadylt er oral capsule extended release 24 hour 120 mg, 180 1 mg, 240 mg, 300 mg, 360 mg, 420 mg TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG 3 (diltiazem hcl er beads) verapamil hcl er oral capsule extended release 24 hour 100 mg, 1 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg verapamil hcl er oral tablet extended release 120 mg, 180 mg, 1 240 mg verapamil hcl oral tablet 120 mg, 40 mg, 80 mg 1 VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 120 MG, 180 MG, 240 MG, 360 MG (verapamil hcl) VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 100 MG, 200 MG, 300 MG (verapamil hcl)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 69 Coverage Requirements & Prescription Drug Name Drug Tier Limits CALCIUM-CHANNEL BLOCKING AGENTS, MISC. - Drugs for High Blood Pressure & Angina CALAN SR ORAL TABLET EXTENDED RELEASE 120 MG, 3 180 MG, 240 MG (verapamil hcl) cartia xt oral capsule extended release 24 hour 120 mg, 180 1 mg, 240 mg, 300 mg diltiazem hcl er beads oral capsule extended release 24 hour 1 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er coated beads oral capsule extended release 24 1 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl er coated beads oral tablet extended release 24 1 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er oral capsule extended release 12 hour 120 mg, 1 60 mg, 90 mg diltiazem hcl er oral capsule extended release 24 hour 120 mg, 1 180 mg, 240 mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg 1 dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, 1 240 mg matzim la oral tablet extended release 24 hour 180 mg, 240 mg, 1 300 mg, 360 mg, 420 mg TARKA ORAL TABLET EXTENDED RELEASE 2-180 MG, 2- 3 240 MG, 4-240 MG (trandolapril-verapamil hcl) taztia xt oral capsule extended release 24 hour 120 mg, 180 1 mg, 240 mg, 300 mg, 360 mg tiadylt er oral capsule extended release 24 hour 120 mg, 180 1 mg, 240 mg, 300 mg, 360 mg, 420 mg TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG 3 (diltiazem hcl er beads) trandolapril-verapamil hcl er oral tablet extended release 1-240 1 mg, 2-180 mg, 2-240 mg, 4-240 mg verapamil hcl er oral capsule extended release 24 hour 100 mg, 1 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg verapamil hcl er oral tablet extended release 120 mg, 180 mg, 1 240 mg verapamil hcl oral tablet 120 mg, 40 mg, 80 mg 1 VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 120 MG, 180 MG, 240 MG, 360 MG (verapamil hcl)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 70 Coverage Requirements & Prescription Drug Name Drug Tier Limits VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 100 MG, 200 MG, 300 MG (verapamil hcl) CARBONIC ANHYDRASE INHIBITORS(HYPOTEN) - Drugs for High Blood Pressure & Angina acetazolamide er oral capsule extended release 12 hour 500 1 mg acetazolamide oral tablet 125 mg, 250 mg 1 methazolamide oral tablet 25 mg, 50 mg 1 CARDIAC DRUGS, MISCELLANEOUS - Drugs for Angina CORLANOR ORAL SOLUTION 5 MG/5ML (ivabradine hcl) 3 PA; SL (20 ml per day.) CORLANOR ORAL TABLET 5 MG, 7.5 MG (ivabradine hcl) 3 PA; SL (2 tablets per day.) ranolazine er oral tablet extended release 12 hour 1000 mg, 1 500 mg PA; SL (1 capsule per day.); VYNDAMAX ORAL CAPSULE 61 MG (tafamidis) 2 SP VYNDAQEL ORAL CAPSULE 20 MG (tafamidis meglumine PA; SL (4 capsules per day.); 2 (cardiac)) SP CARDIOTONIC AGENTS - Drugs for Angina digitek oral tablet 125 mcg, 250 mcg 1 digox oral tablet 125 mcg, 250 mcg 1 digoxin oral solution 0.05 mg/ml 1 digoxin oral tablet 125 mcg, 250 mcg 1 LANOXIN ORAL TABLET 125 MCG, 250 MCG, 62.5 MCG 3 (digoxin) CENTRAL ALPHA-AGONISTS - Drugs for High Blood Pressure & Angina clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg 1 clonidine transdermal patch weekly 0.1 mg/24hr, 0.2 mg/24hr, 1 0.3 mg/24hr hcl oral tablet 1 mg, 2 mg 1 methyldopa oral tablet 250 mg, 500 mg 1 CHOLESTEROL ABSORPTION INHIBITORS - Drugs for Cholesterol ezetimibe oral tablet 10 mg 1 ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 1 mg, 10-80 mg NEXLIZET ORAL TABLET 180-10 MG (bempedoic acid- 2 PA; ST; SL (1 tablet per day.) ezetimibe)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 71 Coverage Requirements & Prescription Drug Name Drug Tier Limits CLASS IA ANTIARRHYTHMICS - Drugs for Angina disopyramide phosphate oral capsule 100 mg, 150 mg 1 NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 2 HOUR 100 MG, 150 MG (disopyramide phosphate) NORPACE ORAL CAPSULE 100 MG, 150 MG (disopyramide 3 phosphate) quinidine gluconate er oral tablet extended release 324 mg 1 quinidine sulfate oral tablet 200 mg, 300 mg 1 CLASS IB ANTIARRHYTHMICS - Drugs for Angina DILANTIN INFATABS ORAL TABLET CHEWABLE 50 MG 3 (phenytoin) DILANTIN ORAL CAPSULE 100 MG, 30 MG (phenytoin sodium 3 extended) DILANTIN ORAL SUSPENSION 125 MG/5ML (phenytoin) 3 mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg 1 PHENYTEK ORAL CAPSULE 200 MG, 300 MG (phenytoin 3 sodium extended) phenytoin infatabs oral tablet chewable 50 mg 1 phenytoin oral suspension 125 mg/5ml 1 phenytoin oral tablet chewable 50 mg 1 phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 1 mg CLASS IC ANTIARRHYTHMICS - Drugs for Angina flecainide acetate oral tablet 100 mg, 150 mg, 50 mg 1 propafenone hcl er oral capsule extended release 12 hour 225 1 mg, 325 mg, 425 mg propafenone hcl oral tablet 150 mg, 225 mg, 300 mg 1 CLASS II ANTIARRHYTHMICS - Drugs for Angina acebutolol hcl oral capsule 200 mg, 400 mg 1 atenolol oral tablet 100 mg, 25 mg, 50 mg 1 BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG 3 (sotalol hcl af) betaxolol hcl oral tablet 10 mg, 20 mg 1 bisoprolol fumarate oral tablet 10 mg, 5 mg 1 carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1 KAPSPARGO SPRINKLE ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 200 MG, 25 MG, 50 MG (metoprolol 3 succinate) Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 72 Coverage Requirements & Prescription Drug Name Drug Tier Limits labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 LOPRESSOR ORAL TABLET 100 MG, 50 MG (metoprolol 3 tartrate) metoprolol succinate er oral tablet extended release 24 hour 1 100 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg 1 pindolol oral tablet 10 mg, 5 mg 1 propranolol hcl er oral capsule extended release 24 hour 120 1 mg, 160 mg, 60 mg, 80 mg propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml 1 propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg 1 sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg 1 sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 SOTYLIZE ORAL SOLUTION 5 MG/ML (sotalol hcl) 3 PA timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1 TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 25 MG, 50 MG (metoprolol succinate) CLASS III ANTIARRHYTHMICS - Drugs for Angina amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg 1 BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG 3 (sotalol hcl af) dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg 1 MULTAQ ORAL TABLET 400 MG (dronedarone hcl) 3 PA PACERONE ORAL TABLET 100 MG, 200 MG, 400 MG 3 (amiodarone hcl) sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg 1 sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 SOTYLIZE ORAL SOLUTION 5 MG/ML (sotalol hcl) 3 PA TIKOSYN ORAL CAPSULE 125 MCG, 250 MCG, 500 MCG 3 (dofetilide) CLASS IV ANTIARRHYTHMICS - Drugs for Angina CALAN SR ORAL TABLET EXTENDED RELEASE 120 MG, 3 180 MG, 240 MG (verapamil hcl) cartia xt oral capsule extended release 24 hour 120 mg, 180 1 mg, 240 mg, 300 mg diltiazem hcl er beads oral capsule extended release 24 hour 1 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 73 Coverage Requirements & Prescription Drug Name Drug Tier Limits diltiazem hcl er coated beads oral capsule extended release 24 1 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl er coated beads oral tablet extended release 24 1 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er oral capsule extended release 12 hour 120 mg, 1 60 mg, 90 mg diltiazem hcl er oral capsule extended release 24 hour 120 mg, 1 180 mg, 240 mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg 1 dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, 1 240 mg matzim la oral tablet extended release 24 hour 180 mg, 240 mg, 1 300 mg, 360 mg, 420 mg taztia xt oral capsule extended release 24 hour 120 mg, 180 1 mg, 240 mg, 300 mg, 360 mg tiadylt er oral capsule extended release 24 hour 120 mg, 180 1 mg, 240 mg, 300 mg, 360 mg, 420 mg TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG 3 (diltiazem hcl er beads) verapamil hcl er oral capsule extended release 24 hour 100 mg, 1 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg verapamil hcl er oral tablet extended release 120 mg, 180 mg, 1 240 mg verapamil hcl oral tablet 120 mg, 40 mg, 80 mg 1 VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 120 MG, 180 MG, 240 MG, 360 MG (verapamil hcl) VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 100 MG, 200 MG, 300 MG (verapamil hcl) DIHYDROPYRIDINES - Drugs for High Blood Pressure & Angina amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg 1 amlodipine besylate-benazepril hcl oral capsule 10-20 mg, 10- 1 40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 1 mg, 5-160 mg, 5-320 mg felodipine er oral tablet extended release 24 hour 10 mg, 2.5 1 mg, 5 mg isradipine oral capsule 2.5 mg, 5 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 74 Coverage Requirements & Prescription Drug Name Drug Tier Limits KATERZIA ORAL SUSPENSION 1 MG/ML (amlodipine 3 PA benzoate) nicardipine hcl oral capsule 20 mg, 30 mg 1 nifedipine er oral tablet extended release 24 hour 30 mg, 60 mg, 1 90 mg nifedipine er osmotic release oral tablet extended release 24 1 hour 30 mg, 60 mg, 90 mg nifedipine oral capsule 10 mg, 20 mg 1 nimodipine oral capsule 30 mg 1 nisoldipine er oral tablet extended release 24 hour 17 mg, 20 1 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg NYMALIZE ORAL SOLUTION 6 MG/ML (nimodipine) 2 SULAR ORAL TABLET EXTENDED RELEASE 24 HOUR 17 3 MG, 34 MG, 8.5 MG (nisoldipine) DIHYDROPYRIDINES (ANTIHYPERTENSIVE) - Drugs for High Blood Pressure & Angina amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg 1 felodipine er oral tablet extended release 24 hour 10 mg, 2.5 1 mg, 5 mg isradipine oral capsule 2.5 mg, 5 mg 1 KATERZIA ORAL SUSPENSION 1 MG/ML (amlodipine 3 PA benzoate) nicardipine hcl oral capsule 20 mg, 30 mg 1 nifedipine er oral tablet extended release 24 hour 30 mg, 60 mg, 1 90 mg nifedipine er osmotic release oral tablet extended release 24 1 hour 30 mg, 60 mg, 90 mg nifedipine oral capsule 10 mg, 20 mg 1 nimodipine oral capsule 30 mg 1 nisoldipine er oral tablet extended release 24 hour 17 mg, 20 1 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg NYMALIZE ORAL SOLUTION 6 MG/ML (nimodipine) 2 SULAR ORAL TABLET EXTENDED RELEASE 24 HOUR 17 3 MG, 34 MG, 8.5 MG (nisoldipine) DIRECT VASODILATORS - Drugs for High Blood Pressure & Angina BIDIL ORAL TABLET 20-37.5 MG (isosorb dinitrate- 2 hydralazine) hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg 1 Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 75 Coverage Requirements & Prescription Drug Name Drug Tier Limits minoxidil oral tablet 10 mg, 2.5 mg 1 , MISCELLANEOUS (HYPOTENSIVE) - Drugs for High Blood Pressure & Angina ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML (theophylline) 3 THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 300 MG, 400 MG (theophylline) theophylline er oral tablet extended release 12 hour 300 mg, 1 450 mg theophylline er oral tablet extended release 24 hour 400 mg, 1 600 mg theophylline oral solution 80 mg/15ml 1 FIBRIC ACID DERIVATIVES - Drugs for Cholesterol fenofibrate oral tablet 145 mg, 160 mg, 54 mg 1 gemfibrozil oral tablet 600 mg 1 LOPID ORAL TABLET 600 MG (gemfibrozil) 3 HMG-COA REDUCTASE INHIBITORS - Drugs for Cholesterol atorvastatin calcium oral tablet 10 mg, 20 mg 1 SL (3 tablets per day.); H-N atorvastatin calcium oral tablet 40 mg, 80 mg 1 SL (31 tablets per 31 days.) EZALLOR SPRINKLE ORAL CAPSULE SPRINKLE 10 MG, 20 3 PA MG, 40 MG, 5 MG (rosuvastatin calcium) ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 1 mg, 10-80 mg FLOLIPID ORAL SUSPENSION 20 MG/5ML, 40 MG/5ML 3 PA fluvastatin sodium er oral tablet extended release 24 hour 80 1 ST mg fluvastatin sodium oral capsule 20 mg, 40 mg 1 lovastatin oral tablet 10 mg, 20 mg, 40 mg 1 H pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80 mg 1 rosuvastatin calcium oral tablet 10 mg 1 SL (3 tablets per day.) rosuvastatin calcium oral tablet 20 mg, 40 mg, 5 mg 1 SL (1 tablet per day.) simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 H-N simvastatin oral tablet 80 mg 1 HYPOTENSIVE AGENTS, MISCELLANEOUS - Drugs for High Blood Pressure & Angina phenoxybenzamine hcl oral capsule 10 mg 1 VECAMYL ORAL TABLET 2.5 MG ( hcl) 3 PA

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 76 Coverage Requirements & Prescription Drug Name Drug Tier Limits LOOP DIURETICS (HYPOTENSIVE AGENTS) - Drugs for High Blood Pressure & Angina bumetanide oral tablet 0.5 mg, 1 mg, 2 mg 1 BUMEX ORAL TABLET 0.5 MG (bumetanide) 3 EDECRIN ORAL TABLET 25 MG (ethacrynic acid) 3 ethacrynic acid oral tablet 25 mg 1 furosemide oral solution 10 mg/ml, 8 mg/ml 1 furosemide oral tablet 20 mg, 40 mg, 80 mg 1 LASIX ORAL TABLET 20 MG, 40 MG, 80 MG (furosemide) 3 torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg 1 MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS - Drugs for the Heart ALDACTAZIDE ORAL TABLET 25-25 MG (spironolactone-hctz) 3 ALDACTAZIDE ORAL TABLET 50-50 MG (spironolactone-hctz) 2 CAROSPIR ORAL SUSPENSION 25 MG/5ML (spironolactone) 3 PA eplerenone oral tablet 25 mg, 50 mg 1 spironolactone oral tablet 100 mg, 25 mg, 50 mg 1 spironolactone-hctz oral tablet 25-25 mg 1 MINERALOCORTICOID(ALDOSTER.)ANTAG(HYPOT) - Drugs for High Blood Pressure & Angina CAROSPIR ORAL SUSPENSION 25 MG/5ML (spironolactone) 3 PA eplerenone oral tablet 25 mg, 50 mg 1 spironolactone oral tablet 100 mg, 25 mg, 50 mg 1 NITRATES AND NITRITES - Drugs for the Heart BIDIL ORAL TABLET 20-37.5 MG (isosorb dinitrate- 2 hydralazine) DILATRATE-SR ORAL CAPSULE EXTENDED RELEASE 40 3 MG (isosorbide dinitrate) ISORDIL TITRADOSE ORAL TABLET 40 MG, 5 MG 3 (isosorbide dinitrate) isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 40 mg, 5 1 mg isosorbide mononitrate er oral tablet extended release 24 hour 1 120 mg, 30 mg, 60 mg isosorbide mononitrate oral tablet 10 mg, 20 mg 1 NITRO-BID TRANSDERMAL OINTMENT 2 % ( nitroglycerin) 2

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 77 Coverage Requirements & Prescription Drug Name Drug Tier Limits NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.3 MG/HR, 0.4 MG/HR, 0.6 MG/HR, 0.8 MG/HR 3 (nitroglycerin) nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg 1 nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 1 0.4 mg/hr, 0.6 mg/hr NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 MG, 3 0.4 MG, 0.6 MG (nitroglycerin) NITRO-TIME ORAL CAPSULE EXTENDED RELEASE 2.5 MG, 3 6.5 MG, 9 MG (nitroglycerin) PCSK9 INHIBITORS - Drugs for Cholesterol REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS PA; ST; SL (3.5 ml (1 2 SOLUTION CARTRIDGE 420 MG/3.5ML (evolocumab) cartridge) per month.) REPATHA SUBCUTANEOUS SOLUTION PREFILLED PA; ST; SL (2 syringes per 2 SYRINGE 140 MG/ML (evolocumab) 28 days.) REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO- 2 PA; ST; SL (2 ml per month.) INJECTOR 140 MG/ML (evolocumab) PHOSPHODIESTERASE TYPE 5 INHIBITORS - Drugs for the Heart PA; SL (2 tablets per day); alyq oral tablet 20 mg 1 SP cilostazol oral tablet 100 mg, 50 mg 1 PA; SL (186 ml per month.); citrate oral suspension reconstituted 10 mg/ml 1 SP sildenafil citrate oral tablet 20 mg 1 SL (0.5 tablet per day.) PA; SL (2 tablets per day); (pah) oral tablet 20 mg 1 SP tadalafil oral tablet 2.5 mg, 5 mg 1 PA; ST; SL (1 tablet per day) POTASSIUM-SPARING DIURETICS (HYPOTEN) - Drugs for High Blood Pressure & Angina amiloride hcl oral tablet 5 mg 1 CAROSPIR ORAL SUSPENSION 25 MG/5ML (spironolactone) 3 PA DYRENIUM ORAL CAPSULE 100 MG, 50 MG (triamterene) 3 eplerenone oral tablet 25 mg, 50 mg 1 spironolactone oral tablet 100 mg, 25 mg, 50 mg 1 triamterene oral capsule 100 mg, 50 mg 1 RENIN INHIBITORS - Drugs for the Heart fumarate oral tablet 150 mg, 300 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 78 Coverage Requirements & Prescription Drug Name Drug Tier Limits TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25 MG, 3 300-12.5 MG, 300-25 MG (aliskiren-hydrochlorothiazide) TEKTURNA ORAL TABLET 150 MG, 300 MG ( aliskiren 3 fumarate) RENIN-ANGIOTEN.-ALDOST. SYS. INHIB, MISC - Drugs for the Heart ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG 3 PA; SL (2 tablets per day.) (sacubitril-valsartan) DIURETICS(HYPOTENSIVE AGENTS) - Drugs for High Blood Pressure & Angina DIURIL ORAL SUSPENSION 250 MG/5ML (chlorothiazide) 2 hydrochlorothiazide oral capsule 12.5 mg 1 hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg 1 THIAZIDE-LIKE DIURETICS(HYPOTENSIVE AGT) - Drugs for High Blood Pressure & Angina chlorthalidone oral tablet 25 mg, 50 mg 1 indapamide oral tablet 1.25 mg, 2.5 mg 1 metolazone oral tablet 10 mg, 2.5 mg, 5 mg 1 VASODILATING AGENTS, MISCELLANEOUS - Drugs for the Heart amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg 1 CALAN SR ORAL TABLET EXTENDED RELEASE 120 MG, 3 180 MG, 240 MG (verapamil hcl) cartia xt oral capsule extended release 24 hour 120 mg, 180 1 mg, 240 mg, 300 mg CORLANOR ORAL SOLUTION 5 MG/5ML (ivabradine hcl) 3 PA; SL (20 ml per day.) CORLANOR ORAL TABLET 5 MG, 7.5 MG (ivabradine hcl) 3 PA; SL (2 tablets per day.) diltiazem hcl er beads oral capsule extended release 24 hour 1 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er coated beads oral capsule extended release 24 1 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl er coated beads oral tablet extended release 24 1 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er oral capsule extended release 12 hour 120 mg, 1 60 mg, 90 mg diltiazem hcl er oral capsule extended release 24 hour 120 mg, 1 180 mg, 240 mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 79 Coverage Requirements & Prescription Drug Name Drug Tier Limits dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, 1 240 mg dipyridamole oral tablet 25 mg, 50 mg, 75 mg 1 isoxsuprine hcl oral tablet 10 mg, 20 mg 1 KATERZIA ORAL SUSPENSION 1 MG/ML (amlodipine 3 PA benzoate) matzim la oral tablet extended release 24 hour 180 mg, 240 mg, 1 300 mg, 360 mg, 420 mg nicardipine hcl oral capsule 20 mg, 30 mg 1 nifedipine er oral tablet extended release 24 hour 30 mg, 60 mg, 1 90 mg nifedipine er osmotic release oral tablet extended release 24 1 hour 30 mg, 60 mg, 90 mg nifedipine oral capsule 10 mg, 20 mg 1 nimodipine oral capsule 30 mg 1 NYMALIZE ORAL SOLUTION 6 MG/ML (nimodipine) 2 taztia xt oral capsule extended release 24 hour 120 mg, 180 1 mg, 240 mg, 300 mg, 360 mg tiadylt er oral capsule extended release 24 hour 120 mg, 180 1 mg, 240 mg, 300 mg, 360 mg, 420 mg TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG 3 (diltiazem hcl er beads) verapamil hcl er oral capsule extended release 24 hour 100 mg, 1 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg verapamil hcl er oral tablet extended release 120 mg, 180 mg, 1 240 mg verapamil hcl oral tablet 120 mg, 40 mg, 80 mg 1 VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 120 MG, 180 MG, 240 MG, 360 MG (verapamil hcl) VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 100 MG, 200 MG, 300 MG (verapamil hcl) CENTRAL NERVOUS SYSTEM AGENTS - Drugs for the Nervous System ADAMANTANES (CNS) - Drugs for Parkinson amantadine hcl oral capsule 100 mg 1 amantadine hcl oral syrup 50 mg/5ml 1 amantadine hcl oral tablet 100 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 80 Coverage Requirements & Prescription Drug Name Drug Tier Limits OSMOLEX ER ORAL TABLET ER 24 HOUR THERAPY PACK 3 129 & 193 MG (amantadine hcl) AMPHETAMINE DERIVATIVES - Drugs for the Nervous System ADIPEX-P ORAL CAPSULE 37.5 MG (phentermine hcl) 3 PA ADIPEX-P ORAL TABLET 37.5 MG (phentermine hcl) 3 PA diethylpropion hcl er oral tablet extended release 24 hour 75 mg 1 PA diethylpropion hcl oral tablet 25 mg 1 PA LOMAIRA ORAL TABLET 8 MG (phentermine hcl) 3 PA phendimetrazine tartrate er oral capsule extended release 24 1 PA hour 105 mg phendimetrazine tartrate oral tablet 35 mg 1 PA phentermine hcl oral capsule 15 mg, 30 mg, 37.5 mg 1 PA phentermine hcl oral tablet 37.5 mg 1 PA AMPHETAMINES - Drugs for the Nervous System ADDERALL XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 5 MG 1 SL (1 capsule per day.) (amphetamine-dextroamphetamine) AMPHETAMINE ER ORAL SUSPENSION EXTENDED 3 SL (15 ml per day.) RELEASE 1.25 MG/ML amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 1 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg benzphetamine hcl oral tablet 25 mg, 50 mg 1 PA dextroamphetamine sulfate er oral capsule extended release 24 1 SL (4 capsules per day.) hour 10 mg, 15 mg dextroamphetamine sulfate er oral capsule extended release 24 1 SL (10 capsules per day.) hour 5 mg dextroamphetamine sulfate oral solution 5 mg/5ml 1 dextroamphetamine sulfate oral tablet 10 mg, 5 mg 1 methamphetamine hcl oral tablet 5 mg 1 PROCENTRA ORAL SOLUTION 5 MG/5ML 3 (dextroamphetamine sulfate) VYVANSE ORAL CAPSULE 10 MG, 20 MG (lisdexamfetamine 3 SL (1 capsule per day.) dimesylate) VYVANSE ORAL CAPSULE 30 MG, 40 MG, 50 MG, 60 MG, 70 3 SL (1 capsule per day) MG (lisdexamfetamine dimesylate) VYVANSE ORAL TABLET CHEWABLE 10 MG, 20 MG, 30 MG, 3 SL (1 tablet per day.) 40 MG, 50 MG, 60 MG (lisdexamfetamine dimesylate)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 81 Coverage Requirements & Prescription Drug Name Drug Tier Limits AND ANTIPYRETICS, MISC. - Drugs for Pain acetaminophen-codeine #2 oral tablet 300-15 mg 1 acetaminophen-codeine #3 oral tablet 300-30 mg 1 acetaminophen-codeine #4 oral tablet 300-60 mg 1 acetaminophen-codeine oral solution 120-12 mg/5ml 1 acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg, 300- 1 60 mg SL (40 capsules per apap-caff-dihydrocodeine oral capsule 320.5-30-16 mg 1 prescription.) SL (40 tablets per apap-caff-dihydrocodeine oral tablet 325-30-16 mg 1 prescription.) bac oral tablet 50-325-40 mg 1 SL (6 tablets per day) BENZHYDROCODONE-ACETAMINOPHEN ORAL TABLET 3 4.08-325 MG, 6.12-325 MG, 8.16-325 MG BUPAP ORAL TABLET 50-300 MG (butalbital-acetaminophen) 3 butalbital-acetaminophen oral tablet 50-300 mg, 50-325 mg 1 butalbital-apap-caff-cod oral capsule 50-325-40-30 mg 1 SL (6 capsules per day.) butalbital-apap-caffeine oral capsule 50-300-40 mg 1 SL (6 capsules per day.) butalbital-apap-caffeine oral capsule 50-325-40 mg 1 SL (6 capsules per day) butalbital-apap-caffeine oral tablet 50-325-40 mg 1 SL (6 tablets per day) endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 1 mg ESGIC ORAL CAPSULE 50-325-40 MG (butalbital-apap- 3 SL (6 capsules per day) caffeine) ESGIC ORAL TABLET 50-325-40 MG (butalbital-apap-caffeine) 3 SL (6 tablets per day) FIORICET ORAL CAPSULE 50-300-40 MG (butalbital-apap- 3 SL (6 capsules per day.) caffeine) gabapentin oral capsule 100 mg, 300 mg, 400 mg 1 gabapentin oral solution 250 mg/5ml 1 gabapentin oral tablet 600 mg, 800 mg 1 GRALISE ORAL 300 (9) & 600(24) MG (gabapentin (once- 3 daily)) hydrocodone-acetaminophen oral solution 10-325 mg/15ml, 7.5- 1 325 mg/15ml hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 1 7.5-325 mg HYOPHEN ORAL TABLET 81.6 MG (meth-hyo-m bl-benz acd- 3 ph sal)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 82 Coverage Requirements & Prescription Drug Name Drug Tier Limits LORTAB ORAL ELIXIR 10-300 MG/15ML (hydrocodone- 3 acetaminophen) NEURONTIN ORAL CAPSULE 100 MG, 300 MG, 400 MG 3 PA; ST (gabapentin) NEURONTIN ORAL SOLUTION 250 MG/5ML (gabapentin) 3 PA; ST NEURONTIN ORAL TABLET 600 MG, 800 MG ( gabapentin) 3 PA; ST oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 1 5-325 mg, 7.5-325 mg PHOSPHASAL ORAL TABLET 81.6 MG (meth-hyo-m bl-na 2 phos-ph sal) TENCON ORAL TABLET 50-325 MG ( butalbital- 3 acetaminophen) SL (40 tablets per tramadol-acetaminophen oral tablet 37.5-325 mg 1 prescription.) TREZIX ORAL CAPSULE 320.5-30-16 MG (apap-caff- SL (40 capsules per 1 dihydrocodeine) prescription.) ULTRACET ORAL TABLET 37.5-325 MG (tramadol- SL (40 tablets per 3 acetaminophen) prescription.) URELLE ORAL TABLET 81 MG (meth-hyo-m bl-na phos-ph 3 sal) URIBEL ORAL CAPSULE 118 MG (meth-hyo-m bl-na phos-ph 3 sal) urin ds oral tablet 81.6 mg 1 URO-458 ORAL TABLET 81 MG 3 uro-mp oral capsule 118 mg 1 USTELL ORAL CAPSULE 120 MG (meth-hyo-m bl-na phos-ph 3 sal) UTIRA-C ORAL TABLET 81.6 MG (meth-hyo-m bl-na phos-ph 2 sal) VILAMIT MB ORAL CAPSULE 118 MG (meth-hyo-m bl-na 3 phos-ph sal) VILEVEV MB ORAL TABLET 81 MG (meth-hyo-m bl-na phos- 3 ph sal) VTOL LQ ORAL SOLUTION 50-325-40 MG/15ML (butalbital- PA; SL (180 ml per 2 apap-caffeine) prescription.) ZEBUTAL ORAL CAPSULE 50-325-40 MG (butalbital-apap- 3 SL (6 capsules per day) caffeine)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 83 Coverage Requirements & Prescription Drug Name Drug Tier Limits ANOREXIGENIC AGENTS AND STIMULANTS, MISC - Drugs for the Nervous System QSYMIA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 11.25-69 MG, 15-92 MG, 3.75-23 MG, 7.5-46 MG 3 PA (phentermine-) ANOREXIGENIC AGENTS, MISCELLANEOUS - Drugs for the Nervous System CONTRAVE ORAL TABLET EXTENDED RELEASE 12 HOUR 3 PA 8-90 MG (naltrexone-bupropion hcl) IMCIVREE SUBCUTANEOUS SOLUTION 10 MG/ML 3 PA; SP (setmelanotide acetate) AGENTS (CNS) - Drugs for Parkinson benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg 1 diphen oral elixir 12.5 mg/5ml 1 di-phen oral elixir 12.5 mg/5ml 3 diphenhydramine hcl oral elixir 12.5 mg/5ml 1 orphenadrine citrate er oral tablet extended release 12 hour 100 1 mg trihexyphenidyl hcl oral solution 0.4 mg/ml 1 trihexyphenidyl hcl oral tablet 2 mg, 5 mg 1 , MISCELLANEOUS - Drugs for Seizures acetazolamide er oral capsule extended release 12 hour 500 1 mg acetazolamide oral tablet 125 mg, 250 mg 1 APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG 3 PA (eslicarbazepine acetate) BANZEL ORAL SUSPENSION 40 MG/ML (rufinamide) 3 BANZEL ORAL TABLET 200 MG, 400 MG ( rufinamide) 3 PA BRIVIACT ORAL SOLUTION 10 MG/ML (brivaracetam) 3 PA BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 3 PA MG (brivaracetam) er oral capsule extended release 12 hour 100 1 mg, 200 mg, 300 mg carbamazepine er oral tablet extended release 12 hour 100 mg, 1 200 mg, 400 mg carbamazepine oral suspension 100 mg/5ml 1 carbamazepine oral tablet 200 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 84 Coverage Requirements & Prescription Drug Name Drug Tier Limits carbamazepine oral tablet chewable 100 mg 1 CARBATROL ORAL CAPSULE EXTENDED RELEASE 12 3 HOUR 100 MG, 200 MG, 300 MG (carbamazepine) DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 3 PA; ST HOUR 250 MG, 500 MG (divalproex sodium) DEPAKOTE ORAL TABLET DELAYED RELEASE 125 MG, 250 3 PA MG, 500 MG (divalproex sodium) DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED 3 PA; ST RELEASE SPRINKLE 125 MG (divalproex sodium) DIACOMIT ORAL CAPSULE 250 MG, 500 MG (stiripentol) 3 PA; SP DIACOMIT ORAL PACKET 250 MG, 500 MG (stiripentol) 3 PA; SP divalproex sodium er oral tablet extended release 24 hour 250 1 mg, 500 mg divalproex sodium oral capsule delayed release sprinkle 125 mg 1 divalproex sodium oral tablet delayed release 125 mg, 250 mg, 1 500 mg EPIDIOLEX ORAL SOLUTION 100 MG/ML (cannabidiol) 3 PA; SP epitol oral tablet 200 mg 1 EQUETRO ORAL CAPSULE EXTENDED RELEASE 12 HOUR 3 100 MG, 200 MG, 300 MG (carbamazepine (antipsychotic)) felbamate oral suspension 600 mg/5ml 1 felbamate oral tablet 400 mg, 600 mg 1 FELBATOL ORAL SUSPENSION 600 MG/5ML (felbamate) 3 PA; ST FELBATOL ORAL TABLET 400 MG, 600 MG ( felbamate) 3 PA; ST FINTEPLA ORAL SOLUTION 2.2 MG/ML (fenfluramine hcl) 3 PA FYCOMPA ORAL SUSPENSION 0.5 MG/ML (perampanel) 3 PA FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 3 PA 8 MG (perampanel) gabapentin oral capsule 100 mg, 300 mg, 400 mg 1 gabapentin oral solution 250 mg/5ml 1 gabapentin oral tablet 600 mg, 800 mg 1 GABITRIL ORAL TABLET 12 MG, 16 MG, 2 MG, 4 MG 3 (tiagabine hcl) GRALISE ORAL 300 (9) & 600(24) MG (gabapentin (once- 3 daily)) KEPPRA ORAL SOLUTION 100 MG/ML (levetiracetam) 3 PA; ST KEPPRA ORAL TABLET 1000 MG, 250 MG, 500 MG, 750 MG 3 PA; ST (levetiracetam)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 85 Coverage Requirements & Prescription Drug Name Drug Tier Limits KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR 3 PA; ST 500 MG, 750 MG (levetiracetam) LAMICTAL ODT ORAL KIT 21 X 25 MG & 7 X 50 MG, 25 & 50 3 PA; ST & 100 MG, 42 X 50 MG & 14X100 MG (lamotrigine) LAMICTAL ODT ORAL TABLET DISPERSIBLE 100 MG, 200 3 PA; ST MG, 25 MG, 50 MG (lamotrigine) LAMICTAL ORAL TABLET 100 MG, 150 MG, 200 MG, 25 MG 3 PA; ST (lamotrigine) LAMICTAL ORAL TABLET CHEWABLE 25 MG, 5 MG 3 PA; ST (lamotrigine) LAMICTAL STARTER ORAL KIT 35 X 25 MG, 42 X 25 MG & 7 3 PA; ST X 100 MG, 84 X 25 MG & 14X100 MG (lamotrigine) LAMICTAL XR ORAL KIT 21 X 25 MG & 7 X 50 MG, 25 & 50 & 3 PA; ST 100 MG, 50 & 100 & 200 MG (lamotrigine) LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 250 MG, 300 MG, 50 MG 3 PA; ST (lamotrigine) lamotrigine er oral tablet extended release 24 hour 100 mg, 200 1 PA; ST mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral kit 25 & 50 & 100 mg 1 PA; ST lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg 1 lamotrigine oral tablet chewable 25 mg, 5 mg 1 lamotrigine oral tablet dispersible 100 mg, 200 mg, 25 mg, 50 1 PA; ST mg lamotrigine starter kit-blue oral kit 35 x 25 mg 1 lamotrigine starter kit-green oral kit 84 x 25 mg & 14x100 mg 1 lamotrigine starter kit-orange oral kit 42 x 25 mg & 7 x 100 mg 1 levetiracetam er oral tablet extended release 24 hour 500 mg, 1 750 mg levetiracetam oral solution 100 mg/ml 1 levetiracetam oral tablet 1000 mg, 250 mg, 500 mg, 750 mg 1 LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 25 MG, PA; ST; SL (93 capsules per 3 50 MG, 75 MG (pregabalin) 31 days.) PA; ST; SL (62 capsules per LYRICA ORAL CAPSULE 225 MG, 300 MG (pregabalin) 3 31 days.) PA; ST; SL (30.52 ml per LYRICA ORAL SOLUTION 20 MG/ML (pregabalin) 3 day.) NEURONTIN ORAL CAPSULE 100 MG, 300 MG, 400 MG 3 PA; ST (gabapentin)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 86 Coverage Requirements & Prescription Drug Name Drug Tier Limits NEURONTIN ORAL SOLUTION 250 MG/5ML (gabapentin) 3 PA; ST NEURONTIN ORAL TABLET 600 MG, 800 MG ( gabapentin) 3 PA; ST oral suspension 300 mg/5ml 1 oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg 1 pregabalin oral capsule 100 mg, 150 mg, 200 mg, 25 mg, 50 SL (93 capsules per 31 1 mg, 75 mg days.) SL (62 capsules per 31 pregabalin oral capsule 225 mg, 300 mg 1 days.) pregabalin oral solution 20 mg/ml 1 SL (30.52 ml per day.) roweepra oral tablet 500 mg 1 rufinamide oral suspension 40 mg/ml 1 rufinamide oral tablet 200 mg, 400 mg 1 PA PA; ST; SL (6 tablets per SABRIL ORAL TABLET 500 MG (vigabatrin) 3 day.); SP subvenite oral tablet 100 mg, 150 mg, 200 mg, 25 mg 1 subvenite starter kit-blue oral kit 35 x 25 mg 1 subvenite starter kit-green oral kit 84 x 25 mg & 14x100 mg 1 subvenite starter kit-orange oral kit 42 x 25 mg & 7 x 100 mg 1 TEGRETOL ORAL SUSPENSION 100 MG/5ML 3 (carbamazepine) TEGRETOL ORAL TABLET 200 MG ( carbamazepine) 3 TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 3 HOUR 100 MG, 200 MG, 400 MG (carbamazepine) tiagabine hcl oral tablet 12 mg, 16 mg, 2 mg, 4 mg 1 TOPAMAX ORAL TABLET 100 MG, 200 MG, 25 MG, 50 MG 3 PA; ST (topiramate) TOPAMAX SPRINKLE ORAL CAPSULE SPRINKLE 15 MG, 25 3 PA; ST MG (topiramate) topiramate oral capsule sprinkle 15 mg, 25 mg 1 topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1 TRILEPTAL ORAL SUSPENSION 300 MG/5ML 3 PA; ST (oxcarbazepine) TRILEPTAL ORAL TABLET 150 MG, 300 MG, 600 MG 3 PA; ST (oxcarbazepine) valproic acid oral capsule 250 mg 1 valproic acid oral solution 250 mg/5ml 1 PA; ST; SL (6 packets per vigabatrin oral packet 500 mg 1 day.) Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 87 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; ST; SL (6 tablets per vigabatrin oral tablet 500 mg 1 day.); SP PA; ST; SL (6 packets per vigadrone oral packet 500 mg 1 day.) VIMPAT ORAL SOLUTION 10 MG/ML (lacosamide) 3 PA VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG 3 PA (lacosamide) XCOPRI ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG 3 PA (cenobamate) XCOPRI ORAL TABLET THERAPY PACK 100 & 150 MG, 14 X 12.5 MG & 14 X 25 MG, 14 X 150 MG & 14 X200 MG, 14 X 50 3 PA MG & 14 X100 MG, 150 & 200 MG, 50 & 200 MG (cenobamate) ZONEGRAN ORAL CAPSULE 100 MG, 25 MG (zonisamide) 3 PA; ST zonisamide oral capsule 100 mg, 25 mg, 50 mg 1 ANTIDEPRESSANTS, MISCELLANEOUS - Drugs for Depression & Psychosis bupropion hcl er (smoking det) oral tablet extended release 12 1 H hour 150 mg bupropion hcl er (sr) oral tablet extended release 12 hour 100 1 mg, 150 mg, 200 mg bupropion hcl er (xl) oral tablet extended release 24 hour 150 1 mg, 300 mg bupropion hcl oral tablet 100 mg, 75 mg 1 mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg 1 mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg 1 REMERON ORAL TABLET 15 MG, 30 MG (mirtazapine) 3 REMERON SOLTAB ORAL TABLET DISPERSIBLE 15 MG, 30 3 MG, 45 MG (mirtazapine) SPRAVATO (56 MG DOSE) NASAL SOLUTION THERAPY PA; SL (8 devices (4 kits) per 3 PACK 28 MG/DEVICE (esketamine hcl) month.) SPRAVATO (84 MG DOSE) NASAL SOLUTION THERAPY PA; SL (12 devices (4 kits) 3 PACK 28 MG/DEVICE (esketamine hcl) per month.) ANTIMANIC AGENTS - Drugs for Personality Disorder aripiprazole oral solution 1 mg/ml 1 aripiprazole oral tablet 10 mg, 15 mg, 20 mg, 30 mg 1 SL (1 tablet per day) aripiprazole oral tablet 2 mg 1 SL (2 tablets per day.) aripiprazole oral tablet 5 mg 1 SL (1.5 tablets per day.) aripiprazole oral tablet dispersible 10 mg, 15 mg 1 SL (1 tablet per day.)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 88 Coverage Requirements & Prescription Drug Name Drug Tier Limits carbamazepine er oral capsule extended release 12 hour 100 1 mg, 200 mg, 300 mg carbamazepine er oral tablet extended release 12 hour 100 mg, 1 200 mg, 400 mg carbamazepine oral suspension 100 mg/5ml 1 carbamazepine oral tablet 200 mg 1 carbamazepine oral tablet chewable 100 mg 1 CARBATROL ORAL CAPSULE EXTENDED RELEASE 12 3 HOUR 100 MG, 200 MG, 300 MG (carbamazepine) DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 3 PA; ST HOUR 250 MG, 500 MG (divalproex sodium) DEPAKOTE ORAL TABLET DELAYED RELEASE 125 MG, 250 3 PA MG, 500 MG (divalproex sodium) DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED 3 PA; ST RELEASE SPRINKLE 125 MG (divalproex sodium) divalproex sodium er oral tablet extended release 24 hour 250 1 mg, 500 mg divalproex sodium oral capsule delayed release sprinkle 125 mg 1 divalproex sodium oral tablet delayed release 125 mg, 250 mg, 1 500 mg epitol oral tablet 200 mg 1 EQUETRO ORAL CAPSULE EXTENDED RELEASE 12 HOUR 3 100 MG, 200 MG, 300 MG (carbamazepine (antipsychotic)) LAMICTAL ODT ORAL KIT 21 X 25 MG & 7 X 50 MG, 25 & 50 3 PA; ST & 100 MG, 42 X 50 MG & 14X100 MG (lamotrigine) LAMICTAL ODT ORAL TABLET DISPERSIBLE 100 MG, 200 3 PA; ST MG, 25 MG, 50 MG (lamotrigine) LAMICTAL ORAL TABLET 100 MG, 150 MG, 200 MG, 25 MG 3 PA; ST (lamotrigine) LAMICTAL ORAL TABLET CHEWABLE 25 MG, 5 MG 3 PA; ST (lamotrigine) LAMICTAL STARTER ORAL KIT 35 X 25 MG, 42 X 25 MG & 7 3 PA; ST X 100 MG, 84 X 25 MG & 14X100 MG (lamotrigine) LAMICTAL XR ORAL KIT 21 X 25 MG & 7 X 50 MG, 25 & 50 & 3 PA; ST 100 MG, 50 & 100 & 200 MG (lamotrigine) LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 250 MG, 300 MG, 50 MG 3 PA; ST (lamotrigine) lamotrigine er oral tablet extended release 24 hour 100 mg, 200 1 PA; ST mg, 25 mg, 250 mg, 300 mg, 50 mg Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 89 Coverage Requirements & Prescription Drug Name Drug Tier Limits lamotrigine oral kit 25 & 50 & 100 mg 1 PA; ST lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg 1 lamotrigine oral tablet chewable 25 mg, 5 mg 1 lamotrigine oral tablet dispersible 100 mg, 200 mg, 25 mg, 50 1 PA; ST mg lamotrigine starter kit-blue oral kit 35 x 25 mg 1 lamotrigine starter kit-green oral kit 84 x 25 mg & 14x100 mg 1 lamotrigine starter kit-orange oral kit 42 x 25 mg & 7 x 100 mg 1 lithium carbonate er oral tablet extended release 300 mg, 450 1 mg lithium carbonate oral capsule 150 mg, 300 mg, 600 mg 1 lithium carbonate oral tablet 300 mg 1 LITHOBID ORAL TABLET EXTENDED RELEASE 300 MG 3 PA (lithium carbonate) olanzapine oral tablet 10 mg, 15 mg, 20 mg, 7.5 mg 1 SL (1 tablet per day) olanzapine oral tablet 2.5 mg 1 SL (2 tablets per day.) olanzapine oral tablet 5 mg 1 SL (3 tablets per day) olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg 1 SL (1 tablet per day) olanzapine oral tablet dispersible 5 mg 1 SL (3 tablets per day) quetiapine fumarate er oral tablet extended release 24 hour 150 1 SL (31 tablets per 31 days.) mg quetiapine fumarate er oral tablet extended release 24 hour 200 1 SL (1 tablet per day.) mg quetiapine fumarate er oral tablet extended release 24 hour 300 1 SL (62 tablets per 31 days.) mg, 400 mg SL (13 tablets per year for quetiapine fumarate er oral tablet extended release 24 hour 50 1 initial fill 3 tablets per day for mg maintenance fill.) quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 1 mg, 400 mg, 50 mg oral solution 1 mg/ml 1 risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg 1 risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg, 1 3 mg, 4 mg SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 5 MG 1 SL (2 tablets per day) (asenapine maleate) SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 2.5 MG 1 SL (2 tablets per day.) (asenapine maleate)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 90 Coverage Requirements & Prescription Drug Name Drug Tier Limits subvenite oral tablet 100 mg, 150 mg, 200 mg, 25 mg 1 subvenite starter kit-blue oral kit 35 x 25 mg 1 subvenite starter kit-green oral kit 84 x 25 mg & 14x100 mg 1 subvenite starter kit-orange oral kit 42 x 25 mg & 7 x 100 mg 1 TEGRETOL ORAL SUSPENSION 100 MG/5ML 3 (carbamazepine) TEGRETOL ORAL TABLET 200 MG ( carbamazepine) 3 TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 3 HOUR 100 MG, 200 MG, 400 MG (carbamazepine) valproic acid oral capsule 250 mg 1 valproic acid oral solution 250 mg/5ml 1 SL (62 capsules per 31 ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg 1 days.) ANTIMIGRAINE AGENTS, MISCELLANEOUS - Treatment SL (7.5 ml (3 bottles) per butorphanol tartrate nasal solution 10 mg/ml 1 prescription.) CAFERGOT ORAL TABLET 1-100 MG (ergotamine-caffeine) 3 caffeine citrate oral solution 20 mg/ml, 60 mg/3ml 1 DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 3 PA; ST HOUR 250 MG, 500 MG (divalproex sodium) DEPAKOTE ORAL TABLET DELAYED RELEASE 125 MG, 250 3 PA MG, 500 MG (divalproex sodium) DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED 3 PA; ST RELEASE SPRINKLE 125 MG (divalproex sodium) dihydroergotamine mesylate injection solution 1 mg/ml 1 PA; SL (8 mL per dihydroergotamine mesylate nasal solution 4 mg/ml 1 prescription.) divalproex sodium er oral tablet extended release 24 hour 250 1 mg, 500 mg divalproex sodium oral capsule delayed release sprinkle 125 mg 1 divalproex sodium oral tablet delayed release 125 mg, 250 mg, 1 500 mg EC-NAPROSYN ORAL TABLET DELAYED RELEASE 375 MG, 3 500 MG (naproxen) ec-naproxen oral tablet delayed release 375 mg, 500 mg 1 ERGOMAR SUBLINGUAL TABLET SUBLINGUAL 2 MG PA; SL (5 tablets per 3 (ergotamine tartrate) prescription.)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 91 Coverage Requirements & Prescription Drug Name Drug Tier Limits ergotamine-caffeine oral tablet 1-100 mg 1 ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 MIGERGOT RECTAL SUPPOSITORY 2-100 MG (ergotamine- 3 caffeine) naproxen oral suspension 125 mg/5ml 1 PA naproxen oral tablet 250 mg, 375 mg, 500 mg 1 naproxen oral tablet delayed release 375 mg, 500 mg 1 naproxen sodium oral tablet 275 mg, 550 mg 1 propranolol hcl er oral capsule extended release 24 hour 120 1 mg, 160 mg, 60 mg, 80 mg propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml 1 propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg 1 timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1 TOPAMAX ORAL TABLET 100 MG, 200 MG, 25 MG, 50 MG 3 PA; ST (topiramate) TOPAMAX SPRINKLE ORAL CAPSULE SPRINKLE 15 MG, 25 3 PA; ST MG (topiramate) topiramate oral capsule sprinkle 15 mg, 25 mg 1 topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1 valproic acid oral capsule 250 mg 1 valproic acid oral solution 250 mg/5ml 1 ANTIPSYCHOTICS, MISCELLANEOUS - Drugs for Depression & Psychosis ADASUVE INHALATION AEROSOL POWDER BREATH 3 ACTIVATED 10 MG (loxapine) loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg 1 molindone hcl oral tablet 10 mg, 25 mg, 5 mg 1 pimozide oral tablet 1 mg, 2 mg 1 ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC - Drugs for Anxiety & Sleep Disorder BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG 3 ST; SL (1 tablet per day.) () buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg 1 DAYVIGO ORAL TABLET 10 MG, 5 MG () 3 ST; SL (1 tablet per day.) diphen oral elixir 12.5 mg/5ml 1 di-phen oral elixir 12.5 mg/5ml 3 diphenhydramine hcl oral elixir 12.5 mg/5ml 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 92 Coverage Requirements & Prescription Drug Name Drug Tier Limits eszopiclone oral tablet 1 mg, 2 mg, 3 mg 1 SL (1 tablet per day) PA; SL (1 capsule per day.); HETLIOZ ORAL CAPSULE 20 MG (tasimelteon) 3 SP hydroxyzine hcl oral syrup 10 mg/5ml 1 hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 1 hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg 1 meprobamate oral tablet 200 mg, 400 mg 1 promethazine hcl oral solution 6.25 mg/5ml 1 promethazine hcl oral syrup 6.25 mg/5ml 1 promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg 1 promethazine hcl rectal suppository 12.5 mg, 25 mg 1 promethegan rectal suppository 12.5 mg, 25 mg, 50 mg 1 ramelteon oral tablet 8 mg 1 ST; SL (1 tablet per day) VISTARIL ORAL CAPSULE 25 MG, 50 MG (hydroxyzine 3 pamoate) zaleplon oral capsule 10 mg, 5 mg 1 SL (1 tablet per day) zolpidem tartrate er oral tablet extended release 12.5 mg, 6.25 1 SL (31 tablets per month) mg zolpidem tartrate oral tablet 10 mg, 5 mg 1 SL (1 tablet per day) ST; SL (8 ml (1 canister) per ZOLPIMIST ORAL SOLUTION 5 MG/ACT (zolpidem tartrate) 3 month) ATYPICAL ANTIPSYCHOTICS - Drugs for Depression & Psychosis aripiprazole oral solution 1 mg/ml 1 aripiprazole oral tablet 10 mg, 15 mg, 20 mg, 30 mg 1 SL (1 tablet per day) aripiprazole oral tablet 2 mg 1 SL (2 tablets per day.) aripiprazole oral tablet 5 mg 1 SL (1.5 tablets per day.) aripiprazole oral tablet dispersible 10 mg, 15 mg 1 SL (1 tablet per day.) PA; ST; SL (1 capsule per CAPLYTA ORAL CAPSULE 42 MG (lumateperone tosylate) 3 day.) clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1 clozapine oral tablet dispersible 100 mg, 12.5 mg, 150 mg, 200 1 mg, 25 mg CLOZARIL ORAL TABLET 100 MG, 200 MG, 25 MG, 50 MG 3 (clozapine) FANAPT ORAL TABLET 1 MG ( iloperidone) 3 SL (86 tablets per year.)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 93 Coverage Requirements & Prescription Drug Name Drug Tier Limits FANAPT ORAL TABLET 10 MG, 12 MG, 4 MG, 6 MG, 8 MG 3 SL (2 tablets per day) (iloperidone) FANAPT ORAL TABLET 2 MG ( iloperidone) 3 SL (56 tablets per year.) FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4 & 6 MG SL (8 tablets (1 pack) per 3 (iloperidone) 365 days.) LATUDA ORAL TABLET 120 MG, 20 MG, 60 MG (lurasidone 3 SL (1 tablet per day.) hcl) LATUDA ORAL TABLET 40 MG (lurasidone hcl) 3 SL (1 tablet per day) LATUDA ORAL TABLET 80 MG (lurasidone hcl) 3 SL (2 tablets per day.) NUPLAZID ORAL CAPSULE 34 MG (pimavanserin tartrate) 3 PA NUPLAZID ORAL TABLET 10 MG (pimavanserin tartrate) 3 PA olanzapine oral tablet 10 mg, 15 mg, 20 mg, 7.5 mg 1 SL (1 tablet per day) olanzapine oral tablet 2.5 mg 1 SL (2 tablets per day.) olanzapine oral tablet 5 mg 1 SL (3 tablets per day) olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg 1 SL (1 tablet per day) olanzapine oral tablet dispersible 5 mg 1 SL (3 tablets per day) olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 3- 1 SL (1 capsule per day) 25 mg, 6-25 mg, 6-50 mg paliperidone er oral tablet extended release 24 hour 1.5 mg, 3 1 SL (1 tablet per day) mg, 9 mg paliperidone er oral tablet extended release 24 hour 6 mg 1 SL (2 tablets per day) quetiapine fumarate er oral tablet extended release 24 hour 150 1 SL (31 tablets per 31 days.) mg quetiapine fumarate er oral tablet extended release 24 hour 200 1 SL (1 tablet per day.) mg quetiapine fumarate er oral tablet extended release 24 hour 300 1 SL (62 tablets per 31 days.) mg, 400 mg SL (13 tablets per year for quetiapine fumarate er oral tablet extended release 24 hour 50 1 initial fill 3 tablets per day for mg maintenance fill.) quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 1 mg, 400 mg, 50 mg REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 3 PA; ST; SL (1 tablet per day.) MG, 4 MG (brexpiprazole) risperidone oral solution 1 mg/ml 1 risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg 1 risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg, 1 3 mg, 4 mg

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 94 Coverage Requirements & Prescription Drug Name Drug Tier Limits SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 5 MG 1 SL (2 tablets per day) (asenapine maleate) SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 2.5 MG 1 SL (2 tablets per day.) (asenapine maleate) SYMBYAX ORAL CAPSULE 3-25 MG, 6-25 MG (olanzapine- 3 SL (1 capsule per day) fluoxetine hcl) VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG 3 ST; SL (1 capsule per day.) (cariprazine hcl) VRAYLAR ORAL CAPSULE THERAPY PACK 1.5 & 3 MG 3 ST; SL (7 capsules per year.) (cariprazine hcl) SL (62 capsules per 31 ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg 1 days.) BARBITURATES (ANTICONVULSANTS) - Drugs for Seizures MYSOLINE ORAL TABLET 250 MG, 50 MG (primidone) 2 PA; ST phenobarbital oral elixir 20 mg/5ml 1 phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 1 mg, 60 mg, 64.8 mg, 97.2 mg primidone oral tablet 250 mg, 50 mg 1 BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) - Drugs for Anxiety & Sleep Disorder ascomp-codeine oral capsule 50-325-40-30 mg 1 bac oral tablet 50-325-40 mg 1 SL (6 tablets per day) BUPAP ORAL TABLET 50-300 MG (butalbital-acetaminophen) 3 butalbital-acetaminophen oral tablet 50-300 mg, 50-325 mg 1 butalbital-apap-caff-cod oral capsule 50-325-40-30 mg 1 SL (6 capsules per day.) butalbital-apap-caffeine oral capsule 50-300-40 mg 1 SL (6 capsules per day.) butalbital-apap-caffeine oral capsule 50-325-40 mg 1 SL (6 capsules per day) butalbital-apap-caffeine oral tablet 50-325-40 mg 1 SL (6 tablets per day) butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg 1 butalbital-aspirin-caffeine oral capsule 50-325-40 mg 1 ESGIC ORAL CAPSULE 50-325-40 MG (butalbital-apap- 3 SL (6 capsules per day) caffeine) ESGIC ORAL TABLET 50-325-40 MG (butalbital-apap-caffeine) 3 SL (6 tablets per day) FIORICET ORAL CAPSULE 50-300-40 MG (butalbital-apap- 3 SL (6 capsules per day.) caffeine) phenobarbital oral elixir 20 mg/5ml 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 95 Coverage Requirements & Prescription Drug Name Drug Tier Limits phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 1 mg, 60 mg, 64.8 mg, 97.2 mg TENCON ORAL TABLET 50-325 MG ( butalbital- 3 acetaminophen) VTOL LQ ORAL SOLUTION 50-325-40 MG/15ML (butalbital- PA; SL (180 ml per 2 apap-caffeine) prescription.) ZEBUTAL ORAL CAPSULE 50-325-40 MG (butalbital-apap- 3 SL (6 capsules per day) caffeine) BENZODIAZEPINES (ANTICONVULSANTS) - Drugs for Seizures clobazam oral suspension 2.5 mg/ml 1 PA clobazam oral tablet 10 mg, 20 mg 1 PA clonazepam oral tablet 0.5 mg, 1 mg, 2 mg 1 clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg, 1 1 mg, 2 mg clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg 1 SL (1 box (2 doses/box) per DIASTAT ACUDIAL RECTAL GEL 10 MG, 20 MG (diazepam) 3 prescription) SL (1 box (2 doses/box) per DIASTAT PEDIATRIC RECTAL GEL 2.5 MG (diazepam) 2 prescription) diazepam intensol oral concentrate 5 mg/ml 1 diazepam oral concentrate 5 mg/ml 1 diazepam oral solution 5 mg/5ml 1 diazepam oral tablet 10 mg, 2 mg, 5 mg 1 SL (1 box (2 doses/box) per diazepam rectal gel 10 mg, 2.5 mg, 20 mg 1 prescription) lorazepam intensol oral concentrate 2 mg/ml 1 lorazepam oral concentrate 2 mg/ml 1 lorazepam oral tablet 0.5 mg, 1 mg, 2 mg 1 NAYZILAM NASAL SOLUTION 5 MG/0.1ML (midazolam PA; SL (1 box per 3 ()) prescription.) ONFI ORAL SUSPENSION 2.5 MG/ML (clobazam) 3 PA; ST ONFI ORAL TABLET 10 MG, 20 MG (clobazam) 3 PA; ST TRANXENE-T ORAL TABLET 7.5 MG ( clorazepate 3 dipotassium) VALTOCO NASAL LIQUID 10 MG/0.1ML, 5 MG/0.1ML PA; SL (2 devices per 3 (diazepam) prescription.)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 96 Coverage Requirements & Prescription Drug Name Drug Tier Limits VALTOCO NASAL LIQUID THERAPY PACK 10 MG/0.1ML, 7.5 PA; SL (2 devices per 3 MG/0.1ML (diazepam) prescription.) BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) - Drugs for Anxiety & Sleep Disorder alprazolam er oral tablet extended release 24 hour 0.5 mg, 1 1 mg, 2 mg, 3 mg alprazolam intensol oral concentrate 1 mg/ml 1 alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg 1 alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg 1 alprazolam xr oral tablet extended release 24 hour 0.5 mg, 1 1 mg, 2 mg, 3 mg chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg 1 chlordiazepoxide- oral tablet 10-25 mg, 5-12.5 mg 1 chlordiazepoxide-clidinium oral capsule 5-2.5 mg 1 clobazam oral suspension 2.5 mg/ml 1 PA clobazam oral tablet 10 mg, 20 mg 1 PA clonazepam oral tablet 0.5 mg, 1 mg, 2 mg 1 clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg, 1 1 mg, 2 mg clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg 1 SL (1 box (2 doses/box) per DIASTAT ACUDIAL RECTAL GEL 10 MG, 20 MG (diazepam) 3 prescription) SL (1 box (2 doses/box) per DIASTAT PEDIATRIC RECTAL GEL 2.5 MG (diazepam) 2 prescription) diazepam intensol oral concentrate 5 mg/ml 1 diazepam oral concentrate 5 mg/ml 1 diazepam oral solution 5 mg/5ml 1 diazepam oral tablet 10 mg, 2 mg, 5 mg 1 SL (1 box (2 doses/box) per diazepam rectal gel 10 mg, 2.5 mg, 20 mg 1 prescription) estazolam oral tablet 1 mg, 2 mg 1 flurazepam hcl oral capsule 15 mg, 30 mg 1 HALCION ORAL TABLET 0.25 MG (triazolam) 3 lorazepam intensol oral concentrate 2 mg/ml 1 lorazepam oral concentrate 2 mg/ml 1 lorazepam oral tablet 0.5 mg, 1 mg, 2 mg 1 midazolam hcl oral syrup 2 mg/ml 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 97 Coverage Requirements & Prescription Drug Name Drug Tier Limits ONFI ORAL SUSPENSION 2.5 MG/ML (clobazam) 3 PA; ST ONFI ORAL TABLET 10 MG, 20 MG (clobazam) 3 PA; ST oxazepam oral capsule 10 mg, 15 mg, 30 mg 1 RESTORIL ORAL CAPSULE 15 MG, 22.5 MG, 30 MG, 7.5 MG 3 (temazepam) temazepam oral capsule 15 mg, 22.5 mg, 30 mg, 7.5 mg 1 TRANXENE-T ORAL TABLET 7.5 MG ( clorazepate 3 dipotassium) triazolam oral tablet 0.125 mg, 0.25 mg 1 BUTYROPHENONES - Drugs for Depression & Psychosis haloperidol lactate oral concentrate 2 mg/ml 1 haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg 1 GENE-RELATED ANTAG. - AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 2 PA; ST 140 MG/ML, 70 MG/ML (-aooe) EMGALITY (300 MG DOSE) SUBCUTANEOUS SOLUTION 2 PA; ST; SL (0.1 mL per day.) PREFILLED SYRINGE 100 MG/ML (-gnlm) EMGALITY SUBCUTANEOUS SOLUTION AUTO-INJECTOR 2 PA; ST; SL (0.04 ml per day.) 120 MG/ML (galcanezumab-gnlm) EMGALITY SUBCUTANEOUS SOLUTION PREFILLED 2 PA; ST; SL (0.04 ml per day.) SYRINGE 120 MG/ML (galcanezumab-gnlm) PA; ST; SL (8 tablets per UBRELVY ORAL TABLET 100 MG, 50 MG () 2 prescription and 8 tablets per month.) CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB. - Drugs for Parkinson carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5- 1 150-200 mg, 50-200-200 mg COMTAN ORAL TABLET 200 MG ( entacapone) 3 entacapone oral tablet 200 mg 1 STALEVO 100 ORAL TABLET 25-100-200 MG (carbidopa- 3 levodopa-entacapone) STALEVO 125 ORAL TABLET 31.25-125-200 MG (carbidopa- 3 levodopa-entacapone) STALEVO 150 ORAL TABLET 37.5-150-200 MG (carbidopa- 3 levodopa-entacapone)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 98 Coverage Requirements & Prescription Drug Name Drug Tier Limits STALEVO 200 ORAL TABLET 50-200-200 MG (carbidopa- 3 levodopa-entacapone) STALEVO 50 ORAL TABLET 12.5-50-200 MG (carbidopa- 3 levodopa-entacapone) STALEVO 75 ORAL TABLET 18.75-75-200 MG (carbidopa- 3 levodopa-entacapone) tolcapone oral tablet 100 mg 1 PA CENTRAL NERVOUS SYSTEM AGENTS, MISC. - Drugs for Attention Deficit Disorder acamprosate calcium oral tablet delayed release 333 mg 1 atomoxetine hcl oral capsule 10 mg, 18 mg, 25 mg, 40 mg 1 SL (2 capsules per day) atomoxetine hcl oral capsule 100 mg, 60 mg, 80 mg 1 SL (1 capsule per day) guanfacine hcl er oral tablet extended release 24 hour 1 mg 1 SL (1 tablet per day) guanfacine hcl er oral tablet extended release 24 hour 2 mg, 4 1 SL (1 tablet per day.) mg guanfacine hcl er oral tablet extended release 24 hour 3 mg 1 SL (2 tablets per day.) guanfacine hcl oral tablet 1 mg, 2 mg 1 memantine hcl oral solution 2 mg/ml 1 memantine hcl oral tablet 10 mg, 28 x 5 mg & 21 x 10 mg, 5 mg 1 NAMENDA TITRATION PAK ORAL TABLET 28 X 5 MG & 21 X 3 10 MG (memantine hcl) NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PACK 7 3 & 14 & 21 &28 -10 MG (memantine hcl-donepezil hcl) NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG (memantine hcl- 3 donepezil hcl) NOURIANZ ORAL TABLET 20 MG, 40 MG (istradefylline) 3 PA; SL (1 tablet per day.) NUEDEXTA ORAL CAPSULE 20-10 MG (dextromethorphan- 2 PA quinidine) RILUTEK ORAL TABLET 50 MG (riluzole) 3 riluzole oral tablet 50 mg 1 TIGLUTIK ORAL SUSPENSION 50 MG/10ML (riluzole) 3 PA; SP PA; SL (1 capsule per day.); VYNDAMAX ORAL CAPSULE 61 MG (tafamidis) 2 SP XYREM ORAL SOLUTION 500 MG/ML (sodium oxybate) 3 PA; SL (18 ml per day.); SP XYWAV ORAL SOLUTION 500 MG/ML (ca, mg, k, and na 3 PA; SL (18 mL per day.); SP oxybates)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 99 Coverage Requirements & Prescription Drug Name Drug Tier Limits CYCLOOXYGENASE-2 (COX-2) INHIBITORS - Drugs for Pain celecoxib oral capsule 100 mg, 200 mg, 50 mg 1 SL (2 capsules per day) SL (31 capsules per 31 celecoxib oral capsule 400 mg 1 days.) DOPAMINE PRECURSORS - Drugs for Parkinson carbidopa oral tablet 25 mg 1 carbidopa-levodopa er oral tablet extended release 25-100 mg, 1 50-200 mg carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 1 mg carbidopa-levodopa oral tablet dispersible 10-100 mg, 25-100 1 mg, 25-250 mg carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5- 1 150-200 mg, 50-200-200 mg DUOPA ENTERAL SUSPENSION 4.63-20 MG/ML (carbidopa- 3 PA levodopa) PA; SL (10 tablets per day.); INBRIJA INHALATION CAPSULE 42 MG (levodopa) 3 SP SINEMET ORAL TABLET 10-100 MG, 25-100 MG (carbidopa- 3 levodopa) STALEVO 100 ORAL TABLET 25-100-200 MG (carbidopa- 3 levodopa-entacapone) STALEVO 125 ORAL TABLET 31.25-125-200 MG (carbidopa- 3 levodopa-entacapone) STALEVO 150 ORAL TABLET 37.5-150-200 MG (carbidopa- 3 levodopa-entacapone) STALEVO 200 ORAL TABLET 50-200-200 MG (carbidopa- 3 levodopa-entacapone) STALEVO 50 ORAL TABLET 12.5-50-200 MG (carbidopa- 3 levodopa-entacapone) STALEVO 75 ORAL TABLET 18.75-75-200 MG (carbidopa- 3 levodopa-entacapone) ERGOT-DERIV. DOPAMINE RECEPTOR AGONISTS - Drugs for Parkinson mesylate oral capsule 5 mg 1 bromocriptine mesylate oral tablet 2.5 mg 1 oral tablet 0.5 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 100 Coverage Requirements & Prescription Drug Name Drug Tier Limits FIBROMYALGIA AGENTS - Drugs for Nerve Pain duloxetine hcl oral capsule delayed release particles 20 mg, 60 1 SL (2 capsules per day.) mg duloxetine hcl oral capsule delayed release particles 30 mg 1 SL (1 capsule per day.) LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 25 MG, PA; ST; SL (93 capsules per 3 50 MG, 75 MG (pregabalin) 31 days.) PA; ST; SL (62 capsules per LYRICA ORAL CAPSULE 225 MG, 300 MG (pregabalin) 3 31 days.) PA; ST; SL (30.52 ml per LYRICA ORAL SOLUTION 20 MG/ML (pregabalin) 3 day.) pregabalin oral capsule 100 mg, 150 mg, 200 mg, 25 mg, 50 SL (93 capsules per 31 1 mg, 75 mg days.) SL (62 capsules per 31 pregabalin oral capsule 225 mg, 300 mg 1 days.) pregabalin oral solution 20 mg/ml 1 SL (30.52 ml per day.) SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG 3 SL (2 tablets per day) (milnacipran hcl) SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG 3 SL (1 pack per 365 days.) (milnacipran hcl) HYDANTOINS - Drugs for Seizures DILANTIN INFATABS ORAL TABLET CHEWABLE 50 MG 3 (phenytoin) DILANTIN ORAL CAPSULE 100 MG, 30 MG (phenytoin sodium 3 extended) DILANTIN ORAL SUSPENSION 125 MG/5ML (phenytoin) 3 PHENYTEK ORAL CAPSULE 200 MG, 300 MG (phenytoin 3 sodium extended) phenytoin infatabs oral tablet chewable 50 mg 1 phenytoin oral suspension 125 mg/5ml 1 phenytoin oral tablet chewable 50 mg 1 phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 1 mg INHALATION ANESTHETICS - Anesthetics FORANE INHALATION SOLUTION (isoflurane) 2 isoflurane inhalation solution 1 sevoflurane inhalation solution 1 terrell inhalation solution 1 ULTANE INHALATION SOLUTION (sevoflurane) 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 101 Coverage Requirements & Prescription Drug Name Drug Tier Limits MONOAMINE OXIDASE B INHIBITORS - Drugs for Parkinson EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24HR, 6 3 MG/24HR, 9 MG/24HR (selegiline) rasagiline mesylate oral tablet 0.5 mg, 1 mg 1 selegiline hcl oral capsule 5 mg 1 selegiline hcl oral tablet 5 mg 1 ZELAPAR ORAL TABLET DISPERSIBLE 1.25 MG (selegiline 3 hcl) MONOAMINE OXIDASE INHIBITORS - Drugs for Depression & Psychosis EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24HR, 6 3 MG/24HR, 9 MG/24HR (selegiline) MARPLAN ORAL TABLET 10 MG ( isocarboxazid) 3 NARDIL ORAL TABLET 15 MG (phenelzine sulfate) 3 PARNATE ORAL TABLET 10 MG (tranylcypromine sulfate) 3 phenelzine sulfate oral tablet 15 mg 1 rasagiline mesylate oral tablet 0.5 mg, 1 mg 1 selegiline hcl oral capsule 5 mg 1 selegiline hcl oral tablet 5 mg 1 tranylcypromine sulfate oral tablet 10 mg 1 ZELAPAR ORAL TABLET DISPERSIBLE 1.25 MG (selegiline 3 hcl) NONERGOT-DERIV.DOPAMINE RECEPTOR - Drugs for Parkinson APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE 30 2 PA; SL (3 ml per day.); SP MG/3ML (apomorphine hcl) KYNMOBI SUBLINGUAL FILM 10 MG, 15 MG, 20 MG, 25 MG, 3 PA; SL (5 films per day.); SP 30 MG (apomorphine hcl) KYNMOBI TITRATION KIT SUBLINGUAL KIT 10/15/20/25/30 3 PA; SP MG (apomorphine hcl) MIRAPEX ORAL TABLET 0.125 MG, 0.5 MG, 0.75 MG, 1 MG 3 ( dihydrochloride) NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24HR, 2 MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 MG/24HR, 8 MG/24HR 3 (rotigotine) pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 1 mg, 0.75 mg, 1 mg, 1.5 mg

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 102 Coverage Requirements & Prescription Drug Name Drug Tier Limits ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 1 mg, 5 mg OPIATE AGONISTS - Drugs for Pain acetaminophen-codeine #2 oral tablet 300-15 mg 1 acetaminophen-codeine #3 oral tablet 300-30 mg 1 acetaminophen-codeine #4 oral tablet 300-60 mg 1 acetaminophen-codeine oral solution 120-12 mg/5ml 1 acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg, 300- 1 60 mg SL (40 capsules per apap-caff-dihydrocodeine oral capsule 320.5-30-16 mg 1 prescription.) SL (40 tablets per apap-caff-dihydrocodeine oral tablet 325-30-16 mg 1 prescription.) ascomp-codeine oral capsule 50-325-40-30 mg 1 belladonna alkaloids-opium rectal suppository 16.2-30 mg 1 belladonna alkaloids-opium rectal suppository 16.2-60 mg 2 BENZHYDROCODONE-ACETAMINOPHEN ORAL TABLET 3 4.08-325 MG, 6.12-325 MG, 8.16-325 MG butalbital-apap-caff-cod oral capsule 50-325-40-30 mg 1 SL (6 capsules per day.) butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg 1 carisoprodol-aspirin-codeine oral tablet 200-325-16 mg 1 codeine sulfate oral tablet 15 mg, 30 mg, 60 mg 1 DILAUDID ORAL LIQUID 1 MG/ML (hydromorphone hcl) 3 DILAUDID ORAL TABLET 2 MG, 4 MG, 8 MG (hydromorphone 3 hcl) endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 1 mg fentanyl citrate buccal lozenge on a handle 1200 mcg, 1600 1 PA; SL (4 lozenges per day) mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 100 mcg/hr, 50 mcg/hr, 75 PA; SL (0.34 patches per 1 mcg/hr day.) PA; SL (15 patches per 31 fentanyl transdermal patch 72 hour 12 mcg/hr, 25 mcg/hr 1 days.) hydrocodone bitartrate er oral capsule extended release 12 PA; ST; SL (2 capsules per 1 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg day.) hydrocodone-acetaminophen oral solution 10-325 mg/15ml, 7.5- 1 325 mg/15ml

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 103 Coverage Requirements & Prescription Drug Name Drug Tier Limits hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 1 7.5-325 mg hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5- 1 200 mg hydromorphone hcl er oral tablet extended release 24 hour 12 PA; ST; SL (2 tablets per 1 mg day.) hydromorphone hcl er oral tablet extended release 24 hour 16 1 PA; ST; SL (1 tablet per day.) mg, 8 mg PA; ST; SL (0 tablet per 100 hydromorphone hcl er oral tablet extended release 24 hour 32 1 days, diagnosis review mg required.) hydromorphone hcl oral liquid 1 mg/ml 1 hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg 1 hydromorphone hcl rectal suppository 3 mg 1 LAZANDA NASAL SOLUTION 100 MCG/ACT, 400 MCG/ACT PA; SL (15 bottles per 3 (fentanyl citrate) month) levorphanol tartrate oral tablet 2 mg, 3 mg 1 ST; SL (4 tablets per day.) LORTAB ORAL ELIXIR 10-300 MG/15ML (hydrocodone- 3 acetaminophen) meperidine hcl oral solution 50 mg/5ml 1 meperidine hcl oral tablet 50 mg 1 methadone hcl intensol oral concentrate 10 mg/ml 1 SL (6 ml per day.) methadone hcl oral concentrate 10 mg/ml 1 SL (6 ml per day.) methadone hcl oral solution 10 mg/5ml 1 PA; SL (11.3 ml per day.) methadone hcl oral solution 5 mg/5ml 1 PA; SL (22.6 ml per day.) methadone hcl oral tablet 10 mg 1 PA; SL (2 tablets per day.) methadone hcl oral tablet 5 mg 1 PA; SL (4 tablets per day.) methadone hcl oral tablet soluble 40 mg 1 SL (1.5 tablets per day.) methadose oral concentrate 10 mg/ml 1 SL (6 ml per day.) methadose oral tablet soluble 40 mg 1 SL (1.5 tablets per day.) methadose sugar-free oral concentrate 10 mg/ml 1 SL (6 ml per day.) morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 1 mg/ml PA; ST; SL (0 capsule per morphine sulfate er beads oral capsule extended release 24 1 100 days, diagnosis review hour 120 mg required.) morphine sulfate er beads oral capsule extended release 24 PA; ST; SL (1 capsule per 1 hour 30 mg, 45 mg, 60 mg, 75 mg, 90 mg day.)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 104 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; SL (0 capsules per 100 morphine sulfate er oral tablet extended release 100 mg, 200 1 days, diagnosis review mg, 60 mg required.) PA; SL (93 tablets per 31 morphine sulfate er oral tablet extended release 15 mg, 30 mg 1 days.) morphine sulfate oral solution 10 mg/5ml, 20 mg/5ml 1 morphine sulfate oral tablet 15 mg, 30 mg 1 morphine sulfate rectal suppository 10 mg, 20 mg, 30 mg, 5 mg 1 PA; ST; SL (0 capsules per MS CONTIN ORAL TABLET EXTENDED RELEASE 100 MG, 3 100 days, diagnosis review 200 MG, 60 MG (morphine sulfate) required.) MS CONTIN ORAL TABLET EXTENDED RELEASE 15 MG, 30 PA; ST; SL (93 tablets per 31 3 MG (morphine sulfate) days.) NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 3 PA; SL (2 tablets per day) HOUR 100 MG, 50 MG (tapentadol hcl) PA; SL (0 capsules per 100 NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 3 days, diagnosis review HOUR 150 MG, 200 MG, 250 MG (tapentadol hcl) required.) NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG ( tapentadol 3 SL (6 tablets per day) hcl) oxycodone hcl oral capsule 5 mg 1 oxycodone hcl oral concentrate 100 mg/5ml 1 oxycodone hcl oral solution 5 mg/5ml 1 oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 mg 1 oxycodone hcl oral tablet 5 mg 1 SL (12 tablets per day.) oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 1 5-325 mg, 7.5-325 mg oxymorphone hcl er oral tablet extended release 12 hour 10 mg, PA; ST; SL (2 tablets per 1 15 mg, 5 mg, 7.5 mg day.) oxymorphone hcl er oral tablet extended release 12 hour 20 mg, PA; ST; SL (0 tablet per 100 1 30 mg, 40 mg days.) oxymorphone hcl oral tablet 10 mg, 5 mg 1 SL (6 tablets per day.) tramadol hcl er oral tablet extended release 24 hour 100 mg, 1 SL (1 tablet per day) 200 mg, 300 mg tramadol hcl oral tablet 50 mg 1 SL (40 tablets per tramadol-acetaminophen oral tablet 37.5-325 mg 1 prescription.) TREZIX ORAL CAPSULE 320.5-30-16 MG (apap-caff- SL (40 capsules per 1 dihydrocodeine) prescription.)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 105 Coverage Requirements & Prescription Drug Name Drug Tier Limits ULTRACET ORAL TABLET 37.5-325 MG (tramadol- SL (40 tablets per 3 acetaminophen) prescription.) XTAMPZA ER ORAL CAPSULE ER 12 HOUR ABUSE- 2 PA; SL (2 tablets per day.) DETERRENT 13.5 MG, 18 MG, 27 MG, 9 MG (oxycodone) PA; SL (0 capsules per 100 XTAMPZA ER ORAL CAPSULE ER 12 HOUR ABUSE- 2 days, diagnosis review DETERRENT 36 MG (oxycodone) required.) OPIATE ANTAGONISTS - Drugs for Overdose or Poisoning BUNAVAIL BUCCAL FILM 4.2-0.7 MG, 6.3-1 MG PA; SL (2 buccal films per 3 (buprenorphine hcl-naloxone hcl) day.) buprenorphine hcl-naloxone hcl sublingual film 12-3 mg 1 SL (2 films per day.) buprenorphine hcl-naloxone hcl sublingual film 2-0.5 mg, 4-1 1 SL (1 film per day.) mg buprenorphine hcl-naloxone hcl sublingual film 8-2 mg 1 SL (3 films per day.) buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2- 1 SL (3 tablets per day.) 0.5 mg, 8-2 mg naloxone hcl injection solution 0.4 mg/ml, 4 mg/10ml 1 naloxone hcl injection solution cartridge 0.4 mg/ml 1 naloxone hcl injection solution prefilled syringe 2 mg/2ml 1 naltrexone hcl oral tablet 50 mg 1 SL (2 auto-injectors per NARCAN NASAL LIQUID 4 MG/0.1ML (naloxone hcl) 2 prescription.) pentazocine-naloxone hcl oral tablet 50-0.5 mg 1 RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML 3 PA; SL (0.6 ml per day.) (methylnaltrexone bromide) RELISTOR SUBCUTANEOUS SOLUTION 8 MG/0.4ML 3 PA; SL (0.4 ml per day.) (methylnaltrexone bromide) SUBOXONE SUBLINGUAL FILM 12-3 MG (buprenorphine hcl- 3 PA; SL (2 films per day.) naloxone hcl) SUBOXONE SUBLINGUAL FILM 2-0.5 MG, 4-1 MG 3 PA; SL (1 film per day.) (buprenorphine hcl-naloxone hcl) SUBOXONE SUBLINGUAL FILM 8-2 MG (buprenorphine hcl- 3 PA; SL (3 films per day.) naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 0.7-0.18 MG, 1 SL (1 tablet per day.) 2.9-0.71 MG (buprenorphine hcl-naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 1.4-0.36 MG, 1 SL (3 tablets per day.) 5.7-1.4 MG (buprenorphine hcl-naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 11.4-2.9 MG, 1 SL (2 tablets per day.) 8.6-2.1 MG (buprenorphine hcl-naloxone hcl)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 106 Coverage Requirements & Prescription Drug Name Drug Tier Limits OPIATE PARTIAL AGONISTS - Drugs for Pain BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450 MCG, 600 3 PA; SL (2 Films per day.) MCG, 75 MCG, 900 MCG (buprenorphine hcl) BELBUCA BUCCAL FILM 750 MCG (buprenorphine hcl) 3 PA; SL (2 films per day.) BUNAVAIL BUCCAL FILM 4.2-0.7 MG, 6.3-1 MG PA; SL (2 buccal films per 3 (buprenorphine hcl-naloxone hcl) day.) SL (3 sublingual tablets per buprenorphine hcl sublingual tablet sublingual 2 mg 1 day.) buprenorphine hcl sublingual tablet sublingual 8 mg 1 SL (3 tablets per day.) buprenorphine hcl-naloxone hcl sublingual film 12-3 mg 1 SL (2 films per day.) buprenorphine hcl-naloxone hcl sublingual film 2-0.5 mg, 4-1 1 SL (1 film per day.) mg buprenorphine hcl-naloxone hcl sublingual film 8-2 mg 1 SL (3 films per day.) buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2- 1 SL (3 tablets per day.) 0.5 mg, 8-2 mg SL (7.5 ml (3 bottles) per butorphanol tartrate nasal solution 10 mg/ml 1 prescription.) pentazocine-naloxone hcl oral tablet 50-0.5 mg 1 SUBOXONE SUBLINGUAL FILM 12-3 MG (buprenorphine hcl- 3 PA; SL (2 films per day.) naloxone hcl) SUBOXONE SUBLINGUAL FILM 2-0.5 MG, 4-1 MG 3 PA; SL (1 film per day.) (buprenorphine hcl-naloxone hcl) SUBOXONE SUBLINGUAL FILM 8-2 MG (buprenorphine hcl- 3 PA; SL (3 films per day.) naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 0.7-0.18 MG, 1 SL (1 tablet per day.) 2.9-0.71 MG (buprenorphine hcl-naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 1.4-0.36 MG, 1 SL (3 tablets per day.) 5.7-1.4 MG (buprenorphine hcl-naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 11.4-2.9 MG, 1 SL (2 tablets per day.) 8.6-2.1 MG (buprenorphine hcl-naloxone hcl) OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS - Drugs for Pain DAYPRO ORAL TABLET 600 MG (oxaprozin) 3 diclofenac potassium oral tablet 50 mg 1 diclofenac sodium er oral tablet extended release 24 hour 100 1 mg diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 1 mg

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 107 Coverage Requirements & Prescription Drug Name Drug Tier Limits diclofenac-misoprostol oral tablet delayed release 50-0.2 mg, 1 75-0.2 mg diflunisal oral tablet 500 mg 1 EC-NAPROSYN ORAL TABLET DELAYED RELEASE 375 MG, 3 500 MG (naproxen) ec-naproxen oral tablet delayed release 375 mg, 500 mg 1 etodolac er oral tablet extended release 24 hour 400 mg, 500 1 mg, 600 mg etodolac oral capsule 200 mg, 300 mg 1 etodolac oral tablet 400 mg, 500 mg 1 FELDENE ORAL CAPSULE 10 MG, 20 MG (piroxicam) 3 flurbiprofen oral tablet 100 mg, 50 mg 1 hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5- 1 200 mg ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 INDOCIN ORAL SUSPENSION 25 MG/5ML (indomethacin) 3 INDOCIN RECTAL SUPPOSITORY 50 MG (indomethacin) 3 indomethacin er oral capsule extended release 75 mg 1 indomethacin oral capsule 25 mg, 50 mg 1 KETOROLAC TROMETHAMINE NASAL SOLUTION 15.75 ST; SL (5 bottles per 3 MG/SPRAY prescription.) ketorolac tromethamine oral tablet 10 mg 1 meclofenamate sodium oral capsule 100 mg, 50 mg 1 mefenamic acid oral capsule 250 mg 1 meloxicam oral tablet 15 mg, 7.5 mg 1 MOBIC ORAL TABLET 15 MG, 7.5 MG (meloxicam) 3 nabumetone oral tablet 500 mg, 750 mg 1 naproxen oral suspension 125 mg/5ml 1 PA naproxen oral tablet 250 mg, 375 mg, 500 mg 1 naproxen oral tablet delayed release 375 mg, 500 mg 1 naproxen sodium oral tablet 275 mg, 550 mg 1 oxaprozin oral tablet 600 mg 1 piroxicam oral capsule 10 mg, 20 mg 1 SPRIX NASAL SOLUTION 15.75 MG/SPRAY (ketorolac ST; SL (5 bottles per 3 tromethamine) prescription.) sulindac oral tablet 150 mg, 200 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 108 Coverage Requirements & Prescription Drug Name Drug Tier Limits PHENOTHIAZINES - Drugs for Depression & Psychosis chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 1 50 mg compro rectal suppository 25 mg 1 fluphenazine hcl oral concentrate 5 mg/ml 1 fluphenazine hcl oral elixir 2.5 mg/5ml 1 fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg 1 perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg 1 perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 1 mg, 4-25 mg, 4-50 mg prochlorperazine maleate oral tablet 10 mg, 5 mg 1 prochlorperazine rectal suppository 25 mg 1 thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg 1 trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg 1 RESPIRATORY AND CNS STIMULANTS - Drugs for the Nervous System SL (40 capsules per apap-caff-dihydrocodeine oral capsule 320.5-30-16 mg 1 prescription.) SL (40 tablets per apap-caff-dihydrocodeine oral tablet 325-30-16 mg 1 prescription.) ascomp-codeine oral capsule 50-325-40-30 mg 1 AZSTARYS ORAL CAPSULE 26.1-5.2 MG, 39.2-7.8 MG, 52.3- 3 PA 10.4 MG (serdexmethylphen-dexmethylphen) bac oral tablet 50-325-40 mg 1 SL (6 tablets per day) butalbital-apap-caff-cod oral capsule 50-325-40-30 mg 1 SL (6 capsules per day.) butalbital-apap-caffeine oral capsule 50-300-40 mg 1 SL (6 capsules per day.) butalbital-apap-caffeine oral capsule 50-325-40 mg 1 SL (6 capsules per day) butalbital-apap-caffeine oral tablet 50-325-40 mg 1 SL (6 tablets per day) butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg 1 butalbital-aspirin-caffeine oral capsule 50-325-40 mg 1 CAFERGOT ORAL TABLET 1-100 MG (ergotamine-caffeine) 3 caffeine citrate oral solution 20 mg/ml, 60 mg/3ml 1 CONCERTA ORAL TABLET EXTENDED RELEASE 18 MG, 27 1 SL (1 tablet per day.) MG, 54 MG (methylphenidate hcl) CONCERTA ORAL TABLET EXTENDED RELEASE 36 MG 1 SL (2 tablets per day.) (methylphenidate hcl)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 109 Coverage Requirements & Prescription Drug Name Drug Tier Limits dexmethylphenidate hcl er oral capsule extended release 24 SL (31 capsules per 31 1 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg days.) dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg 1 ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML (theophylline) 3 ergotamine-caffeine oral tablet 1-100 mg 1 ESGIC ORAL CAPSULE 50-325-40 MG (butalbital-apap- 3 SL (6 capsules per day) caffeine) ESGIC ORAL TABLET 50-325-40 MG (butalbital-apap-caffeine) 3 SL (6 tablets per day) FIORICET ORAL CAPSULE 50-300-40 MG (butalbital-apap- 3 SL (6 capsules per day.) caffeine) FOCALIN ORAL TABLET 10 MG, 2.5 MG, 5 MG 3 (dexmethylphenidate hcl) METHYLIN ORAL SOLUTION 10 MG/5ML, 5 MG/5ML 3 (methylphenidate hcl) methylphenidate hcl er (cd) oral capsule extended release 10 1 SL (31 tablets per 31 days.) mg, 20 mg, 30 mg methylphenidate hcl er (cd) oral capsule extended release 40 SL (31 capsules per 31 1 mg, 50 mg, 60 mg days.) methylphenidate hcl er (la) oral capsule extended release 24 1 SL (1 capsule per day) hour 10 mg, 20 mg, 40 mg methylphenidate hcl er (la) oral capsule extended release 24 1 SL (2 capsules per day.) hour 30 mg methylphenidate hcl er (la) oral capsule extended release 24 1 hour 60 mg methylphenidate hcl er oral tablet extended release 10 mg 1 SL (6 tablets per day.) methylphenidate hcl er oral tablet extended release 20 mg 1 SL (3 tablets per day.) methylphenidate hcl oral solution 10 mg/5ml, 5 mg/5ml 1 methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg 1 methylphenidate hcl oral tablet chewable 10 mg, 2.5 mg, 5 mg 1 MIGERGOT RECTAL SUPPOSITORY 2-100 MG (ergotamine- 3 caffeine) orphenadrine-asa-caffeine oral tablet 50-770-60 mg 1 RITALIN ORAL TABLET 10 MG, 20 MG, 5 MG 3 (methylphenidate hcl) THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 300 MG, 400 MG (theophylline) theophylline er oral tablet extended release 12 hour 300 mg, 1 450 mg

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 110 Coverage Requirements & Prescription Drug Name Drug Tier Limits theophylline er oral tablet extended release 24 hour 400 mg, 1 600 mg theophylline oral solution 80 mg/15ml 1 TREZIX ORAL CAPSULE 320.5-30-16 MG (apap-caff- SL (40 capsules per 1 dihydrocodeine) prescription.) VTOL LQ ORAL SOLUTION 50-325-40 MG/15ML (butalbital- PA; SL (180 ml per 2 apap-caffeine) prescription.) ZEBUTAL ORAL CAPSULE 50-325-40 MG (butalbital-apap- 3 SL (6 capsules per day) caffeine) SALICYLATES - Drugs for Pain ascomp-codeine oral capsule 50-325-40-30 mg 1 aspirin-dipyridamole er oral capsule extended release 12 hour 1 25-200 mg butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg 1 butalbital-aspirin-caffeine oral capsule 50-325-40 mg 1 carisoprodol-aspirin-codeine oral tablet 200-325-16 mg 1 orphenadrine-asa-caffeine oral tablet 50-770-60 mg 1 salsalate oral tablet 500 mg, 750 mg 1 SEL.SEROTONIN,NOREPI REUPTAKE INHIBITOR - Drugs for Depression & Psychosis desvenlafaxine succinate er oral tablet extended release 24 1 SL (1 tablet per day) hour 100 mg, 50 mg desvenlafaxine succinate er oral tablet extended release 24 1 SL (1 tablet per day.) hour 25 mg DRIZALMA SPRINKLE ORAL CAPSULE DELAYED RELEASE 3 PA; SL (2 capsules per day.) SPRINKLE 20 MG, 30 MG, 60 MG (duloxetine hcl) DRIZALMA SPRINKLE ORAL CAPSULE DELAYED RELEASE 3 PA; SL (1 capsule per day.) SPRINKLE 40 MG (duloxetine hcl) duloxetine hcl oral capsule delayed release particles 20 mg, 60 1 SL (2 capsules per day.) mg duloxetine hcl oral capsule delayed release particles 30 mg 1 SL (1 capsule per day.) FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 ST; SL (1 capsule per day.) 120 MG, 20 MG, 40 MG, 80 MG (levomilnacipran hcl) FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR ST; SL (28 capsules per 3 THERAPY PACK 20 & 40 MG (levomilnacipran hcl) year.) SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG 3 SL (2 tablets per day) (milnacipran hcl) SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG 3 SL (1 pack per 365 days.) (milnacipran hcl)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 111 Coverage Requirements & Prescription Drug Name Drug Tier Limits venlafaxine hcl er oral capsule extended release 24 hour 150 1 mg, 37.5 mg, 75 mg venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 1 mg SELECTIVE SEROTONIN AGONISTS - Migraine Treatment SL (4 tablets per malate oral tablet 12.5 mg, 6.25 mg 1 prescription) SL (4 tablets per hydrobromide oral tablet 20 mg, 40 mg 1 prescription) SL (4 tablets per succinate oral tablet 2.5 mg 1 prescription) IMITREX NASAL SOLUTION 20 MG/ACT, 5 MG/ACT SL (6 spray bottles per 3 () prescription) SL (4 tablets per hcl oral tablet 1 mg, 2.5 mg 1 prescription) PA; ST; SL (8 tablets per REYVOW ORAL TABLET 100 MG, 50 MG ( 2 prescription and 8 tablets per succinate) month.) SL (4 tablets per benzoate oral tablet 10 mg, 5 mg 1 prescription) SL (4 tablets per rizatriptan benzoate oral tablet dispersible 10 mg, 5 mg 1 prescription) SL (6 spray bottles per sumatriptan nasal solution 20 mg/act, 5 mg/act 1 prescription) SL (10 tablets per sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg 1 prescription.) sumatriptan succinate refill subcutaneous solution cartridge 4 1 SL (2 kits per prescription) mg/0.5ml, 6 mg/0.5ml sumatriptan succinate subcutaneous solution 6 mg/0.5ml 1 SL (2 kits per prescription) sumatriptan succinate subcutaneous solution auto-injector 4 1 SL (2 kits per prescription) mg/0.5ml, 6 mg/0.5ml SL (4 tablets per oral tablet 2.5 mg, 5 mg 1 prescription) SL (4 tablets per zolmitriptan oral tablet dispersible 2.5 mg, 5 mg 1 prescription) ST; SL (6 units per ZOMIG NASAL SOLUTION 2.5 MG (zolmitriptan) 3 prescription.) ST; SL (1 box per ZOMIG NASAL SOLUTION 5 MG (zolmitriptan) 3 prescription)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 112 Coverage Requirements & Prescription Drug Name Drug Tier Limits SELECTIVE-SEROTONIN REUPTAKE INHIBITORS - Drugs for Depression & Psychosis citalopram hydrobromide oral solution 10 mg/5ml 1 citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 mg 1 escitalopram oxalate oral solution 5 mg/5ml 1 escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg 1 fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg 1 fluoxetine hcl oral capsule delayed release 90 mg 1 SL (4 capsules per 28 days.) fluoxetine hcl oral solution 20 mg/5ml 1 fluoxetine hcl oral tablet 10 mg 1 SL (1 tablet per day.) fluoxetine hcl oral tablet 20 mg 1 fluvoxamine maleate er oral capsule extended release 24 hour 1 SL (2 capsules per day) 100 mg, 150 mg fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg 1 olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 3- 1 SL (1 capsule per day) 25 mg, 6-25 mg, 6-50 mg paroxetine hcl er oral tablet extended release 24 hour 12.5 mg 1 SL (1 tablet per day) paroxetine hcl er oral tablet extended release 24 hour 25 mg, 1 SL (2 tablets per day) 37.5 mg paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg 1 PAXIL ORAL SUSPENSION 10 MG/5ML (paroxetine hcl) 3 sertraline hcl oral concentrate 20 mg/ml 1 sertraline hcl oral tablet 100 mg, 25 mg, 50 mg 1 SYMBYAX ORAL CAPSULE 3-25 MG, 6-25 MG (olanzapine- 3 SL (1 capsule per day) fluoxetine hcl) SEROTONIN MODULATORS - Drugs for Depression & Psychosis nefazodone hcl oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 1 mg trazodone hcl oral tablet 100 mg, 150 mg, 300 mg, 50 mg 1 TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG ( vortioxetine 3 ST; SL (1 tablet per day.) hbr) VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG (vilazodone 3 SL (1 tablet per day) hcl) VIIBRYD STARTER PACK ORAL KIT 10 & 20 MG (vilazodone 3 hcl) - Drugs for Seizures CELONTIN ORAL CAPSULE 300 MG (methsuximide) 2 Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 113 Coverage Requirements & Prescription Drug Name Drug Tier Limits ethosuximide oral capsule 250 mg 1 ethosuximide oral solution 250 mg/5ml 1 ZARONTIN ORAL CAPSULE 250 MG (ethosuximide) 3 ZARONTIN ORAL SOLUTION 250 MG/5ML (ethosuximide) 3 THIOXANTHENES - Drugs for Depression & Psychosis thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 TRICYCLICS, OTHER NOREPI-RU INHIBITORS - Drugs for Depression & Psychosis amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 1 mg, 75 mg amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg 1 chlordiazepoxide-amitriptyline oral tablet 10-25 mg, 5-12.5 mg 1 clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg 1 desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 1 mg, 75 mg doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 1 mg, 75 mg doxepin hcl oral concentrate 10 mg/ml 1 hcl oral tablet 10 mg, 25 mg, 50 mg 1 imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 1 mg NORPRAMIN ORAL TABLET 10 MG, 25 MG (desipramine hcl) 3 hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg 1 nortriptyline hcl oral solution 10 mg/5ml 1 perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 1 mg, 4-25 mg, 4-50 mg protriptyline hcl oral tablet 10 mg, 5 mg 1 trimipramine maleate oral capsule 100 mg, 25 mg, 50 mg 1 VESICULAR MONOAMINE TRANSPORT2 INHIBITOR - Drugs for the Nervous System PA; SL (4 tablets per day.); AUSTEDO ORAL TABLET 12 MG, 9 MG (deutetrabenazine) 2 SP PA; SL (2 tablets per day.); AUSTEDO ORAL TABLET 6 MG (deutetrabenazine) 2 SP tetrabenazine oral tablet 12.5 mg 1 PA tetrabenazine oral tablet 25 mg 1 PA; SP

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 114 Coverage Requirements & Prescription Drug Name Drug Tier Limits WAKEFULNESS-PROMOTING AGENTS - Drugs for the Nervous System armodafinil oral tablet 150 mg, 250 mg 1 PA; SL (1 tablet per day) armodafinil oral tablet 200 mg, 50 mg 1 PA; SL (1 tablet per day.) modafinil oral tablet 100 mg, 200 mg 1 PA; SL (1 tablet per day) SUNOSI ORAL TABLET 150 MG, 75 MG (solriamfetol hcl) 3 PA; SL (1 tablet per day.) PA; SL (2 tablets per day.); WAKIX ORAL TABLET 17.8 MG, 4.45 MG (pitolisant hcl) 3 SP DENTAL AGENTS - Oral Care DENTAL AGENTS - Oral Care FLUORIDEX SENSITIVITY RELIEF DENTAL PASTE 1.1-5 % 3 (sod fluoride-potassium nitrate) NAFRINSE DAILY ACIDULATED MOUTH/THROAT SOLUTION RECONSTITUTED 1 MG/5ML (sodium fluoride- 2 phosphoric acd) PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE 1.1-5 3 % (sod fluoride-potassium nitrate) PREVIDENT 5000 SENSITIVE DENTAL PASTE 1.1-5 % (sod 3 fluoride-potassium nitrate) sodium fluoride 5000 enamel dental paste 1.1-5 % 1 sodium fluoride 5000 sensitive dental paste 1.1-5 % 1 DEVICES - Medical Supplies and Durable Medical Equipment DEVICES - Medical Supplies and Durable Medical Equipment ACCU-CHEK AVIVA IN VITRO SOLUTION (blood glucose 1 calibration) ACCU-CHEK COMPACT PLUS CONTROL IN VITRO 1 SOLUTION (blood glucose calibration) ACCU-CHEK FASTCLIX LANCET KIT KIT (lancets misc.) 1 ACCU-CHEK GUIDE CONTROL IN VITRO LIQUID (blood 1 glucose calibration) ACCU-CHEK GUIDE KIT W/DEVICE (blood glucose monitoring 3 suppl) ACCU-CHEK SMARTVIEW CONTROL IN VITRO LIQUID 1 (blood glucose calibration) ACCU-CHEK SOFTCLIX LANCET DEVICE KIT KIT (lancets 1 misc.) ALCOHOL PREP PADS SHEET 70 % 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 115 Coverage Requirements & Prescription Drug Name Drug Tier Limits SL (1 device per AUTOLET LANCING DEVICE (lancet devices) 3 prescription.) CARETOUCH CONTROL SOL LEVEL 2 IN VITRO LIQUID 3 (blood glucose calibration) SL (1 device per CARETOUCH LANCING/EJECTOR (lancet devices) 3 prescription.) CONTOUR CONTROL IN VITRO LIQUID HIGH (blood glucose 3 calibration) CONTOUR CONTROL IN VITRO LIQUID LOW , NORMAL 2 (blood glucose calibration) CONTOUR NEXT CONTROL IN VITRO SOLUTION LOW , 2 NORMAL (blood glucose calibration) CONTOUR NEXT EZ KIT W/DEVICE (blood glucose monitoring 2 suppl) CONTOUR NEXT LINK KIT W/DEVICE (blood glucose 3 monitoring suppl) CONTOUR NEXT MONITOR KIT W/DEVICE (blood glucose 2 monitoring suppl) CONTOUR NEXT ONE KIT (blood glucose monitoring suppl) 2 EASIVENT (spacer/aero-holding chambers) 2 EASYMAX 15 LEVEL 2-3 CONTROL IN VITRO LIQUID (blood 3 glucose calibration) EASYMAX CONTROL IN VITRO SOLUTION NORMAL (blood 3 glucose calibration) EASYMAX CONTROL NORMAL/HIGH IN VITRO LIQUID 3 (blood glucose calibration) FLEXICHAMBER ADULT MASK/SMALL (spacer/aero-hold 2 chamber mask) FLEXICHAMBER CHILD MASK/LARGE (spacer/aero-hold 2 chamber mask) FLEXICHAMBER CHILD MASK/SMALL (spacer/aero-hold 2 chamber mask) FORTISCARE CONTROL IN VITRO SOLUTION HIGH , LOW , 2 NORMAL (blood glucose calibration) FREESTYLE LIBRE 14 DAY READER DEVICE (continuous 3 PA blood gluc receiver) FREESTYLE LIBRE 14 DAY SENSOR (continuous blood gluc 3 PA sensor) FREESTYLE LIBRE 2 READER DEVICE (continuous blood 3 PA gluc receiver)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 116 Coverage Requirements & Prescription Drug Name Drug Tier Limits FREESTYLE LIBRE 2 SENSOR (continuous blood gluc sensor) 3 PA FREESTYLE LIBRE READER DEVICE (continuous blood gluc 3 PA; SL (1 kit per 999 days.) receiver) FREESTYLE LIBRE SENSOR SYSTEM (continuous blood gluc 3 PA sensor) INSPIREASE RESERVOIR BAGS (spacer/aero-hold chamber 2 bags) INSULIN PEN NEEDLES 29G X 12.7MM , 31G X 5 MM , 32G X 2 4 MM (insulin pen needle) INSULIN PEN NEEDLES 29G X 12MM , 31G X 6 MM , 31G X 8 2 MM INSULIN PEN NEEDLES 33G X 4 MM , 33G X 5 MM , 33G X 6 3 MM (insulin pen needle) INSULIN SYRINGES 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 2 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) SL (1 device per MICROLET NEXT LANCING DEVICE (lancet devices) 3 prescription.) NOVOFINE AUTOCOVER PEN NEEDLE 30G X 8 MM (insulin 2 pen needle) NOVOFINE PEN NEEDLE 32G X 6 MM (insulin pen needle) 2 NOVOFINE PLUS PEN NEEDLE 32G X 4 MM (insulin pen 2 needle) NOVOPEN ECHO DEVICE (injection device for insulin) 3 NOVOTWIST PEN NEEDLE 32G X 5 MM (insulin pen needle) 2 SL (1 device per ONETOUCH DELICA LANCING DEVICE (lancet devices) 1 prescription.) ONETOUCH DELICA PLUS LANCING DEVICE (lancet SL (1 device per 1 devices) prescription.) ONETOUCH ULTRA 2 KIT W/DEVICE (blood glucose 1 monitoring suppl) ONETOUCH ULTRA MINI KIT W/DEVICE (blood glucose 1 monitoring suppl) ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE KIT 1 W/DEVICE (blood glucose monitoring suppl) ONETOUCH VERIO IN VITRO SOLUTION HIGH (blood 1 glucose calibration)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 117 Coverage Requirements & Prescription Drug Name Drug Tier Limits ONETOUCH VERIO IQ SYSTEM KIT W/DEVICE (blood 1 glucose monitoring suppl) ONETOUCH VERIO KIT W/DEVICE (blood glucose monitoring 1 suppl) ONETOUCH VERIO REFLECT KIT W/DEVICE (blood glucose 1 monitoring suppl) ONETOUCH VERIO SYNC SYSTEM KIT W/DEVICE KIT 1 W/DEVICE (blood glucose monitoring suppl) SHARPS CONTAINER 3 SURESTEP PRO HIGH GLUCOSE IN VITRO LIQUID (blood 3 glucose calibration) SURESTEP PRO LOW GLUCOSE IN VITRO LIQUID (blood 3 glucose calibration) SURESTEP PRO NORMAL GLUCOSE IN VITRO LIQUID 3 (blood glucose calibration) TRUE METRIX LEVEL 1 IN VITRO SOLUTION LOW (blood 2 glucose calibration) TRUE METRIX LEVEL 2 IN VITRO SOLUTION NORMAL 2 (blood glucose calibration) TRUE METRIX LEVEL 3 IN VITRO SOLUTION HIGH (blood 2 glucose calibration) DIAGNOSTIC AGENTS ADRENOCORTICAL INSUFFICIENCY PA; ST; SL (20 ml per 24 ACTHAR INJECTION GEL 80 UNIT/ML (corticotropin) 3 days.); SP CORTROSYN INJECTION SOLUTION RECONSTITUTED 0.25 3 MG (cosyntropin) cosyntropin injection solution reconstituted 0.25 mg 1 DIABETES MELLITUS SL (51 strips per prescription ACCU-CHEK GUIDE IN VITRO STRIP (glucose blood) 3 without history 204 strips per prescription with history.) SL (51 strips per prescription CONTOUR NEXT TEST IN VITRO STRIP (glucose blood) 2 without history 204 strips per prescription with history.) SL (51 strips per prescription ONETOUCH ULTRA IN VITRO STRIP (glucose blood) 1 without history 204 strips per prescription with history.)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 118 Coverage Requirements & Prescription Drug Name Drug Tier Limits SL (51 strips per prescription ONETOUCH VERIO IN VITRO STRIP (glucose blood) 1 without history 204 strips per prescription with history.) KETONES KETONE TEST IN VITRO STRIP 2 KETOSTIX IN VITRO STRIP (acetone (urine) test) 2 PANCREATIC FUNCTION tolbutamide oral tablet 500 mg 1 DISINFECTANTS (FOR NON-DERMATOLOGIC USE) - Disinfectants DISINFECTANTS (FOR NON-DERMATOLOGIC USE) - Disinfectants formaldehyde external solution 10 % 1 FORMALDEHYDE EXTERNAL SOLUTION 37 % 3 GLUTARALDEHYDE EXTERNAL SOLUTION 25 % 3 ELECTROLYTIC, CALORIC, AND WATER BALANCE ACIDIFYING AGENTS K-PHOS NO 2 ORAL TABLET 305-700 MG (pot & sod ac 2 phosphates) ALKALINIZING AGENTS cytra k crystals oral packet 3300-1002 mg 1 ORACIT ORAL SOLUTION 490-640 MG/5ML (sod citrate-citric 2 acid) potassium citrate er oral tablet extended release 10 meq (1080 1 mg), 15 meq (1620 mg), 5 meq (540 mg) potassium citrate-citric acid oral solution 1100-334 mg/5ml 1 sod citrate-citric acid oral solution 500-334 mg/5ml 1 tricitrates oral solution 550-500-334 mg/5ml 1 UROCIT-K 10 ORAL TABLET EXTENDED RELEASE 10 MEQ 3 (1080 MG) (potassium citrate) UROCIT-K 15 ORAL TABLET EXTENDED RELEASE 15 MEQ 3 (1620 MG) (potassium citrate) UROCIT-K 5 ORAL TABLET EXTENDED RELEASE 5 MEQ 3 (540 MG) (potassium citrate) AMMONIA DETOXICANTS BUPHENYL ORAL POWDER 3 GM/TSP (sodium 3 PA phenylbutyrate) BUPHENYL ORAL TABLET 500 MG (sodium phenylbutyrate) 3 PA

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 119 Coverage Requirements & Prescription Drug Name Drug Tier Limits CARBAGLU ORAL TABLET 200 MG (carglumic acid) 2 PA; SP constulose oral solution 10 gm/15ml 1 enulose oral solution 10 gm/15ml 1 generlac oral solution 10 gm/15ml 1 KRISTALOSE ORAL PACKET 10 GM, 20 GM (lactulose) 3 lactulose encephalopathy oral solution 10 gm/15ml 1 lactulose oral solution 10 gm/15ml, 20 gm/30ml 1 LITHOSTAT ORAL TABLET 250 MG ( ) 3 PA; ST; SL (17.5 ml per RAVICTI ORAL LIQUID 1.1 GM/ML (glycerol phenylbutyrate) 3 day.); SP sodium phenylbutyrate oral powder 3 gm/tsp 1 PA sodium phenylbutyrate oral tablet 500 mg 1 PA CALORIC AGENTS - Drugs for Nutrition aminoamrms oral capsule 1 aminoreliefrms oral capsule 1 DOJOLVI ORAL LIQUID 100 % (triheptanoin) 3 PA; SP L- POWDER 3 CARBONIC ANHYDRASE INHIBITORS - Drugs for Water Balance acetazolamide er oral capsule extended release 12 hour 500 1 mg acetazolamide oral tablet 125 mg, 250 mg 1 DIURETICS, MISCELLANEOUS - Drugs for Water Balance ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML (theophylline) 3 THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 300 MG, 400 MG (theophylline) theophylline er oral tablet extended release 12 hour 300 mg, 1 450 mg theophylline er oral tablet extended release 24 hour 400 mg, 1 600 mg theophylline oral solution 80 mg/15ml 1 LOOP DIURETICS - Drugs for Water Balance bumetanide oral tablet 0.5 mg, 1 mg, 2 mg 1 BUMEX ORAL TABLET 0.5 MG (bumetanide) 3 EDECRIN ORAL TABLET 25 MG (ethacrynic acid) 3 ethacrynic acid oral tablet 25 mg 1 furosemide oral solution 10 mg/ml, 8 mg/ml 1 Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 120 Coverage Requirements & Prescription Drug Name Drug Tier Limits furosemide oral tablet 20 mg, 40 mg, 80 mg 1 LASIX ORAL TABLET 20 MG, 40 MG, 80 MG (furosemide) 3 torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg 1 OTHER ION-REMOVING AGENTS RADIOGARDASE ORAL CAPSULE 0.5 GM (prussian blue 3 insoluble) PHOSPHATE-REMOVING AGENTS AURYXIA ORAL TABLET 1 GM 210 MG(FE) (ferric citrate) 3 calcium acetate (phos binder) oral capsule 667 mg 1 calcium acetate (phos binder) oral tablet 667 mg 1 calcium acetate oral tablet 667 mg 1 FOSRENOL ORAL PACKET 1000 MG, 750 MG (lanthanum 3 carbonate) lanthanum carbonate oral tablet chewable 1000 mg, 500 mg, 1 750 mg PHOSLYRA ORAL SOLUTION 667 MG/5ML (calcium acetate 3 (phos binder)) RENAGEL ORAL TABLET 800 MG (sevelamer hcl) 3 RENVELA ORAL PACKET 0.8 GM, 2.4 GM (sevelamer 3 carbonate) sevelamer carbonate oral packet 0.8 gm, 2.4 gm 1 sevelamer carbonate oral tablet 800 mg 1 sevelamer hcl oral tablet 400 mg, 800 mg 1 VELPHORO ORAL TABLET CHEWABLE 500 MG (sucroferric 2 oxyhydroxide) POTASSIUM-REMOVING AGENTS LOKELMA ORAL PACKET 10 GM (sodium zirconium 3 PA; SL (3 packets per day.) cyclosilicate) LOKELMA ORAL PACKET 5 GM (sodium zirconium 3 PA; SL (1 packet per day.) cyclosilicate) sodium polystyrene sulfonate oral powder 1 sps oral suspension 15 gm/60ml 1 VELTASSA ORAL PACKET 16.8 GM, 25.2 GM, 8.4 GM 3 PA; SL (1 Packet per day.) (patiromer sorbitex calcium) POTASSIUM-SPARING DIURETICS - Drugs for Water Balance amiloride hcl oral tablet 5 mg 1 amiloride-hydrochlorothiazide oral tablet 5-50 mg 1 Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 121 Coverage Requirements & Prescription Drug Name Drug Tier Limits CAROSPIR ORAL SUSPENSION 25 MG/5ML (spironolactone) 3 PA DYRENIUM ORAL CAPSULE 100 MG, 50 MG (triamterene) 3 eplerenone oral tablet 25 mg, 50 mg 1 MAXZIDE ORAL TABLET 75-50 MG (triamterene-hctz) 3 MAXZIDE-25 ORAL TABLET 37.5-25 MG (triamterene-hctz) 3 spironolactone oral tablet 100 mg, 25 mg, 50 mg 1 triamterene oral capsule 100 mg, 50 mg 1 triamterene-hctz oral capsule 37.5-25 mg 1 triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg 1 REPLACEMENT PREPARATIONS CALCIFOL ORAL WAFER 1342-1.6 MG (ca carb-fa-d-b6-b12- 3 boron-mg) calcium acetate (phos binder) oral capsule 667 mg 1 calcium acetate (phos binder) oral tablet 667 mg 1 calcium acetate oral tablet 667 mg 1 calcium-folic acid plus d oral wafer 1342-1 mg 1 CITRANATAL ESSENCE ORAL THERAPY PACK 35-1 & 300 3 MG (prenat w/o a-fecbgl-fa-dha) EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 MEQ 2 (potassium bicarb-citric acid) effer-k oral tablet effervescent 25 meq 1 GALZIN ORAL CAPSULE 25 MG, 50 MG (zinc acetate (oral)) 3 klor-con 10 oral tablet extended release 10 meq 1 klor-con m10 oral tablet extended release 10 meq 1 klor-con m15 oral tablet extended release 15 meq 3 klor-con m20 oral tablet extended release 20 meq 1 klor-con oral packet 20 meq 1 klor-con oral tablet extended release 8 meq 1 klor-con/ef oral tablet effervescent 25 meq 1 K-PHOS ORAL TABLET 500 MG (potassium phosphate 2 monobasic) K-PHOS-NEUTRAL ORAL TABLET 155-852-130 MG (k phos 2 mono-sod phos di & mono) k-prime oral tablet effervescent 25 meq 1 K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ, 20 3 MEQ, 8 MEQ (potassium chloride) NEONATAL + DHA ORAL 29-1 & 200 MG 3 Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 122 Coverage Requirements & Prescription Drug Name Drug Tier Limits ONEVITE ORAL TABLET 1 MG 3 PHOSLYRA ORAL SOLUTION 667 MG/5ML (calcium acetate 3 (phos binder)) PHOSPHA 250 NEUTRAL ORAL TABLET 155-852-130 MG (k 2 phos mono-sod phos di & mono) phosphorous oral tablet 155-852-130 mg 1 phospho-trin 250 neutral oral tablet 155-852-130 mg 1 potassium chloride crys er oral tablet extended release 10 meq, 1 20 meq potassium chloride crys er oral tablet extended release 15 meq 3 potassium chloride er oral capsule extended release 10 meq, 8 1 meq potassium chloride er oral tablet extended release 10 meq, 20 1 meq, 8 meq potassium chloride oral packet 20 meq 1 potassium chloride oral solution 20 meq/15ml (10%), 40 1 meq/15ml (20%) PREMESISRX ORAL TABLET 1 MG (prenatal ca-b6-b12-fa- 3 ginger) PRENATE DHA ORAL CAPSULE 18-0.6-0.4-300 MG (prenat- 3 feasp-meth-fa-dha w/o a) PRENATE ENHANCE ORAL CAPSULE 28-0.6-0.4-400 MG 3 (prenat w/o a-fe-methfol-fa-dha) PRENATE ESSENTIAL ORAL CAPSULE 18-0.6-0.4-300 MG 3 (prenat-feasp-meth-fa-dha w/o a) PRENATE MINI ORAL CAPSULE 18-0.6-0.4-350 MG (prenat- 3 fecbn-feasp-meth-fa-dha) PRENATE ORAL TABLET CHEWABLE 0.6-0.4 MG (prenat mv- 3 min-methylfolate-fa) PRENATE PIXIE ORAL CAPSULE 10-0.6-0.4-200 MG (prenat- 3 feasp-meth-fa-dha w/o a) PRENATE RESTORE ORAL CAPSULE 27-0.6-0.4-400 MG 3 (prenat w/o a-fe-methfol-fa-dha) PRENATVITE COMPLETE ORAL TABLET 1 MG 3 PRENATVITE PLUS ORAL TABLET 1 MG 3 PRENATVITE RX ORAL TABLET 0.8 MG 3 TRISTART DHA ORAL CAPSULE 31-0.6-0.4-200 MG 3 TRISTART FREE ORAL CAPSULE 33-1 MG (prenat w/o a- 3 fecbn-meth-fa-dha)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 123 Coverage Requirements & Prescription Drug Name Drug Tier Limits TRISTART ONE ORAL CAPSULE 35-1-215 MG (prenat w/o a- 3 fecbn-meth-fa-dha) UDAMIN SP ORAL TABLET 1 MG (multiple vitamins-minerals- 3 fa) VENTRIXYL ORAL TABLET 1 MG (multiple vitamins-minerals- 3 fa) virt-phos 250 neutral oral tablet 155-852-130 mg 1 VITAFOL FE+ ORAL CAPSULE 90-0.6-0.4-200 MG (prenat-fe 3 poly-methfol-fa-dha) VITAFOL-OB+DHA ORAL 65-1 & 250 MG (prenatal mv-min-fe 3 fum-fa-dha) WESTGEL DHA ORAL CAPSULE 31-0.6-0.4-200 MG 3 WILZIN ORAL CAPSULE 25 MG (zinc acetate (oral)) 3 THIAZIDE DIURETICS - Drugs for Water Balance ACCURETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 3 MG (quinapril-hydrochlorothiazide) ALDACTAZIDE ORAL TABLET 25-25 MG (spironolactone-hctz) 3 ALDACTAZIDE ORAL TABLET 50-50 MG (spironolactone-hctz) 2 amiloride-hydrochlorothiazide oral tablet 5-50 mg 1 benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 1 mg, 20-25 mg, 5-6.25 mg bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 1 mg, 5-6.25 mg candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 mg, 1 32-25 mg DIURIL ORAL SUSPENSION 250 MG/5ML (chlorothiazide) 2 EDARBYCLOR ORAL TABLET 40-12.5 MG, 40-25 MG 3 (azilsartan-chlorthalidone) enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg 1 fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg 1 hydrochlorothiazide oral capsule 12.5 mg 1 hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg 1 irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300- 1 12.5 mg lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 1 mg, 20-25 mg losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 1 50-12.5 mg

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 124 Coverage Requirements & Prescription Drug Name Drug Tier Limits LOTENSIN HCT ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20- 3 25 MG (benazepril-hydrochlorothiazide) MAXZIDE ORAL TABLET 75-50 MG (triamterene-hctz) 3 MAXZIDE-25 ORAL TABLET 37.5-25 MG (triamterene-hctz) 3 metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100-50 1 mg, 50-25 mg olmesartan medoxomil-hctz oral tablet 20-12.5 mg, 40-12.5 mg, 1 40-25 mg quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 1 mg, 20-25 mg spironolactone-hctz oral tablet 25-25 mg 1 TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25 MG, 3 300-12.5 MG, 300-25 MG (aliskiren-hydrochlorothiazide) telmisartan-hctz oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg 1 triamterene-hctz oral capsule 37.5-25 mg 1 triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg 1 valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 1 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg ZIAC ORAL TABLET 10-6.25 MG, 2.5-6.25 MG, 5-6.25 MG 3 (bisoprolol-hydrochlorothiazide) THIAZIDE-LIKE DIURETICS - Drugs for Water Balance atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg 1 chlorthalidone oral tablet 25 mg, 50 mg 1 indapamide oral tablet 1.25 mg, 2.5 mg 1 metolazone oral tablet 10 mg, 2.5 mg, 5 mg 1 URICOSURIC AGENTS colchicine-probenecid oral tablet 0.5-500 mg 1 probenecid oral tablet 500 mg 1 VASOPRESSIN ANTAGONISTS - Drugs for Water Balance PA; SL (2 tablets per day.); JYNARQUE ORAL TABLET 15 MG, 30 MG (tolvaptan) 2 SP JYNARQUE ORAL TABLET THERAPY PACK 15 MG, 45 & 15 PA; SL (2 tablets per day.); 2 MG, 60 & 30 MG, 90 & 30 MG (tolvaptan) SP JYNARQUE ORAL TABLET THERAPY PACK 30 & 15 MG 2 PA; SL (2 tablets per day.) (tolvaptan) PA; SL (90 tablets per 365 SAMSCA ORAL TABLET 15 MG (tolvaptan) 2 days.); SP

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 125 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; SL (60 tablets per 365 SAMSCA ORAL TABLET 30 MG (tolvaptan) 3 days.); SP TOLVAPTAN ORAL TABLET 15 MG 2 PA; SP PA; SL (2 tablets per day.); tolvaptan oral tablet 30 mg 1 SP ENZYMES ENZYMES CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000-38000 UNIT, 24000-76000 UNIT, 3000-9500 UNIT, 2 36000-114000 UNIT, 6000-19000 UNIT (pancrelipase (lip-prot- amyl)) PALYNZIQ SUBCUTANEOUS SOLUTION PREFILLED PA; ST; SL (7 mL per year.); 3 SYRINGE 10 MG/0.5ML (pegvaliase-pqpz) SP PALYNZIQ SUBCUTANEOUS SOLUTION PREFILLED PA; ST; SL (3 ml per year.); 3 SYRINGE 2.5 MG/0.5ML (pegvaliase-pqpz) SP PALYNZIQ SUBCUTANEOUS SOLUTION PREFILLED PA; ST; SL (1 ml per day.); 3 SYRINGE 20 MG/ML (pegvaliase-pqpz) SP PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500-35500 UNIT, 16800-56800 UNIT, 21000- 3 ST 54700 UNIT, 2600-8800 UNIT, 37000-97300 UNIT, 4200-14200 UNIT (pancrelipase (lip-prot-amyl)) PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES 16000-57500 UNIT, 24000-86250 UNIT, 4000-14375 UNIT, 3 ST 8000-28750 UNIT (pancrelipase (lip-prot-amyl)) PULMOZYME INHALATION SOLUTION 1 MG/ML (dornase 2 PA; SL (5 ml per day.); SP alfa) SL (60 grams per SANTYL EXTERNAL OINTMENT 250 UNIT/GM ( collagenase) 3 prescription.) STRENSIQ SUBCUTANEOUS SOLUTION 18 MG/0.45ML PA; SL (5.4 ml per month.); 2 (asfotase alfa) SP STRENSIQ SUBCUTANEOUS SOLUTION 28 MG/0.7ML PA; SL (8.4 ml per month.); 2 (asfotase alfa) SP STRENSIQ SUBCUTANEOUS SOLUTION 40 MG/ML PA; SL (12 ml tablets per 2 (asfotase alfa) month.); SP STRENSIQ SUBCUTANEOUS SOLUTION 80 MG/0.8ML PA; SL (9.6 ml (12 vials) per 2 (asfotase alfa) month.); SP SUCRAID ORAL SOLUTION 8500 UNIT/ML (sacrosidase) 2 PA; SP VIOKACE ORAL TABLET 10440-39150 UNIT, 20880-78300 3 ST UNIT (pancrelipase (lip-prot-amyl))

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 126 Coverage Requirements & Prescription Drug Name Drug Tier Limits ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000-63000 UNIT, 2 25000-79000 UNIT, 3000-10000 UNIT, 40000-126000 UNIT, 5000-24000 UNIT (pancrelipase (lip-prot-amyl)) EYE, EAR, NOSE AND THROAT (EENT) PREPS. ALPHA-ADRENERGIC AGONISTS (EENT) - Drugs for the Eye ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % (brimonidine 2 SL (10 ml per prescription) tartrate) ALPHAGAN P OPHTHALMIC SOLUTION 0.15 % (brimonidine 3 SL (10 ml per prescription) tartrate) brimonidine tartrate ophthalmic solution 0.15 % 1 SL (10 ml per prescription) brimonidine tartrate ophthalmic solution 0.2 % 1 COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5 % (brimonidine 2 SL (5 ml per prescription) tartrate-timolol) ANTIALLERGIC AGENTS - Drugs for Allergy ALOCRIL OPHTHALMIC SOLUTION 2 % (nedocromil sodium) 3 ALOMIDE OPHTHALMIC SOLUTION 0.1 % (lodoxamide 3 tromethamine) azelastine hcl nasal solution 0.1 %, 137 mcg/spray 1 azelastine hcl ophthalmic solution 0.05 % 1 cromolyn sodium inhalation nebulization solution 20 mg/2ml 1 cromolyn sodium ophthalmic solution 4 % 1 LASTACAFT OPHTHALMIC SOLUTION 0.25 % (alcaftadine) 3 SL (3 ml per prescription) SL (30.5 grams (1 box) per olopatadine hcl nasal solution 0.6 % 1 prescription.) olopatadine hcl solution 0.1 % ophthalmic (rx) 0.1 % 1 SL (30.5 grams (1 box) per PATANASE NASAL SOLUTION 0.6 % (olopatadine hcl) 3 prescription.) ANTIBACTERIALS (EENT) - Drugs for Infections ak-poly-bac ophthalmic ointment 500-10000 unit/gm 1 AZASITE OPHTHALMIC SOLUTION 1 % (azithromycin) 3 bacitracin ophthalmic ointment 500 unit/gm 1 bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm 1 bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 % 1 BESIVANCE OPHTHALMIC SUSPENSION 0.6 % (besifloxacin 3 hcl)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 127 Coverage Requirements & Prescription Drug Name Drug Tier Limits BLEPH-10 OPHTHALMIC SOLUTION 10 % (sulfacetamide 3 sodium) BLEPHAMIDE OPHTHALMIC SUSPENSION 10-0.2 % 3 (sulfacetamide-prednisolone) BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 10-0.2 % 2 (sulfacetamide-prednisolone) CETRAXAL OTIC SOLUTION 0.2 % (ciprofloxacin hcl) 3 CILOXAN OPHTHALMIC OINTMENT 0.3 % (ciprofloxacin hcl) 3 CILOXAN OPHTHALMIC SOLUTION 0.3 % (ciprofloxacin hcl) 3 CIPRO HC OTIC SUSPENSION 0.2-1 % (ciprofloxacin- 3 hydrocortisone) CIPRODEX OTIC SUSPENSION 0.3-0.1 % (ciprofloxacin- 1 dexamethasone) ciprofloxacin hcl ophthalmic solution 0.3 % 1 ciprofloxacin hcl otic solution 0.2 % 1 CORTISPORIN-TC OTIC SUSPENSION 3.3-3-10-0.5 MG/ML 3 (neomycin-colist-hc-thonzonium) erythromycin ophthalmic ointment 5 mg/gm 1 H-N gatifloxacin ophthalmic solution 0.5 % 1 gentak ophthalmic ointment 0.3 % 1 gentamicin sulfate ophthalmic solution 0.3 % 1 SL (15 ml per prescription.) levofloxacin ophthalmic solution 0.5 % 1 MAXITROL OPHTHALMIC OINTMENT 3.5-10000-0.1 3 (neomycin-polymyxin-dexameth) MAXITROL OPHTHALMIC SUSPENSION 3.5-10000-0.1 3 (neomycin-polymyxin-dexameth) MITOSOL OPHTHALMIC KIT 0.2 MG (mitomycin) 3 MOXEZA OPHTHALMIC SOLUTION 0.5 % (moxifloxacin hcl) 3 moxifloxacin hcl (2x day) ophthalmic solution 0.5 % 1 moxifloxacin hcl ophthalmic solution 0.5 % 1 neomycin-bacitracin zn-polymyx ophthalmic ointment 3.5-400- 1 10000 , 5-400-10000 neomycin-polymyxin-dexameth ophthalmic ointment 3.5-10000- 1 0.1 neomycin-polymyxin-dexameth ophthalmic suspension 3.5- 1 10000-0.1 neomycin-polymyxin-gramicidin ophthalmic solution 1.75- 1 10000-.025

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 128 Coverage Requirements & Prescription Drug Name Drug Tier Limits neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1 1 neomycin-polymyxin-hc otic solution 1 %, 3.5-10000-1 1 neomycin-polymyxin-hc otic suspension 3.5-10000-1 1 neo-polycin hc ophthalmic ointment 1 % 1 neo-polycin ophthalmic ointment 3.5-400-10000 1 OCUFLOX OPHTHALMIC SOLUTION 0.3 % (ofloxacin) 3 ofloxacin ophthalmic solution 0.3 % 1 ofloxacin otic solution 0.3 % 1 polycin ophthalmic ointment 500-10000 unit/gm 1 polymyxin b-trimethoprim ophthalmic solution 10000-0.1 unit/ml- 1 % POLYTRIM OPHTHALMIC SOLUTION 10000-0.1 UNIT/ML-% 3 (polymyxin b-trimethoprim) PRED-G OPHTHALMIC SUSPENSION 0.3-1 % (gentamicin- 3 prednisolone acet) PRED-G S.O.P. OPHTHALMIC OINTMENT 0.3-0.6 % 3 (gentamicin-prednisolone acet) sulfacetamide sodium ophthalmic ointment 10 % 1 sulfacetamide sodium ophthalmic solution 10 % 1 sulfacetamide-prednisolone ophthalmic solution 10-0.23 % 1 TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 % (tobramycin- 3 dexamethasone) TOBRADEX OPHTHALMIC SUSPENSION 0.3-0.1 % 3 (tobramycin-dexamethasone) tobramycin ophthalmic solution 0.3 % 1 SL (5 ml per prescription.) tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 % 1 SL (3.5 grams per TOBREX OPHTHALMIC OINTMENT 0.3 % ( tobramycin) 3 prescription.) TOBREX OPHTHALMIC SOLUTION 0.3 % (tobramycin) 3 SL (5 ml per prescription.) ZYLET OPHTHALMIC SUSPENSION 0.5-0.3 % (loteprednol- 3 tobramycin) ZYMAXID OPHTHALMIC SOLUTION 0.5 % (gatifloxacin) 3 ANTIFUNGALS (EENT) - Drugs for Infections NATACYN OPHTHALMIC SUSPENSION 5 % (natamycin) 3 ANTIVIRALS (EENT) - Drugs for Infections trifluridine ophthalmic solution 1 % 1 ZIRGAN OPHTHALMIC GEL 0.15 % (ganciclovir) 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 129 Coverage Requirements & Prescription Drug Name Drug Tier Limits BETA-ADRENERGIC BLOCKING AGENTS (EENT) - Drugs for the Eye betaxolol hcl ophthalmic solution 0.5 % 1 BETOPTIC-S OPHTHALMIC SUSPENSION 0.25 % (betaxolol 3 hcl) carteolol hcl ophthalmic solution 1 % 1 COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5 % (brimonidine 2 SL (5 ml per prescription) tartrate-timolol) COSOPT OPHTHALMIC SOLUTION 22.3-6.8 MG/ML 3 (dorzolamide hcl-timolol mal) dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 mg/ml 1 ISTALOL OPHTHALMIC SOLUTION 0.5 % (timolol maleate) 3 levobunolol hcl ophthalmic solution 0.5 % 1 timolol maleate ocudose ophthalmic solution 0.5 % 1 timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % 1 timolol maleate ophthalmic solution 0.25 %, 0.5 %, 0.5 % (daily) 1 timolol maleate pf ophthalmic solution 0.5 % 1 TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 0.25 % 2 (timolol maleate) TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 0.5 % 3 (timolol maleate) TIMOPTIC OPHTHALMIC SOLUTION 0.25 %, 0.5 % (timolol 3 maleate) TIMOPTIC-XE OPHTHALMIC GEL FORMING SOLUTION 0.25 3 %, 0.5 % (timolol maleate) CARBONIC ANHYDRASE INHIBITORS (EENT) - Drugs for the Eye acetazolamide er oral capsule extended release 12 hour 500 1 mg acetazolamide oral tablet 125 mg, 250 mg 1 AZOPT OPHTHALMIC SUSPENSION 1 % (brinzolamide) 3 SL (10 ml per prescription) brinzolamide ophthalmic suspension 1 % 1 SL (10 ml per prescription) COSOPT OPHTHALMIC SOLUTION 22.3-6.8 MG/ML 3 (dorzolamide hcl-timolol mal) DORZOLAMIDE HCL SOLUTION 2 % OPHTHALMIC 2 % 3 dorzolamide hcl solution 2 % ophthalmic 2 % 1 dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 mg/ml 1 methazolamide oral tablet 25 mg, 50 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 130 Coverage Requirements & Prescription Drug Name Drug Tier Limits TRUSOPT OPHTHALMIC SOLUTION 2 % (dorzolamide hcl) 3 CORTICOSTEROIDS (EENT) - Drugs for Inflammation ALREX OPHTHALMIC SUSPENSION 0.2 % (loteprednol 3 SL (5 ml per prescription) etabonate) bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 % 1 BLEPHAMIDE OPHTHALMIC SUSPENSION 10-0.2 % 3 (sulfacetamide-prednisolone) BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 10-0.2 % 2 (sulfacetamide-prednisolone) CIPRO HC OTIC SUSPENSION 0.2-1 % (ciprofloxacin- 3 hydrocortisone) CIPRODEX OTIC SUSPENSION 0.3-0.1 % (ciprofloxacin- 1 dexamethasone) cortic-nd otic solution 10-10-1 mg/ml 1 CORTISPORIN-TC OTIC SUSPENSION 3.3-3-10-0.5 MG/ML 3 (neomycin-colist-hc-thonzonium) DERMOTIC OTIC OIL 0.01 % (fluocinolone acetonide) 3 dexamethasone sodium phosphate ophthalmic solution 0.1 % 1 DEXTENZA OPHTHALMIC INSERT 0.4 MG (dexamethasone) 3 DUREZOL OPHTHALMIC EMULSION 0.05 % (difluprednate) 3 flac otic oil 0.01 % 1 FLAREX OPHTHALMIC SUSPENSION 0.1 % (fluorometholone 2 acetate) flunisolide nasal solution 25 mcg/act (0.025%) 1 fluocinolone acetonide otic oil 0.01 % 1 fluorometholone ophthalmic suspension 0.1 % 1 SL (16 grams (1 bottle) per fluticasone propionate nasal suspension 50 mcg/act 1 prescription) FML FORTE OPHTHALMIC SUSPENSION 0.25 % 3 (fluorometholone) FML LIQUIFILM OPHTHALMIC SUSPENSION 0.1 % 3 (fluorometholone) FML OPHTHALMIC OINTMENT 0.1 % ( fluorometholone) 3 hydrocortisone-acetic acid otic solution 1-2 % 1 INVELTYS OPHTHALMIC SUSPENSION 1 % (loteprednol 3 etabonate) LOTEMAX OPHTHALMIC OINTMENT 0.5 % ( loteprednol 3 etabonate)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 131 Coverage Requirements & Prescription Drug Name Drug Tier Limits LOTEMAX SM OPHTHALMIC GEL 0.38 % (loteprednol SL (5 grams per 3 etabonate) prescription.) loteprednol etabonate ophthalmic suspension 0.5 % 1 SL (5 ml per prescription.) MAXIDEX OPHTHALMIC SUSPENSION 0.1 % 2 (dexamethasone) MAXITROL OPHTHALMIC OINTMENT 3.5-10000-0.1 3 (neomycin-polymyxin-dexameth) MAXITROL OPHTHALMIC SUSPENSION 3.5-10000-0.1 3 (neomycin-polymyxin-dexameth) neomycin-polymyxin-dexameth ophthalmic ointment 3.5-10000- 1 0.1 neomycin-polymyxin-dexameth ophthalmic suspension 3.5- 1 10000-0.1 neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1 1 neomycin-polymyxin-hc otic solution 1 %, 3.5-10000-1 1 neomycin-polymyxin-hc otic suspension 3.5-10000-1 1 neo-polycin hc ophthalmic ointment 1 % 1 PRED MILD OPHTHALMIC SUSPENSION 0.12 % 3 (prednisolone acetate) PRED-G OPHTHALMIC SUSPENSION 0.3-1 % (gentamicin- 3 prednisolone acet) PRED-G S.O.P. OPHTHALMIC OINTMENT 0.3-0.6 % 3 (gentamicin-prednisolone acet) prednisolone acetate ophthalmic suspension 1 % 1 prednisolone sodium phosphate ophthalmic solution 1 % 1 sulfacetamide-prednisolone ophthalmic solution 10-0.23 % 1 TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 % (tobramycin- 3 dexamethasone) TOBRADEX OPHTHALMIC SUSPENSION 0.3-0.1 % 3 (tobramycin-dexamethasone) tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 % 1 ZETONNA NASAL AEROSOL SOLUTION 37 MCG/ACT SL (6.1 grams per 3 (ciclesonide) prescription.) ZYLET OPHTHALMIC SUSPENSION 0.5-0.3 % (loteprednol- 3 tobramycin) EENT ANTI-INFECTIVES, MISCELLANEOUS - Drugs for Infections ARZOL SILVER NIT APPLICATORS EXTERNAL 75-25 % 1 (silver nitrate-pot nitrate)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 132 Coverage Requirements & Prescription Drug Name Drug Tier Limits BETADINE OPHTHALMIC PREP OPHTHALMIC SOLUTION 5 3 % (povidone-iodine) chlorhexidine gluconate mouth/throat solution 0.12 % 1 cortic-nd otic solution 10-10-1 mg/ml 1 PERIDEX MOUTH/THROAT SOLUTION 0.12 % (chlorhexidine 3 gluconate) periogard mouth/throat solution 0.12 % 1 PRAMOTIC OTIC LIQUID 1-0.1 % (pramoxine-chloroxylenol) 3 silver nitrate external solution 0.5 %, 10 %, 25 %, 50 % 1 EENT ANTI-INFLAMMATORY AGENTS, MISC. - Drugs for Inflammation PA; SL (60 vials per RESTASIS OPHTHALMIC EMULSION 0.05 % (cyclosporine) 3 prescription.) PA; SL (60 vials per XIIDRA OPHTHALMIC SOLUTION 5 % () 3 prescription.) EENT DRUGS, MISCELLANEOUS acetic acid otic solution 2 % 1 apraclonidine hcl ophthalmic solution 0.5 % 1 cromolyn sodium ophthalmic solution 4 % 1 cromolyn sodium oral concentrate 100 mg/5ml 1 CYSTADROPS OPHTHALMIC SOLUTION 0.37 % (cysteamine 3 PA; SL (20 mL per 21 days) hcl) CYSTARAN OPHTHALMIC SOLUTION 0.44 % (cysteamine PA; SL (60 ml (4 bottles) per 2 hcl) month.); SP DEBACTEROL MOUTH/THROAT SOLUTION 30-50 % (sulfuric 2 acid-sulf phenolics) hydrocortisone-acetic acid otic solution 1-2 % 1 IOPIDINE OPHTHALMIC SOLUTION 1 % (apraclonidine hcl) 3 LACRISERT OPHTHALMIC INSERT 5 MG (artificial tear insert) 2 MUCOSITISRX MOUTH/THROAT PACKET (artificial saliva) 3 OXERVATE OPHTHALMIC SOLUTION 0.002 % (cenegermin- PA; SL (1 ml per day and 56 3 bkbj) ml per 365 days.); SP EENT NONSTEROIDAL ANTI-INFLAM. AGENTS - Drugs for Inflammation ACULAR LS OPHTHALMIC SOLUTION 0.4 % (ketorolac 3 tromethamine) ACULAR OPHTHALMIC SOLUTION 0.5 % (ketorolac 3 tromethamine)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 133 Coverage Requirements & Prescription Drug Name Drug Tier Limits diclofenac sodium ophthalmic solution 0.1 % 1 flurbiprofen sodium ophthalmic solution 0.03 % 1 ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 % 1 NEVANAC OPHTHALMIC SUSPENSION 0.1 % (nepafenac) 3 LOCAL ANESTHETICS (EENT) - Drugs for Numbing AKTEN OPHTHALMIC GEL 3.5 % (lidocaine hcl) 3 ALCAINE OPHTHALMIC SOLUTION 0.5 % (proparacaine hcl) 3 ALTACAINE OPHTHALMIC SOLUTION 0.5 % (tetracaine hcl) 3 cortic-nd otic solution 10-10-1 mg/ml 1 lidocaine viscous hcl mouth/throat solution 2 % 1 PRAMOTIC OTIC LIQUID 1-0.1 % (pramoxine-chloroxylenol) 3 proparacaine hcl ophthalmic solution 0.5 % 1 tetracaine hcl ophthalmic solution 0.5 % 1 MIOTICS - Drugs for the Eye ISOPTO CARPINE OPHTHALMIC SOLUTION 1 %, 2 %, 4 % 3 (pilocarpine hcl) pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % 1 MYDRIATICS - Drugs for the Eye altafrin ophthalmic solution 10 %, 2.5 % 1 atropine sulfate ophthalmic ointment 1 % 1 atropine sulfate ophthalmic solution 1 % 1 CYCLOGYL OPHTHALMIC SOLUTION 0.5 %, 1 %, 2 % 3 (cyclopentolate hcl) CYCLOMYDRIL OPHTHALMIC SOLUTION 0.2-1 % 3 (cyclopentolate-phenylephrine) cyclopentolate hcl ophthalmic solution 0.5 %, 1 %, 2 % 1 homatropaire ophthalmic solution 5 % 1 ISOPTO ATROPINE OPHTHALMIC SOLUTION 1 % (atropine 3 sulfate) phenylephrine hcl ophthalmic solution 10 %, 2.5 % 1 ANALOGS - Drugs for the Eye latanoprost ophthalmic solution 0.005 % 1 LUMIGAN OPHTHALMIC SOLUTION 0.01 % (bimatoprost) 2 ROCKLATAN OPHTHALMIC SOLUTION 0.02-0.005 % 3 SL (2.5 mL per prescription.) (netarsudil-latanoprost) travoprost (bak free) ophthalmic solution 0.004 % 1 SL (2.5 ml per prescription)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 134 Coverage Requirements & Prescription Drug Name Drug Tier Limits XELPROS OPHTHALMIC EMULSION 0.005 % (latanoprost) 3 SL (2.5 ml per prescription.) ST; SL (30 unit of use ZIOPTAN OPHTHALMIC SOLUTION 0.0015 % (tafluprost) 3 droppers per prescription.) RHO KINASE INHIBITORS - Drugs for the Eye RHOPRESSA OPHTHALMIC SOLUTION 0.02 % (netarsudil 3 SL (2.5 ml per prescription.) dimesylate) ROCKLATAN OPHTHALMIC SOLUTION 0.02-0.005 % 3 SL (2.5 mL per prescription.) (netarsudil-latanoprost) VASOCONSTRICTORS ADRENALIN NASAL SOLUTION 0.1 % (epinephrine hcl 2 (nasal)) altafrin ophthalmic solution 10 %, 2.5 % 1 CYCLOMYDRIL OPHTHALMIC SOLUTION 0.2-1 % 3 (cyclopentolate-phenylephrine) phenylephrine hcl ophthalmic solution 10 %, 2.5 % 1 PA; SL (30 single-use vials UPNEEQ OPHTHALMIC SOLUTION 0.1 % (oxymetazoline hcl) 3 per prescription.) GASTROINTESTINAL DRUGS ANTACIDS AND ADSORBENTS SODIUM BICARBONATE ORAL POWDER 3 GASTROINTESTINAL DRUGS - Drugs for the Stomach 5-HT3 RECEPTOR ANTAGONISTS - Drugs for Vomiting and AKYNZEO ORAL CAPSULE 300-0.5 MG (netupitant- SL (1 capsule per 3 palonosetron) prescription.) granisetron hcl oral tablet 1 mg 1 ondansetron hcl oral solution 4 mg/5ml 1 ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg 1 ondansetron odt oral tablet dispersible 4 mg, 8 mg 1 ANTIDIARRHEA AGENTS - Drugs for Diarrhea diphenoxylate-atropine oral liquid 2.5-0.025 mg/5ml 1 diphenoxylate-atropine oral tablet 2.5-0.025 mg 1 LOMOTIL ORAL TABLET 2.5-0.025 MG (diphenoxylate- 3 atropine) MYTESI ORAL TABLET DELAYED RELEASE 125 MG 3 PA; SL (2 tablets per day.) (crofelemer) opium oral tincture 10 mg/ml (1%) 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 135 Coverage Requirements & Prescription Drug Name Drug Tier Limits PYLERA ORAL CAPSULE 140-125-125 MG (bis subcit- SL (120 capsules per 180 3 metronid-tetracyc) days.) PA; SL (3 tablets per day.); XERMELO ORAL TABLET 250 MG (telotristat etiprate) 3 SP ANTIEMETICS, MISCELLANEOUS - Drugs for Vomiting and Nausea dronabinol oral capsule 10 mg, 2.5 mg, 5 mg 1 MARINOL ORAL CAPSULE 10 MG, 2.5 MG, 5 MG (dronabinol) 3 promethazine hcl oral solution 6.25 mg/5ml 1 promethazine hcl oral syrup 6.25 mg/5ml 1 promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg 1 promethazine hcl rectal suppository 12.5 mg, 25 mg 1 promethegan rectal suppository 12.5 mg, 25 mg, 50 mg 1 scopolamine transdermal patch 72 hour 1 mg/3days 1 SYNDROS ORAL SOLUTION 5 MG/ML (dronabinol) 3 PA; SL (4 ml per day.) ANTIHISTAMINES (GI DRUGS) - Drugs for Vomiting and Nausea ANTIVERT ORAL TABLET 50 MG ( meclizine hcl) 2 compro rectal suppository 25 mg 1 prochlorperazine maleate oral tablet 10 mg, 5 mg 1 prochlorperazine rectal suppository 25 mg 1 trimethobenzamide hcl oral capsule 300 mg 1 ANTI-INFLAMMATORY AGENTS (GI DRUGS) - Drugs for Inflammation alosetron hcl oral tablet 0.5 mg, 1 mg 1 PA; SL (2 tablets per day) APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 1 0.375 GM (mesalamine) AZULFIDINE EN-TABS ORAL TABLET DELAYED RELEASE 3 500 MG (sulfasalazine) AZULFIDINE ORAL TABLET 500 MG (sulfasalazine) 3 balsalazide disodium oral capsule 750 mg 1 DIPENTUM ORAL CAPSULE 250 MG (olsalazine sodium) 3 LIALDA ORAL TABLET DELAYED RELEASE 1.2 GM 1 (mesalamine) mesalamine rectal enema 4 gm 1 mesalamine rectal suppository 1000 mg 1 SL (1 suppository per day.) mesalamine-cleanser rectal kit 4 gm 1 SL (4 grams per month.)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 136 Coverage Requirements & Prescription Drug Name Drug Tier Limits ROWASA RECTAL KIT 4 GM (mesalamine-cleanser) 3 SL (4 grams per month.) SFROWASA RECTAL ENEMA 4 GM/60ML (mesalamine) 3 sulfasalazine oral tablet 500 mg 1 sulfasalazine oral tablet delayed release 500 mg 1 ANTIULCER AGENTS AND ACID SUPPRESS.,MISC - Drugs for Ulcers and Stomach Acid PYLERA ORAL CAPSULE 140-125-125 MG (bis subcit- SL (120 capsules per 180 3 metronid-tetracyc) days.) ANTIULCER AGENTS AND ACID SUPPRESSANTS - Drugs for Ulcers and Stomach Acid amoxicillin oral capsule 250 mg, 500 mg 1 amoxicillin oral suspension reconstituted 125 mg/5ml, 200 1 mg/5ml, 250 mg/5ml, 400 mg/5ml amoxicillin oral tablet 500 mg, 875 mg 1 amoxicillin oral tablet chewable 125 mg, 250 mg 1 clarithromycin er oral tablet extended release 24 hour 500 mg 1 clarithromycin oral suspension reconstituted 125 mg/5ml, 250 1 mg/5ml clarithromycin oral tablet 250 mg, 500 mg 1 FLAGYL ORAL CAPSULE 375 MG (metronidazole) 3 FLAGYL ORAL TABLET 500 MG (metronidazole) 3 metronidazole oral capsule 375 mg 1 metronidazole oral tablet 250 mg, 500 mg 1 SODIUM BICARBONATE ORAL POWDER 3 tetracycline hcl oral capsule 250 mg, 500 mg 1 CATHARTICS AND LAXATIVES - Drugs for Constipation cascara sagrada oral fluid extract 1 gm/ml 1 CITRANATAL BLOOM ORAL TABLET 90-1 MG ( prenatal-dss- 3 fecb-fegl-fa) CLENPIQ ORAL SOLUTION 10-3.5-12 MG-GM -GM/160ML 3 (sod picosulfate-mag ox-cit acd) gavilyte-c oral solution reconstituted 240 gm 1 H SL (400 mL per gavilyte-g oral solution reconstituted 236 gm 1 prescription.); H SL (4000 ml per gavilyte-n with flavor pack oral solution reconstituted 420 gm 1 prescription.); H GOLYTELY ORAL SOLUTION RECONSTITUTED 236 GM 3 SL (400 mL per prescription.) (peg 3350-kcl-nabcb-nacl-nasulf) Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 137 Coverage Requirements & Prescription Drug Name Drug Tier Limits mineral oil heavy oral oil 1 MOVIPREP ORAL SOLUTION RECONSTITUTED 100 GM 3 SL (1 kit per prescription.) (peg-kcl-nacl-nasulf-na asc-c) NULYTELY LEMON-LIME ORAL SOLUTION SL (4000 ml per 3 RECONSTITUTED 420 GM (peg 3350-kcl-na bicarb-nacl) prescription.) SL (4000 ml per peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm 1 prescription.); H SL (400 mL per peg-3350/electrolytes oral solution reconstituted 236 gm 1 prescription.); H peg-3350/electrolytes/ascorbat oral solution reconstituted 100 1 SL (1 kit per prescription.) gm peg-kcl-nacl-nasulf-na asc-c oral solution reconstituted 100 gm 1 SL (1 kit per prescription.) peg-prep oral kit 5-210 mg-gm 1 PLENVU ORAL SOLUTION RECONSTITUTED 140 GM (peg- SL (3 cartons per 3 kcl-nacl-nasulf-na asc-c) prescription.) PRENAISSANCE ORAL CAPSULE 29-1.25-325 MG 2 SUPREP BOWEL PREP KIT ORAL SOLUTION 17.5-3.13-1.6 3 SL (354 ml per prescription.) GM/177ML (na sulfate-k sulfate-mg sulf) SUTAB ORAL TABLET 1479-225-188 MG (sodium sulfate-mag 3 sulfate-kcl) TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1-500 3 MG (prenatal-fefum-fa-dss-fish oil) CHOLELITHOLYTIC AGENTS - Drugs for the Stomach CHENODAL ORAL TABLET 250 MG (chenodiol) 3 SP URSO 250 ORAL TABLET 250 MG (ursodiol) 3 URSO FORTE ORAL TABLET 500 MG (ursodiol) 3 ursodiol oral capsule 300 mg 1 ursodiol oral tablet 250 mg, 500 mg 1 DIGESTANTS - Drugs for the Stomach CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000-38000 UNIT, 24000-76000 UNIT, 3000-9500 UNIT, 2 36000-114000 UNIT, 6000-19000 UNIT (pancrelipase (lip-prot- amyl)) PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500-35500 UNIT, 16800-56800 UNIT, 21000- 3 ST 54700 UNIT, 2600-8800 UNIT, 37000-97300 UNIT, 4200-14200 UNIT (pancrelipase (lip-prot-amyl))

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 138 Coverage Requirements & Prescription Drug Name Drug Tier Limits PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES 16000-57500 UNIT, 24000-86250 UNIT, 4000-14375 UNIT, 3 ST 8000-28750 UNIT (pancrelipase (lip-prot-amyl)) VIOKACE ORAL TABLET 10440-39150 UNIT, 20880-78300 3 ST UNIT (pancrelipase (lip-prot-amyl)) ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000-63000 UNIT, 2 25000-79000 UNIT, 3000-10000 UNIT, 40000-126000 UNIT, 5000-24000 UNIT (pancrelipase (lip-prot-amyl)) GI DRUGS, MISCELLANEOUS - Drugs for the Stomach alvimopan oral capsule 12 mg 1 PA; ST; SL (2 capsules per AMITIZA ORAL CAPSULE 24 MCG, 8 MCG (lubiprostone) 3 day.) PA; SL (4 capsules per day.); CHOLBAM ORAL CAPSULE 250 MG, 50 MG (cholic acid) 2 SP CIMZIA PREFILLED KIT SUBCUTANEOUS KIT 2 X 200 PA; SL (1 kit per 21 days.); 2 MG/ML (certolizumab pegol) SP CIMZIA STARTER KIT SUBCUTANEOUS KIT 6 X 200 MG/ML PA; SL (6 mL per 365 days.); 2 (certolizumab pegol) SP ENTEREG ORAL CAPSULE 12 MG (alvimopan) 3 GATTEX SUBCUTANEOUS KIT 5 MG ( (rdna)) 2 PA; SL (1 vial per day.); SP HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PA; SL (3 syringes per 2 PREFILLED SYRINGE KIT 80 MG/0.8ML (adalimumab) year.); SP HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML & 40MG/0.4ML 2 PA; SL (2 kits per year.); SP (adalimumab) HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 PA; SL (2 pens per month.); 2 MG/0.4ML, 80 MG/0.8ML (adalimumab) SP HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 PA; SL (2 syringes per 2 MG/0.8ML (adalimumab) month.); SP HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN- PA; SL (6 pens (1 kit) per 2 INJECTOR KIT 40 MG/0.8ML (adalimumab) year.); SP HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN- PA; SL (3 pens per year.); 2 INJECTOR KIT 80 MG/0.8ML (adalimumab) SP HUMIRA PEN-PEDIATRIC UC START SUBCUTANEOUS PA; SL (3 pens per year.); 2 PEN-INJECTOR KIT 80 MG/0.8ML (adalimumab) SP HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PA; SL (4 pens (1 kit) per 2 PEN-INJECTOR KIT 40 MG/0.8ML (adalimumab) year.); SP

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 139 Coverage Requirements & Prescription Drug Name Drug Tier Limits HUMIRA PEN-PSOR/UVEIT STARTER SUBCUTANEOUS PA; SL (3 pens per year.); PEN-INJECTOR KIT 80 MG/0.8ML & 40MG/0.4ML 2 SP (adalimumab) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 PA; SL (2 syringes per 2 MG/0.1ML, 20 MG/0.2ML, 40 MG/0.4ML (adalimumab) month.); SP HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 40 PA; SL (2 syringes per 2 MG/0.8ML (adalimumab) month.) LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG 2 PA; SL (1 capsule per day.) (linaclotide) PA; ST; SL (2 capsules per LUBIPROSTONE ORAL CAPSULE 24 MCG, 8 MCG 3 day.) MOTEGRITY ORAL TABLET 1 MG, 2 MG (prucalopride 3 PA; SL (1 tablet per day.) succinate) PA; ST; SL (1 tablet per OCALIVA ORAL TABLET 10 MG, 5 MG (obeticholic acid) 3 day.); SP octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 1 PA 200 mcg/ml, 50 mcg/ml, 500 mcg/ml RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML 3 PA; SL (0.6 ml per day.) (methylnaltrexone bromide) RELISTOR SUBCUTANEOUS SOLUTION 8 MG/0.4ML 3 PA; SL (0.4 ml per day.) (methylnaltrexone bromide) SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; SL (1 syringe per 21 2 100 MG/ML (golimumab) days.); SP SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 PA; SL (0.5 ml (1 syringe) 2 MG/0.5ML (golimumab) per month); SP SIMPONI SUBCUTANEOUS SOLUTION PREFILLED PA; SL (1 syringe per 21 2 SYRINGE 100 MG/ML (golimumab) days.); SP SIMPONI SUBCUTANEOUS SOLUTION PREFILLED PA; SL (0.5 ml (1 syringe) 2 SYRINGE 50 MG/0.5ML (golimumab) per month); SP SYMPROIC ORAL TABLET 0.2 MG (naldemedine tosylate) 2 PA; SL (1 tablet per day.) TRULANCE ORAL TABLET 3 MG (plecanatide) 3 PA; ST; SL (1 tablet per day.) VIBERZI ORAL TABLET 100 MG, 75 MG (eluxadoline) 3 PA; SL (2 tablets per day.) XENICAL ORAL CAPSULE 120 MG (orlistat) 3 PA HISTAMINE H2-ANTAGONISTS - Drugs for Ulcers and Stomach Acid cimetidine hcl oral solution 300 mg/5ml, 400 mg/6.67ml 1 cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg 1 famotidine oral suspension reconstituted 40 mg/5ml 1 nizatidine oral solution 15 mg/ml 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 140 Coverage Requirements & Prescription Drug Name Drug Tier Limits NEUROKININ-1 RECEPTOR ANTAGONISTS - Drugs for Vomiting and Nausea AKYNZEO ORAL CAPSULE 300-0.5 MG (netupitant- SL (1 capsule per 3 palonosetron) prescription.) SL (3 capsules per aprepitant oral 80 & 125 mg 1 prescription) SL (1 capsule per aprepitant oral capsule 125 mg, 40 mg 1 prescription) SL (3 capsules per aprepitant oral capsule 80 & 125 mg 1 prescription) SL (2 capsules per aprepitant oral capsule 80 mg 1 prescription) SL (2 capsules per EMEND ORAL CAPSULE 80 MG (aprepitant) 3 prescription) EMEND ORAL SUSPENSION RECONSTITUTED 125 MG/5ML SL (3 pouches per 2 (aprepitant) prescription.) SL (3 capsules per EMEND TRI-PACK ORAL CAPSULE 80 & 125 MG (aprepitant) 3 prescription) PROKINETIC AGENTS - Drugs for the Stomach hcl oral solution 10 mg/10ml, 5 mg/5ml 1 metoclopramide hcl oral tablet 10 mg, 5 mg 1 REGLAN ORAL TABLET 10 MG, 5 MG (metoclopramide hcl) 3 PA; ST; SL (2 tablets per ZELNORM ORAL TABLET 6 MG ( tegaserod maleate) 3 day.) - Drugs for Ulcers and Stomach Acid CYTOTEC ORAL TABLET 100 MCG, 200 MCG (misoprostol) 3 diclofenac-misoprostol oral tablet delayed release 50-0.2 mg, 1 75-0.2 mg misoprostol oral tablet 100 mcg, 200 mcg 1 PROTECTANTS - Drugs for Ulcers and Stomach Acid sucralfate oral suspension 1 gm/10ml 1 sucralfate oral tablet 1 gm 1 PROTON-PUMP INHIBITORS - Drugs for Ulcers and Stomach Acid DEXILANT ORAL CAPSULE DELAYED RELEASE 30 MG, 60 3 SL (1 capsule per day) MG (dexlansoprazole) PA; ST; SL (1 packet per esomeprazole magnesium oral packet 10 mg, 20 mg, 40 mg 1 day)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 141 Coverage Requirements & Prescription Drug Name Drug Tier Limits FIRST-LANSOPRAZOLE ORAL SUSPENSION 3 MG/ML 3 PA (lansoprazole) FIRST-OMEPRAZOLE ORAL SUSPENSION 2 MG/ML 3 PA (omeprazole) lansoprazole oral tablet delayed release dispersible 15 mg, 30 1 PA; ST; SL (1 tablet per day.) mg NEXIUM ORAL PACKET 10 MG, 20 MG, 40 MG PA; ST; SL (1 packet per 3 (esomeprazole magnesium) day) NEXIUM ORAL PACKET 2.5 MG, 5 MG (esomeprazole PA; ST; SL (1 packet per 3 magnesium) day.) SL (1 carton (10 OMECLAMOX-PAK ORAL 500-500-20 MG (amoxicill-clarithro- 3 administrative cards, 80 omeprazole) tablets) per 6 months.) omeprazole oral capsule delayed release 10 mg, 20 mg, 40 mg 1 OMEPRAZOLE+SYRSPEND SF ALKA ORAL SUSPENSION 2 3 PA MG/ML (omeprazole) pantoprazole sodium oral tablet delayed release 20 mg, 40 mg 1 rabeprazole sodium oral tablet delayed release 20 mg 1 SL (1 tablet per day) GOLD COMPOUNDS GOLD COMPOUNDS RIDAURA ORAL CAPSULE 3 MG (auranofin) 3 SP HEAVY METAL ANTAGONISTS - Drugs to Reduce Iron HEAVY METAL ANTAGONISTS - Drugs to Reduce Iron CHEMET ORAL CAPSULE 100 MG (succimer) 2 clovique oral capsule 250 mg 1 PA; SP deferasirox granules oral packet 180 mg, 360 mg, 90 mg 1 PA; SP deferasirox oral packet 180 mg, 360 mg, 90 mg 1 PA; SP deferasirox oral tablet 180 mg, 360 mg, 90 mg 1 PA; SP deferasirox oral tablet soluble 125 mg, 250 mg, 500 mg 1 PA; SP deferiprone oral tablet 500 mg 1 PA; SP DEPEN TITRATABS ORAL TABLET 250 MG ( ) 2 SP FERRIPROX ORAL SOLUTION 100 MG/ML (deferiprone) 2 PA; SP FERRIPROX ORAL TABLET 1000 MG (deferiprone) 3 FERRIPROX ORAL TABLET 500 MG (deferiprone) 3 PA; SP penicillamine oral capsule 250 mg 1 SP penicillamine oral tablet 250 mg 1 SP trientine hcl oral capsule 250 mg 1 PA; SP

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 142 Coverage Requirements & Prescription Drug Name Drug Tier Limits HORMONES AND SYNTHETIC SUBSTITUTES - Hormones ADRENALS - Hormones ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 1 SL (2 blisters per day) MCG/DOSE (fluticasone-salmeterol) ADVAIR HFA INHALATION AEROSOL 115-21 MCG/ACT, 230- 3 SL (0.4 grams per day.) 21 MCG/ACT, 45-21 MCG/ACT (fluticasone-salmeterol) ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT 1 SL (1 blister per day.) (fluticasone furoate) ARNUITY ELLIPTA INHALATION AEROSOL POWDER 1 SL (1 packet per day.) BREATH ACTIVATED 50 MCG/ACT (fluticasone furoate) BREO ELLIPTA INHALATION AEROSOL POWDER BREATH 3 SL (2 inhalers per day.) ACTIVATED 100-25 MCG/INH (fluticasone furoate-vilanterol) BREO ELLIPTA INHALATION AEROSOL POWDER BREATH 3 SL (2 blisters per day.) ACTIVATED 200-25 MCG/INH (fluticasone furoate-vilanterol) BREZTRI AEROSPHERE INHALATION AEROSOL 160-9-4.8 3 SL (0.36 grams per day.) MCG/ACT (budeson-glycopyrrol-formoterol) SL (120 ml (2 boxes) per 30 budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml 1 days.) SL (60 ml (1 box) per 30 budesonide inhalation suspension 1 mg/2ml 1 days.) budesonide oral capsule delayed release particles 3 mg 1 CORTEF ORAL TABLET 10 MG, 20 MG, 5 MG 3 (hydrocortisone) dexamethasone intensol oral concentrate 1 mg/ml 1 dexamethasone oral elixir 0.5 mg/5ml 1 dexamethasone oral solution 0.5 mg/5ml 1 dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 1 mg, 4 mg, 6 mg dexamethasone oral tablet therapy pack 1.5 mg (21), 1.5 mg 1 (35), 1.5 mg (51) FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 50 MCG/BLIST 1 SL (2 packages per day) (fluticasone propionate (inhal)) FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 250 MCG/BLIST (fluticasone propionate 1 SL (4 packages per day) (inhal)) FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 44 1 SL (1 inhaler per month) MCG/ACT (fluticasone propionate hfa)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 143 Coverage Requirements & Prescription Drug Name Drug Tier Limits FLOVENT HFA INHALATION AEROSOL 220 MCG/ACT 1 SL (2 inhalers per month) (fluticasone propionate hfa) fludrocortisone acetate oral tablet 0.1 mg 1 flunisolide nasal solution 25 mcg/act (0.025%) 1 SL (16 grams (1 bottle) per fluticasone propionate nasal suspension 50 mcg/act 1 prescription) FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 1 SL (0.04 mcg per day.) MCG/ACT, 55-14 MCG/ACT hydrocortisone oral tablet 10 mg, 20 mg, 5 mg 1 MEDROL ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG 3 (methylprednisolone) MEDROL ORAL TABLET 2 MG (methylprednisolone) 2 MEDROL ORAL TABLET THERAPY PACK 4 MG 3 (methylprednisolone) methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg 1 methylprednisolone oral tablet therapy pack 4 mg 1 MILLIPRED ORAL TABLET 5 MG (prednisolone) 2 ORAPRED ODT ORAL TABLET DISPERSIBLE 10 MG, 15 MG, 3 30 MG (prednisolone sodium phosphate) PEDIAPRED ORAL SOLUTION 6.7 (5 BASE) MG/5ML 2 (prednisolone sodium phosphate) prednisolone oral solution 15 mg/5ml 1 prednisolone sodium phosphate oral solution 10 mg/5ml, 15 1 mg/5ml, 20 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml prednisolone sodium phosphate oral tablet dispersible 10 mg, 1 15 mg, 30 mg prednisone intensol oral concentrate 5 mg/ml 1 prednisone oral solution 5 mg/5ml 1 prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 1 mg prednisone oral tablet therapy pack 10 mg (21), 10 mg (48), 5 1 mg (21), 5 mg (48) PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT 1 SL (2 inhalers per month) (budesonide) SYMBICORT INHALATION AEROSOL 160-4.5 MCG/ACT, 80- 3 SL (0.34 grams per day.) 4.5 MCG/ACT (budesonide-formoterol fumarate)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 144 Coverage Requirements & Prescription Drug Name Drug Tier Limits TAPERDEX 12-DAY ORAL TABLET THERAPY PACK 1.5 MG 3 (49) (dexamethasone) TAPERDEX 6-DAY ORAL TABLET THERAPY PACK 1.5 MG, 3 1.5 MG (21) (dexamethasone) TAPERDEX 7-DAY ORAL TABLET THERAPY PACK 1.5 MG 3 (27) (dexamethasone) TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-62.5-25 MCG/INH, 200-62.5-25 3 SL (2 blisters per day.) MCG/INH (fluticasone-umeclidin-vilant) UCERIS ORAL TABLET EXTENDED RELEASE 24 HOUR 9 1 MG (budesonide) ALPHA-GLUCOSIDASE INHIBITORS - Drugs for Diabetes acarbose oral tablet 100 mg, 25 mg, 50 mg 1 miglitol oral tablet 100 mg, 25 mg, 50 mg 1 PRECOSE ORAL TABLET 100 MG, 25 MG, 50 MG (acarbose) 3 AMYLINOMIMETICS - Drugs for Diabetes SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN- SL (4 pens (10.8 ml) per 3 INJECTOR 2700 MCG/2.7ML ( acetate) month.) SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN- 3 SL (4 pens (6 ml) per month.) INJECTOR 1500 MCG/1.5ML (pramlintide acetate) ANDROGENS - Hormones ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 2 PA; SL (1 patch per day) MG/24HR, 4 MG/24HR (testosterone) COVARYX HS ORAL TABLET 0.625-1.25 MG (est - 3 methyltest) COVARYX ORAL TABLET 1.25-2.5 MG (est estrogens- 2 methyltest) danazol oral capsule 100 mg, 200 mg, 50 mg 1 DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 100 3 MG/ML, 200 MG/ML (testosterone cypionate) EEMT HS ORAL TABLET 0.625-1.25 MG (est estrogens- 3 methyltest) EEMT ORAL TABLET 1.25-2.5 MG (est estrogens-methyltest) 2 est estrogens-methyltest ds oral tablet 1.25-2.5 mg 1 est estrogens-methyltest hs oral tablet 0.625-1.25 mg 1 est estrogens-methyltest oral tablet 0.625-1.25 mg, 1.25-2.5 mg 1 METHITEST ORAL TABLET 10 MG 2 methyltestosterone oral capsule 10 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 145 Coverage Requirements & Prescription Drug Name Drug Tier Limits oxandrolone oral tablet 10 mg, 2.5 mg 1 PA; SL (100 mg TESTIM TRANSDERMAL GEL 50 MG/5GM (1%) ( testosterone) 1 Testosterone (2 X 5 grams tubes = 10 grams) per day) testosterone cypionate intramuscular solution 100 mg/ml, 200 1 mg/ml testosterone enanthate intramuscular solution 200 mg/ml 1 ANTIDIABETIC AGENTS, MISCELLANEOUS - Drugs for Diabetes CYCLOSET ORAL TABLET 0.8 MG (bromocriptine mesylate) 3 WELCHOL ORAL PACKET 3.75 GM (colesevelam hcl) 1 WELCHOL ORAL TABLET 625 MG (colesevelam hcl) 1 ANTIESTROGENS - Drugs for Women anastrozole oral tablet 1 mg 1 exemestane oral tablet 25 mg 1 KISQALI FEMARA ORAL TABLET THERAPY PACK 200 & 2.5 3 PA; ST; CM MG (ribociclib-letrozole) letrozole oral tablet 2.5 mg 1 ANTIGONADTROPINS - Hormones FIRMAGON (240 MG DOSE) SUBCUTANEOUS SOLUTION 3 SP RECONSTITUTED 120 MG/VIAL (degarelix acetate) FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 3 SP 80 MG (degarelix acetate) PA; SL (1 tablet per day); ORGOVYX ORAL TABLET 120 MG (relugolix) 3 SP; CM ORIAHNN ORAL CAPSULE THERAPY PACK 300-1-0.5 & 300 3 PA; SL (2 capsules per day.) MG (elagolix--norethind) ORILISSA ORAL TABLET 150 MG (elagolix sodium) 3 PA; SL (1 tablet per day.) ORILISSA ORAL TABLET 200 MG (elagolix sodium) 3 PA; SL (2 tablets per day.) ANTIHYPOGLYCEMIC AGENTS, MISCELLANEOUS - Hormones diazoxide oral suspension 50 mg/ml 1 ANTIPARATHYROID AGENTS - Drugs for Bones calcitonin (salmon) injection solution 200 unit/ml 1 calcitonin (salmon) nasal solution 200 unit/act 1 cinacalcet hcl oral tablet 30 mg, 60 mg, 90 mg 1 PA MIACALCIN INJECTION SOLUTION 200 UNIT/ML (calcitonin 3 (salmon))

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 146 Coverage Requirements & Prescription Drug Name Drug Tier Limits ANTITHYROID AGENTS - Drugs for the Thyroid methimazole oral tablet 10 mg, 5 mg 1 propylthiouracil oral tablet 50 mg 1 TAPAZOLE ORAL TABLET 10 MG, 5 MG (methimazole) 3 BIGUANIDES - Drugs for Diabetes ACTOPLUS MET ORAL TABLET 15-500 MG, 15-850 MG 3 SL (3 tablets per day) (pioglitazone hcl-metformin hcl) glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5- 1 500 mg glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 1 mg JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 2.5- 2 SL (2 tablets per day.) 850 MG (linagliptin-metformin hcl) JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 2 SL (2 tablets per day.) HOUR 2.5-1000 MG (linagliptin-metformin hcl) JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 2 SL (1 tablet per day.) HOUR 5-1000 MG (linagliptin-metformin hcl) KAZANO ORAL TABLET 12.5-1000 MG, 12.5-500 MG 2 SL (2 tablets per day.) (alogliptin-metformin hcl) KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 2 SL (62 tablets per month.) HOUR 2.5-1000 MG (saxagliptin-metformin) KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 2 SL (31 tablets per month.) HOUR 5-1000 MG, 5-500 MG (saxagliptin-metformin) metformin hcl er oral tablet extended release 24 hour 500 mg, 1 750 mg metformin hcl oral solution 500 mg/5ml 1 metformin hcl oral tablet 1000 mg, 500 mg, 850 mg 1 pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 mg 1 SL (3 tablets per day) SYNJARDY ORAL TABLET 12.5-1000 MG, 12.5-500 MG, 5- 2 SL (2 tablets per day.) 1000 MG, 5-500 MG (empagliflozin-metformin hcl) SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 2 SL (1 tablet per day.) HOUR 10-1000 MG, 25-1000 MG (empagliflozin-metformin hcl) SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 2 SL (2 tablets per day.) HOUR 12.5-1000 MG, 5-1000 MG (empagliflozin-metformin hcl) TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-5-1000 MG, 25-5-1000 MG (empagliflozin-linaglip- 2 SL (1 tablet per day.) metform)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 147 Coverage Requirements & Prescription Drug Name Drug Tier Limits TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 12.5-2.5-1000 MG, 5-2.5-1000 MG (empagliflozin- 2 SL (2 tablets per day.) linaglip-metform) CONTRACEPTIVES - Drugs for Women afirmelle oral tablet 0.1-20 mg-mcg 1 H altavera oral tablet 0.15-30 mg-mcg 1 H alyacen 1/35 oral tablet 1-35 mg-mcg 1 H alyacen 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H amethia oral tablet 0.15-0.03 &0.01 mg 1 H amethyst oral tablet 90-20 mcg 1 H ANNOVERA VAGINAL RING 0.013-0.15 MG/24HR SL (1 vaginal ring per 327 3 (segesterone-ethinyl estradiol) days); H apri oral tablet 0.15-30 mg-mcg 1 H aranelle oral tablet 0.5/1/0.5-35 mg-mcg 1 H ashlyna oral tablet 0.15-0.03 &0.01 mg 1 H aubra eq oral tablet 0.1-20 mg-mcg 1 H aubra oral tablet 0.1-20 mg-mcg 1 H aurovela 1.5/30 oral tablet 1.5-30 mg-mcg 1 H aurovela 1/20 oral tablet 1-20 mg-mcg 1 H aurovela 24 fe oral tablet 1-20 mg-mcg(24) 1 H aurovela fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H aurovela fe 1/20 oral tablet 1-20 mg-mcg 1 H aviane oral tablet 0.1-20 mg-mcg 1 H ayuna oral tablet 0.15-30 mg-mcg 1 H azurette oral tablet 0.15-0.02/0.01 mg (21/5) 1 H BALCOLTRA ORAL TABLET 0.1-20 MG-MCG(21) 3 H (levonorgest-eth estrad-fe bisg) balziva oral tablet 0.4-35 mg-mcg 1 H blisovi 24 fe oral tablet 1-20 mg-mcg(24) 1 H blisovi fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H blisovi fe 1/20 oral tablet 1-20 mg-mcg 1 H briellyn oral tablet 0.4-35 mg-mcg 1 H camila oral tablet 0.35 mg 1 H camrese lo oral tablet 0.1-0.02 & 0.01 mg 1 H camrese oral tablet 0.15-0.03 &0.01 mg 1 H caziant oral tablet 0.1/0.125/0.15 -0.025 mg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 148 Coverage Requirements & Prescription Drug Name Drug Tier Limits charlotte 24 fe oral tablet chewable 1-20 mg-mcg(24) 1 H chateal eq oral tablet 0.15-30 mg-mcg 1 H chateal oral tablet 0.15-30 mg-mcg 1 H cryselle-28 oral tablet 0.3-30 mg-mcg 1 H cyclafem 1/35 oral tablet 1-35 mg-mcg 1 H cyclafem 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H cyred eq oral tablet 0.15-30 mg-mcg 1 H cyred oral tablet 0.15-30 mg-mcg 1 H dasetta 1/35 oral tablet 1-35 mg-mcg 1 H dasetta 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H daysee oral tablet 0.15-0.03 &0.01 mg 1 H deblitane oral tablet 0.35 mg 1 H delyla oral tablet 0.1-20 mg-mcg 1 H DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 3 SL (5 ml per year.) MG/ML (medroxyprogesterone acetate) DEPO-PROVERA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 150 MG/ML (medroxyprogesterone 3 acetate) DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE 104 MG/0.65ML 2 SL (3.25 ml per year.); H (medroxyprogesterone acetate) desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg 1 H (21/5), 0.15-30 mg-mcg dolishale oral tablet 90-20 mcg 1 H drospiren-eth estrad-levomefol oral tablet 3-0.02-0.451 mg, 3- 1 H 0.03-0.451 mg drospirenone-ethinyl estradiol oral tablet 3-0.02 mg, 3-0.03 mg 1 H elinest oral tablet 0.3-30 mg-mcg 1 H ELLA ORAL TABLET 30 MG (ulipristal acetate) 1 SL (1 tablet per 21 days.); H emoquette oral tablet 0.15-30 mg-mcg 1 H enpresse-28 oral tablet 50-30/75-40/ 125-30 mcg 1 H enskyce oral tablet 0.15-30 mg-mcg 1 H errin oral tablet 0.35 mg 1 H estarylla oral tablet 0.25-35 mg-mcg 1 H ESTROSTEP FE ORAL TABLET 1-20/1-30/1-35 MG-MCG 3 (norethindron-ethinyl estrad-fe)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 149 Coverage Requirements & Prescription Drug Name Drug Tier Limits ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg, 1-50 mg- 1 H mcg falmina oral tablet 0.1-20 mg-mcg 1 H fayosim oral tablet 42-21-21-7 days 1 H femynor oral tablet 0.25-35 mg-mcg 1 H gemmily oral capsule 1-20 mg-mcg(24) 1 H hailey 1.5/30 oral tablet 1.5-30 mg-mcg 1 H hailey 24 fe oral tablet 1-20 mg-mcg(24) 1 H hailey fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H hailey fe 1/20 oral tablet 1-20 mg-mcg 1 H heather oral tablet 0.35 mg 1 H iclevia oral tablet 0.15-0.03 mg 1 H incassia oral tablet 0.35 mg 1 H introvale oral tablet 0.15-0.03 mg 1 H isibloom oral tablet 0.15-30 mg-mcg 1 H jaimiess oral tablet 0.15-0.03 &0.01 mg 1 H jasmiel oral tablet 3-0.02 mg 1 H jencycla oral tablet 0.35 mg 1 H jolessa oral tablet 0.15-0.03 mg 1 H juleber oral tablet 0.15-30 mg-mcg 1 H junel 1.5/30 oral tablet 1.5-30 mg-mcg 1 H junel 1/20 oral tablet 1-20 mg-mcg 1 H junel fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H junel fe 1/20 oral tablet 1-20 mg-mcg 1 H junel fe 24 oral tablet 1-20 mg-mcg(24) 1 H kaitlib fe oral tablet chewable 0.8-25 mg-mcg 1 H kalliga oral tablet 0.15-30 mg-mcg 1 H kariva oral tablet 0.15-0.02/0.01 mg (21/5) 1 H kelnor 1/35 oral tablet 1-35 mg-mcg 1 H kelnor 1/50 oral tablet 1-50 mg-mcg 1 H kurvelo oral tablet 0.15-30 mg-mcg 1 H larin 1.5/30 oral tablet 1.5-30 mg-mcg 1 H larin 1/20 oral tablet 1-20 mg-mcg 1 H larin 24 fe oral tablet 1-20 mg-mcg(24) 1 H larin fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 150 Coverage Requirements & Prescription Drug Name Drug Tier Limits larin fe 1/20 oral tablet 1-20 mg-mcg 1 H larissia oral tablet 0.1-20 mg-mcg 1 H layolis fe oral tablet chewable 0.8-25 mg-mcg 1 H leena oral tablet 0.5/1/0.5-35 mg-mcg 1 H lessina oral tablet 0.1-20 mg-mcg 1 H levonest oral tablet 50-30/75-40/ 125-30 mcg 1 H levonorgest-eth est & eth est oral tablet 42-21-21-7 days 1 H levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01 mg, 1 H 0.15-0.03 &0.01 mg, 0.15-0.03 mg levonorgestrel oral tablet 1.5 mg 1 H levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 1 H mg-mcg, 90-20 mcg levonorg-eth estrad triphasic oral tablet 50-30/75-40/ 125-30 1 H mcg levora 0.15/30 (28) oral tablet 0.15-30 mg-mcg 1 H lillow oral tablet 0.15-30 mg-mcg 1 H LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG / 10 MCG 3 H (norethin-eth estrad-fe biphas) LOESTRIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG 3 (norethindrone acet-ethinyl est) LOESTRIN 1/20 (21) ORAL TABLET 1-20 MG-MCG 3 (norethindrone acet-ethinyl est) LOESTRIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG 3 (norethin ace-eth estrad-fe) lojaimiess oral tablet 0.1-0.02 & 0.01 mg 1 H loryna oral tablet 3-0.02 mg 1 H LOSEASONIQUE ORAL TABLET 0.1-0.02 & 0.01 MG 3 (levonorgest-eth estrad 91-day) low-ogestrel oral tablet 0.3-30 mg-mcg 1 H lo-zumandimine oral tablet 3-0.02 mg 1 H lutera oral tablet 0.1-20 mg-mcg 1 H lyleq oral tablet 0.35 mg 1 H lyza oral tablet 0.35 mg 1 H marlissa oral tablet 0.15-30 mg-mcg 1 H medroxyprogesterone acetate intramuscular suspension 150 1 SL (5 ml per year.); H mg/ml medroxyprogesterone acetate intramuscular suspension 1 H prefilled syringe 150 mg/ml Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 151 Coverage Requirements & Prescription Drug Name Drug Tier Limits merzee oral capsule 1-20 mg-mcg(24) 1 H mibelas 24 fe oral tablet chewable 1-20 mg-mcg(24) 1 H microgestin 1.5/30 oral tablet 1.5-30 mg-mcg 1 H microgestin 1/20 oral tablet 1-20 mg-mcg 1 H microgestin 24 fe oral tablet 1-20 mg-mcg 1 H microgestin fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H microgestin fe 1/20 oral tablet 1-20 mg-mcg 1 H mili oral tablet 0.25-35 mg-mcg 1 H MIRCETTE ORAL TABLET 0.15-0.02/0.01 MG (21/5) 3 (desogestrel-ethinyl estradiol) mono-linyah oral tablet 0.25-35 mg-mcg 1 H NATAZIA ORAL TABLET 3/2-2/2-3/1 MG (estradiol valerate- 2 H dienogest) necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg 1 H NEXTSTELLIS ORAL TABLET 3-14.2 MG ( drospirenone- 3 H estetrol) nikki oral tablet 3-0.02 mg 1 H nora-be oral tablet 0.35 mg 1 H norethin ace-eth estrad-fe oral capsule 1-20 mg-mcg(24) 1 H norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg, 1.5-30 mg- 1 H mcg norethin ace-eth estrad-fe oral tablet chewable 1-20 mg- 1 H mcg(24) norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg, 1.5-30 1 H mg-mcg norethindrone oral tablet 0.35 mg 1 H norethin-eth estradiol-fe oral tablet chewable 0.4-35 mg-mcg, 1 H 0.8-25 mg-mcg norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg 1 H norgestimate-ethinyl estradiol triphasic oral tablet 1 H 0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg norlyda oral tablet 0.35 mg 1 H norlyroc oral tablet 0.35 mg 1 H nortrel 0.5/35 (28) oral tablet 0.5-35 mg-mcg 1 H nortrel 1/35 (21) oral tablet 1-35 mg-mcg 1 H nortrel 1/35 (28) oral tablet 1-35 mg-mcg 1 H nortrel 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 152 Coverage Requirements & Prescription Drug Name Drug Tier Limits NUVARING VAGINAL RING 0.12-0.015 MG/24HR 1 H (etonogestrel-ethinyl estradiol) nylia 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H nymyo oral tablet 0.25-35 mg-mcg 1 H ocella oral tablet 3-0.03 mg 1 H orsythia oral tablet 0.1-20 mg-mcg 1 H philith oral tablet 0.4-35 mg-mcg 1 H pimtrea oral tablet 0.15-0.02/0.01 mg (21/5) 1 H pirmella 1/35 oral tablet 1-35 mg-mcg 1 H pirmella 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H PLAN B ONE-STEP ORAL TABLET 1.5 MG ( levonorgestrel) 1 H portia-28 oral tablet 0.15-30 mg-mcg 1 H previfem oral tablet 0.25-35 mg-mcg 1 H reclipsen oral tablet 0.15-30 mg-mcg 1 H rivelsa oral tablet 42-21-21-7 days 1 H setlakin oral tablet 0.15-0.03 mg 1 H sharobel oral tablet 0.35 mg 1 H simliya oral tablet 0.15-0.02/0.01 mg (21/5) 1 H simpesse oral tablet 0.15-0.03 &0.01 mg 1 H SLYND ORAL TABLET 4 MG (drospirenone) 3 PA; ST; H sprintec 28 oral tablet 0.25-35 mg-mcg 1 H sronyx oral tablet 0.1-20 mg-mcg 1 H syeda oral tablet 3-0.03 mg 1 H tarina 24 fe oral tablet 1-20 mg-mcg(24) 1 H tarina fe 1/20 eq oral tablet 1-20 mg-mcg 1 H tarina fe 1/20 oral tablet 1-20 mg-mcg 1 H tilia fe oral tablet 1-20/1-30/1-35 mg-mcg 1 H tri femynor oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-estarylla oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-legest fe oral tablet 1-20/1-30/1-35 mg-mcg 1 H tri-linyah oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 mcg 1 H tri-lo-marzia oral tablet 0.18/0.215/0.25 mg-25 mcg 1 H tri-lo-mili oral tablet 0.18/0.215/0.25 mg-25 mcg 1 H tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 mcg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 153 Coverage Requirements & Prescription Drug Name Drug Tier Limits tri-mili oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-nymyo oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-previfem oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-sprintec oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H trivora (28) oral tablet 50-30/75-40/ 125-30 mcg 1 H tri-vylibra lo oral tablet 0.18/0.215/0.25 mg-25 mcg 1 H tri-vylibra oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tulana oral tablet 0.35 mg 1 H TWIRLA TRANSDERMAL PATCH WEEKLY 120-30 3 H MCG/24HR (levonorgestrel-eth estradiol) tyblume oral tablet chewable 0.1-20 mg-mcg 1 H tydemy oral tablet 3-0.03-0.451 mg 1 H velivet oral tablet 0.1/0.125/0.15 -0.025 mg 1 H vestura oral tablet 3-0.02 mg 1 H vienva oral tablet 0.1-20 mg-mcg 1 H viorele oral tablet 0.15-0.02/0.01 mg (21/5) 1 H volnea oral tablet 0.15-0.02/0.01 mg (21/5) 1 H vyfemla oral tablet 0.4-35 mg-mcg 1 H vylibra oral tablet 0.25-35 mg-mcg 1 H wera oral tablet 0.5-35 mg-mcg 1 H wymzya fe oral tablet chewable 0.4-35 mg-mcg 1 H xulane transdermal patch weekly 150-35 mcg/24hr 1 H YASMIN 28 ORAL TABLET 3-0.03 MG (drospirenone-ethinyl 3 estradiol) YAZ ORAL TABLET 3-0.02 MG (drospirenone-ethinyl estradiol) 3 zafemy transdermal patch weekly 150-35 mcg/24hr 1 H zarah oral tablet 3-0.03 mg 1 H zovia 1/35 (28) oral tablet 1-35 mg-mcg 1 H zovia 1/35e (28) oral tablet 1-35 mg-mcg 1 H zumandimine oral tablet 3-0.03 mg 1 H DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS - Drugs for Diabetes GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG (empagliflozin- 2 ST; SL (1 tablet per day.) linagliptin) JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 2.5- 2 SL (2 tablets per day.) 850 MG (linagliptin-metformin hcl)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 154 Coverage Requirements & Prescription Drug Name Drug Tier Limits JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 2 SL (2 tablets per day.) HOUR 2.5-1000 MG (linagliptin-metformin hcl) JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 2 SL (1 tablet per day.) HOUR 5-1000 MG (linagliptin-metformin hcl) KAZANO ORAL TABLET 12.5-1000 MG, 12.5-500 MG 2 SL (2 tablets per day.) (alogliptin-metformin hcl) KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 2 SL (62 tablets per month.) HOUR 2.5-1000 MG (saxagliptin-metformin) KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 2 SL (31 tablets per month.) HOUR 5-1000 MG, 5-500 MG (saxagliptin-metformin) NESINA ORAL TABLET 12.5 MG, 25 MG, 6.25 MG (alogliptin 2 SL (1 tablet per day.) benzoate) ONGLYZA ORAL TABLET 2.5 MG, 5 MG (saxagliptin hcl) 2 SL (1 tablet per day) OSENI ORAL TABLET 12.5-15 MG, 12.5-30 MG, 12.5-45 MG, 2 SL (1 tablet per day.) 25-15 MG, 25-30 MG, 25-45 MG (alogliptin-pioglitazone) TRADJENTA ORAL TABLET 5 MG ( linagliptin) 2 SL (1 tablet per day) TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-5-1000 MG, 25-5-1000 MG (empagliflozin-linaglip- 2 SL (1 tablet per day.) metform) TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 12.5-2.5-1000 MG, 5-2.5-1000 MG (empagliflozin- 2 SL (2 tablets per day.) linaglip-metform) AGONIST-ANTAGONISTS - Drugs for Women DUAVEE ORAL TABLET 0.45-20 MG (conj estrogens- 3 SL (1 tablet per day.) bazedoxifene) OSPHENA ORAL TABLET 60 MG (ospemifene) 3 PA; SL (1 tablet per day.) raloxifene hcl oral tablet 60 mg 1 H tamoxifen citrate oral tablet 10 mg 1 tamoxifen citrate oral tablet 20 mg 1 H-N toremifene citrate oral tablet 60 mg 1 ESTROGENS - Drugs for Women ACTIVELLA ORAL TABLET 1-0.5 MG (estradiol-norethindrone 3 acet) afirmelle oral tablet 0.1-20 mg-mcg 1 H ALORA TRANSDERMAL PATCH TWICE WEEKLY 0.025 SL (8 patches (1 box) per 28 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR 3 days.) (estradiol) altavera oral tablet 0.15-30 mg-mcg 1 H alyacen 1/35 oral tablet 1-35 mg-mcg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 155 Coverage Requirements & Prescription Drug Name Drug Tier Limits alyacen 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H amabelz oral tablet 0.5-0.1 mg, 1-0.5 mg 1 amethia oral tablet 0.15-0.03 &0.01 mg 1 H amethyst oral tablet 90-20 mcg 1 H ANGELIQ ORAL TABLET 0.25-0.5 MG, 0.5-1 MG 3 (drospirenone-estradiol) ANNOVERA VAGINAL RING 0.013-0.15 MG/24HR SL (1 vaginal ring per 327 3 (segesterone-ethinyl estradiol) days); H apri oral tablet 0.15-30 mg-mcg 1 H aranelle oral tablet 0.5/1/0.5-35 mg-mcg 1 H ashlyna oral tablet 0.15-0.03 &0.01 mg 1 H aubra eq oral tablet 0.1-20 mg-mcg 1 H aubra oral tablet 0.1-20 mg-mcg 1 H aurovela 1.5/30 oral tablet 1.5-30 mg-mcg 1 H aurovela 1/20 oral tablet 1-20 mg-mcg 1 H aurovela 24 fe oral tablet 1-20 mg-mcg(24) 1 H aurovela fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H aurovela fe 1/20 oral tablet 1-20 mg-mcg 1 H aviane oral tablet 0.1-20 mg-mcg 1 H ayuna oral tablet 0.15-30 mg-mcg 1 H azurette oral tablet 0.15-0.02/0.01 mg (21/5) 1 H BALCOLTRA ORAL TABLET 0.1-20 MG-MCG(21) 3 H (levonorgest-eth estrad-fe bisg) balziva oral tablet 0.4-35 mg-mcg 1 H BIJUVA ORAL CAPSULE 1-100 MG (estradiol-) 3 blisovi 24 fe oral tablet 1-20 mg-mcg(24) 1 H blisovi fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H blisovi fe 1/20 oral tablet 1-20 mg-mcg 1 H briellyn oral tablet 0.4-35 mg-mcg 1 H camrese lo oral tablet 0.1-0.02 & 0.01 mg 1 H camrese oral tablet 0.15-0.03 &0.01 mg 1 H caziant oral tablet 0.1/0.125/0.15 -0.025 mg 1 H charlotte 24 fe oral tablet chewable 1-20 mg-mcg(24) 1 H chateal eq oral tablet 0.15-30 mg-mcg 1 H chateal oral tablet 0.15-30 mg-mcg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 156 Coverage Requirements & Prescription Drug Name Drug Tier Limits CLIMARA PRO TRANSDERMAL PATCH WEEKLY 0.045- 3 SL (4 patches per month.) 0.015 MG/DAY (estradiol-levonorgestrel) COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY (estradiol-norethindrone 3 SL (8 patches per 28 days.) acet) COVARYX HS ORAL TABLET 0.625-1.25 MG (est estrogens- 3 methyltest) COVARYX ORAL TABLET 1.25-2.5 MG (est estrogens- 2 methyltest) cryselle-28 oral tablet 0.3-30 mg-mcg 1 H cyclafem 1/35 oral tablet 1-35 mg-mcg 1 H cyclafem 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H cyred eq oral tablet 0.15-30 mg-mcg 1 H cyred oral tablet 0.15-30 mg-mcg 1 H dasetta 1/35 oral tablet 1-35 mg-mcg 1 H dasetta 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H daysee oral tablet 0.15-0.03 &0.01 mg 1 H DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML, 20 3 MG/ML, 40 MG/ML (estradiol valerate) delyla oral tablet 0.1-20 mg-mcg 1 H DEPO-ESTRADIOL INTRAMUSCULAR OIL 5 MG/ML (estradiol 3 cypionate) desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg 1 H (21/5), 0.15-30 mg-mcg DIVIGEL TRANSDERMAL GEL 0.25 MG/0.25GM, 0.5 MG/0.5GM, 0.75 MG/0.75GM, 1 MG/GM, 1.25 MG/1.25GM 3 (estradiol) dolishale oral tablet 90-20 mcg 1 H drospiren-eth estrad-levomefol oral tablet 3-0.02-0.451 mg, 3- 1 H 0.03-0.451 mg drospirenone-ethinyl estradiol oral tablet 3-0.02 mg, 3-0.03 mg 1 H DUAVEE ORAL TABLET 0.45-20 MG (conj estrogens- 3 SL (1 tablet per day.) bazedoxifene) EEMT HS ORAL TABLET 0.625-1.25 MG (est estrogens- 3 methyltest) EEMT ORAL TABLET 1.25-2.5 MG (est estrogens-methyltest) 2 ELESTRIN TRANSDERMAL GEL 0.52 MG/0.87 GM (0.06%) 3 (estradiol) elinest oral tablet 0.3-30 mg-mcg 1 H Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 157 Coverage Requirements & Prescription Drug Name Drug Tier Limits emoquette oral tablet 0.15-30 mg-mcg 1 H enpresse-28 oral tablet 50-30/75-40/ 125-30 mcg 1 H enskyce oral tablet 0.15-30 mg-mcg 1 H est estrogens-methyltest ds oral tablet 1.25-2.5 mg 1 est estrogens-methyltest hs oral tablet 0.625-1.25 mg 1 est estrogens-methyltest oral tablet 0.625-1.25 mg, 1.25-2.5 mg 1 estarylla oral tablet 0.25-35 mg-mcg 1 H estradiol oral tablet 0.5 mg, 1 mg, 2 mg 1 estradiol transdermal patch twice weekly 0.025 mg/24hr, 0.0375 SL (8 patches (1 box) per 28 1 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr days.) estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 SL (4 patches (1 carton) per mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 1 28 days.) mg/24hr estradiol vaginal cream 0.1 mg/gm 1 estradiol vaginal tablet 10 mcg 1 estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml 1 estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg 1 ESTRING VAGINAL RING 2 MG (estradiol) 2 SL (1 ring per 90 days.) ESTROGEL TRANSDERMAL GEL 0.75 MG/1.25 GM (0.06%) SL (50 grams (1 box) per 3 (estradiol) month.) ESTROSTEP FE ORAL TABLET 1-20/1-30/1-35 MG-MCG 3 (norethindron-ethinyl estrad-fe) ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg, 1-50 mg- 1 H mcg EVAMIST TRANSDERMAL SOLUTION 1.53 MG/SPRAY 2 (estradiol) falmina oral tablet 0.1-20 mg-mcg 1 H fayosim oral tablet 42-21-21-7 days 1 H FEMHRT ORAL TABLET 0.5-2.5 MG-MCG (norethindrone-eth 3 estradiol) FEMRING VAGINAL RING 0.05 MG/24HR, 0.1 MG/24HR 3 SL (1 ring per 3 months.) (estradiol acetate) femynor oral tablet 0.25-35 mg-mcg 1 H fyavolv oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg 1 gemmily oral capsule 1-20 mg-mcg(24) 1 H hailey 1.5/30 oral tablet 1.5-30 mg-mcg 1 H hailey 24 fe oral tablet 1-20 mg-mcg(24) 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 158 Coverage Requirements & Prescription Drug Name Drug Tier Limits hailey fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H hailey fe 1/20 oral tablet 1-20 mg-mcg 1 H iclevia oral tablet 0.15-0.03 mg 1 H introvale oral tablet 0.15-0.03 mg 1 H isibloom oral tablet 0.15-30 mg-mcg 1 H jaimiess oral tablet 0.15-0.03 &0.01 mg 1 H jasmiel oral tablet 3-0.02 mg 1 H jinteli oral tablet 1-5 mg-mcg 1 jolessa oral tablet 0.15-0.03 mg 1 H juleber oral tablet 0.15-30 mg-mcg 1 H junel 1.5/30 oral tablet 1.5-30 mg-mcg 1 H junel 1/20 oral tablet 1-20 mg-mcg 1 H junel fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H junel fe 1/20 oral tablet 1-20 mg-mcg 1 H junel fe 24 oral tablet 1-20 mg-mcg(24) 1 H kaitlib fe oral tablet chewable 0.8-25 mg-mcg 1 H kalliga oral tablet 0.15-30 mg-mcg 1 H kariva oral tablet 0.15-0.02/0.01 mg (21/5) 1 H kelnor 1/35 oral tablet 1-35 mg-mcg 1 H kelnor 1/50 oral tablet 1-50 mg-mcg 1 H kurvelo oral tablet 0.15-30 mg-mcg 1 H larin 1.5/30 oral tablet 1.5-30 mg-mcg 1 H larin 1/20 oral tablet 1-20 mg-mcg 1 H larin 24 fe oral tablet 1-20 mg-mcg(24) 1 H larin fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H larin fe 1/20 oral tablet 1-20 mg-mcg 1 H larissia oral tablet 0.1-20 mg-mcg 1 H layolis fe oral tablet chewable 0.8-25 mg-mcg 1 H leena oral tablet 0.5/1/0.5-35 mg-mcg 1 H lessina oral tablet 0.1-20 mg-mcg 1 H levonest oral tablet 50-30/75-40/ 125-30 mcg 1 H levonorgest-eth est & eth est oral tablet 42-21-21-7 days 1 H levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01 mg, 1 H 0.15-0.03 &0.01 mg, 0.15-0.03 mg levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 1 H mg-mcg, 90-20 mcg Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 159 Coverage Requirements & Prescription Drug Name Drug Tier Limits levonorg-eth estrad triphasic oral tablet 50-30/75-40/ 125-30 1 H mcg levora 0.15/30 (28) oral tablet 0.15-30 mg-mcg 1 H lillow oral tablet 0.15-30 mg-mcg 1 H LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG / 10 MCG 3 H (norethin-eth estrad-fe biphas) LOESTRIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG 3 (norethindrone acet-ethinyl est) LOESTRIN 1/20 (21) ORAL TABLET 1-20 MG-MCG 3 (norethindrone acet-ethinyl est) LOESTRIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG 3 (norethin ace-eth estrad-fe) lojaimiess oral tablet 0.1-0.02 & 0.01 mg 1 H loryna oral tablet 3-0.02 mg 1 H LOSEASONIQUE ORAL TABLET 0.1-0.02 & 0.01 MG 3 (levonorgest-eth estrad 91-day) low-ogestrel oral tablet 0.3-30 mg-mcg 1 H lo-zumandimine oral tablet 3-0.02 mg 1 H lutera oral tablet 0.1-20 mg-mcg 1 H marlissa oral tablet 0.15-30 mg-mcg 1 H MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG 3 (esterified estrogens) MENOSTAR TRANSDERMAL PATCH WEEKLY 14 SL (4 patches (1 carton) per 3 MCG/24HR (estradiol) 28 days.) merzee oral capsule 1-20 mg-mcg(24) 1 H mibelas 24 fe oral tablet chewable 1-20 mg-mcg(24) 1 H microgestin 1.5/30 oral tablet 1.5-30 mg-mcg 1 H microgestin 1/20 oral tablet 1-20 mg-mcg 1 H microgestin 24 fe oral tablet 1-20 mg-mcg 1 H microgestin fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H microgestin fe 1/20 oral tablet 1-20 mg-mcg 1 H mili oral tablet 0.25-35 mg-mcg 1 H mimvey oral tablet 1-0.5 mg 1 MIRCETTE ORAL TABLET 0.15-0.02/0.01 MG (21/5) 3 (desogestrel-ethinyl estradiol) mono-linyah oral tablet 0.25-35 mg-mcg 1 H NATAZIA ORAL TABLET 3/2-2/2-3/1 MG (estradiol valerate- 2 H dienogest) Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 160 Coverage Requirements & Prescription Drug Name Drug Tier Limits necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg 1 H NEXTSTELLIS ORAL TABLET 3-14.2 MG ( drospirenone- 3 H estetrol) nikki oral tablet 3-0.02 mg 1 H norethin ace-eth estrad-fe oral capsule 1-20 mg-mcg(24) 1 H norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg, 1.5-30 mg- 1 H mcg norethin ace-eth estrad-fe oral tablet chewable 1-20 mg- 1 H mcg(24) norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg, 1.5-30 1 H mg-mcg norethindrone-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg- 1 mcg norethin-eth estradiol-fe oral tablet chewable 0.4-35 mg-mcg, 1 H 0.8-25 mg-mcg norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg 1 H norgestimate-ethinyl estradiol triphasic oral tablet 1 H 0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg nortrel 0.5/35 (28) oral tablet 0.5-35 mg-mcg 1 H nortrel 1/35 (21) oral tablet 1-35 mg-mcg 1 H nortrel 1/35 (28) oral tablet 1-35 mg-mcg 1 H nortrel 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H NUVARING VAGINAL RING 0.12-0.015 MG/24HR 1 H (etonogestrel-ethinyl estradiol) nylia 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H nymyo oral tablet 0.25-35 mg-mcg 1 H ocella oral tablet 3-0.03 mg 1 H ORIAHNN ORAL CAPSULE THERAPY PACK 300-1-0.5 & 300 3 PA; SL (2 capsules per day.) MG (elagolix-estradiol-norethind) orsythia oral tablet 0.1-20 mg-mcg 1 H philith oral tablet 0.4-35 mg-mcg 1 H pimtrea oral tablet 0.15-0.02/0.01 mg (21/5) 1 H pirmella 1/35 oral tablet 1-35 mg-mcg 1 H pirmella 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H portia-28 oral tablet 0.15-30 mg-mcg 1 H PREFEST ORAL TABLET 1/1-0.09 MG (15/15) (estradiol- 2 norgestimate)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 161 Coverage Requirements & Prescription Drug Name Drug Tier Limits PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 3 MG, 1.25 MG (estrogens conjugated) PREMARIN VAGINAL CREAM 0.625 MG/GM (estrogens, 3 conjugated) PREMPHASE ORAL TABLET 0.625-5 MG (conj estrog- 3 medroxyprogest ace) PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 3 MG, 0.625-5 MG (conj estrog-medroxyprogest ace) previfem oral tablet 0.25-35 mg-mcg 1 H reclipsen oral tablet 0.15-30 mg-mcg 1 H rivelsa oral tablet 42-21-21-7 days 1 H setlakin oral tablet 0.15-0.03 mg 1 H simliya oral tablet 0.15-0.02/0.01 mg (21/5) 1 H simpesse oral tablet 0.15-0.03 &0.01 mg 1 H sprintec 28 oral tablet 0.25-35 mg-mcg 1 H sronyx oral tablet 0.1-20 mg-mcg 1 H syeda oral tablet 3-0.03 mg 1 H tarina 24 fe oral tablet 1-20 mg-mcg(24) 1 H tarina fe 1/20 eq oral tablet 1-20 mg-mcg 1 H tarina fe 1/20 oral tablet 1-20 mg-mcg 1 H tilia fe oral tablet 1-20/1-30/1-35 mg-mcg 1 H tri femynor oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-estarylla oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-legest fe oral tablet 1-20/1-30/1-35 mg-mcg 1 H tri-linyah oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 mcg 1 H tri-lo-marzia oral tablet 0.18/0.215/0.25 mg-25 mcg 1 H tri-lo-mili oral tablet 0.18/0.215/0.25 mg-25 mcg 1 H tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 mcg 1 H tri-mili oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-nymyo oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-previfem oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-sprintec oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H trivora (28) oral tablet 50-30/75-40/ 125-30 mcg 1 H tri-vylibra lo oral tablet 0.18/0.215/0.25 mg-25 mcg 1 H tri-vylibra oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 162 Coverage Requirements & Prescription Drug Name Drug Tier Limits TWIRLA TRANSDERMAL PATCH WEEKLY 120-30 3 H MCG/24HR (levonorgestrel-eth estradiol) tyblume oral tablet chewable 0.1-20 mg-mcg 1 H tydemy oral tablet 3-0.03-0.451 mg 1 H velivet oral tablet 0.1/0.125/0.15 -0.025 mg 1 H vestura oral tablet 3-0.02 mg 1 H vienva oral tablet 0.1-20 mg-mcg 1 H viorele oral tablet 0.15-0.02/0.01 mg (21/5) 1 H VIVELLE-DOT TRANSDERMAL PATCH TWICE WEEKLY SL (8 patches (1 box) per 28 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.075 1 days.) MG/24HR, 0.1 MG/24HR (estradiol) volnea oral tablet 0.15-0.02/0.01 mg (21/5) 1 H vyfemla oral tablet 0.4-35 mg-mcg 1 H vylibra oral tablet 0.25-35 mg-mcg 1 H wera oral tablet 0.5-35 mg-mcg 1 H wymzya fe oral tablet chewable 0.4-35 mg-mcg 1 H xulane transdermal patch weekly 150-35 mcg/24hr 1 H YASMIN 28 ORAL TABLET 3-0.03 MG (drospirenone-ethinyl 3 estradiol) YAZ ORAL TABLET 3-0.02 MG (drospirenone-ethinyl estradiol) 3 yuvafem vaginal tablet 10 mcg 1 zafemy transdermal patch weekly 150-35 mcg/24hr 1 H zarah oral tablet 3-0.03 mg 1 H zovia 1/35 (28) oral tablet 1-35 mg-mcg 1 H zovia 1/35e (28) oral tablet 1-35 mg-mcg 1 H zumandimine oral tablet 3-0.03 mg 1 H GLYCOGENOLYTIC AGENTS - Hormones BAQSIMI ONE PACK NASAL POWDER 3 MG/DOSE SL (2 intranasal devices per 2 () prescription.) BAQSIMI TWO PACK NASAL POWDER 3 MG/DOSE SL (2 intranasal devices per 2 (glucagon) prescription.) GLUCAGEN HYPOKIT INJECTION SOLUTION SL (2 devices per 2 RECONSTITUTED 1 MG (glucagon hcl (rdna)) prescription.) SL (2 devices per glucagon emergency kit 1 mg injection 1 mg 1 prescription.) SL (2 devices per GLUCAGON EMERGENCY KIT 1 MG INJECTION 1 MG 2 prescription.)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 163 Coverage Requirements & Prescription Drug Name Drug Tier Limits GLUCAGON EMERGENCY KIT INJECTION SOLUTION 2 RECONSTITUTED 1 MG/ML GVOKE HYPOPEN 1-PACK SUBCUTANEOUS SOLUTION 2 SL (0.2 ml per prescription.) AUTO-INJECTOR 0.5 MG/0.1ML (glucagon) GVOKE HYPOPEN 1-PACK SUBCUTANEOUS SOLUTION 2 SL (0.4 ml per prescription.) AUTO-INJECTOR 1 MG/0.2ML (glucagon) GVOKE HYPOPEN 2-PACK SUBCUTANEOUS SOLUTION 2 SL (0.2 ml per prescription.) AUTO-INJECTOR 0.5 MG/0.1ML (glucagon) GVOKE HYPOPEN 2-PACK SUBCUTANEOUS SOLUTION 2 SL (0.4 ml per prescription.) AUTO-INJECTOR 1 MG/0.2ML (glucagon) GVOKE PFS SUBCUTANEOUS SOLUTION PREFILLED SL (2 syringes per 2 SYRINGE 0.5 MG/0.1ML, 1 MG/0.2ML (glucagon) prescription.) GONADOTROPINS - Hormones ELIGARD SUBCUTANEOUS KIT 22.5 MG (leuprolide acetate 3 PA (3 month)) ELIGARD SUBCUTANEOUS KIT 30 MG (leuprolide acetate (4 3 PA month)) ELIGARD SUBCUTANEOUS KIT 45 MG (leuprolide acetate (6 3 PA month)) ELIGARD SUBCUTANEOUS KIT 7.5 MG (leuprolide acetate) 3 PA leuprolide acetate injection kit 1 mg/0.2ml 1 PA SYNAREL NASAL SOLUTION 2 MG/ML (nafarelin acetate) 2 INCRETIN MIMETICS - Drugs for Diabetes ADLYXIN STARTER PACK SUBCUTANEOUS PEN- 3 PA; ST; SL (6 ml per year.) INJECTOR KIT 10 & 20 MCG/0.2ML () ADLYXIN SUBCUTANEOUS SOLUTION PEN-INJECTOR 20 3 PA; ST; SL (6 ml per month.) MCG/0.2ML (lixisenatide) BYDUREON BCISE AUTOINJECTOR SUBCUTANEOUS PA; ST; SL (3.4 ml per 2 AUTO-INJECTOR 2 MG/0.85ML () month.) BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PEN- PA; ST; SL (2.4 mL (one 2 INJECTOR 10 MCG/0.04ML (exenatide) pen) per prescription) BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN- PA; ST; SL (1.2 mL (one 2 INJECTOR 5 MCG/0.02ML (exenatide) pen) per prescription) OZEMPIC SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 PA; ST; SL (1.5 mL per 21 2 MG/1.5ML () days.) OZEMPIC SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 PA; ST; SL (9 ml per 3 2 MG/1.5ML, 4 MG/3ML (semaglutide) months.) RYBELSUS ORAL TABLET 14 MG, 3 MG, 7 MG (semaglutide) 2 PA; ST; SL (1 tablet per day.)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 164 Coverage Requirements & Prescription Drug Name Drug Tier Limits SAXENDA SUBCUTANEOUS SOLUTION PEN-INJECTOR 18 3 PA; SL (0.5 mL per day.) MG/3ML ( -weight management) SOLIQUA SUBCUTANEOUS SOLUTION PEN-INJECTOR 100- 2 SL (18 ml per month.) 33 UNT-MCG/ML (-lixisenatide) TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 PA; ST; SL (2 ml per month.) 0.75 MG/0.5ML, 1.5 MG/0.5ML () TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 3 PA; ST; SL (2 mL per 21 2 MG/0.5ML, 4.5 MG/0.5ML (dulaglutide) days) VICTOZA SOLUTION PEN-INJECTOR 18 MG/3ML PA; ST; SL (6 ml (2 pens) 2 SUBCUTANEOUS 18 MG/3ML (liraglutide) per month.) VICTOZA SOLUTION PEN-INJECTOR 18 MG/3ML PA; ST; SL (6 ml (2 pens) 3 SUBCUTANEOUS 18 MG/3ML (liraglutide) per month.) WEGOVY SUBCUTANEOUS SOLUTION AUTO-INJECTOR 3 PA 2.4 MG/0.75ML (semaglutide-weight management) INTERMEDIATE-ACTING - Drugs for Diabetes HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML (insulin nph isophane & 2 SL (75 ml per prescription.) regular) HUMULIN 70/30 VIAL SUBCUTANEOUS SUSPENSION (70- 1 SL (70 ml per prescription.) 30) 100 UNIT/ML (insulin nph isophane & regular) HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION 2 SL (75 ml per prescription.) PEN-INJECTOR 100 UNIT/ML (insulin nph human (isophane)) HUMULIN N VIAL SUBCUTANEOUS SUSPENSION 100 1 SL (70 ml per prescription.) UNIT/ML (insulin nph human (isophane)) LONG-ACTING INSULINS - Drugs for Diabetes LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN- 1 SL (75 ml per prescription.) INJECTOR 100 UNIT/ML (insulin glargine) LANTUS U-100 VIAL SUBCUTANEOUS SOLUTION 100 1 SL (70 ml per prescription.) UNIT/ML (insulin glargine) SOLIQUA SUBCUTANEOUS SOLUTION PEN-INJECTOR 100- 2 SL (18 ml per month.) 33 UNT-MCG/ML (insulin glargine-lixisenatide) TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION 2 SL (75 ml per prescription.) PEN-INJECTOR 300 UNIT/ML (insulin glargine) TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN- 2 SL (37.5 ml per prescription.) INJECTOR 300 UNIT/ML (insulin glargine) MEGLITINIDES - Drugs for Diabetes nateglinide oral tablet 120 mg, 60 mg 1 SL (3 tablets per day) repaglinide oral tablet 0.5 mg, 1 mg 1 SL (4 tablets per day) repaglinide oral tablet 2 mg 1 SL (8 tablets per day)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 165 Coverage Requirements & Prescription Drug Name Drug Tier Limits PARATHYROID AGENTS - Drugs for Bones NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG, 25 PA; SL (2 cartridges per 3 MCG, 50 MCG, 75 MCG ( (recomb)) month.); SP (RECOMBINANT) SUBCUTANEOUS 3 PA; SP SOLUTION PEN-INJECTOR 620 MCG/2.48ML TYMLOS SUBCUTANEOUS SOLUTION PEN-INJECTOR 3120 3 PA; SP MCG/1.56ML () PITUITARY - Hormones PA; ST; SL (20 ml per 24 ACTHAR INJECTION GEL 80 UNIT/ML (corticotropin) 3 days.); SP desmopressin ace spray refrig nasal solution 0.01 % 1 desmopressin acetate injection solution 4 mcg/ml 1 desmopressin acetate oral tablet 0.1 mg, 0.2 mg 1 desmopressin acetate pf injection solution 4 mcg/ml 1 desmopressin acetate spray nasal solution 0.01 % 1 NOCDURNA SUBLINGUAL TABLET SUBLINGUAL 27.7 MCG, 3 PA; SL (1 tablet per day.) 55.3 MCG (desmopressin acetate) NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS SOLUTION PA; SL (18 ml (9 cartridges) 2 PEN-INJECTOR 10 MG/2ML (somatropin) per month.); SP NUTROPIN AQ NUSPIN 20 SUBCUTANEOUS SOLUTION PA; SL (10 ml (5 cartridges) 2 PEN-INJECTOR 20 MG/2ML (somatropin) per month.); SP NUTROPIN AQ NUSPIN 5 SUBCUTANEOUS SOLUTION PA; SL (36 ml (18 cartridges) 2 PEN-INJECTOR 5 MG/2ML (somatropin) per month.); SP SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 3 PA; SL (1 tablet per day); SP 4 MG, 5 MG, 6 MG (somatropin (non-refrigerated)) STIMATE NASAL SOLUTION 1.5 MG/ML (desmopressin 3 acetate) ZORBTIVE SUBCUTANEOUS SOLUTION RECONSTITUTED 3 PA; SL (1 tablet per day); SP 8.8 MG (somatropin (non-refrigerated)) PROGESTINS - Drugs for Women ACTIVELLA ORAL TABLET 1-0.5 MG (estradiol-norethindrone 3 acet) afirmelle oral tablet 0.1-20 mg-mcg 1 H altavera oral tablet 0.15-30 mg-mcg 1 H alyacen 1/35 oral tablet 1-35 mg-mcg 1 H alyacen 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H amabelz oral tablet 0.5-0.1 mg, 1-0.5 mg 1 amethia oral tablet 0.15-0.03 &0.01 mg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 166 Coverage Requirements & Prescription Drug Name Drug Tier Limits amethyst oral tablet 90-20 mcg 1 H ANGELIQ ORAL TABLET 0.25-0.5 MG, 0.5-1 MG 3 (drospirenone-estradiol) ANNOVERA VAGINAL RING 0.013-0.15 MG/24HR SL (1 vaginal ring per 327 3 (segesterone-ethinyl estradiol) days); H apri oral tablet 0.15-30 mg-mcg 1 H aranelle oral tablet 0.5/1/0.5-35 mg-mcg 1 H ashlyna oral tablet 0.15-0.03 &0.01 mg 1 H aubra eq oral tablet 0.1-20 mg-mcg 1 H aubra oral tablet 0.1-20 mg-mcg 1 H aurovela 1.5/30 oral tablet 1.5-30 mg-mcg 1 H aurovela 1/20 oral tablet 1-20 mg-mcg 1 H aurovela 24 fe oral tablet 1-20 mg-mcg(24) 1 H aurovela fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H aurovela fe 1/20 oral tablet 1-20 mg-mcg 1 H aviane oral tablet 0.1-20 mg-mcg 1 H AYGESTIN ORAL TABLET 5 MG (norethindrone acetate) 3 ayuna oral tablet 0.15-30 mg-mcg 1 H azurette oral tablet 0.15-0.02/0.01 mg (21/5) 1 H BALCOLTRA ORAL TABLET 0.1-20 MG-MCG(21) 3 H (levonorgest-eth estrad-fe bisg) balziva oral tablet 0.4-35 mg-mcg 1 H BIJUVA ORAL CAPSULE 1-100 MG (estradiol-progesterone) 3 blisovi 24 fe oral tablet 1-20 mg-mcg(24) 1 H blisovi fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H blisovi fe 1/20 oral tablet 1-20 mg-mcg 1 H briellyn oral tablet 0.4-35 mg-mcg 1 H camila oral tablet 0.35 mg 1 H camrese lo oral tablet 0.1-0.02 & 0.01 mg 1 H camrese oral tablet 0.15-0.03 &0.01 mg 1 H caziant oral tablet 0.1/0.125/0.15 -0.025 mg 1 H charlotte 24 fe oral tablet chewable 1-20 mg-mcg(24) 1 H chateal eq oral tablet 0.15-30 mg-mcg 1 H chateal oral tablet 0.15-30 mg-mcg 1 H CLIMARA PRO TRANSDERMAL PATCH WEEKLY 0.045- 3 SL (4 patches per month.) 0.015 MG/DAY (estradiol-levonorgestrel)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 167 Coverage Requirements & Prescription Drug Name Drug Tier Limits COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY (estradiol-norethindrone 3 SL (8 patches per 28 days.) acet) CRINONE VAGINAL GEL 4 %, 8 % (progesterone) 3 ST cryselle-28 oral tablet 0.3-30 mg-mcg 1 H cyclafem 1/35 oral tablet 1-35 mg-mcg 1 H cyclafem 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H cyred eq oral tablet 0.15-30 mg-mcg 1 H cyred oral tablet 0.15-30 mg-mcg 1 H dasetta 1/35 oral tablet 1-35 mg-mcg 1 H dasetta 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H daysee oral tablet 0.15-0.03 &0.01 mg 1 H deblitane oral tablet 0.35 mg 1 H delyla oral tablet 0.1-20 mg-mcg 1 H DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 3 SL (5 ml per year.) MG/ML (medroxyprogesterone acetate) DEPO-PROVERA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 150 MG/ML (medroxyprogesterone 3 acetate) DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE 104 MG/0.65ML 2 SL (3.25 ml per year.); H (medroxyprogesterone acetate) desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg 1 H (21/5), 0.15-30 mg-mcg dolishale oral tablet 90-20 mcg 1 H drospiren-eth estrad-levomefol oral tablet 3-0.02-0.451 mg, 3- 1 H 0.03-0.451 mg drospirenone-ethinyl estradiol oral tablet 3-0.02 mg, 3-0.03 mg 1 H elinest oral tablet 0.3-30 mg-mcg 1 H ELLA ORAL TABLET 30 MG (ulipristal acetate) 1 SL (1 tablet per 21 days.); H emoquette oral tablet 0.15-30 mg-mcg 1 H ENDOMETRIN VAGINAL INSERT 100 MG (progesterone) 2 enpresse-28 oral tablet 50-30/75-40/ 125-30 mcg 1 H enskyce oral tablet 0.15-30 mg-mcg 1 H errin oral tablet 0.35 mg 1 H estarylla oral tablet 0.25-35 mg-mcg 1 H estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 168 Coverage Requirements & Prescription Drug Name Drug Tier Limits ESTROSTEP FE ORAL TABLET 1-20/1-30/1-35 MG-MCG 3 (norethindron-ethinyl estrad-fe) ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg, 1-50 mg- 1 H mcg falmina oral tablet 0.1-20 mg-mcg 1 H fayosim oral tablet 42-21-21-7 days 1 H FEMHRT ORAL TABLET 0.5-2.5 MG-MCG (norethindrone-eth 3 estradiol) femynor oral tablet 0.25-35 mg-mcg 1 H fyavolv oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg 1 gemmily oral capsule 1-20 mg-mcg(24) 1 H hailey 1.5/30 oral tablet 1.5-30 mg-mcg 1 H hailey 24 fe oral tablet 1-20 mg-mcg(24) 1 H hailey fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H hailey fe 1/20 oral tablet 1-20 mg-mcg 1 H heather oral tablet 0.35 mg 1 H iclevia oral tablet 0.15-0.03 mg 1 H incassia oral tablet 0.35 mg 1 H introvale oral tablet 0.15-0.03 mg 1 H isibloom oral tablet 0.15-30 mg-mcg 1 H jaimiess oral tablet 0.15-0.03 &0.01 mg 1 H jasmiel oral tablet 3-0.02 mg 1 H jencycla oral tablet 0.35 mg 1 H jinteli oral tablet 1-5 mg-mcg 1 jolessa oral tablet 0.15-0.03 mg 1 H juleber oral tablet 0.15-30 mg-mcg 1 H junel 1.5/30 oral tablet 1.5-30 mg-mcg 1 H junel 1/20 oral tablet 1-20 mg-mcg 1 H junel fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H junel fe 1/20 oral tablet 1-20 mg-mcg 1 H junel fe 24 oral tablet 1-20 mg-mcg(24) 1 H kaitlib fe oral tablet chewable 0.8-25 mg-mcg 1 H kalliga oral tablet 0.15-30 mg-mcg 1 H kariva oral tablet 0.15-0.02/0.01 mg (21/5) 1 H kelnor 1/35 oral tablet 1-35 mg-mcg 1 H kelnor 1/50 oral tablet 1-50 mg-mcg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 169 Coverage Requirements & Prescription Drug Name Drug Tier Limits kurvelo oral tablet 0.15-30 mg-mcg 1 H larin 1.5/30 oral tablet 1.5-30 mg-mcg 1 H larin 1/20 oral tablet 1-20 mg-mcg 1 H larin 24 fe oral tablet 1-20 mg-mcg(24) 1 H larin fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H larin fe 1/20 oral tablet 1-20 mg-mcg 1 H larissia oral tablet 0.1-20 mg-mcg 1 H layolis fe oral tablet chewable 0.8-25 mg-mcg 1 H leena oral tablet 0.5/1/0.5-35 mg-mcg 1 H lessina oral tablet 0.1-20 mg-mcg 1 H levonest oral tablet 50-30/75-40/ 125-30 mcg 1 H levonorgest-eth est & eth est oral tablet 42-21-21-7 days 1 H levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01 mg, 1 H 0.15-0.03 &0.01 mg, 0.15-0.03 mg levonorgestrel oral tablet 1.5 mg 1 H levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 1 H mg-mcg, 90-20 mcg levonorg-eth estrad triphasic oral tablet 50-30/75-40/ 125-30 1 H mcg levora 0.15/30 (28) oral tablet 0.15-30 mg-mcg 1 H lillow oral tablet 0.15-30 mg-mcg 1 H LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG / 10 MCG 3 H (norethin-eth estrad-fe biphas) LOESTRIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG 3 (norethindrone acet-ethinyl est) LOESTRIN 1/20 (21) ORAL TABLET 1-20 MG-MCG 3 (norethindrone acet-ethinyl est) LOESTRIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG 3 (norethin ace-eth estrad-fe) lojaimiess oral tablet 0.1-0.02 & 0.01 mg 1 H loryna oral tablet 3-0.02 mg 1 H LOSEASONIQUE ORAL TABLET 0.1-0.02 & 0.01 MG 3 (levonorgest-eth estrad 91-day) low-ogestrel oral tablet 0.3-30 mg-mcg 1 H lo-zumandimine oral tablet 3-0.02 mg 1 H lutera oral tablet 0.1-20 mg-mcg 1 H lyleq oral tablet 0.35 mg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 170 Coverage Requirements & Prescription Drug Name Drug Tier Limits lyza oral tablet 0.35 mg 1 H marlissa oral tablet 0.15-30 mg-mcg 1 H medroxyprogesterone acetate intramuscular suspension 150 1 SL (5 ml per year.); H mg/ml medroxyprogesterone acetate intramuscular suspension 1 H prefilled syringe 150 mg/ml medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg 1 megestrol acetate oral suspension 40 mg/ml, 625 mg/5ml 1 megestrol acetate oral tablet 20 mg, 40 mg 1 merzee oral capsule 1-20 mg-mcg(24) 1 H mibelas 24 fe oral tablet chewable 1-20 mg-mcg(24) 1 H microgestin 1.5/30 oral tablet 1.5-30 mg-mcg 1 H microgestin 1/20 oral tablet 1-20 mg-mcg 1 H microgestin 24 fe oral tablet 1-20 mg-mcg 1 H microgestin fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H microgestin fe 1/20 oral tablet 1-20 mg-mcg 1 H mili oral tablet 0.25-35 mg-mcg 1 H mimvey oral tablet 1-0.5 mg 1 MIRCETTE ORAL TABLET 0.15-0.02/0.01 MG (21/5) 3 (desogestrel-ethinyl estradiol) mono-linyah oral tablet 0.25-35 mg-mcg 1 H NATAZIA ORAL TABLET 3/2-2/2-3/1 MG (estradiol valerate- 2 H dienogest) necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg 1 H NEXTSTELLIS ORAL TABLET 3-14.2 MG ( drospirenone- 3 H estetrol) nikki oral tablet 3-0.02 mg 1 H nora-be oral tablet 0.35 mg 1 H norethin ace-eth estrad-fe oral capsule 1-20 mg-mcg(24) 1 H norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg, 1.5-30 mg- 1 H mcg norethin ace-eth estrad-fe oral tablet chewable 1-20 mg- 1 H mcg(24) norethindrone acetate oral tablet 5 mg 1 norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg, 1.5-30 1 H mg-mcg norethindrone oral tablet 0.35 mg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 171 Coverage Requirements & Prescription Drug Name Drug Tier Limits norethindrone-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg- 1 mcg norethin-eth estradiol-fe oral tablet chewable 0.4-35 mg-mcg, 1 H 0.8-25 mg-mcg norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg 1 H norgestimate-ethinyl estradiol triphasic oral tablet 1 H 0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg norlyda oral tablet 0.35 mg 1 H norlyroc oral tablet 0.35 mg 1 H nortrel 0.5/35 (28) oral tablet 0.5-35 mg-mcg 1 H nortrel 1/35 (21) oral tablet 1-35 mg-mcg 1 H nortrel 1/35 (28) oral tablet 1-35 mg-mcg 1 H nortrel 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H NUVARING VAGINAL RING 0.12-0.015 MG/24HR 1 H (etonogestrel-ethinyl estradiol) nylia 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H nymyo oral tablet 0.25-35 mg-mcg 1 H ocella oral tablet 3-0.03 mg 1 H ORIAHNN ORAL CAPSULE THERAPY PACK 300-1-0.5 & 300 3 PA; SL (2 capsules per day.) MG (elagolix-estradiol-norethind) orsythia oral tablet 0.1-20 mg-mcg 1 H philith oral tablet 0.4-35 mg-mcg 1 H pimtrea oral tablet 0.15-0.02/0.01 mg (21/5) 1 H pirmella 1/35 oral tablet 1-35 mg-mcg 1 H pirmella 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H PLAN B ONE-STEP ORAL TABLET 1.5 MG ( levonorgestrel) 1 H portia-28 oral tablet 0.15-30 mg-mcg 1 H PREFEST ORAL TABLET 1/1-0.09 MG (15/15) (estradiol- 2 norgestimate) PREMPHASE ORAL TABLET 0.625-5 MG (conj estrog- 3 medroxyprogest ace) PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 3 MG, 0.625-5 MG (conj estrog-medroxyprogest ace) previfem oral tablet 0.25-35 mg-mcg 1 H progesterone intramuscular oil 50 mg/ml 1 progesterone oral capsule 100 mg, 200 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 172 Coverage Requirements & Prescription Drug Name Drug Tier Limits PROVERA ORAL TABLET 10 MG, 2.5 MG, 5 MG 3 (medroxyprogesterone acetate) reclipsen oral tablet 0.15-30 mg-mcg 1 H rivelsa oral tablet 42-21-21-7 days 1 H setlakin oral tablet 0.15-0.03 mg 1 H sharobel oral tablet 0.35 mg 1 H simliya oral tablet 0.15-0.02/0.01 mg (21/5) 1 H simpesse oral tablet 0.15-0.03 &0.01 mg 1 H SLYND ORAL TABLET 4 MG (drospirenone) 3 PA; ST; H sprintec 28 oral tablet 0.25-35 mg-mcg 1 H sronyx oral tablet 0.1-20 mg-mcg 1 H syeda oral tablet 3-0.03 mg 1 H tarina 24 fe oral tablet 1-20 mg-mcg(24) 1 H tarina fe 1/20 eq oral tablet 1-20 mg-mcg 1 H tarina fe 1/20 oral tablet 1-20 mg-mcg 1 H tilia fe oral tablet 1-20/1-30/1-35 mg-mcg 1 H tri femynor oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-estarylla oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-legest fe oral tablet 1-20/1-30/1-35 mg-mcg 1 H tri-linyah oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 mcg 1 H tri-lo-marzia oral tablet 0.18/0.215/0.25 mg-25 mcg 1 H tri-lo-mili oral tablet 0.18/0.215/0.25 mg-25 mcg 1 H tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 mcg 1 H tri-mili oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-nymyo oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-previfem oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-sprintec oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H trivora (28) oral tablet 50-30/75-40/ 125-30 mcg 1 H tri-vylibra lo oral tablet 0.18/0.215/0.25 mg-25 mcg 1 H tri-vylibra oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tulana oral tablet 0.35 mg 1 H TWIRLA TRANSDERMAL PATCH WEEKLY 120-30 3 H MCG/24HR (levonorgestrel-eth estradiol) tyblume oral tablet chewable 0.1-20 mg-mcg 1 H tydemy oral tablet 3-0.03-0.451 mg 1 H Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 173 Coverage Requirements & Prescription Drug Name Drug Tier Limits velivet oral tablet 0.1/0.125/0.15 -0.025 mg 1 H vestura oral tablet 3-0.02 mg 1 H vienva oral tablet 0.1-20 mg-mcg 1 H viorele oral tablet 0.15-0.02/0.01 mg (21/5) 1 H volnea oral tablet 0.15-0.02/0.01 mg (21/5) 1 H vyfemla oral tablet 0.4-35 mg-mcg 1 H vylibra oral tablet 0.25-35 mg-mcg 1 H wera oral tablet 0.5-35 mg-mcg 1 H wymzya fe oral tablet chewable 0.4-35 mg-mcg 1 H xulane transdermal patch weekly 150-35 mcg/24hr 1 H YASMIN 28 ORAL TABLET 3-0.03 MG (drospirenone-ethinyl 3 estradiol) YAZ ORAL TABLET 3-0.02 MG (drospirenone-ethinyl estradiol) 3 zafemy transdermal patch weekly 150-35 mcg/24hr 1 H zarah oral tablet 3-0.03 mg 1 H zovia 1/35 (28) oral tablet 1-35 mg-mcg 1 H zovia 1/35e (28) oral tablet 1-35 mg-mcg 1 H zumandimine oral tablet 3-0.03 mg 1 H RAPID-ACTING INSULINS - Drugs for Diabetes HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN- 2 SL (75 ml per prescription.) INJECTOR 100 UNIT/ML () HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN- SL (75 ml (25 pens) per 2 INJECTOR 200 UNIT/ML (insulin lispro) prescription.) HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (50-50) 100 UNIT/ML (insulin 2 SL (75 ml per prescription.) lispro prot & lispro) HUMALOG MIX 50/50 VIAL SUBCUTANEOUS SUSPENSION 1 SL (70 ml per prescription.) (50-50) 100 UNIT/ML (insulin lispro prot & lispro) HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (75-25) 100 UNIT/ML (insulin 2 SL (75 ml per prescription.) lispro prot & lispro) HUMALOG MIX 75/25 VIAL SUBCUTANEOUS SUSPENSION 1 SL (70 ml per prescription.) (75-25) 100 UNIT/ML (insulin lispro prot & lispro) HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML 1 SL (70 ml per prescription.) (insulin lispro) HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE 100 2 SL (75 ml per prescription.) UNIT/ML (insulin lispro)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 174 Coverage Requirements & Prescription Drug Name Drug Tier Limits HUMALOG U-100 JUNIOR KWIKPEN SUBCUTANEOUS 2 SL (75 ml per prescription.) SOLUTION PEN-INJECTOR 100 UNIT/ML (insulin lispro) LYUMJEV KWIKPEN SUBCUTANEOUS SOLUTION PEN- 2 SL (75 ml per prescription.) INJECTOR 100 UNIT/ML, 200 UNIT/ML (insulin lispro-aabc) LYUMJEV VIAL INJECTION SOLUTION 100 UNIT/ML (insulin 1 SL (70 ml per prescription.) lispro-aabc) SHORT-ACTING INSULINS - Drugs for Diabetes HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML (insulin nph isophane & 2 SL (75 ml per prescription.) regular) HUMULIN 70/30 VIAL SUBCUTANEOUS SUSPENSION (70- 1 SL (70 ml per prescription.) 30) 100 UNIT/ML (insulin nph isophane & regular) HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION 2 SL (75 mL per prescription.) PEN-INJECTOR 500 UNIT/ML (insulin regular human) HUMULIN R U-500 VIAL SUBCUTANEOUS SOLUTION 500 1 SL (80 ml per prescription.) UNIT/ML (insulin regular human) HUMULIN R VIAL INJECTION SOLUTION 100 UNIT/ML 1 SL (70 ml per prescription.) (insulin regular human) SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB - Drugs for Diabetes GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG (empagliflozin- 2 ST; SL (1 tablet per day.) linagliptin) ST; SL (30 tablets per JARDIANCE ORAL TABLET 10 MG, 25 MG (empagliflozin) 2 month.) SYNJARDY ORAL TABLET 12.5-1000 MG, 12.5-500 MG, 5- 2 SL (2 tablets per day.) 1000 MG, 5-500 MG (empagliflozin-metformin hcl) SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 2 SL (1 tablet per day.) HOUR 10-1000 MG, 25-1000 MG (empagliflozin-metformin hcl) SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 2 SL (2 tablets per day.) HOUR 12.5-1000 MG, 5-1000 MG (empagliflozin-metformin hcl) TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-5-1000 MG, 25-5-1000 MG (empagliflozin-linaglip- 2 SL (1 tablet per day.) metform) TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 12.5-2.5-1000 MG, 5-2.5-1000 MG (empagliflozin- 2 SL (2 tablets per day.) linaglip-metform) SOMATOSTATIN AGONISTS - Hormones octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 1 PA 200 mcg/ml, 50 mcg/ml, 500 mcg/ml

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 175 Coverage Requirements & Prescription Drug Name Drug Tier Limits SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML, 0.6 PA; SL (2 ampules per day.); 2 MG/ML, 0.9 MG/ML (pasireotide diaspartate) SP SOMATULINE DEPOT SUBCUTANEOUS SOLUTION 120 3 SP MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML (lanreotide acetate) SOMATOTROPIN AGONISTS - Hormones EGRIFTA SV SUBCUTANEOUS SOLUTION 3 PA RECONSTITUTED 2 MG (tesamorelin acetate) INCRELEX SUBCUTANEOUS SOLUTION 40 MG/4ML PA; SL (52 vials per month.); 2 () SP NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS SOLUTION PA; SL (18 ml (9 cartridges) 2 PEN-INJECTOR 10 MG/2ML (somatropin) per month.); SP NUTROPIN AQ NUSPIN 20 SUBCUTANEOUS SOLUTION PA; SL (10 ml (5 cartridges) 2 PEN-INJECTOR 20 MG/2ML (somatropin) per month.); SP NUTROPIN AQ NUSPIN 5 SUBCUTANEOUS SOLUTION PA; SL (36 ml (18 cartridges) 2 PEN-INJECTOR 5 MG/2ML (somatropin) per month.); SP SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 3 PA; SL (1 tablet per day); SP 4 MG, 5 MG, 6 MG (somatropin (non-refrigerated)) ZORBTIVE SUBCUTANEOUS SOLUTION RECONSTITUTED 3 PA; SL (1 tablet per day); SP 8.8 MG (somatropin (non-refrigerated)) SOMATOTROPIN ANTAGONISTS - Hormones SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED 3 PA; SL (1 vial per day.); SP 10 MG, 15 MG, 20 MG, 25 MG, 30 MG (pegvisomant) SULFONYLUREAS - Drugs for Diabetes AMARYL ORAL TABLET 1 MG, 2 MG, 4 MG (glimepiride) 3 DUETACT ORAL TABLET 30-2 MG, 30-4 MG (pioglitazone hcl- 3 SL (1 tablet per day) glimepiride) glimepiride oral tablet 1 mg, 2 mg, 4 mg 1 glipizide er oral tablet extended release 24 hour 10 mg, 2.5 mg, 1 5 mg glipizide oral tablet 10 mg, 5 mg 1 glipizide xl oral tablet extended release 24 hour 10 mg, 2.5 mg, 1 5 mg glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5- 1 500 mg GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24 3 HOUR 10 MG, 2.5 MG, 5 MG (glipizide) glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg 1 glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 176 Coverage Requirements & Prescription Drug Name Drug Tier Limits glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 1 mg GLYNASE ORAL TABLET 1.5 MG, 3 MG, 6 MG (glyburide 3 micronized) pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg 1 SL (1 tablet per day) tolbutamide oral tablet 500 mg 1 THIAZOLIDINEDIONES - Drugs for Diabetes ACTOPLUS MET ORAL TABLET 15-500 MG, 15-850 MG 3 SL (3 tablets per day) (pioglitazone hcl-metformin hcl) DUETACT ORAL TABLET 30-2 MG, 30-4 MG (pioglitazone hcl- 3 SL (1 tablet per day) glimepiride) OSENI ORAL TABLET 12.5-15 MG, 12.5-30 MG, 12.5-45 MG, 2 SL (1 tablet per day.) 25-15 MG, 25-30 MG, 25-45 MG (alogliptin-pioglitazone) pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg 1 SL (1 tablet per day) pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg 1 SL (1 tablet per day) pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 mg 1 SL (3 tablets per day) THYROID AGENTS - Drugs for the Thyroid ARMOUR THYROID ORAL TABLET 120 MG, 15 MG, 180 MG, 3 240 MG, 30 MG, 300 MG, 60 MG, 90 MG (thyroid) euthyrox oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 1 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg levo-t oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 1 mcg levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 1 mcg, 75 mcg, 88 mcg levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 1 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg 1 NATURE-THROID ORAL TABLET 113.75 MG, 130 MG, 146.25 MG, 16.25 MG, 162.5 MG, 195 MG, 260 MG, 32.5 MG, 325 3 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG (thyroid) np thyroid oral tablet 120 mg, 15 mg, 30 mg, 60 mg, 90 mg 1 TIROSINT-SOL ORAL SOLUTION 100 MCG/ML, 112 MCG/ML, 125 MCG/ML, 13 MCG/ML, 137 MCG/ML, 150 MCG/ML, 175 MCG/ML, 200 MCG/ML, 25 MCG/ML, 37.5 MCG/ML, 44 2 PA MCG/ML, 50 MCG/ML, 62.5 MCG/ML, 75 MCG/ML, 88 MCG/ML (levothyroxine sodium)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 177 Coverage Requirements & Prescription Drug Name Drug Tier Limits unithroid oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 1 mcg WESTHROID ORAL TABLET 130 MG, 195 MG, 32.5 MG, 65 3 MG, 97.5 MG (thyroid) WP THYROID ORAL TABLET 113.75 MG, 130 MG, 16.25 MG, 3 32.5 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG (thyroid) MISCELLANEOUS THERAPEUTIC AGENTS 5-ALPHA-REDUCTASE INHIBITORS dutasteride oral capsule 0.5 mg 1 finasteride oral tablet 5 mg 1 PROSCAR ORAL TABLET 5 MG (finasteride) 3 ALCOHOL DETERRENTS - Drugs for Alcohol Dependence disulfiram oral tablet 250 mg, 500 mg 1 naltrexone hcl oral tablet 50 mg 1 ANTIDOTES - Drugs for Overdose or Poisoning inhalation solution 10 %, 20 % 1 BAQSIMI ONE PACK NASAL POWDER 3 MG/DOSE SL (2 intranasal devices per 2 (glucagon) prescription.) BAQSIMI TWO PACK NASAL POWDER 3 MG/DOSE SL (2 intranasal devices per 2 (glucagon) prescription.) CHEMET ORAL CAPSULE 100 MG (succimer) 2 FOSRENOL ORAL PACKET 1000 MG, 750 MG (lanthanum 3 carbonate) GLUCAGEN HYPOKIT INJECTION SOLUTION SL (2 devices per 2 RECONSTITUTED 1 MG (glucagon hcl (rdna)) prescription.) SL (2 devices per glucagon emergency kit 1 mg injection 1 mg 1 prescription.) SL (2 devices per GLUCAGON EMERGENCY KIT 1 MG INJECTION 1 MG 2 prescription.) GLUCAGON EMERGENCY KIT INJECTION SOLUTION 2 RECONSTITUTED 1 MG/ML GVOKE HYPOPEN 1-PACK SUBCUTANEOUS SOLUTION 2 SL (0.2 ml per prescription.) AUTO-INJECTOR 0.5 MG/0.1ML (glucagon) GVOKE HYPOPEN 1-PACK SUBCUTANEOUS SOLUTION 2 SL (0.4 ml per prescription.) AUTO-INJECTOR 1 MG/0.2ML (glucagon) GVOKE HYPOPEN 2-PACK SUBCUTANEOUS SOLUTION 2 SL (0.2 ml per prescription.) AUTO-INJECTOR 0.5 MG/0.1ML (glucagon)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 178 Coverage Requirements & Prescription Drug Name Drug Tier Limits GVOKE HYPOPEN 2-PACK SUBCUTANEOUS SOLUTION 2 SL (0.4 ml per prescription.) AUTO-INJECTOR 1 MG/0.2ML (glucagon) GVOKE PFS SUBCUTANEOUS SOLUTION PREFILLED SL (2 syringes per 2 SYRINGE 0.5 MG/0.1ML, 1 MG/0.2ML (glucagon) prescription.) lanthanum carbonate oral tablet chewable 1000 mg, 500 mg, 1 750 mg leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg 1 SL (5 tablets per MEPHYTON ORAL TABLET 5 MG ( phytonadione) 3 prescription.) naloxone hcl injection solution 0.4 mg/ml, 4 mg/10ml 1 naloxone hcl injection solution cartridge 0.4 mg/ml 1 naloxone hcl injection solution prefilled syringe 2 mg/2ml 1 naltrexone hcl oral tablet 50 mg 1 SL (5 tablets per phytonadione oral tablet 5 mg 1 prescription.) RADIOGARDASE ORAL CAPSULE 0.5 GM (prussian blue 3 insoluble) RENAGEL ORAL TABLET 800 MG (sevelamer hcl) 3 RENVELA ORAL PACKET 0.8 GM, 2.4 GM (sevelamer 3 carbonate) sevelamer carbonate oral packet 0.8 gm, 2.4 gm 1 sevelamer carbonate oral tablet 800 mg 1 sevelamer hcl oral tablet 400 mg, 800 mg 1 sodium polystyrene sulfonate oral powder 1 sps oral suspension 15 gm/60ml 1 SL (20 packets per VISTOGARD ORAL PACKET 10 GM (uridine triacetate) 2 prescription.) ANTIGOUT AGENTS - Drugs for Gout allopurinol oral tablet 100 mg, 300 mg 1 colchicine-probenecid oral tablet 0.5-500 mg 1 EC-NAPROSYN ORAL TABLET DELAYED RELEASE 375 MG, 3 500 MG (naproxen) ec-naproxen oral tablet delayed release 375 mg, 500 mg 1 febuxostat oral tablet 40 mg, 80 mg 1 ST; SL (1 tablet per day) GLOPERBA ORAL SOLUTION 0.6 MG/5ML (colchicine) 3 PA INDOCIN ORAL SUSPENSION 25 MG/5ML (indomethacin) 3 INDOCIN RECTAL SUPPOSITORY 50 MG (indomethacin) 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 179 Coverage Requirements & Prescription Drug Name Drug Tier Limits indomethacin er oral capsule extended release 75 mg 1 indomethacin oral capsule 25 mg, 50 mg 1 MITIGARE ORAL CAPSULE 0.6 MG (colchicine) 2 naproxen oral suspension 125 mg/5ml 1 PA naproxen oral tablet 250 mg, 375 mg, 500 mg 1 naproxen oral tablet delayed release 375 mg, 500 mg 1 naproxen sodium oral tablet 275 mg, 550 mg 1 probenecid oral tablet 500 mg 1 ZYLOPRIM ORAL TABLET 100 MG, 300 MG (allopurinol) 3 ANTISENSE OLIGONUCLEOTIDES TEGSEDI SUBCUTANEOUS SOLUTION PREFILLED PA; SL (0.22 ml per day.); 2 SYRINGE 284 MG/1.5ML (inotersen sodium) SP BONE ANABOLIC AGENTS NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG, 25 PA; SL (2 cartridges per 3 MCG, 50 MCG, 75 MCG (parathyroid hormone (recomb)) month.); SP TERIPARATIDE (RECOMBINANT) SUBCUTANEOUS 3 PA; SP SOLUTION PEN-INJECTOR 620 MCG/2.48ML TYMLOS SUBCUTANEOUS SOLUTION PEN-INJECTOR 3120 3 PA; SP MCG/1.56ML (abaloparatide) BONE RESORPTION INHIBITORS - Drugs for Bone Loss alendronate sodium oral solution 70 mg/75ml 1 alendronate sodium oral tablet 10 mg, 35 mg, 5 mg, 70 mg 1 ALORA TRANSDERMAL PATCH TWICE WEEKLY 0.025 SL (8 patches (1 box) per 28 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR 3 days.) (estradiol) BONIVA ORAL TABLET 150 MG (ibandronate sodium) 3 calcitonin (salmon) injection solution 200 unit/ml 1 calcitonin (salmon) nasal solution 200 unit/act 1 DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML, 20 3 MG/ML, 40 MG/ML (estradiol valerate) DEPO-ESTRADIOL INTRAMUSCULAR OIL 5 MG/ML (estradiol 3 cypionate) DIVIGEL TRANSDERMAL GEL 0.25 MG/0.25GM, 0.5 MG/0.5GM, 0.75 MG/0.75GM, 1 MG/GM, 1.25 MG/1.25GM 3 (estradiol) ELESTRIN TRANSDERMAL GEL 0.52 MG/0.87 GM (0.06%) 3 (estradiol) estradiol oral tablet 0.5 mg, 1 mg, 2 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 180 Coverage Requirements & Prescription Drug Name Drug Tier Limits estradiol transdermal patch twice weekly 0.025 mg/24hr, 0.0375 SL (8 patches (1 box) per 28 1 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr days.) estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 SL (4 patches (1 carton) per mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 1 28 days.) mg/24hr estradiol vaginal cream 0.1 mg/gm 1 estradiol vaginal tablet 10 mcg 1 estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml 1 ESTRING VAGINAL RING 2 MG (estradiol) 2 SL (1 ring per 90 days.) ESTROGEL TRANSDERMAL GEL 0.75 MG/1.25 GM (0.06%) SL (50 grams (1 box) per 3 (estradiol) month.) EVAMIST TRANSDERMAL SOLUTION 1.53 MG/SPRAY 2 (estradiol) FEMRING VAGINAL RING 0.05 MG/24HR, 0.1 MG/24HR 3 SL (1 ring per 3 months.) (estradiol acetate) FOSAMAX ORAL TABLET 70 MG (alendronate sodium) 3 FOSAMAX PLUS D ORAL TABLET 70-2800 MG-UNIT, 70- 3 5600 MG-UNIT (alendronate-cholecalciferol) ibandronate sodium oral tablet 150 mg 1 MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG 3 (esterified estrogens) MENOSTAR TRANSDERMAL PATCH WEEKLY 14 SL (4 patches (1 carton) per 3 MCG/24HR (estradiol) 28 days.) MIACALCIN INJECTION SOLUTION 200 UNIT/ML (calcitonin 3 (salmon)) PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 3 MG, 1.25 MG (estrogens conjugated) PREMARIN VAGINAL CREAM 0.625 MG/GM (estrogens, 3 conjugated) raloxifene hcl oral tablet 60 mg 1 H risedronate sodium oral tablet 150 mg 1 SL (1 tablet per month) risedronate sodium oral tablet 30 mg, 5 mg 1 risedronate sodium oral tablet 35 mg 1 SL (4 tablets per 28 days.) VIVELLE-DOT TRANSDERMAL PATCH TWICE WEEKLY SL (8 patches (1 box) per 28 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.075 1 days.) MG/24HR, 0.1 MG/24HR (estradiol) yuvafem vaginal tablet 10 mcg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 181 Coverage Requirements & Prescription Drug Name Drug Tier Limits CARBONIC ANHYDRASE INHIBITORS (MISC.) PA; SL (4 tablets per day.); KEVEYIS ORAL TABLET 50 MG (dichlorphenamide) 2 SP CARIOSTATIC AGENTS - Vitamins and Fluoride adc/f (0.5mg/ml) oral solution 0.5 mg/ml 1 cavarest dental gel 1.1 % 1 CLINPRO 5000 DENTAL PASTE 1.1 % (sodium fluoride) 3 DENTA 5000 PLUS DENTAL CREAM 1.1 % (sodium fluoride) 3 DENTAGEL DENTAL GEL 1.1 % (sodium fluoride) 3 easygel dental gel 0.4 % 1 FLORIVA ORAL LIQUID 0.25-400 MG-UNIT/ML (sodium 3 fluoride-vitamin d) FLORIVA PLUS ORAL SOLUTION 0.25 MG/ML (pediatric 3 multivitamins-fl) fluoridex daily renewal mouth/throat concentrate 0.63 % 1 FLUORIDEX DENTAL PASTE 1.1 % (sodium fluoride) 3 FLUORIDEX ENHANCED WHITENING DENTAL PASTE 1.1 % 3 (sodium fluoride) FLUORIDEX SENSITIVITY RELIEF DENTAL PASTE 1.1-5 % 3 (sod fluoride-potassium nitrate) fluoritab oral solution 0.275 (0.125 f) mg/drop 1 H multi-vit/iron/fluoride oral solution 0.25-10 mg/ml 1 multivitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml 1 multi-vitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml 1 multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg 1 multi-vitamin/fluoride/iron oral solution 0.25-10 mg/ml 1 NAFRINSE DAILY ACIDULATED MOUTH/THROAT SOLUTION RECONSTITUTED 1 MG/5ML (sodium fluoride- 2 phosphoric acd) NAFRINSE DAILY/NEUTRAL MOUTH/THROAT SOLUTION 2 RECONSTITUTED 0.05 % (sodium fluoride) nafrinse drops oral solution 0.275 (0.125 f) mg/drop 1 H nafrinse oral tablet chewable 2.2 (1 f) mg 1 H NAFRINSE WEEKLY MOUTH/THROAT SOLUTION 3 RECONSTITUTED 0.2 % (sodium fluoride) POLY-VI-FLOR ORAL SUSPENSION 0.25 MG/ML (pediatric 3 multivitamins-fl)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 182 Coverage Requirements & Prescription Drug Name Drug Tier Limits POLY-VI-FLOR ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 3 1 MG (pediatric multivitamins-fl) POLY-VI-FLOR/IRON ORAL SUSPENSION 0.25-7 MG/ML 3 (ped multivitamins-fl-iron) POLY-VI-FLOR/IRON ORAL TABLET CHEWABLE 0.5-10 MG 3 (ped multivitamins-fl-iron) PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE 1.1 % 3 (sodium fluoride) PREVIDENT 5000 DRY MOUTH DENTAL GEL 1.1 % (sodium 3 fluoride) PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE 1.1-5 3 % (sod fluoride-potassium nitrate) PREVIDENT 5000 ORTHO DEFENSE DENTAL PASTE 1.1 % 3 (sodium fluoride) PREVIDENT 5000 PLUS DENTAL CREAM 1.1 % (sodium 3 fluoride) PREVIDENT 5000 SENSITIVE DENTAL PASTE 1.1-5 % (sod 3 fluoride-potassium nitrate) PREVIDENT DENTAL GEL 1.1 % (sodium fluoride) 3 PREVIDENT MOUTH/THROAT SOLUTION 0.2 % (sodium 3 fluoride) QUFLORA PEDIATRIC ORAL SOLUTION 0.25 MG/ML, 0.5 3 MG/ML (pediatric multivitamins-fl) QUFLORA PEDIATRIC ORAL TABLET CHEWABLE 0.25 MG, 3 0.5 MG, 1 MG (pediatric multivitamins-fl) sf 5000 plus dental cream 1.1 % 1 sf dental gel 1.1 % 1 sodium fluoride 5000 enamel dental paste 1.1-5 % 1 sodium fluoride 5000 plus dental cream 1.1 % 1 sodium fluoride 5000 ppm dental cream 1.1 % 1 sodium fluoride 5000 ppm dental paste 1.1 % 1 sodium fluoride 5000 sensitive dental paste 1.1-5 % 1 sodium fluoride dental cream 1.1 % 1 sodium fluoride dental gel 1.1 % 1 sodium fluoride mouth/throat solution 0.2 % 1 sodium fluoride oral solution 1.1 (0.5 f) mg/ml 1 H sodium fluoride oral tablet 1.1 (0.5 f) mg, 2.2 (1 f) mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 183 Coverage Requirements & Prescription Drug Name Drug Tier Limits sodium fluoride oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) 1 H mg, 2.2 (1 f) mg TRI-VI-FLOR ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML 3 (ped vit a-c-d-methylfolate-fl) TRI-VI-FLORO ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML 3 tri-vite/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml 1 vitamins acd-fluoride oral solution 0.25 mg/ml 1 COMPLEMENT INHIBITORS BERINERT INTRAVENOUS KIT 500 UNIT (c1 esterase PA; ST; SL (0.34 boxes per 3 inhibitor (human)) day.); SP FIRAZYR SUBCUTANEOUS SOLUTION 30 MG/3ML ( 1 PA; SL (0.6 ml per day.); SP acetate) HAEGARDA SUBCUTANEOUS SOLUTION RECONSTITUTED PA; SL (11 vials per month.); 2 2000 UNIT, 3000 UNIT (c1 esterase inhibitor (human)) SP RUCONEST INTRAVENOUS SOLUTION RECONSTITUTED PA; SL (0.27 vials per day.); 3 2100 UNIT (c1 esterase inhibitor (recomb)) SP TAKHZYRO SUBCUTANEOUS SOLUTION 300 MG/2ML PA; SL (0.075 ml per day.); 2 (lanadelumab-flyo) SP DISEASE-MODIFYING ANTIRHEUMATIC AGENTS - Drugs for Arthritis ACTEMRA ACTPEN SUBCUTANEOUS SOLUTION AUTO- PA; ST; SL (3.6 ml per 21 3 INJECTOR 162 MG/0.9ML (tocilizumab) days.); SP ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED PA; ST; SL (4 syringes (3.6 3 SYRINGE 162 MG/0.9ML (tocilizumab) ml) per month.); SP ARAVA ORAL TABLET 10 MG, 20 MG (leflunomide) 3 AZASAN ORAL TABLET 100 MG, 75 MG (azathioprine) 3 azathioprine oral tablet 50 mg 1 AZULFIDINE EN-TABS ORAL TABLET DELAYED RELEASE 3 500 MG (sulfasalazine) AZULFIDINE ORAL TABLET 500 MG (sulfasalazine) 3 CIMZIA PREFILLED KIT SUBCUTANEOUS KIT 2 X 200 PA; SL (1 kit per 21 days.); 2 MG/ML (certolizumab pegol) SP CIMZIA STARTER KIT SUBCUTANEOUS KIT 6 X 200 MG/ML PA; SL (6 mL per 365 days.); 2 (certolizumab pegol) SP cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg 1 cyclosporine modified oral solution 100 mg/ml 1 cyclosporine oral capsule 100 mg, 25 mg 1 DEPEN TITRATABS ORAL TABLET 250 MG ( penicillamine) 2 SP

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 184 Coverage Requirements & Prescription Drug Name Drug Tier Limits ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE 50 PA; ST; SL (0.15mg/ml per 3 MG/ML (etanercept) day.); SP ENBREL SUBCUTANEOUS SOLUTION 25 MG/0.5ML 3 PA; ST; SL (0.15 ml per day.) (etanercept) ENBREL SUBCUTANEOUS SOLUTION PREFILLED PA; ST; SL (0.15mg/ml per 3 SYRINGE 25 MG/0.5ML, 50 MG/ML (etanercept) day.); SP ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 PA; ST; SL (0.29mg per 3 MG (etanercept) day.); SP ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO- PA; ST; SL (0.15mg/ml per 3 INJECTOR 50 MG/ML (etanercept) day.); SP gengraf oral capsule 100 mg, 25 mg 1 gengraf oral solution 100 mg/ml 1 HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PA; SL (3 syringes per 2 PREFILLED SYRINGE KIT 80 MG/0.8ML (adalimumab) year.); SP HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML & 40MG/0.4ML 2 PA; SL (2 kits per year.); SP (adalimumab) HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 PA; SL (2 pens per month.); 2 MG/0.4ML, 80 MG/0.8ML (adalimumab) SP HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 PA; SL (2 syringes per 2 MG/0.8ML (adalimumab) month.); SP HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN- PA; SL (6 pens (1 kit) per 2 INJECTOR KIT 40 MG/0.8ML (adalimumab) year.); SP HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN- PA; SL (3 pens per year.); 2 INJECTOR KIT 80 MG/0.8ML (adalimumab) SP HUMIRA PEN-PEDIATRIC UC START SUBCUTANEOUS PA; SL (3 pens per year.); 2 PEN-INJECTOR KIT 80 MG/0.8ML (adalimumab) SP HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PA; SL (4 pens (1 kit) per 2 PEN-INJECTOR KIT 40 MG/0.8ML (adalimumab) year.); SP HUMIRA PEN-PSOR/UVEIT STARTER SUBCUTANEOUS PA; SL (3 pens per year.); PEN-INJECTOR KIT 80 MG/0.8ML & 40MG/0.4ML 2 SP (adalimumab) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 PA; SL (2 syringes per 2 MG/0.1ML, 20 MG/0.2ML, 40 MG/0.4ML (adalimumab) month.); SP HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 40 PA; SL (2 syringes per 2 MG/0.8ML (adalimumab) month.) hydroxychloroquine sulfate oral tablet 200 mg 1 KEVZARA SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; ST; SL (2.28 ml per 3 150 MG/1.14ML, 200 MG/1.14ML (sarilumab) month.); SP

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 185 Coverage Requirements & Prescription Drug Name Drug Tier Limits KEVZARA SUBCUTANEOUS SOLUTION PREFILLED PA; ST; SL (2.28 ml per 3 SYRINGE 150 MG/1.14ML, 200 MG/1.14ML (sarilumab) month.); SP KINERET SUBCUTANEOUS SOLUTION PREFILLED PA; SL (0.67 ml (1 syringe) 3 SYRINGE 100 MG/0.67ML (anakinra) per day.); SP leflunomide oral tablet 10 mg, 20 mg 1 methotrexate oral tablet 2.5 mg 1 methotrexate sodium (pf) injection solution 1 gm/40ml, 250 1 mg/10ml, 50 mg/2ml methotrexate sodium injection solution 250 mg/10ml, 50 mg/2ml 1 methotrexate sodium injection solution reconstituted 1 gm 1 methotrexate sodium oral tablet 2.5 mg 1 OLUMIANT ORAL TABLET 1 MG (baricitinib) 2 PA; SL (1 tablet per day.) PA; SL (1 tablet per day.); OLUMIANT ORAL TABLET 2 MG (baricitinib) 2 SP ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO- PA; ST; SL (4 auto-injectors 3 INJECTOR 125 MG/ML (abatacept) per month.); SP ORENCIA SUBCUTANEOUS SOLUTION PREFILLED PA; ST; SL (4 syringes per 3 SYRINGE 125 MG/ML (abatacept) month); SP ORENCIA SUBCUTANEOUS SOLUTION PREFILLED PA; ST; SL (0.06 ml per 3 SYRINGE 50 MG/0.4ML (abatacept) day.); SP ORENCIA SUBCUTANEOUS SOLUTION PREFILLED PA; ST; SL (0.1 ml per day.); 3 SYRINGE 87.5 MG/0.7ML (abatacept) SP PA; SL (2 tablets per day.); OTEZLA ORAL TABLET 30 MG (apremilast) 2 SP OTEZLA ORAL TABLET THERAPY PACK 10 & 20 & 30 MG PA; SL (55 tablets (one 2 (apremilast) starter pack) per year.); SP penicillamine oral capsule 250 mg 1 SP penicillamine oral tablet 250 mg 1 SP RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 SL (0.8 ml (4 auto-injectors) 2 MG/0.2ML (methotrexate (anti-rheumatic)) per month.) RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR SL (1 ml (4 auto-injectors) 2 12.5 MG/0.25ML (methotrexate (anti-rheumatic)) per month.) RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 15 SL (1.2 ml (4 auto-injectors) 2 MG/0.3ML (methotrexate (anti-rheumatic)) per month.) RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR SL (1.4 ml (4 auto-injectors) 2 17.5 MG/0.35ML (methotrexate (anti-rheumatic)) per month.) RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 20 SL (1.6 ml (4 auto-injectors) 2 MG/0.4ML (methotrexate (anti-rheumatic)) per month.)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 186 Coverage Requirements & Prescription Drug Name Drug Tier Limits RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR SL (1.8 ml (4 auto-injectors) 2 22.5 MG/0.45ML (methotrexate (anti-rheumatic)) per month.) RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 25 SL (2 ml (4 auto-injectors) 2 MG/0.5ML (methotrexate (anti-rheumatic)) per month.) RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 30 SL (2.4 ml (4 auto-injectors) 2 MG/0.6ML (methotrexate (anti-rheumatic)) per month.) RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 7.5 SL (0.6 ml (4 auto-injectors) 2 MG/0.15ML (methotrexate (anti-rheumatic)) per month.) RIDAURA ORAL CAPSULE 3 MG (auranofin) 3 SP RINVOQ ORAL TABLET EXTENDED RELEASE 24 HOUR 15 PA; SL (1 tablet per day.); 2 MG (upadacitinib) SP SANDIMMUNE ORAL SOLUTION 100 MG/ML (cyclosporine) 3 SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; SL (1 syringe per 21 2 100 MG/ML (golimumab) days.); SP SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 PA; SL (0.5 ml (1 syringe) 2 MG/0.5ML (golimumab) per month); SP SIMPONI SUBCUTANEOUS SOLUTION PREFILLED PA; SL (1 syringe per 21 2 SYRINGE 100 MG/ML (golimumab) days.); SP SIMPONI SUBCUTANEOUS SOLUTION PREFILLED PA; SL (0.5 ml (1 syringe) 2 SYRINGE 50 MG/0.5ML (golimumab) per month); SP sulfasalazine oral tablet 500 mg 1 sulfasalazine oral tablet delayed release 500 mg 1 TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG 2 (methotrexate sodium) XATMEP ORAL SOLUTION 2.5 MG/ML (methotrexate) 3 PA; SL (4 ml per day.) PA; ST; SL (8 mL per day.); XELJANZ ORAL SOLUTION 1 MG/ML (tofacitinib citrate) 2 SP PA; ST; SL (2 tablets per XELJANZ ORAL TABLET 10 MG, 5 MG (tofacitinib citrate) 2 day.); SP XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR PA; ST; SL (1 tablet per 2 11 MG (tofacitinib citrate) day.); SP XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2 PA; ST; SL (1 tablet per day.) 22 MG (tofacitinib citrate) IMMUNOMODULATORY AGENTS - DRUGS FOR THE IMMUNE SYSTEM ACTEMRA ACTPEN SUBCUTANEOUS SOLUTION AUTO- PA; ST; SL (3.6 ml per 21 3 INJECTOR 162 MG/0.9ML (tocilizumab) days.); SP ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED PA; ST; SL (4 syringes (3.6 3 SYRINGE 162 MG/0.9ML (tocilizumab) ml) per month.); SP

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 187 Coverage Requirements & Prescription Drug Name Drug Tier Limits ACTIMMUNE SUBCUTANEOUS SOLUTION 2000000 PA; SL (6.5 ml (13 vials) per 2 UNIT/0.5ML (interferon gamma-1b) month.); SP ALFERON N INJECTION SOLUTION 5000000 UNIT/ML 2 (interferon alfa-n3) ARAVA ORAL TABLET 10 MG, 20 MG (leflunomide) 3 AUBAGIO ORAL TABLET 14 MG, 7 MG (teriflunomide) 3 PA; SL (1 tablet per day.) AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT 30 PA; SL (4 pens (1 box) per 2 MCG/0.5ML (interferon beta-1a) month.); SP AVONEX PREFILLED INTRAMUSCULAR PREFILLED PA; SL (4 syringes (1 box) 2 SYRINGE KIT 30 MCG/0.5ML (interferon beta-1a) per month.); SP AZASAN ORAL TABLET 100 MG, 75 MG (azathioprine) 3 azathioprine oral tablet 50 mg 1 AZULFIDINE EN-TABS ORAL TABLET DELAYED RELEASE 3 500 MG (sulfasalazine) AZULFIDINE ORAL TABLET 500 MG (sulfasalazine) 3 BAFIERTAM ORAL CAPSULE DELAYED RELEASE 95 MG PA; SL (4 capsules per day.); 2 (monomethyl fumarate) SP BETASERON SUBCUTANEOUS KIT 0.3 MG (interferon beta- 2 PA; SL (15 vials per month) 1b) CIMZIA PREFILLED KIT SUBCUTANEOUS KIT 2 X 200 PA; SL (1 kit per 21 days.); 2 MG/ML (certolizumab pegol) SP CIMZIA STARTER KIT SUBCUTANEOUS KIT 6 X 200 MG/ML PA; SL (6 mL per 365 days.); 2 (certolizumab pegol) SP cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg 1 cyclosporine modified oral solution 100 mg/ml 1 cyclosporine oral capsule 100 mg, 25 mg 1 PA; SL (56 capsules per dimethyl fumarate oral capsule delayed release 120 mg 1 year.) dimethyl fumarate oral capsule delayed release 240 mg 1 PA; SL (2 capsules per day.) PA; SL (60 capsules (1 dimethyl fumarate starter pack oral 120 & 240 mg 1 starter pack) per 365 days.) ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE 50 PA; ST; SL (0.15mg/ml per 3 MG/ML (etanercept) day.); SP ENBREL SUBCUTANEOUS SOLUTION 25 MG/0.5ML 3 PA; ST; SL (0.15 ml per day.) (etanercept) ENBREL SUBCUTANEOUS SOLUTION PREFILLED PA; ST; SL (0.15mg/ml per 3 SYRINGE 25 MG/0.5ML, 50 MG/ML (etanercept) day.); SP ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 PA; ST; SL (0.29mg per 3 MG (etanercept) day.); SP

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 188 Coverage Requirements & Prescription Drug Name Drug Tier Limits ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO- PA; ST; SL (0.15mg/ml per 3 INJECTOR 50 MG/ML (etanercept) day.); SP ENSPRYNG SUBCUTANEOUS SOLUTION PREFILLED PA; SL (0.04 ml per day.); 3 SYRINGE 120 MG/ML (satralizumab-mwge) SP gengraf oral capsule 100 mg, 25 mg 1 gengraf oral solution 100 mg/ml 1 GILENYA ORAL CAPSULE 0.25 MG (fingolimod hcl) 3 PA; SL (1 capsule per day.) GILENYA ORAL CAPSULE 0.5 MG (fingolimod hcl) 3 PA; SL (1 capsule per day) glatiramer acetate subcutaneous solution prefilled syringe 20 1 PA; SL (30 ml per month.) mg/ml glatiramer acetate subcutaneous solution prefilled syringe 40 1 PA; SL (12 ml per 21 days.) mg/ml glatopa subcutaneous solution prefilled syringe 20 mg/ml 1 PA; SL (30 ml per month.) glatopa subcutaneous solution prefilled syringe 40 mg/ml 1 PA; SL (12 ml per 21 days.) HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PA; SL (3 syringes per 2 PREFILLED SYRINGE KIT 80 MG/0.8ML (adalimumab) year.); SP HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML & 40MG/0.4ML 2 PA; SL (2 kits per year.); SP (adalimumab) HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 PA; SL (2 pens per month.); 2 MG/0.4ML, 80 MG/0.8ML (adalimumab) SP HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 PA; SL (2 syringes per 2 MG/0.8ML (adalimumab) month.); SP HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN- PA; SL (6 pens (1 kit) per 2 INJECTOR KIT 40 MG/0.8ML (adalimumab) year.); SP HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN- PA; SL (3 pens per year.); 2 INJECTOR KIT 80 MG/0.8ML (adalimumab) SP HUMIRA PEN-PEDIATRIC UC START SUBCUTANEOUS PA; SL (3 pens per year.); 2 PEN-INJECTOR KIT 80 MG/0.8ML (adalimumab) SP HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PA; SL (4 pens (1 kit) per 2 PEN-INJECTOR KIT 40 MG/0.8ML (adalimumab) year.); SP HUMIRA PEN-PSOR/UVEIT STARTER SUBCUTANEOUS PA; SL (3 pens per year.); PEN-INJECTOR KIT 80 MG/0.8ML & 40MG/0.4ML 2 SP (adalimumab) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 PA; SL (2 syringes per 2 MG/0.1ML, 20 MG/0.2ML, 40 MG/0.4ML (adalimumab) month.); SP HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 40 PA; SL (2 syringes per 2 MG/0.8ML (adalimumab) month.) hydroxychloroquine sulfate oral tablet 200 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 189 Coverage Requirements & Prescription Drug Name Drug Tier Limits INTRON A INJECTION SOLUTION 10000000 UNIT/ML, 3 PA; SP 6000000 UNIT/ML (interferon alfa-2b) INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT (interferon 3 PA; SP alfa-2b) KESIMPTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; SL (0.02 ml per day.); 2 20 MG/0.4ML (ofatumumab) SP KINERET SUBCUTANEOUS SOLUTION PREFILLED PA; SL (0.67 ml (1 syringe) 3 SYRINGE 100 MG/0.67ML (anakinra) per day.); SP leflunomide oral tablet 10 mg, 20 mg 1 MAYZENT ORAL TABLET 0.25 MG ( siponimod fumarate) 3 PA; SL (4 tablets per day.) MAYZENT ORAL TABLET 2 MG ( siponimod fumarate) 3 PA; SL (1 tablet per day.) methotrexate oral tablet 2.5 mg 1 methotrexate sodium (pf) injection solution 1 gm/40ml, 250 1 mg/10ml, 50 mg/2ml methotrexate sodium injection solution 250 mg/10ml, 50 mg/2ml 1 methotrexate sodium injection solution reconstituted 1 gm 1 methotrexate sodium oral tablet 2.5 mg 1 ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO- PA; ST; SL (4 auto-injectors 3 INJECTOR 125 MG/ML (abatacept) per month.); SP ORENCIA SUBCUTANEOUS SOLUTION PREFILLED PA; ST; SL (4 syringes per 3 SYRINGE 125 MG/ML (abatacept) month); SP ORENCIA SUBCUTANEOUS SOLUTION PREFILLED PA; ST; SL (0.06 ml per 3 SYRINGE 50 MG/0.4ML (abatacept) day.); SP ORENCIA SUBCUTANEOUS SOLUTION PREFILLED PA; ST; SL (0.1 ml per day.); 3 SYRINGE 87.5 MG/0.7ML (abatacept) SP PA; SL (2 tablets per day.); OTEZLA ORAL TABLET 30 MG (apremilast) 2 SP OTEZLA ORAL TABLET THERAPY PACK 10 & 20 & 30 MG PA; SL (55 tablets (one 2 (apremilast) starter pack) per year.); SP PLEGRIDY INTRAMUSCULAR SOLUTION PREFILLED 3 PA; SL (1 ml per month.) SYRINGE 125 MCG/0.5ML (peginterferon beta-1a) PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION 3 PA; SL (1 ml per year.); SP PEN-INJECTOR 63 & 94 MCG/0.5ML (peginterferon beta-1a) PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 63 & 94 MCG/0.5ML (peginterferon 3 PA; SL (1 ml per year.); SP beta-1a) PLEGRIDY SUBCUTANEOUS SOLUTION PEN-INJECTOR 3 PA; SL (1 ml per month.); SP 125 MCG/0.5ML (peginterferon beta-1a)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 190 Coverage Requirements & Prescription Drug Name Drug Tier Limits PLEGRIDY SUBCUTANEOUS SOLUTION PREFILLED 3 PA; SL (1 ml per month.); SP SYRINGE 125 MCG/0.5ML (peginterferon beta-1a) POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG PA; SL (21 capsules per 3 (pomalidomide) prescription.); SP; CM REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO- PA; ST; SL (6 ml (12 3 INJECTOR 22 MCG/0.5ML, 44 MCG/0.5ML (interferon beta-1a) syringes) per month); SP REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS PA; ST; SL (4.2 mL (1 pack) SOLUTION AUTO-INJECTOR 6X8.8 & 6X22 MCG (interferon 3 per year); SP beta-1a) REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; ST; SL (6 ml (12 3 22 MCG/0.5ML, 44 MCG/0.5ML (interferon beta-1a) syringes) per month); SP REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PA; ST; SL (4.2 ml (1 pack) 3 PREFILLED SYRINGE 6X8.8 & 6X22 MCG (interferon beta-1a) per year); SP REVLIMID ORAL CAPSULE 10 MG, 2.5 MG, 5 MG PA; SL (28 capsules per 2 (lenalidomide) prescription.); SP; CM REVLIMID ORAL CAPSULE 15 MG, 20 MG, 25 MG PA; SL (21 capsules per 2 (lenalidomide) prescription.); SP; CM RIDAURA ORAL CAPSULE 3 MG (auranofin) 3 SP SANDIMMUNE ORAL SOLUTION 100 MG/ML (cyclosporine) 3 SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; SL (1 syringe per 21 2 100 MG/ML (golimumab) days.); SP SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 PA; SL (0.5 ml (1 syringe) 2 MG/0.5ML (golimumab) per month); SP SIMPONI SUBCUTANEOUS SOLUTION PREFILLED PA; SL (1 syringe per 21 2 SYRINGE 100 MG/ML (golimumab) days.); SP SIMPONI SUBCUTANEOUS SOLUTION PREFILLED PA; SL (0.5 ml (1 syringe) 2 SYRINGE 50 MG/0.5ML (golimumab) per month); SP sulfasalazine oral tablet 500 mg 1 sulfasalazine oral tablet delayed release 500 mg 1 PA; SL (28 capsules per THALOMID ORAL CAPSULE 100 MG, 50 MG (thalidomide) 2 prescription.); SP; CM PA; SL (56 capsules per THALOMID ORAL CAPSULE 150 MG, 200 MG (thalidomide) 2 prescription.); SP; CM TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG 2 (methotrexate sodium) XATMEP ORAL SOLUTION 2.5 MG/ML (methotrexate) 3 PA; SL (4 ml per day.) ZEPOSIA 7-DAY STARTER PACK ORAL CAPSULE 3 PA; SL (7 capsules per year.) THERAPY PACK 4 X 0.23MG & 3 X 0.46MG (ozanimod hcl) ZEPOSIA ORAL CAPSULE 0.92 MG (ozanimod hcl) 3 PA; SL (1 capsule per day.)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 191 Coverage Requirements & Prescription Drug Name Drug Tier Limits ZEPOSIA STARTER KIT ORAL CAPSULE THERAPY PACK PA; SL (37 capsules per 3 0.23MG & 0.46MG & 0.92MG (ozanimod hcl) year.) IMMUNOSUPPRESSIVE AGENTS - Drugs for Transplant ARAVA ORAL TABLET 10 MG, 20 MG (leflunomide) 3 AZASAN ORAL TABLET 100 MG, 75 MG (azathioprine) 3 azathioprine oral tablet 50 mg 1 BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 2 PA; SL (4 ml per month.); SP 200 MG/ML (belimumab) BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED 2 PA; SL (4 ml per month.); SP SYRINGE 200 MG/ML (belimumab) cyclophosphamide oral capsule 25 mg, 50 mg 1 CYCLOPHOSPHAMIDE ORAL TABLET 25 MG, 50 MG 2 CM cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg 1 cyclosporine modified oral solution 100 mg/ml 1 cyclosporine oral capsule 100 mg, 25 mg 1 everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg 1 gengraf oral capsule 100 mg, 25 mg 1 gengraf oral solution 100 mg/ml 1 leflunomide oral tablet 10 mg, 20 mg 1 LUPKYNIS ORAL CAPSULE 7.9 MG (voclosporin) 3 PA; SL (6 capsules per day.) MAVENCLAD ORAL TABLET THERAPY PACK 10 MG PA; ST; SL (40 tablets per 3 (cladribine) 720 days.) mercaptopurine oral tablet 50 mg 1 methotrexate oral tablet 2.5 mg 1 methotrexate sodium (pf) injection solution 1 gm/40ml, 250 1 mg/10ml, 50 mg/2ml methotrexate sodium injection solution 250 mg/10ml, 50 mg/2ml 1 methotrexate sodium injection solution reconstituted 1 gm 1 methotrexate sodium oral tablet 2.5 mg 1 mycophenolate mofetil oral capsule 250 mg 1 mycophenolate mofetil oral suspension reconstituted 200 mg/ml 1 mycophenolate mofetil oral tablet 500 mg 1 mycophenolate sodium oral tablet delayed release 180 mg, 360 1 mg ST; SL (30 grams per pimecrolimus external cream 1 % 1 prescription.) PROGRAF ORAL CAPSULE 0.5 MG, 1 MG, 5 MG (tacrolimus) 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 192 Coverage Requirements & Prescription Drug Name Drug Tier Limits PROGRAF ORAL PACKET 0.2 MG, 1 MG (tacrolimus) 3 PA PURIXAN ORAL SUSPENSION 2000 MG/100ML 3 PA; SP (mercaptopurine) RAPAMUNE ORAL SOLUTION 1 MG/ML () 3 SANDIMMUNE ORAL SOLUTION 100 MG/ML (cyclosporine) 3 sirolimus oral solution 1 mg/ml 1 sirolimus oral tablet 0.5 mg, 1 mg, 2 mg 1 ST; SL (30 grams per tacrolimus external ointment 0.03 %, 0.1 % 1 prescription.) tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg 1 TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG 2 (methotrexate sodium) XATMEP ORAL SOLUTION 2.5 MG/ML (methotrexate) 3 PA; SL (4 ml per day.) OTHER MISCELLANEOUS THERAPEUTIC AGENTS ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED PA; SL (4 syringes per 2 220 MG (rilonacept) month); SP CARNITOR ORAL SOLUTION 1 GM/10ML (levocarnitine) 3 CARNITOR ORAL TABLET 330 MG (levocarnitine) 3 CARNITOR SF ORAL SOLUTION 1 GM/10ML (levocarnitine) 3 CERDELGA ORAL CAPSULE 84 MG (eliglustat tartrate) 2 PA; SP CITRANATAL ESSENCE ORAL THERAPY PACK 35-1 & 300 3 MG (prenat w/o a-fecbgl-fa-dha) CITRANATAL MEDLEY ORAL CAPSULE 27-1-200 MG 3 (prenat-fecb-fefum-fa-dha w/o a) CYSTADANE ORAL POWDER (betaine) 2 SP CYSTAGON ORAL CAPSULE 150 MG, 50 MG (cysteamine 2 SP bitartrate) dalfampridine er oral tablet extended release 12 hour 10 mg 1 PA; SL (2 tablets per day) DEMSER ORAL CAPSULE 250 MG (metyrosine) 3 ELMIRON ORAL CAPSULE 100 MG ( 2 ST sodium) ENBRACE HR ORAL CAPSULE (prenat vit-fe gly cys-fa- 3 omega) ENDARI ORAL PACKET 5 GM (glutamine (sickle cell)) 3 PA; SL (6 packets per day.) EVOTAZ ORAL TABLET 300-150 MG (atazanavir-cobicistat) 2 EVRYSDI ORAL SOLUTION RECONSTITUTED 0.75 MG/ML PA; SL (6.7 ml per day, 1280 2 (risdiplam) ml per 180 days.); SP

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 193 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; SL (14 capsules per 21 GALAFOLD ORAL CAPSULE 123 MG (migalastat hcl) 3 days.); SP PA; SL (8 tablets per day.); ISTURISA ORAL TABLET 1 MG (osilodrostat phosphate) 3 SP PA; SL (6 tablets per day.); ISTURISA ORAL TABLET 10 MG (osilodrostat phosphate) 3 SP PA; SL (2 tablets per day.); ISTURISA ORAL TABLET 5 MG (osilodrostat phosphate) 3 SP levocarnitine oral solution 1 gm/10ml 1 levocarnitine oral tablet 330 mg 1 levocarnitine sf oral solution 1 gm/10ml 1 me/naphos/mb/hyo1 oral tablet 81.6 mg 1 metyrosine oral capsule 250 mg 1 miglustat oral capsule 100 mg 1 NEONATAL + DHA ORAL 29-1 & 200 MG 3 NUTRIDOX ORAL KIT 75 MG (doxycycline monohyd-omega 3- 3 e) ORFADIN ORAL CAPSULE 10 MG, 2 MG, 20 MG, 5 MG 1 PA; SP (nitisinone) PHOSPHASAL ORAL TABLET 81.6 MG (meth-hyo-m bl-na 2 phos-ph sal) PREMESISRX ORAL TABLET 1 MG (prenatal ca-b6-b12-fa- 3 ginger) PRENAISSANCE ORAL CAPSULE 29-1.25-325 MG 2 PRENATE DHA ORAL CAPSULE 18-0.6-0.4-300 MG (prenat- 3 feasp-meth-fa-dha w/o a) PRENATE ENHANCE ORAL CAPSULE 28-0.6-0.4-400 MG 3 (prenat w/o a-fe-methfol-fa-dha) PRENATE ESSENTIAL ORAL CAPSULE 18-0.6-0.4-300 MG 3 (prenat-feasp-meth-fa-dha w/o a) PRENATE MINI ORAL CAPSULE 18-0.6-0.4-350 MG (prenat- 3 fecbn-feasp-meth-fa-dha) PRENATE PIXIE ORAL CAPSULE 10-0.6-0.4-200 MG (prenat- 3 feasp-meth-fa-dha w/o a) PRENATE RESTORE ORAL CAPSULE 27-0.6-0.4-400 MG 3 (prenat w/o a-fe-methfol-fa-dha) PREZCOBIX ORAL TABLET 800-150 MG (darunavir-cobicistat) 2 PRIMACARE ORAL CAPSULE 30-1-470 MG (pren-fe-meth-fa- 3 omeg w/o a)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 194 Coverage Requirements & Prescription Drug Name Drug Tier Limits PROCYSBI ORAL CAPSULE DELAYED RELEASE 25 MG, 75 3 PA; ST; SP MG (cysteamine bitartrate) PROCYSBI ORAL PACKET 300 MG, 75 MG (cysteamine 3 SP bitartrate) RELNATE DHA ORAL CAPSULE 28-1-200 MG 3 PA; SL (10 tablets per day.); RUZURGI ORAL TABLET 10 MG (amifampridine) 2 SP PA; SL (16 packets per day.); sapropterin dihydrochloride oral packet 100 mg 1 SP PA; SL (4 packets per day.); sapropterin dihydrochloride oral packet 500 mg 1 SP PA; SL (16 tablets per day); sapropterin dihydrochloride oral tablet 100 mg 1 SP SODIUM SULFACETAMIDE-BAKUCHIOL EXTERNAL LIQUID 3 10 % STRIBILD ORAL TABLET 150-150-200-300 MG (elviteg-cobic- 2 SL (1 tablet per day.) emtricit-tenofdf) SYMTUZA ORAL TABLET 800-150-200-10 MG (darun-cobic- 2 SL (1 tablet per day.) emtricit-tenofaf) THIOLA EC ORAL TABLET DELAYED RELEASE 100 MG, 300 3 SP MG (tiopronin) THIOLA ORAL TABLET 100 MG (tiopronin) 3 SP tiopronin oral tablet 100 mg 1 SP TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1-500 3 MG (prenatal-fefum-fa-dss-fish oil) TRI-CHLOR EXTERNAL LIQUID 80 % (trichloroacetic acid) 2 TRISTART DHA ORAL CAPSULE 31-0.6-0.4-200 MG 3 TRISTART FREE ORAL CAPSULE 33-1 MG (prenat w/o a- 3 fecbn-meth-fa-dha) TRISTART ONE ORAL CAPSULE 35-1-215 MG (prenat w/o a- 3 fecbn-meth-fa-dha) TYBOST ORAL TABLET 150 MG ( cobicistat) 2 URELLE ORAL TABLET 81 MG (meth-hyo-m bl-na phos-ph 3 sal) URIBEL ORAL CAPSULE 118 MG (meth-hyo-m bl-na phos-ph 3 sal) urin ds oral tablet 81.6 mg 1 URO-458 ORAL TABLET 81 MG 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 195 Coverage Requirements & Prescription Drug Name Drug Tier Limits UROGESIC-BLUE ORAL TABLET 81.6 MG (methen-hyosc- 2 meth blue-na phos) uro-mp oral capsule 118 mg 1 USTELL ORAL CAPSULE 120 MG (meth-hyo-m bl-na phos-ph 3 sal) UTIRA-C ORAL TABLET 81.6 MG (meth-hyo-m bl-na phos-ph 2 sal) VILAMIT MB ORAL CAPSULE 118 MG (meth-hyo-m bl-na 3 phos-ph sal) VILEVEV MB ORAL TABLET 81 MG (meth-hyo-m bl-na phos- 3 ph sal) VITAFOL FE+ ORAL CAPSULE 90-0.6-0.4-200 MG (prenat-fe 3 poly-methfol-fa-dha) VITAFOL-OB+DHA ORAL 65-1 & 250 MG (prenatal mv-min-fe 3 fum-fa-dha) vp-pnv-dha oral capsule 28-1-215.8 mg 1 WESTGEL DHA ORAL CAPSULE 31-0.6-0.4-200 MG 3 PA; SL (30 packets per XURIDEN ORAL PACKET 2 GM (uridine triacetate) 2 prescription.); SP PA; SL (4 capsules per day.); ZOKINVY ORAL CAPSULE 50 MG (lonafarnib) 2 SP PA; SL (1 tablet per day.); ZOKINVY ORAL CAPSULE 75 MG (lonafarnib) 2 SP PROTECTIVE AGENTS MESNEX ORAL TABLET 400 MG (mesna) 3 SP; CM NONHORMONAL CONTRACEPTIVES - Drugs for Women NONHORMONAL CONTRACEPTIVES - Drugs for Women CAYA VAGINAL DIAPHRAGM (diaphragm arc-spring) 3 H PHEXXI VAGINAL GEL 1.8-1-0.4 % (lactic ac-citric ac-pot 3 H bitart) WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 2 % 2 H (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM 2 % 2 H (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM 2 % 2 H (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM 2 % 2 H (diaphragm wide seal)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 196 Coverage Requirements & Prescription Drug Name Drug Tier Limits WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM 2 % 2 H (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM 2 % 2 H (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM 2 % 2 H (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM 2 % 2 H (diaphragm wide seal) OXYTOCICS - Drugs for Women OXYTOCICS - Drugs for Women CERVIDIL VAGINAL INSERT 10 MG (dinoprostone) 3 methergine oral tablet 0.2 mg 1 SL (28 tablets per year.) methylergonovine maleate oral tablet 0.2 mg 1 SL (28 tablets per year.) PREPIDIL VAGINAL GEL 0.5 MG/3GM (dinoprostone) 3 PROSTIN E2 VAGINAL SUPPOSITORY 20 MG (dinoprostone) 3 PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PYROGALLIC ACID EXTERNAL OINTMENT 25-2 % 2 RESPIRATORY TRACT AGENTS - Drugs for the Lungs ALPHA AND BETA ADRENERGIC AGONIST(RESPR) - Drugs for Asthma/COPD ADRENALIN NASAL SOLUTION 0.1 % (epinephrine hcl 2 (nasal)) epinephrine solution auto-injector 0.15 mg/0.3ml injection 0.15 SL (4 injections per 1 mg/0.3ml prescription.) epinephrine solution auto-injector 0.3 mg/0.3ml injection 0.3 SL (2 injections per 1 mg/0.3ml prescription.) ANTICHOLINERGIC AGENTS (RESPIR.TRACT) - Drugs for Asthma/COPD ATROVENT HFA INHALATION AEROSOL SOLUTION 17 3 SL (0.87 grams per day.) MCG/ACT (ipratropium bromide hfa) COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 3 SL (0.28 grams per day.) 20-100 MCG/ACT (ipratropium-albuterol) ipratropium bromide inhalation solution 0.02 % 1 ipratropium bromide nasal solution 0.03 %, 0.06 % 1 ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml 1 SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG 2 SL (1 capsule per day) (tiotropium bromide monohydrate)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 197 Coverage Requirements & Prescription Drug Name Drug Tier Limits SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 2 SL (0.15 grams per day.) MCG/ACT, 2.5 MCG/ACT (tiotropium bromide monohydrate) ANTIFIBROTIC AGENTS - Drugs for the Lungs PA; SL (9 capsules per day.); ESBRIET ORAL CAPSULE 267 MG (pirfenidone) 2 SP PA; SL (9 tablets per day.); ESBRIET ORAL TABLET 267 MG (pirfenidone) 2 SP PA; SL (3 tablets per day.); ESBRIET ORAL TABLET 801 MG (pirfenidone) 2 SP PA; SL (2 capsules per day.); OFEV ORAL CAPSULE 100 MG, 150 MG (nintedanib esylate) 3 SP ANTI-INFLAMMATORY AGENTS (RESPIRATORY) - Drugs for Inflammation NUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 100 PA; SL (0.04 mL per day.); 3 MG/ML (mepolizumab) SP NUCALA SUBCUTANEOUS SOLUTION PREFILLED PA; SL (0.04 mL per day.); 3 SYRINGE 100 MG/ML (mepolizumab) SP ANTITUSSIVES - Drugs for Cough and Cold benzonatate oral capsule 100 mg, 200 mg 1 codeine sulfate oral tablet 15 mg, 30 mg, 60 mg 1 diphen oral elixir 12.5 mg/5ml 1 di-phen oral elixir 12.5 mg/5ml 3 diphenhydramine hcl oral elixir 12.5 mg/5ml 1 guaiatussin ac oral syrup 100-10 mg/5ml 1 guaifenesin ac oral syrup 100-10 mg/5ml 1 hydrocodone polst-chlorphen polst er susp oral suspension 1 PA; SL (360 ml per month.) extended release 10-8 mg/5ml PA; SL (120 mL per hydrocodone-homatropine oral syrup 5-1.5 mg/5ml 1 prescription and 360 ml per month.) hydrocodone-homatropine oral tablet 5-1.5 mg 1 PA PA; SL (120 mL per hydromet oral syrup 5-1.5 mg/5ml 1 prescription and 360 ml per month.) maxi-tuss ac oral solution 100-10 mg/5ml 1 promethazine vc/codeine oral syrup 6.25-5-10 mg/5ml 1 PA; SL (360 ml per month.) promethazine-codeine oral solution 6.25-10 mg/5ml 1 PA; SL (360 ml per month.) promethazine-codeine oral syrup 6.25-10 mg/5ml 1 PA; SL (360 ml per month.)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 198 Coverage Requirements & Prescription Drug Name Drug Tier Limits promethazine-dm oral syrup 6.25-15 mg/5ml 1 promethazine-phenyleph-codeine oral syrup 6.25-5-10 mg/5ml 1 PA; SL (360 ml per month.) pseudoephedrine-bromphen-dm oral syrup 30-2-10 mg/5ml 1 TESSALON PERLES ORAL CAPSULE 100 MG (benzonatate) 3 PA; SL (10 capsules per TUSSICAPS ORAL CAPSULE EXTENDED RELEASE 12 3 prescription and 30 capsules HOUR 10-8 MG (hydrocod polst-chlorphen polst) per month.) PA; SL (10 tablets per TUXARIN ER ORAL TABLET EXTENDED RELEASE 12 HOUR 3 prescription and 30 tablets 54.3-8 MG (chlorpheniramine-codeine) per month.) virtussin ac w/alc oral liquid 100-10 mg/5ml 1 CYSTIC FIBROSIS (CFTR) CORRECTORS - Drugs for the Lungs ORKAMBI ORAL PACKET 100-125 MG, 150-188 MG PA; SL (728 packets per 356 2 (lumacaftor-ivacaftor) days.); SP ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG PA; SL (1456 tablets per 356 2 (lumacaftor-ivacaftor) days.); SP SYMDEKO ORAL TABLET THERAPY PACK 100-150 & 150 PA; SL (728 tablets per 356 2 MG (tezacaftor-ivacaftor) days.); SP SYMDEKO ORAL TABLET THERAPY PACK 50-75 & 75 MG PA; SL (728 tablets per 356 2 (tezacaftor-ivacaftor) days.) TRIKAFTA ORAL TABLET THERAPY PACK 100-50-75 & 150 PA; SL (1092 tablets per 356 2 MG (elexacaftor-tezacaftor-ivacaft) days.); SP TRIKAFTA ORAL TABLET THERAPY PACK 50-25-37.5 & 75 2 PA; SP MG (elexacaftor-tezacaftor-ivacaft) CYSTIC FIBROSIS (CFTR) POTENTIATORS - Drugs for the Lungs PA; SL (728 packets per 356 KALYDECO ORAL PACKET 25 MG, 50 MG, 75 MG (ivacaftor) 2 days.); SP PA; SL (780 tablets per 356 KALYDECO ORAL TABLET 150 MG (ivacaftor) 2 days.); SP ORKAMBI ORAL PACKET 100-125 MG, 150-188 MG PA; SL (728 packets per 356 2 (lumacaftor-ivacaftor) days.); SP ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG PA; SL (1456 tablets per 356 2 (lumacaftor-ivacaftor) days.); SP SYMDEKO ORAL TABLET THERAPY PACK 100-150 & 150 PA; SL (728 tablets per 356 2 MG (tezacaftor-ivacaftor) days.); SP SYMDEKO ORAL TABLET THERAPY PACK 50-75 & 75 MG PA; SL (728 tablets per 356 2 (tezacaftor-ivacaftor) days.)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 199 Coverage Requirements & Prescription Drug Name Drug Tier Limits TRIKAFTA ORAL TABLET THERAPY PACK 100-50-75 & 150 PA; SL (1092 tablets per 356 2 MG (elexacaftor-tezacaftor-ivacaft) days.); SP TRIKAFTA ORAL TABLET THERAPY PACK 50-25-37.5 & 75 2 PA; SP MG (elexacaftor-tezacaftor-ivacaft) EXPECTORANTS - Drugs for the Lungs GILPHEX TR ORAL TABLET 10-388 MG (phenylephrine- 3 guaifenesin) guaiatussin ac oral syrup 100-10 mg/5ml 1 guaifenesin ac oral syrup 100-10 mg/5ml 1 IODINE STRONG ORAL SOLUTION 5 % 2 maxi-tuss ac oral solution 100-10 mg/5ml 1 SSKI ORAL SOLUTION 1 GM/ML (potassium iodide 3 (expectorant)) virtussin ac w/alc oral liquid 100-10 mg/5ml 1 FIRST GENERATION ANTIHIST.(RESPIR TRACT) - Drugs for Allergy carbinoxamine maleate oral solution 4 mg/5ml 1 carbinoxamine maleate oral tablet 4 mg 1 clemastine fumarate oral tablet 2.68 mg 1 cyproheptadine hcl oral syrup 2 mg/5ml 1 cyproheptadine hcl oral tablet 4 mg 1 diphen oral elixir 12.5 mg/5ml 1 di-phen oral elixir 12.5 mg/5ml 3 diphenhydramine hcl oral elixir 12.5 mg/5ml 1 promethazine hcl oral solution 6.25 mg/5ml 1 promethazine hcl oral syrup 6.25 mg/5ml 1 promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg 1 promethazine hcl rectal suppository 12.5 mg, 25 mg 1 promethegan rectal suppository 12.5 mg, 25 mg, 50 mg 1 INTERLEUKIN ANTAGONISTS - Drugs for Inflammation DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED PA; ST; SL (2 syringes per 3 SYRINGE 200 MG/1.14ML (dupilumab) month.); SP FASENRA PEN SUBCUTANEOUS SOLUTION AUTO- 3 PA; SL (1 pen per 56 days.) INJECTOR 30 MG/ML (benralizumab) LEUKOTRIENE MODIFIERS - Drugs for Inflammation ACCOLATE ORAL TABLET 10 MG, 20 MG (zafirlukast) 3 montelukast sodium oral packet 4 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 200 Coverage Requirements & Prescription Drug Name Drug Tier Limits montelukast sodium oral tablet 10 mg 1 montelukast sodium oral tablet chewable 4 mg, 5 mg 1 SINGULAIR ORAL PACKET 4 MG (montelukast sodium) 3 zafirlukast oral tablet 10 mg, 20 mg 1 zileuton er oral tablet extended release 12 hour 600 mg 1 ST ZYFLO ORAL TABLET 600 MG (zileuton) 3 ST MAST-CELL STABILIZERS - Drugs for Inflammation ALOCRIL OPHTHALMIC SOLUTION 2 % (nedocromil sodium) 3 cromolyn sodium inhalation nebulization solution 20 mg/2ml 1 cromolyn sodium ophthalmic solution 4 % 1 cromolyn sodium oral concentrate 100 mg/5ml 1 MUCOLYTIC AGENTS - Drugs for the Lungs acetylcysteine inhalation solution 10 %, 20 % 1 PULMOZYME INHALATION SOLUTION 1 MG/ML (dornase 2 PA; SL (5 ml per day.); SP alfa) sodium chloride inhalation nebulization solution 0.9 %, 10 %, 3 1 %, 7 % NASAL PREPARATIONS (STEROIDS) - Drugs for Inflammation flunisolide nasal solution 25 mcg/act (0.025%) 1 SL (16 grams (1 bottle) per fluticasone propionate nasal suspension 50 mcg/act 1 prescription) ORALLY INHALED PREPARATIONS (STEROIDS) - Drugs for Inflammation ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT 1 SL (1 blister per day.) (fluticasone furoate) ARNUITY ELLIPTA INHALATION AEROSOL POWDER 1 SL (1 packet per day.) BREATH ACTIVATED 50 MCG/ACT (fluticasone furoate) SL (120 ml (2 boxes) per 30 budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml 1 days.) SL (60 ml (1 box) per 30 budesonide inhalation suspension 1 mg/2ml 1 days.) FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 50 MCG/BLIST 1 SL (2 packages per day) (fluticasone propionate (inhal)) FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 250 MCG/BLIST (fluticasone propionate 1 SL (4 packages per day) (inhal)) Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 201 Coverage Requirements & Prescription Drug Name Drug Tier Limits FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 44 1 SL (1 inhaler per month) MCG/ACT (fluticasone propionate hfa) FLOVENT HFA INHALATION AEROSOL 220 MCG/ACT 1 SL (2 inhalers per month) (fluticasone propionate hfa) PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT 1 SL (2 inhalers per month) (budesonide) PHOSPHODIESTERASE TYPE 4 INHIBITORS - Drugs for the Lungs DALIRESP ORAL TABLET 250 MCG (roflumilast) 3 PA; SL (31 tablets per year.) DALIRESP ORAL TABLET 500 MCG (roflumilast) 3 PA; SL (1 tablet per day) SECOND GENERATION ANTIHIST(RESPIR TRACT) - Drugs for Allergy azelastine hcl nasal solution 0.1 %, 137 mcg/spray 1 azelastine hcl ophthalmic solution 0.05 % 1 SELECT.BETA-2-ADRENERGIC AGONIST(RESPIR) - Drugs for Asthma/COPD albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act SL (1 inhaler per 1 inhalation 108 (90 base) mcg/act prescription.) albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act SL (6.7 grams per 1 inhalation 108 (90 base) mcg/act prescription.) albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act SL (8.5 grams per 1 inhalation 108 (90 base) mcg/act prescription.) albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 1 0.083%, 0.63 mg/3ml, 1.25 mg/3ml, 2.5 mg/0.5ml albuterol sulfate inhalation nebulization solution (5 mg/ml) 0.5% 1 albuterol sulfate oral syrup 2 mg/5ml 1 albuterol sulfate oral tablet 2 mg, 4 mg 1 PA levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 1 SL (90 ml per prescription.) 0.63 mg/3ml, 1.25 mg/3ml levalbuterol hcl inhalation nebulization solution 1.25 mg/0.5ml 1 SL (30 vials per prescription) SL (15 grams per LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT 3 prescription.) PERFOROMIST INHALATION NEBULIZATION SOLUTION 20 3 SL (2 vials per day) MCG/2ML (formoterol fumarate) SEREVENT DISKUS INHALATION AEROSOL POWDER 2 SL (2 blisters per day.) BREATH ACTIVATED 50 MCG/DOSE (salmeterol xinafoate) STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 2 SL (0.14 grams per day.) 2.5 MCG/ACT (olodaterol hcl)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 202 Coverage Requirements & Prescription Drug Name Drug Tier Limits terbutaline sulfate oral tablet 2.5 mg, 5 mg 1 XOPENEX HFA INHALATION AEROSOL 45 MCG/ACT SL (15 grams per 3 (levalbuterol tartrate) prescription.) VASODILATING AGENTS (RESPIRATORY TRACT) - Drugs for the Lungs ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 PA; SL (3 tablets per day.); 2 MG () SP PA; SL (2 tablets per day); alyq oral tablet 20 mg 1 SP PA; SL (1 tablet per day.); oral tablet 10 mg, 5 mg 1 SP PA; SL (2 tablets per day.); oral tablet 125 mg, 62.5 mg 1 SP PA; SL (1 tablet per day.); OPSUMIT ORAL TABLET 10 MG () 2 SP ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 PA; SL (6 tablets per day.); 3 MG, 0.25 MG, 1 MG, 2.5 MG, 5 MG ( diolamine) SP PA; SL (186 ml per month.); sildenafil citrate oral suspension reconstituted 10 mg/ml 1 SP sildenafil citrate oral tablet 20 mg 1 SL (0.5 tablet per day.) PA; SL (2 tablets per day); tadalafil (pah) oral tablet 20 mg 1 SP PA; SL (2 tablets per day.); TRACLEER ORAL TABLET 125 MG, 62.5 MG ( bosentan) 2 SP PA; SL (4 tablets per day.); TRACLEER ORAL TABLET SOLUBLE 32 MG ( bosentan) 2 SP TYVASO INHALATION SOLUTION 0.6 MG/ML (treprostinil) 2 PA TYVASO REFILL INHALATION SOLUTION 0.6 MG/ML 2 PA (treprostinil) TYVASO STARTER INHALATION SOLUTION 0.6 MG/ML 2 PA (treprostinil) UPTRAVI ORAL TABLET 1000 MCG, 1200 MCG, 1400 MCG, PA; SL (2 tablets per day.); 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG 3 SP () UPTRAVI ORAL TABLET THERAPY PACK 200 & 800 MCG PA; SL (200 tablets per 3 (selexipag) year.); SP VENTAVIS INHALATION SOLUTION 10 MCG/ML, 20 MCG/ML 2 PA; SP () XANTHINE DERIVATIVES - Drugs for Asthma/COPD ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML (theophylline) 3 Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 203 Coverage Requirements & Prescription Drug Name Drug Tier Limits THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 300 MG, 400 MG (theophylline) theophylline er oral tablet extended release 12 hour 300 mg, 1 450 mg theophylline er oral tablet extended release 24 hour 400 mg, 1 600 mg theophylline oral solution 80 mg/15ml 1 SKIN AND MUCOUS MEMBRANE AGENTS - Drugs for the Skin ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) - Drugs for the Skin SL (60 grams per ACZONE EXTERNAL GEL 5 % (dapsone) 1 prescription.) SL (60 grams per ACZONE EXTERNAL GEL 7.5 % (dapsone) 3 prescription.) SL (15 grams per ALTABAX EXTERNAL OINTMENT 1 % ( retapamulin) 3 prescription) PA; SL (30 grams per AMZEEQ EXTERNAL FOAM 4 % (minocycline hcl micronized) 3 prescription.) AVAR CLEANSER EXTERNAL EMULSION 10-5 % 3 (sulfacetamide sodium-sulfur) AVAR-E EMOLLIENT EXTERNAL CREAM 10-5 % 3 (sulfacetamide sodium-sulfur) AVAR-E GREEN EXTERNAL CREAM 10-5 % (sulfacetamide 3 sodium-sulfur) AVAR-E LS EXTERNAL CREAM 10-2 % (sulfacetamide 3 sodium-sulfur) BENZAMYCIN EXTERNAL GEL 5-3 % (benzoyl peroxide- SL (23.3 grams per 2 erythromycin) prescription.) SL (23.3 grams per benzoyl peroxide-erythromycin external gel 5-3 % 1 prescription.) bp 10-1 external emulsion 10-1 % 1 bp cleansing wash external emulsion 10-4 % 1 SL (22 grams per CENTANY EXTERNAL OINTMENT 2 % ( mupirocin) 3 prescription.) CLEOCIN VAGINAL CREAM 2 % (clindamycin phosphate) 3 CLEOCIN VAGINAL SUPPOSITORY 100 MG (clindamycin 2 phosphate) CLEOCIN-T EXTERNAL LOTION 1 % (clindamycin phosphate) 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 204 Coverage Requirements & Prescription Drug Name Drug Tier Limits clindacin etz external swab 1 % 1 clindacin-p external swab 1 % 1 SL (1 bottle (45 grams) per clindamycin phos-benzoyl perox external gel 1.2-5 % 1 month.) clindamycin phosphate external foam 1 % 1 SL (30 grams (1 tube) per clindamycin phosphate external gel 1 % 1 prescription.) clindamycin phosphate external lotion 1 % 1 clindamycin phosphate external solution 1 % 1 SL (30 ml per prescription.) clindamycin phosphate external swab 1 % 1 clindamycin phosphate vaginal cream 2 % 1 CLINDESSE VAGINAL CREAM 2 % (clindamycin phosphate (1 2 dose)) ery external pad 2 % 1 ERYGEL EXTERNAL GEL 2 % (erythromycin) 3 erythromycin external gel 2 % 1 erythromycin external solution 2 % 1 EVOCLIN EXTERNAL FOAM 1 % (clindamycin phosphate) 3 SL (30 grams per gentamicin sulfate external cream 0.1 % 1 prescription.) SL (30 grams per gentamicin sulfate external ointment 0.1 % 1 prescription.) KLARON EXTERNAL LOTION 10 % (sulfacetamide sodium 3 (acne)) METROCREAM EXTERNAL CREAM 0.75 % (metronidazole) 3 METROLOTION EXTERNAL LOTION 0.75 % ( metronidazole) 3 metronidazole external cream 0.75 % 1 metronidazole external gel 0.75 % 1 metronidazole external lotion 0.75 % 1 metronidazole vaginal gel 0.75 % 1 SL (15 grams per mupirocin calcium external cream 2 % 1 prescription) SL (22 grams per mupirocin external ointment 2 % 1 prescription.) SL (1 bottle (45 grams) per neuac external gel 1.2-5 % 1 month.) OVACE PLUS EXTERNAL CREAM 10 % (sulfacetamide 3 sodium) Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 205 Coverage Requirements & Prescription Drug Name Drug Tier Limits OVACE PLUS EXTERNAL SHAMPOO 10 % (sulfacetamide 3 sodium) OVACE PLUS WASH EXTERNAL GEL 10 % (sulfacetamide 3 sodium) OVACE PLUS WASH EXTERNAL LIQUID 10 % (sulfacetamide 3 sodium) OVACE WASH EXTERNAL LIQUID 10 % (sulfacetamide 3 sodium) rosadan external cream 0.75 % 1 rosadan external gel 0.75 % 1 sodium sulfacetamide external shampoo 10 % 1 sodium sulfacetamide wash external liquid 10 % 1 SODIUM SULFACETAMIDE-BAKUCHIOL EXTERNAL LIQUID 3 10 % sss 10-5 external cream 10-5 % 1 sss 10-5 external foam 10-5 % 1 sulfacetamide sodium (acne) external lotion 10 % 1 sulfacetamide sodium external gel 10 % (cleans) 1 sulfacetamide sodium external liquid 10 % 1 sulfacetamide sodium-sulfur external cream 10-2 %, 10-5 % 1 sulfacetamide sodium-sulfur external emulsion 10-5 % 1 sulfacetamide sodium-sulfur external liquid 9-4 %, 9-4.5 % 1 sulfacetamide sodium-sulfur external lotion 10-5 % 1 sulfacetamide sodium-sulfur external pad 10-4 % 1 sulfacetamide sodium-sulfur external suspension 10-5 % 1 sulfacetamide sod-sulfur wash external liquid 9-4 %, 9-4.5 % 1 sulfacetamide-sulfur in external emulsion 10-5 % 1 sulfamez wash external emulsion 10-1 % 1 SUMAXIN EXTERNAL PAD 10-4 % (sulfacetamide sodium- 3 sulfur) vandazole vaginal gel 0.75 % 1 XEPI EXTERNAL CREAM 1 % (ozenoxacin) 3 SL (30 g per prescription.) PA; ST; SL (30 grams per ZILXI EXTERNAL FOAM 1.5 % (minocycline hcl micronized) 3 prescription.)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 206 Coverage Requirements & Prescription Drug Name Drug Tier Limits ANTI-INFLAMMATORY AGENTS, MISC (SKIN) - Drugs for the Skin ST; SL (60 grams per EUCRISA EXTERNAL OINTMENT 2 % (crisaborole) 3 prescription.) ANTIPRURITICS AND LOCAL ANESTHETICS - Drugs for the Skin ANALPRAM HC EXTERNAL CREAM 2.5-1 % (hydrocortisone 3 ace-pramoxine) ANALPRAM HC SINGLES EXTERNAL CREAM 2.5-1 % 3 (hydrocortisone ace-pramoxine) ANALPRAM-HC EXTERNAL CREAM 1-1 % (hydrocortisone 3 ace-pramoxine) ANALPRAM-HC EXTERNAL LOTION 2.5-1 % (hydrocortisone 3 ace-pramoxine) CORTANE-B EXTERNAL LOTION 10-10-1 MG/ML ( hc- 3 pramoxine-chloroxylenol) PA; SL (45 grams per doxepin hcl external cream 5 % 1 prescription.) EPIFOAM EXTERNAL FOAM 1-1 % (pramoxine-hc) 2 glydo external prefilled syringe 2 % 1 hydrocortisone ace-pramoxine external cream 1-1 %, 2.5-1 % 1 hydrocort-pramoxine (perianal) external cream 2.5-1 % 1 lidocaine external ointment 5 % 1 SL (1.19 grams per day.) lidocaine external patch 5 % 1 PA; SL (3 patches per day) lidocaine hcl external solution 4 % 1 lidocaine hcl urethral/mucosal external gel 2 % 1 lidocaine-prilocaine external cream 2.5-2.5 % 1 LIDOPIN EXTERNAL CREAM 3.25 % 3 phenazo oral tablet 200 mg 1 hcl oral tablet 100 mg, 200 mg 1 pramosone external cream 1-1 % 1 PRAMOSONE EXTERNAL CREAM 1-2.5 % (pramoxine-hc) 3 PRAMOSONE EXTERNAL LOTION 1-1 %, 1-2.5 % 2 (pramoxine-hc) PRAMOSONE EXTERNAL OINTMENT 1-1 % ( pramoxine-hc) 2 PRAMOSONE EXTERNAL OINTMENT 1-2.5 % (pramoxine-hc) 3 pramox external gel 1 % 1 premium lidocaine external ointment 5 % 1 SL (1.19 grams per day.) Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 207 Coverage Requirements & Prescription Drug Name Drug Tier Limits PROCTOFOAM HC EXTERNAL FOAM 1-1 % (hydrocortisone 2 ace-pramoxine) PYRIDIUM ORAL TABLET 100 MG, 200 MG (phenazopyridine 3 hcl) ANTIVIRALS (SKIN AND MUCOUS MEMBRANE) - Drugs for the Skin PA; ST; SL (15 grams per acyclovir external ointment 5 % 1 prescription.) ASTRINGENTS - Drugs for the Skin DRYSOL EXTERNAL SOLUTION 20 % (aluminum chloride) 3 AZOLES (SKIN AND MUCOUS MEMBRANE) - Drugs for the Skin clotrimazole mouth/throat troche 10 mg 1 SL (15 grams per clotrimazole-betamethasone external cream 1-0.05 % 1 prescription.) clotrimazole-betamethasone external lotion 1-0.05 % 1 SL (15 grams per econazole nitrate external cream 1 % 1 prescription.) EXELDERM EXTERNAL CREAM 1 % (sulconazole nitrate) 3 EXELDERM EXTERNAL SOLUTION 1 % (sulconazole nitrate) 3 EXTINA EXTERNAL FOAM 2 % (ketoconazole) 3 ST GYNAZOLE-1 VAGINAL CREAM 2 % (butoconazole nitrate (1 3 dose)) JUBLIA EXTERNAL SOLUTION 10 % (efinaconazole) 3 PA; ST; SL (4 ml per month.) SL (30 grams per ketoconazole external cream 2 % 1 prescription.) ketoconazole external foam 2 % 1 ST ketoconazole external shampoo 2 % 1 ketodan external foam 2 % 1 ST miconazole 3 vaginal suppository 200 mg 1 PA; SL (30 grams per oxiconazole nitrate external cream 1 % 1 prescription.) PA; SL (30 grams per OXISTAT EXTERNAL CREAM 1 % (oxiconazole nitrate) 3 prescription.) SULCONAZOLE NITRATE EXTERNAL CREAM 1 % 3 SULCONAZOLE NITRATE EXTERNAL SOLUTION 1 % 3 terconazole vaginal cream 0.4 %, 0.8 % 1 terconazole vaginal suppository 80 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 208 Coverage Requirements & Prescription Drug Name Drug Tier Limits XOLEGEL COREPAK EXTERNAL KIT 2 & 1 % (ketoconazole- 3 hydrocortisone) XOLEGEL DUO/HEAD & SHOULDERS EXTERNAL KIT 2 & 1 3 % (ketoconazole & pyrithione zinc) XOLEGEL DUO/XOLEX EXTERNAL KIT 2 & 1 % 3 (ketoconazole & pyrithione zinc) XOLEGEL EXTERNAL GEL 2 % (ketoconazole) 3 BASIC LOTIONS AND LINIMENTS - Drugs for the Skin GORDOFILM EXTERNAL SOLUTION 16.7-16.7 % (salicylic 2 acid-lactic acid) methyl salicylate external liquid 1 SALVAX DUO PLUS EXTERNAL KIT 6 & 35 % (salicylic acid- 3 urea in lactac) TURPENTINE EXTERNAL SPIRIT 3 ZACARE EXTERNAL KIT 4 & 0.2 %, 8 & 0.2 % (benzoyl 3 peroxide-hyaluronate) BASIC POWDERS AND DEMULCENTS - Drugs for the Skin benzoin compound external tincture 1 BENZOIN EXTERNAL TINCTURE 3 BENZYLAMINES (SKIN AND MUCOUS MEMBRANE) - Drugs for the Skin MENTAX EXTERNAL CREAM 1 % (butenafine hcl) 3 CELL STIMULANTS AND PROLIFERANTS - Drugs for the Skin SL (20 grams per tretinoin external cream 0.025 %, 0.05 %, 0.1 % 1 prescription.) CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) - Drugs for the Skin ala-cort external cream 2.5 % 1 alclometasone dipropionate external cream 0.05 % 1 alclometasone dipropionate external ointment 0.05 % 1 amcinonide external cream 0.1 % 1 amcinonide external lotion 0.1 % 1 amcinonide external ointment 0.1 % 1 ANALPRAM HC EXTERNAL CREAM 2.5-1 % (hydrocortisone 3 ace-pramoxine) ANALPRAM HC SINGLES EXTERNAL CREAM 2.5-1 % 3 (hydrocortisone ace-pramoxine)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 209 Coverage Requirements & Prescription Drug Name Drug Tier Limits ANALPRAM-HC EXTERNAL CREAM 1-1 % (hydrocortisone 3 ace-pramoxine) ANALPRAM-HC EXTERNAL LOTION 2.5-1 % (hydrocortisone 3 ace-pramoxine) anucort-hc rectal suppository 25 mg 1 ANUSOL-HC EXTERNAL CREAM 2.5 % (hydrocortisone) 3 APEXICON E EXTERNAL CREAM 0.05 % (diflorasone diacet SL (30 grams per 2 emoll base) prescription.) ST; SL (60 ml per beser external lotion 0.05 % 1 prescription.) betamethasone dipropionate aug external cream 0.05 % 1 betamethasone dipropionate aug external gel 0.05 % 1 betamethasone dipropionate aug external lotion 0.05 % 1 betamethasone dipropionate aug external ointment 0.05 % 1 betamethasone dipropionate external cream 0.05 % 1 betamethasone dipropionate external lotion 0.05 % 1 betamethasone dipropionate external ointment 0.05 % 1 betamethasone valerate external cream 0.1 % 1 betamethasone valerate external lotion 0.1 % 1 betamethasone valerate external ointment 0.1 % 1 SL (60 grams per calcipotriene-betameth diprop external ointment 0.005-0.064 % 1 prescription) CAPEX EXTERNAL SHAMPOO 0.01 % (fluocinolone 2 acetonide) SL (15 grams per clobetasol prop emollient base external cream 0.05 % 1 prescription.) SL (15 grams per clobetasol propionate e external cream 0.05 % 1 prescription.) SL (15 grams per clobetasol propionate external cream 0.05 % 1 prescription.) SL (15 grams per clobetasol propionate external gel 0.05 % 1 prescription.) clobetasol propionate external liquid 0.05 % 1 SL (59 ml per prescription) SL (15 grams per clobetasol propionate external ointment 0.05 % 1 prescription.) clobetasol propionate external solution 0.05 % 1 SL (25 ml per prescription.) CLOBETAVIX EXTERNAL KIT 0.05 % 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 210 Coverage Requirements & Prescription Drug Name Drug Tier Limits ST; SL (45 grams per clocortolone pivalate external cream 0.1 % 1 prescription) SL (15 grams per clotrimazole-betamethasone external cream 1-0.05 % 1 prescription.) clotrimazole-betamethasone external lotion 1-0.05 % 1 CORDRAN EXTERNAL OINTMENT 0.05 % ( flurandrenolide) 3 ST SL (1 packet per CORDRAN EXTERNAL TAPE 4 MCG/SQCM (flurandrenolide) 3 prescription.) CORTANE-B EXTERNAL LOTION 10-10-1 MG/ML ( hc- 3 pramoxine-chloroxylenol) CORTENEMA RECTAL ENEMA 100 MG/60ML 3 (hydrocortisone) CORTIFOAM EXTERNAL FOAM 10 % (hydrocortisone acetate) 2 CORTI-SAV EXTERNAL CREAM 1-1 % 3 CUTIVATE EXTERNAL LOTION 0.05 % (fluticasone ST; SL (60 ml per 3 propionate) prescription.) DERMA-SMOOTHE/FS BODY EXTERNAL OIL 0.01 % SL (118.28 ml per 3 (fluocinolone acetonide) prescription.) DERMA-SMOOTHE/FS SCALP EXTERNAL OIL 0.01 % 3 (fluocinolone acetonide) ST; SL (60 grams per DESONATE EXTERNAL GEL 0.05 % (desonide) 3 prescription) SL (15 grams per desonide external cream 0.05 % 1 prescription.) ST; SL (60 grams per desonide external gel 0.05 % 1 prescription) desonide external lotion 0.05 % 1 SL (60 ml per prescription.) SL (15 grams per desonide external ointment 0.05 % 1 prescription.) SL (15 grams per DESOWEN EXTERNAL CREAM 0.05 % (desonide) 3 prescription.) SL (15 grams per desoximetasone external cream 0.05 %, 0.25 % 1 prescription.) SL (15 grams per desoximetasone external gel 0.05 % 1 prescription.) SL (60 grams per desoximetasone external ointment 0.05 % 1 prescription.) SL (15 grams per desoximetasone external ointment 0.25 % 1 prescription.)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 211 Coverage Requirements & Prescription Drug Name Drug Tier Limits ST; SL (60 grams per desrx external gel 0.05 % 1 prescription) SL (30 grams per diflorasone diacetate external cream 0.05 % 1 prescription.) DIPROLENE AF EXTERNAL CREAM 0.05 % (betamethasone 3 dipropionate aug) DIPROLENE EXTERNAL OINTMENT 0.05 % ( betamethasone 3 dipropionate aug) ENSTILAR EXTERNAL FOAM 0.005-0.064 % (calcipotriene- SL (60 grams per 3 betameth diprop) prescription.) EPIFOAM EXTERNAL FOAM 1-1 % (pramoxine-hc) 2 SL (118.28 ml per fluocinolone acetonide body external oil 0.01 % 1 prescription.) SL (15 grams per fluocinolone acetonide external cream 0.01 %, 0.025 % 1 prescription.) SL (15 grams per fluocinolone acetonide external ointment 0.025 % 1 prescription.) fluocinolone acetonide external solution 0.01 % 1 SL (60 ml per prescription.) fluocinolone acetonide scalp external oil 0.01 % 1 fluocinonide emulsified base external cream 0.05 % 1 fluocinonide external cream 0.05 % 1 fluocinonide external gel 0.05 % 1 fluocinonide external ointment 0.05 % 1 fluocinonide external solution 0.05 % 1 ST; SL (120 ml per flurandrenolide external cream 0.05 % 1 prescription.) ST; SL (120 ml per flurandrenolide external lotion 0.05 % 1 prescription.) flurandrenolide external ointment 0.05 % 1 ST fluticasone propionate external cream 0.05 % 1 ST; SL (60 ml per fluticasone propionate external lotion 0.05 % 1 prescription.) fluticasone propionate external ointment 0.005 % 1 ST; SL (30 grams per halcinonide external cream 0.1 % 1 prescription.) SL (15 grams per halobetasol propionate external cream 0.05 % 1 prescription.) SL (15 grams per halobetasol propionate external ointment 0.05 % 1 prescription.) Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 212 Coverage Requirements & Prescription Drug Name Drug Tier Limits ST; SL (30 grams per HALOG EXTERNAL OINTMENT 0.1 % ( halcinonide) 3 prescription.) hydrocortisone (perianal) external cream 1 %, 2.5 % 1 hydrocortisone ace-pramoxine external cream 1-1 %, 2.5-1 % 1 hydrocortisone acetate rectal suppository 25 mg, 30 mg 1 hydrocortisone butyrate external cream 0.1 % 1 hydrocortisone butyrate external ointment 0.1 % 1 hydrocortisone butyrate external solution 0.1 % 1 hydrocortisone external cream 2.5 % 1 hydrocortisone external lotion 2.5 % 1 hydrocortisone external ointment 1 %, 2.5 % 1 hydrocortisone rectal enema 100 mg/60ml 1 SL (15 grams per hydrocortisone valerate external cream 0.2 % 1 prescription.) SL (15 grams per hydrocortisone valerate external ointment 0.2 % 1 prescription.) hydrocortisone-iodoquinol external cream 1-1 % 1 hydrocort-pramoxine (perianal) external cream 2.5-1 % 1 mometasone furoate external cream 0.1 % 1 mometasone furoate external ointment 0.1 % 1 mometasone furoate external solution 0.1 % 1 ST; SL (120 ml per nolix external cream 0.05 % 1 prescription.) ST; SL (120 ml per nolix external lotion 0.05 % 1 prescription.) NUCORT EXTERNAL LOTION 2 % (hydrocortisone acetate) 3 oralone mouth/throat paste 0.1 % 1 PANDEL EXTERNAL CREAM 0.1 % (hydrocortisone probutate) 3 pramosone external cream 1-1 % 1 PRAMOSONE EXTERNAL CREAM 1-2.5 % (pramoxine-hc) 3 PRAMOSONE EXTERNAL LOTION 1-1 %, 1-2.5 % 2 (pramoxine-hc) PRAMOSONE EXTERNAL OINTMENT 1-1 % ( pramoxine-hc) 2 PRAMOSONE EXTERNAL OINTMENT 1-2.5 % (pramoxine-hc) 3 prednicarbate external ointment 0.1 % 1 PROCTOFOAM HC EXTERNAL FOAM 1-1 % (hydrocortisone 2 ace-pramoxine)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 213 Coverage Requirements & Prescription Drug Name Drug Tier Limits procto-med hc external cream 2.5 % 1 procto-pak external cream 1 % 1 proctozone-hc external cream 2.5 % 1 SL (30 grams per PSORCON EXTERNAL CREAM 0.05 % 3 prescription.) SCALACORT DK EXTERNAL KIT 2 & 2-2 % (hc & sal acid- 3 sulfur & shampoo) TACLONEX EXTERNAL SUSPENSION 0.005-0.064 % 3 (calcipotriene-betameth diprop) TEMOVATE EXTERNAL CREAM 0.05 % (clobetasol SL (15 grams per 3 propionate) prescription.) TEMOVATE EXTERNAL OINTMENT 0.05 % ( clobetasol SL (15 grams per 3 propionate) prescription.) TEXACORT EXTERNAL SOLUTION 2.5 % (hydrocortisone) 2 TOPICORT EXTERNAL CREAM 0.05 %, 0.25 % SL (15 grams per 3 (desoximetasone) prescription.) SL (15 grams per TOPICORT EXTERNAL GEL 0.05 % (desoximetasone) 3 prescription.) SL (60 grams per TOPICORT EXTERNAL OINTMENT 0.05 % ( desoximetasone) 3 prescription.) SL (15 grams per TOPICORT EXTERNAL OINTMENT 0.25 % ( desoximetasone) 3 prescription.) SL (63 grams per triamcinolone acetonide external aerosol solution 0.147 mg/gm 1 prescription.) triamcinolone acetonide external cream 0.025 %, 0.1 % 1 SL (15 grams per triamcinolone acetonide external cream 0.5 % 1 prescription.) triamcinolone acetonide external lotion 0.025 %, 0.1 % 1 triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 1 % triamcinolone acetonide mouth/throat paste 0.1 % 1 triderm external cream 0.1 % 1 SL (15 grams per triderm external cream 0.5 % 1 prescription.) SL (15 grams per TRIDESILON EXTERNAL CREAM 0.05 % (desonide) 1 prescription.) UCERIS RECTAL FOAM 2 MG/ACT (budesonide) 2 XOLEGEL COREPAK EXTERNAL KIT 2 & 1 % (ketoconazole- 3 hydrocortisone)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 214 Coverage Requirements & Prescription Drug Name Drug Tier Limits EMOLLIENTS, DEMULCENTS, AND PROTECTANTS - Drugs for the Skin INOVA 4/1 ACNE CONTROL THERAPY EXTERNAL KIT 4 & 1 3 & 5 % (benzoyl perox-salicyl ac-vit e) INOVA 8/2 ACNE CONTROL THERAPY EXTERNAL KIT 8 & 2 3 & 5 % (benzoyl perox-salicyl ac-vit e) INOVA EXTERNAL KIT 4 & 5 %, 8 & 5 % (benzoyl peroxide- 3 vitamin e) HYDROXYPYRIDONES (SKIN, MUCOUS MEMBRANE) - Drugs for the Skin ciclodan external solution 8 % 1 ciclopirox external gel 0.77 % 1 ciclopirox external shampoo 1 % 1 ciclopirox external solution 8 % 1 ciclopirox olamine external cream 0.77 % 1 ciclopirox olamine external suspension 0.77 % 1 ciclopirox treatment external kit 8 % 1 LOPROX EXTERNAL KIT 0.77 % (ciclopirox olamine-cleanser) 3 KERATOLYTIC AGENTS - Drugs for the Skin AVAR CLEANSER EXTERNAL EMULSION 10-5 % 3 (sulfacetamide sodium-sulfur) AVAR-E EMOLLIENT EXTERNAL CREAM 10-5 % 3 (sulfacetamide sodium-sulfur) AVAR-E GREEN EXTERNAL CREAM 10-5 % (sulfacetamide 3 sodium-sulfur) AVAR-E LS EXTERNAL CREAM 10-2 % (sulfacetamide 3 sodium-sulfur) AVIDOXY DK COMBINATION KIT 100 MG (doxycycline- 3 suncreen-sal acid) bp 10-1 external emulsion 10-1 % 1 bp cleansing wash external emulsion 10-4 % 1 cerovel external lotion 40 % 1 GORDOFILM EXTERNAL SOLUTION 16.7-16.7 % (salicylic 2 acid-lactic acid) HYDRO 40 EXTERNAL FOAM 40 % (urea) 3 INOVA 4/1 ACNE CONTROL THERAPY EXTERNAL KIT 4 & 1 3 & 5 % (benzoyl perox-salicyl ac-vit e)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 215 Coverage Requirements & Prescription Drug Name Drug Tier Limits INOVA 8/2 ACNE CONTROL THERAPY EXTERNAL KIT 8 & 2 3 & 5 % (benzoyl perox-salicyl ac-vit e) KERALAC EXTERNAL CREAM 47 % (urea) 3 PROMISEB EXTERNAL CREAM (antiseborrheic products, 3 misc.) PYROGALLIC ACID EXTERNAL OINTMENT 25-2 % 2 salicylic acid external solution 26 % 1 salimez external cream 6 % 1 SALVAX DUO PLUS EXTERNAL KIT 6 & 35 % (salicylic acid- 3 urea in lactac) SCALACORT DK EXTERNAL KIT 2 & 2-2 % (hc & sal acid- 3 sulfur & shampoo) selenium sulfide external shampoo 2.25 % 1 sss 10-5 external cream 10-5 % 1 sss 10-5 external foam 10-5 % 1 sulfacetamide sodium-sulfur external cream 10-2 %, 10-5 % 1 sulfacetamide sodium-sulfur external emulsion 10-5 % 1 sulfacetamide sodium-sulfur external liquid 9-4 %, 9-4.5 % 1 sulfacetamide sodium-sulfur external lotion 10-5 % 1 sulfacetamide sodium-sulfur external pad 10-4 % 1 sulfacetamide sodium-sulfur external suspension 10-5 % 1 sulfacetamide sod-sulfur wash external liquid 9-4 %, 9-4.5 % 1 sulfacetamide-sulfur in urea external emulsion 10-5 % 1 sulfamez wash external emulsion 10-1 % 1 SUMAXIN EXTERNAL PAD 10-4 % (sulfacetamide sodium- 3 sulfur) urea external cream 40 %, 41 %, 45 %, 47 % 1 urea external lotion 40 % 1 urea nail external gel 45 % 1 UREMEZ-40 EXTERNAL CREAM 40 % 3 UTOPIC EXTERNAL CREAM 41 % (urea) 3 KERATOPLASTIC AGENTS - Drugs for the Skin COAL TAR EXTERNAL SOLUTION 20 % 3 LOCAL ANTI-INFECTIVES, MISCELLANEOUS - Drugs for the Skin BENZALKONIUM CHLORIDE EXTERNAL SOLUTION 2 benzalkonium chloride external solution 50 % 1 Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 216 Coverage Requirements & Prescription Drug Name Drug Tier Limits BENZAMYCIN EXTERNAL GEL 5-3 % (benzoyl peroxide- SL (23.3 grams per 2 erythromycin) prescription.) SL (23.3 grams per benzoyl peroxide-erythromycin external gel 5-3 % 1 prescription.) chlorhexidine gluconate mouth/throat solution 0.12 % 1 SL (1 bottle (45 grams) per clindamycin phos-benzoyl perox external gel 1.2-5 % 1 month.) CORTANE-B EXTERNAL LOTION 10-10-1 MG/ML ( hc- 3 pramoxine-chloroxylenol) CORTI-SAV EXTERNAL CREAM 1-1 % 3 DEBACTEROL MOUTH/THROAT SOLUTION 30-50 % (sulfuric 2 acid-sulf phenolics) FEM PH VAGINAL GEL 0.9-0.025 % (acetic acid-oxyquinoline) 3 hydrocortisone-iodoquinol external cream 1-1 % 1 INOVA 4/1 ACNE CONTROL THERAPY EXTERNAL KIT 4 & 1 3 & 5 % (benzoyl perox-salicyl ac-vit e) INOVA 8/2 ACNE CONTROL THERAPY EXTERNAL KIT 8 & 2 3 & 5 % (benzoyl perox-salicyl ac-vit e) INOVA EXTERNAL KIT 4 & 5 %, 8 & 5 % (benzoyl peroxide- 3 vitamin e) iodine tincture external tincture 2 % 1 LUGOLS STRONG IODINE EXTERNAL SOLUTION 5-10 % 3 mafenide acetate external packet 5 % 1 SL (1 bottle (45 grams) per neuac external gel 1.2-5 % 1 month.) PERIDEX MOUTH/THROAT SOLUTION 0.12 % (chlorhexidine 3 gluconate) periogard mouth/throat solution 0.12 % 1 selenium sulfide external lotion 2.5 % 1 selenium sulfide external shampoo 2.25 % 1 SILVADENE EXTERNAL CREAM 1 % (silver sulfadiazine) 3 silver sulfadiazine external cream 1 % 1 ssd external cream 1 % 1 SULFAMYLON EXTERNAL CREAM 85 MG/GM (mafenide 3 acetate) SULFAMYLON EXTERNAL PACKET 5 % (mafenide acetate) 3 XOLEGEL DUO/HEAD & SHOULDERS EXTERNAL KIT 2 & 1 3 % (ketoconazole & pyrithione zinc)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 217 Coverage Requirements & Prescription Drug Name Drug Tier Limits XOLEGEL DUO/XOLEX EXTERNAL KIT 2 & 1 % 3 (ketoconazole & pyrithione zinc) ZACARE EXTERNAL KIT 4 & 0.2 %, 8 & 0.2 % (benzoyl 3 peroxide-hyaluronate) zaclir cleansing external lotion 8 % 1 NONSTEROIDAL ANTI-INFLAMMAT.AGENTS(SKIN) - Drugs for the Skin PA; SL (100 grams per diclofenac sodium external gel 3 % 1 prescription.) OXABOROLES - Drugs for the Skin KERYDIN EXTERNAL SOLUTION 5 % (tavaborole) 3 PA; ST; SL (4 ml per month.) tavaborole external solution 5 % 1 PA; ST; SL (4 ml per month.) PIGMENTING AGENTS - Drugs for the Skin methoxsalen rapid oral capsule 10 mg 1 POLYENES (SKIN AND MUCOUS MEMBRANE) - Drugs for the Skin SL (120 grams per nyamyc external powder 100000 unit/gm 1 prescription.) SL (90 grams per nystatin external cream 100000 unit/gm 1 prescription.) SL (90 grams per nystatin external ointment 100000 unit/gm 1 prescription.) SL (120 grams per nystatin external powder 100000 unit/gm 1 prescription.) SL (120 grams per nystop external powder 100000 unit/gm 1 prescription.) SCABICIDES AND PEDICULICIDES - Drugs for the Skin crotan external lotion 10 % 1 SL (117 grams (1 bottle) per ivermectin external lotion 0.5 % 1 prescription.) lindane external shampoo 1 % 1 SL (60 ml per prescription) malathion external lotion 0.5 % 1 OVIDE EXTERNAL LOTION 0.5 % (malathion) 3 permethrin external cream 5 % 1 SL (45 grams per SOOLANTRA EXTERNAL CREAM 1 % (ivermectin) 1 prescription.) spinosad external suspension 0.9 % 1 SULFURATED LIME EXTERNAL SOLUTION 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 218 Coverage Requirements & Prescription Drug Name Drug Tier Limits SKIN AND MUCOUS MEMBRANE AGENTS, MISC. - Drugs for the Skin accutane oral capsule 20 mg, 30 mg, 40 mg 1 acitretin oral capsule 10 mg, 17.5 mg, 25 mg 1 SL (60 grams per ACZONE EXTERNAL GEL 5 % (dapsone) 1 prescription.) SL (60 grams per ACZONE EXTERNAL GEL 7.5 % (dapsone) 3 prescription.) ALEVAMAX EXTERNAL CREAM 3 AMELUZ EXTERNAL GEL 10 % (aminolevulinic acid hcl) 3 amnesteem oral capsule 10 mg, 20 mg, 40 mg 1 ARTISS EXTERNAL SOLUTION (fibrin sealant component) 3 azelaic acid external gel 15 % 1 SL (30 grams per AZELEX EXTERNAL CREAM 20 % (azelaic acid) 3 prescription.) balsam peru-castor oil external ointment 1 SL (60 grams per calcipotriene external cream 0.005 % 1 prescription) calcipotriene external ointment 0.005 % 1 calcipotriene external solution 0.005 % 1 SL (60 mL per prescription) SL (60 grams per calcipotriene-betameth diprop external ointment 0.005-0.064 % 1 prescription) CALCITRENE EXTERNAL OINTMENT 0.005 % ( calcipotriene) 3 SL (100 grams per calcitriol external ointment 3 mcg/gm 1 prescription) CARAC EXTERNAL CREAM 0.5 % (fluorouracil) 2 claravis oral capsule 10 mg, 20 mg, 30 mg, 40 mg 1 CONDYLOX EXTERNAL GEL 0.5 % (podofilox) 3 COSENTYX (300 MG DOSE) SUBCUTANEOUS SOLUTION PA; ST; SL (2 ml (2 Pens) 3 PREFILLED SYRINGE 150 MG/ML (secukinumab) per month.); SP COSENTYX 150 MG/ML SUBCUTANEOUS SOLUTION PA; ST; SL (2 ml (2 Pens) 3 PREFILLED SYRINGE 150 MG/ML (secukinumab) per month.); SP COSENTYX 150 MG/ML SUBCUTANEOUS SOLUTION 3 PA; ST PREFILLED SYRINGE 75 MG/0.5ML (secukinumab) COSENTYX SENSOREADY (300 MG) SUBCUTANEOUS PA; ST; SL (2 ml (2 Pens) 3 SOLUTION AUTO-INJECTOR 150 MG/ML (secukinumab) per month.); SP COSENTYX SENSOREADY PEN SUBCUTANEOUS PA; ST; SL (2 ml (2 Pens) 3 SOLUTION AUTO-INJECTOR 150 MG/ML (secukinumab) per month.); SP

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 219 Coverage Requirements & Prescription Drug Name Drug Tier Limits SL (60 grams per DOVONEX EXTERNAL CREAM 0.005 % (calcipotriene) 3 prescription) DUPIXENT SOLUTION PEN-INJECTOR 200 MG/1.14ML 3 PA; ST; SP SUBCUTANEOUS 200 MG/1.14ML (dupilumab) DUPIXENT SUBCUTANEOUS SOLUTION PEN-INJECTOR PA; ST; SL (4 ml (2 pens) 3 300 MG/2ML (dupilumab) per 23 days.); SP DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED PA; ST; SL (2 syringes per 3 SYRINGE 300 MG/2ML (dupilumab) month.); SP EFUDEX EXTERNAL CREAM 5 % (fluorouracil) 3 ENSTILAR EXTERNAL FOAM 0.005-0.064 % (calcipotriene- SL (60 grams per 3 betameth diprop) prescription.) FEM PH VAGINAL GEL 0.9-0.025 % (acetic acid-oxyquinoline) 3 FINACEA EXTERNAL FOAM 15 % (azelaic acid) 3 FINACEA EXTERNAL GEL 15 % (azelaic acid) 3 FLUOROPLEX EXTERNAL CREAM 1 % (fluorouracil) 3 FLUOROURACIL EXTERNAL CREAM 0.5 % 2 fluorouracil external cream 5 % 1 fluorouracil external solution 2 %, 5 % 1 HALUCORT EXTERNAL GEL (dermatological products, misc.) 3 PA HYPOCYN EXTERNAL SOLUTION (eyelid cleansers) 3 SL (12 packets per imiquimod external cream 5 % 1 prescription.) isotretinoin capsule 10 mg oral 10 mg 1 isotretinoin capsule 20 mg oral 20 mg 1 isotretinoin capsule 30 mg oral 30 mg 1 isotretinoin capsule 40 mg oral 40 mg 1 LEVULAN KERASTICK EXTERNAL SOLUTION 3 RECONSTITUTED 20 % (aminolevulinic acid hcl) LOPROX EXTERNAL KIT 0.77 % (ciclopirox olamine-cleanser) 3 PA; SL (30 grams per MIRVASO EXTERNAL GEL 0.33 % (brimonidine tartrate) 3 prescription.) myorisan oral capsule 10 mg, 20 mg, 30 mg, 40 mg 1 NUVAIL EXTERNAL SOLUTION (dermatological products, 3 misc.) PA; SL (2 tablets per day.); OTEZLA ORAL TABLET 30 MG (apremilast) 2 SP OTEZLA ORAL TABLET THERAPY PACK 10 & 20 & 30 MG PA; SL (55 tablets (one 2 (apremilast) starter pack) per year.); SP

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 220 Coverage Requirements & Prescription Drug Name Drug Tier Limits PANRETIN EXTERNAL GEL 0.1 % (alitretinoin) 3 ST; SL (30 grams per pimecrolimus external cream 1 % 1 prescription.) podocon external solution 25 % 1 podofilox external solution 0.5 % 1 PYROGALLIC ACID EXTERNAL OINTMENT 25-2 % 2 RECTIV RECTAL OINTMENT 0.4 % (nitroglycerin) 3 SL (30 grams per month.) PA; SL (30 grams per REGRANEX EXTERNAL GEL 0.01 % (becaplermin) 2 prescription.) REMIGEN EXTERNAL CREAM 3 PA; SL (30 grams per RHOFADE EXTERNAL CREAM 1 % (oxymetazoline hcl) 3 prescription.) SL (60 grams per SANTYL EXTERNAL OINTMENT 250 UNIT/GM ( collagenase) 3 prescription.) SKYRIZI (150 MG DOSE) SUBCUTANEOUS PREFILLED PA; SL (1 box per 3 2 SYRINGE KIT 75 MG/0.83ML (risankizumab-rzaa) months.); SP SKYRIZI PEN SUBCUTANEOUS SOLUTION AUTO- 2 PA INJECTOR 150 MG/ML (risankizumab-rzaa) SKYRIZI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 2 PA 150 MG/ML (risankizumab-rzaa) STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5ML 2 PA; SP (ustekinumab) STELARA SUBCUTANEOUS SOLUTION PREFILLED PA; SL (0.5 ml (1 prefilled 2 SYRINGE 45 MG/0.5ML (ustekinumab) syringe) per 3 months.); SP STELARA SUBCUTANEOUS SOLUTION PREFILLED PA; SL (1 ml (1 prefilled 2 SYRINGE 90 MG/ML (ustekinumab) syringe) per 3 months.); SP TACLONEX EXTERNAL SUSPENSION 0.005-0.064 % 3 (calcipotriene-betameth diprop) ST; SL (30 grams per tacrolimus external ointment 0.03 %, 0.1 % 1 prescription.) SL (60 grams per TARGRETIN EXTERNAL GEL 1 % (bexarotene) 3 prescription.); SP PA; SL (30 grams per tazarotene external cream 0.1 % 1 prescription.) PA; SL (30 grams per TAZORAC EXTERNAL CREAM 0.05 %, 0.1 % (tazarotene) 3 prescription.) PA; SL (30 grams per TAZORAC EXTERNAL GEL 0.05 %, 0.1 % (tazarotene) 3 prescription.) TETRIX EXTERNAL CREAM (dermatological products, misc.) 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 221 Coverage Requirements & Prescription Drug Name Drug Tier Limits TISSEEL EXTERNAL KIT 10 ML, 2 ML, 4 ML ( fibrin sealant 3 component) TREMFYA SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 PA; SL (1 ml per 42 days.); 2 MG/ML (guselkumab) SP TREMFYA SUBCUTANEOUS SOLUTION PREFILLED PA; SL (2 ml per 2 months.); 2 SYRINGE 100 MG/ML (guselkumab) SP VALCHLOR EXTERNAL GEL 0.016 % (mechlorethamine hcl PA; SL (120 grams per 2 (topical)) prescription.); SP VENELEX EXTERNAL OINTMENT ( balsam peru-castor oil) 3 ST; SL (30 grams per VEREGEN EXTERNAL OINTMENT 15 % ( sinecatechins) 3 prescription.) zenatane oral capsule 10 mg, 20 mg, 30 mg, 40 mg 1 SUNSCREEN AGENTS - Drugs for the Skin AVIDOXY DK COMBINATION KIT 100 MG (doxycycline- 3 suncreen-sal acid) SMOOTH MUSCLE RELAXANTS - Drugs to Relax Muscles ANTIMUSCARINICS - Drugs for the Urinary System hydrobromide er oral tablet extended release 24 1 ST hour 15 mg, 7.5 mg DITROPAN XL ORAL TABLET EXTENDED RELEASE 24 3 HOUR 10 MG, 5 MG ( chloride) hcl oral tablet 100 mg 1 oxybutynin chloride er oral tablet extended release 24 hour 10 1 mg, 15 mg, 5 mg oxybutynin chloride oral syrup 5 mg/5ml 1 oxybutynin chloride oral tablet 5 mg 1 succinate oral tablet 10 mg, 5 mg 1 TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HOUR 4 3 MG, 8 MG ( fumarate) RESPIRATORY SMOOTH MUSCLE RELAXANTS - Drugs for Lungs ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML (theophylline) 3 PA; SL (186 ml per month.); sildenafil citrate oral suspension reconstituted 10 mg/ml 1 SP sildenafil citrate oral tablet 20 mg 1 SL (0.5 tablet per day.) THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 300 MG, 400 MG (theophylline) theophylline er oral tablet extended release 12 hour 300 mg, 1 450 mg Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 222 Coverage Requirements & Prescription Drug Name Drug Tier Limits theophylline er oral tablet extended release 24 hour 400 mg, 1 600 mg theophylline oral solution 80 mg/15ml 1 VITAMINS MULTIVITAMIN PREPARATIONS adc/f (0.5mg/ml) oral solution 0.5 mg/ml 1 ATABEX OB ORAL TABLET 29-1 MG (prenatal vit w/ fe bisg-fa) 3 CITRANATAL ESSENCE ORAL THERAPY PACK 35-1 & 300 3 MG (prenat w/o a-fecbgl-fa-dha) CITRANATAL MEDLEY ORAL CAPSULE 27-1-200 MG 3 (prenat-fecb-fefum-fa-dha w/o a) ELITE-OB ORAL TABLET 50-1.25 MG (prenatal vit-iron 3 carbonyl-fa) ENBRACE HR ORAL CAPSULE (prenat vit-fe gly cys-fa- 3 omega) FLORIVA PLUS ORAL SOLUTION 0.25 MG/ML (pediatric 3 multivitamins-fl) M-NATAL PLUS ORAL TABLET 27-1 MG 3 multi-vit/iron/fluoride oral solution 0.25-10 mg/ml 1 multivitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml 1 multi-vitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml 1 multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg 1 multi-vitamin/fluoride/iron oral solution 0.25-10 mg/ml 1 NEONATAL + DHA ORAL 29-1 & 200 MG 3 NEONATAL 19 ORAL TABLET 1 MG 3 NEONATAL COMPLETE ORAL TABLET 27-1 MG, 29-1 MG 3 NEONATAL FE ORAL TABLET 90-1 MG 3 NEONATAL PLUS ORAL TABLET 27-1 MG ( prenatal vit-fe 3 fumarate-fa) NESTABS ORAL TABLET 32-1 MG (prenat-fe bisgly-fa-w/o vit 3 a) ONE VITE WOMENS PLUS ORAL TABLET 27-1 MG 3 ONEVITE ORAL TABLET 1 MG 3 POLY-VI-FLOR ORAL SUSPENSION 0.25 MG/ML (pediatric 3 multivitamins-fl) POLY-VI-FLOR ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 3 1 MG (pediatric multivitamins-fl)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 223 Coverage Requirements & Prescription Drug Name Drug Tier Limits POLY-VI-FLOR/IRON ORAL SUSPENSION 0.25-7 MG/ML 3 (ped multivitamins-fl-iron) POLY-VI-FLOR/IRON ORAL TABLET CHEWABLE 0.5-10 MG 3 (ped multivitamins-fl-iron) PREMESISRX ORAL TABLET 1 MG (prenatal ca-b6-b12-fa- 3 ginger) PRENAISSANCE ORAL CAPSULE 29-1.25-325 MG 2 prenatal oral tablet 27-1 mg 1 prenatal plus iron oral tablet 29-1 mg 1 prenatal vitamin plus low iron oral tablet 27-1 mg 1 PRENATE DHA ORAL CAPSULE 18-0.6-0.4-300 MG (prenat- 3 feasp-meth-fa-dha w/o a) PRENATE ELITE ORAL TABLET 20-0.6-0.4 MG (prenatal- 3 feaspgly-methylfol-fa) PRENATE ENHANCE ORAL CAPSULE 28-0.6-0.4-400 MG 3 (prenat w/o a-fe-methfol-fa-dha) PRENATE ESSENTIAL ORAL CAPSULE 18-0.6-0.4-300 MG 3 (prenat-feasp-meth-fa-dha w/o a) PRENATE MINI ORAL CAPSULE 18-0.6-0.4-350 MG (prenat- 3 fecbn-feasp-meth-fa-dha) PRENATE ORAL TABLET CHEWABLE 0.6-0.4 MG (prenat mv- 3 min-methylfolate-fa) PRENATE PIXIE ORAL CAPSULE 10-0.6-0.4-200 MG (prenat- 3 feasp-meth-fa-dha w/o a) PRENATE RESTORE ORAL CAPSULE 27-0.6-0.4-400 MG 3 (prenat w/o a-fe-methfol-fa-dha) PRENATVITE COMPLETE ORAL TABLET 1 MG 3 PRENATVITE PLUS ORAL TABLET 1 MG 3 PRENATVITE RX ORAL TABLET 0.8 MG 3 preplus oral tablet 27-1 mg 1 PRETAB ORAL TABLET 29-1 MG 3 PRIMACARE ORAL CAPSULE 30-1-470 MG (pren-fe-meth-fa- 3 omeg w/o a) QUFLORA PEDIATRIC ORAL SOLUTION 0.25 MG/ML, 0.5 3 MG/ML (pediatric multivitamins-fl) QUFLORA PEDIATRIC ORAL TABLET CHEWABLE 0.25 MG, 3 0.5 MG, 1 MG (pediatric multivitamins-fl) RELNATE DHA ORAL CAPSULE 28-1-200 MG 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 224 Coverage Requirements & Prescription Drug Name Drug Tier Limits SELECT-OB ORAL TABLET CHEWABLE 29-1 MG (prenatal 3 vit-fe psac cmplx-fa) TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1-500 3 MG (prenatal-fefum-fa-dss-fish oil) TRINATE ORAL TABLET ( prenatal vit-fe fumarate-fa) 3 TRISTART DHA ORAL CAPSULE 31-0.6-0.4-200 MG 3 TRISTART FREE ORAL CAPSULE 33-1 MG (prenat w/o a- 3 fecbn-meth-fa-dha) TRISTART ONE ORAL CAPSULE 35-1-215 MG (prenat w/o a- 3 fecbn-meth-fa-dha) TRI-VI-FLOR ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML 3 (ped vit a-c-d-methylfolate-fl) TRI-VI-FLORO ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML 3 tri-vite/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml 1 UDAMIN SP ORAL TABLET 1 MG (multiple vitamins-minerals- 3 fa) VENTRIXYL ORAL TABLET 1 MG (multiple vitamins-minerals- 3 fa) VINATE ONE ORAL TABLET 60-1 MG (prenatal vit-fe 3 fumarate-fa) VITAFOL FE+ ORAL CAPSULE 90-0.6-0.4-200 MG (prenat-fe 3 poly-methfol-fa-dha) VITAFOL STRIPS ORAL FILM 1 MG (prenatal-b6-b12-d3-folic 3 acid) VITAFOL-NANO ORAL TABLET 18-0.6-0.4 MG (prenatal-fe 3 fum-methf-fa w/o a) VITAFOL-OB+DHA ORAL 65-1 & 250 MG (prenatal mv-min-fe 3 fum-fa-dha) vitamins acd-fluoride oral solution 0.25 mg/ml 1 VITATHELY WITH GINGER ORAL TABLET 27-1 MG (prenatal 3 vit-fe fumarate-fa) vp-pnv-dha oral capsule 28-1-215.8 mg 1 WESTGEL DHA ORAL CAPSULE 31-0.6-0.4-200 MG 3 VITAMIN A adc/f (0.5mg/ml) oral solution 0.5 mg/ml 1 TRI-VI-FLOR ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML 3 (ped vit a-c-d-methylfolate-fl) TRI-VI-FLORO ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML 3 tri-vite/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml 1 Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 225 Coverage Requirements & Prescription Drug Name Drug Tier Limits vitamins acd-fluoride oral solution 0.25 mg/ml 1 VITAMIN B COMPLEX ATABEX OB ORAL TABLET 29-1 MG (prenatal vit w/ fe bisg-fa) 3 CALCIFOL ORAL WAFER 1342-1.6 MG (ca carb-fa-d-b6-b12- 3 boron-mg) calcium-folic acid plus d oral wafer 1342-1 mg 1 CITRANATAL BLOOM ORAL TABLET 90-1 MG ( prenatal-dss- 3 fecb-fegl-fa) CITRANATAL ESSENCE ORAL THERAPY PACK 35-1 & 300 3 MG (prenat w/o a-fecbgl-fa-dha) CITRANATAL MEDLEY ORAL CAPSULE 27-1-200 MG 3 (prenat-fecb-fefum-fa-dha w/o a) cyanocobalamin injection solution 1000 mcg/ml 1 CYANOCOBALAMIN INJECTION SOLUTION 2000 MCG/ML 3 drospiren-eth estrad-levomefol oral tablet 3-0.02-0.451 mg, 3- 1 H 0.03-0.451 mg ELITE-OB ORAL TABLET 50-1.25 MG (prenatal vit-iron 3 carbonyl-fa) ENBRACE HR ORAL CAPSULE (prenat vit-fe gly cys-fa- 3 omega) folic acid oral tablet 1 mg 1 hematinic/folic acid oral tablet 324-1 mg 1 hemocyte-f oral tablet 324-1 mg 1 leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg 1 M-NATAL PLUS ORAL TABLET 27-1 MG 3 NASCOBAL NASAL SOLUTION 500 MCG/0.1ML 3 (cyanocobalamin) NEONATAL + DHA ORAL 29-1 & 200 MG 3 NEONATAL COMPLETE ORAL TABLET 27-1 MG, 29-1 MG 3 NEONATAL FE ORAL TABLET 90-1 MG 3 NEONATAL PLUS ORAL TABLET 27-1 MG ( prenatal vit-fe 3 fumarate-fa) NESTABS ORAL TABLET 32-1 MG (prenat-fe bisgly-fa-w/o vit 3 a) ONE VITE WOMENS PLUS ORAL TABLET 27-1 MG 3 ONEVITE ORAL TABLET 1 MG 3 POTABA ORAL CAPSULE 500 MG (potassium 3 aminobenzoate)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 226 Coverage Requirements & Prescription Drug Name Drug Tier Limits PREMESISRX ORAL TABLET 1 MG (prenatal ca-b6-b12-fa- 3 ginger) PRENAISSANCE ORAL CAPSULE 29-1.25-325 MG 2 prenatal oral tablet 27-1 mg 1 prenatal plus iron oral tablet 29-1 mg 1 prenatal vitamin plus low iron oral tablet 27-1 mg 1 PRENATE DHA ORAL CAPSULE 18-0.6-0.4-300 MG (prenat- 3 feasp-meth-fa-dha w/o a) PRENATE ELITE ORAL TABLET 20-0.6-0.4 MG (prenatal- 3 feaspgly-methylfol-fa) PRENATE ENHANCE ORAL CAPSULE 28-0.6-0.4-400 MG 3 (prenat w/o a-fe-methfol-fa-dha) PRENATE ESSENTIAL ORAL CAPSULE 18-0.6-0.4-300 MG 3 (prenat-feasp-meth-fa-dha w/o a) PRENATE MINI ORAL CAPSULE 18-0.6-0.4-350 MG (prenat- 3 fecbn-feasp-meth-fa-dha) PRENATE ORAL TABLET CHEWABLE 0.6-0.4 MG (prenat mv- 3 min-methylfolate-fa) PRENATE PIXIE ORAL CAPSULE 10-0.6-0.4-200 MG (prenat- 3 feasp-meth-fa-dha w/o a) PRENATE RESTORE ORAL CAPSULE 27-0.6-0.4-400 MG 3 (prenat w/o a-fe-methfol-fa-dha) PRENATVITE COMPLETE ORAL TABLET 1 MG 3 PRENATVITE PLUS ORAL TABLET 1 MG 3 PRENATVITE RX ORAL TABLET 0.8 MG 3 preplus oral tablet 27-1 mg 1 PRETAB ORAL TABLET 29-1 MG 3 PRIMACARE ORAL CAPSULE 30-1-470 MG (pren-fe-meth-fa- 3 omeg w/o a) RELNATE DHA ORAL CAPSULE 28-1-200 MG 3 SELECT-OB ORAL TABLET CHEWABLE 29-1 MG (prenatal 3 vit-fe psac cmplx-fa) TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1-500 3 MG (prenatal-fefum-fa-dss-fish oil) TRINATE ORAL TABLET ( prenatal vit-fe fumarate-fa) 3 TRISTART DHA ORAL CAPSULE 31-0.6-0.4-200 MG 3 TRISTART FREE ORAL CAPSULE 33-1 MG (prenat w/o a- 3 fecbn-meth-fa-dha)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 227 Coverage Requirements & Prescription Drug Name Drug Tier Limits TRISTART ONE ORAL CAPSULE 35-1-215 MG (prenat w/o a- 3 fecbn-meth-fa-dha) TRI-VI-FLOR ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML 3 (ped vit a-c-d-methylfolate-fl) TRI-VI-FLORO ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML 3 tydemy oral tablet 3-0.03-0.451 mg 1 H UDAMIN SP ORAL TABLET 1 MG (multiple vitamins-minerals- 3 fa) VENTRIXYL ORAL TABLET 1 MG (multiple vitamins-minerals- 3 fa) VINATE ONE ORAL TABLET 60-1 MG (prenatal vit-fe 3 fumarate-fa) VITAFOL FE+ ORAL CAPSULE 90-0.6-0.4-200 MG (prenat-fe 3 poly-methfol-fa-dha) VITAFOL-NANO ORAL TABLET 18-0.6-0.4 MG (prenatal-fe 3 fum-methf-fa w/o a) VITAFOL-OB+DHA ORAL 65-1 & 250 MG (prenatal mv-min-fe 3 fum-fa-dha) VITATHELY WITH GINGER ORAL TABLET 27-1 MG (prenatal 3 vit-fe fumarate-fa) vp-pnv-dha oral capsule 28-1-215.8 mg 1 WESTGEL DHA ORAL CAPSULE 31-0.6-0.4-200 MG 3 VITAMIN C adc/f (0.5mg/ml) oral solution 0.5 mg/ml 1 CITRANATAL BLOOM ORAL TABLET 90-1 MG ( prenatal-dss- 3 fecb-fegl-fa) MOVIPREP ORAL SOLUTION RECONSTITUTED 100 GM 3 SL (1 kit per prescription.) (peg-kcl-nacl-nasulf-na asc-c) peg-3350/electrolytes/ascorbat oral solution reconstituted 100 1 SL (1 kit per prescription.) gm peg-kcl-nacl-nasulf-na asc-c oral solution reconstituted 100 gm 1 SL (1 kit per prescription.) PLENVU ORAL SOLUTION RECONSTITUTED 140 GM (peg- SL (3 cartons per 3 kcl-nacl-nasulf-na asc-c) prescription.) TRI-VI-FLOR ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML 3 (ped vit a-c-d-methylfolate-fl) TRI-VI-FLORO ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML 3 tri-vite/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml 1 vitamins acd-fluoride oral solution 0.25 mg/ml 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 228 Coverage Requirements & Prescription Drug Name Drug Tier Limits VITAMIN D adc/f (0.5mg/ml) oral solution 0.5 mg/ml 1 CALCIFOL ORAL WAFER 1342-1.6 MG (ca carb-fa-d-b6-b12- 3 boron-mg) calcitriol oral capsule 0.25 mcg, 0.5 mcg 1 calcitriol oral solution 1 mcg/ml 1 calcium-folic acid plus d oral wafer 1342-1 mg 1 doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg 1 DRISDOL ORAL CAPSULE 1.25 MG (50000 UT) 3 (ergocalciferol) ERGOCAL ORAL CAPSULE 62.5 MCG (2500 UT) 3 ergocalciferol oral capsule 1.25 mg (50000 ut) 1 FLORIVA ORAL LIQUID 0.25-400 MG-UNIT/ML (sodium 3 fluoride-vitamin d) FOSAMAX PLUS D ORAL TABLET 70-2800 MG-UNIT, 70- 3 5600 MG-UNIT (alendronate-cholecalciferol) paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg 1 ROCALTROL ORAL CAPSULE 0.25 MCG, 0.5 MCG (calcitriol) 3 ROCALTROL ORAL SOLUTION 1 MCG/ML (calcitriol) 3 TRI-VI-FLOR ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML 3 (ped vit a-c-d-methylfolate-fl) TRI-VI-FLORO ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML 3 tri-vite/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml 1 vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut) 1 vitamins acd-fluoride oral solution 0.25 mg/ml 1 ZEMPLAR ORAL CAPSULE 1 MCG, 2 MCG (paricalcitol) 3 VITAMIN E NUTRIDOX ORAL KIT 75 MG (doxycycline monohyd-omega 3- 3 e) WHEAT GERM OIL ORAL OIL 3 VITAMIN K ACTIVITY SL (5 tablets per MEPHYTON ORAL TABLET 5 MG ( phytonadione) 3 prescription.) SL (5 tablets per phytonadione oral tablet 5 mg 1 prescription.)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your highest cost medications; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; SP: Specialty medication; CM: Orally administered anticancer medication. 229 Index of Drugs abacavir sulfate...... 24 adc/f (0.5mg/ml) alprazolam intensol...... 97 abacavir sulfate-lamivudine...... 24 ...... 182, 223, 225, 228, 229 alprazolam xr...... 97 abacavir-lamivudine- ADDERALL XR...... 81 ALPROLIX...... 56 zidovudine...... 24 adefovir dipivoxil...... 27 ALREX...... 131 abiraterone acetate...... 32 ADEMPAS...... 203 ALTABAX ...... 204 acamprosate calcium...... 99 ADIPEX-P...... 81 ALTACAINE ...... 134 acarbose...... 145 ADLYXIN...... 164 altafrin...... 134, 135 ACCOLATE...... 200 ADLYXIN STARTER PACK.... 164 altavera...... 148, 155, 166 ACCU-CHEK AVIVA...... 115 ADRENALIN...... 44, 135, 197 ALUNBRIG...... 32 ACCU-CHEK COMPACT ADVAIR DISKUS...... 51, 143 alvimopan...... 139 PLUS CONTROL...... 115 ADVAIR HFA...... 51, 143 alyacen 1/35...... 148, 155, 166 ACCU-CHEK FASTCLIX ADVATE...... 56 alyacen 7/7/7...... 148, 156, 166 LANCET KIT...... 115 ADYNOVATE...... 56 alyq...... 78, 203 ACCU-CHEK GUIDE...... 115, 118 AEMCOLO...... 29 amabelz...... 156, 166 ACCU-CHEK GUIDE AFINITOR...... 32 amantadine hcl...... 15, 80 CONTROL ...... 115 AFINITOR DISPERZ...... 32 AMARYL...... 176 ACCU-CHEK SMARTVIEW afirmelle...... 148, 155, 166 ambrisentan...... 203 CONTROL ...... 115 AFLURIA QUADRIVALENT...... 42 amcinonide...... 209 ACCU-CHEK SOFTCLIX AFSTYLA ...... 56 AMELUZ...... 219 LANCET DEVICE KIT...... 115 AGRYLIN...... 62 amethia...... 148, 156, 166 ACCUPRIL...... 64, 65 AIMOVIG...... 98 amethyst...... 148, 156, 167 ACCURETIC...... 65, 124 ak-poly-bac...... 127 amiloride hcl...... 78, 121 accutane...... 219 AKTEN...... 134 amiloride-hydrochlorothiazide ACD-A NOCLOT-50...... 53 AKYNZEO...... 135, 141 ...... 121, 124 acebutolol hcl...... 52, 66, 67, 72 ala-cort...... 209 aminoamrms...... 120 acetaminophen-codeine....82, 103 albendazole...... 16 aminocaproic acid...... 56 acetaminophen-codeine #2 ALBENZA ...... 16 aminoreliefrms...... 120 ...... 82, 103 albuterol sulfate...... 51, 202 amiodarone hcl...... 73 acetaminophen-codeine #3 albuterol sulfate hfa...... 51, 202 AMITIZA...... 139 ...... 82, 103 ALCAINE...... 134 amitriptyline hcl...... 114 acetaminophen-codeine #4 alclometasone dipropionate.... 209 amlodipine besylate...... 74, 75, 79 ...... 82, 103 ALCOHOL PREP PADS...... 115 amlodipine besylate-benazepril acetazolamide.....71, 84, 120, 130 ALDACTAZIDE...... 77, 124 hcl...... 65, 74 acetazolamide er.71, 84, 120, 130 ALECENSA...... 32 amlodipine besylate-valsartan acetic acid...... 133 alendronate sodium...... 180 ...... 63, 74 acetylcysteine ...... 178, 201 ALEVAMAX...... 219 amnesteem...... 219 acitretin...... 219 ALFERON N ...... 27, 32, 188 amoxapine...... 114 ACTEMRA ...... 184, 187 alfuzosin hcl er...... 50 amoxicillin...... 16, 137 ACTEMRA ACTPEN ...... 184, 187 ALINIA...... 18 amoxicillin-potassium ACTHAR...... 118, 166 aliskiren fumarate...... 78 clavulanate...... 16 ACTHIB...... 42 ALKERAN...... 32 AMPHETAMINE ER...... 81 ACTIMMUNE ...... 188 allopurinol...... 179 amphetamine- ACTIVELLA...... 155, 166 almotriptan malate...... 112 dextroamphetamine...... 81 ACTOPLUS MET...... 147, 177 ALOCRIL...... 127, 201 ampicillin...... 16 ACULAR...... 133 ALOMIDE...... 14, 127 AMZEEQ...... 204 ACULAR LS...... 133 ALORA...... 155, 180 anagrelide hcl...... 62 acyclovir...... 27, 208 alosetron hcl...... 136 ANALPRAM HC ...... 207, 209 ACZONE...... 204, 219 ALPHAGAN P...... 127 ANALPRAM HC SINGLES ADACEL...... 41, 42 ALPHANATE ...... 56 ...... 207, 209 ADASUVE...... 92 ALPHANINE SD...... 56 ANALPRAM-HC...... 207, 210 alprazolam...... 97 ANASPAZ...... 45 alprazolam er...... 97 anastrozole...... 32, 146

230 ANCOBON...... 29 aubra eq...... 148, 156, 167 BELBUCA...... 107 ANDRODERM...... 145 aurovela 1.5/30...... 148, 156, 167 belladonna alkaloids-opium ANGELIQ...... 156, 167 aurovela 1/20...... 148, 156, 167 ...... 45, 103 ANNOVERA ...... 148, 156, 167 aurovela 24 fe...... 148, 156, 167 BELSOMRA ...... 92 ANORO ELLIPTA ...... 45, 51 aurovela fe 1.5/30... 148, 156, 167 benazepril hcl...... 64, 65 ANTICOAGULANT SODIUM aurovela fe 1/20...... 148, 156, 167 benazepril-hydrochlorothiazide CITRATE ...... 54 AURYXIA...... 121 ...... 65, 124 ANTIVERT...... 12, 136 AUSTEDO...... 114 BENEFIX...... 57 anucort-hc...... 210 AUTOLET LANCING DEVICE 116 BENLYSTA ...... 192 ANUSOL-HC...... 210 AVAR CLEANSER...... 204, 215 BENZALKONIUM CHLORIDE 216 apap-caff-dihydrocodeine AVAR-E EMOLLIENT..... 204, 215 benzalkonium chloride...... 216 ...... 82, 103, 109 AVAR-E GREEN...... 204, 215 BENZAMYCIN...... 204, 217 APEXICON E...... 210 AVAR-E LS...... 204, 215 BENZHYDROCODONE- APOKYN...... 102 aviane...... 148, 156, 167 ACETAMINOPHEN...... 82, 103 apraclonidine hcl...... 133 avidoxy...... 17, 30 BENZNIDAZOLE ...... 18 aprepitant...... 141 AVIDOXY DK...... 30, 215, 222 BENZOIN...... 209 apri...... 148, 156, 167 AVONEX PEN...... 188 benzoin compound...... 209 APRISO...... 136 AVONEX PREFILLED...... 188 benzonatate...... 198 APTIOM...... 84 AYGESTIN...... 167 benzoyl peroxide-erythromycin APTIVUS...... 26 ayuna...... 148, 156, 167 ...... 204, 217 ARAKODA...... 16 AYVAKIT...... 32, 33 benzphetamine hcl...... 81 aranelle...... 148, 156, 167 AZASAN...... 184, 188, 192 benztropine mesylate...... 47, 84 ARANESP (ALBUMIN FREE) AZASITE...... 127 BERINERT...... 184 ...... 53, 55 azathioprine...... 184, 188, 192 beser...... 210 ARAVA...... 184, 188, 192 azelaic acid...... 219 BESIVANCE...... 127 ARCALYST...... 193 azelastine hcl...... 127, 202 BETADINE OPHTHALMIC arformoterol tartrate...... 51 AZELEX...... 219 PREP...... 133 ARIKAYCE...... 15 azithromycin...... 28 betamethasone dipropionate.. 210 aripiprazole...... 88, 93 AZOPT...... 130 betamethasone dipropionate armodafinil...... 115 AZSTARYS...... 109 aug...... 210 ARMOUR THYROID...... 177 AZULFIDINE..... 30, 136, 184, 188 betamethasone valerate...... 210 ARNUITY ELLIPTA ...... 143, 201 AZULFIDINE EN-TABS BETAPACE AF. 49, 66, 67, 72, 73 ARTISS...... 219 ...... 30, 136, 184, 188 BETASERON...... 188 ARZOL SILVER NIT azurette...... 148, 156, 167 betaxolol hcl.... 52, 66, 67, 72, 130 APPLICATORS...... 132 bac...... 82, 95, 109 bethanechol chloride...... 50 ascomp-codeine 95, 103, 109, 111 bacitracin...... 127 BETOPTIC-S...... 130 ashlyna...... 148, 156, 167 bacitracin-polymyxin b...... 127 BEVESPI AEROSPHERE...45, 51 aspirin-dipyridamole er...... 62, 111 bacitra-neomycin-polymyxin-hc BEXSERO...... 42 ASTRAZENECA COVID-19 ...... 127, 131 bicalutamide...... 33 VACCINE...... 42 baclofen...... 49 BIDIL...... 75, 77 ASTRINGYN...... 56 BACTRIM...... 18, 30, 31 BIJUVA...... 156, 167 ATABEX OB...... 60, 223, 226 BACTRIM DS...... 18, 30, 31 BIKTARVY...... 23, 24 atazanavir sulfate...... 26 BAFIERTAM...... 188 BILTRICIDE...... 16 atenolol...... 52, 66, 67, 72 BALCOLTRA ...... 148, 156, 167 bisoprolol fumarate. 52, 66, 67, 72 atenolol-chlorthalidone...... 66, 125 balsalazide disodium...... 136 bisoprolol-hydrochlorothiazide atomoxetine hcl...... 99 balsam peru-castor oil...... 219 ...... 66, 124 atorvastatin calcium...... 76 BALVERSA...... 33 BLEPH-10...... 128 atovaquone...... 18 balziva...... 148, 156, 167 BLEPHAMIDE...... 128, 131 atovaquone-proguanil hcl...... 17 BANZEL ...... 84 BLEPHAMIDE S.O.P...... 128, 131 atropine sulfate...... 134 BAQSIMI ONE PACK..... 163, 178 blisovi 24 fe...... 148, 156, 167 ATROVENT HFA ...... 45, 197 BAQSIMI TWO PACK.....163, 178 blisovi fe 1.5/30...... 148, 156, 167 AUBAGIO...... 188 BARACLUDE...... 28 blisovi fe 1/20...... 148, 156, 167 aubra...... 148, 156, 167 BAXDELA...... 29 BONIVA...... 180

231 BOOSTRIX...... 42 calcipotriene-betameth diprop cefaclor...... 14 bosentan...... 203 ...... 210, 219 cefaclor er...... 14 BOSULIF...... 33 calcitonin (salmon)...... 146, 180 cefadroxil...... 14 bp 10-1...... 204, 215 CALCITRENE ...... 219 cefdinir...... 14 bp cleansing wash...... 204, 215 calcitriol...... 219, 229 cefixime...... 14 BRAFTOVI ...... 33 calcium acetate...... 121, 122 cefpodoxime proxetil...... 14 BREO ELLIPTA ...... 51, 143 calcium acetate (phos binder) cefprozil...... 14 BREZTRI AEROSPHERE ...... 121, 122 cefuroxime axetil...... 14 ...... 45, 51, 143 calcium-folic acid plus d celecoxib...... 100 briellyn...... 148, 156, 167 ...... 122, 226, 229 CELONTIN...... 113 BRILINTA ...... 62 CALQUENCE...... 33 CENTANY ...... 204 brimonidine tartrate...... 127 camila...... 148, 167 cephalexin...... 14 brinzolamide...... 130 camrese...... 148, 156, 167 CERDELGA...... 193 BRIVIACT...... 84 camrese lo...... 148, 156, 167 cerovel...... 215 bromocriptine mesylate...... 100 candesartan cilexetil...... 63 CERVIDIL...... 197 BROVANA...... 51 candesartan cilexetil-hctz..63, 124 CETRAXAL...... 128 BRUKINSA...... 33 capecitabine...... 33 cevimeline hcl...... 50 budesonide...... 143, 201 CAPEX...... 210 CHANTIX...... 48 bumetanide...... 77, 120 CAPLYTA...... 93 CHANTIX CONTINUING BUMEX...... 77, 120 CAPRELSA...... 33 MONTH PAK ...... 48 BUNAVAIL...... 106, 107 captopril...... 64, 65 CHANTIX STARTING MONTH BUPAP...... 82, 95 CARAC...... 219 PAK...... 48 BUPHENYL...... 119 CARBAGLU...... 120 charlotte 24 fe...... 149, 156, 167 buprenorphine hcl...... 107 carbamazepine...... 84, 85, 89 chateal...... 149, 156, 167 buprenorphine hcl-naloxone carbamazepine er...... 84, 89 chateal eq...... 149, 156, 167 hcl...... 106, 107 CARBATROL...... 85, 89 CHEMET...... 142, 178 bupropion hcl...... 88 carbidopa...... 100 CHENODAL...... 138 bupropion hcl er (smoking det). 88 carbidopa-levodopa...... 100 chlordiazepoxide hcl...... 97 bupropion hcl er (sr)...... 88 carbidopa-levodopa er...... 100 chlordiazepoxide-amitriptyline bupropion hcl er (xl)...... 88 carbidopa-levodopa- ...... 97, 114 buspirone hcl...... 92 entacapone...... 98, 100 chlordiazepoxide-clidinium..45, 97 butalbital-acetaminophen....82, 95 carbinoxamine maleate.....12, 200 chlorhexidine gluconate.. 133, 217 butalbital-apap-caff-cod CARDURA...... 49, 62, 63 chloroquine phosphate...... 17 ...... 82, 95, 103, 109 CARDURA XL...... 49, 63 chlorpromazine hcl...... 109 butalbital-apap-caffeine CARETOUCH CONTROL SOL chlorthalidone...... 79, 125 ...... 82, 95, 109 LEVEL 2...... 116 chlorzoxazone...... 48 butalbital-asa-caff-codeine CARETOUCH CHOLBAM...... 139 ...... 95, 103, 109, 111 LANCING/EJECTOR...... 116 cholestyramine...... 68 butalbital-aspirin-caffeine carisoprodol...... 48 cholestyramine light...... 68 ...... 95, 109, 111 carisoprodol-aspirin-codeine ciclodan...... 215 butorphanol tartrate...... 91, 107 ...... 48, 103, 111 ciclopirox...... 215 BYDUREON BCISE CARNITOR...... 193 ciclopirox olamine...... 215 AUTOINJECTOR...... 164 CARNITOR SF...... 193 ciclopirox treatment...... 215 BYETTA 10 MCG PEN ...... 164 CAROSPIR...... 77, 78, 122 cilostazol...... 62, 78 BYETTA 5 MCG PEN ...... 164 carteolol hcl...... 130 CILOXAN...... 128 cabergoline...... 100 cartia xt...... 69, 70, 73, 79 CIMDUO...... 24 CABLIVI...... 54 carvedilol.....49, 50, 63, 66, 67, 72 cimetidine...... 13, 140 CABOMETYX ...... 33 cascara sagrada ...... 137 cimetidine hcl...... 12, 140 CAFERGOT...... 49, 91, 109 CASODEX...... 33 CIMZIA PREFILLED KIT caffeine citrate...... 91, 109 cavarest...... 182 ...... 139, 184, 188 CALAN SR...... 69, 70, 73, 79 CAYA...... 196 CIMZIA STARTER KIT CALCIFOL...... 122, 226, 229 CAYSTON...... 27 ...... 139, 184, 188 calcipotriene...... 219 caziant...... 148, 156, 167 cinacalcet hcl...... 146

232 CIPRO...... 19, 29 colestipol hcl...... 68 CUTIVATE...... 211 CIPRO HC...... 128, 131 colistimethate sodium (cba)...... 29 CUVPOSA...... 45 CIPRODEX...... 128, 131 COLY-MYCIN M...... 29 cyanocobalamin...... 62, 226 ciprofloxacin hcl...... 19, 29, 128 COMBIGAN...... 127, 130 CYANOCOBALAMIN...... 62, 226 citalopram hydrobromide...... 113 COMBIPATCH...... 157, 168 cyclafem 1/35...... 149, 157, 168 CITRANATAL BLOOM COMBIVENT RESPIMAT cyclafem 7/7/7...... 149, 157, 168 ...... 60, 137, 226, 228 ...... 45, 51, 197 cyclobenzaprine hcl ...... 48 CITRANATAL ESSENCE COMBIVIR...... 24 CYCLOGYL...... 134 ...... 60, 122, 193, 223, 226 COMETRIQ...... 33 CYCLOMYDRIL...... 134, 135 CITRANATAL MEDLEY COMPLERA...... 23, 24 cyclopentolate hcl...... 134 ...... 60, 193, 223, 226 compro...... 109, 136 cyclophosphamide...... 33, 192 claravis...... 219 COMTAN...... 98 CYCLOPHOSPHAMIDE... 33, 192 clarithromycin...... 19, 28, 137 CONCERTA ...... 109 cycloserine...... 19 clarithromycin er...... 19, 28, 137 CONDYLOX...... 219 CYCLOSET...... 146 clemastine fumarate...... 12, 200 constulose...... 120 cyclosporine ...... 184, 188, 192 CLENPIQ...... 137 CONTOUR CONTROL ...... 116 cyclosporine modified CLEOCIN...... 27, 204 CONTOUR NEXT CONTROL .116 ...... 184, 188, 192 CLEOCIN-T...... 204 CONTOUR NEXT EZ ...... 116 cyproheptadine hcl...... 12, 200 CLIMARA PRO...... 157, 167 CONTOUR NEXT LINK ...... 116 cyred...... 149, 157, 168 clindacin etz...... 205 CONTOUR NEXT MONITOR . 116 cyred eq...... 149, 157, 168 clindacin-p...... 205 CONTOUR NEXT ONE ...... 116 CYSTADANE ...... 193 clindamycin hcl...... 27 CONTOUR NEXT TEST ...... 118 CYSTADROPS...... 133 clindamycin palmitate hcl...... 27 CONTRAVE ...... 84 CYSTAGON...... 193 clindamycin phos-benzoyl COPIKTRA...... 33 CYSTARAN...... 133 perox...... 205, 217 CORDRAN...... 211 CYTOTEC...... 141 clindamycin phosphate...... 205 CORGARD...... 49, 66, 67 cytra k crystals ...... 119 CLINDESSE...... 205 CORIFACT...... 57 dalfampridine er...... 193 CLINPRO 5000...... 182 CORLANOR...... 71, 79 DALIRESP...... 202 clobazam...... 96, 97 CORTANE-B...... 207, 211, 217 danazol...... 145 clobetasol prop emollient base210 CORTEF...... 143 DANTRIUM...... 48 clobetasol propionate...... 210 CORTENEMA ...... 211 dantrolene sodium...... 48 clobetasol propionate e...... 210 cortic-nd...... 131, 133, 134 dapsone...... 17, 18 CLOBETAVIX...... 210 CORTIFOAM...... 211 DAPTACEL...... 42 clocortolone pivalate...... 211 CORTI-SAV...... 211, 217 DARAPRIM...... 17 clomipramine hcl...... 114 CORTISPORIN-TC...... 128, 131 darifenacin hydrobromide er... 222 clonazepam...... 96, 97 CORTROSYN...... 118 dasetta 1/35...... 149, 157, 168 clonidine...... 44, 71 COSENTYX (300 MG DOSE).219 dasetta 7/7/7...... 149, 157, 168 clonidine hcl...... 44, 71 COSENTYX 150 MG/ML ...... 219 DAURISMO...... 34 clopidogrel bisulfate...... 62 COSENTYX SENSOREADY DAYPRO...... 107 clorazepate dipotassium..... 96, 97 (300 MG)...... 219 daysee...... 149, 157, 168 clotrimazole...... 208 COSENTYX SENSOREADY DAYVIGO...... 92 clotrimazole-betamethasone PEN...... 219 DEBACTEROL...... 133, 217 ...... 208, 211 COSOPT...... 130 deblitane...... 149, 168 clovique...... 142 cosyntropin...... 118 deferasirox...... 142 clozapine...... 93 COVARYX...... 145, 157 deferasirox granules...... 142 CLOZARIL...... 93 COVARYX HS...... 145, 157 deferiprone...... 142 COAGADEX...... 57 CREON...... 126, 138 DELESTROGEN...... 157, 180 COAL TAR...... 216 CRESEMBA...... 19 DELSTRIGO...... 23, 24 COARTEM...... 17 CRINONE...... 168 delyla...... 149, 157, 168 codeine sulfate...... 103, 198 CRIXIVAN...... 26 demeclocycline hcl...... 30 colchicine-probenecid..... 125, 179 cromolyn sodium.....127, 133, 201 DEMSER...... 193 COLESTID...... 68 crotan...... 218 DENTA 5000 PLUS...... 182 COLESTID FLAVORED...... 68 cryselle-28...... 149, 157, 168 DENTAGEL...... 182

233 DEPAKOTE...... 85, 89, 91 diethylpropion hcl...... 81 doxycycline hyclate ...... 17, 30 DEPAKOTE ER...... 85, 89, 91 diethylpropion hcl er...... 81 doxycycline monohydrate ... 17, 30 DEPAKOTE SPRINKLES DIFICID...... 28 DRISDOL...... 229 ...... 85, 89, 91 diflorasone diacetate...... 212 DRIZALMA SPRINKLE...... 111 DEPEN TITRATABS ...... 142, 184 DIFLUCAN...... 20 dronabinol...... 136 DEPO-ESTRADIOL...... 157, 180 diflunisal...... 108 drospiren-eth estrad-levomefol DEPO-PROVERA...... 149, 168 digitek...... 66, 71 ...... 149, 157, 168, 226 DEPO-SUBQ PROVERA 104 digox...... 66, 71 drospirenone-ethinyl estradiol ...... 149, 168 digoxin...... 66, 71 ...... 149, 157, 168 DEPO-TESTOSTERONE ...... 145 dihydroergotamine mesylate DROXIA...... 34 DERMA-SMOOTHE/FS BODY ...... 49, 91 droxidopa...... 44 ...... 211 DILANTIN...... 72, 101 DRYSOL...... 208 DERMA-SMOOTHE/FS DILANTIN INFATABS ...... 72, 101 DUAKLIR PRESSAIR...... 45, 51 SCALP...... 211 DILATRATE-SR...... 77 DUAVEE...... 155, 157 DERMOTIC...... 131 DILAUDID...... 103 DUETACT...... 176, 177 DESCOVY...... 24 diltiazem hcl...... 69, 70, 74, 79 duloxetine hcl...... 101, 111 desipramine hcl...... 114 diltiazem hcl er...... 69, 70, 74, 79 DUOPA...... 100 desmopressin ace spray refrig diltiazem hcl er beads DUPIXENT...... 200, 220 ...... 57, 166 ...... 69, 70, 73, 79 DUREZOL...... 131 desmopressin acetate...... 57, 166 diltiazem hcl er coated beads dutasteride...... 178 desmopressin acetate pf...57, 166 ...... 69, 70, 74, 79 DYRENIUM...... 78, 122 desmopressin acetate spray dilt-xr...... 69, 70, 74, 80 E.E.S. GRANULES...... 20 ...... 57, 166 dimethyl fumarate...... 188 EASIVENT...... 116 desogestrel-ethinyl estradiol dimethyl fumarate starter pack 188 easygel...... 182 ...... 149, 157, 168 DIPENTUM...... 136 EASYMAX 15 LEVEL 2-3 DESONATE...... 211 diphen..... 12, 47, 84, 92, 198, 200 CONTROL...... 116 desonide...... 211 di-phen.... 12, 47, 84, 92, 198, 200 EASYMAX CONTROL...... 116 DESOWEN...... 211 diphenhydramine hcl EASYMAX CONTROL desoximetasone...... 211 ...... 12, 47, 84, 92, 198, 200 NORMAL/HIGH...... 116 desrx...... 212 diphenoxylate-atropine...... 45, 135 EC-NAPROSYN...... 91, 108, 179 desvenlafaxine succinate er....111 DIPROLENE...... 212 ec-naproxen...... 91, 108, 179 dexamethasone...... 143 DIPROLENE AF...... 212 econazole nitrate...... 208 dexamethasone intensol...... 143 dipyridamole...... 62, 80 EDARBI...... 63, 64 dexamethasone sodium disopyramide phosphate...... 72 EDARBYCLOR...... 64, 124 phosphate...... 131 disulfiram...... 178 EDECRIN...... 77, 120 DEXILANT...... 141 DITROPAN XL...... 222 ED-SPAZ...... 45 dexmethylphenidate hcl...... 110 DIURIL...... 79, 124 EDURANT...... 23 dexmethylphenidate hcl er...... 110 divalproex sodium...... 85, 89, 91 EEMT...... 145, 157 DEXTENZA ...... 131 divalproex sodium er.....85, 89, 91 EEMT HS...... 145, 157 dextroamphetamine sulfate...... 81 DIVIGEL...... 157, 180 efavirenz...... 24 dextroamphetamine sulfate er.. 81 dofetilide...... 73 efavirenz-emtricitab-tenofovir DIACOMIT...... 85 DOJOLVI...... 120 ...... 24, 25 DIASTAT ACUDIAL...... 96, 97 dolishale...... 149, 157, 168 efavirenz-lamivudine-tenofovir DIASTAT PEDIATRIC...... 96, 97 donepezil hcl...... 50 ...... 24, 25 diazepam...... 96, 97 DOPTELET...... 55 EFFER-K...... 122 diazepam intensol...... 96, 97 DORZOLAMIDE HCL...... 130 effer-k...... 122 diazoxide...... 146 dorzolamide hcl...... 130 EFUDEX...... 220 diclofenac potassium...... 107 dorzolamide hcl-timolol mal.... 130 EGATEN...... 16 diclofenac sodium... 107, 134, 218 DOVATO...... 23, 24 EGRIFTA SV...... 176 diclofenac sodium er...... 107 DOVONEX...... 220 ELESTRIN...... 157, 180 diclofenac-misoprostol.... 108, 141 doxazosin mesylate...... 49, 63 eletriptan hydrobromide...... 112 dicloxacillin sodium...... 29 doxepin hcl...... 114, 207 ELIGARD...... 34, 164 dicyclomine hcl...... 45 doxercalciferol...... 229 elinest...... 149, 157, 168

234 ELIQUIS...... 54 ergoloid mesylates...... 50 EXTINA...... 208 ELIQUIS DVT/PE STARTER ERGOMAR...... 50, 91 EZALLOR SPRINKLE ...... 76 PACK...... 54 ergotamine-caffeine.... 50, 92, 110 ezetimibe...... 71 ELITE-OB...... 60, 223, 226 ERIVEDGE...... 34 ezetimibe-simvastatin...... 71, 76 ELIXOPHYLLIN ERLEADA...... 34 falmina...... 150, 158, 169 ...... 76, 110, 120, 203, 222 erlotinib hcl...... 34 famciclovir...... 28 ELLA...... 149, 168 errin...... 149, 168 famotidine...... 13, 140 ELMIRON...... 193 ery...... 205 FANAPT...... 93, 94 ELOCTATE ...... 57 ERYGEL...... 205 FANAPT TITRATION PACK ..... 94 EMCYT...... 34 ERYPED 200...... 20 FARYDAK...... 34 EMEND ...... 141 ERYPED 400...... 20 FASENRA PEN...... 200 EMEND TRI-PACK...... 141 ERY-TAB...... 20 fayosim...... 150, 158, 169 EMGALITY ...... 98 ERYTHROCIN STEARATE ...... 20 febuxostat...... 179 EMGALITY (300 MG DOSE).... 98 erythromycin ...... 21, 128, 205 FEIBA...... 57 emoquette...... 149, 158, 168 erythromycin base ...... 21 felbamate...... 85 EMSAM...... 102 erythromycin ethylsuccinate ...... 21 FELBATOL ...... 85 emtricitabine...... 25 ESBRIET...... 198 FELDENE...... 108 emtricitabine-tenofovir df...... 25 escitalopram oxalate...... 113 felodipine er...... 74, 75 EMTRIVA...... 25 ESGIC...... 82, 95, 110 FEM PH...... 217, 220 EMVERM...... 16 esomeprazole magnesium...... 141 FEMHRT...... 158, 169 enalapril maleate...... 64, 65 est estrogens-methyltest .145, 158 FEMRING...... 158, 181 enalapril-hydrochlorothiazide est estrogens-methyltest ds femynor...... 150, 158, 169 ...... 65, 124 ...... 145, 158 fenofibrate...... 76 ENBRACE HR .. 60, 193, 223, 226 est estrogens-methyltest hs fentanyl...... 103 ENBREL...... 185, 188 ...... 145, 158 fentanyl citrate...... 103 ENBREL MINI ...... 185, 188 estarylla...... 149, 158, 168 FERRIPROX...... 142 ENBREL SURECLICK.... 185, 189 estazolam...... 97 FETZIMA ...... 111 ENDARI...... 193 estradiol...... 158, 180, 181 FETZIMA TITRATION ...... 111 endocet...... 82, 103 estradiol valerate...... 158, 181 FINACEA...... 220 ENDOMETRIN ...... 168 estradiol-norethindrone acet finasteride...... 178 ENGERIX-B...... 42 ...... 158, 168 FINTEPLA ...... 85 enoxaparin sodium...... 59 ESTRING...... 158, 181 FIORICET...... 82, 95, 110 enpresse-28...... 149, 158, 168 ESTROGEL...... 158, 181 FIRAZYR...... 184 enskyce ...... 149, 158, 168 ESTROSTEP FE.....149, 158, 169 FIRMAGON...... 34, 146 ENSPRYNG ...... 189 eszopiclone...... 93 FIRMAGON (240 MG DOSE) ENSTILAR ...... 212, 220 ethacrynic acid...... 77, 120 ...... 34, 146 entacapone...... 98 ethambutol hcl...... 19 FIRST-LANSOPRAZOLE...... 142 entecavir...... 28 ethosuximide...... 114 FIRST-OMEPRAZOLE...... 142 ENTEREG ...... 139 ethynodiol diac-eth estradiol FIRVANQ...... 21 ENTRESTO ...... 64, 79 ...... 150, 158, 169 flac...... 131 enulose...... 120 etodolac...... 108 FLAGYL...... 15, 18, 137 EPANED...... 64, 65 etodolac er...... 108 FLAREX...... 131 EPCLUSA...... 21, 22 etoposide...... 34 flavoxate hcl...... 222 EPIDIOLEX...... 85 etravirine...... 24 flecainide acetate...... 72 EPIFOAM...... 207, 212 EUCRISA...... 207 FLEXICHAMBER ADULT epinephrine...... 44, 197 euthyrox...... 177 MASK/SMALL...... 116 epitol...... 85, 89 EVAMIST...... 158, 181 FLEXICHAMBER CHILD EPIVIR...... 25 everolimus...... 34, 192 MASK/LARGE...... 116 EPIVIR HBV...... 25 EVOCLIN...... 205 FLEXICHAMBER CHILD eplerenone...... 77, 78, 122 EVOTAZ...... 26, 193 MASK/SMALL...... 116 EQUETRO...... 85, 89 EVRYSDI...... 193 FLOLIPID...... 76 ERGOCAL...... 229 EXELDERM...... 208 FLORIVA...... 182, 229 ergocalciferol...... 229 exemestane...... 34, 146 FLORIVA PLUS...... 182, 223

235 FLOVENT DISKUS...... 143, 201 FORMALDEHYDE...... 119 glimepiride...... 176 FLOVENT HFA ...... 143, 144, 202 FORTISCARE CONTROL ...... 116 glipizide...... 176 FLUAD QUADRIVALENT...... 42 FOSAMAX...... 181 glipizide er...... 176 FLUARIX QUADRIVALENT...... 42 FOSAMAX PLUS D...... 181, 229 glipizide xl...... 176 FLUCELVAX fosamprenavir calcium...... 26 glipizide-metformin hcl.... 147, 176 QUADRIVALENT...... 42 fosfomycin tromethamine...... 31 GLOPERBA...... 179 fluconazole...... 20 fosinopril sodium...... 64, 65 GLUCAGEN HYPOKIT... 163, 178 flucytosine...... 29 fosinopril sodium-hctz...... 65, 124 glucagon emergency kit.. 163, 178 fludrocortisone acetate...... 144 FOSRENOL...... 121, 178 GLUCAGON EMERGENCY FLULAVAL QUADRIVALENT... 43 FRAGMIN...... 59, 60 KIT...... 163, 164, 178 flunisolide...... 131, 144, 201 FREESTYLE LIBRE 14 DAY GLUCOTROL XL...... 176 fluocinolone acetonide.... 131, 212 READER...... 116 GLUTARALDEHYDE...... 119 fluocinolone acetonide body... 212 FREESTYLE LIBRE 14 DAY glyburide...... 176 fluocinolone acetonide scalp...212 SENSOR...... 116 glyburide micronized...... 176 fluocinonide...... 212 FREESTYLE LIBRE 2 glyburide-metformin...... 147, 177 fluocinonide emulsified base...212 READER...... 116 glycopyrrolate...... 45 FLUORIDEX...... 182 FREESTYLE LIBRE 2 glydo...... 207 fluoridex daily renewal...... 182 SENSOR...... 117 GLYNASE...... 177 FLUORIDEX ENHANCED FREESTYLE LIBRE READER 117 GLYXAMBI...... 154, 175 WHITENING...... 182 FREESTYLE LIBRE SENSOR GOLYTELY ...... 137 FLUORIDEX SENSITIVITY SYSTEM...... 117 goodsense nicotine...... 48 RELIEF...... 115, 182 frovatriptan succinate...... 112 GORDOFILM...... 209, 215 fluoritab...... 182 furosemide...... 77, 120, 121 GRALISE...... 82, 85 fluorometholone...... 131 FUZEON...... 23 granisetron hcl...... 135 FLUOROPLEX...... 220 fyavolv...... 158, 169 GRASTEK...... 41 FLUOROURACIL...... 220 FYCOMPA...... 85 griseofulvin microsize...... 16 fluorouracil...... 220 gabapentin...... 82, 85 griseofulvin ultramicrosize...... 16 fluoxetine hcl...... 113 GABITRIL...... 85 guaiatussin ac...... 198, 200 fluphenazine hcl...... 109 GALAFOLD...... 194 guaifenesin ac...... 198, 200 flurandrenolide...... 212 galantamine hydrobromide...... 50 guanfacine hcl...... 71, 99 flurazepam hcl...... 97 galantamine hydrobromide er... 50 guanfacine hcl er...... 99 flurbiprofen...... 108 GALZIN...... 122 GVOKE HYPOPEN 1-PACK flurbiprofen sodium...... 134 GARDASIL 9...... 43 ...... 164, 178 flutamide...... 34 gatifloxacin...... 128 GVOKE HYPOPEN 2-PACK fluticasone propionate GATTEX ...... 139 ...... 164, 178, 179 ...... 131, 144, 201, 212 gavilyte-c...... 137 GVOKE PFS...... 164, 179 FLUTICASONE- gavilyte-g...... 137 GYNAZOLE-1...... 208 SALMETEROL ...... 52, 144 gavilyte-n with flavor pack...... 137 habitrol...... 48 fluvastatin sodium...... 76 GAVRETO...... 34 HAEGARDA...... 184 fluvastatin sodium er...... 76 GELFILM...... 57 hailey 1.5/30...... 150, 158, 169 fluvoxamine maleate...... 113 gemfibrozil...... 76 hailey 24 fe...... 150, 158, 169 fluvoxamine maleate er...... 113 gemmily...... 150, 158, 169 hailey fe 1.5/30...... 150, 159, 169 FLUZONE HIGH-DOSE generlac...... 120 hailey fe 1/20...... 150, 159, 169 QUADRIVALENT...... 43 gengraf...... 185, 189, 192 halcinonide...... 212 FLUZONE QUADRIVALENT.... 43 gentak...... 128 HALCION...... 97 FML...... 131 gentamicin sulfate...... 128, 205 halobetasol propionate...... 212 FML FORTE ...... 131 GENVOYA...... 23, 25 HALOG...... 213 FML LIQUIFILM...... 131 GILENYA...... 189 haloperidol...... 98 FOCALIN...... 110 GILOTRIF...... 34 haloperidol lactate...... 98 folic acid...... 226 GILPHEX TR...... 44, 200 HALUCORT...... 220 fondaparinux sodium...... 54 glatiramer acetate...... 189 HARVONI...... 21, 22 FORANE...... 101 glatopa...... 189 HAVRIX...... 43 formaldehyde...... 119 GLEOSTINE...... 34 heather...... 150, 169

236 hematinic/folic acid...... 60, 226 hydrocodone-acetaminophen INFANRIX...... 42, 43 HEMLIBRA...... 57 ...... 82, 103, 104 INLYTA...... 35 hemocyte-f...... 60, 226 hydrocodone-homatropine 45, 198 INOVA...... 215, 217 HEMOFIL M...... 57 hydrocodone-ibuprofen... 104, 108 INOVA 4/1 ACNE CONTROL heparin lock flush...... 60 hydrocortisone ...... 144, 213 THERAPY...... 215, 217 heparin sodium (porcine)...... 60 hydrocortisone (perianal)...... 213 INOVA 8/2 ACNE CONTROL heparin sodium (porcine) pf...... 60 hydrocortisone ace-pramoxine THERAPY...... 215, 216, 217 heparin sodium lock flush...... 60 ...... 207, 213 INQOVI...... 35 HEPLISAV-B...... 43 hydrocortisone acetate...... 213 INREBIC...... 35 HETLIOZ...... 93 hydrocortisone butyrate ...... 213 INSPIREASE RESERVOIR HIBERIX...... 43 hydrocortisone valerate...... 213 BAGS...... 117 HIPREX...... 31 hydrocortisone-acetic acid INSULIN PEN NEEDLES...... 117 homatropaire...... 134 ...... 131, 133 INSULIN SYRINGES...... 117 HUMALOG...... 174 hydrocortisone-iodoquinol INTELENCE ...... 24 HUMALOG KWIKPEN...... 174 ...... 213, 217 INTRON A ...... 27, 35, 190 HUMALOG MIX 50/50 hydrocort-pramoxine (perianal) introvale...... 150, 159, 169 KWIKPEN...... 174 ...... 207, 213 INVELTYS...... 131 HUMALOG MIX 50/50 VIAL....174 hydromet...... 46, 198 INVIRASE...... 26 HUMALOG MIX 75/25 hydromorphone hcl...... 104 IODINE STRONG...... 200 KWIKPEN...... 174 hydromorphone hcl er...... 104 iodine tincture...... 217 HUMALOG MIX 75/25 VIAL....174 hydroxychloroquine sulfate IOPIDINE...... 133 HUMALOG U-100 JUNIOR ...... 17, 185, 189 IPOL...... 43 KWIKPEN...... 175 hydroxyurea ...... 35 ipratropium bromide...... 46, 197 HUMATE-P...... 57 hydroxyzine hcl ...... 12, 13, 93 ipratropium-albuterol... 46, 52, 197 HUMIRA...... 140, 185, 189 hydroxyzine pamoate ....12, 13, 93 irbesartan...... 63, 64 HUMIRA PEDIATRIC HYOPHEN...... 31, 46, 82 irbesartan-hydrochlorothiazide CROHNS START....139, 185, 189 hyoscyamine sulfate...... 46 ...... 64, 124 HUMIRA PEN...... 139, 185, 189 hyoscyamine sulfate er...... 46 IRESSA...... 35 HUMIRA PEN-CD/UC/HS hyoscyamine sulfate sl ...... 46 ISENTRESS...... 23 STARTER ...... 139, 185, 189 hyosyne...... 46 ISENTRESS HD...... 23 HUMIRA PEN-PEDIATRIC UC HYPOCYN...... 220 isibloom...... 150, 159, 169 START...... 139, 185, 189 ibandronate sodium...... 181 isoflurane...... 101 HUMIRA PEN-PS/UV/ADOL IBRANCE...... 35 isoniazid...... 19 HS START...... 139, 185, 189 ibuprofen...... 92, 108 ISOPTO ATROPINE...... 134 HUMIRA PEN-PSOR/UVEIT iclevia...... 150, 159, 169 ISOPTO CARPINE...... 134 STARTER ...... 140, 185, 189 ICLUSIG...... 35 ISORDIL TITRADOSE...... 77 HUMULIN 70/30 KWIKPEN IDELVION...... 57 isosorbide dinitrate...... 77 ...... 165, 175 IDHIFA...... 35 isosorbide mononitrate...... 77 HUMULIN 70/30 VIAL.....165, 175 imatinib mesylate...... 35 isosorbide mononitrate er...... 77 HUMULIN N KWIKPEN...... 165 IMBRUVICA...... 35 isotretinoin...... 220 HUMULIN N VIAL...... 165 IMCIVREE...... 84 isoxsuprine hcl...... 80 HUMULIN R U-500 KWIKPEN 175 imipramine hcl...... 114 isradipine...... 74, 75 HUMULIN R U-500 VIAL...... 175 imipramine pamoate...... 114 ISTALOL...... 130 HUMULIN R VIAL...... 175 imiquimod...... 220 ISTURISA...... 194 HYCAMTIN...... 34, 35 IMITREX...... 112 itraconazole...... 20 hydralazine hcl...... 75 IMPAVIDO...... 18 ivermectin...... 16, 218 HYDREA...... 35 INBRIJA...... 100 jaimiess...... 150, 159, 169 HYDRO 40...... 215 incassia...... 150, 169 JAKAFI...... 36 hydrochlorothiazide...... 79, 124 INCRELEX...... 176 JANSSEN COVID-19 hydrocodone bitartrate er...... 103 indapamide...... 79, 125 VACCINE...... 43 hydrocodone polst-chlorphen INDOCIN...... 108, 179 jantoven...... 54 polst er susp...... 13, 198 indomethacin...... 108, 180 JARDIANCE...... 175 indomethacin er...... 108, 180 jasmiel...... 150, 159, 169

237 jencycla...... 150, 169 KOGENATE FS...... 57 leflunomide...... 186, 190, 192 JENTADUETO ...... 147, 154 KOMBIGLYZE XR...... 147, 155 LENVIMA...... 36 JENTADUETO XR...... 147, 155 KOSELUGO...... 36 lessina...... 151, 159, 170 jinteli...... 159, 169 KOVALTRY...... 58 letrozole...... 36, 146 JIVI...... 57 K-PHOS...... 122 leucovorin calcium...... 179, 226 jolessa...... 150, 159, 169 K-PHOS NO 2...... 119 LEUKINE...... 55 JUBLIA...... 208 K-PHOS-NEUTRAL...... 122 leuprolide acetate...... 36, 164 juleber...... 150, 159, 169 k-prime...... 122 levalbuterol hcl...... 52, 202 JULUCA...... 23, 24 KRINTAFEL...... 17 LEVALBUTEROL HFA ...... 52, 202 junel 1.5/30...... 150, 159, 169 KRISTALOSE...... 120 LEVBID...... 46 junel 1/20...... 150, 159, 169 K-TAB...... 122 levetiracetam...... 86 junel fe 1.5/30...... 150, 159, 169 kurvelo...... 150, 159, 170 levetiracetam er...... 86 junel fe 1/20...... 150, 159, 169 KYNMOBI...... 102 levobunolol hcl...... 130 junel fe 24...... 150, 159, 169 KYNMOBI TITRATION KIT .....102 levocarnitine...... 194 JYNARQUE...... 125 labetalol hcl. 49, 51, 63, 66, 67, 73 levocarnitine sf...... 194 kaitlib fe...... 150, 159, 169 LACRISERT...... 133 levocetirizine dihydrochloride....14 KALETRA...... 26 lactulose...... 120 levofloxacin...... 19, 29, 128 kalliga...... 150, 159, 169 lactulose encephalopathy...... 120 levonest...... 151, 159, 170 KALYDECO...... 199 LAMICTAL...... 86, 89 levonorgest-eth est & eth est KAPSPARGO SPRINKLE LAMICTAL ODT ...... 86, 89 ...... 151, 159, 170 ...... 52, 66, 67, 72 LAMICTAL STARTER ...... 86, 89 levonorgest-eth estrad 91-day kariva...... 150, 159, 169 LAMICTAL XR ...... 86, 89 ...... 151, 159, 170 KATERZIA...... 75, 80 lamivudine...... 25 levonorgestrel...... 151, 170 KAZANO...... 147, 155 lamivudine-zidovudine...... 25 levonorgestrel-ethinyl estrad KEFLEX...... 14 lamotrigine...... 86, 90 ...... 151, 159, 170 kelnor 1/35...... 150, 159, 169 lamotrigine er...... 86, 89 levonorg-eth estrad triphasic kelnor 1/50...... 150, 159, 169 lamotrigine starter kit-blue...86, 90 ...... 151, 160, 170 KEPPRA...... 85 lamotrigine starter kit-green 86, 90 levora 0.15/30 (28)..151, 160, 170 KEPPRA XR...... 86 lamotrigine starter kit-orange levorphanol tartrate...... 104 KERALAC...... 216 ...... 86, 90 levo-t...... 177 KERYDIN...... 218 LAMPIT...... 18 levothyroxine sodium...... 177 KESIMPTA...... 190 LANOXIN...... 66, 71 levoxyl...... 177 ketoconazole...... 20, 208 lansoprazole...... 142 LEVSIN...... 46 ketodan...... 208 lanthanum carbonate...... 121, 179 LEVSIN/SL...... 46 KETONE TEST ...... 119 LANTUS SOLOSTAR ...... 165 LEVULAN KERASTICK...... 220 KETOROLAC LANTUS U-100 VIAL...... 165 LEXIVA...... 26 TROMETHAMINE ...... 108 lapatinib ditosylate...... 36 LIALDA...... 136 ketorolac tromethamine.. 108, 134 larin 1.5/30...... 150, 159, 170 lidocaine...... 207 KETOSTIX...... 119 larin 1/20...... 150, 159, 170 lidocaine hcl...... 207 KEVEYIS...... 182 larin 24 fe...... 150, 159, 170 lidocaine hcl urethral/mucosal.207 KEVZARA...... 185, 186 larin fe 1.5/30...... 150, 159, 170 lidocaine viscous hcl...... 134 KINERET...... 186, 190 larin fe 1/20...... 151, 159, 170 lidocaine-prilocaine...... 207 KISQALI...... 36 larissia...... 151, 159, 170 LIDOPIN...... 207 KISQALI FEMARA...... 36, 146 LASIX...... 77, 121 lillow...... 151, 160, 170 KLARON...... 205 LASTACAFT...... 13, 127 lindane...... 218 klor-con...... 122 latanoprost...... 134 linezolid...... 29 klor-con 10...... 122 LATUDA...... 94 LINZESS...... 140 klor-con m10...... 122 layolis fe...... 151, 159, 170 liothyronine sodium...... 177 klor-con m15...... 122 LAZANDA...... 104 lisinopril...... 64, 65 klor-con m20...... 122 L-CYSTINE...... 120 lisinopril-hydrochlorothiazide klor-con/ef...... 122 LEDIPASVIR-SOFOSBUVIR ...... 65, 124 KOATE...... 57 ...... 21, 22 lithium carbonate...... 90 KOATE-DVI...... 57 leena...... 151, 159, 170 lithium carbonate er...... 90

238 LITHOBID...... 90 MARINOL...... 136 methimazole...... 147 LITHOSTAT...... 120 marlissa...... 151, 160, 171 METHITEST ...... 145 LO LOESTRIN FE ...151, 160, 170 MARPLAN...... 102 methocarbamol...... 48 LOESTRIN 1.5/30 (21) MATULANE ...... 36 methotrexate..... 37, 186, 190, 192 ...... 151, 160, 170 matzim la...... 69, 70, 74, 80 methotrexate sodium LOESTRIN 1/20 (21) MAVENCLAD ...... 192 ...... 37, 186, 190, 192 ...... 151, 160, 170 MAVYRET...... 22 methotrexate sodium (pf) LOESTRIN FE 1.5/30 MAXIDEX...... 132 ...... 37, 186, 190, 192 ...... 151, 160, 170 MAXITROL...... 128, 132 methoxsalen rapid...... 218 lojaimiess...... 151, 160, 170 maxi-tuss ac...... 198, 200 methscopolamine bromide...... 46 LOKELMA ...... 121 MAXZIDE...... 122, 125 methyl salicylate...... 209 LOMAIRA...... 81 MAXZIDE-25...... 122, 125 methyldopa...... 44, 71 LOMOTIL...... 46, 135 MAYZENT...... 190 methylergonovine maleate...... 197 LONSURF...... 36 me/naphos/mb/hyo1... 31, 46, 194 METHYLIN...... 110 LOPID...... 76 meclofenamate sodium...... 108 methylphenidate hcl...... 110 lopinavir-ritonavir...... 26 MEDROL...... 144 methylphenidate hcl er...... 110 LOPRESSOR...... 52, 66, 67, 73 medroxyprogesterone acetate methylphenidate hcl er (cd).....110 LOPROX...... 215, 220 ...... 151, 171 methylphenidate hcl er (la)...... 110 lorazepam...... 96, 97 mefenamic acid...... 108 methylprednisolone...... 144 lorazepam intensol...... 96, 97 mefloquine hcl...... 17 methyltestosterone...... 145 LORBRENA ...... 36 megestrol acetate...... 36, 171 metoclopramide hcl...... 141 LORTAB ...... 83, 104 MEKINIST...... 36, 37 metolazone...... 79, 125 loryna...... 151, 160, 170 MEKTOVI...... 37 metoprolol succinate er.52, 67, 73 losartan potassium...... 63, 64 meloxicam...... 108 metoprolol tartrate...... 52, 67, 73 losartan potassium-hctz.... 64, 124 melphalan...... 37 metoprolol-hydrochlorothiazide LOSEASONIQUE... 151, 160, 170 memantine hcl...... 99 ...... 67, 125 LOTEMAX ...... 131 MENACTRA ...... 43 METROCREAM...... 205 LOTEMAX SM ...... 132 MENEST...... 160, 181 METROLOTION ...... 205 LOTENSIN...... 64, 65 MENOSTAR ...... 160, 181 metronidazole..... 15, 18, 137, 205 LOTENSIN HCT ...... 65, 125 MENQUADFI...... 43 metyrosine...... 194 loteprednol etabonate...... 132 MENTAX ...... 209 mexiletine hcl...... 72 lovastatin...... 76 MENVEO...... 43 MIACALCIN...... 146, 181 low-ogestrel...... 151, 160, 170 meperidine hcl...... 104 mibelas 24 fe...... 152, 160, 171 loxapine succinate...... 92 MEPHYTON...... 179, 229 miconazole 3...... 208 lo-zumandimine...... 151, 160, 170 meprobamate...... 93 microgestin 1.5/30...152, 160, 171 LUBIPROSTONE...... 140 mercaptopurine...... 37, 192 microgestin 1/20...... 152, 160, 171 LUGOLS STRONG IODINE....217 merzee...... 152, 160, 171 microgestin 24 fe.....152, 160, 171 LUMAKRAS...... 36 mesalamine...... 136 microgestin fe 1.5/30 LUMIGAN...... 134 mesalamine-cleanser...... 136 ...... 152, 160, 171 LUPKYNIS...... 192 MESNEX...... 196 microgestin fe 1/20..152, 160, 171 lutera...... 151, 160, 170 MESTINON...... 50 MICROLET NEXT LANCING lyleq...... 151, 170 metaxalone...... 48 DEVICE...... 117 LYNPARZA ...... 36 metformin hcl...... 147 midazolam hcl...... 97 LYRICA...... 86, 101 metformin hcl er...... 147 midodrine hcl...... 44 LYSTEDA...... 58 methadone hcl...... 104 MIGERGOT...... 50, 92, 110 LYUMJEV KWIKPEN...... 175 methadone hcl intensol...... 104 miglitol...... 145 LYUMJEV VIAL...... 175 methadose...... 104 miglustat...... 194 lyza...... 151, 171 methadose sugar-free...... 104 mili...... 152, 160, 171 MACROBID...... 31 methamphetamine hcl...... 81 MILLIPRED...... 144 MACRODANTIN...... 31 methazolamide...... 71, 130 mimvey...... 160, 171 mafenide acetate...... 217 methenamine hippurate...... 31 mineral oil heavy...... 138 MALARONE ...... 17 methenamine mandelate...... 31 MINIPRESS...... 49, 63 malathion...... 218 methergine...... 197 minocycline hcl...... 17, 30

239 minoxidil...... 76 NAFRINSE DAILY NEXLIZET...... 66, 71 MIRAPEX...... 102 ACIDULATED...... 115, 182 NEXTSTELLIS ...... 152, 161, 171 MIRCETTE ...... 152, 160, 171 NAFRINSE DAILY/NEUTRAL .182 niacin er (antihyperlipidemic).... 66 mirtazapine...... 88 nafrinse drops...... 182 NIASPAN...... 66 MIRVASO...... 220 NAFRINSE WEEKLY...... 182 nicardipine hcl...... 75, 80 misoprostol...... 141 naloxone hcl...... 106, 179 NICORETTE ...... 48 MITIGARE...... 180 naltrexone hcl...... 106, 178, 179 nicotine polacrilex...... 48 MITOSOL...... 128 NAMENDA TITRATION PAK ....99 nicotine polacrilex mini...... 48 M-M-R II...... 43 NAMZARIC...... 50, 99 nicotine step 1...... 48 M-NATAL PLUS ...... 60, 223, 226 naproxen...... 92, 108, 180 nicotine step 2...... 48 MOBIC...... 108 naproxen sodium...... 92, 108, 180 nicotine step 3...... 48 modafinil...... 115 naratriptan hcl...... 112 NICOTROL...... 48 moexipril hcl...... 64, 65 NARCAN...... 106 NICOTROL NS ...... 48 molindone hcl...... 92 NARDIL...... 102 nifedipine...... 75, 80 mometasone furoate...... 213 NASCOBAL...... 62, 226 nifedipine er...... 75, 80 mondoxyne nl...... 17, 30 NATACYN...... 129 nifedipine er osmotic release mono-linyah...... 152, 160, 171 NATAZIA...... 152, 160, 171 ...... 75, 80 MONONINE ...... 58 nateglinide...... 165 nikki...... 152, 161, 171 monsels ferric subsulfate ...... 58 NATPARA ...... 166, 180 NILANDRON...... 37 montelukast sodium...... 200, 201 NATURE-THROID...... 177 nilutamide...... 37 MONUROL...... 31 NAYZILAM...... 96 nimodipine...... 75, 80 morgidox...... 17, 31 NEBUPENT ...... 18 NINLARO...... 37 morphine sulfate...... 105 necon 0.5/35 (28)....152, 161, 171 nisoldipine er...... 75 morphine sulfate (concentrate)104 nefazodone hcl...... 113 nitazoxanide...... 18 morphine sulfate er...... 105 neomycin sulfate...... 15 NITRO-BID...... 77 morphine sulfate er beads...... 104 neomycin-bacitracin zn- NITRO-DUR...... 78 MOTEGRITY...... 140 polymyx...... 128 nitrofurantoin...... 31 MOVIPREP...... 138, 228 neomycin-polymyxin-dexameth nitrofurantoin macrocrystal...... 31 MOXEZA...... 128 ...... 128, 132 nitrofurantoin monohydrate moxifloxacin hcl...... 19, 29, 128 neomycin-polymyxin- macrocrystals ...... 31 moxifloxacin hcl (2x day) ...... 128 gramicidin...... 128 nitroglycerin...... 78 MOZOBIL...... 55 neomycin-polymyxin-hc .. 129, 132 NITROSTAT ...... 78 MS CONTIN ...... 105 NEONATAL + DHA NITRO-TIME...... 78 MUCOSITISRX...... 133 ...... 60, 122, 194, 223, 226 nizatidine...... 13, 140 MULPLETA ...... 55 NEONATAL 19 ...... 223 NOCDURNA...... 58, 166 MULTAQ ...... 73 NEONATAL COMPLETE nolix...... 213 multi-vit/iron/fluoride..60, 182, 223 ...... 60, 223, 226 nora-be...... 152, 171 multivitamin/fluoride...... 182, 223 NEONATAL FE ...... 60, 223, 226 norethin ace-eth estrad-fe multi-vitamin/fluoride...... 182, 223 NEONATAL PLUS .... 60, 223, 226 ...... 152, 161, 171 multi-vitamin/fluoride/iron neo-polycin...... 129 norethindrone...... 152, 171 ...... 60, 182, 223 neo-polycin hc...... 129, 132 norethindrone acetate...... 171 mupirocin...... 205 NERLYNX ...... 37 norethindrone acet-ethinyl est mupirocin calcium...... 205 NESINA...... 155 ...... 152, 161, 171 MYAMBUTOL ...... 19 NESTABS ...... 60, 223, 226 norethindrone-eth estradiol MYCOBUTIN...... 19, 30 neuac...... 205, 217 ...... 161, 172 mycophenolate mofetil...... 192 NEULASTA ...... 55 norethin-eth estradiol-fe mycophenolate sodium...... 192 NEUPRO...... 102 ...... 152, 161, 172 myorisan...... 220 NEURONTIN...... 83, 86, 87 norgestimate-eth estradiol MYSOLINE...... 95 NEVANAC...... 134 ...... 152, 161, 172 MYTESI...... 135 nevirapine...... 24 norgestimate-ethinyl estradiol nabumetone...... 108 NEXAVAR...... 37 triphasic...... 152, 161, 172 nadolol...... 49, 67, 68 NEXIUM...... 142 norlyda...... 152, 172 nafrinse...... 182 NEXLETOL ...... 66 norlyroc...... 152, 172

240 NORPACE...... 72 ODOMZO...... 37 ORGOVYX...... 37, 146 NORPACE CR...... 72 OFEV...... 198 ORIAHNN...... 146, 161, 172 NORPRAMIN...... 114 ofloxacin...... 29, 129 ORILISSA...... 146 nortrel 0.5/35 (28)... 152, 161, 172 olanzapine...... 90, 94 ORKAMBI...... 199 nortrel 1/35 (21)...... 152, 161, 172 olanzapine-fluoxetine hcl.. 94, 113 orphenadrine citrate er...... 53, 84 nortrel 1/35 (28)...... 152, 161, 172 olmesartan medoxomil...... 63, 64 orphenadrine-asa-caffeine nortrel 7/7/7...... 152, 161, 172 olmesartan medoxomil-hctz ...... 53, 110, 111 nortriptyline hcl...... 114 ...... 64, 125 orsythia...... 153, 161, 172 NORVIR...... 26 olopatadine hcl...... 13, 127 oscimin...... 46 NOURIANZ...... 99 OLUMIANT...... 186 oscimin sr...... 46 NOVOEIGHT...... 58 OMECLAMOX-PAK.... 16, 28, 142 oseltamivir phosphate...... 27 NOVOFINE AUTOCOVER omega-3-acid ethyl esters...... 66 OSENI...... 155, 177 PEN NEEDLE ...... 117 omeprazole...... 142 OSMOLEX ER...... 15, 81 NOVOFINE PEN NEEDLE ..... 117 OMEPRAZOLE+SYRSPEND OSPHENA...... 155 NOVOFINE PLUS PEN SF ALKA...... 142 OTEZLA...... 186, 190, 220 NEEDLE ...... 117 ondansetron hcl...... 135 OVACE PLUS...... 205, 206 NOVOPEN ECHO...... 117 ondansetron odt...... 135 OVACE PLUS WASH...... 206 NOVOSEVEN RT...... 58 ONE VITE WOMENS PLUS OVACE WASH...... 206 NOVOTWIST PEN NEEDLE .. 117 ...... 60, 223, 226 OVIDE...... 218 NOXAFIL...... 20 ONETOUCH DELICA oxandrolone...... 146 np thyroid...... 177 LANCING DEVICE...... 117 oxaprozin...... 108 NUBEQA...... 37 ONETOUCH DELICA PLUS oxazepam...... 98 NUCALA...... 198 LANCING DEVICE...... 117 OXBRYTA...... 54 NUCORT...... 213 ONETOUCH ULTRA ...... 118 oxcarbazepine...... 87 NUCYNTA ...... 105 ONETOUCH ULTRA 2...... 117 OXERVATE...... 133 NUCYNTA ER ...... 105 ONETOUCH ULTRA MINI ...... 117 oxiconazole nitrate...... 208 NUEDEXTA...... 99 ONETOUCH VERIO117, 118, 119 OXISTAT...... 208 NULEV...... 46 ONETOUCH VERIO FLEX oxybutynin chloride...... 222 NULYTELY LEMON-LIME ...... 138 SYSTEM KIT W/DEVICE...... 117 oxybutynin chloride er...... 222 NUPLAZID...... 94 ONETOUCH VERIO IQ oxycodone hcl ...... 105 NUTRIDOX...... 31, 194, 229 SYSTEM...... 118 oxycodone-acetaminophen NUTROPIN AQ NUSPIN 10 ONETOUCH VERIO ...... 83, 105 ...... 166, 176 REFLECT...... 118 oxymorphone hcl...... 105 NUTROPIN AQ NUSPIN 20 ONETOUCH VERIO SYNC oxymorphone hcl er...... 105 ...... 166, 176 SYSTEM KIT W/DEVICE...... 118 OZEMPIC...... 164 NUTROPIN AQ NUSPIN 5 ONEVITE...... 123, 223, 226 OZOBAX...... 49 ...... 166, 176 ONFI...... 96, 98 PACERONE...... 73 NUVAIL...... 220 ONGLYZA...... 155 PALFORZIA...... 41 NUVARING...... 153, 161, 172 ONUREG...... 37 paliperidone er...... 94 NUWIQ...... 58 opium...... 135 PALYNZIQ...... 126 NUZYRA...... 15 OPSUMIT...... 203 PANCREAZE...... 126, 138 nyamyc...... 218 ORACIT...... 119 PANDEL...... 213 nylia 7/7/7...... 153, 161, 172 ORALAIR...... 41 PANRETIN...... 221 NYMALIZE ...... 75, 80 ORALAIR ADULT STARTER pantoprazole sodium...... 142 nymyo...... 153, 161, 172 PACK...... 41 paricalcitol...... 229 nystatin...... 29, 218 ORALAIR CHILDRENS PARNATE...... 102 nystop...... 218 STARTER PACK ...... 41 paromomycin sulfate...... 15 OCALIVA...... 140 oralone...... 213 paroxetine hcl...... 113 ocella...... 153, 161, 172 ORAPRED ODT...... 144 paroxetine hcl er...... 113 octreotide acetate...... 140, 175 ORENCIA...... 186, 190 PASER...... 19 OCUFLOX...... 129 ORENCIA CLICKJECT... 186, 190 PATANASE...... 13, 127 ODACTRA...... 41 ORENITRAM...... 203 PAXIL...... 113 ODEFSEY...... 24, 25 ORFADIN...... 194 PEDIAPRED...... 144

241 PEDVAX HIB...... 43 pindolol...... 49, 67, 68, 73 pregabalin...... 87, 101 peg 3350-kcl-na bicarb-nacl ....138 pioglitazone hcl...... 177 PREMARIN...... 162, 181 peg-3350/electrolytes...... 138 pioglitazone hcl-glimepiride.....177 PREMESISRX 123, 194, 224, 227 peg-3350/electrolytes/ascorbat pioglitazone hcl-metformin hcl premium lidocaine...... 207 ...... 138, 228 ...... 147, 177 PREMPHASE...... 162, 172 PEGASYS...... 27 PIQRAY...... 37 PREMPRO...... 162, 172 peg-kcl-nacl-nasulf-na asc-c pirmella 1/35...... 153, 161, 172 PRENAISSANCE ...... 138, 228 pirmella 7/7/7...... 153, 161, 172 ...... 61, 138, 194, 224, 227 peg-prep...... 138 piroxicam...... 108 prenatal...... 61, 224, 227 PEMAZYRE...... 37 PLAN B ONE-STEP ...... 153, 172 prenatal plus iron...... 61, 224, 227 penicillamine...... 142, 186 PLEGRIDY...... 190, 191 prenatal vitamin plus low iron penicillin v potassium...... 27 PLEGRIDY STARTER PACK. 190 ...... 61, 224, 227 pentamidine isethionate...... 18 PLENVU...... 138, 228 PRENATE...... 123, 224, 227 pentazocine-naloxone hcl106, 107 PNEUMOVAX 23...... 44 PRENATE DHA pentoxifylline er...... 56 podocon...... 221 ...... 61, 123, 194, 224, 227 PERFOROMIST...... 52, 202 podofilox...... 221 PRENATE ELITE ...... 61, 224, 227 PERIDEX...... 133, 217 polycin...... 129 PRENATE ENHANCE perindopril erbumine...... 64, 65 polymyxin b-trimethoprim...... 129 ...... 61, 123, 194, 224, 227 periogard...... 133, 217 POLYTRIM...... 129 PRENATE ESSENTIAL permethrin...... 218 POLY-VI-FLOR...... 182, 183, 223 ...... 61, 123, 194, 224, 227 perphenazine...... 109 POLY-VI-FLOR/IRON PRENATE MINI perphenazine-amitriptyline ...... 60, 61, 183, 224 ...... 61, 123, 194, 224, 227 ...... 109, 114 POMALYST...... 37, 191 PRENATE PIXIE PERTZYE...... 126, 139 portia-28...... 153, 161, 172 ...... 61, 123, 194, 224, 227 PFIZER-BIONTECH COVID- posaconazole...... 20 PRENATE RESTORE 19 VACC...... 43 POTABA...... 226 ...... 61, 123, 194, 224, 227 phenazo...... 207 potassium chloride...... 123 PRENATVITE COMPLETE phenazopyridine hcl...... 207 potassium chloride crys er ...... 123 ...... 61, 123, 224, 227 phendimetrazine tartrate...... 81 potassium chloride er...... 123 PRENATVITE PLUS phendimetrazine tartrate er...... 81 potassium citrate er...... 119 ...... 61, 123, 224, 227 phenelzine sulfate...... 102 potassium citrate-citric acid .....119 PRENATVITE RX phenobarbital...... 95, 96 PRADAXA...... 55 ...... 61, 123, 224, 227 phenoxybenzamine hcl...... 50, 76 pramipexole dihydrochloride... 102 PREPIDIL...... 197 phentermine hcl...... 81 pramosone...... 207, 213 preplus...... 61, 224, 227 phenylephrine hcl...... 134, 135 PRAMOSONE...... 207, 213 PRETAB...... 61, 224, 227 PHENYTEK...... 72, 101 PRAMOTIC...... 133, 134 PRETOMANID...... 19 phenytoin...... 72, 101 pramox...... 207 prevalite...... 68 phenytoin infatabs...... 72, 101 prasugrel hcl...... 62 PREVIDENT...... 183 phenytoin sodium extended pravastatin sodium...... 76 PREVIDENT 5000 BOOSTER ...... 72, 101 praziquantel...... 16 PLUS...... 183 PHEXXI...... 196 prazosin hcl...... 49, 63 PREVIDENT 5000 DRY philith...... 153, 161, 172 PRECOSE...... 145 MOUTH...... 183 PHOSLYRA...... 121, 123 PRED MILD...... 132 PREVIDENT 5000 ENAMEL PHOSPHA 250 NEUTRAL...... 123 PRED-G...... 129, 132 PROTECT...... 115, 183 PHOSPHASAL...... 31, 46, 83, 194 PRED-G S.O.P...... 129, 132 PREVIDENT 5000 ORTHO phosphorous...... 123 prednicarbate...... 213 DEFENSE...... 183 phospho-trin 250 neutral...... 123 prednisolone...... 144 PREVIDENT 5000 PLUS...... 183 phytonadione...... 179, 229 prednisolone acetate...... 132 PREVIDENT 5000 SENSITIVE PIFELTRO...... 24 prednisolone sodium ...... 115, 183 pilocarpine hcl...... 50, 134 phosphate...... 132, 144 previfem...... 153, 162, 172 pimecrolimus...... 192, 221 prednisone...... 144 PREVNAR 13...... 44 pimozide...... 92 prednisone intensol...... 144 PREVYMIS...... 19 pimtrea...... 153, 161, 172 PREFEST...... 161, 172 PREZCOBIX...... 26, 194

242 PREZISTA...... 26 PYRIDIUM...... 208 repaglinide...... 165 PRIFTIN...... 19, 30 pyridostigmine bromide...... 50 REPATHA...... 78 PRIMACARE.....61, 194, 224, 227 pyridostigmine bromide er...... 50 REPATHA PUSHTRONEX primaquine phosphate...... 17 pyrimethamine...... 17 SYSTEM...... 78 primidone...... 95 PYROGALLIC ACID197, 216, 221 REPATHA SURECLICK...... 78 PRIMSOL...... 31 QBRELIS...... 65 RESTASIS...... 133 PRINIVIL...... 64, 65 QINLOCK...... 38 RESTORIL...... 98 probenecid...... 125, 180 QSYMIA...... 84 RETACRIT...... 53, 56 PROCENTRA ...... 81 QUALAQUIN...... 17 RETEVMO...... 38 prochlorperazine...... 109, 136 QUESTRAN...... 68 RETROVIR...... 25 prochlorperazine maleate109, 136 QUESTRAN LIGHT...... 68 REVLIMID...... 38, 191 PROCTOFOAM HC...... 208, 213 quetiapine fumarate...... 90, 94 REXULTI...... 94 procto-med hc...... 214 quetiapine fumarate er...... 90, 94 REYATAZ...... 26 procto-pak...... 214 QUFLORA PEDIATRIC.. 183, 224 REYVOW...... 112 proctozone-hc...... 214 quinapril hcl...... 64, 65 RHOFADE...... 221 PROCYSBI...... 195 quinapril-hydrochlorothiazide RHOPRESSA...... 135 PROFILNINE...... 58 ...... 65, 125 ribavirin...... 28 progesterone...... 172 quinidine gluconate er...... 17, 72 RIDAURA...... 142, 187, 191 PROGRAF...... 192, 193 quinidine sulfate...... 17, 72 rifabutin...... 19, 30 PROMACTA...... 55, 56 quinine sulfate...... 17 rifampin...... 19, 30 promethazine hcl rabeprazole sodium...... 142 RILUTEK...... 99 ...... 12, 13, 93, 136, 200 RADIOGARDASE...... 121, 179 riluzole...... 99 promethazine vc...... 13, 45 RAGWITEK...... 41 rimantadine hcl...... 15 promethazine vc/codeine raloxifene hcl...... 155, 181 RINVOQ...... 187 ...... 13, 45, 198 ramelteon...... 93 risedronate sodium...... 181 promethazine-codeine...... 13, 198 ramipril...... 64, 65 risperidone...... 90, 94 promethazine-dm...... 13, 199 ranolazine er...... 71 RITALIN...... 110 promethazine-phenyleph- RAPAMUNE...... 193 ritonavir...... 26 codeine...... 13, 45, 199 rasagiline mesylate...... 102 rivastigmine...... 50 promethazine-phenylephrine RASUVO...... 186, 187 rivastigmine tartrate...... 50 ...... 13, 45 RAVICTI...... 120 rivelsa...... 153, 162, 173 promethegan.12, 13, 93, 136, 200 RAZADYNE ER...... 50 RIXUBIS...... 58 PROMISEB...... 216 REBIF...... 191 rizatriptan benzoate...... 112 propafenone hcl...... 72 REBIF REBIDOSE...... 191 ROCALTROL...... 229 propafenone hcl er...... 72 REBIF REBIDOSE ROCKLATAN...... 134, 135 proparacaine hcl...... 134 TITRATION PACK...... 191 ropinirole hcl...... 103 propranolol hcl.. 49, 67, 68, 73, 92 REBIF TITRATION PACK...... 191 rosadan...... 206 propranolol hcl er reclipsen...... 153, 162, 173 rosuvastatin calcium...... 76 ...... 49, 67, 68, 73, 92 RECOMBINATE ...... 58 ROWASA...... 137 propylthiouracil...... 147 RECOMBIVAX HB...... 44 roweepra...... 87 PROSCAR...... 178 RECOTHROM...... 58 ROZLYTREK...... 38 PROSTIN E2...... 197 RECOTHROM SPRAY KIT...... 58 RUBRACA...... 38 protriptyline hcl...... 114 RECTIV...... 221 RUCONEST...... 184 PROVERA...... 173 REGLAN...... 141 rufinamide...... 87 pseudoephedrine-bromphen- REGRANEX...... 221 RUKOBIA...... 23 dm...... 13, 44, 199 RELENZA DISKHALER...... 27 RUZURGI...... 195 PSORCON...... 214 RELISTOR...... 106, 140 RYBELSUS...... 164 PULMICORT FLEXHALER RELNATE DHA .61, 195, 224, 227 RYDAPT...... 38 ...... 144, 202 REMERON...... 88 SABRIL...... 87 PULMOZYME...... 126, 201 REMERON SOLTAB ...... 88 SALAGEN...... 50 PURIXAN...... 37, 193 REMIGEN...... 221 salicylic acid...... 216 PYLERA...... 16, 18, 31, 136, 137 RENAGEL...... 121, 179 salimez...... 216 pyrazinamide...... 19 RENVELA...... 121, 179 salsalate...... 111

243 SALVAX DUO PLUS...... 209, 216 sodium fluoride...... 183, 184 STRENSIQ...... 126 SAMSCA...... 125, 126 sodium fluoride 5000 enamel STRIBILD...... 23, 25, 195 SANDIMMUNE ...... 187, 191, 193 ...... 115, 183 STRIVERDI RESPIMAT... 52, 202 SANTYL ...... 126, 221 sodium fluoride 5000 plus...... 183 STROMECTOL ...... 16 SAPHRIS...... 90, 95 sodium fluoride 5000 ppm...... 183 SUBOXONE...... 106, 107 sapropterin dihydrochloride.....195 sodium fluoride 5000 sensitive subvenite...... 87, 91 SAVAYSA...... 54 ...... 115, 183 subvenite starter kit-blue.....87, 91 SAVELLA...... 101, 111 sodium phenylbutyrate...... 120 subvenite starter kit-green .. 87, 91 SAVELLA TITRATION PACK sodium polystyrene sulfonate subvenite starter kit-orange 87, 91 ...... 101, 111 ...... 121, 179 SUCRAID...... 126 SAXENDA...... 165 sodium sulfacetamide...... 206 sucralfate...... 141 SCALACORT DK...... 214, 216 sodium sulfacetamide wash....206 SULAR...... 75 scopolamine...... 46, 136 SODIUM SULFACETAMIDE- SULCONAZOLE NITRATE .....208 SELECT-OB...... 61, 225, 227 BAKUCHIOL...... 195, 206 sulfacetamide sodium..... 129, 206 selegiline hcl...... 102 SOFOSBUVIR-VELPATASVIR sulfacetamide sodium (acne).. 206 selenium sulfide...... 216, 217 ...... 21, 22 sulfacetamide sodium-sulfur SELZENTRY ...... 23 solifenacin succinate...... 222 ...... 206, 216 SEREVENT DISKUS...... 52, 202 SOLIQUA...... 165 sulfacetamide sod-sulfur wash SEROSTIM...... 166, 176 SOLOSEC...... 18 ...... 206, 216 sertraline hcl...... 113 SOMATULINE DEPOT...... 176 sulfacetamide-prednisolone setlakin...... 153, 162, 173 SOMAVERT...... 176 ...... 129, 132 sevelamer carbonate...... 121, 179 SOOLANTRA...... 218 sulfacetamide-sulfur in urea sevelamer hcl ...... 121, 179 sotalol hcl...... 49, 67, 68, 73 ...... 206, 216 sevoflurane...... 101 sotalol hcl (af)...... 49, 67, 68, 73 sulfadiazine...... 30 sf...... 183 SOTYLIZE...... 49, 67, 68, 73 sulfamethoxazole-trimethoprim sf 5000 plus...... 183 SOVALDI...... 21, 22 ...... 18, 30, 31 SFROWASA...... 137 spinosad...... 218 sulfamez wash...... 206, 216 sharobel...... 153, 173 SPIRIVA HANDIHALER....46, 197 SULFAMYLON...... 217 SHARPS CONTAINER...... 118 SPIRIVA RESPIMAT...... 47, 198 sulfasalazine..... 30, 137, 187, 191 SHINGRIX...... 44 spironolactone...... 77, 78, 122 sulfatrim pediatric...... 18, 30, 31 SIGNIFOR...... 176 spironolactone-hctz...... 77, 125 SULFURATED LIME...... 218 sildenafil citrate...... 78, 203, 222 SPORANOX...... 20 sulindac...... 108 silodosin...... 51 SPORANOX PULSEPAK...... 20 sumatriptan...... 112 SILVADENE...... 217 SPRAVATO (56 MG DOSE)..... 88 sumatriptan succinate...... 112 silver nitrate...... 133 SPRAVATO (84 MG DOSE)..... 88 sumatriptan succinate refill..... 112 silver sulfadiazine...... 217 sprintec 28...... 153, 162, 173 SUMAXIN...... 206, 216 simliya...... 153, 162, 173 SPRIX...... 108 SUNOSI...... 115 simpesse...... 153, 162, 173 SPRYCEL...... 38 SUPRAX...... 14, 15 SIMPONI...... 140, 187, 191 sps...... 121, 179 SUPREP BOWEL PREP KIT..138 simvastatin...... 76 sronyx...... 153, 162, 173 SURESTEP PRO HIGH SINEMET...... 100 ssd...... 217 GLUCOSE...... 118 SINGULAIR...... 201 SSKI...... 200 SURESTEP PRO LOW sirolimus...... 193 sss 10-5...... 206, 216 GLUCOSE...... 118 SIRTURO...... 19 STALEVO 100...... 98, 100 SURESTEP PRO NORMAL SIVEXTRO...... 29 STALEVO 125...... 98, 100 GLUCOSE...... 118 SKYRIZI...... 221 STALEVO 150...... 98, 100 SUSTIVA...... 24 SKYRIZI (150 MG DOSE)...... 221 STALEVO 200...... 99, 100 SUTAB...... 138 SKYRIZI PEN...... 221 STALEVO 50...... 99, 100 SUTENT...... 38 SLYND ...... 153, 173 STALEVO 75...... 99, 100 syeda...... 153, 162, 173 sod citrate-citric acid ...... 119 stavudine...... 25 SYMAX DUOTAB...... 47 SODIUM BICARBONATE STELARA...... 221 SYMAX-SL...... 47 ...... 135, 137 STIMATE...... 58, 166 SYMAX-SR...... 47 sodium chloride...... 201 STIVARGA...... 38 SYMBICORT...... 52, 144

244 SYMBYAX...... 95, 113 TEPMETKO ...... 39 tobramycin...... 15, 129 SYMDEKO...... 199 terazosin hcl...... 49, 63 TOBRAMYCIN...... 15 SYMFI...... 24, 25 terbinafine hcl...... 15 tobramycin-dexamethasone SYMFI LO...... 24, 25 terbutaline sulfate...... 52, 203 ...... 129, 132 SYMLINPEN 120 ...... 145 terconazole...... 208 TOBREX...... 129 SYMLINPEN 60 ...... 145 TERIPARATIDE tolbutamide...... 119, 177 SYMPROIC...... 140 (RECOMBINANT) ...... 166, 180 tolcapone...... 99 SYMTUZA...... 25, 26, 195 terrell...... 101 TOLVAPTAN ...... 126 SYNAREL...... 164 TESSALON PERLES...... 199 tolvaptan...... 126 SYNDROS...... 136 TESTIM...... 146 TOPAMAX...... 87, 92 SYNJARDY...... 147, 175 testosterone cypionate...... 146 TOPAMAX SPRINKLE...... 87, 92 SYNJARDY XR...... 147, 175 testosterone enanthate...... 146 TOPICORT...... 214 SYNRIBO...... 38 tetrabenazine...... 114 topiramate...... 87, 92 TABRECTA ...... 38 tetracaine hcl...... 134 TOPROL XL...... 52, 67, 68, 73 TACLONEX ...... 214, 221 tetracycline hcl...... 17, 31, 137 toremifene citrate...... 39, 155 tacrolimus...... 193, 221 TETRIX...... 221 torsemide...... 77, 121 tadalafil...... 78 TEXACORT...... 214 TOUJEO MAX SOLOSTAR.... 165 tadalafil (pah)...... 78, 203 THALOMID...... 191 TOUJEO SOLOSTAR...... 165 TAFINLAR ...... 38 THEO-24...76, 110, 120, 204, 222 TOVIAZ...... 222 TAGRISSO...... 38 theophylline TRACLEER...... 203 TAKHZYRO...... 184 ...... 76, 111, 120, 204, 223 TRADJENTA ...... 155 TALZENNA ...... 38 theophylline er tramadol hcl...... 105 tamoxifen citrate...... 38, 39, 155 .. 76, 110, 111, 120, 204, 222, 223 tramadol hcl er...... 105 tamsulosin hcl...... 51 THIOLA...... 195 tramadol-acetaminophen.. 83, 105 TAPAZOLE...... 147 THIOLA EC...... 195 trandolapril...... 65 TAPERDEX 12-DAY...... 145 thioridazine hcl...... 109 trandolapril-verapamil hcl er66, 70 TAPERDEX 6-DAY...... 145 thiothixene...... 114 tranexamic acid...... 59 TAPERDEX 7-DAY...... 145 THROMBIN-JMI ...... 58 TRANXENE-T ...... 96, 98 TARGRETIN...... 39, 221 THROMBIN-JMI EPISTAXIS.... 58 tranylcypromine sulfate...... 102 tarina 24 fe...... 153, 162, 173 THROMBOGEN...... 58, 59 travoprost (bak free) ...... 134 tarina fe 1/20...... 153, 162, 173 tiadylt er...... 69, 70, 74, 80 trazodone hcl...... 113 tarina fe 1/20 eq...... 153, 162, 173 tiagabine hcl...... 87 TRECATOR ...... 19 TARKA...... 65, 70 TIAZAC...... 69, 70, 74, 80 TRELEGY ELLIPTA ....47, 52, 145 TASIGNA...... 39 TIBSOVO...... 39 TREMFYA ...... 222 tavaborole...... 218 TIGLUTIK...... 99 tretinoin...... 39, 209 TAVALISSE...... 54 TIKOSYN...... 73 TRETTEN ...... 59 tazarotene...... 221 tilia fe...... 153, 162, 173 TREXALL...... 39, 187, 191, 193 TAZORAC...... 221 timolol maleate TREZIX...... 83, 105, 111 taztia xt...... 69, 70, 74, 80 ...... 49, 67, 68, 73, 92, 130 tri femynor...... 153, 162, 173 TAZVERIK...... 39 timolol maleate ocudose...... 130 triamcinolone acetonide...... 214 TEGRETOL...... 87, 91 timolol maleate pf...... 130 triamterene...... 78, 122 TEGRETOL-XR...... 87, 91 TIMOPTIC...... 130 triamterene-hctz...... 122, 125 TEGSEDI...... 180 TIMOPTIC OCUDOSE...... 130 triazolam...... 98 TEKTURNA ...... 79 TIMOPTIC-XE...... 130 TRICARE PRENATAL DHA TEKTURNA HCT ...... 79, 125 tinidazole...... 18 ONE...... 61, 138, 195, 225, 227 telmisartan...... 63, 64 tiopronin...... 195 TRI-CHLOR...... 195 telmisartan-hctz...... 64, 125 TIROSINT-SOL...... 177 TRICITRASOL...... 54 temazepam...... 98 TISSEEL...... 222 tricitrates...... 119 TEMOVATE ...... 214 TIVICAY...... 23 triderm...... 214 temozolomide...... 39 TIVICAY PD...... 23 TRIDESILON...... 214 TENCON...... 83, 96 tizanidine hcl...... 48 trientine hcl...... 142 TENIVAC...... 42 TOBI PODHALER...... 15 tri-estarylla...... 153, 162, 173 tenofovir disoproxil fumarate.....25 TOBRADEX...... 129, 132 trifluoperazine hcl...... 109

245 trifluridine...... 129 TYMLOS ...... 166, 180 VENELEX...... 222 trihexyphenidyl hcl...... 47, 84 TYVASO...... 203 venlafaxine hcl...... 112 TRIJARDY XR 147, 148, 155, 175 TYVASO REFILL...... 203 venlafaxine hcl er...... 112 TRIKAFTA...... 199, 200 TYVASO STARTER...... 203 VENTAVIS...... 203 tri-legest fe...... 153, 162, 173 UBRELVY...... 98 VENTRIXYL...... 124, 225, 228 TRILEPTAL ...... 87 UCERIS...... 145, 214 verapamil hcl...... 69, 70, 74, 80 tri-linyah...... 153, 162, 173 UDAMIN SP...... 124, 225, 228 verapamil hcl er...... 69, 70, 74, 80 tri-lo-estarylla...... 153, 162, 173 UKONIQ...... 39 VEREGEN...... 222 tri-lo-marzia...... 153, 162, 173 ULTANE ...... 101 VERELAN...... 69, 70, 74, 80 tri-lo-mili...... 153, 162, 173 ULTRACET...... 83, 106 VERELAN PM...... 69, 71, 74, 80 tri-lo-sprintec...... 153, 162, 173 unithroid...... 178 VERZENIO...... 39 trimethobenzamide hcl...... 136 UPNEEQ...... 135 vestura...... 154, 163, 174 trimethoprim...... 31 UPTRAVI...... 203 VFEND...... 20 tri-mili...... 154, 162, 173 urea...... 216 VIBERZI...... 140 trimipramine maleate...... 114 urea nail...... 216 VIBRAMYCIN...... 17, 31 TRINATE ...... 61, 225, 227 URELLE...... 32, 47, 83, 195 VICTOZA...... 165 TRINTELLIX ...... 113 UREMEZ-40...... 216 VIEKIRA PAK...... 22 tri-nymyo...... 154, 162, 173 URIBEL...... 32, 47, 83, 195 vienva...... 154, 163, 174 tri-previfem...... 154, 162, 173 urin ds...... 32, 47, 83, 195 vigabatrin...... 87, 88 tri-sprintec...... 154, 162, 173 URO-458...... 32, 47, 83, 195 vigadrone...... 88 TRISTART DHA UROCIT-K 10...... 119 VIIBRYD...... 113 ...... 61, 123, 195, 225, 227 UROCIT-K 15...... 119 VIIBRYD STARTER PACK..... 113 TRISTART FREE UROCIT-K 5...... 119 VILAMIT MB...... 32, 47, 83, 196 ...... 61, 123, 195, 225, 227 UROGESIC-BLUE...... 32, 47, 196 VILEVEV MB...... 32, 47, 83, 196 TRISTART ONE uro-mp...... 32, 47, 83, 196 VIMPAT...... 88 ...... 61, 124, 195, 225, 228 URSO 250...... 138 VINATE ONE...... 62, 225, 228 TRIUMEQ...... 23, 25 URSO FORTE...... 138 VIOKACE...... 126, 139 TRI-VI-FLOR...184, 225, 228, 229 ursodiol...... 138 viorele...... 154, 163, 174 TRI-VI-FLORO 184, 225, 228, 229 USTELL...... 32, 47, 83, 196 VIRACEPT...... 26 tri-vite/fluoride. 184, 225, 228, 229 UTIRA-C...... 32, 47, 83, 196 VIRAMUNE...... 24 trivora (28)...... 154, 162, 173 UTOPIC...... 216 VIRAZOLE...... 28 tri-vylibra...... 154, 162, 173 valacyclovir hcl ...... 28 VIREAD...... 25, 26 tri-vylibra lo...... 154, 162, 173 VALCHLOR...... 222 virt-phos 250 neutral...... 124 TRUE METRIX LEVEL 1 ...... 118 valganciclovir hcl...... 28 virtussin ac w/alc...... 199, 200 TRUE METRIX LEVEL 2 ...... 118 valproic acid...... 87, 91, 92 VISTARIL...... 12, 13, 93 TRUE METRIX LEVEL 3 ...... 118 valsartan...... 63, 64 VISTOGARD...... 179 TRULANCE ...... 140 valsartan-hydrochlorothiazide VITAFOL FE+ TRULICITY...... 165 ...... 64, 125 ...... 62, 124, 196, 225, 228 TRUMENBA ...... 44 VALTOCO...... 96, 97 VITAFOL STRIPS...... 225 TRUSOPT...... 131 VANCOCIN...... 21 VITAFOL-NANO...... 62, 225, 228 TRUVADA...... 25 VANCOCIN HCL...... 21 VITAFOL-OB+DHA TUKYSA...... 39 vancomycin hcl ...... 21 ...... 62, 124, 196, 225, 228 tulana...... 154, 173 vandazole...... 15, 206 vitamin d (ergocalciferol)...... 229 TURALIO...... 39 VAQTA...... 44 vitamins acd-fluoride TURPENTINE ...... 209 VARIVAX...... 44 ...... 184, 225, 226, 228, 229 TUSSICAPS...... 13, 199 VECAMYL...... 76 VITATHELY WITH GINGER TUXARIN ER...... 13, 199 velivet...... 154, 163, 174 ...... 62, 225, 228 TWINRIX...... 44 VELPHORO...... 121 VITRAKVI...... 39, 40 TWIRLA...... 154, 163, 173 VELTASSA...... 121 VIVELLE-DOT...... 163, 181 tyblume...... 154, 163, 173 VEMLIDY...... 28 VIZIMPRO...... 40 TYBOST...... 195 VENCLEXTA ...... 39 volnea...... 154, 163, 174 tydemy...... 154, 163, 173, 228 VENCLEXTA STARTING VONVENDI...... 59 TYKERB...... 39 PACK...... 39 voriconazole...... 20

246 VOSEVI...... 22 XOSPATA...... 40 ZIEXTENZO...... 56 VOTRIENT...... 40 XPOVIO (100 MG ONCE zileuton er...... 201 vp-pnv-dha ...... 62, 196, 225, 228 WEEKLY)...... 40 ZILXI...... 206 VRAYLAR...... 95 XPOVIO (40 MG ONCE ZIOPTAN...... 135 VTOL LQ ...... 83, 96, 111 WEEKLY)...... 40 ziprasidone hcl...... 91, 95 vyfemla...... 154, 163, 174 XPOVIO (40 MG TWICE ZIRGAN...... 129 vylibra...... 154, 163, 174 WEEKLY)...... 40 ZITHROMAX...... 28 VYNDAMAX...... 71, 99 XPOVIO (60 MG ONCE ZITHROMAX TRI-PAK...... 29 VYNDAQEL...... 71 WEEKLY)...... 40 ZITHROMAX Z-PAK...... 29 VYVANSE...... 81 XPOVIO (60 MG TWICE ZOKINVY...... 196 WAKIX...... 115 WEEKLY)...... 40 ZOLINZA...... 40 warfarin sodium...... 54 XPOVIO (80 MG ONCE zolmitriptan...... 112 WEGOVY...... 165 WEEKLY)...... 40 zolpidem tartrate...... 93 WELCHOL...... 68, 146 XPOVIO (80 MG TWICE zolpidem tartrate er...... 93 wera...... 154, 163, 174 WEEKLY)...... 40 ZOLPIMIST...... 93 WESTGEL DHA XTAMPZA ER...... 106 ZOMIG...... 112 ...... 62, 124, 196, 225, 228 XTANDI ...... 40 ZONEGRAN...... 88 WESTHROID...... 178 xulane...... 154, 163, 174 zonisamide...... 88 WHEAT GERM OIL...... 229 XURIDEN...... 196 ZONTIVITY...... 62 WIDE-SEAL DIAPHRAGM 60 196 XYNTHA...... 59 ZORBTIVE...... 166, 176 WIDE-SEAL DIAPHRAGM 65 196 XYNTHA SOLOFUSE...... 59 zovia 1/35 (28)...... 154, 163, 174 WIDE-SEAL DIAPHRAGM 70 196 XYREM...... 99 zovia 1/35e (28)...... 154, 163, 174 WIDE-SEAL DIAPHRAGM 75 196 XYWAV...... 99 ZOVIRAX...... 28 WIDE-SEAL DIAPHRAGM 80 197 YASMIN 28...... 154, 163, 174 ZUBSOLV...... 106, 107 WIDE-SEAL DIAPHRAGM 85 197 YAZ...... 154, 163, 174 zumandimine...... 154, 163, 174 WIDE-SEAL DIAPHRAGM 90 197 YUPELRI...... 47 ZYDELIG...... 40 WIDE-SEAL DIAPHRAGM 95 197 yuvafem...... 163, 181 ZYFLO...... 201 WILATE...... 59 ZACARE...... 209, 218 ZYKADIA...... 41 WILZIN...... 124 zaclir cleansing...... 218 ZYLET...... 129, 132 WP THYROID...... 178 zafemy...... 154, 163, 174 ZYLOPRIM...... 180 wymzya fe ...... 154, 163, 174 zafirlukast...... 201 ZYMAXID...... 129 XALKORI...... 40 zaleplon...... 93 ZYVOX...... 29 XARELTO...... 54, 55 ZANAFLEX...... 48 XARELTO STARTER PACK .....55 zarah...... 154, 163, 174 XATMEP...... 40, 187, 191, 193 ZARONTIN...... 114 XCOPRI...... 88 ZARXIO...... 56 XELJANZ...... 187 ZEBUTAL...... 83, 96, 111 XELJANZ XR...... 187 ZEJULA...... 40 XELPROS...... 135 ZELAPAR...... 102 XENICAL...... 140 ZELBORAF...... 40 XENLETA ...... 29 ZELNORM...... 141 XEPI...... 206 ZEMPLAR...... 229 XERMELO...... 136 zenatane...... 222 XIFAXAN...... 30 ZENPEP...... 127, 139 XIIDRA...... 133 ZEPATIER...... 22 XOFLUZA (40 MG DOSE)...... 19 ZEPOSIA...... 191 XOFLUZA (80 MG DOSE)...... 19 ZEPOSIA 7-DAY STARTER XOLEGEL...... 209 PACK...... 191 XOLEGEL COREPAK.....209, 214 ZEPOSIA STARTER KIT...... 192 XOLEGEL DUO/HEAD & ZETONNA ...... 132 SHOULDERS...... 209, 217 ZIAC...... 67, 125 XOLEGEL DUO/XOLEX. 209, 218 ZIAGEN...... 26 XOPENEX HFA...... 52, 203 zidovudine...... 26

247