Preferred Drug List

Comprehensive PREFERRED DRUG LIST

Coordinated Care

Pharmacy Program Coordinated Care is committed to providing appropriate, high quality, and cost effective drug therapy to all Coordinated Care members. Coordinated Care works with providers and pharmacists to ensure that medications used to treat a variety of conditions and diseases are covered. Coordinated Care covers prescription medications and certain over-the-counter (OTC) medications when ordered by a Washington Medicaid enrolled, Coordinated Care practitioner. The pharmacy program does not cover all medications. Some medications require prior authorization (PA) or have limitations on age, dosage, and maximum quantities.

Apple Health Core Connections Coordinated Care has been selected as the statewide managed care health plan to run the Apple Health Foster Care program starting April 1, 2016. The Apple Health Core Connections program is a new managed care program.

Preferred Drug List The Coordinated Care Preferred Drug List (PDL) is a list of covered drugs. The PDL is a list of drugs members can receive at retail pharmacies. The Coordinated Care PDL is continually evaluated by the Coordinated Care Pharmacy and Therapeutics (P&T) Committee to promote the appropriate and cost-effective use of medications. The P&T Committee is composed of the Coordinated Care Medical Director, Coordinated Care Pharmacy Program Director, and several Washington primary care physicians and specialists.

Pharmacy Benefit Manager Coordinated Care works with Envolve Pharmacy Solutions to process all pharmacy claims for prescribed drugs. Envolve Pharmacy Solutions is Coordinated Care’s Pharmacy Benefit Manager (PBM). Some drugs on the Coordinated Care PDL require a PA and Envolve Pharmacy Solutions is responsible for administering the PA process.

Specialty Pharmacy Program Certain medications are only covered when supplied by Coordinated Care’s specialty pharmacy provider. AcariaHealth is the preferred specialty pharmacy provider of Coordinated Care. All specialty drugs, such as biopharmaceuticals and injectables, require a PA to be approved for payment by Coordinated Care. Coordinated Care’s Medical Director and Pharmacy Director oversee the clinical review of these PA requests. AcariaHealth provides the following services: A dedicated, multilingual team available 24 hours a day, 7 days a week to meet the unique needs of each patient. Disease-specific product education and training

Customized treatment programs and compliance monitoring Prior authorization support Timely delivery to the physician’s office or the patient’s home, as requested Drug or disease state specific prior authorization forms will be available on Coordinated Care’s website.

Dispensing Limits Drugs may be dispensed up to a maximum of a 34 day supply for each new prescription or refill. A total of 85% of the day supply must elapse before a prescription can be refilled.

Maintenance Drug Program Members can obtain a 90 day supply (3 month supply) of maintenance drugs from participating pharmacies. Maintenance medications are used to treat long-term conditions or illnesses. Additional information about the Maintenance Drug Program, including a list of “Maintenance Medications” and participating pharmacies can be found at www.coordinatedcarehealth.com/for-providers/pharmacy- program/ Members may request their practitioner to transfer a current prescription or phone in a prescription directly to Coordinated Care’s mail order pharmacy, Homescripts. Homescripts may be reached at 1- 800-785-4197. Members may also have their extended supply of maintenance medications filled at a Coordinated Care network pharmacy.

Appropriate Use and Safety Edits

The health and safety of the member is a priority of Coordinated Care. One of the ways we address member safety is through point-of-sale (POS) edits at the time a prescription is processed at the pharmacy. These edits are based on FDA recommendations and promote safe and effective medication utilization. Additional information about the drugs that are part of the Appropriate Use and Safety Edits can be found in the Appropriate Use and Safety Edits document located on the Coordinated Care website at www.coordinatedcarehealth.com/for-providers/pharmacy-program/

Second Opinion Network (SON) Washington’s Health Care Authority (HCA) implemented a drug initiative, called the Second Opinion Network (SON). The goal is to reduce therapeutic duplications of psychotropic drugs prescribed to children 17 years of age and younger. Coordinated Care has adopted the guidelines for age limitations and dosing limitations set forth by Washington’s HCA.

Members (17 years of age and younger) who are prescribed medications outside these guidelines for the “first time”, or prescribed prescriptions with “dose escalations”, will be referred by Coordinated Care to the HCA to initiate the process of the second opinion review. After the second opinion review has been completed by the HCA, Coordinated Care will receive a copy of the “SON” from the HCA. The “SON” will have recommendations explaining the approval or unable to approve determination of the psychotropic prescription request. Opioid Policy Effective November 1, 2019, Apple Health will apply a safety limit to the total daily dose of opioids. The dose of different opioids is measured in units called morphine milligram equivalents (MME). An opioid prescription or combinations of opioid prescriptions that exceed a daily dose equal to 120 MME will require the prescriber to complete and sign an opioid attestation form. This safety limit helps ensure prescribers are following best practices.

Prior Authorizations

If a medication is not listed on the PDL, a Prior Authorization (PA) outlining the Medical Necessity for the drug is needed (please see Medical Necessity Requests information below). Furthermore, some medications listed on the Coordinated Care PDL may require a PA. The information should be submitted by the practitioner or pharmacist to Envolve Pharmacy Solutions on the Medication Prior Authorization Form. This form should be faxed to Envolve Pharmacy Solutions at 1-866-399-0929. This document is located on the Coordinated Care website at www.coordinatedcarehealth.com/for- providers/pharmacy-program/

In addition, Providers and Pharmacists can conduct a telephonic prior authorization via phone at 855-757-6565, from 5am – 5pm Pacific Time, Monday through Friday, for all non-specialty drugs. You can visit www.coordinatedcarehealth.com/for-providers/pharmacy-program/ for more details.

Coordinated Care will cover the medication if it is determined that: 1. There is a medical reason the member needs the specific medication. 2. Depending on the medication, other medications on the PDL have not worked. All reviews are performed by a licensed clinical pharmacist using the criteria established by the Coordinated Care P&T Committee. Once approved, Envolve Pharmacy Solutions notifies the practitioner by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, Coordinated Care will notify the member and their practitioner of alternatives and provide information regarding the appeal process.

Step Therapy Some medications listed on the Coordinated Care PDL may require specific medications to be used before the member can receive the step therapy medication. If Coordinated Care has a record that the required medication was tried first, the step therapy medications are automatically covered. If Coordinated Care does not have a record that the required medication was tried, the member and their practitioner may be required to provide additional information. If Coordinated Care does not grant a PA, then Coordinated Care will notify the member and their practitioner and provide information regarding the appeal process.

Quantity Limits Coordinated Care may limit how much of a medication a member can get at one time. If the practitioner feels that the member has a medical reason for getting a larger amount, then the practitioner can submit a PA. If Coordinated Care does not grant a PA, Coordinated Care will notify the member and their practitioner and provide information regarding the appeal process.

Age Limits

Some medications on the Coordinated Care PDL may have age limits. These are set for certain drugs based on FDA approved labeling and for safety concerns and quality standards of care. Age limits align with current FDA alerts for the appropriate use of pharmaceuticals.

Medical Necessity Requests

If a member requires a medication that does not appear on the PDL, then the member or member’s practitioner can make a medical necessity request for the medication. It is anticipated that such exceptions will be rare and that PDL medications will be appropriate to treat the vast majority of medical conditions. Coordinated Care requires: -Documentation of failure of at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications) for the same diagnosis (e.g. migraine, neuropathic pain, etc.); or - Documented intolerance or contraindication to at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications); or - Documented clinical history or presentation where the patient is not a candidate for any of the PDL agents for the indication. All reviews are performed by a licensed clinical pharmacist using the criteria established by the Coordinated Care P&T Committee. If the clinical information provided does not meet the coverage criteria for the requested medication, Coordinated Care will notify the member and their practitioner of alternatives and provide information regarding the appeal process.

30-day Emergency Supply Policy Up to a 30 day supply of medication can be dispensed to any member awaiting a PA determination. The purpose is to avoid interruption of current therapy or delay in the initiation of therapy. All participating pharmacies are authorized to provide up to a 30 day supply of medication and will be reimbursed for the ingredient cost and dispensing fee of the 30 day supply of medication whether or not the PA request is ultimately approved or denied. The pharmacy must call the Envolve Pharmacy Solutions at 1-866- 716-5099 for a prescription override for payment.

Exclusions The following drug categories are not part of Coordinated Care’s PDL and are not covered by the 30 day emergency supply policy: - Drugs that are not approved by the FDA - A drug from a manufacturer without a federal rebate agreement - Drugs prescribed for weight loss or gain - Drugs prescribed for infertility, frigidity, or impotence - Drugs prescribed for sexual or erectile dysfunction - Drugs prescribed for cosmetic purposes or hair growth - Nutritional supplements - DESI, IRS, or LTE drugs - OTC drugs which are not listed on the PDL - Drugs and drug-related supplies for multiple patient use - Drugs prescribed for an indication that is not evidence-based - Drugs prescribed for a non-medically accepted indication or dosing level

Newly Approved Products Coordinated Care reviews new drugs for safety and effectiveness before adding them to the PDL. During this period, access to these medications will be considered through the PA review process. If Coordinated Care does not approve a PA, Coordinated Care will notify the member and their practitioner and provide information regarding the appeal process.

Over-the-Counter Medications Coordinated Care’s PDL covers a variety of Over-the-Counter (OTC) medications. A list of covered OTC medications can be found in the Over-the-Counter Medications section of this document. Please note that this is not an all-inclusive list of covered OTC medications. Over-the-Counter medications are covered when the member has a prescription from a licensed practitioner that meets all the legal requirements for a prescription.

Generic Drugs In most cases, when generic drugs are available, the brand-name drug will not be covered without prior authorization from Coordinated Care. Generic drugs have the same active ingredient as brand-name drugs. If the member or their practitioner feels a brand-name drug is medically necessary, the practitioner can ask for a PA. Coordinated Care will cover the brand-name drug according to clinical guidelines if there is a medical reason the member needs a particular brand-name drug. If Coordinated Care does not grant a PA, Coordinated Care will notify the member and their practitioner and provide information regarding the appeal process. The provision is waived for the following products due to their narrow therapeutic index (NTI) as recognized by current medical and pharmaceutical literature: Aminophylline, Amiodarone, Carbamazepine, Clozapine, Cyclosporine, Digoxin, Disopyramide, Ethosuximide, Flecainide, L- thyroxine, Lithium, Phenytoin, Procainamide, Propafenone, Theophylline, Valproate Sodium, Valproic Acid, and Warfarin.

Drug Efficacy Study and Implementation Drugs

Drug Efficacy Study and Implementation (DESI) products and known related drug products are defined as less than effective by the Food and Drug Administration because there is a lack of substantial evidence of effectiveness for all labeling indications and because a compelling justification for their medical need has not been established. DESI products are not covered by Coordinated Care.

Filling a Prescription

A member can have prescriptions filled at a Coordinated Care network pharmacy. If the member decides to have a prescription filled at a network pharmacy, they can locate a pharmacy near them by contacting a Coordinated Care Member Services Representative. At the pharmacy, the member will need to provide the pharmacist with the prescription and their Coordinated Care ID card. Copayments

Washington Apple Health members will not have copayments for drugs filled at a network pharmacy.

Contact Information Coordinated Care Provider Services: 1-877-644-4613 Fax: 1-877-644-4602 Envolve Pharmacy Solutions Prior Authorizations: 1-866-716-5099 Fax: 1-866-399-0929 Envolve Pharmacy Solutions Help Desk: 1-877-250-6176

Tier Definition:

Drug Tier Tier Definition 1 Preferred Generic 2 Preferred Brand F Formulary NF Non-formulary NP Non-preferred drug CO Carve-out drug MP Maintenance Medication

Legend Description

AL Age Limit Drug is limited to specific age.

Max Daily MDD Dose A limit on the number of times the drug can be taken per day.

Max Package MPL Limit A limit on the amount of drug covered per prescription.

MFL Max Fill Limit There is a limit on the number of times this drug can be refilled.

Max Days’ MDS Supply There is a limit on the amount of this drug that is covered.

Prior PA Authorization Prior Authorization required before prescription can be filled.

There is a limit on the amount of drug covered per prescription, or within QL Quantity Limit a specific time frame.

Rx/OTC Rx/OTC Product has both Rx and OTC National Drug Codes.

Requires trial and failure of one or more preferred products prior to ST Step Therapy coverage.

Specialty drugs are high-cost drugs used to treat complex or rare SP Specialty Drug conditions and may be limited to a specific pharmacy.

Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- Age 5-8: MDD OBESITY/ANOREXIANTS - Drugs to Treat = 1.75; Age 9- ADHD, Sleep and Eating Disorders ADDERALL TABS 5 MG-5 11: MDD =2.25; MG-5 MG-5 MG NP Age 12-17: Amphetamines (amphetamine- MDD = 3; Age Age 5-8: dextroamphetamine) 18+: MDD = MDD=7; Age 9- 2;AL(At least 5 11: MDD=9; yrs old); MP ADDERALL TABS 1.25 Age 12-17: Age 5-8: MG-1.25 MG-1.25 MG-1.25 NP MDD=12; Age MG (amphetamine- MDD=1.167; dextroamphetamine) 18+: Age 9-11: MDD=2;AL(At ADDERALL TABS 7.5 MG- MDD=1.5; Age 7.5 MG-7.5 MG-7.5 MG least 5 yrs old); NP 12-17: MDD=2; MP (amphetamine- dextroamphetamine) Age Age 5-8: 18+:MDD=2;AL MDD=4.67; (At least 5 yrs Age 9-11: old); MP ADDERALL TABS 1.875 MDD=6: Age Age 5-8: MG-1.875 MG-1.875 MG- NP 12-17: MDD=8; 1.875 MG (amphetamine- MDD=7; Age 9- dextroamphetamine) Age 18+: 11: MDD=9; MDD=2;AL(At ADDERALL XR CP24 1.25 Age 12-17: least 5 yrs old); MG-1.25 MG-1.25 MG-1.25 2 MDD=12; Age MP MG (amphetamine- dextroamphetamine) 18+: Age 5-8: MDD=1;AL(At MDD=3.5; Age least 5 yrs old); 9-11: MP ADDERALL TABS 2.5 MG- MDD=4.5; Age Age 5-8: 2.5 MG-2.5 MG-2.5 MG NP 12-17: MDD=6; (amphetamine- MDD=3.5; Age dextroamphetamine) Age 18+: 9-11: MDD=2;AL(At ADDERALL XR CP24 2.5 MDD=4.5; Age MG-2.5 MG-2.5 MG-2.5 least 5 yrs old); 2 12-17: MDD=6; MP MG (amphetamine- dextroamphetamine) Age 18+: Age 5-8: MDD=1;AL(At MDD=2.8; Age least 5 yrs old); 9-11: MP ADDERALL TABS 3.125 MDD=3.6: Age Age 5-8: MG-3.125 MG-3.125 MG- NP 12-17: 3.125 MG (amphetamine- MDD=2.34; dextroamphetamine) MDD=4.8; Age Age 9-11: 18+:MDD=2;AL ADDERALL XR CP24 3.75 MDD=3; Age (At least 5 yrs MG-3.75 MG-3.75 MG-3.75 2 12-17: 4; Age old); MP MG (amphetamine- 18+: dextroamphetamine) Age 5-8: MDD=1;AL(At MDD=2.34; least 5 yrs old); Age 9-11: MP ADDERALL TABS 3.75 MDD=3; Age MG-3.75 MG-3.75 MG-3.75 NP 12-17: MDD=4; MG (amphetamine- ) Age 18+: dextroamphetamine MDD=2;AL(At least 5 yrs old); MP

Coordinated Care of Washington Updated September 1, 2021

1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Age 5-8: Age 5-8: MDD=1.75; MDD=2.2; Age Age 9-11: 9-11: ADDERALL XR CP24 5 MDD=2.25; MG-5 MG-5 MG-5 MG MDD=2.9; Age 2 Age 12-17: ADZENYS XR-ODT TBED NP 12-17: (amphetamine- 15.7 MG dextroamphetamine) MDD=3; Age MDD=3.8; Age 18+:MDD=1;AL 18+: (At least 5 yrs MDD=3.8;AL(At old); MP least 5 yrs old) Age 5-8: MDD= Age 5-8: 1.4; Age 9-11: MDD=1.9; Age ADDERALL XR CP24 6.25 MDD=1.8; Age 9-11: MG-6.25 MG-6.25 MG-6.25 12-17: MDD 2 ADZENYS XR-ODT TBED MDD=2.4; Age MG (amphetamine- 2.4; Age 18+: NP 12-17: dextroamphetamine) MDD=1;AL(At 18.8 MG MDD=3.2; Age least 5 yrs old); 18+: MP MDD=3.2;AL(At Age 5-8: least 5 yrs old) MDD=1.167; Age 5-8: Age 9-11: ADDERALL XR CP24 7.5 MDD=11.3; MDD=1.5; Age Age 9-11: MG-7.5 MG-7.5 MG-7.5 2 12-17: MDD=2; MG (amphetamine- MDD=14.5; dextroamphetamine) Age ADZENYS XR-ODT TBED NP Age 12-17: 18+:MDD=1;AL 3.1 MG MDD=19.4; (At least 5 yrs Age 18+: old); MP MDD=19.4;AL( Age 5-8: At least 5 yrs MDD=28; Age old) 9-11: MDD=36: Age 5-8: ADZENYS ER SUER NP Age 12-17: MDD=5.6; Age (amphetamine) MDD=48; Age 9-11: 18+: MDD=7.1; Age MDD=48;AL(At ADZENYS XR-ODT TBED NP 6.3 MG 12-17: least 5 yrs old) MDD=9.5; Age Age 5-8: 18+: MDD=9.5 MDD=2.8; Age AL(At least 5 9-11: yrs old) ADZENYS XR-ODT TBED MDD=3.6: Age Age 5-8: NP 12-17: MDD=3.7; Age 12.5 MG MDD=4.8; Age 9-11: 18+:MDD=4.8; MDD=4.8; Age AL(At least 5 ADZENYS XR-ODT TBED NP 9.4 MG 12-17: yrs old) MDD=6.4; Age 18+: MDD=6.4;AL(At least 5 yrs old)

Coordinated Care of Washington Updated September 1, 2021

2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Age 5-8: Age 5-8: MDD=28; Age MDD=2.34; Age 9-11: 9-11: MDD=36: amphetamine- NP Age 12-17: MDD=3; Age amphetamine suer MDD=48; Age dextroamphetamine cp24 1 12-17: 4; Age 3.75 mg-3.75 mg-3.75 mg- 18+: 18+: MDD=48;AL(At 3.75 mg MDD=1;AL(At least 5 yrs old) least 5 yrs old); Age 5-8: MP MDD=3.5; Age Age 5-8: 9-11: MDD=1.75; amphetamine sulfate tabs NP MDD=4.5; Age Age 9-11: 10 mg 12-17: MDD=6; amphetamine- MDD=2.25; Age 18+: dextroamphetamine cp24 5 1 Age 12-17: MDD=6;AL(At mg-5 mg-5 mg-5 mg MDD=3; Age least 5 yrs old) 18+:MDD=1;AL Age 5-8: (At least 5 yrs MDD=7; Age 9- old); MP 11: MDD=9; Age 5-8: MDD= amphetamine sulfate tabs NP Age 12-17: 1.4; Age 9-11: 5 mg MDD=12; Age amphetamine- MDD=1.8; Age 18+: dextroamphetamine cp24 1 12-17: MDD MDD=12;AL(At 6.25 mg-6.25 mg-6.25 mg- 2.4; Age 18+: least 5 yrs old) 6.25 mg MDD=1;AL(At Age 5-8: least 5 yrs old); MDD=7; Age 9- MP 11: MDD=9; Age 5-8: amphetamine- Age 12-17: MDD=1.167; dextroamphetamine cp24 1 MDD=12; Age Age 9-11: 1.25 mg-1.25 mg-1.25 mg- 18+: amphetamine- MDD=1.5; Age 1.25 mg dextroamphetamine cp24 MDD=1;AL(At 1 12-17: MDD=2; least 5 yrs old); 7.5 mg-7.5 mg-7.5 mg-7.5 Age mg MP 18+:MDD=1;AL Age 5-8: (At least 5 yrs MDD=3.5; Age old); MP 9-11: Age 5-8: amphetamine- MDD=4.5; Age MDD=7; Age 9- dextroamphetamine cp24 1 12-17: MDD=6; 11: MDD=9; 2.5 mg-2.5 mg-2.5 mg-2.5 Age 18+: amphetamine- Age 12-17: mg MDD=1;AL(At dextroamphetamine tabs 1 MDD=12; Age least 5 yrs old); 1.25 mg-1.25 mg-1.25 mg- 18+: 1.25 mg MP MDD=2;AL(At least 5 yrs old); MP

Coordinated Care of Washington Updated September 1, 2021

3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Age 5-8: Age 5-8: MDD=4.67; MDD=1.167; Age 9-11: Age 9-11: amphetamine- MDD=6: Age amphetamine- MDD=1.5; Age dextroamphetamine tabs dextroamphetamine tabs 1 12-17: MDD=8; 1 12-17: MDD=2; 1.875 mg-1.875 mg-1.875 Age 18+: 7.5 mg-7.5 mg-7.5 mg-7.5 Age mg-1.875 mg mg MDD=2;AL(At 18+:MDD=2;AL least 5 yrs old); (At least 5 yrs MP old); MP Age 5-8: DESOXYN TABS NP PA MDD=3.5; Age (methamphetamine hcl) 9-11: Age 5-8: amphetamine- MDD=4.5; Age dextroamphetamine tabs MDD=3.5; Age 1 12-17: MDD=6; 9-11: 2.5 mg-2.5 mg-2.5 mg-2.5 Age 18+: mg DEXEDRINE CP24 10 MG MDD=4.5; Age MDD=2;AL(At (dextroamphetamine NP 12-17: MDD=6; least 5 yrs old); sulfate) Age 18+: MP MDD=2;AL(At Age 5-8: least 5 yrs old); MDD=2.8; Age MP 9-11: Age 5-8: amphetamine- MDD=3.6: Age dextroamphetamine tabs MDD=2.33;Age 1 12-17: 9-11: MDD=3; 3.125 mg-3.125 mg-3.125 MDD=4.8; Age DEXEDRINE CP24 15 MG mg-3.125 mg Age12-17: 18+:MDD=2;AL (dextroamphetamine NP ) MDD=4; (At least 5 yrs sulfate Age18+:MDD= old); MP 2;AL(At least 5 Age 5-8: yrs old); MP MDD=2.34; Age 5-8: Age 9-11: MDD=7; Age 9- amphetamine- MDD=3; Age dextroamphetamine tabs 11: MDD=9; 1 12-17: MDD=4; DEXEDRINE CP24 5 MG Age 12-17: 3.75 mg-3.75 mg-3.75 mg- Age 18+: 3.75 mg (dextroamphetamine NP MDD=12; Age MDD=2;AL(At sulfate) 18+: least 5 yrs old); MDD=1;AL(At MP least 5 yrs old); Age 5-8: MDD MP = 1.75; Age 9- Age 5-8: 11: MDD MDD=3.5; Age amphetamine- =2.25; Age 12- dextroamphetamine tabs 5 1 9-11: 17: MDD = 3; MDD=4.5; Age mg-5 mg-5 mg-5 mg dextroamphetamine sulfate Age 18+: MDD 1 12-17: MDD=6; = 2;AL(At least cp24 10 mg Age 18+: 5 yrs old); MP MDD=2;AL(At least 5 yrs old); MP

Coordinated Care of Washington Updated September 1, 2021

4 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Age 5-8: PA; Age 5-8: MDD=2.33;Age MDD=1.75; 9-11: MDD=3; Age 9-11: Age12-17: MDD=2.25; dextroamphetamine sulfate 1 dextroamphetamine sulfate cp24 15 mg MDD=4; NP Age 12-17: Age18+:MDD= tabs 20 mg MDD=3;AL(At 2;AL(At least 5 least 5 yrs old - yrs old); MP Up to 17 yrs Age 5-8: old) MDD=7; Age 9- PA; Age 5-8: 11: MDD=9; MDD=1.167; Age 12-17: Age 9-11: dextroamphetamine sulfate 1 MDD=12; Age MDD=1.5; Age cp24 5 mg dextroamphetamine sulfate 18+: NP 12-17: MDD=1;AL(At tabs 30 mg MDD=2;AL(At least 5 yrs old); least 5 yrs old - MP Up to 17 yrs Age 5-8: old) MDD=35; Age PA; Age 5-8: 9-11: MDD=45; MDD=7; Age 9- dextroamphetamine sulfate NP Age 12-17: 11: MDD=9; soln 5 mg/5ml MDD=60; Age dextroamphetamine sulfate NP Age 12-17: 18+: tabs 5 mg MDD=12; Age MDD=60;AL(At 18+: least 5 yrs old) MDD=3;AL(At PA; Age 5-8: least 5 yrs old) MDD=3.5; Age PA; Age 5-8: 9-11: MDD=4.67; dextroamphetamine sulfate NP MDD=4.5; Age Age 9-11: 12-17: MDD=6; MDD=6; Age tabs 10 mg dextroamphetamine sulfate Age 18+: NP 12-17: MDD=3;AL(At tabs 7.5 mg MDD=8;AL(At least 5 yrs old) least 5 yrs old - PA; Age 5-8: Up to 17 yrs MDD=2.33; old) Age 9-11: Age 5-8: MDD= MDD=3; Age 14; Age 9-11: dextroamphetamine sulfate NP 12-17: MDD=18; Age tabs 15 mg MDD=4;AL(At NP 12-17: least 5 yrs old - DYANAVEL XR SUER MDD=24; Age Up to 17 yrs 18+: old) MDD=24;AL(At PA; Age 5-8: least 5 yrs old) MDD=14; Age 9-11: MDD=18; dextroamphetamine sulfate NP Age 12-17: tabs 2.5 mg MDD=24;AL(At least 5 yrs old - Up to 17 yrs old)

Coordinated Care of Washington Updated September 1, 2021

5 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; Age 5-8: methamphetamine hcl tabs NP PA MDD=3.5; Age 9-11: Age 5-8: EVEKEO ODT TBDP 10 NP MDD=4.5; Age MDD=0.7; Age MG 12-17: MDD=6; 9-11: Age 18+: MYDAYIS CP24 12.5 MG- MDD=0.9; Age MDD=6;AL(At NP 12-17: least 5 yrs old) 12.5 MG-12.5 MG-12.5 MG MDD=1.2; Age PA; Age 5-8: 18+: MDD=1.2 MDD=2.33; AL(At least 5 Age 9-11: yrs old) EVEKEO ODT TBDP 15 NP MDD=3; Age Age 5-8: MG 12-17: MDD=4; MDD=2.8; Age Age 18+: 9-11: MDD=4;AL(At MYDAYIS CP24 3.125 MG- MDD=3.6: Age least 5 yrs old) 3.125 MG-3.125 MG-3.125 NP 12-17: PA; Age 5-8: MG MDD=4.8; Age MDD=1.75; 18+:MDD=4.8; Age 9-11: AL(At least 5 MDD=2.25; yrs old) EVEKEO ODT TBDP 20 NP Age 12-17: MG Age 5-8: MDD=3; Age MDD=1.4; Age 18+: 9-11: MDD=3;AL(At MDD=1.8; Age least 5 yrs old) MYDAYIS CP24 6.25 MG- NP 12-17: 6.25 MG-6.25 MG-6.25 MG PA; Age 5-8: MDD=2.4; Age MDD=7; Age 9- 18+:MDD=2.4 11: MDD=9; AL(At least 5 Age 12-17: yrs old) EVEKEO ODT TBDP 5 MG NP MDD=12; Age Age 5-8: 18+: MDD=0.9; Age MDD=12;AL(At 9-11: least 5 yrs old) MYDAYIS CP24 9.375 MG- MDD=1.2; Age Age 5-8: 9.375 MG-9.375 MG-9.375 NP 12-17: MDD=3.5; Age MG MDD=1.6; Age 9-11: 18+: MDD=1.6 AL(At least 5 EVEKEO TABS 10 MG NP MDD=4.5; Age (amphetamine sulfate) 12-17: MDD=6; yrs old) Age 18+: Age 5-8: MDD=6;AL(At MDD=6; Age 9- least 5 yrs old) 11: MDD=7.5; Age 5-8: Age 12-17: MDD =10; Age MDD=7; Age 9- VYVANSE CAPS 10 MG 2 11: MDD=9; 18+: PA. MDD=1;AL(At EVEKEO TABS 5 MG NP Age 12-17: (amphetamine sulfate) MDD=12; Age least 5 yrs old - 18+: Up to 17 yrs MDD=12;AL(At old); MP least 5 yrs old)

Coordinated Care of Washington Updated September 1, 2021

6 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Age 5-8: Age 5-8: MDD=3; Age 9- MDD=0.86; 11: MDD=3.75; Age 9-11: Age 12-17: MDD=1.07; MDD=5; Age Age 12-17: VYVANSE CAPS 20 MG 2 18+: PA, VYVANSE CAPS 70 MG 2 MDD= 1.43; MDD=1;AL(At Age 18+: PA, least 5 yrs old - MDD=1;AL(At Up to 17 yrs least 5 yrs old - old); MP Up to 17 yrs Age 5-8: MDD old); MP =2; Age 9-11: Age 5-8: MDD=2.5; Age MDD=6; Age 9- 12-17: 11: MDD=7.5; MDD=3.34; VYVANSE CAPS 30 MG 2 VYVANSE CHEW 10 MG 2 Age 12-17: Age 18+: PA, MDD= 10; Age MDD=1;AL(At 18+:MDD=1;AL least 5 yrs old - (At least 5 yrs Up to 17 yrs old) old); MP Age 5-8: Age 5-8: MDD=3; Age 9- MDD=1.5; Age 11: MDD=3.8; 9-11: Age 12-17: MDD=1.875; VYVANSE CHEW 20 MG 2 MDD=5; Age Age 12-17: 18+: VYVANSE CAPS 40 MG 2 MDD=2.5; Age MDD=1;AL(At 18+: PA, least 5 yrs old); MDD=1;AL(At MP least 5 yrs old - Age 5-8: MDD Up to 17 yrs =2; Age 9-11: old); MP MDD=2.5; Age Age 5-8: 12-17: MDD=1.2; Age VYVANSE CHEW 30 MG 2 MDD=3.34; 9-11: Age 18+: MDD=1.5; Age MDD=3.34;AL( 12-17: MDD=2; At least 5 yrs VYVANSE CAPS 50 MG 2 Age 18+: PA, old); MP MDD=1;AL(At Age 5-8: least 5 yrs old - MDD=1.5; Age Up to 17 yrs 9-11: old); MP MDD=1.9; Age Age 5-8: VYVANSE CHEW 40 MG 2 12-17: MDD=1; Age 9- MDD=2.5; Age 11: MDD=1.25; 18+:MDD=2.5;; Age 12-17: AL(At least 5 2 MDD=1.67; yrs old); MP VYVANSE CAPS 60 MG Age 18+: PA, MDD=1;AL(At least 5 yrs old - Up to 17 yrs old); MP Coordinated Care of Washington Updated September 1, 2021

7 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Age 5-8: Age 5-17: MDD=1.2; Age atomoxetine hcl caps 80 1 MDD=1.5;AL(At 9-11: mg least 5 yrs old); MDD=1.5; Age MP VYVANSE CHEW 50 MG 2 12-17: MDD=2; AL(At least 4 clonidine hcl (adhd) tb12 1 Age 18+: yrs old); MP MDD=2;;AL(At least 5 yrs old); Age 4-5: MP MDD=2; Age 6- 8: MDD=3; Age guanfacine hcl (adhd) tb24 Age 5-8: 1 9-17: MDD=1; Age 9- 1 mg MDD=4;AL(At 11: MDD=1.25; least 4 yrs old); Age 12-17: MP VYVANSE CHEW 60 MG 2 MDD=1.67; Age 18+: Age 4-5: MDD=1.67;;AL( MDD=1; Age 6- 8: MDD= 1.5; At least 5 yrs guanfacine hcl (adhd) tb24 old); MP 1 Age 9-17: 2 mg MDD=2;AL(At Analeptics least 4 yrs old); QL(45 ml per MP caffeine citrate soln 1 fill retail) Age 4-5: Attention-Deficit/Hyperactivity Disorder (ADHD) MDD=0.667; Age 6-8: Age 5-17: guanfacine hcl (adhd) tb24 1 MDD=1; Age 9- atomoxetine hcl caps 10 1 MDD=12;AL(At 3 mg 17: mg least 5 yrs old); MDD=1.334;AL MP (At least 4 yrs Age 5-17: old); MP atomoxetine hcl caps 100 1 MDD=1.2;AL(A Age 4-5: mg t least 5 yrs MDD=0.5; Age old); MP 6-8: Age 5-17: guanfacine hcl (adhd) tb24 1 MDD=0.75; atomoxetine hcl caps 18 1 MDD=6.67;AL( 4 mg Age 9-17: mg At least 5 yrs MDD=1;AL(At old); MP least 4 yrs old); Age 5-17: MP atomoxetine hcl caps 25 1 MDD=4.8;AL(A Age 4-5: mg t least 5 yrs MDD=2; Age 6- old); MP 8: MDD=3; Age INTUNIV TB24 1 MG NP Age 5-17: )) 9-17: (guanfacine hcl (adhd MDD=4;AL(At atomoxetine hcl caps 40 1 MDD=3;AL(At mg least 5 yrs old); least 4 yrs old); MP MP Age 5-17: Age 4-5: MDD=1; Age 6- atomoxetine hcl caps 60 1 MDD=2;AL(At mg least 5 yrs old); 8: MDD= 1.5; INTUNIV TB24 2 MG NP MP )) Age 9-17: (guanfacine hcl (adhd MDD=2;AL(At least 4 yrs old); MP Coordinated Care of Washington Updated September 1, 2021

8 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Age 4-5: SUNOSI TABS NP PA MDD=0.667; Age 6-8: Histamine H3-Receptor Antagonist/Inverse INTUNIV TB24 3 MG NP MDD=1; Age 9- (guanfacine hcl (adhd)) 17: WAKIX TABS 2 PA MDD=1.334;AL (At least 4 yrs Stimulants - Misc. old); MP PA; Age 5-8: Age 4-5: MDD=2.8; Age MDD=0.5; Age 9-11: MDD=3.6: Age 6-8: ADHANSIA XR CP24 25 NP 12-17: INTUNIV TB24 4 MG NP MDD=0.75; MG (guanfacine hcl (adhd)) Age 9-17: MDD=4.8; Age MDD=1;AL(At 18+:MDD=4.8; least 4 yrs old); AL(At least 5 MP yrs old) PA; Age 5-8: KAPVAY TB12 (clonidine NP AL(At least 4 hcl (adhd)) yrs old); MP MDD=2; Age 9- PA 11: MDD=2.57; QELBREE CP24 NP Age 12-17: ADHANSIA XR CP24 35 Age 5-17: NP MDD=3.43; MG Age 18+: STRATTERA CAPS 10 MG NP MDD=12;AL(At (atomoxetine hcl) least 5 yrs old); MDD=3.43;AL( MP At least 5 yrs old) Age 5-17: PA; Age 5-8: STRATTERA CAPS 100 NP MDD=1.2;AL(A MG (atomoxetine hcl) t least 5 yrs MDD=1.56; old); MP Age 9-11: MDD=2; Age Age 5-17: ADHANSIA XR CP24 45 NP 12-17: STRATTERA CAPS 18 MG NP MDD=6.67;AL( MG MDD=2.67; (atomoxetine hcl) At least 5 yrs Age 18+: old); MP MDD=2.67;AL( Age 5-17: At least 5 yrs STRATTERA CAPS 25 MG NP MDD=4.8;AL(A old) (atomoxetine hcl) t least 5 yrs PA; Age 5-8: old); MP MDD=1.27; Age 5-17: Age 9-11: STRATTERA CAPS 40 MG NP MDD=3;AL(At MDD=1.64; (atomoxetine hcl) least 5 yrs old); ADHANSIA XR CP24 55 NP Age 12-17: MP MG MDD=2.18; Age 5-17: Age 18+: MDD=2.18;AL( STRATTERA CAPS 60 MG NP MDD=2;AL(At (atomoxetine hcl) least 5 yrs old); At least 5 yrs MP old) Age 5-17: STRATTERA CAPS 80 MG NP MDD=1.5;AL(A (atomoxetine hcl) t least 5 yrs old); MP Dopamine and Norepinephrine Reuptake Coordinated Care of Washington Updated September 1, 2021

9 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; Age 5-8: PA; Age 5-8: MDD=1; Age 9- MDD=2.3; Age 11: MDD=1.29; 9-11: MDD=3; Age 12-17: Age 12-17: ADHANSIA XR CP24 70 NP APTENSIO XR CP24 30 NP MDD=4; Age MG MDD=1.71; MG (methylphenidate hcl) Age 18+: 18+: MDD=1.71;AL( MDD=4;AL(At At least 5 yrs least 5 yrs old); old) MP PA; Age 5-8: PA; Age 5-8: MDD=0.82; MDD=1.8; Age Age 9-11: 9-11: MDD=1.06; MDD=2.3; Age APTENSIO XR CP24 40 NP 12-17: MDD=3; ADHANSIA XR CP24 85 NP Age 12-17: MG (methylphenidate hcl) MG MDD=1.41; Age 18+: Age 18+: MDD=3;AL(At MDD=1.41;AL( least 5 yrs old); At least 5 yrs MP old) PA; Age 5-8: PA; Age 5-8: MDD=1.4; Age MDD=7; Age 9- 9-11: 11: MDD=9; MDD=1.8; Age Age 12-17: APTENSIO XR CP24 50 NP 12-17: APTENSIO XR CP24 10 NP MG (methylphenidate hcl) MG (methylphenidate hcl) MDD=12; Age MDD=2.4; Age 18+: MDD=1 18+:MDD=2.4; ;AL(At least 5 AL(At least 5 yrs old); MP yrs old); MP PA; Age 5-8: APTENSIO XR CP24 60 NP PA; AL(At least MDD=4.7; Age MG (methylphenidate hcl) 5 yrs old); MP 9-11: MDD=6; PA; AL(At least armodafinil tabs 1 Age 12-17: 18 yrs old); MP APTENSIO XR CP24 15 NP MDD=8; Age MG (methylphenidate hcl) 18+: AZSTARYS CAPS NP MDD=1;AL(At least 5 yrs old); Age 5-8: MP MDD=3.89; Age 9-11: PA; Age 5-8: MDD=5; Age MDD=3.5; Age CONCERTA TBCR 18 MG 2 12-17: 9-11: (methylphenidate hcl) MDD=6.67; MDD=4.5; Age Age 18+: APTENSIO XR CP24 20 NP 12-17: MDD=6; MG (methylphenidate hcl) MDD=1;AL(At Age 18+: least 5 yrs old); MDD=6;AL(At MP least 5 yrs old); MP

Coordinated Care of Washington Updated September 1, 2021

10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Age 5-8: PA; Age 5-8: MDD=2.59; MDD=8.1; Age Age 9-11: 9-11: MDD=3.33; MDD=10.5; CONCERTA TBCR 27 MG Age 12-17: COTEMPLA XR-ODT NP 2 TBED 8.6 MG Age 12-17: (methylphenidate hcl) MDD=4.44; MDD=14; Age Age 18+: 18+:MDD=1;AL MDD=14;;AL(At (At least 5 yrs least 5 yrs old) old); MP PA; Age 5-8: Age 5-8: MDD=3.5; Age MDD=1.94; 9-11: Age 9-11: DAYTRANA PTCH 10 NP MDD=4.5; Age MDD=2.5; Age MG/9HR 12-17: MDD=6; CONCERTA TBCR 36 MG 2 12-17: (methylphenidate hcl) Age 18+: MDD=3.33; MDD=6;AL(At MDD=2;AL(At least 5 yrs old) least 5 yrs old); PA; Age 5-8: MP MDD=2.3; Age Age 5-8: MDD 9-11: MDD=3; =1.296; Age 9- DAYTRANA PTCH 15 NP Age 12-17: 11: MDD=1.67; MG/9HR MDD=4; Age Age 12-17: 18+: CONCERTA TBCR 54 MG 2 MDD=2.22; (methylphenidate hcl) MDD=4;;AL(At Age 18+: least 5 yrs old) MDD=1;AL(At PA; Age 5-8: least 5 yrs old); MDD=1.8; Age MP 9-11: PA; Age 5-8: DAYTRANA PTCH 20 NP MDD=2.3; Age MDD= 4; Age MG/9HR 12-17: MDD=3; 9-11: Age 18+: MDD=5.2; Age MDD=3;;AL(At COTEMPLA XR-ODT NP 12-17: least 5 yrs old) TBED 17.3 MG MDD=6.9; Age PA; Age 5-8: 18+: MDD=1.2; Age MDD=6.9;;AL( 9-11: At least 5 yrs DAYTRANA PTCH 30 NP MDD=1.5; Age old) MG/9HR 12-17: MDD=2; PA; Age 5-8: Age 18+: MDD=2.7; Age MDD=2;;AL(At 9-11: least 5 yrs old) MDD=3.5; Age Age 5-8: COTEMPLA XR-ODT NP 12-17: MDD=3.5; Age TBED 25.9 MG MDD=4.6; Age 9-11: 18+: MDD=4.5; Age dexmethylphenidate hcl MDD=4.6;AL(A 1 12-17: MDD=6; t least 5 yrs cp24 10 mg Age 18+: old) MDD=1;AL(At least 5 yrs old); MP

Coordinated Care of Washington Updated September 1, 2021

11 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Age 5-8: Age 5-8: MDD=2.3; Age MDD=0.9; Age 9-11: MDD=3; 9-11: Age 12-17: MDD=1.1; Age dexmethylphenidate hcl 1 MDD=4; Age 12-17: cp24 15 mg dexmethylphenidate hcl 1 18+: cp24 40 mg MDD=1.5; Age MDD=1;AL(At 18+: least 5 yrs old); MDD=1.5;;AL(A MP t least 5 yrs Age 5-8: old); MP MDD=1.8; Age Age 5-8: 9-11: MDD=7; Age 9- MDD=2.3; Age 11: MDD=9; dexmethylphenidate hcl 1 12-17: MDD=3; Age 12-17: cp24 20 mg dexmethylphenidate hcl 1 Age 18+: cp24 5 mg MDD=12; Age MDD=1;AL(At 18+: MDD=1 least 5 yrs old); ;AL(At least 5 MP yrs old) Age 5-8: Age 5-8: MDD=1.4; Age MDD=3.5; Age 9-11: 9-11: MDD=1.8; Age MDD=4.5; Age dexmethylphenidate hcl dexmethylphenidate hcl 1 12-17: 1 12-17: MDD=6; cp24 25 mg MDD=2.4; Age tabs 10 mg Age 18+: 18+:MDD=2.4;; MDD=2;AL(At AL(At least 5 least 5 yrs old); yrs old); MP MP Age 5-8: Age 5-8: MDD= MDD=1.2; Age 14; Age 9-11: 9-11: MDD=18; Age MDD=1.5; Age 12-17: dexmethylphenidate hcl 1 12-17: MDD=2; dexmethylphenidate hcl 1 MDD=24; Age cp24 30 mg tabs 2.5 mg Age 18+: 18+: MDD=2;;AL(At MDD=2;AL(At least 5 yrs old); least 5 yrs old); MP MP Age 5-8: Age 5-8: MDD=1; Age 9- MDD=7; Age 9- 11: MDD=1.3; 11: MDD=9; Age 12-17: Age 12-17: dexmethylphenidate hcl 1 MDD=1.7; Age dexmethylphenidate hcl 1 MDD=12; Age cp24 35 mg tabs 5 mg 18+: 18+: PA, MDD=1.7;;AL( MDD=2;AL(At At least 5 yrs least 5 yrs old); old); MP MP

Coordinated Care of Washington Updated September 1, 2021

12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Age 5-8: Age 5-8: MDD=3.5; Age MDD=1.8; Age 9-11: 9-11: MDD=4.5; Age MDD=2.3; Age FOCALIN TABS 10 MG 2 FOCALIN XR CP24 20 MG NP ) 12-17: MDD=6; ) 12-17: MDD=3; (dexmethylphenidate hcl Age 18+: (dexmethylphenidate hcl Age 18+: MDD=2;AL(At MDD=1;AL(At least 5 yrs old); least 5 yrs old); MP MP Age 5-8: MDD= Age 5-8: 14; Age 9-11: MDD=1.4; Age MDD=18; Age 9-11: 12-17: MDD=1.8; Age FOCALIN TABS 2.5 MG 2 MDD=24; Age FOCALIN XR CP24 25 MG NP 12-17: (dexmethylphenidate hcl) (dexmethylphenidate hcl) 18+: MDD=2.4; Age MDD=2;AL(At 18+:MDD=2.4;; least 5 yrs old); AL(At least 5 MP yrs old); MP Age 5-8: Age 5-8: MDD=7; Age 9- MDD=1.2; Age 11: MDD=9; 9-11: Age 12-17: MDD=1.5; Age FOCALIN TABS 5 MG 2 MDD=12; Age FOCALIN XR CP24 30 MG NP 12-17: MDD=2; (dexmethylphenidate hcl) (dexmethylphenidate hcl) 18+: PA, Age 18+: MDD=2;AL(At MDD=2;;AL(At least 5 yrs old); least 5 yrs old); MP MP Age 5-8: Age 5-8: MDD=3.5; Age MDD=1; Age 9- 9-11: 11: MDD=1.3; MDD=4.5; Age Age 12-17: FOCALIN XR CP24 10 MG NP 12-17: MDD=6; FOCALIN XR CP24 35 MG NP MDD=1.7; Age (dexmethylphenidate hcl) (dexmethylphenidate hcl) Age 18+: 18+: MDD=1;AL(At MDD=1.7;;AL(A least 5 yrs old); t least 5 yrs MP old); MP Age 5-8: Age 5-8: MDD=2.3; Age MDD=0.9; Age 9-11: MDD=3; 9-11: Age 12-17: MDD=1.1; Age FOCALIN XR CP24 15 MG NP MDD=4; Age (dexmethylphenidate hcl) FOCALIN XR CP24 40 MG NP 12-17: 18+: (dexmethylphenidate hcl) MDD=1.5; Age MDD=1;AL(At 18+: least 5 yrs old); MDD=1.5;;AL(A MP t least 5 yrs old); MP

Coordinated Care of Washington Updated September 1, 2021

13 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Age 5-8: PA; Age 5-8: MDD=7; Age 9- MDD=0.875; 11: MDD=9; Age 9-11: FOCALIN XR CP24 5 MG NP Age 12-17: MDD=1.125; (dexmethylphenidate hcl) MDD=12; Age JORNAY PM CP24 80 MG NP Age 12-17: 18+: MDD=1 MDD=1.5; Age ;AL(At least 5 18+: yrs old) MDD=1.5;AL(At PA; Age 5-8: least 5 yrs old) MDD=0.7; Age Age 5-8: 9-11: MDD=35; Age MDD=0.9; Age METHYLIN SOLN 10 9-11: MDD=45; JORNAY PM CP24 100 NP methylphenidate 2 Age 12-17: MG 12-17: MG/5ML ( MDD=1.2; Age hcl) MDD=60;AL(At 18+: MDD=1.2 least 5 yrs old); AL(At least 5 MP yrs old) Age 5-8: PA; Age 5-8: MDD=70; Age MDD=3.5; Age METHYLIN SOLN 5 9-11: MDD=90; 9-11: MG/5ML (methylphenidate 2 Age 12-17: hcl) MDD=120;AL(A JORNAY PM CP24 20 MG NP MDD=4.5; Age 12-17: MDD=6; t least 5 yrs Age 18+: old); MP MDD=6;AL(At methylphenidate hcl chew NP PA; AL(At least least 5 yrs old) 10 mg, 2.5 mg, 5 mg 5 yrs old); MP PA; Age 5-8: Age 5-8: MDD=1.75; MDD=7; Age 9- Age 9-11: 11: MDD=9; MDD=2.25; methylphenidate hcl cp24 1 Age 12-17: JORNAY PM CP24 40 MG NP Age 12-17: 10 mg MDD=12; Age MDD=3; Age 18+: MDD=1 18+: ;AL(At least 5 MDD=3;AL(At yrs old); MP least 5 yrs old) PA; Age 5-8: PA; Age 5-8: MDD=7; Age 9- MDD=1.17; 11: MDD=9; Age 9-11: methylphenidate hcl cp24 Age 12-17: MDD=1.5; Age NP JORNAY PM CP24 60 MG NP 10 mg MDD=12; Age 12-17: MDD=2; 18+: MDD=1 Age 18+: ;AL(At least 5 MDD=2;AL(At yrs old); MP least 5 yrs old) PA; Age 5-8: MDD=4.7; Age 9-11: MDD=6; Age 12-17: methylphenidate hcl cp24 NP MDD=8; Age 15 mg 18+: MDD=1;AL(At least 5 yrs old); MP

Coordinated Care of Washington Updated September 1, 2021

14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Age 5-8: PA; Age 5-8: MDD=3.5; Age MDD=1.8; Age 9-11: 9-11: MDD=4.5; Age MDD=2.3; Age methylphenidate hcl cp24 methylphenidate hcl cp24 1 12-17: MDD=6; NP 12-17: MDD=3; 20 mg Age 18+: 40 mg Age 18+: MDD=1;AL(At MDD=3;AL(At least 5 yrs old); least 5 yrs old); MP MP PA; Age 5-8: PA; Age 5-8: MDD=3.5; Age MDD=1.4; Age 9-11: 9-11: MDD=4.5; Age MDD=1.8; Age methylphenidate hcl cp24 methylphenidate hcl cp24 NP 12-17: MDD=6; NP 12-17: 20 mg Age 18+: 50 mg MDD=2.4; Age MDD=6;AL(At 18+:MDD=2.4; least 5 yrs old); AL(At least 5 MP yrs old); MP Age 5-8: Age 5-8: MDD=2.3; Age MDD=1.2; Age 9-11: MDD=3; 9-11: Age 12-17: MDD=1.5; Age methylphenidate hcl cp24 1 MDD=4; Age methylphenidate hcl cp24 1 12-17: MDD=2; 30 mg 60 mg 18+: Age 18+: MDD=4;;AL(At MDD=2 AL(At least 5 yrs old); least 5 yrs old); MP MP PA; Age 5-8: methylphenidate hcl cp24 NP PA; AL(At least MDD=2.3; Age 60 mg 5 yrs old); MP 9-11: MDD=3; Age 5-8: Age 12-17: MDD=7; Age 9- methylphenidate hcl cp24 NP MDD=4; Age 30 mg 11: MDD=9; 18+: Age 12-17: MDD=4;AL(At methylphenidate hcl cpcr 1 MDD=12; Age 10 mg least 5 yrs old); 18+: MP MDD=1;AL(At Age 5-8: least 5 yrs old); MDD=1.8; Age MP 9-11: Age 5-8: MDD=2.3; Age methylphenidate hcl cp24 MDD=3.5; Age 1 12-17: MDD=3; 40 mg 9-11: Age 18+: MDD=4.5; Age methylphenidate hcl cpcr MDD=3;;AL(At 1 12-17: MDD=6; least 5 yrs old); 20 mg Age 18+: MP MDD=1;AL(At least 5 yrs old); MP

Coordinated Care of Washington Updated September 1, 2021

15 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Age 5-8: Age 5-8: MDD=2.33; MDD=7; Age 9- Age 9-11: 11: MDD=9; MDD=3; Age Age 12-17: methylphenidate hcl cpcr 1 12-17: MDD= methylphenidate hcl tabs 1 MDD=12; Age 30 mg 10 mg 4; Age 18+: 18+: MDD=1;;AL(At MDD=3;AL(At least 5 yrs old); least 5 yrs old); MP MP Age 5-8: Age 5-8: MDD=1.75; MDD=3.5; Age Age 9-11: 9-11: MDD=2.25; MDD=4.5; Age methylphenidate hcl cpcr methylphenidate hcl tabs 1 Age 12-17: 1 12-17: MDD=6; 40 mg MDD=3; Age 20 mg Age 18+: 18+:MDD=1;AL MDD=3;AL(At (At least 5 yrs least 5 yrs old); old); MP MP Age 5-8: MDD= Age 5-8: 1.4; Age 9-11: MDD=14; Age MDD=1.8; Age 9-11: MDD=18: methylphenidate hcl cpcr 1 12-17: MDD Age 12-17: 2.4; Age 18+: methylphenidate hcl tabs 5 1 MDD=24; Age 50 mg mg MDD=1;AL(At 18+: least 5 yrs old); MDD=3;AL(At MP least 5 yrs old); Age 5-8: MP MDD=1.167; Age 5-8: Age 9-11: MDD=3.88; MDD=1.5; Age Age 9-11: methylphenidate hcl cpcr 1 12-17: MDD=2; MDD=5; Age 60 mg Age methylphenidate hcl tb24 1 12-17: 18+:MDD=1;AL 18 mg MDD=6.66; (At least 5 yrs Age 18+: old); MP MDD=1;AL(At Age 5-8: least 5 yrs old); MDD=35; Age MP 9-11: MDD=45; Age 5-8: methylphenidate hcl soln 1 Age 12-17: 10 mg/5ml MDD=2.59; MDD=60;AL(At Age 9-11: least 5 yrs old); MDD=3.33; MP methylphenidate hcl tb24 1 Age 12-17: Age 5-8: 27 mg MDD=4.44; MDD=70; Age Age 18+: 9-11: MDD=90; MDD=1;AL(At methylphenidate hcl soln 5 1 Age 12-17: least 5 yrs old); mg/5ml MDD=120;AL( MP At least 5 yrs old); MP

Coordinated Care of Washington Updated September 1, 2021

16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Age 5-8: Age 5-8: MDD=1.94; MDD=2.59; Age 9-11: Age 9-11: MDD=2.5; Age MDD=3.33; methylphenidate hcl tb24 1 12-17: methylphenidate hcl tbcr 27 1 Age 12-17: 36 mg MDD=3.33; mg MDD=4.44; Age 18+: Age MDD=2;AL(At 18+:MDD=1;AL least 5 yrs old); (At least 5 yrs MP old); MP Age 5-8: MDD Age 5-8: =1.296; Age 9- MDD=1.94; 11: MDD=1.66; Age 9-11: Age 12-17: MDD=2.5; Age methylphenidate hcl tb24 1 MDD=2.22; methylphenidate hcl tbcr 36 1 12-17: 54 mg mg Age 18+: MDD=3.33; MDD=1;AL(At MDD=2;AL(At least 5 yrs old); least 5 yrs old); MP MP Age 5-8: Age 5-8: MDD MDD=7; Age 9- =1.296; Age 9- 11: MDD=9; 11: MDD=1.67; methylphenidate hcl tbcr 10 1 Age 12-17: Age 12-17: MDD=12; Age methylphenidate hcl tbcr 54 1 MDD=2.22; mg mg 18+: MDD=1 Age 18+: ;AL(At least 5 MDD=1;AL(At yrs old) least 5 yrs old); Age 5-8: MP MDD=3.89; Age 5-8: MDD Age 9-11: =0.97; Age 9- MDD=5; Age 11: MDD=1.25; methylphenidate hcl tbcr 18 1 12-17: METHYLPHENIDATE Age 12-17: mg MDD=6.67; HYDROCHLORIDE ER NP MDD=1.67; Age 18+: TBCR Age 18+: MDD=1;AL(At MDD=1.67;;AL( least 5 yrs old); At least 5 yrs MP old) Age 5-8: PA; AL(At least modafinil tabs 1 MDD=3.5; Age 18 yrs old); MP 9-11: NUVIGIL TABS PA; AL(At least MDD=4.5; Age NP methylphenidate hcl tbcr 20 (armodafinil) 18 yrs old); MP 1 12-17: MDD=6; mg Age 18+: PROVIGIL TABS NP PA; AL(At least MDD=1;AL(At (modafinil) 18 yrs old); MP PA; AL(At least least 5 yrs old); QUILLICHEW ER CHER NP MP 5 yrs old); MP QUILLIVANT XR SRER NP PA; AL(At least 5 yrs old); MP

Coordinated Care of Washington Updated September 1, 2021

17 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Age 5-8: MDD Age 5-8: =0.97; Age 9- MDD=7; Age 9- 11: MDD=1.25; 11: MDD=9; Age 12-17: Age 12-17: NP RITALIN TABS 10 MG NP MDD=12; Age RELEXXII TBCR MDD=1.67; (methylphenidate hcl) Age 18+: 18+: MDD=1.67;;AL( MDD=3;AL(At At least 5 yrs least 5 yrs old); old) MP Age 5-8: Age 5-8: MDD=7; Age 9- MDD=3.5; Age 11: MDD=9; 9-11: RITALIN LA CP24 10 MG NP Age 12-17: MDD=4.5; Age methylphenidate hcl) MDD=12; Age RITALIN TABS 20 MG NP 12-17: MDD=6; ( (methylphenidate hcl) 18+: MDD=1 Age 18+: ;AL(At least 5 MDD=3;AL(At yrs old); MP least 5 yrs old); Age 5-8: MP MDD=3.5; Age Age 5-8: 9-11: MDD=14; Age MDD=4.5; Age 9-11: MDD=18: RITALIN LA CP24 20 MG NP ) 12-17: MDD=6; Age 12-17: (methylphenidate hcl Age 18+: RITALIN TABS 5 MG NP MDD=24; Age (methylphenidate hcl) MDD=1;AL(At 18+: least 5 yrs old); MDD=3;AL(At MP least 5 yrs old); Age 5-8: MP MDD=2.3; Age 9-11: MDD=3; ALLERGENIC EXTRACTS/BIOLOGICALS MISC Age 12-17: Allergenic Extracts RITALIN LA CP24 30 MG NP MDD=4; Age (methylphenidate hcl) 18+: GRASTEK SUBL 2 PA MDD=4;;AL(At least 5 yrs old); ODACTRA SUBL 2 PA MP ORALAIR ADULT SAMPLE 2 PA Age 5-8: KIT SUBL MDD=1.8; Age 9-11: ORALAIR ADULT 2 PA MDD=2.3; Age STARTER PACK SUBL RITALIN LA CP24 40 MG NP 12-17: MDD=3; (methylphenidate hcl) ORALAIR PA Age 18+: CHILDREN/ADOLESCENT 2 MDD=3;;AL(At S SAMPLE KIT THPK least 5 yrs old); ORALAIR PA MP CHILDREN/ADOLESCENT 2 S STARTER PACK SUBL ORALAIR SUBL 2 PA PALFORZIA INITIAL PA DOSE ESCALATION 2 CSPK

Coordinated Care of Washington Updated September 1, 2021

18 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PALFORZIA LEVEL 1 2 PA KITABIS PAK NEBU 2 PA; SP CSPK (tobramycin) PALFORZIA LEVEL 10 2 PA neomycin sulfate tabs 1 CSPK PALFORZIA LEVEL 11 2 PA paromomycin sulfate caps 1 (MAINTENANCE) PACK PALFORZIA LEVEL 11 2 PA streptomycin sulfate solr 1 (TITRATION) PACK TOBI NEBU (tobramycin) NP PA; SP PALFORZIA LEVEL 2 2 PA CSPK TOBI PODHALER CAPS 2 PA; SP PALFORZIA LEVEL 3 2 PA CSPK tobramycin nebu 300 1 PA PALFORZIA LEVEL 4 2 PA mg/4ml CSPK tobramycin nebu 300 NP PA PALFORZIA LEVEL 5 2 PA mg/5ml CSPK tobramycin nebu 300 NP PA; SP PALFORZIA LEVEL 6 2 PA mg/5ml CSPK tobramycin sulfate soln 1 PALFORZIA LEVEL 7 2 PA CSPK tobramycin sulfate solr 1 PALFORZIA LEVEL 8 2 PA CSPK ANALGESICS - ANTI-INFLAMMATORY - Drugs to Treat Pain, Swelling, Muscle and Joint PALFORZIA LEVEL 9 2 PA CSPK Conditions RAGWITEK SUBL 2 PA Analgesics - Anti-inflammatory Combinations EQUAPAX/IBUPROFEN/M NP PA AMEBICIDES INREX THPK PA Amebicides PRASTERA KIT NP SOLOSEC PACK 2 PA Anti-TNF-alpha - Monoclonal Antibodies HUMIRA PEDIATRIC PA AMINOGLYCOSIDES - Drugs to Treat Bacterial CROHNS DISEASE 2 Infections STARTER PACK PSKT Aminoglycosides HUMIRA PEN PNKT 2 PA; SP amikacin sulfate soln 1 HUMIRA PEN-CD/UC/HS 2 PA; SP STARTER PNKT ARIKAYCE SUSP NP PA HUMIRA PEN-PEDIATRIC PA; SP UC STARTER PACK 2 BETHKIS NEBU 2 PA (tobramycin) PNKT gentamicin in saline soln 1 HUMIRA PEN-PS/UV 2 PA; SP STARTER PNKT gentamicin sulfate soln 1 HUMIRA PSKT 10 2 PA MG/0.1ML, 20 MG/0.2ML HUMATIN CAPS NP HUMIRA PSKT 40 2 PA; SP (paromomycin sulfate) MG/0.4ML, 40 MG/0.8ML Coordinated Care of Washington Updated September 1, 2021

19 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SIMPONI ARIA SOLN NP PA ACTEMRA SOSY NP PA

SIMPONI SOAJ NP PA; SP KEVZARA SOAJ NP PA

SIMPONI SOSY NP PA; SP KEVZARA SOSY NP PA Antirheumatic - Enzyme Inhibitors Nonsteroidal Anti-inflammatory Agents (NSAIDs) OLUMIANT TABS 1 MG NP PA ACTIVE INJECTION KIT 2 PA KET-L KIT PA; SP OLUMIANT TABS 2 MG NP ACTIVE INJECTION KIT 2 PA KETMARC-L KIT PA RINVOQ TB24 NP ANJESO INJ NP PA PA ARTHROTEC 50 TBEC XELJANZ SOLN 1 MG/ML NP NP PA (diclofenac w/ misoprostol) XELJANZ TABS 10 MG NP PA ARTHROTEC 75 TBEC NP PA (diclofenac w/ misoprostol) XELJANZ TABS 5 MG NP PA; SP CELEBREX CAPS NP PA; MP (celecoxib) XELJANZ XR TB24 11 MG NP PA; SP celecoxib caps NP PA; MP XELJANZ XR TB24 22 MG NP PA DAYPRO TABS NP PA; MP Antirheumatic Antimetabolites (oxaprozin) PA DFS DR/MS/MENTH/CAP NP PA OTREXUP SOAJ NP PAK KIT PA RASUVO SOAJ 2 PA DICLOFENAC CAPS NP MP REDITREX SOSY NP PA diclofenac potassium tabs 1 Gold Compounds diclofenac sodium tb24 1 MP MP RIDAURA CAPS 2 diclofenac sodium tbec 1 MP Interleukin-1 Blockers diclofenac sodium- NP PA capsaicin thpk ARCALYST SOLR NP PA; SP diclofenac w/ misoprostol PA Interleukin-1 Receptor Antagonist (IL-1Ra) tbec 75 mg-200 mcg, 0.2 NP mg-50 mg, 50 mg-200 mcg KINERET SOSY NP PA; SP DUEXIS TABS (ibuprofen- NP PA Interleukin-1beta Blockers famotidine) PA EC-NAPROSYN TBEC NP QL(2 ea daily); ILARIS SOLN NP (naproxen) MP etodolac caps 200 mg, 300 MP Interleukin-6 Receptor Inhibitors NP mg ACTEMRA ACTPEN SOAJ NP PA etodolac tabs 400 mg NP PA; MP ACTEMRA SOLN NP PA

Coordinated Care of Washington Updated September 1, 2021

20 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits etodolac tabs 500 mg NP MP ketoprofen cp24 or 200 mg NP PA; MP etodolac tb24 400 mg, 500 NP PA; MP KETOROCAINE-L KIT 2 PA mg, 600 mg PA FELDENE CAPS NP PA; MP KETOROCAINE-LM KIT 2 (piroxicam) ketorolac tromethamine PA FENOPROFEN CALCIUM NP PA; MP 1 CAPS 200 MG soln ij 15 mg/ml, 30 mg/ml KETOROLAC PA fenoprofen calcium caps NP PA; MP 200 mg, 400 mg TROMETHAMINE SOLN IJ 2 30 MG/ML fenoprofen calcium tabs NP PA; MP 600 mg ketorolac tromethamine PA soln im 30 mg/ml, 60 1 FENORTHO CAPS NP PA; MP mg/2ml MP KETOROLAC PA flurbiprofen tabs 1 TROMETHAMINE SOLN NP NA 15.75 MG/SPRAY PA IBU 600-EZS KIT NP QL(20 ea per PA ketorolac tromethamine 1 30 days retail); IBUPAK KIT NP tabs or 10 mg AL(At least 17 yrs old) ibuprofen chew 100 mg 1 LIDOVIX KIT NP PA ibuprofen susp 100 mg/5ml 1 RX/OTC; MP LODINE TABS (etodolac) NP PA; MP ibuprofen susp 40 mg/ml, 1 MP 50 mg/1.25ml meclofenamate sodium NP MP caps ibuprofen tabs 100 mg 1 mefenamic acid caps NP PA; MP ibuprofen tabs 400 mg, 600 1 MP mg, 800 mg, 200 mg meloxicam caps 10 mg, 5 NP PA mg ibuprofen-famotidine tabs NP PA meloxicam tabs 15 mg, 7.5 1 MP mg INDOCIN SUPP 2 MOBIC TABS (meloxicam) NP MP INDOCIN SUSP 2 MOTRIN CHILDRENS 2 indomethacin caps 20 mg NP PA CHEW (ibuprofen) nabumetone tabs 1 MP indomethacin caps 25 mg, 1 MP 50 mg NALFON CAPS 400 MG NP PA; MP indomethacin cpcr 75 mg NP MP NALFON TABS 600 MG NP PA; MP (fenoprofen calcium) INFLATHERM THPK 3 %-3 NP PA %-75 MG NAPRELAN TB24 NP PA ketoprofen caps or 25 mg NP (naproxen sodium) NAPROSYN SUSP NP MP ketoprofen caps or 50 mg, NP MP (naproxen) 75 mg

Coordinated Care of Washington Updated September 1, 2021

21 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NAPROSYN TABS NP MP SPRIX SOLN NP PA (naproxen) MP NAPROXEN COMFORT NP PA sulindac tabs 1 PAC KIT TIVORBEX CAPS 40 MG, PA naproxen sodium tabs 220 1 QL(2 ea daily); NP mg MP 20 MG tolmetin sodium caps 400 MP naproxen sodium tabs 550 NP PA; MP NP mg, 275 mg mg tolmetin sodium tabs 600 MP naproxen sodium tb24 750 NP PA NP mg, 375 mg, 500 mg mg PA naproxen susp 125 mg/5ml 1 MP TORONOVA II SUIK KIT 2 PA naproxen tabs 250 mg, 375 1 MP TORONOVA SUIK KIT 2 mg, 500 mg VIMOVO TBEC (naproxen- NP PA naproxen tbec 375 mg, 500 1 QL(2 ea daily); esomeprazole magnesium) mg MP VIVLODEX CAPS NP PA naproxen-esomeprazole NP PA (meloxicam) magnesium tbec ZIPSOR CAPS NP PA NUDROXIPAK DSDR-50 NP PA KIT ZORVOLEX CAPS 18 MG, NP PA NUDROXIPAK DSDR-75 NP PA 35 MG KIT Phosphodiesterase 4 (PDE4) Inhibitors NUDROXIPAK E-400 KIT NP PA OTEZLA TABS NP PA; SP NUDROXIPAK I-800 KIT NP PA OTEZLA TBPK NP PA; SP NUDROXIPAK M-15 KIT NP PA Pyrimidine Synthesis Inhibitors PA NUDROXIPAK N-500 KIT NP ARAVA TABS 10 MG NP PA; QL(1 ea (leflunomide) daily); MP PA NUDROXIPAK THPK NP ARAVA TABS 20 MG NP QL(1 ea daily); (leflunomide) MP oxaprozin tabs NP PA; MP leflunomide tabs 20 mg, 10 1 QL(1 ea daily); mg MP piroxicam caps NP PA; MP Selective Costimulation Modulators PREVIDOLRX PA NP ORENCIA CLICKJECT NP PA; SP ANALGESIC PAK THPK SOAJ PA QMIIZ ODT TBDP NP ORENCIA SOLR IV 250 NP PA MG READYSHARP PA ORENCIA SOSY SC 125 NP PA; SP ANESTHETICS 2 MG/ML +KETOROLAC KIT ORENCIA SOSY SC 50 NP PA READYSHARP 2 PA MG/0.4ML, 87.5 MG/0.7ML KETOROLAC KIT Soluble Tumor Necrosis Factor Receptor Agents RELAFEN DS TABS NP PA ENBREL MINI SOCT NP PA

Coordinated Care of Washington Updated September 1, 2021

22 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ENBREL SOLN 25 2 PA FIORINAL CAPS NP QL(4 ea daily) MG/0.5ML (butalbital-aspirin-caffeine) ENBREL SOLR 25 MG 2 PA; SP Analgesics Other 7T GUMMY ES CHEW 2 ENBREL SOSY 25 2 PA; SP MG/0.5ML, 50 MG/ML ACETAMINOPHEN CHEW 2 ENBREL SURECLICK 2 PA; SP OR 325 MG SOAJ acetaminophen chew or 80 1 ANALGESICS - NonNarcotic - Drugs to Treat mg, 160 mg Pain, Muscle and Joint Conditions acetaminophen elix or 160 1 Analgesic Combinations mg/5ml, 80 mg/2.5ml acetaminophen- acetaminophen liqd or 160 1 salicylamide- NP mg/5ml phenyltoloxamine caps acetaminophen soln or 160 mg/5ml, 325 mg/10.15ml, 1 ALLZITAL TABS NP 650 mg/20.3ml acetaminophen supp re QL(12 ea per butalbital-acetaminophen NP 1 caps 50 mg-300 mg 650 mg, 120 mg fill retail) butalbital-acetaminophen acetaminophen susp or tabs 25 mg-325 mg, 50 NP 160 mg/5ml, 650 1 mg-300 mg, 50 mg-325 mg mg/20.3ml, 80 mg/2.5ml butalbital-acetaminophen- acetaminophen tabs or 325 1 caffeine caps 40 mg-50 NP mg, 500 mg mg-300 mg acetaminophen tbcr or 650 1 butalbital-acetaminophen- QL(4 ea daily) mg caffeine caps 40 mg-50 NP acetaminophen tbdp or 160 1 mg-325 mg mg, 80 mg butalbital-acetaminophen- FEVERALL INFANTS 2 caffeine soln 40 mg/15ml- NP SUPP 50 mg/15ml-325 mg/15ml FEVERALL JUNIOR 2 QL(12 ea per butalbital-acetaminophen- QL(4 ea daily) STRENGTH SUPP fill retail) caffeine tabs 40 mg-50 mg- 1 TRIAMINIC FEVER 325 mg REDUCERPAIN 2 butalbital-aspirin-caffeine NP QL(4 ea daily) RELIEVER CHILDRENS caps SYRP BUTALBITAL/ACETAMINO TRIAMINIC FEVER PHEN CAPS (butalbital- NP REDUCERPAIN 2 acetaminophen) RELIEVER INFANTS SYRP BUTALBITAL/ASPIRIN/CA NP QL(4 ea daily) FFEINE TABS TYLENOL 8 HOUR ARTHRITISPAIN TBCR 2 ESGIC TABS (butalbital- NP QL(4 ea daily) acetaminophen-caffeine) (acetaminophen) FIORICET CAPS TYLENOL 8 HOUR TBCR 2 (butalbital-acetaminophen- NP (acetaminophen) caffeine)

Coordinated Care of Washington Updated September 1, 2021

23 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TYLENOL CHILDRENS CONZIP CP24 (tramadol NP AL(At least 21 CHEWABLES/PAIN + 2 hcl) yrs old) FEVER CHEW DILAUDID LIQD OR 1 PA; (acetaminophen) MG/ML (hydromorphone NP TYLENOL CHILDRENS 2 hcl) SUSP (acetaminophen) DILAUDID TABS OR 2 TYLENOL EXTRA MG, 4 MG, 8 MG NP STRENGTH TABS 2 (hydromorphone hcl) (acetaminophen) DOLOPHINE TABS NP PA TYLENOL FOR (methadone hcl) CHILDREN/ADULTS 2 DURAGESIC PT72 NP QL(15 ea per SUSP (acetaminophen) (fentanyl) 30 days retail) TYLENOL INFANTS fentanyl citrate lpop bu PA; PAIN+FEVER SUSP 2 1200 mcg, 1600 mcg, 200 NP (acetaminophen) mcg, 400 mcg, 600 mcg, TYLENOL INFANTS SUSP 2 800 mcg (acetaminophen) fentanyl citrate soct ij 100 NP PA TYLENOL TABS 2 mcg/2ml (acetaminophen) fentanyl citrate soln ij 1000 PA Salicylates mcg/20ml, 250 mcg/5ml, NP 2500 mcg/50ml, 500 aspirin chew 1 mcg/10ml, 100 mcg/2ml FENTANYL CITRATE PA aspirin tabs 1 SOLN IJ 250 MCG/5ML, NP 100 MCG/2ML (fentanyl aspirin tbec 1 citrate) MP fentanyl citrate tabs bu 100 diflunisal tabs NP mcg, 200 mcg, 400 mcg, NP ECOTRIN REGULAR 600 mcg, 800 mcg STRENGTH TBEC 2 fentanyl pt72 td 100 QL(15 ea per (aspirin) mcg/hr, 12 mcg/hr, 25 1 30 days retail) mcg/hr, 50 mcg/hr, 75 ECOTRIN TBEC (aspirin) 2 mcg/hr MP fentanyl pt72 td 37.5 PA; salsalate tabs NP mcg/hr, 62.5 mcg/hr, 87.5 NP ANALGESICS - OPIOID - Drugs to Treat Pain, mcg/hr Muscle and Joint Conditions FENTORA TABS (fentanyl NP citrate) Opioid Agonists hydrocodone bitartrate NP PA; ACTIQ LPOP (fentanyl NP PA; cp12 citrate) hydrocodone bitartrate t24a NP PA; ARYMO ER TBEA NP PA; hydromorphone hcl liqd or NP PA; CODEINE SULFATE TABS 2 AL(At least 21 1 mg/ml 15 MG, 60 MG yrs old) HYDROMORPHONE HCL AL(At least 21 2 codeine sulfate tabs 30 mg 1 SUPP RE 3 MG yrs old)

Coordinated Care of Washington Updated September 1, 2021

24 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits hydromorphone hcl tabs or 1 morphine sulfate cp24 or PA; 2 mg, 4 mg, 8 mg 10 mg, 100 mg, 20 mg, 30 NP mg, 40 mg, 50 mg, 60 mg, hydromorphone hcl tb24 or NP PA; 32 mg, 12 mg, 16 mg, 8 mg 80 mg morphine sulfate soln or 10 PA; HYSINGLA ER T24A NP PA; (hydrocodone bitartrate) mg/5ml, 20 mg/5ml, 100 NP mg/5ml, 20 mg/ml KADIAN CP24 10 MG, 100 PA; morphine sulfate supp re MG, 20 MG, 30 MG, 40 NP 1 MG, 50 MG, 60 MG, 80 MG 10 mg, 20 mg, 30 mg (morphine sulfate) morphine sulfate supp re 5 1 QL(24 ea per mg fill retail) KADIAN CP24 200 MG NP PA; morphine sulfate tabs or 15 1 LAZANDA SOLN NP PA; mg, 30 mg morphine sulfate tbcr or QL(3 ea daily) levorphanol tartrate tabs 2 NP PA; 100 mg, 15 mg, 200 mg, 30 1 mg mg, 60 mg levorphanol tartrate tabs 3 PA NP MS CONTIN TBCR NP QL(3 ea daily) mg (morphine sulfate) meperidine hcl soln 50 PA; NP NP PA; mg/5ml NUCYNTA ER TB12 meperidine hcl tabs 50 mg NP NUCYNTA TABS NP PA; OPANA TABS PA; methadone hcl conc or 10 NP PA; QL(2 ml NP mg/ml daily) (oxymorphone hcl) PA; METHADONE HCL POWD NP PA; OXAYDO TABS NP XX PA; methadone hcl soln ij 10 NP PA; oxycodone hcl caps 5 mg NP mg/ml METHADONE HCL SOLN PA; oxycodone hcl conc 100 NP PA; IJ 10 MG/ML (methadone NP mg/5ml hcl) oxycodone hcl soln 5 1 mg/5ml methadone hcl soln or 10 NP PA mg/5ml, 5 mg/5ml oxycodone hcl t12a 15 mg, QL(2 ea daily) 30 mg, 60 mg, 80 mg, 10 NP methadone hcl tabs or 5 NP PA mg, 10 mg mg, 20 mg, 40 mg oxycodone hcl tabs 10 mg, AL(At least 18 methadone hcl tbso or 40 NP PA; QL(0.5 ea 1 mg daily) 20 mg yrs old) METHADONE PA oxycodone hcl tabs 15 mg, 1 HYDROCHLORIDE/SODIU NP 30 mg, 5 mg M CHLORIDE SOSY OXYCONTIN T12A NP QL(2 ea daily) METHADOSE CONC NP PA; QL(2 ml (methadone hcl) daily) oxymorphone hcl tabs 10 NP PA; mg, 5 mg METHADOSE SUGAR- PA; QL(2 ml FREE CONC (methadone NP daily) oxymorphone hcl tb12 10 hcl) mg, 15 mg, 20 mg, 40 mg, 1 5 mg, 7.5 mg, 30 mg morphine sulfate beads NP PA; cp24 Coordinated Care of Washington Updated September 1, 2021

25 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QDOLO SOLN NP PA butalbital-acetaminophen- 1 AL(At least 21 caffeine w/ codeine caps yrs old) ROXICODONE TABS 15 butalbital-aspirin-caffeine 1 AL(At least 21 MG, 30 MG (oxycodone NP w/cod caps yrs old) hcl) FIORICET/CODEINE AL(At least 21 ROXICODONE TABS 5 PA; NP CAPS (butalbital- NP yrs old) MG (oxycodone hcl) acetaminophen-caffeine w/ SUBSYS LIQD NP PA; codeine) FIORINAL/CODEINE #3 AL(At least 21 SYNAPRYN FUSEPAQ NP PA; CAPS (butalbital-aspirin- NP yrs old) SUSR caffeine w/cod) tramadol hcl cp24 100 mg, NP AL(At least 21 hydrocodone- 200 mg, 300 mg yrs old) acetaminophen soln 10 PA; mg/15ml-325 mg/15ml, 2.5 1 tramadol hcl cp24 150 mg NP mg/5ml-108 mg/5ml, 5 PA mg/10ml-217 mg/10ml, 7.5 tramadol hcl tabs 100 mg NP mg/15ml-325 mg/15ml AL(At least 21 hydrocodone- tramadol hcl tabs 50 mg 1 yrs old) acetaminophen tabs 10 mg-300 mg, 5 mg-300 mg, tramadol hcl tb24 100 mg, 1 AL(At least 21 1 200 mg, 300 mg yrs old) 7.5 mg-300 mg, 10 mg-325 mg, 5 mg-325 mg, 7.5 mg- tramadol hcl tb24 100 mg, NP PA; AL(At least 325 mg 200 mg, 300 mg 21 yrs old) hydrocodone- PA; ULTRAM TABS (tramadol NP AL(At least 21 acetaminophen tabs 5 mg- NP hcl) yrs old) 325 mg XTAMPZA ER C12A NP PA; hydrocodone-ibuprofen tabs 10 mg-200 mg, 5 mg- 1 ZOHYDRO ER CP12 NP PA; 200 mg, 7.5 mg-200 mg (hydrocodone bitartrate) LORTAB ELIX NP PA; Opioid Combinations PA; acetaminophen w/ codeine 1 AL(At least 21 NALOCET TABS NP soln yrs old) NORCO TABS 10 MG-325 acetaminophen w/ codeine 1 AL(At least 21 tabs yrs old) MG (hydrocodone- NP acetaminophen) acetaminophen-caff- PA; dihydrocod caps 16 mg-30 NP NORCO TABS 5 MG-325 PA; mg-320.5 mg MG, 7.5 MG-325 MG NP (hydrocodone- acetaminophen-caff- acetaminophen) dihydrocod tabs 16 mg-30 1 mg-325 mg OXYCODONE PA HYDROCHLORIDE/ACET NP acetaminophen-caff- AMINOPHEN SOLN dihydrocod tabs 16 mg-30 NP mg-325 mg oxycodone w/ 1 acetaminophen tabs APADAZ TABS NP PA oxycodone-aspirin tabs 1 BENZHYDROCODONE/A NP PA CETAMINOPHEN TABS

Coordinated Care of Washington Updated September 1, 2021

26 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OXYCODONE/ACETAMIN NP PA; PA required if > OPHEN TABS buprenorphine hcl- 32mg PERCOCET TABS naloxone hcl dihydrate film NP buprenorphine (oxycodone w/ NP 2 mg-8 mg per day;QL(4 acetaminophen) ea daily) PA; PA required if > PRIMLEV TABS NP buprenorphine hcl- 32mg naloxone hcl dihydrate film NP buprenorphine PROLATE SOLN 10 NP PA MG/5ML-300 MG/5ML 3 mg-12 mg per day;QL(2.7 ea daily) PROLATE TABS 10 MG- PA; 300 MG, 5 MG-300 MG, NP PA required if > 7.5 MG-300 MG buprenorphine hcl- 32mg naloxone hcl dihydrate subl 1 buprenorphine tramadol-acetaminophen 1 AL(At least 21 0.5 mg-2 mg per day;QL(16 tabs yrs old) ea daily) ULTRACET TABS NP AL(At least 21 PA required if > (tramadol-acetaminophen) yrs old) buprenorphine hcl- 32mg Opioid Partial Agonists naloxone hcl dihydrate subl 1 buprenorphine PA; 2 mg-8 mg per day;QL(4 BELBUCA FILM NP ea daily) BUNAVAIL FILM 0.3 MG- NP PA; QL(8 ea buprenorphine ptwk 1 2.1 MG daily) PA BUNAVAIL FILM 0.7 MG- NP PA; QL(4 ea butorphanol tartrate soln NP 4.2 MG daily) BUTRANS PTWK NP BUNAVAIL FILM 1 MG-6.3 NP PA; QL(2.7 ea (buprenorphine) MG daily) pentazocine w/ naloxone NP PA; BUPRENEX SOLN NP tabs (buprenorphine hcl) PROBUPHINE IMPLANT 2 PA buprenorphine hcl film bu PA; KIT IMPL 150 mcg, 300 mcg, 450 NP mcg, 600 mcg, 75 mcg, SUBLOCADE SOSY 100 2 QL(0..5 ml per 750 mcg, 900 mcg MG/0.5ML 30 days retail) SUBLOCADE SOSY 300 QL(1.5 ml per buprenorphine hcl soln ij NP 2 0.3 mg/ml MG/1.5ML 30 days retail) PA required if > buprenorphine hcl subl sl 2 NP PA; QL(16 ea mg daily) SUBOXONE FILM 0.5 MG- 32mg 2 MG (buprenorphine hcl- 2 buprenorphine buprenorphine hcl subl sl 8 NP PA; QL(4 ea naloxone hcl dihydrate) per day;QL(16 mg daily) ea daily) buprenorphine hcl- PA; QL(16 ea PA required if > naloxone hcl dihydrate film NP daily) SUBOXONE FILM 1 MG-4 32mg 0.5 mg-2 mg MG (buprenorphine hcl- 2 buprenorphine PA required if > naloxone hcl dihydrate) per day;QL(8 buprenorphine hcl- 32mg ea daily) naloxone hcl dihydrate film NP buprenorphine PA required if > 1 mg-4 mg per day;QL(8 SUBOXONE FILM 2 MG-8 32mg ea daily) MG (buprenorphine hcl- 2 buprenorphine naloxone hcl dihydrate) per day;QL(4 ea daily) Coordinated Care of Washington Updated September 1, 2021

27 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA required if > PA; QL(120 gm 32mg FORTESTA GEL NP per 30 days SUBOXONE FILM 3 MG- (testosterone) 12 MG (buprenorphine hcl- 2 buprenorphine retail) naloxone hcl dihydrate) per day;QL(2.7 PA ea daily) JATENZO CAPS NP ZUBSOLV SUBL 0.18 MG- PA; QL(32.6 ea NP METHITEST TABS NP PA; QL(5 ea 0.7 MG daily) daily) ZUBSOLV SUBL 0.36 MG- PA; QL(16.3 ea PA; QL(5 ea NP methyltestosterone caps NP 1.4 MG daily) daily) ZUBSOLV SUBL 0.71 MG- NP PA; QL(7.9 ea NATESTO GEL NP PA 2.9 MG daily) ZUBSOLV SUBL 1.4 MG- PA; QL(4 ea PA; QL(300 gm NP TESTIM GEL NP 5.7 MG daily) (testosterone) per 30 days retail); MP ZUBSOLV SUBL 2.1 MG- NP PA; QL(2.7 ea 8.6 MG daily) TESTOPEL PLLT NP PA ZUBSOLV SUBL 2.9 MG- NP PA; QL(2 ea 11.4 MG daily) TESTOSTERONE ST; QL(2 ml CYPIONATE SOLN IJ 200 NP per 28 days ANDROGENS-ANABOLIC - Drugs to Regulate MG/ML retail) Hormones PA; QL(4 ml testosterone cypionate soln 1 per 28 days Anabolic Steroids im 100 mg/ml retail) ANADROL-50 TABS 2 PA PA; QL(2 ml testosterone cypionate soln 1 per 28 days PA im 200 mg/ml oxandrolone tabs 1 retail) Androgens ST; QL(2 ml testosterone enanthate NP per 28 days ANDRODERM PT24 2 PA; QL(1 ea soln im daily) retail) ANDROGEL GEL 25 PA; QL(300 gm PA; QL(300 gm MG/2.5GM, 50 MG/5GM NP per 30 days testosterone gel td 1 % 1 per 30 days (testosterone) retail); MP retail) ANDROGEL GEL 40.5 PA; QL(150 gm ST; QL(120 gm testosterone gel td 10 NP per 30 days MG/2.5GM, 20.25 NP per 30 days mg/act MG/1.25GM (testosterone) retail) retail) PA; QL(300 gm PA; QL(150 gm testosterone gel td 25 ANDROGEL PUMP GEL NP per 30 days 1 per 30 days (testosterone) mg/2.5gm, 1 %, 50 mg/5gm retail) retail); MP ST testosterone gel td 40.5 ST; QL(150 gm AVEED SOLN NP mg/2.5gm, 1.62 %, 20.25 NP per 30 days mg/1.25gm retail) danazol caps 1 TESTOSTERONE PLLT IL PA DEPO-TESTOSTERONE PA; QL(4 ml 100 MG, 200 MG, 25 MG, NP SOLN 100 MG/ML NP per 28 days 50 MG (testosterone cypionate) retail) PA; QL(180 ml testosterone soln td 30 NP per 30 days DEPO-TESTOSTERONE PA; QL(2 ml mg/act SOLN 200 MG/ML NP per 28 days retail) (testosterone cypionate) retail)

Coordinated Care of Washington Updated September 1, 2021

28 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; QL(300 gm RECTIV OINT 2 PA VOGELXO GEL NP per 30 days (testosterone) retail); MP ANTACIDS PA; QL(300 gm VOGELXO PUMP GEL NP per 30 days (testosterone) Antacid Combinations retail) ST; QL(2 ml MAG-AL LIQD 2 XYOSTED SOAJ 100 NP MG/0.5ML, 75 MG/0.5ML per 28 days Antacids - Bicarbonate retail); SP SODIUM BICARBONATE NP PA; RX/OTC ST; QL(2 ml POWD OR XYOSTED SOAJ 50 NP MG/0.5ML per 28 days retail) Antacids - Calcium Salts ANORECTAL AND RELATED PRODUCTS - calcium carbonate (antacid) 1 QL(16.67 ml Rectal Drugs to Treat Pain, Swelling and Itching susp daily) CALCIUM CARBONATE 2 Intrarectal Steroids TABS 648 MG CORTENEMA ENEM QL(420 ml per (hydrocortisone NP fill retail) ANTHELMINTICS - Drugs to Treat Worm (intrarectal)) Infections CORTIFOAM FOAM NP PA Anthelmintics AL(At least 18 albendazole tabs 1 hydrocortisone (intrarectal) 1 QL(420 ml per yrs old) enem fill retail) PA; AL(At least albendazole tabs NP UCERIS FOAM RE 2 NP PA 18 yrs old) MG/ACT ALBENZA TABS NP PA; AL(At least Rectal Combinations (albendazole) 18 yrs old) LIDOCAINE HCL- PA BENZNIDAZOLE TABS NP PA HYDROCORTISONE NP ACETATE WITH ALOE BILTRICIDE TABS NP PA GEL (praziquantel) lidocaine-hydrocortisone EGATEN TABS 2 acetate (rectal) crea ex 0.5 1 %-3 % PA; QL(1 ea lidocaine-hydrocortisone PA EMVERM CHEW NP per 14 days retail) acetate (rectal) kit re 0.5 NP %-3 %, 1 %-3 %, 2.5 %-3 ivermectin tabs or 3 mg 1 %, 2 %-2 % PA PROCTOFOAM HC FOAM NP PA praziquantel tabs NP Rectal Steroids 1 fill per 30 days;QL(60 ml ANUSOL-HC CREA NP pyrantel pamoate susp 1 per fill retail,60 (hydrocortisone (rectal)) ml per 30 days hydrocortisone (rectal) crea 1 retail) STROMECTOL TABS NP PROCTOCORT CREA NP (ivermectin) (hydrocortisone (rectal)) ANTI-INFECTIVE AGENTS - MISC. - Drugs to Vasodilating Agents Treat Bacterial Infections Coordinated Care of Washington Updated September 1, 2021

29 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Anti-infective Agents - Misc. methenamine-hyosc- methylene blue-sod phos- NP PA AEMCOLO TBEC NP phenyl sal tabs PA methenamine-hyoscamine- bacitracin solr 1 methylene blue-sodium NP phosphate tabs FIRST-METRONIDAZOLE NP PA 50 SUSR sulfamethoxazole- PA trimethoprim soln iv 80 1 FLAGYL CAPS 375 MG NP PA (metronidazole) mg/5ml-400 mg/5ml sulfamethoxazole- FLAGYL TABS 500 MG NP (metronidazole) trimethoprim susp or 40 1 mg/5ml-200 mg/5ml IMPAVIDO CAPS NP sulfamethoxazole- METRONIDAZOLE PA trimethoprim tabs or 160 1 BENZOATE/SYRSPEND NP mg-800 mg, 80 mg-400 mg SF PH4 SUSR URIMAR-T TABS NP PA metronidazole caps 375 NP PA mg UROGESIC-BLUE TABS PA (methenamine- NP metronidazole tabs 250 1 hyoscamine-methylene mg, 500 mg blue-sodium phosphate) NEBUPENT SOLR 2 PA (pentamidine isethionate) Antiprotozoal Agents ALINIA SUSR 100 MG/5ML 2 PA pentamidine isethionate 1 PA solr ALINIA TABS 500 MG 2 PA PRIMSOL SOLN 2 (nitazoxanide) tinidazole tabs 1 atovaquone susp 1 PA trimethoprim tabs 1 LAMPIT TABS 2 PA MEPRON SUSP NP XIFAXAN TABS 200 MG 2 (atovaquone) PA XIFAXAN TABS 550 MG 2 PA; MP nitazoxanide tabs or 1 Anti-infective Misc. - Combinations Carbapenems BACTRIM DS TABS ertapenem sodium solr 1 PA (sulfamethoxazole- NP trimethoprim) Glycopeptides BACTRIM TABS FIRVANQ SOLR 2 (sulfamethoxazole- NP trimethoprim) VANCOCIN CAPS NP QL(8 ea daily) methenamine-hyosc- PA (vancomycin hcl) methylene blue-benzoic NP VANCOCIN HCL CAPS NP QL(4 ea daily) acid-phenyl sal tabs (vancomycin hcl) methenamine-hyosc- VANCOMYCIN HCL + NP PA methylene blue-sod phos- NP SYRSPENDSF PH4 SUSP phenyl sal caps

Coordinated Care of Washington Updated September 1, 2021

30 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits vancomycin hcl caps or 1 QL(4 ea daily) MACROBID CAPS 125 mg (nitrofurantoin monohyd NP macro) vancomycin hcl caps or 1 QL(8 ea daily) 250 mg MACRODANTIN CAPS 100 MG, 50 MG vancomycin hcl solr iv 1 1 QL(14 ea per NP gm, 1000 mg fill retail) (nitrofurantoin macrocrystal) vancomycin hcl solr iv 500 1 QL(14 ea per mg 30 days retail) MACRODANTIN CAPS 25 PA MG (nitrofurantoin NP VANCOMYCIN PA macrocrystal) HYDROCHLORIDE SOLR NP OR 250 MG/5ML methenamine hippurate 1 tabs Leprostatics methenamine mandelate 1 dapsone tabs 1 MP tabs MONUROL PACK NP PA Lincosamides (fosfomycin tromethamine) CLEOCIN CAPS OR 75 nitrofurantoin macrocrystal 1 MG, 150 MG, 300 MG NP caps 100 mg, 50 mg (clindamycin hcl) nitrofurantoin macrocrystal NP PA CLEOCIN PEDIATRIC caps 25 mg GRANULES SOLR NP nitrofurantoin monohyd 1 (clindamycin palmitate macro caps hydrochloride) nitrofurantoin susp 1 clindamycin hcl caps 1 ANTIANGINAL AGENTS - Drugs to Treat Chest clindamycin palmitate 1 hydrochloride solr Pain Monobactams Antianginals-Other PA; SP RANEXA TB12 NP PA; MP CAYSTON SOLR 2 (ranolazine) Oxazolidinones ranolazine tb12 1 PA; MP linezolid susr 1 Nitrates PA linezolid tabs 1 DILATRATE SR CPCR NP

SIVEXTRO TABS NP QL(6 ea per fill GONITRO PACK NP retail) ISORDIL TITRADOSE ZYVOX SUSR (linezolid) NP TABS 40 MG (isosorbide NP dinitrate) ZYVOX TABS (linezolid) NP ISORDIL TITRADOSE MP Urinary Anti-infectives TABS 5 MG (isosorbide NP dinitrate) fosfomycin tromethamine NP PA pack isosorbide dinitrate tabs 30 1 MP mg, 10 mg, 20 mg, 5 mg HIPREX TABS NP (methenamine hippurate) isosorbide dinitrate tabs 40 1 mg

Coordinated Care of Washington Updated September 1, 2021

31 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits isosorbide mononitrate 1 QL(2 ea daily); hydroxyzine pamoate caps 1 tabs 10 mg, 20 mg MP 100 mg, 25 mg isosorbide mononitrate 1 QL(1 ea daily); hydroxyzine pamoate caps 1 MP tb24 120 mg, 30 mg, 60 mg MP 50 mg NITRO-BID OINT 2 MP meprobamate tabs NP PA

NITRO-DUR PT24 0.1 MP VISTARIL CAPS 25 MG NP MG/HR, 0.2 MG/HR, 0.4 NP (hydroxyzine pamoate) MG/HR, 0.6 MG/HR VISTARIL CAPS 50 MG NP MP (nitroglycerin) (hydroxyzine pamoate) NITRO-DUR PT24 0.3 NP PA MG/HR, 0.8 MG/HR Benzodiazepines nitroglycerin cpcr or 6.5 MP ALPRAZOLAM INTENSOL NP 1 CONC mg, 9 mg, 2.5 mg alprazolam tabs 0.25 mg, QL(4 ea daily) PA 1 nitroglycerin in d5w soln 1 0.5 mg, 1 mg, 2 mg nitroglycerin pt24 td 0.1 MP alprazolam tb24 0.5 mg, 1 NP PA mg/hr, 0.2 mg/hr, 0.4 1 mg, 2 mg, 3 mg mg/hr, 0.6 mg/hr alprazolam tbdp 0.25 mg, NP 0.5 mg, 1 mg, 2 mg NITROGLYCERIN SOLN NP PA IV 5 MG/ML ATIVAN SOLN IJ 4 MG/ML, 2 MG/ML NP nitroglycerin soln tl 0.4 NP PA mg/spray (lorazepam) ATIVAN TABS OR 0.5 MG, QL(3 ea daily) nitroglycerin subl sl 0.3 mg, 1 MP NP 0.4 mg, 0.6 mg 2 MG (lorazepam) NITROLINGUAL PA ATIVAN TABS OR 1 MG NP QL(4 ea daily) PUMPSPRAY SOLN NP (lorazepam) (nitroglycerin) chlordiazepoxide hcl caps 1 QL(4 ea daily) NITROMIST AERS NP PA clorazepate dipotassium 1 QL(3 ea daily) tabs NITROSTAT SUBL NP MP (nitroglycerin) diazepam conc or 5 mg/ml 1 ANTIANXIETY AGENTS - Drugs to Treat Anxiety DIAZEPAM SOAJ IM 10 2 MG/2ML Antianxiety Agents - Misc. DIAZEPAM SOLN IJ 5 QL(3 ea daily); 2 buspirone hcl tabs 1 MG/ML MP diazepam soln ij 5 mg/ml, 1 droperidol soln 1 50 mg/10ml QL(500 ml per diazepam soln or 5 mg/5ml 1 DROPERIDOL SOLN 2 fill retail) diazepam tabs or 10 mg, 2 QL(4 ea daily) hydroxyzine hcl soln im 25 1 1 mg/ml, 50 mg/ml mg, 5 mg hydroxyzine hcl syrp or 10 1 lorazepam conc or 2 mg/ml 1 mg/5ml lorazepam soln ij 4 mg/ml, hydroxyzine hcl tabs or 10 1 MP 1 mg, 25 mg, 50 mg 2 mg/ml, 20 mg/10ml

Coordinated Care of Washington Updated September 1, 2021

32 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits lorazepam tabs or 0.5 mg, 1 QL(3 ea daily) lidocaine in d5w soln 1 PA 2 mg MP lorazepam tabs or 1 mg 1 QL(4 ea daily) mexiletine hcl caps 1 oxazepam caps 10 mg, 30 NP QL(4 ea daily) Antiarrhythmics Type I-C mg, 15 mg flecainide acetate tabs 1 MP TRANXENE T TABS NP QL(3 ea daily) (clorazepate dipotassium) propafenone hcl cp12 1 MP VALIUM TABS (diazepam) NP QL(4 ea daily) propafenone hcl tabs 1 MP XANAX TABS (alprazolam) NP QL(4 ea daily) RYTHMOL SR CP12 NP MP (propafenone hcl) XANAX XR TB24 NP PA (alprazolam) Antiarrhythmics Type III ANTIARRHYTHMICS - Drugs to treat abnormal amiodarone hcl soln iv 450 PA heart rhythms mg/9ml, 50 mg/ml, 900 1 Antiarrhythmics - Misc. mg/18ml, 150 mg/3ml amiodarone hcl tabs or 100 MP ADENOCARD SOLN 2 PA 1 (adenosine) mg, 200 mg, 400 mg amiodarone hcl tabs or 100 PA; MP adenosine soln 12 mg/4ml, 1 PA NP 3 mg/ml, 6 mg/2ml mg, 200 mg, 400 mg amiodarone hcl tabs or 400 1 Antiarrhythmics Type I-A mg disopyramide phosphate 1 MP AMIODARONE caps HYDROCHLORIDE/DEXT NORPACE CAPS NP MP ROSE SOLN 5 %-450 2 (disopyramide phosphate) MG/250ML, 5 %-900 MG/500ML NORPACE CR CP12 NP CORVERT SOLN (ibutilide 2 PA procainamide hcl soln 1 PA fumarate) dofetilide caps 1 MP quinidine gluconate tbcr 1 MP ibutilide fumarate soln 1 PA quinidine sulfate tabs NP MULTAQ TABS NP Antiarrhythmics Type I-B PA lidocaine hcl (cardiac) sosy 1 PA NEXTERONE SOLN 2 TIKOSYN CAPS MP LIDOCAINE HCL SOLN IV 2 PA NP 100 MG/5ML (dofetilide) LIDOCAINE PA ANTIASTHMATIC AND BRONCHODILATOR HYDROCHLORIDE SOSY 2 AGENTS - Drugs to Treat Lung Conditions IV 100 MG/10ML, 100 MG/5ML Anti-Inflammatory Agents LIDOCAINE PA QL(240 ml per HYDROCHLORIDE/DEXT 2 cromolyn sodium nebu 1 30 days retail); ROSE SOLN 2 MG/ML-5 % MP

Coordinated Care of Washington Updated September 1, 2021

33 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily); Antiasthmatic - Monoclonal Antibodies montelukast sodium pack 1 MP PA; MP CINQAIR SOLN 2 QL(1 ea daily); montelukast sodium tabs 1 MP FASENRA PEN SOAJ 2 PA SINGULAIR CHEW NP QL(1 ea daily); (montelukast sodium) MP FASENRA SOSY 2 PA; MP SINGULAIR PACK NP QL(1 ea daily); NUCALA SOAJ 100 NP PA (montelukast sodium) MP MG/ML SINGULAIR TABS NP QL(1 ea daily); NUCALA SOLR 100 MG NP PA; MP (montelukast sodium) MP zafirlukast tabs 1 MP NUCALA SOSY 100 NP PA MG/ML zileuton tb12 NP MP XOLAIR SOLR 2 PA ZYFLO TABS NP PA; MP XOLAIR SOSY 2 PA Selective Phosphodiesterase 4 (PDE4) Inhibitors Asthma and Bronchodilator Agent Combinations DALIRESP TABS 2 PA dyphylline-guaifenesin liqd NP PA Steroid Inhalants Bronchodilators - Anticholinergics ALVESCO AERS NP MP QL(26 gm per ATROVENT HFA AERS 2 30 days retail); ARMONAIR DIGIHALER NP PA MP AEPB ST; MP INCRUSE ELLIPTA AEPB NP ARNUITY ELLIPTA AEPB NP MP QL(375 ml per ASMANEX HFA AERO 100 NP MP ipratropium bromide soln 1 25 days retail); MCG/ACT, 200 MCG/ACT MP ASMANEX HFA AERO 50 NP LONHALA MAGNAIR NP MP MCG/ACT REFILL KIT SOLN ASMANEX TWISTHALER MP LONHALA MAGNAIR NP MP 120 METERED DOSES NP STARTER KIT SOLN AEPB SPIRIVA HANDIHALER 2 MP ASMANEX TWISTHALER MP CAPS 14 METERED DOSES NP AEPB SPIRIVA RESPIMAT NP PA; MP AERS ASMANEX TWISTHALER MP 30 METERED DOSES NP TUDORZA PRESSAIR NP ST; MP AEPB AEPB ASMANEX TWISTHALER MP YUPELRI SOLN NP 60 METERED DOSES NP Leukotriene Modulators AEPB ASMANEX TWISTHALER MP ACCOLATE TABS NP MP (zafirlukast) 7 METERED DOSES NP AEPB QL(1 ea daily); montelukast sodium chew 1 MP

Coordinated Care of Washington Updated September 1, 2021

34 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(120 ml per Limit 2 Inhalers 30 days retail); per budesonide (inhalation) 1 AL(At least 1 month;QL(6.7 susp yrs old - Up to albuterol sulfate aers in 108 1 gm per fill mcg/act 8 yrs old); MP retail,13.4 gm FLOVENT DISKUS AEPB QL(2 ea daily); per 30 days 100 MCG/BLIST, 250 2 MP retail) MCG/BLIST QL(18 gm per QL(60 ea per albuterol sulfate aers in 108 NP fill retail,36 gm FLOVENT DISKUS AEPB 2 mcg/act per 30 days 50 MCG/BLIST 25 days retail); MP retail) QL(12 gm per Limit 2 Inhalers FLOVENT HFA AERO 110 2 25 days retail); per MCG/ACT, 220 MCG/ACT MP albuterol sulfate aers in 108 1 month;QL(8.5 mcg/act gm per fill QL(11 gm per retail,17 gm per FLOVENT HFA AERO 44 2 MCG/ACT 25 days retail); 30 days retail) MP QL(375 ml per PULMICORT FLEXHALER QL(1 ea per 30 albuterol sulfate nebu in 1 25 days retail); 2 0.083 % AEPB days retail); MP MP QL(120 ml per ALBUTEROL SULFATE 2 QL(2 ml daily); 30 days retail); NEBU IN 0.5 % MP PULMICORT SUSP NP AL(At least 1 (budesonide (inhalation)) yrs old - Up to albuterol sulfate nebu in 0.5 1 QL(2 ml daily); 8 yrs old); MP %, 2.5 mg/0.5ml MP MP QL(375 ml per QVAR REDIHALER AERB NP albuterol sulfate nebu in 1 30 days retail); 0.63 mg/3ml, 1.25 mg/3ml MP Sympathomimetics albuterol sulfate syrp or 2 1 MP ADVAIR DISKUS AEPB 2 QL(2 ea daily); mg/5ml (fluticasone-salmeterol) MP albuterol sulfate tabs or 2 1 MP ADVAIR HFA AERO 2 QL(0.4 gm mg, 4 mg daily); MP albuterol sulfate tb12 or 4 1 MP AIRDUO DIGIHALER NP PA mg, 8 mg 113/14 AEPB ANORO ELLIPTA AEPB NP MP AIRDUO DIGIHALER NP PA 232/14 AEPB ARCAPTA NEOHALER NP MP AIRDUO DIGIHALER NP PA CAPS 55/14 AEPB ST; MP AIRDUO RESPICLICK PA; MP arformoterol tartrate nebu NP 113/14 AEPB (fluticasone- NP BEVESPI AEROSPHERE NP MP salmeterol) AERO AIRDUO RESPICLICK PA; MP BREO ELLIPTA AEPB 25 NP ST; AL(At least 232/14 AEPB (fluticasone- NP MCG/INH-100 MCG/INH 18 yrs old); MP salmeterol) ST; QL(2 ea AIRDUO RESPICLICK PA; MP BREO ELLIPTA AEPB 25 NP daily); AL(At 55/14 AEPB (fluticasone- NP MCG/INH-200 MCG/INH least 18 yrs salmeterol) old); MP

Coordinated Care of Washington Updated September 1, 2021

35 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BREZTRI AEROSPHERE NP Limit 2 Inhalers AERO per PROAIR HFA AERS month;QL(0.57 BROVANA NEBU NP ST; MP 2 (arformoterol tartrate) (albuterol sulfate) gm daily,8.5 gm per fill budesonide-formoterol 1 MP retail) fumarate dihydrate aero PROAIR RESPICLICK NP COMBIVENT RESPIMAT 2 QL(4 gm per fill AEPB AERS retail); MP Limit 2 Inhalers DUAKLIR PRESSAIR NP PA per AEPB PROVENTIL HFA AERS 2 ) month;QL(0.45 DULERA AERO 5 MP (albuterol sulfate gm daily,7 gm MCG/ACT-100 MCG/ACT, 2 per fill retail) 5 MCG/ACT-200 QL(6.7 gm per MCG/ACT PROVENTIL HFA AERS NP fill retail,13.4 DULERA AERO 5 2 (albuterol sulfate) gm per 30 days MCG/ACT-50 MCG/ACT retail) fluticasone-salmeterol aepb PA; MP SEREVENT DISKUS 2 QL(2 ea daily); 14 mcg/act-113 mcg/act, NP AEPB MP 14 mcg/act-232 mcg/act, STIOLTO RESPIMAT 2 MP 14 mcg/act-55 mcg/act AERS fluticasone-salmeterol aepb QL(2 ea daily); STRIVERDI RESPIMAT NP MP 50 mcg/dose-500 MP AERS mcg/dose, 50 mcg/act-100 mcg/act, 50 mcg/act-250 1 SYMBICORT AERO MP mcg/act, 50 mcg/dose-100 (budesonide-formoterol 2 mcg/dose, 50 mcg/dose- fumarate dihydrate) 250 mcg/dose terbutaline sulfate soln ij 1 NP fluticasone-salmeterol aepb PA; QL(2 ea mg/ml 50 mcg/dose-500 daily); MP terbutaline sulfate tabs or NP MP mcg/dose, 50 mcg/dose- NP 2.5 mg, 5 mg 100 mcg/dose, 50 TRELEGY ELLIPTA AEPB MP mcg/dose-250 mcg/dose 25 MCG/INH-62.5 NP formoterol fumarate nebu NP MP MCG/INH-100 MCG/INH TRELEGY ELLIPTA AEPB QL(12 ml ipratropium-albuterol soln 1 25 MCG/INH-62.5 NP daily); MP MCG/INH-200 MCG/INH levalbuterol hcl nebu 0.31 MP UTIBRON NEOHALER NP MP mg/3ml, 0.63 mg/3ml, 1.25 NP CAPS mg/3ml QL(18 gm per levalbuterol hcl nebu 1.25 ST; MP NP VENTOLIN HFA AERS NP fill retail,36 gm mg/0.5ml (albuterol sulfate) per 30 days levalbuterol tartrate aero NP retail) QL(8 gm per fill PERFOROMIST NEBU MP VENTOLIN HFA AERS NP retail,16 gm per NP (albuterol sulfate) (formoterol fumarate) 30 days retail) PROAIR DIGIHALER NP PA XOPENEX ST; MP AEPB CONCENTRATE NEBU NP (levalbuterol hcl) Coordinated Care of Washington Updated September 1, 2021

36 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits XOPENEX HFA AERO NP QL(1 ea daily); (levalbuterol tartrate) XARELTO TABS 20 MG 2 AL(At least 18 yrs old); MP XOPENEX NEBU NP MP (levalbuterol hcl) Heparins And Heparinoid-Like Agents Xanthines ARIXTRA SOLN NP PA; SP (fondaparinux sodium) aminophylline soln 1 PA enoxaparin sodium soln ij 1 QL(42 ml per 7 ELIXOPHYLLIN ELIX NP MP 300 mg/3ml days retail) QL(14 ml per 7 MP THEO-24 CP24 NP enoxaparin sodium soln sc 1 days retail)3 rtl 100 mg/ml, 150 mg/ml MAX fill,180 rtl theophylline soln 80 1 QL(475 ml per day(s) supply, mg/15ml fill retail); MP QL(12 ml per 7 MP theophylline tb12 300 mg 1 enoxaparin sodium soln sc 1 days retail)3 rtl 120 mg/0.8ml, 80 mg/0.8ml MAX fill,180 rtl theophylline tb12 450 mg 1 day(s) supply, QL(5 ml per 7 theophylline tb24 400 mg, MP 1 enoxaparin sodium soln sc 1 days retail)3 rtl 600 mg 30 mg/0.3ml MAX fill,180 rtl day(s) supply, THEOPHYLLINE/D5W 2 PA SOLN QL(6 ml per 7 enoxaparin sodium soln sc 1 days retail)3 rtl ANTICOAGULANTS - Blood Thinners 40 mg/0.4ml MAX fill,180 rtl Coumarin Anticoagulants day(s) supply, QL(9 ml per 7 warfarin sodium tabs 1 MP enoxaparin sodium soln sc 1 days retail)3 rtl 60 mg/0.6ml MAX fill,180 rtl Direct Factor Xa Inhibitors day(s) supply, ELIQUIS STARTER PACK 2 QL(4 ea daily); PA; SP TBPK MP fondaparinux sodium soln NP ELIQUIS TABS 2 QL(4 ea daily); FRAGMIN SOLN NP SP MP heparin (porcine) in sodium PA SAVAYSA TABS NP chloride soln 0.9 %-1000 2 unit/500ml XARELTO STARTER 2 PACK TBPK heparin (porcine) in sodium PA QL(35 ea per chloride soln 0.9 %-1000 1 180 days unit/500ml, 0.9 %-2000 XARELTO TABS 10 MG 2 retail); AL(At unit/l least 18 yrs heparin sod (porcine) in 1 PA old); MP d5w soln QL(2 ea daily); heparin sodium (porcine) PA XARELTO TABS 15 MG 2 AL(At least 18 lock flush & nacl lock flush 1 yrs old); MP kit XARELTO TABS 2.5 MG 2 heparin sodium (porcine) 1 PA lock flush soln heparin sodium (porcine) 1 PA soln Coordinated Care of Washington Updated September 1, 2021

37 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HEPARIN SODIUM SOLN 2 PA FYCOMPA TABS 2 PA; MP

HEPARIN SODIUM SOSY 2 PA Anticonvulsants - Benzodiazepines HEPARIN PA clobazam susp 1 SODIUM/DEXTROSE 2 SOLN clobazam tabs 1 HEPARIN SODIUM/NACL PA 2 clonazepam tabs 0.5 mg, 1 1 QL(4 ea daily); 0.45% SOLN mg, 2 mg MP HEPARIN PA clonazepam tbdp 0.125 PA SODIUM/SODIUM 2 mg, 0.25 mg, 0.5 mg, 1 mg, NP CHLORIDE SOLN 2 mg HEPARIN PA DIASTAT ACUDIAL GEL PA; QL(1 ea SODIUM/SODIUM 2 (diazepam NP per fill retail) CHLORIDE SOSY (anticonvulsant)) HEPARIN/SODIUM 2 PA DIASTAT PEDIATRIC GEL PA; QL(1 ea CHLORIDE SOLN (diazepam NP per fill retail) LOVENOX SOLN IJ 300 QL(42 ml per 7 (anticonvulsant)) MG/3ML (enoxaparin NP days retail) diazepam (anticonvulsant) 1 QL(1 ea per fill sodium) gel retail) QL(14 ml per 7 LOVENOX SOLN SC 100 KLONOPIN TABS NP QL(4 ea daily); NP days retail)3 rtl (clonazepam) MP MG/ML, 150 MG/ML MAX fill,180 rtl (enoxaparin sodium) day(s) supply, NAYZILAM SOLN NP QL(12 ml per 7 LOVENOX SOLN SC 120 ONFI SUSP (clobazam) NP NP days retail)3 rtl MG/0.8ML, 80 MG/0.8ML MAX fill,180 rtl (enoxaparin sodium) day(s) supply, ONFI TABS (clobazam) NP QL(5 ml per 7 PA LOVENOX SOLN SC 30 days retail)3 rtl SYMPAZAN FILM NP MG/0.3ML (enoxaparin NP sodium) MAX fill,180 rtl day(s) supply, VALTOCO LIQD NP QL(6 ml per 7 LOVENOX SOLN SC 40 days retail)3 rtl VALTOCO LQPK NP MG/0.4ML (enoxaparin NP sodium) MAX fill,180 rtl day(s) supply, Anticonvulsants - Misc. APTIOM TABS NP PA LOVENOX SOLN SC 60 QL(9 ml per 7 days retail)3 rtl MG/0.6ML (enoxaparin NP BANZEL SUSP 40 MG/ML PA sodium) MAX fill,180 rtl NP day(s) supply, (rufinamide) BANZEL TABS 200 MG NP PA; SP Thrombin Inhibitors (rufinamide) MP PRADAXA CAPS 2 BANZEL TABS 400 MG NP PA (rufinamide) ANTICONVULSANTS - Drugs to Treat Seizures BRIVIACT SOLN IV 50 2 PA MG/5ML AMPA Glutamate Receptor Antagonists BRIVIACT SOLN OR 10 NP PA FYCOMPA SUSP 2 PA; MP MG/ML

Coordinated Care of Washington Updated September 1, 2021

38 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BRIVIACT TABS OR 10 PA LAMICTAL CHEWABLE PA MG, 100 MG, 25 MG, 50 NP DISPERSIBLE CHEW NP MG, 75 MG (lamotrigine) carbamazepine chew 1 MP LAMICTAL ODT KIT NP PA carbamazepine cp12 1 MP LAMICTAL ODT KIT NP PA (lamotrigine) carbamazepine susp 1 MP LAMICTAL ODT TBDP 100 PA MG, 200 MG, 25 MG, 50 NP carbamazepine tabs 1 MP MG (lamotrigine) LAMICTAL STARTER/NOT PA MP carbamazepine tb12 1 TAKING NP CARBAMAZEPINE KIT CARBATROL CP12 NP MP (lamotrigine) (carbamazepine) LAMICTAL PA DIACOMIT CAPS NP PA STARTER/TAKING CARBAMAZEPINE/NOT NP DIACOMIT PACK NP PA TAKING VALPROATE KIT (lamotrigine) ELEPSIA XR TB24 NP PA LAMICTAL PA STARTER/TAKING NP EPIDIOLEX SOLN NP VALPROATE KIT (lamotrigine) FANATREX FUSEPAQ PA NP LAMICTAL TABS NP MP SUSP (lamotrigine) PA FINTEPLA SOLN NP LAMICTAL XR KIT NP PA gabapentin caps 100 mg, 1 QL(4 ea daily); LAMICTAL XR TB24 100 PA 400 mg MP MG, 200 MG, 250 MG, 300 NP gabapentin caps 300 mg 1 MP MG, 25 MG, 50 MG (lamotrigine) gabapentin soln 250 MP 1 lamotrigine chew 25 mg, 5 NP PA mg/5ml, 300 mg/6ml mg MP gabapentin tabs 600 mg 1 lamotrigine kit 25 mg, NP PA QL(4 ea daily); gabapentin tabs 800 mg 1 lamotrigine tabs 100 mg, 1 MP MP 150 mg, 200 mg, 25 mg KEPPRA SOLN IV 500 NP PA lamotrigine tb24 100 mg, PA MG/5ML (levetiracetam) 200 mg, 250 mg, 300 mg, NP KEPPRA SOLN OR 100 NP QL(30 ml 25 mg, 50 mg MG/ML (levetiracetam) daily); MP lamotrigine tbdp 100 mg, NP PA KEPPRA TABS OR 1000 NP MP 200 mg, 25 mg, 50 mg MG (levetiracetam) levetiracetam in sodium 1 PA KEPPRA TABS OR 250 QL(4 ea daily); chloride soln MG, 750 MG, 500 MG NP MP (levetiracetam) KEPPRA XR TB24 NP MP (levetiracetam)

Coordinated Care of Washington Updated September 1, 2021

39 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LEVETIRACETAM SOLN PA pregabalin caps 225 mg, 1 QL(2 ea daily) IV 500 MG/100ML-820 300 mg MG/100ML, 540 pregabalin soln 20 mg/ml 1 QL(30 ml daily) MG/100ML-1500 2 MG/100ML, 750 MP MG/100ML-1000 primidone tabs 1 MG/100ML (levetiracetam QUDEXY XR CS24 NP PA in sodium chloride) (topiramate) levetiracetam soln iv 500 1 PA PA mg/5ml rufinamide susp 40 mg/ml NP levetiracetam soln or 100 1 QL(30 ml PA; SP mg/ml, 500 mg/5ml daily); MP rufinamide tabs 200 mg NP levetiracetam tabs or 1000 1 MP rufinamide tabs 400 mg NP PA mg PA levetiracetam tabs or 250 1 QL(4 ea daily); SPRITAM TB3D NP mg, 750 mg, 500 mg MP TEGRETOL SUSP MP levetiracetam tb24 or 500 1 MP 2 mg, 750 mg (carbamazepine) LYRICA CAPS 100 MG, PA; QL(3 ea TEGRETOL TABS 2 MP 150 MG, 200 MG, 25 MG, NP daily) (carbamazepine) 50 MG, 75 MG (pregabalin) TEGRETOL-XR TB12 2 MP (carbamazepine) LYRICA CAPS 225 MG, NP PA; QL(2 ea 300 MG (pregabalin) daily) TOPAMAX SPRINKLE NP QL(6 ea daily); CPSP 15 MG (topiramate) MP LYRICA SOLN 20 MG/ML NP PA; QL(30 ml (pregabalin) daily) TOPAMAX SPRINKLE NP QL(8 ea daily); CPSP 25 MG (topiramate) MP MYSOLINE TABS NP MP (primidone) TOPAMAX TABS NP QL(3 ea daily); NEURONTIN CAPS 100 QL(4 ea daily); (topiramate) MP NP QL(6 ea daily); MG, 400 MG (gabapentin) MP topiramate cpsp 15 mg 1 NEURONTIN CAPS 300 MP MP NP QL(8 ea daily); MG (gabapentin) topiramate cpsp 25 mg 1 MP NEURONTIN SOLN 250 NP MP MG/5ML (gabapentin) topiramate cs24 100 mg, PA 150 mg, 200 mg, 25 mg, 50 NP NEURONTIN TABS 600 NP MP MG (gabapentin) mg topiramate tabs 100 mg, QL(3 ea daily); NEURONTIN TABS 800 NP QL(4 ea daily); 1 MG (gabapentin) MP 200 mg, 25 mg, 50 mg MP MP TRILEPTAL SUSP 300 2 MP oxcarbazepine susp 1 MG/5ML (oxcarbazepine) MP TRILEPTAL TABS 150 MP oxcarbazepine tabs 1 MG, 300 MG, 600 MG NP (oxcarbazepine) OXTELLAR XR TB24 NP PA TROKENDI XR CP24 NP PA; MP pregabalin caps 100 mg, QL(3 ea daily) 150 mg, 200 mg, 25 mg, 50 1 VIMPAT SOLN IV 200 2 PA mg, 75 mg MG/20ML

Coordinated Care of Washington Updated September 1, 2021

40 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIMPAT SOLN OR 10 2 MP DILANTIN-125 SUSP NP MP MG/ML (phenytoin) VIMPAT TABS OR 100 2 QL(2 ea daily) fosphenytoin sodium soln 1 PA MG, 50 MG VIMPAT TABS OR 150 2 MP PEGANONE TABS NP MG, 200 MG PHENYTEK CAPS MP ZONEGRAN CAPS NP MP (zonisamide) (phenytoin sodium NP extended) zonisamide caps 1 MP phenytoin chew 1 MP Carbamates phenytoin sodium extended 1 MP felbamate susp 1 PA; MP caps phenytoin sodium soln 1 PA felbamate tabs 1 PA; MP phenytoin susp 1 MP FELBATOL SUSP 2 PA; MP (felbamate) Succinimides FELBATOL TABS 2 PA; MP (felbamate) CELONTIN CAPS NP PA PA XCOPRI TABS NP ethosuximide caps 250 mg 1 XCOPRI TBPK NP PA ethosuximide soln 250 1 mg/5ml GABA Modulators ZARONTIN CAPS 250 MG NP GABITRIL TABS (tiagabine 2 PA; MP (ethosuximide) hcl) ZARONTIN SOLN 250 NP PA SABRIL PACK (vigabatrin) 2 PA; SP; MP MG/5ML (ethosuximide) Valproic Acid SABRIL TABS (vigabatrin) 2 PA; MP DEPAKOTE ER TB24 NP MP (divalproex sodium) tiagabine hcl tabs 1 PA; MP DEPAKOTE SPRINKLES 2 MP vigabatrin pack 1 PA; SP; MP CSDR (divalproex sodium) DEPAKOTE TBEC NP MP vigabatrin tabs 1 PA; MP (divalproex sodium) divalproex sodium csdr 1 MP Hydantoins MP CEREBYX SOLN 2 PA divalproex sodium tb24 1 (fosphenytoin sodium) DILANTIN CAPS 100 MG MP divalproex sodium tbec 1 MP (phenytoin sodium NP extended) valproate sodium soln iv 1 100 mg/ml, 500 mg/5ml DILANTIN CAPS 30 MG 2 MP valproate sodium soln or 1 MP 250 mg/5ml DILANTIN INFATABS NP MP CHEW (phenytoin) valproic acid caps 1 MP

Coordinated Care of Washington Updated September 1, 2021

41 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANTIDEPRESSANTS - Drugs to Treat Age 6-99: Depression CELEXA TABS 10 MG NP MDD=4;;AL(At (citalopram hydrobromide) least 6 yrs old); Alpha-2 Receptor Antagonists (Tetracyclics) MP QL(1 ea daily); mirtazapine tabs 1 Age 6-99: MP CELEXA TABS 20 MG NP MDD=2;AL(At QL(1 ea daily); (citalopram hydrobromide) least 6 yrs old); mirtazapine tbdp 1 MP MP Age 6-99: REMERON SOLTAB TBDP NP QL(1 ea daily); (mirtazapine) MP CELEXA TABS 40 MG NP MDD=1;AL(At (citalopram hydrobromide) least 6 yrs old); REMERON TABS NP QL(1 ea daily); (mirtazapine) MP MP PA; Age 6-99: Antidepressants - Misc. citalopram hydrobromide NP MDD=20;AL(At APLENZIN TB24 NP PA soln 10 mg/5ml least 6 yrs old); MP bupropion hcl tabs 100 mg, 1 QL(3 ea daily); Age 6-99: 75 mg MP citalopram hydrobromide 1 MDD=4;;AL(At bupropion hcl tb12 100 mg, 1 QL(2 ea daily); tabs 10 mg least 6 yrs old); 150 mg, 200 mg MP MP bupropion hcl tb24 150 mg, 1 QL(1 ea daily); Age 6-99: 300 mg MP citalopram hydrobromide 1 MDD=2;AL(At tabs 20 mg least 6 yrs old); bupropion hcl tb24 450 mg 1 MP FORFIVO XL TB24 NP Age 6-99: (bupropion hcl) citalopram hydrobromide 1 MDD=1;AL(At PA; MP tabs 40 mg least 6 yrs old); maprotiline hcl tabs NP MP escitalopram oxalate soln 5 PA WELLBUTRIN SR TB12 NP QL(2 ea daily); NP (bupropion hcl) MP mg/5ml escitalopram oxalate tabs QL(1 ea daily); WELLBUTRIN XL TB24 NP QL(1 ea daily); 1 (bupropion hcl) MP 10 mg, 20 mg, 5 mg MP Monoamine Oxidase Inhibitors (MAOIs) fluoxetine hcl caps 10 mg, 1 QL(4 ea daily); 20 mg MP MP EMSAM PT24 2 QL(2 ea daily); fluoxetine hcl caps 40 mg 1 MP MARPLAN TABS NP MP fluoxetine hcl cpdr 90 mg NP NARDIL TABS (phenelzine NP MP sulfate) Age 2-3: MDD=10; Age PARNATE TABS NP MP fluoxetine hcl soln 20 (tranylcypromine sulfate) 1 4-17: MDD=15; mg/5ml Age 18+: phenelzine sulfate tabs 1 MP MDD=20; MP PA; QL(1 ea tranylcypromine sulfate 1 MP fluoxetine hcl tabs 10 mg NP tabs daily); MP fluoxetine hcl tabs 20 mg, NP PA Selective Serotonin Reuptake Inhibitors (SSRIs) 60 mg

Coordinated Care of Washington Updated September 1, 2021

42 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FLUOXETINE PA trazodone hcl tabs 100 mg, 1 MP HYDROCHLORIDE TABS NP 150 mg, 50 mg (fluoxetine hcl) QL(2 ea daily); trazodone hcl tabs 300 mg 1 fluvoxamine maleate cp24 NP PA MP 100 mg, 150 mg PA; QL(1 ea QL(3 ea daily); fluvoxamine maleate tabs 1 TRINTELLIX TABS NP daily); AL(At 100 mg MP least 18 yrs old); MP fluvoxamine maleate tabs 1 QL(2 ea daily); 25 mg, 50 mg MP VIIBRYD STARTER PACK NP PA KIT LEXAPRO TABS NP QL(1 ea daily); (escitalopram oxalate) MP PA; QL(1 ea VIIBRYD TABS NP daily); MP paroxetine hcl tabs 10 mg, 1 QL(2 ea daily); 20 mg, 30 mg, 40 mg MP Serotonin-Norepinephrine Reuptake Inhibitors paroxetine hcl tb24 37.5 NP PA Age 7-99: MDD mg, 12.5 mg, 25 mg CYMBALTA CPEP 20 MG NP (duloxetine hcl) = 3;AL(At least 7 yrs old); MP PAXIL CR TB24 NP PA (paroxetine hcl) Age 7-99: MDD CYMBALTA CPEP 30 MG NP = 2;AL(At least PAXIL SUSP 10 MG/5ML NP PA; QL(40 ml (duloxetine hcl) daily); MP 7 yrs old); MP PAXIL TABS 10 MG, 20 QL(2 ea daily); Age 7-99: MDD CYMBALTA CPEP 60 MG NP = 1;AL(At least MG, 30 MG, 40 MG NP MP (duloxetine hcl) (paroxetine hcl) 7 yrs old); MP PEXEVA TABS NP DESVENLAFAXINE ER NP TB24 PROZAC CAPS 10 MG, 20 QL(4 ea daily); NP desvenlafaxine succinate NP PA; QL(4 ea MG (fluoxetine hcl) MP tb24 100 mg daily); MP PROZAC CAPS 40 MG QL(2 ea daily); NP desvenlafaxine succinate NP PA; QL(1 ea (fluoxetine hcl) MP tb24 25 mg, 50 mg daily); MP sertraline hcl conc 20 NP PA; QL(10 ml PA; Age 7-99: mg/ml daily); MP DRIZALMA SPRINKLE NP MDD = 3;AL(At CSDR 20 MG QL(2 ea daily); least 7 yrs old) sertraline hcl tabs 100 mg 1 MP PA; Age 7-99: DRIZALMA SPRINKLE NP MDD = 2;AL(At sertraline hcl tabs 25 mg, 1 QL(1.5 ea CSDR 30 MG 50 mg daily); MP least 7 yrs old) PA; Age 7-99: ZOLOFT CONC 20 MG/ML NP PA; QL(10 ml (sertraline hcl) daily); MP DRIZALMA SPRINKLE NP MDD = CSDR 40 MG 1.5;AL(At least ZOLOFT TABS 100 MG NP QL(2 ea daily); (sertraline hcl) MP 7 yrs old) ZOLOFT TABS 25 MG, 50 QL(1.5 ea PA; Age 7-99: NP DRIZALMA SPRINKLE NP MG (sertraline hcl) daily); MP CSDR 60 MG MDD = 1;AL(At least 7 yrs old) Serotonin Modulators Age 7-99: MDD nefazodone hcl tabs 100 NP PA; MP duloxetine hcl cpep 20 mg 1 = 3;AL(At least mg, 150 mg, 200 mg 7 yrs old); MP nefazodone hcl tabs 250 NP MP Age 7-99: MDD mg, 50 mg duloxetine hcl cpep 30 mg 1 = 2;AL(At least 7 yrs old); MP Coordinated Care of Washington Updated September 1, 2021

43 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; Age 7-99: doxepin hcl conc 1 MP MDD = duloxetine hcl cpep 40 mg NP 1.5;AL(At least imipramine hcl tabs 1 MP 7 yrs old); MP Age 7-99: MDD imipramine pamoate caps NP duloxetine hcl cpep 60 mg 1 = 1;AL(At least 7 yrs old); MP NORPRAMIN TABS 10 MG NP MP (desipramine hcl) EFFEXOR XR CP24 NP QL(2 ea daily); (venlafaxine hcl) MP NORPRAMIN TABS 25 MG NP QL(2 ea daily) (desipramine hcl) FETZIMA CP24 NP nortriptyline hcl caps 10 1 MP mg, 50 mg, 25 mg, 75 mg FETZIMA TITRATION NP PACK C4PK nortriptyline hcl soln 10 NP QL(20 ml mg/5ml daily); MP PRISTIQ TB24 100 MG NP PA; QL(4 ea (desvenlafaxine succinate) daily); MP PAMELOR CAPS NP MP PRISTIQ TB24 25 MG, 50 PA; QL(1 ea (nortriptyline hcl) MG (desvenlafaxine NP daily); MP MP succinate) protriptyline hcl tabs NP MP venlafaxine hcl cp24 75 1 QL(2 ea daily); trimipramine maleate caps NP mg, 150 mg, 37.5 mg MP venlafaxine hcl tabs 100 MP ANTIDIABETICS - Drugs to Regulate Blood mg, 25 mg, 37.5 mg, 50 1 Sugar mg, 75 mg Alpha-Glucosidase Inhibitors venlafaxine hcl tb24 150 PA; QL(1 ea mg, 225 mg, 75 mg, 37.5 NP daily); MP acarbose tabs 1 MP mg GLYSET TABS ( ) NP PA Tricyclic Agents miglitol amitriptyline hcl tabs 1 MP miglitol tabs NP PA amoxapine tabs 1 MP PRECOSE TABS NP MP (acarbose) ANAFRANIL CAPS 25 MG NP PA Antidiabetic - Amylin Analogs (clomipramine hcl) SYMLINPEN 120 SOPN 2 PA ANAFRANIL CAPS 50 MG, NP PA; MP 75 MG (clomipramine hcl) SYMLINPEN 60 SOPN 2 PA clomipramine hcl caps 25 NP PA mg Antidiabetic Combinations clomipramine hcl caps 50 NP PA; MP ACTOPLUS MET TABS PA; QL(2 ea mg, 75 mg (pioglitazone hcl-metformin NP daily) desipramine hcl tabs 100 MP hcl) mg, 150 mg, 75 mg, 10 mg, 1 alogliptin-metformin hcl NP QL(2 ea daily); 50 mg tabs MP desipramine hcl tabs 25 mg 1 QL(2 ea daily) PA; QL(1 ea alogliptin-pioglitazone tabs 1 daily); MP doxepin hcl caps 1 MP

Coordinated Care of Washington Updated September 1, 2021

44 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DUETACT TABS PA SYNJARDY XR TB24 NP (pioglitazone hcl- NP glimepiride) TRIJARDY XR TB24 NP PA glipizide-metformin hcl tabs 1 MP XIGDUO XR TB24 2 MP glyburide-metformin tabs 1 MP XULTOPHY 100/3.6 SOPN NP PA GLYXAMBI TABS NP PA Biguanides MP INVOKAMET TABS 2 FORTAMET TB24 NP PA (metformin hcl) INVOKAMET XR TB24 NP GLUMETZA TB24 NP PA (metformin hcl) JANUMET TABS 2 MP metformin hcl soln 500 NP PA mg/5ml JANUMET XR TB24 2 MP metformin hcl tabs 1000 1 QL(2 ea daily); QL(2 ea daily); mg MP JENTADUETO TABS 2 AL(At least 18 QL(5 ea daily); metformin hcl tabs 500 mg 1 yrs old); MP MP QL(3 ea daily); JENTADUETO XR TB24 NP metformin hcl tabs 850 mg 1 MP KAZANO TABS (alogliptin- QL(2 ea daily); NP metformin hcl tb24 1000 NP PA metformin hcl) MP mg, 500 mg QL(2 ea daily); QL(4 ea daily); KOMBIGLYZE XR TB24 NP metformin hcl tb24 500 mg 1 2.5 MG-1000 MG AL(At least 18 MP yrs old) QL(2 ea daily); metformin hcl tb24 750 mg 1 KOMBIGLYZE XR TB24 5 QL(1 ea daily); MP MG-1000 MG, 5 MG-500 NP AL(At least 18 MG yrs old) METFORMIN NP PA HYDROCHLORIDE SOLN OSENI TABS (alogliptin- NP PA; QL(1 ea pioglitazone) daily); MP RIOMET ER SRER NP PA pioglitazone hcl-glimepiride NP PA PA tabs RIOMET SOLN NP pioglitazone hcl-metformin NP PA; QL(2 ea Diabetic Other hcl tabs 15 mg-500 mg daily) BAQSIMI ONE PACK 2 PA pioglitazone hcl-metformin NP QL(2 ea daily) POWD hcl tabs 15 mg-850 mg BAQSIMI TWO PACK 2 PA QTERN TABS NP PA POWD CVS GLUCOSE CHEW 2 QL(50 ea per SEGLUROMET TABS NP 30 days retail) PA CVS SOFT GLUCOSE 2 QL(50 ea per SOLIQUA 100/33 SOPN NP CHEW 30 days retail) STEGLUJAN TABS NP PA DEX4 QUICK DISSOLVE 2 QL(50 ea per GLUCOSE CHEW 30 days retail) SYNJARDY TABS NP diazoxide susp NP PA

Coordinated Care of Washington Updated September 1, 2021

45 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLUCAGEN HYPOKIT 2 ONGLYZA TABS 2.5 MG NP SOLR PA; QL(1 ea QL(1 ea daily) glucagon (rdna) kit NP ONGLYZA TABS 5 MG NP per fill retail) GLUCAGON QL(1 ea daily); TRADJENTA TABS 2 AL(At least 18 EMERGENCY KIT FOR 2 LOW BLOOD SUGAR yrs old); MP SOLR Dopamine Receptor Agonists - Antidiabetic GLUCAGON PA; QL(1 ea PA EMERGENCY KIT KIT NP per fill retail) CYCLOSET TABS NP (glucagon (rdna)) Incretin Mimetic Agents (GLP-1 Receptor QL(50 ea per GLUCOSE CHEW 2 30 days retail) ADLYXIN SOPN NP QL(50 ea per GNP GLUCOSE CHEW 2 ADLYXIN STARTER PACK NP 30 days retail) PNKT GNP QUICK DISSOLVE 2 QL(50 ea per PA GLUCOSE CHEW 30 days retail) BYDUREON BCISE AUIJ NP GVOKE HYPOPEN 1- NP PA QL(4 ea per 28 PACK SOAJ 2 days retail); BYDUREON PEN PEN AL(At least 18 GVOKE HYPOPEN 2- NP PA PACK SOAJ yrs old) QL(2.4 ml per GVOKE PFS SOSY NP PA BYETTA SOPN 10 2 30 days retail); PA MCG/0.04ML AL(At least 18 KORLYM TABS 2 yrs old) LEADER QUICK QL(50 ea per QL(1.2 ml per DISSOLVE GLUCOSE 2 30 days retail) BYETTA SOPN 5 2 30 days retail); CHEW MCG/0.02ML AL(At least 18 yrs old) PROGLYCEM SUSP NP PA (diazoxide) OZEMPIC SOPN NP QL(50 ea per SM GLUCOSE CHEW 2 30 days retail) RYBELSUS TABS NP WALGREENS GLUCOSE 2 QL(50 ea per CHEW 30 days retail) TRULICITY SOPN 0.75 MG/0.5ML, 3 MG/0.5ML, NP ZEGALOGUE SOAJ NP PA 4.5 MG/0.5ML TRULICITY SOPN 1.5 NP QL(0.14 ml ZEGALOGUE SOSY NP PA MG/0.5ML daily) Limit 9ml per Dipeptidyl Peptidase-4 (DPP-4) Inhibitors VICTOZA SOPN 2 month;QL(0.3 alogliptin benzoate tabs NP QL(1 ea daily) ml daily) Insulin Sensitizing Agents JANUVIA TABS 100 MG, 2 MP 25 MG ACTOS TABS (pioglitazone NP QL(1 ea daily); QL(1 ea daily); hcl) MP JANUVIA TABS 50 MG 2 MP AVANDIA TABS NP QL(1 ea daily) NESINA TABS (alogliptin NP QL(1 ea daily) benzoate) Coordinated Care of Washington Updated September 1, 2021

46 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1 QL(1 ea daily); QL(40 ml per pioglitazone hcl tabs MP HUMALOG MIX 75/25 2 SUSP 30 days retail); MP Insulin QL(40 ml per QL(40 ml per 2 ADMELOG SOLN NP 30 days retail); HUMALOG SOCT 30 days retail); MP MP ADMELOG SOLOSTAR QL(1 ml daily); QL(40 ml per NP HUMALOG SOLN 2 30 days retail); SOPN MP MP PA AFREZZA POWD NP QL(30 ml per 30 days ST; QL(40 ml HUMULIN 70/30 KWIKPEN 2 retail,90 ml per APIDRA SOLN NP per 30 days SUPN 90 days mail); retail) MP ST; QL(30 ml QL(40 ml per APIDRA SOLOSTAR NP per 30 days SOPN HUMULIN 70/30 SUSP 2 30 days retail); retail) MP PA; QL(30 ml QL(30 ml per per 30 days HUMULIN N KWIKPEN 2 BASAGLAR KWIKPEN SUPN 30 days retail); NP retail,90 ml per MP SOPN 90 days mail); MP QL(40 ml per HUMULIN N SUSP 2 30 days retail); QL(30 ml per MP FIASP FLEXTOUCH NP SOPN 30 days retail); MP QL(40 ml per HUMULIN R SOLN 2 30 days retail); FIASP PENFILL SOCT NP QL(30 ml per MP 90 days retail) HUMULIN R U-500 2 MP QL(30 ml per (CONCENTRATED) SOLN FIASP SOLN NP 30 days retail); MP HUMULIN R U-500 2 MP KWIKPEN SOPN HUMALOG JUNIOR 2 QL(1 ml daily) KWIKPEN SOPN QL(30 ml per INSULIN ASPART NP 30 days retail); FLEXPEN SOPN HUMALOG KWIKPEN 2 QL(1 ml daily); MP SOPN 100 UNIT/ML MP QL(30 ml per QL(40 ml per 30 days HUMALOG KWIKPEN 2 30 days retail); INSULIN ASPART SOPN 200 UNIT/ML NP retail,90 ml per MP PENFILL SOCT 90 days mail); QL(30 ml per MP HUMALOG MIX 50/50 2 30 days retail); KWIKPEN SUPN INSULIN ASPART QL(30 ml per MP PROTAMINE/INSULIN 2 30 days retail); QL(40 ml per ASPART FLEXPEN SUPN MP HUMALOG MIX 50/50 2 30 days retail); SUSP INSULIN ASPART QL(40 ml per MP PROTAMINE/INSULIN 2 30 days retail); QL(30 ml per ASPART SUSP MP HUMALOG MIX 75/25 2 30 days retail); KWIKPEN SUPN QL(30 ml per MP INSULIN ASPART SOLN NP 30 days retail); MP

Coordinated Care of Washington Updated September 1, 2021

47 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INSULIN LISPRO JUNIOR NP QL(1 ml daily) QL(40 ml per KWIKPEN SOPN NOVOLIN 70/30 SUSP NP 30 days retail); MP INSULIN LISPRO NP QL(1 ml daily); KWIKPEN SOPN MP QL(30 ml per NOVOLIN N FLEXPEN NP 30 days retail); INSULIN LISPRO QL(30 ml per RELION SUPN PROTAMINE/INSULIN 2 30 days retail); MP LISPRO KWIKPEN SUPN MP QL(30 ml per NOVOLIN N FLEXPEN NP 30 days retail); QL(40 ml per SUPN INSULIN LISPRO SOLN NP 30 days retail); MP MP QL(40 ml per NOVOLIN N RELION NP 30 days retail); QL(40 ml per SUSP INSULIN LISPRO SOLN NP 90 days retail); MP MP QL(40 ml per MP NOVOLIN N SUSP NP 30 days retail); LANTUS SOLN 2 MP QL(30 ml per QL(40 ml per NOVOLIN R RELION NP 30 days retail); 30 days SOLN LANTUS SOLOSTAR 2 retail,90 ml per MP SOPN 90 days mail); QL(40 ml per MP NOVOLIN R SOLN NP 30 days retail); PA; QL(30 ml MP per 30 days LANTUS SOLOSTAR QL(30 ml per NP retail,90 ml per NOVOLOG FLEXPEN NP SOPN RELION SOPN 30 days retail); 90 days mail); MP MP QL(30 ml per LEVEMIR FLEXTOUCH MP NOVOLOG FLEXPEN 2 2 SOPN 30 days retail); SOPN MP LEVEMIR SOLN 2 MP NOVOLOG MIX 70/30 QL(30 ml per PREFILLED FLEXPEN 2 30 days retail); LYUMJEV KWIKPEN NP RELION SUPN MP SOPN NOVOLOG MIX 70/30 QL(30 ml per LYUMJEV SOLN NP PREFILLED FLEXPEN 2 30 days retail); SUPN MP QL(30 ml per QL(40 ml per 30 days NOVOLOG MIX 70/30 2 NOVOLIN 70/30 FLEXPEN RELION SUSP 30 days retail); NP retail,90 ml per MP RELION SUPN 90 days mail); MP QL(40 ml per NOVOLOG MIX 70/30 2 SUSP 30 days retail); QL(30 ml per MP 30 days NOVOLIN 70/30 FLEXPEN NP retail,90 ml per QL(30 ml per SUPN 30 days 90 days mail); NOVOLOG PENFILL MP 2 retail,90 ml per SOCT 90 days mail); QL(40 ml per MP NOVOLIN 70/30 RELION NP SUSP 30 days retail); MP QL(30 ml per NOVOLOG RELION SOLN NP 30 days retail); MP

Coordinated Care of Washington Updated September 1, 2021

48 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(30 ml per GLUCOTROL TABS NP MP NOVOLOG SOLN 2 30 days retail); (glipizide) MP GLUCOTROL XL TB24 NP MP SEMGLEE SOLN 2 MP (glipizide) MP PA; QL(30 ml glyburide micronized tabs 1 per 30 days MP SEMGLEE SOPN NP retail,90 ml per glyburide tabs 1 90 days mail); GLYNASE TABS (glyburide NP MP MP micronized) TOUJEO MAX SOLOSTAR NP SOPN tolbutamide tabs NP TOUJEO SOLOSTAR NP ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs SOPN to Treat Diarrhea TRESIBA FLEXTOUCH NP SOPN Antidiarrheal - Chloride Channel Antagonists TRESIBA SOLN NP MYTESI TBEC NP Meglitinide Analogues Antidiarrheal/Probiotic Agents - Misc. QL(3 ea daily); bismuth subsalicylate susp nateglinide tabs 1 1 MP 525 mg/30ml, 527 mg/30ml RX/OTC repaglinide tabs 1 MP PRODIGEN CAPS NP RX/OTC STARLIX TABS NP QL(3 ea daily); PROVAD CAPS NP (nateglinide) MP RX/OTC Sodium-Glucose Co-Transporter 2 (SGLT2) ZELAC CAPS NP FARXIGA TABS 2 MP Antidiarrheal/Probiotic Combinations RESTORA RX CAPS NP INVOKANA TABS 2 MP QL(1 ea daily); Antiperistaltic Agents JARDIANCE TABS 2 MP ANTI-DIARRHEAL LIQD 2 STEGLATRO TABS NP diphenoxylate w/ atropine 1 liqd Sulfonylureas diphenoxylate w/ atropine 1 AMARYL TABS 1 MG, 2 NP QL(1 ea daily); tabs MG (glimepiride) MP LOMOTIL TABS NP AMARYL TABS 4 MG NP QL(2 ea daily); (diphenoxylate w/ atropine) (glimepiride) MP loperamide hcl tabs 1 glimepiride tabs 1 mg, 2 1 QL(1 ea daily); mg MP QL(2 ea daily); MOTOFEN TABS NP glimepiride tabs 4 mg 1 MP opium tincture tinc 1 PA glipizide tabs 1 MP ANTIDOTES AND SPECIFIC ANTAGONISTS glipizide tb24 1 MP

Coordinated Care of Washington Updated September 1, 2021

49 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Antidotes - Chelating Agents naloxone hcl soct 0.4 1 mg/ml CHEMET CAPS 2 naloxone hcl soln 0.4 1 mg/ml, 4 mg/10ml deferasirox pack 180 mg, 1 360 mg, 90 mg naloxone hcl sosy 2 1 deferasirox tabs 180 mg, SP; MP mg/2ml 1 AL(At least 18 360 mg, 90 mg naltrexone hcl tabs 1 yrs old) deferasirox tbso 125 mg, 1 SP; MP 250 mg, 500 mg NARCAN LIQD 2 PA; MP deferiprone tabs NP QL(1 ea per 28 VIVITROL SUSR 2 days retail) EXJADE TBSO NP SP; MP (deferasirox) ANTIEMETICS - Drugs to Treat Nausea and Vomiting FERRIPROX SOLN 100 NP PA; MP MG/ML 5-HT3 Receptor Antagonists FERRIPROX TABS 1000 PA NP ALOXI SOLN NP PA MG (palonosetron hcl) FERRIPROX TABS 500 NP PA; MP MG (deferiprone) ANZEMET TABS NP FERRIPROX TWICE-A- NP PA DAY TABS granisetron hcl soln 1 JADENU SPRINKLE PACK NP granisetron hcl tabs 1 (deferasirox) ondansetron hcl soln ij 40 JADENU TABS NP SP; MP 1 (deferasirox) mg/20ml, 4 mg/2ml ondansetron hcl soln or 4 QL(50 ml per PENTETATE CALCIUM NP PA 1 TRISODIUM SOLN mg/5ml fill retail) ondansetron hcl tabs or 24 QL(1 ea daily) PENTETATE ZINC NP PA 1 TRISODIUM SOLN mg Antidotes and Specific Antagonists ondansetron hcl tabs or 4 1 QL(6 ea daily) mg BAL IN OIL SOLN 2 PA ondansetron hcl tabs or 8 1 QL(3 ea daily) mg deferoxamine mesylate solr 1 ondansetron tbdp 1 QL(2 ea daily) VISTOGARD PACK 2 palonosetron hcl soln NP PA Opioid Antagonists palonosetron hcl sosy NP EVZIO SOAJ NP PA PALONOSETRON NP KLOXXADO LIQD 2 HYDROCHLORIDE SOLN SANCUSO PTCH NP LIFEMS NALOXONE NP PA PSKT SUSTOL PRSY NP naloxone hcl soaj 2 NP PA mg/0.4ml ZOFRAN TABS 4 MG NP QL(6 ea daily) (ondansetron hcl) Coordinated Care of Washington Updated September 1, 2021

50 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZOFRAN TABS 8 MG NP QL(3 ea daily) Substance P/Neurokinin 1 (NK1) Receptor (ondansetron hcl) aprepitant caps 1 ZUPLENZ FILM NP aprepitant misc 1 Antiemetics - Anticholinergic PA ANTIVERT TABS 2 CINVANTI EMUL NP PA EMEND CAPS OR 40 MG, NP DIMENHYDRINATE SOLN NP 80 MG (aprepitant) meclizine hcl chew 1 RX/OTC EMEND SOLR IV 150 MG PA (fosaprepitant NP meclizine hcl tabs 1 RX/OTC dimeglumine) EMEND SUSR OR 125 NP PA MECLIZINE 2 MG/5ML HYDROCHLORIDE TABS EMEND TRIPACK CAPS NP scopolamine pt72 1 (aprepitant) fosaprepitant dimeglumine NP PA TIGAN CAPS OR 300 MG NP solr (trimethobenzamide hcl) VARUBI TBPK NP TIGAN SOLN IM 100 NP PA MG/ML ANTIFUNGALS - Drugs to Treat Fungal Infections TRANSDERM SCOP PT72 NP (scopolamine) Antifungal - Glucan Synthesis Inhibitors TRANSDERM-SCOP PT72 NP PA (scopolamine) BREXAFEMME TABS NP trimethobenzamide hcl 1 CANCIDAS SOLR NP PA caps (caspofungin acetate) Antiemetics - Miscellaneous caspofungin acetate solr 50 1 PA mg, 70 mg AKYNZEO CAPS OR 0.5 NP PA MG-300 MG CASPOFUNGIN ACETATE 2 PA SOLR 50 MG, 70 MG AKYNZEO SOLN IV 0.25 2 PA MG/20ML-235 MG/20ML ERAXIS SOLR 2 PA AKYNZEO SOLR IV 0.25 2 PA MG-235 MG micafungin sodium solr 50 1 PA mg, 100 mg BONJESTA TBCR NP PA MYCAMINE SOLR NP PA DICLEGIS TBEC NP PA (doxylamine-pyridoxine) Antifungals doxylamine-pyridoxine tbec 1 PA ABELCET SUSP 2 PA dronabinol caps NP PA AMBISOME SUSR 2 PA

MARINOL CAPS NP PA amphotericin b solr 1 PA (dronabinol) PA ANCOBON CAPS NP PA SYNDROS SOLN NP (flucytosine)

Coordinated Care of Washington Updated September 1, 2021

51 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits flucytosine caps NP PA NOXAFIL SOLN IV 300 2 PA MG/16.7ML griseofulvin microsize susp 1 NOXAFIL SUSP OR 40 NP PA; MP MG/ML griseofulvin microsize tabs 1 NOXAFIL TBEC OR 100 NP PA; MP MG (posaconazole) griseofulvin ultramicrosize 1 tabs posaconazole tbec NP PA; MP QL(6 ea daily) nystatin tabs 1 SPORANOX CAPS 100 NP PA; QL(1 ea MG (itraconazole) daily) QL(1 ea terbinafine hcl tabs 1 daily,90 ea per SPORANOX PULSEPAK NP PA; QL(1 ea 120 days retail) CAPS (itraconazole) daily) SPORANOX SOLN 10 NP PA Imidazole-Related Antifungals MG/ML (itraconazole) CRESEMBA CAPS OR PA NP TOLSURA CAPS NP PA; QL(1 ea 186 MG daily) CRESEMBA SOLR IV 372 PA 2 VFEND IV SOLR NP PA MG (voriconazole) DIFLUCAN SUSR 10 QL(70 ml per VFEND SUSR NP PA MG/ML, 40 MG/ML NP fill retail) (voriconazole) (fluconazole) VFEND TABS NP PA DIFLUCAN TABS 100 MG NP QL(1 ea daily) (voriconazole) (fluconazole) voriconazole solr iv 200 mg 1 PA DIFLUCAN TABS 150 MG NP QL(2 ea per fill (fluconazole) retail) voriconazole susr or 40 NP PA DIFLUCAN TABS 200 MG NP QL(2 ea daily) mg/ml (fluconazole) voriconazole tabs or 200 NP PA DIFLUCAN TABS 50 MG NP QL(7 ea per fill mg, 50 mg (fluconazole) retail) ANTIHISTAMINES - Drugs to Treat Allergies fluconazole in nacl soln 1 PA Antihistamines - Alkylamines fluconazole susr 10 mg/ml, 1 QL(70 ml per 40 mg/ml fill retail) chlorpheniramine maleate 1 QL(120 ea per tabs fill retail) fluconazole tabs 100 mg 1 QL(1 ea daily) dexchlorpheniramine NP QL(2 ea per fill maleate soln fluconazole tabs 150 mg 1 retail) Antihistamines - Combinations fluconazole tabs 200 mg 1 QL(2 ea daily) CLOBETEX THPK 2 PA QL(7 ea per fill fluconazole tabs 50 mg 1 Antihistamines - Ethanolamines retail) carbinoxamine maleate PA; QL(1 ea NP itraconazole caps 100 mg NP soln 4 mg/5ml daily) carbinoxamine maleate NP itraconazole soln 10 mg/ml 1 PA tabs 4 mg CARBINOXAMINE NP ketoconazole tabs NP PA MALEATE TABS 6 MG

Coordinated Care of Washington Updated September 1, 2021

52 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits clemastine fumarate tabs NP QL(240 ml per promethazine hcl soln or 1 fill retail); AL(At 6.25 mg/5ml least 2 yrs old) DICOPANOL FUSEPAQ NP SUSR QL(12 ea per promethazine hcl supp re 1 fill retail); AL(At DICOPANOL RAPIDPAQ NP 50 mg, 12.5 mg, 25 mg SUSR least 2 yrs old) diphenhydramine hcl caps QL(4 ea daily) QL(240 ml per 1 promethazine hcl syrp or 1 fill retail); AL(At or 50 mg, 25 mg 6.25 mg/5ml least 2 yrs old) diphenhydramine hcl elix or 1 QL(240 ml per 12.5 mg/5ml fill retail) promethazine hcl tabs or 1 AL(At least 2 diphenhydramine hcl liqd or QL(240 ml per 25 mg, 12.5 mg, 50 mg yrs old) 12.5 mg/5ml, 25 mg/10ml, 1 fill retail) Antihistamines - Piperidines 50 mg/20ml cyproheptadine hcl syrp 1 diphenhydramine hcl soln ij 1 PA 50 mg/ml cyproheptadine hcl tabs 1 diphenhydramine hcl tabs 1 QL(4 ea daily) or 25 mg ANTIHYPERLIPIDEMICS - Drugs to Treat High KARBINAL ER SUER NP Cholesterol Adenosine Triphosphate-Citrate Lyase (ACL) RYVENT TABS NP NEXLETOL TABS 2 PA Antihistamines - Non-Sedating Antihyperlipidemics - Combinations cetirizine hcl syrp 1 mg/ml, 1 RX/OTC 5 mg/5ml ezetimibe-simvastatin tabs NP PA cetirizine hcl tabs 10 mg 1 NEXLIZET TABS NP PA cetirizine hcl tabs 5 mg, 10 1 QL(1 ea daily) mg OMEGA-3 RX COMPLETE NP PA THPK CLARINEX TABS NP PA (desloratadine) OMEGA-3/D-3 WELLNESS NP PA PACK KIT desloratadine tabs NP PA ROSZET TABS NP PA desloratadine tbdp NP PA SURE RESULT O3D3 NP PA SYSTEM KIT levocetirizine RX/OTC dihydrochloride soln 2.5 NP VYTORIN TABS NP PA mg/5ml (ezetimibe-simvastatin) Antihyperlipidemics - Misc. levocetirizine NP RX/OTC dihydrochloride tabs 5 mg icosapent ethyl caps NP PA loratadine soln 1 LOVAZA CAPS (omega-3- NP PA Antihistamines - Phenothiazines acid ethyl esters) omega-3-acid ethyl esters PA PHENERGAN SOLN NP PA NP (promethazine hcl) caps PA promethazine hcl soln ij 50 NP PA VASCEPA CAPS NP mg/ml, 25 mg/ml Bile Acid Sequestrants Coordinated Care of Washington Updated September 1, 2021

53 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cholestyramine light pack 1 MP fenofibrate micronized caps NP PA; QL(1 ea 134 mg, 200 mg daily) MP cholestyramine light powd 1 fenofibrate micronized caps NP PA; QL(2 ea 67 mg daily) MP cholestyramine pack 1 fenofibrate tabs 120 mg, 40 1 MP mg, 145 mg, 48 mg MP cholestyramine powd 1 QL(1 ea daily); fenofibrate tabs 160 mg 1 MP PA colesevelam hcl pack NP QL(3 ea daily); fenofibrate tabs 54 mg 1 MP colesevelam hcl tabs NP PA FENOFIBRIC ACID TABS NP PA 105 MG COLESTID FLAVORED NP PA GRAN (colestipol hcl) fenofibric acid tabs 105 mg, NP PA 35 mg COLESTID FLAVORED NP PA PACK (colestipol hcl) FENOGLIDE TABS NP MP (fenofibrate) COLESTID GRAN 5 GM NP PA (colestipol hcl) FIBRICOR TABS NP PA (fenofibric acid) COLESTID PACK 5 GM NP PA (colestipol hcl) QL(2 ea daily); gemfibrozil tabs 1 MP COLESTID TABS 1 GM NP MP (colestipol hcl) LIPOFEN CAPS NP PA (fenofibrate) colestipol hcl gran 5 gm NP PA QL(2 ea daily); LOPID TABS (gemfibrozil) NP colestipol hcl pack 5 gm NP PA MP TRICOR TABS NP MP colestipol hcl tabs 1 gm 1 MP (fenofibrate) PA; QL(1 ea TRIGLIDE TABS NP QUESTRAN LIGHT POWD NP MP daily); MP (cholestyramine light) TRILIPIX CPDR (choline NP PA QUESTRAN PACK NP MP fenofibrate) (cholestyramine) HMG CoA Reductase Inhibitors QUESTRAN POWD NP MP (cholestyramine) ALTOPREV TB24 NP WELCHOL PACK PA NP QL(1 ea daily); (colesevelam hcl) atorvastatin calcium tabs 1 MP WELCHOL TABS NP PA (colesevelam hcl) CRESTOR TABS 10 MG, MP 20 MG (rosuvastatin NP Fibric Acid Derivatives calcium) PA ANTARA CAPS NP CRESTOR TABS 40 MG, 5 NP MG (rosuvastatin calcium) choline fenofibrate cpdr NP PA EQUAPAX/ATORVASTATI NP PA N CALCIUM/COQ10 THPK fenofibrate caps 150 mg, NP PA 50 mg EZALLOR SPRINKLE NP PA CPSP fenofibrate micronized caps NP PA 130 mg, 43 mg FLOLIPID SUSP 2 PA

Coordinated Care of Washington Updated September 1, 2021

54 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits fluvastatin sodium caps 20 NP niacin (antihyperlipidemic) NP PA; MP mg, 40 mg tabs 500 mg fluvastatin sodium tb24 80 NP PA niacin (antihyperlipidemic) MP mg tbcr 1000 mg, 500 mg, 750 1 mg LESCOL XL TB24 NP PA (fluvastatin sodium) NIASPAN TBCR (niacin NP MP (antihyperlipidemic)) LIPITOR TABS NP QL(1 ea daily); (atorvastatin calcium) MP Proprotein Convertase Subtilisin/Kexin Type 9 LIVALO TABS NP PRALUENT SOAJ NP PA; SP lovastatin tabs 10 mg, 20 QL(1 ea daily); 1 REPATHA PUSHTRONEX 2 PA; MP mg MP SYSTEM SOCT QL(2 ea daily); lovastatin tabs 40 mg 1 PA; MP MP REPATHA SOSY 2 PRAVACHOL TABS QL(1 ea daily); NP REPATHA SURECLICK 2 PA; SP; MP (pravastatin sodium) MP SOAJ QL(1 ea daily); pravastatin sodium tabs 1 ANTIHYPERTENSIVES - Drugs to Treat High MP Blood Pressure rosuvastatin calcium tabs 1 MP 10 mg, 20 mg ACE Inhibitors ACCUPRIL TABS PA; QL(1 ea rosuvastatin calcium tabs 1 NP 40 mg, 5 mg (quinapril hcl) daily) QL(2 ea daily); SIMVASTATIN SUSP 20 2 PA ALTACE CAPS (ramipril) NP MG/5ML MP benazepril hcl tabs 10 mg, QL(1 ea daily); simvastatin tabs 5 mg, 10 1 QL(1 ea daily); 1 mg, 20 mg, 40 mg MP 20 mg, 5 mg MP QL(2 ea daily); MP benazepril hcl tabs 40 mg 1 simvastatin tabs 80 mg 1 MP QL(3 ea daily); ZOCOR TABS 10 MG, 20 NP QL(1 ea daily); captopril tabs 1 MG, 40 MG (simvastatin) MP MP enalapril maleate soln 1 ZOCOR TABS 80 MG NP MP NP (simvastatin) mg/ml enalapril maleate tabs 10 1 QL(2 ea daily); ZYPITAMAG TABS NP mg, 2.5 mg, 20 mg, 5 mg MP Intestinal Cholesterol Absorption Inhibitors enalaprilat inj 1 ezetimibe tabs 1 MP EPANED SOLN (enalapril NP maleate) MP ZETIA TABS (ezetimibe) NP QL(1 ea daily); fosinopril sodium tabs 1 MP Microsomal Triglyceride Transfer Protein (MTP) lisinopril tabs 10 mg, 20 1 QL(2 ea daily); JUXTAPID CAPS 2 PA; MP mg, 30 mg, 40 mg, 5 mg MP QL(1 ea daily); lisinopril tabs 2.5 mg 1 Nicotinic Acid Derivatives MP niacin (antihyperlipidemic) MP 1 LOTENSIN TABS 10 MG, NP QL(1 ea daily); tabs 500 mg 20 MG (benazepril hcl) MP

Coordinated Care of Washington Updated September 1, 2021

55 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LOTENSIN TABS 40 MG NP QL(2 ea daily); candesartan cilexetil tabs NP PA (benazepril hcl) MP 16 mg, 32 mg, 8 mg moexipril hcl tabs NP candesartan cilexetil tabs 4 NP mg perindopril erbumine tabs NP COZAAR TABS (losartan NP QL(1 ea daily); potassium) MP QL(2 ea daily); QL(1 ea daily); PRINIVIL TABS (lisinopril) NP DIOVAN TABS (valsartan) NP MP MP QBRELIS SOLN NP EDARBI TABS NP quinapril hcl tabs 10 mg, 5 PA; QL(1 ea QL(1 ea daily); NP irbesartan tabs 1 mg daily) MP quinapril hcl tabs 20 mg, 40 QL(1 ea daily) NP losartan potassium tabs or 1 QL(1 ea daily); mg 100 mg, 25 mg, 50 mg MP QL(2 ea daily); ramipril caps 1 MICARDIS TABS NP PA; QL(1 ea MP (telmisartan) daily) trandolapril tabs 1 mg, 2 NP QL(1 ea daily) MP mg olmesartan medoxomil tabs 1 QL(2 ea daily) PA; QL(1 ea trandolapril tabs 4 mg NP telmisartan tabs NP daily) VASOTEC TABS (enalapril QL(2 ea daily); QL(1 ea daily); NP valsartan tabs 1 maleate) MP MP ZESTRIL TABS 10 MG, 20 QL(2 ea daily); MG, 30 MG, 40 MG, 5 MG NP MP Antiadrenergic Antihypertensives (lisinopril) CARDURA TABS NP MP (doxazosin mesylate) ZESTRIL TABS 2.5 MG NP QL(1 ea daily); (lisinopril) MP Age 4-5: MDD=2; Age 6- Agents for Pheochromocytoma 8: MDD=3; Age DEMSER CAPS PA CATAPRES TABS 0.1 MG NP NP ( ) 9-17: (metyrosine) clonidine hcl MDD=4;AL(At least 4 yrs old); DIBENZYLINE CAPS NP (phenoxybenzamine hcl) MP PA Age 4-5: metyrosine caps NP MDD=1; Age 6- phenoxybenzamine hcl 8: MDD= 1.5; 1 CATAPRES TABS 0.2 MG NP caps ) Age 9-17: (clonidine hcl MDD=2;AL(At phentolamine mesylate solr 1 least 4 yrs old); MP Angiotensin II Receptor Antagonists Age 4-5: ATACAND TABS NP PA MDD=0.667; (candesartan cilexetil) Age 6-8: CATAPRES TABS 0.3 MG MDD=1; Age 9- AVAPRO TABS NP QL(1 ea daily); NP (irbesartan) MP (clonidine hcl) 17: MDD=1.334;AL BENICAR TABS NP MP (olmesartan medoxomil) (At least 4 yrs old); MP

Coordinated Care of Washington Updated September 1, 2021

56 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CATAPRES-TTS-1 PTWK NP MP MINIPRESS CAPS NP MP (clonidine) (prazosin hcl) CATAPRES-TTS-2 PTWK NP MP prazosin hcl caps 1 MP (clonidine) MP CATAPRES-TTS-3 PTWK NP MP terazosin hcl caps 1 (clonidine) Age 4-5: Antihypertensive Combinations MDD=2; Age 6- ACCURETIC TABS 10 QL(3 ea daily); 8: MDD=3; Age MG-12.5 MG (quinapril- NP MP clonidine hcl tabs 0.1 mg 1 9-17: hydrochlorothiazide) MDD=4;AL(At ACCURETIC TABS 12.5 QL(4 ea daily); least 4 yrs old); MG-20 MG (quinapril- NP MP MP hydrochlorothiazide) Age 4-5: ACCURETIC TABS 20 QL(2 ea daily); MDD=1; Age 6- MG-25 MG (quinapril- NP MP 8: MDD= 1.5; hydrochlorothiazide) clonidine hcl tabs 0.2 mg 1 Age 9-17: MDD=2;AL(At amlodipine besylate- 1 PA; QL(1 ea least 4 yrs old); benazepril hcl caps daily); MP MP amlodipine besylate- NP PA Age 4-5: olmesartan medoxomil tabs MDD=0.667; amlodipine besylate- 1 PA; MP Age 6-8: valsartan tabs MDD=1; Age 9- clonidine hcl tabs 0.3 mg 1 amlodipine-valsartan- NP PA 17: hydrochlorothiazide tabs MDD=1.334;AL ATACAND HCT TABS PA (At least 4 yrs (candesartan cilexetil- NP old); MP hydrochlorothiazide) clonidine ptwk 1 MP atenolol & chlorthalidone 1 QL(1 ea daily); tabs MP MP doxazosin mesylate tabs 1 AVALIDE TABS QL(1 ea daily); Age 4-5: MDD (irbesartan- NP MP =2, Age 6-8: hydrochlorothiazide) MDD=3; Age 9- AZOR TABS (amlodipine PA guanfacine hcl tabs 1 mg 1 17: besylate-olmesartan NP MDD=4;AL(At medoxomil) least 4 yrs old); benazepril & 1 QL(1 ea daily); MP hydrochlorothiazide tabs MP Age 4-5: BENAZEPRIL QL(1 ea daily); MDD=1; Age 6- HCL/HYDROCHLOROTHI 2 MP 8: MDD= 1.5; AZIDE TABS guanfacine hcl tabs 2 mg 1 Age 9-17: BENICAR HCT TABS MP MDD=2;AL(At (olmesartan medoxomil- NP least 4 yrs old); hydrochlorothiazide) MP bisoprolol & 1 QL(1 ea daily); methyldopa tabs 1 MP hydrochlorothiazide tabs MP candesartan cilexetil- NP PA hydrochlorothiazide tabs Coordinated Care of Washington Updated September 1, 2021

57 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits captopril & NP QL(2 ea daily) METOPROLOL PA; QL(1 ea hydrochlorothiazide tabs SUCCINATE NP daily) DIOVAN HCT TABS QL(1 ea daily); ER/HYDROCHLOROTHIA (valsartan- NP MP ZIDE TB24 hydrochlorothiazide) MICARDIS HCT TABS PA; QL(1 ea (telmisartan- NP daily) DUTOPROL TB24 NP PA; QL(1 ea daily) hydrochlorothiazide) PA olmesartan medoxomil- PA EDARBYCLOR TABS NP amlodipine- NP hydrochlorothiazide tabs enalapril maleate & 1 QL(2 ea daily); hydrochlorothiazide tabs MP olmesartan medoxomil- 1 MP hydrochlorothiazide tabs EXFORGE HCT TABS NP PA PRESTALIA TABS NP PA EXFORGE TABS PA; MP (amlodipine besylate- NP propranolol & 1 QL(2 ea daily); valsartan) hydrochlorothiazide tabs MP quinapril- QL(3 ea daily); fosinopril sodium & 1 QL(1 ea daily); hydrochlorothiazide tabs MP hydrochlorothiazide tabs 10 1 MP HYZAAR TABS (losartan QL(1 ea daily); mg-12.5 mg potassium & NP MP quinapril- QL(4 ea daily); hydrochlorothiazide) hydrochlorothiazide tabs 1 MP 12.5 mg-20 mg irbesartan- 1 QL(1 ea daily); hydrochlorothiazide tabs MP quinapril- QL(2 ea daily); lisinopril & QL(2 ea daily); hydrochlorothiazide tabs 20 1 MP mg-25 mg hydrochlorothiazide tabs 10 1 MP mg-12.5 mg, 12.5 mg-20 TARKA TBCR (trandolapril- NP PA mg verapamil hcl) lisinopril & QL(1 ea daily); TEKTURNA HCT TABS NP PA hydrochlorothiazide tabs 20 1 MP mg-25 mg telmisartan-amlodipine tabs NP PA LOPRESSOR HCT TABS QL(2 ea daily); (metoprolol & NP MP telmisartan- NP PA; QL(1 ea hydrochlorothiazide) hydrochlorothiazide tabs daily) TENORETIC 100 TABS QL(1 ea daily); losartan potassium & 1 QL(1 ea daily); NP hydrochlorothiazide tabs MP (atenolol & chlorthalidone) MP LOTENSIN HCT TABS QL(1 ea daily); TENORETIC 50 TABS NP QL(1 ea daily); (benazepril & NP MP (atenolol & chlorthalidone) MP hydrochlorothiazide) trandolapril-verapamil hcl NP PA LOTREL CAPS PA; QL(1 ea tbcr (amlodipine besylate- NP daily); MP TRIBENZOR TABS PA benazepril hcl) (olmesartan medoxomil- NP amlodipine- methyldopa & NP PA hydrochlorothiazide tabs hydrochlorothiazide) TWYNSTA TABS PA metoprolol & 1 QL(2 ea daily); NP hydrochlorothiazide tabs MP (telmisartan-amlodipine) valsartan- 1 QL(1 ea daily); hydrochlorothiazide tabs MP

Coordinated Care of Washington Updated September 1, 2021

58 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 ea daily); VASERETIC TABS COARTEM TABS 2 QL(24 ea per (enalapril maleate & NP MP fill retail) hydrochlorothiazide) MALARONE TABS NP ZESTORETIC TABS 10 QL(2 ea daily); (atovaquone-proguanil hcl) MG-12.5 MG, 12.5 MG-20 MP NP PYRIMETHAMINE/LEUCO NP PA MG (lisinopril & VORIN CAPS hydrochlorothiazide) ZESTORETIC TABS 20 QL(1 ea daily); Antimalarials MG-25 MG (lisinopril & NP MP ARAKODA TABS NP PA hydrochlorothiazide) QL(2 ea ZIAC TABS (bisoprolol & NP QL(1 ea daily); hydrochlorothiazide) MP daily)180 rtl chloroquine phosphate tabs 1 MAX day(s) Antihypertensives - Misc. 250 mg supply,365 rtl lmt day(s), VECAMYL TABS NP PA QL(5 ea per 30 Direct Renin Inhibitors days retail)180 chloroquine phosphate tabs 1 rtl MAX day(s) aliskiren fumarate tabs NP PA 500 mg supply,365 rtl lmt day(s), TEKTURNA TABS NP PA (aliskiren fumarate) DARAPRIM TABS NP PA Selective Aldosterone Receptor Antagonists hydroxychloroquine sulfate 1 QL(3 ea daily) eplerenone tabs 1 MP tabs KRINTAFEL TABS NP PA INSPRA TABS NP MP (eplerenone) mefloquine hcl tabs 1 MP Vasodilators PLAQUENIL TABS QL(3 ea daily) hydralazine hcl soln ij 20 1 PA mg/ml (hydroxychloroquine NP sulfate) hydralazine hcl tabs or 100 1 MP mg, 25 mg, 50 mg, 10 mg primaquine phosphate tabs 1 minoxidil tabs 1 MP PRIMAQUINE PHOSPHATE TABS 2 NIPRIDE RTU SOLN 0.9 PA (primaquine phosphate) %-20 MG/100ML, 0.9 %-50 2 MG/100ML pyrimethamine tabs NP PA NITROPRESS SOLN PA 2 QUALAQUIN CAPS NP (nitroprusside sodium) (quinine sulfate) PA nitroprusside sodium soln 1 quinine sulfate caps 1 ANTIMALARIALS - Drugs to Treat Malaria (Parasitic Infections) ANTIMYASTHENIC/CHOLINERGIC AGENTS Antimalarial Combinations Antimyasthenic/Cholinergic Agents BLOXIVERZ SOLN PA atovaquone-proguanil hcl 1 2 tabs (neostigmine methylsulfate) FIRDAPSE TABS NP PA

Coordinated Care of Washington Updated September 1, 2021

59 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GUANIDINE HCL TABS NP PASER PACK NP

MESTINON SOLN 60 PA PRETOMANID TABS NP PA MG/5ML (pyridostigmine 2 bromide) PRIFTIN TABS 2 MESTINON TABS 60 MG NP PA (pyridostigmine bromide) pyrazinamide tabs 1 MESTINON TIMESPAN TBCR (pyridostigmine NP rifabutin caps 1 bromide) neostigmine methylsulfate PA RIFADIN CAPS (rifampin) NP soln 10 mg/10ml, 5 1 mg/10ml rifampin caps 1 NEOSTIGMINE PA RIFAMPIN/SYRSPEND SF NP PA METHYLSULFATE SOLN 2 PH4 SUSP 3 MG/3ML, 5 MG/5ML, 10 MG/10ML, 5 MG/10ML SIRTURO TABS 2 NEOSTIGMINE PA TRECATOR TABS 2 METHYLSULFATE SOSY 2 2 MG/2ML, 3 MG/3ML, 4 MG/4ML, 5 MG/5ML ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer pyridostigmine bromide 1 PA soln 60 mg/5ml Alkylating Agents pyridostigmine bromide 1 ALKERAN TABS NP tabs 60 mg, 30 mg (melphalan) pyridostigmine bromide 1 cyclophosphamide caps or 1 tbcr 180 mg 25 mg, 50 mg PA REGONOL SOLN 2 CYCLOPHOSPHAMIDE 2 TABS OR 25 MG, 50 MG PA RUZURGI TABS NP GLEOSTINE CAPS 2 PA

ANTIMYCOBACTERIAL AGENTS - Drugs to LEUKERAN TABS 2 PA Treat Tuberculosis (Bacterial Infections) Antimycobacterial Agents melphalan tabs 1 cycloserine caps 1 MYLERAN TABS 2 PA MP ethambutol hcl tabs 1 TEMODAR CAPS NP PA (temozolomide) isoniazid syrp 1 MP temozolomide caps 1 PA MP isoniazid tabs 1 Antimetabolites MYAMBUTOL TABS NP MP capecitabine tabs 1 PA; SP (ethambutol hcl) MYCOBUTIN CAPS NP mercaptopurine tabs 1 (rifabutin) methotrexate sodium soln 1

Coordinated Care of Washington Updated September 1, 2021

60 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits methotrexate sodium solr 1 BREYANZI SUSP CO methotrexate sodium tabs 1 KYMRIAH SUSP CO

ONUREG TABS 2 PA TECARTUS SUSP CO

PURIXAN SUSP 2 PA YESCARTA SUSP CO

TABLOID TABS 2 Antineoplastic - EGFR Inhibitors erlotinib hcl tabs 1 PA; SP TREXALL TABS 2 GILOTRIF TABS 2 PA XATMEP SOLN 2 IRESSA TABS 2 PA XELODA TABS NP PA; SP (capecitabine) TAGRISSO TABS 2 PA Antineoplastic - Angiogenesis Inhibitors PA TARCEVA TABS (erlotinib NP PA; SP INLYTA TABS 2 hcl) LENVIMA 10 MG DAILY 2 PA VIZIMPRO TABS 2 PA DOSE CPPK LENVIMA 12MG DAILY 2 PA Antineoplastic - Hedgehog Pathway Inhibitors DOSE CPPK DAURISMO TABS 2 PA LENVIMA 14 MG DAILY 2 PA DOSE CPPK ERIVEDGE CAPS 2 PA LENVIMA 18 MG DAILY 2 PA DOSE CPPK ODOMZO CAPS 2 PA; SP LENVIMA 20 MG DAILY 2 PA DOSE CPPK Antineoplastic - Hormonal and Related Agents abiraterone acetate tabs PA; SP LENVIMA 24 MG DAILY 2 PA 1 DOSE CPPK 250 mg abiraterone acetate tabs PA LENVIMA 4 MG DAILY 2 PA NP DOSE CPPK 500 mg LENVIMA 8 MG DAILY 2 PA anastrozole tabs 1 DOSE CPPK Antineoplastic - Anti-HER2 Agents ARIMIDEX TABS NP (anastrozole) TUKYSA TABS 2 PA AROMASIN TABS NP SP (exemestane) Antineoplastic - BCL-2 Inhibitors bicalutamide tabs 1 VENCLEXTA STARTING 2 PA PACK TBPK CASODEX TABS NP VENCLEXTA TABS 2 PA (bicalutamide) DEPO-PROVERA SUSP 2 PA Antineoplastic - Cellular Immunotherapy PA; SP ABECMA SUSP CO ELIGARD KIT 2

Coordinated Care of Washington Updated September 1, 2021

61 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EMCYT CAPS 2 PA toremifene citrate tabs NP PA

ERLEADA TABS 2 PA TRELSTAR MIXJECT 2 PA SUSR SP exemestane tabs 1 VANTAS KIT 2 PA; SP FARESTON TABS NP PA PA (toremifene citrate) XTANDI CAPS 2 FEMARA TABS (letrozole) NP XTANDI TABS 2 PA flutamide caps 1 YONSA TABS NP PA PA; Limit 5ml PA; SP hydroxyprogesterone ZOLADEX IMPL 2 1 per caproate (antineoplastic) month;QL(0.16 soln ZYTIGA TABS 250 MG NP PA; SP 7 ml daily) (abiraterone acetate) letrozole tabs 1 ZYTIGA TABS 500 MG NP PA (abiraterone acetate) PA; SP leuprolide acetate kit 1 Antineoplastic - Immunomodulators LEUPROLIDE PA POMALYST CAPS 2 PA; SP ACETATE/BUPIVACAINE 2 HYDROCHLORIDE SOLN Antineoplastic - PDGFR-alpha Inhibitors LUPRON DEPOT (1- 2 PA; SP AYVAKIT TABS 2 PA MONTH) KIT LUPRON DEPOT (3- 2 PA; SP Antineoplastic - XPO1 Inhibitors MONTH) KIT XPOVIO 100 MG ONCE 2 PA LUPRON DEPOT (4- 2 PA; SP WEEKLY TBPK MONTH) KIT XPOVIO 40 MG ONCE 2 PA LUPRON DEPOT (6- 2 PA; SP WEEKLY TBPK MONTH) KIT XPOVIO 40 MG TWICE 2 PA LYSODREN TABS 2 PA WEEKLY TBPK XPOVIO 60 MG ONCE 2 PA megestrol acetate susp 1 WEEKLY TBPK XPOVIO 60 MG TWICE 2 PA megestrol acetate tabs 1 WEEKLY TBPK XPOVIO 80 MG ONCE PA NILANDRON TABS NP PA 2 (nilutamide) WEEKLY TBPK PA XPOVIO 80 MG TWICE 2 PA nilutamide tabs 1 WEEKLY TBPK PA NUBEQA TABS 2 PA XPOVIO TBPK 2

ORGOVYX TABS 2 PA Antineoplastic Combinations INQOVI TABS 2 PA SOLTAMOX SOLN NP PA KISQALI FEMARA 200 2 PA tamoxifen citrate tabs 1 MP DOSE TBPK

Coordinated Care of Washington Updated September 1, 2021

62 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KISQALI FEMARA 400 2 PA IBRANCE CAPS 100 MG, 2 PA; SP DOSE TBPK 125 MG, 75 MG KISQALI FEMARA 600 2 PA IBRANCE TABS 100 MG, 2 PA DOSE TBPK 125 MG, 75 MG LONSURF TABS 2 PA ICLUSIG TABS 10 MG, 30 2 PA MG Antineoplastic Enzyme Inhibitors ICLUSIG TABS 15 MG, 45 2 PA; SP MG AFINITOR DISPERZ TBSO 2 PA; SP IDHIFA TABS 2 PA AFINITOR TABS 10 MG 2 PA; SP imatinib mesylate tabs 1 PA; SP AFINITOR TABS 2.5 MG, 5 NP PA; SP MG, 7.5 MG (everolimus) IMBRUVICA CAPS 2 PA ALECENSA CAPS 2 PA IMBRUVICA TABS 2 PA ALUNBRIG TABS 2 PA INREBIC CAPS 2 PA ALUNBRIG TBPK 2 PA JAKAFI TABS 2 PA BALVERSA TABS 2 PA KISQALI TBPK 2 PA; SP BOSULIF TABS 2 PA KOSELUGO CAPS 2 PA BRAFTOVI CAPS 2 PA lapatinib ditosylate tabs 1 PA; SP BRUKINSA CAPS 2 PA LORBRENA TABS 2 PA CABOMETYX TABS 2 PA LUMAKRAS TABS 2 PA CALQUENCE CAPS 2 PA LYNPARZA TABS 2 PA CAPRELSA TABS 2 PA MEKINIST TABS 2 PA COMETRIQ KIT 2 PA MEKTOVI TABS 2 PA COPIKTRA CAPS 2 PA NERLYNX TABS 2 PA COTELLIC TABS 2 PA NEXAVAR TABS 2 PA; SP everolimus tabs 1 PA; SP NINLARO CAPS 2 PA FARYDAK CAPS 2 PA PEMAZYRE TABS 2 PA FOTIVDA CAPS 2 PA PIQRAY 200MG DAILY 2 PA DOSE TBPK GAVRETO CAPS 2 PA PIQRAY 250MG DAILY 2 PA DOSE TBPK GLEEVEC TABS (imatinib NP PA; SP mesylate) Coordinated Care of Washington Updated September 1, 2021

63 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PIQRAY 300MG DAILY 2 PA VOTRIENT TABS 2 PA DOSE TBPK PA; SP QINLOCK TABS 2 PA XALKORI CAPS 2 PA RETEVMO CAPS 2 PA XOSPATA TABS 2 PA ROZLYTREK CAPS 2 PA ZEJULA CAPS 2 PA RUBRACA TABS 2 PA ZELBORAF TABS 2 PA; SP RYDAPT CAPS 2 PA ZOLINZA CAPS 2 PA SPRYCEL TABS 2 PA; SP ZYDELIG TABS 2 PA STIVARGA TABS 2 PA; SP ZYKADIA TABS 2 sunitinib malate caps NP PA; SP Antineoplastic Radiopharmaceuticals LUTATHERA SOLN CO SUTENT CAPS (sunitinib 2 PA; SP malate) Antineoplastics Misc. TABRECTA TABS 2 PA ACTIMMUNE SOLN 2 PA; SP TAFINLAR CAPS 2 PA; SP bexarotene caps 1 PA; SP TALZENNA CAPS 2 PA HYDREA CAPS NP (hydroxyurea) TASIGNA CAPS 150 MG, 2 PA; SP 200 MG hydroxyurea caps 1 TASIGNA CAPS 50 MG 2 PA INTRON A SOLN 2 PA; SP TEPMETKO TABS 2 PA INTRON A SOLR 2 PA; SP TIBSOVO TABS 2 PA MATULANE CAPS NP PA TRUSELTIQ CPPK 2 PA TARGRETIN CAPS OR 75 NP PA; SP MG (bexarotene) TURALIO CAPS 2 PA tretinoin (chemotherapy) 1 PA caps TYKERB TABS (lapatinib 2 PA; SP ditosylate) Chemotherapy Rescue/Antidote/Protective Agents PA UKONIQ TABS 2 leucovorin calcium tabs or 1 10 mg, 15 mg, 25 mg, 5 mg PA VERZENIO TABS 2 MESNEX TABS 2 PA VITRAKVI CAPS 2 Mitotic Inhibitors PA VITRAKVI SOLN 2 PA etoposide caps 1 Topoisomerase I Inhibitors

Coordinated Care of Washington Updated September 1, 2021

64 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HYCAMTIN CAPS 2 PA bromocriptine mesylate NP PA tabs ANTIPARKINSON AND RELATED THERAPY carbidopa-levodopa tabs MP AGENTS - Drugs to Treat Parkinson's Disease 10 mg-100 mg, 25 mg-100 1 mg, 25 mg-250 mg Antiparkinson Adjunctive Therapy carbidopa-levodopa tbcr 25 1 MP carbidopa tabs 1 MP mg-100 mg, 50 mg-200 mg carbidopa-levodopa tbdp LODOSYN TABS NP MP (carbidopa) 10 mg-100 mg, 25 mg-100 NP mg, 25 mg-250 mg NOURIANZ TABS 2 PA carbidopa-levodopa- NP entacapone tabs Antiparkinson Anticholinergics CARBIDOPA/LEVODOPA NP benztropine mesylate soln 1 ODT TBDP ij 1 mg/ml DUOPA SUSP NP benztropine mesylate tabs 1 MP or 0.5 mg, 1 mg, 2 mg GOCOVRI CP24 NP PA COGENTIN SOLN 2 (benztropine mesylate) INBRIJA CAPS NP PA QL(500 ml per trihexyphenidyl hcl soln 0.4 1 30 days retail); mg/ml KYNMOBI FILM NP MP KYNMOBI TITRATION KIT PA trihexyphenidyl hcl tabs 2 1 MP NP mg, 5 mg KIT Antiparkinson COMT Inhibitors MIRAPEX ER TB24 PA (pramipexole NP COMTAN TABS NP MP dihydrochloride) (entacapone) MIRAPEX TABS QL(3 ea daily); entacapone tabs 1 MP (pramipexole NP AL(At least 18 dihydrochloride) yrs old); MP ONGENTYS CAPS NP NEUPRO PT24 NP TASMAR TABS NP MP (tolcapone) OSMOLEX ER T4PK NP PA MP tolcapone tabs 1 OSMOLEX ER TB24 NP PA Antiparkinson Dopaminergics PARLODEL CAPS NP PA (bromocriptine mesylate) amantadine hcl caps 100 1 MP mg PARLODEL TABS NP PA (bromocriptine mesylate) amantadine hcl syrp 50 1 MP mg/5ml pramipexole QL(3 ea daily); dihydrochloride tabs 0.125 AL(At least 18 amantadine hcl tabs 100 NP 1 mg mg, 0.25 mg, 0.5 mg, 0.75 yrs old); MP mg, 1 mg, 1.5 mg APOKYN SOCT NP pramipexole PA dihydrochloride tb24 0.375 bromocriptine mesylate NP PA NP caps mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg Coordinated Care of Washington Updated September 1, 2021

65 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits REQUIP XL TB24 12 MG, PA XADAGO TABS NP 6 MG (ropinirole NP hydrochloride) ZELAPAR TBDP NP REQUIP XL TB24 4 MG, 8 MG (ropinirole NP ANTIPSYCHOTICS/ANTIMANIC AGENTS - hydrochloride) Drugs to Treat Mood Disorders ropinirole hydrochloride 1 QL(6 ea daily); Antimanic Agents tabs 0.25 mg, 3 mg, 4 mg MP lithium carbonate caps 150 1 MP ropinirole hydrochloride QL(3 ea daily); mg, 300 mg, 600 mg tabs 0.5 mg, 1 mg, 2 mg, 5 1 MP mg lithium carbonate tabs 300 1 MP mg ropinirole hydrochloride NP PA tb24 12 mg, 6 mg lithium carbonate tbcr 300 1 MP mg, 450 mg ropinirole hydrochloride NP tb24 2 mg, 4 mg, 8 mg LITHOBID TBCR (lithium NP MP carbonate) NP RYTARY CPCR Antipsychotics - Misc. SINEMET TABS NP MP CAPLYTA CAPS NP (carbidopa-levodopa) STALEVO 100 TABS EQUETRO CP12 2 PA (carbidopa-levodopa- NP entacapone) Age 6-12: STALEVO 125 TABS MDD=4; (carbidopa-levodopa- NP GEODON CAPS OR 20 NP Age;;13-17: entacapone) MG (ziprasidone hcl) MDD=8;;AL(At least 6 yrs old); STALEVO 150 TABS MP (carbidopa-levodopa- NP entacapone) Age 6-12: MDD=2; STALEVO 200 TABS GEODON CAPS OR 40 NP Age;;13-17: (carbidopa-levodopa- NP MG (ziprasidone hcl) MDD=4;;AL(At entacapone) least 6 yrs old); STALEVO 50 TABS MP (carbidopa-levodopa- NP Age 6-12: entacapone) MDD=1.34; STALEVO 75 TABS GEODON CAPS OR 60 NP Age 13-17: (carbidopa-levodopa- NP MG (ziprasidone hcl) MDD=2.67;AL( entacapone) At least 6 yrs Antiparkinson Monoamine Oxidase Inhibitors old); MP Age 6-12: AZILECT TABS (rasagiline NP PA mesylate) MDD=1; GEODON CAPS OR 80 NP Age;;13-17: rasagiline mesylate tabs NP PA MG (ziprasidone hcl) MDD=2;;AL(At least 6 yrs old); selegiline hcl caps 1 MP MP AL(At least 18 selegiline hcl tabs 1 MP GEODON SOLR IM 20 MG 2 yrs old - Up to (ziprasidone mesylate) 64 yrs old)

Coordinated Care of Washington Updated September 1, 2021

66 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Age 6-12: Age 6-12: MDD=0.34;Age MDD=4; Age;;13-17: 2 13-17: ziprasidone hcl caps 20 mg 1 LATUDA TABS 120 MG MDD=0.67;AL( MDD=8;;AL(At At least 6 yrs least 6 yrs old); old); MP MP Age 6-12: Age 6-12: MDD=2;Age MDD=2; Age;;13-17: LATUDA TABS 20 MG 2 13-17: MDD=4; ziprasidone hcl caps 40 mg 1 Age 18+: MDD=4;;AL(At MDD=1;AL(At least 6 yrs old); least 6 yrs old) MP Age 6-12: Age 6-12: MDD=1;Age MDD=1.34; 13-17: MDD=2; Age 13-17: ziprasidone hcl caps 60 mg 1 LATUDA TABS 40 MG 2 Age 18+: MDD=2.67;AL( MDD=1;AL(At At least 6 yrs least 6 yrs old); old); MP MP Age 6-12: Age 6-12: MDD=1; MDD=0.67;Age Age;;13-17: ziprasidone hcl caps 80 mg 1 13-17: MDD=2;;AL(At least 6 yrs old); LATUDA TABS 60 MG 2 MDD=1.34; Age 18+: MP MDD=1;AL(At AL(At least 18 least 6 yrs old); ziprasidone mesylate solr 1 yrs old - Up to MP 64 yrs old) Age 6-12: MDD=0.5;Age Benzisoxazoles AL(At least 18 2 13-17: FANAPT TABS NP LATUDA TABS 80 MG MDD=1;AL(At yrs old) least 6 yrs old); FANAPT TITRATION NP PA; AL(At least MP PACK TABS 18 yrs old) NUPLAZID CAPS 2 PA AL(At least 18 INVEGA SUSTENNA 2 yrs old - Up to SUSY NUPLAZID TABS 2 PA 64 yrs old) INVEGA TB24 NP PA; AL(At least PA; Minimum (paliperidone) 18 yrs old) VRAYLAR CAPS 1.5 MG, 2 age 18yo;AL(At AL(At least 18 3 MG, 4.5 MG, 6 MG least 18 yrs INVEGA TRINZA SUSY 2 yrs old - Up to old); MP 64 yrs old); MP PA; Minimum PA; AL(At least paliperidone tb24 NP 2 age 18yo;AL(At 18 yrs old) VRAYLAR CPPK least 18 yrs old) PERSERIS PRSY NP PA; AL(At least 18 yrs old) AL(At least 18 RISPERDAL CONSTA 2 SRER yrs old - Up to 64 yrs old); SP

Coordinated Care of Washington Updated September 1, 2021

67 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Age 3-5: Age 3-5: MDD=2; Age 6- MDD=2; Age 6- 12: MDD=4; 12: MDD=4; RISPERDAL SOLN 1 NP 1 ) Age 13- 17: risperidone soln 1 mg/ml Age 13- 17: MG/ML (risperidone MDD=6;AL(At MDD=6;AL(At least 3 yrs old); least 3 yrs old); MP MP AL(At least 3 Age 3-5: risperidone tabs 0.25 mg 1 MDD=4; yrs old); MP Age;;6-12: Age 3-5: RISPERDAL TABS 0.5 MG NP MDD=8; Age MDD=4; (risperidone) 13-;;17: Age;;6-12: MDD=12;;AL(A MDD=8; Age risperidone tabs 0.5 mg 1 t least 3 yrs 13-;;17: old); MP MDD=12;;AL(At Age 3-5: least 3 yrs old); MDD=2; MP Age;;6-12: Age 3-5: RISPERDAL TABS 1 MG NP MDD=4; Age MDD=2; (risperidone) 13-;;17: Age;;6-12: MDD=6;;AL(At MDD=4; Age risperidone tabs 1 mg 1 least 3 yrs old); 13-;;17: MP MDD=6;;AL(At Age 3-5: least 3 yrs old); MDD=1; MP Age;;6-12: Age 3-5: RISPERDAL TABS 2 MG NP MDD=2; Age MDD=1; (risperidone) 13-;;17: Age;;6-12: MDD=3;;AL(At MDD=2; Age risperidone tabs 2 mg 1 least 3 yrs old); 13-;;17: MP MDD=3;;AL(At Age 3-5: least 3 yrs old); MDD=0.67; MP Age 6-12: Age 3-5: RISPERDAL TABS 3 MG NP MDD=1.34; MDD=0.67; (risperidone) Age 13-17: Age 6-12: MDD=2;AL(At 1 MDD=1.34; least 3 yrs old); risperidone tabs 3 mg Age 13-17: MP MDD=2;AL(At Age 3-5: least 3 yrs old); MDD=0.5;;;Age MP 6-12: MDD=1; Age 3-5: RISPERDAL TABS 4 MG NP Age;;13-17: (risperidone) MDD=0.5;;;Age MDD=1.5;;AL( 6-12: MDD=1; At least 3 yrs risperidone tabs 4 mg 1 Age;;13-17: old); MP MDD=1.5;;AL(A t least 3 yrs old); MP

Coordinated Care of Washington Updated September 1, 2021

68 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Age 3-5: HALDOL DECANOATE 50 MDD=8; Age 6- SOLN (haloperidol NP 12: MDD=16; decanoate) risperidone tbdp 0.25 mg 1 Age 13-17: HALDOL SOLN NP MDD=24;AL(At (haloperidol lactate) least 3 yrs old); MP haloperidol decanoate soln 1 Age 3-5: Age 6-12: MDD=4; Age 6- MDD=5; 12: MDD=8; haloperidol lactate conc or 1 Age;;13-17: risperidone tbdp 0.5 mg 1 Age 13- 17: 2 mg/ml MDD=7.5;;AL(A MDD=12;AL(At t least 6 yrs least 3 yrs old); old); MP MP haloperidol lactate soln ij 5 1 Age 3-5: mg/ml MDD=2; Age 6- 12: MDD=4; Age 6-12: risperidone tbdp 1 mg 1 Age 13- 17: MDD=20;;;Age 13-17: MDD=6;AL(At haloperidol tabs 0.5 mg 1 least 3 yrs old); MDD=30;;AL(At MP least 6 yrs old); MP Age 3-5: MDD=1; Age 6- Age 6-12: 12: MDD=2; MDD=10;;;Age 13-17: risperidone tbdp 2 mg 1 Age 13- 17: haloperidol tabs 1 mg 1 MDD=3;AL(At MDD=15;;AL(At least 3 yrs old); least 6 yrs old); MP MP Age 3-5: Age 6-12: MDD=0.67; MDD=1; Age 6-12: 1 Age;;13-17: haloperidol tabs 10 mg MDD=1.5;;AL(A 1 MDD=1.34; risperidone tbdp 3 mg Age 13-17: t least 6 yrs MDD=2;AL(At old); MP least 3 yrs old); Age 6-12; MP MDD=5;;Age 13-17: Age 3-5: haloperidol tabs 2 mg 1 MDD=0.5; Age MDD=7.5;;AL(A 6-12: MDD=1; t least 6 yrs risperidone tbdp 4 mg 1 Age 13-17: old); MP MDD=1.5;AL(A Age 6-12: t least 3 yrs MDD=0.5; old); MP 1 Age;;13-17: haloperidol tabs 20 mg MDD=0.75;;AL( Butyrophenones At least 6 yrs HALDOL DECANOATE old); MP 100 SOLN (haloperidol NP decanoate)

Coordinated Care of Washington Updated September 1, 2021

69 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Age 6-12: Age 13-17: MDD=2; CLOZARIL TABS 25 MG NP MDD 28;AL(At Age;;13-17: ) haloperidol tabs 5 mg 1 (clozapine least 13 yrs MDD=3;;AL(At old) least 6 yrs old); Age 13-17: MP CLOZARIL TABS 50 MG NP MDD 14;;AL(At Dibenzapines (clozapine) least 13 yrs old) PA ADASUVE AEPB NP PA; Age 13 - AL(At least 18 FAZACLO TBDP 100 MG 17: MDD = asenapine maleate subl NP NP yrs old); MP (clozapine) 7;AL(At least 13 yrs old) Age 13-17: MDD 7;AL(At PA; Age 13 - clozapine tabs 100 mg 1 least 13 yrs FAZACLO TBDP 25 MG NP 17: MDD = old) (clozapine) 28;AL(At least 13 yrs old) Age 13 - 17: QL(4 ea daily); 1 MDD = loxapine succinate caps 1 clozapine tabs 200 mg 3.5;AL(At least MP 13 yrs old) AL(At least 18 Age 13-17: olanzapine solr im 10 mg 1 yrs old - Up to 64 yrs old) 1 MDD 28;AL(At clozapine tabs 25 mg least 13 yrs Age 6-12: old) MDD=1; Age Age 13-17: 1 13-17: olanzapine tabs or 10 mg MDD=2;AL(At 1 MDD 14;;AL(At clozapine tabs 50 mg least 13 yrs least 6 yrs old); old) MP PA; Age 13 - Age 6-12; 17: MDD = MDD=0.67; clozapine tbdp 100 mg NP Age 13-17: 7;AL(At least olanzapine tabs or 15 mg 1 13 yrs old) MDD=1.34;AL( At least 6 yrs clozapine tbdp 12.5 mg, NP AL(At least 13 old); MP 150 mg, 200 mg yrs old) Age 6-12: PA; Age 13 - MDD=4; Age 17: MDD = clozapine tbdp 25 mg NP 1 13-17: 28;AL(At least olanzapine tabs or 2.5 mg MDD=8;AL(At 13 yrs old) least 6 yrs old); Age 13-17: MP CLOZARIL TABS 100 MG NP MDD 7;AL(At Age 6-12: (clozapine) least 13 yrs MDD=0.5; Age old) 1 13-17: Age 13 - 17: olanzapine tabs or 20 mg MDD=1;AL(At CLOZARIL TABS 200 MG NP MDD = least 6 yrs old); (clozapine) 3.5;AL(At least MP 13 yrs old)

Coordinated Care of Washington Updated September 1, 2021

70 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Age 6-12: Age 6-12: MDD=2; Age MDD=16;;;Age 13-17: 13-17: olanzapine tabs or 5 mg 1 quetiapine fumarate tabs 1 MDD=4;AL(At 25 mg MDD=32;;AL(At least 6 yrs old); least 6 yrs old); MP MP Age 6-12: Age 6-12: MDD=1.34; MDD=1.34; Age 13-17: Age 13-17: olanzapine tabs or 7.5 mg 1 quetiapine fumarate tabs 1 MDD=2.67;AL( 300 mg MDD=2.67;AL( At least 6 yrs At least 6 yrs old); MP old); MP Age 6-12: Age 6-12: MDD=1; Age MDD=1; Age 13-17: 13-17: olanzapine tbdp or 10 mg 1 quetiapine fumarate tabs 1 MDD=2;AL(At 400 mg MDD=2;AL(At least 6 yrs old); least 6 yrs old); MP MP Age 6-12: Age 6-12: MDD=0.667; MDD=8; Age 13-17: Age;;13-17: olanzapine tbdp or 15 mg 1 quetiapine fumarate tabs 1 MDD=1.34;AL( 50 mg MDD=16;;AL(At At least 6 yrs least 6 yrs old); old); MP MP Age 6-12: Age 6-12: MDD=0.5; Age MDD=2.67; 13-17: Age 13-17: olanzapine tbdp or 20 mg 1 quetiapine fumarate tb24 1 MDD=1;AL(At 150 mg MDD=5.34;AL( least 6 yrs old); At least 6 yrs MP old); MP Age 6-12: Age 6-12: MDD=2; Age MDD=2; Age 13-17: 13-17: olanzapine tbdp or 5 mg 1 quetiapine fumarate tb24 1 MDD=4;AL(At 200 mg MDD=4;AL(At least 6 yrs old); least 6 yrs old); MP MP Age 6-12: Age 6-12: MDD=4; MDD=1.34; quetiapine fumarate tabs 1 Age;;13-17: quetiapine fumarate tb24 1 Age 13-17: 100 mg MDD=8;;AL(At 300 mg MDD=2.67;AL( least 6 yrs old); At least 6 yrs MP old); MP Age 6-12: Age 6-12: MDD=2; Age MDD=1; Age quetiapine fumarate tabs 1 13-17: quetiapine fumarate tb24 1 13-17: 200 mg MDD=4;AL(At 400 mg MDD=2;AL(At least 6 yrs old); least 6 yrs old); MP MP

Coordinated Care of Washington Updated September 1, 2021

71 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Age 6-12: Age 6-12: MDD=8;;;Age MDD=2.67; quetiapine fumarate tb24 1 13-17: SEROQUEL XR TB24 150 NP Age 13-17: 50 mg MDD=16;;AL(A MG (quetiapine fumarate) MDD=5.34;AL( t least 6 yrs At least 6 yrs old); MP old); MP SAPHRIS SUBL 10 MG, AL(At least 18 Age 6-12: 2.5 MG, 5 MG (asenapine NP yrs old); MP MDD=2; Age maleate) SEROQUEL XR TB24 200 NP 13-17: MG (quetiapine fumarate) MDD=4;AL(At SAPHRIS SUBL 5 MG NP AL(At least 18 yrs old); MP least 6 yrs old); MP PA SECUADO PT24 NP Age 6-12: Age 6-12: MDD=1.34; MDD=4; SEROQUEL XR TB24 300 NP Age 13-17: MG (quetiapine fumarate) MDD=2.67;AL( SEROQUEL TABS 100 MG NP Age;;13-17: (quetiapine fumarate) MDD=8;;AL(At At least 6 yrs least 6 yrs old); old); MP MP Age 6-12: Age 6-12: MDD=1; Age MDD=2; Age SEROQUEL XR TB24 400 NP 13-17: MG (quetiapine fumarate) MDD=2;AL(At SEROQUEL TABS 200 MG NP 13-17: (quetiapine fumarate) MDD=4;AL(At least 6 yrs old); least 6 yrs old); MP MP Age 6-12: Age 6-12: MDD=8;;;Age MDD=16;;;Age SEROQUEL XR TB24 50 NP 13-17: MG (quetiapine fumarate) MDD=16;;AL(At SEROQUEL TABS 25 MG NP 13-17: (quetiapine fumarate) MDD=32;;AL(A least 6 yrs old); t least 6 yrs MP PA; AL(At least old); MP VERSACLOZ SUSP NP Age 6-12: 13 yrs old) MDD=1.34; PA; AL(At least ZYPREXA RELPREVV 18 yrs old - Up SEROQUEL TABS 300 MG NP Age 13-17: NP (quetiapine fumarate) MDD=2.67;AL( SUSR to 64 yrs old); At least 6 yrs SP old); MP AL(At least 18 ZYPREXA SOLR IM 10 NP yrs old - Up to Age 6-12: MG (olanzapine) MDD=1; Age 64 yrs old) SEROQUEL TABS 400 MG NP 13-17: Age 6-12: (quetiapine fumarate) MDD=2;AL(At MDD=1; Age least 6 yrs old); ZYPREXA TABS OR 10 NP 13-17: MP MG (olanzapine) MDD=2;AL(At Age 6-12: least 6 yrs old); MDD=8; MP SEROQUEL TABS 50 MG NP Age;;13-17: (quetiapine fumarate) MDD=16;;AL(A t least 6 yrs old); MP

Coordinated Care of Washington Updated September 1, 2021

72 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Age 6-12; Age 6-12: MDD=0.67; MDD=2; Age ZYPREXA TABS OR 15 NP Age 13-17: ZYPREXA ZYDIS TBDP 5 NP 13-17: MG (olanzapine) MDD=1.34;AL( MG (olanzapine) MDD=4;AL(At At least 6 yrs least 6 yrs old); old); MP MP Age 6-12: Dihydroindolones MDD=4; Age 1 QL(4 ea daily); ZYPREXA TABS OR 2.5 NP 13-17: molindone hcl tabs 10 mg MP MG (olanzapine) MDD=8;AL(At least 6 yrs old); molindone hcl tabs 25 mg, 1 MP 5 mg Age 6-12: Phenothiazines MDD=0.5; Age chlorpromazine hcl soln ij 1 ZYPREXA TABS OR 20 NP 13-17: 25 mg/ml, 50 mg/2ml MG (olanzapine) MDD=1;AL(At least 6 yrs old); chlorpromazine hcl tabs or 1 QL(10 ea MP 10 mg daily); MP Age 6-12: chlorpromazine hcl tabs or QL(3 ea daily); MDD=2; Age 100 mg, 200 mg, 25 mg, 50 1 MP mg ZYPREXA TABS OR 5 MG NP 13-17: (olanzapine) MDD=4;AL(At fluphenazine decanoate 1 least 6 yrs old); soln MP fluphenazine hcl conc or 5 1 Age 6-12: mg/ml MDD=1.34; fluphenazine hcl elix or 2.5 1 ZYPREXA TABS OR 7.5 NP Age 13-17: mg/5ml MG (olanzapine) MDD=2.67;AL( fluphenazine hcl soln ij 2.5 1 At least 6 yrs mg/ml old); MP fluphenazine hcl tabs or 1 1 MP Age 6-12: mg, 10 mg, 2.5 mg, 5 mg MDD=1; Age Age 6-12: ZYPREXA ZYDIS TBDP 10 NP 13-17: MG (olanzapine) MDD=2;AL(At MDD=0.75; Age 13-17: least 6 yrs old); perphenazine tabs 16 mg 1 MP MDD=1.5;AL(At least 6 yrs old); Age 6-12: MP MDD=0.667; Age 6-12: ZYPREXA ZYDIS TBDP 15 NP Age 13-17: MG (olanzapine) MDD=1.34;AL( MDD=6; Age 13-17: At least 6 yrs perphenazine tabs 2 mg 1 old); MP MDD=12;AL(At least 6 yrs old); Age 6-12: MP MDD=0.5; Age Age 6-12: ZYPREXA ZYDIS TBDP 20 NP 13-17: MG (olanzapine) MDD=1;AL(At MDD=3; Age 13-17: least 6 yrs old); perphenazine tabs 4 mg 1 MP MDD=6;AL(At least 6 yrs old); MP

Coordinated Care of Washington Updated September 1, 2021

73 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Age 6-12: PA; Age 3-5: MDD=1.5; Age MDD=0.25;Age 13-17: ABILIFY MYCITE 6-12: perphenazine tabs 8 mg 1 MDD=3;AL(At MAINTENANCE KIT TABS NP MDD=1;Age least 6 yrs old); 20 MG 13-17: MP MDD=1.5;AL(At least 3 yrs old) prochlorperazine edisylate 1 PA soln PA; Age 3-5: MDD=0.167;Ag prochlorperazine maleate 1 MP tabs ABILIFY MYCITE e 6-12: MAINTENANCE KIT TABS NP MDD=0.67;Age prochlorperazine supp 1 30 MG 13-17: MDD=1;AL(At QL(3 ea daily); thioridazine hcl tabs 1 least 3 yrs old) MP PA; Age 3-5: QL(3 ea daily); trifluoperazine hcl tabs 1 MDD=1;Age 6- MP ABILIFY MYCITE 12: Quinolinone Derivatives MAINTENANCE KIT TABS NP MDD=4;Age AL(At least 18 5 MG 13-17: MDD=6;AL(At 2 yrs old - Up to ABILIFY MAINTENA PRSY 64 yrs old); SP; least 3 yrs old) MP PA; Age 3-5: AL(At least 18 MDD=0.5;Age ABILIFY MYCITE 6-12: 2 yrs old - Up to ABILIFY MAINTENA SRER 64 yrs old); SP; STARTER KIT TABS 10 NP MDD=2;Age MP MG 13-17: MDD=3 ;AL(At least 3 PA; Age 3-5: yrs old) MDD=0.5;Age ABILIFY MYCITE 6-12: PA; Age 3-5: MAINTENANCE KIT TABS NP MDD=2;Age MDD=0.34 10 MG 13-17: MDD=3 ABILIFY MYCITE ;Age 6-12: ;AL(At least 3 STARTER KIT TABS 15 NP MDD=1.34;Age yrs old) MG 13-17: MDD=2;AL(At PA; Age 3-5: least 3 yrs old) MDD=0.34 ABILIFY MYCITE ;Age 6-12: ABILIFY MYCITE NP PA; AL(At least MAINTENANCE KIT TABS NP MDD=1.34;Age STARTER KIT TABS 2 MG 3 yrs old) 15 MG 13-17: PA; Age 3-5: MDD=2;AL(At MDD=0.25;Age least 3 yrs old) ABILIFY MYCITE 6-12: ABILIFY MYCITE PA; AL(At least STARTER KIT TABS 20 NP MDD=1;Age MAINTENANCE KIT TABS NP 3 yrs old) MG 13-17: 2 MG MDD=1.5;AL(At least 3 yrs old)

Coordinated Care of Washington Updated September 1, 2021

74 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; Age 3-5: PA; Age 3-5: MDD=0.167;Ag MDD=0.167;Ag ABILIFY MYCITE e 6-12: e 6-12: STARTER KIT TABS 30 NP MDD=0.67;Age ABILIFY MYCITE TABS 30 NP MG MDD=0.67;Age MG 13-17: 13-17: MDD=1;AL(At MDD=1;AL(At least 3 yrs old) least 3 yrs old) PA; Age 3-5: PA; Age 3-5: MDD=1;Age 6- MDD=1;Age 6- ABILIFY MYCITE 12: 12: NP MDD=4;Age ABILIFY MYCITE TABS 5 NP MDD=4;Age STARTER KIT TABS 5 MG MG 13-17: 13-17: MDD=6;AL(At MDD=6;;AL(At least 3 yrs old) least 3 yrs old) PA; Age 3-5: Age 3-5: MDD=0.5;Age MDD=0.5;Age 6-12: 6-12: ABILIFY MYCITE TABS 10 NP MDD=2;Age MG MDD=2;Age ABILIFY TABS 10 MG NP 13-17: (aripiprazole) 13-17: MDD=3;AL(At MDD=3;AL(At least 3 yrs old) least 3 yrs old); PA; Age 3-5: MP MDD=0.34 Age 3-5: ;Age 6-12: MDD=0.34 ABILIFY MYCITE TABS 15 NP MDD=1.34;Age ;Age 6-12: MG ABILIFY TABS 15 MG NP MDD=1.34;Age 13-17: (aripiprazole) MDD=2;AL(At 13-17: least 3 yrs old) MDD=2.;AL(At PA; Age 3-5: least 3 yrs old) MDD=2.5;Age Age 3-5: 6-12: MDD=2.5;Age ABILIFY MYCITE TABS 2 NP MDD=10;Age 6-12: MG 13-17: ABILIFY TABS 2 MG NP MDD=10;Age MDD=15;;AL(A (aripiprazole) 13-17: t least 3 yrs MDD=15;AL(At old) least 3 yrs old); PA; Age 3-5: MP MDD=0.25;Age Age 3-5: 6-12: MDD=0.25;Age ABILIFY MYCITE TABS 20 NP MDD=1;Age 6-12: MG 13-17: ABILIFY TABS 20 MG NP MDD=1;Age MDD=1.5;;AL( (aripiprazole) 13-17: At least 3 yrs MDD=1.5;AL(At old) least 3 yrs old); MP

Coordinated Care of Washington Updated September 1, 2021

75 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Age 3-5: Age 3-5: MDD=0.167;Ag MDD=0.167;Ag e 6-12: e 6-12: MDD=0.67;Age ABILIFY TABS 30 MG NP MDD=0.67;Age aripiprazole tabs 30 mg 1 (aripiprazole) 13-17: 13-17: MDD=1;AL(At MDD=1;AL(At least 3 yrs old); least 3 yrs old); MP MP Age 3-5: Age 3-5: MDD=1;Age 6- MDD=1;Age 6- 12: 12: MDD=4;Age ABILIFY TABS 5 MG NP MDD=4;Age aripiprazole tabs 5 mg 1 (aripiprazole) 13-17: 13-17: MDD=6;AL(At MDD=6;AL(At least 3 yrs old); least 3 yrs old); MP MP PA; AL(At least PA; AL(At least aripiprazole soln 1 mg/ml NP aripiprazole tbdp 10 mg, 15 NP 3 yrs old); MP mg 3 yrs old); MP Age 3-5: PA; AL(At least MDD=0.5;Age ARISTADA INITIO PRSY NP 18 yrs old - Up 6-12: to 64 yrs old) MDD=2;Age aripiprazole tabs 10 mg 1 AL(At least 18 13-17: ARISTADA PRSY 1064 2 yrs old - Up to MDD=3;AL(At MG/3.9ML 64 yrs old); SP; least 3 yrs old); MP MP ARISTADA PRSY 441 AL(At least 18 Age 3-5: MG/1.6ML, 662 MG/2.4ML, 2 yrs old - Up to MDD=0.34 882 MG/3.2ML 64 yrs old); MP ;Age 6-12: AL(At least 18 aripiprazole tabs 15 mg 1 MDD=1.34;Age REXULTI TABS NP 13-17: yrs old); MP MDD=2.;AL(At Thioxanthenes least 3 yrs old) QL(3 ea daily); thiothixene caps 1 Age 3-5: MP MDD=2.5;Age 6-12: ANTISEPTICS & DISINFECTANTS MDD=10;Age aripiprazole tabs 2 mg 1 13-17: Antiseptics & Disinfectants QL(90 ml per MDD=15;AL(At formaldehyde soln 1 least 3 yrs old); fill retail) MP ANTIVIRALS - Drugs to Treat Viral Infections Age 3-5: MDD=0.25;Age Antiretrovirals 6-12: abacavir sulfate soln 20 QL(30 ml daily) MDD=1;Age 1 aripiprazole tabs 20 mg 1 mg/ml 13-17: MDD=1.5;AL(A abacavir sulfate tabs 300 1 QL(2 ea daily) t least 3 yrs mg old); MP abacavir sulfate-lamivudine 1 QL(1 ea daily) tabs

Coordinated Care of Washington Updated September 1, 2021

76 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits abacavir sulfate- 1 QL(2 ea daily) efavirenz-lamivudine- PA lamivudine-zidovudine tabs tenofovir disoproxil NP fumarate tabs APTIVUS CAPS 250 MG 2 QL(4 ea daily) emtricitabine caps 1 QL(1 ea daily) APTIVUS SOLN 100 2 QL(10 ml daily) MG/ML emtricitabine-tenofovir 1 QL(1 ea daily) disoproxil fumarate tabs atazanavir sulfate caps 1 QL(2 ea daily) EMTRIVA CAPS 200 MG 2 QL(1 ea daily) ATRIPLA TABS (efavirenz- QL(1 ea daily) (emtricitabine) emtricitabine-tenofovir 2 EMTRIVA SOLN 10 2 QL(24 ml daily) disoproxil fumarate) MG/ML PA BIKTARVY TABS NP EPIVIR SOLN 10 MG/ML NP QL(30 ml daily) (lamivudine) PA; QL(4 ml EPIVIR TABS 150 MG QL(2 ea daily) CABENUVA SUER 400 2 NP MG/2ML-600 MG/2ML per 28 days (lamivudine) retail) EPIVIR TABS 300 MG NP QL(1 ea daily) PA; QL(6 ml (lamivudine) CABENUVA SUER 600 2 per 28 days MG/3ML-900 MG/3ML retail) EPZICOM TABS (abacavir NP QL(1 ea daily) sulfate-lamivudine) CIMDUO TABS NP PA etravirine tabs 100 mg 1 QL(4 ea daily) COMBIVIR TABS NP PA; QL(2 ea (lamivudine-zidovudine) daily) etravirine tabs 200 mg 1 QL(2 ea daily) QL(1 ea daily) COMPLERA TABS 2 EVOTAZ TABS 2 QL(1 ea daily) QL(9 ea daily) CRIXIVAN CAPS 200 MG 2 fosamprenavir calcium tabs 1 QL(6 ea daily) CRIXIVAN CAPS 400 MG 2 FUZEON SOLR 2

DELSTRIGO TABS 2 GENVOYA TABS 2 QL(1 ea daily) PA; QL(1 ea DESCOVY TABS NP INTELENCE TABS 100 2 QL(4 ea daily) daily) MG (etravirine) didanosine cpdr 1 QL(1 ea daily) INTELENCE TABS 200 2 QL(2 ea daily) MG (etravirine) DOVATO TABS NP PA INTELENCE TABS 25 MG 2 QL(4 ea daily) PA; QL(1 ea EDURANT TABS 2 daily) INVIRASE TABS 2 QL(4 ea daily) efavirenz caps 200 mg 1 QL(1 ea daily) ISENTRESS CHEW 100 2 QL(6 ea daily) MG efavirenz caps 50 mg 1 QL(2 ea daily) ISENTRESS CHEW 25 MG 2 QL(12 ea daily) efavirenz tabs 600 mg 1 QL(1 ea daily) ISENTRESS HD TABS 2 efavirenz-emtricitabine- QL(1 ea daily) tenofovir disoproxil 1 ISENTRESS PACK 100 2 QL(2 ea daily) fumarate tabs MG

Coordinated Care of Washington Updated September 1, 2021

77 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ISENTRESS TABS 400 2 QL(2 ea daily) PREZCOBIX TABS 2 QL(1 ea daily) MG PA PREZISTA SUSP 100 2 QL(12 ml daily) JULUCA TABS NP MG/ML KALETRA SOLN 100 PREZISTA TABS 150 MG 2 QL(3 ea daily) MG/5ML-400 MG/5ML 2 (lopinavir-ritonavir) PREZISTA TABS 600 MG, 2 QL(2 ea daily) 75 MG KALETRA TABS 25 MG- 2 QL(4 ea daily) 100 MG (lopinavir-ritonavir) PREZISTA TABS 800 MG 2 QL(1 ea daily) KALETRA TABS 50 MG- 2 QL(6 ea daily) 200 MG (lopinavir-ritonavir) RETROVIR CAPS 100 MG NP QL(6 ea daily) (zidovudine) lamivudine soln 10 mg/ml 1 QL(30 ml daily) RETROVIR IV INFUSION 2 SOLN lamivudine tabs 150 mg 1 QL(2 ea daily) RETROVIR SYRP 50 NP QL(60 ml daily) lamivudine tabs 300 mg 1 QL(1 ea daily) MG/5ML (zidovudine) REYATAZ CAPS 150 MG, QL(2 ea daily) lamivudine-zidovudine tabs 1 QL(2 ea daily) 200 MG, 300 MG NP (atazanavir sulfate) QL(56 ml daily) LEXIVA SUSP 50 MG/ML 2 REYATAZ PACK 50 MG 2 QL(6 ea daily) LEXIVA TABS 700 MG NP QL(12 ea daily) (fosamprenavir calcium) ritonavir tabs 1 lopinavir-ritonavir soln 100 1 PA mg/5ml-400 mg/5ml RUKOBIA TB12 NP lopinavir-ritonavir tabs 25 1 QL(4 ea daily) SELZENTRY SOLN 20 2 mg-100 mg MG/ML lopinavir-ritonavir tabs 50 1 QL(6 ea daily) SELZENTRY TABS 150 2 QL(2 ea daily) mg-200 mg MG nevirapine susp 50 mg/5ml 1 QL(40 ml daily) QL 2 per SELZENTRY TABS 25 2 day;SL(2 ea MG, 75 MG nevirapine tabs 200 mg 1 daily) SELZENTRY TABS 300 2 QL(4 ea daily) nevirapine tb24 100 mg 1 QL(3 ea daily) MG stavudine caps 15 mg, 20 1 QL(2 ea daily) nevirapine tb24 400 mg 1 QL(1 ea daily) mg, 30 mg, 40 mg STAVUDINE CAPS 15 MG, 2 QL(2 ea daily) NORVIR PACK 100 MG NP PA 20 MG, 30 MG, 40 MG QL(1 ea daily) NORVIR SOLN 80 MG/ML NP PA; QL(15 ml STRIBILD TABS 2 daily) SUSTIVA CAPS 200 MG NP QL(1 ea daily) NORVIR TABS 100 MG NP QL(12 ea daily) (efavirenz) (ritonavir) SUSTIVA CAPS 50 MG NP QL(2 ea daily) ODEFSEY TABS 2 (efavirenz) SUSTIVA TABS 600 MG NP QL(1 ea daily) PIFELTRO TABS 2 (efavirenz)

Coordinated Care of Washington Updated September 1, 2021

78 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SYMFI LO TABS PA VOCABRIA TABS NP PA (efavirenz-lamivudine- NP tenofovir disoproxil ZIAGEN SOLN 20 MG/ML NP QL(30 ml daily) fumarate) (abacavir sulfate) SYMFI TABS (efavirenz- PA ZIAGEN TABS 300 MG NP QL(2 ea daily) lamivudine-tenofovir NP (abacavir sulfate) disoproxil fumarate) zidovudine caps 100 mg 1 QL(6 ea daily) SYMTUZA TABS NP PA zidovudine syrp 50 mg/5ml 1 QL(60 ml daily) TEMIXYS TABS NP PA zidovudine tabs 300 mg 1 QL(2 ea daily) tenofovir disoproxil 1 QL(1 ea daily) fumarate tabs Antiviral Combinations PA TIVICAY PD TBSO NP ACYCLOVIX THPK NP PA TIVICAY TABS 10 MG, 25 2 MG CMV Agents PA TIVICAY TABS 50 MG 2 QL(2 ea daily) cidofovir soln 1 PA; QL(1 ea CYTOVENE SOLR PA TRIUMEQ TABS NP NP daily) (ganciclovir sodium) TRIZIVIR TABS (abacavir QL(2 ea daily) foscarnet sodium soln 1 PA sulfate-lamivudine- NP zidovudine) FOSCAVIR SOLN 2 PA (foscarnet sodium) TROGARZO SOLN 2 PA ganciclovir sodium solr 1 PA TRUVADA TABS PA; QL(1 ea (emtricitabine-tenofovir NP daily) GANCICLOVIR SOLN 500 NP PA disoproxil fumarate) MG/10ML QL(1 ea daily) GANCICLOVIR SOLN 500 2 PA TYBOST TABS 2 MG/250ML PA VIRACEPT TABS 250 MG 2 QL(9 ea daily) PREVYMIS SOLN 2 PA VIRACEPT TABS 625 MG 2 QL(4 ea daily) PREVYMIS TABS 2 VALCYTE SOLR 50 VIRAMUNE SUSP 50 2 QL(40 ml daily) NP MG/5ML (nevirapine) MG/ML (valganciclovir hcl) VALCYTE TABS 450 MG QL(2 ea daily) VIRAMUNE TABS 200 MG NP NP (nevirapine) (valganciclovir hcl) valganciclovir hcl solr 50 VIRAMUNE XR TB24 NP QL(1 ea daily) 1 (nevirapine) mg/ml valganciclovir hcl tabs 450 QL(2 ea daily) VIREAD POWD 40 MG/GM 2 QL(240 gm per 1 30 days retail) mg VIREAD TABS 150 MG, 2 QL(1 ea daily) Hepatitis Agents 200 MG, 250 MG VIREAD TABS 300 MG QL(1 ea daily) adefovir dipivoxil tabs 1 (tenofovir disoproxil NP BARACLUDE SOLN 0.05 NP fumarate) MG/ML Coordinated Care of Washington Updated September 1, 2021

79 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BARACLUDE TABS 0.5 NP SP VOSEVI TABS CO MG, 1 MG (entecavir) entecavir tabs 1 SP ZEPATIER TABS CO

EPCLUSA TABS 100 MG- CO Herpes Agents 400 MG, 50 MG-200 MG QL(50 ea per acyclovir caps 200 mg 1 EPIVIR HBV SOLN 5 2 30 days retail) MG/ML acyclovir sodium soln 1 PA EPIVIR HBV TABS 100 NP MG (lamivudine (hbv)) QL(400 ml per acyclovir susp 200 mg/5ml 1 HARVONI PACK 33.75 30 days retail) MG-150 MG, 45 MG-200 CO QL(3 ea daily) MG acyclovir tabs 400 mg 1 QL(50 ea per HARVONI TABS 45 MG- CO acyclovir tabs 800 mg 1 200 MG, 90 MG-400 MG 30 days retail) HEPSERA TABS (adefovir NP famciclovir tabs 1 dipivoxil) PA lamivudine (hbv) tabs 1 SITAVIG TABS NP valacyclovir hcl tabs 1 gm, QL(21 ea per LEDIPASVIR/SOFOSBUVI CO 1 R TABS 1000 mg 21 days retail) valacyclovir hcl tabs 500 1 QL(60 ea per MAVYRET TABS CO mg 30 days retail) VALTREX TABS 1 GM QL(21 ea per PEGASYS PROCLICK CO NP SOLN (valacyclovir hcl) 21 days retail) PEGASYS SOLN CO VALTREX TABS 500 MG NP QL(60 ea per (valacyclovir hcl) 30 days retail) PEGINTRON KIT CO ZOVIRAX SUSP OR 200 NP QL(400 ml per MG/5ML (acyclovir) 30 days retail) RIBASPHERE RIBAPAK CO TBPK Influenza Agents RIBASPHERE TABS CO oseltamivir phosphate caps 1 ribavirin (hepatitis c) caps CO oseltamivir phosphate susr 1 PA ribavirin (hepatitis c) tabs CO RAPIVAB SOLN 2 SOFOSBUVIR/VELPATAS QL(20 ea per CO RELENZA DISKHALER NP VIR TABS AEPB fill retail); AL(At least 5 yrs old) SOVALDI PACK CO rimantadine hydrochloride 1 tabs SOVALDI TABS CO TAMIFLU CAPS NP (oseltamivir phosphate) VEMLIDY TABS NP PA; SP TAMIFLU SUSR NP (oseltamivir phosphate) VIEKIRA PAK TBPK CO XOFLUZA TBPK NP

Coordinated Care of Washington Updated September 1, 2021

80 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Respiratory Syncytial Virus (RSV) Agents bisoprolol fumarate tabs or 1 QL(1 ea daily); 10 mg, 5 mg MP PA ribavirin solr 1 BREVIBLOC PREMIXED DOUBLESTRENGTH VIRAZOLE SOLR NP PA NP (ribavirin) SOLN (esmolol hcl-sodium chloride) BETA BLOCKERS - Drugs to Treat High Blood BREVIBLOC PREMIXED Pressure SOLN (esmolol hcl-sodium NP Alpha-Beta Blockers chloride) QL(1 ea daily); BREVIBLOC SOLN 100 PA carvedilol phosphate cp24 1 NP MP MG/10ML (esmolol hcl) BREVIBLOC SOLN 4.1 carvedilol tabs 12.5 mg, 1 QL(3 ea daily); 3.125 mg, 6.25 mg MP MG/ML-2000 MG/100ML, QL(4 ea daily); 5.9 MG/ML-2500 NP carvedilol tabs 25 mg 1 MP MG/250ML (esmolol hcl- sodium chloride) COREG CR CP24 NP QL(1 ea daily); (carvedilol phosphate) MP BYSTOLIC TABS NP COREG TABS 12.5 MG, QL(3 ea daily); PA 3.125 MG, 6.25 MG NP MP esmolol hcl soln 1 (carvedilol) esmolol hcl-sodium 1 COREG TABS 25 MG NP QL(4 ea daily); chloride soln (carvedilol) MP ESMOLOL PA PA labetalol hcl soln iv 5 mg/ml 1 HYDROCHLORIDE 2 INWATER DOUBLE QL(3 ea daily); labetalol hcl tabs or 100 mg 1 STRENGTH SOLN MP ESMOLOL PA QL(6 ea daily); labetalol hcl tabs or 200 mg 1 HYDROCHLORIDE 2 MP INWATER SOLN QL(8 ea daily); labetalol hcl tabs or 300 mg 1 ESMOLOL 2 PA MP HYDROCHLORIDE SOSY LABETALOL PA 2 KAPSPARGO SPRINKLE NP PA HYDROCHLORIDE SOLN CS24 LABETALOL PA 2 LOPRESSOR TABS 100 NP QL(2 ea daily); HYDROCHLORIDE SOSY MG (metoprolol tartrate) MP LABETALOL PA LOPRESSOR TABS 50 NP QL(3 ea daily); HYDROCHLORIDE/SODIU 2 MG (metoprolol tartrate) MP M CHLORIDE SOLN metoprolol succinate tb24 1 QL(1 ea daily); Beta Blockers Cardio-Selective 100 mg, 25 mg, 50 mg MP acebutolol hcl caps 1 MP metoprolol succinate tb24 1 QL(2 ea daily); 200 mg MP QL(2 ea daily); atenolol tabs 1 metoprolol tartrate soln iv 5 1 PA MP mg/5ml ATENOLOL/SYRSPEND PA NP metoprolol tartrate tabs or 1 QL(2 ea daily); SF PH4 SUSP 100 mg, 25 mg MP MP betaxolol hcl tabs 1 metoprolol tartrate tabs or 1 37.5 mg, 75 mg

Coordinated Care of Washington Updated September 1, 2021

81 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits metoprolol tartrate tabs or 1 QL(3 ea daily); SOTYLIZE SOLN 2 MP 50 mg MP TENORMIN TABS NP QL(2 ea daily); timolol maleate tabs NP (atenolol) MP TOPROL XL TB24 100 QL(1 ea daily); CALCIUM CHANNEL BLOCKERS - Drugs to MG, 25 MG, 50 MG NP MP Treat High Blood Pressure (metoprolol succinate) Calcium Channel Blocker Combinations TOPROL XL TB24 200 MG NP QL(2 ea daily); PA (metoprolol succinate) MP CONSENSI TABS NP Beta Blockers Non-Selective Calcium Channel Blockers BETAPACE AF TABS QL(2 ea daily); QL(1 ea daily); NP amlodipine besylate tabs 1 (sotalol hcl (afib/afl)) MP MP BETAPACE TABS (sotalol NP QL(2 ea daily); AMLODIPINE PA hcl) MP BESYLATE/SYRSPEND NP QL(2 ea daily); SF PH4 SUSP CORGARD TABS (nadolol) NP MP CALAN SR TBCR NP QL(2 ea daily); ) HEMANGEOL SOLN NP (verapamil hcl MP CARDENE IV SOLN 2 PA INDERAL LA CP24 NP QL(2 ea daily); (propranolol hcl) MP CARDIZEM CD CP24 120 PA; QL(1 ea MG, 180 MG, 300 MG INDERAL XL CP24 NP NP daily); MP (diltiazem hcl coated beads) INNOPRAN XL CP24 120 NP MG, 80 MG CARDIZEM CD CP24 240 PA; QL(2 ea QL(2 ea daily); MG (diltiazem hcl coated NP daily); MP nadolol tabs 1 MP beads) CARDIZEM CD CP24 360 MP pindolol tabs NP MG (diltiazem hcl coated NP propranolol hcl cp24 or 60 QL(2 ea daily); beads) mg, 80 mg, 120 mg, 160 1 MP CARDIZEM LA TB24 120 NP PA mg MG propranolol hcl soln iv 1 1 PA CARDIZEM LA TB24 180 PA mg/ml MG, 240 MG, 300 MG, 360 NP MG, 420 MG (diltiazem hcl propranolol hcl soln or 20 1 MP mg/5ml, 40 mg/5ml coated beads) propranolol hcl tabs or 10 MP CARDIZEM TABS NP QL(3 ea daily); mg, 20 mg, 80 mg, 40 mg, 1 (diltiazem hcl) MP 60 mg CLEVIPREX EMUL 2 PA QL(2 ea daily); sotalol hcl (afib/afl) tabs 1 MP CONJUPRI TABS NP sotalol hcl tabs 120 mg, 1 QL(2 ea daily); 160 mg, 80 mg MP diltiazem hcl coated beads QL(1 ea daily); cp24 120 mg, 180 mg, 300 1 MP sotalol hcl tabs 240 mg 1 MP mg diltiazem hcl coated beads PA; QL(1 ea SOTALOL 2 HYDROCHLORIDE SOLN cp24 120 mg, 180 mg, 300 NP daily); MP mg

Coordinated Care of Washington Updated September 1, 2021

82 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits diltiazem hcl coated beads 1 QL(2 ea daily); NICARDIPINE PA cp24 240 mg MP HYDROCHLORIDE/SODIU 2 M CHLORIDE SOSY 0.9 diltiazem hcl coated beads NP PA; QL(2 ea cp24 240 mg daily); MP %-1 MG/10ML nifedipine caps 10 mg, 20 QL(4 ea daily); diltiazem hcl coated beads 1 MP 1 cp24 360 mg mg MP diltiazem hcl coated beads PA nifedipine tb24 30 mg, 90 1 QL(1 ea daily); tb24 180 mg, 240 mg, 300 NP mg MP QL(2 ea daily); mg, 360 mg, 420 mg nifedipine tb24 60 mg 1 MP diltiazem hcl cp12 or 120 1 QL(2 ea daily); mg, 60 mg, 90 mg MP nimodipine caps NP diltiazem hcl cp24 or 120 1 QL(1 ea daily); mg, 180 mg MP nisoldipine tb24 17 mg, 34 NP PA mg, 8.5 mg diltiazem hcl cp24 or 240 1 QL(2 ea daily); mg MP nisoldipine tb24 20 mg, NP diltiazem hcl extended PA; QL(1 ea 25.5 mg, 30 mg, 40 mg NORVASC TABS QL(1 ea daily); release beads cp24 120 NP daily); MP NP mg, 180 mg, 240 mg, 300 (amlodipine besylate) MP mg, 360 mg NYMALIZE SOLN 6 NP diltiazem hcl extended QL(1 ea daily); MG/ML release beads cp24 420 MP 1 PROCARDIA CAPS NP QL(4 ea daily); mg, 120 mg, 180 mg, 240 (nifedipine) MP mg, 300 mg, 360 mg PROCARDIA XL TB24 30 NP QL(1 ea daily); diltiazem hcl soln iv 25 PA MG, 90 MG (nifedipine) MP mg/5ml, 125 mg/25ml, 50 1 PROCARDIA XL TB24 60 NP QL(2 ea daily); mg/10ml MG (nifedipine) MP DILTIAZEM HCL SOLR IV 2 PA PA 100 MG SULAR TB24 (nisoldipine) NP diltiazem hcl tabs or 120 1 QL(3 ea daily); TIAZAC CP24 120 MG, PA; QL(1 ea mg, 30 mg, 60 mg, 90 mg MP 180 MG, 240 MG, 300 MG, NP daily); MP QL(1 ea daily); 360 MG (diltiazem hcl felodipine tb24 1 MP extended release beads) TIAZAC CP24 420 MG QL(1 ea daily); NP isradipine caps (diltiazem hcl extended NP MP release beads) KATERZIA SUSP NP PA verapamil hcl cp24 or 100 NP QL(2 ea daily) nicardipine hcl caps or 20 NP mg, 200 mg mg, 30 mg verapamil hcl cp24 or 120 NP PA; QL(2 ea nicardipine hcl soln iv 2.5 1 PA mg, 180 mg, 240 mg daily) mg/ml verapamil hcl cp24 or 300 NP QL(1 ea daily) NICARDIPINE 2 PA mg, 360 mg HYDROCHLORIDE SOLN verapamil hcl soln iv 2.5 1 PA NICARDIPINE PA mg/ml HYDROCHLORIDE/SODIU 2 verapamil hcl tabs or 40 1 QL(3 ea daily); M CHLORIDE SOLN 0.9 mg, 120 mg, 80 mg MP %-40 MG/200ML verapamil hcl tbcr or 120 1 QL(2 ea daily); mg, 180 mg, 240 mg MP Coordinated Care of Washington Updated September 1, 2021

83 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VERELAN CP24 120 MG, PA; QL(2 ea milrinone lactate in 1 PA 180 MG, 240 MG NP daily) dextrose soln (verapamil hcl) milrinone lactate soln 1 PA VERELAN CP24 360 MG NP QL(1 ea daily) (verapamil hcl) CARDIOVASCULAR AGENTS - MISC. - Drugs to VERELAN PM CP24 100 PA; QL(2 ea Treat Heart and Circulation Conditions MG, 200 MG (verapamil NP daily) hcl) Cardiovascular Agents Misc. - Combinations amlodipine besylate- PA VERELAN PM CP24 300 NP PA; QL(1 ea NP MG (verapamil hcl) daily) atorvastatin calcium tabs PA CARDIOTONICS - Drugs to Treat Heart Failure BIDIL TABS NP and Abnormal Heart Rhythm CADUET TABS PA Cardiac Glycosides (amlodipine besylate- NP atorvastatin calcium) digoxin soln ij 0.25 mg/ml 1 QL(2 ea daily); ENTRESTO TABS 2 MP digoxin soln or 0.05 mg/ml 1 MP Impotence Agents digoxin tabs or 0.25 mg, MP PA 250 mcg, 0.125 mg, 125 1 CIALIS TABS (tadalafil) NP mcg tadalafil tabs NP PA LANOXIN PEDIATRIC NP SOLN Prostaglandin Vasodilators LANOXIN SOLN IJ 0.25 NP MG/ML (digoxin) ORENITRAM TBCR NP PA LANOXIN TABS OR 250 NP MP PA; MP MCG, 125 MCG (digoxin) TYVASO REFILL SOLN 2 LANOXIN TABS OR 62.5 NP PA; MP MCG TYVASO SOLN 2 Inotropes TYVASO STARTER SOLN 2 PA; MP dobutamine hcl soln 1 PA VENTAVIS SOLN 2 PA; SP; MP DOBUTAMINE HCL/D5W 2 PA SOLN Pulmonary Hypertension - Endothelin Receptor DOBUTAMINE PA ambrisentan tabs 1 PA; SP; MP HYDROCHLORIDE/ 2 DEXTROSE 5% SOLN bosentan tabs 1 PA; SP; MP DOBUTAMINE PA HYDROCHLORIDE/DEXT 2 LETAIRIS TABS 2 PA; SP; MP ROSE 5% SOLN (ambrisentan) PA; SP dopamine hcl soln 1 PA OPSUMIT TABS NP DOPAMINE PA TRACLEER TABS 125 2 PA; SP; MP HYDROCHLORIDE/DEXT 2 MG, 62.5 MG (bosentan) ROSE SOLN TRACLEER TBSO 32 MG 2 PA; MP DOPAMINE/D5W SOLN 2 PA Pulmonary Hypertension - Phosphodiesterase

Coordinated Care of Washington Updated September 1, 2021

84 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADCIRCA TABS (tadalafil NP PA; MP cefadroxil susr 1 (pulmonary hypertension)) REVATIO SUSR 10 PA; SP cefadroxil tabs 1 MG/ML (sildenafil citrate NP (pulmonary hypertension)) CEFAZOLIN SODIUM 2 PA REVATIO TABS 20 MG PA; SP; MP SOLN IV 1 GM/50ML-4 % (sildenafil citrate NP CEFAZOLIN SODIUM 2 PA (pulmonary hypertension)) SOLR IJ 100 GM, 300 GM sildenafil citrate (pulmonary PA; SP cefazolin sodium solr ij 500 1 PA hypertension) susr 10 NP mg, 1 gm, 10 gm mg/ml cefazolin sodium solr iv 1 1 PA gm sildenafil citrate (pulmonary 1 PA; SP; MP hypertension) tabs 20 mg CEFAZOLIN SODIUM PA SOSY IV 1 GM/10ML, 2 2 tadalafil (pulmonary 1 PA; MP hypertension) tabs GM/20ML Pulmonary Hypertension - Prostacyclin Receptor CEFAZOLIN PA SODIUM/DEXTROSE 2 UPTRAVI TABS OR 1000 PA SOLN MCG, 1200 MCG, 1400 NP MCG, 1600 MCG, 400 CEFAZOLIN PA MCG, 600 MCG, 800 MCG SODIUM/DEXTROSE 2 SOLR UPTRAVI TABS OR 200 NP PA; QL(2 ea MCG daily); MP CEFAZOLIN PA SODIUM/SODIUM 2 UPTRAVI TBPK OR NP PA CHLORIDE SOLN PA Pulmonary Hypertension - Sol Guanylate Cyclase CEFAZOLIN SOLN 2 PA; MP ADEMPAS TABS 2 CEFAZOLIN/SODIUM 2 PA CHLORIDE SOLN Sinus Node Inhibitors cephalexin caps 1 CORLANOR SOLN 5 2 PA MG/5ML cephalexin susr 1 CORLANOR TABS 5 MG, 2 PA; MP 7.5 MG cephalexin tabs 1 Transthyretin Stabilizers KEFLEX CAPS NP VYNDAMAX CAPS 2 PA (cephalexin) Cephalosporins - 2nd Generation VYNDAQEL CAPS 2 PA cefaclor caps 250 mg, 500 1 mg Vasoactive Soluble Guanylate Cyclase Stimulator CEFACLOR ER TB12 NP VERQUVO TABS 2 PA cefaclor susr 125 mg/5ml, 1 AL(Up to 12 yrs CEPHALOSPORINS - Drugs to Treat Bacterial 250 mg/5ml, 375 mg/5ml old ) Infections CEFOTAN SOLR 2 PA Cephalosporins - 1st Generation (cefotetan disodium) cefadroxil caps 1 cefotetan disodium solr 1 1 PA gm, 2 gm

Coordinated Care of Washington Updated September 1, 2021

85 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CEFOTETAN/DEXTROSE 2 PA ceftriaxone sodium solr ij 1 1 PA; QL(3 ea SOLR gm, 250 mg, 500 mg per fill retail) cefoxitin sodium solr ij 10 1 PA CEFTRIAXONE SODIUM 2 PA gm SOLR IJ 100 GM CEFOXITIN SODIUM PA ceftriaxone sodium solr ij 2 1 PA SOLR IV 1 GM-4 %, 2 GM- 2 gm 2.2 % ceftriaxone sodium solr iv 1 1 PA cefoxitin sodium solr iv 2 1 PA gm, 2 gm, 10 gm gm, 1 gm CEFTRIAXONE/DEXTROS 2 PA AL(Up to 12 yrs cefprozil susr 125 mg/5ml 1 E SOLR old ) FORTAZ SOLR IJ 1 GM 2 PA QL(100 ml per (ceftazidime) 1 fill retail); PA cefprozil susr 250 mg/5ml AL(Up to 12 yrs FORTAZ SOLR IJ 500 MG 2 old ) FORTAZ SOLR IV 2 GM 2 PA cefprozil tabs 250 mg, 500 1 QL(20 ea per mg fill retail) SUPRAX CAPS 400 MG NP PA QL(20 ea per (cefixime) cefuroxime axetil tabs 1 fill retail) SUPRAX CHEW 100 MG, NP PA 200 MG cefuroxime sodium solr 1 PA SUPRAX SUSR 100 PA Cephalosporins - 3rd Generation MG/5ML, 200 MG/5ML NP QL(20 ea per (cefixime) cefdinir caps 300 mg 1 fill retail) SUPRAX SUSR 500 NP MG/5ML cefdinir susr 125 mg/5ml, 1 250 mg/5ml TAZICEF SOLN 2 PA cefditoren pivoxil tabs 1 Cephalosporins - 4th Generation cefixime caps NP PA cefepime hcl solr 1 PA PA cefixime susr NP CEFEPIME 2 PA HYDROCHLORIDE SOLR PA cefotaxime sodium solr 1 CEFEPIME SOLN 2 PA cefpodoxime proxetil susr 1 CEFEPIME/DEXTROSE 2 PA SOLR cefpodoxime proxetil tabs 1 Cephalosporins - Siderophores PA ceftazidime solr ij 2 gm, 1 1 PA FETROJA SOLR 2 gm, 6 gm CONTRACEPTIVES - Drugs to Prevent ceftazidime solr iv 1 gm, 2 1 PA gm Pregnancy CEFTAZIDIME/DEXTROS 2 PA Combination Contraceptives - Oral E SOLR BALCOLTRA TABS 2 MP ceftriaxone sodium in 1 PA dextrose soln

Coordinated Care of Washington Updated September 1, 2021

86 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BEYAZ TABS MP norethin acet & estrad-fe 1 (drospirenone-ethinyl 2 caps 1 mg-20 mcg-75 mg estradiol-levomefolate norethin acet & estrad-fe 1 MP calcium) chew 1 mg-20 mcg-75 mg desogestrel & ethinyl MP 1 norethin acet & estrad-fe 1 MP estradiol tabs tabs 1 mg-20 mcg-75 mg desogestrel-ethinyl 1 MP norethin acet & estrad-fe estradiol (biphasic) tabs tabs 1.5 mg-30 mcg-75 mg, 1 desogestrel-ethinyl 1 MP 1 mg-20 mcg-75 mg estradiol (triphasic) tabs norethindrone & eth MP drospirenone-ethinyl 1 MP estradiol tabs 0.5 mg-35 1 estradiol tabs mcg, 0.4 mg-35 mcg drospirenone-ethinyl MP norethindrone & eth 1 estradiol-levomefolate 1 estradiol tabs 1 mg-35 mcg calcium tabs norethindrone & ethinyl 1 MP ESTROSTEP FE TABS MP estradiol-fe chew (norethindrone acetate- 2 norethindrone acet & eth 1 ethinyl estradiol-fe) estra tabs ethynodiol diacet & eth MP 1 norethindrone acetate- 1 MP estrad tabs ethinyl estradiol-fe tabs MP FALESSA KIT 2 norethindrone-eth estradiol 1 MP (triphasic) tabs GENERESS FE CHEW MP norethindrone-eth estradiol 1 (norethindrone & ethinyl 2 (triphasic) tabs estradiol-fe) norgestimate-ethinyl 1 levonorgestrel & eth 1 MP estradiol (triphasic) tabs estradiol tabs norgestimate-ethinyl 1 MP levonorgestrel-eth estradiol 1 MP estradiol (triphasic) tabs (triphasic) tabs norgestimate-ethinyl 1 MP levonorgestrel-ethinyl 1 MP estradiol tabs estradiol (91-day) tabs norgestrel & ethinyl MP levonorgestrel-ethinyl 1 MP estradiol tabs 0.3 mg-30 1 estradiol (continuous) tabs mcg LO LOESTRIN FE TABS 2 MP QUARTETTE TABS MP (levonorgestrel-ethinyl 2 LOSEASONIQUE TABS MP estradiol (91-day)) (levonorgestrel-ethinyl 2 estradiol (91-day)) SAFYRAL TABS MP (drospirenone-ethinyl 2 MINASTRIN 24 FE CHEW 2 MP estradiol-levomefolate (norethin acet & estrad-fe) calcium) MIRCETTE TABS MP SEASONIQUE TABS MP (desogestrel-ethinyl 2 (levonorgestrel-ethinyl 2 estradiol (biphasic)) estradiol (91-day)) MP NATAZIA TABS 2 TAYTULLA CAPS (norethin 2 acet & estrad-fe) NEXTSTELLIS TABS 2 TYBLUME CHEW 2

Coordinated Care of Washington Updated September 1, 2021

87 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits YASMIN 28 TABS MP DEPO-PROVERA MP (drospirenone-ethinyl 2 CONTRACEPTIVE SUSP 2 estradiol) (medroxyprogesterone acetate (contraceptive)) YAZ TABS (drospirenone- 2 MP ethinyl estradiol) DEPO-PROVERA MP CONTRACEPTIVE SUSY 2 Combination Contraceptives - Transdermal (medroxyprogesterone norelgestromin-ethinyl 1 acetate (contraceptive)) estradiol ptwk DEPO-SUBQ PROVERA 2 MP TWIRLA PTWK 2 104 SUSY medroxyprogesterone MP Combination Contraceptives - Vaginal acetate (contraceptive) 1 ANNOVERA RING 2 MP susp medroxyprogesterone MP etonogestrel-ethinyl 1 MP acetate (contraceptive) 1 estradiol ring susy NUVARING RING MP Progestin Contraceptives - Oral (etonogestrel-ethinyl 2 estradiol) norethindrone 1 MP (contraceptive) tabs Copper Contraceptives - IUD ORTHO MICRONOR MP PARAGARD TABS (norethindrone 2 INTRAUTERINE COPPER 2 (contraceptive)) CONTRACEPTIVE T380A MP IUD SLYND TABS 2 Emergency Contraceptives CORTICOSTEROIDS - Steroid Hormone Drugs to ELLA TABS 2 MP Treat Systemic Swelling Conditions Glucocorticosteroids levonorgestrel (emergency 1 MP oc) tabs ACTIVE INJECTION KIT D 2 PA KIT PLAN B ONE-STEP TABS MP (levonorgestrel (emergency 2 ALKINDI SPRINKLE CPSP NP PA oc)) BETAMETHASONE NP PA Progestin Contraceptives - IUD COMBO SUSP MP KYLEENA IUD 2 betamethasone sod 1 PA phosphate & acetate susp LILETTA IUD 2 MP BETAMETHASONE PA SODIUM PHOSPHATE 2 MIRENA IUD 2 SP; MP SOLN budesonide cpep 1 SKYLA IUD 2 MP Progestin Contraceptives - Implants budesonide tb24 1 NEXPLANON IMPL 2 MP CELESTONE-SOLUSPAN PA SUSP (betamethasone sod NP Progestin Contraceptives - Injectable phosphate & acetate) CONTRAST ALLERGY NP PA PREMED PACK KIT Coordinated Care of Washington Updated September 1, 2021

88 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CORTEF TABS NP DXEVO 11-DAY TBPK NP PA (hydrocortisone) PA DEPO-MEDROL SUSP 20 2 PA EMFLAZA SUSP NP MG/ML DEPO-MEDROL SUSP 80 PA EMFLAZA TABS NP PA MG/ML, 40 MG/ML NP (methylprednisolone ENTOCORT EC CPEP NP acetate) (budesonide) PA DEXABLISS TBPK NP PA HEMADY TABS NP

DEXAMETHASONE (LA) 2 PA hydrocortisone tabs 1 SUSP KENALOG-10 SUSP 2 PA dexamethasone elix 0.5 1 mg/5ml KENALOG-40 SUSP NP PA DEXAMETHASONE 2 (triamcinolone acetonide) INTENSOL CONC PA DEXAMETHASONE PA KENALOG-80 SUSP 2 SODIUM PHOSPHATE 2 PA SOLN IJ 10 MG/ML MAS CARE-PAK KIT 2 dexamethasone sodium PA MEDROL DOSEPAK TBPK NP phosphate soln ij 10 mg/ml, 1 (methylprednisolone) 100 mg/10ml MEDROL TABS 16 MG, 32 dexamethasone sodium PA; QL(150 ml MG, 8 MG, 4 MG NP phosphate soln ij 120 1 per 30 days (methylprednisolone) mg/30ml, 20 mg/5ml, 4 retail) PA mg/ml MEDROL TABS 2 MG NP DEXAMETHASONE PA; QL(150 ml methylprednisolone acetate 1 PA SODIUM PHOSPHATE 2 per 30 days susp 40 mg/ml SOLN IJ 4 MG/ML retail) METHYLPREDNISOLONE PA DEXAMETHASONE PA ACETATE SUSP 50 2 SODIUM PHOSPHATE 2 MG/ML, 80 MG/ML SOSY IJ 10 MG/ML methylprednisolone acetate 1 DEXAMETHASONE PA susp 80 mg/ml, 40 mg/ml SODIUM PHOSPHATE/SODIUM 2 methylprednisolone sod 1 CHLORIDE SOLN 0.9 %-6 succ solr MG/25ML methylprednisolone tabs 1 dexamethasone soln 0.5 1 PA mg/5ml methylprednisolone tbpk 1 dexamethasone tabs 1 mg, PA 1.5 mg, 2 mg, 4 mg, 0.5 1 MILLIPRED DP TBPK NP mg, 0.75 mg, 6 mg MILLIPRED TABS NP PA dexamethasone tbpk 1.5 NP PA mg ORAPRED ODT TBDP PA DEXONTO 0.4% SOLN 2 PA (prednisolone sodium NP phosphate) DOUBLEDEX KIT 2 PA

Coordinated Care of Washington Updated September 1, 2021

89 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ORTIKOS CP24 NP PA SOLU-MEDROL SOLR 2 NP PA GM P-CARE D40 KIT 2 PA SOLU-MEDROL SOLR 500 MG, 1000 MG, 125 MG, 40 NP P-CARE D80 KIT 2 PA MG (methylprednisolone sod succ) PA P-CARE K40 KIT 2 TOPIDEX KIT 2 PA PA P-CARE K80 KIT 2 TRIAMCINOLONE 2 PA ACETONIDE PF SUSP PEDIAPRED SOLN triamcinolone acetonide (prednisolone sodium NP susp 200 mg/5ml, 40 1 phosphate) mg/ml, 400 mg/10ml POD-CARE 100K KIT 2 PA TRIAMCINOLONE ACETONIDE SUSP 40 2 prednisolone sodium MG/ML phosphate soln or 10 1 mg/5ml, 25 mg/5ml, 5 TRIAMCINOLONE PA mg/5ml, 6.7 mg/5ml ACETONIDE SUSP 50 2 MG/ML prednisolone sodium QL(240 ml per phosphate soln or 15 1 fill retail) TRIAMCINOLONE 2 PA mg/5ml DIACETATE SUSP prednisolone sodium QL(150 ml per TRIAMCINOLONE SUSP 2 PA phosphate soln or 20 1 fill retail) mg/5ml UCERIS TB24 OR 9 MG NP (budesonide) prednisolone sodium phosphate tbdp or 10 mg, 1 ZCORT 7-DAY TBPK NP PA 15 mg, 30 mg PA prednisolone soln 1 ZILRETTA SRER NP Mineralocorticoids PREDNISONE INTENSOL 2 CONC fludrocortisone acetate tabs 1 MP prednisone soln 1 COUGH/COLD/ALLERGY - Drugs to Treat prednisone tabs 1 Cough, Cold and Allergy Symptoms Antitussives prednisone tbpk 1 dextromethorphan hbr syrp 1 PRO-C-DURE 5 KIT KIT 2 PA Cough/Cold/Allergy Combinations PA PRO-C-DURE 6 KIT KIT 2 cetirizine-pseudoephedrine 1 tb12 PA RAYOS TBEC NP CLARINEX-D 12 HOUR NP TB12 READYSHARP 2 PA DEXAMETHASONE KIT dextromethorphan- guaifenesin liqd 15 1 SOLU-CORTEF SOLR 2 PA mg/7.5ml-150 mg/7.5ml, 20 mg/10ml-200 mg/10ml

Coordinated Care of Washington Updated September 1, 2021

90 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits dextromethorphan- QL(240 ml per ACANYA GEL (clindamycin guaifenesin syrp 10 1 fill retail) phosphate-benzoyl NP mg/5ml-10 mg/5ml-100 peroxide) mg/5ml-100 mg/5ml ACIOXIAY CREA NP PA loratadine & 1 QL(1 ea daily) pseudoephedrine tb24 ACZONE GEL (dapsone NP PA (topical)) SEMPREX-D CAPS NP ADAINZDE GEL NP PA Expectorants guaifenesin liqd 100 QL(240 ml per ADAINZOXIA GEL NP PA mg/5ml, 200 mg/10ml, 400 1 fill retail) mg/20ml adapalene crea 0.1 % 1 guaifenesin soln 100 QL(240 ml per RX/OTC mg/5ml, 200 mg/10ml, 300 1 fill retail) adapalene gel 0.1 % 1 mg/15ml adapalene gel 0.3 % 1 guaifenesin syrp 100 1 QL(240 ml per mg/5ml 6 days retail) adapalene gel 0.3 % NP Misc. Respiratory Inhalants HYPER-SAL NEBU NP adapalene pads 0.1 % NP (sodium chloride (inhalant)) ADAPALENE SOLN 0.1 % NP HYPERSAL NEBU 3.5 % NP PA adapalene-benzoyl 1 HYPERSAL NEBU 7 % NP peroxide gel (sodium chloride (inhalant)) ADAPALENE/BENZOYL PA NEBUSAL NEBU 2 PA PEROXIDE/CLINDAMYCI NP N GEL sodium chloride (inhalant) 1 nebu ADAPALENE/BENZOYL PA PEROXIDE/NIACINAMIDE NP Mucolytics GEL acetylcysteine soln 1 AKLIEF CREA NP

DERMATOLOGICALS - Drugs to Treat Skin ALTRENO LOTN NP Conditions PA Acne Products AMZEEQ FOAM NP PA; QL(2 ea ABSORICA CAPS 10 MG, ARAZLO LOTN NP NP daily); AL(At 20 MG, 40 MG least 10 yrs (isotretinoin) old) ATRALIN GEL (tretinoin) NP ABSORICA CAPS 25 MG, NP PA AVAR LS CLEANSER 35 MG (isotretinoin) LIQD (sulfacetamide 2 sodium w/ sulfur) ABSORICA CAPS 30 MG NP PA; AL(At least (isotretinoin) 10 yrs old) AVAR-E LS CREA PA ABSORICA LD CAPS NP PA (sulfacetamide sodium w/ NP sulfur) AZELAIC NP PA ACID/NIACINAMIDE CREA Coordinated Care of Washington Updated September 1, 2021

91 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AZELEX CREA NP clindamycin phosphate- NP PA tretinoin gel BENZACLIN GEL CLINDAMYCIN PA (clindamycin phosphate- NP PHOSPHATE/NIACINAMI NP benzoyl peroxide) DE GEL BENZACLIN WITH PUMP CLINDAMYCIN PA GEL (clindamycin NP PHOSPHATE/NIACINAMI NP phosphate-benzoyl DE LOTN peroxide) CLINDAMYCIN PA BENZAMYCIN GEL PHOSPHATE/NIACINAMI NP (benzoyl peroxide- NP DE/TRETINOIN CREA erythromycin) CLINDAMYCIN/NIACINAM PA benzoyl peroxide- 1 IDE/SPIRONOLACTONE/T NP erythromycin gel RETINOIN GEL BENZOYL PA PA PEROXIDE/CLINDAMYCI NP CLINDAVIX KIT NP N/NIACINAMIDE GEL dapsone (topical) gel NP PA BENZOYL PA PEROXIDE/CLINDAMYCI NP DAPSONE/NIACINAMIDE NP PA N/NIACINAMIDE/TRETINO GEL IN GEL DAPSONE/NIACINAMIDE/ NP PA CLENIA PLUS SUSP NP SPIRONOLACTONE GEL PA CLEOCIN-T GEL QL(60 ml per DEOXIA GEL NP (clindamycin phosphate NP fill retail) PA (topical)) DEOXIA LOTN NP CLEOCIN-T LOTN PA (clindamycin phosphate NP DIADIMAXIA GEL NP (topical)) DIAOXIA GEL NP PA CLINDAGEL GEL QL(60 ml per (clindamycin phosphate NP fill retail) DIASDIMAXIA GEL NP PA (topical)) PA clindamycin phosphate NP PA DIASOXIA GEL NP (topical) foam DIFFERIN CREA 0.1 % clindamycin phosphate 1 QL(60 ml per NP (topical) gel fill retail) (adapalene) DIFFERIN GEL 0.1 % RX/OTC clindamycin phosphate 1 2 (topical) lotn (adapalene) DIFFERIN GEL 0.3 % PA clindamycin phosphate 1 NP (topical) soln (adapalene) clindamycin phosphate 1 DIFFERIN LOTN 0.1 % NP (topical) swab PA clindamycin phosphate- DIMOXIA GEL NP benzoyl peroxide 1 (refrigerate) gel DRAXACE LOTION NP PA CLEANSER SUSP clindamycin phosphate- 1 benzoyl peroxide gel DRAXACE SUSP NP PA

Coordinated Care of Washington Updated September 1, 2021

92 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DRIXECE SUSP NP PA NIACINAMIDE/TRETINOIN NP PA CREA PA ECEOXIA CREA NP NIACINAMIDE/TRETINOIN NP PA GEL PA EPIDUO FORTE GEL NP ONEXTON GEL NP PA EPIDUO GEL (adapalene- NP PA benzoyl peroxide) ONZDEOXIA GEL NP ERYGEL GEL NP PA PA (erythromycin (acne aid)) OXIATAR CREA NP erythromycin (acne aid) gel NP PA OXIAVARRY CREA NP PA erythromycin (acne aid) NP PA PLEXION CLEANSER PA pads LIQD (sulfacetamide NP sodium w/ sulfur) erythromycin (acne aid) 1 soln PLEXION CLEANSING NP PA CLOTHS PADS ETHOXIA CREA NP PA PLEXION CREA PA EVOCLIN FOAM PA (sulfacetamide sodium w/ NP (clindamycin phosphate NP sulfur) (topical)) PLEXION LOTN PA NP FABIOR FOAM NP (sulfacetamide sodium w/ sulfur) HYALURONIC ACID PA SODIUM/NIACINAMIDE/T NP PLIXDA PADS NP RETINOIN CREA QL(45 gm per PA; QL(2 ea ) NP fill retail); RETIN-A CREA (tretinoin AL(Up to 35 yrs isotretinoin caps 10 mg, 20 1 daily); AL(At mg, 40 mg least 10 yrs old ) old) QL(45 gm per fill retail); isotretinoin caps 25 mg, 35 1 PA RETIN-A GEL (tretinoin) NP mg AL(Up to 35 yrs PA; AL(At least old ) isotretinoin caps 30 mg 1 10 yrs old) RETIN-A MICRO GEL 0.04 PA PA %, 0.1 % (tretinoin NP ITHOXIA CREA NP microsphere) KLARON LOTN PA; QL(120 ml RETIN-A MICRO GEL 0.06 NP PA (sulfacetamide sodium NP per fill retail) % (acne)) RETIN-A MICRO PUMP PA GEL 0.04 %, 0.1 % NP NIACINAMIDE/SPIRONOL NP PA ACTONE GEL (tretinoin microsphere) RETIN-A MICRO PUMP PA NIACINAMIDE/SPIRONOL NP PA NP ACTONE/TRETINOIN GEL GEL 0.08 % NIACINAMIDE/SULFACET PA SALICYLIC PA AMIDE SODIUM NP ACID/SULFACETAMIDE NP MONOHYDRATE CREA SODIUM MONOHYDRATE SUSP NIACINAMIDE/TAZAROTE NP PA NE CREA Coordinated Care of Washington Updated September 1, 2021

93 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SODIUM PA SUMAXIN WASH LIQD PA NP SULFACETAMIDE/SULFU NP (sulfacetamide sodium w/ R CLEANSER IN UREA sulfur) EMUL TARDEOXIA CREA NP PA SODIUM PA NP SULFACETAMIDE/SULFU TARDIMAXIA GEL NP PA R PADS 4.8 %-9.8 % SODIUM TAROXIA CREA NP PA SULFACETAMIDE/SULFU NP R SUSP 5 %-10 % TAROXIA GEL NP PA sulfacetamide sodium NP PA; QL(120 ml (acne) lotn per fill retail) TAZAROTENE FOAM NP sulfacetamide sodium w/ PA sulfur crea 2 %-10 %, 4.8 NP QL(45 gm per %-9.8 % tretinoin crea 0.05 %, 0.1 1 fill retail); %, 0.025 % AL(Up to 35 yrs sulfacetamide sodium w/ NP old ) sulfur crea 5 %-10 % QL(45 gm per sulfacetamide sodium w/ NP tretinoin gel 0.01 %, 0.025 1 fill retail); sulfur emul 1 %-10 % % AL(Up to 35 yrs sulfacetamide sodium w/ 1 old ) sulfur emul 5 %-10 % tretinoin gel 0.05 % 1 sulfacetamide sodium w/ NP PA sulfur foam 5 %-10 % tretinoin microsphere gel NP PA sulfacetamide sodium w/ 1 sulfur liqd 2 %-10 % VARDIMAXIA GEL NP PA sulfacetamide sodium w/ PA sulfur liqd 4 %-9 %, 4.5 %- NP VAROXIA CREA NP PA 9 %, 4.8 %-9.8 % VAROXIA GEL NP PA sulfacetamide sodium w/ NP PA sulfur lotn 4.8 %-9.8 % VELTIN GEL (clindamycin NP PA sulfacetamide sodium w/ NP PA; QL(60 gm phosphate-tretinoin) sulfur lotn 5 %-10 % per fill retail) sulfacetamide sodium w/ PA WINLEVI CREA NP sulfur pads 4 %-10 %, 4 %- NP ZIANA GEL (clindamycin NP PA 4 %-10 %-10 % phosphate-tretinoin) sulfacetamide sodium w/ NP sulfur susp 4 %-8 % Agents for External Genital and Perianal Warts PA sulfacetamide sodium- NP PA VEREGEN OINT NP sulfur in urea vehicle emul SUMADAN WASH LIQD PA Analgesics - Topical (sulfacetamide sodium w/ NP A.A.G.C. KIT IN NP PA sulfur) TERODERM CREA SUMAXIN PADS PA ACTIVE-PREP KIT IV NP PA (sulfacetamide sodium w/ NP CREA sulfur) ACTIVE-TRAMADOL KIT NP PA CREA

Coordinated Care of Washington Updated September 1, 2021

94 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BACLOFEN CREA EX 2 % NP PA DICLOVIX KIT NP PA

ENOVARX-BACLOFEN NP PA DICLOVIX M THPK NP PA CREA PA ENOVARX-TRAMADOL NP PA DICLOZOR THPK NP CREA PA NEURAPTINE CREA NP PA DIMENTHO THPK NP DUAL COMPLEX NP PA Anti-inflammatory Agents - Topical FORMULA 1 KIT CREA ACTIVE-KETOPROFEN PA NP ENOVARX-DICLOFENAC NP PA KIT CREA SODIUM CREA PA ACTIVE-PREP KIT I CREA NP ENOVARX-IBUPROFEN NP PA CREA ACTIVE-PREP KIT II NP PA CREA ENOVARX-NAPROXEN NP PA CREA ACTIVE-PREP KIT III NP PA CREA FBL KIT CREA NP PA AIF #2 DRUG PA NP FLECTOR PTCH NP PA PREPARATIONKIT CREA (diclofenac epolamine) AIF #3 DRUG NP PA PA PREPARATION KIT CREA FROTEK CREA NP BIIFENAC 1000 THPK NP PA GABAPENTIN/NAPROXE PA N SOD MULTI-PHASIC NP BIIFENAC 500 THPK NP PA TRANSDERMAL CMPD KIT CREA DERMACINRX LEXITRAL PA K.B.G.L. IN TERODERM NP PA PHARMAPAK THPK NP CREAM CREA (diclofenac sodium- capsaicin (topical)) KETOPHENE RAPIDPAQ NP PA CREA DFS/MS/MENTH/CAP PAK NP PA KIT KETOROLAC 2% GEL NP PA GEL diclofenac epolamine ptch NP PA LICART PT24 NP PA diclofenac sodium (topical) 1 QL(6.68 gm gel 1 % daily); RX/OTC NAPRO 15% PA COMPOUNDING KIT NP diclofenac sodium (topical) 1 CREA soln 1.5 % NP #2 DRUG NP PA diclofenac sodium- NP PA PREPARATION KIT CREA capsaicin (topical) thpk PENNSAID SOLN NP PA DICLOFONO GEL NP PA REXAPHENAC CREA NP PA DICLOPR KIT NP PA TRIPLE COMPLEX NP PA DICLOSTREAM THPK NP PA FORMULA 3KIT CREA VAROPHEN KIT NP PA DICLOTREX THPK NP PA

Coordinated Care of Washington Updated September 1, 2021

95 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VENNGEL ONE KIT NP PA ciclopirox sham ex 1 % 1

VOLTAREN GEL PA; QL(6.68 ciclopirox soln ex 8 % NP PA (diclofenac sodium NP gm daily); (topical)) RX/OTC QL(45 gm per PA clotrimazole (topical) crea 1 fill retail); VP FC KIT CREA NP RX/OTC VP GKL KIT CREA NP PA QL(30 ml per clotrimazole (topical) soln 1 fill retail); XRYLIX THPK NP PA RX/OTC clotrimazole w/ 1 Antibiotics - Topical betamethasone crea PA clotrimazole w/ 1 ALTABAX OINT NP betamethasone lotn bacitracin zinc oint 1 DERMACINRX NP PA THERAZOLE PAK THPK bacitracin-polymyxin b oint 1 DIFMETIOXRIME SOLN NP PA PA CENTANY AT KIT NP ECONASIL KIT NP PA PA CENTANY OINT NP econazole nitrate crea NP gentamicin sulfate (topical) 1 ECONAZOLE PA crea NITRATE/NIACINAMIDE NP CREA gentamicin sulfate (topical) 1 oint ECOZA FOAM NP PA mupirocin calcium (topical) NP PA crea ERTACZO CREA NP PA mupirocin oint 1 EXELDERM CREA NP (sulconazole nitrate) NEO-SYNALAR CREA NP EXELDERM SOLN NP NEO-SYNALAR KIT KIT NP EXODERM LOTN NP PA XEPI CREA NP EXTINA FOAM NP PA Antifungals - Topical (ketoconazole (topical)) FLUCONAZOLE/IBUPROF PA ACTIVE-PREP KIT V NP PA CREA EN/ITRACONAZOLE/TER NP BINAFINE ciclopirox gel ex 0.77 % NP HYDROCHLORIDE SOLN PA; RX/OTC ciclopirox kit ex 8 % NP PA FUNGIMEZ SOLN NP HYDROCORTISONE/IOD PA ciclopirox olamine crea 1 OQUINOL/KETOCONAZO NP LE CREA ciclopirox olamine susp 1 HYDROCORTISONE/KET NP PA OCONAZOLE CREA

Coordinated Care of Washington Updated September 1, 2021

96 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits IMIOXIA CREA NP PA NAFTIN GEL 1 % (naftifine NP PA hcl) PA; QL(4 ml JUBLIA SOLN NP per 30 days NAFTIN GEL 2 % NP retail) nystatin (topical) crea 1 PA; QL(10 ml KERYDIN SOLN NP (tavaborole) per 30 days nystatin (topical) oint 1 retail) ketoconazole (topical) crea 1 nystatin (topical) powd 1 ketoconazole (topical) foam NP PA nystatin-triamcinolone crea 1 ketoconazole (topical) 1 QL(120 ml per nystatin-triamcinolone oint 1 sham fill retail) PA KETODAN KIT KIT NP PA ONYCHO-MED KIT NP PA LOPROX CREA (ciclopirox NP oxiconazole nitrate crea NP olamine) PA OXISTAT CREA NP PA LOPROX KIT NP (oxiconazole nitrate) LOPROX KIT KIT NP PA OXISTAT LOTN NP PA LOPROX SHAMPOO NP PEDIZOLPAK THPK NP SHAM (ciclopirox) PENLAC NAIL LACQUER PA LOPROX SUSP (ciclopirox NP NP olamine) SOLN (ciclopirox) PA luliconazole crea NP PA PHEODOYO CREA NP PA LUZU CREA (luliconazole) NP PA PHEYO CREA NP MICATIN CREA RECURA CREA NP PA (miconazole nitrate NP (topical)) sulconazole nitrate crea NP miconazole nitrate (topical) 1 crea sulconazole nitrate soln NP miconazole-zinc oxide- NP PA PA; QL(10 ml white petrolatum oint tavaborole soln NP per 30 days naftifine hcl crea 1 % NP retail) VUSION OINT PA naftifine hcl crea 2 % NP PA (miconazole-zinc oxide- NP white petrolatum) PA naftifine hcl gel 1 % NP XOLEGEL COREPAK KIT NP PA NAFTIFINE PA XOLEGEL DUO/HEAD & NP PA HYDROCHLORIDE CREA NP SHOULDERS KIT (naftifine hcl) XOLEGEL DUO/XOLEX NP PA NAFTIN CREA 2 % NP PA KIT (naftifine hcl)

Coordinated Care of Washington Updated September 1, 2021

97 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits XOLEGEL GEL NP TARGRETIN GEL EX 1 % 2 PA

ZOLPAK KIT NP PA TOLAK CREA 2 PA

Antineoplastic or Premalignant Lesion Agents - VALCHLOR GEL 2 PA PA AMELUZ GEL 2 Antipruritics - Topical CARAC CREA (fluorouracil NP PA; QL(30 gm doxepin hcl (antipruritic) 1 PA (topical)) per fill retail) crea diclofenac sodium (actinic 1 PA PRUDOXIN CREA NP PA keratoses) gel (doxepin hcl (antipruritic)) DICLOFENAC PA ZONALON CREA (doxepin NP PA SODIUM/HYALURONIC NP hcl (antipruritic)) ACID SODIUM SALT/NIACINAMIDE GEL Antipsoriatics acitretin caps 1 EFUDEX CREA NP QL(40 gm per (fluorouracil (topical)) fill retail) QL(60 gm per calcipotriene crea 1 FLUOROPLEX CREA 2 PA fill retail) CALCIPOTRIENE FOAM NP PA fluorouracil (topical) crea NP PA; QL(30 gm 0.5 % per fill retail) calcipotriene foam NP PA fluorouracil (topical) crea 5 1 QL(40 gm per % fill retail) calcipotriene oint 1 fluorouracil (topical) soln 2 1 PA; QL(10 ml %, 5 % per fill retail) QL(60 ml per calcipotriene soln 1 HYALUCIL-4 CREA 2 PA fill retail) IMIQUIMOD/LEVOCETIRI PA calcitriol (topical) oint NP ZINEDIHYDROCHLORIDE NP COSENTYX NP ST; SP /NIACINAMIDE GEL SENSOREADY PEN SOAJ IMIQUIMOD/LEVOCETIRI PA COSENTYX SOSY 150 NP ST; SP ZINEDIHYDROCHLORIDE NP MG/ML /TRETINOIN GEL COSENTYX SOSY 75 NP PA KLISYRI OINT NP PA MG/0.5ML DOVONEX CREA NP QL(60 gm per LEVULAN KERASTICK 2 PA (calcipotriene) fill retail) SOLR DRITHO-CREME HP NP ORMECA KIT 2 PA CREA PA PANRETIN GEL 2 PA ILUMYA SOSY NP

PICATO GEL 2 PA methoxsalen rapid caps NP PA NUDERMRXPAK 120 NP PA QUIHOXVAR GEL NP THPK PA SOLARAVIX THPK 2 PA NUDERMRXPAK 60 THPK NP

Coordinated Care of Washington Updated September 1, 2021

98 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OXSORALEN ULTRA NP CICLOPIROX/SALICYLIC NP PA CAPS (methoxsalen rapid) ACID SHAM SILIQ SOSY NP PA HAXCHLO SHAM NP PA PA QL(120 ml per SKYRIZI PEN SOAJ NP selenium sulfide lotn 1 fill retail) PA SKYRIZI PSKT NP sulfacetamide sodium liqd 1 SKYRIZI SOSY NP PA Antivirals - Topical PA SORIATANE CAPS NP acyclovir topical crea NP (acitretin) PA; QL(30 gm SORILUX FOAM NP PA acyclovir topical oint NP per 30 days retail) STELARA SOLN SC 45 NP PA MG/0.5ML DENAVIR CREA NP PA STELARA SOSY SC 45 NP ST; SP PA MG/0.5ML, 90 MG/ML XERESE CREA NP PA TALTZ SOAJ NP ZOVIRAX CREA EX 5 % NP PA (acyclovir topical) TALTZ SOSY NP PA PA; QL(30 gm ZOVIRAX OINT EX 5 % NP per 30 days PA; AL(Up to (acyclovir topical) tazarotene crea NP retail) 21 yrs old ) AL(Up to 21 yrs Burn Products TAZORAC CREA 0.05 % NP old ) mafenide acetate pack 1 PA TAZORAC CREA 0.1 % NP PA; AL(Up to (tazarotene) 21 yrs old ) SILVADENE CREA (silver NP sulfadiazine) TAZORAC GEL 0.05 %, NP AL(Up to 21 yrs 0.1 % old ) silver sulfadiazine crea 1 TREMFYA SOPN NP PA SULFAMYLON CREA 85 2 PA MG/GM TREMFYA SOSY NP PA SULFAMYLON PACK 5 % NP PA (mafenide acetate) VECTICAL OINT (calcitriol NP (topical)) Corticosteroids - Topical ZITHRANOL SHAM NP ADVANCED ALLERGY NP PA COLLECTION KIT KIT Antiseborrheic Products ALA-SCALP LOTN NP PA CICLOPIROX PA alclometasone dipropionate OLAMINE/CLOBETASOL NP NP PROPIONATE/SALICYLIC crea ACID SHAM alclometasone dipropionate NP CICLOPIROX PA oint OLAMINE/CLOBETASOL NP NP PA SHAM amcinonide crea amcinonide lotn NP PA

Coordinated Care of Washington Updated September 1, 2021

99 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AMCINONIDE OINT NP PA CHLOOXIA OINT NP PA

APEXICON E CREA NP PA CHLOOXIA SOLN NP PA

BESER KIT NP PA clobetasol propionate crea 1 betamethasone NP PA clobetasol propionate NP PA dipropionate (topical) crea emollient base crea betamethasone 1 clobetasol propionate NP PA dipropionate (topical) lotn emulsion foam betamethasone NP PA clobetasol propionate foam NP PA dipropionate (topical) oint betamethasone PA clobetasol propionate gel 1 dipropionate augmented NP crea clobetasol propionate liqd NP PA betamethasone PA dipropionate augmented NP clobetasol propionate lotn NP PA gel betamethasone PA clobetasol propionate oint 1 dipropionate augmented NP lotn clobetasol propionate sham NP PA betamethasone PA dipropionate augmented NP clobetasol propionate soln 1 oint CLOBETASOL PA betamethasone valerate 1 QL(45 gm per PROPIONATE/LEVOCETI crea 0.1 % fill retail) RIZINE NP DIHYDROCHLORIDE betamethasone valerate NP PA foam 0.12 % SHAM CLOBETASOL PA betamethasone valerate 1 QL(60 ml per lotn 0.1 % fill retail) PROPIONATE/NIACINAMI NP DE CREA betamethasone valerate 1 oint 0.1 % CLOBETASOL PA PA PROPIONATE/NIACINAMI NP BRYHALI LOTN NP DE OINT CALCIPOTRIENE PA CLOBETASOL PA ANHYDROUS/CLOBETAS NP PROPIONATE/NIACINAMI NP OL PROPIONATE SOLN DE SOLN calcipotriene- CLOBETAVIX KIT NP PA betamethasone 1 dipropionate oint CLOBEX LIQD (clobetasol NP PA calcipotriene- PA propionate) betamethasone NP CLOBEX LOTN (clobetasol NP PA dipropionate susp propionate) CAPEX SHAM NP PA CLOBEX SHAM NP PA (clobetasol propionate) PA CHLOOXIA CREA NP clocortolone pivalate crea NP PA

Coordinated Care of Washington Updated September 1, 2021

100 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLODAN KIT KIT NP PA DIPROLENE AF CREA PA (betamethasone NP dipropionate augmented) CLODERM CREA NP PA (clocortolone pivalate) DIPROLENE OINT PA NP CORDRAN CREA 0.025 % NP PA (betamethasone dipropionate augmented) CORDRAN CREA 0.05 % NP PA PA (flurandrenolide) DUOBRII LOTN NP PA CORDRAN LOTN 0.05 % NP PA ELLZIA PAK THPK NP (flurandrenolide) PA CORDRAN OINT 0.05 % NP PA ENSTILAR FOAM NP (flurandrenolide) EPIFOAM FOAM NP PA CORDRAN TAPE 4 NP PA MCG/SQCM fluocinolone acetonide crea NP PA CUTIVATE LOTN NP PA (fluticasone propionate) PA DERMA-SMOOTHE/FS PA fluocinolone acetonide oil NP BODY OIL (fluocinolone NP PA acetonide) fluocinolone acetonide oint NP DERMA-SMOOTHE/FS PA fluocinolone acetonide soln NP PA SCALP OIL (fluocinolone NP acetonide) FLUOCINOLONE PA ACETONIDE/NIACINAMID NP DESONATE GEL NP PA (desonide) E CREA PA desonide crea 1 fluocinonide crea NP

PA fluocinonide emulsified NP PA desonide gel NP base crea desonide lotn NP PA fluocinonide gel NP PA desonide oint 1 fluocinonide oint NP PA

DESOWEN CREA NP fluocinonide soln NP PA (desonide) PA desoximetasone crea NP PA FLUOPAR KIT NP PA desoximetasone gel NP PA FLUOVIX PLUS THPK NP PA desoximetasone liqd NP PA FLUOVIX THPK NP PA desoximetasone oint NP PA flurandrenolide crea NP PA diflorasone diacetate crea NP PA flurandrenolide lotn NP PA diflorasone diacetate oint NP PA flurandrenolide oint NP

PA fluticasone propionate crea 1 DIOCHLOY SOLN NP 0.05 %

Coordinated Care of Washington Updated September 1, 2021

101 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits fluticasone propionate lotn NP PA KENALOG AERS PA 0.05 % (triamcinolone acetonide NP (topical)) fluticasone propionate oint 1 0.005 % LEXETTE FOAM NP PA halcinonide crea NP PA lidocaine-hydrocortisone NP PA acetate crea halobetasol propionate 1 crea LOCOID CREA NP PA (hydrocortisone butyrate) HALOBETASOL NP PA PROPIONATE FOAM LOCOID LIPOCREAM PA CREA (hydrocortisone NP halobetasol propionate oint 1 butyrate hydrophilic lipo base) HALOG CREA NP PA (halcinonide) LOCOID LOTN NP PA (hydrocortisone butyrate) HALOG OINT NP PA LOCOID SOLN NP PA (hydrocortisone butyrate) HALOG SOLN NP PA LUXIQ FOAM NP PA hydrocortisone (topical) 1 (betamethasone valerate) crea 2.5 %, 0.5 % mometasone furoate crea 1 hydrocortisone (topical) NP PA lotn 2.5 %, 2 %, 1 % mometasone furoate oint 1 hydrocortisone (topical) 1 RX/OTC oint 1 % mometasone furoate soln 1 hydrocortisone (topical) 1 oint 2.5 %, 0.5 % NIACINAMIDE/TRIAMCIN PA OLONE ACETONIDE NP hydrocortisone acetate 1 CREA (topical) crea NUCORT LOTN NP PA hydrocortisone butyrate NP PA crea OLUX FOAM (clobetasol NP PA hydrocortisone butyrate NP PA propionate) hydrophilic lipo base crea OLUX-E FOAM (clobetasol NP PA hydrocortisone butyrate NP PA propionate emulsion) lotn PANDEL CREA NP PA hydrocortisone butyrate NP PA oint prednicarbate crea NP PA hydrocortisone butyrate NP PA soln prednicarbate oint NP PA hydrocortisone valerate NP PA crea PSORCON CREA NP PA hydrocortisone valerate NP PA oint QUINIXIL THPK NP PA IMPEKLO LOTN NP PA SCALACORT DK KIT NP PA IMPOYZ CREA 2 SCARZEN SKIN REPAIR NP PA KIT

Coordinated Care of Washington Updated September 1, 2021

102 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SERNIVO EMUL NP PA triamcinolone acetonide 1 (topical) crea 0.1 % PA SILA III THPK NP triamcinolone acetonide 1 QL(15 gm per (topical) crea 0.5 % fill retail) SYNALAR CREA NP PA triamcinolone acetonide QL(60 ml per (fluocinolone acetonide) (topical) lotn 0.025 %, 0.1 1 fill retail) SYNALAR CREAM KIT KIT NP PA % triamcinolone acetonide SYNALAR OINT NP PA (topical) oint 0.025 %, 0.1 1 (fluocinolone acetonide) %, 0.05 % SYNALAR OINTMENT KIT PA NP triamcinolone acetonide NP PA KIT (topical) oint 0.05 % SYNALAR SOLN PA NP triamcinolone acetonide 1 QL(15 gm per (fluocinolone acetonide) (topical) oint 0.5 % fill retail) PA SYNALAR TS KIT NP triamcinolone acetonide- NP PA dimethicone-silicone kit TACLONEX OINT TRIAMSIL COMBIPAK NP PA (calcipotriene- NP THPK betamethasone dipropionate) TRIAMSIL MULTIPAK NP PA THPK TACLONEX SUSP PA TRIDESILON CREA (calcipotriene- NP NP betamethasone (desonide) dipropionate) ULTRAVATE LOTN NP PA TASOPROL KIT NP PA VANOS CREA NP PA (fluocinonide) TEMOVATE CREA NP (clobetasol propionate) VERDESO FOAM NP PA TEMOVATE OINT NP (clobetasol propionate) WYNZORA CREA NP PA NP PA TEXACORT SOLN Eczema Agents TOPICORT CREA PA NP DUPIXENT SOPN 200 NP PA (desoximetasone) MG/1.14ML, 300 MG/2ML TOPICORT GEL PA NP DUPIXENT SOSY 200 NP PA (desoximetasone) MG/1.14ML TOPICORT LIQD PA NP DUPIXENT SOSY 300 NP PA; SP (desoximetasone) MG/2ML TOPICORT OINT NP PA Emollient/Keratolytic Agents (desoximetasone) QL(325 ml per CEROVEL LOTN 2 TOVET KIT KIT NP PA fill retail) PA; QL(200 gm triamcinolone acetonide NP PA urea crea 1 per fill retail); (topical) aers 0.147 mg/gm RX/OTC triamcinolone acetonide 1 QL(454 gm per PA; QL(200 gm (topical) crea 0.025 % fill retail) urea crea NP per fill retail); RX/OTC

Coordinated Care of Washington Updated September 1, 2021

103 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1 QL(325 ml per PA; QL(30 gm urea lotn fill retail) TACROLIMUS NP MONOHYDRATE CREA per 28 days retail) Emollients Keratolytic/Antimitotic Agents lactic acid (ammonium 1 PA; RX/OTC lactate) crea CIMETIDINE/LIDOCAINE/ NP PA SALICYLIC ACID CREA lactic acid (ammonium 1 PA; RX/OTC lactate) lotn GUANENDRUX CREA NP PA PA LACTIC ACID LOTN 2 QL(4 ml per fill podofilox soln 1 retail) Enzymes - Topical salicylic acid crea 1 SANTYL OINT NP PA QL(240 gm per salicylic acid gel 1 Immunomodulating Agents - Topical fill retail) ALDARA CREA NP QL(48 ea per PA (imiquimod) 180 days retail) salicylic acid lotn 1 imiquimod crea 3.75 % NP PA SALIMEZ CREA 2 QL(48 ea per imiquimod crea 5 % 1 Local Anesthetics - Topical 180 days retail) 1ST MEDX- NP PA ZYCLARA CREA NP PA PATCH/LIDOCAINE PTCH (imiquimod) ACCUCAINE KIT NP PA ZYCLARA PUMP CREA NP PA 2.5 % ANACAINE OINT NP PA ZYCLARA PUMP CREA NP PA 3.75 % (imiquimod) APRIZIO PAK II KIT NP PA Immunosuppressive Agents - Topical PA; QL(30 gm APRIZIO PAK KIT NP PA ELIDEL CREA NP per 28 days (pimecrolimus) retail) ASTERO GEL NP PA; RX/OTC HYALURONIC ACID PA BENZOCAINE/LIDOCAINE NP PA SODIUM/NIACINAMIDE/T NP /TETRACAINE OINT ACROLIMUS CREA CADIRAMD KIT NP PA NIACINAMIDE/TACROLIM NP PA US MONOHYDRATE OINT CRYODOSE TA AERO NP PA; RX/OTC OXIANUJO OINT NP PA DERMACINRX PHN PAK NP PA PA; QL(30 gm THPK pimecrolimus crea 1 per 28 days DERMACINRX ZRM PAK PA retail) NP THPK PA; QL(30 gm PA PROTOPIC OINT NP per 28 days DERMALID THPK NP (tacrolimus (topical)) retail) PA; RX/OTC PA; QL(30 gm EHA LOTION 4% LOTN NP tacrolimus (topical) oint NP per 28 days PA; RX/OTC retail) EHA LOTION LOTN NP

Coordinated Care of Washington Updated September 1, 2021

104 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EMPRICAINE II KIT NP PA PA; QL(30 gm lidocaine hcl gel ex 2 % NP per fill retail); RX/OTC ENOVARX-LIDOCAINE NP PA HCL CREA lidocaine hcl lotn ex 3 % 1 ENZNONUTY OINT NP PA QL(30 ml per lidocaine hcl prsy ex 2 % 1 ethyl chloride aero NP PA fill retail) lidocaine hcl soln ex 4 % 1 ETHYL CHLORIDE/FINE NP PA PINPOINT AERO LIDOCAINE PA HYDROCHLORIDE CREA NP ETHYL CHLORIDE/FINE NP PA STREAM AERO EX 4.12 % ETHYL PA LIDOCAINE PA CHLORIDE/MEDIUM JET NP HYDROCHLORIDE/EPINE NP STREAM AERO PHRINE/TETRACAINE ETHYL PA HYDROCHLORIDE SOLN CHLORIDE/MEDIUM NP lidocaine oint 1 STREAM AERO ETHYL CHLORIDE/MIST NP PA lidocaine ptch 1 AERO PA; RX/OTC FLEXIN PTCH NP PA; RX/OTC lidocaine-menthol ptch NP lidocaine-prilocaine crea 1 GEBAUERS PAIN EASE NP PA; RX/OTC AERO lidocaine-prilocaine kit NP PA GEBAUERS SPRAY AND NP PA; RX/OTC STRETCH AERO lidocaine-transparent NP PA GEN7T LOTN NP PA dressing kit LIDOCAINE/TETRACAINE NP PA GEN7T PLUS LOTN NP PA CREA PA LIDODERM PTCH NP GEN7T PLUS PTCH NP (lidocaine) PA GEN7T PTCH NP PA LIDOPIN CREA NP PA L.E.T. GEL NP PA LIDOPURE PATCH KIT NP PA; RX/OTC LDO PLUS GEL NP PA; RX/OTC LIDORX GEL NP PA LEVATIO PATCH PTCH NP PA; RX/OTC LIDOSTREAM KIT NP LIDOCAINE AND PA LIDOTHOL GEL NP PA TETRACAINECREAM NP CREA LIDOTHOL PTCH NP PA lidocaine hcl crea ex 3 % 1 RX/OTC LIDOTRAL CREA NP PA QL(30 ml per lidocaine hcl gel ex 2 % 1 fill retail) LIDOVEX CREA NP PA

Coordinated Care of Washington Updated September 1, 2021

105 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LIDTOPIC MAX CREA NP PA VEINPUNCTURE PX1 PA PHLEBOTOMY SYSTEM NP KIT LMR PLUS KIT NP PA WPR PLUS WOUND NP PA MEDI-DERM/L-RX CREA NP PA; RX/OTC HEALING SYSTEM THPK ZILACAINE PATCH THPK NP PA MEDI-PATCH RX PTCH NP PA; RX/OTC ZTLIDO PTCH NP PA MICROVIX LP THPK NP PA Misc. Topical NUVAKAAN II KIT NP PA DRYSOL SOLN 2 PAINGO KFT KIT NP PA Phosphodiesterase 4 (PDE4) Inhibitors - Topical PA PLIAGLIS CREA NP EUCRISA OINT NP PA PRAMOX GEL GEL NP PA Rosacea Agents PA PREPIV SUPPLY KIT NP PA AVEIDAOXIA GEL NP

PRILO PATCH II KIT NP PA azelaic acid gel 1 PA PRILO PATCH KIT NP PA doxycycline (rosacea) cpdr NP

PRILOHEAL PLUS 30 KIT NP PA FINACEA FOAM 2 PA FINACEA GEL (azelaic 2 PRILOVIXIL KIT NP acid) PA PRIZOPAK II KIT NP PA ivermectin (rosacea) crea NP PA IVERMECTIN CREA EX 1 NP PA PRIZOTRAL II KIT NP % PRIZOTRAL KIT NP PA IVERMECTIN/METRONID PA AZOLE/NIACINAMIDE NP QUTENZA KIT NP PA GEL METROCREAM CREA NP QL(45 gm per REAL HEAL-I KIT NP PA (metronidazole (topical)) fill retail) METROGEL GEL NP RENOVO PTCH NP PA; RX/OTC (metronidazole (topical)) METROLOTION LOTN NP SKYADERM-LP KIT NP PA (metronidazole (topical)) PA metronidazole (topical) 1 QL(45 gm per SOOTHEE PTCH NP crea 0.75 % fill retail) metronidazole (topical) gel QL(45 gm per SX1 MEDICATED POST- NP PA 1 OPERATIVE SYSTEM KIT 0.75 % fill retail) PA metronidazole (topical) gel 1 SYNERA PTCH NP 1 % SYNVEXIA TC CREA NP PA; RX/OTC

Coordinated Care of Washington Updated September 1, 2021

106 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits metronidazole (topical) lotn 1 pyrethrins-piperonyl 1 0.75 % butoxide liqd MIRVASO GEL NP PA pyrethrins-piperonyl 1 butoxide sham PA NORITATE CREA NP SKLICE LOTN (ivermectin 2 RX/OTC (pediculicide)) ORACEA CPDR NP PA QL(120 ml per (doxycycline (rosacea)) fill retail,240 ml RHOFADE CREA NP PA spinosad susp 1 per 30 days retail); AL(At ROSADAN KIT KIT NP PA least 1 yrs old) SULFURATED LIME SOLN NP SOOLANTRA CREA NP PA (ivermectin (rosacea)) VANALICE GEL 2 ZILXI FOAM NP PA Wound Care Products Scabicides & Pediculicides REGRANEX GEL 2 PA crotamiton lotn 1 DIAGNOSTIC PRODUCTS ELIMITE CREA NP (permethrin) Diagnostic Tests ivermectin (pediculicide) 2 RX/OTC lotn CHEMSTRIP-K STRP 1 lindane sham NP KETONE STRP 1 PA; QL(59 ml KETONE TEST STRIPS 1 per fill STRP malathion lotn NP retail,118 ml per 30 days KETOSTIX STRP 1 retail) INSULIN QL(120 ml per USERS fill retail,240 ml LIMITED TO NATROBA SUSP 2 (spinosad) per 30 days 150 PER 30 retail); AL(At RELION TRUE METRIX DAYS, NON- least 1 yrs old) BLOODGLUCOSE TEST 1 INSULIN STRIPS STRP USERS NIX CREME RINSE LIQD 2 (permethrin) LIMITED TO PA; QL(59 ml 100 PER 90 per fill DAYS;QL(5 ea OVIDE LOTN (malathion) NP retail,118 ml daily); RX/OTC per 30 days retail) permethrin crea 1 permethrin liqd 1 permethrin lotn 1

Coordinated Care of Washington Updated September 1, 2021

107 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INSULIN PANCREAZE CPEP NP USERS LIMITED TO PERTZYE CPEP NP 150 PER 30 TRUE METRIX BLOOD DAYS, NON- GLUCOSETEST STRIPS 1 INSULIN VIOKACE TABS NP STRP USERS MP LIMITED TO ZENPEP CPEP 2 100 PER 90 DAYS;QL(5 ea DIURETICS - Drugs to Treat Heart, Circulation daily); RX/OTC Conditions and Blood Pressure INSULIN Carbonic Anhydrase Inhibitors USERS acetazolamide cp12 1 MP LIMITED TO 150 PER 30 PA TRUE METRIX SELF DAYS, NON- acetazolamide sodium solr 1 MONITORING BLOOD 1 INSULIN MP GLUCOSE STRIPS STRP USERS acetazolamide tabs 1 LIMITED TO 100 PER 90 KEVEYIS TABS NP DAYS;QL(5 ea MP daily); RX/OTC methazolamide tabs 1 INSULIN Diuretic Combinations USERS LIMITED TO ALDACTAZIDE TABS 25 MP 150 PER 30 MG-25 MG (spironolactone NP DAYS, NON- & hydrochlorothiazide) TRUETRACK BLOOD 1 ALDACTAZIDE TABS 50 GLUCOSE TEST STRP INSULIN NP USERS MG-50 MG LIMITED TO amiloride & 1 MP 100 PER 90 hydrochlorothiazide tabs DAYS;QL(5 ea daily); RX/OTC DYAZIDE CAPS QL(1 ea daily); (triamterene & NP MP INSULIN hydrochlorothiazide) USERS LIMITED TO MAXZIDE TABS QL(1 ea daily); 150 PER 30 (triamterene & NP MP DAYS, NON- hydrochlorothiazide) TRUETRACK TEST STRP 1 INSULIN MAXZIDE-25 TABS QL(1 ea daily); USERS (triamterene & NP MP LIMITED TO hydrochlorothiazide) 100 PER 90 spironolactone & 1 MP DAYS;QL(5 ea hydrochlorothiazide tabs daily); RX/OTC triamterene & 1 QL(1 ea daily); DIGESTIVE AIDS - Drugs to Treat Low Digestive hydrochlorothiazide caps MP Enzymes triamterene & 1 QL(1 ea daily); Digestive Enzymes hydrochlorothiazide tabs MP Loop Diuretics CREON CPEP 2 MP

Coordinated Care of Washington Updated September 1, 2021

108 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits bumetanide soln ij 0.25 1 PA hydrochlorothiazide tabs 1 MP mg/ml MP bumetanide tabs or 0.5 mg, 1 MP indapamide tabs 1 1 mg, 2 mg MP BUMEX TABS NP MP metolazone tabs 1 (bumetanide) SODIUM DIURIL SOLR 2 PA EDECRIN TABS NP MP (chlorothiazide sodium) (ethacrynic acid) PA ENDOCRINE AND METABOLIC AGENTS - ethacrynate sodium solr 1 MISC. - Drugs to Treat Bone Disease and Regulate Hormones ethacrynic acid tabs 1 MP Adrenal Steroid Inhibitors PA furosemide soln ij 10 mg/ml 1 ISTURISA TABS CO furosemide soln or 10 1 MP mg/ml, 8 mg/ml Bone Density Regulators ACTONEL TABS 150 MG PA furosemide tabs or 20 mg, 1 MP NP 40 mg, 80 mg (risedronate sodium) MP PA; QL(4 ea LASIX TABS (furosemide) NP ACTONEL TABS 35 MG NP per 28 days (risedronate sodium) retail); MP SODIUM EDECRIN SOLR NP PA (ethacrynate sodium) ACTONEL TABS 5 MG NP QL(1 ea daily); (risedronate sodium) MP QL(1 ea daily); torsemide tabs 1 MP alendronate sodium soln 70 1 QL(10.8 ml mg/75ml daily); MP Potassium Sparing Diuretics alendronate sodium tabs 1 QL(0.15 ea ALDACTONE TABS NP MP 35 mg, 70 mg daily); MP (spironolactone) alendronate sodium tabs 5 QL(1 ea daily); QL(4 ea daily); 1 amiloride hcl tabs 1 mg, 10 mg MP MP PA; QL(4 ea ATELVIA TBEC NP per 28 days CAROSPIR SUSP NP (risedronate sodium) retail); MP DYRENIUM CAPS NP PA (triamterene) BINOSTO TBEF NP spironolactone tabs 1 MP BONIVA SOLN IV 3 PA MG/3ML (ibandronate NP triamterene caps NP sodium) BONIVA TABS OR 150 MG NP MP Thiazides and Thiazide-Like Diuretics (ibandronate sodium) chlorothiazide sodium solr 1 PA PA; QL(2 ml calcitonin (salmon) soln ij 1 per 30 days 200 unit/ml chlorthalidone tabs 1 MP retail) Limit 2 per DIURIL SUSP NP calcitonin (salmon) soln na 1 month;QL(7.4 200 unit/act ml per 30 days hydrochlorothiazide caps 1 MP retail); MP EVENITY SOSY NP PA

Coordinated Care of Washington Updated September 1, 2021

109 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; QL(2.48 ml zoledronic acid conc 4 1 PA FORTEO SOPN 2 per 31 days mg/5ml retail) ZOLEDRONIC ACID SOLN 2 PA FOSAMAX PLUS D TABS NP PA 4 MG/100ML zoledronic acid soln 4 1 PA FOSAMAX TABS NP QL(0.15 ea mg/100ml, 5 mg/100ml (alendronate sodium) daily); MP Corticotropin ibandronate sodium soln iv NP PA 3 mg/3ml ACTHAR GEL 2 PA ibandronate sodium tabs or 1 MP 150 mg Fertility Regulators PA; QL(2 ml CHORIONIC 2 PA MIACALCIN SOLN NP GONADOTROPIN SOLR (calcitonin (salmon)) per 30 days retail) NOVAREL SOLR 2 PA PA NATPARA CART NP PREGNYL W/DILUENT PA BENZYLALCOHOL/NACL 2 pamidronate disodium soln NP PA 30 mg/10ml, 90 mg/10ml SOLR PAMIDRONATE PA GnRH/LHRH Antagonists DISODIUM SOLN 6 NP PA MG/ML ORILISSA TABS 150 MG 2 pamidronate disodium solr NP PA ORILISSA TABS 200 MG 2 PA; SP 30 mg, 90 mg PROLIA SOSY 2 PA Growth Hormone Receptor Antagonists SOMAVERT SOLR 2 PA; SP RECLAST SOLN NP PA (zoledronic acid) Growth Hormone Releasing Hormones (GHRH) risedronate sodium tabs NP PA 150 mg EGRIFTA SOLR 2 MG 2 PA risedronate sodium tabs 30 NP QL(1 ea daily) PA mg EGRIFTA SV SOLR 2 PA; QL(4 ea Growth Hormones risedronate sodium tabs 35 NP per 28 days mg retail); MP GENOTROPIN MINIQUICK 2 PA; SP SOLR risedronate sodium tabs 5 NP QL(1 ea daily); mg MP GENOTROPIN SOLR 2 PA; SP PA; QL(4 ea risedronate sodium tbec 35 NP per 28 days HUMATROPE COMBO PA mg NP retail); MP PACK SOLR PA; QL(2.48 ml HUMATROPE SOLR NP PA TERIPARATIDE SOPN 2 per 31 days retail) NORDITROPIN FLEXPRO 2 PA SOPN TYMLOS SOPN NP PA NUTROPIN AQ NUSPIN NP PA 10 SOPN XGEVA SOLN 2 PA; SP NUTROPIN AQ NUSPIN NP PA 20 SOPN

Coordinated Care of Washington Updated September 1, 2021

110 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NUTROPIN AQ NUSPIN 5 NP PA BRINEURA KIT CO SOPN BUPHENYL POWD PA OMNITROPE SOCT 10 NP PA; SP NP MG/1.5ML (sodium phenylbutyrate) BUPHENYL TABS (sodium PA OMNITROPE SOCT 5 NP PA NP MG/1.5ML phenylbutyrate) OMNITROPE SOLR 5.8 NP PA calcitriol caps 1 MG SAIZEN SOLR NP PA calcitriol soln 1 SAIZENPREP PA CARBAGLU TABS 2 PA RECONSTITUTIONKIT NP SOLR CARNITOR SF SOLN QL(30 ml daily) (levocarnitine (metabolic NP SEROSTIM SOLR NP PA modifiers)) PA CARNITOR SOLN 1 QL(30 ml daily) ZOMACTON SOLR 10 MG NP GM/10ML (levocarnitine NP PA; SP (metabolic modifiers)) ZOMACTON SOLR 5 MG NP CARNITOR TABS 330 MG QL(3 ea daily) PA (levocarnitine (metabolic NP ZORBTIVE SOLR NP modifiers)) Hormone Receptor Modulators cinacalcet hcl tabs 1 SP EVISTA TABS (raloxifene NP QL(1 ea daily); hcl) MP CRYSVITA SOLN CO PA OSPHENA TABS NP CYSTADANE POWD 2 PA QL(1 ea daily); raloxifene hcl tabs 1 PA MP doxercalciferol caps NP Insulin-Like Growth Factors (Somatomedins) GALAFOLD CAPS 2 PA INCRELEX SOLN 2 PA; SP KUVAN PACK (sapropterin NP PA; SP dihydrochloride) LHRH/GnRH Agonist Analog Pituitary KUVAN TABS (sapropterin NP PA; SP FENSOLVI KIT 2 PA; SP dihydrochloride) PA levocarnitine (metabolic 1 QL(30 ml daily) LUPANETA PACK KIT 2 modifiers) soln 1 gm/10ml levocarnitine (metabolic QL(3 ea daily) LUPRON DEPOT-PED (1- 2 PA; SP 1 MONTH) KIT modifiers) tabs 330 mg PA LUPRON DEPOT-PED (3- 2 PA; SP nitisinone caps 1 MONTH) KIT PA SUPPRELIN LA KIT 2 PA; SP NITYR TABS 2

SYNAREL SOLN 2 PA NULIBRY SOLR CO PA; SP ORFADIN CAPS 10 MG, 2 NP PA TRIPTODUR SRER 2 MG, 5 MG (nitisinone) Metabolic Modifiers Coordinated Care of Washington Updated September 1, 2021

111 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ORFADIN CAPS 20 MG 2 PA DDAVP TABS OR 0.1 MG, QL(6 ea daily) 0.2 MG (desmopressin NP ORFADIN SUSP 4 MG/ML 2 PA acetate) desmopressin acetate soln 1 PA PALYNZIQ SOSY CO ij 4 mcg/ml DESMOPRESSIN PA paricalcitol caps NP PA ACETATE SOLN NA 1.5 NP MG/ML RAVICTI LIQD NP PA desmopressin acetate 1 QL(5 ml per fill spray refrigerated soln retail) RAYALDEE CPCR NP PA desmopressin acetate 1 QL(5 ml per fill spray soln retail) REVCOVI SOLN CO desmopressin acetate tabs 1 QL(6 ea daily) or 0.1 mg, 0.2 mg ROCALTROL CAPS NP (calcitriol) NOCDURNA SUBL NP PA ROCALTROL SOLN NP (calcitriol) STIMATE SOLN NP PA sapropterin dihydrochloride NP PA; SP pack Progesterone Receptor Antagonists MIFEPREX TABS sapropterin dihydrochloride NP PA; SP NP tabs (mifepristone) SENSIPAR TABS 2 SP mifepristone tabs 1 (cinacalcet hcl) Prolactin Inhibitors sodium phenylbutyrate 1 PA powd cabergoline tabs 1 sodium phenylbutyrate tabs 1 PA Somatostatic Agents PA STRENSIQ SOLN 2 BYNFEZIA PEN SOPN NP PA PA XURIDEN PACK 2 MYCAPSSA CPDR 2 PA ZEMPLAR CAPS NP PA octreotide acetate soln 100 PA (paricalcitol) mcg/ml, 500 mcg/ml, 50 1 Mineralocorticoid Receptor Antagonists mcg/ml, 1000 mcg/5ml, 1000 mcg/ml, 200 mcg/ml KERENDIA TABS 2 PA SANDOSTATIN LAR NP PA; SP Posterior Pituitary Hormones DEPOT KIT DDAVP SOLN IJ 4 PA SANDOSTATIN SOLN NP PA MCG/ML (desmopressin NP (octreotide acetate) acetate) SIGNIFOR LAR SRER NP PA PA; QL(5 ml DDAVP SOLN NA 0.01 % NP per fill retail) SIGNIFOR SOLN 2 PA DDAVP SOLN NA 0.01 % QL(5 ml per fill (desmopressin acetate NP retail) SOMATULINE DEPOT 2 PA; SP spray) SOLN Vasopressin Receptor Antagonists

Coordinated Care of Washington Updated September 1, 2021

112 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits JYNARQUE TABS 15 MG, 2 PA; SP PREFEST TABS NP 30 MG MP JYNARQUE TBPK 15 MG, NP PA PREMPHASE TABS 2 MP SAMSCA TABS (tolvaptan) 2 PA; SP PREMPRO TABS 2 tolvaptan tabs 1 PA; SP Estrogens ALORA PTTW 0.025 PA; MP ESTROGENS - Hormone Replacement/Modifying MG/24HR, 0.075 NP Drugs MG/24HR, 0.1 MG/24HR, 0.05 MG/24HR Estrogen Combinations CLIMARA PTWK NP ACTIVELLA TABS 0.5 MG- (estradiol) 1 MG (estradiol & NP norethindrone acetate) DELESTROGEN OIL 10 NP PA MG/ML ANGELIQ TABS 2 DELESTROGEN OIL 20 BI-EST 50:50 PA MG/ML, 40 MG/ML NP COMPOUNDINGKIT NP (estradiol valerate) CREA DEPO-ESTRADIOL OIL 2 BI-EST 80:20 PA PROGESTERONE NP DIVIGEL GEL NP COMPOUNDING KIT CREA EC-RX ESTRADIOL 0.4% NP CREA BIJUVA CAPS NP EC-RX ESTRADIOL 0.6% NP CREA CLIMARA PRO PTWK 2 ELESTRIN GEL NP COMBIPATCH PTTW 2 MP ESTRACE TABS NP MP DUAVEE TABS 2 PA (estradiol) estradiol pttw td 0.025 MP estradiol & norethindrone MP 1 mg/24hr, 0.0375 mg/24hr, 1 acetate tabs 0.1 mg-0.5 mg 0.075 mg/24hr, 0.1 mg/24hr, 0.05 mg/24hr estradiol & norethindrone 1 acetate tabs 0.5 mg-1 mg estradiol ptwk td 0.025 ESTRIOL- PA mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr, 0.05 mg/24hr, 1 PROGESTERONE NP COMPOUNDING KIT 0.06 mg/24hr, 37.5 CREA mcg/24hr FEMHRT TABS estradiol tabs or 0.5 mg, 1 1 MP (norethindrone acetate- NP mg, 2 mg ethinyl estradiol) estradiol valerate oil 1 MYFEMBREE TABS 2 PA ESTROGEL GEL NP norethindrone acetate- 1 ethinyl estradiol tabs EVAMIST SOLN NP ORIAHNN CPPK 2 PA

Coordinated Care of Washington Updated September 1, 2021

113 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MENEST TABS 2 MP moxifloxacin hcl tabs NP QL(56 ea per MENOSTAR PTWK NP ofloxacin tabs NP fill retail) MINIVELLE PTTW 0.025 PA; MP GASTROINTESTINAL AGENTS - MISC. - MG/24HR, 0.075 NP Miscellaneous Gastrointestinal Drugs MG/24HR, 0.1 MG/24HR (estradiol) 5-HT4 Receptor Agonists PA MINIVELLE PTTW 0.0375 NP MP MOTEGRITY TABS NP MG/24HR (estradiol) MINIVELLE PTTW 0.05 NP PA Agents for Chronic Idiopathic Constipation (CIC) MG/24HR (estradiol) TRULANCE TABS NP PA; QL(1 ea daily) PREMARIN SOLR IJ 25 NP PA MG Antiflatulents PREMARIN TABS OR 0.3 MP MG, 0.45 MG, 0.625 MG, 2 simethicone caps 125 mg 1 0.9 MG, 1.25 MG simethicone chew 125 mg, 1 VIVELLE-DOT PTTW PA; MP 80 mg 0.025 MG/24HR, 0.075 NP MG/24HR, 0.1 MG/24HR simethicone susp 40 1 (estradiol) mg/0.6ml VIVELLE-DOT PTTW MP Bile Acid Synthesis Disorder Agents 0.0375 MG/24HR NP CHOLBAM CAPS NP QL(5 ea daily); (estradiol) MP VIVELLE-DOT PTTW 0.05 NP PA Farnesoid X Receptor (FXR) Agonists MG/24HR (estradiol) OCALIVA TABS NP FLUOROQUINOLONES - Drugs to Treat Bacterial Infections Gallstone Solubilizing Agents Fluoroquinolones ACTIGALL CAPS (ursodiol) NP QL(3 ea daily); MP BAXDELA TABS OR 450 NP PA MG CHENODAL TABS NP CIPRO SUSR 5 2 GM/100ML, 500 MG/5ML URSO 250 TABS (ursodiol) NP QL(7 ea daily); MP CIPRO TABS 250 MG, 500 NP MG (ciprofloxacin hcl) URSO FORTE TABS NP ciprofloxacin hcl tabs 100 QL(6 ea per fill (ursodiol) 1 QL(3 ea daily); mg retail) ursodiol caps 300 mg 1 ciprofloxacin hcl tabs 250 MP 1 QL(7 ea daily); mg, 500 mg, 750 mg ursodiol tabs 250 mg 1 MP ciprofloxacin susr NP ursodiol tabs 500 mg 1 levofloxacin soln 25 mg/ml NP URSODIOL/SYRSPEND NP PA QL(1 ea SF PH4 SUSP levofloxacin tabs 250 mg, 1 daily,14 ea per 500 mg, 750 mg Gastrointestinal Antiallergy Agents fill retail)

Coordinated Care of Washington Updated September 1, 2021

114 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cromolyn sodium 1 CIMZIA KIT NP ST; SP (mastocytosis) conc GASTROCROM CONC CIMZIA STARTER KIT KIT NP ST; SP (cromolyn sodium NP (mastocytosis)) COLAZAL CAPS NP QL(9 ea daily) (balsalazide disodium) Gastrointestinal Chloride Channel Activators DELZICOL CPDR NP QL(6 ea daily); AMITIZA CAPS 2 PA; MP (mesalamine) MP (lubiprostone) DIPENTUM CAPS NP lubiprostone caps 1 PA; MP PA Gastrointestinal Stimulants ENTYVIO SOLR NP GIMOTI SOLN NP PA INFLECTRA SOLR NP PA LIALDA TBEC metoclopramide hcl soln ij NP PA 2 5 mg/ml (mesalamine) mesalamine cp24 or 0.375 MP metoclopramide hcl soln or 1 1 10 mg/10ml, 5 mg/5ml gm mesalamine cpdr or 400 QL(6 ea daily); metoclopramide hcl tabs or 1 1 10 mg, 5 mg mg MP QL(60 ml daily) metoclopramide hcl tbdp or 1 mesalamine enem re 4 gm 1 5 mg mesalamine supp re 1000 METOCLOPRAMIDE ODT 2 1 TBDP mg REGLAN TABS NP mesalamine tbec or 1.2 gm 1 (metoclopramide hcl) mesalamine tbec or 800 NP QL(3 ea daily) Ileal Bile Acid Transporter (IBAT) Inhibitors mg PA BYLVAY (PELLETS) CPSP 2 mesalamine w/ cleanser kit NP PA PA BYLVAY CAPS 2 PENTASA CPCR 2 QL(8 ea daily); MP Inflammatory Bowel Agents REMICADE SOLR NP PA APRISO CP24 2 MP (mesalamine) RENFLEXIS SOLR NP PA ASACOL HD TBEC NP QL(3 ea daily) (mesalamine) ROWASA KIT (mesalamine NP PA w/ cleanser) AVSOLA SOLR NP PA SFROWASA ENEM NP AZULFIDINE EN-TABS NP MP TBEC (sulfasalazine) STELARA SOLN IV 130 NP PA MG/26ML AZULFIDINE TABS NP MP (sulfasalazine) sulfasalazine tabs 1 MP balsalazide disodium caps 1 QL(9 ea daily) sulfasalazine tbec 1 MP CANASA SUPP 2 (mesalamine) Intestinal Acidifiers

Coordinated Care of Washington Updated September 1, 2021

115 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits lactulose (encephalopathy) 1 MP RENVELA TABS NP PA; MP soln (sevelamer carbonate) Irritable Bowel Syndrome (IBS) Agents sevelamer carbonate pack NP PA; MP 0.8 gm, 2.4 gm alosetron hcl tabs NP PA sevelamer carbonate tabs 1 PA; MP 800 mg LINZESS CAPS 2 PA sevelamer hcl tabs NP PA; MP LOTRONEX TABS NP PA (alosetron hcl) VELPHORO CHEW NP PA VIBERZI TABS NP PA Short Bowel Syndrome (SBS) Agents PA ZELNORM TABS NP GATTEX KIT 2 PA Peripheral Opioid Receptor Antagonists Tryptophan Hydroxylase Inhibitors PA alvimopan caps NP XERMELO TABS 2 PA; SP ENTEREG CAPS NP PA GENITOURINARY AGENTS - MISCELLANEOUS (alvimopan) - Miscellaneous Drugs to Treat Reproductive MOVANTIK TABS 2 PA Organs and Urinary System Acidifiers RELISTOR SOLN NP PA K-PHOS NO 2 TABS 2 RELISTOR TABS NP PA Alkalinizers PA SYMPROIC TABS NP ORACIT SOLN NP Phosphate Binder Agents pot & sod citrates w/citric 1 ac soln AURYXIA TABS NP PA potassium citrate (alkalinizer) tbcr 10 meq, 1 calcium acetate (phosphate 1 MP binder) caps 1080 mg, 15 meq, 1620 mg potassium citrate QL(1.433 ea calcium acetate (phosphate 1 RX/OTC; MP 1 binder) tabs (alkalinizer) tbcr 540 mg daily) FOSRENOL CHEW 1000 PA; MP potassium citrate-citric acid 1 MG, 500 MG, 750 MG NP pack 1002 mg-3300 mg (lanthanum carbonate) potassium citrate-citric acid RX/OTC soln 334 mg/5ml-1100 FOSRENOL PACK 1000 NP PA MG, 750 MG mg/5ml, 334 mg/5ml-334 1 PA; MP mg/5ml-1100 mg/5ml-1100 lanthanum carbonate chew NP mg/5ml sodium citrate & citric acid QL(500 ml per PHOSLYRA SOLN 2 MP soln 334 mg/5ml-334 1 30 days retail); mg/5ml-500 mg/5ml-500 RX/OTC RENAGEL TABS NP PA; MP (sevelamer hcl) mg/5ml UROCIT-K 10 TBCR RENVELA PACK NP PA; MP (sevelamer carbonate) (potassium citrate NP (alkalinizer))

Coordinated Care of Washington Updated September 1, 2021

116 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits UROCIT-K 15 TBCR PROSCAR TABS NP QL(1 ea daily); (potassium citrate NP (finasteride) MP (alkalinizer)) RAPAFLO CAPS NP MP UROCIT-K 5 TBCR QL(1.433 ea (silodosin) (potassium citrate NP daily) MP (alkalinizer)) silodosin caps NP QL(2 ea daily); Cystinosis Agents tamsulosin hcl caps 1 MP CYSTAGON CAPS 2 UROXATRAL TB24 NP MP (alfuzosin hcl) PROCYSBI CPDR 25 MG, NP 75 MG Urinary Analgesics PROCYSBI PACK 300 MG, NP PA 75 MG phenazopyridine hcl tabs 1 Genitourinary Irrigants PYRIDIUM TABS NP (phenazopyridine hcl) sodium chloride (gu 1 irrigant) soln Urinary Stone Agents Hyperoxaluria Agents LITHOSTAT TABS 2 PA OXLUMO SOLN CO THIOLA EC TBEC 2 PA Interstitial Cystitis Agents THIOLA TABS (tiopronin) NP PA ELMIRON CAPS 2 PA; QL(3 ea daily) tiopronin tabs 1 PA PENTOSAN PA POLYSULFATE SODIUM 2 DR CPDR GOUT AGENTS - Drugs to Treat Gout RIMSO-50 SOLN 2 PA Gout Agent Combinations colchicine w/ probenecid 1 MP Prostatic Hypertrophy Agents tabs alfuzosin hcl tb24 1 MP Gout Agents allopurinol sodium solr 1 PA AVODART CAPS NP MP (dutasteride) allopurinol tabs 1 MP CARDURA XL TB24 NP ALOPRIM SOLR 2 PA dutasteride caps 1 MP (allopurinol sodium) colchicine caps 1 dutasteride-tamsulosin hcl NP PA caps PA; QL(6 ea QL(1 ea daily); colchicine tabs NP finasteride tabs 1 per fill retail) MP COLCRYS TABS NP PA; QL(6 ea FLOMAX CAPS NP QL(2 ea daily); (colchicine) per fill retail) (tamsulosin hcl) MP febuxostat tabs NP PA; MP JALYN CAPS (dutasteride- NP PA tamsulosin hcl) GLOPERBA SOLN NP PA

Coordinated Care of Washington Updated September 1, 2021

117 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KRYSTEXXA SOLN NP PA HEMLIBRA SOLN CO

MITIGARE CAPS NP PA HEMOFIL M SOLR CO (colchicine) ULORIC TABS (febuxostat) NP PA; MP HUMATE-P SOLR CO

ZYLOPRIM TABS NP MP IDELVION SOLR CO (allopurinol) Uricosurics IXINITY SOLR CO MP probenecid tabs 1 JIVI SOLR CO

HEMATOLOGICAL AGENTS - MISC. - Drugs to KOATE SOLR CO Treat Blood Disorders Aminolevulinate Synthase 1-Directed siRNA KOATE-DVI SOLR CO

GIVLAARI SOLN CO KOGENATE FS KIT CO Antihemophilic Products KOVALTRY SOLR CO ADVATE SOLR CO MONONINE SOLR CO ADYNOVATE SOLR CO NOVOEIGHT SOLR CO AFSTYLA KIT CO NOVOSEVEN RT SOLR CO ALPHANATE SOLR CO NUWIQ KIT CO ALPHANATE/VON WILLEBRANDFACTOR CO NUWIQ SOLR CO COMPLEX/HUMAN SOLR ALPHANINE SD SOLR CO OBIZUR SOLR CO

ALPROLIX SOLR CO PROFILNINE SD SOLR CO

BENEFIX KIT CO PROFILNINE SOLR CO

COAGADEX SOLR CO REBINYN SOLR CO

CORIFACT KIT CO RECOMBINATE SOLR CO

ELOCTATE SOLR CO RIASTAP SOLR CO

ESPEROCT SOLR CO RIXUBIS SOLR CO

FEIBA SOLR CO SEVENFACT SOLR CO

FIBRYGA SOLR CO TRETTEN SOLR CO

HELIXATE FS KIT CO VONVENDI SOLR CO

Coordinated Care of Washington Updated September 1, 2021

118 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits WILATE KIT CO Platelet Aggregation Inhibitors AGGRENOX CP12 NP MP XYNTHA KIT CO (aspirin-dipyridamole) AGRYLIN CAPS NP MP XYNTHA SOLOFUSE KIT CO (anagrelide hcl) Bradykinin B2 Receptor Antagonists anagrelide hcl caps 1 MP FIRAZYR SOLN (icatibant NP PA; SP MP acetate) aspirin-dipyridamole cp12 1 PA icatibant acetate soln 1 ASPIRIN/OMEPRAZOLE NP PA TBEC PA; SP icatibant acetate soln 1 BRILINTA TABS 2 QL(2 ea daily); MP Complement Inhibitors QL(2 ea daily); cilostazol tabs 1 BERINERT KIT NP PA MP clopidogrel bisulfate tabs 1 CINRYZE SOLR NP PA 300 mg clopidogrel bisulfate tabs 1 QL(1 ea daily); EMPAVELI SOLN 2 PA 75 mg MP MP HAEGARDA SOLR 2 PA dipyridamole tabs 1

RUCONEST SOLR NP PA DURLAZA CP24 NP PA EFFIENT TABS (prasugrel NP PA; QL(1 ea SOLIRIS SOLN 2 hcl) daily) PA ULTOMIRIS SOLN 2 PA KENGREAL SOLR NP Hemataologic - Tyrosine Kinase Inhibitors PLAVIX TABS (clopidogrel NP QL(1 ea daily); bisulfate) MP PA TAVALISSE TABS NP PA; QL(1 ea prasugrel hcl tabs NP daily) Hematorheologic Agents YOSPRALA TBEC NP PA pentoxifylline tbcr 1 MP ZONTIVITY TABS NP Hemin PANHEMATIN SOLR 2 PA Protamine protamine sulfate soln 1 PA Human Protein C CEPROTIN SOLR 2 PA Thrombolytic Enzymes ACTIVASE SOLR 2 PA Plasma Kallikrein Inhibitors PA CATHFLO ACTIVASE 2 PA KALBITOR SOLN 2 SOLR ORLADEYO CAPS NP PA RETAVASE HALF-KIT KIT NP PA

TAKHZYRO SOLN NP PA RETAVASE KIT NP PA

Coordinated Care of Washington Updated September 1, 2021

119 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TNKASE KIT 2 PA Folic Acid/Folates folic acid caps or 0.8 mg, 1 HEMATOPOIETIC AGENTS - Drugs to Treat 800 mcg Blood Disorders folic acid soln ij 5 mg/ml 1 PA Agents for Gaucher Disease RX/OTC; MP CERDELGA CAPS NP PA; MP folic acid tabs or 1 mg 1

CEREZYME SOLR NP PA folic acid tabs or 800 mcg 1

ELELYSO SOLR NP PA Hematopoietic Growth Factors ARANESP ALBUMIN 2 PA miglustat caps 1 PA; MP FREE SOLN ARANESP ALBUMIN 2 PA VPRIV SOLR NP PA FREE SOSY DOPTELET TABS NP PA ZAVESCA CAPS 2 PA; MP (miglustat) 2 PA; SP Agents for Sickle Cell Disease EPOGEN SOLN ADAKVEO SOLN CO FULPHILA SOSY NP PA

DROXIA CAPS 2 MP GRANIX SOLN 2 PA

ENDARI PACK NP PA GRANIX SOSY 2 PA

OXBRYTA TABS NP PA LEUKINE SOLR NP PA

SIKLOS TABS 2 MIRCERA SOSY NP PA

Cobalamins MULPLETA TABS NP PA B-12 COMPLIANCE 2 PA INJECTIONKIT KIT NEULASTA ONPRO KIT NP PA; SP PSKT cyanocobalamin soln 1000 1 mcg/ml NEULASTA SOSY NP PA; SP CYANOCOBALAMIN 2 PA; SP SOLN 2000 MCG/ML NEUPOGEN SOLN 2 hydroxocobalamin acetate 1 PA PA; SP soln NEUPOGEN SOSY 2 PA METHYLCOBALAMIN 2 PA NIVESTYM SOLN NP SOLN PA METHYLCOBALAMIN 2 PA NIVESTYM SOSY NP SOLR NPLATE SOLR NP PA PHYSICIANS EZ USE B- 2 PA 12 COMPLIANCE KIT KIT PA VITAMIN DEFICIENCY PA NYVEPRIA SOSY NP INJECTABLE SYSTEM- 2 B12 KIT

Coordinated Care of Washington Updated September 1, 2021

120 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PROCRIT SOLN 10000 PA; SP Iron UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 NP ferrous gluconate tabs 1 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML ferrous sulfate elix 220 1 QL(16 ml daily) mg/5ml PROMACTA PACK 12.5 NP PA MG, 25 MG FERROUS SULFATE LIQD 2 220 MG/5ML PROMACTA TABS 12.5 2 PA; QL(1 ea MG, 25 MG daily); SP ferrous sulfate soln 15 1 QL(3.4 ml mg/ml daily) PROMACTA TABS 50 MG, 2 PA; SP; MP 75 MG FERROUS SULFATE 2 SOLN 300 MG/6.8ML REBLOZYL SOLR CO ferrous sulfate syrp 300 1 mg/5ml RETACRIT SOLN 10000 PA UNIT/ML, 2000 UNIT/ML, ferrous sulfate tabs 325 1 MP mg, 65 mg 20000 UNIT/2ML, 20000 NP UNIT/ML, 3000 UNIT/ML, FERROUS SULFATE 2 4000 UNIT/ML, 40000 TBEC 324 MG UNIT/ML ferrous sulfate tbec 325 mg 1 MP UDENYCA SOSY NP PA INFED SOLN 2 PA ZARXIO SOSY NP PA INJECTAFER SOLN 2 PA ZIEXTENZO SOSY NP PA VENOFER SOLN 2 PA Hematopoietic Mixtures HEMOSTATICS - Drugs to Stop Bleeding/Treat fe bisglycinate chelate-vit 1 c-vit b12-folic acid caps Blood Disorders fe fum-iron polysacch Hemostatics - Systemic complex-fa-b complex-c- 1 AMICAR SOLN 0.25 NP PA zn-mn-cu caps GM/ML (aminocaproic acid) fe fumarate-vitamin c- RX/OTC 1 AMICAR TABS 1000 MG NP vitamin b12-folic acid caps (aminocaproic acid) ferrous fumarate w/ b12-vit 1 AMICAR TABS 500 MG NP QL(24 ea per c-fa-ifc caps (aminocaproic acid) fill retail) ferrous fumarate-fa-b QL(1 ea daily) aminocaproic acid soln iv 1 PA complex-c-zn-mg-mn-cu 1 250 mg/ml tabs aminocaproic acid soln or 1 folic acid-vitamin b6- 1 0.25 gm/ml vitamin b12 tabs aminocaproic acid tabs or 1 iron combinations caps 1 RX/OTC 1000 mg iron polysaccharide aminocaproic acid tabs or 1 QL(24 ea per complex-vit b12-folic acid 1 500 mg fill retail) caps CYKLOKAPRON SOLN 2 PA (tranexamic acid) LIPO-B SOLN 2 PA

Coordinated Care of Washington Updated September 1, 2021

121 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(30 ea per 5 QL(1 ea daily); AMBIEN TABS (zolpidem NP LYSTEDA TABS NP days retail); tartrate) AL(At least 18 (tranexamic acid) AL(At least 12 yrs old) yrs old) DORAL TABS (quazepam) NP tranexamic acid soln iv 1 PA 1000 mg/10ml PA; AL(At least EDLUAR SUBL NP QL(30 ea per 5 18 yrs old) tranexamic acid tabs or days retail); AL(At least 18 1 estazolam tabs NP 650 mg AL(At least 12 yrs old) yrs old) PA; AL(At least eszopiclone tabs NP TRANEXAMIC PA 18 yrs old) ACID/SODIUM CHLORIDE 2 QL(1 ea daily); SOLN flurazepam hcl caps NP AL(At least 18 HYPNOTICS/SEDATIVES/SLEEP DISORDER yrs old) AGENTS QL(1 ea daily); HALCION TABS NP Barbiturate Hypnotics (triazolam) AL(At least 18 yrs old) AMYTAL SODIUM SOLR 2 PA INTERMEZZO SUBL NP AL(At least 18 NEMBUTAL SODIUM PA (zolpidem tartrate) yrs old) SOLN (pentobarbital 2 LUNESTA TABS NP PA; AL(At least sodium) (eszopiclone) 18 yrs old) PA midazolam hcl soln ij 5 pentobarbital sodium soln 1 mg/5ml, 10 mg/2ml, 2 MP mg/2ml, 5 mg/ml, 10 1 phenobarbital elix 1 mg/10ml, 50 mg/10ml, 25 mg/5ml phenobarbital soln 1 MP midazolam hcl syrp or 2 NP mg/ml phenobarbital tabs 1 MP MIDAZOLAM 2 SECONAL SODIUM CAPS NP PA HYDROCHLORIDE SOLN MIDAZOLAM PA Hypnotic Combinations HYDROCHLORIDE/SODIU MIDAZOLAM/KETAMINE PA M CHLORIDE SOSY 0.9 NP %-2 MG/2ML, 0.9 %-5 HYDROCHLORIDE/ONDA NP NSETRON MG/5ML, 0.9 %-55 HYDROCHLORIDE TROC MG/55ML MIDAZOLAM SOSY IJ 2 MKO MELT DOSE PACK NP PA 2 TROC MG/2ML MIDAZOLAM/SODIUM Hypnotics - Tricyclic Agents CHLORIDE SOLN 0.9 %- PA; AL(At least 2 doxepin hcl (sleep) tabs NP 100 MG/100ML, 0.9 %-50 18 yrs old) MG/50ML SILENOR TABS (doxepin PA; AL(At least NP MIDAZOLAM/SYRSPEND NP PA hcl (sleep)) 18 yrs old) SF PH4 SUSP Non-Barbiturate Hypnotics quazepam tabs NP AMBIEN CR TBCR NP AL(At least 18 (zolpidem tartrate) yrs old)

Coordinated Care of Washington Updated September 1, 2021

122 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily); psyllium powd 33 %, 49 %, RESTORIL CAPS 15 MG, NP AL(At least 18 68 %, 30 %, 30.9 %, 25 %, 30 MG (temazepam) 1 yrs old) 51.7 %, 48.57 %, 58.6 %, 28.3 % RESTORIL CAPS 22.5 NP AL(At least 18 MG, 7.5 MG (temazepam) yrs old) Laxative Combinations QL(1 ea daily); bisacodyl-peg 3350-pot temazepam caps 15 mg, 1 AL(At least 18 30 mg chloride-sod bicarb-sod NP yrs old) chloride kit temazepam caps 22.5 mg, 1 AL(At least 18 7.5 mg yrs old) CLENPIQ SOLN NP QL(1 ea daily); GOLYTELY SOLR 2.97 triazolam tabs 1 AL(At least 18 GM-5.86 GM-6.74 GM- yrs old) 22.74 GM-236 GM (peg NP PA; QL(1 ea 3350-kcl-sod bicarb-sod daily); AL(At chloride-sod sulfate) zaleplon caps NP least 18 yrs MOVIPREP SOLR (peg PA old) 3350-kcl-nacl-na sulfate-na NP ascorbate-ascorbic acid) zolpidem tartrate subl sl 1 AL(At least 18 1.75 mg, 3.5 mg yrs old) NULYTELY SOLR (peg QL(1 ea daily); 3350-potassium chloride- NP zolpidem tartrate tabs or 10 1 AL(At least 18 sod bicarbonate-sod mg, 5 mg yrs old) chloride) NULYTELY/FLAVOR zolpidem tartrate tbcr or 1 AL(At least 18 6.25 mg, 12.5 mg yrs old) PACKS SOLR (peg 3350- NP potassium chloride-sod ZOLPIMIST SOLN NP PA; AL(At least bicarbonate-sod chloride) 18 yrs old) Orexin Receptor Antagonists PCP 100 KIT NP PA; AL(At least BELSOMRA TABS NP peg 3350-kcl-nacl-na PA 18 yrs old) sulfate-na ascorbate- NP PA; AL(At least ascorbic acid solr DAYVIGO TABS NP 18 yrs old) peg 3350-kcl-sod bicarb- Selective Melatonin Receptor Agonists sod chloride-sod sulfate solr 2.98 gm-5.84 gm-6.72 1 HETLIOZ CAPS NP PA gm-22.72 gm-240 gm, 2.97 gm-5.86 gm-6.74 gm-22.74 HETLIOZ LQ SUSP NP PA gm-236 gm peg 3350-potassium PA; AL(At least ramelteon tabs 1 chloride-sod bicarbonate- 1 18 yrs old); MP sod chloride solr ROZEREM TABS NP PA; AL(At least (ramelteon) 18 yrs old); MP PLENVU SOLR NP LAXATIVES - Bowel Treatment Drugs SUPREP BOWEL PREP NP KIT SOLN Bulk Laxatives SUTAB TABS NP Laxatives - Miscellaneous

Coordinated Care of Washington Updated September 1, 2021

123 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GIALAX KIT NP docusate sodium liqd 100 mg/10ml, 150 mg/15ml, 50 1 glycerin (laxative) supp 1 mg/5ml docusate sodium syrp 60 1 GLYCERIN ADULT SUPP 2 mg/15ml (glycerin (laxative)) docusate sodium tabs 100 1 QL(3 ea daily) KRISTALOSE PACK 10 NP mg GM, 20 GM ENEMEEZ PLUS ENEM 2 LACTULOSE PACK 10 GM NP MACROLIDES - Drugs to Treat Bacterial lactulose soln 10 gm/15ml, 1 MP Infections 20 gm/30ml polyethylene glycol 3350 QL(34 gm Azithromycin 1 PA; QL(20 ea powd daily) azithromycin pack 1 gm 1 per fill retail) Lubricant Laxatives PA; QL(20 ea azithromycin pack 1 gm NP mineral oil oil NP PA; RX/OTC per fill retail) azithromycin susr 100 1 QL(30 ml per Saline Laxatives mg/5ml fill retail) magnesium citrate soln 1 azithromycin susr 200 1 QL(60 ml per mg/5ml fill retail) QL(990 ml per magnesium hydroxide susp 1 QL(6 ea per fill 30 days retail) azithromycin tabs 250 mg 1 retail) OSMOPREP TABS NP QL(14 ea per azithromycin tabs 500 mg 1 fill retail) sodium phosphates enem 1 QL(8 ea per 28 azithromycin tabs 600 mg 1 days retail) Stimulant Laxatives ZITHROMAX PACK 1 GM PA; QL(20 ea QL(10 ea per NP bisacodyl supp re 10 mg 1 (azithromycin) per fill retail) fill retail) ZITHROMAX SUSR 100 QL(30 ml per QL(12 ea per NP bisacodyl supp re 10 mg 1 MG/5ML (azithromycin) fill retail) fill retail) ZITHROMAX SUSR 200 NP QL(60 ml per bisacodyl tbec or 5 mg 1 QL(1 ea daily) MG/5ML (azithromycin) fill retail) ZITHROMAX TABS 250 NP QL(6 ea per fill sennosides liqd 1 MG (azithromycin) retail) ZITHROMAX TABS 500 NP QL(14 ea per sennosides syrp 1 MG (azithromycin) fill retail) sennosides tabs 1 ZITHROMAX TRI-PAK NP QL(14 ea per TABS (azithromycin) fill retail) SENOKOT TABS 2 ZITHROMAX Z-PAK TABS NP QL(6 ea per fill (sennosides) (azithromycin) retail) Surfactant Laxatives Clarithromycin docusate calcium caps 1 clarithromycin susr 125 1 mg/5ml docusate sodium caps 250 QL(3 ea daily) 1 clarithromycin susr 250 1 QL(200 ml per mg, 100 mg mg/5ml fill retail)

Coordinated Care of Washington Updated September 1, 2021

124 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits clarithromycin tabs 250 mg, 1 QL(28 ea per BAND-AID MIRASORB RX/OTC 500 mg fill retail) GAUZE SPONGES 2 QL(14 ea per LARGE 4" X 4" PADS clarithromycin tb24 500 mg NP fill retail) BIOGUARD GAUZE RX/OTC SPONGES 4"X4" 12 PLY 2 Erythromycins PADS E.E.S. GRANULES SUSR (erythromycin NP BORDERED GAUZE 2 RX/OTC ethylsuccinate) PADS CARRASMART FOAM RX/OTC ERYPED 200 SUSR 2 (erythromycin NP PADS ethylsuccinate) CARRASMART PADS 2 RX/OTC ERYPED 400 SUSR (erythromycin NP COPA ISLAND RX/OTC ethylsuccinate) BORDERED FOAM 2 DRESSING 4"X4" PADS erythromycin base cpep 1 250 mg COPA PLUS RX/OTC HYDROPHILIC FOAM 2 erythromycin base tabs NP DRESSING 4"X4" PADS 250 mg, 500 mg COVRSITE COVER 2 RX/OTC erythromycin base tbec 1 DRESSING PADS 250 mg, 333 mg, 500 mg COVRSITE PLUS RX/OTC erythromycin COMPOSITE DRESSING 2 ethylsuccinate susr 200 1 PADS mg/5ml, 400 mg/5ml CRUAD GAUZE PADS 4" 2 RX/OTC erythromycin 1 X 4" PADS ethylsuccinate tabs 400 mg CURITY ALL PURPOSE RX/OTC erythromycin NP PA SPONGES 4"X4" 4PLY 2 ethylsuccinate tabs 400 mg PADS erythromycin stearate tabs NP CURITY ALL PURPOSE RX/OTC SPONGES 4"X4" 2 Fidaxomicin 4PLY/SOFT POUCH PADS DIFICID SUSR 40 MG/ML NP PA CURITY ALL PURPOSE 2 RX/OTC SPONGES 4"X4" PADS DIFICID TABS 200 MG NP CURITY AMD RX/OTC ANTIMICROBIALGAUZE 2 MEDICAL DEVICES AND SUPPLIES SPONGES 4"X4" 12 PLY PADS Bandages-Dressings-Tape CURITY COVER SPONGE 2 RX/OTC 4"X4" PADS AMD FOAM DRESSING 2 RX/OTC 4"X4" PADS CURITY COVER 2 RX/OTC AMD FOAM RX/OTC SPONGES 4"X4" PADS DRESSING/TOPSHEET 2 CURITY DRESSING RX/OTC 4"X4" PADS SPONGES 4"X4" 6 PLY 2 PADS BAND-AID GAUZE PADS 2 RX/OTC LARGE4" X 4" PADS CURITY GAUZE PADS 2 RX/OTC 4"X4" 12 PLY PADS

Coordinated Care of Washington Updated September 1, 2021

125 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CURITY GAUZE SPONGE RX/OTC 2 DERMACEA TYPE VII 2 RX/OTC 4"X4" 12 PLY PADS GAUZE 4"X4" 8 PLY PADS CURITY GAUZE SPONGE 2 RX/OTC DERMACEA X-RAY RX/OTC 4"X4" 16 PLY PADS SPONGES 4"X4" 16 PLY 2 PADS CURITY GAUZE SPONGE 2 RX/OTC 4"X4" 8 PLY PADS DERMALEVIN ADHESIVE RX/OTC FOAMDRESSING 4"X4" 2 CURITY GAUZE SPONGE 2 RX/OTC 4"X4"16 PLY PADS PADS CURITY GAUZE RX/OTC DRYMAX EXTRA PADS 2 RX/OTC SPONGES 4"X4" 12 PLY 2 PADS EQL GAUZE PADS 2 RX/OTC CURITY GAUZE RX/OTC 4"X4"/LARGE PADS SPONGES 4"X4" 8 PLY 2 EXCILON AMD RX/OTC PADS ANTIMICROBIALDRAIN 2 CURITY RX/OTC SPONGES 4"X4" 6 PLY SPONGES/CELLULOSEFI 2 PADS LLED/4"X4" PADS EXCILON AMD RX/OTC ANTIMICROBIALNON- CVS GAUZE PADS 4"X4" 2 RX/OTC 2 12-PLY PADS WOVEN SPONGES 4"X4" 6 PLY PADS CVS GAUZE PADS RX/OTC STERILE 4"X4" 12-PLY 2 EXCILON DRAIN 2 RX/OTC PADS SPONGE 4"X4" PADS EXCILON DRAIN RX/OTC DERMACEA DRAIN 2 RX/OTC SPONGES 4"X4" PADS SPONGES 4"X4" 6 PLY 2 PADS DERMACEA GAUZE RX/OTC SPONGE 4"X4" 12 PLY 2 GAUZE DRESSING 4"X4" 2 RX/OTC PADS PADS DERMACEA GAUZE RX/OTC GAUZE PADS 4"X4" PADS 2 RX/OTC SPONGE 4"X4" 16 PLY 2 PADS GAUZE SPONGES 4"X4" 2 RX/OTC 12 PLY PADS DERMACEA GAUZE RX/OTC SPONGE 4"X4" 8 PLY 2 HM STERILE PADS PADS 2 RX/OTC PADS HYDROCELL ADHESIVE 2 RX/OTC DERMACEA I.V. DRAIN 2 RX/OTC DRESSING 4"X4" PADS SPONGES 4"X4" PADS HYDROCELL DRESSING 2 RX/OTC DERMACEA NON-WOVEN RX/OTC 4"X4" PADS SPONGES 4"X4" 4 PLY 2 PADS J & J GAUZE 4"X4" 12 PLY 2 RX/OTC PADS DERMACEA NON-WOVEN RX/OTC SPONGES 4"X4" 6 PLY 2 J & J GAUZE 4"X4" 8 PLY 2 RX/OTC PADS PADS DERMACEA TYPE VII RX/OTC J & J GAUZE SPONGES 2 RX/OTC GAUZE 4"X4" 12 PLY 2 12-PLY 4" X 4" MISC PADS J & J GAUZE SPONGES 2 RX/OTC DERMACEA TYPE VII RX/OTC 16-PLY 4" X 4" MISC GAUZE 4"X4" 16 PLY 2 J & J GAUZE SPONGES 2 RX/OTC PADS 8-PLY4" X 4" MISC

Coordinated Care of Washington Updated September 1, 2021

126 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KENDALL HYDROPHILIC RX/OTC TOPPER DRESSING 2 RX/OTC FOAMDRESSING 4"X4" 2 SPONGES 4"X4" MISC PADS Contraceptives KERLIX SPONGES 4" X 4" RX/OTC 2 AIMSCO LUBRICATED 12 PLY PADS 2 MISC KERLIX SPONGES 4" X 4" 2 RX/OTC 16 PLY PADS CAYA DPRH 2 MIRASORB SPONGES 4" 2 RX/OTC X 4" MISC CONDOMS MISC 2 NU GAUZE 4PLY 4"X4" RX/OTC 2 DUREX EXTRA 2 PADS SENSITIVE DEVI NU GAUZE GENERAL- RX/OTC DUREX REALFEEL NON- 2 USE SPONGES 4"X4" 4 2 LATEX DEVI PLY MISC FANTASY LUBRICATED 2 OPTIFOAM PADS 2 RX/OTC MISC FANTASY POLYMEM NON- 2 RX/OTC LUBRICATED/SPERMICID 2 ADHESIVE PAD PADS E MISC QC ALL PURPOSE RX/OTC 2 FC FEMALE CONDOM 2 DRESSINGS4"X4" PADS MISC RX/OTC QC STERILE PADS PADS 2 FC2 FEMALE CONDOM 2 MISC RA STERILE PADS 4"X4" 2 RX/OTC PADS FEMCAP DEVI 2 RAY-TEC X-RAY RX/OTC K-Y ME & YOU EXTRA 2 DETECTABLESPONGES 2 LUBRICATED DEVI 4" X 4" 16 PLY MISC K-Y ME & YOU INTENSE 2 RESTORE FOAM RX/OTC DEVI DRESSING BORDERED 2 4"X4" PADS KAMELEON LUBRICATED 2 MISC RESTORE FOAM RX/OTC DRESSING NON- 2 KIMONO COLORS DEVI 2 BORDERED 4"X4" PADS KIMONO LUBRICATED 2 RESTORE ODOR RX/OTC MISC ABSORBING DRESSING 2 4"X4" PADS KIMONO MICRO THIN 2 MISC SM GAUZE PADS 4"X4" 2 RX/OTC PADS KIMONO MICRO THIN PLUS SPERMICIDE 2 SM STERILE PADS PADS 2 RX/OTC LUBRICATED MISC RX/OTC KIMONO PLUS SOF-WICK 4"X4" PADS 2 SPERMICIDE 2 LUBRICATED MISC STERILE PADS 4"X4" 2 RX/OTC PADS KIMONO PLUS SPERMICIDE/LUBRICATE 2 TEGADERM FOAM RX/OTC 2 D MISC DRESSING 4"X4" PADS KIMONO PS LUBRICATED 2 MISC Coordinated Care of Washington Updated September 1, 2021

127 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KIMONO PS PLUS REALITY LATEX SPERMICIDE/LUBRICATE 2 CONDOMS/LUBRICATED 2 D MISC MISC KIMONO SENSATION 2 REALITY LATEX/ULTRA 2 LUBRICATED MISC TEXTURED DEVI KIMONO SENSATION REALITY LATEX/ULTRA 2 PLUS SPERMICIDE 2 THIN DEVI LUBRICATED MISC TRUSTEX COLOR 2 KIMONO SPECIAL DEVI 2 CONDOMS + LUBE MISC TRUSTEX LUBRICATED 2 LIFESTYLES ASSORTED 2 EXTRALARGE MISC COLORS MISC TRUSTEX LUBRICATED 2 LIFESTYLES EXTRA 2 EXTRASTRENGTH MISC STRENGTH MISC TRUSTEX LUBRICATED 2 LIFESTYLES FORM 2 MISC FITTING MISC TRUSTEX LIFESTYLES 2 LUBRICATED/RIBBED/ST 2 LUBRICATED MISC UDDED MISC LIFESTYLES RIBBED 2 TRUSTEX MISC LUBRICATED/SPERMICID 2 E EXTRA LARGE MISC LIFESTYLES SKYN 2 ORIGINAL MISC TRUSTEX LIFESTYLES LUBRICATED/SPERMICID 2 SPERMICIDALLYLUBRIC 2 E EXTRA STRENGTH ATED MISC MISC TRUSTEX LIFESTYLES STUDDED 2 MISC LUBRICATED/SPERMICID 2 E MISC LIFESTYLES ULTRA 2 SENSITIVE MISC TRUSTEX NATURAL LIFESTYLES ULTRA CONDOMS 2 SENSITIVE/SPERMICIDE 2 +LUBE/LUBRICATED MISC MISC TRUSTEX NON- LIFESTYLES VIBRA- 2 2 RIBBED MISC LUBRICATED MISC LIFESTYLES VIBRA- TRUSTEX WITH RIBBED/SPERMICIDE 2 NONOXYNOL- 2 MISC 9/RIBBED/STUDDED MISC LIFESTYLES XTRA 2 PLEASURE MISC TRUSTEX/RIA 2 LUBRICATED MISC MAXX LUBRICATED MISC 2 TRUSTEX/RIA LUBRICATED 2 MAXX PLUS SPERMICIDE 2 LUBRICATED MISC SPERMICIDE MISC TRUSTEX/RIA OMNIFLEX DIAPHRAGM 2 DPRH LUBRICATED/SPERMICID 2 E MISC PREMIUM CONDOMS 2 LUBRICATED MISC Coordinated Care of Washington Updated September 1, 2021

128 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUSTEX/RIA NON- 2 AIMSCO TWIST LANCETS 200 / LUBRICATED MISC 1 month;QL(6.67 32G MISC WIDE-SEAL SILICONE ea daily) DIAPHRAGM KIT 60 2 AIMSCO TWIST LANCETS 200 / DPRH 1 month;QL(6.67 33G MISC WIDE-SEAL SILICONE ea daily) 2 DIAPHRAGM KIT 65 ALTERNATE SITE 2 QL(1 ea per DPRH LANCING DEVICE MISC 180 days retail) WIDE-SEAL SILICONE AQUA LANCE QL(1 ea per DIAPHRAGM KIT 70 2 ADJUSTABLE LANCING 2 180 days retail) DPRH DEVICE DEVI WIDE-SEAL SILICONE 200 / DIAPHRAGM KIT 75 2 AURORA LANCET SUPER 1 THIN30G MISC month;QL(6.67 DPRH ea daily) WIDE-SEAL SILICONE 200 / DIAPHRAGM KIT 80 2 AURORA LANCET THIN 1 23G MISC month;QL(6.67 DPRH ea daily) WIDE-SEAL SILICONE AUTO-LANCET MINI MISC 2 QL(1 ea per DIAPHRAGM KIT 85 2 180 days retail) DPRH AUTO-LANCET MISC 2 QL(1 ea per WIDE-SEAL SILICONE 180 days retail) DIAPHRAGM KIT 90 2 AUTOLET IMPRESSION 2 QL(1 ea per DPRH LANCING DEVICE MISC 180 days retail) WIDE-SEAL SILICONE AUTOLET LANCING 2 QL(1 ea per DIAPHRAGM KIT 95 2 DEVICE MISC 180 days retail) DPRH AUTOLET MINI MISC 2 QL(1 ea per Diabetic Supplies 180 days retail) 1ST TIER UNILET 200 / AUTOLET PLUS MISC 2 QL(1 ea per COMFORTOUCH 1 month;QL(6.67 180 days retail) LANCETS 28G MISC ea daily) 200 / 1ST TIER UNILET 200 / BD LANCET ULTRAFINE 1 30G MISC month;QL(6.67 COMFORTOUCH 1 month;QL(6.67 ea daily) LANCETS 30G MISC ea daily) CARDIOCOM LANCING 2 QL(1 ea per ADJUSTABLE LANCING 2 QL(1 ea per DEVICE MISC 180 days retail) DEVICE MISC 180 days retail) CAREONE ADVANCED 2 QL(1 ea per 200 / LANCINGDEVICE MISC 180 days retail) ADVANCED MOBILE 1 month;QL(6.67 LANCET 30G MISC 200 / ea daily) CAREONE LANCET 1 month;QL(6.67 SUPER THIN/30G MISC ADVOCATE LANCING 2 QL(1 ea per ea daily) DEVICE MISC 180 days retail) 200 / ADVOCATE RAPID-SAFE QL(1 ea per CAREONE LANCET THIN 1 2 MISC month;QL(6.67 LANCING DEVICE MISC 180 days retail) ea daily) 200 / CARESENS LANCETS QL(6.67 ea AGAMATRIX ULTRA-THIN 1 month;QL(6.67 1 LANCETS 33G MISC MISC daily) ea daily) CARETOUCH LANCING QL(1 ea per DEVICEWITH EJECTOR 2 180 days retail) MISC Coordinated Care of Washington Updated September 1, 2021

129 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLEANLET LANCETS 28G 200 / 200 / 1 month;QL(6.67 DROPLET LANCETS 1 month;QL(6.67 MISC ULTRA THIN 30G MISC ea daily) ea daily) COMFORT ASSURED 200 / DROPLET LANCING 2 QL(1 ea per LANCETS SUPER THIN 1 month;QL(6.67 DEVICE MISC 180 days retail) 28G MISC ea daily) DRUG MART QL(1 ea per 2 COMFORT LANCETS 200 / ADJUSTABLE LANCING 180 days retail) 1 month;QL(6.67 DEVICE MISC MISC ea daily) 200 / 200 / DRUG MART LANCETS 1 THIN MISC month;QL(6.67 CVS LANCETS 21G MISC 1 month;QL(6.67 ea daily) ea daily) DRUG MART UNILET 200 / 1 CVS LANCETS MICRO 200 / LANCETSSUPER THIN month;QL(6.67 1 month;QL(6.67 30G MISC ea daily) THIN 33G MISC ea daily) DRUG MART UNILET 200 / 1 CVS LANCETS MICRO- 200 / LANCETSULTRA THIN month;QL(6.67 1 month;QL(6.67 28G MISC ea daily) THIN 33G MISC ea daily) DRUG MART UNILET 200 / 1 CVS LANCETS ORIGINAL 200 / MICRO THIN LANCETS month;QL(6.67 1 month;QL(6.67 33G MISC ea daily) MISC ea daily) 200 / E-Z JECT LANCETS 21G 1 CVS LANCETS THIN 26G 200 / month;QL(6.67 1 month;QL(6.67 MISC ea daily) MISC ea daily) 200 / E-Z JECT LANCETS 1 CVS LANCETS ULTRA 200 / month;QL(6.67 1 month;QL(6.67 COLOR MISC ea daily) THIN 30G MISC ea daily) 200 / 1 CVS LANCETS ULTRA- 200 / E-Z JECT LANCETS MISC month;QL(6.67 1 month;QL(6.67 ea daily) THIN 30G MISC ea daily) 200 / CVS LANCING DEVICE QL(1 ea per E-Z JECT LANCETS 1 2 SUPER THIN 30G MISC month;QL(6.67 MISC 180 days retail) ea daily) CVS ULTRA THIN 200 / 200 / 1 month;QL(6.67 E-Z JECT LANCETS THIN 1 month;QL(6.67 LANCETS MISC 26G MISC ea daily) ea daily) DIATHRIVE LANCETS 200 / 200 / 1 month;QL(6.67 E-ZJECT LANCETS 1 month;QL(6.67 MISC MICRO-THIN 33G MISC ea daily) ea daily) 200 / EASY MINI EJECT QL(1 ea per DIATHRIVE LANCETS 1 2 ULTRA THIN 30G MISC month;QL(6.67 LANCING DEVICE MISC 180 days retail) ea daily) EASY MINI LANCING 2 QL(1 ea per DIATHRIVE LANCING 2 QL(1 ea per DEVICE MISC 180 days retail) DEVICE MISC 180 days retail) 200 / DROPLET GENTEEL QL(1 ea per EASY TOUCH LANCETS 1 2 26G/PULL-TOP MISC month;QL(6.67 LANCING DEVICE MISC 180 days retail) ea daily)

Coordinated Care of Washington Updated September 1, 2021

130 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH LANCETS 200 / 200 / 1 month;QL(6.67 FORA LANCETS MISC 1 month;QL(6.67 28G/PULL-TOP MISC ea daily) ea daily) 200 / FORA LANCING DEVICE QL(1 ea per EASY TOUCH LANCETS 1 2 28G/TWIST MISC month;QL(6.67 MISC 180 days retail) ea daily) FORA LANCING 2 QL(1 ea per 200 / DEVICE/CLEARCAP MISC 180 days retail) EASY TOUCH LANCETS 1 month;QL(6.67 30G/PULL-TOP MISC FREDS PHARMACY QL(1 ea per ea daily) AUTOLET LANCING 2 180 days retail) 200 / DEVICE MISC EASY TOUCH LANCETS 1 month;QL(6.67 30G/TWIST MISC FREDS PHARMACY 200 / ea daily) UNILET LANCETS SUPER 1 month;QL(6.67 200 / THIN 30G MISC ea daily) EASY TOUCH LANCETS 1 month;QL(6.67 32G/PULL-TOP MISC FREDS PHARMACY 200 / ea daily) UNILET LANCETS ULTRA 1 month;QL(6.67 200 / THIN 28G MISC ea daily) EASY TOUCH LANCETS 1 month;QL(6.67 32G/TWIST MISC GENTEEL LANCING QL(1 ea per ea daily) DEVICE/GLORIOUS 2 180 days retail) 200 / GOLD MISC EASY TOUCH LANCETS 1 month;QL(6.67 33G/TWIST MISC GENTEEL LANCING QL(1 ea per ea daily) DEVICE/PRECIOUS 2 180 days retail) EASY TOUCH LANCING 2 QL(1 ea per PLATINUM MISC DEVICE/EJECTOR MISC 180 days retail) GENTEEL LANCING QL(1 ea per EMBRACE LANCING QL(1 ea per DEVICE/STATELY SILVER 2 180 days retail) DEVICE WITH EJECTOR 2 180 days retail) MISC MISC GENTEEL PLUS LANCING QL(1 ea per 2 EQL COLOR LANCETS 200 / DEVICE/BUFF BLACK 180 days retail) 1 month;QL(6.67 MISC 21G MISC ea daily) GENTEEL PLUS LANCING QL(1 ea per 2 EQL COLOR LANCETS 200 / DEVICE/BUTTERFLY 180 days retail) 1 month;QL(6.67 BLUE MISC MICRO THIN 33G MISC ea daily) GENTEEL PLUS LANCING QL(1 ea per 2 EQL SUPER THIN 200 / DEVICE/PLAYFUL 180 days retail) 1 month;QL(6.67 PURPLE MISC LANCETS 30G MISC ea daily) GENTEEL PLUS LANCING QL(1 ea per 2 EQL THIN LANCETS 26G 200 / DEVICE/PRINCESS PINK 180 days retail) 1 month;QL(6.67 MISC MISC ea daily) GENTEEL PLUS LANCING QL(1 ea per 2 EZ-LETS LANCETS 26G 200 / DEVICE/WILLOWY WHITE 180 days retail) 1 month;QL(6.67 MISC SUPER-SOFT MISC ea daily) 200 / GENTLE-LET GP 1 EZ-LETS LANCETS 28G 200 / month;QL(6.67 1 month;QL(6.67 LANCETS MISC ea daily) ULTRA-SOFT MISC ea daily) GENTLE-LET LANCETS 200 / 200 / GENERAL PURPOSE 1 month;QL(6.67 EZ-LETS LANCETS 30G 1 MISC month;QL(6.67 STYLE/FINE POINT MISC ea daily) ea daily)

Coordinated Care of Washington Updated September 1, 2021

131 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GENTLE-LET LANCETS 200 / H-E-B INCONTROL 200 / GENERAL PURPOSE 1 month;QL(6.67 LANCETS SUPER THIN 1 month;QL(6.67 STYLE/MEDIUM POINT ea daily) 30G MISC ea daily) MISC H-E-B INCONTROL 200 / GENTLE-LET LANCETS 200 / LANCETS ULTRA THIN 1 month;QL(6.67 SAFETY STYLE/FINE 1 month;QL(6.67 28G MISC ea daily) POINT MISC ea daily) HEALTH CARE LANCING 2 QL(1 ea per GENTLE-LET LANCETS 200 / DEVICE MISC 180 days retail) SAFETY STYLE/MEDIUM 1 month;QL(6.67 HEALTHY ACCENTS QL(1 ea per POINT MISC ea daily) AUTOLET IMPRESSION 2 180 days retail) GLOBAL LANCING 2 QL(1 ea per LANCING DEVICE MISC DEVICE MISC 180 days retail) HEALTHY ACCENTS 200 / 200 / UNILET LANCETS SUPER 1 month;QL(6.67 GNP LANCETS 21G MISC 1 month;QL(6.67 THIN 30G MISC ea daily) ea daily) 200 / GNP LANCETS MICRO 200 / HY-VEE LANCETS MISC 1 month;QL(6.67 1 month;QL(6.67 ea daily) THIN 33G MISC ea daily) 200 / 200 / HY-VEE THIN LANCETS 1 month;QL(6.67 GNP LANCETS SUPER 1 MISC THIN 30G MISC month;QL(6.67 ea daily) ea daily) IN TOUCH LANCING 2 QL(1 ea per 200 / DEVICE MISC 180 days retail) GNP LANCETS THIN 26G 1 month;QL(6.67 MISC 200 / ea daily) KINNEY LANCETS MISC 1 month;QL(6.67 200 / ea daily) GNP LANCETS THIN 1 month;QL(6.67 MISC 200 / ea daily) KINNEY THIN LANCETS 1 MISC month;QL(6.67 GOJJI LANCING QL(1 ea per ea daily) DEVICE/CLEAR CAP 2 180 days retail) KROGER AUTOLET 2 QL(1 ea per MISC LANCING DEVICE MISC 180 days retail) GOJJI STERILE LANCETS 1 QL(6.67 ea KROGER HEALTHPRO 200 / 30G MISC daily) TWIST LANCETS/26G 1 month;QL(6.67 GOODSENSE LANCETS 200 / MISC ea daily) MICRO-THIN 33G 1 month;QL(6.67 200 / UNIVERSAL MISC ea daily) KROGER LANCETS 21G 1 MISC month;QL(6.67 GOODSENSE LANCETS 200 / ea daily) ULTRA-THIN 26G 1 month;QL(6.67 200 / UNIVERSAL MISC ea daily) KROGER LANCETS 1 month;QL(6.67 MICRO THIN33G MISC GOODSENSE LANCING 2 QL(1 ea per ea daily) DEVICE MISC 180 days retail) 200 / H-E-B INCONTROL QL(1 ea per KROGER LANCETS MISC 1 month;QL(6.67 ADVANCEDLANCING 2 180 days retail) ea daily) DEVICE MISC 200 / H-E-B INCONTROL 200 / KROGER LANCETS 1 SUPER THIN MISC month;QL(6.67 LANCETS MICRO THIN 1 month;QL(6.67 ea daily) 33G MISC ea daily)

Coordinated Care of Washington Updated September 1, 2021

132 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 200 / QL(1 ea per KROGER LANCETS THIN 1 LANZO MISC 2 26G MISC month;QL(6.67 180 days retail) ea daily) LEADER ADVANCED 2 QL(1 ea per 200 / LANCING DEVICE MISC 180 days retail) KROGER LANCETS THIN 1 month;QL(6.67 MISC LIBERTY MINI LANCING 2 QL(1 ea per ea daily) DEVICE MISC 180 days retail) 200 / LITE TOUCH LANCING QL(1 ea per KROGER LANCETS 1 2 ULTRATHIN30G MISC month;QL(6.67 PEN MISC 180 days retail) ea daily) LIVE BETTER ADVANCED 2 QL(1 ea per KROGER LANCING 2 QL(1 ea per LANCING DEVICE MISC 180 days retail) DEVICE MISC 180 days retail) 200 / LANCET DEVICE QL(1 ea per LIVE BETTER LANCET 1 2 SUPERTHIN 30G MISC month;QL(6.67 ADJUSTABLE MISC 180 days retail) ea daily) LANCET DEVICE WITH 2 QL(1 ea per 200 / EJECTOR MISC 180 days retail) LIVE BETTER LANCET 1 ULTRATHIN 28G MISC month;QL(6.67 200 / ea daily) LANCETS 26G TWIST 1 month;QL(6.67 TOP MISC 200 / ea daily) LONGS LANCETS 1 STANDARD MISC month;QL(6.67 200 / ea daily) LANCETS 28G MISC 1 month;QL(6.67 200 / ea daily) LONGS LANCETS THIN 1 MISC month;QL(6.67 200 / ea daily) LANCETS 30G MISC 1 month;QL(6.67 200 / ea daily) MEDISENSE THIN 1 LANCETS MISC month;QL(6.67 200 / ea daily) LANCETS MISC 1 month;QL(6.67 MEIJER COLOR 200 / ea daily) LANCETS UNIVERSAL 1 month;QL(6.67 200 / 33G MISC ea daily) LANCETS SAFETY SEAL 1 month;QL(6.67 21G MISC 200 / ea daily) MEIJER LANCETS MISC 1 month;QL(6.67 200 / ea daily) LANCETS SAFETY SEAL 1 month;QL(6.67 26G MISC 200 / ea daily) MEIJER LANCETS THIN 1 MISC month;QL(6.67 200 / ea daily) LANCETS SAFETY SEAL 1 month;QL(6.67 28G MISC 200 / ea daily) MEIJER LANCETS 1 UNIVERSAL21G MISC month;QL(6.67 200 / ea daily) LANCETS THIN MISC 1 month;QL(6.67 200 / ea daily) MEIJER LANCETS 1 UNIVERSAL30G MISC month;QL(6.67 200 / ea daily) LANCETS ULTRA THIN 1 month;QL(6.67 MISC 200 / ea daily) MEIJER LANCETS 1 month;QL(6.67 UNIVERSAL33G MISC LANCING DEVICE 2 QL(1 ea per ea daily) ADJUSTABLE MISC 180 days retail) 200 / QL(1 ea per MEIJER SUPER THIN 1 month;QL(6.67 LANCING DEVICE MISC 2 LANCETS MISC 180 days retail) ea daily)

Coordinated Care of Washington Updated September 1, 2021

133 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea per PREFERRED PLUS 200 / MICROLET NEXT MISC 2 180 days retail) LANCETS SUPER THIN 1 month;QL(6.67 30G MISC ea daily) MINI LANCING DEVICE 2 QL(1 ea per MISC 180 days retail) 200 / PREFERRED PLUS 1 month;QL(6.67 MM LANCING DEVICE 2 QL(1 ea per LANCETS THIN 26G MISC MISC 180 days retail) ea daily) 200 / PRODIGY LANCING 2 QL(1 ea per MONOLET LANCETS 1 DEVICE MISC 180 days retail) MISC month;QL(6.67 ea daily) 200 / PRODIGY TWIST TOP 1 month;QL(6.67 200 / LANCETS MISC MONOLET OPD LANCETS 1 ea daily) MISC month;QL(6.67 ea daily) 200 / PSS SELECT GP 1 month;QL(6.67 MULTI-LANCET DEVICE 2 QL(1 ea per LANCETS MISC MISC 180 days retail) ea daily) 200 / 200 / PSS SELECT SAFETY NOVA SUREFLEX 1 1 month;QL(6.67 LANCETS MISC month;QL(6.67 LANCETS MISC ea daily) ea daily) PX ADVANCED LANCING QL(1 ea per NOVA SUREFLEX 2 QL(1 ea per 2 LANCING DEVICE MISC 180 days retail) DEVICE MISC 180 days retail) PX LANCET AUTO QL(1 ea per ON CALL LANCING 2 QL(1 ea per 2 DEVICE MISC 180 days retail) INJECTOR MISC 180 days retail) ON CALL PLUS LANCING QL(1 ea per 200 / 2 PX LANCETS ULTRA 1 DEVICE MISC 180 days retail) THIN MISC month;QL(6.67 ea daily) ONETOUCH DELICA 2 QL(1 ea per LANCING DEVICE MISC 180 days retail) QC ADVANCED LANCING 2 QL(1 ea per DEVICE MISC 180 days retail) ONETOUCH DELICA QL(1 ea per PLUS LANCING DEVICE 2 180 days retail) 200 / QC LANCETS SUPER 1 MISC THIN MISC month;QL(6.67 ea daily) ONETOUCH DELICA QL(1 ea per SAFETY LACING DEVICE 2 180 days retail) 200 / QC LANCETS ULTRA 1 MISC THIN MISC month;QL(6.67 ea daily) 200 / PC LANCETS SUPER 1 month;QL(6.67 200 / THIN 30G MISC QC UNILET LANCETS 1 ea daily) 28G/ULTRA THIN MISC month;QL(6.67 ea daily) 200 / PERFECT LANCETS 30G 1 month;QL(6.67 200 / MISC QC UNILET LANCETS 1 ea daily) 33G/MICRO THIN MISC month;QL(6.67 ea daily) 200 / PHARMACY COUNTER 1 month;QL(6.67 200 / LANCETS MISC RA E-ZJECT LANCETS 1 ea daily) 28G MISC month;QL(6.67 ea daily) 200 / PRECISION THINS GP 1 month;QL(6.67 200 / LANCET MISC RA E-ZJECT LANCETS 1 ea daily) THIN 26G MISC month;QL(6.67 ea daily) PREFERRED PLUS 200 / LANCETS COLORED 21G 1 month;QL(6.67 200 / RA E-ZJECT LANCETS 1 MISC ea daily) THIN 28G MISC month;QL(6.67 ea daily)

Coordinated Care of Washington Updated September 1, 2021

134 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RA E-ZJECT LANCETS 200 / 200 / 1 month;QL(6.67 SAFETY SEAL LANCETS 1 month;QL(6.67 ULTRATHIN 30G MISC 30G MISC ea daily) ea daily) 200 / 200 / REALITY LANCETS MISC 1 month;QL(6.67 SB LANCETS THIN MISC 1 month;QL(6.67 ea daily) ea daily) RELION 2-IN-1 LANCET 2 QL(1 ea per 200 / DEVICES 30G MISC 180 days retail) SB LANCETS ULTRA 1 THIN MISC month;QL(6.67 ea daily) RELION 2-IN-1 LANCING 2 QL(1 ea per DEVICE 25G MISC 180 days retail) SELECT-LITE LANCING 2 QL(1 ea per DEVICE MISC 180 days retail) RELION 2-IN-1 LANCING 2 QL(1 ea per DEVICE 30G MISC 180 days retail) SHOPKO AUTOLET 2 QL(1 ea per LANCING DEVICE MISC 180 days retail) RELION LANCETS 200 / 1 month;QL(6.67 SHOPKO UNILET 200 / MICRO-THIN33G MISC ea daily) LANCETS SUPER THIN 1 month;QL(6.67 30G MISC ea daily) RELION LANCETS THIN 200 / 1 month;QL(6.67 SHOPKO UNILET 200 / 26G MISC ea daily) LANCETS ULTRA THIN 1 month;QL(6.67 28G MISC ea daily) RELION LANCETS 200 / 1 month;QL(6.67 SIMPLE DIAGNOSTICS QL(1 ea per ULTRA-THIN30G MISC 2 ea daily) LANCING DEVICE MISC 180 days retail) RELION LANCING 2 QL(1 ea per 200 / DEVICE MISC 180 days retail) SM MICRO THIN 1 LANCETS 33G MISC month;QL(6.67 ea daily) RELION ULTRA THIN 1 QL(6.67 ea LANCETS/30G MISC daily) SM TRUEDRAW LANCING 2 QL(1 ea per DEVICE MISC 180 days retail) RELION ULTRA THIN 200 / 1 month;QL(6.67 SMART DIABETES QL(1 ea per LANCETS30G MISC ea daily) VANTAGE LANCING 2 180 days retail) RELION ULTRA THIN 200 / DEVICE MISC PLUS LANCETS 32G 1 month;QL(6.67 SMART SENSE COLOR 200 / MISC ea daily) LANCETS UNIVERSAL 1 month;QL(6.67 RELION ULTRA THIN 200 / 33G MISC ea daily) PLUS LANCETS 33G 1 month;QL(6.67 SMART SENSE 200 / MISC ea daily) STANDARD LANCETS 1 month;QL(6.67 UNIVERSAL 21G MISC ea daily) REXALL LANCETS ULTRA 200 / 1 month;QL(6.67 SMART SENSE SUPER 200 / THIN MISC ea daily) THIN LANCETS 1 month;QL(6.67 UNIVERSAL 30G MISC ea daily) RIGHTEST GD500 2 QL(1 ea per LANCING DEVICE MISC 180 days retail) SMART SENSE THIN 200 / 200 / LANCETSUNIVERSAL 1 month;QL(6.67 RIGHTEST GL300 1 month;QL(6.67 26G MISC ea daily) LANCETS MISC ea daily) SOLUS V2 LANCING 2 QL(1 ea per DEVICE MISC 180 days retail) SAFETY SEAL LANCETS 200 / 1 month;QL(6.67 200 / 28G MISC ea daily) STERILANCE TL MISC 1 month;QL(6.67 ea daily)

Coordinated Care of Washington Updated September 1, 2021

135 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SUPER THIN LANCETS 200 / TRUE METRIX CONTROL QL(1 ea per 90 1 month;QL(6.67 SOLUTION LEVEL 2 2 days retail) MISC ea daily) SOLN SURE COMFORT 2 QL(1 ea per TRUE METRIX CONTROL LANCING PEN MISC 180 days retail) SOLUTION LEVEL 3 2 SOLN SURE-PEN MISC 2 QL(1 ea per 180 days retail) TRUECONTROL QL(1 ea per 90 200 / GLUCOSE CONTROL 2 days retail) SURELITE LANCETS 1 LEVEL 0 LIQD MISC month;QL(6.67 ea daily) TRUECONTROL QL(1 ea per 90 200 / GLUCOSE CONTROL 2 days retail) TECHLITE AST LANCETS 1 month;QL(6.67 LEVEL 1 LIQD MISC ea daily) TRUEDRAW LANCING 2 QL(1 ea per 200 / DEVICE MISC 180 days retail) TECHLITE LANCETS 30G 1 month;QL(6.67 TRUEPLUS LANCETS 200 / MISC ea daily) 1 month;QL(6.67 26G MISC 200 / ea daily) TECHLITE LANCETS 1 month;QL(6.67 TRUEPLUS LANCETS 200 / MISC ea daily) 1 month;QL(6.67 28G MISC 200 / ea daily) TGT LANCET MICRO 1 month;QL(6.67 TRUEPLUS LANCETS 200 / THIN 33G MISC ea daily) 1 month;QL(6.67 28G SUPER THIN MISC 200 / ea daily) TGT LANCET THIN 26G 1 month;QL(6.67 TRUEPLUS LANCETS 200 / MISC ea daily) 1 month;QL(6.67 30G MISC 200 / ea daily) TGT LANCET ULTRA 1 month;QL(6.67 200 / THIN 30G MISC TRUEPLUS LANCETS 1 ea daily) 30G ULTRA THIN MISC month;QL(6.67 ea daily) TGT LANCING DEVICE 2 QL(1 ea per MISC 180 days retail) 200 / TRUEPLUS LANCETS 1 month;QL(6.67 200 / 33G MISC THINLETS GP LANCETS 1 month;QL(6.67 ea daily) MISC ea daily) ULTI-LANCE AUTOMATIC/ 2 QL(1 ea per TODAYS HEALTH QL(1 ea per CLEAR TIP MISC 180 days retail) 2 ADVANCED LANCING 180 days retail) ULTILET CLASSIC 200 / DEVICE MISC 1 month;QL(6.67 LANCETS MISC 200 / ea daily) TODAYS HEALTH SUPER 1 month;QL(6.67 UNILET COMFORTOUCH 200 / THINLANCETS 30G MISC ea daily) 1 month;QL(6.67 LANCET MISC 200 / ea daily) TODAYS HEALTH ULTRA 1 200 / THINLANCETS 28G MISC month;QL(6.67 ea daily) UNILET EXCELITE II MISC 1 month;QL(6.67 TRUE METRIX CONTROL QL(1 ea per 90 ea daily) SOLUTION LEVEL 1 2 days retail) 200 / SOLN UNILET EXCELITE MISC 1 month;QL(6.67 ea daily)

Coordinated Care of Washington Updated September 1, 2021

136 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits UNILET G.P. LANCET 200 / 200 / 1 month;QL(6.67 VALUMARK LANCET 1 month;QL(6.67 MISC SUPER THIN 30G MISC ea daily) ea daily) UNILET G.P. SUPERLITE 200 / 200 / 1 month;QL(6.67 VALUMARK LANCET 1 month;QL(6.67 LANCET MISC ULTRA THIN 28G MISC ea daily) ea daily) UNILET GP 28 ULTRA 200 / VIDA MIA AUTOLET 2 QL(1 ea per 1 month;QL(6.67 LANCINGDEVICE MISC 180 days retail) THIN MISC ea daily) VIDA MIA UNILET 200 / 200 / LANCETS SUPER THIN 1 month;QL(6.67 UNILET LANCET MISC 1 month;QL(6.67 30G MISC ea daily) ea daily) VIDA MIA UNILET 200 / 200 / LANCETS ULTRA THIN 1 month;QL(6.67 UNILET LANCETS 1 MICRO-THIN33G MISC month;QL(6.67 28G MISC ea daily) ea daily) VIVAGUARD LANCING 2 QL(1 ea per UNILET LANCETS 1 QL(6.67 ea DEVICE MISC 180 days retail) MICRO-THIN33G MISC daily) WALGREENS COMFORT 200 / 1 UNILET LANCETS 200 / ASSUREDLANCETS month;QL(6.67 1 month;QL(6.67 MICRO THIN/33G MISC ea daily) SUPER-THIN30G MISC ea daily) WALGREENS COMFORT 200 / 1 UNILET LANCETS 200 / ASSUREDLANCETS month;QL(6.67 1 month;QL(6.67 SUPER THIN/28G MISC ea daily) ULTRA-THIN 28G MISC ea daily) 200 / 200 / WALGREENS THIN 1 month;QL(6.67 UNILET SUPERLITE 1 LANCETS MISC LANCET MISC month;QL(6.67 ea daily) ea daily) Misc. Devices 200 / UNIVERSAL 1 LANCETS 1 month;QL(6.67 ALCOHOL PREP PADS 2 RX/OTC THIN26G MISC PADS ea daily) 200 / ALCOHOL SWABS PADS 2 RX/OTC UNIVERSAL 1 LANCETS 1 month;QL(6.67 ULTRA THIN 30G MISC ea daily) ALCOHOL SWABSTICK 2 RX/OTC PADS UNIVERSAL 1 200 / LANCETS/33G/MICRO- 2 month;QL(6.67 APLICARE ALCOHOL 2 RX/OTC THIN MISC ea daily) SWABSTICK PADS 200 / BD SWABS SINGLE USE 2 RX/OTC VALUE PLUS LANCETS 1 month;QL(6.67 BUTTERFLY PADS STANDARD 21G MISC ea daily) BD SWABS SINGLE USE 2 RX/OTC 200 / PADS VALUE PLUS LANCETS 1 CURITY ALCOHOL RX/OTC SUPERTHIN 30G MISC month;QL(6.67 ea daily) PREPS/MEDIUM 2 PLY 2 200 / PADS VALUE PLUS LANCETS 1 CURITY ALCOHOL RX/OTC THIN 26G MISC month;QL(6.67 2 ea daily) SWABS PADS RX/OTC VALUE PLUS LANCING 2 QL(1 ea per CVS PREP PADS PADS 2 DEVICE MISC 180 days retail)

Coordinated Care of Washington Updated September 1, 2021

137 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH ALCOHOL RX/OTC 1ST TIER UNIFINE 2 QL(5 ea daily) PREP PADS/MEDIUM 2 PENTIPS31GX6MM MISC PADS 1ST TIER UNIFINE 2 QL(5 ea daily); FIFTY50 ALCOHOL PREP 2 RX/OTC PENTIPS31GX8MM MISC RX/OTC PADS PADS 1ST TIER UNIFINE 2 QL(5 ea daily); GNP ALCOHOL SWABS 2 RX/OTC PENTIPS32GX4MM MISC RX/OTC PADS 1ST TIER UNIFINE 2 QL(5 ea daily) HM STERILE ALCOHOL 2 RX/OTC PENTIPS32GX6MM MISC PREP PADS PADS 1ST TIER UNIFINE 2 QL(5 ea daily) MEIJER ALCOHOL RX/OTC PENTIPS33GX4MM MISC SWABS EXTRA-THICK 2 1ST TIER UNIFINE QL(5 ea daily); PADS PENTIPSPLUS 31GX8MM 2 RX/OTC PRO COMFORT 2 RX/OTC MISC ALCOHOL PADS PADS 1ST TIER UNIFINE QL(5 ea daily); QC ALCOHOL SWABS 2 RX/OTC PENTIPSPLUS 32GX4MM 2 RX/OTC PADS MISC RA ALCOHOL SWABS 2 RX/OTC 1ST TIER UNIFINE QL(5 ea daily) PADS PENTIPSPLUS 33GX4MM 2 MISC REALITY SWABS PADS 2 RX/OTC 1ST TIER UNIFINE QL(5 ea daily); PENTIPSPLUS/MINI/31GX 2 RX/OTC RELION ALCOHOL 2 RX/OTC SWABS PADS 5MM MISC 1ST TIER UNIFINE QL(5 ea daily); SB ALCOHOL PREP 2 RX/OTC PADS PADS PENTIPSPLUS/ORIGINAL/ 2 RX/OTC 29GX12MM MISC SHOPKO ALCOHOL 2 RX/OTC SWABS PADS 1ST TIER UNIFINE QL(5 ea daily) PENTIPSPLUS/ULTRA 2 SM ALCOHOL PREP 2 RX/OTC PADS PADS SHORT/31GX6MM MISC 2-3ML SYRINGE/LUER RX/OTC TGT ALCOHOL SWABS 2 RX/OTC 2 PADS LOCK TIP MISC WEBCOL ALCOHOL RX/OTC 2-3ML SYRINGE/LUER 2 RX/OTC PREP LARGE 1 PLY 2 SLIP TIP MISC PADS 3ML LUER LOCK SAFETY 2 RX/OTC WEBCOL ALCOHOL RX/OTC SYRINGES MISC PREP LARGE 2 PLY 2 3ML SYRINGE/INTERLINK RX/OTC PADS SYRINGE CANNULA 2 WEBCOL ALCOHOL RX/OTC MISC PREP MEDIUM 2 PLY 2 3ML SYRINGE/INTERLINK RX/OTC PADS VIAL ACCESS CANNULA 2 MISC Parenteral Therapy Supplies ABOUTTIME PEN 2 QL(5 ea daily); 1ST TIER UNIFINE QL(5 ea daily); NEEDLE 32GX 5/32" MISC RX/OTC PENTIPS/MINI/31GX5MM 2 RX/OTC MISC ABOUTTIME PEN QL(5 ea daily); NEEDLES 30GX 5/16" 2 RX/OTC 1ST TIER UNIFINE QL(5 ea daily); MISC PENTIPS29GX12MM 2 RX/OTC MISC

Coordinated Care of Washington Updated September 1, 2021

138 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ABOUTTIME PEN QL(5 ea daily); ASSURE ID INSULIN QL(5 ea daily); NEEDLES 31G X 3/16" 2 RX/OTC SAFETYSYRINGE/U- 2 RX/OTC MISC 100/0.5ML/29G X 1/2" ABOUTTIME PEN QL(5 ea daily); MISC NEEDLES 31G X 5/16" 2 RX/OTC ASSURE ID INSULIN QL(5 ea daily); MISC SAFETYSYRINGE/U- 2 RX/OTC ADVOCATE INSULIN PEN QL(5 ea daily) 100/1ML/29G X 1/2" MISC NEEDLES 29GX12.7MM 2 ASSURE ID SAFETY PEN QL(5 ea daily); MISC NEEDLES 30G X 5/16" 2 RX/OTC ADVOCATE INSULIN PEN QL(5 ea daily); MISC NEEDLES 31GX5MM 2 RX/OTC ASSURE ID SAFETY PEN QL(5 ea daily); MISC NEEDLES 31G X 3/16" 2 RX/OTC ADVOCATE INSULIN PEN QL(5 ea daily); MISC NEEDLES 31GX8MM 2 RX/OTC AURORA PEN NEEDLES 2 QL(5 ea daily); MISC 29GX12MM MISC RX/OTC ADVOCATE INSULIN PEN 2 QL(5 ea daily) AURORA PEN NEEDLES 2 QL(5 ea daily) NEEDLES MISC 31G X6MM MISC ADVOCATE INSULIN QL(5 ea daily); AURORA PEN NEEDLES 2 QL(5 ea daily); SYRINGE/U- 2 RX/OTC 31G X8MM MISC RX/OTC 100/0.3ML/29GX1/2" MISC AURORA UNIFINE 2 QL(5 ea daily); ADVOCATE INSULIN QL(5 ea daily); PENTIPS/32GX5/32" MISC RX/OTC SYRINGE/U- 2 RX/OTC AURORA UNIFINE QL(5 ea daily); 100/0.3ML/30GX5/16" PENTIPS/MINI/31GX3/16" 2 RX/OTC MISC MISC ADVOCATE INSULIN QL(5 ea daily) B-D INSULIN SYRINGE QL(5 ea daily) SYRINGE/U- 2 ULTRAFINE II/0.3ML/31G 2 100/0.3ML/31GX5/16" X 5/16" MISC MISC B-D INSULIN SYRINGE QL(5 ea daily) ADVOCATE INSULIN QL(5 ea daily); ULTRAFINE II/0.5ML/31G 2 SYRINGE/U- 2 RX/OTC X 5/16" MISC 100/0.5ML/29GX1/2" MISC B-D INSULIN SYRINGE QL(5 ea daily) ADVOCATE INSULIN QL(5 ea daily); ULTRAFINE II/1ML/31G X 2 SYRINGE/U- 2 RX/OTC 5/16" MISC 100/0.5ML/30GX5/16" MISC B-D INSULIN SYRINGE QL(5 ea daily) ULTRAFINE/0.3ML/30G X 2 ADVOCATE INSULIN QL(5 ea daily) 1/2" MISC SYRINGE/U- 2 100/0.5ML/31GX5/16" B-D INSULIN SYRINGE QL(5 ea daily) MISC ULTRAFINE/0.5ML/30G X 2 1/2" MISC ADVOCATE INSULIN QL(5 ea daily); SYRINGE/U- 2 RX/OTC BD LO-DOSE INSULIN QL(5 ea daily); 100/1ML/29GX1/2" MISC SYRINGE MICROFINE 2 RX/OTC IV/0.5ML/28G X 1/2" MISC ADVOCATE INSULIN QL(5 ea daily); SYRINGE/U- 2 RX/OTC BD 3ML SYRINGE LUER- 2 RX/OTC 100/1ML/30GX5/16" MISC LOK TIP MISC ADVOCATE INSULIN QL(5 ea daily) BD 3ML SYRINGE SLIP 2 RX/OTC SYRINGE/U- 2 TIP MISC 100/1ML/31GX5/16" MISC

Coordinated Care of Washington Updated September 1, 2021

139 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD BLUNT FILL RX/OTC BD INSULIN SYRINGE QL(5 ea daily) NEEDLE/18GX 1-1/2" 2 ULTRA-FINE/0.3ML/31G X 2 MISC 8MM MISC BD ECLIPSE 18G X 1-1/2" 2 RX/OTC BD INSULIN SYRINGE QL(5 ea daily) MISC ULTRA-FINE/0.5ML/30G X 2 BD HYPODERMIC RX/OTC 12.7MM MISC NEEDLE REGULAR 2 BD INSULIN SYRINGE QL(5 ea daily) BEVEL 18G X 1-1/2" MISC ULTRA-FINE/0.5ML/31G X 2 BD HYPODERMIC RX/OTC 8MM MISC NEEDLE REGULAR 2 BD INSULIN SYRINGE QL(5 ea daily) BEVEL THIN WALL 18G X ULTRA-FINE/1/2 2 1-1/2" MISC UNIT/0.3ML/31G X 8MM BD HYPODERMIC RX/OTC MISC NEEDLE SHORT BEVEL 2 BD INSULIN SYRINGE QL(5 ea daily) 18G X 1-1/2" MISC ULTRA-FINE/1ML/30G X 2 12.7MM MISC BD HYPODERMIC 2 RX/OTC NEEDLES 18GX1.5" MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily); ULTRA-FINE/1ML/31G X 2 LUER-LOK/U-100/1ML 2 RX/OTC 8MM MISC MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily); ULTRAFINE HALF- 2 UNIT/0.3ML/31G X 5/16" MICROFINE IV/U- 2 RX/OTC 100/0.5ML/28G X 1/2" MISC MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) ULTRAFINE/0.3ML/30G X 2 MICROFINE IV/U- 2 1/2" MISC 100/1ML/27G X 5/8" MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily); ULTRAFINE/0.3ML/31G X 2 MICROFINE IV/U- 2 RX/OTC 5/16" MISC 100/1ML/28G X 1/2" MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily); ULTRAFINE/0.5ML/30G X 2 1/2" MISC MICROFINE/U- 2 RX/OTC 100/0.5ML/28G X 1/2" BD INSULIN SYRINGE QL(5 ea daily) MISC ULTRAFINE/0.5ML/31G X 2 BD INSULIN SYRINGE QL(5 ea daily) 5/16" MISC MICROFINE/U- 2 BD INSULIN SYRINGE QL(5 ea daily) 100/1ML/27G X 5/8" MISC ULTRAFINE/1ML/30G X 2 BD INSULIN SYRINGE QL(5 ea daily); 1/2" MISC MICROFINE/U- 2 RX/OTC BD INSULIN SYRINGE QL(5 ea daily); 100/1ML/28G X 1/2" MISC ULTRAFINE/U- 2 RX/OTC BD INSULIN SYRINGE QL(5 ea daily); 100/0.3ML/29G X 1/2" SAFETYGLIDE/1ML/29G X 2 RX/OTC MISC 1/2" MISC BD INSULIN SYRINGE QL(5 ea daily); ULTRAFINE/U- RX/OTC BD INSULIN SYRINGE 2 QL(5 ea daily); 2 SLIP TIP/U-100/1ML MISC RX/OTC 100/0.5ML/29G X 1/2" MISC BD INSULIN SYRINGE QL(5 ea daily) ULTRA-FINE/0.3ML/30G X 2 12.7MM MISC Coordinated Care of Washington Updated September 1, 2021

140 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD INSULIN SYRINGE QL(5 ea daily); BD PEN QL(5 ea daily) 2 ULTRAFINE/U- RX/OTC NEEDLE/ORIGINAL/ULTR 2 100/1ML/29G X 1/2" MISC A-FINE/29G X 12.7MM BD INSULIN SYRINGE QL(5 ea daily) MISC ULTRAFINE/U- 2 BD PEN QL(5 ea daily); 100/1ML/31G X 5/16" NEEDLE/SHORT/ULTRA- 2 RX/OTC MISC FINE/31G X 8MM MISC BD INSULIN QL(5 ea daily); BD SAFETY-GLIDE QL(5 ea daily); 2 SYRINGE/0.3ML/29G X RX/OTC INSULIN 2 RX/OTC 12.7MM MISC SYRINGE/0.5ML/29G X BD INSULIN QL(5 ea daily); 1/2" MISC SYRINGE/0.5ML/29G X 2 RX/OTC BD SAFETY-LOK INSULIN QL(5 ea daily); 12.7MM MISC SYRINGE/PERM 2 RX/OTC BD INSULIN QL(5 ea daily); NEEDLE/UF/1ML/29G X SYRINGE/1ML/27G X 2 RX/OTC 1/2" MISC 12.7MM MISC BD SAFETYGLIDE RX/OTC BD INSULIN QL(5 ea daily); HYPODERMICNEEDLE 2 SYRINGE/1ML/29G X 2 RX/OTC 18G X 1-1/2" MISC 12.7MM MISC BD SAFETYGLIDE QL(5 ea daily); BD INSULIN QL(5 ea daily) INSULIN 2 RX/OTC SYRINGE/0.3ML/29G X SYRINGE/DETACHABLE 2 NEEDLE/U-100/1ML/25G 1/2" MISC X 1" MISC BD SAFETYGLIDE QL(5 ea daily) BD INSULIN QL(5 ea daily) INSULIN 2 SYRINGE/0.3ML/31G X SYRINGE/DETACHABLE 2 NEEDLE/U-100/1ML/25G 5/16" MISC X 5/8" MISC BD SAFETYGLIDE QL(5 ea daily); BD INSULIN QL(5 ea daily) INSULIN 2 RX/OTC SYSYRINGE/0.5ML/30G X SYRINGE/DETACHABLE 2 NEEDLE/U-100/1ML/26G 5/16" MISC X 1/2" MISC CAREFINE PEN NEEDLE 2 QL(5 ea daily); 32GX4MM MISC RX/OTC BD INSULIN SYRINGE/U- 2 QL(5 ea daily); 100/1ML/27G X 1/2" MISC RX/OTC CAREFINE PEN 2 QL(5 ea daily); NEEDLES 29GX1/2" MISC RX/OTC BD NEEDLE/18G 1-1/2" 2 RX/OTC MISC CAREFINE PEN QL(5 ea daily); BD PEN QL(5 ea daily) NEEDLES 30GX5/16" 2 RX/OTC NEEDLE/MICRO/ULTRA- 2 MISC FINE/32G X 6MM MISC CAREFINE PEN QL(5 ea daily) BD PEN QL(5 ea daily); NEEDLES 31GX6MM 2 NEEDLE/MINI/ULTRA- 2 RX/OTC MISC FINE/31G X 5MM MISC CAREFINE PEN QL(5 ea daily); BD PEN NEEDLE/NANO QL(5 ea daily); NEEDLES 31GX8MM 2 RX/OTC 2ND GEN/32G X 5/32" 2 RX/OTC MISC MISC CAREFINE PEN QL(5 ea daily); BD PEN QL(5 ea daily); NEEDLES 32GX5MM 2 RX/OTC NEEDLE/NANO/ULTRA- 2 RX/OTC MISC FINE/32G X 4MM MISC

Coordinated Care of Washington Updated September 1, 2021

141 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CAREFINE PEN QL(5 ea daily) CAREONE UNIFINE QL(5 ea daily); NEEDLES 32GX6MM 2 PENTIPS PLUS PEN 2 RX/OTC MISC NEEDLES 31GX8MM CAREONE INSULIN QL(5 ea daily) MISC SYRINGES/0.3ML/30G X 2 CAREONE UNIFINE QL(5 ea daily); 1/2" MISC PENTIPS PLUS PEN 2 RX/OTC CAREONE INSULIN QL(5 ea daily) NEEDLES 32GX4MM SYRINGES/0.3ML/31G X 2 MISC 5/16" MISC CAREONE UNIFINE QL(5 ea daily) CAREONE INSULIN QL(5 ea daily) PENTIPS PLUS PEN 2 SYRINGES/0.5ML/30G X 2 NEEDLES/33G X 5/32" 1/2" MISC MISC CAREONE INSULIN QL(5 ea daily) CARETOUCH PEN QL(5 ea daily) SYRINGES/0.5ML/31G X 2 NEEDLES 31G X 6 MM 2 5/16" MISC MISC CAREONE INSULIN QL(5 ea daily) CARETOUCH PEN QL(5 ea daily); SYRINGES/1ML/30G X 2 NEEDLES 31GX 5MM 2 RX/OTC 1/2" MISC MISC CAREONE INSULIN QL(5 ea daily) CARETOUCH PEN QL(5 ea daily); SYRINGES/1ML/31GX5/16 2 NEEDLES 31GX 8MM 2 RX/OTC " MISC MISC CAREONE UNIFINE QL(5 ea daily); CARETOUCH PEN QL(5 ea daily); PENTIPS 29GX12MM 2 RX/OTC NEEDLES 32GX 4MM 2 RX/OTC MISC MISC CARETOUCH PEN QL(5 ea daily); CAREONE UNIFINE 2 QL(5 ea daily); PENTIPS 31GX5MM MISC RX/OTC NEEDLES 32GX 5MM 2 RX/OTC MISC CAREONE UNIFINE 2 QL(5 ea daily) PENTIPS 31GX6MM MISC CLEVER CHOICE QL(5 ea daily); COMFORT EZINSULIN 2 RX/OTC CAREONE UNIFINE 2 QL(5 ea daily); PEN NEEDLES 31GX8MM PENTIPS 31GX8MM MISC RX/OTC MISC CAREONE UNIFINE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily) PENTIPS PEN NEEDLES 2 RX/OTC COMFORT EZINSULIN 2 32GX4MM MISC PEN NEEDLES 33GX4MM CAREONE UNIFINE QL(5 ea daily); MISC PENTIPS PLUS PEN 2 RX/OTC CLEVER CHOICE QL(5 ea daily); NEEDLES 29GX12MM COMFORT EZINSULIN 2 RX/OTC MISC SYRINGE/0.3ML/29G X CAREONE UNIFINE QL(5 ea daily); 1/2" MISC PENTIPS PLUS PEN 2 RX/OTC CLEVER CHOICE QL(5 ea daily) NEEDLES 31GX5MM COMFORT EZINSULIN 2 MISC SYRINGE/0.3ML/30G X CAREONE UNIFINE QL(5 ea daily) 1/2" MISC PENTIPS PLUS PEN 2 CLEVER CHOICE QL(5 ea daily); NEEDLES 31GX6MM COMFORT EZINSULIN 2 RX/OTC MISC SYRINGE/0.3ML/30G X 5/16" MISC

Coordinated Care of Washington Updated September 1, 2021

142 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLEVER CHOICE QL(5 ea daily) CLEVER CHOICE QL(5 ea daily); COMFORT EZINSULIN 2 COMFORT EZPEN 2 RX/OTC SYRINGE/0.3ML/31G X NEEDLES 31GX5MM 5/16" MISC MISC CLEVER CHOICE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily) COMFORT EZINSULIN 2 RX/OTC COMFORT EZPEN 2 SYRINGE/0.5ML/28G X NEEDLES 31GX6MM 1/2" MISC MISC CLEVER CHOICE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); COMFORT EZINSULIN 2 RX/OTC COMFORT EZPEN 2 RX/OTC SYRINGE/0.5ML/29G X NEEDLES 31GX8MM 1/2" MISC MISC CLEVER CHOICE QL(5 ea daily) CLEVER CHOICE QL(5 ea daily); COMFORT EZINSULIN 2 COMFORT EZPEN 2 RX/OTC SYRINGE/0.5ML/30G X NEEDLES 32GX4MM 1/2" MISC MISC CLEVER CHOICE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); COMFORT EZINSULIN RX/OTC 2 COMFORT EZPEN 2 RX/OTC SYRINGE/0.5ML/30G X NEEDLES 32GX5MM 5/16" MISC MISC CLEVER CHOICE QL(5 ea daily) CLEVER CHOICE QL(5 ea daily) COMFORT EZINSULIN 2 COMFORT EZPEN 2 SYRINGE/0.5ML/31G X NEEDLES 32GX6MM 5/16" MISC MISC CLEVER CHOICE QL(5 ea daily) CLEVER CHOICE QL(5 ea daily) COMFORT EZINSULIN 2 COMFORT EZPEN 2 SYRINGE/1.0ML/30G X NEEDLES 32GX8MM 1/2" MISC MISC CLEVER CHOICE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily) COMFORT EZINSULIN 2 RX/OTC COMFORT EZPEN 2 SYRINGE/1ML/28G X 1/2" NEEDLES 33GX4MM MISC MISC CLEVER CHOICE QL(5 ea daily); CLICKFINE PEN NEEDLE 2 QL(5 ea daily); COMFORT EZINSULIN 2 RX/OTC 32GX5/32" MISC RX/OTC SYRINGE/1ML/29G X 1/2" CLICKFINE PEN NEEDLE QL(5 ea daily) MISC UNIVERSAL/31GX1/4" 2 CLEVER CHOICE QL(5 ea daily); MISC COMFORT EZINSULIN 2 RX/OTC CLICKFINE PEN NEEDLE QL(5 ea daily); SYRINGE/1ML/30G X UNIVERSAL/31GX5/16" 2 RX/OTC 5/16" MISC MISC CLEVER CHOICE QL(5 ea daily) CLICKFINE PEN QL(5 ea daily) COMFORT EZINSULIN 2 NEEDLES 31G X 1/4" 2 SYRINGE/U- MISC 100/1ML/31GX5/16" MISC CLICKFINE PEN QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); NEEDLES 31G X 3/16" 2 RX/OTC COMFORT EZPEN 2 RX/OTC MISC NEEDLES 29GX12MM MISC

Coordinated Care of Washington Updated September 1, 2021

143 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLICKFINE PEN QL(5 ea daily); COMFORT ASSIST QL(5 ea daily) 2 NEEDLES 31G X 5/16" RX/OTC INSULIN 2 MISC SYRINGE/1ML/31G X CLICKFINE PEN QL(5 ea daily); 5/16" MISC NEEDLES 31G X 8MM 2 RX/OTC COMFORT EZ INSULIN QL(5 ea daily) MISC SYRINGE/U- 2 CLICKFINE PEN QL(5 ea daily); 100/0.5ML/31G X 5/16" NEEDLES 32G X 5/32" 2 RX/OTC MISC MISC COMFORT EZ INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/31G 2 CLICKFINE PEN 2 QL(5 ea daily) NEEDLES/31GX1/4" MISC X 5/16" MISC CLICKFINE UNIVERSAL QL(5 ea daily); COMFORT EZ 2 QL(5 ea daily); PEN NEEDLES 31GX5/16" 2 RX/OTC MICRO/32G X 4MM MISC RX/OTC MISC COMFORT EZ 2 QL(5 ea daily); COMFORT ASSIST QL(5 ea daily); SHORT/31G X 8MM MISC RX/OTC 2 INSULIN SYRINGE RX/OTC COMFORT EZ/31G X 5MM 2 QL(5 ea daily); 0.3ML/29G X 1/2" MISC MISC RX/OTC COMFORT ASSIST QL(5 ea daily); COMFORT EZ/31G X 6MM 2 QL(5 ea daily) INSULIN 2 RX/OTC MISC SYRINGE/0.3ML/30G X COMFORT TOUCH PEN QL(5 ea daily) 5/16" MISC NEEDLES/31G X 4MM 2 COMFORT ASSIST QL(5 ea daily) MISC INSULIN 2 COMFORT TOUCH PEN QL(5 ea daily); SYRINGE/0.3ML/31G X NEEDLES/31G X 5MM 2 RX/OTC 5/16" MISC MISC COMFORT ASSIST QL(5 ea daily); COMFORT TOUCH PEN QL(5 ea daily) INSULIN 2 RX/OTC NEEDLES/31G X 6 MM 2 SYRINGE/0.5ML/29G X MISC 1/2" MISC COMFORT TOUCH PEN QL(5 ea daily); COMFORT ASSIST QL(5 ea daily); NEEDLES/31G X 8 MM 2 RX/OTC INSULIN 2 RX/OTC MISC SYRINGE/0.5ML/30G X 5/16" MISC COMFORT TOUCH PEN QL(5 ea daily); NEEDLES/32G X 4MM 2 RX/OTC COMFORT ASSIST QL(5 ea daily) MISC INSULIN 2 SYRINGE/0.5ML/31G X COMFORT TOUCH PEN QL(5 ea daily); 5/16" MISC NEEDLES/32G X 5MM 2 RX/OTC MISC COMFORT ASSIST QL(5 ea daily); COMFORT TOUCH PEN QL(5 ea daily) INSULIN 2 RX/OTC SYRINGE/1ML/29G X 1/2" NEEDLES/32G X 6MM 2 MISC MISC COMFORT ASSIST QL(5 ea daily); COMFORT TOUCH PEN QL(5 ea daily) NEEDLES/32G X 8MM 2 INSULIN 2 RX/OTC SYRINGE/1ML/30G X MISC 5/16" MISC COMFORT TOUCH PEN QL(5 ea daily) NEEDLES/33G X 5/32" 2 MISC

Coordinated Care of Washington Updated September 1, 2021

144 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DIATHRIVE PEN QL(5 ea daily) DROPLET INSULIN QL(5 ea daily) NEEDLE/31 G X 6MM 2 SYRINGE U-100/1ML/31G 2 MISC X 5/16" MISC DIATHRIVE PEN QL(5 ea daily); DROPLET INSULIN QL(5 ea daily) NEEDLE/31 GX 8MM 2 RX/OTC SYRINGE/U- 2 MISC 100/0.3ML/31G X 5/16" MISC DIATHRIVE PEN 2 QL(5 ea daily); NEEDLE/31GX 5MM MISC RX/OTC DROPLET INSULIN QL(5 ea daily) SYRINGE/U- DIATHRIVE PEN 2 QL(5 ea daily); 2 NEEDLE/32GX 4MM MISC RX/OTC 100/0.5ML/30G X 1/2" MISC DROPLET INSULIN QL(5 ea daily); SYRINGE 0.3ML/29G X 2 RX/OTC DROPLET INSULIN QL(5 ea daily) 1/2" MISC SYRINGE/U- 2 100/0.5ML/31G X 5/16" DROPLET INSULIN QL(5 ea daily); MISC SYRINGE 0.5ML/29G X 2 RX/OTC 1/2" MISC DROPLET INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/30G 2 DROPLET INSULIN QL(5 ea daily); X 1/2" MISC SYRINGE 1ML/29G X 1/2" 2 RX/OTC MISC DROPLET INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/31G 2 DROPLET INSULIN QL(5 ea daily) X 5/16" MISC SYRINGE U-100/0.3/31G 2 X 5/16" MISC DROPLET PEN NEEDLES 2 QL(5 ea daily); 29G X1/2" MISC RX/OTC DROPLET INSULIN QL(5 ea daily) DROPLET PEN NEEDLES QL(5 ea daily); SYRINGE U- 2 2 100/0.3ML/30G X 1/2" 29GX12MM MISC RX/OTC MISC DROPLET PEN NEEDLES 2 QL(5 ea daily); DROPLET INSULIN QL(5 ea daily); 30G X 5/16" MISC RX/OTC SYRINGE U- RX/OTC 2 DROPLET PEN NEEDLES 2 QL(5 ea daily); 100/0.3ML/30G X 5/16" 31G X3/16" MISC RX/OTC MISC DROPLET PEN NEEDLES 2 QL(5 ea daily); DROPLET INSULIN QL(5 ea daily) 31G X5/16" MISC RX/OTC SYRINGE U- 2 DROPLET PEN NEEDLES 2 QL(5 ea daily); 100/0.5ML/30G X 1/2" 31GX5MM MISC RX/OTC MISC DROPLET PEN NEEDLES 2 QL(5 ea daily) DROPLET INSULIN QL(5 ea daily); 31GX6MM MISC SYRINGE U- 2 RX/OTC 100/0.5ML/30G X 5/16" DROPLET PEN NEEDLES 2 QL(5 ea daily); MISC 31GX8MM MISC RX/OTC DROPLET INSULIN QL(5 ea daily) DROPLET PEN NEEDLES 2 QL(5 ea daily) 32G X 1/4" MISC SYRINGE U- 2 100/0.5ML/31G X 5/16" DROPLET PEN NEEDLES 2 QL(5 ea daily); MISC 32G X 3/16" MISC RX/OTC DROPLET INSULIN QL(5 ea daily) DROPLET PEN NEEDLES 2 QL(5 ea daily) SYRINGE U-100/1ML/30G 2 32G X 5/16" MISC X 1/2" MISC DROPLET PEN NEEDLES 2 QL(5 ea daily); DROPLET INSULIN QL(5 ea daily); 32G X 5/32" MISC RX/OTC SYRINGE U-100/1ML/30G 2 RX/OTC DROPLET PEN NEEDLES 2 QL(5 ea daily); X 5/16" MISC 32GX4MM MISC RX/OTC Coordinated Care of Washington Updated September 1, 2021

145 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DROPLET PEN NEEDLES 2 QL(5 ea daily); EASY COMFORT PEN 2 QL(5 ea daily); 32GX5MM MISC RX/OTC NEEDLES31GX3/16" MISC RX/OTC DROPLET PEN NEEDLES 2 QL(5 ea daily) EASY COMFORT PEN 2 QL(5 ea daily); 32GX6MM MISC NEEDLES31GX5/16" MISC RX/OTC DROPLET PEN NEEDLES 2 QL(5 ea daily) EASY COMFORT PEN 2 QL(5 ea daily); 32GX8MM MISC NEEDLES32GX5/32" MISC RX/OTC DROPSAFE SAFETY PEN QL(5 ea daily); EASY COMFORT PEN QL(5 ea daily) NEEDLES/31G X 5/16" 2 RX/OTC NEEDLES33G X 4MM 2 MISC MISC DROPSAFE SAFTEY PEN QL(5 ea daily) EASY GLIDE PEN QL(5 ea daily) NEEDLES/31G X 1/4" 2 NEEDLES 33G X 5/32" 2 MISC MISC DRUG MART UNIFINE 2 QL(5 ea daily); EASY GLIDE RX/OTC PENTIPS 31GX5MM MISC RX/OTC SYRINGE/LUER 2 DRUG MART UNIFINE QL(5 ea daily); LLOCK/3ML MISC 2 PENTIPS29G X 12MM RX/OTC EASY TOUCH 32GX5MM 2 QL(5 ea daily); MISC MISC RX/OTC DRUG MART UNIFINE 2 QL(5 ea daily) EASY TOUCH 32GX6MM 2 QL(5 ea daily) PENTIPS31GX6MM MISC MISC DRUG MART UNIFINE 2 QL(5 ea daily); EASY TOUCH FLIPLOCK RX/OTC PENTIPS31GX8MM MISC RX/OTC NEEDLES 18GX1-1/2" 2 MISC DRUG MART UNIFINE 2 QL(5 ea daily); PENTIPS32GX4MM MISC RX/OTC EASY TOUCH FLIPLOCK QL(5 ea daily); DRUG MART UNIFINE QL(5 ea daily); SAFETY INSULIN 2 RX/OTC PENTIPSPLUS 32GX4MM 2 RX/OTC SYRINGE 1ML/29GX1/2" MISC MISC EASY COMFORT INSULIN QL(5 ea daily); EASY TOUCH FLIPLOCK QL(5 ea daily) SYRINGE/0.5ML/30G X 2 RX/OTC SAFETY INSULIN 2 5/16" MISC SYRINGE 1ML/30GX1/2" MISC EASY COMFORT INSULIN QL(5 ea daily) SYRINGE/0.5ML/31G X 2 EASY TOUCH FLIPLOCK QL(5 ea daily); 5/16" MISC SAFETY INSULIN 2 RX/OTC SYRINGE 1ML/30GX5/16" EASY COMFORT INSULIN QL(5 ea daily); MISC SYRINGE/1ML/30G X 2 RX/OTC 5/16" MISC EASY TOUCH FLIPLOCK QL(5 ea daily) SAFETY INSULIN 2 EASY COMFORT INSULIN QL(5 ea daily) SYRINGE 1ML/31GX5/16" SYRINGE/1ML/31G X 2 MISC 5/16" MISC EASY TOUCH RX/OTC EASY COMFORT INSULIN QL(5 ea daily) HYPODERMIC NEEDLES 2 SYRINGE/U- 2 18GX1-1/2" MISC 100/0.5ML/30G X 1/2" MISC EASY TOUCH INSULIN QL(5 ea daily); SYRINGE/0.3ML/30G X 2 RX/OTC EASY COMFORT INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/U-100/1ML/30G 2 X 1/2" MISC EASY TOUCH INSULIN QL(5 ea daily) SYRINGE/0.3ML/31G X 2 EASY COMFORT PEN 2 QL(5 ea daily) 5/16" MISC NEEDLES31GX1/4" MISC

Coordinated Care of Washington Updated September 1, 2021

146 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH INSULIN QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily); SYRINGE/0.5ML/29G X 2 RX/OTC SYRINGE/U-100/1ML/27G 2 RX/OTC 1/2" MISC X 1/2" MISC EASY TOUCH INSULIN QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X 2 RX/OTC SYRINGE/U-100/1ML/28G 2 RX/OTC 5/16" MISC X 1/2" MISC EASY TOUCH INSULIN QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily); SYRINGE/1ML/30G X 2 RX/OTC SYRINGE/U-100/1ML/29G 2 RX/OTC 5/16" MISC X 1/2" MISC EASY TOUCH INSULIN QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily) SYRINGE/SAFETY/U- 2 RX/OTC SYRINGE/U-100/1ML/30G 2 100/0.5ML/29G X 1/2" X 1/2" MISC MISC EASY TOUCH INSULIN QL(5 ea daily) EASY TOUCH INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/31G 2 SYRINGE/SAFETY/U- 2 RX/OTC X 5/16" MISC 100/0.5ML/30G X 5/16" EASY TOUCH PEN QL(5 ea daily); MISC NEEDLE 30G X 5/16" 2 RX/OTC EASY TOUCH INSULIN QL(5 ea daily); MISC SYRINGE/SAFETY/U- 2 RX/OTC EASY TOUCH PEN 2 QL(5 ea daily); 100/1ML/29G X 1/2" MISC NEEDLES 29GX1/2" MISC RX/OTC EASY TOUCH INSULIN QL(5 ea daily) EASY TOUCH PEN 2 QL(5 ea daily) SYRINGE/SAFETY/U- 2 NEEDLES 31GX1/4" MISC 100/1ML/30G X 1/2" MISC EASY TOUCH PEN QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily) NEEDLES 31GX5/16" 2 RX/OTC SYRINGE/U- 2 MISC 100/0.3ML/30G X 1/2" MISC EASY TOUCH PEN 2 QL(5 ea daily) NEEDLES 32GX1/4" MISC EASY TOUCH INSULIN QL(5 ea daily) EASY TOUCH PEN QL(5 ea daily); SYRINGE/U- 2 100/0.5ML/27G X 1/2" NEEDLES 32GX3/16" 2 RX/OTC MISC MISC EASY TOUCH INSULIN QL(5 ea daily); EASY TOUCH PEN QL(5 ea daily); NEEDLES 32GX5/32" 2 RX/OTC SYRINGE/U- 2 RX/OTC 100/0.5ML/28G X 1/2" MISC MISC EASY TOUCH PEN QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily); NEEDLES/31G X 3/16" 2 RX/OTC MISC SYRINGE/U- 2 RX/OTC 100/0.5ML/29G X 1/2" EASY TOUCH SAFETY QL(5 ea daily); MISC PEN NEEDLES/30G X 2 RX/OTC EASY TOUCH INSULIN QL(5 ea daily) 5/16" MISC EASY TOUCH QL(5 ea daily); SYRINGE/U- 2 100/0.5ML/30G X 1/2" SHEATHLOCK SAFETY 2 RX/OTC MISC INSULIN SYRINGE EASY TOUCH INSULIN QL(5 ea daily) 1ML/29GX1/2" MISC EASY TOUCH QL(5 ea daily); SYRINGE/U- 2 100/0.5ML/31G X 5/16" SHEATHLOCK SAFETY 2 RX/OTC MISC INSULIN SYRINGE 1ML/30GX5/16" MISC

Coordinated Care of Washington Updated September 1, 2021

147 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH QL(5 ea daily) EQL INSULIN QL(5 ea daily); SHEATHLOCK SAFETY 2 SYRINGE/0.5ML/29G X 2 RX/OTC INSULIN SYRINGE 1/2" MISC 1ML/31GX5/16" MISC EQL INSULIN QL(5 ea daily); EASY TOUCH QL(5 ea daily) SYRINGE/0.5ML/30G X 2 RX/OTC SHEATHLOCK SAFETY 2 5/16" MISC SYRINGE 1ML/30GX1/2" EQL INSULIN QL(5 ea daily) MISC SYRINGE/0.5ML/31G X 2 EASYPOINT NEEDLE/18G 2 RX/OTC 5/16" MISC X 1-1/2" MISC EQL INSULIN QL(5 ea daily); ELITE-THIN INSULIN QL(5 ea daily) SYRINGE/1ML/29G X 1/2" 2 RX/OTC SYRINGE/0.3ML/31G X 2 MISC 5/16" MISC EQL INSULIN QL(5 ea daily); ELITE-THIN INSULIN QL(5 ea daily); SYRINGE/1ML/30G X 2 RX/OTC SYRINGE/0.5ML/29G X 2 RX/OTC 5/16" MISC 1/2" MISC EQL INSULIN QL(5 ea daily) ELITE-THIN INSULIN QL(5 ea daily); SYRINGE/1ML/31G X 2 SYRINGE/0.5ML/30G X 2 RX/OTC 5/16" MISC 5/16" MISC EXCEL COMFORT POINT QL(5 ea daily) ELITE-THIN INSULIN QL(5 ea daily); INSULIN PEN NEEDLES 2 SYRINGE/1ML/30G X 2 RX/OTC 31G X 4MM MISC 5/16" MISC EXEL COMFORT POINT QL(5 ea daily); ELITE-THIN INSULIN QL(5 ea daily); INSULIN PEN NEEDLES 2 RX/OTC SYRINGE/U- 2 RX/OTC 29G X 12MM MISC 100/0.5ML/28G X 1/2" EXEL COMFORT POINT QL(5 ea daily) MISC INSULIN PEN NEEDLES 2 ELITE-THIN INSULIN QL(5 ea daily) 31G X 6MM MISC SYRINGE/U- 2 EXEL COMFORT POINT QL(5 ea daily); 100/0.5ML/31G X 5/16" INSULIN PEN NEEDLES 2 RX/OTC MISC 31G X 8MM MISC ELITE-THIN INSULIN QL(5 ea daily); EXEL COMFORT POINT QL(5 ea daily); SYRINGE/U-100/1ML/28G 2 RX/OTC INSULIN 2 RX/OTC X 1/2" MISC SYRINGE/0.3ML/29G X ELITE-THIN INSULIN QL(5 ea daily); 1/2" MISC SYRINGE/U-100/1ML/29G 2 RX/OTC EXEL COMFORT POINT QL(5 ea daily); X 1/2" MISC INSULIN 2 RX/OTC ELITE-THIN INSULIN QL(5 ea daily) SYRINGE/0.3ML/30G X SYRINGE/U-100/1ML/31G 2 5/16" MISC X 5/16" MISC EXEL COMFORT POINT QL(5 ea daily); EQL INSULIN QL(5 ea daily); INSULIN 2 RX/OTC SYRINGE/0.3ML/29G X 2 RX/OTC SYRINGE/0.5ML/28G X 1/2" MISC 1/2" MISC EQL INSULIN QL(5 ea daily); EXEL COMFORT POINT QL(5 ea daily); SYRINGE/0.3ML/30G X 2 RX/OTC INSULIN 2 RX/OTC 5/16" MISC SYRINGE/0.5ML/29G X EQL INSULIN QL(5 ea daily) 1/2" MISC SYRINGE/0.3ML/31G X 2 5/16" MISC

Coordinated Care of Washington Updated September 1, 2021

148 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EXEL COMFORT POINT QL(5 ea daily); FREDS PHARMACY QL(5 ea daily); INSULIN 2 RX/OTC UNIFINE PENTIPS PLUS 2 RX/OTC SYRINGE/0.5ML/30G X 31GX5MM MISC 5/16" MISC FREDS PHARMACY QL(5 ea daily); EXEL COMFORT POINT QL(5 ea daily); UNIFINE PENTIPS PLUS 2 RX/OTC INSULIN 2 RX/OTC 31GX8MM MISC SYRINGE/1ML/28G X 1/2" FREESTYLE PRECISION QL(5 ea daily); MISC INSULIN SYRINGE/U- 2 RX/OTC EXEL COMFORT POINT QL(5 ea daily); 100/0.5ML/30G X 5/16" INSULIN 2 RX/OTC MISC SYRINGE/1ML/29G X 1/2" FREESTYLE PRECISION QL(5 ea daily) MISC INSULIN SYRINGE/U- 2 EXEL COMFORT POINT QL(5 ea daily); 100/0.5ML/31G X 5/16" INSULIN 2 RX/OTC MISC SYRINGE/1ML/30G X FREESTYLE PRECISION QL(5 ea daily) 5/16" MISC INSULIN SYRINGE/U- 2 FIFTY50 PEN NEEDLES 2 QL(5 ea daily); 100/1ML/31G X 5/16" 31G X3/16" (5MM) MISC RX/OTC MISC FIFTY50 PEN NEEDLES 2 QL(5 ea daily); FREESTYLE PRECISION QL(5 ea daily); ) MISC 31G X5/16" (8MM RX/OTC INSULIN SYRINGES/U- 2 RX/OTC 100/1ML/30G X 5/16" FIFTY50 PEN NEEDLES 2 QL(5 ea daily); 31GX5MM MISC RX/OTC MISC FIFTY50 PEN QL(5 ea daily); GLOBAL EASE INJECT QL(5 ea daily); NEEDLES/31GX8MM 2 RX/OTC PEN NEEDLES 2 RX/OTC MISC 29GX12MM MISC FIFTY50 PEN QL(5 ea daily); GLOBAL EASE INJECT QL(5 ea daily); NEEDLES/32GX4MM 2 RX/OTC PEN NEEDLES 31GX8MM 2 RX/OTC MISC MISC FIFTY50 PEN QL(5 ea daily) GLOBAL EASE INJECT QL(5 ea daily); NEEDLES/32GX6MM 2 PEN NEEDLES 32GX4MM 2 RX/OTC MISC MISC FIFTY50 SUPERIOR QL(5 ea daily) GLOBAL EASE INJECT QL(5 ea daily); PEN NEEEDLES 2 RX/OTC COMFORTINSULIN 2 SYRINGE/0.3ML/31G X 31GX5MM MISC 5/16" MISC GLOBAL EASY GLIDE QL(5 ea daily) FIFTY50 SUPERIOR QL(5 ea daily) INSULINSYRINGE/U- 2 100/0.3ML/31G X 5/16" COMFORTINSULIN 2 SYRINGE/0.5ML/31G X MISC 5/16" MISC GLOBAL EASY GLIDE QL(5 ea daily); FIFTY50 SUPERIOR QL(5 ea daily) PEN NEEDLES 32GX4MM 2 RX/OTC MISC COMFORTINSULIN 2 SYRINGE/1ML/31G X GLOBAL INJECT EASE QL(5 ea daily); 5/16" MISC INSULIN SYRINGE/U- 2 RX/OTC FREDS PHARMACY QL(5 ea daily); 100/0.3ML/29G X 1/2" MISC UNIFINE PENTIPS PEN 2 RX/OTC NEEDLES 32GX4MM MISC

Coordinated Care of Washington Updated September 1, 2021

149 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLOBAL INJECT EASE QL(5 ea daily) GLOBAL INJECT EASE QL(5 ea daily) INSULIN SYRINGE/U- 2 INSULIN SYRINGE/U- 2 100/0.3ML/30G X 1/2" 100/1ML/31G X 5/16" MISC MISC GLOBAL INJECT EASE QL(5 ea daily); GLOBAL INSULIN QL(5 ea daily) INSULIN SYRINGE/U- 2 RX/OTC SYRINGE/U- 2 100/0.3ML/30G X 5/16" 100/0.3ML/30G X 1/2" MISC MISC GLOBAL INJECT EASE QL(5 ea daily) GLOBAL INSULIN QL(5 ea daily); INSULIN SYRINGE/U- 2 SYRINGES/U- 2 RX/OTC 100/0.3ML/31G X 5/16" 100/0.3ML/30GX5/16" MISC MISC GLOBAL INJECT EASE QL(5 ea daily); GLUCOPRO INSULIN QL(5 ea daily) INSULIN SYRINGE/U- 2 RX/OTC SYRINGE/U- 2 100/0.5ML/28G X 1/2" 100/0.3ML/30G X 1/2" MISC MISC GLOBAL INJECT EASE QL(5 ea daily); GLUCOPRO INSULIN QL(5 ea daily); INSULIN SYRINGE/U- RX/OTC 2 SYRINGE/U- 2 RX/OTC 100/0.5ML/29G X 1/2" 100/0.3ML/30G X 5/16" MISC MISC GLOBAL INJECT EASE QL(5 ea daily) GLUCOPRO INSULIN QL(5 ea daily) INSULIN SYRINGE/U- 2 SYRINGE/U- 2 100/0.5ML/30G X 1/2" 100/0.3ML/31G X 5/16" MISC MISC GLOBAL INJECT EASE QL(5 ea daily); GLUCOPRO INSULIN QL(5 ea daily) INSULIN SYRINGE/U- 2 RX/OTC SYRINGE/U- 2 100/0.5ML/30G X 5/16" 100/0.5ML/30G X 1/2" MISC MISC GLOBAL INJECT EASE QL(5 ea daily) GLUCOPRO INSULIN QL(5 ea daily); INSULIN SYRINGE/U- 2 SYRINGE/U- 2 RX/OTC 100/0.5ML/31G X 5/16" 100/0.5ML/30G X 5/16" MISC MISC GLOBAL INJECT EASE QL(5 ea daily); GLUCOPRO INSULIN QL(5 ea daily) 2 INSULIN SYRINGE/U- RX/OTC SYRINGE/U- 2 100/1ML/28G X 1/2" MISC 100/0.5ML/31G X 5/16" GLOBAL INJECT EASE QL(5 ea daily); MISC INSULIN SYRINGE/U- 2 RX/OTC GLUCOPRO INSULIN QL(5 ea daily) 100/1ML/29G X 1/2" MISC SYRINGE/U-100/1ML/30G 2 GLOBAL INJECT EASE QL(5 ea daily) X 1/2" MISC INSULIN SYRINGE/U- 2 GLUCOPRO INSULIN QL(5 ea daily); 100/1ML/30G X 1/2" MISC SYRINGE/U-100/1ML/30G 2 RX/OTC GLOBAL INJECT EASE QL(5 ea daily); X 5/16" MISC INSULIN SYRINGE/U- 2 RX/OTC GLUCOPRO INSULIN QL(5 ea daily) 100/1ML/30G X 5/16" SYRINGE/U-100/1ML/31G 2 MISC X 5/16" MISC GNP CLICKFINE QL(5 ea daily) UNIVERSAL PEN 2 NEEDLES 31GX1/4" MISC

Coordinated Care of Washington Updated September 1, 2021

150 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GNP CLICKFINE QL(5 ea daily); GNP ULTRA COMFORT QL(5 ea daily); UNIVERSAL PEN RX/OTC 2 INSULIN 2 RX/OTC NEEDLES 31GX5/16" SYRINGE/0.3ML/29G X MISC 1/2" MISC GNP INSULIN QL(5 ea daily); GNP ULTRA COMFORT QL(5 ea daily); SYRINGE/0.3ML/29G X 2 RX/OTC INSULIN 2 RX/OTC 1/2" MISC SYRINGE/0.3ML/30G X GNP INSULIN QL(5 ea daily); 5/16" SHORT MISC SYRINGE/0.3ML/30G X 2 RX/OTC GNP ULTRA COMFORT QL(5 ea daily); 5/16" MISC INSULIN 2 RX/OTC GNP INSULIN QL(5 ea daily) SYRINGE/0.5ML/28G X SYRINGE/0.3ML/31G X 2 1/2" MISC 5/16" MISC GNP ULTRA COMFORT QL(5 ea daily); GNP INSULIN QL(5 ea daily); INSULIN 2 RX/OTC SYRINGE/0.5ML/28G X 2 RX/OTC SYRINGE/0.5ML/29G X 1/2" MISC 1/2" MISC GNP INSULIN QL(5 ea daily); GNP ULTRA COMFORT QL(5 ea daily); SYRINGE/0.5ML/29G X 2 RX/OTC INSULIN 2 RX/OTC 1/2" MISC SYRINGE/1ML/28G X 1/2" MISC GNP INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X 2 RX/OTC GNP ULTRA COMFORT QL(5 ea daily); 5/16" MISC INSULIN 2 RX/OTC SYRINGE/1ML/29G X 1/2" GNP INSULIN QL(5 ea daily) MISC SYRINGE/0.5ML/31G X 2 5/16" MISC GOODSENSE CLICKFINE QL(5 ea daily); SAFETY PEN 2 RX/OTC GNP INSULIN QL(5 ea daily); NEEDLE/31G X 3/16" SYRINGE/1ML/28G X 1/2" 2 RX/OTC MISC MISC GOODSENSE PEN QL(5 ea daily); GNP INSULIN QL(5 ea daily); NEEDLE/PENFINE 2 RX/OTC SYRINGE/1ML/29G X 1/2" 2 RX/OTC CLASSIC/31G X 3/16" MISC MISC GNP INSULIN QL(5 ea daily); GOODSENSE PEN QL(5 ea daily); SYRINGE/1ML/30G X 2 RX/OTC NEEDLE/PENFINE 2 RX/OTC 5/16" MISC CLASSIC/31G X 5/16" GNP INSULIN QL(5 ea daily) MISC SYRINGE/1ML/31G X 2 GOODSENSE PEN QL(5 ea daily) 5/16" MISC NEEDLE/PENFINE 2 GNP ULTICARE PEN QL(5 ea daily); CLASSIC/32G X 1/4" MISC NEEDLES/31GX5/16" 2 RX/OTC GOODSENSE PEN QL(5 ea daily); MISC NEEDLE/PENFINE 2 RX/OTC GNP ULTICARE PEN QL(5 ea daily); CLASSIC/32G X 5/32" NEEDLES/32GX 5/32" 2 RX/OTC MISC MISC H-E-B IN CONTROL PEN 2 QL(5 ea daily); GNP ULTICARE PEN 2 QL(5 ea daily) NEEDLE 31GX3/16" MISC RX/OTC NEEDLES/32GX1/4" MISC H-E-B IN CONTROL PEN QL(5 ea daily); GNP ULTICARE PEN QL(5 ea daily); NEEDLES 31GX5MM 2 RX/OTC NEEDLES31G X 5MM 2 RX/OTC MISC MISC Coordinated Care of Washington Updated September 1, 2021

151 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits H-E-B IN CONTROL PEN QL(5 ea daily) HEALTHWISE INSULIN QL(5 ea daily) 2 NEEDLES 31GX6MM SYRINGE/U- 2 MISC 100/0.5ML/31G X 5/16" H-E-B IN CONTROL PEN QL(5 ea daily); MISC NEEDLES 31GX8MM 2 RX/OTC HEALTHWISE INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/30G 2 RX/OTC H-E-B IN CONTROL PEN QL(5 ea daily); X 5/16" MISC NEEDLES/NANO/32GX4M 2 RX/OTC HEALTHWISE INSULIN QL(5 ea daily) M MISC SYRINGE/U-100/1ML/31G 2 H-E-B IN CONTROL QL(5 ea daily) X 5/16" MISC UNIFINEPENTIPS PLUS 2 HEALTHWISE MICRON QL(5 ea daily); 31GX1/4" MISC PEN NEEDLES/32G X 2 RX/OTC H-E-B IN CONTROL QL(5 ea daily); 5/32" MISC UNIFINEPENTIPS PLUS 2 RX/OTC HEALTHWISE MINI PEN QL(5 ea daily) 31GX3/16" MISC NEEDLES 31GX6MM 2 H-E-B IN CONTROL QL(5 ea daily); MISC UNIFINEPENTIPS PLUS 2 RX/OTC HEALTHWISE PEN QL(5 ea daily); 31GX5/16" MISC NEEDLES 29GX12MM 2 RX/OTC H-E-B IN CONTROL QL(5 ea daily); MISC UNIFINEPENTIPS PLUS 2 RX/OTC HEALTHWISE SHORT QL(5 ea daily); 31GX5MM MISC PEN NEEDLES 31GX8MM 2 RX/OTC H-E-B IN CONTROL QL(5 ea daily); MISC UNIFINEPENTIPS PLUS 2 RX/OTC HEALTHWISE SHORT QL(5 ea daily); 32GX4MM MISC PEN NEEDLES/31G X 2 RX/OTC H-E-B IN CONTROL QL(5 ea daily); 3/16" MISC UNIFINEPENTIPS PLUS 2 RX/OTC HEALTHWISE SHORT QL(5 ea daily); 32GX5/32" MISC PEN NEEDLES/31G X 2 RX/OTC H-E-B IN CONTROL QL(5 ea daily) 5/16" MISC UNIFINEPENTIPS PLUS 2 HEALTHWISE UNIFINE QL(5 ea daily); 33GX5/32" MISC PENTIPS PEN NEEDLES 2 RX/OTC H-E-B INCONTROL PEN QL(5 ea daily); 32GX4MM MISC NEEDLES 29GX12MM 2 RX/OTC HEALTHY ACCENTS QL(5 ea daily); MISC UNIFINE PENTIPS PEN 2 RX/OTC HEALTHWISE INSULIN QL(5 ea daily); NEEDLES 29GX12MM MISC SYRINGE/U- 2 RX/OTC 100/0.3ML/30G X 5/16" HEALTHY ACCENTS QL(5 ea daily); MISC UNIFINE PENTIPS PEN 2 RX/OTC HEALTHWISE INSULIN QL(5 ea daily) NEEDLES 31GX5MM MISC SYRINGE/U- 2 100/0.3ML/31G X 5/16" HEALTHY ACCENTS QL(5 ea daily) MISC UNIFINE PENTIPS PEN 2 HEALTHWISE INSULIN QL(5 ea daily); NEEDLES 31GX6MM MISC SYRINGE/U- 2 RX/OTC 100/0.5ML/30G X 5/16" HEALTHY ACCENTS QL(5 ea daily); MISC UNIFINE PENTIPS PEN 2 RX/OTC NEEDLES 31GX8MM MISC

Coordinated Care of Washington Updated September 1, 2021

152 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HEALTHY ACCENTS QL(5 ea daily); INSULIN QL(5 ea daily); UNIFINE PENTIPS PEN 2 RX/OTC SYRINGE/1ML/28G X 1/2" 2 RX/OTC NEEDLES 32GX4MM MISC MISC INSULIN QL(5 ea daily); HM ULTICARE INSULIN QL(5 ea daily) SYRINGE/1ML/29G X 1/2" 2 RX/OTC SYRINGE/1ML/30G X 1/2" 2 MISC MISC INSULIN QL(5 ea daily); HM ULTICARE INSULIN QL(5 ea daily) SYRINGE/1ML/30G X 2 RX/OTC SYRINGE/U- 2 5/16" MISC 100/0.3ML/31G X 5/16" INSULIN QL(5 ea daily); MISC SYRINGE/NEEDLE 2 RX/OTC HM ULTICARE MINI PEN QL(5 ea daily); 0.3ML/30G X 5/16" MISC NEEDLES/31G X 5MM 2 RX/OTC INSULIN QL(5 ea daily) (3/16") MISC SYRINGE/NEEDLE 2 HM ULTICARE SHORT QL(5 ea daily); 0.3ML/31G X 5/16" MISC PEN NEEDLES 31GX8MM 2 RX/OTC INSULIN QL(5 ea daily); MISC SYRINGE/NEEDLE 2 RX/OTC HYPODERMIC NEEDLE 2 RX/OTC 0.5ML/29G X 1/2" MISC 18G X 1-1/2" MISC INSULIN QL(5 ea daily); HYPODERMIC NEEDLES 2 RX/OTC SYRINGE/NEEDLE 2 RX/OTC 18GX1-1/2" MISC 0.5ML/30G X 5/16" MISC INSULIN QL(5 ea daily) INSULIN QL(5 ea daily) SYRINGE/0.3ML/29G X 1" 2 SYRINGE/NEEDLE 2 MISC 0.5ML/31G X 5/16" MISC INSULIN QL(5 ea daily); INSULIN QL(5 ea daily); SYRINGE/0.3ML/29G X 2 RX/OTC SYRINGE/NEEDLE 2 RX/OTC 1/2" MISC 1ML/29G X 1/2" MISC INSULIN QL(5 ea daily); INSULIN QL(5 ea daily); SYRINGE/0.3ML/30G X 2 RX/OTC SYRINGE/NEEDLE 2 RX/OTC 5/16" MISC 1ML/30G X 5/16" MISC INSULIN QL(5 ea daily) INSULIN QL(5 ea daily) SYRINGE/0.3ML/31G X 2 SYRINGE/NEEDLE 2 5/16" MISC 1ML/31G X 5/16" MISC INSULIN QL(5 ea daily) INSULIN SYRINGE/U- QL(5 ea daily); SYRINGE/0.5ML/27G X 2 100/0.3ML/29G X 1/2" 2 RX/OTC 1/2" MISC MISC INSULIN QL(5 ea daily); INSULIN SYRINGE/U- QL(5 ea daily); SYRINGE/0.5ML/28G X 2 RX/OTC 100/0.5ML/29G X 1/2" 2 RX/OTC 1/2" MISC MISC INSULIN QL(5 ea daily) INSULIN SYRINGE/U- 2 QL(5 ea daily); SYRINGE/0.5ML/30G X 2 100/1ML/29G X 1/2" MISC RX/OTC 1/2" MISC INSULIN SYRINGE/U- QL(5 ea daily) INSULIN QL(5 ea daily); 100/1ML/30G X 5/16" 2 SYRINGE/0.5ML/30G X 2 RX/OTC MISC 5/16" MISC INSULIN SYRINGE/U- QL(5 ea daily); INSULIN QL(5 ea daily) 100/1ML/30G X 5/16" 2 RX/OTC SYRINGE/0.5ML/31G X 2 MISC 5/16" MISC Coordinated Care of Washington Updated September 1, 2021

153 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INSULIN SYRINGE/U- QL(5 ea daily) INSUPEN 33GX4MM MISC 2 QL(5 ea daily) 100/1ML/31G X 5/16" 2 MISC INSUPEN PEN NEEDLES 2 QL(5 ea daily); INSULIN QL(5 ea daily) 32G X4MM MISC RX/OTC SYRINGES/0.5ML/27GX1/ 2 INSUPEN SENSITIVE 2 QL(5 ea daily) 2" MISC 32GX6MM MISC INSULIN QL(5 ea daily); INSUPEN SENSITIVE 2 QL(5 ea daily) SYRINGES/0.5ML/28GX1/ 2 RX/OTC 32GX8MM MISC 2" MISC INSUPEN ULTRAFIN 2 QL(5 ea daily); INSULIN QL(5 ea daily); 29GX12MM MISC RX/OTC SYRINGES/0.5ML/29GX1/ 2 RX/OTC INSUPEN ULTRAFIN 2 QL(5 ea daily); 2" MISC 30GX8MM MISC RX/OTC INSULIN QL(5 ea daily); INSUPEN ULTRAFIN 2 QL(5 ea daily) SYRINGES/0.5ML/30GX5/ 2 RX/OTC 31GX6MM MISC 16" MISC INSUPEN ULTRAFIN 2 QL(5 ea daily); INSULIN QL(5 ea daily) 31GX8MM MISC RX/OTC SYRINGES/0.5ML/31GX 2 5/16" MISC KINRAY INSULIN QL(5 ea daily) SYRINGE PREFERRED 2 INSULIN QL(5 ea daily) PLUS/0.3ML/31G X 5/16" SYRINGES/0.5ML/31GX5/ 2 MISC 16" MISC KINRAY INSULIN QL(5 ea daily) INSULIN QL(5 ea daily); SYRINGE PREFERRED 2 SYRINGES/1ML/27GX/1/2" 2 RX/OTC PLUS/0.5ML/31G X 5/16" MISC MISC INSULIN QL(5 ea daily); KINRAY INSULIN QL(5 ea daily) SYRINGES/1ML/27GX1/2" 2 RX/OTC SYRINGE PREFERRED 2 MISC PLUS/1ML/31G X 5/16" INSULIN QL(5 ea daily); MISC SYRINGES/1ML/28GX1/2" 2 RX/OTC KINRAY INSULIN QL(5 ea daily); MISC SYRINGE/0.5ML/29G X 2 RX/OTC INSULIN QL(5 ea daily); 1/2" MISC SYRINGES/1ML/29GX1/2" 2 RX/OTC KMART VALU PLUS QL(5 ea daily); MISC INSULIN 2 RX/OTC INSULIN QL(5 ea daily) SYRINGE/1ML/29G MISC SYRINGES/1ML/30GX1/2" 2 KMART VALU PLUS QL(5 ea daily); MISC INSULIN 2 RX/OTC INSULIN QL(5 ea daily) SYRINGE/1ML/30G MISC SYRINGES/1ML/31GX5/16 2 KROGER INSULIN QL(5 ea daily); " MISC SYRINGE/0.3ML/29G X 2 RX/OTC INSUPEN 29G X 12MM 2 QL(5 ea daily); 1/2" MISC MISC RX/OTC KROGER INSULIN QL(5 ea daily); INSUPEN 31G X 5MM 2 QL(5 ea daily); SYRINGE/0.3ML/30G X 2 RX/OTC MISC RX/OTC 5/16" MISC INSUPEN 31G X 8MM 2 QL(5 ea daily); KROGER INSULIN QL(5 ea daily) MISC RX/OTC SYRINGE/0.3ML/31G X 2 5/16" MISC INSUPEN 32G X 4MM 2 QL(5 ea daily); MISC RX/OTC

Coordinated Care of Washington Updated September 1, 2021

154 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KROGER INSULIN QL(5 ea daily); LEADER INSULIN QL(5 ea daily) SYRINGE/0.5ML/29G X 2 RX/OTC SYRINGE/0.3ML/31G X 2 1/2" MISC 5/16" MISC KROGER INSULIN QL(5 ea daily); LEADER INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X 2 RX/OTC SYRINGE/0.5ML/28G X 2 RX/OTC 5/16" MISC 1/2" MISC KROGER INSULIN QL(5 ea daily) LEADER INSULIN QL(5 ea daily); SYRINGE/0.5ML/31G X 2 SYRINGE/0.5ML/29G X 2 RX/OTC 5/16" MISC 1/2" MISC KROGER INSULIN QL(5 ea daily); LEADER INSULIN QL(5 ea daily); SYRINGE/1ML/29G X 1/2" 2 RX/OTC SYRINGE/0.5ML/30G X 2 RX/OTC MISC 5/16" MISC KROGER INSULIN QL(5 ea daily); LEADER INSULIN QL(5 ea daily) SYRINGE/1ML/30G X 2 RX/OTC SYRINGE/0.5ML/31G X 2 5/16" MISC 5/16" MISC KROGER INSULIN QL(5 ea daily) LEADER INSULIN QL(5 ea daily); SYRINGE/1ML/31G X 2 SYRINGE/1ML/28G X 1/2" 2 RX/OTC 5/16" MISC MISC KROGER PEN NEEDLES 2 QL(5 ea daily); LEADER INSULIN QL(5 ea daily); 29G X12MM MISC RX/OTC SYRINGE/1ML/29G X 1/2" 2 RX/OTC MISC KROGER PEN NEEDLES 2 QL(5 ea daily); 31G X8MM MISC RX/OTC LEADER INSULIN QL(5 ea daily); SYRINGE/1ML/30G X 2 RX/OTC KROGER PEN NEEDLES 2 QL(5 ea daily) 31GX1/4" MISC 5/16" MISC KROGER PEN QL(5 ea daily) LEADER INSULIN QL(5 ea daily) NEEDLES/31G X1/4" 2 SYRINGE/1ML/31G X 2 MISC 5/16" MISC KROGER PEN QL(5 ea daily); LEADER UNIFINE QL(5 ea daily); NEEDLES/31G X3/16" 2 RX/OTC PENTIPS 2 RX/OTC MISC PLUS/MINI/31GX3/16" MISC KROGER PEN QL(5 ea daily); NEEDLES/31G X5/16" 2 RX/OTC LEADER UNIFINE QL(5 ea daily); MISC PENTIPS 2 RX/OTC PLUS/SHORT/31GX5/16" KROGER PEN QL(5 ea daily); MISC NEEDLES/32G X5/32" 2 RX/OTC MISC LEADER UNIFINE QL(5 ea daily); PENTIPS/MINI/31GX3/16" 2 RX/OTC KROGER PEN QL(5 ea daily) MISC NEEDLES/33G X5/32" 2 MISC LEADER UNIFINE QL(5 ea daily); PENTIPS/NANO/32GX5/32 2 RX/OTC LEADER INSULIN QL(5 ea daily); " MISC SYRINGE/0.3ML/29G X 2 RX/OTC 1/2" MISC LEADER UNIFINE QL(5 ea daily); PENTIPS/PLUS/32GX5/32" 2 RX/OTC LEADER INSULIN QL(5 ea daily); MISC SYRINGE/0.3ML/30G X 2 RX/OTC 5/16" MISC LITETOUCH INSULIN PEN QL(5 ea daily); NEEDLES/32G X 2 RX/OTC 4MM/MINI MISC

Coordinated Care of Washington Updated September 1, 2021

155 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LITETOUCH INSULIN QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily); SYRINGE/0.3ML/29G X 2 RX/OTC SYRINGE/U-100/1ML/30G 2 RX/OTC 1/2" MISC X 5/16" MISC LITETOUCH INSULIN QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily) SYRINGE/0.3ML/30G X 2 RX/OTC SYRINGE/U-100/1ML/31G 2 5/16" MISC X 5/16" MISC LITETOUCH INSULIN QL(5 ea daily) LITETOUCH PEN QL(5 ea daily) SYRINGE/0.3ML/31G X 2 NEEDLES 29GX12.7MM 2 5/16" MISC MISC LITETOUCH INSULIN QL(5 ea daily); LITETOUCH PEN QL(5 ea daily) SYRINGE/0.5ML/30G X 2 RX/OTC NEEDLES 31G X 6MM 2 5/16" MISC MISC LITETOUCH INSULIN QL(5 ea daily) LITETOUCH PEN QL(5 ea daily) SYRINGE/0.5ML/31G X 2 NEEDLES 31G X 2 5/16" MISC 6MM/ULTRA SHORT LITETOUCH INSULIN QL(5 ea daily); MISC SYRINGE/1ML/30G X 2 RX/OTC LITETOUCH PEN QL(5 ea daily); 5/16" MISC NEEDLES 31GX8MM 2 RX/OTC LITETOUCH INSULIN QL(5 ea daily); SHORT MISC SYRINGE/U- 2 RX/OTC LITETOUCH PEN QL(5 ea daily); 100/0.3ML/30G X 5/16" NEEDLES/31G X 3/16" 2 RX/OTC MISC MISC LITETOUCH INSULIN QL(5 ea daily) LITETOUCH PEN QL(5 ea daily); SYRINGE/U- 2 NEEDLES/31G X 2 RX/OTC 100/0.3ML/31G X 5/16" 5MM/MINI MISC MISC LITETOUCH PEN QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily); NEEDLES/31G X 2 RX/OTC SYRINGE/U- 2 RX/OTC 8MM/SHORT MISC 100/0.5ML/28G X 1/2" LONGS INSULIN QL(5 ea daily) MISC SYRINGE/0.5ML/31G X 2 LITETOUCH INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/U- 2 RX/OTC MAGELLAN INSULIN QL(5 ea daily); 100/0.5ML/29G X 1/2" SAFETY SYRINGE/U- 2 RX/OTC MISC 100/0.3ML/29G X 1/2" LITETOUCH INSULIN QL(5 ea daily); MISC SYRINGE/U- 2 RX/OTC MAGELLAN INSULIN QL(5 ea daily); 100/0.5ML/30G X 5/16" SAFETY SYRINGE/U- 2 RX/OTC MISC 100/0.3ML/30G X 5/16" LITETOUCH INSULIN QL(5 ea daily) MISC SYRINGE/U- 2 MAGELLAN INSULIN QL(5 ea daily); 100/0.5ML/31G X 5/16" SAFETY SYRINGE/U- 2 RX/OTC MISC 100/0.5ML/29G X 1/2" LITETOUCH INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/28G 2 RX/OTC MAGELLAN INSULIN QL(5 ea daily); X 1/2" MISC SAFETY SYRINGE/U- 2 RX/OTC LITETOUCH INSULIN QL(5 ea daily); 100/0.5ML/30G X 5/16" SYRINGE/U-100/1ML/29G 2 RX/OTC MISC X 1/2" MISC

Coordinated Care of Washington Updated September 1, 2021

156 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MAGELLAN INSULIN QL(5 ea daily); MEIJER PEN NEEDLES 2 QL(5 ea daily); SAFETY SYRINGE/U- 2 RX/OTC 29G X12MM MISC RX/OTC 100/1ML/29G X 1/2" MISC MEIJER PEN NEEDLES 2 QL(5 ea daily) MAGELLAN INSULIN QL(5 ea daily); 31G X6MM MISC SAFETY SYRINGE/U- RX/OTC 2 MEIJER PEN NEEDLES 2 QL(5 ea daily); 100/1ML/30G X 5/16" 31G X8MM MISC RX/OTC MISC MICRODOT PEN QL(5 ea daily) MARATHON MEDICAL QL(5 ea daily); NEEDLE/31G X 6 MM 2 PENTIPS29GX12MM 2 RX/OTC MISC MISC MICRODOT PEN QL(5 ea daily); MARATHON MEDICAL 2 QL(5 ea daily); NEEDLE/32G X 4 MM 2 RX/OTC PENTIPS31GX5MM MISC RX/OTC MISC MARATHON MEDICAL 2 QL(5 ea daily); MICRODOT PEN QL(5 ea daily) PENTIPS31GX8MM MISC RX/OTC NEEDLE/33G X 4 MM 2 MARATHON MEDICAL 2 QL(5 ea daily); MISC PENTIPS32GX4MM MISC RX/OTC MM INSULIN SYRINGE/U- QL(5 ea daily); MAXI-COMFORT INSULIN QL(5 ea daily); 100/0.3ML/30G X 5/16" 2 RX/OTC SYRINGE/U- 2 RX/OTC MISC 100/0.5ML/28GX1/2" MISC MM INSULIN SYRINGE/U- QL(5 ea daily) MAXI-COMFORT INSULIN QL(5 ea daily); 100/0.3ML/31G X 5/16" 2 SYRINGE/U- 2 RX/OTC MISC 100/1ML/28GX1/2" MISC MM INSULIN SYRINGE/U- QL(5 ea daily); MAXICOMFORT II PEN QL(5 ea daily) 100/1/2ML/30G X 5/16" 2 RX/OTC NEEDLES/31G X 1/4" 2 MISC MISC MM INSULIN SYRINGE/U- QL(5 ea daily) MAXICOMFORT INSULIN QL(5 ea daily) 100/1/2ML/31G X 5/16" 2 SYRINGES 27G X 1/2" 2 MISC MISC MM INSULIN SYRINGE/U- QL(5 ea daily); MAXICOMFORT INSULIN QL(5 ea daily); 100/1ML/30G X 5/16" 2 RX/OTC SYRINGES 27G X 1/2" 2 RX/OTC MISC MISC MM INSULIN SYRINGE/U- QL(5 ea daily) MEDIC INSULIN QL(5 ea daily); 100/1ML/31G X 5/16" 2 SYRINGE/0.3ML/30G X 2 RX/OTC MISC 5/16" MISC MM PEN NEEDLES 31G X 2 QL(5 ea daily) MEDIC INSULIN QL(5 ea daily); 1/4" MISC SYRINGE/0.5ML/30G X 2 RX/OTC MM PEN NEEDLES 31G X 2 QL(5 ea daily); 5/16" MISC 3/16" MISC RX/OTC MEDICINE SHOPPE PEN QL(5 ea daily); MM PEN NEEDLES 31G X 2 QL(5 ea daily); NEEDLES 29G X 12MM 2 RX/OTC 5/16" MISC RX/OTC MISC MM PEN NEEDLES 32G X 2 QL(5 ea daily); MEDICINE SHOPPE PEN QL(5 ea daily) 5/32" MISC RX/OTC NEEDLES 31G X 6MM 2 MISC MONOJECT BLUNTIP RX/OTC SYRINGE/3ML/CANNULA/ 2 MEDICINE SHOPPE PEN QL(5 ea daily); IV ACCESS MISC NEEDLES 31G X 8MM 2 RX/OTC MISC MONOJECT HYPO/ALUM 2 RX/OTC HUB/18G X 1-1/2" MISC

Coordinated Care of Washington Updated September 1, 2021

157 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MONOJECT HYPO/ALUM RX/OTC MONOJECT INSULIN QL(5 ea daily); HUB/LUER LOCK/SHORT 2 SYRINGE/SOFTPACK/1M 2 RX/OTC BEVEL/18G X 1-1/2" MISC L/27G X 1/2" MISC MONOJECT RX/OTC MONOJECT INSULIN QL(5 ea daily); 2 HYPO/POLYPROPYLENE SYRINGE/SOFTPACK/U- 2 RX/OTC HUB/18G X 1-1/2" MISC 100/0.5ML/28G X 1/2" MONOJECT RX/OTC MISC HYPO/POLYPROPYLENE 2 MONOJECT INSULIN QL(5 ea daily); HUB/LL/SHORT SYRINGE/U- 2 RX/OTC BEVEL/18G X 1-1/2" MISC 100/0.3ML/30G X 5/16" MISC MONOJECT INSULIN 2 QL(5 ea daily); SYRINGE/1ML MISC RX/OTC MONOJECT INSULIN QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily) SYRINGE/U- 2 RX/OTC SYRINGE/1ML/31G X 2 100/0.5ML/30G X 5/16" 5/16" MISC MISC MONOJECT INSULIN QL(5 ea daily) MONOJECT INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/28G 2 RX/OTC SYRINGE/DETACH 2 NEEDLE/1ML/25G X 5/8" X 1/2" MISC MISC MONOJECT INSULIN QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/30G 2 RX/OTC X 5/16" MISC SYRINGE/DETACH 2 RX/OTC NEEDLE/1ML/27G X 1/2" MONOJECT INSULIN QL(5 ea daily); MISC SYRINGEREGULAR LUER 2 RX/OTC MONOJECT INSULIN QL(5 ea daily); TIP/SOFTPACK/1ML MISC SYRINGE/PERM 2 RX/OTC MONOJECT MAGELLAN RX/OTC NEEDLE/1ML/28G X 1/2" SAFETYNEEDLE 18GX1- 2 MISC 1/2" MISC MONOJECT INSULIN QL(5 ea daily); MONOJECT PHARMACY RX/OTC SYRINGE/PERM 2 RX/OTC TRAY/LUER LOCK/3ML 2 NEEDLE/U-100/0.5ML/28G MISC X 1/2" MISC MONOJECT STANDARD RX/OTC MONOJECT INSULIN QL(5 ea daily); HYPODERMIC 2 SYRINGE/SAFETY/PERM 2 RX/OTC NEEDLE/POLYPROPYLE NEEDLE/0.3ML/29G X 1/2" NE/18GX1-1/2" MISC MISC MONOJECT RX/OTC MONOJECT INSULIN QL(5 ea daily); SYRINGE/LUER 2 SYRINGE/SAFETY/PERM 2 RX/OTC LOCK/3ML MISC NEEDLE/0.3ML/29GX1/2" MONOJECT RX/OTC MISC SYRINGE/LUER-LOCK 2 MONOJECT INSULIN QL(5 ea daily); TIP/3ML MISC SYRINGE/SAFETY/PERM 2 RX/OTC MONOJECT RX/OTC NEEDLE/0.5ML/29G X 1/2" SYRINGE/REG LUER/3ML 2 MISC MISC MONOJECT INSULIN QL(5 ea daily); MONOJECT RX/OTC SYRINGE/SAFETY/PERM 2 RX/OTC SYRINGE/REGULARTIP/3 2 NEEDLE/1ML/29G X 1/2" ML MISC MISC

Coordinated Care of Washington Updated September 1, 2021

158 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MONOJECT ULTRA QL(5 ea daily); NOKOR VENTED NEEDLE RX/OTC COMFORT INSULIN 2 RX/OTC THINWALL NON-CORING 2 SYRINGE/0.3ML/29G X 18GX1-1/2" MISC 1/2" MISC NOVOFINE AUTOCOVER QL(5 ea daily); MONOJECT ULTRA QL(5 ea daily); PEN NEEDLE 30G X 8MM 2 RX/OTC COMFORT INSULIN 2 RX/OTC MISC SYRINGE/0.3ML/30G X NOVOFINE PEN NEEDLE 2 QL(5 ea daily) 5/16" MISC 32G X 4MM MISC MONOJECT ULTRA QL(5 ea daily) NOVOFINE PLUS PEN 2 QL(5 ea daily); COMFORT INSULIN 2 NEEDLE32G X 4MM MISC RX/OTC SYRINGE/0.3ML/31G X 5/16" MISC NOVOTWIST PEN 2 QL(5 ea daily); NEEDLE 32GX 5MM MISC RX/OTC MONOJECT ULTRA QL(5 ea daily); PATIENT SAFE SYRINGE RX/OTC COMFORT INSULIN 2 RX/OTC 2 SYRINGE/0.5ML/28G X 3ML MISC 1/2" MISC PC UNIFINE PENTIPS 2 QL(5 ea daily); MONOJECT ULTRA QL(5 ea daily); 29G X1/2" MISC RX/OTC PC UNIFINE PENTIPS QL(5 ea daily); COMFORT INSULIN 2 RX/OTC 2 SYRINGE/0.5ML/29G X 31G X5MM MINI MISC RX/OTC 1/2" MISC PC UNIFINE PENTIPS QL(5 ea daily) MONOJECT ULTRA QL(5 ea daily); 31G X6MM ULTRA 2 SHORT MISC COMFORT INSULIN 2 RX/OTC SYRINGE/0.5ML/30G X PC UNIFINE PENTIPS 2 QL(5 ea daily); 5/16" MISC 31G X8MM SHORT MISC RX/OTC MONOJECT ULTRA QL(5 ea daily) PEN NEEDLES 29G X 2 QL(5 ea daily); COMFORT INSULIN 2 12MM MISC RX/OTC SYRINGE/0.5ML/31G X PEN NEEDLES 29GX1/2" 2 QL(5 ea daily); 5/16" MISC MISC RX/OTC MONOJECT ULTRA QL(5 ea daily); PEN NEEDLES 2 QL(5 ea daily); COMFORT INSULIN 2 RX/OTC 29GX12MM MISC RX/OTC SYRINGE/1ML/28G X 1/2" MISC PEN NEEDLES 30GX5/16" 2 QL(5 ea daily); MISC RX/OTC MONOJECT ULTRA QL(5 ea daily); PEN NEEDLES 30GX8MM QL(5 ea daily); COMFORT INSULIN 2 RX/OTC 2 SYRINGE/1ML/29G X 1/2" MISC RX/OTC MISC PEN NEEDLES 31G X 1/4" 2 QL(5 ea daily) MS INSULIN QL(5 ea daily) SHORT MISC SYRINGE/0.3ML/31G X 2 PEN NEEDLES 31G X 2 QL(5 ea daily); 5/16" MISC 3/16" MISC RX/OTC MS INSULIN QL(5 ea daily) PEN NEEDLES 31G X 2 QL(5 ea daily); SYRINGE/0.5ML/31G X 2 5MM MISC RX/OTC 5/16" MISC PEN NEEDLES 31G X 2 QL(5 ea daily) MS INSULIN QL(5 ea daily) 6MM MISC SYRINGE/1ML/31G X 2 PEN NEEDLES 31G X 2 QL(5 ea daily); 5/16" MISC 8MM MISC RX/OTC NOKOR ADMIX NEEDLE RX/OTC PEN NEEDLES 31GX5/16" 2 QL(5 ea daily); THIN WALL NON-CORING 2 MISC RX/OTC 18G X 1-1/2" MISC

Coordinated Care of Washington Updated September 1, 2021

159 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PEN NEEDLES 31GX6MM 2 QL(5 ea daily) POLY HUB NEEDLE/18G 2 RX/OTC (1/4") MISC X 1-1-1/2" MISC PEN NEEDLES 31GX8MM 2 QL(5 ea daily); PRECISION SURE-DOSE QL(5 ea daily); ) MISC (5/16" RX/OTC INSULIN 2 RX/OTC SYRINGE/0.3ML/30G X PEN NEEDLES 31GX8MM 2 QL(5 ea daily); MISC RX/OTC 5/16" MISC PRECISION SURE-DOSE QL(5 ea daily); PEN NEEDLES 32G X 2 QL(5 ea daily); 4MM MISC RX/OTC INSULIN 2 RX/OTC SYRINGE/0.5ML/28G X PEN NEEDLES 32G X 2 QL(5 ea daily); 1/2" MISC 5MM MISC RX/OTC PRECISION SURE-DOSE QL(5 ea daily); PEN NEEDLES 32G X QL(5 ea daily) 2 INSULIN 2 RX/OTC 6MM MISC SYRINGE/0.5ML/29G X PEN NEEDLES 32GX4MM 2 QL(5 ea daily); 1/2" MISC MISC RX/OTC PRECISION SURE-DOSE QL(5 ea daily) PEN NEEDLES 33G X QL(5 ea daily) 2 INSULIN 2 5/32" MISC SYRINGE/0.5ML/30G X 3/8" MISC PEN NEEDLES/29G X 1/2" 2 QL(5 ea daily); MISC RX/OTC PRECISION SURE-DOSE QL(5 ea daily); INSULIN RX/OTC PEN NEEDLES/31G X 1/4" 2 QL(5 ea daily) 2 MISC SYRINGE/1ML/28G X 1/2" MISC PEN NEEDLES/31G X 2 QL(5 ea daily); 3/16" MISC RX/OTC PRECISION SURE-DOSE QL(5 ea daily); PLUSINSULIN RX/OTC PEN NEEDLES/31G X 2 QL(5 ea daily); 2 5/16" MISC RX/OTC SYRINGE/0.3ML/29G X 1/2" MISC PEN NEEDLES/31G X 2 QL(5 ea daily) 6MM MISC PRECISION SURE-DOSE QL(5 ea daily); PLUSINSULIN 2 RX/OTC PEN NEEDLES/32G X 2 QL(5 ea daily); SYRINGE/1ML/29G X 1/2" 5/32" MISC RX/OTC MISC PENTIPS 29G X 12MM 2 QL(5 ea daily); PREFERRED PLUS QL(5 ea daily); MISC RX/OTC INSULIN SYRINGE/U- 2 RX/OTC PENTIPS 29GX12MM 2 QL(5 ea daily); 100/0.3ML/29G X 1/2" MISC RX/OTC MISC PENTIPS 31G X 5MM 2 QL(5 ea daily); PREFERRED PLUS QL(5 ea daily); MISC RX/OTC INSULIN SYRINGE/U- 2 RX/OTC 100/0.3ML/30G X 5/16" PENTIPS 31G X 8MM 2 QL(5 ea daily); MISC RX/OTC MISC QL(5 ea daily); PREFERRED PLUS QL(5 ea daily); PENTIPS 31GX5MM MISC 2 RX/OTC INSULIN SYRINGE/U- 2 RX/OTC QL(5 ea daily) 100/0.5ML/28G X 1/2" PENTIPS 31GX6MM MISC 2 MISC QL(5 ea daily); PREFERRED PLUS QL(5 ea daily); PENTIPS 31GX8MM MISC 2 RX/OTC INSULIN SYRINGE/U- 2 RX/OTC 100/0.5ML/29G X 1/2" PENTIPS 32G X 4MM 2 QL(5 ea daily); MISC MISC RX/OTC PENTIPS 32GX4MM MISC 2 QL(5 ea daily); RX/OTC

Coordinated Care of Washington Updated September 1, 2021

160 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREFERRED PLUS QL(5 ea daily); PRO COMFORT INSULIN QL(5 ea daily); INSULIN SYRINGE/U- 2 RX/OTC SYRINGES/1ML/30G X 2 RX/OTC 100/0.5ML/30G X 5/16" 5/16" MISC MISC PRO COMFORT INSULIN QL(5 ea daily) PREFERRED PLUS QL(5 ea daily); SYRINGES/1ML/31G X 2 INSULIN SYRINGE/U- 2 RX/OTC 5/16" MISC 100/1ML/28G X 1/2" MISC PRO COMFORT PEN QL(5 ea daily); PREFERRED PLUS QL(5 ea daily); NEEDLES/31G X 8MM 2 RX/OTC INSULIN SYRINGE/U- 2 RX/OTC MISC 100/1ML/29G X 1/2" MISC PRO COMFORT PEN QL(5 ea daily); PREFERRED PLUS QL(5 ea daily); NEEDLES/32G X 4MM 2 RX/OTC INSULIN SYRINGE/U- 2 RX/OTC MISC 100/1ML/30G X 5/16" PRO COMFORT PEN QL(5 ea daily); MISC NEEDLES/32G X 5MM 2 RX/OTC PREFERRED PLUS QL(5 ea daily); MISC UNIFINE PENTIPS 29G X 2 RX/OTC PRO COMFORT PEN QL(5 ea daily) 12MM MISC NEEDLES/32G X 6MM 2 PREFERRED PLUS QL(5 ea daily) MISC UNIFINE PENTIPS 31G X 2 PRODIGY INSULIN QL(5 ea daily) 6MM ULTRA SHORT SYRING/U-100/0.3ML/31G 2 MISC X 5/16" MISC PREFERRED PLUS QL(5 ea daily); PRODIGY INSULIN QL(5 ea daily) UNIFINE PENTIPS 31G X 2 RX/OTC SYRINGE/1/2ML/31G X 2 8MM SHORT MISC 5/16" MISC PREFERRED PLUS QL(5 ea daily); PRODIGY INSULIN QL(5 ea daily); UNIFINE PENTIPS 2 RX/OTC SYRINGE/1ML/28G X 1/2" 2 RX/OTC 32GX4MM MISC MISC PREFERRED PLUS QL(5 ea daily); PURE COMFORT PEN 2 QL(5 ea daily) UNIFINE 2 RX/OTC NEEDLE 32G X6MM MISC PENTIPS/MINI/31GX5MM MISC PURE COMFORT PEN 2 QL(5 ea daily) NEEDLE 32G X8MM MISC PREVENT SAFETY PEN 2 QL(5 ea daily) NEEDLES 31GX1/4" MISC PURE COMFORT PEN QL(5 ea daily); NEEDLE/32G X 5MM 2 RX/OTC PREVENT SAFETY PEN QL(5 ea daily); MISC NEEDLES 31GX5/16" 2 RX/OTC MISC PURE COMFORT PEN 2 QL(5 ea daily); NEEDLE/32G X4MM MISC RX/OTC PRO COMFORT INSULIN QL(5 ea daily) SYRINGES/0.5ML/30G X 2 PX EXTRA SHORT PEN QL(5 ea daily) 1/2" MISC NEEDLES 31GX6MM 2 MISC PRO COMFORT INSULIN QL(5 ea daily); SYRINGES/0.5ML/30G X 2 RX/OTC PX INSULIN SYRINGE/U- QL(5 ea daily) 5/16" MISC 100/0.5ML/30G X 1/2" 2 MISC PRO COMFORT INSULIN QL(5 ea daily) SYRINGES/0.5ML/31G X 2 PX MINI PEN NEEDLES 2 QL(5 ea daily); 5/16" MISC 31GX5MM MISC RX/OTC PRO COMFORT INSULIN QL(5 ea daily) PX PEN NEEDLE 2 QL(5 ea daily); SYRINGES/1ML/30G X 2 29GX12MM MISC RX/OTC 1/2" MISC

Coordinated Care of Washington Updated September 1, 2021

161 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PX PEN NEEDLE 2 QL(5 ea daily); RELION INSULIN QL(5 ea daily); 31GX8MM MISC RX/OTC SYRINGE/U- 2 RX/OTC PX SHORTLENGTH PEN QL(5 ea daily); 100/0.5ML/29G X 1/2" NEEDLES/31GX8MM 2 RX/OTC MISC MISC RELION INSULIN QL(5 ea daily) SYRINGE/U- QC PEN NEEDLES 29G X 2 QL(5 ea daily); 2 12MM MISC RX/OTC 100/0.5ML/31G X 5/16" MISC QC PEN NEEDLES 31G X 2 QL(5 ea daily) 6MM MISC RELION INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/31G 2 QC PEN NEEDLES 31G X 2 QL(5 ea daily); X 5/16" MISC 8MM MISC RX/OTC RELION MINI PEN QL(5 ea daily) QC UNIFINE PENTIPS 2 QL(5 ea daily); NEEDLES 31GX6MM 2 32GX4MM MISC RX/OTC MISC RA INSULIN QL(5 ea daily); RELION PEN NEEDLES 2 QL(5 ea daily); SYRINGE/0.5ML/29G X 2 RX/OTC 29GX12MM MISC RX/OTC 1/2" MISC RELION PEN NEEDLES 2 QL(5 ea daily) RA INSULIN QL(5 ea daily); 31G X6MM MISC SYRINGE/1ML/29G X 1/2" 2 RX/OTC MISC RELION PEN NEEDLES 2 QL(5 ea daily); 31G X8MM MISC RX/OTC RA INSULIN SYRINGE/U- QL(5 ea daily); 100/0.5ML/30G X 5/16" 2 RX/OTC RELION PEN NEEDLES 2 QL(5 ea daily); MISC 31GX5/16" MISC RX/OTC RA INSULIN SYRINGE/U- QL(5 ea daily); RELION PEN NEEDLES 2 QL(5 ea daily) 100/1 ML/30G X 5/16" 2 RX/OTC 31GX6MM MISC MISC RELION PEN NEEDLES 2 QL(5 ea daily); 31GX8MM MISC RX/OTC RA PEN NEEDLES 31G X 2 QL(5 ea daily); 5MM3/16" MISC RX/OTC RELION PEN NEEDLES 2 QL(5 ea daily); 32G X4MM MISC RX/OTC RA PEN NEEDLES 31G X 2 QL(5 ea daily); 8MM5/16" MISC RX/OTC RELION PEN NEEDLES 2 QL(5 ea daily); REALITY INSULIN QL(5 ea daily); 32G X5/32" MISC RX/OTC SYRINGE/U- 2 RX/OTC RELION PEN NEEDLES 2 QL(5 ea daily); 100/0.5ML/28G X 1/2" 32GX4MM MISC RX/OTC MISC RELION PEN 2 QL(5 ea daily) REALITY INSULIN QL(5 ea daily); NEEDLES/31G X1/4" MISC SYRINGE/U- RX/OTC 2 RELION SHORT PEN 2 QL(5 ea daily); 100/0.5ML/29G X 1/2" NEEDLES31GX8MM MISC RX/OTC MISC SAFESNAP INSULIN QL(5 ea daily); REALITY INSULIN QL(5 ea daily); SYRINGE/0.3ML/30G X 2 RX/OTC SYRINGE/U-100/1ML/28G 2 RX/OTC 5/16" MISC X 1/2" MISC SAFESNAP INSULIN QL(5 ea daily); REALITY INSULIN QL(5 ea daily); SYRINGE/0.5ML/29G X 2 RX/OTC SYRINGE/U-100/1ML/29G 2 RX/OTC 1/2" MISC X 1/2" MISC SAFESNAP INSULIN QL(5 ea daily); RELION INSULIN QL(5 ea daily) SYRINGE/0.5ML/30G X 2 RX/OTC SYRINGE/U- 2 5/16" MISC 100/0.3ML/31G X 5/16" MISC

Coordinated Care of Washington Updated September 1, 2021

162 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SAFESNAP INSULIN QL(5 ea daily); SECURESAFE SAFETY QL(5 ea daily); SYRINGE/1ML/28G X 1/2" 2 RX/OTC INSULIN SYRINGES/U- 2 RX/OTC MISC 100/1ML/29GX1/2" MISC SAFESNAP INSULIN QL(5 ea daily); SECURESAFE SAFETY QL(5 ea daily); SYRINGE/1ML/29G X 1/2" 2 RX/OTC PEN NEEDLES/30G X 2 RX/OTC MISC 5/16" MISC SAFESNAP 2 RX/OTC SHOPKO UNIFINE QL(5 ea daily); SYRINGE/3ML MISC PENTIPS PEN 2 RX/OTC SAFETY INSULIN QL(5 ea daily); NEEDLES/MICRO/32GX4 SYRINGES 2 RX/OTC MM MISC 0.5ML/29GX1/2" MISC SHOPKO UNIFINE QL(5 ea daily); SAFETY INSULIN QL(5 ea daily); PENTIPS PEN 2 RX/OTC SYRINGES 2 RX/OTC NEEDLES/MINI/31GX5MM 0.5ML/30GX5/16" MISC MISC SAFETY INSULIN QL(5 ea daily); SHOPKO UNIFINE QL(5 ea daily); SYRINGES 1ML/27GX1/2" 2 RX/OTC PENTIPS PEN 2 RX/OTC MISC NEEDLES/ORIGINAL/29G X12MM MISC SAFETY INSULIN QL(5 ea daily); SYRINGES 1ML/29GX1/2" 2 RX/OTC SHOPKO UNIFINE QL(5 ea daily); MISC PENTIPS PEN 2 RX/OTC NEEDLES/SHORT/31GX8 SAFETY INSULIN QL(5 ea daily) MM MISC SYRINGES 1ML/30GX1/2" 2 MISC SHOPKO UNIFINE QL(5 ea daily); PENTIPS PLUS PEN 2 RX/OTC SAFETY-LOK SYRINGE 2 RX/OTC NEEDLES/MICRO/REMOV 3ML LUER-LOK MISC R/32GX4MM MISC SB INSULIN SYRINGE/U- QL(5 ea daily); SHOPKO UNIFINE QL(5 ea daily); 100/0.5ML/29G X 1/2" 2 RX/OTC PENTIPS PLUS PEN 2 RX/OTC MISC NEEDLES/MINI/REMOVE SB INSULIN SYRINGE/U- QL(5 ea daily); R/31GX5MM MISC 100/0.5ML/30G X 5/16" 2 RX/OTC SHOPKO UNIFINE QL(5 ea daily); MISC PENTIPS PLUS PEN 2 RX/OTC SB INSULIN SYRINGE/U- 2 QL(5 ea daily); NEEDLES/REMOVER/29G 100/1ML/29G X 1/2" MISC RX/OTC X12MM MISC SB INSULIN SYRINGE/U- QL(5 ea daily); SHOPKO UNIFINE QL(5 ea daily); 100/1ML/30G X 5/16" 2 RX/OTC PENTIPS PLUS PEN 2 RX/OTC MISC NEEDLES/SHORT/REMO SB INSULIN SYRINGE/U- QL(5 ea daily) VR/31GX8MM MISC 100/1ML/31G X 5/16" 2 SURE COMFORT QL(5 ea daily); MISC INSULIN SYRINGE/U- 2 RX/OTC SECURESAFE SAFETY RX/OTC 100/0.3ML/29G X 1/2" MISC HYPODERMIC 2 NEEDLE/18G X 1-1/2" SURE COMFORT QL(5 ea daily) MISC INSULIN SYRINGE/U- 2 SECURESAFE SAFETY QL(5 ea daily); 100/0.3ML/30G X 1/2" INSULIN SYRINGES/U- 2 RX/OTC MISC 100/0.5ML/29GX1/2" MISC

Coordinated Care of Washington Updated September 1, 2021

163 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SURE COMFORT QL(5 ea daily); SURE COMFORT QL(5 ea daily) INSULIN SYRINGE/U- 2 RX/OTC INSULIN SYRINGE/U- 2 100/0.3ML/30G X 5/16" 100/1ML/31G X 5/16" MISC MISC SURE COMFORT QL(5 ea daily) SURE COMFORT PEN QL(5 ea daily) INSULIN SYRINGE/U- 2 NEEDLES29GX1/2" 2 100/0.3ML/31G X 5/16 12.7MM MISC MISC SURE COMFORT PEN QL(5 ea daily); SURE COMFORT QL(5 ea daily) NEEDLES30GX5/16" 2 RX/OTC INSULIN SYRINGE/U- 2 SHORT MISC 100/0.3ML/31G X 5/16" SURE COMFORT PEN QL(5 ea daily); MISC NEEDLES31GX3/16" 2 RX/OTC SURE COMFORT QL(5 ea daily); (5MM) MISC INSULIN SYRINGE/U- 2 RX/OTC SURE COMFORT PEN QL(5 ea daily); 100/0.5ML/28G X 1/2" NEEDLES31GX5/16" 2 RX/OTC MISC (8MM) MISC SURE COMFORT QL(5 ea daily); SURE COMFORT PEN 2 QL(5 ea daily); INSULIN SYRINGE/U- 2 RX/OTC NEEDLES32GX5/32" MISC RX/OTC 100/0.5ML/29G X 1/2" MISC SURE COMFORT PEN 2 QL(5 ea daily) NEEDLES32GX6MM MISC SURE COMFORT QL(5 ea daily) SURE-FINE PEN QL(5 ea daily) INSULIN SYRINGE/U- 2 100/0.5ML/30G X 1/2" NEEDLES 29GX1/2" 2 MISC 12.7MM MISC SURE COMFORT QL(5 ea daily); SURE-FINE PEN QL(5 ea daily); NEEDLES 31GX3/16" 5MM 2 RX/OTC INSULIN SYRINGE/U- 2 RX/OTC 100/0.5ML/30G X 5/16" MISC MISC SURE-FINE PEN QL(5 ea daily); SURE COMFORT QL(5 ea daily) NEEDLES 31GX5/16" 8MM 2 RX/OTC MISC INSULIN SYRINGE/U- 2 100/0.5ML/31G X 5/16 SURE-JECT INSULIN QL(5 ea daily); MISC SYRINGE/U- 2 RX/OTC SURE COMFORT QL(5 ea daily); 100/0.3ML/29G X 1/2" INSULIN SYRINGE/U- 2 RX/OTC MISC 100/1ML/28G X 1/2" MISC SURE-JECT INSULIN QL(5 ea daily); SURE COMFORT QL(5 ea daily); SYRINGE/U- 2 RX/OTC INSULIN SYRINGE/U- 2 RX/OTC 100/0.3ML/30G X 5/16" 100/1ML/29G X 1/2" MISC MISC SURE COMFORT QL(5 ea daily) SURE-JECT INSULIN QL(5 ea daily) INSULIN SYRINGE/U- 2 SYRINGE/U- 2 100/1ML/30G X 1/2" MISC 100/0.3ML/31G X 5/16" MISC SURE COMFORT QL(5 ea daily); SURE-JECT INSULIN QL(5 ea daily); INSULIN SYRINGE/U- 2 RX/OTC 100/1ML/30G X 5/16" SYRINGE/U- 2 RX/OTC MISC 100/0.5ML/28G X 1/2" MISC

Coordinated Care of Washington Updated September 1, 2021

164 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SURE-JECT INSULIN QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily) SYRINGE/U- 2 RX/OTC SYRINGEU- 2 100/0.5ML/29G X 1/2" 100/0.3ML/31G X 5/16" MISC MISC SURE-JECT INSULIN QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily); SYRINGE/U- 2 RX/OTC SYRINGEU- 2 RX/OTC 100/0.5ML/30G X 5/16" 100/0.5ML/29G X 1/2" MISC MISC SURE-JECT INSULIN QL(5 ea daily) TECHLITE INSULIN QL(5 ea daily) SYRINGE/U- 2 SYRINGEU- 2 100/0.5ML/31G X 5/16" 100/0.5ML/30G X 1/2" MISC MISC SURE-JECT INSULIN QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily); 2 SYRINGE/U-100/1ML/28G RX/OTC SYRINGEU- 2 RX/OTC X 1/2" MISC 100/0.5ML/30G X 5/16" SURE-JECT INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/29G 2 RX/OTC TECHLITE INSULIN QL(5 ea daily) X 1/2" MISC SYRINGEU- 2 SURE-JECT INSULIN QL(5 ea daily); 100/0.5ML/31G X 5/16" SYRINGE/U-100/1ML/30G 2 RX/OTC MISC X 5/16" MISC TECHLITE INSULIN QL(5 ea daily); SURE-JECT INSULIN QL(5 ea daily) SYRINGEU-100/1ML/29G 2 RX/OTC SYRINGE/U-100/1ML/31G 2 X 1/2" MISC X 5/16" MISC TECHLITE INSULIN QL(5 ea daily) SYRINGEU-100/1ML/30G 2 SYRINGE/BLUNT 2 RX/OTC PLASTIC CANNULA MISC X 1/2" MISC TECHLITE INSULIN QL(5 ea daily); SYRINGE/LUER 2 RX/OTC LOCK/3ML MISC SYRINGEU-100/1ML/30G 2 RX/OTC X 5/16" MISC SYRINGE/LUER SLIP/3ML 2 RX/OTC MISC TECHLITE INSULIN QL(5 ea daily) SYRINGEU-100/1ML/31G 2 SYRINGES/LUER RX/OTC X 5/16" MISC LOCK/WITHOUT 2 NEEDLE/3ML MISC TECHLITE PEN NEEDLES 2 QL(5 ea daily); 29GX 12 MM MISC RX/OTC TECHLITE INSULIN QL(5 ea daily); TECHLITE PEN NEEDLES QL(5 ea daily); SYRINGEU- 2 RX/OTC 2 100/0.3ML/29G X 1/2" 31GX 5MM MISC RX/OTC MISC TECHLITE PEN QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily) NEEDLES/31GX 5MM 2 RX/OTC MISC SYRINGEU- 2 100/0.3ML/30G X 1/2" TECHLITE PEN QL(5 ea daily) MISC NEEDLES/31GX 6 MM 2 TECHLITE INSULIN QL(5 ea daily); MISC SYRINGEU- 2 RX/OTC TECHLITE PEN QL(5 ea daily); 100/0.3ML/30G X 5/16" NEEDLES/31GX 8MM 2 RX/OTC MISC MISC TECHLITE PEN QL(5 ea daily); NEEDLES/32GX 4MM 2 RX/OTC MISC

Coordinated Care of Washington Updated September 1, 2021

165 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TECHLITE PEN QL(5 ea daily) TOPCARE ULTRA QL(5 ea daily); NEEDLES/32GX 6MM 2 COMFORT INSULIN RX/OTC MISC SYRINGE/U- 2 TECHLITE PEN QL(5 ea daily) 100/0.3ML/29G X 1/2" NEEDLES/32GX 8MM 2 MISC MISC TOPCARE ULTRA QL(5 ea daily); TODAYS HEALTH MINI QL(5 ea daily) COMFORT INSULIN RX/OTC PEN NEEDLES 31G X 1/4" 2 SYRINGE/U- 2 MISC 100/0.5ML/29G X 1/2" MISC TODAYS HEALTH QL(5 ea daily); ORIGINAL PEN NEEDLES 2 RX/OTC TOPCARE ULTRA QL(5 ea daily); 29G X 1/2" MISC COMFORT INSULIN 2 RX/OTC SYRINGE/U-100/1ML/29G TODAYS HEALTH SHORT QL(5 ea daily); X 1/2" MISC PEN NEEDLES 31G X 2 RX/OTC 5/16" MISC TRUE COMFORT INSULIN QL(5 ea daily) SYRINGE/0.5ML/31G X 2 TOPCARE CLICKFINE QL(5 ea daily) 5/16" MISC UNIVERSAL PEN EEDLES 2 31GX1/4" MISC TRUE COMFORT INSULIN QL(5 ea daily) SYRINGE/1ML/31G X 2 TOPCARE CLICKFINE QL(5 ea daily); 5/16" MISC UNIVERSAL PEN EEDLES 2 RX/OTC 31GX5/16" MISC TRUE COMFORT PEN QL(5 ea daily); NEEDLES31G X 5MM 2 RX/OTC TOPCARE ULTRA QL(5 ea daily); MISC COMFORT INSULIN 2 RX/OTC SYRINGE/0.3ML/30G X TRUE COMFORT PEN QL(5 ea daily) 5/16" MISC NEEDLES31G X 6MM 2 MISC TOPCARE ULTRA QL(5 ea daily) TRUE COMFORT PEN QL(5 ea daily); COMFORT INSULIN 2 SYRINGE/0.3ML/31G X NEEDLES32G X 4MM 2 RX/OTC 5/16" MISC MISC TOPCARE ULTRA QL(5 ea daily); TRUE COMFORT PRO QL(5 ea daily); INSULINSYRINGE/0.5ML/ 2 RX/OTC COMFORT INSULIN 2 RX/OTC SYRINGE/0.5ML/30G X 30G X 5/16" MISC 5/16" MISC TRUE COMFORT PRO QL(5 ea daily) TOPCARE ULTRA QL(5 ea daily) INSULINSYRINGE/0.5ML/ 2 31G X 5/16" MISC COMFORT INSULIN 2 SYRINGE/0.5ML/31G X TRUE COMFORT PRO QL(5 ea daily); 5/16" MISC INSULINSYRINGE/1ML/30 2 RX/OTC TOPCARE ULTRA QL(5 ea daily); G X 5/16" MISC COMFORT INSULIN 2 RX/OTC TRUE COMFORT PRO QL(5 ea daily) SYRINGE/1ML/30G X INSULINSYRINGE/1ML/31 2 5/16" MISC G X 5/16" MISC TOPCARE ULTRA QL(5 ea daily) TRUE COMFORT PRO QL(5 ea daily) COMFORT INSULIN 2 INSULINSYRINGE/U- 2 SYRINGE/1ML/31G X 100/0.5ML/30G X 1/2" 5/16" MISC MISC TRUE COMFORT PRO QL(5 ea daily) INSULINSYRINGE/U- 2 100/1ML/30G X 1/2" MISC

Coordinated Care of Washington Updated September 1, 2021

166 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUE COMFORT PRO QL(5 ea daily); TRUEPLUS INSULIN QL(5 ea daily); PEN NEEDLES 31G X 2 RX/OTC SYRINGE/U- 2 RX/OTC 5MM MISC 100/0.5ML/28G X 1/2" TRUE COMFORT PRO QL(5 ea daily) MISC PEN NEEDLES 31G X 2 TRUEPLUS INSULIN QL(5 ea daily); 6MM MISC SYRINGE/U- 2 RX/OTC TRUE COMFORT PRO QL(5 ea daily); 100/0.5ML/29G X 1/2" PEN NEEDLES 31G X 2 RX/OTC MISC 8MM MISC TRUEPLUS INSULIN QL(5 ea daily); TRUE COMFORT PRO QL(5 ea daily); SYRINGE/U- 2 RX/OTC PEN NEEDLES 32G X 2 RX/OTC 100/0.5ML/30G X 5/16" 4MM MISC MISC TRUE COMFORT PRO QL(5 ea daily); TRUEPLUS INSULIN QL(5 ea daily) PEN NEEDLES 32G X 2 RX/OTC SYRINGE/U- 2 5MM MISC 100/0.5ML/31G X 5/16" MISC TRUE COMFORT PRO QL(5 ea daily) PEN NEEDLES 32G X 2 TRUEPLUS INSULIN QL(5 ea daily); 6MM MISC SYRINGE/U-100/1ML/28G 2 RX/OTC X 1/2" MISC TRUE COMFORT PRO QL(5 ea daily) PEN NEEDLES 33G X 2 TRUEPLUS INSULIN QL(5 ea daily); 4MM MISC SYRINGE/U-100/1ML/29G 2 RX/OTC X 1/2" MISC TRUEPLUS 5-BEVEL PEN QL(5 ea daily) NEEDLES 29GX12.7MM 2 TRUEPLUS INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/30G 2 RX/OTC X 5/16" MISC TRUEPLUS 5-BEVEL PEN QL(5 ea daily); NEEDLES 31GX5MM 2 RX/OTC TRUEPLUS INSULIN QL(5 ea daily) MISC SYRINGE/U-100/1ML/31G 2 X 5/16" MISC TRUEPLUS 5-BEVEL PEN QL(5 ea daily) NEEDLES 31GX6MM 2 TRUEPLUS PEN QL(5 ea daily); MISC NEEDLES 29GX12MM 2 RX/OTC MISC TRUEPLUS 5-BEVEL PEN QL(5 ea daily); NEEDLES 31GX8MM 2 RX/OTC TRUEPLUS PEN QL(5 ea daily); MISC NEEDLES 31GX5MM 2 RX/OTC MISC TRUEPLUS 5-BEVEL PEN QL(5 ea daily); NEEDLES 32GX4MM 2 RX/OTC TRUEPLUS PEN QL(5 ea daily) MISC NEEDLES 31GX6MM 2 MISC TRUEPLUS INSULIN QL(5 ea daily); TRUEPLUS PEN QL(5 ea daily); SYRINGE/U- 2 RX/OTC 100/0.3ML/29G X 1/2" NEEDLES 31GX8MM 2 RX/OTC MISC MISC TRUEPLUS INSULIN QL(5 ea daily); TRUEPLUS PEN QL(5 ea daily); NEEDLES 32GX4MM 2 RX/OTC SYRINGE/U- 2 RX/OTC 100/0.3ML/30G X 5/16" MISC MISC ULTICARE INSULIN QL(5 ea daily); TRUEPLUS INSULIN QL(5 ea daily) SAFETY 2 RX/OTC SYRINGE/0.5ML/29G X SYRINGE/U- 2 100/0.3ML/31G X 5/16" 1/2" MISC MISC

Coordinated Care of Washington Updated September 1, 2021

167 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTICARE INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) SAFETY 2 RX/OTC SYRINGE/SHORT/0.5ML/3 2 SYRINGE/1ML/29G X 1/2" 1G X 5/16" MISC MISC ULTICARE INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); SYRINGE/SHORT/1ML/30 2 RX/OTC SYRINGE/0.3ML/29G X 2 RX/OTC G X 5/16" MISC 1/2" MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily) SYRINGE/SHORT/1ML/31 2 SYRINGE/0.3ML/30G X 2 G X 5/16" MISC 1/2" MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily); SYRINGE/U- 2 SYRINGE/0.3ML/30G X 2 RX/OTC 100/0.3ML/30G X 1/2" 5/16" MISC MISC ULTICARE INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) SYRINGE/0.5ML/28G X 2 RX/OTC SYRINGE/U- 2 1/2" MISC 100/0.3ML/31G X 5/16" ULTICARE INSULIN QL(5 ea daily); MISC SYRINGE/0.5ML/29G X 2 RX/OTC ULTICARE INSULIN QL(5 ea daily) 1/2" MISC SYRINGE/U- 2 ULTICARE INSULIN QL(5 ea daily) 100/0.5ML/30G X 1/2" SYRINGE/0.5ML/30G X 2 MISC 1/2" MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily); SYRINGE/U- 2 SYRINGE/0.5ML/30G X 2 RX/OTC 100/0.5ML/31G X 5/16" 5/16" MISC MISC ULTICARE INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) SYRINGE/1ML/28G X 1/2" 2 RX/OTC SYRINGE/U-100/1ML/30G 2 MISC X 1/2" MISC ULTICARE INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) SYRINGE/1ML/29G X 1/2" 2 RX/OTC SYRINGE/U-100/1ML/31G 2 MISC X 5/16" MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily) SYRINGE/1ML/30G X 1/2" 2 SYRINGEULTRAFINE U- 2 MISC 100/0.3ML/31G X 5/16" MISC ULTICARE INSULIN QL(5 ea daily); SYRINGE/1ML/30G X 2 RX/OTC ULTICARE INSULIN QL(5 ea daily) 5/16" MISC SYRINGEULTRAFINE U- 2 100/0.5ML/31G X 5/16" ULTICARE INSULIN QL(5 ea daily); MISC SYRINGE/SHORT/0.3ML/3 2 RX/OTC 0G X 5/16" MISC ULTICARE INSULIN QL(5 ea daily) SYRINGEULTRAFINE U- 2 ULTICARE INSULIN QL(5 ea daily) 100/1ML/31G X 5/16" SYRINGE/SHORT/0.3ML/3 2 MISC 1G X 5/16" MISC ULTICARE MICRO PEN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); NEEDLES 31G X 8MM 2 RX/OTC SYRINGE/SHORT/0.5ML/3 2 RX/OTC MISC 0G X 5/16" MISC

Coordinated Care of Washington Updated September 1, 2021

168 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTICARE MICRO PEN QL(5 ea daily); ULTICARE SHORT QL(5 ea daily); NEEDLES 32G X 4MM 2 RX/OTC SAFETY PEN NEEDLES 2 RX/OTC MISC 30G X 5/16" MISC ULTICARE MICRO PEN QL(5 ea daily) ULTIGUARD SAFEPACK QL(5 ea daily) NEEDLES/31G X 1/4" 2 INSULIN SYRINGE 2 MISC 0.3ML/30G X 1/2"/SHARPS ULTICARE MICRO PEN QL(5 ea daily); C MISC NEEDLES/31G X 5/16" 2 RX/OTC ULTIGUARD SAFEPACK QL(5 ea daily) MISC INSULIN SYRINGE 1/2ML 2 ULTICARE MICRO PEN QL(5 ea daily); 30G X 1/2"/SHARPS C NEEDLES/32G X 4MM 2 RX/OTC MISC MISC ULTIGUARD SAFEPACK QL(5 ea daily) ULTICARE MICRO PEN QL(5 ea daily); INSULIN SYRINGE 1ML 2 NEEDLES/32G X 5/32" 2 RX/OTC 30G X 1/2"/SHARPS CON MISC MISC ULTICARE MINI PEN QL(5 ea daily) ULTIGUARD SAFEPACK QL(5 ea daily) NEEDLES 31GX6MM 2 INSULIN SYRINGE 1ML 2 MISC 31G X 5/16"/SHARPS CO MISC ULTICARE MINI PEN QL(5 ea daily) NEEDLES ULTI-FINE IV 2 ULTIGUARD SAFEPACK QL(5 ea daily) MISC INSULIN 2 SYRINGE/0.3ML/30G X ULTICARE MINI PEN QL(5 ea daily) 1/2"/SHARPS C MISC NEEDLES/31G X 6MM 2 MISC ULTIGUARD SAFEPACK QL(5 ea daily) INSULIN 2 ULTICARE MINI PEN QL(5 ea daily) SYRINGE/0.3ML/31G X NEEDLES/32G X 1/4" 2 5/16"/SHARPS MISC MISC ULTIGUARD SAFEPACK QL(5 ea daily) ULTICARE MINI PEN QL(5 ea daily) 2 INSULIN 2 NEEDLES31GX6MM MISC SYRINGE/0.5ML/30G X ULTICARE ORIGINAL QL(5 ea daily) 1/2"/SHARPS C MISC PEN NEEDLES ULTI-FINE 2 ULTIGUARD SAFEPACK QL(5 ea daily); MISC MINI PEN NEEDLE/31G X 2 RX/OTC ULTICARE PEN NEEDLES 2 QL(5 ea daily); 3/16"/SHARPS CONTAI 31GX 5MM/MINI MISC RX/OTC MISC ULTICARE PEN QL(5 ea daily) ULTIGUARD SAFEPACK QL(5 ea daily) NEEDLES/29GX 12.7MM 2 PEN NEEDLE/29G X 2 MISC 1/2"/SHARPS CONTAINER ULTICARE SHORT PEN QL(5 ea daily); MISC NEEDLES 31GX8MM 2 RX/OTC ULTIGUARD QL(5 ea daily); MISC SAFEPACK/MICROPEN 2 RX/OTC ULTICARE SHORT PEN QL(5 ea daily); NEEDLE/32G X 5/32" NEEDLES ULTI-FINE IV 2 RX/OTC MISC MISC ULTIGUARD QL(5 ea daily); ULTICARE SHORT PEN QL(5 ea daily); SAFEPACK/MICROPEN RX/OTC NEEDLES/31G X 8MM 2 RX/OTC NEEDLE/32G X 2 MISC 5/32"/SHARPS CONTA MISC

Coordinated Care of Washington Updated September 1, 2021

169 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTIGUARD QL(5 ea daily) ULTILET INSULIN QL(5 ea daily) SAFEPACK/MINI PEN SYRINGE/SHORT/0.3ML/3 2 NEEDLE/31G X 2 1G X 5/16" MISC 1/4"/SHARPS CONTAIN ULTILET INSULIN QL(5 ea daily); MISC SYRINGE/SHORT/0.5ML/3 2 RX/OTC ULTIGUARD QL(5 ea daily); 0G X 5/16" MISC SAFEPACK/MINI PEN RX/OTC ULTILET INSULIN QL(5 ea daily) NEEDLE/31G X 2 SYRINGE/SHORT/0.5ML/3 2 3/16"/SHARPS CONTAI 1G X 5/16" MISC MISC ULTILET INSULIN QL(5 ea daily); ULTIGUARD QL(5 ea daily) SYRINGE/SHORT/1ML/30 2 RX/OTC SAFEPACK/MINI PEN G X 5/16" MISC NEEDLE/32G X 2 1/4"/SHARPS CONTAIN ULTILET INSULIN QL(5 ea daily) MISC SYRINGE/SHORT/1ML/31 2 G X 5/16" MISC ULTIGUARD QL(5 ea daily); SAFEPACK/SHORTPEN RX/OTC ULTILET INSULIN QL(5 ea daily) NEEDLE/31G X 2 SYRINGE/U- 2 5/16"/SHARPS CONTA 100/0.5ML/30G X 1/2" MISC MISC ULTIGUARD QL(5 ea daily) ULTILET INSULIN QL(5 ea daily) SAFEPACK/SYRINGE/NE SYRINGE/U-100/1ML/30G 2 EDLE/31G X 2 X 1/2" MISC 5/16"/SHARPS CONTAIN ULTILET PEN NEEDLE 2 QL(5 ea daily) MISC 29GX12.7MM MISC ULTILET INSULIN QL(5 ea daily); ULTILET PEN NEEDLE 2 QL(5 ea daily); SYRINGE/0.3ML/30G X 2 RX/OTC 31GX5MM MISC RX/OTC 8MM MISC ULTILET PEN NEEDLE 2 QL(5 ea daily); ULTILET INSULIN QL(5 ea daily) 31GX8MM MISC RX/OTC SYRINGE/0.3ML/31G X 2 ULTILET PEN NEEDLE 2 QL(5 ea daily); 8MM MISC 32GX4MM MISC RX/OTC ULTILET INSULIN QL(5 ea daily); ULTILET PEN NEEDLE 2 QL(5 ea daily); SYRINGE/0.5ML/30G X 2 RX/OTC 32GX4MM/SHORT MISC RX/OTC 8MM MISC ULTILET SHORT PEN QL(5 ea daily); ULTILET INSULIN QL(5 ea daily); NEEDLES 31GX5/16" 2 RX/OTC SYRINGE/1ML/30G X 2 RX/OTC MISC 8MM MISC ULTILET SHORT PEN 2 QL(5 ea daily); ULTILET INSULIN QL(5 ea daily) NEEDLES31GX3/16" MISC RX/OTC SYRINGE/1ML/31G X 2 ULTRA COMFORT QL(5 ea daily); 8MM MISC INSULIN SYRINGE/U- 2 RX/OTC ULTILET INSULIN QL(5 ea daily) 100/0.3ML/30G X 5/16" SYRINGE/SHORT/0.3ML/3 2 MISC 0G X 12.7MM MISC ULTRA FLO INSULIN PEN 2 QL(5 ea daily); ULTILET INSULIN QL(5 ea daily); NEEDLE 31GX5MM MISC RX/OTC SYRINGE/SHORT/0.3ML/3 2 RX/OTC ULTRA FLO INSULIN PEN 2 QL(5 ea daily); 0G X 5/16" MISC NEEDLE 32GX4MM MISC RX/OTC ULTRA FLO INSULIN PEN 2 QL(5 ea daily) NEEDLE 33GX4MM MISC

Coordinated Care of Washington Updated September 1, 2021

170 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTRA FLO INSULIN PEN 2 QL(5 ea daily); ULTRA FLO INSULIN QL(5 ea daily); NEEDLES MISC RX/OTC SYRINGE 1ML/30GX5/16" 2 RX/OTC MISC ULTRA FLO INSULIN PEN 2 QL(5 ea daily); NEELE 31GX8MM MISC RX/OTC ULTRA FLO INSULIN QL(5 ea daily) ULTRA FLO INSULIN QL(5 ea daily); SYRINGE 1ML/31GX5/16" 2 SYRINGE 0.3ML/29G X 2 RX/OTC MISC 1/2" MISC ULTRA THIN PEN QL(5 ea daily); ULTRA FLO INSULIN QL(5 ea daily) NEEDLES 32G X 4MM 2 RX/OTC SYRINGE 0.3ML/30GX1/2" 2 MISC MISC ULTRA-COMFORT QL(5 ea daily); ULTRA FLO INSULIN QL(5 ea daily); INSULIN SYRINGE/U- 2 RX/OTC SYRINGE 2 RX/OTC 100/0.3ML/29G X 1/2" 0.3ML/30GX5/16" MISC MISC ULTRA FLO INSULIN QL(5 ea daily) ULTRA-COMFORT QL(5 ea daily); SYRINGE 2 INSULIN SYRINGE/U- 2 RX/OTC 0.3ML/31GX5/16" MISC 100/0.3ML/30G X 5/16" MISC ULTRA FLO INSULIN QL(5 ea daily); SYRINGE 0.5ML/29GX1/2" 2 RX/OTC ULTRA-COMFORT QL(5 ea daily) MISC INSULIN SYRINGE/U- 2 100/0.3ML/31G X 5/16" ULTRA FLO INSULIN QL(5 ea daily) MISC SYRINGE 0.5ML/30GX1/2" 2 MISC ULTRA-COMFORT QL(5 ea daily); INSULIN SYRINGE/U- 2 RX/OTC ULTRA FLO INSULIN QL(5 ea daily); 100/0.5ML/28G X 1/2" SYRINGE 2 RX/OTC MISC 0.5ML/30GX5/16" MISC ULTRA-COMFORT QL(5 ea daily); ULTRA FLO INSULIN QL(5 ea daily) INSULIN SYRINGE/U- 2 RX/OTC SYRINGE 2 100/0.5ML/29G X 1/2" 0.5ML/31GX5/16" MISC MISC ULTRA FLO INSULIN QL(5 ea daily) ULTRA-COMFORT QL(5 ea daily); SYRINGE 1/2 2 INSULIN SYRINGE/U- 2 RX/OTC UNIT/0.3ML/30GX1/2" 100/0.5ML/30G X 5/16" MISC MISC ULTRA FLO INSULIN QL(5 ea daily); ULTRA-COMFORT QL(5 ea daily) SYRINGE 1/2 RX/OTC 2 INSULIN SYRINGE/U- 2 UNIT/0.3ML/30GX5/16" 100/0.5ML/31G X 5/16" MISC MISC ULTRA FLO INSULIN QL(5 ea daily) ULTRA-COMFORT QL(5 ea daily); SYRINGE 1/2 2 INSULIN SYRINGE/U- 2 RX/OTC UNIT/0.3ML/31GX5/16" 100/1ML/28G X 1/2" MISC MISC ULTRA-COMFORT QL(5 ea daily); ULTRA FLO INSULIN QL(5 ea daily); INSULIN SYRINGE/U- 2 RX/OTC SYRINGE 1M/29GX1/2" 2 RX/OTC 100/1ML/29G X 1/2" MISC MISC ULTRA-COMFORT QL(5 ea daily); ULTRA FLO INSULIN QL(5 ea daily) INSULIN SYRINGE/U- 2 RX/OTC SYRINGE 1ML/30GX1/2" 2 100/1ML/30G X 5/16" MISC MISC

Coordinated Care of Washington Updated September 1, 2021

171 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTRA-COMFORT QL(5 ea daily) ULTRACARE INSULIN QL(5 ea daily) INSULIN SYRINGE/U- 2 SYRINGE/U- 2 100/1ML/31G X 5/16" 100/0.5ML/30G X 1/2" MISC MISC ULTRA-THIN II INSULIN QL(5 ea daily); ULTRACARE INSULIN QL(5 ea daily); SYRINGE SHORT/U- 2 RX/OTC SYRINGE/U- 2 RX/OTC 100/0.3ML/30GX5/16" 100/0.5ML/30G X 5/16" MISC MISC ULTRA-THIN II INSULIN QL(5 ea daily) ULTRACARE INSULIN QL(5 ea daily) SYRINGE SHORT/U- 2 SYRINGE/U- 2 100/0.3ML/31GX5/16" 100/0.5ML/31G X 5/16" MISC MISC ULTRA-THIN II INSULIN QL(5 ea daily); ULTRACARE INSULIN QL(5 ea daily) SYRINGE SHORT/U- 2 RX/OTC SYRINGE/U-100/1ML/30G 2 100/0.5ML/30GX5/16" X 1/2" MISC MISC ULTRACARE INSULIN QL(5 ea daily); ULTRA-THIN II INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/30G 2 RX/OTC SYRINGE SHORT/U- 2 X 5/16" MISC 100/0.5ML/31GX5/16" ULTRACARE INSULIN QL(5 ea daily) MISC SYRINGE/U-100/1ML/31G 2 ULTRA-THIN II INSULIN QL(5 ea daily); X 5/16" MISC SYRINGE SHORT/U- 2 RX/OTC ULTRACARE PEN QL(5 ea daily) 100/1ML/30GX5/16" MISC NEEDLES/31G X 1/4" 2 ULTRA-THIN II INSULIN QL(5 ea daily) MISC SYRINGE SHORT/U- 2 ULTRACARE PEN QL(5 ea daily); 100/1ML/31GX5/16" MISC NEEDLES/31G X 3/16" 2 RX/OTC ULTRA-THIN II INSULIN QL(5 ea daily); MISC SYRINGE/U- 2 RX/OTC ULTRACARE PEN QL(5 ea daily); 100/0.5ML/29GX1/2" MISC NEEDLES/31G X 5/16" 2 RX/OTC ULTRA-THIN II INSULIN QL(5 ea daily); MISC SYRINGE/U- 2 RX/OTC ULTRACARE PEN QL(5 ea daily) 100/1ML/29GX1/2" MISC NEEDLES/32G X 1/14" 2 ULTRA-THIN II MINI PEN QL(5 ea daily); MISC NEEEDLES/31GX3/16" 2 RX/OTC ULTRACARE PEN QL(5 ea daily); MISC NEEDLES/32G X 3/16" 2 RX/OTC ULTRA-THIN II PEN 2 QL(5 ea daily) MISC NEEDLES 29GX1/2" MISC ULTRACARE PEN QL(5 ea daily); ULTRA-THIN II PEN QL(5 ea daily); NEEDLES/32G X 5/32" 2 RX/OTC NEEDLES/SHORT/31GX5/ 2 RX/OTC MISC 16" MISC ULTRACARE PEN QL(5 ea daily) ULTRACARE INSULIN QL(5 ea daily); NEEDLES/33G X 5/32" 2 SYRINGE/U- 2 RX/OTC MISC 100/0.3ML/30G X 5/16" UNIFINE PEN 2 QL(5 ea daily); MISC NEEDLE/32G X4MM MISC RX/OTC ULTRACARE INSULIN QL(5 ea daily) UNIFINE PENTIPS 2 QL(5 ea daily); SYRINGE/U- 2 29GX12MM MISC RX/OTC 100/0.3ML/31G X 5/16" MISC UNIFINE PENTIPS 31G X 2 QL(5 ea daily); 3/16" MISC RX/OTC Coordinated Care of Washington Updated September 1, 2021

172 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits UNIFINE PENTIPS 2 QL(5 ea daily); VANISHPOINT INSULIN QL(5 ea daily) 31GX5MM MISC RX/OTC SYRINGE/0.5ML/30G X 2 1/2" MISC UNIFINE PENTIPS 2 QL(5 ea daily) 31GX6MM MISC VANISHPOINT INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X 2 RX/OTC UNIFINE PENTIPS 2 QL(5 ea daily); 31GX8MM MISC RX/OTC 5/16" MISC VANISHPOINT INSULIN QL(5 ea daily); UNIFINE PENTIPS 2 QL(5 ea daily); 32GX4MM MISC RX/OTC SYRINGE/1ML/29G X 1/2" 2 RX/OTC MISC UNIFINE PENTIPS 2 QL(5 ea daily) 32GX6MM MISC VANISHPOINT INSULIN QL(5 ea daily); SYRINGE/1ML/30G X 2 RX/OTC UNIFINE PENTIPS 2 QL(5 ea daily) 5/16" MISC 33GX4MM MISC VIDA MIA UNIFINE 2 QL(5 ea daily); UNIFINE PENTIPS PLUS 2 QL(5 ea daily); PENTIPS32GX4MM MISC RX/OTC 29GX12MM MISC RX/OTC VIDA MIA UNIFINE QL(5 ea daily) UNIFINE PENTIPS PLUS 2 QL(5 ea daily); PENTIPSMINI 31GX6MM 2 31GX5MM MISC RX/OTC MISC UNIFINE PENTIPS PLUS 2 QL(5 ea daily) VIDA MIA UNIFINE QL(5 ea daily); 31GX6MM MISC PENTIPSORIGINAL 2 RX/OTC UNIFINE PENTIPS PLUS 2 QL(5 ea daily); 29GX12MM MISC 31GX8MM MISC RX/OTC VIDA MIA UNIPFINE QL(5 ea daily); UNIFINE PENTIPS PLUS 2 QL(5 ea daily); PENTIPSSHORT 2 RX/OTC 32GX4MM MISC RX/OTC 31GX8MM MISC UNIFINE PENTIPS PLUS 2 QL(5 ea daily) VP INSULIN SYRINGE/U- QL(5 ea daily); 33GX 5/32" MISC 100/0.3ML/29G X 1/2" 2 RX/OTC MISC UNIFINE PENTIPS PLUS 2 QL(5 ea daily) 33GX4MM MISC WEGMANS UNIFINE QL(5 ea daily); UNIFINE SAFECONTROL QL(5 ea daily); PENTIPS PLUS 32GX4MM 2 RX/OTC PEN NEEDLE/30G X 5/16" 2 RX/OTC MISC MISC WEGMANS UNIFINE QL(5 ea daily); VALUE HEALTH INSULIN QL(5 ea daily); PENTIPS 2 RX/OTC PLUS/MINI/31GX5MM SYRINGE/U- 2 RX/OTC 100/0.5ML/29G X 1/2" MISC MISC WEGMANS UNIFINE QL(5 ea daily); VALUE HEALTH INSULIN QL(5 ea daily); PENTIPS 2 RX/OTC SYRINGE/U-100/1ML/29G 2 RX/OTC PLUS/SHORT/31GX8MM X 1/2" MISC MISC VALUMARK PEN QL(5 ea daily); WEGMANS UNIFINE QL(5 ea daily) NEEDLES 29GX12MM 2 RX/OTC PENTIPS PLUS/ULTRA 2 MISC SHORT/31GX6MM MISC VALUMARK PEN QL(5 ea daily) ZEVRX INSULIN QL(5 ea daily) NEEDLES 31GX 6MM 2 SYRINGE/0.5ML/30G X 2 MISC 1/2" MISC VALUMARK PEN QL(5 ea daily); ZEVRX INSULIN QL(5 ea daily); NEEDLES 31GX 8MM 2 RX/OTC SYRINGE/0.5ML/30G X 2 RX/OTC MISC 5/16" MISC

Coordinated Care of Washington Updated September 1, 2021

173 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZEVRX INSULIN QL(5 ea daily) AEROCHAMBER PLUS QL(2 ea per SYRINGE/1ML/30G X 1/2" 2 FLOW-VU/LARGE MASK 2 360 days MISC MISC retail); RX/OTC ZEVRX INSULIN QL(5 ea daily); QL(2 ea per SYRINGE/1ML/30G X 2 RX/OTC AEROCHAMBER PLUS 2 FLOW-VU/MASK MISC 360 days 5/16" MISC retail); RX/OTC ZEVRX PEN NEEDLES 2 QL(5 ea daily); AEROCHAMBER PLUS QL(2 ea per 31G X 5MM MISC RX/OTC FLOW-VU/MEDIUM MASK 2 360 days MISC retail); RX/OTC ZEVRX PEN NEEDLES 2 QL(5 ea daily) 31G X 6MM MISC AEROCHAMBER PLUS QL(2 ea per FLOW-VU/SMALL MASK 2 360 days ZEVRX PEN NEEDLES 2 QL(5 ea daily); 31G X 8MM MISC RX/OTC MISC retail); RX/OTC AEROCHAMBER Z-STAT QL(2 ea per ZEVRX PEN NEEDLES 2 QL(5 ea daily); 32G X 4MM MISC RX/OTC PLUS VALVED HOLDING 2 360 days CHAMBER W/FLOW VU retail); RX/OTC Respiratory Therapy Supplies MISC QL(1 ml per ACE AEROSOL CLOUD QL(2 ea per 2 360 days AEROCHAMBER Z-STAT 2 ENHANCER MISC PLUS/FLOWSIGNAL MISC 360 days retail); RX/OTC retail); RX/OTC QL(1 ml per QL(2 ea per ACTIVITY POUCH MISC 2 360 days AEROCHAMBER Z-STAT 2 PLUS/LARGE MASK MISC 360 days retail); RX/OTC retail); RX/OTC QL(1 ml per AEROCHAMBER Z-STAT QL(2 ea per ADULT AEROSOL MASK 2 360 days MISC PLUS/MEDIUM MASK 2 360 days retail); RX/OTC MISC retail); RX/OTC ADULT MASK DEVI 2 RX/OTC QL(2 ea per AEROCHAMBER Z-STAT 2 PLUS/SMALL MASK MISC 360 days QL(1 ml per retail); RX/OTC ADULT MASK LARGE 2 360 days MISC QL(2 ea per retail); RX/OTC AEROCHAMBER/FLOWSI 2 GNAL MISC 360 days QL(1 ml per retail); RX/OTC ADULT MASK MISC 2 360 days QL(1 ml per retail); RX/OTC AEROTRACH PLUS MISC 2 360 days AEROBIKA DEVI 2 RX/OTC retail); RX/OTC AEROVENT PLUS QL(2 ea per AEROCHAMBER MINI QL(2 ea per HOLDING 2 360 days AEROSOLCHAMBER 2 360 days CHAMBER/COLLAPSIBLE retail); RX/OTC DEVI retail); RX/OTC DEVI QL(2 ea per AEROCHAMBER MV QL(1 ml per 2 360 days AIRS PEDIATRIC 2 MISC AEROSOL MASK MISC 360 days retail); RX/OTC retail); RX/OTC QL(2 ea per ALL FLOW 1000 PFT RX/OTC AEROCHAMBER PLUS 2 2 FLOW VU MISC 360 days FILTER DEVI retail); RX/OTC ALL FLOW 1000 QL(1 ml per QL(2 ea per PULMONARY FUNCTION 2 360 days AEROCHAMBER PLUS 2 FLOW-VU MISC 360 days FILTER MISC retail); RX/OTC retail); RX/OTC ALL FLOW 2000 PFT 2 RX/OTC FILTER DEVI Coordinated Care of Washington Updated September 1, 2021

174 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ALL FLOW 3000 PFT 2 RX/OTC QL(2 ea per FILTER DEVI BREATHERITE RIGID 2 SPACERW/MASK MISC 360 days retail); RX/OTC ALL FLOW 4000 PFT 2 RX/OTC FILTER DEVI BREATHERITE VALVED RX/OTC MDI ALL FLOW 5000 PFT 2 RX/OTC 2 FILTER DEVI CHAMBER/COLLAPSIBLE DEVI ALL FLOW 6000 PFT 2 RX/OTC FILTER DEVI BREATHERITE VALVED RX/OTC MDI CHAMBER/RIGID 2 ALL FLOW 7000 PFT 2 RX/OTC DEVI FILTER DEVI QL(2 ea per QL(2 ea per BREATHERITE W/LARGE 2 MASK MISC 360 days ARIAL CHAMBER DEVI 2 360 days retail); RX/OTC retail); RX/OTC QL(2 ea per BREATHE EASE QL(1 ml per BREATHERITE 2 W/MEDIUM MASK MISC 360 days NEBULIZER MASK/CHILD 2 360 days retail); RX/OTC MISC retail); RX/OTC QL(2 ea per BREATHE EASE QL(1 ml per BREATHERITE W/SMALL 2 MASK MISC 360 days NEBULIZER 2 360 days retail); RX/OTC MASK/INFANT MISC retail); RX/OTC BUBBLES THE FISH II QL(1 ml per QL(2 ea per PEDIATRIC MASK/PVC 2 360 days BREATHE EASE/LARGE 2 MASK DEVI 360 days MISC retail); RX/OTC retail); RX/OTC QL(1 ml per QL(2 ea per CARETOUCH 2 CPAP 2 360 days BREATHE EASE/MEDIUM 2 HOSE HANGER MISC MASK DEVI 360 days retail); RX/OTC retail); RX/OTC QL(1 ml per QL(2 ea per CARETOUCH CPAP & 2 360 days BREATHE EASE/SMALL 2 BIPAP HOSE/6FT MISC MASK DEVI 360 days retail); RX/OTC retail); RX/OTC QL(1 ml per BREATHERITE QL(2 ea per CARETOUCH CPAP 2 MASK WIPES MISC 360 days COLLAPSIBLEADULT 2 360 days retail); RX/OTC SPACER W/MASK MISC retail); RX/OTC CARETOUCH CPAP QL(1 ml per BREATHERITE QL(2 ea per NEUTRALIZING PRE- 2 360 days COLLAPSIBLECHILD 2 360 days WASH MISC retail); RX/OTC SPACER W/MASK MISC retail); RX/OTC QL(1 ml per BREATHERITE QL(2 ea per CARETOUCH CPAP TUBE 2 CLEANING BRUSH MISC 360 days COLLAPSIBLEINFANT 2 360 days retail); RX/OTC SPACER W/MASK MISC retail); RX/OTC QL(1 ml per BREATHERITE QL(2 ea per CARETOUCH UNIVERSAL 2 360 days CPAPFILTERS MISC COLLAPSIBLESMALL 2 360 days retail); RX/OTC CHILD SPACER W/MASK retail); RX/OTC MISC CLEVER CHOICE ANTI- QL(2 ea per STATICVALVED 360 days BREATHERITE QL(2 ea per HOLDING 2 retail); RX/OTC COLLAPSIBLESPACER 2 360 days CHAMBER/ADULT LARGE W/ NEONATE MASK MISC retail); RX/OTC DEVI QL(2 ea per BREATHERITE MISC 2 360 days retail); RX/OTC

Coordinated Care of Washington Updated September 1, 2021

175 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLEVER CHOICE ANTI- QL(2 ea per QL(2 ea per STATICVALVED 360 days EASIVENT/MASK-SMALL 2 2 MISC 360 days HOLDING retail); RX/OTC retail); RX/OTC CHAMBER/MEDIUM DEVI QL(1 ml per CLEVER CHOICE ANTI- QL(2 ea per EASY FLOW 300 MM 2 HOSE MISC 360 days STATICVALVED 360 days retail); RX/OTC HOLDING 2 retail); RX/OTC QL(1 ml per CHAMBER/MEDIUM/3 EASY FLOW 400 MM 2 HOSE MISC 360 days YEA DEVI retail); RX/OTC CLEVER CHOICE ANTI- QL(2 ea per QL(1 ml per STATICVALVED 360 days EASY FLOW AIR NOZZLE 2 2 MISC 360 days HOLDING retail); RX/OTC retail); RX/OTC CHAMBER/SMALL DEVI EASY FLOW BLACK/BLUE 2 RX/OTC CLEVER CHOICE ANTI- QL(2 ea per DEVI STATICVALVED 360 days HOLDING 2 retail); RX/OTC EASY FLOW 2 RX/OTC CHAMBER/SMALL BLACK/ORANGE DEVI INFANT DEVI EASY FLOW BLACK/RED 2 RX/OTC DEVI CO MONITOR DEVI 2 RX/OTC EASY FLOW 2 RX/OTC CO MONITOR QL(1 ml per BLACK/WHITE DEVI REPLACEMENT TPIECES 2 360 days EASY FLOW 2 RX/OTC MISC retail); RX/OTC BLACK/YELLOW DEVI COMPACT SPACE QL(2 ea per QL(1 ml per CHAMBER/ANTI-STATIC 2 360 days EASY FLOW HEPA 2 FILTER MISC 360 days DEVI retail); RX/OTC retail); RX/OTC COMPACT SPACE QL(2 ea per EASY FLOW WHITE/BLUE 2 RX/OTC CHAMBER/ANTI- 2 360 days DEVI STATIC/LARGE MASK retail); RX/OTC EASY FLOW 2 RX/OTC DEVI WHITE/GREEN DEVI COMPACT SPACE QL(2 ea per EASY FLOW WHITE/PINK 2 RX/OTC CHAMBER/ANTI- 2 360 days DEVI STATIC/MEDIUM MASK retail); RX/OTC DEVI EASY FLOW 2 RX/OTC WHITE/WHITE DEVI COMPACT SPACE QL(2 ea per EASY FLOW RX/OTC CHAMBER/ANTI- 2 360 days 2 STATIC/SMALL MASK retail); RX/OTC WHITE/YELLOW DEVI DEVI QL(1 ml per EBASE CONTROLLER KIT 2 360 days QL(2 ea per MISC EASIVENT MISC 2 360 days retail); RX/OTC retail); RX/OTC QL(1 ml per EFLOW SCF AEROSOL 2 360 days QL(2 ea per HEAD MISC EASIVENT/MASK-LARGE 2 retail); RX/OTC MISC 360 days retail); RX/OTC QL(1 ml per ELITE DC AUTO 2 360 days QL(2 ea per ADAPTER MISC EASIVENT/MASK- 2 retail); RX/OTC MEDIUM MISC 360 days retail); RX/OTC QL(2 ea per EQ SPACE CHAMBER 2 ANTI-STATIC DEVI 360 days retail); RX/OTC Coordinated Care of Washington Updated September 1, 2021

176 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EQ SPACE CHAMBER QL(2 ea per INSPIRACHAMBER/SOOT QL(2 ea per ANTI-STATIC/LARGE 2 360 days HERMASK/INSPIRAMASK 2 360 days MASK DEVI retail); RX/OTC /SMALL DEVI retail); RX/OTC EQ SPACE CHAMBER QL(2 ea per QL(2 ea per ANTI-STATIC/MEDIUM 2 360 days INSPIREASE DRUG 2 DELIVERYSYSTEM MISC 360 days MASK DEVI retail); RX/OTC retail); RX/OTC EQ SPACE CHAMBER QL(2 ea per INSPIREASE RESERVOIR 2 QL(3 ea per ANTI-STATIC/SMALL 2 360 days BAGS MISC 180 days retail) MASK DEVI retail); RX/OTC QL(2 ea per QL(1 ml per LITEAIRE DEVI 2 360 days FILTER AIR PP MISC 2 360 days retail); RX/OTC retail); RX/OTC QL(1 ml per QL(2 ea per LITETOUCH MASK 2 LARGE MISC 360 days FLEXICHAMBER DEVI 2 360 days retail); RX/OTC retail); RX/OTC QL(1 ml per LITETOUCH MASK 2 FLYP HYPERSONIQ QL(1 ml per 360 days 2 360 days MEDIUM MISC retail); RX/OTC CARTRIDGE MISC retail); RX/OTC QL(1 ml per LITETOUCH MASK 2 FULL KIT NEBULIZER QL(1 ml per 360 days 2 360 days SMALL MISC retail); RX/OTC SET MISC retail); RX/OTC QL(2 ea per HUDSON RCI SEE-THRU QL(1 ml per MICROCHAMBER DEVI 2 360 days AEROSOL MASK 2 360 days retail); RX/OTC ELONGATED/ADULT retail); RX/OTC QL(2 ea per MISC MICROCHAMBER MISC 2 360 days IN-CHECK DIAL RX/OTC retail); RX/OTC INSPIRATORYFLOW 2 QL(1 ml per TRAINER DEVI MICROELITE FILTER 2 REPLACEMENTS MISC 360 days IN-CHECK INSPIRATORY RX/OTC retail); RX/OTC FLOWMETER/NASAL 2 MICROELITE QL(1 ml per WITH MASK DEVI RECHARGEABLE 2 360 days IN-CHECK INSPIRATORY 2 RX/OTC BATTERY MISC retail); RX/OTC FLOWMETER/ORAL DEVI QL(2 ea per INNOSPIRE QL(1 ml per MICROSPACER MISC 2 360 days REPLACEMENT FILTER 2 360 days retail); RX/OTC MISC retail); RX/OTC QL(1 ml per INSPIRACHAMBER/ANTI- QL(2 ea per MINIELITE FILTER 2 360 days REPLACEMENTS MISC STATIC 2 360 days retail); RX/OTC VALVED/MOUTHPIECE retail); RX/OTC MINIELITE QL(1 ml per DEVI RECHARGEABLE 2 360 days QL(2 ea per BATTERY MISC retail); RX/OTC INSPIRACHAMBER/LARG 2 E DEVI 360 days RX/OTC retail); RX/OTC MISTASSIST DEVI 2 INSPIRACHAMBER/SOOT QL(2 ea per QL(1 ml per HERMASK/INSPIRAMASK 2 360 days NEBULIZER AIR 2 TUBE/PLUGS MISC 360 days /MEDIUM DEVI retail); RX/OTC retail); RX/OTC NEBULIZER CUP/TUBING 2 RX/OTC DEVI Coordinated Care of Washington Updated September 1, 2021

177 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NEBULIZER PEDIATRIC QL(1 ml per PARI ALTERA QL(1 ml per 2 360 days NEBULIZER HANDSET 2 360 days MASK MISC retail); RX/OTC MISC retail); RX/OTC QL(1 ml per QL(1 ml per NOSE CLIP MISC 2 360 days PARI BABY CONVERSION 2 KITSIZE 1 MISC 360 days retail); RX/OTC retail); RX/OTC OMBRA TABLE TOP RX/OTC 2 PARI BABY CONVERSION QL(1 ml per COMPRESSOR DEVI 2 360 days KITSIZE 2 MISC ONE FLOW FVC RX/OTC retail); RX/OTC MONITORING 2 PARI BABY CONVERSION QL(1 ml per SPIROMETER DEVI 2 360 days KITSIZE 3 MISC OPTICHAMBER QL(2 ea per retail); RX/OTC ADVANTAGE/LARGE 2 360 days PARI ERAPID NEBULIZER QL(1 ml per MASK MISC retail); RX/OTC 2 360 days HANDSET MISC OPTICHAMBER QL(2 ea per retail); RX/OTC ADVANTAGE/MEDIUM 2 360 days PARI EXPIRATORY QL(1 ml per FACE MASK MISC retail); RX/OTC 2 360 days FILTER VALVE SET DEVI OPTICHAMBER QL(2 ea per retail); RX/OTC 2 ADVANTAGE/SMALL 360 days PARI MANUAL 2 RX/OTC FACE MASK MISC retail); RX/OTC INTERRUPTER DEVI OPTICHAMBER QL(2 ea per QL(1 ml per 2 360 days PARI MASK SET MISC 2 360 days DIAMOND MISC retail); RX/OTC retail); RX/OTC OPTICHAMBER QL(2 ea per QL(1 ml per DIAMOND/LARGEFACE 2 360 days PARI SOFT PLASTIC 2 ADULT MASK MISC 360 days MASK DEVI retail); RX/OTC retail); RX/OTC OPTICHAMBER QL(2 ea per QL(1 ml per DIAMOND/MEDIUM FACE 2 360 days PARI SOFT PLASTIC 2 PEDIATRIC MASK MISC 360 days MASK MISC retail); RX/OTC retail); RX/OTC OPTICHAMBER QL(2 ea per PARI TREK S COMBO 2 RX/OTC DIAMOND/SMALLFACE 2 360 days PACK DEVI MASK MISC retail); RX/OTC QL(1 ml per PARI VORTEX ADULT 2 OPTICHAMBER FACE QL(2 ea per 360 days 2 360 days MASK MISC retail); RX/OTC MASK/LARGE MISC retail); RX/OTC PEDIATRIC QL(1 ml per 2 OPTICHAMBER FACE QL(2 ea per MOUTHPIECE/DISPOSAB 360 days 2 360 days LE MISC retail); RX/OTC MASK/MEDIUM MISC retail); RX/OTC QL(1 ml per 2 OPTICHAMBER FACE QL(2 ea per PFLEX MISC 360 days 2 360 days retail); RX/OTC MASK/SMALL MISC retail); RX/OTC PHARMACIST CHOICE QL(1 ml per OPTIHALER MDI DRUG QL(2 ea per NEBULIZER/CPAP/INHAL 2 360 days 2 360 days ER CHAMBER MASK retail); RX/OTC DELIVERY SYSTEM DEVI retail); RX/OTC WIPES MISC QL(2 ea per QL(1 ml per OPTIHALER MISC 2 360 days PILLOW MASK/ADULT 2 MISC 360 days retail); RX/OTC retail); RX/OTC

Coordinated Care of Washington Updated September 1, 2021

178 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PILLOW MASK/CHILD QL(1 ml per QL(1 ml per 2 360 days SIDESTREAM ADULT 2 360 days MISC FACE MASK MISC retail); RX/OTC retail); RX/OTC PILLOW QL(1 ml per QL(1 ml per 2 360 days SIDESTREAM PEDIATRIC 2 360 days MASK/PEDIATRIC MISC FACEMASK MISC retail); RX/OTC retail); RX/OTC QL(2 ea per SIDESTREAM PEDIATRIC QL(1 ml per POCKET CHAMBER DEVI 2 360 days FACEMASK/SAMI THE 2 360 days retail); RX/OTC SEAL MISC retail); RX/OTC QL(2 ea per SIDESTREAM PEDIATRIC QL(1 ml per POCKET SPACER DEVI 2 360 days FACEMASK/TUCKER THE 2 360 days retail); RX/OTC TURTLE MISC retail); RX/OTC PRIMEAIRE DUAL- RX/OTC QL(1 ml per VALVED HOLDING 2 SIDESTREAM PLUS 2 ADULT FACE MASK MISC 360 days CHAMBER DEVI retail); RX/OTC PRO COMFORT INHALER QL(2 ea per SILICONE MASK FOR QL(1 ml per SPACER CHAMBER 2 360 days BREATHERITE 2 360 days ADULT MISC retail); RX/OTC CHAMBER/ADULT MISC retail); RX/OTC PRO COMFORT INHALER QL(2 ea per SILICONE MASK FOR QL(1 ml per SPACER CHAMBER 2 360 days BREATHERITE 2 360 days CHILD MISC retail); RX/OTC CHAMBER/INFANT MISC retail); RX/OTC PRO COMFORT INHALER QL(2 ea per SILICONE MASK FOR QL(1 ml per 2 SPACER CHAMBER 360 days BREATHERITE 2 360 days INFANT DEVI retail); RX/OTC CHAMBER/PEDIATRIC retail); RX/OTC PROCARE SPACER QL(2 ea per MISC CHAMBER W/ADULT 2 360 days SILICONE MASK FOR QL(1 ml per MASK DEVI retail); RX/OTC BREATHRITE 2 360 days PROCARE SPACER QL(2 ea per CHAMBER/ADULT MISC retail); RX/OTC CHAMBER W/CHILD 2 360 days QL(1 ml per MASK DEVI retail); RX/OTC SOOTHENEB NBL 100 2 CHILD MASK MISC 360 days retail); RX/OTC PRONEB ULTRA FILTER QL(1 ml per 2 360 days QL(1 ml per SET MISC retail); RX/OTC SOOTHENEB NBL 100 2 MEDICATION CUP MISC 360 days retail); RX/OTC QUAKE DEVI 2 RX/OTC QL(1 ml per SOOTHENEB NBL 100 2 360 days QL(1 ml per MESH CAP MISC REPLACEMENT AIR 2 360 days retail); RX/OTC FILTER MISC retail); RX/OTC QL(1 ml per SOOTHENEB NBL100 2 360 days QL(1 ml per ADULT MASK MISC REPLACEMENT FILTERS 2 retail); RX/OTC MISC 360 days retail); RX/OTC SPIRO PD DEVI 2 RX/OTC QL(2 ea per RITEFLO DEVI 2 360 days QL(1 ml per retail); RX/OTC THRESHOLD IMT MISC 2 360 days SAMI THE SEAL QL(1 ml per retail); RX/OTC REPLACEMENTFILTERS 2 360 days THRESHOLD PEP DEVI 2 RX/OTC MISC retail); RX/OTC

Coordinated Care of Washington Updated September 1, 2021

179 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ml per Migraine Combinations 2 TUBING/WING TIP MISC 360 days AL(At least 18 retail); RX/OTC CAFERGOT TABS NP (ergotamine w/ caffeine) yrs old) QL(2 ea per ergotamine w/ caffeine VALVED HOLDING 2 360 days 1 CHAMBER DEVI supp re 2 mg-100 mg retail); RX/OTC ergotamine w/ caffeine tabs 1 AL(At least 18 VORTEX HOLDING RX/OTC or 1 mg-100 mg yrs old) CHAMBER/MASK/CHILDS 2 DEVI MIGRAINE PACK THPK NP PA VORTEX HOLDING RX/OTC CHAMBER/MASK/CHILDS 2 MIGRANOW THPK NP PA /FROG DEVI sumatriptan-naproxen NP PA VORTEX HOLDING RX/OTC sodium tabs CHAMBER/MASK/TODDL 2 ER DEVI TREXIMET TABS PA (sumatriptan-naproxen NP VORTEX HOLDING RX/OTC sodium) CHAMBER/MASK/TODDL 2 ER/LADY BUG DEVI Migraine Products - NSAIDs VORTEX VALVED QL(2 ea per CAMBIA PACK 2 PA HOLDING CHAMBER 2 360 days DEVI retail); RX/OTC Migraine Products QL(2 ea per D.H.E. 45 SOLN PA; AL(At least WATCHHALER DEVI 2 360 days (dihydroergotamine NP 18 yrs old) retail); RX/OTC mesylate) QL(1 ml per dihydroergotamine PA; AL(At least WINDMILL TRAINER 2 1 MISC 360 days mesylate soln 18 yrs old) retail); RX/OTC ERGOMAR SUBL 2 MIGRAINE PRODUCTS - Drugs to Treat Migraine Headaches MIGRANAL SOLN PA; AL(At least Calcitonin Gene-Related Peptide (CGRP) (dihydroergotamine NP 18 yrs old) mesylate) AIMOVIG SOAJ 140 NP PA MG/ML Serotonin Agonists QL(6 ea per 30 PA; SP almotriptan malate tabs NP AIMOVIG SOAJ 70 MG/ML NP days retail) AJOVY SOAJ NP PA QL(9 ea per 30 AMERGE TABS NP days retail); PA; SP (naratriptan hcl) AL(At least 18 AJOVY SOSY NP yrs old) EMGALITY SOAJ 2 PA PA; QL(6 ea per 30 days eletriptan hydrobromide EMGALITY SOSY 2 PA NP retail); AL(At tabs least 18 yrs old) NURTEC TBDP NP PA FROVA TABS (frovatriptan NP PA UBRELVY TABS NP PA succinate) frovatriptan succinate tabs NP PA VYEPTI SOLN NP PA

Coordinated Care of Washington Updated September 1, 2021

180 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6 ea per 30 QL(12 ea per IMITREX SOLN NA 20 NP days retail); rizatriptan benzoate tabs 1 30 days retail); MG/ACT, 5 MG/ACT AL(At least 12 10 mg, 5 mg AL(At least 6 (sumatriptan) yrs old) yrs old) QL(2 ml per 30 rizatriptan benzoate tbdp 1 IMITREX SOLN SC 6 days retail); 10 mg, 5 mg MG/0.5ML (sumatriptan NP succinate) AL(At least 12 QL(6 ea per 30 yrs old) days retail); sumatriptan soln 1 IMITREX STATDOSE AL(At least 12 REFILL SOCT 4 MG/0.5ML NP yrs old) (sumatriptan succinate) sumatriptan succinate soaj 1 QL(2 ml per 30 sc 4 mg/0.5ml IMITREX STATDOSE NP days retail); QL(2 ml per 30 REFILL SOCT 6 MG/0.5ML AL(At least 12 (sumatriptan succinate) sumatriptan succinate soaj 1 days retail); yrs old) sc 6 mg/0.5ml AL(At least 12 IMITREX STATDOSE yrs old) SYSTEM SOAJ 4 NP sumatriptan succinate soct 1 MG/0.5ML (sumatriptan sc 4 mg/0.5ml succinate) QL(2 ml per 30 IMITREX STATDOSE QL(2 ml per 30 sumatriptan succinate soct 1 days retail); SYSTEM SOAJ 6 NP days retail); sc 6 mg/0.5ml AL(At least 12 MG/0.5ML (sumatriptan AL(At least 12 yrs old) succinate) yrs old) QL(2 ml per 30 QL(9 ea per 30 IMITREX TABS OR 50 MG, sumatriptan succinate soln 1 days retail); NP days retail); sc 6 mg/0.5ml AL(At least 12 100 MG, 25 MG AL(At least 12 (sumatriptan succinate) yrs old) yrs old) QL(2 ml per 30 QL(12 ea per sumatriptan succinate sosy NP days retail); MAXALT TABS (rizatriptan NP 30 days retail); sc 6 mg/0.5ml AL(At least 12 benzoate) AL(At least 6 yrs old) yrs old) QL(9 ea per 30 MAXALT-MLT TBDP NP sumatriptan succinate tabs 1 days retail); (rizatriptan benzoate) or 50 mg, 100 mg, 25 mg AL(At least 12 QL(9 ea per 30 yrs old) 1 days retail); PA naratriptan hcl tabs AL(At least 18 TOSYMRA SOLN NP yrs old) ZEMBRACE SYMTOUCH NP PA ONZETRA XSAIL EXHP NP PA SOAJ PA; QL(6 ea zolmitriptan soln na 2.5 mg NP per 30 days AL(At least 12 RELPAX TABS (eletriptan NP zolmitriptan soln na 5 mg NP ) retail); AL(At yrs old) hydrobromide least 18 yrs old) PA; QL(6 ea per 30 days zolmitriptan tabs or 2.5 mg, REYVOW TABS NP PA NP retail); AL(At 5 mg least 18 yrs old)

Coordinated Care of Washington Updated September 1, 2021

181 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; QL(6 ea CALCIUM TABS 200 UNIT- 2 per 30 days 600 MG zolmitriptan tbdp or 2.5 mg, NP retail); AL(At 5 mg least 18 yrs calcium tabs 600 mg 1 old) oyster shell tabs 1 ZOMIG SOLN NA 2.5 MG NP (zolmitriptan) QC CALCIUM 500MG/D3 2 TABS ZOMIG SOLN NA 5 MG NP AL(At least 12 (zolmitriptan) yrs old) RA CALCIUM TABS 2 PA; QL(6 ea per 30 days Fluoride ZOMIG TABS OR 2.5 MG, NP retail); AL(At 5 MG (zolmitriptan) sodium fluoride chew 0.25 1 MP least 18 yrs mg, 0.5 mg, 1 mg, 2.2 mg old) sodium fluoride soln 0.125 1 MP PA; QL(6 ea mg/drop per 30 days ZOMIG ZMT TBDP NP sodium fluoride soln 0.5 RX/OTC; MP zolmitriptan) retail); AL(At 1 ( least 18 yrs mg/ml old) sodium fluoride tabs 0.5 1 mg, 1 mg MINERALS & ELECTROLYTES Phosphate Calcium K-PHOS NEUTRAL TABS QL(8 ea daily); CAL-QUICK LIQD 2 PA (pot phosphate monobasic NP MP w/ sod phosphate dibasic & monobasic) CALCIUM CARBONATE 2 CHEW 500 MG K-PHOS TABS 2 calcium carbonate tabs 1250 mg, 500 mg, 600 mg, 1 pot phosphate monobasic QL(8 ea daily); 1500 mg w/ sod phosphate dibasic & 1 MP monobasic tabs calcium carbonate- 1 cholecalciferol chew Potassium calcium carbonate- 1 cholecalciferol tabs EFFER-K TBEF 2 K-TAB TBCR 10 MEQ MP calcium carbonate-vitamin 1 PA NP d chew 400 unit-600 mg (potassium chloride) calcium carbonate-vitamin QL(2 ea daily) K-TAB TBCR 20 MEQ NP d tabs 200 unit-600 mg, 1 (potassium chloride) 400 unit-600 mg K-TAB TBCR 8 MEQ NP PA; MP calcium carbonate-vitamin (potassium chloride) d tabs 400 unit-500 mg, 1 PA 200 unit-200 unit-500 mg- potassium acetate soln 1 500 mg potassium bicarbonate tbef 1 MP calcium carbonate-vitamin 1 d w/ minerals chew potassium chloride cpcr or 1 MP 10 meq CALCIUM CHEW 500 MG 2 potassium chloride cpcr or 1 8 meq

Coordinated Care of Washington Updated September 1, 2021

182 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits potassium chloride MP ASTAGRAF XL CP24 NP PA microencapsulated crystals 1 er tbcr AZASAN TABS NP PA; QL(3 ea daily); MP potassium chloride pack or 1 PA 20 meq azathioprine tabs 1 MP POTASSIUM CHLORIDE PA SOLN IV 0.4 MEQ/ML, 10 CELLCEPT CAPS 250 MG NP QL(2 ea daily); MEQ/100ML, 10 (mycophenolate mofetil) MP MEQ/50ML, 20 2 CELLCEPT SUSR 200 MP MEQ/100ML, 20 MG/ML (mycophenolate NP MEQ/50ML, 40 mofetil) MEQ/100ML CELLCEPT TABS 500 MG NP QL(4 ea daily); potassium chloride soln iv PA (mycophenolate mofetil) MP 10 meq/100ml, 10 QL(4 ea daily); cyclosporine caps 1 meq/50ml, 20 meq/100ml, 1 MP 20 meq/50ml, 40 meq/100ml, 2 meq/ml cyclosporine modified (for QL(4 ea daily); microemulsion) caps 100 1 MP potassium chloride soln or 1 MP mg, 25 mg 10 % cyclosporine modified (for NP PA; QL(4 ea potassium chloride soln or 1 PA; MP microemulsion) caps 50 mg daily); MP 20 % cyclosporine modified (for QL(8 ml daily); potassium chloride tbcr or 1 MP microemulsion) soln 100 1 MP 10 meq, 8 meq mg/ml potassium chloride tbcr or NP PA 20 meq ENSPRYNG SOSY 2 MISCELLANEOUS THERAPEUTIC CLASSES ENVARSUS XR TB24 NP PA

Chelating Agents everolimus NP (immunosuppressant) tabs CUPRIMINE CAPS NP PA (penicillamine) GAMIFANT SOLN CO DEPEN TITRATABS TABS 2 PA (penicillamine) IMURAN TABS NP MP (azathioprine) penicillamine caps 1 PA LUPKYNIS CAPS NP PA penicillamine tabs 1 PA mycophenolate mofetil 1 QL(2 ea daily); caps or 250 mg MP SYPRINE CAPS (trientine NP PA hcl) mycophenolate mofetil susr 1 MP or 200 mg/ml trientine hcl caps 1 PA mycophenolate mofetil tabs 1 QL(4 ea daily); Immunomodulators or 500 mg MP PA; SP mycophenolate sodium NP PA; QL(2 ea REVLIMID CAPS 2 tbec 180 mg daily); MP mycophenolate sodium PA; QL(4 ea THALOMID CAPS 2 PA; SP; MP NP tbec 360 mg daily); MP Immunosuppressive Agents MYFORTIC TBEC 180 MG NP PA; QL(2 ea (mycophenolate sodium) daily); MP

Coordinated Care of Washington Updated September 1, 2021

183 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MYFORTIC TBEC 360 MG NP PA; QL(4 ea LOKELMA PACK NP PA (mycophenolate sodium) daily); MP NEORAL CAPS 100 MG, QL(4 ea daily); sodium polystyrene 1 QL(454 gm per sulfonate powd fill retail) 25 MG (cyclosporine NP MP modified (for sodium polystyrene 1 microemulsion)) sulfonate susp NEORAL SOLN 100 QL(8 ml daily); VELTASSA PACK 2 MG/ML (cyclosporine NP MP modified (for Progeria Treatment Agents microemulsion)) PROGRAF CAPS OR 0.5 QL(3 ea daily); ZOKINVY CAPS CO MG, 1 MG, 5 MG NP MP (tacrolimus) Systemic Lupus Erythematosus Agents PA PROGRAF PACK OR 0.2 NP PA BENLYSTA SOAJ 2 MG, 1 MG BENLYSTA SOLR 2 PA PROGRAF SOLN IV 5 2 PA MG/ML BENLYSTA SOSY 2 PA RAPAMUNE SOLN 1 NP PA; MP MG/ML (sirolimus) RAPAMUNE TABS 0.5 MP MOUTH/THROAT/DENTAL AGENTS MG, 1 MG, 2 MG NP Anesthetics Topical Oral (sirolimus) lidocaine hcl (mouth-throat) 1 QL(100 ml per REZUROCK TABS 2 PA soln fill retail) Anti-infectives - Throat SANDIMMUNE CAPS 100 NP QL(4 ea daily); MG, 25 MG (cyclosporine) MP clotrimazole troc 1 SANDIMMUNE SOLN 100 NP PA; QL(8 ml MG/ML daily); MP nystatin (mouth-throat) 1 QL(120 ml per susp fill retail) sirolimus soln 1 mg/ml NP PA; MP Antiseptics - Mouth/Throat sirolimus tabs 0.5 mg, 1 MP 1 chlorhexidine gluconate 1 mg, 2 mg (mouth-throat) soln QL(3 ea daily); tacrolimus caps 1 MP Dental Products ZORTRESS TABS 0.25 sodium fluoride (dental) 1 MP crea MG, 0.5 MG, 0.75 MG NP (everolimus sodium fluoride (dental) gel 1 MP (immunosuppressant)) sodium fluoride (dental) 1 MP ZORTRESS TABS 1 MG NP soln Irrigation Solutions stannous fluoride conc 1 RX/OTC; MP irrigation solutions, 1 PA physiological soln Steroids - Mouth/Throat/Dental PA triamcinolone acetonide 1 QL(5 gm per fill ringer's irrigation soln 1 (mouth) pste retail) Potassium Removing Agents Throat Products - Misc.

Coordinated Care of Washington Updated September 1, 2021

184 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(900 ml per QL(900 ml per AQUORAL SOLN 2 fill retail); RA DRY MOUTH SOLN 2 fill retail); RX/OTC RX/OTC BIOTENE DRY MOUTH QL(900 ml per SALAGEN TABS 5 MG NP QL(6 ea daily); MOISTURIZING SPRAY 2 fill retail); (pilocarpine hcl (oral)) MP SOLN RX/OTC SALAGEN TABS 7.5 MG NP BOCASAL PACK NP (pilocarpine hcl (oral)) QL(900 ml per SALIVAMAX PACK NP CAPHOSOL SOLN 2 fill retail); QL(900 ml per RX/OTC XEROSTOMIA RELIEF 2 fill retail); SPRAY SOLN cevimeline hcl caps 1 MP RX/OTC QL(900 ml per MULTIVITAMINS CVS DRY MOUTH SPRAY 2 SOLN fill retail); RX/OTC B-Complex w/ Folic Acid QL(900 ml per b-complex w/ c & folic acid QL(1 ea daily); EQL DRY MOUTH ORAL 2 fill retail); caps 1 mg-1.5 mg-1.7 mg-5 1 RX/OTC RINSE SOLN mg-6 mcg-10 mg-20 mg- RX/OTC 100 mg-150 mcg EVOXAC CAPS NP MP ( ) b-complex w/ c & folic acid RX/OTC cevimeline hcl tabs 0.006 mg-0.3 mg-1 QL(900 ml per mg-1.5 mg-1.7 mg-10 mg- MOI-STIR SOLN 2 fill retail); 10 mg-20 mg-100 mg, 0.01 RX/OTC mcg-1 mg-1.5 mg-1.7 mg- QL(900 ml per 10 mg-10 mg-20 mg-60 MOUTH KOTE REMINT 2 mg-300 mcg, 1 mg-1 mg- SOLN fill retail); RX/OTC 1.5 mg-1.5 mg-1.7 mg-1.7 QL(900 ml per mg-6 mcg-6 mcg-10 mg-10 MOUTH KOTE SOLN 2 fill retail); mg-10 mg-10 mg-20 mg-20 RX/OTC mg-100 mg-100 mg-300 mcg-300 mcg, 1 mg-1 mg- MUCOSITISRX PACK NP 1.5 mg-1.7 mg-8 mg-20 1 mg-30 mcg-200 mg-300 NEUTRASAL PACK NP mcg, 1 mg-1.5 mg-1.7 mg- 6 mcg-10 mg-10 mg-20 QL(900 ml per mg-100 mg-300 mcg, 1.5 NUMOISYN LIQD 2 fill retail); mg-1.7 mg-5 mg-6 mcg-10 RX/OTC mg-20 mg-100 mg-150 mcg-1000 mcg, 1.5 mg-1.7 NUMOISYN LOZG NP RX/OTC (artificial saliva) mg-6 mcg-10 mg-10 mg-20 ORAL RELIEF SPRAY QL(900 ml per mg-100 mg-300 mcg-1000 FOR DRYMOUTH & 2 fill retail); mcg, 0.5 mg-4 mg-5 mcg- DISCOMFORT SOLN RX/OTC 15 mg-15 mg-18 mg-100 mg-500 mg pilocarpine hcl (oral) tabs 5 1 QL(6 ea daily); mg MP b-complex w/ c & folic acid tabs 1 mg-1.5 mg-1.5 mg-5 1 pilocarpine hcl (oral) tabs 1 mg-10 mg-20 mg-50 mg-60 7.5 mg mg-300 mcg Multiple Vitamins w/ Minerals

Coordinated Care of Washington Updated September 1, 2021

185 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BACMIN TABS 1 RX/OTC NUTRICAP TABS 1 RX/OTC multiple vitamins w/ RX/OTC ONEVITE TABS 2 QL(1 ea daily) minerals tabs 0.05 mg-0.15 mg-1 mg-3 mg-10 mg-15 REQ 49+ TABS 1 RX/OTC mg-20 mcg-20 mg-20 mg- 25 mg-25 mg-50 mcg-50 RX/OTC mcg-50 mg-60 unit-100 SIDEROL TABS 1 mg-400 unit-500 mg, 0.1 STROVITE FORTE TABS RX/OTC mg-0.15 mg-0.8 mg-3 mg-5 (multiple vitamins w/ 1 mg-20 mg-20 mg-22.5 mg- minerals) 25 mg-25 mg-27 mg-30 unit-50 mcg-50 mg-100 STROVITE ONE TABS 1 RX/OTC mg-500 mg-5000 unit, 0.667 mg-1.667 mg-3.333 THRIVITE 19 TABS 2 QL(1 ea daily) mg-5 mcg-5 mg-5 mg- 16.667 mcg-16.667 mg- UDAMIN SP TABS 2 QL(1 ea daily) 16.667 mg-16.667 mg- 16.667 mg-26.667 mg- VENTRIXYL TABS 2 QL(1 ea daily) 33.333 mcg-50 mcg-66.667 mg-66.667 mg-66.667 unit- VITAROCA PLUS TABS RX/OTC 133.333 mg-133.333 mg- (multiple vitamins w/ 1 133.333 unit-166.667 mg- minerals) 333.333 mcg-333.333 mg- 1 Ped MV w/ Fluoride 1666.667 unit, 1 mg-1.25 mg-3.4 mg-5 mg-10 mg-25 pediatric multivitamins w/fl QL(1 ea daily); mg-35 mg-35 mg-35 mg-35 chew 0.25 mg-0.3 mg-1.05 AL(Up to 13 yrs mg-35 mg-70 mcg-75 mcg- mg-1.05 mg-1.2 mg-4.5 old ); RX/OTC 125 mcg-125 mcg-125 unit- mcg-13.5 mg-15 unit-60 150 mcg-400 mcg-400 unit- mg-400 unit-2500 unit, 0.25 500 mg, 1 mg-10 mg-25 mg-1.05 mg-1.05 mg-1.2 mg-25 mg-25 mg-25 mg-33 mg-4.5 mcg-13.5 mg-15 mg-50 mcg-50 mg-60 mg- unit-60 mg-300 mcg-400 100 unit-125 mg-200 unit- unit-2500 unit, 0.3 mg-1 300 mcg-500 mg-5000 unit, mg-1.05 mg-1.05 mg-1.2 1 1 mg-10 mg-25 mg-25 mg- mg-4.5 mcg-13.5 mg-15 25 mg-25 mg-33 mg-50 unit-60 mg-400 unit-2500 mcg-50 mg-80 mg-100 unit, 1 mg-1.05 mg-1.05 unit-125 mg-200 unit-300 mg-1.2 mg-4.5 mcg-13.5 mcg-500 mg-5000 unit, 2.5 mg-15 unit-60 mg-300 mg-5 mg-20 mg-20 mg-20 mcg-400 unit-2500 unit, 0.3 mg-25 mg-25 mg-50 mcg- mg-0.5 mg-1.05 mg-1.05 50 mcg-50 mg-50 unit-66 mg-1.2 mg-4.5 mcg-13.5 mg-100 mg-200 mcg-200 mg-15 unit-60 mg-400 unit- mcg-400 unit-500 mg-1000 2500 unit mcg-5000 unit NICADAN TABS 1 RX/OTC

NICADAN ZX TABS 1 RX/OTC

Coordinated Care of Washington Updated September 1, 2021

186 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits pediatric multivitamins w/fl QL(50 ml per pediatric multiple vitamin w/ soln 0.4 mg/ml-0.5 mg/ml- fill retail); minerals & c chew 0.013 0.5 mg/ml-0.6 mg/ml-2 AL(Up to 13 yrs mg-0.043 mg-0.175 mg- mcg/ml-5 unit/ml-8 mg/ml- old ); RX/OTC 0.333 mg-0.75 mg-3 mg-5 35 mg/ml-400 unit/ml-1500 1 mcg-5 unit-7.5 mcg-10 mg- unit/ml, 0.25 mg/ml-0.4 11 mg-14 mg-16.75 mcg- mg/ml-0.5 mg/ml-0.6 25 mcg-31.25 mg-66.75 mg/ml-2 mcg/ml-5 unit/ml-8 mcg-85 mg-150 unit-250 mg/ml-35 mg/ml-400 unit, 0.25 mg-1 mg-1 mg- unit/ml-1500 unit/ml 1.25 mg-1.5 mcg-2 mg-5 pediatric vitamins acd w/ QL(50 ml per mcg-5 mcg-7.5 mg-7.5 unit- 15 mcg-22.5 mcg-25 unit- fluoride soln 0.25 mg/ml-35 1 fill retail); mg/ml-400 unit/ml-1500 AL(Up to 13 yrs 100 mcg-1250 unit, 0.25 unit/ml old ); RX/OTC mg-1 mg-1 mg-1.25 mg-1.5 pediatric vitamins acd w/ QL(50 ml per mcg-5 mcg-7.5 mg-7.5 unit- 15 mcg-22.5 mcg-50 mcg- fluoride soln 0.5 mg/ml-35 1 fill retail); mg/ml-400 unit/ml-1500 AL(Up to 13 yrs 100 mcg-200 unit-750 unit, unit/ml old ) 0.5 mg-0.5 mg-0.5 mg-0.75 mg-0.85 mg-1 mg-1 mg- Ped MV w/ Iron 1.25 mg-2.5 mg-2.5 mg-2.5 mg-3 mcg-3 mg-5 mg-5 BPROTECTED PEDIA 2 QL(60 ml per POLY-VITE/IRON SOLN fill retail) mg-10 mcg-15 unit-20 mcg- PC PEDIATRIC POLY- QL(60 ml per 25 mg-30 mcg-50 mg-60 VITAMIN DROPS/IRON 2 fill retail) mg-75 mcg-75 mcg-200 SOLN mcg-200 unit-2500 unit, 0.5 mg-1.25 mg-1.5 mcg-2.5 1 pediatric multiple vitamins 1 mg-9 unit-10 mg-15 mcg- w/ iron chew 20 mcg-20 mcg-37.5 mcg- 100 mcg-200 unit-1000 POLY-VI-SOL/IRON SOLN 2 QL(60 ml per fill retail) unit, 0.5 mg-1.25 mg-2.5 mg-3 mcg-9 unit-15 mcg-15 POLY-VITA/IRON SOLN 2 QL(60 ml per fill retail) mg-19 mg-37.5 mcg-100 mcg-200 unit-1000 unit, 0.5 QL(60 ml per POLY-VITE/IRON SOLN 2 mg-1.3 mg-1.5 mcg-2.5 fill retail) mg-4.1 mg-7.5 mcg-15 Ped Multi Vitamins w/Fl & FE mcg-15 mg-38 mcg-100 ped multivitamins w/fl & QL(50 ml per mcg-300 mcg, 0.5 mg-1.3 iron soln 0.25 mg/ml-0.4 fill retail); mg-1.5 mcg-2.5 mg-9 unit- 15 mcg-15 mg-19 mg-38 mg/ml-0.5 mg/ml-0.6 1 AL(Up to 13 yrs mg/ml-5 unit/ml-8 mg/ml-10 old ); RX/OTC mcg-100 mcg-200 unit- mg/ml-35 mg/ml-400 1000 unit, 0.5 mg-1.3 mg- unit/ml-1500 unit/ml 1.5 mcg-2.5 mg-9 unit-15 mcg-15 mg-38 mcg-100 QUFLORA FE PEDIATRIC 2 mcg-300 unit-1000 unit, 0.5 LIQD mg-1.3 mg-2.5 mcg-2.5 Ped Multiple Vitamins w/ Minerals mg-10 mcg-10 unit-15 mg- RX/OTC 19 mg-20 mcg-38 mcg-100 AQUADEKS LIQD 2 mcg-100 unit-1000 unit, 0.6 mcg-1.1 mg-1.33 mg-6 mcg-6 mg-45 mg-150 mcg- 183 unit-500 mcg, 1 mg- 1.35 mg-2.6 mg-3 mcg-10 Coordinated Care of Washington Updated September 1, 2021

187 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mg-20 mcg-20 mcg-21 mg- unit-20 mg-40 mcg-40 mcg- 30 mcg-130 mcg-200 unit- 42 mcg-60 mcg-260 mcg- 200 unit-1050 unit, 1 mg- 400 unit-2100 unit, 2 mg- 1.35 mg-2.6 mg-3 mcg- 2.7 mg-5.2 mg-6 mcg-16.5 8.25 unit-10 mg-20 mcg-20 unit-20 mg-40 mcg-40 mcg- mcg-21 mcg-30 mcg-130 42 mcg-60 mcg-260 mcg- mcg-200 unit-1050 unit, 1 600 unit-2100 unit mg-1.35 mg-2.6 mg-3 mcg- Pediatric Multiple Vitamins 8.25 unit-10 mg-20 mcg-20 mcg-21 mcg-30 mcg-70 BPROTECTED PEDIA 2 mcg-200 unit-1050 unit, 1 POLY-VITE SOLN mg-1.35 mg-2.6 mg-3 mcg- INFUVITE PEDIATRIC 2 PA 9 unit-20 mcg-20 mcg-20 SOLN mg-21 mcg-37.5 mcg-100 PA mcg-300 unit-1050 unit, 1 M.V.I. PEDIATRIC SOLR 2 mg-1.5 mg-1.7 mg-2 mg- 2.5 mg-2.5 mg-3.75 mcg- POLY-VI-SOL SOLN 2 6.25 mg-7.5 mg-10 mg- 12.5 mg-15 mcg-15 mg-15 POLY-VITA SOLN 2 unit-37.5 mcg-50 mcg-60 POLY-VITE PEDIATRIC 2 mg-75 mcg-200 mcg-300 SOLN unit-2500 unit, 1 mg-1.5 mg-2.5 mg-2.5 mg-3 mcg- Pediatric Vitamins 10 unit-20 mg-37.5 mcg-75 mcg-187.5 mcg-200 mcg- pediatric vitamins adc soln 1 200 unit-212.5 mcg-1250 unit, 1 mg-2.5 mg-5 mcg-5 TRI-VI-SOL A/C/D SOLN 2 mg-20 mcg-20 unit-30 mg- 38 mg-40 mcg-75 mcg-200 Prenatal Vitamins mcg-200 unit-2000 unit, CLASSIC PRENATAL 2 QL(1 ea daily); 1.05 mg-1.05 mg-1.2 mg- TABS MP 4.5 mcg-10 mg-15 unit-60 CO-NATAL FA TABS 2 QL(1 ea daily); mg-300 mcg-400 unit-1998 RX/OTC; MP unit, 1.05 mg-1.05 mg-1.2 COMPLETE NATAL DHA 2 MP mg-4.5 mcg-13.5 mg-15 MISC unit-60 mg-200 mg-300 QL(1 ea daily); mcg-400 unit-2500 unit, 1.5 COMPLETENATE CHEW 2 mg-1.7 mg-1.9 mg-6 mcg- MP QL(1 ea daily); 10 mg-12 mg-15 mg-100 CVS PRENATAL TABS 2 mcg-100 mg-200 mcg-200 MP unit-1000 mcg-1500 unit- MP 16000 unit, 1.5 mg-1.7 mg- ENFAMIL EXPECTA MISC 2 1.9 mg-6 mcg-10 mg-12 EQL PRENATAL 2 QL(1 ea daily); mg-15 mg-100 mcg-100 FORMULA TABS MP mg-200 mcg-200 unit-1000 QL(1 ea daily); mcg-3000 unit-16000 unit, GNP PRENATAL TABS 2 1.5 mg-1.7 mg-1.9 mg-6 MP mcg-10 mg-12 mg-15 mg- GOODSENSE PRENATAL 2 QL(1 ea daily); 100 mcg-100 mg-200 mcg- VITAMINS TABS MP 200 unit-1000 mcg-5000 HM PRENATAL TABS 2 QL(1 ea daily); unit-16000 unit, 2 mg-2.7 MP mg-5.2 mg-6 mcg-16.5 Coordinated Care of Washington Updated September 1, 2021

188 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KP PRENATAL 2 QL(1 ea daily); PRENATAL LOW IRON 2 QL(1 ea daily); MULTIVITAMINS TABS MP TABS MP M-NATAL PLUS TABS 2 RX/OTC; MP PRENATAL MP MULTIVITAMIN + DHA 2 MISC MULTI PRENATAL TABS 2 QL(1 ea daily); MP PRENATAL 2 QL(1 ea daily); MULTIVITAMIN TABS MP NATALVIT TABS 2 QL(1 ea daily); MP PRENATAL ONE DAILY 2 QL(1 ea daily); NEONATAL COMPLETE RX/OTC; MP TABS MP TABS 0.2 MG-1.84 MG-2 PRENATAL PLUS IRON 2 QL(1 ea daily); MG-2 MG-3 MG-5 MG-9.2 TABS MP MG-10 MCG-10 MG-12 2 PRENATAL TABS 0.8 MG- QL(1 ea daily); MCG-20 MG-25 MG-27 1.5 MG-1.7 MG-2.6 MG-4 MP MG-120 MG-200 MG-1000 MCG-11 UNIT-18 MG-25 MCG-1200 MCG MG-27 MG-100 MG-263 NEONATAL COMPLETE QL(1 ea daily); MG-400 UNIT-4000 UNIT, TABS 3 MG-3 MG-3 MG-3 RX/OTC; MP 0.8 MG-1.7 MG-1.8 MG-2.6 MG-7 MG-8 MCG-15 MG- MG-8 MCG-20 MG-25 MG- 18.4 MG-20 MG-25 MCG- 2 28 MG-30 UNIT-120 MG- 29 MG-30 MCG-100 MG- 200 MG-400 UNIT-4000 120 MG-150 MCG-200 UNIT, 1.5 MG-1.7 MG-2.6 MG-1000 MCG-1200 MCG MG-4 MCG-5 MG-10 MCG- 2 NEONATAL PLUS TABS 2 RX/OTC; MP 18 MG-25 MG-27 MG-100 MG-200 MG-800 MCG- 1200 MCG, 1.7 MG-1.8 NEONATAL VITAMIN 2 QL(1 ea daily); TABS MP MG-2.6 MG-8 MCG-20 RX/OTC; MP MG-25 MG-28 MG-30 NIVA-PLUS TABS 2 UNIT-120 MG-200 MG-400 UNIT-800 MCG-4000 ONE VITE WOMENS RX/OTC; MP UNIT, 1.7 MG-1.84 MG-2.6 PRENATALVITAMIN PLUS 2 MG-4 MCG-11 UNIT-18 TABS MG-25 MG-27 MG-100 ONE VITE WOMENS 2 QL(1 ea daily); MG-160 MG-200 MG-400 PRENATALVITAMIN TABS MP UNIT-800 MCG-4000 UNIT QL(1 ea daily); PNV TABS 29-1 TABS 2 PRENATAL TABS 1 MG- RX/OTC; MP MP 1.84 MG-2 MG-3 MG-10 PRENATAL 19 CHEW 1 QL(1 ea daily); MCG-10 MG-10 MG-12 2 MG-3 MG-3 MG-7 MG-12 MP MCG-20 MG-25 MG-27 MG-120 MG-200 MG-1200 MCG-15 MG-20 MG-20 2 MG-29 MG-30 UNIT-100 MCG MG-200 MG-400 UNIT- prenatal vit w/ ferrous QL(1 ea daily); 1000 UNIT fumarate-folic acid chew 1 MP PRENATAL 19 TABS 1 RX/OTC; MP mg-3 mg-3 mg-6 mg-7 mg- 1 MG-3 MG-3 MG-7 MG-12 12 mcg-20 mg-20 mg-25 mg-29 mg-30 unit-100 mg- MCG-15 MG-20 MG-20 2 MG-25 MG-29 MG-30 200 mg-400 unit-1000 unit UNIT-100 MG-200 MG-400 UNIT-1000 UNIT

Coordinated Care of Washington Updated September 1, 2021

189 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits prenatal vit w/ ferrous MP TRINATAL RX 1 TABS 2 QL(1 ea daily); fumarate-folic acid tabs 1 MP mg-1.8 mg-2 mg-4 mg-12 VINATE ONE TABS 2 QL(1 ea daily); mcg-20 mg-22 mg-25 mg- 1 MP 25 mg-25 mg-28 mg-120 mg-200 mg-400 unit-3000 VITATHELY/GINGER 2 RX/OTC; MP unit TABS VOL-PLUS TABS 2 RX/OTC; MP prenatal vit w/ iron 1 QL(1 ea daily); carbonyl-folic acid tabs MP QL(1 ea daily); VOL-TAB RX TABS 2 PRENATAL VITAMIN & 2 QL(1 ea daily); MP MINERAL TABS MP WESTAB PLUS TABS 2 RX/OTC; MP PRENATAL VITAMIN 2 QL(1 ea daily); TABS MP MUSCULOSKELETAL THERAPY AGENTS - PRENATAL 2 QL(1 ea daily); Drugs to Treat Spasms VITAMIN/IRON TABS MP Central Muscle Relaxants PRENATAL VITAMINS 2 RX/OTC; MP PLUS LOW IRON TABS ACTIVE- PA CYCLOBENZAPRINE KIT NP PRENATAL VITAMINS 2 QL(1 ea daily); TABS MP CREA RX/OTC; MP AMRIX CP24 NP PA PRENATRYL TABS 2 (cyclobenzaprine hcl) RX/OTC; MP baclofen tabs or 10 mg, 20 1 MP PREPLUS TABS 2 mg PRETAB TABS 2 QL(1 ea daily); baclofen tabs or 5 mg 1 RX/OTC; MP PA PX PRENATAL 2 QL(1 ea daily); carisoprodol tabs NP MULTIVITAMINS TABS MP CHLORZOXAZONE TABS QC PRENATAL TABS 2 QL(1 ea daily); NP MP 250 MG RA PRENATAL QL(1 ea daily); chlorzoxazone tabs 500 NP FORMULA/FOLICACID 2 MP mg, 375 mg, 750 mg TABS cyclobenzaprine hcl cp24 NP PA QL(1 ea daily); 15 mg, 30 mg RA PRENATAL TABS 2 MP cyclobenzaprine hcl tabs 1 QL(3 ea daily) 10 mg, 5 mg RIGHT STEP PRENATAL 2 QL(1 ea daily); TABS MP cyclobenzaprine hcl tabs 1 QL(1 ea daily); 7.5 mg SE-NATAL 19 CHEW 2 MP cyclobenzaprine hcl tabs NP PA QL(1 ea daily); 7.5 mg SE-NATAL 19 TABS 2 RX/OTC; MP CYCLOPHENE NP PA RAPIDPAQ CREA SM PRENATAL VITAMINS 2 QL(1 ea daily); TABS MP ENOVARX- PA CYCLOBENZAPRINE HCL NP THERANATAL CORE 2 RX/OTC; MP NUTRITION TABS CREA FIRST-BACLOFEN 1 PA THRIVITE RX TABS 2 QL(1 ea daily); 2 MP SUSP

Coordinated Care of Washington Updated September 1, 2021

190 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FIRST-BACLOFEN 5 2 PA dantrolene sodium caps or NP PA SUSP 25 mg, 50 mg metaxalone tabs 400 mg NP dantrolene sodium solr iv 1 PA 20 mg PA metaxalone tabs 800 mg NP RYANODEX SUSR 2 PA methocarbamol soln ij 1000 NP PA Muscle Relaxant Combinations mg/10ml carisoprodol w/ aspirin & NP PA methocarbamol tabs or 500 1 codeine tabs mg, 750 mg carisoprodol w/ aspirin tabs NP PA orphenadrine citrate soln ij NP PA 30 mg/ml, 60 mg/2ml CYCLO/GABA10/300 NP PA orphenadrine citrate tb12 NP PACK THPK or 100 mg METAXALL CP KIT NP PA OZOBAX SOLN NP PA NOPIOID-LMC KIT THPK NP PA ROBAXIN SOLN NP PA (methocarbamol) NOPIOID-TC KIT THPK NP PA ROBAXIN-750 TABS NP (methocarbamol) NORGESIC FORTE TABS PA (orphenadrine w/ aspirin & NP SKELAXIN TABS NP PA (metaxalone) caff) PA orphenadrine w/ aspirin & NP PA SOMA TABS (carisoprodol) NP caff tabs TABRADOL FUSEPAQ PA NP TIZANIDINE COMFORT NP PA SUSP PAC MISC TABRADOL RAPIDPAQ NP PA NASAL AGENTS - SYSTEMIC AND TOPICAL - SUSP Drugs to treat the Nose or Sinus tizanidine hcl caps 2 mg, 4 NP PA mg, 6 mg Nasal Agent Combinations QL(18 ea azelastine hcl-fluticasone tizanidine hcl tabs 2 mg 1 NP daily); MP propionate susp QL(9 ea daily); DERMACINRX AZENASE PA tizanidine hcl tabs 4 mg 1 NP MP PAK THPK DYMISTA SUSP ZANAFLEX CAPS 2 MG, 4 NP PA MG, 6 MG (tizanidine hcl) (azelastine hcl-fluticasone NP propionate) ZANAFLEX TABS 4 MG NP QL(9 ea daily); (tizanidine hcl) MP Nasal Agents - Misc. ALZAIR ALLERGY PA Direct Muscle Relaxants BLOCKER NASAL SPRAY NP DANTRIUM CAPS NP PA POWD (dantrolene sodium) DERMACINRX TICANASE NP PA DANTRIUM IV SOLR 2 PA PAK THPK (dantrolene sodium) QL(50 ml per saline soln 1 dantrolene sodium caps or NP fill retail) 100 mg Nasal Antiallergy

Coordinated Care of Washington Updated September 1, 2021

191 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits azelastine hcl soln 1 QL(1 ml daily) Sympathomimetic Decongestants ADRENALIN SOLN NA 0.1 2 olopatadine hcl (nasal) soln NP PA %

PATANASE SOLN NP PA epinephrine hcl (nasal) soln 1 (olopatadine hcl (nasal)) Nasal Anticholinergics pseudoephedrine hcl tabs 1 QL(30 ml per SUDAFED PE ipratropium bromide (nasal) 1 25 days retail); 2 soln 0.03 % CHILDRENS NASAL MP DECONGESTANT SOLN QL(15 ml per NEUROMUSCULAR AGENTS - Drugs to ipratropium bromide (nasal) 1 30 days retail); soln 0.06 % Relax/Paralyze Muscles MP ALS Agents Nasal Steroids EXSERVAN FILM NP PA BECONASE AQ SUSP NP RADICAVA SOLN CO budesonide (nasal) susp 1 MP QL(25 ml per RILUTEK TABS (riluzole) NP flunisolide (nasal) soln NP fill retail) riluzole tabs 1 MP QL(16 gm per fluticasone propionate 1 30 days retail); (nasal) susp PA RX/OTC TIGLUTIK SUSP NP QL(16 ml per Muscular Dystrophy Agents fluticasone propionate 1 30 days retail); (nasal) susp RX/OTC AMONDYS 45 SOLN CO PA; QL(17 gm EXONDYS 51 SOLN CO mometasone furoate NP per fill retail); (nasal) susp AL(At least 2 yrs old) VILTEPSO SOLN CO PA; QL(17 gm NASONEX SUSP VYONDYS 53 SOLN CO NP per fill retail); (mometasone furoate AL(At least 2 (nasal)) Spinal Muscular Atrophy Agents (SMA) yrs old) EVRYSDI SOLR CO OMNARIS SUSP NP SPINRAZA SOLN CO QNASL AERS NP ZOLGENSMA 10.1-10.5 CO QNASL CHILDRENS NP KG KIT AERS ZOLGENSMA 10.6-11.0 CO QL(17 ml per KG KIT triamcinolone acetonide 1 fill retail); AL(At (nasal) aero least 2 yrs old) ZOLGENSMA 11.1-11.5 CO KG KIT XHANCE EXHU NP ZOLGENSMA 11.6-12.0 CO KG KIT ZETONNA AERS NP

Coordinated Care of Washington Updated September 1, 2021

192 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZOLGENSMA 12.1-12.5 CO LACRISERT INST 2 KG KIT QL(15 ml per ZOLGENSMA 12.6-13.0 CO polyvinyl alcohol soln 1 KG KIT fill retail) REFRESH PLUS SOLN ZOLGENSMA 13.1-13.5 CO KG KIT (carboxymethylcellulose 2 sodium (ophth)) ZOLGENSMA 2.6-3.0 KG CO KIT REFRESH TEARS SOLN (carboxymethylcellulose 2 ZOLGENSMA 3.1-3.5 KG CO KIT sodium (ophth)) white petrolatum-mineral oil ZOLGENSMA 3.6-4.0 KG CO 1 KIT oint Beta-blockers - Ophthalmic ZOLGENSMA 4.1-4.5 KG CO KIT betaxolol hcl (ophth) soln NP ZOLGENSMA 4.6-5.0 KG CO KIT BETIMOL SOLN NP PA ZOLGENSMA 5.1-5.5 KG CO KIT BETOPTIC-S SUSP NP ZOLGENSMA 5.6-6.0 KG QL(0.5 ml CO carteolol hcl (ophth) soln NP KIT daily) ZOLGENSMA 6.1-6.5 KG CO MP KIT COMBIGAN SOLN 2 ZOLGENSMA 6.6-7.0 KG CO COSOPT PF SOLN KIT (dorzolamide hcl-timolol NP ZOLGENSMA 7.1-7.5 KG CO maleate) KIT COSOPT SOLN PA; QL(10 ml ZOLGENSMA 7.6-8.0 KG CO (dorzolamide hcl-timolol NP per fill retail); KIT maleate) MP ZOLGENSMA 8.1-8.5 KG CO dorzolamide hcl-timolol 1 KIT maleate soln 0.5 %-2 % ZOLGENSMA 8.6-9.0 KG CO dorzolamide hcl-timolol NP QL(10 ml per KIT maleate soln 0.5 %-2 % fill retail); MP ZOLGENSMA 9.1-9.5 KG CO dorzolamide hcl-timolol QL(10 ml per KIT maleate soln 5 mg/ml-20 1 fill retail); MP mg/ml, 6.8 mg/ml-22.3 ZOLGENSMA 9.6-10.0 KG CO KIT mg/ml dorzolamide hcl-timolol QL(10 ml per NUTRIENTS maleate soln 6.8 mg/ml- 1 fill retail) 22.3 mg/ml Lipids ISTALOL SOLN (timolol NP MP DOJOLVI LIQD CO maleate (ophth)) levobunolol hcl soln 1 MP OPHTHALMIC AGENTS - Drugs to Treat the Eye timolol maleate (ophth) solg 1 MP Artificial Tears and Lubricants 0.25 %, 0.5 % carboxymethylcellulose 1 sodium (ophth) soln Coordinated Care of Washington Updated September 1, 2021

193 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MP QL(15 ml per timolol maleate (ophth) 1 tropicamide soln 0.5 % 1 soln 0.25 %, 0.5 % fill retail); MP timolol maleate (ophth) 1 tropicamide soln 1 % 1 MP soln 0.5 % TROPICAMIDE/CYCLOPE PA TIMOLOL/BRIMONIDE/DO 2 RZOLAMIDE SOLN NTOLATE TIMOLOL/BRIMONIDINE/ HYDROCHLORIDE/PHEN NP DORZOLAMIDE/LATANOP 2 YLEPHRINE HYDRO ROST SOLN SOLN TROPICAMIDE/CYCLOPE PA TIMOLOL/DORZOLAMIDE/ 2 LATANOPROST SOLN NTOLATE/PHENYLEPHRI NP NE SOLN TIMOLOL/LATANOPROST 2 SOLN TROPICAMIDE/PHENYLE 2 PHRINE SOLN TIMOPTIC OCUDOSE NP QL(60 ea per SOLN 0.25 % fill retail) TROPICAMIDE/PROPARA PA CAINE/PHENYLEPHRINE/ NP TIMOPTIC OCUDOSE KETOROLAC SOLN SOLN 0.5 % (timolol 2 maleate (ophth)) Miotics ISOPTO CARPINE SOLN PA TIMOPTIC SOLN (timolol NP MP NP maleate (ophth)) (pilocarpine hcl) PHOSPHOLINE IODIDE TIMOPTIC-XE SOLG 2 MP NP (timolol maleate (ophth)) SOLR Cycloplegic Mydriatics pilocarpine hcl soln NP PA atropine sulfate 1 MP (ophthalmic) oint Ophthalmic Adrenergic Agents ALPHAGAN P SOLN 0.1 % 2 MP ATROPINE SULFATE 2 MONOHYDRATE SOLN ALPHAGAN P SOLN 0.15 2 MP ATROPINE SULFATE 2 MP % (brimonidine tartrate) SOLN OP 1 % apraclonidine hcl soln NP CYCLOGYL SOLN 0.5 % NP QL(15 ml per (cyclopentolate hcl) fill retail); MP BRIMONIDE/DORZOLAMI 2 CYCLOGYL SOLN 2 %, 1 NP MP DE P-F SOLN % (cyclopentolate hcl) brimonidine tartrate soln 1 MP CYCLOMYDRIL SOLN 2 MP 0.15 % brimonidine tartrate soln 1 QL(15 ml per cyclopentolate hcl soln 0.5 1 QL(15 ml per 0.2 % fill retail); MP % fill retail); MP IOPIDINE SOLN NP cyclopentolate hcl soln 2 1 MP %, 1 % SIMBRINZA SUSP 2 MP ISOPTO ATROPINE SOLN NP PA; MP Ophthalmic Anti-infectives MYDRIACYL SOLN NP MP (tropicamide) AZASITE SOLN NP phenylephrine hcl 1 (mydriatic) soln BACIGUENT OINT NP

Coordinated Care of Washington Updated September 1, 2021

194 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits bacitracin (ophthalmic) oint NP POLYTRIM SOLN NP QL(10 ml per (polymyxin b-trimethoprim) fill retail) bacitracin-polymyxin b QL(4 gm per fill NP sulfacetamide sodium 1 (ophth) oint retail) (ophth) oint BESIVANCE SUSP NP sulfacetamide sodium 1 QL(15 ml per (ophth) soln fill retail) BLEPH-10 SOLN QL(15 ml per QL(5 ml per fill tobramycin (ophth) soln 1 (sulfacetamide sodium NP fill retail) retail) (ophth)) QL(4 gm per fill TOBREX OINT NP CILOXAN OINT NP QL(4 gm per fill retail) retail) TOBREX SOLN NP QL(5 ml per fill CILOXAN SOLN NP (tobramycin (ophth)) retail) (ciprofloxacin hcl (ophth)) QL(8 ml per fill trifluridine soln 1 ciprofloxacin hcl (ophth) 1 retail) soln VIGAMOX SOLN QL(3 ml per fill QL(4 gm per fill 2 erythromycin (ophth) oint 1 (moxifloxacin hcl (ophth)) retail) retail) ZIRGAN GEL NP PA gatifloxacin (ophth) soln NP PA ZYMAXID SOLN NP PA gentamicin sulfate (ophth) NP QL(4 gm per fill (gatifloxacin (ophth)) oint retail) Ophthalmic Gene Therapy gentamicin sulfate (ophth) 1 soln LUXTURNA SUSP CO KLARITY-A SOLN NP Ophthalmic Immunomodulators levofloxacin (ophth) soln NP CEQUA SOLN NP PA

MITOSOL KIT NP CYCLOSPORINE IN NP PA KLARITY EMUL MOXEZA SOLN 2 MP (moxifloxacin hcl (ophth)) RESTASIS EMUL 2 moxifloxacin hcl (ophth) QL(3 ml per fill 1 RESTASIS MULTIDOSE 2 MP soln retail) EMUL moxifloxacin hcl (ophth) 1 Ophthalmic Integrin Antagonists soln XIIDRA SOLN NP PA NATACYN SUSP 2 Ophthalmic Kinase Inhibitors neomycin-bacitracin zn- NP QL(4 gm per fill polymyxin oint retail) RHOPRESSA SOLN NP neomycin-polymyxin- NP gramicidin soln ROCKLATAN SOLN NP OCUFLOX SOLN NP (ofloxacin (ophth)) Ophthalmic Local Anesthetics ofloxacin (ophth) soln 1 AKTEN GEL NP ALCAINE SOLN PA polymyxin b-trimethoprim 1 QL(10 ml per 2 soln fill retail) (proparacaine hcl)

Coordinated Care of Washington Updated September 1, 2021

195 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits proparacaine hcl soln 1 loteprednol etabonate gel NP PA tetracaine hcl (ophth) soln 1 loteprednol etabonate susp NP PA

Ophthalmic Nerve Growth Factors MAXIDEX SUSP NP PA OXERVATE SOLN 2 MAXITROL OINT 0.1 %- QL(4 gm per fill 3.5 MG/GM-10000 NP retail) Ophthalmic Steroids UNIT/GM (neomycin- ALREX SUSP NP PA polymy-dexameth) MAXITROL SUSP 0.1 %- QL(5 ml per fill bacitracin-poly-neomycin- NP 3.5 MG/ML-10000 NP retail) hc oint UNIT/ML (neomycin- polymy-dexameth) BLEPHAMIDE S.O.P. NP PA; QL(4 gm OINT per fill retail) neomycin-polymy- QL(4 gm per fill 1 BLEPHAMIDE SUSP NP PA dexameth oint 0.1 %-3.5 retail) mg/gm-10000 unit/gm dexamethasone sodium 1 QL(5 ml per fill neomycin-polymy- QL(5 ml per fill phosphate (ophth) soln retail) dexameth susp 0.1 %-3.5 1 retail) mg/ml-10000 unit/ml DOUBLE PM SOLR NP PA neomycin-polymyxin-hc NP QL(8 ml per fill DUREZOL EMUL 2 (ophth) susp retail) PRED FORTE SUSP PA; QL(0.5 ml EYSUVIS SUSP NP PA (prednisolone acetate NP daily) (ophth)) NP FLAREX SUSP PRED MILD SUSP NP QL(10 ml per fill retail) fluorometholone (ophth) 1 susp PRED-G S.O.P. OINT NP

FML FORTE SUSP NP PRED-G SUSP NP FML LIQUIFILM SUSP NP prednisolone acetate 1 QL(0.5 ml (fluorometholone (ophth)) (ophth) susp daily) QL(4 gm per fill FML OINT NP PREDNISOLONE 2 QL(0.5 ml retail) ACETATE P-F SUSP daily) INVELTYS SUSP NP PA PREDNISOLONE PA ACETATE/MOXIFLOXACI NP KLARITY-B SOLN NP PA N SUSP PA PREDNISOLONE PA KLARITY-L EMUL NP ACETATE/MOXIFLOXACI NP N/BROMFENAC SUSP LOTEMAX GEL NP PA (loteprednol etabonate) PREDNISOLONE PA ACETATE/MOXIFLOXACI NP LOTEMAX OINT NP PA N/NEPAFENAC SUSP PA PREDNISOLONE PA LOTEMAX SM GEL NP ACETATE/NEPAFENAC NP SUSP LOTEMAX SUSP NP PA (loteprednol etabonate) Coordinated Care of Washington Updated September 1, 2021

196 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREDNISOLONE SODIUM ACUVAIL SOLN NP PHOSPHATE SOLN OP 1 NP % QL(5 ml per fill ALOCRIL SOLN NP PREDNISOLONE SODIUM PA retail) PHOSPHATE/BROMFENA NP ALOMIDE SOLN NP QL(10 ml per C SOLN fill retail) PREDNISOLONE SODIUM QL(6 ml per fill azelastine hcl (ophth) soln NP PHOSPHATE/GATIFLOXA NP retail) CIN/BROMFENAC SOLN AZOPT SUSP NP MP PREDNISOLONE SODIUM PA (brinzolamide) PHOSPHATE/MOXIFLOXA NP CIN SOLN bepotastine besilate soln NP PREDNISOLONE SODIUM PA BEPREVE SOLN NP PHOSPHATE/MOXIFLOXA NP (bepotastine besilate) CIN/BROMFENAC SOLN brinzolamide susp 1 MP PREDNISOLONE- NP GATIFLOXACIN SUSP bromfenac sodium (ophth) NP soln PREDNISOLONE/BROMF NP ENAC SUSP BROMSITE SOLN NP PREDNISOLONE/GATIFL OXACIN/BROMFENAC NP cromolyn sodium (ophth) 1 SUSP soln sulfacetamide sod- 1 CYSTADROPS SOLN 2 PA prednisolone soln PA; MP TOBRADEX OINT 2 QL(4 gm per fill CYSTARAN SOLN 2 retail) PA diclofenac sodium (ophth) 1 TOBRADEX ST SUSP NP soln QL(10 ml per TOBRADEX SUSP dorzolamide hcl soln 1 (tobramycin- NP fill retail); MP dexamethasone) DORZOLAMIDE HCL 2 QL(10 ml per SOLN fill retail); MP tobramycin- 1 dexamethasone susp epinastine hcl (ophth) soln NP TRIESENCE SUSP NP QL(3 ml per fill flurbiprofen sodium soln 1 retail) TRIPLE PMB SOLR NP PA ILEVRO SUSP 2 TRIPLE PMK SOLR NP PA ketorolac tromethamine 1 QL(0.167 ml ZYLET SUSP NP (ophth) soln 0.4 % daily) ketorolac tromethamine 1 Ophthalmics - Misc. (ophth) soln 0.5 % ACULAR LS SOLN QL(0.167 ml ketotifen fumarate (ophth) 1 QL(10 ml per (ketorolac tromethamine NP daily) soln fill retail) (ophth)) LASTACAFT SOLN NP ACULAR SOLN (ketorolac NP tromethamine (ophth))

Coordinated Care of Washington Updated September 1, 2021

197 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NEVANAC SUSP NP ofloxacin (otic) soln 1 olopatadine hcl soln 0.2 %, NP RX/OTC Otic Combinations 0.1 % CIPRO HC SUSP 2 PAZEO SOLN NP RX/OTC CIPRODEX SUSP QL(8 ml per fill PROLENSA SOLN NP (ciprofloxacin- 2 retail) dexamethasone) TRUSOPT SOLN QL(10 ml per NP ciprofloxacin- 1 QL(8 ml per fill (dorzolamide hcl) fill retail); MP dexamethasone susp retail) UPNEEQ SOLN 2 PA ciprofloxacin-fluocinolone NP acetonide soln ZERVIATE SOLN NP COLY-MYCIN S SUSP NP Prostaglandins - Ophthalmic CORTISPORIN-TC SUSP NP bimatoprost soln NP neomycin-polymyxin-hc QL(10 ml per QL(3 ml per fill 1 latanoprost soln 1 (otic) soln fill retail) retail); MP neomycin-polymyxin-hc 1 QL(10 ml per LUMIGAN SOLN NP (otic) susp fill retail) OTOVEL SOLN TRAVATAN Z SOLN NP MP (ciprofloxacin-fluocinolone NP (travoprost) acetonide) MP travoprost soln 1 PRAMOTIC LIQD 2 QL(0.34 ml daily) VYZULTA SOLN NP Otic Steroids PA; QL(3 ml DERMOTIC OIL XALATAN SOLN NP (fluocinolone acetonide 2 (latanoprost) per fill retail); MP (otic)) fluocinolone acetonide NP PA 1 XELPROS EMUL (otic) oil ZIOPTAN SOLN NP hydrocortisone w/acetic 1 QL(10 ml per acid soln fill retail) OTIC AGENTS - Drugs to Treat the Ear OXYTOCICS - Drugs to Prevent/Control Uterine Bleeding Otic Agents - Miscellaneous Oxytocics QL(15 ml per acetic acid (otic) soln 1 fill retail) methylergonovine maleate 1 tabs isopropyl alcohol-glycerin 1 liqd PASSIVE IMMUNIZING AND TREATMENT AGENTS - Antibody Drugs to Treat Low Immune Otic Anti-infectives System CETRAXAL SOLN NP (ciprofloxacin hcl (otic)) Immune Serums HYPERRHO S/D SOSY 2 AL(At least 18 ciprofloxacin hcl (otic) soln NP yrs old)

Coordinated Care of Washington Updated September 1, 2021

198 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RHOGAM ULTRA- 2 AL(At least 18 amoxicillin & pot FILTERED PLUS SOSY yrs old) clavulanate susr 28.5 mg/5ml-200 mg/5ml, 42.9 1 Monoclonal Antibodies mg/5ml-600 mg/5ml, 57 SYNAGIS SOLN 2 PA mg/5ml-400 mg/5ml, 62.5 mg/5ml-250 mg/5ml PENICILLINS - Drugs to Treat Bacterial Infections amoxicillin & pot QL(30 ea per clavulanate tabs 125 mg- 1 fill retail) Aminopenicillins 250 mg amoxicillin caps 1 amoxicillin & pot QL(20 ea per clavulanate tabs 125 mg- 1 fill retail) amoxicillin chew 1 875 mg, 125 mg-500 mg amoxicillin & pot QL(40 ea per amoxicillin susr 1 clavulanate tb12 62.5 mg- 1 30 days retail) 1000 mg amoxicillin tabs 1 ampicillin & sulbactam 1 PA sodium solr ampicillin caps 1 AUGMENTIN ES-600 SUSR (amoxicillin & pot NP ampicillin sodium solr 1 clavulanate) AUGMENTIN SUSR 31.25 NP PA Natural Penicillins MG/5ML-125 MG/5ML BICILLIN L-A SUSP 2 PA AUGMENTIN SUSR 62.5 MG/5ML-250 MG/5ML NP PENICILLIN G PA (amoxicillin & pot POTASSIUM IN ISO- 2 clavulanate) OSMOTIC DEXTROSE SOLN AUGMENTIN TABS 125 QL(20 ea per MG-500 MG (amoxicillin & NP fill retail) penicillin g potassium solr PA pot clavulanate) 5000000 unit, 20 mu, NP 20000000 unit BICILLIN C-R SUSP 2 PA penicillin g potassium solr PA piperacillin sodium- 1 PA 5000000 unit, 20000000 1 tazobactam sodium solr unit UNASYN BULK PACK PA PENICILLIN G PROCAINE 2 PA SOLR (ampicillin & NP SUSP sulbactam sodium) penicillin g sodium solr 1 PA UNASYN SOLR (ampicillin NP PA & sulbactam sodium) penicillin v potassium solr 1 ZOSYN SOLN 0.25 PA GM/50ML-2 GM/50ML-5 %, penicillin v potassium tabs 1 0.375 GM/50ML-3 2 GM/50ML-5 %, 0.5 Penicillin Combinations GM/100ML-4 GM/100ML-5 amoxicillin & pot QL(20 ea per % clavulanate chew 28.5 mg- 1 fill retail) 200 mg, 57 mg-400 mg Penicillinase-Resistant Penicillins dicloxacillin sodium caps 1

Coordinated Care of Washington Updated September 1, 2021

199 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(20 ea per PHARMACEUTICAL ADJUVANTS PROMETRIUM CAPS 200 NP 90 days retail); MG (progesterone) Semi Solid Vehicles MP RX/OTC PROVERA TABS MP lanolin oint 1 (medroxyprogesterone NP acetate) PROGESTINS - Hormone Replacement/Modifying Drugs PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. - Drugs to Treat Mental and Progestins Emotional Conditions AYGESTIN TABS NP MP (norethindrone acetate) Agents for Chemical Dependency MP EC-RX PROGESTERONE NP PA acamprosate calcium tbec 1 10% CREA ANTABUSE TABS NP MP EC-RX PROGESTERONE NP PA (disulfiram) 20% CREA disulfiram tabs 1 MP hydroxyprogesterone 1 PA caproate oil PA MAKENA OIL IM 250 PA LUCEMYRA TABS NP MG/ML 2 (hydroxyprogesterone Anti-Cataplectic Agents caproate) XYREM SOLN NP PA MAKENA SOAJ SC 275 NP PA MG/1.1ML XYWAV SOLN NP PA medroxyprogesterone 1 MP acetate tabs Antidementia Agents ACETYL L-CARNITINE PA megestrol acetate 1 MP NP (appetite) susp CAPS MP ARICEPT TABS 23 MG NP PA norethindrone acetate tabs 1 (donepezil hydrochloride) PROGESTERONE 10% PA PA; QL(1 ea NP ARICEPT TABS 5 MG, 10 daily); AL(At KIT CREA MG (donepezil NP QL(30 ea per hydrochloride) least 18 yrs progesterone caps or 100 1 90 days retail); old); MP mg MP donepezil hydrochloride NP PA QL(20 ea per tabs 23 mg progesterone caps or 200 1 90 days retail); QL(1 ea daily); mg donepezil hydrochloride 1 AL(At least 18 MP tabs 5 mg, 10 mg PROGESTERONE PA yrs old); MP COMPOUNDINGKIT NP donepezil hydrochloride 1 CREA tbdp 10 mg, 5 mg EXELON PT24 13.3 PA progesterone oil im 50 1 NP mg/ml MG/24HR (rivastigmine) QL(30 ea per PA; QL(1 ea PROMETRIUM CAPS 100 EXELON PT24 4.6 NP 90 days retail); NP daily); AL(At MG (progesterone) MG/24HR, 9.5 MG/24HR least 18 yrs MP (rivastigmine) old); MP

Coordinated Care of Washington Updated September 1, 2021

200 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; QL(1 ea RAZADYNE TABS 12 MG, QL(2 ea daily); galantamine hydrobromide NP daily); AL(At 8 MG (galantamine NP AL(At least 18 cp24 16 mg, 24 mg, 8 mg least 18 yrs hydrobromide) yrs old); MP old); MP PA; QL(2 ea RAZADYNE TABS 4 MG PA; QL(6 ml NP daily); AL(At daily); AL(At (galantamine galantamine hydrobromide NP hydrobromide) least 18 yrs soln 4 mg/ml least 18 yrs old); MP old); MP rivastigmine pt24 13.3 NP PA QL(2 ea daily); mg/24hr galantamine hydrobromide NP AL(At least 18 tabs 12 mg, 8 mg PA; QL(1 ea yrs old); MP rivastigmine pt24 4.6 NP daily); AL(At PA; QL(2 ea mg/24hr, 9.5 mg/24hr least 18 yrs galantamine hydrobromide NP daily); AL(At old); MP tabs 4 mg least 18 yrs QL(2 ea daily); old); MP rivastigmine tartrate caps NP AL(At least 18 memantine hcl cp24 14 NP PA yrs old); MP mg, 21 mg, 28 mg, 7 mg Combination Psychotherapeutics QL(10 ml daily); AL(At chlordiazepoxide- NP memantine hcl soln 10 1 amitriptyline tabs mg/5ml, 2 mg/ml least 18 yrs old); MP PA; Age 6-12: MDD=0.84; QL(49 ea per olanzapine-fluoxetine hcl fill retail); AL(At NP Age 13-17: memantine hcl tabs 1 caps 12 mg-25 mg, 12 mg- MDD=1.67;AL( least 18 yrs 50 mg old) At least 6 yrs old) QL(2 ea daily); memantine hcl tabs 10 mg, 1 AL(At least 18 PA; Age 6-12: 5 mg MDD=3.34; yrs old); MP olanzapine-fluoxetine hcl NP Age 13-17: QL(2 ea daily); caps 3 mg-25 mg MDD=6.67;AL( NAMENDA TABS NP AL(At least 18 (memantine hcl) At least 6 yrs yrs old); MP old) QL(49 ea per NAMENDA TITRATION PA; Age 6-12: NP fill retail); AL(At MDD=1.67; PAK TABS (memantine least 18 yrs olanzapine-fluoxetine hcl hcl) NP Age 13-17: old) caps 6 mg-25 mg, 6 mg-50 MDD=3.34;AL( mg At least 6 yrs NAMENDA XR CP24 NP PA (memantine hcl) old) NAMENDA XR TITRATION PA Age 6-12: NP MDD=6; Age PACK CP24 perphenazine-amitriptyline PA 1 13-17: NAMZARIC C4PK NP tabs 2 mg-10 mg, 2 mg-25 MDD=12.;AL(At mg PA least 6 yrs old); NAMZARIC CP24 NP MP PA; QL(1 ea RAZADYNE ER CP24 (galantamine NP daily); AL(At hydrobromide) least 18 yrs old); MP

Coordinated Care of Washington Updated September 1, 2021

201 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Age 6-12: AVONEX PSKT 2 SP MDD=3; Age perphenazine-amitriptyline 1 13-17: BAFIERTAM CPDR NP tabs 4 mg-10 mg, 4 mg-25 MDD=6.;AL(At mg, 4 mg-50 mg least 6 yrs old); MP BETASERON KIT 2 PA; Age 6-12: COPAXONE SOSY 2 MDD=0.84; (glatiramer acetate) SYMBYAX CAPS 12 MG- Age 13-17: 50 MG (olanzapine- NP dalfampridine tb12 NP PA ) MDD=1.67;AL( fluoxetine hcl At least 6 yrs old) dimethyl fumarate cpdr 1 PA; Age 6-12: MDD=3.34; dimethyl fumarate misc 1 SYMBYAX CAPS 3 MG-25 Age 13-17: MG (olanzapine-fluoxetine NP EXTAVIA KIT NP ) MDD=6.67;AL( hcl At least 6 yrs old) GILENYA CAPS NP PA; Age 6-12: MDD=1.67; glatiramer acetate sosy NP SYMBYAX CAPS 6 MG-25 Age 13-17: MG, 6 MG-50 MG NP KESIMPTA SOAJ 2 PA ) MDD=3.34;AL( (olanzapine-fluoxetine hcl At least 6 yrs old) LEMTRADA SOLN NP Fibromyalgia Agents MAVENCLAD TBPK NP PA PA; QL(2 ea SAVELLA TABS NP daily); MP MAYZENT STARTER NP PACK TBPK PA; QL(55 ea SAVELLA TITRATION NP PACK MISC per 365 days MAYZENT TABS NP retail) PA Movement Disorder Drug Therapy OCREVUS SOLN NP AUSTEDO TABS 2 PA PLEGRIDY SOPN SC NP

INGREZZA CAPS NP PA PLEGRIDY SOSY IM NP

INGREZZA CPPK NP PA PLEGRIDY SOSY SC NP ST PA; SP; MP tetrabenazine tabs 1 PLEGRIDY STARTER NP ST PACK SOPN XENAZINE TABS PA; SP; MP NP PLEGRIDY STARTER NP ST (tetrabenazine) PACK SOSY Multiple Sclerosis Agents PONVORY 14-DAY NP PA STARTER PACK TBPK AMPYRA TB12 NP PA (dalfampridine) PONVORY TABS NP PA AUBAGIO TABS NP REBIF REBIDOSE SOAJ NP AVONEX PEN AJKT 2 SP

Coordinated Care of Washington Updated September 1, 2021

202 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits REBIF REBIDOSE NP PRILOPENTIN THPK NP PA TITRATIONPACK SOAJ REBIF SOSY NP Premenstrual Dysphoric Disorder (PMDD) Agents fluoxetine hcl (pmdd) tabs NP PA REBIF TITRATION PACK NP 10 mg, 20 mg SOSY SARAFEM TABS NP PA TECFIDERA CPDR NP PA (fluoxetine hcl (pmdd)) (dimethyl fumarate) Pseudobulbar Affect (PBA) Agents TECFIDERA STARTER PA PACK MISC (dimethyl NP NUEDEXTA CAPS NP PA; MP fumarate) Psychotherapeutic and Neurological Agents - TYSABRI CONC NP ergoloid mesylates tabs 1 MP VUMERITY CPDR NP PA pimozide tabs 1 MP ZEPOSIA 7-DAY NP PA STARTER PACK CPPK Restless Leg Syndrome (RLS) Agents PA ZEPOSIA CAPS NP HORIZANT TBCR NP PA ZEPOSIA STARTER KIT NP PA CPPK Smoking Deterrents QL(2 ea daily); Postherpetic Neuralgia (PHN)/Neuropathic Pain APO-VARENICLINE TABS 2 AL(At least 18 CONVENIENCE PAK NP PA yrs old) THPK QL(2 ea daily); bupropion hcl (smoking 1 AL(At least 18 GABACAINE THPK NP PA deterrent) tb12 yrs old) GABAPAL THPK NP PA QL(2 ea daily); CHANTIX CONTINUING 2 AL(At least 18 MONTHPAK TABS GPL PAK THPK NP PA yrs old) QL(53 ea per GRALISE MISC NP PA 180 days CHANTIX STARTING 2 retail); AL(At MONTH PAK TABS GRALISE TABS NP PA least 18 yrs old) LIDO GB-300 THPK NP PA QL(2 ea daily); CHANTIX TABS 2 AL(At least 18 LIDOTIN THPK NP PA yrs old) PA QL(1 ea LIPRITIN II THPK NP daily)180 rtl NICODERM CQ PT24 NP ) MAX day(s) LIPRITIN THPK NP PA (nicotine supply,365 rtl lmt day(s), LYRICA CR TB24 NP PA (pregabalin (once-daily)) QL(24 ea daily)180 rtl PA NICORETTE GUM 4 MG, 2 NP PENTICAN THPK NP ) MAX day(s) MG (nicotine polacrilex supply,365 rtl pregabalin (once-daily) NP PA lmt day(s), tb24 Coordinated Care of Washington Updated September 1, 2021

203 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(20 ea paroxetine mesylate NP PA daily)180 rtl (vasomotor) caps NICORETTE LOZG 2 MG, NP ) MAX day(s) 4 MG (nicotine polacrilex supply,365 rtl RESPIRATORY AGENTS - MISC. - Drugs to lmt day(s), Treat Lung Conditions QL(20 ea Alpha-Proteinase Inhibitor (Human) daily)180 rtl ARALAST NP SOLR 2 PA NICORETTE MINI LOZG NP ) MAX day(s) (nicotine polacrilex supply,365 rtl 2 PA lmt day(s), GLASSIA SOLN QL(24 ea PROLASTIN-C SOLN 2 PA NICORETTE STARTER daily)180 rtl KIT GUM (nicotine NP MAX day(s) PROLASTIN-C SOLR 2 PA polacrilex) supply,365 rtl lmt day(s), ZEMAIRA SOLR 2 PA QL(24 ea daily)180 rtl nicotine polacrilex gum 4 Cystic Fibrosis Agents 1 MAX day(s) PA mg, 2 mg supply,365 rtl BRONCHITOL CAPS 2 lmt day(s), BRONCHITOL 2 PA QL(20 ea TOLERANCE TEST CAPS daily)180 rtl PA nicotine polacrilex lozg 2 1 MAX day(s) KALYDECO PACK 25 MG 2 mg, 4 mg supply,365 rtl lmt day(s), KALYDECO PACK 50 MG, 2 PA; SP 75 MG QL(1 ea daily)180 rtl KALYDECO TABS 150 MG 2 PA; SP nicotine pt24 1 MAX day(s) supply,365 rtl ORKAMBI PACK 100 MG- 2 PA lmt day(s), 125 MG, 150 MG-188 MG PA; 180 rtl ORKAMBI TABS 100 MG- 2 PA; SP NICOTINE MAX day(s) 125 MG, 125 MG-200 MG TRANSDERMAL SYSTEM NP PA; SP KIT supply,365 rtl PULMOZYME SOLN 2 lmt day(s), PA NICOTROL INHALER NP QL(504 ea per SYMDEKO TBPK 2 INHA 30 days retail) QL(120 ml per TRIKAFTA TBPK NP PA NICOTROL NS SOLN NP 30 days retail) Pulmonary Fibrosis Agents Transthyretin Amyloidosis Agents ESBRIET CAPS 2 PA ONPATTRO SOLN 2 PA ESBRIET TABS 2 PA TEGSEDI SOSY 2 PA OFEV CAPS 2 PA Vasomotor Symptom Agents BRISDELLE CAPS PA SULFONAMIDES - Drugs to Treat Bacterial (paroxetine mesylate NP Infections (vasomotor)) Sulfonamides

Coordinated Care of Washington Updated September 1, 2021

204 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SULFADIAZINE TABS 2 doxycycline hyclate caps or 1 50 mg, 100 mg TETRACYCLINES - Drugs to Treat Bacterial DOXYCYCLINE HYCLATE NP Infections DR TBEC Aminomethylcyclines doxycycline hyclate solr iv 1 PA 100 mg PA NUZYRA SOLR IV 100 MG 2 doxycycline hyclate tabs or 100 mg, 150 mg, 20 mg, 50 1 NUZYRA TABS OR 150 NP MG mg, 75 mg doxycycline hyclate tbec or NP PA Fluorocyclines 200 mg, 50 mg XERAVA SOLR 2 PA doxycycline hyclate tbec or 80 mg, 100 mg, 150 mg, 75 NP Glycylcyclines mg PA tigecycline solr 1 MINOCIN SOLR IV 100 2 PA MG PA TIGECYCLINE SOLR 2 minocycline hcl caps 100 1 mg, 50 mg, 75 mg TYGACIL SOLR PA NP minocycline hcl cp24 135 NP (tigecycline) mg, 45 mg, 90 mg Tetracycline Combinations minocycline hcl tabs 100 NP BENZODOX 30 KIT THPK NP PA mg, 50 mg, 75 mg minocycline hcl tb24 105 PA PA BENZODOX 60 KIT THPK NP mg, 115 mg, 135 mg, 45 NP mg, 55 mg, 65 mg, 80 mg, Tetracyclines 90 mg PA ACTICLATE TABS 2 MINOLIRA TB24 NP (doxycycline hyclate) demeclocycline hcl tabs NP MORGIDOX 1X100MG KIT NP

DORYX MPC TBEC NP MORGIDOX 2X100MG KIT NP PA DORYX TBEC 200 MG, 50 NP PA NUTRIDOX KIT NP MG (doxycycline hyclate) SEYSARA TABS NP DORYX TBEC 80 MG NP (doxycycline hyclate) SOLODYN TB24 NP PA doxycycline (monohydrate) NP (minocycline hcl) caps 150 mg, 75 mg tetracycline hcl caps 1 doxycycline (monohydrate) 1 caps 50 mg, 100 mg VIBRAMYCIN CAPS 100 NP doxycycline (monohydrate) NP PA MG (doxycycline hyclate) susr 25 mg/5ml VIBRAMYCIN SUSR 25 PA doxycycline (monohydrate) MG/5ML (doxycycline NP tabs 150 mg, 50 mg, 75 1 (monohydrate)) mg, 100 mg VIBRAMYCIN SYRP 50 NP MG/5ML

Coordinated Care of Washington Updated September 1, 2021

205 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits XIMINO CP24 135 MG, 45 NP NATURE-THROID TABS MG, 90 MG 113.75 MG, 146.25 MG, XIMINO CP24 135 MG, 45 16.25 MG, 195 MG, 260 2 MG, 90 MG (minocycline NP MG, 32.5 MG, 325 MG, hcl) 48.75 MG, 81.25 MG, 97.5 MG THYROID AGENTS - Drugs to Regulate Thyroid NATURE-THROID TABS 2 MP Hormones 130 MG, 65 MG Antithyroid Agents SYNTHROID TABS NP MP methimazole tabs 1 MP (levothyroxine sodium) THYQUIDITY SOLN NP propylthiouracil tabs 1 MP thyroid tabs 1 MP TAPAZOLE TABS NP MP (methimazole) TIROSINT CAPS 100 Thyroid Hormones MCG, 112 MCG, 125 MCG, 13 MCG, 137 MCG, 150 ARMOUR THYROID TABS MP MCG, 175 MCG, 200 MCG, NP 120 MG, 15 MG, 30 MG, 2 25 MCG, 50 MCG, 75 60 MG, 90 MG (thyroid) MCG, 88 MCG ARMOUR THYROID TABS 2 MP (levothyroxine sodium) 180 MG, 240 MG, 300 MG TIROSINT CAPS 75 MCG NP CYTOMEL TABS NP MP (liothyronine sodium) TIROSINT-SOL SOLN NP levothyroxine sodium caps or 100 mcg, 112 mcg, 125 WESTHROID TABS 130 2 MP mcg, 13 mcg, 137 mcg, NP MG, 65 MG 150 mcg, 175 mcg, 200 WESTHROID TABS 195 2 mcg, 25 mcg, 50 mcg, 75 MG, 32.5 MG, 97.5 MG mcg, 88 mcg WP THYROID TABS LEVOTHYROXINE 113.75 MG, 16.25 MG, 2 SODIUM SOLN IV 100 NP 32.5 MG, 48.75 MG, 81.25 MCG/5ML, 200 MCG/5ML, MG, 97.5 MG 500 MCG/5ML WP THYROID TABS 130 2 MP levothyroxine sodium tabs MP MG, 65 MG or 300 mcg, 100 mcg, 112 mcg, 125 mcg, 137 mcg, 1 TOXOIDS 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 Toxoid Combinations mcg, 88 mcg QL(1 ml per liothyronine sodium tabs 1 MP 999 days ADACEL SUSP 2 retail); AL(At least 18 yrs NATURE-THROID NT-2.5 2 TABS old) QL(1 ml per 999 days BOOSTRIX SUSP 2 retail); AL(At least 18 yrs old)

Coordinated Care of Washington Updated September 1, 2021

206 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ml per GLYCATE TABS NP DIPHTHERIA/TETANUS 999 days TOXOIDS ADSORBED 2 retail); AL(At glycopyrrolate soln ij 0.2 PEDIATRIC SUSP least 18 yrs mg/ml, 0.4 mg/2ml, 1 1 old) mg/5ml, 4 mg/20ml QL(1 ml per GLYCOPYRROLATE 999 days SOSY IJ 0.2 MG/ML, 0.4 NP INFANRIX SUSP 2 retail); AL(At MG/2ML, 0.6 MG/3ML, 1 least 18 yrs MG/5ML old) GLYCOPYRROLATE QL(1 ml per SOSY IV 0.6 MG/3ML, 1 NP 999 days MG/5ML TDVAX SUSP 2 retail); AL(At glycopyrrolate tabs or 1 1 QL(4 ea daily) least 18 yrs mg, 2 mg old) GLYCOPYRROLATE NP QL(1 ml per TABS OR 1.5 MG 999 days TENIVAC INJ 2 retail); AL(At GLYRX-PF SOLN 0.2 NP least 18 yrs MG/ML, 0.4 MG/2ML old) hyoscyamine sulfate elix or 1 MP QL(1 ml per 0.125 mg/5ml TETANUS/DIPHTHERIA 999 days hyoscyamine sulfate soln ij 1 TOXOIDS-ADSORBED 2 retail); AL(At 0.5 mg/ml ADULT SUSP least 18 yrs hyoscyamine sulfate soln 1 MP old) or 0.125 mg/ml ULCER DRUGS - Drugs to Treat Bowel, Intestine hyoscyamine sulfate subl sl 1 MP and Stomach Conditions 0.125 mg Antispasmodics hyoscyamine sulfate tabs 1 MP or 0.125 mg ANASPAZ TBDP NP PA; MP (hyoscyamine sulfate) hyoscyamine sulfate tb12 1 QL(4 ea daily); or 0.375 mg MP BELLADONNA/OPIUM NP SUPP hyoscyamine sulfate tbdp 1 MP or 0.125 mg BENTYL SOLN NP (dicyclomine hcl) LEVBID TB12 NP QL(4 ea daily); (hyoscyamine sulfate) MP chlordiazepoxide hcl- NP clidinium bromide caps LEVSIN SOLN IJ 0.5 MG/ML (hyoscyamine NP CUVPOSA SOLN NP sulfate) LEVSIN TABS OR 0.125 PA; MP dicyclomine hcl caps or 10 1 NP mg MG (hyoscyamine sulfate) LEVSIN/SL SUBL PA; MP dicyclomine hcl soln im 10 1 NP mg/ml (hyoscyamine sulfate) LIBRAX CAPS PA dicyclomine hcl soln or 10 1 QL(40 ml daily) mg/5ml (chlordiazepoxide hcl- NP clidinium bromide) dicyclomine hcl tabs or 20 1 mg methscopolamine bromide 1 tabs 2.5 mg, 5 mg

Coordinated Care of Washington Updated September 1, 2021

207 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits propantheline bromide tabs 1 PA; Max Limit: 60 days per DEXILANT CPDR NP SYMAX DUOTAB TBCR NP MP 365 days.;QL(1 ea daily); MP H-2 Antagonists PA; QL(1 ea PA; QL(27 ml ESOMEP-EZS KIT NP per 30 days cimetidine hcl soln NP daily); MP retail) MP Max Limit: 60 cimetidine tabs NP days per 365 esomeprazole magnesium PA 1 days.;QL(1 ea famotidine in nacl soln NP cpdr 20 mg daily); RX/OTC; MP famotidine soln iv 20 PA mg/2ml, 200 mg/20ml, 40 NP PA; Max Limit: mg/4ml 60 days per esomeprazole magnesium NP 365 days.;QL(1 cpdr 20 mg famotidine susr or 40 1 ea daily); mg/5ml RX/OTC; MP famotidine tabs or 40 mg 1 MP esomeprazole magnesium 1 QL(1 ea daily); cpdr 20 mg RX/OTC; MP nizatidine caps 150 mg, NP 300 mg Max Limit: 60 days per 365 esomeprazole magnesium nizatidine soln 15 mg/ml NP PA 1 days;QL(1 ea cpdr 20 mg daily); RX/OTC; PEPCID TABS 20 MG NP PA; RX/OTC; MP (famotidine) MP PA; Max Limit: PEPCID TABS 40 MG MP NP esomeprazole magnesium NP 60 days per (famotidine) cpdr 40 mg 365 days.;QL(1 Misc. Anti-Ulcer ea daily) PA; Max Limit: CARAFATE SUSP 1 2 MP GM/10ML (sucralfate) esomeprazole magnesium NP 60 days per pack 10 mg, 20 mg, 40 mg 365 days.;QL(1 CARAFATE TABS 1 GM QL(4 ea daily); NP ea daily) (sucralfate) MP esomeprazole sodium solr PA MP 1 sucralfate susp 1 gm/10ml 1 40 mg QL(4 ea daily); PA; Max Limit: sucralfate tabs 1 gm 1 MP ESOMEPRAZOLE NP 60 days per STRONTIUM CPDR 365 days.;QL(1 Proton Pump Inhibitors ea daily) PA; Max Limit: PA; Max Limit: ACIPHEX SPRINKLE 60 days per NP FIRST-LANSOPRAZOLE NP 60 days per CPSP 10 MG, 5 MG 365 days.;QL(1 SUSP 365 days.;QL(1 ea daily) ml daily) PA; Max Limit: PA; Max Limit: ACIPHEX TBEC 60 days per NP FIRST-OMEPRAZOLE 60 days per (rabeprazole sodium) 365 days.;QL(1 NP 365 ea daily); MP SUSP days.;QL(10 ml daily); MP

Coordinated Care of Washington Updated September 1, 2021

208 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; Max Limit: Max Limit: 60 60 days per days per 365 lansoprazole cpdr 15 mg NP 365 days;QL(1 omeprazole cpdr 20 mg 1 days.;QL(1 ea ea daily); daily); RX/OTC; RX/OTC MP PA; Max Limit: Max Limit: 60 NP 60 days per 1 days per 365 lansoprazole cpdr 30 mg 365 days.;QL(1 omeprazole cpdr 40 mg days;QL(1 ea ea daily) daily); MP Max Limit: 60 Max Limit: 60 NP days per 365 1 days per 365 lansoprazole tbdd 15 mg days.;QL(1 ea omeprazole tbec 20 mg days.;QL(1 ea daily); RX/OTC daily) Max Limit: 60 Max Limit: 60 days per 365 days per 365 lansoprazole tbdd 15 mg NP pantoprazole sodium pack 1 days;QL(1 ea or 40 mg days.;QL(1 ea daily); RX/OTC daily) PA; Max Limit: pantoprazole sodium solr iv 1 PA 60 days per 40 mg lansoprazole tbdd 30 mg NP 365 days.;QL(1 Max Limit: 60 ea daily) pantoprazole sodium tbec 1 days per 365 Max Limit: 60 or 20 mg, 40 mg days.;QL(1 ea NEXIUM 24HR CPDR days per 365 daily); MP (esomeprazole 2 days.;QL(1 ea PA; Max Limit: magnesium) daily); RX/OTC; 60 days per MP PREVACID 24HR CPDR NP (lansoprazole) 365 days;QL(1 PA; Max Limit: ea daily); NEXIUM CPDR 40 MG 60 days per RX/OTC (esomeprazole NP magnesium) 365 days.;QL(1 PA; Max Limit: ea daily) 60 days per PREVACID CPDR 15 MG NP NEXIUM I.V. SOLR 2 PA lansoprazole) 365 days;QL(1 (esomeprazole sodium) ( ea daily); PA; Max Limit: RX/OTC NEXIUM PACK 10 MG, 20 60 days per PA; Max Limit: MG, 40 MG (esomeprazole NP magnesium) 365 days.;QL(1 PREVACID CPDR 30 MG NP 60 days per ea daily) (lansoprazole) 365 days.;QL(1 PA; Max Limit: ea daily) NEXIUM PACK 2.5 MG, 5 60 days per Max Limit: 60 NP PREVACID SOLUTAB MG 365 days.;QL(1 NP days per 365 TBDD 15 MG days.;QL(1 ea ea daily) (lansoprazole) PA; Max Limit: daily); RX/OTC OMEPRAZOLE + 60 days per PREVACID SOLUTAB PA; Max Limit: SYRSPEND SFALKA NP 365 60 days per TBDD 30 MG NP SUSP days.;QL(10 ml (lansoprazole) 365 days.;QL(1 daily); MP ea daily) PA; Max Limit: Max Limit: 60 60 days per omeprazole cpdr 10 mg NP 2 days per 365 365 days.;QL(1 PRILOSEC PACK days.;QL(1 ea ea daily) daily) Coordinated Care of Washington Updated September 1, 2021

209 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Max Limit: 60 ZEGERID CAPS 20 MG- PA; QL(1 ea PROTONIX PACK OR 40 2 days per 365 1100 MG (omeprazole- NP daily); RX/OTC MG (pantoprazole sodium) days.;QL(1 ea sodium bicarbonate) daily) PA; Max Limit: ZEGERID CAPS 40 MG- PROTONIX SOLR IV 40 2 PA NP 60 days per ) 1100 MG (omeprazole- MG (pantoprazole sodium sodium bicarbonate) 365 days.;QL(1 Max Limit: 60 ea daily) PROTONIX TBEC OR 20 days per 365 ZEGERID PACK 20 MG- Max Limit: 60 MG, 40 MG (pantoprazole 2 sodium) days.;QL(1 ea 1680 MG, 40 MG-1680 MG 2 days per 365 daily); MP (omeprazole-sodium days.;QL(1 ea PA; Max Limit: bicarbonate) daily) RABEPRAZOLE SODIUM NP 60 days per URINARY ANTISPASMODICS - Drugs to Treat DR SPRINKLE CPSP 365 days.;QL(1 Miscellaneous Bladder Spasms ea daily) Urinary Antispasmodic - Antimuscarinics PA; Max Limit: darifenacin hydrobromide MP NP 60 days per NP rabeprazole sodium tbec 365 days.;QL(1 tb24 15 mg ea daily); MP darifenacin hydrobromide NP PA; MP tb24 7.5 mg Ulcer Drugs - Prostaglandins DETROL LA CP24 PA; QL(1 ea CYTOTEC TABS NP MP NP (misoprostol) (tolterodine tartrate) daily); MP MP DETROL TABS (tolterodine NP PA; QL(2 ea misoprostol tabs 1 tartrate) daily); MP DITROPAN XL TB24 NP QL(2 ea daily); Ulcer Therapy Combinations (oxybutynin chloride) MP amoxicillin-clarithromycin PA NP ENABLEX TB24 7.5 MG NP PA; MP w/ lansoprazole misc (darifenacin hydrobromide) HELIDAC THERAPY MISC 2 GELNIQUE GEL NP PA PA OMECLAMOX-PAK MISC NP GELNIQUE PUMP GEL NP PA Max Limit: 60 QL(480 ml per omeprazole-sodium oxybutynin chloride syrp 5 NP days per 365 1 30 days retail); bicarbonate caps 20 mg- days.;QL(1 ea mg/5ml 1100 mg MP daily); RX/OTC oxybutynin chloride tabs 5 QL(3 ea daily); PA; Max Limit: 1 omeprazole-sodium mg MP NP 60 days per bicarbonate caps 40 mg- 365 days.;QL(1 oxybutynin chloride tb24 10 QL(2 ea daily); 1100 mg 1 ea daily) mg, 15 mg, 5 mg MP Max Limit: 60 PA; RX/OTC omeprazole-sodium OXYTROL PTTW NP 1 days per 365 bicarbonate pack 20 mg- days.;QL(1 ea PA; MP 1680 mg, 40 mg-1680 mg solifenacin succinate tabs NP daily) tolterodine tartrate cp24 2 NP PA; QL(1 ea PYLERA CAPS 2 mg, 4 mg daily); MP PA tolterodine tartrate tabs 1 NP PA; QL(2 ea TALICIA CPDR NP mg, 2 mg daily); MP TOVIAZ TB24 2 MP

Coordinated Care of Washington Updated September 1, 2021

210 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits trospium chloride cp24 60 NP PNEUMOVAX 23 INJ 2 AL(At least 18 mg yrs old) trospium chloride tabs 20 NP QL(2 ea daily); PNEUMOVAX 23/1 DOSE 2 AL(At least 18 mg MP INJ yrs old) PA VESICARE LS SUSP NP PREVNAR 13 SUSP 2 AL(At least 18 yrs old) VESICARE TABS PA; MP NP TRUMENBA SUSY 2 AL(At least 18 (solifenacin succinate) yrs old) Urinary Antispasmodics - Beta-3 Adrenergic Viral Vaccines GEMTESA TABS NP limit 0.5 per 180 MYRBETRIQ TB24 25 MG, MP NP AFLURIA QUADRIVALENT 2 days;QL(0.5 ml 50 MG 2020-2021 SUSP per fill retail); Urinary Antispasmodics - Cholinergic Agonists AL(At least 7 yrs old) MP bethanechol chloride tabs 1 Limit 0.25 per 180 Urinary Antispasmodics - Direct Muscle Relaxants AFLURIA QUADRIVALENT 2 days;QL(0.25 flavoxate hcl tabs NP MP 2020-2021 SUSY ml per fill retail); AL(At least 7 yrs old) VACCINES limit 0.5 per Bacterial Vaccines 180 QL(3 ea per AFLURIA QUADRIVALENT 2 days;QL(0.5 ml 999 days 2020-2021 SUSY per fill retail); ACTHIB SOLR 2 retail); AL(At AL(At least 7 least 18 yrs yrs old) old) ENGERIX-B INJ IM 10 2 AL(At least 18 AL(At least 18 MCG/0.5ML yrs old) BEXSERO SUSY 2 yrs old) ENGERIX-B INJ IM 20 2 AL(At least 7 QL(3 ea per MCG/ML yrs old) 999 days ENGERIX-B SUSP IJ 10 2 AL(At least 18 HIBERIX SOLR 2 retail); AL(At MCG/0.5ML, 20 MCG/ML yrs old) least 18 yrs limit 0.5 per old) 180 days;QL(0.5 ml MENACTRA INJ 2 AL(At least 18 FLUAD 2020-2021 SUSY 2 yrs old) per fill retail); AL(At least 9 MENQUADFI INJ 2 AL(At least 18 yrs old) yrs old) limit 0.5 per MENVEO SOLR 2 AL(At least 18 yrs old) 180 FLUAD QUADRIVALENT 2 days;QL(0.5 ml QL(3 ml per 2021-2022 PRSY per fill retail); 999 days AL(At least 65 PEDVAX HIB SUSP 2 retail); AL(At yrs old) least 18 yrs old)

Coordinated Care of Washington Updated September 1, 2021

211 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits limit 0.5 per Limit 0.7 per FLUAD QUADRIVALENT 180 180 days;QL(0.5 ml FLUZONE HIGH-DOSE PF days;QL(0.7 ml INFLUENZA VACCINE 2 2 FOR ADULTS PRSY per fill retail); 2021-2022 SUSY per fill retail); AL(At least 65 AL(At least 65 yrs old) yrs old) limit 0.5 per limit 0.5 per 180 FLUZONE 180 days FLUARIX QUADRIVALENT 2 days;QL(0.5 ml QUADRIVALENT 2020- 2 ;QL(0.5 ml per 2020-2021 SUSY per fill retail); 2021 SUSP fill retail); AL(At AL(At least 7 least 7 yrs old) yrs old) limit 0.5 per limit 0.5 per 180 180 FLUZONE days;QL(0.5 ml FLUBLOK QUADRIVALENT 2020- 2 QUADRIVALENT 2020- 2 days;QL(0.5 ml per fill retail); per fill retail); 2021 SUSP AL(At least 7 2021 SOSY AL(At least 18 yrs old) yrs old) limit 0.5 per limit 0.5 per 180 180 FLUZONE days;QL(0.5 ml FLUCELVAX QUADRIVALENT 2020- 2 QUADRIVALENT 2020- 2 days;QL(0.5 ml per fill retail); per fill retail); 2021 SUSY AL(At least 7 2021 SUSP AL(At least 7 yrs old) yrs old) AL(At least 18 GARDASIL 9 SUSP 2 limit 0.5 per yrs old) 180 AL(At least 18 FLUCELVAX GARDASIL 9 SUSY 2 2 days;QL(0.5 ml yrs old) QUADRIVALENT 2020- per fill retail); 2021 SUSY AL(At least 18 AL(At least 7 HAVRIX SUSP 2 yrs old) yrs old) AL(At least 7 limit 0.5 per M-M-R II SOLR 2 180 yrs old) FLULAVAL AL(At least 18 2 days;QL(0.5 ml RECOMBIVAX HB SUSP 2 QUADRIVALENT 2020- per fill retail); yrs old) 2021 SUSY AL(At least 7 Limit 2 doses yrs old) per Limit 1 dose lifetime;QL(2 per SHINGRIX SUSR 2 ea per 999 days retail); FLUMIST 2 season;QL(1 QUADRIVALENT SUSP ea per fill AL(At least 50 retail); AL(At yrs old) least 9 yrs old) AL(At least 18 TWINRIX SUSY 2 Limit 0.7 per yrs old) 180 AL(At least 18 VAQTA SUSP 2 FLUZONE HIGH-DOSE PF 2 days;QL(0.7 ml yrs old) 2020-2021 SUSY per fill retail); VARIVAX INJ 2 AL(At least 18 AL(At least 65 yrs old) yrs old) ZOSTAVAX SUSR 2 AL(At least 50 yrs old)

Coordinated Care of Washington Updated September 1, 2021

212 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREMARIN CREA VA 2 MP VAGINAL AND RELATED PRODUCTS 0.625 MG/GM Vaginal Anti-infectives VAGIFEM TABS (estradiol NP CLEOCIN CREA VA 2 % QL(40 gm per vaginal) (clindamycin phosphate NP fill retail) Vaginal Progestins vaginal) CRINONE GEL NP PA CLEOCIN SUPP VA 100 2 MG FIRST-PROGESTERONE PA clindamycin phosphate 1 QL(40 gm per VGS 100 COMPOUNDING NP vaginal crea fill retail) KIT SUPP CLINDESSE CREA NP PA FIRST-PROGESTERONE PA VGS 200 NP QL(45 gm per COMPOUNDING KIT clotrimazole vaginal crea 1 fill retail) SUPP GYNAZOLE-1 CREA NP VASOPRESSORS - Drugs to Treat Heart and Circulation Conditions QL(70 gm per metronidazole vaginal gel 1 fill retail) Anaphylaxis Therapy Agents ADRENALIN SOLN IJ 1 miconazole nitrate vaginal 1 QL(45 gm per 2 crea 2 % fill retail) MG/ML ADRENALIN SOLN IJ 1 PA miconazole nitrate vaginal 1 QL(45 gm per NP crea 4 % 30 days retail) MG/ML, 30 MG/30ML ADRENALIN SOLN IJ 30 PA miconazole nitrate vaginal 1 QL(3 ea per fill supp 200 mg retail) MG/30ML (epinephrine NP (anaphylaxis)) NUVESSA GEL 2 ADYPHREN AMP II KIT NP PA KIT terconazole vaginal crea 1 QL(45 gm per 0.4 % fill retail) ADYPHREN AMP KIT KIT NP PA terconazole vaginal crea 1 QL(20 gm per 0.8 % fill retail) ADYPHREN II KIT NP PA terconazole vaginal supp NP QL(3 ea per fill PA 80 mg retail) ADYPHREN KIT KIT NP Vaginal Contraceptive - pH Modulators AUVI-Q SOAJ 0.1 NP PA MG/0.1ML PHEXXI GEL 2 PA PA; QL(2 ea AUVI-Q SOAJ 0.15 NP Vaginal Estrogens MG/0.15ML, 0.3 MG/0.3ML per 25 days retail) ESTRACE CREA (estradiol NP MP vaginal) epinephrine (anaphylaxis) QL(2 ea per 25 soaj 0.15 mg/0.15ml, 0.15 1 days retail) estradiol vaginal crea 0.1 1 MP mg/0.3ml, 0.3 mg/0.3ml mg/gm PA; QL(2 ea estradiol vaginal tabs 10 epinephrine (anaphylaxis) NP per 25 days 1 soaj 0.3 mg/0.3ml mcg retail) ESTRING RING 2 epinephrine (anaphylaxis) NP PA soln 30 mg/30ml FEMRING RING NP

Coordinated Care of Washington Updated September 1, 2021

213 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EPINEPHRINE 2 PHENYLEPHRINE PA PROFESSIONAL KIT HYDROCHLORIDE SOLN IV 10 MG/ML 2 EPINEPHRINESNAP-EMS 2 KIT (phenylephrine hcl (pressors)) EPINEPHRINESNAP-V 2 KIT VAZCULEP SOLN PA (phenylephrine hcl 2 EPINEPHRINESNAP-V NP PA (pressors)) KIT PA; QL(2 ea VITAMINS EPIPEN 2-PAK SOAJ NP per 25 days (epinephrine (anaphylaxis)) retail) Oil Soluble Vitamins PA; QL(2 ea cholecalciferol caps 1000 1 QL(100 ea per EPIPEN-JR 2-PAK SOAJ NP unit, 25 mcg fill retail) (epinephrine (anaphylaxis)) per 25 days retail) cholecalciferol caps 10000 1 unit, 250 mcg EPISNAP KIT NP PA cholecalciferol liqd 10 1 mcg/ml, 400 unit/ml SYMJEPI SOSY 0.15 2 QL(2 ea per 25 MG/0.3ML, 0.3 MG/0.3ML days retail) cholecalciferol tabs 1000 1 PA; QL(2 ea unit, 25 mcg SYMJEPI SOSY 0.15 NP per 25 days MG/0.3ML, 0.3 MG/0.3ML D-VI-SOL LIQD 2 retail) (cholecalciferol) Neurogenic Orthostatic Hypotension (NOH) - ergocalciferol caps 1 MP droxidopa caps NP PA phytonadione tabs 1 NORTHERA CAPS NP PA (droxidopa) Water Soluble Vitamins Vasopressors niacin cpcr 1 ephedrine sulfate 1 PA (pressors) soln niacin tabs 1 EPHEDRINE SULFATE 2 PA SOLN IV 50 MG/ML niacinamide tabs 1 EPINEPHRINE HCL SOLN 2 PA 1 MG/ML niacinamide tbcr 1 epinephrine soln ij 1 mg/ml 1 PA pyridoxine hcl tabs 1 LEVOPHED SOLN PA 2 thiamine hcl soln ij 100 1 PA (norepinephrine bitartrate) mg/ml QL(100 ea per midodrine hcl tabs 1 thiamine hcl tabs or 100 mg 1 34 days retail) norepinephrine bitartrate 1 PA soln phenylephrine hcl 1 PA (pressors) soln

Coordinated Care of Washington Updated September 1, 2021

214 Index 1ST MEDX-PATCH/LIDOCAINE ABILIFY MAINTENA 74 ACTIQ 24 104 ABILIFY MYCITE 75 ACTIVASE 119 1ST TIER UNIFINE PENTIPS/MINI/31GX5MM 138 ABILIFY MYCITE ACTIVE INJECTION KIT D 88 1ST TIER UNIFINE MAINTENANCE KIT 74 ACTIVE INJECTION KIT KET- PENTIPS29GX12MM 138 ABILIFY MYCITE STARTER L 20 1ST TIER UNIFINE KIT 74,75 ACTIVE INJECTION KIT PENTIPS31GX6MM 138 abiraterone acetate 61 KETMARC-L 20 1ST TIER UNIFINE ABOUTTIME PEN NEEDLE ACTIVE-CYCLOBENZAPRINE PENTIPS31GX8MM 138 32GX 5/32" 138 KIT 190 1ST TIER UNIFINE ABOUTTIME PEN NEEDLES ACTIVE-KETOPROFEN KIT 95 PENTIPS32GX4MM 138 30GX 5/16" 138 ACTIVE-PREP KIT I 95 1ST TIER UNIFINE ABOUTTIME PEN NEEDLES PENTIPS32GX6MM 138 31G X 3/16" 139 ACTIVE-PREP KIT II 95 1ST TIER UNIFINE ABOUTTIME PEN NEEDLES ACTIVE-PREP KIT III 95 PENTIPS33GX4MM 138 31G X 5/16" 139 ACTIVE-PREP KIT IV 94 1ST TIER UNIFINE ABSORICA 91 ACTIVE-PREP KIT V 96 PENTIPSPLUS 31GX8MM 138 ABSORICA LD 91 1ST TIER UNIFINE ACTIVE-TRAMADOL KIT 94 PENTIPSPLUS 32GX4MM 138 acamprosate calcium 200 ACTIVELLA 113 1ST TIER UNIFINE ACANYA 91 ACTIVITY POUCH 174 PENTIPSPLUS 33GX4MM 138 acarbose 44 ACTONEL 109 1ST TIER UNIFINE ACCOLATE 34 PENTIPSPLUS/MINI/31GX5MM ACTOPLUS MET 44 138 ACCUCAINE 104 ACTOS 46 1ST TIER UNIFINE ACCUPRIL 55 ACULAR 197 PENTIPSPLUS/ORIGINAL/29GX ACCURETIC 57 ACULAR LS 197 12MM 138 ACE AEROSOL CLOUD 1ST TIER UNIFINE ENHANCER 174 ACUVAIL 197 PENTIPSPLUS/ULTRA acyclovir 80 SHORT/31GX6MM 138 acebutolol hcl 81 1ST TIER UNILET ACETAMINOPHEN 23 acyclovir sodium 80 COMFORTOUCH LANCETS acetaminophen 23 acyclovir topical 99 28G 129 acetaminophen w/ codeine 26 ACYCLOVIX 79 1ST TIER UNILET acetaminophen-caff-dihydrocod ACZONE 91 COMFORTOUCH LANCETS 26 ADACEL 206 30G 129 acetaminophen-salicylamide- 2-3ML SYRINGE/LUER LOCK ADAINZDE 91 phenyltoloxamine 23 TIP 138 ADAINZOXIA 91 2-3ML SYRINGE/LUER SLIP TIP acetazolamide 108 138 acetazolamide sodium 108 ADAKVEO 120 3ML LUER LOCK SAFETY acetic acid (otic) 198 adapalene 91 SYRINGES 138 ACETYL L-CARNITINE 200 ADAPALENE 91 3ML SYRINGE/INTERLINK adapalene-benzoyl peroxide 91 SYRINGE CANNULA 138 acetylcysteine 91 3ML SYRINGE/INTERLINK VIAL ADAPALENE/BENZOYL ACIOXIAY 91 PEROXIDE/CLINDAMYCIN 91 ACCESS CANNULA 138 ACIPHEX 208 ADAPALENE/BENZOYL 7T GUMMY ES 23 ACIPHEX SPRINKLE 208 PEROXIDE/NIACINAMIDE 91 A.A.G.C. KIT IN ADASUVE 70 TERODERM 94 acitretin 98 abacavir sulfate 76 ACTEMRA 20 ADCIRCA 85 abacavir sulfate-lamivudine 76 ACTEMRA ACTPEN 20 ADDERALL 1 abacavir sulfate-lamivudine- ACTHAR 110 ADDERALL XR 1,2 zidovudine 77 ACTHIB 211 adefovir dipivoxil 79 ABECMA 61 ACTICLATE 205 ADEMPAS 85 ABELCET 51 ACTIGALL 114 ADENOCARD 33 ABILIFY 75,76 ACTIMMUNE 64 adenosine 33

Index 1 ADHANSIA XR 9,10 ADVOCATE RAPID-SAFE AIF #2 DRUG ADJUSTABLE LANCING LANCING DEVICE 129 PREPARATIONKIT 95 DEVICE 129 ADYNOVATE 118 AIF #3 DRUG PREPARATION ADLYXIN 46 ADYPHREN AMP II KIT 213 KIT 95 AIMOVIG 180 ADLYXIN STARTER PACK 46 ADYPHREN AMP KIT 213 AIMSCO LUBRICATED 127 ADMELOG 47 ADYPHREN II 213 AIMSCO TWIST LANCETS ADMELOG SOLOSTAR 47 ADYPHREN KIT 213 32G 129 ADRENALIN 192,213 ADZENYS ER 2 AIMSCO TWIST LANCETS ADULT AEROSOL MASK 174 ADZENYS XR-ODT 2 33G 129 ADULT MASK 174 AEMCOLO 30 AIRDUO DIGIHALER 113/1435 ADULT MASK LARGE 174 AEROBIKA 174 AIRDUO DIGIHALER 232/1435 ADVAIR DISKUS 35 AEROCHAMBER MINI AIRDUO DIGIHALER 55/14 35 AIRDUO RESPICLICK ADVAIR HFA 35 AEROSOLCHAMBER 174 AEROCHAMBER MV 174 113/14 35 ADVANCED ALLERGY AIRDUO RESPICLICK COLLECTION KIT 99 AEROCHAMBER PLUS FLOW VU 174 232/14 35 ADVANCED MOBILE LANCET AIRDUO RESPICLICK 55/1435 30G 129 AEROCHAMBER PLUS AIRS PEDIATRIC AEROSOL ADVATE 118 FLOW-VU 174 AEROCHAMBER PLUS MASK 174 ADVOCATE INSULIN PEN FLOW-VU/LARGE MASK 174 AJOVY 180 NEEDLES 139 AEROCHAMBER PLUS AKLIEF 91 ADVOCATE INSULIN PEN FLOW-VU/MASK 174 NEEDLES 29GX12.7MM 139 AEROCHAMBER PLUS AKTEN 195 ADVOCATE INSULIN PEN FLOW-VU/MEDIUM AKYNZEO 51 NEEDLES 31GX5MM 139 MASK 174 ADVOCATE INSULIN PEN ALA-SCALP 99 AEROCHAMBER PLUS albendazole 29 NEEDLES 31GX8MM 139 FLOW-VU/SMALL MASK 174 ADVOCATE INSULIN AEROCHAMBER Z-STAT ALBENZA 29 SYRINGE/U- PLUS VALVED HOLDING albuterol sulfate 35 100/0.3ML/29GX1/2" 139 CHAMBER W/FLOW VU 174 ALBUTEROL SULFATE 35 ADVOCATE INSULIN AEROCHAMBER Z-STAT SYRINGE/U- PLUS/FLOWSIGNAL 174 albuterol sulfate 35 100/0.3ML/30GX5/16" 139 AEROCHAMBER Z-STAT ALCAINE 195 ADVOCATE INSULIN PLUS/LARGE MASK 174 SYRINGE/U- alclometasone dipropionate 99 AEROCHAMBER Z-STAT ALCOHOL PREP PADS 137 100/0.3ML/31GX5/16" 139 PLUS/MEDIUM MASK 174 ADVOCATE INSULIN AEROCHAMBER Z-STAT ALCOHOL SWABS 137 SYRINGE/U- PLUS/SMALL MASK 174 ALCOHOL SWABSTICK 137 100/0.5ML/29GX1/2" 139 AEROCHAMBER/FLOWSIGNA ALDACTAZIDE 108 ADVOCATE INSULIN L 174 ALDACTONE 109 SYRINGE/U- AEROTRACH PLUS 174 100/0.5ML/30GX5/16" 139 AEROVENT PLUS HOLDING ALDARA 104 ADVOCATE INSULIN ALECENSA 63 SYRINGE/U- CHAMBER/COLLAPSIBLE 100/0.5ML/31GX5/16" 139 174 alendronate sodium 109 ADVOCATE INSULIN AFINITOR 63 alfuzosin hcl 117 SYRINGE/U-100/1ML/29GX1/2" AFINITOR DISPERZ 63 ALINIA 30 139 AFLURIA QUADRIVALENT aliskiren fumarate 59 ADVOCATE INSULIN 2020-2021 211 SYRINGE/U-100/1ML/30GX5/16" AFREZZA 47 ALKERAN 60 139 AFSTYLA 118 ALKINDI SPRINKLE 88 ADVOCATE INSULIN ALL FLOW 1000 PFT SYRINGE/U-100/1ML/31GX5/16" AGAMATRIX ULTRA-THIN 129 FILTER 174 139 LANCETS 33G ALL FLOW 1000 PULMONARY ADVOCATE LANCING AGGRENOX 119 FUNCTION FILTER 174 DEVICE 129 AGRYLIN 119

Index 2 ALL FLOW 2000 PFT AMBISOME 51 ampicillin sodium 199 FILTER 174 ambrisentan 84 AMPYRA 202 ALL FLOW 3000 PFT FILTER 175 amcinonide 99 AMRIX 190 ALL FLOW 4000 PFT AMCINONIDE 100 AMYTAL SODIUM 122 FILTER 175 AMD FOAM DRESSING AMZEEQ 91 ALL FLOW 5000 PFT 4"X4" 125 ANACAINE 104 FILTER 175 AMD FOAM ALL FLOW 6000 PFT DRESSING/TOPSHEET ANADROL-50 28 FILTER 175 4"X4" 125 ANAFRANIL 44 ALL FLOW 7000 PFT AMELUZ 98 anagrelide hcl 119 FILTER 175 AMERGE 180 allopurinol 117 ANASPAZ 207 AMICAR 121 allopurinol sodium 117 anastrozole 61 amikacin sulfate 19 ALLZITAL 23 ANCOBON 51 amiloride & ANDRODERM 28 almotriptan malate 180 hydrochlorothiazide 108 ANDROGEL 28 ALOCRIL 197 amiloride hcl 109 ANDROGEL PUMP 28 alogliptin benzoate 46 aminocaproic acid 121 ANGELIQ 113 alogliptin-metformin hcl 44 aminophylline 37 ANJESO 20 alogliptin-pioglitazone 44 amiodarone hcl 33 ALOMIDE 197 AMIODARONE ANNOVERA 88 ALOPRIM 117 HYDROCHLORIDE/DEXTROS ANORO ELLIPTA 35 ALORA 113 E 33 ANTABUSE 200 AMITIZA 115 alosetron hcl 116 ANTARA 54 amitriptyline hcl 44 ALOXI 50 ANTI-DIARRHEAL 49 amlodipine besylate 82 ALPHAGAN P 194 ANTIVERT 51 amlodipine besylate- ANUSOL-HC 29 ALPHANATE 118 atorvastatin calcium 84 ALPHANATE/VON amlodipine besylate-benazepril ANZEMET 50 WILLEBRANDFACTOR hcl 57 APADAZ 26 COMPLEX/HUMAN 118 amlodipine besylate-olmesartan APEXICON E 100 medoxomil 57 ALPHANINE SD 118 APIDRA 47 alprazolam 32 amlodipine besylate- valsartan 57 APIDRA SOLOSTAR 47 ALPRAZOLAM INTENSOL 32 AMLODIPINE APLENZIN 42 ALPROLIX 118 BESYLATE/SYRSPEND SF APLICARE ALCOHOL ALREX 196 PH4 82 SWABSTICK 137 amlodipine-valsartan- APO-VARENICLINE 203 ALTABAX 96 hydrochlorothiazide 57 ALTACE 55 AMONDYS 45 192 APOKYN 65 ALTERNATE SITE LANCING amoxapine 44 apraclonidine hcl 194 DEVICE 129 aprepitant 51 ALTOPREV 54 amoxicillin 199 amoxicillin & pot APRISO 115 ALTRENO 91 clavulanate 199 APRIZIO PAK 104 ALUNBRIG 63 amoxicillin-clarithromycin w/ APRIZIO PAK II 104 lansoprazole 210 ALVESCO 34 APTENSIO XR 10 amphetamine 3 alvimopan 116 APTIOM 38 ALZAIR ALLERGY BLOCKER amphetamine sulfate 3 NASAL SPRAY 191 amphetamine- APTIVUS 77 amantadine hcl 65 dextroamphetamine 3,4 AQUA LANCE ADJUSTABLE amphotericin b 51 LANCING DEVICE 129 AMARYL 49 AQUADEKS 187 ampicillin 199 AMBIEN 122 AQUORAL 185 AMBIEN CR 122 ampicillin & sulbactam sodium 199 ARAKODA 59

Index 3 ARALAST NP 204 ASTERO 104 AVANDIA 46 ARANESP ALBUMIN ATACAND 56 AVAPRO 56 FREE 120 ATACAND HCT 57 AVAR LS CLEANSER 91 ARAVA 22 atazanavir sulfate 77 AVAR-E LS 91 ARAZLO 91 ATELVIA 109 AVEED 28 ARCALYST 20 atenolol 81 AVEIDAOXIA 106 ARCAPTA NEOHALER 35 atenolol & chlorthalidone 57 AVODART 117 arformoterol tartrate 35 ATENOLOL/SYRSPEND SF AVONEX 202 ARIAL CHAMBER 175 PH4 81 AVONEX PEN 202 ARICEPT 200 ATIVAN 32 AVSOLA 115 ARIKAYCE 19 atomoxetine hcl 8 AYGESTIN 200 ARIMIDEX 61 atorvastatin calcium 54 AYVAKIT 62 aripiprazole 76 atovaquone 30 AZASAN 183 ARISTADA 76 atovaquone-proguanil hcl 59 AZASITE 194 ARISTADA INITIO 76 ATRALIN 91 azathioprine 183 ARIXTRA 37 ATRIPLA 77 azelaic acid 106 armodafinil 10 ATROPINE SULFATE 194 AZELAIC ARMONAIR DIGIHALER 34 atropine sulfate ACID/NIACINAMIDE 91 ARMOUR THYROID 206 (ophthalmic) 194 azelastine hcl 192 ATROPINE SULFATE ARNUITY ELLIPTA 34 MONOHYDRATE 194 azelastine hcl (ophth) 197 AROMASIN 61 ATROVENT HFA 34 azelastine hcl-fluticasone propionate 191 ARTHROTEC 50 20 AUBAGIO 202 AZELEX 92 ARTHROTEC 75 20 AUGMENTIN 199 AZILECT 66 ARYMO ER 24 AUGMENTIN ES-600 199 azithromycin 124 ASACOL HD 115 AURORA LANCET SUPER AZOPT 197 asenapine maleate 70 THIN30G 129 AURORA LANCET THIN AZOR 57 ASMANEX HFA 34 23G 129 AZSTARYS 10 ASMANEX TWISTHALER 120 AURORA PEN NEEDLES METERED DOSES 34 29GX12MM 139 AZULFIDINE 115 ASMANEX TWISTHALER 14 AURORA PEN NEEDLES 31G AZULFIDINE EN-TABS 115 METERED DOSES 34 X6MM 139 B-12 COMPLIANCE ASMANEX TWISTHALER 30 AURORA PEN NEEDLES 31G INJECTIONKIT 120 METERED DOSES 34 X8MM 139 b-complex w/ c & folic acid 185 ASMANEX TWISTHALER 60 AURORA UNIFINE METERED DOSES 34 B-D INSULIN SYRINGE PENTIPS/32GX5/32" 139 ULTRAFINE II/0.3ML/31G X ASMANEX TWISTHALER 7 AURORA UNIFINE METERED DOSES 34 5/16" 139 PENTIPS/MINI/31GX3/16" B-D INSULIN SYRINGE aspirin 24 139 ULTRAFINE II/0.5ML/31G X aspirin-dipyridamole 119 AURYXIA 116 5/16" 139 ASPIRIN/OMEPRAZOLE 119 AUSTEDO 202 B-D INSULIN SYRINGE ASSURE ID INSULIN AUTO-LANCET 129 ULTRAFINE II/1ML/31G X 5/16" 139 SAFETYSYRINGE/U- AUTO-LANCET MINI 129 100/0.5ML/29G X 1/2" 139 B-D INSULIN SYRINGE ASSURE ID INSULIN AUTOLET IMPRESSION ULTRAFINE/0.3ML/30G X SAFETYSYRINGE/U- LANCING DEVICE 129 1/2" 139 AUTOLET LANCING 100/1ML/29G X 1/2" 139 B-D INSULIN SYRINGE ASSURE ID SAFETY PEN DEVICE 129 ULTRAFINE/0.5ML/30G X NEEDLES 30G X 5/16" 139 AUTOLET MINI 129 1/2" 139 ASSURE ID SAFETY PEN AUTOLET PLUS 129 BACIGUENT 194 NEEDLES 31G X 3/16" 139 AUVI-Q 213 bacitracin 30 ASTAGRAF XL 183 AVALIDE 57 bacitracin (ophthalmic) 195

Index 4 bacitracin zinc 96 BD INSULIN SYRINGE BD INSULIN SYRINGE bacitracin-poly-neomycin-hc MICROFINE IV/U- ULTRAFINE/U-100/0.3ML/29G X 196 100/1ML/27G X 5/8" 140 1/2" 140 bacitracin-polymyxin b 96 BD INSULIN SYRINGE BD INSULIN SYRINGE bacitracin-polymyxin b MICROFINE IV/U- ULTRAFINE/U-100/0.5ML/29G X 100/1ML/28G X 1/2" 140 1/2" 140 (ophth) 195 BD INSULIN SYRINGE BD INSULIN SYRINGE BACLOFEN 95 MICROFINE/U-100/0.5ML/28G ULTRAFINE/U-100/1ML/29G X baclofen 190 X 1/2" 140 1/2" 141 BACMIN 186 BD INSULIN SYRINGE BD INSULIN SYRINGE BACTRIM 30 MICROFINE/U-100/1ML/27G X ULTRAFINE/U-100/1ML/31G X 5/8" 140 5/16" 141 BACTRIM DS 30 BD INSULIN SYRINGE BD INSULIN BAFIERTAM 202 MICROFINE/U-100/1ML/28G X SYRINGE/0.3ML/29G X BAL IN OIL 50 1/2" 140 12.7MM 141 BD INSULIN SYRINGE BD INSULIN BALCOLTRA 86 SAFETYGLIDE/1ML/29G X SYRINGE/0.5ML/29G X balsalazide disodium 115 1/2" 140 12.7MM 141 BALVERSA 63 BD INSULIN SYRINGE SLIP BD INSULIN SYRINGE/1ML/27G BAND-AID GAUZE PADS TIP/U-100/1ML 140 X 12.7MM 141 LARGE4" X 4" 125 BD INSULIN SYRINGE BD INSULIN SYRINGE/1ML/29G BAND-AID MIRASORB GAUZE ULTRA-FINE/0.3ML/30G X X 12.7MM 141 SPONGES LARGE 4" X 4" 125 12.7MM 140 BD INSULIN BANZEL 38 BD INSULIN SYRINGE SYRINGE/DETACHABLE ULTRA-FINE/0.3ML/31G X NEEDLE/U-100/1ML/25G X BAQSIMI ONE PACK 45 8MM 140 1" 141 BAQSIMI TWO PACK 45 BD INSULIN SYRINGE BD INSULIN BARACLUDE 79,80 ULTRA-FINE/0.5ML/30G X SYRINGE/DETACHABLE BASAGLAR KWIKPEN 47 12.7MM 140 NEEDLE/U-100/1ML/25G X BD INSULIN SYRINGE 5/8" 141 BAXDELA 114 ULTRA-FINE/0.5ML/31G X BD INSULIN BD LO-DOSE INSULIN 8MM 140 SYRINGE/DETACHABLE SYRINGE MICROFINE BD INSULIN SYRINGE NEEDLE/U-100/1ML/26G X IV/0.5ML/28G X 1/2" 139 ULTRA-FINE/1/2 1/2" 141 BD 3ML SYRINGE LUER-LOK UNIT/0.3ML/31G X 8MM 140 BD INSULIN SYRINGE/U- TIP 139 BD INSULIN SYRINGE 100/1ML/27G X 1/2" 141 BD 3ML SYRINGE SLIP ULTRA-FINE/1ML/30G X BD LANCET ULTRAFINE TIP 139 12.7MM 140 30G 129 BD BLUNT FILL NEEDLE/18GX BD INSULIN SYRINGE BD NEEDLE/18G 1-1/2" 141 1-1/2" 140 ULTRA-FINE/1ML/31G X BD PEN BD ECLIPSE 18G X 1-1/2" 140 8MM 140 NEEDLE/MICRO/ULTRA- BD HYPODERMIC NEEDLE BD INSULIN SYRINGE FINE/32G X 6MM 141 REGULAR BEVEL 18G X 1- ULTRAFINE HALF- BD PEN NEEDLE/MINI/ULTRA- 1/2" 140 UNIT/0.3ML/31G X 5/16" 140 FINE/31G X 5MM 141 BD HYPODERMIC NEEDLE BD INSULIN SYRINGE BD PEN NEEDLE/NANO 2ND REGULAR BEVEL THIN WALL ULTRAFINE/0.3ML/30G X GEN/32G X 5/32" 141 18G X 1-1/2" 140 1/2" 140 BD PEN BD HYPODERMIC NEEDLE BD INSULIN SYRINGE NEEDLE/NANO/ULTRA- SHORT BEVEL 18G X 1- ULTRAFINE/0.3ML/31G X FINE/32G X 4MM 141 1/2" 140 5/16" 140 BD PEN BD HYPODERMIC NEEDLES BD INSULIN SYRINGE NEEDLE/ORIGINAL/ULTRA- 18GX1.5" 140 ULTRAFINE/0.5ML/30G X FINE/29G X 12.7MM 141 BD INSULIN SYRINGE LUER- 1/2" 140 BD PEN LOK/U-100/1ML 140 BD INSULIN SYRINGE NEEDLE/SHORT/ULTRA- BD INSULIN SYRINGE ULTRAFINE/0.5ML/31G X FINE/31G X 8MM 141 MICROFINE IV/U- 5/16" 140 BD SAFETY-GLIDE INSULIN 100/0.5ML/28G X 1/2" 140 BD INSULIN SYRINGE SYRINGE/0.5ML/29G X ULTRAFINE/1ML/30G X 1/2" 141 1/2" 140

Index 5 BD SAFETY-LOK INSULIN BEPREVE 197 bisacodyl-peg 3350-pot chloride- SYRINGE/PERM BERINERT 119 sod bicarb-sod chloride 123 NEEDLE/UF/1ML/29G X bismuth subsalicylate 49 BESER 100 1/2" 141 bisoprolol & BD SAFETYGLIDE BESIVANCE 195 hydrochlorothiazide 57 HYPODERMICNEEDLE 18G X BETAMETHASONE bisoprolol fumarate 81 1-1/2" 141 COMBO 88 BD SAFETYGLIDE INSULIN betamethasone dipropionate BLEPH-10 195 SYRINGE/0.3ML/29G X (topical) 100 BLEPHAMIDE 196 1/2" 141 betamethasone dipropionate BLEPHAMIDE S.O.P. 196 BD SAFETYGLIDE INSULIN augmented 100 BLOXIVERZ 59 SYRINGE/0.3ML/31G X betamethasone sod phosphate 5/16" 141 & acetate 88 BOCASAL 185 BD SAFETYGLIDE INSULIN BETAMETHASONE SODIUM BONIVA 109 SYSYRINGE/0.5ML/30G X PHOSPHATE 88 BONJESTA 51 5/16" 141 betamethasone valerate 100 BOOSTRIX 206 BD SWABS SINGLE USE 137 BETAPACE 82 BORDERED GAUZE 125 BD SWABS SINGLE USE BETAPACE AF 82 BUTTERFLY 137 bosentan 84 BECONASE AQ 192 BETASERON 202 BOSULIF 63 BELBUCA 27 betaxolol hcl 81 BPROTECTED PEDIA POLY- BELLADONNA/OPIUM 207 betaxolol hcl (ophth) 193 VITE 188 bethanechol chloride 211 BPROTECTED PEDIA POLY- BELSOMRA 123 VITE/IRON 187 BETHKIS 19 benazepril & BRAFTOVI 63 hydrochlorothiazide 57 BETIMOL 193 BREATHE EASE NEBULIZER benazepril hcl 55 BETOPTIC-S 193 MASK/CHILD 175 BENAZEPRIL BEVESPI AEROSPHERE 35 BREATHE EASE NEBULIZER HCL/HYDROCHLOROTHIAZIDE bexarotene 64 MASK/INFANT 175 57 BREATHE EASE/LARGE BENEFIX 118 BEXSERO 211 MASK 175 BENICAR 56 BEYAZ 87 BREATHE EASE/MEDIUM MASK 175 BENICAR HCT 57 BI-EST 50:50 COMPOUNDINGKIT 113 BREATHE EASE/SMALL BENLYSTA 184 BI-EST 80:20 MASK 175 BENTYL 207 PROGESTERONE BREATHERITE 175 BENZACLIN 92 COMPOUNDING KIT 113 BREATHERITE BENZACLIN WITH PUMP 92 bicalutamide 61 COLLAPSIBLEADULT SPACER BICILLIN C-R 199 W/MASK 175 BENZAMYCIN 92 BREATHERITE BENZHYDROCODONE/ACETA BICILLIN L-A 199 COLLAPSIBLECHILD SPACER MINOPHEN 26 BIDIL 84 W/MASK 175 BENZNIDAZOLE 29 BIIFENAC 1000 95 BREATHERITE BENZOCAINE/LIDOCAINE/TET BIIFENAC 500 95 COLLAPSIBLEINFANT SPACER RACAINE 104 W/MASK 175 BIJUVA 113 BENZODOX 30 KIT 205 BREATHERITE BIKTARVY 77 COLLAPSIBLESMALL CHILD BENZODOX 60 KIT 205 BILTRICIDE 29 SPACER W/MASK 175 benzoyl peroxide- BREATHERITE erythromycin 92 bimatoprost 198 COLLAPSIBLESPACER W/ BENZOYL BINOSTO 109 NEONATE MASK 175 PEROXIDE/CLINDAMYCIN/NIAC BIOGUARD GAUZE BREATHERITE RIGID INAMIDE 92 SPONGES 4"X4" 12 PLY 125 SPACERW/MASK 175 BENZOYL BIOTENE DRY MOUTH BREATHERITE VALVED MDI PEROXIDE/CLINDAMYCIN/NIAC MOISTURIZING SPRAY 185 CHAMBER/COLLAPSIBLE 175 INAMIDE/TRETINOIN 92 bisacodyl 124 BREATHERITE VALVED MDI benztropine mesylate 65 CHAMBER/RIGID 175 bepotastine besilate 197

Index 6 BREATHERITE W/LARGE buspirone hcl 32 calcium carbonate- MASK 175 butalbital-acetaminophen 23 cholecalciferol 182 BREATHERITE W/MEDIUM calcium carbonate-vitamin MASK 175 butalbital-acetaminophen- d 182 BREATHERITE W/SMALL caffeine 23 calcium carbonate-vitamin d w/ MASK 175 butalbital-acetaminophen- minerals 182 caffeine w/ codeine 26 BREO ELLIPTA 35 CALQUENCE 63 butalbital-aspirin-caffeine 23 BREVIBLOC 81 butalbital-aspirin-caffeine CAMBIA 180 BREVIBLOC PREMIXED 81 w/cod 26 CANASA 115 BREVIBLOC PREMIXED BUTALBITAL/ACETAMINOPH CANCIDAS 51 DOUBLESTRENGTH 81 EN 23 candesartan cilexetil 56 BREXAFEMME 51 BUTALBITAL/ASPIRIN/CAFFEI NE 23 candesartan cilexetil- BREYANZI 61 hydrochlorothiazide 57 butorphanol tartrate 27 BREZTRI AEROSPHERE 36 capecitabine 60 BUTRANS 27 BRILINTA 119 CAPEX 100 BYDUREON BCISE 46 BRIMONIDE/DORZOLAMIDE P- CAPHOSOL 185 BYDUREON PEN 46 F 194 CAPLYTA 66 brimonidine tartrate 194 BYETTA 46 CAPRELSA 63 BRINEURA 111 BYLVAY 115 captopril 55 brinzolamide 197 BYLVAY (PELLETS) 115 captopril & BRISDELLE 204 BYNFEZIA PEN 112 hydrochlorothiazide 58 BRIVIACT 38,39 BYSTOLIC 81 CARAC 98 bromfenac sodium (ophth) 197 CABENUVA 77 CARAFATE 208 bromocriptine mesylate 65 cabergoline 112 CARBAGLU 111 BROMSITE 197 CABOMETYX 63 carbamazepine 39 BRONCHITOL 204 CADIRAMD 104 CARBATROL 39 BRONCHITOL TOLERANCE CADUET 84 carbidopa 65 TEST 204 CAFERGOT 180 carbidopa-levodopa 65 BROVANA 36 caffeine citrate 8 carbidopa-levodopa-entacapone BRUKINSA 63 CAL-QUICK 182 65 BRYHALI 100 CARBIDOPA/LEVODOPA CALAN SR 82 BUBBLES THE FISH II ODT 65 PEDIATRIC MASK/PVC 175 calcipotriene 98 carbinoxamine maleate 52 budesonide 88 CALCIPOTRIENE 98 CARBINOXAMINE budesonide (inhalation) 35 CALCIPOTRIENE MALEATE 52 ANHYDROUS/CLOBETASOL carboxymethylcellulose sodium budesonide (nasal) 192 PROPIONATE 100 (ophth) 193 budesonide-formoterol fumarate calcipotriene-betamethasone CARDENE IV 82 dihydrate 36 dipropionate 100 CARDIOCOM LANCING bumetanide 109 calcitonin (salmon) 109 DEVICE 129 BUMEX 109 calcitriol 111 CARDIZEM 82 BUNAVAIL 27 calcitriol (topical) 98 CARDIZEM CD 82 BUPHENYL 111 CALCIUM 182 CARDIZEM LA 82 BUPRENEX 27 calcium 182 CARDURA 56 buprenorphine 27 calcium acetate (phosphate CARDURA XL 117 buprenorphine hcl 27 binder) 116 CAREFINE PEN NEEDLE buprenorphine hcl-naloxone hcl CALCIUM 32GX4MM 141 dihydrate 27 CARBONATE 29,182 CAREFINE PEN NEEDLES bupropion hcl 42 calcium carbonate 182 29GX1/2" 141 bupropion hcl (smoking calcium carbonate CAREFINE PEN NEEDLES deterrent) 203 (antacid) 29 30GX5/16" 141

Index 7 CAREFINE PEN NEEDLES CARESENS LANCETS 129 CEFAZOLIN 85 31GX6MM 141 CARETOUCH 2 CPAP HOSE CEFAZOLIN SODIUM 85 CAREFINE PEN NEEDLES HANGER 175 cefazolin sodium 85 31GX8MM 141 CARETOUCH CPAP & BIPAP CAREFINE PEN NEEDLES HOSE/6FT 175 CEFAZOLIN SODIUM 85 32GX5MM 141 CARETOUCH CPAP MASK CEFAZOLIN CAREFINE PEN NEEDLES WIPES 175 SODIUM/DEXTROSE 85 32GX6MM 142 CARETOUCH CPAP CEFAZOLIN SODIUM/SODIUM CAREONE ADVANCED NEUTRALIZING PRE- CHLORIDE 85 LANCINGDEVICE 129 WASH 175 CEFAZOLIN/SODIUM CAREONE INSULIN CARETOUCH CPAP TUBE CHLORIDE 85 SYRINGES/0.3ML/30G X CLEANING BRUSH 175 cefdinir 86 1/2" 142 CARETOUCH LANCING cefditoren pivoxil 86 CAREONE INSULIN DEVICEWITH EJECTOR 129 SYRINGES/0.3ML/31G X CARETOUCH PEN NEEDLES CEFEPIME 86 5/16" 142 31G X 6 MM 142 cefepime hcl 86 CAREONE INSULIN CARETOUCH PEN NEEDLES CEFEPIME SYRINGES/0.5ML/30G X 31GX 5MM 142 HYDROCHLORIDE 86 1/2" 142 CARETOUCH PEN NEEDLES CEFEPIME/DEXTROSE 86 CAREONE INSULIN 31GX 8MM 142 cefixime 86 SYRINGES/0.5ML/31G X CARETOUCH PEN NEEDLES 5/16" 142 32GX 4MM 142 CEFOTAN 85 CAREONE INSULIN CARETOUCH PEN NEEDLES cefotaxime sodium 86 SYRINGES/1ML/30G X 32GX 5MM 142 cefotetan disodium 85 1/2" 142 CARETOUCH UNIVERSAL CAREONE INSULIN CPAPFILTERS 175 CEFOTETAN/DEXTROSE 86 SYRINGES/1ML/31GX5/16" carisoprodol 190 cefoxitin sodium 86 142 CEFOXITIN SODIUM 86 CAREONE LANCET SUPER carisoprodol w/ aspirin 191 THIN/30G 129 carisoprodol w/ aspirin & cefoxitin sodium 86 CAREONE LANCET THIN 129 codeine 191 cefpodoxime proxetil 86 CAREONE UNIFINE PENTIPS CARNITOR 111 cefprozil 86 29GX12MM 142 CARNITOR SF 111 ceftazidime 86 CAREONE UNIFINE PENTIPS CAROSPIR 109 CEFTAZIDIME/DEXTROSE 86 31GX5MM 142 CARRASMART 125 CAREONE UNIFINE PENTIPS ceftriaxone sodium 86 31GX6MM 142 CARRASMART FOAM 125 CEFTRIAXONE SODIUM 86 CAREONE UNIFINE PENTIPS carteolol hcl (ophth) 193 ceftriaxone sodium 86 31GX8MM 142 carvedilol 81 ceftriaxone sodium in CAREONE UNIFINE PENTIPS dextrose 86 PEN NEEDLES 32GX4MM 142 carvedilol phosphate 81 CASODEX 61 CEFTRIAXONE/DEXTROSE CAREONE UNIFINE PENTIPS 86 PLUS PEN NEEDLES caspofungin acetate 51 cefuroxime axetil 86 29GX12MM 142 CASPOFUNGIN CAREONE UNIFINE PENTIPS ACETATE 51 cefuroxime sodium 86 PLUS PEN NEEDLES CATAPRES 56 CELEBREX 20 31GX5MM 142 celecoxib 20 CAREONE UNIFINE PENTIPS CATAPRES-TTS-1 57 PLUS PEN NEEDLES CATAPRES-TTS-2 57 CELESTONE-SOLUSPAN 88 31GX6MM 142 CATAPRES-TTS-3 57 CELEXA 42 CAREONE UNIFINE PENTIPS CELLCEPT 183 PLUS PEN NEEDLES CATHFLO ACTIVASE 119 31GX8MM 142 CAYA 127 CELONTIN 41 CAREONE UNIFINE PENTIPS CAYSTON 31 CENTANY 96 PLUS PEN NEEDLES cefaclor 85 CENTANY AT 96 32GX4MM 142 cephalexin 85 CAREONE UNIFINE PENTIPS CEFACLOR ER 85 PLUS PEN NEEDLES/33G X cefadroxil 85 CEPROTIN 119 5/32" 142 CEQUA 195

Index 8 CERDELGA 120 cilostazol 119 CLEVER CHOICE ANTI- CEREBYX 41 CILOXAN 195 STATICVALVED HOLDING CHAMBER/SMALL 176 CEREZYME 120 CIMDUO 77 CLEVER CHOICE ANTI- CEROVEL 103 cimetidine 208 STATICVALVED HOLDING cetirizine hcl 53 cimetidine hcl 208 CHAMBER/SMALL CIMETIDINE/LIDOCAINE/SALI INFANT 176 cetirizine-pseudoephedrine 90 CLEVER CHOICE COMFORT CETRAXAL 198 CYLIC ACID 104 CIMZIA 115 EZINSULIN PEN NEEDLES cevimeline hcl 185 31GX8MM 142 CIMZIA STARTER KIT 115 CHANTIX 203 CLEVER CHOICE COMFORT CHANTIX CONTINUING cinacalcet hcl 111 EZINSULIN PEN NEEDLES MONTHPAK 203 CINQAIR 34 33GX4MM 142 CLEVER CHOICE COMFORT CHANTIX STARTING MONTH CINRYZE 119 PAK 203 EZINSULIN CINVANTI 51 SYRINGE/0.3ML/29G X CHEMET 50 CIPRO 114 1/2" 142 CHEMSTRIP-K 107 CIPRO HC 198 CLEVER CHOICE COMFORT CHENODAL 114 EZINSULIN CIPRODEX 198 CHLOOXIA 100 SYRINGE/0.3ML/30G X ciprofloxacin 114 1/2" 142 chlordiazepoxide hcl 32 ciprofloxacin hcl 114 CLEVER CHOICE COMFORT chlordiazepoxide hcl-clidinium ciprofloxacin hcl (ophth) 195 EZINSULIN bromide 207 SYRINGE/0.3ML/30G X chlordiazepoxide-amitriptyline ciprofloxacin hcl (otic) 198 5/16" 142 201 ciprofloxacin-dexamethasone CLEVER CHOICE COMFORT chlorhexidine gluconate (mouth- 198 EZINSULIN throat) 184 ciprofloxacin-fluocinolone SYRINGE/0.3ML/31G X chloroquine phosphate 59 acetonide 198 5/16" 143 chlorothiazide sodium 109 citalopram hydrobromide 42 CLEVER CHOICE COMFORT chlorpheniramine maleate 52 CLARINEX 53 EZINSULIN CLARINEX-D 12 HOUR 90 SYRINGE/0.5ML/28G X chlorpromazine hcl 73 1/2" 143 chlorthalidone 109 clarithromycin 124,125 CLEVER CHOICE COMFORT CHLORZOXAZONE 190 CLASSIC PRENATAL 188 EZINSULIN chlorzoxazone 190 CLEANLET LANCETS SYRINGE/0.5ML/29G X 28G 130 1/2" 143 CHOLBAM 114 clemastine fumarate 53 CLEVER CHOICE COMFORT cholecalciferol 214 EZINSULIN CLENIA PLUS 92 cholestyramine 54 SYRINGE/0.5ML/30G X CLENPIQ 123 cholestyramine light 54 1/2" 143 CLEOCIN 31,213 CLEVER CHOICE COMFORT choline fenofibrate 54 CLEOCIN PEDIATRIC EZINSULIN CHORIONIC GRANULES 31 SYRINGE/0.5ML/30G X GONADOTROPIN 110 CLEOCIN-T 92 5/16" 143 CIALIS 84 CLEVER CHOICE ANTI- CLEVER CHOICE COMFORT ciclopirox 96 STATICVALVED HOLDING EZINSULIN CHAMBER/ADULT SYRINGE/0.5ML/31G X ciclopirox olamine 96 5/16" 143 CICLOPIROX LARGE 175 CLEVER CHOICE ANTI- CLEVER CHOICE COMFORT OLAMINE/CLOBETASOL 99 EZINSULIN CICLOPIROX STATICVALVED HOLDING CHAMBER/MEDIUM 176 SYRINGE/1.0ML/30G X OLAMINE/CLOBETASOL 1/2" 143 PROPIONATE/SALICYLIC CLEVER CHOICE ANTI- STATICVALVED HOLDING CLEVER CHOICE COMFORT ACID 99 EZINSULIN SYRINGE/1ML/28G CICLOPIROX/SALICYLIC CHAMBER/MEDIUM/3 YEA 176 X 1/2" 143 ACID 99 CLEVER CHOICE COMFORT cidofovir 79 EZINSULIN SYRINGE/1ML/29G X 1/2" 143

Index 9 CLEVER CHOICE COMFORT clindamycin palmitate clozapine 70 EZINSULIN SYRINGE/1ML/30G hydrochloride 31 CLOZARIL 70 X 5/16" 143 clindamycin phosphate CLEVER CHOICE COMFORT (topical) 92 CO MONITOR 176 EZINSULIN SYRINGE/U- clindamycin phosphate CO MONITOR REPLACEMENT 100/1ML/31GX5/16" 143 vaginal 213 TPIECES 176 CLEVER CHOICE COMFORT clindamycin phosphate-benzoyl CO-NATAL FA 188 EZPEN NEEDLES peroxide 92 COAGADEX 118 29GX12MM 143 clindamycin phosphate-benzoyl CLEVER CHOICE COMFORT peroxide (refrigerate) 92 COARTEM 59 EZPEN NEEDLES clindamycin phosphate- CODEINE SULFATE 24 31GX5MM 143 tretinoin 92 codeine sulfate 24 CLEVER CHOICE COMFORT CLINDAMYCIN COGENTIN 65 EZPEN NEEDLES PHOSPHATE/NIACINAMIDE 31GX6MM 143 92 COLAZAL 115 CLEVER CHOICE COMFORT CLINDAMYCIN colchicine 117 EZPEN NEEDLES PHOSPHATE/NIACINAMIDE/T colchicine w/ probenecid 117 RETINOIN 92 31GX8MM 143 COLCRYS 117 CLEVER CHOICE COMFORT CLINDAMYCIN/NIACINAMIDE/ EZPEN NEEDLES SPIRONOLACTONE/TRETINO colesevelam hcl 54 32GX4MM 143 IN 92 COLESTID 54 CLEVER CHOICE COMFORT CLINDAVIX 92 COLESTID FLAVORED 54 EZPEN NEEDLES CLINDESSE 213 32GX5MM 143 colestipol hcl 54 CLEVER CHOICE COMFORT clobazam 38 COLY-MYCIN S 198 EZPEN NEEDLES clobetasol propionate 100 COMBIGAN 193 32GX6MM 143 clobetasol propionate emollient COMBIPATCH 113 CLEVER CHOICE COMFORT base 100 EZPEN NEEDLES clobetasol propionate COMBIVENT RESPIMAT 36 32GX8MM 143 emulsion 100 COMBIVIR 77 CLEVER CHOICE COMFORT CLOBETASOL COMETRIQ 63 EZPEN NEEDLES PROPIONATE/LEVOCETIRIZI COMFORT ASSIST INSULIN 33GX4MM 143 NE DIHYDROCHLORIDE100 SYRINGE 0.3ML/29G X CLEVIPREX 82 CLOBETASOL 1/2" 144 CLICKFINE PEN NEEDLE PROPIONATE/NIACINAMIDE COMFORT ASSIST INSULIN 32GX5/32" 143 100 SYRINGE/0.3ML/30G X CLICKFINE PEN NEEDLE CLOBETAVIX 100 5/16" 144 UNIVERSAL/31GX1/4" 143 CLOBETEX 52 COMFORT ASSIST INSULIN CLICKFINE PEN NEEDLE CLOBEX 100 SYRINGE/0.3ML/31G X UNIVERSAL/31GX5/16" 143 5/16" 144 CLICKFINE PEN NEEDLES 31G clocortolone pivalate 100 COMFORT ASSIST INSULIN X 1/4" 143 CLODAN KIT 101 SYRINGE/0.5ML/29G X CLICKFINE PEN NEEDLES 31G CLODERM 101 1/2" 144 X 3/16" 143 clomipramine hcl 44 COMFORT ASSIST INSULIN CLICKFINE PEN NEEDLES 31G SYRINGE/0.5ML/30G X X 5/16" 144 clonazepam 38 5/16" 144 CLICKFINE PEN NEEDLES 31G clonidine 57 COMFORT ASSIST INSULIN X 8MM 144 clonidine hcl 57 SYRINGE/0.5ML/31G X CLICKFINE PEN NEEDLES 32G 5/16" 144 X 5/32" 144 clonidine hcl (adhd) 8 COMFORT ASSIST INSULIN CLICKFINE PEN clopidogrel bisulfate 119 SYRINGE/1ML/29G X 1/2" 144 NEEDLES/31GX1/4" 144 clorazepate dipotassium 32 COMFORT ASSIST INSULIN CLICKFINE UNIVERSAL PEN clotrimazole 184 SYRINGE/1ML/30G X NEEDLES 31GX5/16" 144 5/16" 144 CLIMARA 113 clotrimazole (topical) 96 COMFORT ASSIST INSULIN CLIMARA PRO 113 clotrimazole vaginal 213 SYRINGE/1ML/31G X CLINDAGEL 92 clotrimazole w/ 5/16" 144 betamethasone 96 clindamycin hcl 31

Index 10 COMFORT ASSURED CONZIP 24 CURITY ALL PURPOSE LANCETS SUPER THIN COPA ISLAND BORDERED SPONGES 4"X4" 125 28G 130 FOAM DRESSING 4"X4" 125 CURITY ALL PURPOSE COMFORT EZ INSULIN COPA PLUS HYDROPHILIC SPONGES 4"X4" 4PLY 125 SYRINGE/U-100/0.5ML/31G X FOAM DRESSING 4"X4" 125 CURITY ALL PURPOSE 5/16" 144 COPAXONE 202 SPONGES 4"X4" 4PLY/SOFT COMFORT EZ INSULIN POUCH 125 SYRINGE/U-100/1ML/31G X COPIKTRA 63 CURITY AMD 5/16" 144 CORDRAN 101 ANTIMICROBIALGAUZE COMFORT EZ MICRO/32G X COREG 81 SPONGES 4"X4" 12 PLY 125 4MM 144 CURITY COVER SPONGE COMFORT EZ SHORT/31G X COREG CR 81 4"X4" 125 8MM 144 CORGARD 82 CURITY COVER SPONGES COMFORT EZ/31G X 5MM 144 CORIFACT 118 4"X4" 125 COMFORT EZ/31G X 6MM 144 CORLANOR 85 CURITY DRESSING SPONGES 4"X4" 6 PLY 125 COMFORT LANCETS 130 CORTEF 89 CURITY GAUZE PADS 4"X4" 12 COMFORT TOUCH PEN CORTENEMA 29 PLY 125 NEEDLES/31G X 4MM 144 CORTIFOAM 29 CURITY GAUZE SPONGE 4"X4" COMFORT TOUCH PEN 12 PLY 126 NEEDLES/31G X 5MM 144 CORTISPORIN-TC 198 CURITY GAUZE SPONGE 4"X4" COMFORT TOUCH PEN CORVERT 33 16 PLY 126 NEEDLES/31G X 6 MM 144 COSENTYX 98 CURITY GAUZE SPONGE 4"X4" COMFORT TOUCH PEN COSENTYX SENSOREADY 8 PLY 126 NEEDLES/31G X 8 MM 144 PEN 98 CURITY GAUZE SPONGE COMFORT TOUCH PEN COSOPT 193 4"X4"16 PLY 126 NEEDLES/32G X 4MM 144 CURITY GAUZE SPONGES COMFORT TOUCH PEN COSOPT PF 193 4"X4" 12 PLY 126 NEEDLES/32G X 5MM 144 COTELLIC 63 CURITY GAUZE SPONGES COMFORT TOUCH PEN COTEMPLA XR-ODT 11 4"X4" 8 PLY 126 144 NEEDLES/32G X 6MM COVRSITE COVER CURITY COMFORT TOUCH PEN SPONGES/CELLULOSEFILLED/ 144 DRESSING 125 NEEDLES/32G X 8MM COVRSITE PLUS 4"X4" 126 COMFORT TOUCH PEN CUTIVATE 101 NEEDLES/33G X 5/32" 144 COMPOSITE DRESSING125 COMPACT SPACE COZAAR 56 CUVPOSA 207 CHAMBER/ANTI-STATIC 176 CREON 108 CVS DRY MOUTH SPRAY 185 COMPACT SPACE CRESEMBA 52 CVS GAUZE PADS 4"X4" 12- CHAMBER/ANTI- PLY 126 STATIC/LARGE MASK 176 CRESTOR 54 CVS GAUZE PADS STERILE COMPACT SPACE CRINONE 213 4"X4" 12-PLY 126 CHAMBER/ANTI- CRIXIVAN 77 CVS GLUCOSE 45 STATIC/MEDIUM MASK 176 cromolyn sodium 33 CVS LANCETS 21G 130 COMPACT SPACE cromolyn sodium CVS LANCETS MICRO THIN CHAMBER/ANTI-STATIC/SMALL (mastocytosis) 115 33G 130 MASK 176 cromolyn sodium (ophth) 197 CVS LANCETS MICRO-THIN COMPLERA 77 crotamiton 107 33G 130 COMPLETE NATAL DHA 188 CRUAD GAUZE PADS 4" X CVS LANCETS ORIGINAL 130 COMPLETENATE 188 4" 125 CVS LANCETS THIN 26G 130 COMTAN 65 CRYODOSE TA 104 CVS LANCETS ULTRA THIN CONCERTA 10,11 CRYSVITA 111 30G 130 CVS LANCETS ULTRA-THIN CONDOMS 127 CUPRIMINE 183 30G 130 CONJUPRI 82 CURITY ALCOHOL CVS LANCING DEVICE 130 CONSENSI 82 PREPS/MEDIUM 2 PLY 137 CURITY ALCOHOL CVS PRENATAL 188 CONTRAST ALLERGY PREMED CVS PREP PADS 137 PACK 88 SWABS 137 CONVENIENCE PAK 203 CVS SOFT GLUCOSE 45

Index 11 CVS ULTRA THIN DAYVIGO 123 DERMACINRX PHN PAK 104 LANCETS 130 DDAVP 112 DERMACINRX THERAZOLE cyanocobalamin 120 deferasirox 50 PAK 96 CYANOCOBALAMIN 120 DERMACINRX TICANASE deferiprone 50 CYCLO/GABA10/300 PAK 191 PACK 191 deferoxamine mesylate 50 DERMACINRX ZRM PAK 104 cyclobenzaprine hcl 190 DELESTROGEN 113 DERMALEVIN ADHESIVE CYCLOGYL 194 DELSTRIGO 77 FOAMDRESSING 4"X4" 126 DERMALID 104 CYCLOMYDRIL 194 DELZICOL 115 DERMOTIC 198 cyclopentolate hcl 194 demeclocycline hcl 205 DESCOVY 77 CYCLOPHENE RAPIDPAQ190 DEMSER 56 desipramine hcl 44 cyclophosphamide 60 DENAVIR 99 desloratadine 53 CYCLOPHOSPHAMIDE 60 DEOXIA 92 desmopressin acetate 112 cycloserine 60 DEPAKOTE 41 DESMOPRESSIN CYCLOSET 46 DEPAKOTE ER 41 ACETATE 112 cyclosporine 183 DEPAKOTE SPRINKLES 41 desmopressin acetate 112 CYCLOSPORINE IN DEPEN TITRATABS 183 desmopressin acetate KLARITY 195 DEPO-ESTRADIOL 113 spray 112 cyclosporine modified (for DEPO-MEDROL 89 desmopressin acetate spray microemulsion) 183 refrigerated 112 CYKLOKAPRON 121 DEPO-PROVERA 61 desogestrel & ethinyl CYMBALTA 43 DEPO-PROVERA estradiol 87 CONTRACEPTIVE 88 desogestrel-ethinyl estradiol cyproheptadine hcl 53 DEPO-SUBQ PROVERA (biphasic) 87 CYSTADANE 111 104 88 desogestrel-ethinyl estradiol CYSTADROPS 197 DEPO-TESTOSTERONE 28 (triphasic) 87 CYSTAGON 117 DERMA-SMOOTHE/FS DESONATE 101 BODY 101 desonide 101 CYSTARAN 197 DERMA-SMOOTHE/FS CYTOMEL 206 SCALP 101 DESOWEN 101 CYTOTEC 210 DERMACEA DRAIN desoximetasone 101 CYTOVENE 79 SPONGES 4"X4" 126 DESOXYN 4 DERMACEA GAUZE SPONGE DESVENLAFAXINE ER 43 D-VI-SOL 214 4"X4" 12 PLY 126 D.H.E. 45 180 DERMACEA GAUZE SPONGE desvenlafaxine succinate 43 dalfampridine 202 4"X4" 16 PLY 126 DETROL 210 DERMACEA GAUZE SPONGE DETROL LA 210 DALIRESP 34 4"X4" 8 PLY 126 danazol 28 DEX4 QUICK DISSOLVE DERMACEA I.V. DRAIN GLUCOSE 45 SPONGES 4"X4" 126 DANTRIUM 191 DEXABLISS 89 DANTRIUM IV 191 DERMACEA NON-WOVEN SPONGES 4"X4" 4 PLY 126 dexamethasone 89 dantrolene sodium 191 DERMACEA NON-WOVEN DEXAMETHASONE (LA) 89 dapsone 31 SPONGES 4"X4" 6 PLY 126 DEXAMETHASONE dapsone (topical) 92 DERMACEA TYPE VII GAUZE INTENSOL 89 4"X4" 12 PLY 126 DAPSONE/NIACINAMIDE 92 DEXAMETHASONE SODIUM DERMACEA TYPE VII GAUZE PHOSPHATE 89 DAPSONE/NIACINAMIDE/SPIR 4"X4" 16 PLY 126 ONOLACTONE 92 dexamethasone sodium DERMACEA TYPE VII GAUZE phosphate 89 DARAPRIM 59 4"X4" 8 PLY 126 DEXAMETHASONE SODIUM darifenacin hydrobromide 210 DERMACEA X-RAY PHOSPHATE 89 DAURISMO 61 SPONGES 4"X4" 16 PLY 126 dexamethasone sodium DERMACINRX AZENASE phosphate (ophth) 196 DAYPRO 20 PAK 191 DAYTRANA 11 DERMACINRX LEXITRAL PHARMAPAK 95

Index 12 DEXAMETHASONE SODIUM diclofenac sodium- DIPENTUM 115 PHOSPHATE/SODIUM capsaicin 20 diphenhydramine hcl 53 CHLORIDE 89 diclofenac sodium-capsaicin dexchlorpheniramine (topical) 95 diphenoxylate w/ atropine 49 maleate 52 DICLOFENAC DIPHTHERIA/TETANUS DEXEDRINE 4 SODIUM/HYALURONIC ACID TOXOIDS ADSORBED PEDIATRIC 207 DEXILANT 208 SODIUM SALT/NIACINAMIDE 98 DIPROLENE 101 dexmethylphenidate hcl 11,12 diclofenac w/ misoprostol 20 DIPROLENE AF 101 DEXONTO 0.4% 89 DICLOFONO 95 dipyridamole 119 dextroamphetamine sulfate 4,5 DICLOPR 95 disopyramide phosphate 33 dextromethorphan hbr 90 DICLOSTREAM 95 disulfiram 200 dextromethorphan-guaifenesin 90,91 DICLOTREX 95 DITROPAN XL 210 DFS DR/MS/MENTH/CAP DICLOVIX 95 DIURIL 109 PAK 20 DICLOVIX M 95 divalproex sodium 41 DFS/MS/MENTH/CAP PAK 95 dicloxacillin sodium 199 DIVIGEL 113 DIACOMIT 39 DICLOZOR 95 dobutamine hcl 84 DIADIMAXIA 92 DICOPANOL FUSEPAQ 53 DOBUTAMINE HCL/D5W 84 DIAOXIA 92 DICOPANOL RAPIDPAQ 53 DOBUTAMINE DIASDIMAXIA 92 dicyclomine hcl 207 HYDROCHLORIDE/ DEXTROSE DIASOXIA 92 5% 84 didanosine 77 DOBUTAMINE DIASTAT ACUDIAL 38 DIFFERIN 92 HYDROCHLORIDE/DEXTROSE DIASTAT PEDIATRIC 38 DIFICID 125 5% 84 DIATHRIVE LANCETS 130 diflorasone diacetate 101 docusate calcium 124 DIATHRIVE LANCETS ULTRA DIFLUCAN 52 docusate sodium 124 THIN 30G 130 DIATHRIVE LANCING diflunisal 24 dofetilide 33 DEVICE 130 DIFMETIOXRIME 96 DOJOLVI 193 DIATHRIVE PEN NEEDLE/31 G digoxin 84 DOLOPHINE 24 X 6MM 145 dihydroergotamine donepezil hydrochloride 200 DIATHRIVE PEN NEEDLE/31 mesylate 180 GX 8MM 145 dopamine hcl 84 DIATHRIVE PEN NEEDLE/31GX DILANTIN 41 DOPAMINE 5MM 145 DILANTIN INFATABS 41 HYDROCHLORIDE/DEXTROSE DIATHRIVE PEN NEEDLE/32GX DILANTIN-125 41 84 DOPAMINE/D5W 84 4MM 145 DILATRATE SR 31 diazepam 32 DOPTELET 120 DILAUDID 24 DIAZEPAM 32 DORAL 122 diltiazem hcl 83 diazepam 32 DORYX 205 DILTIAZEM HCL 83 diazepam (anticonvulsant) 38 DORYX MPC 205 diltiazem hcl 83 diazoxide 45 diltiazem hcl coated dorzolamide hcl 197 DIBENZYLINE 56 beads 82,83 DORZOLAMIDE HCL 197 DICLEGIS 51 diltiazem hcl extended release dorzolamide hcl-timolol DICLOFENAC 20 beads 83 maleate 193 DIMENHYDRINATE 51 diclofenac epolamine 95 DOUBLE PM 196 DIMENTHO 95 diclofenac potassium 20 DOUBLEDEX 89 dimethyl fumarate 202 diclofenac sodium 20 DOVATO 77 diclofenac sodium (actinic DIMOXIA 92 DOVONEX 98 keratoses) 98 DIOCHLOY 101 doxazosin mesylate 57 diclofenac sodium (ophth) 197 DIOVAN 56 doxepin hcl 44 diclofenac sodium (topical) 95 DIOVAN HCT 58 doxepin hcl (antipruritic) 98

Index 13 doxepin hcl (sleep) 122 DROPLET INSULIN DRUG MART UNIFINE doxercalciferol 111 SYRINGE/U-100/1ML/31G X PENTIPS31GX8MM 146 5/16" 145 DRUG MART UNIFINE doxycycline (monohydrate) 205 DROPLET LANCETS ULTRA PENTIPS32GX4MM 146 doxycycline (rosacea) 106 THIN 30G 130 DRUG MART UNIFINE doxycycline hyclate 205 DROPLET LANCING PENTIPSPLUS 32GX4MM 146 DOXYCYCLINE HYCLATE DEVICE 130 DRUG MART UNILET DR 205 DROPLET PEN NEEDLES 29G LANCETSSUPER THIN X1/2" 145 30G 130 doxylamine-pyridoxine 51 DROPLET PEN NEEDLES DRUG MART UNILET DRAXACE 92 29GX12MM 145 LANCETSULTRA THIN DRAXACE LOTION DROPLET PEN NEEDLES 30G 28G 130 CLEANSER 92 X 5/16" 145 DRUG MART UNILET MICRO DRITHO-CREME HP 98 DROPLET PEN NEEDLES 31G THIN LANCETS 33G 130 DRIXECE 93 X3/16" 145 DRYMAX EXTRA 126 DROPLET PEN NEEDLES 31G DRYSOL 106 DRIZALMA SPRINKLE 43 X5/16" 145 dronabinol 51 DROPLET PEN NEEDLES DUAKLIR PRESSAIR 36 droperidol 32 31GX5MM 145 DUAL COMPLEX FORMULA 1 DROPLET PEN NEEDLES KIT 95 DROPERIDOL 32 31GX6MM 145 DUAVEE 113 DROPLET GENTEEL LANCING DROPLET PEN NEEDLES DUETACT 45 DEVICE 130 31GX8MM 145 DROPLET INSULIN SYRINGE DROPLET PEN NEEDLES 32G DUEXIS 20 0.3ML/29G X 1/2" 145 X 1/4" 145 DULERA 36 DROPLET INSULIN SYRINGE DROPLET PEN NEEDLES 32G duloxetine hcl 43,44 0.5ML/29G X 1/2" 145 X 3/16" 145 DROPLET INSULIN SYRINGE DROPLET PEN NEEDLES 32G DUOBRII 101 1ML/29G X 1/2" 145 X 5/16" 145 DUOPA 65 DROPLET INSULIN SYRINGE DROPLET PEN NEEDLES 32G DUPIXENT 103 U-100/0.3/31G X 5/16" 145 X 5/32" 145 DROPLET INSULIN SYRINGE DURAGESIC 24 DROPLET PEN NEEDLES DUREX EXTRA U-100/0.3ML/30G X 1/2" 145 32GX4MM 145 DROPLET INSULIN SYRINGE SENSITIVE 127 DROPLET PEN NEEDLES DUREX REALFEEL NON- U-100/0.3ML/30G X 5/16" 145 32GX5MM 146 DROPLET INSULIN SYRINGE DROPLET PEN NEEDLES LATEX 127 U-100/0.5ML/30G X 1/2" 145 32GX6MM 146 DUREZOL 196 DROPLET INSULIN SYRINGE DROPLET PEN NEEDLES DURLAZA 119 U-100/0.5ML/30G X 5/16" 145 32GX8MM 146 dutasteride 117 DROPLET INSULIN SYRINGE DROPSAFE SAFETY PEN U-100/0.5ML/31G X 5/16" 145 NEEDLES/31G X 5/16" 146 dutasteride-tamsulosin hcl 117 DROPLET INSULIN SYRINGE DROPSAFE SAFTEY PEN DUTOPROL 58 U-100/1ML/30G X 1/2" 145 NEEDLES/31G X 1/4" 146 DXEVO 11-DAY 89 DROPLET INSULIN SYRINGE drospirenone-ethinyl DYANAVEL XR 5 U-100/1ML/30G X 5/16" 145 estradiol 87 DROPLET INSULIN SYRINGE drospirenone-ethinyl estradiol- DYAZIDE 108 U-100/1ML/31G X 5/16" 145 levomefolate calcium 87 DYMISTA 191 DROPLET INSULIN DROXIA 120 SYRINGE/U-100/0.3ML/31G X dyphylline-guaifenesin 34 5/16" 145 droxidopa 214 DYRENIUM 109 DROPLET INSULIN DRUG MART ADJUSTABLE E-Z JECT LANCETS 130 LANCING DEVICE 130 SYRINGE/U-100/0.5ML/30G X E-Z JECT LANCETS 21G 130 1/2" 145 DRUG MART LANCETS THIN 130 E-Z JECT LANCETS DROPLET INSULIN COLOR 130 SYRINGE/U-100/0.5ML/31G X DRUG MART UNIFINE PENTIPS 31GX5MM 146 E-Z JECT LANCETS SUPER 5/16" 145 THIN 30G 130 DROPLET INSULIN DRUG MART UNIFINE PENTIPS29G X 12MM 146 E-Z JECT LANCETS THIN SYRINGE/U-100/1ML/30G X 26G 130 1/2" 145 DRUG MART UNIFINE PENTIPS31GX6MM 146

Index 14 E-ZJECT LANCETS MICRO- EASY FLOW EASY TOUCH INSULIN THIN 33G 130 WHITE/YELLOW 176 SYRINGE/U-100/0.3ML/30G X E.E.S. GRANULES 125 EASY GLIDE PEN NEEDLES 1/2" 147 EASIVENT 176 33G X 5/32" 146 EASY TOUCH INSULIN EASY GLIDE SYRINGE/LUER SYRINGE/U-100/0.5ML/27G X EASIVENT/MASK-LARGE 176 LLOCK/3ML 146 1/2" 147 EASIVENT/MASK-MEDIUM EASY MINI EJECT LANCING EASY TOUCH INSULIN 176 DEVICE 130 SYRINGE/U-100/0.5ML/28G X EASIVENT/MASK-SMALL 176 EASY MINI LANCING 1/2" 147 EASY COMFORT INSULIN DEVICE 130 EASY TOUCH INSULIN SYRINGE/0.5ML/30G X EASY TOUCH SYRINGE/U-100/0.5ML/29G X 5/16" 146 32GX5MM 146 1/2" 147 EASY COMFORT INSULIN EASY TOUCH EASY TOUCH INSULIN SYRINGE/0.5ML/31G X 32GX6MM 146 SYRINGE/U-100/0.5ML/30G X 5/16" 146 EASY TOUCH ALCOHOL 1/2" 147 EASY COMFORT INSULIN PREP PADS/MEDIUM 138 EASY TOUCH INSULIN SYRINGE/1ML/30G X EASY TOUCH FLIPLOCK SYRINGE/U-100/0.5ML/31G X 5/16" 146 NEEDLES 18GX1-1/2" 146 5/16" 147 EASY COMFORT INSULIN EASY TOUCH FLIPLOCK EASY TOUCH INSULIN SYRINGE/1ML/31G X SAFETY INSULIN SYRINGE SYRINGE/U-100/1ML/27G X 5/16" 146 1ML/29GX1/2" 146 1/2" 147 EASY COMFORT INSULIN EASY TOUCH FLIPLOCK EASY TOUCH INSULIN SYRINGE/U-100/0.5ML/30G X SAFETY INSULIN SYRINGE SYRINGE/U-100/1ML/28G X 1/2" 146 1ML/30GX1/2" 146 1/2" 147 EASY COMFORT INSULIN EASY TOUCH FLIPLOCK EASY TOUCH INSULIN SYRINGE/U-100/1ML/30G X SAFETY INSULIN SYRINGE SYRINGE/U-100/1ML/29G X 1/2" 146 1ML/30GX5/16" 146 1/2" 147 EASY COMFORT PEN EASY TOUCH FLIPLOCK EASY TOUCH INSULIN NEEDLES31GX1/4" 146 SAFETY INSULIN SYRINGE SYRINGE/U-100/1ML/30G X EASY COMFORT PEN 1ML/31GX5/16" 146 1/2" 147 NEEDLES31GX3/16" 146 EASY TOUCH HYPODERMIC EASY TOUCH INSULIN EASY COMFORT PEN NEEDLES 18GX1-1/2" 146 SYRINGE/U-100/1ML/31G X NEEDLES31GX5/16" 146 EASY TOUCH INSULIN 5/16" 147 EASY COMFORT PEN SYRINGE/0.3ML/30G X EASY TOUCH LANCETS NEEDLES32GX5/32" 146 5/16" 146 26G/PULL-TOP 130 EASY COMFORT PEN EASY TOUCH INSULIN EASY TOUCH LANCETS NEEDLES33G X 4MM 146 SYRINGE/0.3ML/31G X 28G/PULL-TOP 131 EASY FLOW 300 MM 5/16" 146 EASY TOUCH LANCETS HOSE 176 EASY TOUCH INSULIN 28G/TWIST 131 EASY FLOW 400 MM SYRINGE/0.5ML/29G X EASY TOUCH LANCETS HOSE 176 1/2" 147 30G/PULL-TOP 131 EASY FLOW AIR NOZZLE 176 EASY TOUCH INSULIN EASY TOUCH LANCETS SYRINGE/0.5ML/30G X EASY FLOW BLACK/BLUE176 30G/TWIST 131 5/16" 147 EASY TOUCH LANCETS EASY FLOW EASY TOUCH INSULIN 32G/PULL-TOP 131 BLACK/ORANGE 176 SYRINGE/1ML/30G X EASY TOUCH LANCETS EASY FLOW BLACK/RED 176 5/16" 147 32G/TWIST 131 EASY FLOW EASY TOUCH INSULIN EASY TOUCH LANCETS BLACK/WHITE 176 SYRINGE/SAFETY/U- 33G/TWIST 131 EASY FLOW 100/0.5ML/29G X 1/2" 147 EASY TOUCH LANCING BLACK/YELLOW 176 EASY TOUCH INSULIN DEVICE/EJECTOR 131 EASY FLOW HEPA SYRINGE/SAFETY/U- EASY TOUCH PEN NEEDLE FILTER 176 100/0.5ML/30G X 5/16" 147 30G X 5/16" 147 EASY FLOW WHITE/BLUE 176 EASY TOUCH INSULIN EASY TOUCH PEN NEEDLES EASY FLOW SYRINGE/SAFETY/U- 29GX1/2" 147 WHITE/GREEN 176 100/1ML/29G X 1/2" 147 EASY TOUCH PEN NEEDLES EASY FLOW WHITE/PINK 176 EASY TOUCH INSULIN 31GX1/4" 147 EASY FLOW SYRINGE/SAFETY/U- EASY TOUCH PEN NEEDLES WHITE/WHITE 176 100/1ML/30G X 1/2" 147 31GX5/16" 147

Index 15 EASY TOUCH PEN NEEDLES EFLOW SCF AEROSOL EMCYT 62 32GX1/4" 147 HEAD 176 EMEND 51 EASY TOUCH PEN NEEDLES EFUDEX 98 EMEND TRIPACK 51 32GX3/16" 147 EGATEN 29 EASY TOUCH PEN NEEDLES EMFLAZA 89 EGRIFTA 110 32GX5/32" 147 EMGALITY 180 EASY TOUCH PEN EGRIFTA SV 110 EMPAVELI 119 NEEDLES/31G X 3/16" 147 EHA LOTION 104 EASY TOUCH SAFETY PEN EMPRICAINE II 105 EHA LOTION 4% 104 NEEDLES/30G X 5/16" 147 EMSAM 42 ELELYSO 120 EASY TOUCH SHEATHLOCK emtricitabine 77 SAFETY INSULIN SYRINGE ELEPSIA XR 39 emtricitabine-tenofovir disoproxil 1ML/29GX1/2" 147 ELESTRIN 113 EASY TOUCH SHEATHLOCK fumarate 77 SAFETY INSULIN SYRINGE eletriptan hydrobromide 180 EMTRIVA 77 1ML/30GX5/16" 147 ELIDEL 104 EMVERM 29 EASY TOUCH SHEATHLOCK ELIGARD 61 ENABLEX 210 SAFETY INSULIN SYRINGE 1ML/31GX5/16" 148 ELIMITE 107 enalapril maleate 55 EASY TOUCH SHEATHLOCK ELIQUIS 37 enalapril maleate & SAFETY SYRINGE ELIQUIS STARTER PACK 37 hydrochlorothiazide 58 1ML/30GX1/2" 148 ELITE DC AUTO enalaprilat 55 EASYPOINT NEEDLE/18G X 1- ADAPTER 176 ENBREL 23 1/2" 148 ELITE-THIN INSULIN ENBREL MINI 22 176 EBASE CONTROLLER KIT SYRINGE/0.3ML/31G X ENBREL SURECLICK 23 20 5/16" 148 EC-NAPROSYN ENDARI 120 EC-RX ESTRADIOL 0.4% 113 ELITE-THIN INSULIN SYRINGE/0.5ML/29G X ENEMEEZ PLUS 124 113 EC-RX ESTRADIOL 0.6% 1/2" 148 ENFAMIL EXPECTA 188 EC-RX PROGESTERONE ELITE-THIN INSULIN 10% 200 SYRINGE/0.5ML/30G X ENGERIX-B 211 EC-RX PROGESTERONE 5/16" 148 ENOVARX-BACLOFEN 95 20% 200 ELITE-THIN INSULIN ENOVARX- ECEOXIA 93 SYRINGE/1ML/30G X CYCLOBENZAPRINE HCL 190 ECONASIL 96 5/16" 148 ENOVARX-DICLOFENAC ELITE-THIN INSULIN SODIUM 95 96 econazole nitrate SYRINGE/U-100/0.5ML/28G X ENOVARX-IBUPROFEN 95 ECONAZOLE 1/2" 148 ENOVARX-LIDOCAINE 96 NITRATE/NIACINAMIDE ELITE-THIN INSULIN HCL 105 24 ECOTRIN SYRINGE/U-100/0.5ML/31G X ENOVARX-NAPROXEN 95 ECOTRIN REGULAR 5/16" 148 STRENGTH 24 ELITE-THIN INSULIN ENOVARX-TRAMADOL 95 ECOZA 96 SYRINGE/U-100/1ML/28G X enoxaparin sodium 37 EDARBI 56 1/2" 148 ENSPRYNG 183 ELITE-THIN INSULIN ENSTILAR 101 EDARBYCLOR 58 SYRINGE/U-100/1ML/29G X EDECRIN 109 1/2" 148 entacapone 65 EDLUAR 122 ELITE-THIN INSULIN entecavir 80 EDURANT 77 SYRINGE/U-100/1ML/31G X ENTEREG 116 5/16" 148 ENTOCORT EC 89 efavirenz 77 ELIXOPHYLLIN 37 efavirenz-emtricitabine-tenofovir ENTRESTO 84 ELLA 88 disoproxil fumarate 77 ENTYVIO 115 efavirenz-lamivudine-tenofovir ELLZIA PAK 101 ENVARSUS XR 183 disoproxil fumarate 77 ELMIRON 117 ENZNONUTY 105 EFFER-K 182 ELOCTATE 118 EFFEXOR XR 44 EMBRACE LANCING DEVICE EPANED 55 EFFIENT 119 WITH EJECTOR 131 EPCLUSA 80

Index 16 EPHEDRINE SULFATE 214 EQL INSULIN ESMOLOL HYDROCHLORIDE ephedrine sulfate SYRINGE/0.5ML/30G X INWATER 81 (pressors) 214 5/16" 148 ESMOLOL HYDROCHLORIDE EPIDIOLEX 39 EQL INSULIN INWATER DOUBLE SYRINGE/0.5ML/31G X STRENGTH 81 EPIDUO 93 5/16" 148 ESOMEP-EZS 208 EPIDUO FORTE 93 EQL INSULIN esomeprazole magnesium 208 EPIFOAM 101 SYRINGE/1ML/29G X 1/2" 148 esomeprazole sodium 208 epinastine hcl (ophth) 197 EQL INSULIN ESOMEPRAZOLE epinephrine 214 SYRINGE/1ML/30G X STRONTIUM 208 epinephrine (anaphylaxis) 213 5/16" 148 ESPEROCT 118 EPINEPHRINE HCL 214 EQL INSULIN estazolam 122 SYRINGE/1ML/31G X ESTRACE 113 epinephrine hcl (nasal) 192 5/16" 148 EPINEPHRINE EQL PRENATAL estradiol 113 PROFESSIONAL 214 FORMULA 188 estradiol & norethindrone EPINEPHRINESNAP-EMS 214 EQL SUPER THIN LANCETS acetate 113 EPINEPHRINESNAP-V 214 30G 131 estradiol vaginal 213 EPIPEN 2-PAK 214 EQL THIN LANCETS estradiol valerate 113 26G 131 EPIPEN-JR 2-PAK 214 EQUAPAX/ATORVASTATIN ESTRING 213 EPISNAP 214 CALCIUM/COQ10 54 ESTRIOL-PROGESTERONE COMPOUNDING KIT 113 EPIVIR 77 EQUAPAX/IBUPROFEN/MINR EX 19 ESTROGEL 113 EPIVIR HBV 80 EQUETRO 66 ESTROSTEP FE 87 eplerenone 59 ERAXIS 51 eszopiclone 122 EPOGEN 120 ergocalciferol 214 ethacrynate sodium 109 EPZICOM 77 ergoloid mesylates 203 ethacrynic acid 109 EQ SPACE CHAMBER ANTI- STATIC 176 ERGOMAR 180 ethambutol hcl 60 EQ SPACE CHAMBER ANTI- ergotamine w/ caffeine 180 ethosuximide 41 STATIC/LARGE MASK 177 ERIVEDGE 61 ETHOXIA 93 EQ SPACE CHAMBER ANTI- STATIC/MEDIUM MASK 177 ERLEADA 62 ethyl chloride 105 EQ SPACE CHAMBER ANTI- erlotinib hcl 61 ETHYL CHLORIDE/FINE STATIC/SMALL MASK 177 ERTACZO 96 PINPOINT 105 ETHYL CHLORIDE/FINE EQL COLOR LANCETS ertapenem sodium 30 21G 131 STREAM 105 EQL COLOR LANCETS MICRO ERYGEL 93 ETHYL CHLORIDE/MEDIUM THIN 33G 131 ERYPED 200 125 JET STREAM 105 ETHYL CHLORIDE/MEDIUM EQL DRY MOUTH ORAL ERYPED 400 125 RINSE 185 STREAM 105 EQL GAUZE PADS erythromycin (acne aid) 93 ETHYL CHLORIDE/MIST 105 4"X4"/LARGE 126 erythromycin (ophth) 195 ethynodiol diacet & eth EQL INSULIN erythromycin base 125 estrad 87 SYRINGE/0.3ML/29G X erythromycin etodolac 20,21 1/2" 148 ethylsuccinate 125 etonogestrel-ethinyl estradiol88 EQL INSULIN erythromycin stearate 125 SYRINGE/0.3ML/30G X etoposide 64 5/16" 148 ESBRIET 204 etravirine 77 EQL INSULIN escitalopram oxalate 42 EUCRISA 106 SYRINGE/0.3ML/31G X ESGIC 23 5/16" 148 EVAMIST 113 EQL INSULIN esmolol hcl 81 EVEKEO 6 SYRINGE/0.5ML/29G X esmolol hcl-sodium EVEKEO ODT 6 1/2" 148 chloride 81 ESMOLOL EVENITY 109 HYDROCHLORIDE 81 everolimus 63

Index 17 everolimus exemestane 62 FELBATOL 41 (immunosuppressant) 183 EXFORGE 58 FELDENE 21 EVISTA 111 EXFORGE HCT 58 felodipine 83 EVOCLIN 93 EXJADE 50 FEMARA 62 EVOTAZ 77 EXODERM 96 FEMCAP 127 EVOXAC 185 EXONDYS 51 192 FEMHRT 113 EVRYSDI 192 EXSERVAN 192 FEMRING 213 EVZIO 50 EXTAVIA 202 fenofibrate 54 EXCEL COMFORT POINT INSULIN PEN NEEDLES 31G X EXTINA 96 fenofibrate micronized 54 4MM 148 EYSUVIS 196 FENOFIBRIC ACID 54 EXCILON AMD EZ-LETS LANCETS 26G fenofibric acid 54 ANTIMICROBIALDRAIN SUPER-SOFT 131 FENOGLIDE 54 SPONGES 4"X4" 6 PLY 126 EZ-LETS LANCETS 28G EXCILON AMD ULTRA-SOFT 131 FENOPROFEN CALCIUM 21 ANTIMICROBIALNON-WOVEN EZ-LETS LANCETS 30G 131 fenoprofen calcium 21 SPONGES 4"X4" 6 PLY 126 FENORTHO 21 EXCILON DRAIN SPONGE EZALLOR SPRINKLE 54 4"X4" 126 ezetimibe 55 FENSOLVI 111 EXCILON DRAIN SPONGES ezetimibe-simvastatin 53 fentanyl 24 4"X4" 6 PLY 126 FABIOR 93 fentanyl citrate 24 EXEL COMFORT POINT INSULIN PEN NEEDLES 29G X FALESSA 87 FENTANYL CITRATE 24 12MM 148 famciclovir 80 fentanyl citrate 24 EXEL COMFORT POINT famotidine 208 FENTORA 24 INSULIN PEN NEEDLES 31G X famotidine in nacl 208 FERRIPROX 50 6MM 148 EXEL COMFORT POINT FANAPT 67 FERRIPROX TWICE-A-DAY 50 INSULIN PEN NEEDLES 31G X FANAPT TITRATION ferrous fumarate w/ b12-vit c-fa- 8MM 148 PACK 67 ifc 121 EXEL COMFORT POINT FANATREX FUSEPAQ 39 ferrous fumarate-fa-b complex-c- zn-mg-mn-cu 121 INSULIN SYRINGE/0.3ML/29G X FANTASY LUBRICATED 127 ferrous gluconate 121 1/2" 148 FANTASY EXEL COMFORT POINT LUBRICATED/SPERMICIDE ferrous sulfate 121 INSULIN SYRINGE/0.3ML/30G X 127 FERROUS SULFATE 121 5/16" 148 EXEL COMFORT POINT FARESTON 62 ferrous sulfate 121 INSULIN SYRINGE/0.5ML/28G X FARXIGA 49 FERROUS SULFATE 121 1/2" 148 FARYDAK 63 ferrous sulfate 121 EXEL COMFORT POINT FASENRA 34 INSULIN SYRINGE/0.5ML/29G X FERROUS SULFATE 121 1/2" 148 FASENRA PEN 34 ferrous sulfate 121 EXEL COMFORT POINT FAZACLO 70 FETROJA 86 INSULIN SYRINGE/0.5ML/30G X FBL KIT 95 FETZIMA 44 5/16" 149 EXEL COMFORT POINT FC FEMALE CONDOM 127 FETZIMA TITRATION PACK44 INSULIN SYRINGE/1ML/28G X FC2 FEMALE CONDOM 127 FEVERALL INFANTS 23 1/2" 149 fe bisglycinate chelate-vit c-vit FEVERALL JUNIOR EXEL COMFORT POINT b12-folic acid 121 STRENGTH 23 INSULIN SYRINGE/1ML/29G X fe fum-iron polysacch complex- FIASP 47 fa-b complex-c-zn-mn-cu 121 1/2" 149 FIASP FLEXTOUCH 47 EXEL COMFORT POINT fe fumarate-vitamin c-vitamin INSULIN SYRINGE/1ML/30G X b12-folic acid 121 FIASP PENFILL 47 5/16" 149 febuxostat 117 FIBRICOR 54 EXELDERM 96 FEIBA 118 FIBRYGA 118 EXELON 200 felbamate 41 FIFTY50 ALCOHOL PREP PADS 138

Index 18 FIFTY50 PEN NEEDLES 31G FLOMAX 117 flutamide 62 X3/16" (5MM) 149 FLOVENT DISKUS 35 fluticasone propionate 101,102 FIFTY50 PEN NEEDLES 31G X5/16" (8MM) 149 FLOVENT HFA 35 fluticasone propionate FIFTY50 PEN NEEDLES FLUAD 2020-2021 211 (nasal) 192 31GX5MM 149 FLUAD QUADRIVALENT 2021- fluticasone-salmeterol 36 FIFTY50 PEN 2022 211 fluvastatin sodium 55 NEEDLES/31GX8MM 149 FLUAD QUADRIVALENT fluvoxamine maleate 43 FIFTY50 PEN INFLUENZA VACCINE FOR FLUZONE HIGH-DOSE PF 2020- NEEDLES/32GX4MM 149 ADULTS 212 2021 212 FIFTY50 PEN FLUARIX QUADRIVALENT FLUZONE HIGH-DOSE PF 2021- NEEDLES/32GX6MM 149 2020-2021 212 2022 212 FIFTY50 SUPERIOR FLUBLOK QUADRIVALENT FLUZONE QUADRIVALENT COMFORTINSULIN 2020-2021 212 2020-2021 212 SYRINGE/0.3ML/31G X FLUCELVAX QUADRIVALENT FLYP HYPERSONIQ 5/16" 149 2020-2021 212 CARTRIDGE 177 FIFTY50 SUPERIOR fluconazole 52 COMFORTINSULIN FML 196 SYRINGE/0.5ML/31G X fluconazole in nacl 52 FML FORTE 196 5/16" 149 FLUCONAZOLE/IBUPROFEN/I FML LIQUIFILM 196 TRACONAZOLE/TERBINAFIN FIFTY50 SUPERIOR FOCALIN 13 COMFORTINSULIN E HYDROCHLORIDE 96 SYRINGE/1ML/31G X flucytosine 52 FOCALIN XR 13,14 5/16" 149 fludrocortisone acetate 90 folic acid 120 FILTER AIR PP 177 FLULAVAL QUADRIVALENT folic acid-vitamin b6-vitamin FINACEA 106 2020-2021 212 b12 121 FLUMIST fondaparinux sodium 37 finasteride 117 QUADRIVALENT 212 FORA LANCETS 131 FINTEPLA 39 flunisolide (nasal) 192 FORA LANCING DEVICE 131 FIORICET 23 fluocinolone acetonide 101 FORA LANCING FIORICET/CODEINE 26 fluocinolone acetonide DEVICE/CLEARCAP 131 FIORINAL 23 (otic) 198 FORFIVO XL 42 FIORINAL/CODEINE #3 26 FLUOCINOLONE ACETONIDE/NIACINAMIDE formaldehyde 76 FIRAZYR 119 101 formoterol fumarate 36 FIRDAPSE 59 fluocinonide 101 FORTAMET 45 FIRST-BACLOFEN 1 190 fluocinonide emulsified FORTAZ 86 FIRST-BACLOFEN 5 191 base 101 FORTEO 110 FLUOPAR 101 FIRST-LANSOPRAZOLE 208 FORTESTA 28 fluorometholone (ophth) 196 FIRST-METRONIDAZOLE FOSAMAX 110 50 30 FLUOROPLEX 98 FOSAMAX PLUS D 110 FIRST-OMEPRAZOLE 208 fluorouracil (topical) 98 fosamprenavir calcium 77 FIRST-PROGESTERONE VGS FLUOVIX 101 100 COMPOUNDING KIT 213 fosaprepitant dimeglumine 51 FLUOVIX PLUS 101 FIRST-PROGESTERONE VGS foscarnet sodium 79 fluoxetine hcl 42 200 COMPOUNDING KIT 213 FOSCAVIR 79 FIRVANQ 30 fluoxetine hcl (pmdd) 203 fosfomycin tromethamine 31 FLAGYL 30 FLUOXETINE fosinopril sodium 55 FLAREX 196 HYDROCHLORIDE 43 fluphenazine decanoate 73 fosinopril sodium & flavoxate hcl 211 hydrochlorothiazide 58 fluphenazine hcl 73 flecainide acetate 33 fosphenytoin sodium 41 flurandrenolide 101 FLECTOR 95 FOSRENOL 116 flurazepam hcl 122 FLEXICHAMBER 177 FOTIVDA 63 flurbiprofen 21 FLEXIN 105 FRAGMIN 37 flurbiprofen sodium 197 FLOLIPID 54

Index 19 FREDS PHARMACY AUTOLET GAUZE DRESSING GENTLE-LET LANCETS LANCING DEVICE 131 4"X4" 126 SAFETY STYLE/FINE FREDS PHARMACY UNIFINE GAUZE PADS 4"X4" 126 POINT 132 PENTIPS PEN NEEDLES GAUZE SPONGES 4"X4" 12 GENTLE-LET LANCETS 32GX4MM 149 PLY 126 SAFETY STYLE/MEDIUM FREDS PHARMACY UNIFINE GAVRETO 63 POINT 132 PENTIPS PLUS 31GX5MM 149 GENVOYA 77 GEBAUERS PAIN EASE 105 FREDS PHARMACY UNIFINE GEODON 66 PENTIPS PLUS 31GX8MM 149 GEBAUERS SPRAY AND FREDS PHARMACY UNILET STRETCH 105 GIALAX 124 LANCETS SUPER THIN GELNIQUE 210 GILENYA 202 30G 131 GELNIQUE PUMP 210 GILOTRIF 61 FREDS PHARMACY UNILET LANCETS ULTRA THIN gemfibrozil 54 GIMOTI 115 28G 131 GEMTESA 211 GIVLAARI 118 FREESTYLE PRECISION GEN7T 105 GLASSIA 204 INSULIN SYRINGE/U- GEN7T PLUS 105 glatiramer acetate 202 100/0.5ML/30G X 5/16" 149 FREESTYLE PRECISION GENERESS FE 87 GLEEVEC 63 INSULIN SYRINGE/U- GENOTROPIN 110 GLEOSTINE 60 100/0.5ML/31G X 5/16" 149 GENOTROPIN glimepiride 49 FREESTYLE PRECISION MINIQUICK 110 glipizide 49 INSULIN SYRINGE/U- gentamicin in saline 19 glipizide-metformin hcl 45 100/1ML/31G X 5/16" 149 gentamicin sulfate 19 FREESTYLE PRECISION GLOBAL EASE INJECT PEN INSULIN SYRINGES/U- gentamicin sulfate NEEDLES 29GX12MM 149 100/1ML/30G X 5/16" 149 (ophth) 195 GLOBAL EASE INJECT PEN FROTEK 95 gentamicin sulfate (topical) 96 NEEDLES 31GX8MM 149 GENTEEL LANCING GLOBAL EASE INJECT PEN FROVA 180 DEVICE/GLORIOUS NEEDLES 32GX4MM 149 frovatriptan succinate 180 GOLD 131 GLOBAL EASE INJECT PEN FULL KIT NEBULIZER GENTEEL LANCING NEEEDLES 31GX5MM 149 SET 177 DEVICE/PRECIOUS GLOBAL EASY GLIDE FULPHILA 120 PLATINUM 131 INSULINSYRINGE/U- FUNGIMEZ 96 GENTEEL LANCING 100/0.3ML/31G X 5/16" 149 DEVICE/STATELY GLOBAL EASY GLIDE PEN furosemide 109 SILVER 131 NEEDLES 32GX4MM 149 FUZEON 77 GENTEEL PLUS LANCING GLOBAL INJECT EASE INSULIN FYCOMPA 38 DEVICE/BUFF BLACK 131 SYRINGE/U-100/0.3ML/29G X GENTEEL PLUS LANCING 1/2" 149 GABACAINE 203 DEVICE/BUTTERFLY GLOBAL INJECT EASE INSULIN GABAPAL 203 BLUE 131 SYRINGE/U-100/0.3ML/30G X gabapentin 39 GENTEEL PLUS LANCING 1/2" 150 GABAPENTIN/NAPROXEN SOD DEVICE/PLAYFUL GLOBAL INJECT EASE INSULIN MULTI-PHASIC TRANSDERMAL PURPLE 131 SYRINGE/U-100/0.3ML/30G X CMPD KIT 95 GENTEEL PLUS LANCING 5/16" 150 GABITRIL 41 DEVICE/PRINCESS GLOBAL INJECT EASE INSULIN PINK 131 SYRINGE/U-100/0.3ML/31G X GALAFOLD 111 GENTEEL PLUS LANCING 5/16" 150 galantamine hydrobromide 201 DEVICE/WILLOWY GLOBAL INJECT EASE INSULIN GAMIFANT 183 WHITE 131 SYRINGE/U-100/0.5ML/28G X GANCICLOVIR 79 GENTLE-LET GP 1/2" 150 LANCETS 131 GLOBAL INJECT EASE INSULIN ganciclovir sodium 79 GENTLE-LET LANCETS SYRINGE/U-100/0.5ML/29G X GARDASIL 9 212 GENERAL PURPOSE 1/2" 150 GASTROCROM 115 STYLE/FINE POINT 131 GLOBAL INJECT EASE INSULIN GENTLE-LET LANCETS SYRINGE/U-100/0.5ML/30G X gatifloxacin (ophth) 195 GENERAL PURPOSE 1/2" 150 GATTEX 116 STYLE/MEDIUM POINT 132

Index 20 GLOBAL INJECT EASE INSULIN GLUCOPRO INSULIN GNP INSULIN SYRINGE/U-100/0.5ML/30G X SYRINGE/U-100/1ML/31G X SYRINGE/1ML/29G X 1/2" 151 5/16" 150 5/16" 150 GNP INSULIN GLOBAL INJECT EASE INSULIN GLUCOSE 46 SYRINGE/1ML/30G X SYRINGE/U-100/0.5ML/31G X GLUCOTROL 49 5/16" 151 5/16" 150 GNP INSULIN GLOBAL INJECT EASE INSULIN GLUCOTROL XL 49 SYRINGE/1ML/31G X SYRINGE/U-100/1ML/28G X GLUMETZA 45 5/16" 151 1/2" 150 glyburide 49 GNP LANCETS 21G 132 GLOBAL INJECT EASE INSULIN glyburide micronized 49 GNP LANCETS MICRO THIN SYRINGE/U-100/1ML/29G X 33G 132 1/2" 150 glyburide-metformin 45 GNP LANCETS SUPER THIN GLOBAL INJECT EASE INSULIN GLYCATE 207 30G 132 SYRINGE/U-100/1ML/30G X glycerin (laxative) 124 GNP LANCETS THIN 132 1/2" 150 GLOBAL INJECT EASE INSULIN GLYCERIN ADULT 124 GNP LANCETS THIN 26G 132 SYRINGE/U-100/1ML/30G X glycopyrrolate 207 GNP PRENATAL 188 5/16" 150 GLYCOPYRROLATE 207 GNP QUICK DISSOLVE GLOBAL INJECT EASE INSULIN glycopyrrolate 207 GLUCOSE 46 SYRINGE/U-100/1ML/31G X GNP ULTICARE PEN 5/16" 150 GLYCOPYRROLATE 207 NEEDLES/31GX5/16" 151 GLOBAL INSULIN SYRINGE/U- GLYNASE 49 GNP ULTICARE PEN 100/0.3ML/30G X 1/2" 150 GLYRX-PF 207 NEEDLES/32GX 5/32" 151 GLOBAL INSULIN SYRINGES/U- GNP ULTICARE PEN 100/0.3ML/30GX5/16" 150 GLYSET 44 NEEDLES/32GX1/4" 151 GLOBAL LANCING GLYXAMBI 45 GNP ULTICARE PEN DEVICE 132 GNP ALCOHOL SWABS 138 NEEDLES31G X 5MM 151 GLOPERBA 117 GNP CLICKFINE UNIVERSAL GNP ULTRA COMFORT GLUCAGEN HYPOKIT 46 PEN NEEDLES INSULIN SYRINGE/0.3ML/29G X 1/2" 151 glucagon (rdna) 46 31GX1/4" 150 GNP CLICKFINE UNIVERSAL GNP ULTRA COMFORT GLUCAGON EMERGENCY PEN NEEDLES INSULIN SYRINGE/0.3ML/30G X KIT 46 5/16" SHORT 151 GLUCAGON EMERGENCY KIT 31GX5/16" 151 GNP GLUCOSE 46 GNP ULTRA COMFORT FOR LOW BLOOD SUGAR 46 INSULIN SYRINGE/0.5ML/28G X GLUCOPRO INSULIN GNP INSULIN 1/2" 151 SYRINGE/U-100/0.3ML/30G X SYRINGE/0.3ML/29G X GNP ULTRA COMFORT 1/2" 150 1/2" 151 INSULIN SYRINGE/0.5ML/29G X GLUCOPRO INSULIN GNP INSULIN 1/2" 151 SYRINGE/U-100/0.3ML/30G X SYRINGE/0.3ML/30G X GNP ULTRA COMFORT 5/16" 150 5/16" 151 INSULIN SYRINGE/1ML/28G X GLUCOPRO INSULIN GNP INSULIN 1/2" 151 SYRINGE/U-100/0.3ML/31G X SYRINGE/0.3ML/31G X GNP ULTRA COMFORT 5/16" 150 5/16" 151 INSULIN SYRINGE/1ML/29G X GLUCOPRO INSULIN GNP INSULIN 1/2" 151 SYRINGE/0.5ML/28G X SYRINGE/U-100/0.5ML/30G X GOCOVRI 65 1/2" 150 1/2" 151 GNP INSULIN GOJJI LANCING GLUCOPRO INSULIN DEVICE/CLEAR CAP 132 SYRINGE/U-100/0.5ML/30G X SYRINGE/0.5ML/29G X 1/2" 151 GOJJI STERILE LANCETS 5/16" 150 30G 132 GLUCOPRO INSULIN GNP INSULIN SYRINGE/U-100/0.5ML/31G X SYRINGE/0.5ML/30G X GOLYTELY 123 5/16" 150 5/16" 151 GONITRO 31 GLUCOPRO INSULIN GNP INSULIN GOODSENSE CLICKFINE SYRINGE/U-100/1ML/30G X SYRINGE/0.5ML/31G X SAFETY PEN NEEDLE/31G X 1/2" 150 5/16" 151 3/16" 151 GLUCOPRO INSULIN GNP INSULIN GOODSENSE LANCETS SYRINGE/U-100/1ML/30G X SYRINGE/1ML/28G X MICRO-THIN 33G 5/16" 150 1/2" 151 UNIVERSAL 132

Index 21 GOODSENSE LANCETS H-E-B IN CONTROL HEALTHWISE INSULIN ULTRA-THIN 26G UNIFINEPENTIPS PLUS SYRINGE/U-100/1ML/30G X UNIVERSAL 132 31GX5MM 152 5/16" 152 GOODSENSE LANCING H-E-B IN CONTROL HEALTHWISE INSULIN DEVICE 132 UNIFINEPENTIPS PLUS SYRINGE/U-100/1ML/31G X GOODSENSE PEN 32GX4MM 152 5/16" 152 NEEDLE/PENFINE H-E-B IN CONTROL HEALTHWISE MICRON PEN CLASSIC/31G X 3/16" 151 UNIFINEPENTIPS PLUS NEEDLES/32G X 5/32" 152 GOODSENSE PEN 32GX5/32" 152 HEALTHWISE MINI PEN NEEDLE/PENFINE H-E-B IN CONTROL NEEDLES 31GX6MM 152 CLASSIC/31G X 5/16" 151 UNIFINEPENTIPS PLUS HEALTHWISE PEN NEEDLES GOODSENSE PEN 33GX5/32" 152 29GX12MM 152 NEEDLE/PENFINE H-E-B INCONTROL HEALTHWISE SHORT PEN CLASSIC/32G X 1/4" 151 ADVANCEDLANCING NEEDLES 31GX8MM 152 GOODSENSE PEN DEVICE 132 HEALTHWISE SHORT PEN NEEDLE/PENFINE H-E-B INCONTROL LANCETS NEEDLES/31G X 3/16" 152 CLASSIC/32G X 5/32" 151 MICRO THIN 33G 132 HEALTHWISE SHORT PEN GOODSENSE PRENATAL H-E-B INCONTROL LANCETS NEEDLES/31G X 5/16" 152 VITAMINS 188 SUPER THIN 30G 132 HEALTHWISE UNIFINE GPL PAK 203 H-E-B INCONTROL LANCETS PENTIPS PEN NEEDLES GRALISE 203 ULTRA THIN 28G 132 32GX4MM 152 H-E-B INCONTROL PEN HEALTHY ACCENTS AUTOLET granisetron hcl 50 NEEDLES 29GX12MM 152 IMPRESSION LANCING GRANIX 120 HAEGARDA 119 DEVICE 132 GRASTEK 18 halcinonide 102 HEALTHY ACCENTS UNIFINE PENTIPS PEN NEEDLES griseofulvin microsize 52 HALCION 122 29GX12MM 152 griseofulvin ultramicrosize 52 HALDOL 69 HEALTHY ACCENTS UNIFINE guaifenesin 91 HALDOL DECANOATE PENTIPS PEN NEEDLES GUANENDRUX 104 100 69 31GX5MM 152 HALDOL DECANOATE 50 69 HEALTHY ACCENTS UNIFINE guanfacine hcl 57 PENTIPS PEN NEEDLES guanfacine hcl (adhd) 8 halobetasol propionate 102 31GX6MM 152 HALOBETASOL GUANIDINE HCL 60 HEALTHY ACCENTS UNIFINE PROPIONATE 102 PENTIPS PEN NEEDLES GVOKE HYPOPEN 1-PACK 46 HALOG 102 31GX8MM 152 GVOKE HYPOPEN 2-PACK 46 haloperidol 69,70 HEALTHY ACCENTS UNIFINE GVOKE PFS 46 haloperidol decanoate 69 PENTIPS PEN NEEDLES 32GX4MM 153 GYNAZOLE-1 213 haloperidol lactate 69 H-E-B IN CONTROL PEN HEALTHY ACCENTS UNILET HARVONI 80 LANCETS SUPER THIN NEEDLE 31GX3/16" 151 H-E-B IN CONTROL PEN HAVRIX 212 30G 132 NEEDLES 31GX5MM 151 HAXCHLO 99 HELIDAC THERAPY 210 H-E-B IN CONTROL PEN HEALTH CARE LANCING HELIXATE FS 118 NEEDLES 31GX6MM 152 DEVICE 132 HEMADY 89 H-E-B IN CONTROL PEN HEALTHWISE INSULIN HEMANGEOL 82 NEEDLES 31GX8MM 152 SYRINGE/U-100/0.3ML/30G X H-E-B IN CONTROL PEN 5/16" 152 HEMLIBRA 118 NEEDLES/NANO/32GX4MM HEALTHWISE INSULIN HEMOFIL M 118 152 SYRINGE/U-100/0.3ML/31G X heparin (porcine) in sodium H-E-B IN CONTROL 5/16" 152 chloride 37 UNIFINEPENTIPS PLUS HEALTHWISE INSULIN heparin sod (porcine) in d5w 37 31GX1/4" 152 SYRINGE/U-100/0.5ML/30G X HEPARIN SODIUM 38 H-E-B IN CONTROL 5/16" 152 UNIFINEPENTIPS PLUS HEALTHWISE INSULIN heparin sodium (porcine) 37 31GX3/16" 152 SYRINGE/U-100/0.5ML/31G X heparin sodium (porcine) lock H-E-B IN CONTROL 5/16" 152 flush 37 UNIFINEPENTIPS PLUS heparin sodium (porcine) lock 31GX5/16" 152 flush & nacl lock flush 37

Index 22 HEPARIN HUMIRA PEN-PS/UV hydroxocobalamin acetate 120 SODIUM/DEXTROSE 38 STARTER 19 hydroxychloroquine sulfate 59 HEPARIN SODIUM/NACL HUMULIN 70/30 47 hydroxyprogesterone 0.45% 38 HUMULIN 70/30 HEPARIN SODIUM/SODIUM caproate 200 KWIKPEN 47 hydroxyprogesterone caproate CHLORIDE 38 HUMULIN N 47 HEPARIN/SODIUM (antineoplastic) 62 CHLORIDE 38 HUMULIN N KWIKPEN 47 hydroxyurea 64 HEPSERA 80 HUMULIN R 47 hydroxyzine hcl 32 HETLIOZ 123 HUMULIN R U-500 hydroxyzine pamoate 32 (CONCENTRATED) 47 hyoscyamine sulfate 207 HETLIOZ LQ 123 HUMULIN R U-500 HIBERIX 211 KWIKPEN 47 HYPER-SAL 91 HIPREX 31 HY-VEE LANCETS 132 HYPERRHO S/D 198 HM PRENATAL 188 HY-VEE THIN LANCETS 132 HYPERSAL 91 HM STERILE ALCOHOL PREP HYALUCIL-4 98 HYPODERMIC NEEDLE 18G X PADS 138 HYALURONIC ACID 1-1/2" 153 HM STERILE PADS 126 SODIUM/NIACINAMIDE/TACR HYPODERMIC NEEDLES HM ULTICARE INSULIN OLIMUS 104 18GX1-1/2" 153 SYRINGE/1ML/30G X 1/2" 153 HYALURONIC ACID HYSINGLA ER 25 HM ULTICARE INSULIN SODIUM/NIACINAMIDE/TRETI HYZAAR 58 SYRINGE/U-100/0.3ML/31G X NOIN 93 ibandronate sodium 110 5/16" 153 HYCAMTIN 65 IBRANCE 63 HM ULTICARE MINI PEN hydralazine hcl 59 NEEDLES/31G X 5MM IBU 600-EZS 21 (3/16") 153 HYDREA 64 IBUPAK 21 HYDROCELL ADHESIVE HM ULTICARE SHORT PEN ibuprofen 21 NEEDLES 31GX8MM 153 DRESSING 4"X4" 126 HORIZANT 203 HYDROCELL DRESSING ibuprofen-famotidine 21 HUDSON RCI SEE-THRU 4"X4" 126 ibutilide fumarate 33 AEROSOL MASK hydrochlorothiazide 109 icatibant acetate 119 ELONGATED/ADULT 177 hydrocodone bitartrate 24 ICLUSIG 63 HUMALOG 47 hydrocodone- icosapent ethyl 53 HUMALOG JUNIOR acetaminophen 26 KWIKPEN 47 hydrocodone-ibuprofen 26 IDELVION 118 HUMALOG KWIKPEN 47 hydrocortisone 89 IDHIFA 63 HUMALOG MIX 50/50 47 hydrocortisone (intrarectal) 29 ILARIS 20 HUMALOG MIX 50/50 hydrocortisone (rectal) 29 ILEVRO 197 KWIKPEN 47 hydrocortisone (topical) 102 ILUMYA 98 HUMALOG MIX 75/25 47 hydrocortisone acetate imatinib mesylate 63 HUMALOG MIX 75/25 (topical) 102 IMBRUVICA 63 KWIKPEN 47 hydrocortisone butyrate 102 HUMATE-P 118 IMIOXIA 97 hydrocortisone butyrate imipramine hcl 44 HUMATIN 19 hydrophilic lipo base 102 imipramine pamoate 44 HUMATROPE 110 hydrocortisone valerate 102 HUMATROPE COMBO hydrocortisone w/acetic imiquimod 104 PACK 110 acid 198 IMIQUIMOD/LEVOCETIRIZINEDI HUMIRA 19 HYDROCORTISONE/IODOQUI HYDROCHLORIDE/NIACINAMID HUMIRA PEDIATRIC CROHNS NOL/KETOCONAZOLE 96 E 98 DISEASE STARTER PACK 19 HYDROCORTISONE/KETOCO IMIQUIMOD/LEVOCETIRIZINEDI HYDROCHLORIDE/TRETINOIN HUMIRA PEN 19 NAZOLE 96 hydromorphone hcl 24 98 HUMIRA PEN-CD/UC/HS IMITREX 181 STARTER 19 HYDROMORPHONE HCL 24 IMITREX STATDOSE HUMIRA PEN-PEDIATRIC UC hydromorphone hcl 25 STARTER PACK 19 REFILL 181

Index 23 IMITREX STATDOSE INSPRA 59 INSULIN SYRINGE/NEEDLE SYSTEM 181 INSULIN ASPART 47 1ML/31G X 5/16" 153 INSULIN SYRINGE/U- IMPAVIDO 30 INSULIN ASPART IMPEKLO 102 100/0.3ML/29G X 1/2" 153 FLEXPEN 47 INSULIN SYRINGE/U- IMPOYZ 102 INSULIN ASPART 100/0.5ML/29G X 1/2" 153 IMURAN 183 PENFILL 47 INSULIN SYRINGE/U- INSULIN ASPART 100/1ML/29G X 1/2" 153 IN TOUCH LANCING PROTAMINE/INSULIN DEVICE 132 INSULIN SYRINGE/U- ASPART 47 100/1ML/30G X 5/16" 153 IN-CHECK DIAL INSULIN ASPART INSPIRATORYFLOW INSULIN SYRINGE/U- PROTAMINE/INSULIN 100/1ML/31G X 5/16" 154 TRAINER 177 ASPART FLEXPEN 47 IN-CHECK INSPIRATORY INSULIN FLOWMETER/NASAL WITH INSULIN LISPRO 48 SYRINGES/0.5ML/27GX1/2" MASK 177 INSULIN LISPRO JUNIOR 154 IN-CHECK INSPIRATORY KWIKPEN 48 INSULIN FLOWMETER/ORAL 177 INSULIN LISPRO SYRINGES/0.5ML/28GX1/2" INBRIJA 65 KWIKPEN 48 154 INSULIN LISPRO INSULIN INCRELEX 111 PROTAMINE/INSULIN LISPRO SYRINGES/0.5ML/29GX1/2" INCRUSE ELLIPTA 34 KWIKPEN 48 154 indapamide 109 INSULIN SYRINGE/0.3ML/29G INSULIN X 1" 153 INDERAL LA 82 SYRINGES/0.5ML/30GX5/16" INSULIN SYRINGE/0.3ML/29G 154 INDERAL XL 82 X 1/2" 153 INSULIN INDOCIN 21 INSULIN SYRINGE/0.3ML/30G SYRINGES/0.5ML/31GX indomethacin 21 X 5/16" 153 5/16" 154 INSULIN SYRINGE/0.3ML/31G INSULIN INFANRIX 207 X 5/16" 153 SYRINGES/0.5ML/31GX5/16" INFED 121 INSULIN SYRINGE/0.5ML/27G 154 INFLATHERM 21 X 1/2" 153 INSULIN INSULIN SYRINGE/0.5ML/28G INFLECTRA 115 SYRINGES/1ML/27GX/1/2" X 1/2" 153 154 INFUVITE PEDIATRIC 188 INSULIN SYRINGE/0.5ML/30G INSULIN INGREZZA 202 X 1/2" 153 SYRINGES/1ML/27GX1/2" 154 INJECTAFER 121 INSULIN SYRINGE/0.5ML/30G INSULIN X 5/16" 153 SYRINGES/1ML/28GX1/2" 154 INLYTA 61 INSULIN SYRINGE/0.5ML/31G INSULIN INNOPRAN XL 82 X 5/16" 153 SYRINGES/1ML/29GX1/2" 154 INNOSPIRE REPLACEMENT INSULIN SYRINGE/1ML/28G X INSULIN FILTER 177 1/2" 153 SYRINGES/1ML/30GX1/2" 154 INQOVI 62 INSULIN SYRINGE/1ML/29G X INSULIN 1/2" 153 SYRINGES/1ML/31GX5/16" INREBIC 63 INSULIN SYRINGE/1ML/30G X INSPIRACHAMBER/ANTI- 154 5/16" 153 INSUPEN 29G X 12MM 154 STATIC INSULIN SYRINGE/NEEDLE VALVED/MOUTHPIECE 177 0.3ML/30G X 5/16" 153 INSUPEN 31G X 5MM 154 INSPIRACHAMBER/LARGE INSULIN SYRINGE/NEEDLE INSUPEN 31G X 8MM 154 177 0.3ML/31G X 5/16" 153 INSUPEN 32G X 4MM 154 INSPIRACHAMBER/SOOTHER INSULIN SYRINGE/NEEDLE MASK/INSPIRAMASK/MEDIUM 0.5ML/29G X 1/2" 153 INSUPEN 33GX4MM 154 177 INSULIN SYRINGE/NEEDLE INSUPEN PEN NEEDLES 32G INSPIRACHAMBER/SOOTHER 0.5ML/30G X 5/16" 153 X4MM 154 MASK/INSPIRAMASK/SMALL INSULIN SYRINGE/NEEDLE INSUPEN SENSITIVE 177 0.5ML/31G X 5/16" 153 32GX6MM 154 INSPIREASE DRUG INSULIN SYRINGE/NEEDLE INSUPEN SENSITIVE DELIVERYSYSTEM 177 1ML/29G X 1/2" 153 32GX8MM 154 INSPIREASE RESERVOIR INSULIN SYRINGE/NEEDLE INSUPEN ULTRAFIN BAGS 177 1ML/30G X 5/16" 153 29GX12MM 154

Index 24 INSUPEN ULTRAFIN ivermectin (rosacea) 106 KAZANO 45 30GX8MM 154 IVERMECTIN/METRONIDAZO KEFLEX 85 INSUPEN ULTRAFIN LE/NIACINAMIDE 106 KENALOG 102 31GX6MM 154 IXINITY 118 INSUPEN ULTRAFIN KENALOG-10 89 31GX8MM 154 J & J GAUZE 4"X4" 12 PLY 126 KENALOG-40 89 INTELENCE 77 J & J GAUZE 4"X4" 8 KENALOG-80 89 INTERMEZZO 122 PLY 126 KENDALL HYDROPHILIC INTRON A 64 J & J GAUZE SPONGES 12- FOAMDRESSING 4"X4" 127 INTUNIV 8,9 PLY 4" X 4" 126 KENGREAL 119 J & J GAUZE SPONGES 16- INVEGA 67 PLY 4" X 4" 126 KEPPRA 39 INVEGA SUSTENNA 67 J & J GAUZE SPONGES 8- KEPPRA XR 39 INVEGA TRINZA 67 PLY4" X 4" 126 KERENDIA 112 INVELTYS 196 JADENU 50 KERLIX SPONGES 4" X 4" 12 PLY 127 INVIRASE 77 JADENU SPRINKLE 50 JAKAFI 63 KERLIX SPONGES 4" X 4" 16 INVOKAMET 45 PLY 127 INVOKAMET XR 45 JALYN 117 KERYDIN 97 INVOKANA 49 JANUMET 45 KESIMPTA 202 IOPIDINE 194 JANUMET XR 45 ketoconazole 52 ipratropium bromide 34 JANUVIA 46 ketoconazole (topical) 97 ipratropium bromide (nasal)192 JARDIANCE 49 KETODAN KIT 97 ipratropium-albuterol 36 JATENZO 28 KETONE 107 irbesartan 56 JENTADUETO 45 KETONE TEST STRIPS 107 irbesartan-hydrochlorothiazide JENTADUETO XR 45 KETOPHENE RAPIDPAQ 95 58 JIVI 118 ketoprofen 21 IRESSA 61 JORNAY PM 14 KETOROCAINE-L 21 iron combinations 121 JUBLIA 97 KETOROCAINE-LM 21 iron polysaccharide complex-vit JULUCA 78 b12-folic acid 121 KETOROLAC 2% GEL 95 irrigation solutions, JUXTAPID 55 ketorolac tromethamine 21 physiological 184 JYNARQUE 113 KETOROLAC ISENTRESS 77,78 K-PHOS 182 TROMETHAMINE 21 ISENTRESS HD 77 K-PHOS NEUTRAL 182 ketorolac tromethamine 21 isoniazid 60 K-PHOS NO 2 116 KETOROLAC TROMETHAMINE 21 isopropyl alcohol-glycerin 198 K-TAB 182 ketorolac tromethamine 21 ISOPTO ATROPINE 194 K-Y ME & YOU EXTRA LUBRICATED 127 ketorolac tromethamine ISOPTO CARPINE 194 (ophth) 197 K-Y ME & YOU INTENSE127 ISORDIL TITRADOSE 31 KETOSTIX 107 K.B.G.L. IN TERODERM isosorbide dinitrate 31 CREAM 95 ketotifen fumarate (ophth) 197 isosorbide mononitrate 32 KADIAN 25 KEVEYIS 108 isotretinoin 93 KALBITOR 119 KEVZARA 20 isradipine 83 KALETRA 78 KIMONO COLORS 127 ISTALOL 193 KALYDECO 204 KIMONO LUBRICATED 127 ISTURISA 109 KAMELEON KIMONO MICRO THIN 127 ITHOXIA 93 LUBRICATED 127 KIMONO MICRO THIN PLUS itraconazole 52 KAPSPARGO SPRINKLE 81 SPERMICIDE KAPVAY 9 LUBRICATED 127 ivermectin 29 KIMONO PLUS SPERMICIDE IVERMECTIN 106 KARBINAL ER 53 LUBRICATED 127 ivermectin (pediculicide) 107 KATERZIA 83

Index 25 KIMONO PLUS KOVALTRY 118 KROGER PEN NEEDLES/31G SPERMICIDE/LUBRICATED KP PRENATAL X3/16" 155 127 MULTIVITAMINS 189 KROGER PEN NEEDLES/31G KIMONO PS LUBRICATED127 KRINTAFEL 59 X5/16" 155 KROGER PEN NEEDLES/32G KIMONO PS PLUS KRISTALOSE 124 SPERMICIDE/LUBRICATED X5/32" 155 128 KROGER AUTOLET LANCING KROGER PEN NEEDLES/33G DEVICE 132 X5/32" 155 KIMONO SENSATION KROGER HEALTHPRO TWIST LUBRICATED 128 KRYSTEXXA 118 KIMONO SENSATION PLUS LANCETS/26G 132 KROGER INSULIN KUVAN 111 SPERMICIDE SYRINGE/0.3ML/29G X KYLEENA 88 LUBRICATED 128 1/2" 154 KYMRIAH 61 KIMONO SPECIAL 128 KROGER INSULIN KYNMOBI 65 KINERET 20 SYRINGE/0.3ML/30G X KYNMOBI TITRATION KIT 65 KINNEY LANCETS 132 5/16" 154 L.E.T. 105 KINNEY THIN LANCETS 132 KROGER INSULIN SYRINGE/0.3ML/31G X labetalol hcl 81 KINRAY INSULIN SYRINGE 5/16" 154 PREFERRED PLUS/0.3ML/31G LABETALOL KROGER INSULIN HYDROCHLORIDE 81 X 5/16" 154 SYRINGE/0.5ML/29G X KINRAY INSULIN SYRINGE LABETALOL 1/2" 155 HYDROCHLORIDE/SODIUM PREFERRED PLUS/0.5ML/31G KROGER INSULIN X 5/16" 154 CHLORIDE 81 SYRINGE/0.5ML/30G X LACRISERT 193 KINRAY INSULIN SYRINGE 5/16" 155 PREFERRED PLUS/1ML/31G X KROGER INSULIN LACTIC ACID 104 5/16" 154 SYRINGE/0.5ML/31G X lactic acid (ammonium KINRAY INSULIN 5/16" 155 lactate) 104 SYRINGE/0.5ML/29G X KROGER INSULIN LACTULOSE 124 1/2" 154 SYRINGE/1ML/29G X lactulose 124 KISQALI 63 1/2" 155 KISQALI FEMARA 200 KROGER INSULIN lactulose (encephalopathy) 116 DOSE 62 SYRINGE/1ML/30G X LAMICTAL 39 KISQALI FEMARA 400 5/16" 155 LAMICTAL CHEWABLE DOSE 63 KROGER INSULIN DISPERSIBLE 39 KISQALI FEMARA 600 SYRINGE/1ML/31G X LAMICTAL ODT 39 DOSE 63 5/16" 155 LAMICTAL STARTER/NOT KITABIS PAK 19 KROGER LANCETS 132 TAKING CARBAMAZEPINE 39 KLARITY-A 195 KROGER LANCETS 21G 132 LAMICTAL STARTER/TAKING KLARITY-B 196 KROGER LANCETS MICRO CARBAMAZEPINE/NOT TAKING VALPROATE 39 KLARITY-L 196 THIN33G 132 KROGER LANCETS SUPER LAMICTAL STARTER/TAKING KLARON 93 THIN 132 VALPROATE 39 KLISYRI 98 KROGER LANCETS LAMICTAL XR 39 KLONOPIN 38 THIN 133 lamivudine 78 KLOXXADO 50 KROGER LANCETS THIN lamivudine (hbv) 80 26G 133 KMART VALU PLUS INSULIN KROGER LANCETS lamivudine-zidovudine 78 SYRINGE/1ML/29G 154 ULTRATHIN30G 133 lamotrigine 39 KMART VALU PLUS INSULIN KROGER LANCING LAMPIT 30 SYRINGE/1ML/30G 154 DEVICE 133 KOATE 118 LANCET DEVICE KROGER PEN NEEDLES 29G ADJUSTABLE 133 KOATE-DVI 118 X12MM 155 LANCET DEVICE WITH KOGENATE FS 118 KROGER PEN NEEDLES 31G EJECTOR 133 X8MM 155 KOMBIGLYZE XR 45 KROGER PEN NEEDLES LANCETS 133 KORLYM 46 31GX1/4" 155 LANCETS 26G TWIST KOSELUGO 63 KROGER PEN NEEDLES/31G TOP 133 X1/4" 155 LANCETS 28G 133

Index 26 LANCETS 30G 133 LEADER INSULIN LEVBID 207 LANCETS SAFETY SEAL SYRINGE/1ML/30G X LEVEMIR 48 5/16" 155 21G 133 LEVEMIR FLEXTOUCH 48 LANCETS SAFETY SEAL LEADER INSULIN 26G 133 SYRINGE/1ML/31G X LEVETIRACETAM 40 LANCETS SAFETY SEAL 5/16" 155 levetiracetam 40 28G 133 LEADER QUICK DISSOLVE levetiracetam in sodium LANCETS THIN 133 GLUCOSE 46 chloride 39 LEADER UNIFINE PENTIPS LANCETS ULTRA THIN 133 PLUS/MINI/31GX3/16" 155 levobunolol hcl 193 LANCING DEVICE 133 LEADER UNIFINE PENTIPS levocarnitine (metabolic LANCING DEVICE PLUS/SHORT/31GX5/16" modifiers) 111 ADJUSTABLE 133 155 levocetirizine dihydrochloride53 lanolin 200 LEADER UNIFINE levofloxacin 114 LANOXIN 84 PENTIPS/MINI/31GX3/16" levofloxacin (ophth) 195 155 LANOXIN PEDIATRIC 84 levonorgestrel & eth LEADER UNIFINE estradiol 87 lansoprazole 209 PENTIPS/NANO/32GX5/32" levonorgestrel (emergency lanthanum carbonate 116 155 oc) 88 LEADER UNIFINE levonorgestrel-eth estradiol LANTUS 48 PENTIPS/PLUS/32GX5/32" LANTUS SOLOSTAR 48 (triphasic) 87 155 levonorgestrel-ethinyl estradiol LANZO 133 LEDIPASVIR/SOFOSBUVIR (91-day) 87 lapatinib ditosylate 63 80 levonorgestrel-ethinyl estradiol leflunomide 22 LASIX 109 (continuous) 87 LEMTRADA 202 LASTACAFT 197 LEVOPHED 214 LENVIMA 10 MG DAILY levorphanol tartrate 25 latanoprost 198 DOSE 61 LATUDA 67 LENVIMA 12MG DAILY levothyroxine sodium 206 LEVOTHYROXINE LAZANDA 25 DOSE 61 LENVIMA 14 MG DAILY SODIUM 206 LDO PLUS 105 DOSE 61 levothyroxine sodium 206 LEADER ADVANCED LANCING LENVIMA 18 MG DAILY LEVSIN 207 DEVICE 133 DOSE 61 LEVSIN/SL 207 LEADER INSULIN LENVIMA 20 MG DAILY SYRINGE/0.3ML/29G X DOSE 61 LEVULAN KERASTICK 98 1/2" 155 LENVIMA 24 MG DAILY LEXAPRO 43 LEADER INSULIN DOSE 61 LEXETTE 102 SYRINGE/0.3ML/30G X LENVIMA 4 MG DAILY 5/16" 155 DOSE 61 LEXIVA 78 LEADER INSULIN LENVIMA 8 MG DAILY LIALDA 115 SYRINGE/0.3ML/31G X DOSE 61 LIBERTY MINI LANCING 5/16" 155 LESCOL XL 55 DEVICE 133 LEADER INSULIN LIBRAX 207 SYRINGE/0.5ML/28G X LETAIRIS 84 1/2" 155 letrozole 62 LICART 95 LEADER INSULIN leucovorin calcium 64 LIDO GB-300 203 SYRINGE/0.5ML/29G X LEUKERAN 60 lidocaine 105 1/2" 155 LEUKINE 120 LIDOCAINE AND LEADER INSULIN TETRACAINECREAM 105 SYRINGE/0.5ML/30G X leuprolide acetate 62 LIDOCAINE HCL 33 5/16" 155 LEUPROLIDE LEADER INSULIN ACETATE/BUPIVACAINE lidocaine hcl 105 SYRINGE/0.5ML/31G X HYDROCHLORIDE 62 lidocaine hcl (cardiac) 33 5/16" 155 levalbuterol hcl 36 lidocaine hcl (mouth-throat) 184 LEADER INSULIN LIDOCAINE HCL- SYRINGE/1ML/28G X 1/2" 155 levalbuterol tartrate 36 LEVATIO PATCH 105 HYDROCORTISONE ACETATE LEADER INSULIN WITH ALOE 29 SYRINGE/1ML/29G X 1/2" 155

Index 27 LIDOCAINE LIFESTYLES XTRA LITETOUCH INSULIN HYDROCHLORIDE 33,105 PLEASURE 128 SYRINGE/U-100/0.5ML/31G X LIDOCAINE LILETTA 88 5/16" 156 HYDROCHLORIDE/DEXTROSE lindane 107 LITETOUCH INSULIN 33 SYRINGE/U-100/1ML/28G X LIDOCAINE linezolid 31 1/2" 156 HYDROCHLORIDE/EPINEPHRI LINZESS 116 LITETOUCH INSULIN NE/TETRACAINE liothyronine sodium 206 SYRINGE/U-100/1ML/29G X HYDROCHLORIDE 105 LIPITOR 55 1/2" 156 lidocaine in d5w 33 LITETOUCH INSULIN lidocaine-hydrocortisone LIPO-B 121 SYRINGE/U-100/1ML/30G X acetate 102 LIPOFEN 54 5/16" 156 lidocaine-hydrocortisone acetate LIPRITIN 203 LITETOUCH INSULIN SYRINGE/U-100/1ML/31G X (rectal) 29 LIPRITIN II 203 lidocaine-menthol 105 5/16" 156 lisinopril 55 LITETOUCH MASK lidocaine-prilocaine 105 lisinopril & LARGE 177 lidocaine-transparent hydrochlorothiazide 58 LITETOUCH MASK dressing 105 LITE TOUCH LANCING MEDIUM 177 LIDOCAINE/TETRACAINE 105 PEN 133 LITETOUCH MASK SMALL177 LIDODERM 105 LITEAIRE 177 LITETOUCH PEN NEEDLES LIDOPIN 105 LITETOUCH INSULIN PEN 29GX12.7MM 156 LITETOUCH PEN NEEDLES LIDOPURE PATCH 105 NEEDLES/32G X 4MM/MINI 155 31G X 6MM 156 LIDORX 105 LITETOUCH INSULIN LITETOUCH PEN NEEDLES LIDOSTREAM 105 SYRINGE/0.3ML/29G X 31G X 6MM/ULTRA LIDOTHOL 105 1/2" 156 SHORT 156 LITETOUCH INSULIN LITETOUCH PEN NEEDLES LIDOTIN 203 SYRINGE/0.3ML/30G X 31GX8MM SHORT 156 LIDOTRAL 105 5/16" 156 LITETOUCH PEN LIDOVEX 105 LITETOUCH INSULIN NEEDLES/31G X 3/16" 156 LITETOUCH PEN LIDOVIX 21 SYRINGE/0.3ML/31G X 5/16" 156 NEEDLES/31G X LIDTOPIC MAX 106 LITETOUCH INSULIN 5MM/MINI 156 LIFEMS NALOXONE 50 SYRINGE/0.5ML/30G X LITETOUCH PEN LIFESTYLES ASSORTED 5/16" 156 NEEDLES/31G X COLORS 128 LITETOUCH INSULIN 8MM/SHORT 156 LIFESTYLES EXTRA SYRINGE/0.5ML/31G X lithium carbonate 66 STRENGTH 128 5/16" 156 LITHOBID 66 LIFESTYLES FORM LITETOUCH INSULIN FITTING 128 SYRINGE/1ML/30G X LITHOSTAT 117 LIFESTYLES 5/16" 156 LIVALO 55 LUBRICATED 128 LITETOUCH INSULIN LIVE BETTER ADVANCED LIFESTYLES RIBBED 128 SYRINGE/U-100/0.3ML/30G X LANCING DEVICE 133 LIFESTYLES SKYN 5/16" 156 LIVE BETTER LANCET ORIGINAL 128 LITETOUCH INSULIN SUPERTHIN 30G 133 LIFESTYLES SYRINGE/U-100/0.3ML/31G X LIVE BETTER LANCET SPERMICIDALLYLUBRICATED 5/16" 156 ULTRATHIN 28G 133 128 LITETOUCH INSULIN LMR PLUS 106 LIFESTYLES STUDDED 128 SYRINGE/U-100/0.5ML/28G X LO LOESTRIN FE 87 1/2" 156 LIFESTYLES ULTRA LITETOUCH INSULIN LOCOID 102 SENSITIVE 128 SYRINGE/U-100/0.5ML/29G X LOCOID LIPOCREAM 102 LIFESTYLES ULTRA 1/2" 156 SENSITIVE/SPERMICIDE 128 LODINE 21 LITETOUCH INSULIN LODOSYN 65 LIFESTYLES VIBRA- SYRINGE/U-100/0.5ML/30G X RIBBED 128 LOKELMA 184 LIFESTYLES VIBRA- 5/16" 156 RIBBED/SPERMICIDE 128 LOMOTIL 49

Index 28 LONGS INSULIN LUPRON DEPOT (1- maprotiline hcl 42 SYRINGE/0.5ML/31G X MONTH) 62 MARATHON MEDICAL 5/16" 156 LUPRON DEPOT (3- PENTIPS29GX12MM 157 LONGS LANCETS MONTH) 62 MARATHON MEDICAL STANDARD 133 LUPRON DEPOT (4- PENTIPS31GX5MM 157 LONGS LANCETS THIN 133 MONTH) 62 MARATHON MEDICAL LONHALA MAGNAIR REFILL LUPRON DEPOT (6- PENTIPS31GX8MM 157 KIT 34 MONTH) 62 MARATHON MEDICAL LONHALA MAGNAIR STARTER LUPRON DEPOT-PED (1- PENTIPS32GX4MM 157 KIT 34 MONTH) 111 MARINOL 51 LONSURF 63 LUPRON DEPOT-PED (3- MONTH) 111 MARPLAN 42 loperamide hcl 49 LUTATHERA 64 MAS CARE-PAK 89 LOPID 54 LUXIQ 102 MATULANE 64 lopinavir-ritonavir 78 LUXTURNA 195 MAVENCLAD 202 LOPRESSOR 81 LUZU 97 MAVYRET 80 LOPRESSOR HCT 58 LYNPARZA 63 MAXALT 181 LOPROX 97 LYRICA 40 MAXALT-MLT 181 LOPROX KIT 97 LYRICA CR 203 MAXI-COMFORT INSULIN SYRINGE/U- LOPROX SHAMPOO 97 LYSODREN 62 loratadine 53 100/0.5ML/28GX1/2" 157 LYSTEDA 122 MAXI-COMFORT INSULIN loratadine & SYRINGE/U-100/1ML/28GX1/2" pseudoephedrine 91 LYUMJEV 48 LYUMJEV KWIKPEN 48 157 lorazepam 32,33 MAXICOMFORT II PEN LORBRENA 63 M-M-R II 212 NEEDLES/31G X 1/4" 157 LORTAB 26 M-NATAL PLUS 189 MAXICOMFORT INSULIN SYRINGES 27G X 1/2" 157 losartan potassium 56 M.V.I. PEDIATRIC 188 MAXIDEX 196 losartan potassium & MACROBID 31 hydrochlorothiazide 58 MACRODANTIN 31 MAXITROL 196 LOSEASONIQUE 87 mafenide acetate 99 MAXX LUBRICATED 128 LOTEMAX 196 MAXX PLUS SPERMICIDE MAG-AL 29 LUBRICATED 128 LOTEMAX SM 196 MAGELLAN INSULIN SAFETY MAXZIDE 108 LOTENSIN 55,56 SYRINGE/U-100/0.3ML/29G X MAXZIDE-25 108 LOTENSIN HCT 58 1/2" 156 MAGELLAN INSULIN SAFETY MAYZENT 202 loteprednol etabonate 196 SYRINGE/U-100/0.3ML/30G X MAYZENT STARTER LOTREL 58 5/16" 156 PACK 202 LOTRONEX 116 MAGELLAN INSULIN SAFETY meclizine hcl 51 SYRINGE/U-100/0.5ML/29G X lovastatin 55 MECLIZINE 1/2" 156 HYDROCHLORIDE 51 LOVAZA 53 MAGELLAN INSULIN SAFETY meclofenamate sodium 21 LOVENOX 38 SYRINGE/U-100/0.5ML/30G X MEDI-DERM/L-RX 106 loxapine succinate 70 5/16" 156 MAGELLAN INSULIN SAFETY MEDI-PATCH RX 106 lubiprostone 115 SYRINGE/U-100/1ML/29G X MEDIC INSULIN LUCEMYRA 200 1/2" 157 SYRINGE/0.3ML/30G X luliconazole 97 MAGELLAN INSULIN SAFETY 5/16" 157 LUMAKRAS 63 SYRINGE/U-100/1ML/30G X MEDIC INSULIN 5/16" 157 SYRINGE/0.5ML/30G X LUMIGAN 198 magnesium citrate 124 5/16" 157 LUNESTA 122 magnesium hydroxide 124 MEDICINE SHOPPE PEN LUPANETA PACK 111 MAKENA 200 NEEDLES 29G X 12MM 157 LUPKYNIS 183 MEDICINE SHOPPE PEN MALARONE 59 NEEDLES 31G X 6MM 157 malathion 107

Index 29 MEDICINE SHOPPE PEN MESTINON 60 methylprednisolone sod NEEDLES 31G X 8MM 157 MESTINON TIMESPAN 60 succ 89 MEDISENSE THIN methyltestosterone 28 METAXALL CP 191 LANCETS 133 metoclopramide hcl 115 MEDROL 89 metaxalone 191 METOCLOPRAMIDE ODT 115 MEDROL DOSEPAK 89 metformin hcl 45 metolazone 109 medroxyprogesterone METFORMIN acetate 200 HYDROCHLORIDE 45 metoprolol & medroxyprogesterone acetate methadone hcl 25 hydrochlorothiazide 58 metoprolol succinate 81 (contraceptive) 88 METHADONE HCL 25 mefenamic acid 21 METOPROLOL SUCCINATE methadone hcl 25 ER/HYDROCHLOROTHIAZIDE mefloquine hcl 59 METHADONE 58 megestrol acetate 62 HYDROCHLORIDE/SODIUM metoprolol tartrate 81,82 CHLORIDE 25 megestrol acetate METROCREAM 106 (appetite) 200 METHADOSE 25 MEIJER ALCOHOL SWABS METHADOSE SUGAR- METROGEL 106 EXTRA-THICK 138 FREE 25 METROLOTION 106 MEIJER COLOR LANCETS methamphetamine hcl 6 metronidazole 30 UNIVERSAL 33G 133 methazolamide 108 metronidazole (topical) 106 MEIJER LANCETS 133 methenamine hippurate 31 METRONIDAZOLE MEIJER LANCETS THIN 133 methenamine mandelate 31 BENZOATE/SYRSPEND SF MEIJER LANCETS 30 methenamine-hyosc-methylene PH4 UNIVERSAL21G 133 metronidazole vaginal 213 MEIJER LANCETS blue-benzoic acid-phenyl UNIVERSAL30G 133 sal 30 metyrosine 56 MEIJER LANCETS methenamine-hyosc-methylene mexiletine hcl 33 UNIVERSAL33G 133 blue-sod phos-phenyl sal 30 MIACALCIN 110 MEIJER PEN NEEDLES 29G methenamine-hyoscamine- X12MM 157 methylene blue-sodium micafungin sodium 51 MEIJER PEN NEEDLES 31G phosphate 30 MICARDIS 56 X6MM 157 methimazole 206 MICARDIS HCT 58 MEIJER PEN NEEDLES 31G METHITEST 28 MICATIN 97 X8MM 157 MEIJER SUPER THIN methocarbamol 191 miconazole nitrate (topical) 97 LANCETS 133 methotrexate sodium 60 miconazole nitrate vaginal 213 MEKINIST 63 methoxsalen rapid 98 miconazole-zinc oxide-white MEKTOVI 63 methscopolamine petrolatum 97 meloxicam 21 bromide 207 MICROCHAMBER 177 METHYLCOBALAMIN 120 MICRODOT PEN NEEDLE/31G melphalan 60 methyldopa 57 X 6 MM 157 memantine hcl 201 methyldopa & MICRODOT PEN NEEDLE/32G MENACTRA 211 hydrochlorothiazide 58 X 4 MM 157 MENEST 114 methylergonovine MICRODOT PEN NEEDLE/33G maleate 198 X 4 MM 157 MENOSTAR 114 MICROELITE FILTER MENQUADFI 211 METHYLIN 14 REPLACEMENTS 177 MENVEO 211 methylphenidate hcl 16,17 MICROELITE RECHARGEABLE METHYLPHENIDATE BATTERY 177 meperidine hcl 25 HYDROCHLORIDE ER 17 MICROLET NEXT 134 meprobamate 32 methylprednisolone 89 MICROSPACER 177 MEPRON 30 methylprednisolone MICROVIX LP 106 mercaptopurine 60 acetate 89 MIDAZOLAM 122 mesalamine 115 METHYLPREDNISOLONE ACETATE 89 midazolam hcl 122 mesalamine w/ cleanser 115 methylprednisolone MIDAZOLAM MESNEX 64 acetate 89 HYDROCHLORIDE 122

Index 30 MIDAZOLAM MM INSULIN SYRINGE/U- MONOJECT INSULIN HYDROCHLORIDE/SODIUM 100/0.3ML/30G X 5/16" 157 SYRINGE/PERM CHLORIDE 122 MM INSULIN SYRINGE/U- NEEDLE/1ML/28G X 1/2" 158 MIDAZOLAM/KETAMINE 100/0.3ML/31G X 5/16" 157 MONOJECT INSULIN HYDROCHLORIDE/ONDANSET MM INSULIN SYRINGE/U- SYRINGE/PERM NEEDLE/U- RON HYDROCHLORIDE 122 100/1/2ML/30G X 5/16" 157 100/0.5ML/28G X 1/2" 158 MIDAZOLAM/SODIUM MM INSULIN SYRINGE/U- MONOJECT INSULIN CHLORIDE 122 100/1/2ML/31G X 5/16" 157 SYRINGE/SAFETY/PERM MIDAZOLAM/SYRSPEND SF MM INSULIN SYRINGE/U- NEEDLE/0.3ML/29G X 1/2" 158 PH4 122 100/1ML/30G X 5/16" 157 MONOJECT INSULIN midodrine hcl 214 MM INSULIN SYRINGE/U- SYRINGE/SAFETY/PERM MIFEPREX 112 100/1ML/31G X 5/16" 157 NEEDLE/0.3ML/29GX1/2" 158 MM LANCING DEVICE 134 MONOJECT INSULIN mifepristone 112 MM PEN NEEDLES 31G X SYRINGE/SAFETY/PERM miglitol 44 1/4" 157 NEEDLE/0.5ML/29G X 1/2" 158 miglustat 120 MM PEN NEEDLES 31G X MONOJECT INSULIN MIGRAINE PACK 180 3/16" 157 SYRINGE/SAFETY/PERM MM PEN NEEDLES 31G X NEEDLE/1ML/29G X 1/2" 158 MIGRANAL 180 5/16" 157 MONOJECT INSULIN MIGRANOW 180 MM PEN NEEDLES 32G X SYRINGE/SOFTPACK/1ML/27G MILLIPRED 89 5/32" 157 X 1/2" 158 MONOJECT INSULIN MILLIPRED DP 89 MOBIC 21 modafinil 17 SYRINGE/SOFTPACK/U- milrinone lactate 84 100/0.5ML/28G X 1/2" 158 milrinone lactate in dextrose 84 moexipril hcl 56 MONOJECT INSULIN MINASTRIN 24 FE 87 MOI-STIR 185 SYRINGE/U-100/0.3ML/30G X molindone hcl 73 5/16" 158 mineral oil 124 MONOJECT INSULIN MINI LANCING DEVICE 134 mometasone furoate 102 SYRINGE/U-100/0.5ML/30G X MINIELITE FILTER mometasone furoate 5/16" 158 REPLACEMENTS 177 (nasal) 192 MONOJECT INSULIN MINIELITE RECHARGEABLE MONOJECT BLUNTIP SYRINGE/U-100/1ML/28G X BATTERY 177 SYRINGE/3ML/CANNULA/IV 1/2" 158 ACCESS 157 MONOJECT INSULIN MINIPRESS 57 MONOJECT HYPO/ALUM MINIVELLE 114 SYRINGE/U-100/1ML/30G X HUB/18G X 1-1/2" 157 5/16" 158 MINOCIN 205 MONOJECT HYPO/ALUM MONOJECT INSULIN minocycline hcl 205 HUB/LUER LOCK/SHORT SYRINGEREGULAR LUER BEVEL/18G X 1-1/2" 158 MINOLIRA 205 TIP/SOFTPACK/1ML 158 MONOJECT MONOJECT MAGELLAN minoxidil 59 HYPO/POLYPROPYLENE SAFETYNEEDLE 18GX1- MIRAPEX 65 HUB/18G X 1-1/2" 158 1/2" 158 MIRAPEX ER 65 MONOJECT MONOJECT PHARMACY HYPO/POLYPROPYLENE MIRASORB SPONGES 4" X TRAY/LUER LOCK/3ML 158 HUB/LL/SHORT BEVEL/18G X MONOJECT STANDARD 4" 127 1-1/2" 158 MIRCERA 120 HYPODERMIC MONOJECT INSULIN NEEDLE/POLYPROPYLENE/18 MIRCETTE 87 SYRINGE/1ML 158 GX1-1/2" 158 MIRENA 88 MONOJECT INSULIN MONOJECT SYRINGE/LUER SYRINGE/1ML/31G X mirtazapine 42 LOCK/3ML 158 5/16" 158 MONOJECT SYRINGE/LUER- MIRVASO 107 MONOJECT INSULIN LOCK TIP/3ML 158 misoprostol 210 SYRINGE/DETACH MONOJECT SYRINGE/REG MISTASSIST 177 NEEDLE/1ML/25G X 5/8" 158 LUER/3ML 158 MONOJECT INSULIN MITIGARE 118 MONOJECT SYRINGE/DETACH SYRINGE/REGULARTIP/3ML MITOSOL 195 NEEDLE/1ML/27G X 1/2" 158 158 MKO MELT DOSE PACK 122

Index 31 MONOJECT ULTRA COMFORT MS INSULIN NAPROXEN COMFORT INSULIN SYRINGE/0.3ML/29G X SYRINGE/1ML/31G X PAC 22 1/2" 159 5/16" 159 naproxen sodium 22 MONOJECT ULTRA COMFORT MUCOSITISRX 185 naproxen-esomeprazole INSULIN SYRINGE/0.3ML/30G X MULPLETA 120 magnesium 22 5/16" 159 naratriptan hcl 181 MONOJECT ULTRA COMFORT MULTAQ 33 INSULIN SYRINGE/0.3ML/31G X MULTI PRENATAL 189 NARCAN 50 5/16" 159 MULTI-LANCET DEVICE 134 NARDIL 42 MONOJECT ULTRA COMFORT multiple vitamins w/ NASONEX 192 INSULIN SYRINGE/0.5ML/28G X minerals 186 NATACYN 195 1/2" 159 MONOJECT ULTRA COMFORT mupirocin 96 NATALVIT 189 INSULIN SYRINGE/0.5ML/29G X mupirocin calcium (topical) 96 NATAZIA 87 1/2" 159 MYAMBUTOL 60 nateglinide 49 MONOJECT ULTRA COMFORT MYCAMINE 51 INSULIN SYRINGE/0.5ML/30G X NATESTO 28 5/16" 159 MYCAPSSA 112 NATPARA 110 MONOJECT ULTRA COMFORT MYCOBUTIN 60 NATROBA 107 INSULIN SYRINGE/0.5ML/31G X mycophenolate mofetil 183 NATURE-THROID 206 5/16" 159 mycophenolate sodium 183 MONOJECT ULTRA COMFORT NATURE-THROID NT-2.5 206 INSULIN SYRINGE/1ML/28G X MYDAYIS 6 NAYZILAM 38 1/2" 159 MYDRIACYL 194 NEBULIZER AIR MONOJECT ULTRA COMFORT MYFEMBREE 113 TUBE/PLUGS 177 INSULIN SYRINGE/1ML/29G X NEBULIZER CUP/TUBING 177 1/2" 159 MYFORTIC 183,184 MYLERAN 60 NEBULIZER PEDIATRIC MONOLET LANCETS 134 MASK 178 MONOLET OPD LANCETS134 MYRBETRIQ 211 NEBUPENT 30 MONONINE 118 MYSOLINE 40 NEBUSAL 91 montelukast sodium 34 MYTESI 49 nefazodone hcl 43 MONUROL 31 nabumetone 21 NEMBUTAL SODIUM 122 MORGIDOX 1X100MG 205 nadolol 82 NEO-SYNALAR 96 MORGIDOX 2X100MG 205 naftifine hcl 97 NEO-SYNALAR KIT 96 morphine sulfate 25 NAFTIFINE HYDROCHLORIDE 97 neomycin sulfate 19 morphine sulfate beads 25 NAFTIN 97 neomycin-bacitracin zn- MOTEGRITY 114 polymyxin 195 NALFON 21 neomycin-polymy- MOTOFEN 49 NALOCET 26 dexameth 196 MOTRIN CHILDRENS 21 naloxone hcl 50 neomycin-polymyxin-gramicidin MOUTH KOTE 185 195 naltrexone hcl 50 neomycin-polymyxin-hc MOUTH KOTE REMINT 185 NAMENDA 201 (ophth) 196 MOVANTIK 116 NAMENDA TITRATION neomycin-polymyxin-hc MOVIPREP 123 PAK 201 (otic) 198 MOXEZA 195 NAMENDA XR 201 NEONATAL COMPLETE 189 moxifloxacin hcl 114 NAMENDA XR TITRATION NEONATAL PLUS 189 PACK 201 moxifloxacin hcl (ophth) 195 NEONATAL VITAMIN 189 NAMZARIC 201 MS CONTIN 25 NEORAL 184 NAPRELAN 21 neostigmine methylsulfate 60 MS INSULIN NAPRO 15% COMPOUNDING SYRINGE/0.3ML/31G X NEOSTIGMINE KIT 95 5/16" 159 METHYLSULFATE 60 NAPROSYN 21 MS INSULIN NERLYNX 63 naproxen 22 SYRINGE/0.5ML/31G X NESINA 46 5/16" 159

Index 32 NEULASTA 120 nicotine polacrilex 204 norethin acet & estrad-fe 87 NEULASTA ONPRO KIT 120 NICOTINE TRANSDERMAL norethindrone & eth estradiol87 NEUPOGEN 120 SYSTEM 204 norethindrone & ethinyl estradiol- NICOTROL INHALER 204 NEUPRO 65 fe 87 NICOTROL NS 204 norethindrone NEURAPTINE 95 nifedipine 83 (contraceptive) 88 NEURONTIN 40 norethindrone acet & eth NILANDRON 62 NEUTRASAL 185 estra 87 nilutamide 62 NEVANAC 198 norethindrone acetate 200 nimodipine 83 norethindrone acetate-ethinyl nevirapine 78 NINLARO 63 estradiol 113 NEXAVAR 63 norethindrone acetate-ethinyl NIPRIDE RTU 59 NEXIUM 209 estradiol-fe 87 nisoldipine 83 NEXIUM 24HR 209 norethindrone-eth estradiol nitazoxanide 30 (triphasic) 87 NEXIUM I.V. 209 nitisinone 111 NORGESIC FORTE 191 NEXLETOL 53 NITRO-BID 32 norgestimate-ethinyl NEXLIZET 53 estradiol 87 NITRO-DUR 32 NEXPLANON 88 norgestimate-ethinyl estradiol nitrofurantoin 31 (triphasic) 87 NEXTERONE 33 nitrofurantoin macrocrystal 31 norgestrel & ethinyl estradiol 87 NEXTSTELLIS 87 nitrofurantoin monohyd NORITATE 107 niacin 214 macro 31 NORPACE 33 niacin (antihyperlipidemic) 55 nitroglycerin 32 NORPACE CR 33 niacinamide 214 NITROGLYCERIN 32 NORPRAMIN 44 NIACINAMIDE/SPIRONOLACTO nitroglycerin 32 NE 93 NORTHERA 214 NIACINAMIDE/SPIRONOLACTO nitroglycerin in d5w 32 nortriptyline hcl 44 NITROLINGUAL NE/TRETINOIN 93 NORVASC 83 NIACINAMIDE/SULFACETAMID PUMPSPRAY 32 E SODIUM NITROMIST 32 NORVIR 78 MONOHYDRATE 93 NITROPRESS 59 NOSE CLIP 178 NIACINAMIDE/TACROLIMUS nitroprusside sodium 59 NOURIANZ 65 MONOHYDRATE 104 NITROSTAT 32 NOVA SUREFLEX NIACINAMIDE/TAZAROTENE LANCETS 134 93 NITYR 111 NOVA SUREFLEX LANCING NIACINAMIDE/TRETINOIN 93 NIVA-PLUS 189 DEVICE 134 NIACINAMIDE/TRIAMCINOLON NIVESTYM 120 NOVAREL 110 E ACETONIDE 102 NIX CREME RINSE 107 NOVOEIGHT 118 NIASPAN 55 nizatidine 208 NOVOFINE AUTOCOVER PEN NICADAN 186 NEEDLE 30G X 8MM 159 NOCDURNA 112 NICADAN ZX 186 NOVOFINE PEN NEEDLE 32G X NOKOR ADMIX NEEDLE THIN 4MM 159 nicardipine hcl 83 WALL NON-CORING 18G X 1- NOVOFINE PLUS PEN NICARDIPINE 1/2" 159 NEEDLE32G X 4MM 159 HYDROCHLORIDE 83 NOKOR VENTED NEEDLE NOVOLIN 70/30 48 NICARDIPINE THINWALL NON-CORING HYDROCHLORIDE/SODIUM 18GX1-1/2" 159 NOVOLIN 70/30 FLEXPEN 48 CHLORIDE 83 NOPIOID-LMC KIT 191 NOVOLIN 70/30 FLEXPEN RELION 48 NICODERM CQ 203 NOPIOID-TC KIT 191 NICORETTE 203,204 NOVOLIN 70/30 RELION 48 NORCO 26 NOVOLIN N 48 NICORETTE MINI 204 NORDITROPIN NICORETTE STARTER FLEXPRO 110 NOVOLIN N FLEXPEN 48 KIT 204 norelgestromin-ethinyl NOVOLIN N FLEXPEN nicotine 204 estradiol 88 RELION 48 norepinephrine bitartrate 214 NOVOLIN N RELION 48

Index 33 NOVOLIN R 48 NUTROPIN AQ NUSPIN OMEGA-3/D-3 WELLNESS NOVOLIN R RELION 48 10 110 PACK 53 NUTROPIN AQ NUSPIN omeprazole 209 NOVOLOG 49 20 110 OMEPRAZOLE + SYRSPEND NOVOLOG FLEXPEN 48 NUTROPIN AQ NUSPIN SFALKA 209 NOVOLOG FLEXPEN 5 111 omeprazole-sodium RELION 48 NUVAKAAN II 106 bicarbonate 210 NOVOLOG MIX 70/30 48 NUVARING 88 OMNARIS 192 NOVOLOG MIX 70/30 NUVESSA 213 OMNIFLEX DIAPHRAGM 128 PREFILLED FLEXPEN 48 NOVOLOG MIX 70/30 NUVIGIL 17 OMNITROPE 111 PREFILLED FLEXPEN NUWIQ 118 ON CALL LANCING RELION 48 NUZYRA 205 DEVICE 134 ON CALL PLUS LANCING NOVOLOG MIX 70/30 NYMALIZE 83 RELION 48 DEVICE 134 NOVOLOG PENFILL 48 nystatin 52 ondansetron 50 NOVOLOG RELION 48 nystatin (mouth-throat) 184 ondansetron hcl 50 NOVOSEVEN RT 118 nystatin (topical) 97 ONE FLOW FVC MONITORING nystatin-triamcinolone 97 SPIROMETER 178 NOVOTWIST PEN NEEDLE ONE VITE WOMENS 32GX 5MM 159 NYVEPRIA 120 PRENATALVITAMIN 189 NOXAFIL 52 OBIZUR 118 ONE VITE WOMENS NP #2 DRUG PREPARATION OCALIVA 114 PRENATALVITAMIN PLUS 189 KIT 95 OCREVUS 202 ONETOUCH DELICA LANCING NPLATE 120 DEVICE 134 octreotide acetate 112 NU GAUZE 4PLY 4"X4" 127 ONETOUCH DELICA PLUS NU GAUZE GENERAL-USE OCUFLOX 195 LANCING DEVICE 134 ONETOUCH DELICA SAFETY SPONGES 4"X4" 4 PLY 127 ODACTRA 18 LACING DEVICE 134 NUBEQA 62 ODEFSEY 78 ONEVITE 186 NUCALA 34 ODOMZO 61 ONEXTON 93 NUCORT 102 OFEV 204 ONFI 38 NUCYNTA 25 ofloxacin 114 ONGENTYS 65 NUCYNTA ER 25 ofloxacin (ophth) 195 ONGLYZA 46 NUDERMRXPAK 120 98 ofloxacin (otic) 198 ONPATTRO 204 NUDERMRXPAK 60 98 olanzapine 70,71 ONUREG 61 NUDROXIPAK 22 olanzapine-fluoxetine hcl 201 ONYCHO-MED 97 NUDROXIPAK DSDR-50 22 olmesartan medoxomil 56 ONZDEOXIA 93 NUDROXIPAK DSDR-75 22 olmesartan medoxomil- ONZETRA XSAIL 181 NUDROXIPAK E-400 22 amlodipine-hydrochlorothiazide 58 OPANA 25 NUDROXIPAK I-800 22 olmesartan medoxomil- opium tincture 49 NUDROXIPAK M-15 22 hydrochlorothiazide 58 OPSUMIT 84 NUDROXIPAK N-500 22 olopatadine hcl 198 OPTICHAMBER NUEDEXTA 203 olopatadine hcl (nasal) 192 ADVANTAGE/LARGE NULIBRY 111 OLUMIANT 20 MASK 178 NULYTELY 123 OLUX 102 OPTICHAMBER ADVANTAGE/MEDIUM FACE NULYTELY/FLAVOR OLUX-E 102 MASK 178 PACKS 123 OMBRA TABLE TOP OPTICHAMBER NUMOISYN 185 COMPRESSOR 178 ADVANTAGE/SMALL FACE NUPLAZID 67 OMECLAMOX-PAK 210 MASK 178 NURTEC 180 OMEGA-3 RX COMPLETE53 OPTICHAMBER DIAMOND178 NUTRICAP 186 omega-3-acid ethyl esters 53 OPTICHAMBER DIAMOND/LARGEFACE NUTRIDOX 205 MASK 178

Index 34 OPTICHAMBER OSPHENA 111 PALFORZIA LEVEL 2 19 DIAMOND/MEDIUM FACE OTEZLA 22 PALFORZIA LEVEL 3 19 MASK 178 OPTICHAMBER OTOVEL 198 PALFORZIA LEVEL 4 19 DIAMOND/SMALLFACE OTREXUP 20 PALFORZIA LEVEL 5 19 MASK 178 OVIDE 107 PALFORZIA LEVEL 6 19 OPTICHAMBER FACE MASK/LARGE 178 oxandrolone 28 PALFORZIA LEVEL 7 19 OPTICHAMBER FACE oxaprozin 22 PALFORZIA LEVEL 8 19 MASK/MEDIUM 178 OXAYDO 25 PALFORZIA LEVEL 9 19 OPTICHAMBER FACE oxazepam 33 paliperidone 67 MASK/SMALL 178 OPTIFOAM 127 OXBRYTA 120 palonosetron hcl 50 PALONOSETRON OPTIHALER 178 oxcarbazepine 40 OXERVATE 196 HYDROCHLORIDE 50 OPTIHALER MDI DRUG PALYNZIQ 112 DELIVERY SYSTEM 178 OXIANUJO 104 PAMELOR 44 ORACEA 107 OXIATAR 93 pamidronate disodium 110 ORACIT 116 OXIAVARRY 93 PAMIDRONATE ORAL RELIEF SPRAY FOR oxiconazole nitrate 97 DRYMOUTH & DISODIUM 110 DISCOMFORT 185 OXISTAT 97 pamidronate disodium 110 ORALAIR 18 OXLUMO 117 PANCREAZE 108 ORALAIR ADULT SAMPLE OXSORALEN ULTRA 99 PANDEL 102 KIT 18 OXTELLAR XR 40 PANHEMATIN 119 ORALAIR ADULT STARTER oxybutynin chloride 210 PACK 18 PANRETIN 98 ORALAIR oxycodone hcl 25 pantoprazole sodium 209 CHILDREN/ADOLESCENTS OXYCODONE PARAGARD INTRAUTERINE SAMPLE KIT 18 HYDROCHLORIDE/ACETAMI COPPER CONTRACEPTIVE ORALAIR NOPHEN 26 T380A 88 CHILDREN/ADOLESCENTS oxycodone w/ PARI ALTERA NEBULIZER STARTER PACK 18 acetaminophen 26 HANDSET 178 ORAPRED ODT 89 oxycodone-aspirin 26 PARI BABY CONVERSION ORENCIA 22 OXYCODONE/ACETAMINOPH KITSIZE 1 178 EN 27 PARI BABY CONVERSION 22 ORENCIA CLICKJECT OXYCONTIN 25 KITSIZE 2 178 84 PARI BABY CONVERSION ORENITRAM oxymorphone hcl 25 ORFADIN 111,112 KITSIZE 3 178 OXYTROL 210 PARI ERAPID NEBULIZER 62 ORGOVYX oyster shell 182 HANDSET 178 113 ORIAHNN OZEMPIC 46 PARI EXPIRATORY FILTER ORILISSA 110 VALVE SET 178 OZOBAX 191 PARI MANUAL 204 ORKAMBI P-CARE D40 90 INTERRUPTER 178 119 ORLADEYO P-CARE D80 90 PARI MASK SET 178 ORMECA 98 P-CARE K40 90 PARI SOFT PLASTIC ADULT 191 MASK 178 orphenadrine citrate P-CARE K80 90 orphenadrine w/ aspirin & PARI SOFT PLASTIC caff 191 PAINGO KFT 106 PEDIATRIC MASK 178 ORTHO MICRONOR 88 PALFORZIA INITIAL DOSE PARI TREK S COMBO ESCALATION 18 PACK 178 90 ORTIKOS PALFORZIA LEVEL 1 19 PARI VORTEX ADULT 80 oseltamivir phosphate PALFORZIA LEVEL 10 19 MASK 178 OSENI 45 PALFORZIA LEVEL 11 paricalcitol 112 OSMOLEX ER 65 (MAINTENANCE) 19 PARLODEL 65 OSMOPREP 124 PALFORZIA LEVEL 11 PARNATE 42 (TITRATION) 19

Index 35 paromomycin sulfate 19 PEN NEEDLES PENNSAID 95 paroxetine hcl 43 29GX1/2" 159 pentamidine isethionate 30 PEN NEEDLES paroxetine mesylate 29GX12MM 159 PENTASA 115 (vasomotor) 204 PEN NEEDLES pentazocine w/ naloxone 27 PASER 60 30GX5/16" 159 PENTETATE CALCIUM PATANASE 192 PEN NEEDLES TRISODIUM 50 PATIENT SAFE SYRINGE 30GX8MM 159 PENTETATE ZINC 3ML 159 PEN NEEDLES 31G X 1/4" TRISODIUM 50 PAXIL 43 SHORT 159 PENTICAN 203 PEN NEEDLES 31G X PAXIL CR 43 3/16" 159 PENTIPS 29G X 12MM 160 PAZEO 198 PEN NEEDLES 31G X PENTIPS 29GX12MM 160 PC LANCETS SUPER THIN 5MM 159 PENTIPS 31G X 5MM 160 30G 134 PEN NEEDLES 31G X PENTIPS 31G X 8MM 160 PC PEDIATRIC POLY-VITAMIN 6MM 159 DROPS/IRON 187 PEN NEEDLES 31G X PENTIPS 31GX5MM 160 PC UNIFINE PENTIPS 29G 8MM 159 PENTIPS 31GX6MM 160 X1/2" 159 PEN NEEDLES PENTIPS 31GX8MM 160 PC UNIFINE PENTIPS 31G 31GX5/16" 159 X5MM MINI 159 PEN NEEDLES 31GX6MM PENTIPS 32G X 4MM 160 PC UNIFINE PENTIPS 31G (1/4") 160 PENTIPS 32GX4MM 160 X6MM ULTRA SHORT 159 PEN NEEDLES pentobarbital sodium 122 PC UNIFINE PENTIPS 31G 31GX8MM 160 PENTOSAN POLYSULFATE X8MM SHORT 159 PEN NEEDLES 31GX8MM SODIUM DR 117 PCP 100 123 (5/16") 160 PEN NEEDLES 32G X pentoxifylline 119 ped multivitamins w/fl & PEPCID 208 iron 187 4MM 160 PEDIAPRED 90 PEN NEEDLES 32G X PERCOCET 27 5MM 160 PERFECT LANCETS 30G 134 PEDIATRIC PEN NEEDLES 32G X MOUTHPIECE/DISPOSABLE 6MM 160 PERFOROMIST 36 178 PEN NEEDLES perindopril erbumine 56 pediatric multiple vitamin w/ 32GX4MM 160 permethrin 107 minerals & c 187 PEN NEEDLES 33G X pediatric multiple vitamins w/ 5/32" 160 perphenazine 73,74 iron 187 PEN NEEDLES/29G X perphenazine-amitriptyline pediatric multivitamins 1/2" 160 201,202 w/fl 186,187 PEN NEEDLES/31G X PERSERIS 67 pediatric vitamins acd w/ 1/4" 160 PERTZYE 108 fluoride 187 PEN NEEDLES/31G X PEXEVA 43 pediatric vitamins adc 188 3/16" 160 PEDIZOLPAK 97 PEN NEEDLES/31G X PFLEX 178 5/16" 160 PHARMACIST CHOICE PEDVAX HIB 211 NEBULIZER/CPAP/INHALER peg 3350-kcl-nacl-na sulfate-na PEN NEEDLES/31G X 6MM 160 CHAMBER MASK WIPES 178 ascorbate-ascorbic acid 123 PHARMACY COUNTER peg 3350-kcl-sod bicarb-sod PEN NEEDLES/32G X 160 LANCETS 134 chloride-sod sulfate 123 5/32" peg 3350-potassium chloride-sod penicillamine 183 phenazopyridine hcl 117 bicarbonate-sod chloride 123 penicillin g potassium 199 phenelzine sulfate 42 PEGANONE 41 PENICILLIN G POTASSIUM IN PHENERGAN 53 PEGASYS 80 ISO-OSMOTIC phenobarbital 122 DEXTROSE 199 PEGASYS PROCLICK 80 PENICILLIN G phenoxybenzamine hcl 56 PEGINTRON 80 PROCAINE 199 phentolamine mesylate 56 PEMAZYRE 63 penicillin g sodium 199 phenylephrine hcl PEN NEEDLES 29G X penicillin v potassium 199 (mydriatic) 194 12MM 159 phenylephrine hcl PENLAC NAIL LACQUER 97 (pressors) 214

Index 36 PHENYLEPHRINE PLIXDA 93 PRASTERA 19 HYDROCHLORIDE 214 PNEUMOVAX 23 211 prasugrel hcl 119 PHENYTEK 41 PNEUMOVAX 23/1 PRAVACHOL 55 phenytoin 41 DOSE 211 pravastatin sodium 55 phenytoin sodium 41 PNV TABS 29-1 189 praziquantel 29 phenytoin sodium extended 41 POCKET CHAMBER 179 prazosin hcl 57 PHEODOYO 97 POCKET SPACER 179 PRECISION SURE-DOSE PHEXXI 213 POD-CARE 100K 90 INSULIN SYRINGE/0.3ML/30G X PHEYO 97 podofilox 104 5/16" 160 PHOSLYRA 116 POLY HUB NEEDLE/18G X 1- PRECISION SURE-DOSE INSULIN SYRINGE/0.5ML/28G X PHOSPHOLINE IODIDE 194 1-1/2" 160 POLY-VI-SOL 188 1/2" 160 PHYSICIANS EZ USE B-12 PRECISION SURE-DOSE COMPLIANCE KIT 120 POLY-VI-SOL/IRON 187 INSULIN SYRINGE/0.5ML/29G X phytonadione 214 POLY-VITA 188 1/2" 160 PICATO 98 POLY-VITA/IRON 187 PRECISION SURE-DOSE PIFELTRO 78 POLY-VITE PEDIATRIC 188 INSULIN SYRINGE/0.5ML/30G X 3/8" 160 PILLOW MASK/ADULT 178 POLY-VITE/IRON 187 PRECISION SURE-DOSE PILLOW MASK/CHILD 179 polyethylene glycol 3350 124 INSULIN SYRINGE/1ML/28G X PILLOW POLYMEM NON-ADHESIVE 1/2" 160 MASK/PEDIATRIC 179 PAD 127 PRECISION SURE-DOSE pilocarpine hcl 194 polymyxin b-trimethoprim 195 PLUSINSULIN SYRINGE/0.3ML/29G X pilocarpine hcl (oral) 185 POLYTRIM 195 1/2" 160 pimecrolimus 104 polyvinyl alcohol 193 PRECISION SURE-DOSE pimozide 203 POMALYST 62 PLUSINSULIN pindolol 82 PONVORY 202 SYRINGE/1ML/29G X 1/2" 160 PONVORY 14-DAY STARTER PRECISION THINS GP pioglitazone hcl 47 LANCET 134 PACK 202 pioglitazone hcl-glimepiride 45 PRECOSE 44 posaconazole 52 pioglitazone hcl-metformin PRED FORTE 196 hcl 45 pot & sod citrates w/citric piperacillin sodium-tazobactam ac 116 PRED MILD 196 sodium 199 pot phosphate monobasic w/ PRED-G 196 PIQRAY 200MG DAILY sod phosphate dibasic & PRED-G S.O.P. 196 DOSE 63 monobasic 182 PIQRAY 250MG DAILY potassium acetate 182 prednicarbate 102 DOSE 63 potassium bicarbonate 182 prednisolone 90 prednisolone acetate PIQRAY 300MG DAILY potassium chloride 182,183 DOSE 64 (ophth) 196 piroxicam 22 POTASSIUM CHLORIDE 183 PREDNISOLONE ACETATE P- PLAN B ONE-STEP 88 potassium chloride 183 F 196 potassium chloride PREDNISOLONE PLAQUENIL 59 microencapsulated crystals ACETATE/MOXIFLOXACIN PLAVIX 119 er 183 196 PLEGRIDY 202 potassium citrate PREDNISOLONE PLEGRIDY STARTER (alkalinizer) 116 ACETATE/MOXIFLOXACIN/BRO PACK 202 potassium citrate-citric MFENAC 196 PREDNISOLONE PLENVU 123 acid 116 PRADAXA 38 ACETATE/MOXIFLOXACIN/NEP PLEXION 93 AFENAC 196 PRALUENT 55 PLEXION CLEANSER 93 PREDNISOLONE pramipexole PLEXION CLEANSING ACETATE/NEPAFENAC 196 dihydrochloride 65 CLOTHS 93 prednisolone sodium PRAMOTIC 198 PLIAGLIS 106 phosphate 90 PRAMOX GEL 106

Index 37 PREDNISOLONE SODIUM PREFERRED PLUS UNIFINE PREVIDOLRX ANALGESIC PHOSPHATE 197 PENTIPS 31G X 8MM PAK 22 PREDNISOLONE SODIUM SHORT 161 PREVNAR 13 211 PHOSPHATE/BROMFENAC PREFERRED PLUS UNIFINE PREVYMIS 79 197 PENTIPS 32GX4MM 161 PREDNISOLONE SODIUM PREFERRED PLUS UNIFINE PREZCOBIX 78 PHOSPHATE/GATIFLOXACIN/B PENTIPS/MINI/31GX5MM PREZISTA 78 ROMFENAC 197 161 PRIFTIN 60 PREDNISOLONE SODIUM PREFEST 113 PRILO PATCH 106 PHOSPHATE/MOXIFLOXACIN pregabalin 40 197 PRILO PATCH II 106 PREDNISOLONE SODIUM pregabalin (once-daily) 203 PRILOHEAL PLUS 30 106 PREGNYL W/DILUENT PHOSPHATE/MOXIFLOXACIN/B PRILOPENTIN 203 ROMFENAC 197 BENZYLALCOHOL/NACL 11 PREDNISOLONE- 0 PRILOSEC 209 GATIFLOXACIN 197 PREMARIN 114,213 PRILOVIXIL 106 PREDNISOLONE/BROMFENAC PREMIUM CONDOMS primaquine phosphate 59 197 LUBRICATED 128 PRIMAQUINE PHOSPHATE 59 PREDNISOLONE/GATIFLOXACI PREMPHASE 113 N/BROMFENAC 197 PRIMEAIRE DUAL-VALVED PREMPRO 113 prednisone 90 HOLDING CHAMBER 179 PRENATAL 189 primidone 40 PREDNISONE INTENSOL 90 PREFERRED PLUS INSULIN PRENATAL 19 189 PRIMLEV 27 SYRINGE/U-100/0.3ML/29G X PRENATAL LOW IRON 189 PRIMSOL 30 1/2" 160 PRENATAL PRINIVIL 56 PREFERRED PLUS INSULIN MULTIVITAMIN 189 PRISTIQ 44 SYRINGE/U-100/0.3ML/30G X PRENATAL MULTIVITAMIN + 5/16" 160 DHA 189 PRIZOPAK II 106 PREFERRED PLUS INSULIN PRENATAL ONE DAILY 189 PRIZOTRAL 106 SYRINGE/U-100/0.5ML/28G X PRENATAL PLUS IRON 189 PRIZOTRAL II 106 1/2" 160 prenatal vit w/ ferrous fumarate- PRO COMFORT ALCOHOL PREFERRED PLUS INSULIN folic acid 189,190 PADS 138 SYRINGE/U-100/0.5ML/29G X prenatal vit w/ iron carbonyl- PRO COMFORT INHALER 1/2" 160 folic acid 190 SPACER CHAMBER PREFERRED PLUS INSULIN PRENATAL VITAMIN 190 ADULT 179 SYRINGE/U-100/0.5ML/30G X PRO COMFORT INHALER 5/16" 161 PRENATAL VITAMIN & MINERAL 190 SPACER CHAMBER PREFERRED PLUS INSULIN CHILD 179 SYRINGE/U-100/1ML/28G X PRENATAL VITAMIN/IRON 190 PRO COMFORT INHALER 1/2" 161 SPACER CHAMBER PREFERRED PLUS INSULIN PRENATAL VITAMINS 190 INFANT 179 SYRINGE/U-100/1ML/29G X PRENATAL VITAMINS PLUS PRO COMFORT INSULIN 1/2" 161 LOW IRON 190 SYRINGES/0.5ML/30G X PREFERRED PLUS INSULIN PRENATRYL 190 1/2" 161 SYRINGE/U-100/1ML/30G X PREPIV SUPPLY 106 PRO COMFORT INSULIN 5/16" 161 PREPLUS 190 SYRINGES/0.5ML/30G X PREFERRED PLUS LANCETS 5/16" 161 COLORED 21G 134 PRESTALIA 58 PRO COMFORT INSULIN PREFERRED PLUS LANCETS PRETAB 190 SYRINGES/0.5ML/31G X SUPER THIN 30G 134 5/16" 161 PREFERRED PLUS LANCETS PRETOMANID 60 PREVACID 209 PRO COMFORT INSULIN THIN 26G 134 SYRINGES/1ML/30G X PREFERRED PLUS UNIFINE PREVACID 24HR 209 1/2" 161 PENTIPS 29G X 12MM 161 PREVACID SOLUTAB 209 PRO COMFORT INSULIN PREFERRED PLUS UNIFINE PREVENT SAFETY PEN SYRINGES/1ML/30G X PENTIPS 31G X 6MM ULTRA NEEDLES 31GX1/4" 161 5/16" 161 SHORT 161 PREVENT SAFETY PEN NEEDLES 31GX5/16" 161

Index 38 PRO COMFORT INSULIN PROGRAF 184 PX EXTRA SHORT PEN SYRINGES/1ML/31G X PROLASTIN-C 204 NEEDLES 31GX6MM 161 5/16" 161 PX INSULIN SYRINGE/U- PRO COMFORT PEN PROLATE 27 100/0.5ML/30G X 1/2" 161 NEEDLES/31G X 8MM 161 PROLENSA 198 PX LANCET AUTO PRO COMFORT PEN PROLIA 110 INJECTOR 134 NEEDLES/32G X 4MM 161 PX LANCETS ULTRA PRO COMFORT PEN PROMACTA 121 THIN 134 NEEDLES/32G X 5MM 161 promethazine hcl 53 PX MINI PEN NEEDLES PRO COMFORT PEN PROMETRIUM 200 31GX5MM 161 NEEDLES/32G X 6MM 161 PRONEB ULTRA FILTER PX PEN NEEDLE PRO-C-DURE 5 KIT 90 SET 179 29GX12MM 161 PRO-C-DURE 6 KIT 90 propafenone hcl 33 PX PEN NEEDLE 31GX8MM 162 PROAIR DIGIHALER 36 propantheline bromide 208 PX PRENATAL PROAIR HFA 36 proparacaine hcl 196 MULTIVITAMINS 190 PROAIR RESPICLICK 36 propranolol & PX SHORTLENGTH PEN NEEDLES/31GX8MM 162 probenecid 118 hydrochlorothiazide 58 PYLERA 210 PROBUPHINE IMPLANT propranolol hcl 82 KIT 27 propylthiouracil 206 pyrantel pamoate 29 procainamide hcl 33 PROSCAR 117 pyrazinamide 60 PROCARDIA 83 protamine sulfate 119 pyrethrins-piperonyl butoxide 107 PROCARDIA XL 83 PROTONIX 210 PYRIDIUM 117 PROCARE SPACER CHAMBER PROTOPIC 104 pyridostigmine bromide 60 W/ADULT MASK 179 protriptyline hcl 44 PROCARE SPACER CHAMBER pyridoxine hcl 214 PROVAD 49 W/CHILD MASK 179 pyrimethamine 59 prochlorperazine 74 PROVENTIL HFA 36 PYRIMETHAMINE/LEUCOVORI prochlorperazine edisylate 74 PROVERA 200 N 59 prochlorperazine maleate 74 PROVIGIL 17 QBRELIS 56 PROCRIT 121 PROZAC 43 QC ADVANCED LANCING DEVICE 134 PROCTOCORT 29 PRUDOXIN 98 QC ALCOHOL SWABS 138 PROCTOFOAM HC 29 pseudoephedrine hcl 192 QC ALL PURPOSE PROCYSBI 117 PSORCON 102 DRESSINGS4"X4" 127 PRODIGEN 49 PSS SELECT GP QC CALCIUM 500MG/D3 182 PRODIGY INSULIN SYRING/U- LANCETS 134 QC LANCETS SUPER 100/0.3ML/31G X 5/16" 161 PSS SELECT SAFETY THIN 134 PRODIGY INSULIN LANCETS 134 QC LANCETS ULTRA SYRINGE/1/2ML/31G X psyllium 123 THIN 134 5/16" 161 PULMICORT 35 QC PEN NEEDLES 29G X PRODIGY INSULIN PULMICORT FLEXHALER35 12MM 162 SYRINGE/1ML/28G X 1/2" 161 QC PEN NEEDLES 31G X PRODIGY LANCING PULMOZYME 204 6MM 162 DEVICE 134 PURE COMFORT PEN QC PEN NEEDLES 31G X PRODIGY TWIST TOP NEEDLE 32G X6MM 161 8MM 162 LANCETS 134 PURE COMFORT PEN QC PRENATAL 190 PROFILNINE 118 NEEDLE 32G X8MM 161 PURE COMFORT PEN QC STERILE PADS 127 PROFILNINE SD 118 NEEDLE/32G X 5MM 161 QC UNIFINE PENTIPS progesterone 200 PURE COMFORT PEN 32GX4MM 162 PROGESTERONE 10% NEEDLE/32G X4MM 161 QC UNILET LANCETS KIT 200 PURIXAN 61 28G/ULTRA THIN 134 PROGESTERONE PX ADVANCED LANCING QC UNILET LANCETS 134 COMPOUNDINGKIT 200 DEVICE 134 33G/MICRO THIN PROGLYCEM 46 QDOLO 26

Index 39 QELBREE 9 RA PRENATAL 190 REALITY LATEX/ULTRA QINLOCK 64 RA PRENATAL THIN 128 REALITY SWABS 138 QMIIZ ODT 22 FORMULA/FOLICACID 190 RA STERILE PADS REBIF 203 QNASL 192 4"X4" 127 REBIF REBIDOSE 202 QNASL CHILDRENS 192 rabeprazole sodium 210 REBIF REBIDOSE QTERN 45 RABEPRAZOLE SODIUM DR TITRATIONPACK 203 QUAKE 179 SPRINKLE 210 REBIF TITRATION PACK 203 RADICAVA 192 QUALAQUIN 59 REBINYN 118 RAGWITEK 19 QUARTETTE 87 REBLOZYL 121 raloxifene hcl 111 quazepam 122 RECLAST 110 ramelteon 123 QUDEXY XR 40 RECOMBINATE 118 ramipril 56 QUESTRAN 54 RECOMBIVAX HB 212 RANEXA 31 QUESTRAN LIGHT 54 RECTIV 29 ranolazine 31 quetiapine fumarate 71 RECURA 97 RAPAFLO 117 QUFLORA FE PEDIATRIC 187 REDITREX 20 RAPAMUNE 184 QUIHOXVAR 98 REFRESH PLUS 193 RAPIVAB 80 QUILLICHEW ER 17 REFRESH TEARS 193 rasagiline mesylate 66 QUILLIVANT XR 17 REGLAN 115 RASUVO 20 quinapril hcl 56 REGONOL 60 RAVICTI 112 quinapril-hydrochlorothiazide REGRANEX 107 58 RAY-TEC X-RAY RELAFEN DS 22 quinidine gluconate 33 DETECTABLESPONGES 4" X 4" 16 PLY 127 RELENZA DISKHALER 80 quinidine sulfate 33 RAYALDEE 112 RELEXXII 18 quinine sulfate 59 RAYOS 90 RELION 2-IN-1 LANCET QUINIXIL 102 RAZADYNE 201 DEVICES 30G 135 QUTENZA 106 RELION 2-IN-1 LANCING RAZADYNE ER 201 QVAR REDIHALER 35 DEVICE 25G 135 READYSHARP ANESTHETICS RELION 2-IN-1 LANCING RA ALCOHOL SWABS 138 +KETOROLAC 22 DEVICE 30G 135 RA CALCIUM 182 READYSHARP RELION ALCOHOL RA DRY MOUTH 185 DEXAMETHASONE 90 SWABS 138 READYSHARP RELION INSULIN SYRINGE/U- RA E-ZJECT LANCETS KETOROLAC 22 28G 134 100/0.3ML/31G X 5/16" 162 RA E-ZJECT LANCETS THIN REAL HEAL-I 106 RELION INSULIN SYRINGE/U- 26G 134 REALITY INSULIN 100/0.5ML/29G X 1/2" 162 RA E-ZJECT LANCETS THIN SYRINGE/U-100/0.5ML/28G X RELION INSULIN SYRINGE/U- 28G 134 1/2" 162 100/0.5ML/31G X 5/16" 162 RA E-ZJECT LANCETS REALITY INSULIN RELION INSULIN SYRINGE/U- ULTRATHIN 30G 135 SYRINGE/U-100/0.5ML/29G X 100/1ML/31G X 5/16" 162 RA INSULIN 1/2" 162 RELION LANCETS MICRO- SYRINGE/0.5ML/29G X REALITY INSULIN THIN33G 135 1/2" 162 SYRINGE/U-100/1ML/28G X RELION LANCETS THIN RA INSULIN SYRINGE/1ML/29G 1/2" 162 26G 135 X 1/2" 162 REALITY INSULIN RELION LANCETS ULTRA- RA INSULIN SYRINGE/U- SYRINGE/U-100/1ML/29G X THIN30G 135 100/0.5ML/30G X 5/16" 162 1/2" 162 RELION LANCING RA INSULIN SYRINGE/U-100/1 REALITY LANCETS 135 DEVICE 135 ML/30G X 5/16" 162 REALITY LATEX RELION MINI PEN NEEDLES RA PEN NEEDLES 31G X CONDOMS/LUBRICATED 12 31GX6MM 162 5MM3/16" 162 8 RELION PEN NEEDLES RA PEN NEEDLES 31G X REALITY LATEX/ULTRA 29GX12MM 162 8MM5/16" 162 TEXTURED 128 RELION PEN NEEDLES 31G X6MM 162

Index 40 RELION PEN NEEDLES 31G RESTORE FOAM DRESSING ringer's irrigation 184 X8MM 162 NON-BORDERED 4"X4" 127 RINVOQ 20 RELION PEN NEEDLES RESTORE ODOR 31GX5/16" 162 ABSORBING DRESSING RIOMET 45 RELION PEN NEEDLES 4"X4" 127 RIOMET ER 45 31GX6MM 162 RESTORIL 123 risedronate sodium 110 RELION PEN NEEDLES RETACRIT 121 31GX8MM 162 RISPERDAL 68 RELION PEN NEEDLES 32G RETAVASE 119 RISPERDAL CONSTA 67 X4MM 162 RETAVASE HALF-KIT 119 risperidone 68 RELION PEN NEEDLES 32G RETEVMO 64 RITALIN 18 X5/32" 162 RELION PEN NEEDLES RETIN-A 93 RITALIN LA 18 32GX4MM 162 RETIN-A MICRO 93 RITEFLO 179 RELION PEN NEEDLES/31G RETIN-A MICRO PUMP 93 ritonavir 78 X1/4" 162 RELION SHORT PEN RETROVIR 78 rivastigmine 201 NEEDLES31GX8MM 162 RETROVIR IV INFUSION 78 rivastigmine tartrate 201 RELION TRUE METRIX REVATIO 85 RIXUBIS 118 BLOODGLUCOSE TEST REVCOVI 112 rizatriptan benzoate 181 STRIPS 107 RELION ULTRA THIN REVLIMID 183 ROBAXIN 191 LANCETS/30G 135 REXALL LANCETS ULTRA ROBAXIN-750 191 THIN 135 RELION ULTRA THIN ROCALTROL 112 LANCETS30G 135 REXAPHENAC 95 ROCKLATAN 195 RELION ULTRA THIN PLUS REXULTI 76 ropinirole hydrochloride 66 LANCETS 32G 135 REYATAZ 78 RELION ULTRA THIN PLUS ROSADAN KIT 107 REYVOW 181 LANCETS 33G 135 rosuvastatin calcium 55 RELISTOR 116 REZUROCK 184 ROSZET 53 RELPAX 181 RHOFADE 107 ROWASA 115 REMERON 42 RHOGAM ULTRA-FILTERED ROXICODONE 26 REMERON SOLTAB 42 PLUS 199 RHOPRESSA 195 ROZEREM 123 REMICADE 115 RIASTAP 118 ROZLYTREK 64 RENAGEL 116 RIBASPHERE 80 RUBRACA 64 RENFLEXIS 115 RIBASPHERE RIBAPAK 80 RUCONEST 119 RENOVO 106 ribavirin 81 rufinamide 40 RENVELA 116 ribavirin (hepatitis c) 80 RUKOBIA 78 repaglinide 49 RIDAURA 20 RUZURGI 60 REPATHA 55 REPATHA PUSHTRONEX rifabutin 60 RYANODEX 191 SYSTEM 55 RIFADIN 60 RYBELSUS 46 REPATHA SURECLICK 55 rifampin 60 RYDAPT 64 REPLACEMENT AIR RIFAMPIN/SYRSPEND SF RYTARY 66 FILTER 179 PH4 60 RYTHMOL SR 33 REPLACEMENT FILTERS 179 RIGHT STEP PRENATAL 190 RYVENT 53 REQ 49+ 186 RIGHTEST GD500 LANCING SABRIL 41 REQUIP XL 66 DEVICE 135 SAFESNAP INSULIN RESTASIS 195 RIGHTEST GL300 SYRINGE/0.3ML/30G X RESTASIS MULTIDOSE 195 LANCETS 135 5/16" 162 RILUTEK 192 RESTORA RX 49 SAFESNAP INSULIN riluzole 192 SYRINGE/0.5ML/29G X RESTORE FOAM DRESSING 1/2" 162 BORDERED 4"X4" 127 rimantadine hydrochloride 80 RIMSO-50 117

Index 41 SAFESNAP INSULIN SB ALCOHOL PREP SEVENFACT 118 SYRINGE/0.5ML/30G X PADS 138 SEYSARA 205 5/16" 162 SB INSULIN SYRINGE/U- SAFESNAP INSULIN 100/0.5ML/29G X 1/2" 163 SFROWASA 115 SYRINGE/1ML/28G X 1/2" 163 SB INSULIN SYRINGE/U- SHINGRIX 212 SAFESNAP INSULIN 100/0.5ML/30G X 5/16" 163 SHOPKO ALCOHOL SYRINGE/1ML/29G X 1/2" 163 SB INSULIN SYRINGE/U- SWABS 138 SAFESNAP SYRINGE/3ML163 100/1ML/29G X 1/2" 163 SHOPKO AUTOLET LANCING SAFETY INSULIN SYRINGES SB INSULIN SYRINGE/U- DEVICE 135 0.5ML/29GX1/2" 163 100/1ML/30G X 5/16" 163 SHOPKO UNIFINE PENTIPS SAFETY INSULIN SYRINGES SB INSULIN SYRINGE/U- PEN 0.5ML/30GX5/16" 163 100/1ML/31G X 5/16" 163 NEEDLES/MICRO/32GX4MM SAFETY INSULIN SYRINGES SB LANCETS THIN 135 163 1ML/27GX1/2" 163 SB LANCETS ULTRA SHOPKO UNIFINE PENTIPS SAFETY INSULIN SYRINGES THIN 135 PEN NEEDLES/MINI/31GX5MM 1ML/29GX1/2" 163 SCALACORT DK 102 163 SAFETY INSULIN SYRINGES SCARZEN SKIN REPAIR 102 SHOPKO UNIFINE PENTIPS 1ML/30GX1/2" 163 PEN SAFETY SEAL LANCETS scopolamine 51 NEEDLES/ORIGINAL/29GX12M 28G 135 SE-NATAL 19 190 M 163 SAFETY SEAL LANCETS SEASONIQUE 87 SHOPKO UNIFINE PENTIPS 30G 135 PEN SAFETY-LOK SYRINGE 3ML SECONAL SODIUM 122 NEEDLES/SHORT/31GX8MM LUER-LOK 163 SECUADO 72 163 SAFYRAL 87 SECURESAFE SAFETY SHOPKO UNIFINE PENTIPS SAIZEN 111 HYPODERMIC NEEDLE/18G X PLUS PEN 1-1/2" 163 NEEDLES/MICRO/REMOVR/32 SAIZENPREP SECURESAFE SAFETY RECONSTITUTIONKIT 111 GX4MM 163 INSULIN SYRINGES/U- SHOPKO UNIFINE PENTIPS SALAGEN 185 100/0.5ML/29GX1/2" 163 PLUS PEN salicylic acid 104 SECURESAFE SAFETY NEEDLES/MINI/REMOVER/31G SALICYLIC INSULIN SYRINGES/U- X5MM 163 ACID/SULFACETAMIDE 100/1ML/29GX1/2" 163 SHOPKO UNIFINE PENTIPS SODIUM MONOHYDRATE 93 SECURESAFE SAFETY PEN PLUS PEN SALIMEZ 104 NEEDLES/30G X 5/16" 163 NEEDLES/REMOVER/29GX12M saline 191 SEGLUROMET 45 M 163 SELECT-LITE LANCING SHOPKO UNIFINE PENTIPS SALIVAMAX 185 DEVICE 135 PLUS PEN salsalate 24 selegiline hcl 66 NEEDLES/SHORT/REMOVR/31 SAMI THE SEAL selenium sulfide 99 GX8MM 163 REPLACEMENTFILTERS 179 SHOPKO UNILET LANCETS SAMSCA 113 SELZENTRY 78 SUPER THIN 30G 135 SANCUSO 50 SEMGLEE 49 SHOPKO UNILET LANCETS SEMPREX-D 91 ULTRA THIN 28G 135 SANDIMMUNE 184 SIDEROL 186 sennosides 124 SANDOSTATIN 112 SIDESTREAM ADULT FACE SANDOSTATIN LAR SENOKOT 124 MASK 179 DEPOT 112 SENSIPAR 112 SIDESTREAM PEDIATRIC SANTYL 104 SEREVENT DISKUS 36 FACEMASK 179 SAPHRIS 72 SIDESTREAM PEDIATRIC SERNIVO 103 FACEMASK/SAMI THE sapropterin dihydrochloride 112 SEROQUEL 72 SEAL 179 SARAFEM 203 SEROQUEL XR 72 SIDESTREAM PEDIATRIC SAVAYSA 37 SEROSTIM 111 FACEMASK/TUCKER THE SAVELLA 202 TURTLE 179 sertraline hcl 43 SIDESTREAM PLUS ADULT SAVELLA TITRATION sevelamer carbonate 116 FACE MASK 179 PACK 202 sevelamer hcl 116 SIGNIFOR 112

Index 42 SIGNIFOR LAR 112 SM STERILE PADS 127 SOMAVERT 110 SIKLOS 120 SM TRUEDRAW LANCING SOOLANTRA 107 SILA III 103 DEVICE 135 SOOTHEE 106 SMART DIABETES VANTAGE sildenafil citrate (pulmonary LANCING DEVICE 135 SOOTHENEB NBL 100 CHILD hypertension) 85 SMART SENSE COLOR MASK 179 SILENOR 122 LANCETS UNIVERSAL SOOTHENEB NBL 100 SILICONE MASK FOR 33G 135 MEDICATION CUP 179 BREATHERITE SMART SENSE STANDARD SOOTHENEB NBL 100 MESH CHAMBER/ADULT 179 LANCETS UNIVERSAL CAP 179 SOOTHENEB NBL100 ADULT SILICONE MASK FOR 21G 135 BREATHERITE SMART SENSE SUPER THIN MASK 179 CHAMBER/INFANT 179 LANCETS UNIVERSAL SORIATANE 99 SILICONE MASK FOR 30G 135 SORILUX 99 BREATHERITE SMART SENSE THIN sotalol hcl 82 CHAMBER/PEDIATRIC 179 LANCETSUNIVERSAL sotalol hcl (afib/afl) 82 SILICONE MASK FOR 26G 135 SOTALOL BREATHRITE SODIUM BICARBONATE 29 CHAMBER/ADULT 179 HYDROCHLORIDE 82 sodium chloride (gu SOTYLIZE 82 SILIQ 99 irrigant) 117 silodosin 117 sodium chloride (inhalant) 91 SOVALDI 80 SILVADENE 99 sodium citrate & citric spinosad 107 silver sulfadiazine 99 acid 116 SPINRAZA 192 SIMBRINZA 194 SODIUM DIURIL 109 SPIRIVA HANDIHALER 34 simethicone 114 SODIUM EDECRIN 109 SPIRIVA RESPIMAT 34 SIMPLE DIAGNOSTICS sodium fluoride 182 SPIRO PD 179 LANCING DEVICE 135 sodium fluoride (dental) 184 spironolactone 109 SIMPONI 20 sodium phenylbutyrate 112 spironolactone & SIMPONI ARIA 20 sodium phosphates 124 hydrochlorothiazide 108 SIMVASTATIN 55 sodium polystyrene SPORANOX 52 simvastatin 55 sulfonate 184 SPORANOX PULSEPAK 52 SODIUM SPRITAM 40 SINEMET 66 SULFACETAMIDE/SULFUR SINGULAIR 34 94 SPRIX 22 sirolimus 184 SODIUM SPRYCEL 64 SIRTURO 60 SULFACETAMIDE/SULFUR STALEVO 100 66 CLEANSER IN UREA 94 STALEVO 125 66 SITAVIG 80 SOF-WICK 4"X4" 127 STALEVO 150 66 SIVEXTRO 31 SOFOSBUVIR/VELPATASVIR SKELAXIN 191 80 STALEVO 200 66 SKLICE 107 SOLARAVIX 98 STALEVO 50 66 SKYADERM-LP 106 solifenacin succinate 210 STALEVO 75 66 SKYLA 88 SOLIQUA 100/33 45 stannous fluoride 184 SKYRIZI 99 SOLIRIS 119 STARLIX 49 SKYRIZI PEN 99 SOLODYN 205 stavudine 78 SLYND 88 SOLOSEC 19 STAVUDINE 78 SM ALCOHOL PREP SOLTAMOX 62 STEGLATRO 49 PADS 138 SOLU-CORTEF 90 STEGLUJAN 45 SM GAUZE PADS 4"X4" 127 SOLU-MEDROL 90 STELARA 99,115 SM GLUCOSE 46 SOLUS V2 LANCING STERILANCE TL 135 SM MICRO THIN LANCETS DEVICE 135 STERILE PADS 4"X4" 127 33G 135 SOMA 191 SM PRENATAL VITAMINS 190 STIMATE 112 SOMATULINE DEPOT 112 STIOLTO RESPIMAT 36

Index 43 STIVARGA 64 SURE COMFORT INSULIN SURE COMFORT PEN STRATTERA 9 SYRINGE/U-100/0.3ML/29G X NEEDLES32GX5/32" 164 1/2" 163 SURE COMFORT PEN STRENSIQ 112 SURE COMFORT INSULIN NEEDLES32GX6MM 164 streptomycin sulfate 19 SYRINGE/U-100/0.3ML/30G X SURE RESULT O3D3 STRIBILD 78 1/2" 163 SYSTEM 53 SURE COMFORT INSULIN SURE-FINE PEN NEEDLES STRIVERDI RESPIMAT 36 SYRINGE/U-100/0.3ML/30G X 29GX1/2" 12.7MM 164 STROMECTOL 29 5/16" 164 SURE-FINE PEN NEEDLES STROVITE FORTE 186 SURE COMFORT INSULIN 31GX3/16" 5MM 164 STROVITE ONE 186 SYRINGE/U-100/0.3ML/31G X SURE-FINE PEN NEEDLES 5/16 164 31GX5/16" 8MM 164 SUBLOCADE 27 SURE COMFORT INSULIN SURE-JECT INSULIN SUBOXONE 27,28 SYRINGE/U-100/0.3ML/31G X SYRINGE/U-100/0.3ML/29G X SUBSYS 26 5/16" 164 1/2" 164 SURE-JECT INSULIN sucralfate 208 SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/28G X SYRINGE/U-100/0.3ML/30G X SUDAFED PE CHILDRENS 1/2" 164 5/16" 164 NASAL DECONGESTANT 192 SURE COMFORT INSULIN SURE-JECT INSULIN SULAR 83 SYRINGE/U-100/0.5ML/29G X SYRINGE/U-100/0.3ML/31G X sulconazole nitrate 97 1/2" 164 5/16" 164 sulfacetamide sod- SURE COMFORT INSULIN SURE-JECT INSULIN prednisolone 197 SYRINGE/U-100/0.5ML/30G X SYRINGE/U-100/0.5ML/28G X sulfacetamide sodium 99 1/2" 164 1/2" 164 SURE COMFORT INSULIN SURE-JECT INSULIN sulfacetamide sodium (acne)94 SYRINGE/U-100/0.5ML/30G X SYRINGE/U-100/0.5ML/29G X sulfacetamide sodium 5/16" 164 1/2" 165 (ophth) 195 SURE COMFORT INSULIN SURE-JECT INSULIN sulfacetamide sodium w/ SYRINGE/U-100/0.5ML/31G X SYRINGE/U-100/0.5ML/30G X sulfur 94 5/16 164 5/16" 165 sulfacetamide sodium-sulfur in SURE COMFORT INSULIN SURE-JECT INSULIN urea vehicle 94 SYRINGE/U-100/1ML/28G X SYRINGE/U-100/0.5ML/31G X SULFADIAZINE 205 1/2" 164 5/16" 165 sulfamethoxazole-trimethoprim SURE COMFORT INSULIN SURE-JECT INSULIN 30 SYRINGE/U-100/1ML/29G X SYRINGE/U-100/1ML/28G X SULFAMYLON 99 1/2" 164 1/2" 165 sulfasalazine 115 SURE COMFORT INSULIN SURE-JECT INSULIN SYRINGE/U-100/1ML/30G X SYRINGE/U-100/1ML/29G X SULFURATED LIME 107 1/2" 164 1/2" 165 sulindac 22 SURE COMFORT INSULIN SURE-JECT INSULIN SUMADAN WASH 94 SYRINGE/U-100/1ML/30G X SYRINGE/U-100/1ML/30G X sumatriptan 181 5/16" 164 5/16" 165 SURE COMFORT INSULIN SURE-JECT INSULIN sumatriptan succinate 181 SYRINGE/U-100/1ML/31G X SYRINGE/U-100/1ML/31G X sumatriptan-naproxen 5/16" 164 5/16" 165 sodium 180 SURE COMFORT LANCING SURE-PEN 136 SUMAXIN 94 PEN 136 SURELITE LANCETS 136 SURE COMFORT PEN SUMAXIN WASH 94 SUSTIVA 78 sunitinib malate 64 NEEDLES29GX1/2" 12.7MM 164 SUSTOL 50 SUNOSI 9 SURE COMFORT PEN SUTAB 123 SUPER THIN LANCETS 136 NEEDLES30GX5/16" SUTENT 64 SUPPRELIN LA 111 SHORT 164 SURE COMFORT PEN SX1 MEDICATED POST- SUPRAX 86 NEEDLES31GX3/16" OPERATIVE SYSTEM 106 SUPREP BOWEL PREP (5MM) 164 SYMAX DUOTAB 208 KIT 123 SURE COMFORT PEN SYMBICORT 36 NEEDLES31GX5/16" SYMBYAX 202 (8MM) 164

Index 44 SYMDEKO 204 TALZENNA 64 TECHLITE INSULIN SYRINGEU- SYMFI 79 TAMIFLU 80 100/1ML/29G X 1/2" 165 TECHLITE INSULIN SYRINGEU- SYMFI LO 79 tamoxifen citrate 62 100/1ML/30G X 1/2" 165 SYMJEPI 214 tamsulosin hcl 117 TECHLITE INSULIN SYRINGEU- SYMLINPEN 120 44 TAPAZOLE 206 100/1ML/30G X 5/16" 165 TECHLITE INSULIN SYRINGEU- SYMLINPEN 60 44 TARCEVA 61 100/1ML/31G X 5/16" 165 SYMPAZAN 38 TARDEOXIA 94 TECHLITE LANCETS 136 SYMPROIC 116 TARDIMAXIA 94 TECHLITE LANCETS 30G 136 SYMTUZA 79 TARGRETIN 64,98 TECHLITE PEN NEEDLES 29GX SYNAGIS 199 TARKA 58 12 MM 165 SYNALAR 103 TAROXIA 94 TECHLITE PEN NEEDLES 31GX 5MM 165 SYNALAR CREAM KIT 103 TASIGNA 64 TECHLITE PEN NEEDLES/31GX SYNALAR OINTMENT KIT 103 TASMAR 65 5MM 165 SYNALAR TS 103 TASOPROL 103 TECHLITE PEN NEEDLES/31GX 6 MM 165 SYNAPRYN FUSEPAQ 26 tavaborole 97 TECHLITE PEN NEEDLES/31GX SYNAREL 111 TAVALISSE 119 8MM 165 SYNDROS 51 TAYTULLA 87 TECHLITE PEN NEEDLES/32GX 4MM 165 SYNERA 106 TAZAROTENE 94 TECHLITE PEN NEEDLES/32GX SYNJARDY 45 tazarotene 99 6MM 166 SYNJARDY XR 45 TAZICEF 86 TECHLITE PEN NEEDLES/32GX SYNTHROID 206 TAZORAC 99 8MM 166 TEGADERM FOAM DRESSING SYNVEXIA TC 106 TDVAX 207 4"X4" 127 SYPRINE 183 TECARTUS 61 TEGRETOL 40 SYRINGE/BLUNT PLASTIC TECFIDERA 203 TEGRETOL-XR 40 CANNULA 165 TECFIDERA STARTER TEGSEDI 204 SYRINGE/LUER PACK 203 LOCK/3ML 165 TECHLITE AST TEKTURNA 59 SYRINGE/LUER SLIP/3ML 165 LANCETS 136 TEKTURNA HCT 58 SYRINGES/LUER TECHLITE INSULIN telmisartan 56 LOCK/WITHOUT SYRINGEU-100/0.3ML/29G X telmisartan-amlodipine 58 NEEDLE/3ML 165 1/2" 165 TECHLITE INSULIN telmisartan-hydrochlorothiazide TABLOID 61 58 TABRADOL FUSEPAQ 191 SYRINGEU-100/0.3ML/30G X 1/2" 165 temazepam 123 TABRADOL RAPIDPAQ 191 TECHLITE INSULIN TEMIXYS 79 TABRECTA 64 SYRINGEU-100/0.3ML/30G X TEMODAR 60 TACLONEX 103 5/16" 165 TECHLITE INSULIN TEMOVATE 103 tacrolimus 184 SYRINGEU-100/0.3ML/31G X temozolomide 60 tacrolimus (topical) 104 5/16" 165 TENIVAC 207 TACROLIMUS TECHLITE INSULIN tenofovir disoproxil fumarate 79 MONOHYDRATE 104 SYRINGEU-100/0.5ML/29G X tadalafil 84 1/2" 165 TENORETIC 100 58 tadalafil (pulmonary TECHLITE INSULIN TENORETIC 50 58 hypertension) 85 SYRINGEU-100/0.5ML/30G X TENORMIN 82 TAFINLAR 64 1/2" 165 TECHLITE INSULIN TEPMETKO 64 TAGRISSO 61 SYRINGEU-100/0.5ML/30G X terazosin hcl 57 TAKHZYRO 119 5/16" 165 terbinafine hcl 52 TALICIA 210 TECHLITE INSULIN terbutaline sulfate 36 TALTZ 99 SYRINGEU-100/0.5ML/31G X 5/16" 165 terconazole vaginal 213

Index 45 TERIPARATIDE 110 TIGLUTIK 192 TOLAK 98 TESTIM 28 TIKOSYN 33 tolbutamide 49 TESTOPEL 28 timolol maleate 82 tolcapone 65 testosterone 28 timolol maleate tolmetin sodium 22 TESTOSTERONE 28 (ophth) 193,194 TOLSURA 52 TIMOLOL/BRIMONIDE/DORZ testosterone 28 OLAMIDE 194 tolterodine tartrate 210 TESTOSTERONE TIMOLOL/BRIMONIDINE/DOR tolvaptan 113 CYPIONATE 28 ZOLAMIDE/LATANOPROST TOPAMAX 40 testosterone cypionate 28 194 TIMOLOL/DORZOLAMIDE/LAT TOPAMAX SPRINKLE 40 testosterone enanthate 28 TOPCARE CLICKFINE TETANUS/DIPHTHERIA ANOPROST 194 TIMOLOL/LATANOPROST UNIVERSAL PEN EEDLES TOXOIDS-ADSORBED 31GX1/4" 166 ADULT 207 194 TIMOPTIC 194 TOPCARE CLICKFINE tetrabenazine 202 UNIVERSAL PEN EEDLES tetracaine hcl (ophth) 196 TIMOPTIC OCUDOSE 194 31GX5/16" 166 tetracycline hcl 205 TIMOPTIC-XE 194 TOPCARE ULTRA COMFORT tinidazole 30 INSULIN SYRINGE/0.3ML/30G X TEXACORT 103 5/16" 166 TGT ALCOHOL SWABS 138 tiopronin 117 TOPCARE ULTRA COMFORT TGT LANCET MICRO THIN TIROSINT 206 INSULIN SYRINGE/0.3ML/31G X 33G 136 TIROSINT-SOL 206 5/16" 166 TGT LANCET THIN 26G 136 TIVICAY 79 TOPCARE ULTRA COMFORT INSULIN SYRINGE/0.5ML/30G X TGT LANCET ULTRA THIN TIVICAY PD 79 30G 136 5/16" 166 TIVORBEX 22 TGT LANCING DEVICE 136 TOPCARE ULTRA COMFORT TIZANIDINE COMFORT INSULIN SYRINGE/0.5ML/31G X THALOMID 183 PAC 191 5/16" 166 THEO-24 37 tizanidine hcl 191 TOPCARE ULTRA COMFORT theophylline 37 TNKASE 120 INSULIN SYRINGE/1ML/30G X 5/16" 166 THEOPHYLLINE/D5W 37 TOBI 19 TOPCARE ULTRA COMFORT THERANATAL CORE TOBI PODHALER 19 INSULIN SYRINGE/1ML/31G X NUTRITION 190 TOBRADEX 197 5/16" 166 thiamine hcl 214 TOPCARE ULTRA COMFORT TOBRADEX ST 197 THINLETS GP LANCETS 136 INSULIN SYRINGE/U- tobramycin 19 THIOLA 117 100/0.3ML/29G X 1/2" 166 tobramycin (ophth) 195 TOPCARE ULTRA COMFORT THIOLA EC 117 tobramycin sulfate 19 INSULIN SYRINGE/U- thioridazine hcl 74 tobramycin- 100/0.5ML/29G X 1/2" 166 TOPCARE ULTRA COMFORT thiothixene 76 dexamethasone 197 THRESHOLD IMT 179 INSULIN SYRINGE/U- TOBREX 195 100/1ML/29G X 1/2" 166 THRESHOLD PEP 179 TODAYS HEALTH ADVANCED TOPICORT 103 THRIVITE 19 186 LANCING DEVICE 136 TODAYS HEALTH MINI PEN TOPIDEX 90 THRIVITE RX 190 NEEDLES 31G X 1/4" 166 topiramate 40 THYQUIDITY 206 TODAYS HEALTH ORIGINAL TOPPER DRESSING SPONGES thyroid 206 PEN NEEDLES 29G X 4"X4" 127 tiagabine hcl 41 1/2" 166 TOPROL XL 82 TODAYS HEALTH SHORT TIAZAC 83 PEN NEEDLES 31G X toremifene citrate 62 TIBSOVO 64 5/16" 166 TORONOVA II SUIK 22 TIGAN 51 TODAYS HEALTH SUPER TORONOVA SUIK 22 THINLANCETS 30G 136 torsemide 109 tigecycline 205 TODAYS HEALTH ULTRA TIGECYCLINE 205 THINLANCETS 28G 136 TOSYMRA 181 TOUJEO MAX SOLOSTAR 49

Index 46 TOUJEO SOLOSTAR 49 TRIAMINIC FEVER trospium chloride 211 TOVET KIT 103 REDUCERPAIN RELIEVER TRUE COMFORT INSULIN CHILDRENS 23 TOVIAZ 210 SYRINGE/0.5ML/31G X TRIAMINIC FEVER 5/16" 166 TRACLEER 84 REDUCERPAIN RELIEVER TRUE COMFORT INSULIN TRADJENTA 46 INFANTS 23 SYRINGE/1ML/31G X tramadol hcl 26 TRIAMSIL COMBIPAK 103 5/16" 166 TRUE COMFORT PEN tramadol-acetaminophen 27 TRIAMSIL MULTIPAK 103 triamterene 109 NEEDLES31G X 5MM 166 trandolapril 56 TRUE COMFORT PEN triamterene & NEEDLES31G X 6MM 166 trandolapril-verapamil hcl 58 hydrochlorothiazide 108 tranexamic acid 122 TRUE COMFORT PEN triazolam 123 NEEDLES32G X 4MM 166 TRANEXAMIC ACID/SODIUM TRIBENZOR 58 TRUE COMFORT PRO CHLORIDE 122 TRICOR 54 INSULINSYRINGE/0.5ML/30G X TRANSDERM SCOP 51 5/16" 166 TRANSDERM-SCOP 51 TRIDESILON 103 TRUE COMFORT PRO TRANXENE T 33 trientine hcl 183 INSULINSYRINGE/0.5ML/31G X tranylcypromine sulfate 42 TRIESENCE 197 5/16" 166 trifluoperazine hcl 74 TRUE COMFORT PRO TRAVATAN Z 198 INSULINSYRINGE/1ML/30G X travoprost 198 trifluridine 195 5/16" 166 trazodone hcl 43 TRIGLIDE 54 TRUE COMFORT PRO trihexyphenidyl hcl 65 INSULINSYRINGE/1ML/31G X TRECATOR 60 5/16" 166 TRELEGY ELLIPTA 36 TRIJARDY XR 45 TRUE COMFORT PRO TRELSTAR MIXJECT 62 TRIKAFTA 204 INSULINSYRINGE/U- TREMFYA 99 TRILEPTAL 40 100/0.5ML/30G X 1/2" 166 TRILIPIX 54 TRUE COMFORT PRO TRESIBA 49 INSULINSYRINGE/U- TRESIBA FLEXTOUCH 49 trimethobenzamide hcl 51 100/1ML/30G X 1/2" 166 tretinoin 94 trimethoprim 30 TRUE COMFORT PRO PEN NEEDLES 31G X 5MM 167 tretinoin (chemotherapy) 64 trimipramine maleate 44 TRINATAL RX 1 190 TRUE COMFORT PRO PEN tretinoin microsphere 94 NEEDLES 31G X 6MM 167 TRETTEN 118 TRINTELLIX 43 TRUE COMFORT PRO PEN TRIPLE COMPLEX FORMULA TREXALL 61 NEEDLES 31G X 8MM 167 3KIT 95 TRUE COMFORT PRO PEN TREXIMET 180 TRIPLE PMB 197 NEEDLES 32G X 4MM 167 TRI-VI-SOL A/C/D 188 TRIPLE PMK 197 TRUE COMFORT PRO PEN TRIAMCINOLONE 90 NEEDLES 32G X 5MM 167 TRIPTODUR 111 TRUE COMFORT PRO PEN triamcinolone acetonide 90 TRIUMEQ 79 NEEDLES 32G X 6MM 167 TRIAMCINOLONE TRIZIVIR 79 TRUE COMFORT PRO PEN ACETONIDE 90 NEEDLES 33G X 4MM 167 triamcinolone acetonide TROGARZO 79 TRUE METRIX BLOOD (mouth) 184 TROKENDI XR 40 GLUCOSETEST STRIPS 108 triamcinolone acetonide tropicamide 194 TRUE METRIX CONTROL (nasal) 192 TROPICAMIDE/CYCLOPENTO SOLUTION LEVEL 1 136 triamcinolone acetonide TRUE METRIX CONTROL 103 LATE (topical) HYDROCHLORIDE/PHENYLE SOLUTION LEVEL 2 136 TRIAMCINOLONE ACETONIDE TRUE METRIX CONTROL 90 PHRINE HYDRO 194 PF TROPICAMIDE/CYCLOPENTO SOLUTION LEVEL 3 136 triamcinolone acetonide- TRUE METRIX SELF 103 LATE/PHENYLEPHRINE 194 dimethicone-silicone TROPICAMIDE/PHENYLEPHR MONITORING BLOOD TRIAMCINOLONE GLUCOSE STRIPS 108 90 INE 194 DIACETATE TROPICAMIDE/PROPARACAI TRUECONTROL GLUCOSE NE/PHENYLEPHRINE/KETOR CONTROL LEVEL 0 136 OLAC 194

Index 47 TRUECONTROL GLUCOSE TRUEPLUS PEN NEEDLES TUDORZA PRESSAIR 34 CONTROL LEVEL 1 136 29GX12MM 167 TUKYSA 61 TRUEDRAW LANCING TRUEPLUS PEN NEEDLES DEVICE 136 31GX5MM 167 TURALIO 64 TRUEPLUS 5-BEVEL PEN TRUEPLUS PEN NEEDLES TWINRIX 212 NEEDLES 29GX12.7MM 167 31GX6MM 167 TWIRLA 88 TRUEPLUS 5-BEVEL PEN TRUEPLUS PEN NEEDLES NEEDLES 31GX5MM 167 31GX8MM 167 TWYNSTA 58 TRUEPLUS 5-BEVEL PEN TRUEPLUS PEN NEEDLES TYBLUME 87 NEEDLES 31GX6MM 167 32GX4MM 167 TYBOST 79 TRUEPLUS 5-BEVEL PEN TRUETRACK BLOOD TYGACIL 205 NEEDLES 31GX8MM 167 GLUCOSE TEST 108 TRUEPLUS 5-BEVEL PEN TRUETRACK TEST 108 TYKERB 64 NEEDLES 32GX4MM 167 TRULANCE 114 TYLENOL 24 TRUEPLUS INSULIN TRULICITY 46 TYLENOL 8 HOUR 23 SYRINGE/U-100/0.3ML/29G X TYLENOL 8 HOUR 1/2" 167 TRUMENBA 211 ARTHRITISPAIN 23 TRUEPLUS INSULIN TRUSELTIQ 64 SYRINGE/U-100/0.3ML/30G X TYLENOL CHILDRENS 24 5/16" 167 TRUSOPT 198 TYLENOL CHILDRENS TRUEPLUS INSULIN TRUSTEX COLOR CONDOMS CHEWABLES/PAIN + SYRINGE/U-100/0.3ML/31G X + LUBE 128 FEVER 24 5/16" 167 TRUSTEX LUBRICATED 128 TYLENOL EXTRA TRUEPLUS INSULIN TRUSTEX LUBRICATED STRENGTH 24 SYRINGE/U-100/0.5ML/28G X EXTRALARGE 128 TYLENOL FOR 1/2" 167 TRUSTEX LUBRICATED CHILDREN/ADULTS 24 TRUEPLUS INSULIN EXTRASTRENGTH 128 TYLENOL INFANTS 24 SYRINGE/U-100/0.5ML/29G X TRUSTEX TYLENOL INFANTS 1/2" 167 LUBRICATED/RIBBED/STUDD PAIN+FEVER 24 TRUEPLUS INSULIN ED 128 TYMLOS 110 SYRINGE/U-100/0.5ML/30G X TRUSTEX TYSABRI 203 5/16" 167 LUBRICATED/SPERMICIDE TRUEPLUS INSULIN 128 TYVASO 84 SYRINGE/U-100/0.5ML/31G X TRUSTEX TYVASO REFILL 84 5/16" 167 LUBRICATED/SPERMICIDE TYVASO STARTER 84 EXTRA LARGE 128 TRUEPLUS INSULIN UBRELVY 180 SYRINGE/U-100/1ML/28G X TRUSTEX 1/2" 167 LUBRICATED/SPERMICIDE UCERIS 29,90 TRUEPLUS INSULIN EXTRA STRENGTH 128 UDAMIN SP 186 SYRINGE/U-100/1ML/29G X TRUSTEX NATURAL UDENYCA 121 1/2" 167 CONDOMS TRUEPLUS INSULIN +LUBE/LUBRICATED 128 UKONIQ 64 SYRINGE/U-100/1ML/30G X TRUSTEX NON- ULORIC 118 5/16" 167 LUBRICATED 128 ULTI-LANCE AUTOMATIC/ TRUEPLUS INSULIN TRUSTEX WITH CLEAR TIP 136 SYRINGE/U-100/1ML/31G X NONOXYNOL- ULTICARE INSULIN SAFETY 5/16" 167 9/RIBBED/STUDDED 128 SYRINGE/0.5ML/29G X TRUEPLUS LANCETS TRUSTEX/RIA 1/2" 167 26G 136 LUBRICATED 128 ULTICARE INSULIN SAFETY TRUEPLUS LANCETS TRUSTEX/RIA LUBRICATED SYRINGE/1ML/29G X 1/2" 168 28G 136 SPERMICIDE 128 ULTICARE INSULIN TRUEPLUS LANCETS 28G TRUSTEX/RIA SYRINGE/0.3ML/29G X SUPER THIN 136 LUBRICATED/SPERMICIDE 1/2" 168 TRUEPLUS LANCETS 128 ULTICARE INSULIN 30G 136 TRUSTEX/RIA NON- SYRINGE/0.3ML/30G X TRUEPLUS LANCETS 30G LUBRICATED 129 1/2" 168 ULTRA THIN 136 TRUVADA 79 ULTICARE INSULIN TRUEPLUS LANCETS TUBING/WING TIP 180 SYRINGE/0.3ML/30G X 33G 136 5/16" 168

Index 48 ULTICARE INSULIN ULTICARE INSULIN ULTIGUARD SAFEPACK SYRINGE/0.5ML/28G X SYRINGEULTRAFINE U- INSULIN SYRINGE/0.3ML/30G X 1/2" 168 100/0.3ML/31G X 5/16" 168 1/2"/SHARPS C 169 ULTICARE INSULIN ULTICARE INSULIN ULTIGUARD SAFEPACK SYRINGE/0.5ML/29G X SYRINGEULTRAFINE U- INSULIN SYRINGE/0.3ML/31G X 1/2" 168 100/0.5ML/31G X 5/16" 168 5/16"/SHARPS 169 ULTICARE INSULIN ULTICARE INSULIN ULTIGUARD SAFEPACK SYRINGE/0.5ML/30G X SYRINGEULTRAFINE U- INSULIN SYRINGE/0.5ML/30G X 1/2" 168 100/1ML/31G X 5/16" 168 1/2"/SHARPS C 169 ULTICARE INSULIN ULTICARE MICRO PEN ULTIGUARD SAFEPACK MINI SYRINGE/0.5ML/30G X NEEDLES 31G X 8MM 168 PEN NEEDLE/31G X 5/16" 168 ULTICARE MICRO PEN 3/16"/SHARPS CONTAI 169 ULTICARE INSULIN NEEDLES 32G X 4MM 169 ULTIGUARD SAFEPACK PEN SYRINGE/1ML/28G X 1/2" 168 ULTICARE MICRO PEN NEEDLE/29G X 1/2"/SHARPS ULTICARE INSULIN NEEDLES/31G X 1/4" 169 CONTAINER 169 SYRINGE/1ML/29G X 1/2" 168 ULTICARE MICRO PEN ULTIGUARD ULTICARE INSULIN NEEDLES/31G X 5/16" 169 SAFEPACK/MICROPEN SYRINGE/1ML/30G X 1/2" 168 ULTICARE MICRO PEN NEEDLE/32G X 5/32" 169 ULTICARE INSULIN NEEDLES/32G X 4MM 169 ULTIGUARD SYRINGE/1ML/30G X ULTICARE MICRO PEN SAFEPACK/MICROPEN 5/16" 168 NEEDLES/32G X 5/32" 169 NEEDLE/32G X 5/32"/SHARPS ULTICARE INSULIN ULTICARE MINI PEN CONTA 169 SYRINGE/SHORT/0.3ML/30G X NEEDLES 31GX6MM 169 ULTIGUARD SAFEPACK/MINI 5/16" 168 ULTICARE MINI PEN PEN NEEDLE/31G X ULTICARE INSULIN NEEDLES ULTI-FINE IV 169 1/4"/SHARPS CONTAIN 170 SYRINGE/SHORT/0.3ML/31G X ULTICARE MINI PEN ULTIGUARD SAFEPACK/MINI 5/16" 168 NEEDLES/31G X 6MM 169 PEN NEEDLE/31G X ULTICARE INSULIN ULTICARE MINI PEN 3/16"/SHARPS CONTAI 170 SYRINGE/SHORT/0.5ML/30G X NEEDLES/32G X 1/4" 169 ULTIGUARD SAFEPACK/MINI 5/16" 168 ULTICARE MINI PEN PEN NEEDLE/32G X ULTICARE INSULIN NEEDLES31GX6MM 169 1/4"/SHARPS CONTAIN 170 SYRINGE/SHORT/0.5ML/31G X ULTICARE ORIGINAL PEN ULTIGUARD 5/16" 168 NEEDLES ULTI-FINE 169 SAFEPACK/SHORTPEN ULTICARE INSULIN ULTICARE PEN NEEDLES NEEDLE/31G X 5/16"/SHARPS SYRINGE/SHORT/1ML/30G X 31GX 5MM/MINI 169 CONTA 170 5/16" 168 ULTICARE PEN ULTIGUARD ULTICARE INSULIN NEEDLES/29GX 12.7MM 169 SAFEPACK/SYRINGE/NEEDLE/ SYRINGE/SHORT/1ML/31G X ULTICARE SHORT PEN 31G X 5/16"/SHARPS 5/16" 168 NEEDLES 31GX8MM 169 CONTAIN 170 ULTICARE INSULIN ULTICARE SHORT PEN ULTILET CLASSIC SYRINGE/U-100/0.3ML/30G X NEEDLES ULTI-FINE IV 169 LANCETS 136 1/2" 168 ULTICARE SHORT PEN ULTILET INSULIN ULTICARE INSULIN NEEDLES/31G X 8MM 169 SYRINGE/0.3ML/30G X SYRINGE/U-100/0.3ML/31G X ULTICARE SHORT SAFETY 8MM 170 5/16" 168 PEN NEEDLES 30G X ULTILET INSULIN ULTICARE INSULIN 5/16" 169 SYRINGE/0.3ML/31G X SYRINGE/U-100/0.5ML/30G X ULTIGUARD SAFEPACK 8MM 170 1/2" 168 INSULIN SYRINGE 0.3ML/30G ULTILET INSULIN ULTICARE INSULIN X 1/2"/SHARPS C 169 SYRINGE/0.5ML/30G X SYRINGE/U-100/0.5ML/31G X ULTIGUARD SAFEPACK 8MM 170 5/16" 168 INSULIN SYRINGE 1/2ML 30G ULTILET INSULIN ULTICARE INSULIN X 1/2"/SHARPS C 169 SYRINGE/1ML/30G X 8MM170 SYRINGE/U-100/1ML/30G X ULTIGUARD SAFEPACK ULTILET INSULIN 1/2" 168 INSULIN SYRINGE 1ML 30G X SYRINGE/1ML/31G X 8MM170 ULTICARE INSULIN 1/2"/SHARPS CON 169 ULTILET INSULIN SYRINGE/U-100/1ML/31G X ULTIGUARD SAFEPACK SYRINGE/SHORT/0.3ML/30G X 5/16" 168 INSULIN SYRINGE 1ML 31G X 12.7MM 170 5/16"/SHARPS CO 169

Index 49 ULTILET INSULIN ULTRA FLO INSULIN ULTRA-COMFORT INSULIN SYRINGE/SHORT/0.3ML/30G X SYRINGE SYRINGE/U-100/1ML/29G X 5/16" 170 0.5ML/29GX1/2" 171 1/2" 171 ULTILET INSULIN ULTRA FLO INSULIN ULTRA-COMFORT INSULIN SYRINGE/SHORT/0.3ML/31G X SYRINGE SYRINGE/U-100/1ML/30G X 5/16" 170 0.5ML/30GX1/2" 171 5/16" 171 ULTILET INSULIN ULTRA FLO INSULIN ULTRA-COMFORT INSULIN SYRINGE/SHORT/0.5ML/30G X SYRINGE SYRINGE/U-100/1ML/31G X 5/16" 170 0.5ML/30GX5/16" 171 5/16" 172 ULTILET INSULIN ULTRA FLO INSULIN ULTRA-THIN II INSULIN SYRINGE/SHORT/0.5ML/31G X SYRINGE SYRINGE SHORT/U- 5/16" 170 0.5ML/31GX5/16" 171 100/0.3ML/30GX5/16" 172 ULTILET INSULIN ULTRA FLO INSULIN ULTRA-THIN II INSULIN SYRINGE/SHORT/1ML/30G X SYRINGE 1/2 SYRINGE SHORT/U- 5/16" 170 UNIT/0.3ML/30GX1/2" 171 100/0.3ML/31GX5/16" 172 ULTILET INSULIN ULTRA FLO INSULIN ULTRA-THIN II INSULIN SYRINGE/SHORT/1ML/31G X SYRINGE 1/2 SYRINGE SHORT/U- 5/16" 170 UNIT/0.3ML/30GX5/16" 171 100/0.5ML/30GX5/16" 172 ULTILET INSULIN SYRINGE/U- ULTRA FLO INSULIN ULTRA-THIN II INSULIN 100/0.5ML/30G X 1/2" 170 SYRINGE 1/2 SYRINGE SHORT/U- ULTILET INSULIN SYRINGE/U- UNIT/0.3ML/31GX5/16" 171 100/0.5ML/31GX5/16" 172 100/1ML/30G X 1/2" 170 ULTRA FLO INSULIN ULTRA-THIN II INSULIN ULTILET PEN NEEDLE SYRINGE 1M/29GX1/2" 171 SYRINGE SHORT/U- 29GX12.7MM 170 ULTRA FLO INSULIN 100/1ML/30GX5/16" 172 ULTILET PEN NEEDLE SYRINGE 1ML/30GX1/2" 171 ULTRA-THIN II INSULIN 31GX5MM 170 ULTRA FLO INSULIN SYRINGE SHORT/U- ULTILET PEN NEEDLE SYRINGE 100/1ML/31GX5/16" 172 31GX8MM 170 1ML/30GX5/16" 171 ULTRA-THIN II INSULIN ULTILET PEN NEEDLE ULTRA FLO INSULIN SYRINGE/U- 32GX4MM 170 SYRINGE 100/0.5ML/29GX1/2" 172 ULTILET PEN NEEDLE 1ML/31GX5/16" 171 ULTRA-THIN II INSULIN 32GX4MM/SHORT 170 ULTRA THIN PEN NEEDLES SYRINGE/U-100/1ML/29GX1/2" ULTILET SHORT PEN 32G X 4MM 171 172 NEEDLES 31GX5/16" 170 ULTRA-COMFORT INSULIN ULTRA-THIN II MINI PEN ULTILET SHORT PEN SYRINGE/U-100/0.3ML/29G X NEEEDLES/31GX3/16" 172 NEEDLES31GX3/16" 170 1/2" 171 ULTRA-THIN II PEN NEEDLES ULTOMIRIS 119 ULTRA-COMFORT INSULIN 29GX1/2" 172 ULTRA COMFORT INSULIN SYRINGE/U-100/0.3ML/30G X ULTRA-THIN II PEN SYRINGE/U-100/0.3ML/30G X 5/16" 171 NEEDLES/SHORT/31GX5/16" 5/16" 170 ULTRA-COMFORT INSULIN 172 ULTRA FLO INSULIN PEN SYRINGE/U-100/0.3ML/31G X ULTRACARE INSULIN NEEDLE 31GX5MM 170 5/16" 171 SYRINGE/U-100/0.3ML/30G X ULTRA FLO INSULIN PEN ULTRA-COMFORT INSULIN 5/16" 172 NEEDLE 32GX4MM 170 SYRINGE/U-100/0.5ML/28G X ULTRACARE INSULIN ULTRA FLO INSULIN PEN 1/2" 171 SYRINGE/U-100/0.3ML/31G X NEEDLE 33GX4MM 170 ULTRA-COMFORT INSULIN 5/16" 172 ULTRA FLO INSULIN PEN SYRINGE/U-100/0.5ML/29G X ULTRACARE INSULIN NEEDLES 171 1/2" 171 SYRINGE/U-100/0.5ML/30G X ULTRA FLO INSULIN PEN ULTRA-COMFORT INSULIN 1/2" 172 NEELE 31GX8MM 171 SYRINGE/U-100/0.5ML/30G X ULTRACARE INSULIN ULTRA FLO INSULIN SYRINGE 5/16" 171 SYRINGE/U-100/0.5ML/30G X 0.3ML/29G X 1/2" 171 ULTRA-COMFORT INSULIN 5/16" 172 ULTRA FLO INSULIN SYRINGE SYRINGE/U-100/0.5ML/31G X ULTRACARE INSULIN 0.3ML/30GX1/2" 171 5/16" 171 SYRINGE/U-100/0.5ML/31G X ULTRA FLO INSULIN SYRINGE ULTRA-COMFORT INSULIN 5/16" 172 0.3ML/30GX5/16" 171 SYRINGE/U-100/1ML/28G X ULTRACARE INSULIN ULTRA FLO INSULIN SYRINGE 1/2" 171 SYRINGE/U-100/1ML/30G X 0.3ML/31GX5/16" 171 1/2" 172

Index 50 ULTRACARE INSULIN UNIFINE SAFECONTROL PEN valsartan-hydrochlorothiazide SYRINGE/U-100/1ML/30G X NEEDLE/30G X 5/16" 173 58 5/16" 172 UNILET COMFORTOUCH VALTOCO 38 ULTRACARE INSULIN LANCET 136 VALTREX 80 SYRINGE/U-100/1ML/31G X UNILET EXCELITE 136 VALUE HEALTH INSULIN 5/16" 172 UNILET EXCELITE II 136 ULTRACARE PEN SYRINGE/U-100/0.5ML/29G X NEEDLES/31G X 1/4" 172 UNILET G.P. LANCET 137 1/2" 173 ULTRACARE PEN UNILET G.P. SUPERLITE VALUE HEALTH INSULIN NEEDLES/31G X 3/16" 172 LANCET 137 SYRINGE/U-100/1ML/29G X ULTRACARE PEN UNILET GP 28 ULTRA 1/2" 173 NEEDLES/31G X 5/16" 172 THIN 137 VALUE PLUS LANCETS ULTRACARE PEN UNILET LANCET 137 STANDARD 21G 137 NEEDLES/32G X 1/14" 172 VALUE PLUS LANCETS UNILET LANCETS MICRO- SUPERTHIN 30G 137 ULTRACARE PEN THIN33G 137 NEEDLES/32G X 3/16" 172 VALUE PLUS LANCETS THIN UNILET LANCETS SUPER- 26G 137 ULTRACARE PEN THIN30G 137 NEEDLES/32G X 5/32" 172 VALUE PLUS LANCING UNILET LANCETS ULTRA- DEVICE 137 ULTRACARE PEN THIN 28G 137 NEEDLES/33G X 5/32" 172 UNILET SUPERLITE VALUMARK LANCET SUPER THIN 30G 137 ULTRACET 27 LANCET 137 VALUMARK LANCET ULTRA ULTRAM 26 UNIVERSAL 1 LANCETS THIN 28G 137 THIN26G 137 ULTRAVATE 103 VALUMARK PEN NEEDLES UNIVERSAL 1 LANCETS 29GX12MM 173 UNASYN 199 ULTRA THIN 30G 137 UNIVERSAL 1 VALUMARK PEN NEEDLES UNASYN BULK PACK 199 31GX 6MM 173 UNIFINE PEN NEEDLE/32G LANCETS/33G/MICRO-THIN VALUMARK PEN NEEDLES X4MM 172 137 31GX 8MM 173 UNIFINE PENTIPS UPNEEQ 198 VALVED HOLDING 29GX12MM 172 UPTRAVI 85 CHAMBER 180 UNIFINE PENTIPS 31G X urea 103 VANALICE 107 3/16" 172 UNIFINE PENTIPS URIMAR-T 30 VANCOCIN 30 31GX5MM 173 UROCIT-K 10 116 VANCOCIN HCL 30 UNIFINE PENTIPS UROCIT-K 15 117 vancomycin hcl 31 31GX6MM 173 UROCIT-K 5 117 VANCOMYCIN HCL + UNIFINE PENTIPS SYRSPENDSF PH4 30 31GX8MM 173 UROGESIC-BLUE 30 VANCOMYCIN UNIFINE PENTIPS UROXATRAL 117 HYDROCHLORIDE 31 32GX4MM 173 URSO 250 114 VANISHPOINT INSULIN UNIFINE PENTIPS URSO FORTE 114 SYRINGE/0.5ML/30G X 32GX6MM 173 1/2" 173 UNIFINE PENTIPS ursodiol 114 VANISHPOINT INSULIN 33GX4MM 173 URSODIOL/SYRSPEND SF SYRINGE/0.5ML/30G X UNIFINE PENTIPS PLUS PH4 114 5/16" 173 29GX12MM 173 UTIBRON NEOHALER 36 VANISHPOINT INSULIN UNIFINE PENTIPS PLUS VAGIFEM 213 SYRINGE/1ML/29G X 1/2" 173 31GX5MM 173 VANISHPOINT INSULIN UNIFINE PENTIPS PLUS valacyclovir hcl 80 SYRINGE/1ML/30G X 31GX6MM 173 VALCHLOR 98 5/16" 173 UNIFINE PENTIPS PLUS VALCYTE 79 31GX8MM 173 VANOS 103 UNIFINE PENTIPS PLUS valganciclovir hcl 79 VANTAS 62 32GX4MM 173 VALIUM 33 VAQTA 212 UNIFINE PENTIPS PLUS 33GX valproate sodium 41 VARDIMAXIA 94 5/32" 173 UNIFINE PENTIPS PLUS valproic acid 41 VARIVAX 212 33GX4MM 173 valsartan 56 VAROPHEN 95 VAROXIA 94

Index 51 VARUBI 51 VIDA MIA UNIPFINE VORTEX HOLDING VASCEPA 53 PENTIPSSHORT CHAMBER/MASK/TODDLER/LA 31GX8MM 173 DY BUG 180 VASERETIC 59 VIEKIRA PAK 80 VORTEX VALVED HOLDING VASOTEC 56 vigabatrin 41 CHAMBER 180 VOSEVI 80 VAZCULEP 214 VIGAMOX 195 VOTRIENT 64 VECAMYL 59 VIIBRYD 43 VP FC KIT 96 VECTICAL 99 VIIBRYD STARTER PACK 43 VEINPUNCTURE PX1 VP GKL KIT 96 VILTEPSO 192 PHLEBOTOMY SYSTEM 106 VP INSULIN SYRINGE/U- VELPHORO 116 VIMOVO 22 100/0.3ML/29G X 1/2" 173 VELTASSA 184 VIMPAT 40,41 VPRIV 120 VELTIN 94 VINATE ONE 190 VRAYLAR 67 VEMLIDY 80 VIOKACE 108 VUMERITY 203 VENCLEXTA 61 VIRACEPT 79 VUSION 97 VENCLEXTA STARTING VIRAMUNE 79 VYEPTI 180 PACK 61 VIRAMUNE XR 79 VYNDAMAX 85 venlafaxine hcl 44 VIRAZOLE 81 VYNDAQEL 85 VENNGEL ONE 96 VIREAD 79 VYONDYS 53 192 VENOFER 121 VISTARIL 32 VYTORIN 53 VENTAVIS 84 VISTOGARD 50 VYVANSE 6,7 VENTOLIN HFA 36 VITAMIN DEFICIENCY VYZULTA 198 INJECTABLE SYSTEM- VENTRIXYL 186 WAKIX 9 verapamil hcl 83 B12 120 VITAROCA PLUS 186 WALGREENS COMFORT VERDESO 103 ASSUREDLANCETS MICRO VITATHELY/GINGER 190 VEREGEN 94 THIN/33G 137 VITRAKVI 64 WALGREENS COMFORT VERELAN 84 VIVAGUARD LANCING ASSUREDLANCETS SUPER VERELAN PM 84 DEVICE 137 THIN/28G 137 VERQUVO 85 VIVELLE-DOT 114 WALGREENS GLUCOSE 46 VERSACLOZ 72 VIVITROL 50 WALGREENS THIN LANCETS 137 VERZENIO 64 VIVLODEX 22 warfarin sodium 37 VESICARE 211 VIZIMPRO 61 WATCHHALER 180 VESICARE LS 211 VOCABRIA 79 WEBCOL ALCOHOL PREP VFEND 52 VOGELXO 29 LARGE 1 PLY 138 VFEND IV 52 VOGELXO PUMP 29 WEBCOL ALCOHOL PREP VIBERZI 116 VOL-PLUS 190 LARGE 2 PLY 138 WEBCOL ALCOHOL PREP VIBRAMYCIN 205 VOL-TAB RX 190 MEDIUM 2 PLY 138 VICTOZA 46 VOLTAREN 96 WEGMANS UNIFINE PENTIPS VIDA MIA AUTOLET VONVENDI 118 PLUS 32GX4MM 173 LANCINGDEVICE 137 WEGMANS UNIFINE PENTIPS VIDA MIA UNIFINE voriconazole 52 PLUS/MINI/31GX5MM 173 PENTIPS32GX4MM 173 VORTEX HOLDING WEGMANS UNIFINE PENTIPS VIDA MIA UNIFINE CHAMBER/MASK/CHILDS PLUS/SHORT/31GX8MM 173 PENTIPSMINI 31GX6MM 173 180 WEGMANS UNIFINE PENTIPS VIDA MIA UNIFINE VORTEX HOLDING PLUS/ULTRA PENTIPSORIGINAL CHAMBER/MASK/CHILDS/FR SHORT/31GX6MM 173 29GX12MM 173 OG 180 WELCHOL 54 VORTEX HOLDING VIDA MIA UNILET LANCETS WELLBUTRIN SR 42 SUPER THIN 30G 137 CHAMBER/MASK/TODDLER VIDA MIA UNILET LANCETS 180 WELLBUTRIN XL 42 ULTRA THIN 28G 137 WESTAB PLUS 190

Index 52 WESTHROID 206 XIMINO 206 ZCORT 7-DAY 90 white petrolatum-mineral oil 193 XOFLUZA 80 ZEGALOGUE 46 WIDE-SEAL SILICONE XOLAIR 34 ZEGERID 210 DIAPHRAGM KIT 60 129 XOLEGEL 98 ZEJULA 64 WIDE-SEAL SILICONE DIAPHRAGM KIT 65 129 XOLEGEL COREPAK 97 ZELAC 49 WIDE-SEAL SILICONE XOLEGEL DUO/HEAD & ZELAPAR 66 DIAPHRAGM KIT 70 129 SHOULDERS 97 ZELBORAF 64 WIDE-SEAL SILICONE XOLEGEL DUO/XOLEX 97 ZELNORM 116 DIAPHRAGM KIT 75 129 XOPENEX 37 ZEMAIRA 204 WIDE-SEAL SILICONE XOPENEX DIAPHRAGM KIT 80 129 CONCENTRATE 36 ZEMBRACE SYMTOUCH 181 WIDE-SEAL SILICONE ZEMPLAR 112 DIAPHRAGM KIT 85 129 XOPENEX HFA 37 WIDE-SEAL SILICONE XOSPATA 64 ZENPEP 108 DIAPHRAGM KIT 90 129 XPOVIO 62 ZEPATIER 80 WIDE-SEAL SILICONE XPOVIO 100 MG ONCE ZEPOSIA 203 DIAPHRAGM KIT 95 129 WEEKLY 62 ZEPOSIA 7-DAY STARTER WILATE 119 XPOVIO 40 MG ONCE PACK 203 WINDMILL TRAINER 180 WEEKLY 62 ZEPOSIA STARTER KIT 203 WINLEVI 94 XPOVIO 40 MG TWICE WEEKLY 62 ZERVIATE 198 WP THYROID 206 XPOVIO 60 MG ONCE ZESTORETIC 59 WPR PLUS WOUND HEALING WEEKLY 62 ZESTRIL 56 SYSTEM 106 XPOVIO 60 MG TWICE ZETIA 55 WYNZORA 103 WEEKLY 62 ZETONNA 192 XADAGO 66 XPOVIO 80 MG ONCE WEEKLY 62 ZEVRX INSULIN XALATAN 198 XPOVIO 80 MG TWICE SYRINGE/0.5ML/30G X XALKORI 64 WEEKLY 62 1/2" 173 XANAX 33 XRYLIX 96 ZEVRX INSULIN XANAX XR 33 XTAMPZA ER 26 SYRINGE/0.5ML/30G X 5/16" 173 XARELTO 37 XTANDI 62 ZEVRX INSULIN XARELTO STARTER PACK 37 XULTOPHY 100/3.6 45 SYRINGE/1ML/30G X 1/2" 174 XATMEP 61 XURIDEN 112 ZEVRX INSULIN SYRINGE/1ML/30G X XCOPRI 41 XYNTHA 119 5/16" 174 XELJANZ 20 XYNTHA SOLOFUSE 119 ZEVRX PEN NEEDLES 31G X XELJANZ XR 20 XYOSTED 29 5MM 174 XELODA 61 XYREM 200 ZEVRX PEN NEEDLES 31G X 6MM 174 XELPROS 198 XYWAV 200 ZEVRX PEN NEEDLES 31G X XENAZINE 202 YASMIN 28 88 8MM 174 XEPI 96 YAZ 88 ZEVRX PEN NEEDLES 32G X 4MM 174 XERAVA 205 YESCARTA 61 ZIAC 59 XERESE 99 YONSA 62 ZIAGEN 79 XERMELO 116 YOSPRALA 119 ZIANA 94 XEROSTOMIA RELIEF YUPELRI 34 zidovudine 79 SPRAY 185 zafirlukast 34 XGEVA 110 ZIEXTENZO 121 zaleplon 123 XHANCE 192 ZILACAINE PATCH 106 ZANAFLEX 191 XIFAXAN 30 zileuton 34 ZARONTIN 41 XIGDUO XR 45 ZILRETTA 90 ZARXIO 121 XIIDRA 195 ZILXI 107 ZAVESCA 120 ZIOPTAN 198

Index 53 ziprasidone hcl 67 zolpidem tartrate 123 ziprasidone mesylate 67 ZOLPIMIST 123 ZIPSOR 22 ZOMACTON 111 ZIRGAN 195 ZOMIG 182 ZITHRANOL 99 ZOMIG ZMT 182 ZITHROMAX 124 ZONALON 98 ZITHROMAX TRI-PAK 124 ZONEGRAN 41 ZITHROMAX Z-PAK 124 zonisamide 41 ZOCOR 55 ZONTIVITY 119 ZOFRAN 50,51 ZORBTIVE 111 ZOHYDRO ER 26 ZORTRESS 184 ZOKINVY 184 ZORVOLEX 22 ZOLADEX 62 ZOSTAVAX 212 zoledronic acid 110 ZOSYN 199 ZOLEDRONIC ACID 110 ZOVIRAX 80,99 zoledronic acid 110 ZTLIDO 106 ZOLGENSMA 10.1-10.5 ZUBSOLV 28 KG 192 ZUPLENZ 51 ZOLGENSMA 10.6-11.0 KG 192 ZYCLARA 104 ZOLGENSMA 11.1-11.5 ZYCLARA PUMP 104 KG 192 ZYDELIG 64 ZOLGENSMA 11.6-12.0 KG 192 ZYFLO 34 ZOLGENSMA 12.1-12.5 ZYKADIA 64 KG 193 ZYLET 197 ZOLGENSMA 12.6-13.0 ZYLOPRIM 118 KG 193 ZOLGENSMA 13.1-13.5 ZYMAXID 195 KG 193 ZYPITAMAG 55 ZOLGENSMA 2.6-3.0 KG 193 ZYPREXA 72,73 ZOLGENSMA 3.1-3.5 KG 193 ZYPREXA RELPREVV 72 ZOLGENSMA 3.6-4.0 KG 193 ZYPREXA ZYDIS 73 ZOLGENSMA 4.1-4.5 KG 193 ZYTIGA 62 ZOLGENSMA 4.6-5.0 KG 193 ZYVOX 31 ZOLGENSMA 5.1-5.5 KG 193 ZOLGENSMA 5.6-6.0 KG 193 ZOLGENSMA 6.1-6.5 KG 193 ZOLGENSMA 6.6-7.0 KG 193 ZOLGENSMA 7.1-7.5 KG 193 ZOLGENSMA 7.6-8.0 KG 193 ZOLGENSMA 8.1-8.5 KG 193 ZOLGENSMA 8.6-9.0 KG 193 ZOLGENSMA 9.1-9.5 KG 193 ZOLGENSMA 9.6-10.0 KG 193 ZOLINZA 64 zolmitriptan 181 ZOLOFT 43 ZOLPAK 98

Index 54