Health Partners Plans CHIP Formulary Updated 01/01/2021

2021 Formulary

Introduction be notified through correspondence from Prescription quantities cannot be altered unless the Health Partners Plans Pharmacy approved by the physician, and must be within department when applicable. the limits of the plan’s days’ supply. Health Partners Plans, Inc. is pleased to provide the 2021 KidzPartners Formulary. This Prescribed medications or regimens that are formulary covers members under the Product Selection Criteria non-formulary require prior authorization. KidzPartners (Children’s Health Insurance Program) plan. The drugs listed in the The Health Partners Plans P&T Committee will KidzPartners Formulary are intended to provide consider all FDA approved drugs for inclusion Immediate Need sufficient options to treat the majority of in the formulary. The evaluation process (5/15-day Emergency Supply) patients who require drug therapy in an includes a literature review, and expert opinion ambulatory setting. Excluded from coverage by respected medical professionals. Formal If a member presents at a pharmacy with a are drugs from specific manufacturers who reviews are prepared which typically address prescription which requires prior authorization, have not contracted with the rebate program of the following information: whether for a non-formulary drug or otherwise, the Federal government. 1. Safety and if the prior authorization cannot be 2. Effectiveness processed immediately, Health Partners Plans The drugs listed in the KidzPartners Formulary will allow the pharmacy to dispense an interim have been reviewed and approved by the 3. Comparison studies 4. Approved indications supply of the prescription under the following Health Partners Plans Pharmacy and circumstances: Therapeutics Committee. These drug products 5. Adverse effects have been selected to provide the most 6. Contraindications If the recipient is in immediate need of the clinically appropriate and cost-effective 7. Pharmacokinetics medication in the professional judgment of the medications for KidzPartners members. There 8. Patient compliance considerations pharmacist and if the prescription is for a new may be occasions when an unlisted drug is 9. Medical outcome and medication (one that the recipient has not taken desired for medical management of a specific pharmacoeconomic studies before or that is taken for an acute condition), patient. In those instances, the unlisted Health Partners Plans will allow the pharmacy medication may be requested through Prior When a new drug is considered for formulary to dispense a 5-day supply of the medication to Authorization/ Medical Exception. inclusion, an attempt will be made to examine afford the recipient or pharmacy the opportunity the drug relative to similar drugs currently on to initiate the request for prior authorization. formulary. In addition, entire therapeutic Preface classes are periodically reviewed. This review If the prescription is for an ongoing medication process may result in deletion of a drug(s) in a (one that is continuously prescribed for the The KidzPartners Formulary is organized by particular therapeutic class in an effort to treatment of an illness or condition that is sections, which refer to either a drug/ continually promote the most clinically useful chronic in nature in which there has not been a pharmacologic class or disease state. Each and cost-effective agents. break in treatment for greater than 30 Days), section contains a list of drugs selected to be Health Partners Plans will allow the pharmacy on this formulary. Prescribing a drug product Plan Limits to dispense a 15-day supply of the medication that is available generically is encouraged automatically, unless Health Partners Plans when appropriate. Unless exceptions are mailed to the member, with a copy to the noted, all applicable dosage forms and A maximum of up to a 30-day supply of prescriber, an advance written notice of the strengths of the referenced product generally medication is eligible for coverage. The reduction or termination of the medication at are covered. prescriber is urged to prescribe in amounts that least 10 days prior to the end of the period for adhere to accepted standards of care. The which the medication was previously days’ supply must be accurately determined by authorized. Pharmacy and Therapeutics the dispensing pharmacist to assure (P&T) Committee compliance with plan parameters. Health Partners Plans will respond to the Specific limits based on FDA guidelines, request for prior authorization within 24 hours The actions of the Health Partners Plans medication package inserts and accepted from when the request was received. If the P&T Committee are communicated through standards of care may apply to medication prior authorization is denied, the member is the Provider Newsletter to all physicians treatments under clinical review. entitled to appeal the decision through several and posted on our website. Pharmacy avenues. The 5-day or 15-day requirement providers in the KidzPartners network will does not apply when the pharmacist Health Partners Plans CHIP Formulary Updated 01/01/2021 determines that taking the medication, either When the above two criteria are met, a generic • Medications used for non-FDA approved alone or along with other medication that the can be substituted with the full expectation that indications recipient may be taking, would jeopardize the the substituted product will produce the same • Prescription costs that exceed $1,000 health and safety of the recipient. clinical effect and safety profile as the brand per claim name product. • Prescriptions that exceed set plan limits Formulary Product (days’ supply, quantity, cost) State laws or regulation may indicate the ability Descriptions • Prescriptions processed by non-network to practice generic substitution for selected pharmacies products or categories of drugs. This formulary lists all specific strengths and • New-to-market products • High-end oral and self-administered dosage forms that are covered. When a There are now many brand name products that strength or dosage form is specified, only injectable medications are repackaged or distributed under a generic • Medications with Health Partners Plans the product identified will be covered. Other label. These generic versions should always be strengths/ dosage forms of the referenced P&T Committee approved treatment considered therapeutically equivalent and guidelines product are not covered. substitutable for the source branded product irrespective of rating. To request a prior authorization the For specific questions please contact the physician or a member of his/her staff Health Partners Plans Pharmacy department at Drugs Efficacy Study should contact Health Partners Plans either 215-991-4300. by fax at 866-240-3712, or phone at 215-991- Implementation (DESI) Drugs 4300. All non-emergency requests can be Generic Substitution faxed 24 hours per day; calls should be Health Partners Plans does not reimburse for placed from 9:00 A.M. to 6:00 P.M., Monday DESI drugs. DESI drugs are those drugs first Generic substitution is the process by which a through Friday. marketed between 1938 and 1962 which were generic equivalent is dispensed rather than the approved as safe, but not required to show brand name product. The appropriate use of In the event of an immediate need after effectiveness for FDA product approval. The generic drugs is one method of providing cost business hours, the call should be made to DESI program subsequently made a conscious drug therapy. Health Partners Plans KidzPartners Member Relations at determination of fully effective for most of these will not cover any drugs by companies that do 1-888-888-1212. The call will be evaluated and products and they remain in the marketplace. A not participate in the Federal Rebate Program routed to a pharmacist-on-call. few DESI products remain classified as less or are DESI drugs. Generic drugs must be than fully effective while awaiting final prescribed and dispensed when an A-rated The physician may use the Health Partners administrative disposition. Also classified as generic drug is available. Brand necessary Plans Prior Authorization/Medical Exception DESI are many products listed as identical, prescriptions for drugs with A-rated generics form or a letter of request, but must include the similar, or related to actual DESI products. require prior authorization. following information for quick and appropriate review to take place: Examples of DESI Drugs include: The MAC list sets a ceiling price for the Midrin • Name and recipient number of member reimbursement of certain multisource Vytone • Date of birth of member prescription drugs. This price will typically cover Anusol HC suppositories • Physician’s name, license number, the acquisition of most generics but not Donnatal and specialty branded versions of the same drug. The Tigan • Physician’s phone and fax numbers products selected for inclusion on the MAC list Naldecon are commonly prescribed and dispensed and • Name of primary care physician if different have usually gone through the FDA’s review and approval process. This process assures Prior Authorization (PA) • Drug name, strength, and quantity the following requirements have been met: of medication To ensure that select medications are utilized • Days supply (duration of therapy) and The generic drug will contain the same active appropriately, Prior Authorization may be number of refills ingredient(s) and be the same strength and required for the dispensing of specific products. • Route of administration dosage form as the brand name counterpart. These medications may require Prior • Diagnosis Authorization for the following reasons: • Medical rationale for request The FDA has given the generic an “A” rating • Formulary medications used, duration and compared to the branded counterpart indicating • Non-formulary medications, or benefit therapy result bioequivalence and has determined the generic exceptions required by medical necessity • Additional clinical information that may is therapeutically equivalent to the referenced • All brand name medications when there is contribute to the review decision brand. The ratings of generic drugs are an A-rated generic equivalent available (e.g., labs) available by referring to the FDA reference • Medications and/or treatments under clinical Approved Drug Products with Therapeutic investigation Upon receiving the Prior Authorization/ Medical Equivalence Evaluations (Orange Book). Exception Request from the prescriber, Health Health Partners Plans CHIP Formulary Updated 01/01/2021

Partners Plans will render a decision within 24 sumatriptan Imitrex provider in his/her choice of prescription drugs. hours. The Medical Director will review each triamcinolone acetonide Kenalog-40 Health Partners Plans does not assume prior authorization request and make the final fondaparinux sodium Arixtra responsibility for the actions or omissions of decision. After Medical Director review, the enoxaparin sodium Lovenox any medical provider based upon reliance, in clinical pharmacist will prepare the request for whole or in part, on the information contained the denial/approval letter. A denial letter will be Managed Drug Limitations herein. The medical provider should consult mailed to the member or parent/guardian. A the drug manufacturer product literature or (MDL) copy of the member denial letter is also faxed standard references for more detailed to the prescribing physician. information. The United States Food and Drug Administration If the Prior Authorization/Medical Exception (FDA) publishes guidelines on the safest and The information contained in this document is Request is denied, the prescriber can submit a most efficient ways to use certain drugs. Many proprietary information subject to a licensing drug products on the KidzPartners Formulary written appeal to Health Partners Plans' agreement. The information may not be copied Complaint & Grievance Unit explaining the have quantity limits based upon the dosage in whole or in part without the written medical necessity of the medical treatment in described in product labeling. permission of Health Partners Plans. All rights question. At any time during normal business reserved. hours, the prescribing physician can discuss Drugs subject to quantity limits may change. the denial with a clinical pharmacist or can Contact Health Partners Plans' Pharmacy Trade names are the intellectual property of the have a peer to peer discussion with the medical department at 215-991-4300 for more respective product owners. director. information.

Health Partners Plans Step Therapy Specialty and Injectable Step therapy is a process that encourages the Medication Program use of medications preferred by Health Partners Plans as the first course of treatment. Health Partners Plans supports appropriate use If the preferred medication is not clinically of injectables and has established procedures effective or if the member suffers side effects, for prescribing and suppliers. Under the another medication may be approved as the direction of the Health Partners Plans second course of treatment. Pharmacy department, the physician provider has the primary responsibility for obtaining Editor Prior Authorization for medications included in this program. Call the Health Partners Plans Pharmacy department at 215-991-4300 for Your comments and suggestions regarding the authorization on specialty medications. KidzPartners 2021 Formulary are encouraged. Your input is vital to this formulary’s continued The following specialty and injectable success. All responses will be reviewed and medications, although not limited to, can be considered. Please send your comments to: obtained through the retail pharmacy benefit without prior authorization. Attn: Pharmacy Director Health Partners Plans GENERIC NAME BRAND NAME 901 Market Street, Suite 500 ceftriaxone Rocephin Philadelphia, PA 19107 cyanocobalamin Vitamin B-12 Phone: 215-991-4300 epinephrine Epipen, Epipen  Jr. Internet: www.healthpartnersplans.com fluphenazine decanoate Prolixin Decanoate glucagon Glucagon Notice haloperidol decanoate Haldol Decanoate heparin sodium Heparin The information contained in the KidzPartners Insulin Formulary and its appendices is provided by medroxyprogesterone Depo-Provera acetate 150 mg only Health Partners Plans solely for the methylprednisolone Depo-Medrol convenience of medical providers and our acetate members. Health Partners Plans neither methylprednisolone Solu-Medrol warrants nor assures accuracy of such sod. succ. information, nor is it intended to be penicillin g benzathine Bicillin L.A. comprehensive in nature. This formulary is not penicillin g potassium Pfizerpen intended to be a substitute for the knowledge, expertise, skill and judgment of the medical LEGEND TIER DESCRIPTION

1 Preferred

2 Non-Preferred

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

The member (or his/her physician) is required to get prior PA Prior Authorization authorization before filling the prescription for this drug. Without prior approval, we may not cover this drug.

This prescription drug may only be covered if the member meets the AL1 Age Limit minimum or maximum age limit.

C Custom This drug has unique restrictions.

There is a limit on the amount of this drug that is covered per QLC Quantity Limit (Custom) prescription, or within a specific time frame.

PAGE 4 LAST UPDATED 03/2021 LIST OF COVERED PRESCRIPTION MEDICATIONS

DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ANALGESICS

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS

ARTHROTEC 50-0.2 MG TAB DR Non-Preferred diclofenac w/ misoprostol ARTHROTEC 75-0.2 MG TAB DR Non-Preferred diclofenac w/ misoprostol

BUTALBITAL-ASPIRIN-CAFFEINE 50- PA 325-40 MG TAB Preferred QLC Max 18 tabs/caps per butalbital-aspirin-caffeine month

PA butalbital-aspirin-caffeine cap 50-325-40 Preferred mg QLC Max 18 tabs/caps per month CAMBIA 50 MG PACKET Non-Preferred diclofenac potassium (migraine) CELEBREX 100 MG CAP Non-Preferred QL 2 / 1 days celecoxib CELEBREX 200 MG CAP Non-Preferred QL 2 / 1 days celecoxib CELEBREX 400 MG CAP Non-Preferred QL 1 / 1 days celecoxib CELEBREX 50 MG CAP Non-Preferred QL 2 / 1 days celecoxib

celecoxib cap 100 mg Preferred QL 2 / 1 days

celecoxib cap 200 mg Preferred QL 2 / 1 days

celecoxib cap 400 mg Preferred QL 1 / 1 days

celecoxib cap 50 mg Preferred QL 2 / 1 days

DAYPRO 600 MG TAB Non-Preferred QL 3 / 1 days oxaprozin DICLOFENAC 35 MG CAP Non-Preferred diclofenac DICLOFENAC EPOLAMINE 1.3 % PATCH Non-Preferred diclofenac epolamine diclofenac potassium tab 50 mg Non-Preferred

PAGE 5 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

diclofenac potassium tab 50 mg Non-Preferred QL 4 / 1 days

diclofenac sodium tab delayed release Preferred QL 4 / 1 days 25 mg diclofenac sodium tab delayed release Preferred QL 4 / 1 days 50 mg diclofenac sodium tab delayed release Preferred QL 2 / 1 days 75 mg

diclofenac sodium tab er 24hr 100 mg Non-Preferred QL 2 / 1 days

diclofenac sodium soln 1.5% Preferred diclofenac w/ misoprostol tab delayed Non-Preferred release 50-0.2 mg diclofenac w/ misoprostol tab delayed Non-Preferred release 75-0.2 mg

diflunisal tab 500 mg Non-Preferred QL 3 / 1 days

DUEXIS 800-26.6 MG TAB Non-Preferred ibuprofen-famotidine

etodolac cap 200 mg Non-Preferred QL 5 / 1 days

etodolac cap 300 mg Non-Preferred QL 3 / 1 days

etodolac tab 400 mg Preferred QL 60 / 30 days

etodolac tab 500 mg Non-Preferred QL 2 / 1 days

etodolac tab er 24hr 400 mg Non-Preferred etodolac tab er 24hr 500 mg Non-Preferred etodolac tab er 24hr 600 mg Non-Preferred FELDENE 10 MG CAP Non-Preferred QL 1 / 1 days piroxicam FELDENE 20 MG CAP Non-Preferred QL 1 / 1 days piroxicam fenoprofen calcium cap 400 mg Non-Preferred

fenoprofen calcium tab 600 mg Non-Preferred QL 5 / 1 days

FLECTOR 1.3 % PATCH Non-Preferred diclofenac epolamine

flurbiprofen tab 100 mg Preferred QL 3 / 1 days

flurbiprofen tab 50 mg Preferred QL 3 / 1 days

PAGE 6 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

ibuprofen susp 100 mg/5ml Preferred QLC 30 mL/day

ibuprofen tab 400 mg Preferred QL 6 / 1 days

ibuprofen tab 400 mg Preferred QL 6 / 1 days

ibuprofen tab 600 mg Preferred QL 5 / 1 days

ibuprofen tab 600 mg Preferred QL 5 / 1 days

ibuprofen tab 800 mg Preferred QL 4 / 1 days

ibuprofen tab 800 mg Preferred QL 4 / 1 days

INDOCIN 25 MG/5ML SUSPENSION Non-Preferred indomethacin INDOCIN 50 MG SUPPOS Non-Preferred indomethacin INDOMETHACIN 20 MG CAP Non-Preferred indomethacin

indomethacin cap 25 mg Preferred QL 4 / 1 days

indomethacin cap 50 mg Preferred QL 4 / 1 days

indomethacin cap er 75 mg Preferred QL 3 / 1 days

KETOPROFEN 25 MG CAP Non-Preferred ketoprofen KETOPROFEN 50 MG CAP Non-Preferred ketoprofen KETOPROFEN 75 MG CAP Non-Preferred ketoprofen

ketoprofen cap er 24hr 200 mg Non-Preferred QL 1 / 1 days

KETOROLAC TROMETHAMINE 15.75 MG/SPRAY SOLUTION Non-Preferred ketorolac tromethamine

ketorolac tromethamine tab 10 mg Preferred QLC 20 tablets per 90 days

LICART 1.3 % PATCH 24HR Non-Preferred diclofenac epolamine

meclofenamate sodium cap 100 mg Non-Preferred QL 4 / 1 days

meclofenamate sodium cap 50 mg Non-Preferred QL 4 / 1 days

mefenamic acid cap 250 mg Non-Preferred

PAGE 7 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS meloxicam cap 10 mg Non-Preferred meloxicam cap 5 mg Non-Preferred

meloxicam tab 15 mg Preferred QL 1 / 1 days

meloxicam tab 7.5 mg Preferred QL 2 / 1 days

MOBIC 15 MG TAB Non-Preferred QL 1 / 1 days meloxicam MOBIC 7.5 MG TAB Non-Preferred QL 2 / 1 days meloxicam

nabumetone tab 500 mg Preferred QL 4 / 1 days

nabumetone tab 500 mg Non-Preferred

nabumetone tab 750 mg Preferred QL 2 / 1 days

nabumetone tab 750 mg Non-Preferred NALFON 400 MG CAP Non-Preferred fenoprofen calcium NALFON 600 MG TAB Non-Preferred fenoprofen calcium NAPRELAN 375 MG TAB ER 24H Non-Preferred naproxen sodium NAPRELAN 500 MG TAB ER 24H Non-Preferred naproxen sodium NAPRELAN 750 MG TAB ER 24H Non-Preferred naproxen sodium

naproxen susp 125 mg/5ml Preferred QL 1800 / 30 days

naproxen tab 250 mg Preferred QL 3 / 1 days

naproxen tab 375 mg Preferred QL 4 / 1 days

naproxen tab 500 mg Preferred QL 3 / 1 days

naproxen tab ec 375 mg Non-Preferred QL 2 / 1 days

naproxen tab ec 375 mg Preferred QL 2 / 1 days

naproxen tab ec 500 mg Non-Preferred QL 2 / 1 days

naproxen tab ec 500 mg Preferred QL 2 / 1 days

naproxen sodium tab 275 mg Preferred QL 3 / 1 days

PAGE 8 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

naproxen sodium tab 550 mg Preferred QL 3 / 1 days

naproxen sodium tab er 24hr 375 mg Non-Preferred (base equiv) naproxen sodium tab er 24hr 500 mg Non-Preferred (base equiv) NAPROXEN SODIUM ER 750 MG TAB ER 24H Non-Preferred naproxen sodium naproxen-esomeprazole magnesium tab Non-Preferred dr 375-20 mg naproxen-esomeprazole magnesium tab Non-Preferred dr 500-20 mg

oxaprozin tab 600 mg Non-Preferred QL 3 / 1 days

PENNSAID 2 % SOLUTION Non-Preferred diclofenac sodium (topical)

piroxicam cap 10 mg Preferred QL 1 / 1 days

piroxicam cap 20 mg Preferred QL 1 / 1 days

QMIIZ ODT 15 MG TAB DISP Non-Preferred meloxicam QMIIZ ODT 7.5 MG TAB DISP Non-Preferred meloxicam RELAFEN DS 1000 MG TAB Non-Preferred nabumetone

salsalate tab 500 mg Preferred QL 6 / 1 days

salsalate tab 750 mg Preferred QL 4 / 1 days

SPRIX 15.75 MG/SPRAY SOLUTION Non-Preferred ketorolac tromethamine

sulindac tab 150 mg Preferred QL 2 / 1 days

sulindac tab 200 mg Preferred QL 2 / 1 days

TIVORBEX 20 MG CAP Non-Preferred indomethacin TIVORBEX 40 MG CAP Non-Preferred indomethacin TOLMETIN SODIUM 200 MG TAB Non-Preferred QL 4 / 1 days tolmetin sodium

PAGE 9 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

tolmetin sodium cap 400 mg Non-Preferred QL 4 / 1 days

tolmetin sodium tab 600 mg Non-Preferred QL 3 / 1 days

VIMOVO 375-20 MG TAB DR Non-Preferred naproxen-esomeprazole magnesium VIMOVO 500-20 MG TAB DR Non-Preferred naproxen-esomeprazole magnesium VIVLODEX 10 MG CAP Non-Preferred meloxicam VIVLODEX 5 MG CAP Non-Preferred meloxicam VOLTAREN 1 % GEL Non-Preferred QL 500 / 30 days diclofenac sodium (topical) ZIPSOR 25 MG CAP Non-Preferred diclofenac potassium ZORVOLEX 18 MG CAP Non-Preferred diclofenac ZORVOLEX 35 MG CAP Non-Preferred diclofenac OPIOID ANALGESICS, LONG-ACTING

ARYMO ER 15 MG TBER DETER QL 90 / 30 days Non-Preferred morphine sulfate PA

ARYMO ER 30 MG TBER DETER QL 60 / 30 days Non-Preferred morphine sulfate PA

ARYMO ER 60 MG TBER DETER QL 60 / 30 days Non-Preferred morphine sulfate PA

BELBUCA 150 MCG FILM QL 60 / 30 days Non-Preferred buprenorphine hcl PA

BELBUCA 300 MCG FILM QL 60 / 30 days Non-Preferred buprenorphine hcl PA

BELBUCA 450 MCG FILM QL 60 / 30 days Non-Preferred buprenorphine hcl PA

BELBUCA 600 MCG FILM QL 60 / 30 days Non-Preferred buprenorphine hcl PA

PAGE 10 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

BELBUCA 75 MCG FILM QL 60 / 30 days Non-Preferred buprenorphine hcl PA

BELBUCA 750 MCG FILM QL 60 / 30 days Non-Preferred buprenorphine hcl PA

BELBUCA 900 MCG FILM QL 60 / 30 days Non-Preferred buprenorphine hcl PA

BUPRENORPHINE 10 MCG/HR QL 4 / 28 days PATCH WK Non-Preferred buprenorphine PA

BUPRENORPHINE 15 MCG/HR QL 4 / 28 days PATCH WK Non-Preferred buprenorphine PA

BUPRENORPHINE 20 MCG/HR QL 4 / 28 days PATCH WK Non-Preferred buprenorphine PA

buprenorphine td patch weekly 10 QL 4 / 28 days Non-Preferred mcg/hr PA

buprenorphine td patch weekly 15 QL 4 / 28 days Non-Preferred mcg/hr PA

buprenorphine td patch weekly 20 QL 4 / 28 days Non-Preferred mcg/hr PA

QL 4 / 28 days buprenorphine td patch weekly 5 mcg/hr Non-Preferred PA

buprenorphine td patch weekly 7.5 QL 4 / 28 days Non-Preferred mcg/hr PA

BUTRANS 10 MCG/HR PATCH WK QL 4 / 28 days Preferred buprenorphine PA

BUTRANS 15 MCG/HR PATCH WK QL 4 / 28 days Preferred buprenorphine PA

BUTRANS 20 MCG/HR PATCH WK QL 4 / 28 days Preferred buprenorphine PA

BUTRANS 5 MCG/HR PATCH WK QL 4 / 28 days Preferred buprenorphine PA

PAGE 11 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

BUTRANS 7.5 MCG/HR PATCH WK QL 4 / 28 days Preferred buprenorphine PA

QL 30 / 30 days CONZIP 100 MG CAP ER 24H Non-Preferred PA tramadol hcl AL1 At least 18 yrs old

QL 30 / 30 days CONZIP 200 MG CAP ER 24H Non-Preferred PA tramadol hcl AL1 At least 18 yrs old

QL 30 / 30 days CONZIP 300 MG CAP ER 24H Non-Preferred PA tramadol hcl AL1 At least 18 yrs old

DOLOPHINE 10 MG TAB Non-Preferred PA methadone hcl DOLOPHINE 5 MG TAB Non-Preferred PA methadone hcl

DURAGESIC-100 100 MCG/HR PATCH QL 10 / 30 days 72HR Non-Preferred fentanyl PA

DURAGESIC-12 12 MCG/HR PATCH QL 10 / 30 days 72HR Non-Preferred fentanyl PA DURAGESIC-25 25 MCG/HR PATCH 72HR Non-Preferred PA fentanyl

DURAGESIC-50 50 MCG/HR PATCH QL 10 / 30 days 72HR Non-Preferred fentanyl PA

DURAGESIC-75 75 MCG/HR PATCH QL 10 / 30 days 72HR Non-Preferred fentanyl PA

EXALGO 12 MG TAB ER 24H QL 30 / 30 days Non-Preferred hydromorphone hcl PA

EXALGO 16 MG TAB ER 24H QL 30 / 30 days Non-Preferred hydromorphone hcl PA

EXALGO 32 MG TAB ER 24H QL 30 / 30 days Non-Preferred hydromorphone hcl PA

PAGE 12 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

EXALGO 8 MG TAB ER 24H QL 30 / 30 days Non-Preferred hydromorphone hcl PA

QL 10 / 30 days fentanyl td patch 72hr 100 mcg/hr Preferred PA

QL 10 / 30 days fentanyl td patch 72hr 12 mcg/hr Preferred PA

QL 10 / 30 days fentanyl td patch 72hr 25 mcg/hr Preferred PA

QL 10 / 30 days fentanyl td patch 72hr 37.5 mcg/hr Non-Preferred PA

QL 10 / 30 days fentanyl td patch 72hr 50 mcg/hr Preferred PA

QL 10 / 30 days fentanyl td patch 72hr 62.5 mcg/hr Non-Preferred PA

QL 10 / 30 days fentanyl td patch 72hr 75 mcg/hr Preferred PA

QL 10 / 30 days fentanyl td patch 72hr 87.5 mcg/hr Non-Preferred PA

hydrocodone bitartrate cap er 12hr 10 Non-Preferred PA mg hydrocodone bitartrate cap er 12hr 15 Non-Preferred PA mg hydrocodone bitartrate cap er 12hr 20 Non-Preferred PA mg hydrocodone bitartrate cap er 12hr 30 Non-Preferred PA mg hydrocodone bitartrate cap er 12hr 40 Non-Preferred PA mg hydrocodone bitartrate cap er 12hr 50 Non-Preferred PA mg hydrocodone bitartrate tab er 24hr deter Non-Preferred PA 100 mg hydrocodone bitartrate tab er 24hr deter Non-Preferred PA 120 mg

PAGE 13 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS hydrocodone bitartrate tab er 24hr deter Non-Preferred PA 20 mg hydrocodone bitartrate tab er 24hr deter Non-Preferred PA 30 mg hydrocodone bitartrate tab er 24hr deter Non-Preferred PA 40 mg hydrocodone bitartrate tab er 24hr deter Non-Preferred PA 60 mg hydrocodone bitartrate tab er 24hr deter Non-Preferred PA 80 mg

QL 30 / 30 days hydromorphone hcl tab er 24hr 12 mg Non-Preferred PA

QL 30 / 30 days hydromorphone hcl tab er 24hr 16 mg Non-Preferred PA

QL 30 / 30 days hydromorphone hcl tab er 24hr 32 mg Non-Preferred PA

QL 30 / 30 days hydromorphone hcl tab er 24hr 8 mg Non-Preferred PA

HYSINGLA ER 100 MG TB24 DETER Non-Preferred PA hydrocodone bitartrate HYSINGLA ER 120 MG TB24 DETER Non-Preferred PA hydrocodone bitartrate HYSINGLA ER 20 MG TB24 DETER Non-Preferred PA hydrocodone bitartrate HYSINGLA ER 30 MG TB24 DETER Non-Preferred PA hydrocodone bitartrate HYSINGLA ER 40 MG TB24 DETER Non-Preferred PA hydrocodone bitartrate HYSINGLA ER 60 MG TB24 DETER Non-Preferred PA hydrocodone bitartrate HYSINGLA ER 80 MG TB24 DETER Non-Preferred PA hydrocodone bitartrate

KADIAN 10 MG CAP ER 24H QL 60 / 30 days Non-Preferred morphine sulfate PA

KADIAN 100 MG CAP ER 24H QL 30 / 30 days Non-Preferred morphine sulfate PA

PAGE 14 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

KADIAN 20 MG CAP ER 24H QL 60 / 30 days Non-Preferred morphine sulfate PA

KADIAN 200 MG CAP ER 24H QL 30 / 30 days Non-Preferred morphine sulfate PA

KADIAN 30 MG CAP ER 24H QL 30 / 30 days Non-Preferred morphine sulfate PA

KADIAN 40 MG CAP ER 24H QL 30 / 30 days Non-Preferred morphine sulfate PA

KADIAN 50 MG CAP ER 24H QL 30 / 30 days Non-Preferred morphine sulfate PA

KADIAN 60 MG CAP ER 24H QL 30 / 30 days Non-Preferred morphine sulfate PA

KADIAN 80 MG CAP ER 24H QL 30 / 30 days Non-Preferred morphine sulfate PA

methadone hcl conc 10 mg/ml Non-Preferred PA

methadone hcl conc 10 mg/ml Non-Preferred PA

methadone hcl soln 10 mg/5ml Non-Preferred PA

methadone hcl soln 5 mg/5ml Non-Preferred PA

methadone hcl tab 10 mg Non-Preferred PA

methadone hcl tab 5 mg Non-Preferred PA

METHADOSE 10 MG/ML CONC Non-Preferred PA methadone hcl METHADOSE SUGAR-FREE 10 MG/ML CONC Non-Preferred PA methadone hcl MORPHABOND ER 100 MG TB12 DETER Non-Preferred PA morphine sulfate MORPHABOND ER 15 MG TB12 DETER Non-Preferred PA morphine sulfate MORPHABOND ER 30 MG TB12 DETER Non-Preferred PA morphine sulfate

PAGE 15 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MORPHABOND ER 60 MG TB12 DETER Non-Preferred PA morphine sulfate

QL 60 / 30 days morphine sulfate cap er 24hr 10 mg Preferred PA

QL 30 / 30 days morphine sulfate cap er 24hr 100 mg Preferred PA

QL 60 / 30 days morphine sulfate cap er 24hr 20 mg Preferred PA

QL 30 / 30 days morphine sulfate cap er 24hr 30 mg Preferred PA

QL 30 / 30 days morphine sulfate cap er 24hr 50 mg Preferred PA

QL 30 / 30 days morphine sulfate cap er 24hr 60 mg Preferred PA

QL 30 / 30 days morphine sulfate cap er 24hr 80 mg Preferred PA

QL 3 / 1 days morphine sulfate tab er 100 mg Preferred PA

QL 3 / 1 days morphine sulfate tab er 15 mg Preferred PA

QL 3 / 1 days morphine sulfate tab er 200 mg Preferred PA

QL 3 / 1 days morphine sulfate tab er 30 mg Preferred PA

QL 3 / 1 days morphine sulfate tab er 60 mg Preferred PA

MORPHINE SULFATE ER 40 MG CAP QL 30 / 30 days ER 24H Preferred morphine sulfate PA

MORPHINE SULFATE ER BEADS 120 QL 30 / 30 days MG CAP ER 24H Non-Preferred morphine sulfate beads PA

PAGE 16 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

MORPHINE SULFATE ER BEADS 30 QL 30 / 30 days MG CAP ER 24H Non-Preferred morphine sulfate beads PA

MORPHINE SULFATE ER BEADS 45 QL 30 / 30 days MG CAP ER 24H Non-Preferred morphine sulfate beads PA

MORPHINE SULFATE ER BEADS 60 QL 30 / 30 days MG CAP ER 24H Non-Preferred morphine sulfate beads PA

MORPHINE SULFATE ER BEADS 75 QL 30 / 30 days MG CAP ER 24H Non-Preferred morphine sulfate beads PA

MORPHINE SULFATE ER BEADS 90 QL 30 / 30 days MG CAP ER 24H Non-Preferred morphine sulfate beads PA

MS CONTIN 100 MG TAB ER QL 3 / 1 days Non-Preferred morphine sulfate PA

MS CONTIN 15 MG TAB ER QL 3 / 1 days Non-Preferred morphine sulfate PA

MS CONTIN 200 MG TAB ER QL 3 / 1 days Non-Preferred morphine sulfate PA

MS CONTIN 30 MG TAB ER QL 3 / 1 days Non-Preferred morphine sulfate PA

MS CONTIN 60 MG TAB ER QL 3 / 1 days Non-Preferred morphine sulfate PA

NUCYNTA ER 100 MG TAB ER 12H QL 60 / 30 days Non-Preferred tapentadol hcl PA

NUCYNTA ER 150 MG TAB ER 12H QL 60 / 30 days Non-Preferred tapentadol hcl PA

NUCYNTA ER 200 MG TAB ER 12H QL 60 / 30 days Non-Preferred tapentadol hcl PA

NUCYNTA ER 250 MG TAB ER 12H QL 60 / 30 days Non-Preferred tapentadol hcl PA

NUCYNTA ER 50 MG TAB ER 12H QL 60 / 30 days Non-Preferred tapentadol hcl PA

PAGE 17 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS OPANA ER 10 MG TB12 DETER Non-Preferred PA oxymorphone hcl OPANA ER 15 MG TB12 DETER Non-Preferred PA oxymorphone hcl OPANA ER 20 MG TB12 DETER Non-Preferred PA oxymorphone hcl OPANA ER 30 MG TB12 DETER Non-Preferred PA oxymorphone hcl OPANA ER 40 MG TB12 DETER Non-Preferred PA oxymorphone hcl OPANA ER 5 MG TB12 DETER Non-Preferred PA oxymorphone hcl OPANA ER 7.5 MG TB12 DETER Non-Preferred PA oxymorphone hcl

QL 2 / 1 days oxycodone hcl tab er 12hr deter 10 mg Non-Preferred PA

QL 2 / 1 days oxycodone hcl tab er 12hr deter 15 mg Non-Preferred PA

QL 2 / 1 days oxycodone hcl tab er 12hr deter 20 mg Non-Preferred PA

QL 2 / 1 days oxycodone hcl tab er 12hr deter 30 mg Non-Preferred PA

QL 2 / 1 days oxycodone hcl tab er 12hr deter 40 mg Non-Preferred PA

QL 2 / 1 days oxycodone hcl tab er 12hr deter 60 mg Non-Preferred PA

QL 2 / 1 days oxycodone hcl tab er 12hr deter 80 mg Non-Preferred PA

OXYCODONE HCL ER 10 MG TB12 QL 2 / 1 days DETER Non-Preferred oxycodone hcl PA

OXYCODONE HCL ER 20 MG TB12 QL 2 / 1 days DETER Non-Preferred oxycodone hcl PA

OXYCODONE HCL ER 40 MG TB12 QL 2 / 1 days DETER Non-Preferred oxycodone hcl PA

PAGE 18 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

OXYCONTIN 10 MG TB12 DETER QL 2 / 1 days Non-Preferred oxycodone hcl PA

OXYCONTIN 15 MG TB12 DETER QL 2 / 1 days Non-Preferred oxycodone hcl PA

OXYCONTIN 20 MG TB12 DETER QL 2 / 1 days Non-Preferred oxycodone hcl PA

OXYCONTIN 30 MG TB12 DETER QL 2 / 1 days Non-Preferred oxycodone hcl PA

OXYCONTIN 40 MG TB12 DETER QL 2 / 1 days Non-Preferred oxycodone hcl PA

OXYCONTIN 60 MG TB12 DETER QL 2 / 1 days Non-Preferred oxycodone hcl PA

OXYCONTIN 80 MG TB12 DETER QL 2 / 1 days Non-Preferred oxycodone hcl PA

oxymorphone hcl tab er 12hr 10 mg Non-Preferred PA

oxymorphone hcl tab er 12hr 15 mg Non-Preferred PA

oxymorphone hcl tab er 12hr 20 mg Non-Preferred PA

oxymorphone hcl tab er 12hr 30 mg Non-Preferred PA

oxymorphone hcl tab er 12hr 40 mg Non-Preferred PA

oxymorphone hcl tab er 12hr 5 mg Non-Preferred PA

oxymorphone hcl tab er 12hr 7.5 mg Non-Preferred PA

QL 30 / 30 days tramadol hcl cap er 24hr biphasic Non-Preferred PA release 100 mg AL1 At least 18 yrs old

QL 30 / 30 days tramadol hcl cap er 24hr biphasic Non-Preferred PA release 200 mg AL1 At least 18 yrs old

QL 30 / 30 days tramadol hcl cap er 24hr biphasic Non-Preferred PA release 300 mg AL1 At least 18 yrs old

PAGE 19 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 30 / 30 days

tramadol hcl tab er 24hr 100 mg Non-Preferred PA

AL1 At least 18 yrs old

QL 30 / 30 days

tramadol hcl tab er 24hr 200 mg Non-Preferred PA

AL1 At least 18 yrs old

QL 30 / 30 days

tramadol hcl tab er 24hr 300 mg Non-Preferred PA

AL1 At least 18 yrs old

QL 30 / 30 days tramadol hcl tab er 24hr biphasic release Non-Preferred PA 100 mg AL1 At least 18 yrs old

QL 30 / 30 days tramadol hcl tab er 24hr biphasic release Non-Preferred PA 200 mg AL1 At least 18 yrs old

QL 30 / 30 days tramadol hcl tab er 24hr biphasic release Non-Preferred PA 300 mg AL1 At least 18 yrs old

XTAMPZA ER 13.5 MG CP12 DETER QL 60 / 30 days Preferred oxycodone PA

XTAMPZA ER 18 MG CP12 DETER QL 60 / 30 days Preferred oxycodone PA

XTAMPZA ER 27 MG CP12 DETER QL 60 / 30 days Preferred oxycodone PA

XTAMPZA ER 36 MG CP12 DETER QL 60 / 30 days Preferred oxycodone PA

XTAMPZA ER 9 MG CP12 DETER QL 60 / 30 days Preferred oxycodone PA

ZOHYDRO ER 10 MG CAP ER 12H Non-Preferred PA hydrocodone bitartrate ZOHYDRO ER 15 MG CAP ER 12H Non-Preferred PA hydrocodone bitartrate

PAGE 20 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ZOHYDRO ER 20 MG CAP ER 12H Non-Preferred PA hydrocodone bitartrate ZOHYDRO ER 30 MG CAP ER 12H Non-Preferred PA hydrocodone bitartrate ZOHYDRO ER 40 MG CAP ER 12H Non-Preferred PA hydrocodone bitartrate ZOHYDRO ER 50 MG CAP ER 12H Non-Preferred PA hydrocodone bitartrate OPIOID ANALGESICS, SHORT-ACTING

ABSTRAL 100 MCG SL TAB Non-Preferred C Opioid safety limits fentanyl citrate apply ABSTRAL 200 MCG SL TAB Non-Preferred C Opioid safety limits fentanyl citrate apply ABSTRAL 300 MCG SL TAB Non-Preferred C Opioid safety limits fentanyl citrate apply ABSTRAL 400 MCG SL TAB Non-Preferred C Opioid safety limits fentanyl citrate apply ABSTRAL 600 MCG SL TAB Non-Preferred C Opioid safety limits fentanyl citrate apply ABSTRAL 800 MCG SL TAB Non-Preferred C Opioid safety limits fentanyl citrate apply

AL1 At least 18 yrs old acetaminophen w/ codeine soln 120-12 Preferred mg/5ml C Opioid safety limits apply

QL 13 / 1 days acetaminophen w/ codeine tab 300-15 Preferred AL1 At least 18 yrs old mg C Opioid safety limits apply

QL 13 / 1 days acetaminophen w/ codeine tab 300-15 Preferred AL1 At least 18 yrs old mg C Opioid safety limits apply

QL 12 / 1 days acetaminophen w/ codeine tab 300-30 Preferred AL1 At least 18 yrs old mg C Opioid safety limits apply

QL 12 / 1 days acetaminophen w/ codeine tab 300-30 Preferred AL1 At least 18 yrs old mg C Opioid safety limits apply

PAGE 21 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 6 / 1 days acetaminophen w/ codeine tab 300-60 Preferred AL1 At least 18 yrs old mg C Opioid safety limits apply

QL 6 / 1 days acetaminophen w/ codeine tab 300-60 Preferred AL1 At least 18 yrs old mg C Opioid safety limits apply acetaminophen-caffeine-dihydrocodeine Non-Preferred C Opioid safety limits tab 325-30-16 mg apply ACTIQ 1200 MCG LOZ HANDLE Non-Preferred C Opioid safety limits fentanyl citrate apply ACTIQ 1600 MCG LOZ HANDLE Non-Preferred C Opioid safety limits fentanyl citrate apply ACTIQ 200 MCG LOZ HANDLE Non-Preferred C Opioid safety limits fentanyl citrate apply ACTIQ 400 MCG LOZ HANDLE Non-Preferred C Opioid safety limits fentanyl citrate apply ACTIQ 600 MCG LOZ HANDLE Non-Preferred C Opioid safety limits fentanyl citrate apply ACTIQ 800 MCG LOZ HANDLE Non-Preferred C Opioid safety limits fentanyl citrate apply APADAZ 4.08-325 MG TAB Non-Preferred C Opioid safety limits benzhydrocodone hcl-acetaminophen apply APADAZ 6.12-325 MG TAB Non-Preferred C Opioid safety limits benzhydrocodone hcl-acetaminophen apply APADAZ 8.16-325 MG TAB Non-Preferred C Opioid safety limits benzhydrocodone hcl-acetaminophen apply APAP-CAFF-DIHYDROCODEINE 320.5-30-16 MG CAP Non-Preferred C Opioid safety limits acetaminophen-caff-dihydrocod apply APAP-CAFF-DIHYDROCODEINE 325- 30-16 MG TAB Non-Preferred C Opioid safety limits acetaminophen-caff-dihydrocod apply BENZHYDROCODONE- ACETAMINOPHEN 4.08-325 MG TAB Preferred C Opioid safety limits benzhydrocodone hcl-acetaminophen apply BENZHYDROCODONE- ACETAMINOPHEN 6.12-325 MG TAB Preferred C Opioid safety limits benzhydrocodone hcl-acetaminophen apply

PAGE 22 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS BENZHYDROCODONE- ACETAMINOPHEN 8.16-325 MG TAB Preferred C Opioid safety limits benzhydrocodone hcl-acetaminophen apply

AL1 At least 18 yrs old butalbital-acetaminophen-caff w/ cod Opioid safety limits Non-Preferred C cap 50-300-40-30 mg apply QLC Max 18 tabs/caps per month

AL1 At least 18 yrs old butalbital-acetaminophen-caff w/ cod Opioid safety limits Non-Preferred C cap 50-325-40-30 mg apply QLC Max 18 tabs/caps per month

AL1 At least 18 yrs old butalbital-aspirin-caff w/ codeine cap 50- Opioid safety limits Non-Preferred C 325-40-30 mg apply QLC Max 18 tabs/caps per month

AL1 At least 18 yrs old butalbital-aspirin-caff w/ codeine cap 50- Opioid safety limits Non-Preferred C 325-40-30 mg apply QLC Max 18 tabs/caps per month

butorphanol tartrate nasal soln 10 mg/ml Non-Preferred C Opioid safety limits apply

QL 3 / 1 days carisoprodol w/ aspirin & codeine tab Non-Preferred AL1 At least 18 yrs old 200-325-16 mg C Opioid safety limits apply

QL 3 / 1 days CARISOPRODOL-ASPIRIN-CODEINE 200-325-16 MG TAB Non-Preferred AL1 At least 18 yrs old carisoprodol w/ aspirin & codeine C Opioid safety limits apply CODEINE SULFATE 15 MG TAB Non-Preferred C Opioid safety limits codeine sulfate apply CODEINE SULFATE 30 MG TAB Non-Preferred C Opioid safety limits codeine sulfate apply CODEINE SULFATE 60 MG TAB Non-Preferred C Opioid safety limits codeine sulfate apply

codeine sulfate tab 30 mg Non-Preferred C Opioid safety limits apply

PAGE 23 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

codeine sulfate tab 60 mg Non-Preferred C Opioid safety limits apply DEMEROL 100 MG TAB Non-Preferred C Opioid safety limits meperidine hcl apply DILAUDID 1 MG/ML LIQUID Non-Preferred C Opioid safety limits hydromorphone hcl apply DILAUDID 2 MG TAB Non-Preferred C Opioid safety limits hydromorphone hcl apply DILAUDID 4 MG TAB Non-Preferred C Opioid safety limits hydromorphone hcl apply DILAUDID 8 MG TAB Non-Preferred C Opioid safety limits hydromorphone hcl apply DSUVIA 30 MCG SL TAB Non-Preferred C Opioid safety limits sufentanil citrate apply FENTANYL CITRATE 100 MCG TAB Non-Preferred C Opioid safety limits fentanyl citrate apply FENTANYL CITRATE 200 MCG TAB Non-Preferred C Opioid safety limits fentanyl citrate apply FENTANYL CITRATE 400 MCG TAB Non-Preferred C Opioid safety limits fentanyl citrate apply FENTANYL CITRATE 600 MCG TAB Non-Preferred C Opioid safety limits fentanyl citrate apply FENTANYL CITRATE 800 MCG TAB Non-Preferred C Opioid safety limits fentanyl citrate apply fentanyl citrate lozenge on a handle Non-Preferred C Opioid safety limits 1200 mcg apply fentanyl citrate lozenge on a handle Non-Preferred C Opioid safety limits 1600 mcg apply fentanyl citrate lozenge on a handle 200 Non-Preferred C Opioid safety limits mcg apply fentanyl citrate lozenge on a handle 400 Non-Preferred C Opioid safety limits mcg apply fentanyl citrate lozenge on a handle 600 Non-Preferred C Opioid safety limits mcg apply fentanyl citrate lozenge on a handle 800 Non-Preferred C Opioid safety limits mcg apply FENTORA 100 MCG TAB Non-Preferred C Opioid safety limits fentanyl citrate apply FENTORA 200 MCG TAB Non-Preferred C Opioid safety limits fentanyl citrate apply

PAGE 24 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS FENTORA 400 MCG TAB Non-Preferred C Opioid safety limits fentanyl citrate apply FENTORA 600 MCG TAB Non-Preferred C Opioid safety limits fentanyl citrate apply FENTORA 800 MCG TAB Non-Preferred C Opioid safety limits fentanyl citrate apply

C Opioid safety limits FIORINAL 50-325-40 MG CAP Non-Preferred apply butalbital-aspirin-caffeine QLC Max 18 tabs/caps per month

AL1 At least 18 yrs old FIORINAL/CODEINE #3 50-325-40-30 C Opioid safety limits MG CAP Non-Preferred apply butalbital-aspirin-caffeine w/cod QLC Max 18 tabs/caps per month hydrocodone-acetaminophen soln 10- Non-Preferred C Opioid safety limits 325 mg/15ml apply hydrocodone-acetaminophen soln 7.5- Non-Preferred C Opioid safety limits 325 mg/15ml apply hydrocodone-acetaminophen soln 7.5- Non-Preferred C Opioid safety limits 325 mg/15ml apply hydrocodone-acetaminophen soln 7.5- Non-Preferred C Opioid safety limits 325 mg/15ml apply hydrocodone-acetaminophen tab 10-300 Preferred C Opioid safety limits mg apply hydrocodone-acetaminophen tab 10-300 Non-Preferred C Opioid safety limits mg apply

QL 6 / 1 days hydrocodone-acetaminophen tab 10-325 Preferred mg C Opioid safety limits apply

QL 6 / 1 days hydrocodone-acetaminophen tab 10-325 Preferred mg C Opioid safety limits apply hydrocodone-acetaminophen tab 2.5- Preferred C Opioid safety limits 325 mg apply hydrocodone-acetaminophen tab 5-300 Preferred C Opioid safety limits mg apply

QL 12 / 1 days hydrocodone-acetaminophen tab 5-325 Preferred mg C Opioid safety limits apply

PAGE 25 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS hydrocodone-acetaminophen tab 5-325 Non-Preferred C Opioid safety limits mg apply hydrocodone-acetaminophen tab 7.5- Preferred C Opioid safety limits 300 mg apply

QL 8 / 1 days hydrocodone-acetaminophen tab 7.5- Preferred 325 mg C Opioid safety limits apply hydrocodone-acetaminophen tab 7.5- Non-Preferred C Opioid safety limits 325 mg apply

hydrocodone-ibuprofen tab 10-200 mg Non-Preferred C Opioid safety limits apply

hydrocodone-ibuprofen tab 5-200 mg Non-Preferred C Opioid safety limits apply

hydrocodone-ibuprofen tab 5-200 mg Non-Preferred C Opioid safety limits apply

QL 5 / 1 days hydrocodone-ibuprofen tab 7.5-200 mg Non-Preferred C Opioid safety limits apply HYDROMORPHONE HCL 3 MG SUPPOS Non-Preferred C Opioid safety limits hydromorphone hcl apply

hydromorphone hcl liqd 1 mg/ml Non-Preferred C Opioid safety limits apply

hydromorphone hcl tab 2 mg Non-Preferred C Opioid safety limits apply

hydromorphone hcl tab 4 mg Non-Preferred C Opioid safety limits apply

hydromorphone hcl tab 8 mg Non-Preferred C Opioid safety limits apply IBUDONE 10-200 MG TAB Non-Preferred C Opioid safety limits hydrocodone-ibuprofen apply LAZANDA 100 MCG/ACT SOLUTION Non-Preferred C Opioid safety limits fentanyl citrate apply LAZANDA 400 MCG/ACT SOLUTION Non-Preferred C Opioid safety limits fentanyl citrate apply

levorphanol tartrate tab 2 mg Non-Preferred C Opioid safety limits apply

levorphanol tartrate tab 3 mg Non-Preferred C Opioid safety limits apply LORTAB 10-300 MG/15ML ELIXIR Non-Preferred C Opioid safety limits hydrocodone-acetaminophen apply

PAGE 26 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MEPERIDINE HCL 100 MG TAB Non-Preferred C Opioid safety limits meperidine hcl apply MEPERIDINE HCL 50 MG TAB Non-Preferred C Opioid safety limits meperidine hcl apply MEPERIDINE HCL 50 MG/5ML SOLUTION Non-Preferred C Opioid safety limits meperidine hcl apply

meperidine hcl tab 100 mg Non-Preferred C Opioid safety limits apply

meperidine hcl tab 50 mg Non-Preferred C Opioid safety limits apply MORPHINE SULFATE 10 MG SUPPOS Non-Preferred C Opioid safety limits morphine sulfate apply MORPHINE SULFATE 20 MG SUPPOS Non-Preferred C Opioid safety limits morphine sulfate apply MORPHINE SULFATE 30 MG SUPPOS Non-Preferred C Opioid safety limits morphine sulfate apply MORPHINE SULFATE 5 MG SUPPOS Non-Preferred C Opioid safety limits morphine sulfate apply

morphine sulfate oral soln 10 mg/5ml Preferred C Opioid safety limits apply morphine sulfate oral soln 100 mg/5ml Preferred C Opioid safety limits (20 mg/ml) apply morphine sulfate oral soln 100 mg/5ml Preferred C Opioid safety limits (20 mg/ml) apply

morphine sulfate oral soln 20 mg/5ml Preferred C Opioid safety limits apply

morphine sulfate tab 15 mg Preferred C Opioid safety limits apply

morphine sulfate tab 30 mg Preferred C Opioid safety limits apply NALOCET 2.5-300 MG TAB Non-Preferred C Opioid safety limits oxycodone w/ acetaminophen apply

QL 6 / 1 days NORCO 10-325 MG TAB Non-Preferred hydrocodone-acetaminophen C Opioid safety limits apply NORCO 5-325 MG TAB Non-Preferred C Opioid safety limits hydrocodone-acetaminophen apply NORCO 7.5-325 MG TAB Non-Preferred C Opioid safety limits hydrocodone-acetaminophen apply

PAGE 27 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NUCYNTA 100 MG TAB Non-Preferred C Opioid safety limits tapentadol hcl apply NUCYNTA 50 MG TAB Non-Preferred C Opioid safety limits tapentadol hcl apply NUCYNTA 75 MG TAB Non-Preferred C Opioid safety limits tapentadol hcl apply OPANA 10 MG TAB Non-Preferred C Opioid safety limits oxymorphone hcl apply OPANA 5 MG TAB Non-Preferred C Opioid safety limits oxymorphone hcl apply OXAYDO 5 MG TAB Non-Preferred C Opioid safety limits oxycodone hcl apply OXAYDO 7.5 MG TAB Non-Preferred C Opioid safety limits oxycodone hcl apply

oxycodone hcl cap 5 mg Non-Preferred C Opioid safety limits apply oxycodone hcl conc 100 mg/5ml (20 Non-Preferred C Opioid safety limits mg/ml) apply

oxycodone hcl soln 5 mg/5ml Preferred C Opioid safety limits apply

oxycodone hcl tab 10 mg Preferred C Opioid safety limits apply

oxycodone hcl tab 15 mg Preferred C Opioid safety limits apply

oxycodone hcl tab 20 mg Preferred C Opioid safety limits apply

oxycodone hcl tab 30 mg Preferred C Opioid safety limits apply

oxycodone hcl tab 5 mg Preferred C Opioid safety limits apply oxycodone w/ acetaminophen tab 10- Preferred C Opioid safety limits 325 mg apply oxycodone w/ acetaminophen tab 10- Preferred C Opioid safety limits 325 mg apply

QL 12 / 1 days oxycodone w/ acetaminophen tab 2.5- Preferred 325 mg C Opioid safety limits apply

QL 12 / 1 days oxycodone w/ acetaminophen tab 5-325 Preferred mg C Opioid safety limits apply

PAGE 28 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 12 / 1 days oxycodone w/ acetaminophen tab 5-325 Preferred mg C Opioid safety limits apply

QL 12 / 1 days oxycodone w/ acetaminophen tab 7.5- Preferred 325 mg C Opioid safety limits apply

QL 12 / 1 days oxycodone w/ acetaminophen tab 7.5- Preferred 325 mg C Opioid safety limits apply OXYCODONE-ACETAMINOPHEN 2.5- 300 MG TAB Non-Preferred C Opioid safety limits oxycodone w/ acetaminophen apply

oxycodone-aspirin tab 4.8355-325 mg Non-Preferred C Opioid safety limits apply

oxycodone-ibuprofen tab 5-400 mg Non-Preferred C Opioid safety limits apply

oxymorphone hcl tab 10 mg Non-Preferred C Opioid safety limits apply

oxymorphone hcl tab 5 mg Non-Preferred C Opioid safety limits apply

QL 12 / 1 days pentazocine w/ naloxone tab 50-0.5 mg Non-Preferred C Opioid safety limits apply PERCOCET 10-325 MG TAB Non-Preferred C Opioid safety limits oxycodone w/ acetaminophen apply

QL 12 / 1 days PERCOCET 2.5-325 MG TAB Non-Preferred oxycodone w/ acetaminophen C Opioid safety limits apply

QL 12 / 1 days PERCOCET 5-325 MG TAB Non-Preferred oxycodone w/ acetaminophen C Opioid safety limits apply

QL 12 / 1 days PERCOCET 7.5-325 MG TAB Non-Preferred oxycodone w/ acetaminophen C Opioid safety limits apply PRIMLEV 10-300 MG TAB Non-Preferred C Opioid safety limits oxycodone w/ acetaminophen apply PRIMLEV 5-300 MG TAB Non-Preferred C Opioid safety limits oxycodone w/ acetaminophen apply PRIMLEV 7.5-300 MG TAB Non-Preferred C Opioid safety limits oxycodone w/ acetaminophen apply

PAGE 29 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PROLATE 10-300 MG TAB Non-Preferred C Opioid safety limits oxycodone w/ acetaminophen apply PROLATE 5-300 MG TAB Non-Preferred C Opioid safety limits oxycodone w/ acetaminophen apply PROLATE 7.5-300 MG TAB Non-Preferred C Opioid safety limits oxycodone w/ acetaminophen apply

AL1 At least 18 yrs old QDOLO 5 MG/ML SOLUTION Non-Preferred tramadol hcl C Opioid safety limits apply ROXICODONE 15 MG TAB Non-Preferred C Opioid safety limits oxycodone hcl apply ROXICODONE 30 MG TAB Non-Preferred C Opioid safety limits oxycodone hcl apply ROXICODONE 5 MG TAB Non-Preferred C Opioid safety limits oxycodone hcl apply SUBSYS 100 MCG LIQUID Non-Preferred C Opioid safety limits fentanyl apply SUBSYS 1200 (600 X 2) MCG LIQUID Non-Preferred C Opioid safety limits fentanyl apply SUBSYS 1600 (800 X 2) MCG LIQUID Non-Preferred C Opioid safety limits fentanyl apply SUBSYS 200 MCG LIQUID Non-Preferred C Opioid safety limits fentanyl apply SUBSYS 400 MCG LIQUID Non-Preferred C Opioid safety limits fentanyl apply SUBSYS 600 MCG LIQUID Non-Preferred C Opioid safety limits fentanyl apply SUBSYS 800 MCG LIQUID Non-Preferred C Opioid safety limits fentanyl apply

AL1 At least 18 yrs old tramadol hcl tab 100 mg Preferred C Opioid safety limits apply

AL1 At least 18 yrs old tramadol hcl tab 50 mg Preferred C Opioid safety limits apply

QL 240 / 30 days tramadol-acetaminophen tab 37.5-325 Preferred AL1 At least 18 yrs old mg C Opioid safety limits apply

PAGE 30 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 12 / 1 days TYLENOL WITH CODEINE #3 300-30 MG TAB Non-Preferred AL1 At least 18 yrs old acetaminophen w/ codeine C Opioid safety limits apply

QL 6 / 1 days TYLENOL WITH CODEINE #4 300-60 MG TAB Non-Preferred AL1 At least 18 yrs old acetaminophen w/ codeine C Opioid safety limits apply

QL 240 / 30 days ULTRACET 37.5-325 MG TAB Non-Preferred AL1 At least 18 yrs old tramadol-acetaminophen C Opioid safety limits apply

AL1 At least 18 yrs old ULTRAM 50 MG TAB Non-Preferred tramadol hcl C Opioid safety limits apply ANESTHETICS

LOCAL ANESTHETICS

APRIZIO PAK 2.5-2.5 % KIT Non-Preferred lidocaine-prilocaine-transparent dressing APRIZIO PAK II 2.5-2.5 % KIT Non-Preferred lidocaine-prilocaine-transparent dressing EMPRICAINE-II 2.5-2.5 % KIT Non-Preferred lidocaine-prilocaine-transparent dressing GEN7T PLUS 3.5-7 % PATCH Non-Preferred lidocaine-menthol

lidocaine oint 5% Preferred QL 35.4 / 30 days

lidocaine oint 5% Preferred QL 35.4 / 30 days

lidocaine patch 5% Preferred QL 30 / 30 days

LIDOCAINE HCL 4 % SOLUTION Preferred lidocaine hcl (mouth-throat) lidocaine hcl cream 3% Preferred lidocaine hcl cream 3.88% Preferred lidocaine hcl lotion 3% Non-Preferred lidocaine hcl lotion 3% Non-Preferred lidocaine hcl lotion 3% Non-Preferred

PAGE 31 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS lidocaine hcl lotion 3% Non-Preferred lidocaine hcl soln 4% Preferred

lidocaine hcl urethral/mucosal gel 2% Preferred AL1 At least 3 yrs old

lidocaine hcl urethral/mucosal gel Preferred AL1 At least 3 yrs old prefilled syringe 2% lidocaine hcl urethral/mucosal gel Preferred AL1 At least 3 yrs old prefilled syringe 2% lidocaine hcl local inj 1% Preferred lidocaine hcl local preservative free (pf) Preferred inj 1%

lidocaine hcl viscous soln 2% Preferred AL1 At least 3 yrs old

lidocaine-prilocaine cream 2.5-2.5% Preferred QL 150 / 30 days

lidocaine-prilocaine cream kit 2.5-2.5% Non-Preferred lidocaine-prilocaine cream kit 2.5-2.5% Non-Preferred lidocaine-prilocaine cream kit 2.5-2.5% Non-Preferred lidocaine-prilocaine cream kit 2.5-2.5% Non-Preferred lidocaine-prilocaine cream kit 2.5-2.5% Non-Preferred lidocaine-prilocaine cream kit 2.5-2.5% Non-Preferred

lidocaine-prilocaine cream kit 2.5-2.5% Non-Preferred QL 150 / 30 days

lidocaine-prilocaine cream kit 2.5-2.5% Non-Preferred lidocaine-prilocaine cream kit 2.5-2.5% Non-Preferred lidocaine-prilocaine cream kit 2.5-2.5% Non-Preferred lidocaine-prilocaine cream kit 2.5-2.5% Non-Preferred lidocaine-prilocaine cream kit 2.5-2.5% Non-Preferred lidocaine-prilocaine cream kit 2.5-2.5% Non-Preferred lidocaine-prilocaine cream kit 2.5-2.5% Non-Preferred lidocaine-prilocaine cream kit 2.5-2.5% Non-Preferred lidocaine-prilocaine cream kit 2.5-2.5% Non-Preferred lidocaine-prilocaine cream kit 2.5-2.5% Non-Preferred lidocaine-prilocaine cream kit 2.5-2.5% Non-Preferred lidocaine-prilocaine cream kit 2.5-2.5% Non-Preferred

PAGE 32 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS lidocaine-prilocaine cream kit 2.5-2.5% Non-Preferred lidocaine-prilocaine cream kit 2.5-2.5% Non-Preferred LIDOCAINE-TETRACAINE 7-7 % CREAM Non-Preferred lidocaine-tetracaine LIDODERM 5 % PATCH Non-Preferred QL 1 / 1 days lidocaine LIDOTRAL 3.88 % CREAM Non-Preferred lidocaine hcl midazolam hcl syrup 2 mg/ml (base Non-Preferred equivalent) PLIAGLIS 7-7 % CREAM Non-Preferred lidocaine-tetracaine PRILO PATCH II 2.5-2.5 & 5 % KIT Non-Preferred lidocaine-prilocaine PRILOVIXIL 2.5-2.5 % KIT Non-Preferred lidocaine-prilocaine-transparent dressing PRIZOPAK II 2.5-2.5 % KIT Non-Preferred lidocaine-prilocaine-transparent dressing QUTENZA 8 % KIT Non-Preferred capsaicin & cleansing gel QUTENZA (2 PATCH) 8 % KIT Non-Preferred capsaicin & cleansing gel SKYADERM-LP 2.5-2.5 % KIT Non-Preferred lidocaine-prilocaine-transparent dressing SYNERA 70-70 MG PATCH Non-Preferred lidocaine-tetracaine ZTLIDO 1.8 % PATCH Non-Preferred lidocaine ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS

ALCOHOL DETERRENTS/ANTI-CRAVING

acamprosate calcium tab delayed Preferred QL 6 / 1 days release 333 mg

disulfiram tab 250 mg Preferred QL 1 / 1 days

disulfiram tab 500 mg Preferred QL 1 / 1 days

naltrexone hcl tab 50 mg Preferred

PAGE 33 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VIVITROL 380 MG RECON SUSP Preferred QL 1 / 28 days naltrexone OPIOID DEPENDENCE TREATMENTS

BUNAVAIL 2.1-0.3 MG FILM Maximum 24 mg/day buprenorphine hcl-naloxone hcl Non-Preferred C (total buprenorphine dihydrate equivalents)

BUNAVAIL 4.2-0.7 MG FILM Maximum 24 mg/day buprenorphine hcl-naloxone hcl Non-Preferred C (total buprenorphine dihydrate equivalents)

BUNAVAIL 6.3-1 MG FILM Maximum 24 mg/day buprenorphine hcl-naloxone hcl Non-Preferred C (total buprenorphine dihydrate equivalents)

PA buprenorphine hcl sl tab 2 mg (base Preferred Maximum 24 mg/day equiv) C (total buprenorphine equivalents)

PA buprenorphine hcl sl tab 8 mg (base Preferred Maximum 24 mg/day equiv) C (total buprenorphine equivalents)

buprenorphine hcl-naloxone hcl sl film Maximum 24 mg/day Preferred C 12-3 mg (base equiv) (total buprenorphine equivalents)

buprenorphine hcl-naloxone hcl sl film 2- Maximum 24 mg/day Preferred C 0.5 mg (base equiv) (total buprenorphine equivalents)

buprenorphine hcl-naloxone hcl sl film 4- Maximum 24 mg/day Preferred C 1 mg (base equiv) (total buprenorphine equivalents)

buprenorphine hcl-naloxone hcl sl film 8- Maximum 24 mg/day Preferred C 2 mg (base equiv) (total buprenorphine equivalents)

buprenorphine hcl-naloxone hcl sl tab 2- Maximum 24 mg/day Preferred C 0.5 mg (base equiv) (total buprenorphine equivalents)

buprenorphine hcl-naloxone hcl sl tab 8- Maximum 24 mg/day Preferred C 2 mg (base equiv) (total buprenorphine equivalents) LUCEMYRA 0.18 MG TAB Non-Preferred QL 16 / 1 days lofexidine hcl PROBUPHINE IMPLANT KIT 74.2 MG IMPLANT Non-Preferred buprenorphine hcl

PAGE 34 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SUBLOCADE 100 MG/0.5ML SOLN PRSYR Preferred QLC 0.02 mL/day buprenorphine SUBLOCADE 300 MG/1.5ML SOLN PRSYR Preferred QLC 0.06 mL/day buprenorphine

SUBOXONE 12-3 MG FILM Maximum 24 mg/day buprenorphine hcl-naloxone hcl Non-Preferred C (total buprenorphine dihydrate equivalents)

SUBOXONE 2-0.5 MG FILM Maximum 24 mg/day buprenorphine hcl-naloxone hcl Non-Preferred C (total buprenorphine dihydrate equivalents)

SUBOXONE 4-1 MG FILM Maximum 24 mg/day buprenorphine hcl-naloxone hcl Non-Preferred C (total buprenorphine dihydrate equivalents)

SUBOXONE 8-2 MG FILM Maximum 24 mg/day buprenorphine hcl-naloxone hcl Non-Preferred C (total buprenorphine dihydrate equivalents)

ZUBSOLV 0.7-0.18 MG SL TAB Maximum 24 mg/day buprenorphine hcl-naloxone hcl Non-Preferred C (total buprenorphine dihydrate equivalents)

ZUBSOLV 1.4-0.36 MG SL TAB Maximum 24 mg/day buprenorphine hcl-naloxone hcl Non-Preferred C (total buprenorphine dihydrate equivalents)

ZUBSOLV 11.4-2.9 MG SL TAB Maximum 24 mg/day buprenorphine hcl-naloxone hcl Non-Preferred C (total buprenorphine dihydrate equivalents)

ZUBSOLV 2.9-0.71 MG SL TAB Maximum 24 mg/day buprenorphine hcl-naloxone hcl Non-Preferred C (total buprenorphine dihydrate equivalents)

ZUBSOLV 5.7-1.4 MG SL TAB Maximum 24 mg/day buprenorphine hcl-naloxone hcl Non-Preferred C (total buprenorphine dihydrate equivalents)

ZUBSOLV 8.6-2.1 MG SL TAB Maximum 24 mg/day buprenorphine hcl-naloxone hcl Non-Preferred C (total buprenorphine dihydrate equivalents) OPIOID REVERSAL AGENTS

LIFEMS NALOXONE 2 MG/2ML PREF SY KT Preferred naloxone hcl NALOXONE HCL 2 MG/0.4ML SOLN A- INJ Preferred naloxone hcl

PAGE 35 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS naloxone hcl inj 0.4 mg/ml Preferred naloxone hcl inj 4 mg/10ml Preferred naloxone hcl soln cartridge 0.4 mg/ml Preferred naloxone hcl soln prefilled syringe 2 Preferred mg/2ml NARCAN 4 MG/0.1ML LIQUID Preferred naloxone hcl SMOKING CESSATION AGENTS

bupropion hcl (smoking deterrent) tab er Preferred QL 60 / 30 days 12hr 150 mg

QL 2 / 1 days CHANTIX 0.5 MG TAB Preferred varenicline tartrate C Max 180 tablets per 365 days

QL 2 / 1 days CHANTIX 1 MG TAB Preferred varenicline tartrate C Max 180 tablets per 365 days

CHANTIX CONTINUING MONTH PAK 1 QL 2 / 1 days MG TAB Preferred C Max 180 tablets per varenicline tartrate 365 days

CHANTIX STARTING MONTH PAK 0.5 QL 2 / 1 days MG X 11 & 1 MG X 42 TAB Preferred C Max 1 fill every 180 varenicline tartrate days NICOTROL 10 MG INHALER Non-Preferred QL 168 / 30 days nicotine NICOTROL NS 10 MG/ML SOLUTION Non-Preferred QL 60 / 30 days nicotine ZYBAN 150 MG TAB ER 12H Non-Preferred QL 60 / 30 days bupropion hcl (smoking deterrent) ANTIBACTERIALS

AMINOGLYCOSIDES

ARIKAYCE 590 MG/8.4ML SUSPENSION Non-Preferred QLC 8.4 mL/day amikacin sulfate liposome

gentamicin sulfate ophth oint 0.3% Preferred QL 7 / 18 days

gentamicin sulfate ophth soln 0.3% Preferred QL 15 / 18 days

gentamicin sulfate cream 0.1% Preferred

PAGE 36 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS gentamicin sulfate oint 0.1% Preferred

neomycin sulfate tab 500 mg Preferred QL 8 / 1 days

paromomycin sulfate cap 250 mg Non-Preferred QL 16 / 1 days

tobramycin ophth soln 0.3% Preferred QL 5 / 18 days

TOBREX 0.3 % OINTMENT Non-Preferred QL 3.5 / 18 days tobramycin (ophth) TOBREX 0.3 % SOLUTION Non-Preferred tobramycin (ophth) ANTIBACTERIALS, OTHER

BACITRACIN OPHTH OINT 500 Non-Preferred QLC 7 grams per fill UNIT/GM BENZAMYCIN 5-3 % GEL Non-Preferred benzoyl peroxide-erythromycin benzoyl peroxide-erythromycin gel 5-3% Preferred CENTANY 2 % OINTMENT Non-Preferred mupirocin CENTANY AT 2 % KIT Non-Preferred mupirocin CLEOCIN 100 MG SUPPOS Preferred clindamycin phosphate vaginal CLEOCIN 2 % CREAM Non-Preferred clindamycin phosphate vaginal CLEOCIN-T 1 % GEL Non-Preferred clindamycin phosphate (topical) CLEOCIN-T 1 % LOTION Non-Preferred clindamycin phosphate (topical) CLEOCIN-T 1 % SWAB Non-Preferred clindamycin phosphate (topical) CLINDACIN ETZ 1 % KIT Non-Preferred clindamycin phosphate & cleanser CLINDACIN PAC 1 % KIT Non-Preferred clindamycin phosphate & cleanser CLINDAGEL 1 % GEL Non-Preferred clindamycin phosphate (topical)

clindamycin hcl cap 150 mg Preferred QL 12 / 1 days

clindamycin hcl cap 300 mg Preferred QL 6 / 1 days

PAGE 37 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS clindamycin hcl cap 75 mg Preferred clindamycin palmitate hcl for soln 75 Preferred QL 120 / 1 days mg/5ml (base equiv) clindamycin phosphate gel 1% Preferred clindamycin phosphate lotion 1% Preferred clindamycin phosphate soln 1% Preferred clindamycin phosphate swab 1% Non-Preferred clindamycin phosphate swab 1% Non-Preferred clindamycin phosphate swab 1% Preferred clindamycin phosphate vaginal cream Preferred 2% CLINDESSE 2 % CREAM Preferred clindamycin phosphate (one dose) FIRVANQ 25 MG/ML RECON SOLN Preferred vancomycin hcl FIRVANQ 50 MG/ML RECON SOLN Preferred vancomycin hcl FLAGYL 250 MG TAB Non-Preferred metronidazole FLAGYL 375 MG CAP Non-Preferred metronidazole FLAGYL 500 MG TAB Non-Preferred metronidazole fosfomycin tromethamine powd pack 3 Non-Preferred gm (base equivalent) FURADANTIN 25 MG/5ML SUSPENSION Non-Preferred QL 90 / 1 days nitrofurantoin HIPREX 1 GM TAB Non-Preferred methenamine hippurate HYOPHEN 81.6 MG TAB methenamine-hyosc-methylene blue- Non-Preferred benzoic acid-phenyl sal MACROBID 100 MG CAP Non-Preferred QL 2 / 1 days nitrofurantoin monohyd macro MACRODANTIN 100 MG CAP Non-Preferred nitrofurantoin macrocrystal

PAGE 38 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MACRODANTIN 25 MG CAP Non-Preferred QL 2 / 1 days nitrofurantoin macrocrystal MACRODANTIN 50 MG CAP Non-Preferred nitrofurantoin macrocrystal methenamine hippurate tab 1 gm Preferred methenamine mandelate tab 0.5 gm Non-Preferred methenamine mandelate tab 1 gm Non-Preferred *methenamine-hyos-meth blue-sod Non-Preferred phos-phen sal tab 81.6 mg*** *methenamine-hyos-meth blue-sod Non-Preferred phos-phen sal tab 81.6 mg*** *methenamine-hyos-meth blue-sod Non-Preferred phos-phen sal tab 81.6 mg*** *methenamine-hyos-meth blue-sod Non-Preferred phos-phen sal tab 81.6 mg*** *methenamine-hyosc-meth blue-sod Non-Preferred phos-phen sal cap 120 mg*** *methenamine-hyosc-meth blue-sod Non-Preferred phos-phen sal tab 81 mg*** *methenamine-hyosc-meth blue-sod Non-Preferred phos-phen sal tab 81 mg*** *methenamine-hyosc-meth blue-sod Non-Preferred phos-phen sal tab 81 mg*** *methenamine-hyoscamine-meth blue- Non-Preferred sod phos tab 81.6 mg*** *methenamine-hyoscamine-meth blue- Non-Preferred sod phos tab 81.6 mg*** METROGEL-VAGINAL 0.75 % GEL Non-Preferred metronidazole vaginal metronidazole cap 375 mg Non-Preferred

metronidazole tab 250 mg Preferred QL 120 / 30 days

metronidazole tab 500 mg Preferred QL 4 / 1 days

metronidazole vaginal gel 0.75% Preferred QL 70 / 1 days

metronidazole vaginal gel 0.75% Non-Preferred QL 70 / days

MONUROL 3 GM PACKET Non-Preferred fosfomycin tromethamine

PAGE 39 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS mupirocin oint 2% Preferred mupirocin calcium cream 2% Non-Preferred

nitrofurantoin susp 25 mg/5ml Preferred QL 90 / 1 days

nitrofurantoin macrocrystalline cap 100 Preferred QL 4 / 1 days mg nitrofurantoin macrocrystalline cap 25 Preferred QL 2 / 1 days mg nitrofurantoin macrocrystalline cap 50 Preferred QL 4 / 1 days mg nitrofurantoin monohydrate Preferred QL 2 / 1 days macrocrystalline cap 100 mg NUVESSA 1.3 % GEL Non-Preferred metronidazole vaginal SOLOSEC 2 GM PACKET Non-Preferred secnidazole TINDAMAX 500 MG TAB Non-Preferred tinidazole

tinidazole tab 250 mg Non-Preferred QL 4 / 1 days

tinidazole tab 500 mg Non-Preferred QL 4 / 1 days

URIMAR-T 120 MG TAB methenamine-hyosc-methylene blue-sod Non-Preferred phos-phenyl sal UROGESIC-BLUE 81.6 MG TAB methenamine-hyoscamine-methylene Non-Preferred blue-sodium phosphate VANCOCIN 250 MG CAP Non-Preferred vancomycin hcl VANCOCIN HCL 125 MG CAP Non-Preferred vancomycin hcl VANCOMYCIN HCL 250 MG/5ML RECON SOLN Non-Preferred vancomycin hcl vancomycin hcl cap 125 mg (base Preferred QL 4 / 1 days equivalent) vancomycin hcl cap 250 mg (base Preferred QL 8 / 1 days equivalent) XIFAXAN 200 MG TAB Non-Preferred rifaximin

PAGE 40 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS XIFAXAN 550 MG TAB Non-Preferred rifaximin ZINPLAVA 1000 MG/40ML SOLUTION Non-Preferred bezlotoxumab BETA-LACTAM, CEPHALOSPORINS

CEFACLOR 125 MG/5ML RECON SUSP Non-Preferred cefaclor CEFACLOR 250 MG CAP Non-Preferred QL 4 / 1 days cefaclor CEFACLOR 250 MG/5ML RECON SUSP Non-Preferred cefaclor CEFACLOR 375 MG/5ML RECON SUSP Non-Preferred cefaclor CEFACLOR 500 MG CAP Non-Preferred QL 4 / 1 days cefaclor

cefaclor cap 250 mg Non-Preferred QL 4 / 1 days

cefaclor cap 500 mg Non-Preferred QL 4 / 1 days

CEFACLOR ER 500 MG TAB ER 12H Non-Preferred QL 2 / 1 days cefaclor monohydrate CEFADROXIL 1 GM TAB Non-Preferred QL 2 / 1 days cefadroxil

cefadroxil cap 500 mg Preferred QL 8 / 1 days

cefadroxil for susp 250 mg/5ml Preferred QLC 10 mL/day

cefadroxil for susp 500 mg/5ml Preferred QLC 20 mL/day

cefadroxil tab 1 gm Non-Preferred QL 2 / 1 days

cefdinir cap 300 mg Preferred QL 2 / 1 days

cefdinir for susp 125 mg/5ml Preferred QL 12 / 1 days

cefdinir for susp 250 mg/5ml Preferred QL 12 / 1 days

cefixime cap 400 mg Non-Preferred cefixime for susp 100 mg/5ml Non-Preferred cefixime for susp 200 mg/5ml Non-Preferred

PAGE 41 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS cefpodoxime proxetil for susp 100 Non-Preferred QL 40 / 1 days mg/5ml

cefpodoxime proxetil for susp 50 mg/5ml Non-Preferred QL 40 / 1 days

cefpodoxime proxetil tab 100 mg Preferred QL 3 / 1 days

cefpodoxime proxetil tab 200 mg Preferred QL 4 / 1 days

cefprozil for susp 125 mg/5ml Preferred QL 10 / 1 days

cefprozil for susp 250 mg/5ml Preferred QL 10 / 1 days

cefprozil tab 250 mg Preferred QL 1 / 1 days

cefprozil tab 500 mg Preferred QL 1 / 1 days

CEFTIN 125 MG/5ML RECON SUSP Preferred cefuroxime axetil CEFTIN 250 MG/5ML RECON SUSP Preferred cefuroxime axetil ceftriaxone sodium for inj 1 gm Preferred

ceftriaxone sodium for inj 10 gm Preferred QL 1 / 1 days

ceftriaxone sodium for inj 2 gm Preferred QL 2 / 1 days

ceftriaxone sodium for inj 250 mg Preferred QL 2 / 1 days

ceftriaxone sodium for inj 500 mg Preferred QL 2 / 1 days

ceftriaxone sodium for iv soln 1 gm Preferred QL 2 / 1 days

ceftriaxone sodium for iv soln 2 gm Preferred QL 2 / 1 days

cefuroxime axetil tab 250 mg Preferred QL 2 / 1 days

cefuroxime axetil tab 500 mg Preferred QL 2 / 1 days

CEPHALEXIN 250 MG TAB Non-Preferred cephalexin CEPHALEXIN 500 MG TAB Non-Preferred cephalexin

cephalexin cap 250 mg Preferred QL 8 / 1 days

cephalexin cap 500 mg Preferred QL 8 / 1 days

cephalexin cap 750 mg Non-Preferred

cephalexin for susp 125 mg/5ml Preferred QL 80 / 1 days

PAGE 42 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

cephalexin for susp 250 mg/5ml Preferred QL 80 / 1 days

KEFLEX 250 MG CAP Non-Preferred cephalexin KEFLEX 500 MG CAP Non-Preferred cephalexin KEFLEX 750 MG CAP Non-Preferred cephalexin SUPRAX 100 MG CHEW TAB Non-Preferred cefixime SUPRAX 100 MG/5ML RECON SUSP Non-Preferred cefixime SUPRAX 200 MG CHEW TAB Non-Preferred cefixime SUPRAX 200 MG/5ML RECON SUSP Non-Preferred cefixime SUPRAX 400 MG CAP Non-Preferred cefixime SUPRAX 500 MG/5ML RECON SUSP Non-Preferred cefixime BETA-LACTAM, PENICILLINS

amoxicillin (trihydrate) cap 250 mg Preferred QL 4 / 1 days

amoxicillin (trihydrate) cap 500 mg Preferred QL 4 / 1 days

amoxicillin (trihydrate) chew tab 125 mg Preferred QL 4 / 1 days

amoxicillin (trihydrate) chew tab 250 mg Preferred QL 4 / 1 days

amoxicillin (trihydrate) for susp 125 Preferred QL 25 / 1 days mg/5ml amoxicillin (trihydrate) for susp 200 Preferred QL 25 / 1 days mg/5ml amoxicillin (trihydrate) for susp 250 Preferred QL 25 / 1 days mg/5ml amoxicillin (trihydrate) for susp 400 Preferred QL 25 / 1 days mg/5ml

amoxicillin (trihydrate) tab 500 mg Preferred QL 8 / 1 days

amoxicillin (trihydrate) tab 875 mg Preferred QL 4 / 1 days

amoxicillin & k clavulanate chew tab Non-Preferred QL 2 / 1 days 200-28.5 mg

PAGE 43 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS amoxicillin & k clavulanate chew tab Non-Preferred QL 2 / 1 days 400-57 mg amoxicillin & k clavulanate for susp 200- Preferred QL 25 / 1 days 28.5 mg/5ml amoxicillin & k clavulanate for susp 250- Preferred QL 750 / 30 days 62.5 mg/5ml amoxicillin & k clavulanate for susp 400- Preferred QL 25 / 1 days 57 mg/5ml amoxicillin & k clavulanate for susp 600- Preferred QL 30 / 1 days 42.9 mg/5ml amoxicillin & k clavulanate tab 250-125 Preferred QL 3 / 1 days mg amoxicillin & k clavulanate tab 500-125 Preferred QL 3 / 1 days mg amoxicillin & k clavulanate tab 875-125 Preferred QL 2 / 1 days mg amoxicillin & k clavulanate tab er 12hr Non-Preferred 1000-62.5 mg ampicillin cap 500 mg Preferred AUGMENTIN 125-31.25 MG/5ML RECON SUSP Non-Preferred amoxicillin & pot clavulanate AUGMENTIN 250-62.5 MG/5ML RECON SUSP Non-Preferred amoxicillin & pot clavulanate AUGMENTIN XR 1000-62.5 MG TAB ER 12H Non-Preferred amoxicillin & pot clavulanate BICILLIN L-A 1200000 UNIT/2ML SUSPENSION Preferred QL 4 / 365 days penicillin g benzathine BICILLIN L-A 2400000 UNIT/4ML SUSPENSION Preferred QL 12 / 365 days penicillin g benzathine BICILLIN L-A 600000 UNIT/ML SUSPENSION Preferred penicillin g benzathine

dicloxacillin sodium cap 250 mg Preferred QL 8 / 1 days

dicloxacillin sodium cap 500 mg Preferred QL 8 / 1 days

PAGE 44 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MOXATAG 775 MG TAB ER 24H Non-Preferred amoxicillin penicillin g potassium for inj 20000000 Preferred unit penicillin g potassium for inj 20000000 Preferred unit penicillin g potassium for inj 5000000 Preferred unit penicillin g potassium for inj 5000000 Preferred unit penicillin g sodium for inj 5000000 unit Preferred penicillin v potassium for soln 125 Preferred QL 40 / 1 days mg/5ml penicillin v potassium for soln 250 Preferred QL 40 / 1 days mg/5ml

penicillin v potassium tab 250 mg Preferred QL 4 / 1 days

penicillin v potassium tab 500 mg Preferred QL 4 / 1 days

MACROLIDES

AZASITE 1 % SOLUTION Non-Preferred azithromycin (ophth)

azithromycin for susp 100 mg/5ml Preferred QL 25 / 1 days

azithromycin for susp 200 mg/5ml Preferred QL 25 / 1 days

azithromycin powd pack for susp 1 gm Preferred QL 3 / 1 days

QL 4 / 1 days azithromycin tab 250 mg Preferred C Max 5 day supply per fill

azithromycin tab 500 mg Preferred QL 10 / 23 days

azithromycin tab 600 mg Preferred QL 2 / 1 days

clarithromycin for susp 125 mg/5ml Preferred QL 20 / 1 days

clarithromycin for susp 250 mg/5ml Preferred QL 20 / 1 days

clarithromycin tab 250 mg Preferred QL 2 / 1 days

clarithromycin tab 500 mg Preferred QL 3 / 1 days

clarithromycin tab er 24hr 500 mg Non-Preferred QL 2 / 1 days

PAGE 45 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS DIFICID 200 MG TAB Non-Preferred fidaxomicin DIFICID 40 MG/ML RECON SUSP Non-Preferred fidaxomicin E.E.S. GRANULES 200 MG/5ML RECON SUSP Preferred erythromycin ethylsuccinate ERYGEL 2 % GEL Non-Preferred erythromycin (acne aid) ERYPED 200 200 MG/5ML RECON SUSP Preferred erythromycin ethylsuccinate ERYPED 400 400 MG/5ML RECON SUSP Preferred erythromycin ethylsuccinate ERYTHROCIN STEARATE 250 MG TAB Non-Preferred erythromycin stearate erythromycin gel 2% Non-Preferred erythromycin pads 2% Preferred erythromycin pads 2% Preferred erythromycin soln 2% Preferred

erythromycin ophth oint 5 mg/gm Preferred QL 7 / 18 days

erythromycin tab 250 mg Non-Preferred QL 8 / 1 days

erythromycin tab 500 mg Non-Preferred QL 8 / 1 days

erythromycin tab delayed release 250 Non-Preferred mg erythromycin tab delayed release 250 Non-Preferred mg erythromycin tab delayed release 250 Non-Preferred mg erythromycin tab delayed release 333 Non-Preferred mg erythromycin tab delayed release 333 Non-Preferred mg erythromycin tab delayed release 333 Non-Preferred mg

PAGE 46 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS erythromycin tab delayed release 500 Non-Preferred mg erythromycin tab delayed release 500 Non-Preferred mg erythromycin tab delayed release 500 Non-Preferred mg erythromycin w/ delayed release Non-Preferred QL 8 / 1 days particles cap 250 mg erythromycin ethylsuccinate for susp Non-Preferred 200 mg/5ml erythromycin ethylsuccinate for susp Non-Preferred 400 mg/5ml erythromycin ethylsuccinate tab 400 mg Non-Preferred

erythromycin ethylsuccinate tab 400 mg Non-Preferred QL 10 / 1 days

ZITHROMAX 1 GM PACKET Non-Preferred azithromycin ZITHROMAX 100 MG/5ML RECON SUSP Non-Preferred azithromycin ZITHROMAX 200 MG/5ML RECON SUSP Non-Preferred azithromycin ZITHROMAX 250 MG TAB Non-Preferred C Max 5 day supply per azithromycin fill ZITHROMAX 500 MG TAB Non-Preferred azithromycin ZITHROMAX TRI-PAK 500 MG TAB Non-Preferred azithromycin ZITHROMAX Z-PAK 250 MG TAB Non-Preferred C Max 5 day supply per azithromycin fill QUINOLONES

AVELOX 400 MG TAB Non-Preferred QL 14 / 30 days moxifloxacin hcl BAXDELA 450 MG TAB Non-Preferred delafloxacin meglumine BESIVANCE 0.6 % SUSPENSION Non-Preferred besifloxacin hcl CILOXAN 0.3 % OINTMENT Non-Preferred ciprofloxacin hcl (ophth)

PAGE 47 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CILOXAN 0.3 % SOLUTION Non-Preferred ciprofloxacin hcl (ophth) CIPRO 250 MG TAB Non-Preferred QL 2 / 1 days ciprofloxacin hcl CIPRO 250 MG/5ML (5%) RECON SUSP Preferred QL 15 / 1 days ciprofloxacin CIPRO 500 MG TAB Non-Preferred QL 2 / 1 days ciprofloxacin hcl CIPRO 500 MG/5ML (10%) RECON SUSP Preferred QL 15 / 1 days ciprofloxacin ciprofloxacin for oral susp 250 mg/5ml Non-Preferred QL 15 / 1 days (5%) (5 gm/100ml) ciprofloxacin for oral susp 500 mg/5ml Non-Preferred QL 15 / 1 days (10%) (10 gm/100ml) ciprofloxacin hcl tab 100 mg (base Preferred QL 2 / 1 days equiv) ciprofloxacin hcl tab 250 mg (base Preferred QL 2 / 1 days equiv) ciprofloxacin hcl tab 500 mg (base Preferred QL 2 / 1 days equiv) ciprofloxacin hcl tab 750 mg (base Preferred QL 2 / 1 days equiv) ciprofloxacin hcl ophth soln 0.3% (base Preferred QL 5 / 18 days equivalent) ciprofloxacin hcl otic soln 0.2% (base Non-Preferred equivalent) CIPROFLOXACIN-CIPROFLOX HCL ER 500 MG TAB ER 24H Non-Preferred ciprofloxacin-ciprofloxacin hcl gatifloxacin ophth soln 0.5% Preferred LEVAQUIN 500 MG TAB Non-Preferred QL 1 / 1 days levofloxacin LEVAQUIN 750 MG TAB Non-Preferred QL 1 / 1 days levofloxacin

levofloxacin oral soln 25 mg/ml Non-Preferred QL 30 / 1 days

levofloxacin tab 250 mg Preferred QL 1 / 1 days

PAGE 48 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

levofloxacin tab 500 mg Preferred QL 1 / 1 days

levofloxacin tab 750 mg Preferred QL 1 / 1 days

levofloxacin ophth soln 0.5% Non-Preferred MOXEZA 0.5 % SOLUTION Non-Preferred moxifloxacin hcl (ophth) moxifloxacin hcl tab 400 mg (base Non-Preferred QL 14 / 30 days equiv) moxifloxacin hcl ophth soln 0.5% (base Non-Preferred eq) (2 times daily) moxifloxacin hcl ophth soln 0.5% (base Non-Preferred equiv) OCUFLOX 0.3 % SOLUTION Non-Preferred ofloxacin (ophth)

ofloxacin tab 300 mg Non-Preferred QL 28 / 26 days

ofloxacin tab 400 mg Non-Preferred QL 28 / 26 days

ofloxacin ophth soln 0.3% Preferred QL 10 / 7 days

ofloxacin otic soln 0.3% Preferred OTIPRIO 6 % SUSPENSION Non-Preferred ciprofloxacin (otic) VIGAMOX 0.5 % SOLUTION Non-Preferred moxifloxacin hcl (ophth) ZYMAXID 0.5 % SOLUTION Non-Preferred gatifloxacin (ophth) SULFONAMIDES

AVC VAGINAL 15 % CREAM Non-Preferred sulfanilamide vaginal BLEPH-10 10 % SOLUTION Non-Preferred QL 15 / 18 days sulfacetamide sodium (ophth) KLARON 10 % LOTION Non-Preferred sulfacetamide sodium (acne) silver sulfadiazine cream 1% Preferred silver sulfadiazine cream 1% Preferred sulfacetamide sodium lotion 10% (acne) Preferred sulfacetamide sodium ophth oint 10% Non-Preferred

PAGE 49 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

sulfacetamide sodium ophth soln 10% Preferred QL 15 / 18 days

SULFADIAZINE 500 MG TAB Preferred QL 8 / 1 days sulfadiazine sulfamethoxazole-trimethoprim susp Preferred 200-40 mg/5ml sulfamethoxazole-trimethoprim susp Preferred 200-40 mg/5ml sulfamethoxazole-trimethoprim tab 400- Preferred 80 mg sulfamethoxazole-trimethoprim tab 800- Preferred 160 mg TETRACYCLINES

AMZEEQ 4 % FOAM Non-Preferred minocycline hcl micronized (acne) demeclocycline hcl tab 150 mg Non-Preferred demeclocycline hcl tab 300 mg Non-Preferred DORYX 200 MG TAB DR Non-Preferred doxycycline hyclate DORYX 50 MG TAB DR Non-Preferred doxycycline hyclate DORYX 80 MG TAB DR Non-Preferred doxycycline hyclate DORYX MPC 120 MG TAB DR Non-Preferred doxycycline hyclate DOXYCYCLINE 40 MG CAP DR Non-Preferred doxycycline (rosacea) doxycycline monohydrate cap 100 mg Preferred doxycycline monohydrate cap 150 mg Non-Preferred doxycycline monohydrate cap 50 mg Preferred doxycycline monohydrate cap 75 mg Non-Preferred doxycycline monohydrate for susp 25 Preferred mg/5ml

doxycycline monohydrate tab 100 mg Preferred QL 2 / 1 days

doxycycline monohydrate tab 150 mg Non-Preferred QL 2 / 1 days

doxycycline monohydrate tab 50 mg Preferred QL 1 / 1 days

PAGE 50 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

doxycycline monohydrate tab 75 mg Preferred QL 2 / 1 days

DOXYCYCLINE HYCLATE 80 MG TAB DR Non-Preferred doxycycline hyclate

doxycycline hyclate cap 100 mg Preferred QL 60 / 30 days

doxycycline hyclate cap 100 mg Non-Preferred QL 60 / 30 days

doxycycline hyclate cap 50 mg Preferred QL 60 / 30 days

doxycycline hyclate cap 50 mg Non-Preferred QL 60 / 30 days

doxycycline hyclate tab 100 mg Preferred QL 60 / 30 days

doxycycline hyclate tab 150 mg Non-Preferred doxycycline hyclate tab 20 mg Preferred doxycycline hyclate tab 75 mg Non-Preferred doxycycline hyclate tab delayed release Non-Preferred 100 mg doxycycline hyclate tab delayed release Non-Preferred 150 mg doxycycline hyclate tab delayed release Non-Preferred 200 mg doxycycline hyclate tab delayed release Non-Preferred 50 mg doxycycline hyclate tab delayed release Non-Preferred 75 mg MINOCIN 50 MG CAP Non-Preferred QL 2 / 1 days minocycline hcl

minocycline hcl cap 100 mg Preferred QL 2 / 1 days

minocycline hcl cap 50 mg Preferred QL 2 / 1 days

minocycline hcl cap 75 mg Preferred QL 2 / 1 days

minocycline hcl tab 100 mg Non-Preferred minocycline hcl tab 50 mg Non-Preferred minocycline hcl tab 75 mg Non-Preferred minocycline hcl tab er 24hr 105 mg Non-Preferred minocycline hcl tab er 24hr 115 mg Non-Preferred

PAGE 51 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS minocycline hcl tab er 24hr 135 mg Non-Preferred minocycline hcl tab er 24hr 45 mg Non-Preferred minocycline hcl tab er 24hr 55 mg Non-Preferred minocycline hcl tab er 24hr 65 mg Non-Preferred minocycline hcl tab er 24hr 80 mg Non-Preferred minocycline hcl tab er 24hr 90 mg Non-Preferred MINOCYCLINE HCL ER 135 MG CAP ER 24H Non-Preferred minocycline hcl MINOCYCLINE HCL ER 45 MG CAP ER 24H Non-Preferred minocycline hcl MINOCYCLINE HCL ER 90 MG CAP ER 24H Non-Preferred minocycline hcl MINOLIRA 105 MG TAB ER 24H Non-Preferred minocycline hcl MINOLIRA 135 MG TAB ER 24H Non-Preferred minocycline hcl MORGIDOX 1 X 100 MG KIT Non-Preferred doxycycline hyclate w/ cleanser MORGIDOX 1 X 50 MG KIT Non-Preferred doxycycline hyclate w/ cleanser MORGIDOX 2 X 100 MG KIT Non-Preferred doxycycline hyclate w/ cleanser NUZYRA 150 MG TAB Non-Preferred omadacycline tosylate ORACEA 40 MG CAP DR Non-Preferred doxycycline (rosacea) SOLODYN 105 MG TAB ER 24H Non-Preferred minocycline hcl SOLODYN 115 MG TAB ER 24H Non-Preferred minocycline hcl SOLODYN 55 MG TAB ER 24H Non-Preferred minocycline hcl SOLODYN 65 MG TAB ER 24H Non-Preferred minocycline hcl SOLODYN 80 MG TAB ER 24H Non-Preferred minocycline hcl

PAGE 52 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

tetracycline hcl cap 250 mg Preferred QL 120 / 30 days

tetracycline hcl cap 500 mg Preferred QL 120 / 30 days

VIBRAMYCIN 100 MG CAP Non-Preferred QL 60 / 30 days doxycycline hyclate VIBRAMYCIN 25 MG/5ML RECON SUSP Non-Preferred doxycycline (monohydrate) VIBRAMYCIN 50 MG/5ML SYRUP Non-Preferred doxycycline calcium XIMINO 135 MG CAP ER 24H Non-Preferred minocycline hcl XIMINO 45 MG CAP ER 24H Non-Preferred minocycline hcl XIMINO 90 MG CAP ER 24H Non-Preferred minocycline hcl ANTICONVULSANTS

ANTICONVULSANTS, OTHER

BRIVIACT 10 MG TAB Non-Preferred QL 2 / 1 days brivaracetam BRIVIACT 10 MG/ML SOLUTION Non-Preferred brivaracetam BRIVIACT 100 MG TAB Non-Preferred QL 2 / 1 days brivaracetam BRIVIACT 25 MG TAB Non-Preferred QL 2 / 1 days brivaracetam BRIVIACT 50 MG TAB Non-Preferred QL 2 / 1 days brivaracetam BRIVIACT 75 MG TAB Non-Preferred QL 2 / 1 days brivaracetam DIACOMIT 250 MG CAP Non-Preferred stiripentol DIACOMIT 250 MG PACKET Non-Preferred stiripentol DIACOMIT 500 MG CAP Non-Preferred stiripentol DIACOMIT 500 MG PACKET Non-Preferred stiripentol

PAGE 53 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS EPIDIOLEX 100 MG/ML SOLUTION Non-Preferred cannabidiol FINTEPLA 2.2 MG/ML SOLUTION Non-Preferred fenfluramine hcl (anticonvulsant) KEPPRA 100 MG/ML SOLUTION Non-Preferred levetiracetam KEPPRA 1000 MG TAB Non-Preferred levetiracetam KEPPRA 250 MG TAB Non-Preferred levetiracetam KEPPRA 500 MG TAB Non-Preferred levetiracetam KEPPRA 750 MG TAB Non-Preferred levetiracetam KEPPRA XR 500 MG TAB ER 24H Non-Preferred levetiracetam KEPPRA XR 750 MG TAB ER 24H Non-Preferred levetiracetam

levetiracetam oral soln 100 mg/ml Preferred QL 30 / 1 days

levetiracetam tab 1000 mg Preferred QL 4 / 1 days

levetiracetam tab 1000 mg Preferred

levetiracetam tab 250 mg Preferred QL 4 / 1 days

levetiracetam tab 500 mg Preferred QL 4 / 1 days

levetiracetam tab 500 mg Preferred

levetiracetam tab 750 mg Preferred QL 4 / 1 days

levetiracetam tab 750 mg Preferred

levetiracetam tab er 24hr 500 mg Preferred QL 6 / 1 days

levetiracetam tab er 24hr 500 mg Preferred

levetiracetam tab er 24hr 750 mg Preferred QL 4 / 1 days

levetiracetam tab er 24hr 750 mg Preferred NAYZILAM 5 MG/0.1ML SOLUTION Preferred QL 10 / 30 days midazolam (anticonvulsant) POTIGA 200 MG TAB Non-Preferred ezogabine

PAGE 54 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS POTIGA 50 MG TAB Non-Preferred ezogabine SPRITAM 1000 MG TAB Non-Preferred levetiracetam SPRITAM 250 MG TAB Non-Preferred levetiracetam SPRITAM 500 MG TAB Non-Preferred levetiracetam SPRITAM 750 MG TAB Non-Preferred levetiracetam CALCIUM CHANNEL MODIFYING AGENTS

CELONTIN 300 MG CAP Non-Preferred methsuximide

ethosuximide cap 250 mg Preferred QL 6 / 1 days

ethosuximide soln 250 mg/5ml Preferred QL 30 / 1 days

ZARONTIN 250 MG CAP Non-Preferred ethosuximide ZARONTIN 250 MG/5ML SOLUTION Non-Preferred ethosuximide

zonisamide cap 100 mg Preferred QL 6 / 1 days

zonisamide cap 25 mg Preferred QL 4 / 1 days

zonisamide cap 50 mg Preferred QL 4 / 1 days

GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS

clobazam suspension 2.5 mg/ml Preferred clobazam tab 10 mg Preferred clobazam tab 20 mg Preferred DEPAKENE 250 MG CAP Non-Preferred valproic acid DEPAKENE 250 MG/5ML SOLUTION Non-Preferred valproate sodium DEPAKOTE 125 MG TAB DR Non-Preferred divalproex sodium DEPAKOTE 250 MG TAB DR Non-Preferred divalproex sodium DEPAKOTE 500 MG TAB DR Non-Preferred divalproex sodium

PAGE 55 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS DEPAKOTE ER 250 MG TAB ER 24H Non-Preferred divalproex sodium DEPAKOTE ER 500 MG TAB ER 24H Non-Preferred divalproex sodium DEPAKOTE SPRINKLES 125 MG CAP DR Non-Preferred divalproex sodium DIASTAT ACUDIAL 10 MG GEL Non-Preferred diazepam (anticonvulsant) DIASTAT ACUDIAL 20 MG GEL Non-Preferred diazepam (anticonvulsant) DIASTAT PEDIATRIC 2.5 MG GEL Non-Preferred diazepam (anticonvulsant) diazepam rectal gel delivery system 10 Preferred QL 2 / 30 days mg diazepam rectal gel delivery system 2.5 Preferred QL 2 / 30 days mg diazepam rectal gel delivery system 20 Preferred QL 2 / 30 days mg divalproex sodium cap delayed release Preferred sprinkle 125 mg divalproex sodium tab delayed release Preferred 125 mg divalproex sodium tab delayed release Preferred 250 mg divalproex sodium tab delayed release Preferred 500 mg divalproex sodium tab er 24 hr 250 mg Preferred divalproex sodium tab er 24 hr 500 mg Preferred divalproex sodium tab release 250 mg Preferred divalproex sodium tab release 500 mg Preferred GABAPAL 100 & 3.88 MG & % THER PACK Non-Preferred gabapentin-lidocaine-silicone

gabapentin cap 100 mg Preferred QL 6 / 1 days

gabapentin cap 300 mg Preferred QL 6 / 1 days

gabapentin cap 400 mg Preferred QL 6 / 1 days

PAGE 56 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS gabapentin oral soln 250 mg/5ml Preferred gabapentin oral soln 250 mg/5ml Preferred

gabapentin tab 600 mg Preferred QL 6 / 1 days

gabapentin tab 800 mg Preferred QL 4 / 1 days

GABITRIL 12 MG TAB Non-Preferred QL 4 / 1 days tiagabine hcl GABITRIL 16 MG TAB Non-Preferred QL 3 / 1 days tiagabine hcl GABITRIL 2 MG TAB Non-Preferred QL 14 / 1 days tiagabine hcl GABITRIL 4 MG TAB Non-Preferred QL 14 / 1 days tiagabine hcl GRALISE 300 MG TAB Non-Preferred gabapentin (once-daily) GRALISE 600 MG TAB Non-Preferred gabapentin (once-daily) LIDOTIN 100-3.88 MG-% THER PACK Non-Preferred gabapentin-lidocaine-silicone LIPRITIN 100 MG THER PACK gabapentin & lidocaine-prilocaine & Non-Preferred transparent dressing MYSOLINE 250 MG TAB Non-Preferred primidone MYSOLINE 50 MG TAB Non-Preferred primidone NEURONTIN 100 MG CAP Non-Preferred gabapentin NEURONTIN 250 MG/5ML SOLUTION Non-Preferred gabapentin NEURONTIN 300 MG CAP Non-Preferred gabapentin NEURONTIN 400 MG CAP Non-Preferred gabapentin NEURONTIN 600 MG TAB Non-Preferred gabapentin NEURONTIN 800 MG TAB Non-Preferred gabapentin

PAGE 57 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ONFI 10 MG TAB Non-Preferred clobazam ONFI 2.5 MG/ML SUSPENSION Non-Preferred clobazam ONFI 20 MG TAB Non-Preferred clobazam PENTICAN 100 & 5 MG & % THER PACK Non-Preferred gabapentin & lidocaine phenobarbital elixir 20 mg/5ml Preferred phenobarbital elixir 20 mg/5ml Preferred phenobarbital tab 100 mg Preferred phenobarbital tab 15 mg Preferred phenobarbital tab 16.2 mg Preferred phenobarbital tab 30 mg Preferred phenobarbital tab 32.4 mg Preferred phenobarbital tab 60 mg Preferred phenobarbital tab 64.8 mg Preferred phenobarbital tab 97.2 mg Preferred

primidone tab 250 mg Preferred QL 8 / 1 days

primidone tab 50 mg Preferred QL 8 / 1 days

SABRIL 500 MG PACKET Non-Preferred QL 120 / 30 days vigabatrin SABRIL 500 MG TAB Non-Preferred vigabatrin SYMPAZAN 10 MG FILM Non-Preferred clobazam SYMPAZAN 20 MG FILM Non-Preferred clobazam SYMPAZAN 5 MG FILM Non-Preferred clobazam

tiagabine hcl tab 12 mg Non-Preferred QL 4 / 1 days

tiagabine hcl tab 16 mg Non-Preferred QL 3 / 1 days

tiagabine hcl tab 2 mg Non-Preferred QL 14 / 1 days

PAGE 58 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

tiagabine hcl tab 4 mg Non-Preferred QL 14 / 1 days

valproate sodium oral soln 250 mg/5ml Preferred (base equiv) valproate sodium oral soln 250 mg/5ml Preferred (base equiv) valproic acid cap 250 mg Preferred VALTOCO 10 MG DOSE 10 MG/0.1ML LIQUID Preferred QL 10 / 30 days diazepam (anticonvulsant) VALTOCO 15 MG DOSE 7.5 MG/0.1ML LIQD THPK Preferred QL 10 / 30 days diazepam (anticonvulsant) VALTOCO 20 MG DOSE 10 MG/0.1ML LIQD THPK Preferred QL 10 / 30 days diazepam (anticonvulsant) VALTOCO 5 MG DOSE 5 MG/0.1ML LIQUID Preferred QL 10 / 30 days diazepam (anticonvulsant)

vigabatrin powd pack 500 mg Non-Preferred QL 120 / 30 days

vigabatrin powd pack 500 mg Non-Preferred QL 120 / 30 days

vigabatrin tab 500 mg Non-Preferred GLUTAMATE REDUCING AGENTS

felbamate susp 600 mg/5ml Non-Preferred QL 30 / 1 days

felbamate tab 400 mg Non-Preferred QL 9 / 1 days

felbamate tab 600 mg Non-Preferred QL 6 / 1 days

FELBATOL 400 MG TAB Non-Preferred felbamate FELBATOL 600 MG TAB Non-Preferred felbamate FELBATOL 600 MG/5ML SUSPENSION Non-Preferred felbamate FYCOMPA 0.5 MG/ML SUSPENSION Non-Preferred perampanel FYCOMPA 10 MG TAB Non-Preferred perampanel FYCOMPA 12 MG TAB Non-Preferred perampanel

PAGE 59 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS FYCOMPA 2 MG TAB Non-Preferred perampanel FYCOMPA 4 MG TAB Non-Preferred perampanel FYCOMPA 6 MG TAB Non-Preferred perampanel FYCOMPA 8 MG TAB Non-Preferred perampanel LAMICTAL 100 MG TAB Non-Preferred lamotrigine LAMICTAL 150 MG TAB Non-Preferred QL 3 / 1 days lamotrigine LAMICTAL 200 MG TAB Non-Preferred QL 3 / 1 days lamotrigine LAMICTAL 25 MG CHEW TAB Non-Preferred lamotrigine LAMICTAL 25 MG TAB Non-Preferred lamotrigine LAMICTAL 5 MG CHEW TAB Non-Preferred lamotrigine LAMICTAL ODT 100 MG TAB DISP Non-Preferred lamotrigine LAMICTAL ODT 200 MG TAB DISP Non-Preferred lamotrigine LAMICTAL ODT 21 X 25 MG & 7 X 50 MG KIT Non-Preferred lamotrigine LAMICTAL ODT 25 & 50 & 100 MG KIT Non-Preferred lamotrigine LAMICTAL ODT 25 MG TAB DISP Non-Preferred lamotrigine LAMICTAL ODT 42 X 50 MG & 14X100 MG KIT Non-Preferred lamotrigine LAMICTAL ODT 50 MG TAB DISP Non-Preferred lamotrigine LAMICTAL STARTER 35 X 25 MG KIT Non-Preferred lamotrigine LAMICTAL STARTER 42 X 25 MG & 7 X 100 MG KIT Non-Preferred lamotrigine

PAGE 60 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS LAMICTAL STARTER 84 X 25 MG & 14X100 MG KIT Non-Preferred lamotrigine LAMICTAL XR 100 MG TAB ER 24H Non-Preferred lamotrigine LAMICTAL XR 200 MG TAB ER 24H Non-Preferred lamotrigine LAMICTAL XR 21 X 25 MG & 7 X 50 MG KIT Non-Preferred lamotrigine LAMICTAL XR 25 & 50 & 100 MG KIT Non-Preferred lamotrigine LAMICTAL XR 25 MG TAB ER 24H Non-Preferred lamotrigine LAMICTAL XR 250 MG TAB ER 24H Non-Preferred lamotrigine LAMICTAL XR 300 MG TAB ER 24H Non-Preferred lamotrigine LAMICTAL XR 50 & 100 & 200 MG KIT Non-Preferred lamotrigine LAMICTAL XR 50 MG TAB ER 24H Non-Preferred lamotrigine lamotrigine orally disintegrating tab 100 Non-Preferred mg lamotrigine orally disintegrating tab 200 Non-Preferred mg lamotrigine orally disintegrating tab 25 Non-Preferred mg lamotrigine orally disintegrating tab 50 Non-Preferred mg

lamotrigine tab 100 mg Preferred QL 5 / 1 days

lamotrigine tab 100 mg Preferred

lamotrigine tab 150 mg Preferred QL 3 / 1 days

lamotrigine tab 150 mg Preferred QL 3 / 1 days

lamotrigine tab 200 mg Preferred QL 3 / 1 days

lamotrigine tab 200 mg Preferred QL 3 / 1 days

PAGE 61 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS lamotrigine tab 25 mg Preferred lamotrigine tab 25 mg Preferred lamotrigine tab 25 mg (42) & 100 mg (7) Non-Preferred starter kit lamotrigine tab 25 mg (42) & 100 mg (7) Non-Preferred starter kit lamotrigine tab 35 x 25 mg starter kit Non-Preferred lamotrigine tab 35 x 25 mg starter kit Non-Preferred lamotrigine tab 84 x 25 mg & 14 x 100 Non-Preferred mg starter kit lamotrigine tab 84 x 25 mg & 14 x 100 Non-Preferred mg starter kit lamotrigine tab chewable dispersible 25 Non-Preferred mg lamotrigine tab chewable dispersible 5 Non-Preferred mg lamotrigine tab disint 21 x 25 mg & 7 x Non-Preferred 50 mg titration kit lamotrigine tab disint 25 (14) & 50 mg Non-Preferred (14) & 100 mg (7) kit lamotrigine tab disint 42 x 50mg & 14 x Non-Preferred 100mg titration kit lamotrigine tab er 24hr 100 mg Non-Preferred lamotrigine tab er 24hr 200 mg Non-Preferred lamotrigine tab er 24hr 25 mg Non-Preferred lamotrigine tab er 24hr 250 mg Non-Preferred lamotrigine tab er 24hr 300 mg Non-Preferred lamotrigine tab er 24hr 50 mg Non-Preferred QUDEXY XR 100 MG CP24 SPRNK Non-Preferred topiramate QUDEXY XR 150 MG CP24 SPRNK Non-Preferred topiramate QUDEXY XR 200 MG CP24 SPRNK Non-Preferred topiramate QUDEXY XR 25 MG CP24 SPRNK Non-Preferred topiramate

PAGE 62 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QUDEXY XR 50 MG CP24 SPRNK Non-Preferred topiramate TOPAMAX 100 MG TAB Non-Preferred topiramate TOPAMAX 200 MG TAB Non-Preferred topiramate TOPAMAX 25 MG TAB Non-Preferred topiramate TOPAMAX 50 MG TAB Non-Preferred topiramate TOPAMAX SPRINKLE 15 MG CAP SPRINK Non-Preferred topiramate TOPAMAX SPRINKLE 25 MG CAP SPRINK Non-Preferred topiramate topiramate cap er 24hr sprinkle 100 mg Preferred topiramate cap er 24hr sprinkle 150 mg Preferred topiramate cap er 24hr sprinkle 200 mg Preferred topiramate cap er 24hr sprinkle 25 mg Preferred topiramate cap er 24hr sprinkle 50 mg Preferred

topiramate sprinkle cap 15 mg Preferred QL 4 / 1 days

topiramate sprinkle cap 25 mg Preferred QL 4 / 1 days

topiramate tab 100 mg Preferred QL 4 / 1 days

topiramate tab 200 mg Preferred QL 4 / 1 days

topiramate tab 25 mg Preferred QL 4 / 1 days

topiramate tab 50 mg Preferred QL 4 / 1 days

TROKENDI XR 100 MG CAP ER 24H Non-Preferred QL 90 / 30 days topiramate TROKENDI XR 200 MG CAP ER 24H Non-Preferred QL 60 / 30 days topiramate TROKENDI XR 25 MG CAP ER 24H Non-Preferred QL 120 / 30 days topiramate TROKENDI XR 50 MG CAP ER 24H Non-Preferred QL 60 / 30 days topiramate

PAGE 63 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS XCOPRI 100 MG TAB Non-Preferred cenobamate XCOPRI 14 X 12.5 MG & 14 X 25 MG TAB THPK Non-Preferred cenobamate XCOPRI 14 X 150 MG & 14 X200 MG TAB THPK Non-Preferred cenobamate XCOPRI 14 X 50 MG & 14 X100 MG TAB THPK Non-Preferred cenobamate XCOPRI 150 MG TAB Non-Preferred cenobamate XCOPRI 200 MG TAB Non-Preferred cenobamate XCOPRI 50 MG TAB Non-Preferred cenobamate XCOPRI (250 MG DAILY DOSE) 50 & 200 MG TAB THPK Non-Preferred cenobamate XCOPRI (350 MG DAILY DOSE) 150 & 200 MG TAB THPK Non-Preferred cenobamate SODIUM CHANNEL AGENTS

APTIOM 200 MG TAB Non-Preferred eslicarbazepine acetate APTIOM 400 MG TAB Non-Preferred eslicarbazepine acetate APTIOM 600 MG TAB Non-Preferred eslicarbazepine acetate APTIOM 800 MG TAB Non-Preferred eslicarbazepine acetate BANZEL 200 MG TAB Non-Preferred rufinamide BANZEL 40 MG/ML SUSPENSION Non-Preferred rufinamide BANZEL 400 MG TAB Non-Preferred rufinamide

carbamazepine cap er 12hr 100 mg Preferred QL 4 / 1 days

PAGE 64 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

carbamazepine cap er 12hr 200 mg Preferred QL 4 / 1 days

carbamazepine cap er 12hr 300 mg Preferred QL 4 / 1 days

carbamazepine chew tab 100 mg Preferred QL 8 / 1 days

carbamazepine susp 100 mg/5ml Preferred QL 80 / 1 days

carbamazepine tab 200 mg Preferred QL 8 / 1 days

carbamazepine tab 200 mg Preferred

carbamazepine tab er 12hr 100 mg Preferred QL 4 / 1 days

carbamazepine tab er 12hr 200 mg Preferred QL 4 / 1 days

carbamazepine tab er 12hr 400 mg Preferred QL 4 / 1 days

CARBATROL 100 MG CAP ER 12H Non-Preferred carbamazepine CARBATROL 200 MG CAP ER 12H Non-Preferred carbamazepine CARBATROL 300 MG CAP ER 12H Non-Preferred carbamazepine DILANTIN 100 MG CAP Preferred QL 12 / 1 days phenytoin sodium extended DILANTIN 125 MG/5ML SUSPENSION Non-Preferred phenytoin DILANTIN 30 MG CAP Preferred QL 9 / 1 days phenytoin sodium extended DILANTIN INFATABS 50 MG CHEW TAB Non-Preferred QL 8 / 1 days phenytoin oxcarbazepine susp 300 mg/5ml (60 Preferred QL 40 / 1 days mg/ml)

oxcarbazepine tab 150 mg Preferred QL 4 / 1 days

oxcarbazepine tab 300 mg Preferred QL 4 / 1 days

oxcarbazepine tab 600 mg Preferred QL 4 / 1 days

OXTELLAR XR 150 MG TAB ER 24H Non-Preferred oxcarbazepine OXTELLAR XR 300 MG TAB ER 24H Non-Preferred oxcarbazepine

PAGE 65 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS OXTELLAR XR 600 MG TAB ER 24H Non-Preferred oxcarbazepine PEGANONE 250 MG TAB Non-Preferred ethotoin PHENYTEK 200 MG CAP Non-Preferred QL 2 / 1 days phenytoin sodium extended PHENYTEK 300 MG CAP Non-Preferred QL 1 / 1 days phenytoin sodium extended

phenytoin chew tab 50 mg Preferred QL 8 / 1 days

phenytoin chew tab 50 mg Preferred phenytoin susp 125 mg/5ml Preferred

phenytoin susp 125 mg/5ml Preferred QL 15 / 1 days

phenytoin sodium extended cap 100 mg Preferred QL 12 / 1 days

phenytoin sodium extended cap 200 mg Preferred QL 2 / 1 days

phenytoin sodium extended cap 300 mg Preferred QL 1 / 1 days

rufinamide susp 40 mg/ml Non-Preferred TEGRETOL 100 MG/5ML SUSPENSION Non-Preferred carbamazepine TEGRETOL 200 MG TAB Non-Preferred carbamazepine TEGRETOL-XR 100 MG TAB ER 12H Non-Preferred carbamazepine TEGRETOL-XR 200 MG TAB ER 12H Non-Preferred carbamazepine TEGRETOL-XR 400 MG TAB ER 12H Non-Preferred carbamazepine TRILEPTAL 150 MG TAB Non-Preferred oxcarbazepine TRILEPTAL 300 MG TAB Non-Preferred oxcarbazepine TRILEPTAL 300 MG/5ML SUSPENSION Non-Preferred oxcarbazepine TRILEPTAL 600 MG TAB Non-Preferred oxcarbazepine

PAGE 66 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VIMPAT 10 MG/ML SOLUTION Non-Preferred lacosamide VIMPAT 100 MG TAB Preferred QL 2 / 1 days lacosamide VIMPAT 150 MG TAB Preferred QL 2 / 1 days lacosamide VIMPAT 200 MG TAB Preferred QL 2 / 1 days lacosamide VIMPAT 50 MG TAB Preferred QL 2 / 1 days lacosamide ANTIDEMENTIA AGENTS

CHOLINESTERASE INHIBITORS

ARICEPT 10 MG TAB Non-Preferred QL 1 / 1 days donepezil hydrochloride ARICEPT 23 MG TAB Non-Preferred QL 1 / 1 days donepezil hydrochloride ARICEPT 5 MG TAB Non-Preferred QL 1 / 1 days donepezil hydrochloride donepezil hydrochloride orally Non-Preferred QL 1 / 1 days disintegrating tab 10 mg donepezil hydrochloride orally Non-Preferred QL 2 / 1 days disintegrating tab 5 mg

QL 1 / 1 days donepezil hydrochloride tab 10 mg Preferred PA

donepezil hydrochloride tab 23 mg Non-Preferred QL 1 / 1 days

QL 1 / 1 days donepezil hydrochloride tab 5 mg Preferred PA

EXELON 13.3 MG/24HR PATCH 24HR Non-Preferred QL 1 / 1 days rivastigmine EXELON 4.6 MG/24HR PATCH 24HR Non-Preferred QL 1 / 1 days rivastigmine EXELON 9.5 MG/24HR PATCH 24HR Non-Preferred QL 1 / 1 days rivastigmine galantamine hydrobromide cap er 24hr Non-Preferred 16 mg galantamine hydrobromide cap er 24hr Non-Preferred 24 mg

PAGE 67 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS galantamine hydrobromide cap er 24hr 8 Non-Preferred mg galantamine hydrobromide oral soln 4 Non-Preferred mg/ml

galantamine hydrobromide tab 12 mg Preferred PA

galantamine hydrobromide tab 4 mg Preferred PA

galantamine hydrobromide tab 8 mg Preferred PA

NAMZARIC 14-10 MG CAP ER 24H Non-Preferred memantine hcl-donepezil hcl NAMZARIC 21-10 MG CAP ER 24H Non-Preferred memantine hcl-donepezil hcl NAMZARIC 28-10 MG CAP ER 24H Non-Preferred memantine hcl-donepezil hcl NAMZARIC 7 & 14 & 21 &28 -10 MG CP24 THPK Non-Preferred memantine hcl-donepezil hcl NAMZARIC 7-10 MG CAP ER 24H Non-Preferred memantine hcl-donepezil hcl RAZADYNE 12 MG TAB Non-Preferred galantamine hydrobromide RAZADYNE 4 MG TAB Non-Preferred galantamine hydrobromide RAZADYNE 8 MG TAB Non-Preferred galantamine hydrobromide RAZADYNE ER 16 MG CAP ER 24H Non-Preferred galantamine hydrobromide RAZADYNE ER 24 MG CAP ER 24H Non-Preferred galantamine hydrobromide RAZADYNE ER 8 MG CAP ER 24H Non-Preferred galantamine hydrobromide

rivastigmine td patch 24hr 13.3 mg/24hr Non-Preferred QL 1 / 1 days

rivastigmine td patch 24hr 4.6 mg/24hr Non-Preferred QL 1 / 1 days

rivastigmine td patch 24hr 9.5 mg/24hr Non-Preferred QL 1 / 1 days

rivastigmine tartrate cap 1.5 mg (base QL 60 / 30 days Preferred equivalent) PA

PAGE 68 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

rivastigmine tartrate cap 3 mg (base QL 60 / 30 days Preferred equivalent) PA

rivastigmine tartrate cap 4.5 mg (base QL 60 / 30 days Preferred equivalent) PA

rivastigmine tartrate cap 6 mg (base QL 60 / 30 days Preferred equivalent) PA

N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST

memantine hcl cap er 24hr 14 mg Non-Preferred memantine hcl cap er 24hr 21 mg Non-Preferred memantine hcl cap er 24hr 28 mg Non-Preferred memantine hcl cap er 24hr 7 mg Non-Preferred memantine hcl oral solution 2 mg/ml Non-Preferred

QL 10 / 1 days memantine hcl oral solution 2 mg/ml Non-Preferred PA

QL 60 / 30 days memantine hcl tab 10 mg Preferred PA

memantine hcl tab 28 x 5 mg & 21 x 10 QL 2 / 1 days Preferred mg titration pack PA

QL 2 / 1 days memantine hcl tab 5 mg Preferred PA

NAMENDA 10 MG TAB Non-Preferred QL 60 / 30 days memantine hcl NAMENDA 5 MG TAB Non-Preferred QL 2 / 1 days memantine hcl NAMENDA TITRATION PAK 28 X 5 MG & 21 X 10 MG TAB Non-Preferred QL 2 / 1 days memantine hcl NAMENDA XR 14 MG CAP ER 24H Non-Preferred memantine hcl NAMENDA XR 21 MG CAP ER 24H Non-Preferred memantine hcl NAMENDA XR 28 MG CAP ER 24H Non-Preferred memantine hcl

PAGE 69 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NAMENDA XR 7 MG CAP ER 24H Non-Preferred memantine hcl NAMENDA XR TITRATION PACK 7 & 14 & 21 &28 MG CAP ER 24H Non-Preferred memantine hcl ANTIDEPRESSANTS

ANTIDEPRESSANTS, OTHER

APLENZIN 174 MG TAB ER 24H Non-Preferred bupropion hydrobromide APLENZIN 348 MG TAB ER 24H Non-Preferred bupropion hydrobromide APLENZIN 522 MG TAB ER 24H Non-Preferred bupropion hydrobromide

bupropion hcl tab 100 mg Preferred QL 120 / 30 days

bupropion hcl tab 75 mg Preferred QL 120 / 30 days

bupropion hcl tab er 12hr 100 mg Preferred QL 60 / 30 days

bupropion hcl tab er 12hr 150 mg Preferred QL 60 / 30 days

bupropion hcl tab er 12hr 200 mg Preferred QL 60 / 30 days

bupropion hcl tab er 24hr 150 mg Preferred QL 60 / 30 days

bupropion hcl tab er 24hr 300 mg Preferred QL 30 / 30 days

bupropion hcl tab er 24hr 450 mg Preferred chlordiazepoxide-amitriptyline tab 10-25 Preferred QL 6 / 1 days mg chlordiazepoxide-amitriptyline tab 5-12.5 Preferred QL 6 / 1 days mg FORFIVO XL 450 MG TAB ER 24H Non-Preferred bupropion hcl mirtazapine orally disintegrating tab 15 Non-Preferred QL 1 / 1 days mg mirtazapine orally disintegrating tab 30 Non-Preferred QL 1 / 1 days mg mirtazapine orally disintegrating tab 45 Non-Preferred QL 1 / 1 days mg

mirtazapine tab 15 mg Preferred QL 1 / 1 days

PAGE 70 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

mirtazapine tab 30 mg Preferred QL 1 / 1 days

mirtazapine tab 45 mg Preferred QL 1 / 1 days

mirtazapine tab 7.5 mg Preferred QL 1 / 1 days

QL 30 / 30 days

olanzapine-fluoxetine hcl cap 12-25 mg Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 30 / 30 days

olanzapine-fluoxetine hcl cap 12-50 mg Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 30 / 30 days

olanzapine-fluoxetine hcl cap 3-25 mg Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 30 / 30 days

olanzapine-fluoxetine hcl cap 6-25 mg Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 30 / 30 days

olanzapine-fluoxetine hcl cap 6-50 mg Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 8 / 1 days

perphenazine-amitriptyline tab 2-10 mg Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 8 / 1 days

perphenazine-amitriptyline tab 2-25 mg Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 4 / 1 days

perphenazine-amitriptyline tab 4-10 mg Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

PAGE 71 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 4 / 1 days

perphenazine-amitriptyline tab 4-50 mg Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required REMERON 15 MG TAB Non-Preferred QL 1 / 1 days mirtazapine REMERON 30 MG TAB Non-Preferred QL 1 / 1 days mirtazapine REMERON SOLTAB 15 MG TAB DISP Non-Preferred QL 1 / 1 days mirtazapine REMERON SOLTAB 30 MG TAB DISP Non-Preferred QL 1 / 1 days mirtazapine REMERON SOLTAB 45 MG TAB DISP Non-Preferred QL 1 / 1 days mirtazapine SPRAVATO (56 MG DOSE) 28 MG/DEVICE SOLN THPK Non-Preferred QL 8 / 14 days esketamine hcl SPRAVATO (84 MG DOSE) 28 MG/DEVICE SOLN THPK Non-Preferred QL 12 / 14 days esketamine hcl

QL 30 / 30 days SYMBYAX 12-50 MG CAP Non-Preferred AL1 At least 18 yrs old olanzapine-fluoxetine hcl C Age restriction, clinical PA required

QL 30 / 30 days SYMBYAX 3-25 MG CAP Non-Preferred AL1 At least 18 yrs old olanzapine-fluoxetine hcl C Age restriction, clinical PA required

QL 30 / 30 days SYMBYAX 6-25 MG CAP Non-Preferred AL1 At least 18 yrs old olanzapine-fluoxetine hcl C Age restriction, clinical PA required

QL 30 / 30 days SYMBYAX 6-50 MG CAP Non-Preferred AL1 At least 18 yrs old olanzapine-fluoxetine hcl C Age restriction, clinical PA required WELLBUTRIN SR 100 MG TAB ER 12H Non-Preferred QL 60 / 30 days bupropion hcl WELLBUTRIN SR 150 MG TAB ER 12H Non-Preferred QL 60 / 30 days bupropion hcl

PAGE 72 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS WELLBUTRIN SR 200 MG TAB ER 12H Non-Preferred QL 60 / 30 days bupropion hcl WELLBUTRIN XL 150 MG TAB ER 24H Non-Preferred QL 60 / 30 days bupropion hcl WELLBUTRIN XL 300 MG TAB ER 24H Non-Preferred QL 30 / 30 days bupropion hcl MONOAMINE OXIDASE INHIBITORS

EMSAM 12 MG/24HR PATCH 24HR Non-Preferred selegiline EMSAM 6 MG/24HR PATCH 24HR Non-Preferred selegiline EMSAM 9 MG/24HR PATCH 24HR Non-Preferred selegiline MARPLAN 10 MG TAB Non-Preferred isocarboxazid NARDIL 15 MG TAB Non-Preferred phenelzine sulfate phenelzine sulfate tab 15 mg Preferred

tranylcypromine sulfate tab 10 mg Non-Preferred QL 6 / 1 days

SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITOR/SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITOR)

BRISDELLE 7.5 MG CAP Non-Preferred paroxetine mesylate (vasomotor) CELEXA 10 MG TAB Non-Preferred QL 45 / 30 days citalopram hydrobromide CELEXA 20 MG TAB Non-Preferred QL 45 / 30 days citalopram hydrobromide CELEXA 40 MG TAB Non-Preferred QL 45 / 30 days citalopram hydrobromide citalopram hydrobromide oral soln 10 Preferred QL 20 / 1 days mg/5ml citalopram hydrobromide tab 10 mg Preferred QL 45 / 30 days (base equiv) citalopram hydrobromide tab 20 mg Preferred QL 45 / 30 days (base equiv) citalopram hydrobromide tab 40 mg Preferred QL 45 / 30 days (base equiv) desvenlafaxine tab er 24hr 100 mg Non-Preferred

PAGE 73 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS desvenlafaxine tab er 24hr 50 mg Non-Preferred DESVENLAFAXINE ER 100 MG TAB ER 24H Non-Preferred desvenlafaxine DESVENLAFAXINE ER 50 MG TAB ER 24H Non-Preferred desvenlafaxine desvenlafaxine succinate tab er 24hr Preferred 100 mg (base equiv) desvenlafaxine succinate tab er 24hr 25 Preferred mg (base equiv) desvenlafaxine succinate tab er 24hr 50 Preferred mg (base equiv) EFFEXOR XR 150 MG CAP ER 24H Non-Preferred QL 2 / 1 days venlafaxine hcl EFFEXOR XR 37.5 MG CAP ER 24H Non-Preferred QL 1 / 1 days venlafaxine hcl EFFEXOR XR 75 MG CAP ER 24H Non-Preferred QL 3 / 1 days venlafaxine hcl escitalopram oxalate soln 5 mg/5ml Non-Preferred QL 20 / 1 days (base equiv) escitalopram oxalate tab 10 mg (base Preferred QL 45 / 30 days equiv) escitalopram oxalate tab 20 mg (base Preferred QL 1 / 1 days equiv) escitalopram oxalate tab 5 mg (base Preferred QL 45 / 30 days equiv) FETZIMA 120 MG CAP ER 24H Non-Preferred levomilnacipran hcl FETZIMA 20 MG CAP ER 24H Non-Preferred levomilnacipran hcl FETZIMA 40 MG CAP ER 24H Non-Preferred levomilnacipran hcl FETZIMA 80 MG CAP ER 24H Non-Preferred levomilnacipran hcl FETZIMA TITRATION 20 & 40 MG CP24 THPK Non-Preferred levomilnacipran hcl FLUOXETINE HCL 60 MG TAB Non-Preferred fluoxetine hcl

PAGE 74 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

fluoxetine hcl cap 10 mg Preferred QL 3 / 1 days

fluoxetine hcl cap 20 mg Preferred QL 4 / 1 days

fluoxetine hcl cap 40 mg Preferred QL 2 / 1 days

fluoxetine hcl cap delayed release 90 Non-Preferred mg

fluoxetine hcl solution 20 mg/5ml Preferred QL 10 / 1 days

fluoxetine hcl tab 10 mg Preferred QL 90 / 30 days

fluoxetine hcl tab 20 mg Preferred QL 120 / 30 days

fluoxetine hcl tab 60 mg Non-Preferred FLUOXETINE HCL (PMDD) 10 MG CAP Preferred QL 3 / 1 days fluoxetine hcl (pmdd) FLUOXETINE HCL (PMDD) 10 MG TAB Non-Preferred QL 3 / 1 days fluoxetine hcl (pmdd) FLUOXETINE HCL (PMDD) 20 MG CAP Preferred QL 4 / 1 days fluoxetine hcl (pmdd) FLUOXETINE HCL (PMDD) 20 MG TAB Non-Preferred QL 4 / 1 days fluoxetine hcl (pmdd) fluvoxamine maleate cap er 24hr 100 Non-Preferred mg fluvoxamine maleate cap er 24hr 150 Non-Preferred mg

fluvoxamine maleate tab 100 mg Preferred QL 3 / 1 days

fluvoxamine maleate tab 25 mg Preferred QL 1 / 1 days

fluvoxamine maleate tab 50 mg Preferred QL 45 / 30 days

KHEDEZLA 100 MG TAB ER 24H Non-Preferred desvenlafaxine KHEDEZLA 50 MG TAB ER 24H Non-Preferred desvenlafaxine LEXAPRO 10 MG TAB Non-Preferred QL 45 / 30 days escitalopram oxalate LEXAPRO 20 MG TAB Non-Preferred QL 1 / 1 days escitalopram oxalate LEXAPRO 5 MG TAB Non-Preferred QL 45 / 30 days escitalopram oxalate

PAGE 75 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

maprotiline hcl tab 25 mg Non-Preferred QL 2 / 1 days

maprotiline hcl tab 50 mg Non-Preferred QL 2 / 1 days

maprotiline hcl tab 75 mg Non-Preferred QL 2 / 1 days

nefazodone hcl tab 100 mg Non-Preferred QL 2 / 1 days

nefazodone hcl tab 150 mg Non-Preferred QL 120 / 30 days

nefazodone hcl tab 200 mg Non-Preferred QL 3 / 1 days

nefazodone hcl tab 250 mg Non-Preferred QL 2 / 1 days

nefazodone hcl tab 50 mg Non-Preferred QL 2 / 1 days

paroxetine hcl tab 10 mg Preferred QL 45 / 30 days

paroxetine hcl tab 20 mg Preferred QL 45 / 30 days

paroxetine hcl tab 30 mg Preferred QL 2 / 1 days

paroxetine hcl tab 40 mg Preferred QL 45 / 30 days

paroxetine hcl tab er 24hr 12.5 mg Non-Preferred paroxetine hcl tab er 24hr 25 mg Non-Preferred paroxetine hcl tab er 24hr 37.5 mg Non-Preferred paroxetine mesylate cap 7.5 mg (base Non-Preferred equiv) PAXIL 10 MG TAB Non-Preferred QL 45 / 30 days paroxetine hcl PAXIL 10 MG/5ML SUSPENSION Non-Preferred paroxetine hcl PAXIL 20 MG TAB Non-Preferred QL 45 / 30 days paroxetine hcl PAXIL 30 MG TAB Non-Preferred QL 2 / 1 days paroxetine hcl PAXIL 40 MG TAB Non-Preferred QL 45 / 30 days paroxetine hcl PAXIL CR 12.5 MG TAB ER 24H Non-Preferred paroxetine hcl PAXIL CR 25 MG TAB ER 24H Non-Preferred paroxetine hcl PAXIL CR 37.5 MG TAB ER 24H Non-Preferred paroxetine hcl

PAGE 76 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PEXEVA 10 MG TAB Non-Preferred paroxetine mesylate PEXEVA 20 MG TAB Non-Preferred paroxetine mesylate PEXEVA 30 MG TAB Non-Preferred paroxetine mesylate PEXEVA 40 MG TAB Non-Preferred paroxetine mesylate PRISTIQ 100 MG TAB ER 24H Non-Preferred desvenlafaxine succinate PRISTIQ 25 MG TAB ER 24H Non-Preferred desvenlafaxine succinate PRISTIQ 50 MG TAB ER 24H Non-Preferred desvenlafaxine succinate PROZAC 10 MG CAP Non-Preferred QL 3 / 1 days fluoxetine hcl PROZAC 20 MG CAP Non-Preferred fluoxetine hcl PROZAC 40 MG CAP Non-Preferred QL 2 / 1 days fluoxetine hcl SARAFEM 10 MG TAB Non-Preferred QL 3 / 1 days fluoxetine hcl (pmdd) SARAFEM 20 MG TAB Non-Preferred fluoxetine hcl (pmdd) sertraline hcl oral concentrate for Preferred QL 300 / 30 days solution 20 mg/ml

sertraline hcl tab 100 mg Preferred QL 60 / 30 days

sertraline hcl tab 25 mg Preferred QL 45 / 30 days

sertraline hcl tab 50 mg Preferred QL 45 / 30 days

trazodone hcl tab 100 mg Preferred QL 3 / 1 days

trazodone hcl tab 150 mg Preferred QL 3 / 1 days

trazodone hcl tab 300 mg Preferred QL 2 / 1 days

trazodone hcl tab 50 mg Preferred QL 3 / 1 days

TRINTELLIX 10 MG TAB Non-Preferred vortioxetine hbr

PAGE 77 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TRINTELLIX 20 MG TAB Non-Preferred vortioxetine hbr TRINTELLIX 5 MG TAB Non-Preferred vortioxetine hbr venlafaxine hcl cap er 24hr 150 mg Preferred QL 2 / 1 days (base equivalent) venlafaxine hcl cap er 24hr 37.5 mg Preferred QL 1 / 1 days (base equivalent) venlafaxine hcl cap er 24hr 75 mg (base Preferred QL 3 / 1 days equivalent) venlafaxine hcl tab 100 mg (base Preferred QL 3 / 1 days equivalent) venlafaxine hcl tab 25 mg (base Preferred QL 3 / 1 days equivalent) venlafaxine hcl tab 37.5 mg (base Preferred QL 3 / 1 days equivalent) venlafaxine hcl tab 50 mg (base Preferred QL 3 / 1 days equivalent) venlafaxine hcl tab 75 mg (base Preferred QL 3 / 1 days equivalent) venlafaxine hcl tab er 24hr 150 mg Non-Preferred (base equivalent) venlafaxine hcl tab er 24hr 225 mg Non-Preferred (base equivalent) venlafaxine hcl tab er 24hr 37.5 mg Non-Preferred (base equivalent) venlafaxine hcl tab er 24hr 75 mg (base Non-Preferred QL 90 / 30 days equivalent) VIIBRYD 10 MG TAB Non-Preferred vilazodone hcl VIIBRYD 20 MG TAB Non-Preferred vilazodone hcl VIIBRYD 40 MG TAB Non-Preferred vilazodone hcl VIIBRYD STARTER PACK 10 & 20 MG KIT Non-Preferred vilazodone hcl ZOLOFT 100 MG TAB Non-Preferred QL 60 / 30 days sertraline hcl

PAGE 78 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ZOLOFT 20 MG/ML CONC Non-Preferred QL 10 / 1 days sertraline hcl ZOLOFT 25 MG TAB Non-Preferred QL 45 / 30 days sertraline hcl ZOLOFT 50 MG TAB Non-Preferred QL 45 / 30 days sertraline hcl TRICYCLICS

amitriptyline hcl tab 10 mg Preferred QL 3 / 1 days

amitriptyline hcl tab 100 mg Preferred QL 3 / 1 days

amitriptyline hcl tab 150 mg Preferred QL 3 / 1 days

amitriptyline hcl tab 25 mg Preferred QL 3 / 1 days

amitriptyline hcl tab 50 mg Preferred QL 3 / 1 days

amitriptyline hcl tab 75 mg Preferred QL 3 / 1 days

amoxapine tab 100 mg Preferred QL 4 / 1 days

amoxapine tab 150 mg Preferred QL 4 / 1 days

amoxapine tab 25 mg Preferred QL 4 / 1 days

amoxapine tab 50 mg Preferred QL 4 / 1 days

ANAFRANIL 25 MG CAP Non-Preferred QL 150 / 30 days clomipramine hcl ANAFRANIL 50 MG CAP Non-Preferred QL 150 / 30 days clomipramine hcl ANAFRANIL 75 MG CAP Non-Preferred QL 90 / 30 days clomipramine hcl

clomipramine hcl cap 25 mg Non-Preferred QL 150 / 30 days

clomipramine hcl cap 50 mg Non-Preferred QL 150 / 30 days

clomipramine hcl cap 75 mg Non-Preferred QL 90 / 30 days

desipramine hcl tab 10 mg Non-Preferred QL 2 / 1 days

desipramine hcl tab 100 mg Non-Preferred QL 2 / 1 days

desipramine hcl tab 150 mg Non-Preferred QL 2 / 1 days

desipramine hcl tab 25 mg Non-Preferred QL 2 / 1 days

PAGE 79 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

desipramine hcl tab 50 mg Non-Preferred QL 2 / 1 days

desipramine hcl tab 75 mg Non-Preferred QL 2 / 1 days

doxepin hcl cap 10 mg Preferred QL 2 / 1 days

doxepin hcl cap 100 mg Preferred QL 3 / 1 days

doxepin hcl cap 150 mg Preferred QL 2 / 1 days

doxepin hcl cap 25 mg Preferred QL 2 / 1 days

doxepin hcl cap 50 mg Preferred QL 2 / 1 days

doxepin hcl cap 75 mg Preferred QL 2 / 1 days

doxepin hcl conc 10 mg/ml Preferred QL 30 / 1 days

imipramine hcl tab 10 mg Preferred QL 6 / 1 days

imipramine hcl tab 25 mg Preferred QL 6 / 1 days

imipramine hcl tab 50 mg Preferred QL 6 / 1 days

imipramine pamoate cap 100 mg Non-Preferred imipramine pamoate cap 125 mg Non-Preferred imipramine pamoate cap 150 mg Non-Preferred imipramine pamoate cap 75 mg Non-Preferred NORPRAMIN 10 MG TAB Non-Preferred QL 2 / 1 days desipramine hcl NORPRAMIN 25 MG TAB Non-Preferred QL 2 / 1 days desipramine hcl

nortriptyline hcl cap 10 mg Preferred QL 3 / 1 days

nortriptyline hcl cap 25 mg Preferred QL 3 / 1 days

nortriptyline hcl cap 50 mg Preferred QL 2 / 1 days

nortriptyline hcl cap 75 mg Preferred QL 3 / 1 days

nortriptyline hcl soln 10 mg/5ml Non-Preferred QL 75 / 1 days

PAMELOR 10 MG CAP Non-Preferred QL 3 / 1 days nortriptyline hcl PAMELOR 25 MG CAP Non-Preferred QL 3 / 1 days nortriptyline hcl

PAGE 80 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PAMELOR 50 MG CAP Non-Preferred QL 2 / 1 days nortriptyline hcl PAMELOR 75 MG CAP Non-Preferred QL 3 / 1 days nortriptyline hcl

protriptyline hcl tab 10 mg Non-Preferred QL 6 / 1 days

protriptyline hcl tab 5 mg Non-Preferred QL 6 / 1 days

SURMONTIL 100 MG CAP Non-Preferred trimipramine maleate SURMONTIL 25 MG CAP Non-Preferred trimipramine maleate SURMONTIL 50 MG CAP Non-Preferred trimipramine maleate TOFRANIL 10 MG TAB Non-Preferred imipramine hcl TOFRANIL 25 MG TAB Non-Preferred imipramine hcl TOFRANIL 50 MG TAB Non-Preferred imipramine hcl trimipramine maleate cap 100 mg Non-Preferred trimipramine maleate cap 25 mg Non-Preferred trimipramine maleate cap 50 mg Non-Preferred ANTIEMETICS

ANTIEMETICS, OTHER

BARHEMSYS 5 MG/2ML SOLUTION Non-Preferred amisulpride (antiemetic) BONJESTA 20-20 MG TAB ER Preferred QL 60 / 30 days doxylamine-pyridoxine DICLEGIS 10-10 MG TAB DR Non-Preferred doxylamine-pyridoxine DIMENHYDRINATE 50 MG/ML SOLUTION Non-Preferred dimenhydrinate doxylamine-pyridoxine tab delayed Non-Preferred release 10-10 mg GIMOTI 15 MG/ACT SOLUTION Non-Preferred metoclopramide hcl

PAGE 81 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

meclizine hcl tab 12.5 mg Preferred QL 120 / 30 days

meclizine hcl tab 25 mg Preferred QL 120 / 30 days

METOCLOPRAMIDE HCL 10 MG TAB DISP Non-Preferred metoclopramide hcl metoclopramide hcl inj 5 mg/ml (base Preferred equivalent) metoclopramide hcl orally disintegrating Non-Preferred tab 5 mg (base eq) metoclopramide hcl soln 5 mg/5ml (10 Preferred QL 40 / 1 days mg/10ml) (base equiv) metoclopramide hcl soln 5 mg/5ml (10 Preferred QL 40 / 1 days mg/10ml) (base equiv) metoclopramide hcl tab 10 mg (base Preferred QL 4 / 1 days equivalent) metoclopramide hcl tab 5 mg (base Preferred QL 4 / 1 days equivalent)

QL 4 / 1 days

perphenazine tab 16 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 4 / 1 days

perphenazine tab 2 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 4 / 1 days

perphenazine tab 4 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 4 / 1 days

perphenazine tab 8 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

prochlorperazine suppos 25 mg Preferred QL 12 / days

prochlorperazine suppos 25 mg Preferred QL 12 / days

prochlorperazine edisylate inj 10 mg/2ml Preferred

PAGE 82 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS prochlorperazine maleate tab 10 mg Preferred QL 4 / 1 days (base equivalent) prochlorperazine maleate tab 5 mg Preferred QL 4 / 1 days (base equivalent)

AL1 At least 6 yrs old promethazine hcl suppos 12.5 mg Non-Preferred C Age restriction, clinical PA required

AL1 At least 6 yrs old promethazine hcl suppos 12.5 mg Non-Preferred C Age restriction, clinical PA required

AL1 At least 6 yrs old promethazine hcl suppos 12.5 mg Preferred C Age restriction, clinical PA required

AL1 At least 6 yrs old promethazine hcl suppos 12.5 mg Preferred C Age restriction, clinical PA required

AL1 At least 6 yrs old promethazine hcl suppos 25 mg Non-Preferred C Age restriction, clinical PA required

AL1 At least 6 yrs old promethazine hcl suppos 25 mg Non-Preferred C Age restriction, clinical PA required

AL1 At least 6 yrs old promethazine hcl suppos 25 mg Preferred C Age restriction, clinical PA required

AL1 At least 6 yrs old promethazine hcl suppos 25 mg Preferred C Age restriction, clinical PA required

AL1 At least 6 yrs old promethazine hcl suppos 50 mg Preferred C Age restriction, clinical PA required

AL1 At least 6 yrs old promethazine hcl suppos 50 mg Preferred C Age restriction, clinical PA required

QL 4 / 1 days

promethazine hcl tab 50 mg Preferred AL1 At least 6 yrs old

C Age restriction, clinical PA required REGLAN 10 MG TAB Non-Preferred metoclopramide hcl

PAGE 83 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS REGLAN 5 MG TAB Non-Preferred metoclopramide hcl scopolamine td patch 72hr 1 mg/3days Non-Preferred TIGAN 100 MG/ML SOLUTION Non-Preferred trimethobenzamide hcl TIGAN 300 MG CAP Non-Preferred QL 3 / 1 days trimethobenzamide hcl TRANSDERM-SCOP (1.5 MG) 1 MG/3DAYS PATCH 72HR Preferred scopolamine

trimethobenzamide hcl cap 300 mg Preferred QL 3 / 1 days

EMETOGENIC THERAPY ADJUNCTS

AKYNZEO 235-0.25 MG RECON SOLN Non-Preferred fosnetupitant choride-palonosetron hcl AKYNZEO 235-0.25 MG/20ML SOLUTION Non-Preferred fosnetupitant choride-palonosetron hcl AKYNZEO 300-0.5 MG CAP Non-Preferred netupitant-palonosetron ALOXI 0.25 MG/5ML SOLUTION Preferred palonosetron hcl ANZEMET 100 MG TAB Non-Preferred dolasetron mesylate ANZEMET 50 MG TAB Non-Preferred dolasetron mesylate

aprepitant capsule 125 mg Non-Preferred QL 2 / 28 days

aprepitant capsule 40 mg Non-Preferred QL 1 / 30 days

aprepitant capsule 80 mg Non-Preferred QL 4 / 28 days

aprepitant capsule therapy pack 80 & Non-Preferred QL 6 / 28 days 125 mg aprepitant capsule therapy pack 80 & Non-Preferred 125 mg CESAMET 1 MG CAP Non-Preferred nabilone CINVANTI 130 MG/18ML EMULSION Preferred aprepitant

dronabinol cap 10 mg Non-Preferred QL 90 / 30 days

PAGE 84 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

dronabinol cap 2.5 mg Non-Preferred QL 180 / 30 days

dronabinol cap 5 mg Non-Preferred QL 180 / 30 days

EMEND 125 MG CAP Preferred QL 2 / 28 days aprepitant EMEND 125 MG/5ML RECON SUSP Non-Preferred aprepitant EMEND 150 MG RECON SOLN Non-Preferred fosaprepitant dimeglumine EMEND 40 MG CAP Preferred QL 1 / 30 days aprepitant EMEND 80 MG CAP Preferred QL 4 / 28 days aprepitant EMEND TRI-PACK 80 & 125 MG CAP Preferred QL 6 / 28 days aprepitant FOSAPREPITANT DIMEGLUMINE 150 MG RECON SOLN Non-Preferred fosaprepitant dimeglumine fosaprepitant dimeglumine for iv infusion Non-Preferred 150 mg (base eq) granisetron hcl inj 1 mg/ml Preferred granisetron hcl inj 4 mg/4ml (1 mg/ml) Preferred granisetron hcl tab 1 mg Non-Preferred MARINOL 10 MG CAP Non-Preferred QL 90 / 30 days dronabinol MARINOL 2.5 MG CAP Non-Preferred QL 180 / 30 days dronabinol MARINOL 5 MG CAP Non-Preferred QL 180 / 30 days dronabinol ondansetron orally disintegrating tab 4 Preferred QL 3 / 1 days mg ondansetron orally disintegrating tab 8 Preferred QL 3 / 1 days mg ondansetron hcl inj 4 mg/2ml (2 mg/ml) Preferred ondansetron hcl inj 40 mg/20ml (2 Preferred mg/ml)

ondansetron hcl oral soln 4 mg/5ml Preferred QL 50 / 25 days

PAGE 85 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

ondansetron hcl tab 4 mg Preferred QL 3 / 1 days

ondansetron hcl tab 8 mg Preferred QL 3 / 1 days

PALONOSETRON HCL 0.25 MG/2ML SOLUTION Preferred palonosetron hcl PALONOSETRON HCL 0.25 MG/5ML SOLUTION Preferred palonosetron hcl palonosetron hcl iv soln 0.25 mg/5ml Preferred (base equivalent) palonosetron hcl iv soln pref syr 0.25 Preferred mg/5ml (base equiv) SANCUSO 3.1 MG/24HR PATCH Non-Preferred granisetron SUSTOL 10 MG/0.4ML PRSYR Non-Preferred granisetron SYNDROS 5 MG/ML SOLUTION Non-Preferred dronabinol VARUBI (180 MG DOSE) 2 X 90 MG TAB THPK Non-Preferred rolapitant hcl ZOFRAN 4 MG TAB Non-Preferred QL 3 / 1 days ondansetron hcl ZOFRAN 8 MG TAB Non-Preferred QL 3 / 1 days ondansetron hcl ZOFRAN ODT 4 MG TAB DISP Non-Preferred QL 3 / 1 days ondansetron ZOFRAN ODT 8 MG TAB DISP Non-Preferred QL 3 / 1 days ondansetron ZUPLENZ 4 MG FILM Non-Preferred ondansetron ZUPLENZ 8 MG FILM Non-Preferred ondansetron ANTIFUNGALS

ANCOBON 250 MG CAP Non-Preferred flucytosine ANCOBON 500 MG CAP Non-Preferred flucytosine

PAGE 86 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CICLODAN CREAM 0.77 % KIT Non-Preferred ciclopirox olamine & cleanser CICLODAN SOLUTION 8 % KIT Non-Preferred ciclopirox ciclopirox gel 0.77% Non-Preferred ciclopirox shampoo 1% Non-Preferred ciclopirox solution 8% Non-Preferred

ciclopirox solution 8% Preferred QL 6.6 / 30 days

ciclopirox olamine cream 0.77% (base Non-Preferred equiv) ciclopirox olamine cream 0.77% (base Preferred equiv) ciclopirox olamine susp 0.77% (base Preferred equiv) CICLOPIROX TREATMENT 8 % KIT Non-Preferred ciclopirox

clotrimazole troche 10 mg Preferred QL 5 / 1 days

clotrimazole cream 1% Preferred QL 30 / 7 days

clotrimazole soln 1% Non-Preferred QL 30 / 24 days

CLOTRIMAZOLE 1% CREAM (RX) Preferred QL 30 / 7 days

CRESEMBA 186 MG CAP Non-Preferred isavuconazonium sulfate DIFLUCAN 10 MG/ML RECON SUSP Non-Preferred fluconazole DIFLUCAN 100 MG TAB Non-Preferred QL 2 / 1 days fluconazole DIFLUCAN 150 MG TAB Non-Preferred QL 2 / 1 days fluconazole DIFLUCAN 200 MG TAB Non-Preferred QL 2 / 1 days fluconazole DIFLUCAN 40 MG/ML RECON SUSP Non-Preferred fluconazole DIFLUCAN 50 MG TAB Non-Preferred QL 2 / 1 days fluconazole econazole nitrate cream 1% Non-Preferred

PAGE 87 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ERTACZO 2 % CREAM Non-Preferred sertaconazole nitrate EXELDERM 1 % CREAM Non-Preferred sulconazole nitrate EXELDERM 1 % SOLUTION Non-Preferred sulconazole nitrate EXTINA 2 % FOAM Non-Preferred ketoconazole (topical)

fluconazole for susp 10 mg/ml Preferred QL 40 / 1 days

fluconazole for susp 40 mg/ml Preferred QL 10 / 1 days

fluconazole tab 100 mg Preferred QL 2 / 1 days

fluconazole tab 150 mg Preferred QL 2 / 1 days

fluconazole tab 200 mg Preferred QL 2 / 1 days

fluconazole tab 50 mg Preferred QL 2 / 1 days

flucytosine cap 250 mg Non-Preferred flucytosine cap 500 mg Non-Preferred

griseofulvin microsize susp 125 mg/5ml Preferred QL 40 / 1 days

griseofulvin microsize tab 500 mg Preferred QL 60 / 30 days

griseofulvin ultramicrosize tab 125 mg Non-Preferred QL 3 / 1 days

griseofulvin ultramicrosize tab 250 mg Non-Preferred QL 3 / 1 days

GYNAZOLE-1 2 % CREAM Non-Preferred butoconazole nitrate (one dose) itraconazole cap 100 mg Non-Preferred itraconazole oral soln 10 mg/ml Non-Preferred JUBLIA 10 % SOLUTION Non-Preferred efinaconazole KERYDIN 5 % SOLUTION Non-Preferred tavaborole

ketoconazole tab 200 mg Non-Preferred QL 2 / 1 days

ketoconazole cream 2% Preferred ketoconazole foam 2% Non-Preferred ketoconazole shampoo 2% Preferred

PAGE 88 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS LOPROX 0.77 % (SUSP) KIT Non-Preferred ciclopirox olamine & cleanser LOPROX 0.77 % CREAM Non-Preferred ciclopirox olamine LOPROX 0.77 % KIT Non-Preferred ciclopirox olamine & cleanser LOPROX 0.77 % SUSPENSION Non-Preferred ciclopirox olamine LOPROX 1 % SHAMPOO Non-Preferred ciclopirox LULICONAZOLE 1 % CREAM Non-Preferred luliconazole LUZU 1 % CREAM Non-Preferred luliconazole MENTAX 1 % CREAM Non-Preferred butenafine hcl MICONAZOLE 3 200 MG SUPPOS Non-Preferred QL 1 / 1 days miconazole nitrate vaginal MICONAZOLE-ZINC OXIDE- PETROLAT 0.25-15-81.35 % Non-Preferred OINTMENT miconazole-zinc oxide-white petrolatum naftifine hcl cream 1% Non-Preferred naftifine hcl cream 2% Non-Preferred naftifine hcl gel 1% Non-Preferred NAFTIN 1 % GEL Non-Preferred naftifine hcl NAFTIN 2 % CREAM Non-Preferred naftifine hcl NAFTIN 2 % GEL Non-Preferred naftifine hcl NATACYN 5 % SUSPENSION Non-Preferred natamycin NIZORAL 2 % SHAMPOO Non-Preferred ketoconazole (topical) NOXAFIL 100 MG TAB DR Non-Preferred posaconazole NOXAFIL 40 MG/ML SUSPENSION Non-Preferred posaconazole

PAGE 89 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

nystatin tab 500000 unit Preferred QL 6 / 1 days

nystatin susp 100000 unit/ml Preferred nystatin cream 100000 unit/gm Preferred nystatin oint 100000 unit/gm Preferred nystatin topical powder 100000 unit/gm Preferred nystatin topical powder 100000 unit/gm Preferred nystatin topical powder 100000 unit/gm Preferred nystatin-triamcinolone cream 100000- Preferred 0.1 unit/gm-% nystatin-triamcinolone oint 100000-0.1 Non-Preferred unit/gm-% ONMEL 200 MG TAB Non-Preferred itraconazole ORAVIG 50 MG TAB Non-Preferred miconazole (mouth-throat) oxiconazole nitrate cream 1% Non-Preferred OXISTAT 1 % CREAM Non-Preferred oxiconazole nitrate OXISTAT 1 % LOTION Non-Preferred oxiconazole nitrate PENLAC 8 % SOLUTION Non-Preferred ciclopirox posaconazole tab delayed release 100 Non-Preferred mg SPORANOX 10 MG/ML SOLUTION Non-Preferred itraconazole SPORANOX 100 MG CAP Non-Preferred itraconazole SPORANOX PULSEPAK 100 MG CAP Non-Preferred itraconazole SULCONAZOLE NITRATE 1 % CREAM Non-Preferred sulconazole nitrate SULCONAZOLE NITRATE 1 % SOLUTION Non-Preferred sulconazole nitrate tavaborole soln 5% Non-Preferred

PAGE 90 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

terbinafine hcl tab 250 mg Preferred QL 90 / 365 days

terconazole vaginal cream 0.4% Non-Preferred QL 45 / 14 days

terconazole vaginal cream 0.8% Non-Preferred QL 20 / 14 days

terconazole vaginal suppos 80 mg Non-Preferred QL 3 / 14 days

TOLSURA 65 MG CAP Non-Preferred itraconazole VFEND 200 MG TAB Non-Preferred voriconazole VFEND 40 MG/ML RECON SUSP Non-Preferred voriconazole VFEND 50 MG TAB Non-Preferred voriconazole voriconazole for susp 40 mg/ml Non-Preferred voriconazole tab 200 mg Non-Preferred voriconazole tab 50 mg Non-Preferred VUSION 0.25-15-81.35 % OINTMENT Non-Preferred miconazole-zinc oxide-white petrolatum ANTIGOUT AGENTS

allopurinol tab 100 mg Preferred QL 8 / 1 days

allopurinol tab 300 mg Preferred QL 2 / 1 days

QL 90 / 30 days colchicine cap 0.6 mg Preferred PA

QL 90 / 30 days colchicine tab 0.6 mg Preferred PA

colchicine w/ probenecid tab 0.5-500 mg Preferred COLCRYS 0.6 MG TAB Non-Preferred QL 90 / 30 days colchicine DUZALLO 200-200 MG TAB Non-Preferred lesinurad-allopurinol DUZALLO 200-300 MG TAB Non-Preferred lesinurad-allopurinol febuxostat tab 40 mg Non-Preferred febuxostat tab 80 mg Non-Preferred

PAGE 91 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS GLOPERBA 0.6 MG/5ML SOLUTION Non-Preferred colchicine KRYSTEXXA 8 MG/ML SOLUTION Non-Preferred pegloticase MITIGARE 0.6 MG CAP Non-Preferred QL 90 / 30 days colchicine

probenecid tab 500 mg Preferred QL 4 / 1 days

ULORIC 40 MG TAB Non-Preferred febuxostat ULORIC 80 MG TAB Non-Preferred febuxostat ZURAMPIC 200 MG TAB Non-Preferred lesinurad ZYLOPRIM 100 MG TAB Non-Preferred allopurinol ZYLOPRIM 300 MG TAB Non-Preferred QL 2 / 1 days allopurinol ANTIMIGRAINE AGENTS

ANTIMIGRAINE AGENTS, OTHER

AIMOVIG 140 MG/ML SOLN A-INJ QL 1 / 28 days Preferred erenumab-aooe PA

AIMOVIG 70 MG/ML SOLN A-INJ QL 1 / 28 days Preferred erenumab-aooe PA

AJOVY 225 MG/1.5ML SOLN A-INJ Non-Preferred QLC 0.05 mL/day fremanezumab-vfrm AJOVY 225 MG/1.5ML SOLN PRSYR Non-Preferred QLC 0.05 mL/day fremanezumab-vfrm

EMGALITY 120 MG/ML SOLN A-INJ QL 2 / 28 days Preferred galcanezumab-gnlm PA

EMGALITY 120 MG/ML SOLN PRSYR QL 2 / 28 days Preferred galcanezumab-gnlm PA

EMGALITY (300 MG DOSE) 100 QL 3 / 30 days MG/ML SOLN PRSYR Preferred galcanezumab-gnlm PA

NURTEC 75 MG TAB DISP QL 8 / 30 days Preferred rimegepant sulfate PA

PAGE 92 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

UBRELVY 100 MG TAB QL 16 / 30 days Non-Preferred ubrogepant PA

UBRELVY 50 MG TAB QL 16 / 30 days Non-Preferred ubrogepant PA

ERGOT ALKALOIDS

CAFERGOT 1-100 MG TAB Non-Preferred ergotamine w/ caffeine D.H.E. 45 1 MG/ML SOLUTION Non-Preferred dihydroergotamine mesylate dihydroergotamine mesylate inj 1 mg/ml Non-Preferred dihydroergotamine mesylate nasal spray Non-Preferred 4 mg/ml ERGOMAR 2 MG SL TAB Non-Preferred ergotamine tartrate MIGERGOT 2-100 MG SUPPOS Non-Preferred ergotamine w/ caffeine MIGRANAL 4 MG/ML SOLUTION Non-Preferred dihydroergotamine mesylate PROPHYLACTIC

VYEPTI 100 MG/ML SOLUTION Non-Preferred eptinezumab-jjmr SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS

almotriptan malate tab 12.5 mg Non-Preferred almotriptan malate tab 6.25 mg Non-Preferred AMERGE 1 MG TAB Non-Preferred naratriptan hcl AMERGE 2.5 MG TAB Non-Preferred naratriptan hcl eletriptan hydrobromide tab 20 mg (base Non-Preferred equivalent) eletriptan hydrobromide tab 40 mg (base Non-Preferred equivalent) FROVA 2.5 MG TAB Non-Preferred frovatriptan succinate frovatriptan succinate tab 2.5 mg (base Non-Preferred equivalent)

PAGE 93 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS IMITREX 100 MG TAB Non-Preferred sumatriptan succinate IMITREX 20 MG/ACT SOLUTION Non-Preferred sumatriptan IMITREX 25 MG TAB Non-Preferred sumatriptan succinate IMITREX 5 MG/ACT SOLUTION Non-Preferred sumatriptan IMITREX 50 MG TAB Non-Preferred sumatriptan succinate IMITREX 6 MG/0.5ML SOLUTION Non-Preferred sumatriptan succinate IMITREX STATDOSE REFILL 4 MG/0.5ML SOLN CART Non-Preferred sumatriptan succinate IMITREX STATDOSE REFILL 6 MG/0.5ML SOLN CART Non-Preferred sumatriptan succinate IMITREX STATDOSE SYSTEM 4 MG/0.5ML SOLN A-INJ Non-Preferred sumatriptan succinate IMITREX STATDOSE SYSTEM 6 MG/0.5ML SOLN A-INJ Non-Preferred sumatriptan succinate MAXALT 10 MG TAB Non-Preferred rizatriptan benzoate MAXALT-MLT 10 MG TAB DISP Non-Preferred rizatriptan benzoate MAXALT-MLT 5 MG TAB DISP Non-Preferred rizatriptan benzoate

naratriptan hcl tab 1 mg (base equiv) Preferred QL 9 / 24 days

naratriptan hcl tab 2.5 mg (base equiv) Preferred QL 9 / 24 days

ONZETRA XSAIL 11 MG/NOSEPC EXHP Non-Preferred sumatriptan succinate RELPAX 20 MG TAB Non-Preferred eletriptan hydrobromide RELPAX 40 MG TAB Non-Preferred eletriptan hydrobromide

PAGE 94 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

REYVOW 100 MG TAB QL 8 / 30 days Non-Preferred lasmiditan succinate PA

REYVOW 50 MG TAB QL 4 / 30 days Non-Preferred lasmiditan succinate PA

rizatriptan benzoate oral disintegrating Preferred QL 9 / 30 days tab 10 mg (base eq) rizatriptan benzoate oral disintegrating Preferred QL 9 / 30 days tab 5 mg (base eq) rizatriptan benzoate tab 10 mg (base Preferred QL 9 / 30 days equivalent) rizatriptan benzoate tab 5 mg (base Preferred QL 9 / 30 days equivalent)

sumatriptan nasal spray 20 mg/act Preferred QL 6 / 24 days

sumatriptan nasal spray 5 mg/act Preferred QL 6 / 24 days

sumatriptan succinate inj 6 mg/0.5ml Preferred QL 2 / 24 days

sumatriptan succinate solution auto- Preferred injector 4 mg/0.5ml sumatriptan succinate solution auto- Preferred QL 2 / 24 days injector 6 mg/0.5ml sumatriptan succinate solution cartridge Preferred 4 mg/0.5ml sumatriptan succinate solution cartridge Preferred QL 2 / 24 days 6 mg/0.5ml sumatriptan succinate solution prefilled Preferred syringe 6 mg/0.5ml

sumatriptan succinate tab 100 mg Preferred QL 9 / 24 days

sumatriptan succinate tab 25 mg Preferred QL 9 / 24 days

sumatriptan succinate tab 50 mg Preferred QL 9 / 24 days

sumatriptan-naproxen sodium tab 85- Non-Preferred 500 mg SUMAVEL DOSEPRO 6 MG/0.5ML SOLN J-INJ Non-Preferred sumatriptan succinate TOSYMRA 10 MG/ACT SOLUTION Non-Preferred sumatriptan

PAGE 95 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TREXIMET 10-60 MG TAB Non-Preferred sumatriptan-naproxen sodium TREXIMET 85-500 MG TAB Non-Preferred sumatriptan-naproxen sodium ZEMBRACE SYMTOUCH 3 MG/0.5ML SOLN A-INJ Non-Preferred sumatriptan succinate ZOLMITRIPTAN 2.5 MG SOLUTION Non-Preferred zolmitriptan ZOLMITRIPTAN 5 MG SOLUTION Non-Preferred zolmitriptan zolmitriptan orally disintegrating tab 2.5 Preferred mg zolmitriptan orally disintegrating tab 5 Preferred mg zolmitriptan tab 2.5 mg Preferred zolmitriptan tab 5 mg Preferred ZOMIG 2.5 MG SOLUTION Preferred zolmitriptan ZOMIG 2.5 MG TAB Non-Preferred zolmitriptan ZOMIG 5 MG SOLUTION Preferred zolmitriptan ZOMIG 5 MG TAB Non-Preferred zolmitriptan ZOMIG ZMT 2.5 MG TAB DISP Non-Preferred zolmitriptan ZOMIG ZMT 5 MG TAB DISP Non-Preferred zolmitriptan ANTIMYASTHENIC AGENTS

PARASYMPATHOMIMETICS

pyridostigmine bromide oral soln 60 Preferred mg/5ml

pyridostigmine bromide tab 60 mg Preferred QL 8 / 1 days

pyridostigmine bromide tab er 180 mg Preferred

PAGE 96 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ANTIMYCOBACTERIALS

ANTIMYCOBACTERIALS, OTHER

dapsone tab 100 mg Preferred QL 1 / 1 days

dapsone tab 25 mg Preferred QL 3 / 1 days

rifabutin cap 150 mg Preferred QL 2 / 1 days

ANTITUBERCULARS

ethambutol hcl tab 100 mg Preferred QL 10 / 1 days

ethambutol hcl tab 400 mg Preferred QL 10 / 1 days

isoniazid syrup 50 mg/5ml Preferred QL 90 / 1 days

isoniazid tab 100 mg Preferred QL 3 / 1 days

isoniazid tab 300 mg Preferred QL 3 / 1 days

PYRAZINAMIDE 500 MG TAB Preferred QL 8 / 1 days pyrazinamide

pyrazinamide tab 500 mg Preferred QL 8 / 1 days

rifampin cap 150 mg Preferred QL 2 / 1 days

rifampin cap 300 mg Preferred QL 2 / 1 days

ANTINEOPLASTICS

ALKYLATING AGENTS

cyclophosphamide cap 25 mg Preferred cyclophosphamide cap 50 mg Preferred LEUKERAN 2 MG TAB Preferred chlorambucil melphalan tab 2 mg Preferred MYLERAN 2 MG TAB Preferred busulfan TEMODAR 100 MG CAP Non-Preferred temozolomide TEMODAR 140 MG CAP Non-Preferred temozolomide TEMODAR 180 MG CAP Non-Preferred temozolomide

PAGE 97 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TEMODAR 20 MG CAP Non-Preferred temozolomide TEMODAR 250 MG CAP Non-Preferred temozolomide TEMODAR 5 MG CAP Non-Preferred temozolomide

temozolomide cap 100 mg Preferred PA

temozolomide cap 140 mg Preferred PA

temozolomide cap 180 mg Preferred PA

temozolomide cap 20 mg Preferred PA

temozolomide cap 250 mg Preferred PA

temozolomide cap 5 mg Preferred PA

ANTIANDROGENS

abiraterone acetate tab 250 mg Preferred PA

abiraterone acetate tab 500 mg Preferred

QL 1 / 1 days bicalutamide tab 50 mg Preferred PA

CASODEX 50 MG TAB Non-Preferred QL 1 / 1 days bicalutamide ERLEADA 60 MG TAB Preferred PA apalutamide FLUTAMIDE 125 MG CAP Preferred QL 6 / 1 days flutamide

flutamide cap 125 mg Preferred QL 6 / 1 days

NUBEQA 300 MG TAB Preferred PA darolutamide XTANDI 40 MG CAP Preferred PA enzalutamide XTANDI 40 MG TAB Preferred PA enzalutamide XTANDI 80 MG TAB Preferred PA enzalutamide YONSA 125 MG TAB Non-Preferred abiraterone acetate

PAGE 98 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ZYTIGA 250 MG TAB Non-Preferred abiraterone acetate ZYTIGA 500 MG TAB Non-Preferred abiraterone acetate ANTIANGIOGENIC AGENTS

POMALYST 1 MG CAP Non-Preferred pomalidomide POMALYST 2 MG CAP Non-Preferred pomalidomide POMALYST 3 MG CAP Non-Preferred pomalidomide POMALYST 4 MG CAP Non-Preferred pomalidomide REVLIMID 10 MG CAP Preferred PA lenalidomide REVLIMID 15 MG CAP Preferred PA lenalidomide REVLIMID 2.5 MG CAP Preferred PA lenalidomide REVLIMID 20 MG CAP Preferred PA lenalidomide REVLIMID 25 MG CAP Preferred PA lenalidomide REVLIMID 5 MG CAP Preferred PA lenalidomide THALOMID 100 MG CAP Preferred PA thalidomide THALOMID 150 MG CAP Preferred thalidomide THALOMID 200 MG CAP Preferred PA thalidomide THALOMID 50 MG CAP Preferred PA thalidomide ANTIESTROGENS/MODIFIERS

EMCYT 140 MG CAP Preferred estramustine phosphate sodium FARESTON 60 MG TAB Non-Preferred QL 1 / 1 days toremifene citrate

PAGE 99 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SOLTAMOX 10 MG/5ML SOLUTION Non-Preferred tamoxifen citrate tamoxifen citrate tab 10 mg (base Preferred QL 2 / 1 days equivalent) tamoxifen citrate tab 20 mg (base Preferred QL 2 / 1 days equivalent) toremifene citrate tab 60 mg (base Non-Preferred QL 1 / 1 days equivalent) ANTIMETABOLITES

capecitabine tab 150 mg Preferred PA

capecitabine tab 500 mg Preferred PA

DROXIA 200 MG CAP Preferred hydroxyurea (sickle cell anemia) DROXIA 300 MG CAP Preferred hydroxyurea (sickle cell anemia) DROXIA 400 MG CAP Preferred hydroxyurea (sickle cell anemia) fluorouracil cream 5% Preferred fluorouracil soln 2% Preferred fluorouracil soln 5% Preferred HYDREA 500 MG CAP Non-Preferred hydroxyurea hydroxyurea cap 500 mg Preferred mercaptopurine tab 50 mg Preferred SIKLOS 100 MG TAB Non-Preferred hydroxyurea (sickle cell anemia) SIKLOS 1000 MG TAB Non-Preferred hydroxyurea (sickle cell anemia) TABLOID 40 MG TAB Preferred thioguanine XELODA 150 MG TAB Non-Preferred capecitabine XELODA 500 MG TAB Non-Preferred capecitabine

PAGE 100 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ANTINEOPLASTICS, OTHER

ALUNBRIG 180 MG TAB QL 30 / 30 days Preferred brigatinib PA

ALUNBRIG 30 MG TAB QL 60 / 30 days Preferred brigatinib PA

ALUNBRIG 90 & 180 MG TAB THPK QL 30 / 30 days Preferred brigatinib PA

ALUNBRIG 90 MG TAB QL 30 / 30 days Preferred brigatinib PA

AYVAKIT 100 MG TAB QL 30 / 30 days Preferred avapritinib PA

AYVAKIT 200 MG TAB QL 30 / 30 days Preferred avapritinib PA

AYVAKIT 300 MG TAB QL 30 / 30 days Preferred avapritinib PA

BALVERSA 3 MG TAB Preferred erdafitinib BALVERSA 4 MG TAB Preferred erdafitinib BALVERSA 5 MG TAB Preferred erdafitinib

BRUKINSA 80 MG CAP QL 120 / 30 days Preferred zanubrutinib PA

COPIKTRA 15 MG CAP Preferred PA duvelisib COPIKTRA 25 MG CAP Preferred PA duvelisib HEMANGEOL 4.28 MG/ML SOLUTION Preferred PA propranolol hcl IDHIFA 100 MG TAB Preferred PA enasidenib mesylate IDHIFA 50 MG TAB Preferred PA enasidenib mesylate

PAGE 101 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS INQOVI 35-100 MG TAB Non-Preferred QL 5 / 28 days decitabine-cedazuridine INREBIC 100 MG CAP Preferred PA fedratinib hcl

leucovorin calcium tab 10 mg Preferred QL 2 / 1 days

leucovorin calcium tab 15 mg Preferred QL 1 / 1 days

leucovorin calcium tab 25 mg Preferred QL 1 / 1 days

leucovorin calcium tab 5 mg Preferred QL 3 / 1 days

LONSURF 15-6.14 MG TAB Preferred PA trifluridine-tipiracil LONSURF 20-8.19 MG TAB Preferred PA trifluridine-tipiracil LYSODREN 500 MG TAB Preferred mitotane NINLARO 2.3 MG CAP Preferred PA ixazomib citrate NINLARO 3 MG CAP Preferred PA ixazomib citrate NINLARO 4 MG CAP Preferred PA ixazomib citrate

PEMAZYRE 13.5 MG TAB QL 14 / 21 days Preferred pemigatinib PA

PEMAZYRE 4.5 MG TAB QL 14 / 21 days Preferred pemigatinib PA

PEMAZYRE 9 MG TAB QL 14 / 21 days Preferred pemigatinib PA

QINLOCK 50 MG TAB Non-Preferred QL 90 / 30 days ripretinib

RETEVMO 40 MG CAP QL 180 / 30 days Preferred selpercatinib PA

RETEVMO 80 MG CAP QL 120 / 30 days Preferred selpercatinib PA

ROZLYTREK 100 MG CAP Preferred PA entrectinib

PAGE 102 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ROZLYTREK 200 MG CAP Preferred PA entrectinib RUBRACA 200 MG TAB Preferred PA rucaparib camsylate RUBRACA 250 MG TAB Preferred PA rucaparib camsylate RUBRACA 300 MG TAB Preferred PA rucaparib camsylate RYDAPT 25 MG CAP Preferred PA midostaurin

TABRECTA 150 MG TAB QL 120 / 30 days Preferred capmatinib hcl PA

TABRECTA 200 MG TAB QL 120 / 30 days Preferred capmatinib hcl PA

TAZVERIK 200 MG TAB QL 240 / 30 days Preferred tazemetostat hbr PA

TIBSOVO 250 MG TAB Preferred PA ivosidenib TURALIO 200 MG CAP Preferred PA pexidartinib hcl VITRAKVI 100 MG CAP Preferred PA larotrectinib sulfate VITRAKVI 20 MG/ML SOLUTION Preferred PA larotrectinib sulfate VITRAKVI 25 MG CAP Preferred PA larotrectinib sulfate VIZIMPRO 15 MG TAB Preferred PA dacomitinib VIZIMPRO 30 MG TAB Preferred PA dacomitinib VIZIMPRO 45 MG TAB Preferred PA dacomitinib XOSPATA 40 MG TAB Preferred PA gilteritinib fumarate XPOVIO (100 MG ONCE WEEKLY) 20 MG TAB THPK Preferred PA selinexor

PAGE 103 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS XPOVIO (40 MG ONCE WEEKLY) 20 MG TAB THPK Preferred PA selinexor XPOVIO (40 MG TWICE WEEKLY) 20 MG TAB THPK Preferred PA selinexor XPOVIO (60 MG ONCE WEEKLY) 20 MG TAB THPK Preferred PA selinexor XPOVIO (60 MG TWICE WEEKLY) 20 MG TAB THPK Preferred PA selinexor XPOVIO (80 MG ONCE WEEKLY) 20 MG TAB THPK Preferred PA selinexor XPOVIO (80 MG TWICE WEEKLY) 20 MG TAB THPK Preferred PA selinexor ZOLADEX 10.8 MG IMPLANT Preferred PA goserelin acetate ZOLADEX 3.6 MG IMPLANT Preferred PA goserelin acetate ZOLINZA 100 MG CAP Preferred PA vorinostat AROMATASE INHIBITORS, 3RD GENERATION

anastrozole tab 1 mg Preferred QL 1 / 1 days

ARIMIDEX 1 MG TAB Non-Preferred QL 1 / 1 days anastrozole AROMASIN 25 MG TAB Non-Preferred QL 1 / 1 days exemestane

exemestane tab 25 mg Preferred QL 1 / 1 days

FEMARA 2.5 MG TAB Non-Preferred letrozole

letrozole tab 2.5 mg Preferred PA

ENZYME INHIBITORS

ETOPOSIDE 50 MG CAP Preferred etoposide

PAGE 104 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MOLECULAR TARGET INHIBITORS

AFINITOR 10 MG TAB Preferred PA everolimus AFINITOR 2.5 MG TAB Preferred PA everolimus AFINITOR 5 MG TAB Preferred PA everolimus AFINITOR 7.5 MG TAB Preferred PA everolimus AFINITOR DISPERZ 2 MG TAB SOL Preferred PA everolimus AFINITOR DISPERZ 3 MG TAB SOL Preferred PA everolimus AFINITOR DISPERZ 5 MG TAB SOL Preferred PA everolimus ALECENSA 150 MG CAP Preferred PA alectinib hcl BOSULIF 100 MG TAB Preferred PA bosutinib BOSULIF 400 MG TAB Preferred PA bosutinib BOSULIF 500 MG TAB Preferred PA bosutinib BRAFTOVI 50 MG CAP Preferred PA encorafenib BRAFTOVI 75 MG CAP Preferred PA encorafenib CABOMETYX 20 MG TAB Preferred PA cabozantinib s-malate CABOMETYX 40 MG TAB Preferred PA cabozantinib s-malate CABOMETYX 60 MG TAB Preferred PA cabozantinib s-malate

CALQUENCE 100 MG CAP QL 60 / 30 days Preferred acalabrutinib PA

CAPRELSA 100 MG TAB Preferred PA vandetanib CAPRELSA 300 MG TAB Preferred PA vandetanib

PAGE 105 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS COMETRIQ (100 MG DAILY DOSE) 80 & 20 MG KIT Preferred PA cabozantinib s-malate COMETRIQ (140 MG DAILY DOSE) 3 X 20 MG & 80 MG KIT Preferred PA cabozantinib s-malate COMETRIQ (60 MG DAILY DOSE) 20 MG KIT Preferred PA cabozantinib s-malate COTELLIC 20 MG TAB Preferred PA cobimetinib fumarate DAURISMO 100 MG TAB Preferred PA glasdegib maleate DAURISMO 25 MG TAB Preferred PA glasdegib maleate ERIVEDGE 150 MG CAP Preferred PA vismodegib erlotinib hcl tab 100 mg (base Preferred PA equivalent) erlotinib hcl tab 150 mg (base Preferred PA equivalent)

erlotinib hcl tab 25 mg (base equivalent) Preferred PA

everolimus tab 2.5 mg Non-Preferred PA

everolimus tab 5 mg Non-Preferred PA

everolimus tab 7.5 mg Non-Preferred PA

FARYDAK 10 MG CAP Preferred PA panobinostat lactate FARYDAK 15 MG CAP Preferred PA panobinostat lactate FARYDAK 20 MG CAP Preferred PA panobinostat lactate

GAVRETO 100 MG CAP QL 120 / 30 days Preferred pralsetinib PA

GILOTRIF 20 MG TAB Preferred PA afatinib dimaleate GILOTRIF 30 MG TAB Preferred PA afatinib dimaleate

PAGE 106 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS GILOTRIF 40 MG TAB Preferred PA afatinib dimaleate GLEEVEC 100 MG TAB Non-Preferred PA imatinib mesylate GLEEVEC 400 MG TAB Non-Preferred PA imatinib mesylate

IBRANCE 100 MG CAP QL 30 / 30 days Preferred palbociclib PA

IBRANCE 100 MG TAB QL 30 / 30 days Preferred palbociclib PA

IBRANCE 125 MG CAP QL 30 / 30 days Preferred palbociclib PA

IBRANCE 125 MG TAB QL 30 / 30 days Preferred palbociclib PA

IBRANCE 75 MG CAP QL 30 / 30 days Preferred palbociclib PA

IBRANCE 75 MG TAB QL 30 / 30 days Preferred palbociclib PA

ICLUSIG 10 MG TAB Preferred PA ponatinib hcl ICLUSIG 15 MG TAB Preferred PA ponatinib hcl ICLUSIG 30 MG TAB Preferred PA ponatinib hcl ICLUSIG 45 MG TAB Preferred PA ponatinib hcl imatinib mesylate tab 100 mg (base Preferred PA equivalent) imatinib mesylate tab 400 mg (base Preferred PA equivalent) IMBRUVICA 140 MG CAP Preferred PA ibrutinib IMBRUVICA 140 MG TAB Preferred PA ibrutinib IMBRUVICA 280 MG TAB Preferred PA ibrutinib

PAGE 107 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS IMBRUVICA 420 MG TAB Preferred PA ibrutinib IMBRUVICA 560 MG TAB Preferred PA ibrutinib IMBRUVICA 70 MG CAP Preferred PA ibrutinib INLYTA 1 MG TAB Preferred PA axitinib INLYTA 5 MG TAB Preferred PA axitinib IRESSA 250 MG TAB Preferred PA gefitinib JAKAFI 10 MG TAB Preferred PA ruxolitinib phosphate JAKAFI 15 MG TAB Preferred PA ruxolitinib phosphate JAKAFI 20 MG TAB Preferred PA ruxolitinib phosphate JAKAFI 25 MG TAB Preferred PA ruxolitinib phosphate JAKAFI 5 MG TAB Preferred PA ruxolitinib phosphate KISQALI (200 MG DOSE) 200 MG TAB THPK Preferred PA ribociclib succinate KISQALI (400 MG DOSE) 200 MG TAB THPK Preferred PA ribociclib succinate KISQALI (600 MG DOSE) 200 MG TAB THPK Preferred PA ribociclib succinate KISQALI FEMARA (400 MG DOSE) 200 & 2.5 MG TAB THPK Preferred PA ribociclib succinate-letrozole KISQALI FEMARA (600 MG DOSE) 200 & 2.5 MG TAB THPK Preferred PA ribociclib succinate-letrozole KISQALI FEMARA(200 MG DOSE) 200 & 2.5 MG TAB THPK Preferred PA ribociclib succinate-letrozole

PAGE 108 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS KOSELUGO 10 MG CAP Preferred PA selumetinib sulfate KOSELUGO 25 MG CAP Preferred PA selumetinib sulfate lapatinib ditosylate tab 250 mg (base Non-Preferred equiv) LENVIMA (10 MG DAILY DOSE) 10 MG CAP THPK Preferred PA lenvatinib mesylate LENVIMA (12 MG DAILY DOSE) 3 X 4 MG CAP THPK Preferred PA lenvatinib mesylate LENVIMA (14 MG DAILY DOSE) 10 & 4 MG CAP THPK Preferred PA lenvatinib mesylate LENVIMA (18 MG DAILY DOSE) 10 MG & 2 X 4 MG CAP THPK Preferred PA lenvatinib mesylate LENVIMA (20 MG DAILY DOSE) 2 X 10 MG CAP THPK Preferred PA lenvatinib mesylate LENVIMA (24 MG DAILY DOSE) 2 X 10 MG & 4 MG CAP THPK Preferred PA lenvatinib mesylate LENVIMA (4 MG DAILY DOSE) 4 MG CAP THPK Preferred PA lenvatinib mesylate LENVIMA (8 MG DAILY DOSE) 2 X 4 MG CAP THPK Preferred PA lenvatinib mesylate LORBRENA 100 MG TAB Preferred PA lorlatinib LORBRENA 25 MG TAB Preferred PA lorlatinib LYNPARZA 100 MG TAB Preferred PA olaparib LYNPARZA 150 MG TAB Preferred PA olaparib LYNPARZA 50 MG CAP Preferred PA olaparib MEKINIST 0.5 MG TAB Preferred PA trametinib dimethyl sulfoxide

PAGE 109 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MEKINIST 2 MG TAB Preferred PA trametinib dimethyl sulfoxide MEKTOVI 15 MG TAB Non-Preferred PA binimetinib NERLYNX 40 MG TAB Preferred PA neratinib maleate

NEXAVAR 200 MG TAB QL 4 / 1 days Preferred sorafenib tosylate PA

ODOMZO 200 MG CAP Preferred PA sonidegib phosphate PIQRAY (200 MG DAILY DOSE) 200 MG TAB THPK Preferred PA alpelisib PIQRAY (250 MG DAILY DOSE) 200 & 50 MG TAB THPK Preferred PA alpelisib PIQRAY (300 MG DAILY DOSE) 2 X 150 MG TAB THPK Preferred PA alpelisib SPRYCEL 100 MG TAB Preferred PA dasatinib SPRYCEL 140 MG TAB Preferred PA dasatinib SPRYCEL 20 MG TAB Preferred PA dasatinib SPRYCEL 50 MG TAB Preferred PA dasatinib SPRYCEL 70 MG TAB Preferred PA dasatinib SPRYCEL 80 MG TAB Preferred PA dasatinib STIVARGA 40 MG TAB Preferred PA regorafenib

SUTENT 12.5 MG CAP QL 3 / 1 days Preferred sunitinib malate PA

SUTENT 25 MG CAP QL 1 / 1 days Preferred sunitinib malate PA

SUTENT 37.5 MG CAP Preferred PA sunitinib malate

PAGE 110 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

SUTENT 50 MG CAP QL 1 / 1 days Preferred sunitinib malate PA

TAFINLAR 50 MG CAP Preferred PA dabrafenib mesylate TAFINLAR 75 MG CAP Preferred PA dabrafenib mesylate TAGRISSO 40 MG TAB Preferred PA osimertinib mesylate TAGRISSO 80 MG TAB Preferred PA osimertinib mesylate TALZENNA 0.25 MG CAP Preferred PA talazoparib tosylate TALZENNA 1 MG CAP Preferred PA talazoparib tosylate TARCEVA 100 MG TAB Non-Preferred PA erlotinib hcl TARCEVA 150 MG TAB Non-Preferred PA erlotinib hcl TARCEVA 25 MG TAB Non-Preferred PA erlotinib hcl TASIGNA 150 MG CAP Preferred PA nilotinib hcl TASIGNA 200 MG CAP Preferred PA nilotinib hcl TASIGNA 50 MG CAP Preferred PA nilotinib hcl TEPMETKO 225 MG TAB Non-Preferred tepotinib hcl

TUKYSA 150 MG TAB QL 120 / 30 days Preferred tucatinib PA

TUKYSA 50 MG TAB QL 120 / 30 days Preferred tucatinib PA

TYKERB 250 MG TAB Preferred PA lapatinib ditosylate UKONIQ 200 MG TAB Non-Preferred umbralisib tosylate VENCLEXTA 10 MG TAB Preferred PA venetoclax

PAGE 111 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VENCLEXTA 100 MG TAB Preferred PA venetoclax VENCLEXTA 50 MG TAB Preferred PA venetoclax VENCLEXTA STARTING PACK 10 & 50 & 100 MG TAB THPK Preferred PA venetoclax VERZENIO 100 MG TAB Preferred PA abemaciclib VERZENIO 150 MG TAB Preferred PA abemaciclib VERZENIO 200 MG TAB Preferred PA abemaciclib VERZENIO 50 MG TAB Preferred PA abemaciclib VOTRIENT 200 MG TAB Preferred PA pazopanib hcl XALKORI 200 MG CAP Preferred PA crizotinib XALKORI 250 MG CAP Preferred PA crizotinib ZEJULA 100 MG CAP Preferred PA niraparib tosylate ZELBORAF 240 MG TAB Preferred PA vemurafenib ZYDELIG 100 MG TAB Preferred PA idelalisib ZYDELIG 150 MG TAB Preferred PA idelalisib ZYKADIA 150 MG CAP Preferred PA ceritinib ZYKADIA 150 MG TAB Preferred PA ceritinib RETINOIDS

tretinoin cap 10 mg Preferred

PAGE 112 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ANTIPARASITICS

ANTIHELMINTHICS

ivermectin tab 3 mg Preferred ivermectin lotion 0.5% Non-Preferred NATROBA 0.9 % SUSPENSION Preferred QL 240 / 30 days spinosad SKLICE 0.5 % LOTION Non-Preferred QL 234 / 30 days ivermectin (pediculicide)

spinosad susp 0.9% Preferred QL 240 / 30 days

ANTIPROTOZOALS

ALINIA 100 MG/5ML RECON SUSP Preferred nitazoxanide ARAKODA 100 MG TAB Non-Preferred tafenoquine succinate atovaquone-proguanil hcl tab 250-100 Preferred QL 1 / 1 days mg atovaquone-proguanil hcl tab 62.5-25 Preferred QL 3 / 1 days mg

chloroquine phosphate tab 250 mg Preferred QL 2 / 1 days

chloroquine phosphate tab 500 mg Preferred QL 1 / 1 days

COARTEM 20-120 MG TAB Preferred artemether-lumefantrine

hydroxychloroquine sulfate tab 200 mg Preferred QL 4 / 1 days

KRINTAFEL 150 MG TAB Preferred tafenoquine succinate MALARONE 250-100 MG TAB Non-Preferred QL 1 / 1 days atovaquone-proguanil hcl MALARONE 62.5-25 MG TAB Non-Preferred QL 3 / 1 days atovaquone-proguanil hcl

mefloquine hcl tab 250 mg Preferred QL 5 / 26 days

nitazoxanide tab 500 mg Non-Preferred PLAQUENIL 200 MG TAB Non-Preferred hydroxychloroquine sulfate PRIMAQUINE PHOSPHATE 26.3 MG TAB Preferred QL 2 / 1 days primaquine phosphate

PAGE 113 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS primaquine phosphate tab 26.3 mg (15 Preferred QL 2 / 1 days mg base) QUALAQUIN 324 MG CAP Non-Preferred quinine sulfate quinine sulfate cap 324 mg Non-Preferred PEDICULICIDES/SCABICIDES

CROTAN 10 % LOTION Non-Preferred crotamiton ELIMITE 5 % CREAM Non-Preferred permethrin EURAX 10 % CREAM Non-Preferred crotamiton EURAX 10 % LOTION Non-Preferred crotamiton lindane shampoo 1% Non-Preferred

malathion lotion 0.5% Non-Preferred QL 118 / 30 days

OVIDE 0.5 % LOTION Non-Preferred malathion permethrin cream 5% Preferred ANTIPARKINSON AGENTS

ANTICHOLINERGICS

benztropine mesylate tab 0.5 mg Preferred QL 4 / 1 days

benztropine mesylate tab 1 mg Preferred QL 4 / 1 days

benztropine mesylate tab 2 mg Preferred QL 4 / 1 days

trihexyphenidyl hcl oral soln 0.4 mg/ml Preferred QL 38 / 1 days

trihexyphenidyl hcl tab 2 mg Preferred QL 7 / 1 days

trihexyphenidyl hcl tab 5 mg Preferred QL 3 / 1 days

ANTIPARKINSON AGENTS, OTHER

amantadine hcl cap 100 mg Preferred QL 4 / 1 days

amantadine hcl syrup 50 mg/5ml Preferred QL 40 / 1 days

amantadine hcl tab 100 mg Preferred QL 4 / 1 days

PAGE 114 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS carbidopa-levodopa-entacapone tabs Non-Preferred 12.5-50-200 mg carbidopa-levodopa-entacapone tabs Non-Preferred 18.75-75-200 mg carbidopa-levodopa-entacapone tabs Non-Preferred 25-100-200 mg carbidopa-levodopa-entacapone tabs Non-Preferred 31.25-125-200 mg carbidopa-levodopa-entacapone tabs Non-Preferred 37.5-150-200 mg carbidopa-levodopa-entacapone tabs Non-Preferred 50-200-200 mg COMTAN 200 MG TAB Non-Preferred entacapone entacapone tab 200 mg Preferred GOCOVRI 137 MG CAP ER 24H Non-Preferred amantadine hcl GOCOVRI 68.5 MG CAP ER 24H Non-Preferred amantadine hcl NOURIANZ 20 MG TAB Non-Preferred istradefylline NOURIANZ 40 MG TAB Non-Preferred istradefylline ONGENTYS 25 MG CAP Non-Preferred opicapone ONGENTYS 50 MG CAP Non-Preferred opicapone OSMOLEX ER 129 & 193 MG TB24 THPK Non-Preferred amantadine hcl OSMOLEX ER 129 MG TAB ER 24H Non-Preferred amantadine hcl OSMOLEX ER 193 MG TAB ER 24H Non-Preferred amantadine hcl OSMOLEX ER 258 MG TAB ER 24H Non-Preferred amantadine hcl STALEVO 100 25-100-200 MG TAB Non-Preferred carbidopa-levodopa-entacapone STALEVO 125 31.25-125-200 MG TAB Non-Preferred carbidopa-levodopa-entacapone

PAGE 115 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS STALEVO 150 37.5-150-200 MG TAB Non-Preferred carbidopa-levodopa-entacapone STALEVO 200 50-200-200 MG TAB Non-Preferred carbidopa-levodopa-entacapone STALEVO 50 12.5-50-200 MG TAB Non-Preferred carbidopa-levodopa-entacapone STALEVO 75 18.75-75-200 MG TAB Non-Preferred carbidopa-levodopa-entacapone TASMAR 100 MG TAB Non-Preferred QL 3 / 1 days tolcapone

tolcapone tab 100 mg Non-Preferred QL 3 / 1 days

DOPAMINE AGONISTS

bromocriptine mesylate cap 5 mg (base Preferred QL 20 / 1 days equivalent) bromocriptine mesylate tab 2.5 mg Preferred QL 20 / 1 days (base equivalent) KYNMOBI 10 MG FILM Non-Preferred apomorphine hydrochloride KYNMOBI 15 MG FILM Non-Preferred apomorphine hydrochloride KYNMOBI 20 MG FILM Non-Preferred apomorphine hydrochloride KYNMOBI 25 MG FILM Non-Preferred apomorphine hydrochloride KYNMOBI 30 MG FILM Non-Preferred apomorphine hydrochloride MIRAPEX 0.125 MG TAB Non-Preferred QL 90 / 30 days pramipexole dihydrochloride MIRAPEX 0.25 MG TAB Non-Preferred QL 90 / 30 days pramipexole dihydrochloride MIRAPEX 0.5 MG TAB Non-Preferred QL 90 / 30 days pramipexole dihydrochloride MIRAPEX 0.75 MG TAB Non-Preferred pramipexole dihydrochloride MIRAPEX 1 MG TAB Non-Preferred QL 90 / 30 days pramipexole dihydrochloride MIRAPEX 1.5 MG TAB Non-Preferred QL 90 / 30 days pramipexole dihydrochloride

PAGE 116 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MIRAPEX ER 0.375 MG TAB ER 24H Non-Preferred pramipexole dihydrochloride MIRAPEX ER 0.75 MG TAB ER 24H Non-Preferred pramipexole dihydrochloride MIRAPEX ER 1.5 MG TAB ER 24H Non-Preferred pramipexole dihydrochloride MIRAPEX ER 2.25 MG TAB ER 24H Non-Preferred pramipexole dihydrochloride MIRAPEX ER 3 MG TAB ER 24H Non-Preferred pramipexole dihydrochloride MIRAPEX ER 3.75 MG TAB ER 24H Non-Preferred pramipexole dihydrochloride MIRAPEX ER 4.5 MG TAB ER 24H Non-Preferred pramipexole dihydrochloride NEUPRO 1 MG/24HR PATCH 24HR Non-Preferred rotigotine NEUPRO 2 MG/24HR PATCH 24HR Non-Preferred rotigotine NEUPRO 3 MG/24HR PATCH 24HR Non-Preferred rotigotine NEUPRO 4 MG/24HR PATCH 24HR Non-Preferred rotigotine NEUPRO 6 MG/24HR PATCH 24HR Non-Preferred rotigotine NEUPRO 8 MG/24HR PATCH 24HR Non-Preferred rotigotine PARLODEL 2.5 MG TAB Preferred bromocriptine mesylate PARLODEL 5 MG CAP Preferred bromocriptine mesylate pramipexole dihydrochloride tab 0.125 Preferred QL 90 / 30 days mg

pramipexole dihydrochloride tab 0.25 mg Preferred QL 90 / 30 days

pramipexole dihydrochloride tab 0.5 mg Preferred QL 90 / 30 days

pramipexole dihydrochloride tab 0.75 mg Preferred QL 3 / 1 days

pramipexole dihydrochloride tab 1 mg Preferred QL 90 / 30 days

pramipexole dihydrochloride tab 1.5 mg Preferred QL 90 / 30 days

PAGE 117 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS pramipexole dihydrochloride tab er 24hr Non-Preferred 0.375 mg pramipexole dihydrochloride tab er 24hr Non-Preferred 0.75 mg pramipexole dihydrochloride tab er 24hr Non-Preferred 1.5 mg pramipexole dihydrochloride tab er 24hr Non-Preferred 2.25 mg pramipexole dihydrochloride tab er 24hr Non-Preferred 3 mg pramipexole dihydrochloride tab er 24hr Non-Preferred 3.75 mg pramipexole dihydrochloride tab er 24hr Non-Preferred 4.5 mg REQUIP 0.25 MG TAB Non-Preferred ropinirole hydrochloride REQUIP 0.5 MG TAB Non-Preferred ropinirole hydrochloride REQUIP 1 MG TAB Non-Preferred ropinirole hydrochloride REQUIP 2 MG TAB Non-Preferred ropinirole hydrochloride REQUIP 3 MG TAB Non-Preferred QL 90 / 30 days ropinirole hydrochloride REQUIP 4 MG TAB Non-Preferred QL 90 / 30 days ropinirole hydrochloride REQUIP 5 MG TAB Non-Preferred ropinirole hydrochloride REQUIP XL 12 MG TAB ER 24H Non-Preferred ropinirole hydrochloride REQUIP XL 2 MG TAB ER 24H Non-Preferred ropinirole hydrochloride REQUIP XL 4 MG TAB ER 24H Non-Preferred ropinirole hydrochloride REQUIP XL 6 MG TAB ER 24H Non-Preferred ropinirole hydrochloride REQUIP XL 8 MG TAB ER 24H Non-Preferred ropinirole hydrochloride

ropinirole hydrochloride tab 0.25 mg Preferred QL 3 / 1 days

PAGE 118 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

ropinirole hydrochloride tab 0.5 mg Preferred QL 3 / 1 days

ropinirole hydrochloride tab 1 mg Preferred QL 3 / 1 days

ropinirole hydrochloride tab 2 mg Preferred QL 3 / 1 days

ropinirole hydrochloride tab 3 mg Preferred QL 90 / 30 days

ropinirole hydrochloride tab 4 mg Preferred QL 90 / 30 days

ropinirole hydrochloride tab 5 mg Preferred QL 3 / 1 days

ropinirole hydrochloride tab er 24hr 12 Non-Preferred mg (base equivalent) ropinirole hydrochloride tab er 24hr 2 mg Non-Preferred (base equivalent) ropinirole hydrochloride tab er 24hr 4 mg Non-Preferred (base equivalent) ropinirole hydrochloride tab er 24hr 6 mg Non-Preferred (base equivalent) ropinirole hydrochloride tab er 24hr 8 mg Non-Preferred (base equivalent) DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS

carbidopa tab 25 mg Non-Preferred carbidopa & levodopa orally Non-Preferred disintegrating tab 10-100 mg carbidopa & levodopa orally Non-Preferred disintegrating tab 25-100 mg carbidopa & levodopa orally Non-Preferred disintegrating tab 25-250 mg

carbidopa & levodopa tab 10-100 mg Preferred QL 20 / 1 days

carbidopa & levodopa tab 25-100 mg Preferred QL 8 / 1 days

carbidopa & levodopa tab 25-250 mg Preferred QL 8 / 1 days

carbidopa & levodopa tab er 25-100 mg Preferred QL 12 / 1 days

carbidopa & levodopa tab er 50-200 mg Preferred QL 12 / 1 days

DUOPA 4.63-20 MG/ML SUSPENSION Non-Preferred carbidopa-levodopa INBRIJA 42 MG CAP Non-Preferred levodopa

PAGE 119 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS LODOSYN 25 MG TAB Non-Preferred carbidopa RYTARY 23.75-95 MG CAP ER Non-Preferred carbidopa-levodopa RYTARY 36.25-145 MG CAP ER Non-Preferred carbidopa-levodopa RYTARY 48.75-195 MG CAP ER Non-Preferred carbidopa-levodopa RYTARY 61.25-245 MG CAP ER Non-Preferred carbidopa-levodopa SINEMET 10-100 MG TAB Non-Preferred carbidopa-levodopa SINEMET 25-100 MG TAB Non-Preferred carbidopa-levodopa SINEMET 25-250 MG TAB Non-Preferred carbidopa-levodopa SINEMET CR 25-100 MG TAB ER Non-Preferred carbidopa-levodopa SINEMET CR 50-200 MG TAB ER Non-Preferred carbidopa-levodopa MONOAMINE OXIDASE B (MAO-B) INHIBITORS

AZILECT 0.5 MG TAB Non-Preferred rasagiline mesylate AZILECT 1 MG TAB Non-Preferred rasagiline mesylate rasagiline mesylate tab 0.5 mg (base Non-Preferred equiv) rasagiline mesylate tab 1 mg (base Non-Preferred equiv)

selegiline hcl cap 5 mg Preferred QL 2 / 1 days

selegiline hcl tab 5 mg Preferred QL 2 / 1 days

XADAGO 100 MG TAB Non-Preferred safinamide mesylate XADAGO 50 MG TAB Non-Preferred safinamide mesylate ZELAPAR 1.25 MG TAB DISP Non-Preferred selegiline hcl

PAGE 120 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ANTIPSYCHOTICS

1ST GENERATION/TYPICAL

ADASUVE 10 MG AER POW BA QL 1 / 1 days Non-Preferred loxapine AL1 At least 18 yrs old

AL1 At least 18 yrs old chlorpromazine hcl inj 25 mg/ml Non-Preferred C Age restriction, clinical PA required

AL1 At least 18 yrs old chlorpromazine hcl inj 50 mg/2ml Non-Preferred C Age restriction, clinical PA required

QL 5 / 1 days

chlorpromazine hcl tab 10 mg Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 5 / 1 days

chlorpromazine hcl tab 100 mg Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 4 / 1 days

chlorpromazine hcl tab 200 mg Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 5 / 1 days

chlorpromazine hcl tab 25 mg Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 5 / 1 days

chlorpromazine hcl tab 50 mg Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 10 / 26 days

fluphenazine decanoate inj 25 mg/ml Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 20 / 1 days

fluphenazine hcl elixir 2.5 mg/5ml Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

PAGE 121 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 4 / 1 days

fluphenazine hcl inj 2.5 mg/ml Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 8 / 1 days

fluphenazine hcl oral conc 5 mg/ml Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 4 / 1 days

fluphenazine hcl tab 1 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 4 / 1 days

fluphenazine hcl tab 10 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 4 / 1 days

fluphenazine hcl tab 2.5 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 4 / 1 days

fluphenazine hcl tab 5 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 20 / 1 days HALDOL 5 MG/ML SOLUTION Preferred AL1 At least 18 yrs old haloperidol lactate C Age restriction, clinical PA required

QL 4 / 1 days HALDOL DECANOATE 100 MG/ML SOLUTION Non-Preferred AL1 At least 18 yrs old haloperidol decanoate C Age restriction, clinical PA required

QL 4 / 1 days HALDOL DECANOATE 50 MG/ML SOLUTION Non-Preferred AL1 At least 18 yrs old haloperidol decanoate C Age restriction, clinical PA required

PAGE 122 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 5 / 1 days

haloperidol tab 1 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 5 / 1 days

haloperidol tab 10 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 5 / 1 days

haloperidol tab 2 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 5 / 1 days

haloperidol tab 20 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 5 / 1 days

haloperidol tab 5 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 4 / 28 days haloperidol decanoate im soln 100 Preferred AL1 At least 18 yrs old mg/ml C Age restriction, clinical PA required

QL 9 / 28 days

haloperidol decanoate im soln 50 mg/ml Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 20 / 1 days

haloperidol lactate inj 5 mg/ml Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 50 / 1 days

haloperidol lactate oral conc 2 mg/ml Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 8 / 1 days loxapine succinate cap 10 mg Preferred AL1 At least 18 yrs old

PAGE 123 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 5 / 1 days loxapine succinate cap 25 mg Preferred AL1 At least 18 yrs old

QL 12 / 1 days loxapine succinate cap 5 mg Preferred AL1 At least 18 yrs old

QL 5 / 1 days loxapine succinate cap 50 mg Preferred AL1 At least 18 yrs old

molindone hcl tab 10 mg Non-Preferred AL1 At least 18 yrs old

molindone hcl tab 25 mg Non-Preferred AL1 At least 18 yrs old

molindone hcl tab 5 mg Non-Preferred AL1 At least 18 yrs old

QL 10 / 1 days

pimozide tab 1 mg Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 5 / 1 days

pimozide tab 2 mg Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 8 / 1 days

thioridazine hcl tab 10 mg Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 8 / 1 days

thioridazine hcl tab 100 mg Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 8 / 1 days

thioridazine hcl tab 25 mg Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 8 / 1 days

thioridazine hcl tab 50 mg Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

PAGE 124 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 6 / 1 days

thiothixene cap 10 mg Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 6 / 1 days

thiothixene cap 2 mg Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 6 / 1 days

thiothixene cap 5 mg Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 4 / 1 days trifluoperazine hcl tab 1 mg (base Preferred AL1 At least 18 yrs old equivalent) C Age restriction, clinical PA required

QL 4 / 1 days trifluoperazine hcl tab 10 mg (base Preferred AL1 At least 18 yrs old equivalent) C Age restriction, clinical PA required

QL 4 / 1 days trifluoperazine hcl tab 2 mg (base Preferred AL1 At least 18 yrs old equivalent) C Age restriction, clinical PA required

QL 4 / 1 days trifluoperazine hcl tab 5 mg (base Preferred AL1 At least 18 yrs old equivalent) C Age restriction, clinical PA required 2ND GENERATION/ATYPICAL

QL 60 / 30 days ABILIFY 10 MG TAB Non-Preferred AL1 At least 18 yrs old aripiprazole C Age restriction, clinical PA required

QL 60 / 30 days ABILIFY 15 MG TAB Non-Preferred AL1 At least 18 yrs old aripiprazole C Age restriction, clinical PA required

PAGE 125 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 60 / 30 days ABILIFY 2 MG TAB Non-Preferred AL1 At least 18 yrs old aripiprazole C Age restriction, clinical PA required

QL 30 / 30 days ABILIFY 20 MG TAB Non-Preferred AL1 At least 18 yrs old aripiprazole C Age restriction, clinical PA required

QL 30 / 30 days ABILIFY 30 MG TAB Non-Preferred AL1 At least 18 yrs old aripiprazole C Age restriction, clinical PA required

QL 60 / 30 days ABILIFY 5 MG TAB Non-Preferred AL1 At least 18 yrs old aripiprazole C Age restriction, clinical PA required

QL 1 / 28 days ABILIFY MAINTENA 300 MG PRSYR Preferred AL1 At least 18 yrs old aripiprazole C Age restriction, clinical PA required

QL 1 / 28 days ABILIFY MAINTENA 300 MG SRER Preferred AL1 At least 18 yrs old aripiprazole C Age restriction, clinical PA required

QL 1 / 28 days ABILIFY MAINTENA 400 MG PRSYR Preferred AL1 At least 18 yrs old aripiprazole C Age restriction, clinical PA required

QL 1 / 28 days ABILIFY MAINTENA 400 MG SRER Preferred AL1 At least 18 yrs old aripiprazole C Age restriction, clinical PA required

QL 30 / 30 days ABILIFY MYCITE 10 MG TAB Non-Preferred AL1 At least 18 yrs old aripiprazole C Age restriction, clinical PA required

PAGE 126 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 30 / 30 days ABILIFY MYCITE 2 MG TAB Non-Preferred AL1 At least 18 yrs old aripiprazole C Age restriction, clinical PA required

QL 30 / 30 days ABILIFY MYCITE 20 MG TAB Non-Preferred AL1 At least 18 yrs old aripiprazole C Age restriction, clinical PA required

QL 30 / 30 days ABILIFY MYCITE 30 MG TAB Non-Preferred AL1 At least 18 yrs old aripiprazole C Age restriction, clinical PA required

QL 30 / 30 days ABILIFY MYCITE 5 MG TAB Non-Preferred AL1 At least 18 yrs old aripiprazole C Age restriction, clinical PA required

QL 25 / 1 days

aripiprazole oral solution 1 mg/ml Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days aripiprazole orally disintegrating tab 10 Non-Preferred AL1 At least 18 yrs old mg C Age restriction, clinical PA required

QL 60 / 30 days aripiprazole orally disintegrating tab 15 Non-Preferred AL1 At least 18 yrs old mg C Age restriction, clinical PA required

QL 60 / 30 days

aripiprazole tab 10 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days

aripiprazole tab 15 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

PAGE 127 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 30 / 30 days

aripiprazole tab 20 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 30 / 30 days

aripiprazole tab 30 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days

aripiprazole tab 5 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

AL1 At least 18 yrs old ARISTADA 1064 MG/3.9ML PRSYR Preferred C Age restriction, clinical aripiprazole lauroxil PA required QLC 3.9 mL/56 days

AL1 At least 18 yrs old ARISTADA 441 MG/1.6ML PRSYR Preferred C Age restriction, clinical aripiprazole lauroxil PA required QLC 1.6 mL/28 days

AL1 At least 18 yrs old ARISTADA 662 MG/2.4ML PRSYR Preferred C Age restriction, clinical aripiprazole lauroxil PA required QLC 2.4 mL/28 days

AL1 At least 18 yrs old ARISTADA 882 MG/3.2ML PRSYR Preferred C Age restriction, clinical aripiprazole lauroxil PA required QLC 3.2 mL/42 days

AL1 At least 18 yrs old ARISTADA INITIO 675 MG/2.4ML PRSYR Preferred C Age restriction, clinical aripiprazole lauroxil PA required QLC 2.4 mL/42 days

QL 60 / 30 days asenapine maleate sl tab 10 mg (base Non-Preferred AL1 At least 18 yrs old equiv) C Age restriction, clinical PA required

PAGE 128 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 60 / 30 days asenapine maleate sl tab 5 mg (base Non-Preferred AL1 At least 18 yrs old equiv) C Age restriction, clinical PA required

QL 30 / 30 days CAPLYTA 42 MG CAP Non-Preferred AL1 At least 18 yrs old lumateperone tosylate C Age restriction, clinical PA required

QL 60 / 30 days FANAPT 1 MG TAB Non-Preferred AL1 At least 18 yrs old iloperidone C Age restriction, clinical PA required

QL 60 / 30 days FANAPT 10 MG TAB Non-Preferred AL1 At least 18 yrs old iloperidone C Age restriction, clinical PA required

QL 60 / 30 days FANAPT 12 MG TAB Non-Preferred AL1 At least 18 yrs old iloperidone C Age restriction, clinical PA required

QL 60 / 30 days FANAPT 2 MG TAB Non-Preferred AL1 At least 18 yrs old iloperidone C Age restriction, clinical PA required

QL 60 / 30 days FANAPT 4 MG TAB Non-Preferred AL1 At least 18 yrs old iloperidone C Age restriction, clinical PA required

QL 60 / 30 days FANAPT 6 MG TAB Non-Preferred AL1 At least 18 yrs old iloperidone C Age restriction, clinical PA required

QL 60 / 30 days FANAPT 8 MG TAB Non-Preferred AL1 At least 18 yrs old iloperidone C Age restriction, clinical PA required

PAGE 129 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

AL1 At least 18 yrs old GEODON 20 MG CAP Non-Preferred ziprasidone hcl C Age restriction, clinical PA required

QL 2 / 1 days GEODON 20 MG RECON SOLN Non-Preferred AL1 At least 18 yrs old ziprasidone mesylate C Age restriction, clinical PA required

QL 3 / 1 days GEODON 40 MG CAP Non-Preferred AL1 At least 18 yrs old ziprasidone hcl C Age restriction, clinical PA required GEODON 60 MG CAP Non-Preferred ziprasidone hcl GEODON 80 MG CAP Non-Preferred ziprasidone hcl

QL 30 / 30 days INVEGA 1.5 MG TAB ER 24H Non-Preferred AL1 At least 18 yrs old paliperidone C Age restriction, clinical PA required

QL 30 / 30 days INVEGA 3 MG TAB ER 24H Non-Preferred AL1 At least 18 yrs old paliperidone C Age restriction, clinical PA required

QL 60 / 30 days INVEGA 6 MG TAB ER 24H Non-Preferred AL1 At least 18 yrs old paliperidone C Age restriction, clinical PA required

QL 30 / 30 days INVEGA 9 MG TAB ER 24H Non-Preferred AL1 At least 18 yrs old paliperidone C Age restriction, clinical PA required

AL1 At least 18 yrs old INVEGA SUSTENNA 117 MG/0.75ML SUSP PRSYR Preferred C Age restriction, clinical paliperidone palmitate PA required QLC 0.75 mL/28 days

AL1 At least 18 yrs old INVEGA SUSTENNA 156 MG/ML SUSP PRSYR Preferred C Age restriction, clinical paliperidone palmitate PA required QLC 1 mL/28 days

PAGE 130 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

AL1 At least 18 yrs old INVEGA SUSTENNA 234 MG/1.5ML SUSP PRSYR Preferred C Age restriction, clinical paliperidone palmitate PA required QLC 1.5 mL/28 days

AL1 At least 18 yrs old INVEGA SUSTENNA 39 MG/0.25ML SUSP PRSYR Preferred C Age restriction, clinical paliperidone palmitate PA required QLC 0.25 mL/28 days

AL1 At least 18 yrs old INVEGA SUSTENNA 78 MG/0.5ML SUSP PRSYR Preferred C Age restriction, clinical paliperidone palmitate PA required QLC 0.5 mL/28 days

AL1 At least 18 yrs old INVEGA TRINZA 273 MG/0.875ML SUSP PRSYR Preferred C Age restriction, clinical paliperidone palmitate PA required QLC 0.875 mL/84 days

AL1 At least 18 yrs old INVEGA TRINZA 410 MG/1.315ML SUSP PRSYR Preferred C Age restriction, clinical paliperidone palmitate PA required QLC 1.315 mL/84 days

AL1 At least 18 yrs old INVEGA TRINZA 546 MG/1.75ML SUSP PRSYR Preferred C Age restriction, clinical paliperidone palmitate PA required QLC 1.75 mL/84 days

AL1 At least 18 yrs old INVEGA TRINZA 819 MG/2.625ML SUSP PRSYR Preferred C Age restriction, clinical paliperidone palmitate PA required QLC 2.625 mL/84 days

QL 30 / 30 days LATUDA 120 MG TAB Non-Preferred AL1 At least 18 yrs old lurasidone hcl C Age restriction, clinical PA required

QL 30 / 30 days LATUDA 20 MG TAB Non-Preferred AL1 At least 18 yrs old lurasidone hcl C Age restriction, clinical PA required

PAGE 131 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 30 / 30 days LATUDA 60 MG TAB Non-Preferred AL1 At least 18 yrs old lurasidone hcl C Age restriction, clinical PA required

QL 60 / 30 days LATUDA 80 MG TAB Non-Preferred AL1 At least 18 yrs old lurasidone hcl C Age restriction, clinical PA required

AL1 At least 18 yrs old NUPLAZID 10 MG TAB Non-Preferred pimavanserin tartrate C Age restriction, clinical PA required

AL1 At least 18 yrs old NUPLAZID 17 MG TAB Non-Preferred pimavanserin tartrate C Age restriction, clinical PA required

AL1 At least 18 yrs old NUPLAZID 34 MG CAP Non-Preferred pimavanserin tartrate C Age restriction, clinical PA required

QL 90 / 30 days

olanzapine for im inj 10 mg Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 30 / 30 days olanzapine orally disintegrating tab 10 Non-Preferred AL1 At least 18 yrs old mg C Age restriction, clinical PA required

QL 30 / 30 days olanzapine orally disintegrating tab 15 Non-Preferred AL1 At least 18 yrs old mg C Age restriction, clinical PA required

QL 30 / 30 days olanzapine orally disintegrating tab 20 Non-Preferred AL1 At least 18 yrs old mg C Age restriction, clinical PA required

QL 30 / 30 days

olanzapine orally disintegrating tab 5 mg Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

PAGE 132 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 60 / 30 days

olanzapine tab 15 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days

olanzapine tab 2.5 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days

olanzapine tab 20 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days

olanzapine tab 5 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days

olanzapine tab 7.5 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 30 / 30 days

paliperidone tab er 24hr 1.5 mg Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 30 / 30 days

paliperidone tab er 24hr 3 mg Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days

paliperidone tab er 24hr 6 mg Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 30 / 30 days

paliperidone tab er 24hr 9 mg Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

PAGE 133 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

AL1 At least 18 yrs old PERSERIS 90 MG PRSYR Preferred C Age restriction, clinical risperidone PA required QLC 0.04 mL/day

QL 90 / 30 days

quetiapine fumarate tab 100 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 120 / 30 days

quetiapine fumarate tab 200 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 120 / 30 days

quetiapine fumarate tab 25 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days

quetiapine fumarate tab 300 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days

quetiapine fumarate tab 400 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 120 / 30 days

quetiapine fumarate tab 50 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 30 / 30 days

quetiapine fumarate tab er 24hr 150 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 30 / 30 days

quetiapine fumarate tab er 24hr 200 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

PAGE 134 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 60 / 30 days

quetiapine fumarate tab er 24hr 400 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days

quetiapine fumarate tab er 24hr 50 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days REXULTI 0.25 MG TAB Non-Preferred AL1 At least 18 yrs old brexpiprazole C Age restriction, clinical PA required

QL 60 / 30 days REXULTI 0.5 MG TAB Non-Preferred AL1 At least 18 yrs old brexpiprazole C Age restriction, clinical PA required

QL 60 / 30 days REXULTI 1 MG TAB Non-Preferred AL1 At least 18 yrs old brexpiprazole C Age restriction, clinical PA required

QL 30 / 30 days REXULTI 2 MG TAB Non-Preferred AL1 At least 18 yrs old brexpiprazole C Age restriction, clinical PA required

QL 30 / 30 days REXULTI 3 MG TAB Non-Preferred AL1 At least 18 yrs old brexpiprazole C Age restriction, clinical PA required

QL 30 / 30 days REXULTI 4 MG TAB Non-Preferred AL1 At least 18 yrs old brexpiprazole C Age restriction, clinical PA required

QL 150 / 30 days RISPERDAL 0.25 MG TAB Non-Preferred AL1 At least 18 yrs old risperidone C Age restriction, clinical PA required

PAGE 135 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 150 / 30 days RISPERDAL 1 MG TAB Non-Preferred AL1 At least 18 yrs old risperidone C Age restriction, clinical PA required

AL1 At least 18 yrs old RISPERDAL 1 MG/ML SOLUTION Non-Preferred C Age restriction, clinical risperidone PA required QLC 8 mL/day

QL 90 / 30 days RISPERDAL 2 MG TAB Non-Preferred AL1 At least 18 yrs old risperidone C Age restriction, clinical PA required

QL 60 / 30 days RISPERDAL 3 MG TAB Non-Preferred AL1 At least 18 yrs old risperidone C Age restriction, clinical PA required

QL 60 / 30 days RISPERDAL 4 MG TAB Non-Preferred AL1 At least 18 yrs old risperidone C Age restriction, clinical PA required

QL 2 / 28 days RISPERDAL CONSTA 12.5 MG SRER Preferred AL1 At least 18 yrs old risperidone microspheres C Age restriction, clinical PA required

QL 2 / 28 days RISPERDAL CONSTA 25 MG SRER Preferred AL1 At least 18 yrs old risperidone microspheres C Age restriction, clinical PA required

QL 2 / 28 days RISPERDAL CONSTA 37.5 MG SRER Preferred AL1 At least 18 yrs old risperidone microspheres C Age restriction, clinical PA required

QL 2 / 28 days RISPERDAL CONSTA 50 MG SRER Preferred AL1 At least 18 yrs old risperidone microspheres C Age restriction, clinical PA required

PAGE 136 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 60 / 30 days risperidone orally disintegrating tab 0.5 Non-Preferred AL1 At least 18 yrs old mg C Age restriction, clinical PA required

QL 60 / 30 days

risperidone orally disintegrating tab 1 mg Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days

risperidone orally disintegrating tab 2 mg Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days

risperidone orally disintegrating tab 3 mg Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days

risperidone orally disintegrating tab 4 mg Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

AL1 At least 18 yrs old

risperidone soln 1 mg/ml Preferred C Age restriction, clinical PA required QLC 8 mL/day

QL 150 / 30 days

risperidone tab 0.25 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 150 / 30 days

risperidone tab 0.5 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 150 / 30 days

risperidone tab 1 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

PAGE 137 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 60 / 30 days

risperidone tab 3 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days

risperidone tab 4 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days SAPHRIS 10 MG SL TAB Non-Preferred AL1 At least 18 yrs old asenapine maleate C Age restriction, clinical PA required

QL 60 / 30 days SAPHRIS 2.5 MG SL TAB Non-Preferred AL1 At least 18 yrs old asenapine maleate C Age restriction, clinical PA required

QL 60 / 30 days SAPHRIS 5 MG SL TAB Non-Preferred AL1 At least 18 yrs old asenapine maleate C Age restriction, clinical PA required

AL1 At least 18 yrs old SECUADO 3.8 MG/24HR PATCH 24HR Non-Preferred asenapine C Age restriction, clinical PA required

AL1 At least 18 yrs old SECUADO 5.7 MG/24HR PATCH 24HR Non-Preferred asenapine C Age restriction, clinical PA required

AL1 At least 18 yrs old SECUADO 7.6 MG/24HR PATCH 24HR Non-Preferred asenapine C Age restriction, clinical PA required

QL 90 / 30 days SEROQUEL 100 MG TAB Non-Preferred AL1 At least 18 yrs old quetiapine fumarate C Age restriction, clinical PA required

QL 120 / 30 days SEROQUEL 200 MG TAB Non-Preferred AL1 At least 18 yrs old quetiapine fumarate C Age restriction, clinical PA required

PAGE 138 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 60 / 30 days SEROQUEL 300 MG TAB Non-Preferred AL1 At least 18 yrs old quetiapine fumarate C Age restriction, clinical PA required

QL 60 / 30 days SEROQUEL 400 MG TAB Non-Preferred AL1 At least 18 yrs old quetiapine fumarate C Age restriction, clinical PA required

QL 120 / 30 days SEROQUEL 50 MG TAB Non-Preferred AL1 At least 18 yrs old quetiapine fumarate C Age restriction, clinical PA required

QL 30 / 30 days SEROQUEL XR 150 MG TAB ER 24H Non-Preferred AL1 At least 18 yrs old quetiapine fumarate C Age restriction, clinical PA required

QL 30 / 30 days SEROQUEL XR 200 MG TAB ER 24H Non-Preferred AL1 At least 18 yrs old quetiapine fumarate C Age restriction, clinical PA required

QL 60 / 30 days SEROQUEL XR 300 MG TAB ER 24H Non-Preferred AL1 At least 18 yrs old quetiapine fumarate C Age restriction, clinical PA required

QL 60 / 30 days SEROQUEL XR 400 MG TAB ER 24H Non-Preferred AL1 At least 18 yrs old quetiapine fumarate C Age restriction, clinical PA required

QL 60 / 30 days SEROQUEL XR 50 MG TAB ER 24H Non-Preferred AL1 At least 18 yrs old quetiapine fumarate C Age restriction, clinical PA required

AL1 At least 18 yrs old VRAYLAR 1.5 & 3 MG CAP THPK Non-Preferred cariprazine hcl C Age restriction, clinical PA required

QL 30 / 30 days VRAYLAR 1.5 MG CAP Non-Preferred AL1 At least 18 yrs old cariprazine hcl C Age restriction, clinical PA required

PAGE 139 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 30 / 30 days VRAYLAR 3 MG CAP Non-Preferred AL1 At least 18 yrs old cariprazine hcl C Age restriction, clinical PA required

QL 30 / 30 days VRAYLAR 4.5 MG CAP Non-Preferred AL1 At least 18 yrs old cariprazine hcl C Age restriction, clinical PA required

QL 30 / 30 days VRAYLAR 6 MG CAP Non-Preferred AL1 At least 18 yrs old cariprazine hcl C Age restriction, clinical PA required

QL 3 / 1 days

ziprasidone hcl cap 20 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 3 / 1 days

ziprasidone hcl cap 40 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 3 / 1 days

ziprasidone hcl cap 60 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 3 / 1 days

ziprasidone hcl cap 80 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 2 / 1 days ziprasidone mesylate for inj 20 mg (base Non-Preferred AL1 At least 18 yrs old equivalent) C Age restriction, clinical PA required

QL 90 / 30 days ZYPREXA 10 MG RECON SOLN Non-Preferred AL1 At least 18 yrs old olanzapine C Age restriction, clinical PA required

PAGE 140 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 60 / 30 days ZYPREXA 15 MG TAB Non-Preferred AL1 At least 18 yrs old olanzapine C Age restriction, clinical PA required

QL 60 / 30 days ZYPREXA 2.5 MG TAB Non-Preferred AL1 At least 18 yrs old olanzapine C Age restriction, clinical PA required

QL 60 / 30 days ZYPREXA 20 MG TAB Non-Preferred AL1 At least 18 yrs old olanzapine C Age restriction, clinical PA required

QL 60 / 30 days ZYPREXA 5 MG TAB Non-Preferred AL1 At least 18 yrs old olanzapine C Age restriction, clinical PA required

QL 60 / 30 days ZYPREXA 7.5 MG TAB Non-Preferred AL1 At least 18 yrs old olanzapine C Age restriction, clinical PA required

QL 2 / 28 days ZYPREXA RELPREVV 210 MG RECON SUSP Preferred AL1 At least 18 yrs old olanzapine pamoate C Age restriction, clinical PA required

QL 2 / 28 days ZYPREXA RELPREVV 300 MG RECON SUSP Preferred AL1 At least 18 yrs old olanzapine pamoate C Age restriction, clinical PA required

QL 2 / 28 days ZYPREXA RELPREVV 405 MG RECON SUSP Preferred AL1 At least 18 yrs old olanzapine pamoate C Age restriction, clinical PA required

QL 30 / 30 days ZYPREXA ZYDIS 10 MG TAB DISP Non-Preferred AL1 At least 18 yrs old olanzapine C Age restriction, clinical PA required

PAGE 141 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 30 / 30 days ZYPREXA ZYDIS 20 MG TAB DISP Non-Preferred AL1 At least 18 yrs old olanzapine C Age restriction, clinical PA required

QL 30 / 30 days ZYPREXA ZYDIS 5 MG TAB DISP Non-Preferred AL1 At least 18 yrs old olanzapine C Age restriction, clinical PA required TREATMENT-RESISTANT

QL 9 / 1 days clozapine orally disintegrating tab 100 Non-Preferred AL1 At least 18 yrs old mg C Age restriction, clinical PA required

QL 2 / 1 days clozapine orally disintegrating tab 12.5 Non-Preferred AL1 At least 18 yrs old mg C Age restriction, clinical PA required

QL 6 / 1 days clozapine orally disintegrating tab 150 Non-Preferred AL1 At least 18 yrs old mg C Age restriction, clinical PA required

QL 4 / 1 days clozapine orally disintegrating tab 200 Non-Preferred AL1 At least 18 yrs old mg C Age restriction, clinical PA required

QL 3 / 1 days

clozapine orally disintegrating tab 25 mg Non-Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 270 / 30 days

clozapine tab 100 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 120 / 30 days

clozapine tab 200 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

PAGE 142 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 180 / 30 days

clozapine tab 25 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 90 / 30 days

clozapine tab 50 mg Preferred AL1 At least 18 yrs old

C Age restriction, clinical PA required

QL 270 / 30 days CLOZARIL 100 MG TAB Non-Preferred AL1 At least 18 yrs old clozapine C Age restriction, clinical PA required

QL 120 / 30 days CLOZARIL 200 MG TAB Non-Preferred AL1 At least 18 yrs old clozapine C Age restriction, clinical PA required

QL 180 / 30 days CLOZARIL 25 MG TAB Non-Preferred AL1 At least 18 yrs old clozapine C Age restriction, clinical PA required

QL 90 / 30 days CLOZARIL 50 MG TAB Non-Preferred AL1 At least 18 yrs old clozapine C Age restriction, clinical PA required

AL1 At least 18 yrs old FAZACLO 100 MG TAB DISP Non-Preferred clozapine C Age restriction, clinical PA required

QL 2 / 1 days FAZACLO 12.5 MG TAB DISP Non-Preferred AL1 At least 18 yrs old clozapine C Age restriction, clinical PA required

AL1 At least 18 yrs old FAZACLO 150 MG TAB DISP Non-Preferred clozapine C Age restriction, clinical PA required

AL1 At least 18 yrs old FAZACLO 200 MG TAB DISP Non-Preferred clozapine C Age restriction, clinical PA required

PAGE 143 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

AL1 At least 18 yrs old VERSACLOZ 50 MG/ML SUSPENSION Non-Preferred clozapine C Age restriction, clinical PA required ANTISPASTICITY AGENTS

baclofen tab 10 mg Preferred QL 5 / 1 days

baclofen tab 20 mg Preferred QL 4 / 1 days

baclofen tab 5 mg Preferred QL 120 / 30 days

BOTOX 100 UNIT RECON SOLN Preferred PA onabotulinumtoxina BOTOX 200 UNIT RECON SOLN Preferred PA onabotulinumtoxina DANTRIUM 25 MG CAP Non-Preferred dantrolene sodium DANTRIUM 50 MG CAP Non-Preferred dantrolene sodium

dantrolene sodium cap 100 mg Preferred QL 4 / 1 days

dantrolene sodium cap 25 mg Preferred QL 4 / 1 days

dantrolene sodium cap 50 mg Preferred QL 4 / 1 days

tizanidine hcl cap 2 mg (base Non-Preferred equivalent) tizanidine hcl cap 4 mg (base Non-Preferred equivalent) tizanidine hcl cap 6 mg (base Non-Preferred equivalent)

tizanidine hcl tab 2 mg (base equivalent) Preferred QL 6 / 1 days

tizanidine hcl tab 4 mg (base equivalent) Preferred QL 6 / 1 days

XEOMIN 100 UNIT RECON SOLN Non-Preferred incobotulinumtoxina XEOMIN 200 UNIT RECON SOLN Non-Preferred incobotulinumtoxina XEOMIN 50 UNIT RECON SOLN Non-Preferred incobotulinumtoxina ZANAFLEX 2 MG CAP Non-Preferred tizanidine hcl

PAGE 144 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ZANAFLEX 4 MG CAP Non-Preferred tizanidine hcl ZANAFLEX 4 MG TAB Non-Preferred tizanidine hcl ZANAFLEX 6 MG CAP Non-Preferred tizanidine hcl ANTIVIRALS

ANTI-CYTOMEGALOVIRUS (CMV) AGENTS

PREVYMIS 240 MG TAB Preferred PA letermovir PREVYMIS 480 MG TAB Preferred PA letermovir VALCYTE 450 MG TAB Non-Preferred valganciclovir hcl VALCYTE 50 MG/ML RECON SOLN Preferred valganciclovir hcl valganciclovir hcl for soln 50 mg/ml Non-Preferred (base equiv) valganciclovir hcl tab 450 mg (base Preferred equivalent) ANTI-HEPATITIS B (HBV) AGENTS

adefovir dipivoxil tab 10 mg Preferred BARACLUDE 0.05 MG/ML SOLUTION Preferred QL 20 / 1 days entecavir BARACLUDE 0.5 MG TAB Non-Preferred QL 1 / 1 days entecavir BARACLUDE 1 MG TAB Non-Preferred QL 1 / 1 days entecavir

entecavir tab 0.5 mg Preferred QL 1 / 1 days

entecavir tab 1 mg Preferred QL 1 / 1 days

EPIVIR HBV 100 MG TAB Non-Preferred lamivudine (hbv) EPIVIR HBV 5 MG/ML SOLUTION Preferred lamivudine (hbv) HEPSERA 10 MG TAB Preferred adefovir dipivoxil

PAGE 145 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS lamivudine tab 100 mg (hbv) Preferred VEMLIDY 25 MG TAB Non-Preferred QL 1 / 1 days tenofovir alafenamide fumarate ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING AGENTS

DAKLINZA 30 MG TAB Non-Preferred daclatasvir dihydrochloride DAKLINZA 60 MG TAB Non-Preferred daclatasvir dihydrochloride EPCLUSA 200-50 MG TAB Non-Preferred QL 28 / 28 days sofosbuvir-velpatasvir EPCLUSA 400-100 MG TAB Non-Preferred QL 28 / 28 days sofosbuvir-velpatasvir HARVONI 33.75-150 MG PACKET Non-Preferred ledipasvir-sofosbuvir HARVONI 45-200 MG PACKET Non-Preferred ledipasvir-sofosbuvir HARVONI 45-200 MG TAB Non-Preferred ledipasvir-sofosbuvir HARVONI 90-400 MG TAB Non-Preferred ledipasvir-sofosbuvir LEDIPASVIR-SOFOSBUVIR 90-400 MG TAB Non-Preferred ledipasvir-sofosbuvir

MAVYRET 100-40 MG TAB QL 3 / 1 days Preferred glecaprevir-pibrentasvir PA

SOFOSBUVIR-VELPATASVIR 400-100 QL 28 / 28 days MG TAB Preferred sofosbuvir-velpatasvir PA SOVALDI 150 MG PACKET Non-Preferred sofosbuvir SOVALDI 200 MG PACKET Non-Preferred sofosbuvir SOVALDI 200 MG TAB Non-Preferred sofosbuvir SOVALDI 400 MG TAB Non-Preferred sofosbuvir VIEKIRA PAK 12.5-75-50 &250 MG TAB THPK Non-Preferred ombitasvir-paritaprevir-ritonavir- dasabuvir

PAGE 146 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VOSEVI 400-100-100 MG TAB Non-Preferred QL 1 / 1 days sofosbuvir-velpatasvir-voxilaprevir

ZEPATIER 50-100 MG TAB QL 28 / 28 days Preferred elbasvir-grazoprevir PA

ANTI-HEPATITIS C (HCV) AGENTS, OTHER

MODERIBA (1200 MG PACK) 600 MG TAB THPK Non-Preferred ribavirin (hepatitis c) PEGASYS 180 MCG/0.5ML SOLUTION Non-Preferred peginterferon alfa-2a PEGASYS 180 MCG/ML SOLUTION Non-Preferred peginterferon alfa-2a PEGASYS PROCLICK 180 MCG/0.5ML SOLUTION Non-Preferred peginterferon alfa-2a PEGINTRON 50 MCG/0.5ML KIT Non-Preferred QL 4 / 28 days peginterferon alfa-2b REBETOL 40 MG/ML SOLUTION Non-Preferred ribavirin (hepatitis c) RIBASPHERE 400 MG TAB Non-Preferred ribavirin (hepatitis c) RIBASPHERE 600 MG TAB Non-Preferred ribavirin (hepatitis c) RIBASPHERE RIBAPAK (1000 PACK) 400 & 600 MG TAB THPK Non-Preferred ribavirin (hepatitis c) RIBASPHERE RIBAPAK (1200 PACK) 600 MG TAB THPK Non-Preferred ribavirin (hepatitis c) ribavirin cap 200 mg Preferred

ribavirin cap 200 mg Preferred QL 7 / 1 days

ribavirin tab 200 mg Non-Preferred ribavirin tab 200 mg Non-Preferred

ribavirin tab 200 mg Non-Preferred QL 7 / 1 days

ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)

BIKTARVY 50-200-25 MG TAB bictegravir-emtricitabine-tenofovir Preferred QL 1 / 1 days alafenamide fumarate

PAGE 147 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS GENVOYA 150-150-200-10 MG TAB elvitegravir-cobicistat-emtricitabine- Preferred QL 1 / 1 days tenofovir alafenamide ISENTRESS 100 MG CHEW TAB Preferred QL 6 / 1 days raltegravir potassium ISENTRESS 100 MG PACKET Preferred raltegravir potassium ISENTRESS 25 MG CHEW TAB Preferred QL 6 / 1 days raltegravir potassium ISENTRESS 400 MG TAB Preferred QL 2 / 1 days raltegravir potassium ISENTRESS HD 600 MG TAB Non-Preferred QL 2 / 1 days raltegravir potassium STRIBILD 150-150-200-300 MG TAB elvitegravir-cobicistat-emtricitabine- Non-Preferred QL 1 / 1 days tenofovir df TIVICAY 10 MG TAB Preferred QL 60 / 30 days dolutegravir sodium TIVICAY 25 MG TAB Preferred QL 60 / 30 days dolutegravir sodium TIVICAY 50 MG TAB Preferred QL 60 / 30 days dolutegravir sodium TIVICAY PD 5 MG TAB SOL Preferred QL 180 / 30 days dolutegravir sodium VOCABRIA 30 MG TAB Non-Preferred cabotegravir sodium ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)

ATRIPLA 600-200-300 MG TAB efavirenz-emtricitabine-tenofovir Preferred QL 30 / 30 days disoproxil fumarate COMPLERA 200-25-300 MG TAB emtricitabine-rilpivirine-tenofovir Preferred QL 1 / 1 days disoproxil fumarate DELSTRIGO 100-300-300 MG TAB doravirine-lamivudine-tenofovir Preferred QL 30 / 30 days disoproxil fumarate EDURANT 25 MG TAB Preferred QL 1 / 1 days rilpivirine hcl

efavirenz cap 200 mg Preferred QL 90 / 30 days

PAGE 148 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

efavirenz cap 50 mg Preferred QL 90 / 30 days

efavirenz tab 600 mg Preferred QL 30 / 30 days

efavirenz-emtricitabine-tenofovir df tab Non-Preferred 600-200-300 mg efavirenz-lamivudine-tenofovir df tab Non-Preferred 400-300-300 mg efavirenz-lamivudine-tenofovir df tab Non-Preferred 600-300-300 mg INTELENCE 100 MG TAB Non-Preferred QL 120 / 30 days etravirine INTELENCE 200 MG TAB Non-Preferred QL 2 / 1 days etravirine INTELENCE 25 MG TAB Non-Preferred etravirine

nevirapine susp 50 mg/5ml Non-Preferred QL 1200 / 30 days

nevirapine tab 200 mg Preferred QL 2 / 1 days

nevirapine tab er 24hr 100 mg Non-Preferred

nevirapine tab er 24hr 400 mg Non-Preferred QL 1 / 1 days

ODEFSEY 200-25-25 MG TAB emtricitabine-rilpivirine-tenofovir Preferred QL 1 / 1 days alafenamide fumarate PIFELTRO 100 MG TAB Non-Preferred QL 60 / 30 days doravirine RESCRIPTOR 200 MG TAB Non-Preferred QL 180 / 30 days delavirdine mesylate SUSTIVA 200 MG CAP Non-Preferred QL 90 / 30 days efavirenz SUSTIVA 50 MG CAP Non-Preferred QL 90 / 30 days efavirenz SUSTIVA 600 MG TAB Non-Preferred QL 30 / 30 days efavirenz SYMFI 600-300-300 MG TAB efavirenz-lamivudine-tenofovir disoproxil Preferred QL 30 / 30 days fumarate SYMFI LO 400-300-300 MG TAB efavirenz-lamivudine-tenofovir disoproxil Preferred QL 30 / 30 days fumarate

PAGE 149 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VIRAMUNE 200 MG TAB Non-Preferred QL 2 / 1 days nevirapine VIRAMUNE 50 MG/5ML SUSPENSION Non-Preferred QL 1200 / 30 days nevirapine VIRAMUNE XR 400 MG TAB ER 24H Non-Preferred QL 1 / 1 days nevirapine ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)

abacavir sulfate soln 20 mg/ml (base Preferred QL 900 / 30 days equiv)

abacavir sulfate tab 300 mg (base equiv) Preferred QL 2 / 1 days

abacavir sulfate-lamivudine tab 600-300 Preferred QL 1 / 1 days mg abacavir sulfate-lamivudine-zidovudine Non-Preferred QL 2 / 1 days tab 300-150-300 mg CIMDUO 300-300 MG TAB Preferred QL 1 / 1 days lamivudine-tenofovir disoproxil fumarate COMBIVIR 150-300 MG TAB Non-Preferred QL 2 / 1 days lamivudine-zidovudine didanosine delayed release capsule 250 Non-Preferred QL 1 / 1 days mg didanosine delayed release capsule 400 Non-Preferred QL 1 / 1 days mg emtricitabine caps 200 mg Non-Preferred emtricitabine-tenofovir disoproxil Non-Preferred fumarate tab 100-150 mg emtricitabine-tenofovir disoproxil Non-Preferred fumarate tab 133-200 mg emtricitabine-tenofovir disoproxil Non-Preferred fumarate tab 167-250 mg emtricitabine-tenofovir disoproxil Non-Preferred fumarate tab 200-300 mg EMTRIVA 10 MG/ML SOLUTION Preferred QL 720 / 30 days emtricitabine EMTRIVA 200 MG CAP Preferred QL 1 / 1 days emtricitabine EPIVIR 10 MG/ML SOLUTION Non-Preferred lamivudine EPIVIR 150 MG TAB Non-Preferred QL 2 / 1 days lamivudine

PAGE 150 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS EPIVIR 300 MG TAB Non-Preferred QL 1 / 1 days lamivudine EPZICOM 600-300 MG TAB Non-Preferred QL 1 / 1 days abacavir sulfate-lamivudine

lamivudine oral soln 10 mg/ml Preferred QL 900 / 30 days

lamivudine tab 150 mg Preferred QL 2 / 1 days

lamivudine tab 300 mg Preferred QL 1 / 1 days

lamivudine-zidovudine tab 150-300 mg Preferred QL 2 / 1 days

RETROVIR 100 MG CAP Non-Preferred zidovudine RETROVIR 50 MG/5ML SYRUP Non-Preferred zidovudine STAVUDINE 15 MG CAP Non-Preferred QL 120 / 30 days stavudine STAVUDINE 20 MG CAP Non-Preferred QL 120 / 30 days stavudine STAVUDINE 30 MG CAP Non-Preferred QL 2 / 1 days stavudine STAVUDINE 40 MG CAP Non-Preferred QL 2 / 1 days stavudine stavudine cap 15 mg Non-Preferred stavudine cap 20 mg Non-Preferred

stavudine cap 30 mg Non-Preferred QL 2 / 1 days

stavudine cap 40 mg Non-Preferred QL 2 / 1 days

TEMIXYS 300-300 MG TAB Non-Preferred lamivudine-tenofovir disoproxil fumarate

tenofovir disoproxil fumarate tab 300 mg Preferred QL 30 / 30 days

TRIZIVIR 300-150-300 MG TAB Non-Preferred QL 2 / 1 days abacavir sulfate-lamivudine-zidovudine TRUVADA 100-150 MG TAB emtricitabine-tenofovir disoproxil Preferred QL 1 / 1 days fumarate TRUVADA 133-200 MG TAB emtricitabine-tenofovir disoproxil Preferred QL 1 / 1 days fumarate

PAGE 151 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TRUVADA 167-250 MG TAB emtricitabine-tenofovir disoproxil Preferred QL 1 / 1 days fumarate TRUVADA 200-300 MG TAB emtricitabine-tenofovir disoproxil Preferred QL 1 / 1 days fumarate VIDEX 2 GM RECON SOLN Preferred QL 1200 / 30 days didanosine VIDEX 4 GM RECON SOLN Preferred didanosine VIDEX EC 125 MG CAP DR Non-Preferred QL 2 / 1 days didanosine VIDEX EC 200 MG CAP DR Non-Preferred QL 2 / 1 days didanosine VIDEX EC 250 MG CAP DR Non-Preferred QL 1 / 1 days didanosine VIDEX EC 400 MG CAP DR Non-Preferred QL 1 / 1 days didanosine VIREAD 150 MG TAB Preferred QL 2 / 1 days tenofovir disoproxil fumarate VIREAD 200 MG TAB Preferred QL 1 / 1 days tenofovir disoproxil fumarate VIREAD 250 MG TAB Preferred QL 1 / 1 days tenofovir disoproxil fumarate VIREAD 300 MG TAB Non-Preferred QL 30 / 30 days tenofovir disoproxil fumarate VIREAD 40 MG/GM POWDER Preferred tenofovir disoproxil fumarate ZERIT 20 MG CAP Non-Preferred stavudine ZERIT 30 MG CAP Non-Preferred QL 2 / 1 days stavudine ZERIT 40 MG CAP Non-Preferred QL 2 / 1 days stavudine ZIAGEN 20 MG/ML SOLUTION Non-Preferred abacavir sulfate ZIAGEN 300 MG TAB Non-Preferred QL 2 / 1 days abacavir sulfate

zidovudine cap 100 mg Preferred QL 180 / 30 days

PAGE 152 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

zidovudine syrup 10 mg/ml Preferred QL 1800 / 30 days

zidovudine tab 300 mg Preferred QL 60 / 30 days

ANTI-HIV AGENTS, OTHER

CABENUVA 400 & 600 MG/2ML SUSP Non-Preferred QLC 4 mL/28 days cabotegravir & rilpivirine CABENUVA 600 & 900 MG/3ML SUSP Non-Preferred QLC 6 mL/28 days cabotegravir & rilpivirine DESCOVY 200-25 MG TAB emtricitabine-tenofovir alafenamide Preferred QL 1 / 1 days fumarate DOVATO 50-300 MG TAB Preferred dolutegravir sodium-lamivudine FUZEON 90 MG RECON SOLN Non-Preferred QL 60 / 30 days enfuvirtide JULUCA 50-25 MG TAB Preferred QL 1 / 1 days dolutegravir sodium-rilpivirine hcl RUKOBIA 600 MG TAB ER 12H Non-Preferred QL 60 / 30 days fostemsavir tromethamine SELZENTRY 150 MG TAB Non-Preferred QL 2 / 1 days maraviroc SELZENTRY 20 MG/ML SOLUTION Non-Preferred maraviroc SELZENTRY 25 MG TAB Non-Preferred maraviroc SELZENTRY 300 MG TAB Non-Preferred QL 120 / 30 days maraviroc SELZENTRY 75 MG TAB Non-Preferred maraviroc TRIUMEQ 600-50-300 MG TAB Preferred QL 1 / 1 days abacavir-dolutegravir-lamivudine TROGARZO 200 MG/1.33ML SOLUTION Non-Preferred ibalizumab-uiyk TYBOST 150 MG TAB Non-Preferred QL 1 / 1 days cobicistat ANTI-HIV AGENTS, PROTEASE INHIBITORS

APTIVUS 100 MG/ML SOLUTION Non-Preferred QL 300 / 30 days tipranavir

PAGE 153 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS APTIVUS 250 MG CAP Non-Preferred QL 120 / 30 days tipranavir atazanavir sulfate cap 150 mg (base Preferred QL 2 / 1 days equiv) atazanavir sulfate cap 200 mg (base Preferred QL 60 / 30 days equiv) atazanavir sulfate cap 300 mg (base Preferred QL 1 / 1 days equiv) CRIXIVAN 200 MG CAP Non-Preferred QL 360 / 30 days indinavir sulfate CRIXIVAN 400 MG CAP Non-Preferred QL 180 / 30 days indinavir sulfate EVOTAZ 300-150 MG TAB Preferred QL 1 / 1 days atazanavir sulfate-cobicistat fosamprenavir calcium tab 700 mg (base Non-Preferred QL 120 / 30 days equiv) INVIRASE 500 MG TAB Non-Preferred QL 120 / 30 days saquinavir mesylate KALETRA 100-25 MG TAB Preferred QL 300 / 30 days lopinavir-ritonavir KALETRA 200-50 MG TAB Preferred QL 120 / 30 days lopinavir-ritonavir KALETRA 400-100 MG/5ML SOLUTION Preferred QL 400 / 30 days lopinavir-ritonavir LEXIVA 50 MG/ML SUSPENSION Non-Preferred QL 56 / 1 days fosamprenavir calcium LEXIVA 700 MG TAB Non-Preferred fosamprenavir calcium lopinavir-ritonavir soln 400-100 mg/5ml Non-Preferred QL 400 / 30 days (80-20 mg/ml) NORVIR 100 MG PACKET Preferred QL 360 / 30 days ritonavir NORVIR 100 MG TAB Non-Preferred ritonavir NORVIR 80 MG/ML SOLUTION Preferred QL 480 / 30 days ritonavir PREZCOBIX 800-150 MG TAB Preferred QL 1 / 1 days darunavir-cobicistat PREZISTA 100 MG/ML SUSPENSION Preferred QL 12 / 1 days darunavir ethanolate

PAGE 154 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PREZISTA 150 MG TAB Preferred QL 120 / 30 days darunavir ethanolate PREZISTA 600 MG TAB Preferred QL 2 / 1 days darunavir ethanolate PREZISTA 75 MG TAB Preferred QL 180 / 30 days darunavir ethanolate PREZISTA 800 MG TAB Preferred QL 1 / 1 days darunavir ethanolate REYATAZ 150 MG CAP Non-Preferred QL 2 / 1 days atazanavir sulfate REYATAZ 200 MG CAP Non-Preferred QL 60 / 30 days atazanavir sulfate REYATAZ 300 MG CAP Non-Preferred QL 1 / 1 days atazanavir sulfate REYATAZ 50 MG PACKET Preferred atazanavir sulfate

ritonavir tab 100 mg Preferred QL 360 / 30 days

SYMTUZA 800-150-200-10 MG TAB darunavir-cobicistat-emtricitabine- Non-Preferred QL 30 / 30 days tenofovir alafenamide VIRACEPT 250 MG TAB Non-Preferred QL 270 / 30 days nelfinavir mesylate VIRACEPT 625 MG TAB Non-Preferred QL 120 / 30 days nelfinavir mesylate ANTI-INFLUENZA AGENTS

FLUMADINE 100 MG TAB Non-Preferred rimantadine hydrochloride oseltamivir phosphate cap 30 mg (base Preferred QLC Max 21 day supply equiv) every 365 days oseltamivir phosphate cap 45 mg (base Preferred QLC Max 21 day supply equiv) every 365 days oseltamivir phosphate cap 75 mg (base Preferred QLC Max 21 day supply equiv) every 365 days oseltamivir phosphate for susp 6 mg/ml Preferred QLC Max 21 day supply (base equiv) every 365 days RAPIVAB 200 MG/20ML SOLUTION Non-Preferred peramivir RELENZA DISKHALER 5 MG/BLISTER AER POW BA Preferred zanamivir

PAGE 155 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS rimantadine hydrochloride tab 100 mg Non-Preferred TAMIFLU 30 MG CAP Non-Preferred QLC Max 21 day supply oseltamivir phosphate every 365 days TAMIFLU 45 MG CAP Non-Preferred QLC Max 21 day supply oseltamivir phosphate every 365 days TAMIFLU 6 MG/ML RECON SUSP Non-Preferred QLC Max 21 day supply oseltamivir phosphate every 365 days TAMIFLU 75 MG CAP Non-Preferred QLC Max 21 day supply oseltamivir phosphate every 365 days XOFLUZA (40 MG DOSE) 2 X 20 MG TAB THPK Non-Preferred baloxavir marboxil XOFLUZA (80 MG DOSE) 2 X 40 MG TAB THPK Non-Preferred baloxavir marboxil ANTIHERPETIC AGENTS

acyclovir cap 200 mg Preferred QL 5 / 1 days

acyclovir susp 200 mg/5ml Preferred QL 50 / 1 days

acyclovir tab 400 mg Preferred QL 5 / 1 days

acyclovir tab 800 mg Preferred QL 5 / 1 days

acyclovir cream 5% Non-Preferred acyclovir oint 5% Non-Preferred DENAVIR 1 % CREAM Non-Preferred penciclovir

famciclovir tab 125 mg Preferred QL 3 / 1 days

famciclovir tab 250 mg Preferred QL 3 / 1 days

famciclovir tab 500 mg Preferred QL 90 / 30 days

SITAVIG 50 MG TAB Non-Preferred acyclovir

trifluridine ophth soln 1% Preferred QL 7.5 / 18 days

valacyclovir hcl tab 1 gm Preferred QL 4 / 1 days

valacyclovir hcl tab 500 mg Preferred QL 4 / 1 days

VALTREX 1 GM TAB Non-Preferred valacyclovir hcl

PAGE 156 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VALTREX 500 MG TAB Non-Preferred valacyclovir hcl XERESE 5-1 % CREAM Non-Preferred acyclovir-hydrocortisone ZOVIRAX 200 MG CAP Non-Preferred QL 5 / 1 days acyclovir ZOVIRAX 200 MG/5ML SUSPENSION Non-Preferred acyclovir ZOVIRAX 400 MG TAB Non-Preferred acyclovir ZOVIRAX 5 % CREAM Non-Preferred acyclovir topical ZOVIRAX 5 % OINTMENT Non-Preferred acyclovir topical ZOVIRAX 800 MG TAB Non-Preferred acyclovir ANXIOLYTICS

ANXIOLYTICS, OTHER

buspirone hcl tab 10 mg Preferred QL 6 / 1 days

buspirone hcl tab 15 mg Preferred QL 4 / 1 days

buspirone hcl tab 30 mg Preferred QL 2 / 1 days

buspirone hcl tab 5 mg Preferred QL 6 / 1 days

buspirone hcl tab 7.5 mg Preferred QL 4 / 1 days

meprobamate tab 200 mg Non-Preferred QL 6 / 1 days

meprobamate tab 400 mg Non-Preferred QL 6 / 1 days

BENZODIAZEPINES

AL1 At least 21 yrs old alprazolam orally disintegrating tab 0.25 Non-Preferred mg C Age restriction, clinical PA required

AL1 At least 21 yrs old alprazolam orally disintegrating tab 0.5 Non-Preferred mg C Age restriction, clinical PA required

AL1 At least 21 yrs old alprazolam orally disintegrating tab 1 mg Non-Preferred C Age restriction, clinical PA required

PAGE 157 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

AL1 At least 21 yrs old alprazolam orally disintegrating tab 2 mg Non-Preferred C Age restriction, clinical PA required

QL 6 / 1 days

alprazolam tab 0.25 mg Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 6 / 1 days

alprazolam tab 0.5 mg Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 6 / 1 days

alprazolam tab 1 mg Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 3 / 1 days

alprazolam tab 2 mg Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

AL1 At least 21 yrs old alprazolam tab er 24hr 0.5 mg Non-Preferred C Age restriction, clinical PA required

AL1 At least 21 yrs old alprazolam tab er 24hr 0.5 mg Non-Preferred C Age restriction, clinical PA required

AL1 At least 21 yrs old alprazolam tab er 24hr 1 mg Non-Preferred C Age restriction, clinical PA required

AL1 At least 21 yrs old alprazolam tab er 24hr 1 mg Non-Preferred C Age restriction, clinical PA required

AL1 At least 21 yrs old alprazolam tab er 24hr 2 mg Non-Preferred C Age restriction, clinical PA required

AL1 At least 21 yrs old alprazolam tab er 24hr 2 mg Non-Preferred C Age restriction, clinical PA required

AL1 At least 21 yrs old alprazolam tab er 24hr 3 mg Non-Preferred C Age restriction, clinical PA required

PAGE 158 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

AL1 At least 21 yrs old alprazolam tab er 24hr 3 mg Non-Preferred C Age restriction, clinical PA required

ALPRAZOLAM INTENSOL 1 MG/ML AL1 At least 21 yrs old CONC Non-Preferred C Age restriction, clinical alprazolam PA required

AL1 At least 21 yrs old ATIVAN 0.5 MG TAB Non-Preferred lorazepam C Age restriction, clinical PA required

AL1 At least 21 yrs old ATIVAN 1 MG TAB Non-Preferred lorazepam C Age restriction, clinical PA required

AL1 At least 21 yrs old ATIVAN 2 MG TAB Non-Preferred lorazepam C Age restriction, clinical PA required ATIVAN 2 MG/ML SOLUTION Non-Preferred lorazepam ATIVAN 4 MG/ML SOLUTION Non-Preferred lorazepam

QL 10 / 1 days

chlordiazepoxide hcl cap 10 mg Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 12 / 1 days

chlordiazepoxide hcl cap 25 mg Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 8 / 1 days

chlordiazepoxide hcl cap 5 mg Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 90 / 30 days clonazepam orally disintegrating tab Preferred AL1 At least 21 yrs old 0.125 mg C Age restriction, clinical PA required

QL 90 / 30 days clonazepam orally disintegrating tab Preferred AL1 At least 21 yrs old 0.25 mg C Age restriction, clinical PA required

PAGE 159 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 90 / 30 days clonazepam orally disintegrating tab 0.5 Preferred AL1 At least 21 yrs old mg C Age restriction, clinical PA required

QL 90 / 30 days clonazepam orally disintegrating tab 1 Preferred AL1 At least 21 yrs old mg C Age restriction, clinical PA required

QL 90 / 30 days clonazepam orally disintegrating tab 2 Preferred AL1 At least 21 yrs old mg C Age restriction, clinical PA required

QL 6 / 1 days

clonazepam tab 0.5 mg Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 6 / 1 days

clonazepam tab 1 mg Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 6 / 1 days

clonazepam tab 2 mg Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 6 / 1 days

clorazepate dipotassium tab 15 mg Non-Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 4 / 1 days

clorazepate dipotassium tab 3.75 mg Non-Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 4 / 1 days

clorazepate dipotassium tab 7.5 mg Non-Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

AL1 At least 21 yrs old DIAZEPAM 10 MG/2ML SOLN A-INJ Non-Preferred diazepam C Age restriction, clinical PA required

PAGE 160 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

AL1 At least 21 yrs old DIAZEPAM 5 MG/ML SOLUTION Non-Preferred diazepam C Age restriction, clinical PA required

QL 8 / 1 days

diazepam conc 5 mg/ml Non-Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 8 / 1 days

diazepam conc 5 mg/ml Non-Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

AL1 At least 21 yrs old diazepam inj 5 mg/ml Non-Preferred C Age restriction, clinical PA required

QL 40 / 1 days

diazepam oral soln 1 mg/ml Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 4 / 1 days

diazepam tab 10 mg Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 4 / 1 days

diazepam tab 2 mg Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 4 / 1 days

diazepam tab 5 mg Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

AL1 At least 21 yrs old KLONOPIN 0.5 MG TAB Non-Preferred clonazepam C Age restriction, clinical PA required

AL1 At least 21 yrs old KLONOPIN 1 MG TAB Non-Preferred clonazepam C Age restriction, clinical PA required

AL1 At least 21 yrs old KLONOPIN 2 MG TAB Non-Preferred clonazepam C Age restriction, clinical PA required

PAGE 161 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 5 / 1 days

lorazepam conc 2 mg/ml Non-Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 5 / 1 days

lorazepam conc 2 mg/ml Non-Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required lorazepam inj 2 mg/ml Preferred lorazepam inj 4 mg/ml Preferred

QL 6 / 1 days

lorazepam tab 0.5 mg Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 6 / 1 days

lorazepam tab 1 mg Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 4 / 1 days

lorazepam tab 2 mg Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 8 / 1 days

oxazepam cap 10 mg Non-Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 4 / 1 days

oxazepam cap 15 mg Non-Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

QL 4 / 1 days

oxazepam cap 30 mg Non-Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required

AL1 At least 21 yrs old TRANXENE-T 7.5 MG TAB Non-Preferred clorazepate dipotassium C Age restriction, clinical PA required

PAGE 162 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 6 / 1 days XANAX 0.25 MG TAB Non-Preferred AL1 At least 21 yrs old alprazolam C Age restriction, clinical PA required

QL 6 / 1 days XANAX 0.5 MG TAB Non-Preferred AL1 At least 21 yrs old alprazolam C Age restriction, clinical PA required

QL 6 / 1 days XANAX 1 MG TAB Non-Preferred AL1 At least 21 yrs old alprazolam C Age restriction, clinical PA required

QL 3 / 1 days XANAX 2 MG TAB Non-Preferred AL1 At least 21 yrs old alprazolam C Age restriction, clinical PA required

AL1 At least 21 yrs old XANAX XR 0.5 MG TAB ER 24H Non-Preferred alprazolam C Age restriction, clinical PA required

AL1 At least 21 yrs old XANAX XR 1 MG TAB ER 24H Non-Preferred alprazolam C Age restriction, clinical PA required

AL1 At least 21 yrs old XANAX XR 2 MG TAB ER 24H Non-Preferred alprazolam C Age restriction, clinical PA required

AL1 At least 21 yrs old XANAX XR 3 MG TAB ER 24H Non-Preferred alprazolam C Age restriction, clinical PA required BIPOLAR AGENTS

MOOD STABILIZERS

EQUETRO 100 MG CAP ER 12H Preferred carbamazepine (antipsychotic) EQUETRO 200 MG CAP ER 12H Preferred carbamazepine (antipsychotic) EQUETRO 300 MG CAP ER 12H Preferred carbamazepine (antipsychotic)

lithium carbonate cap 150 mg Preferred QL 4 / 1 days

PAGE 163 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

lithium carbonate cap 300 mg Preferred QL 4 / 1 days

lithium carbonate cap 600 mg Preferred QL 4 / 1 days

lithium carbonate tab 300 mg Preferred QL 4 / 1 days

lithium carbonate tab er 300 mg Preferred QL 4 / 1 days

lithium carbonate tab er 450 mg Preferred QL 4 / 1 days

BLOOD GLUCOSE REGULATORS

ANTIDIABETIC AGENTS

acarbose tab 100 mg Preferred QL 3 / 1 days

acarbose tab 25 mg Preferred QL 3 / 1 days

acarbose tab 50 mg Preferred QL 3 / 1 days

ACTOPLUS MET 15-500 MG TAB Non-Preferred QL 90 / 30 days pioglitazone hcl-metformin hcl ACTOPLUS MET 15-850 MG TAB Non-Preferred QL 90 / 30 days pioglitazone hcl-metformin hcl ACTOPLUS MET XR 15-1000 MG TAB ER 24H Non-Preferred pioglitazone hcl-metformin hcl ACTOPLUS MET XR 30-1000 MG TAB ER 24H Non-Preferred pioglitazone hcl-metformin hcl ACTOS 15 MG TAB Non-Preferred QL 30 / 30 days pioglitazone hcl ACTOS 30 MG TAB Non-Preferred QL 30 / 30 days pioglitazone hcl ACTOS 45 MG TAB Non-Preferred QL 30 / 30 days pioglitazone hcl ADLYXIN 20 MCG/0.2ML SOLN PEN Non-Preferred lixisenatide ADLYXIN STARTER PACK 10 & 20 MCG/0.2ML PEN KIT Non-Preferred lixisenatide alogliptin benzoate tab 12.5 mg (base Non-Preferred equiv) alogliptin benzoate tab 25 mg (base Non-Preferred equiv)

PAGE 164 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS alogliptin benzoate tab 6.25 mg (base Non-Preferred equiv) alogliptin-metformin hcl tab 12.5-1000 Non-Preferred mg alogliptin-metformin hcl tab 12.5-500 mg Non-Preferred alogliptin-pioglitazone tab 12.5-15 mg Non-Preferred alogliptin-pioglitazone tab 12.5-30 mg Non-Preferred alogliptin-pioglitazone tab 12.5-45 mg Non-Preferred alogliptin-pioglitazone tab 25-15 mg Non-Preferred alogliptin-pioglitazone tab 25-30 mg Non-Preferred alogliptin-pioglitazone tab 25-45 mg Non-Preferred AMARYL 1 MG TAB Non-Preferred QL 60 / 30 days glimepiride AMARYL 2 MG TAB Non-Preferred QL 90 / 30 days glimepiride AMARYL 4 MG TAB Non-Preferred QL 60 / 30 days glimepiride AVANDIA 2 MG TAB Non-Preferred rosiglitazone maleate AVANDIA 4 MG TAB Non-Preferred rosiglitazone maleate BYDUREON 2 MG PEN Non-Preferred QL 4 / 28 days exenatide BYDUREON 2 MG SRER Non-Preferred QL 4 / 28 days exenatide BYDUREON BCISE 2 MG/0.85ML A-INJ Non-Preferred QL 3.4 / 28 days exenatide BYETTA 10 MCG PEN 10 MCG/0.04ML SOLN PEN Non-Preferred QL 2.4 / 30 days exenatide BYETTA 5 MCG PEN 5 MCG/0.02ML SOLN PEN Non-Preferred QL 1.2 / 30 days exenatide CHLORPROPAMIDE 100 MG TAB Non-Preferred QL 7 / 1 days chlorpropamide CHLORPROPAMIDE 250 MG TAB Non-Preferred QL 3 / 1 days chlorpropamide

PAGE 165 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS DUETACT 30-2 MG TAB Non-Preferred QL 30 / 30 days pioglitazone hcl-glimepiride DUETACT 30-4 MG TAB Non-Preferred QL 30 / 30 days pioglitazone hcl-glimepiride FARXIGA 10 MG TAB Preferred PA dapagliflozin propanediol FARXIGA 5 MG TAB Preferred PA dapagliflozin propanediol FORTAMET 1000 MG TAB ER 24H Non-Preferred QL 60 / 30 days metformin hcl FORTAMET 500 MG TAB ER 24H Non-Preferred QL 90 / 30 days metformin hcl

glimepiride tab 1 mg Preferred QL 60 / 30 days

glimepiride tab 2 mg Preferred QL 90 / 30 days

glimepiride tab 4 mg Preferred QL 60 / 30 days

glipizide tab 10 mg Preferred QL 4 / 1 days

glipizide tab 5 mg Preferred QL 4 / 1 days

glipizide tab er 24hr 10 mg Preferred QL 60 / 30 days

glipizide tab er 24hr 10 mg Preferred QL 2 / 1 days

glipizide tab er 24hr 2.5 mg Preferred QL 8 / 1 days

glipizide tab er 24hr 2.5 mg Preferred QL 8 / 1 days

glipizide tab er 24hr 5 mg Preferred QL 4 / 1 days

glipizide tab er 24hr 5 mg Preferred QL 4 / 1 days

glipizide-metformin hcl tab 2.5-250 mg Preferred QL 7 / 1 days

glipizide-metformin hcl tab 2.5-500 mg Preferred QL 5 / 1 days

glipizide-metformin hcl tab 5-500 mg Preferred QL 4 / 1 days

GLUCOPHAGE 1000 MG TAB Non-Preferred QL 75 / 30 days metformin hcl GLUCOPHAGE 500 MG TAB Non-Preferred QL 150 / 30 days metformin hcl GLUCOPHAGE 850 MG TAB Non-Preferred QL 90 / 30 days metformin hcl

PAGE 166 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS GLUCOPHAGE XR 500 MG TAB ER 24H Non-Preferred metformin hcl GLUCOPHAGE XR 750 MG TAB ER 24H Non-Preferred QL 3 / 1 days metformin hcl GLUCOTROL 10 MG TAB Non-Preferred glipizide GLUCOTROL 5 MG TAB Non-Preferred glipizide GLUCOTROL XL 10 MG TAB ER 24H Non-Preferred QL 2 / 1 days glipizide GLUCOTROL XL 2.5 MG TAB ER 24H Non-Preferred glipizide GLUCOTROL XL 5 MG TAB ER 24H Non-Preferred glipizide GLUMETZA 1000 MG TAB ER 24H Non-Preferred QL 60 / 30 days metformin hcl GLUMETZA 500 MG TAB ER 24H Non-Preferred QL 90 / 30 days metformin hcl

glyburide tab 1.25 mg Preferred QL 4 / 1 days

glyburide tab 2.5 mg Preferred QL 4 / 1 days

glyburide tab 5 mg Preferred QL 4 / 1 days

glyburide micronized tab 1.5 mg Preferred QL 2 / 1 days

glyburide micronized tab 3 mg Preferred QL 2 / 1 days

glyburide micronized tab 6 mg Preferred QL 2 / 1 days

glyburide-metformin tab 1.25-250 mg Preferred QL 4 / 1 days

glyburide-metformin tab 2.5-500 mg Preferred QL 4 / 1 days

glyburide-metformin tab 5-500 mg Preferred QL 4 / 1 days

GLYNASE 1.5 MG TAB Non-Preferred QL 2 / 1 days glyburide micronized GLYNASE 3 MG TAB Non-Preferred QL 2 / 1 days glyburide micronized GLYNASE 6 MG TAB Non-Preferred QL 2 / 1 days glyburide micronized

PAGE 167 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS GLYSET 100 MG TAB Non-Preferred miglitol GLYSET 25 MG TAB Non-Preferred miglitol GLYSET 50 MG TAB Non-Preferred miglitol GLYXAMBI 10-5 MG TAB Non-Preferred empagliflozin-linagliptin GLYXAMBI 25-5 MG TAB Non-Preferred empagliflozin-linagliptin INVOKAMET 150-1000 MG TAB Preferred PA canagliflozin-metformin hcl INVOKAMET 150-500 MG TAB Preferred PA canagliflozin-metformin hcl INVOKAMET 50-1000 MG TAB Preferred PA canagliflozin-metformin hcl INVOKAMET 50-500 MG TAB Preferred PA canagliflozin-metformin hcl INVOKAMET XR 150-1000 MG TAB ER 24H Non-Preferred canagliflozin-metformin hcl INVOKAMET XR 150-500 MG TAB ER 24H Non-Preferred canagliflozin-metformin hcl INVOKAMET XR 50-1000 MG TAB ER 24H Non-Preferred canagliflozin-metformin hcl INVOKAMET XR 50-500 MG TAB ER 24H Non-Preferred canagliflozin-metformin hcl INVOKANA 100 MG TAB Preferred PA canagliflozin INVOKANA 300 MG TAB Preferred PA canagliflozin

JANUMET 50-1000 MG TAB QL 2 / 1 days Preferred sitagliptin-metformin hcl PA

JANUMET 50-500 MG TAB QL 2 / 1 days Preferred sitagliptin-metformin hcl PA

PAGE 168 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

JANUMET XR 100-1000 MG TAB ER QL 1 / 1 days 24H Preferred sitagliptin-metformin hcl PA

JANUMET XR 50-1000 MG TAB ER QL 2 / 1 days 24H Preferred sitagliptin-metformin hcl PA

JANUMET XR 50-500 MG TAB ER 24H QL 2 / 1 days Preferred sitagliptin-metformin hcl PA

JANUVIA 100 MG TAB QL 1 / 1 days Preferred sitagliptin phosphate PA

JANUVIA 25 MG TAB QL 1 / 1 days Preferred sitagliptin phosphate PA

JANUVIA 50 MG TAB QL 1 / 1 days Preferred sitagliptin phosphate PA

JARDIANCE 10 MG TAB QL 30 / 30 days Preferred empagliflozin PA

JARDIANCE 25 MG TAB QL 30 / 30 days Preferred empagliflozin PA

JENTADUETO 2.5-1000 MG TAB QL 60 / 30 days Preferred linagliptin-metformin hcl PA

JENTADUETO 2.5-500 MG TAB QL 60 / 30 days Preferred linagliptin-metformin hcl PA

JENTADUETO 2.5-850 MG TAB QL 60 / 30 days Preferred linagliptin-metformin hcl PA

JENTADUETO XR 2.5-1000 MG TAB ER 24H Non-Preferred linagliptin-metformin hcl JENTADUETO XR 5-1000 MG TAB ER 24H Non-Preferred linagliptin-metformin hcl KAZANO 12.5-1000 MG TAB Non-Preferred alogliptin-metformin hcl KAZANO 12.5-500 MG TAB Non-Preferred alogliptin-metformin hcl

PAGE 169 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS KOMBIGLYZE XR 2.5-1000 MG TAB ER 24H Non-Preferred saxagliptin-metformin hcl KOMBIGLYZE XR 5-1000 MG TAB ER 24H Non-Preferred saxagliptin-metformin hcl KOMBIGLYZE XR 5-500 MG TAB ER 24H Non-Preferred saxagliptin-metformin hcl metformin hcl oral soln 500 mg/5ml Non-Preferred

metformin hcl tab 1000 mg Preferred QL 75 / 30 days

metformin hcl tab 500 mg Preferred QL 150 / 30 days

metformin hcl tab 850 mg Preferred QL 90 / 30 days

metformin hcl tab er 24hr 500 mg Preferred QL 150 / 30 days

metformin hcl tab er 24hr 750 mg Preferred QL 90 / 30 days

metformin hcl tab er 24hr modified Non-Preferred QL 60 / 30 days release 1000 mg metformin hcl tab er 24hr modified Non-Preferred QL 90 / 30 days release 500 mg metformin hcl tab er 24hr osmotic 1000 Non-Preferred QL 60 / 30 days mg metformin hcl tab er 24hr osmotic 500 Non-Preferred QL 90 / 30 days mg miglitol tab 100 mg Non-Preferred miglitol tab 25 mg Non-Preferred miglitol tab 50 mg Non-Preferred

nateglinide tab 120 mg Preferred QL 3 / 1 days

nateglinide tab 60 mg Preferred QL 3 / 1 days

NESINA 12.5 MG TAB Non-Preferred alogliptin benzoate NESINA 25 MG TAB Non-Preferred alogliptin benzoate NESINA 6.25 MG TAB Non-Preferred alogliptin benzoate ONGLYZA 2.5 MG TAB Non-Preferred saxagliptin hcl

PAGE 170 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ONGLYZA 5 MG TAB Non-Preferred saxagliptin hcl OSENI 12.5-15 MG TAB Non-Preferred alogliptin-pioglitazone OSENI 12.5-30 MG TAB Non-Preferred alogliptin-pioglitazone OSENI 12.5-45 MG TAB Non-Preferred alogliptin-pioglitazone OSENI 25-15 MG TAB Non-Preferred alogliptin-pioglitazone OSENI 25-30 MG TAB Non-Preferred alogliptin-pioglitazone OSENI 25-45 MG TAB Non-Preferred alogliptin-pioglitazone

OZEMPIC (0.25 OR 0.5 MG/DOSE) 2 QL 1.5 / 28 days MG/1.5ML SOLN PEN Preferred semaglutide PA

OZEMPIC (1 MG/DOSE) 2 MG/1.5ML QL 3 / 28 days SOLN PEN Preferred semaglutide PA OZEMPIC (1 MG/DOSE) 4 MG/3ML SOLN PEN Preferred PA semaglutide

QL 30 / 30 days pioglitazone hcl tab 15 mg (base equiv) Preferred PA

QL 30 / 30 days pioglitazone hcl tab 30 mg (base equiv) Preferred PA

QL 30 / 30 days pioglitazone hcl tab 45 mg (base equiv) Preferred PA

pioglitazone hcl-glimepiride tab 30-2 mg Non-Preferred QL 30 / 30 days

pioglitazone hcl-glimepiride tab 30-4 mg Non-Preferred QL 30 / 30 days

pioglitazone hcl-metformin hcl tab 15- Non-Preferred QL 90 / 30 days 500 mg pioglitazone hcl-metformin hcl tab 15- Non-Preferred QL 90 / 30 days 850 mg PRANDIN 1 MG TAB Non-Preferred QL 120 / 30 days repaglinide

PAGE 171 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PRANDIN 2 MG TAB Non-Preferred QL 240 / 30 days repaglinide PRECOSE 100 MG TAB Non-Preferred QL 3 / 1 days acarbose PRECOSE 25 MG TAB Non-Preferred QL 3 / 1 days acarbose PRECOSE 50 MG TAB Non-Preferred QL 3 / 1 days acarbose QTERN 10-5 MG TAB Non-Preferred dapagliflozin-saxagliptin QTERN 5-5 MG TAB Non-Preferred dapagliflozin-saxagliptin

repaglinide tab 0.5 mg Preferred QL 120 / 30 days

repaglinide tab 1 mg Preferred QL 120 / 30 days

repaglinide tab 2 mg Preferred QL 240 / 30 days

repaglinide-metformin hcl tab 1-500 mg Non-Preferred repaglinide-metformin hcl tab 2-500 mg Non-Preferred RIOMET 500 MG/5ML SOLUTION Non-Preferred metformin hcl RIOMET ER 500 MG/5ML SRER Non-Preferred metformin hcl RYBELSUS 14 MG TAB Non-Preferred semaglutide RYBELSUS 3 MG TAB Non-Preferred semaglutide RYBELSUS 7 MG TAB Non-Preferred semaglutide SEGLUROMET 2.5-1000 MG TAB Non-Preferred QL 60 / 30 days ertugliflozin-metformin hcl SEGLUROMET 2.5-500 MG TAB Non-Preferred QL 60 / 30 days ertugliflozin-metformin hcl SEGLUROMET 7.5-1000 MG TAB Non-Preferred QL 60 / 30 days ertugliflozin-metformin hcl SEGLUROMET 7.5-500 MG TAB Non-Preferred QL 60 / 30 days ertugliflozin-metformin hcl STARLIX 120 MG TAB Non-Preferred QL 3 / 1 days nateglinide

PAGE 172 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS STARLIX 60 MG TAB Non-Preferred QL 3 / 1 days nateglinide STEGLATRO 15 MG TAB Non-Preferred QL 1 / 1 days ertugliflozin l-pyroglutamic acid STEGLATRO 5 MG TAB Non-Preferred QL 1 / 1 days ertugliflozin l-pyroglutamic acid STEGLUJAN 15-100 MG TAB Non-Preferred ertugliflozin-sitagliptin STEGLUJAN 5-100 MG TAB Non-Preferred ertugliflozin-sitagliptin SYMLINPEN 120 2700 MCG/2.7ML SOLN PEN Non-Preferred pramlintide acetate SYMLINPEN 60 1500 MCG/1.5ML SOLN PEN Non-Preferred pramlintide acetate SYNJARDY 12.5-1000 MG TAB Preferred PA empagliflozin-metformin hcl SYNJARDY 12.5-500 MG TAB Preferred PA empagliflozin-metformin hcl SYNJARDY 5-1000 MG TAB Preferred PA empagliflozin-metformin hcl SYNJARDY 5-500 MG TAB Preferred PA empagliflozin-metformin hcl SYNJARDY XR 10-1000 MG TAB ER 24H Non-Preferred empagliflozin-metformin hcl SYNJARDY XR 12.5-1000 MG TAB ER 24H Non-Preferred empagliflozin-metformin hcl SYNJARDY XR 25-1000 MG TAB ER 24H Non-Preferred empagliflozin-metformin hcl SYNJARDY XR 5-1000 MG TAB ER 24H Non-Preferred empagliflozin-metformin hcl TANZEUM 30 MG PEN Non-Preferred albiglutide TANZEUM 50 MG PEN Non-Preferred albiglutide

PAGE 173 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TOLAZAMIDE 250 MG TAB Non-Preferred QL 4 / 1 days tolazamide TOLAZAMIDE 500 MG TAB Non-Preferred QL 2 / 1 days tolazamide

tolbutamide tab 500 mg Non-Preferred QL 6 / 1 days

TRADJENTA 5 MG TAB Preferred PA linagliptin TRIJARDY XR 10-5-1000 MG TAB ER 24H Non-Preferred QL 30 / 30 days empagliflozin-linagliptin-metformin TRIJARDY XR 12.5-2.5-1000 MG TAB ER 24H Non-Preferred QL 60 / 30 days empagliflozin-linagliptin-metformin TRIJARDY XR 25-5-1000 MG TAB ER 24H Non-Preferred QL 30 / 30 days empagliflozin-linagliptin-metformin TRIJARDY XR 5-2.5-1000 MG TAB ER 24H Non-Preferred QL 60 / 30 days empagliflozin-linagliptin-metformin

TRULICITY 0.75 MG/0.5ML SOLN PEN QL 2 / 28 days Preferred dulaglutide PA

TRULICITY 1.5 MG/0.5ML SOLN PEN QL 2 / 28 days Preferred dulaglutide PA

TRULICITY 3 MG/0.5ML SOLN PEN QL 2 / 28 days Preferred dulaglutide PA

TRULICITY 4.5 MG/0.5ML SOLN PEN QL 2 / 28 days Preferred dulaglutide PA

VICTOZA 18 MG/3ML SOLN PEN QL 9 / 30 days Preferred liraglutide PA

XIGDUO XR 10-1000 MG TAB ER 24H Non-Preferred dapagliflozin-metformin hcl XIGDUO XR 10-500 MG TAB ER 24H Non-Preferred dapagliflozin-metformin hcl XIGDUO XR 2.5-1000 MG TAB ER 24H Non-Preferred dapagliflozin-metformin hcl XIGDUO XR 5-1000 MG TAB ER 24H Non-Preferred dapagliflozin-metformin hcl

PAGE 174 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS XIGDUO XR 5-500 MG TAB ER 24H Non-Preferred dapagliflozin-metformin hcl GLYCEMIC AGENTS

BAQSIMI ONE PACK 3 MG/DOSE POWDER Preferred glucagon BAQSIMI TWO PACK 3 MG/DOSE POWDER Preferred glucagon GLUCAGEN DIAGNOSTIC 1 MG RECON SOLN Preferred QL 2 / 22 days glucagon hcl rdna (diagnostic) GLUCAGEN HYPOKIT 1 MG RECON SOLN Preferred QL 1 / 22 days glucagon hcl (rdna) glucagon (rdna) for inj kit 1 mg Preferred GLUCAGON EMERGENCY 1 MG KIT Preferred QL 1 / 26 days glucagon (rdna) GVOKE HYPOPEN 1-PACK 0.5 MG/0.1ML SOLN A-INJ Non-Preferred QLC 0.4 mL/30 days glucagon GVOKE HYPOPEN 1-PACK 1 MG/0.2ML SOLN A-INJ Non-Preferred QLC 0.4 mL/30 days glucagon GVOKE HYPOPEN 2-PACK 0.5 MG/0.1ML SOLN A-INJ Non-Preferred QLC 0.4 mL/30 days glucagon GVOKE HYPOPEN 2-PACK 1 MG/0.2ML SOLN A-INJ Non-Preferred QLC 0.4 mL/30 days glucagon GVOKE PFS 0.5 MG/0.1ML SOLN PRSYR Non-Preferred QLC 0.4 mL/30 days glucagon GVOKE PFS 1 MG/0.2ML SOLN PRSYR Non-Preferred QLC 0.4 mL/30 days glucagon INSULINS

ADMELOG 100 UNIT/ML SOLUTION Preferred QL 40 / 30 days insulin lispro ADMELOG SOLOSTAR 100 UNIT/ML SOLN PEN Preferred QL 45 / 30 days insulin lispro

PAGE 175 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS AFREZZA 12 UNIT POWDER Non-Preferred insulin regular (human) AFREZZA 4 & 8 & 12 UNIT POWDER Non-Preferred insulin regular (human) AFREZZA 4 UNIT POWDER Non-Preferred insulin regular (human) AFREZZA 8 UNIT POWDER Non-Preferred insulin regular (human) AFREZZA 90 X 4 UNIT & 90X8 UNIT POWDER Non-Preferred insulin regular (human) AFREZZA 90 X 8 UNIT & 90X12 UNIT POWDER Non-Preferred insulin regular (human) APIDRA 100 UNIT/ML SOLUTION Preferred QL 40 / 30 days insulin glulisine APIDRA SOLOSTAR 100 UNIT/ML SOLN PEN Preferred QL 45 / 30 days insulin glulisine BASAGLAR KWIKPEN 100 UNIT/ML SOLN PEN Preferred QL 45 / 30 days insulin glargine FIASP 100 UNIT/ML SOLUTION Non-Preferred insulin aspart (with niacinamide) FIASP FLEXTOUCH 100 UNIT/ML SOLN PEN Non-Preferred insulin aspart (with niacinamide) FIASP PENFILL 100 UNIT/ML SOLN CART Non-Preferred insulin aspart (with niacinamide) HUMALOG 100 UNIT/ML SOLN CART Non-Preferred QL 40 / 30 days insulin lispro HUMALOG 100 UNIT/ML SOLUTION Non-Preferred QL 40 / 30 days insulin lispro HUMALOG JUNIOR KWIKPEN 100 UNIT/ML SOLN PEN Non-Preferred QL 45 / 30 days insulin lispro HUMALOG KWIKPEN 100 UNIT/ML SOLN PEN Non-Preferred QL 45 / 30 days insulin lispro HUMALOG KWIKPEN 200 UNIT/ML SOLN PEN Non-Preferred QL 18 / 23 days insulin lispro

PAGE 176 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS HUMALOG MIX 50/50 (50-50) 100 UNIT/ML SUSPENSION Preferred QL 40 / 30 days insulin lispro protamine & lispro HUMALOG MIX 50/50 KWIKPEN (50- 50) 100 UNIT/ML SUSP PEN Preferred QL 45 / 30 days insulin lispro protamine & lispro HUMALOG MIX 75/25 (75-25) 100 UNIT/ML SUSPENSION Preferred QL 40 / 30 days insulin lispro protamine & lispro HUMALOG MIX 75/25 KWIKPEN (75- 25) 100 UNIT/ML SUSP PEN Preferred QL 45 / 30 days insulin lispro protamine & lispro HUMULIN R U-500 (CONCENTRATED) 500 UNIT/ML SOLUTION Preferred QL 20 / 30 days insulin regular (human) HUMULIN R U-500 KWIKPEN 500 UNIT/ML SOLN PEN Preferred QL 15 / 30 days insulin regular (human) INSULIN ASP PROT & ASP FLEXPEN (70-30) 100 UNIT/ML SUSP PEN Preferred QL 45 / 30 days insulin aspart protamine & aspart (human) INSULIN ASPART 100 UNIT/ML SOLUTION Preferred QL 40 / 30 days insulin aspart INSULIN ASPART FLEXPEN 100 UNIT/ML SOLN PEN Preferred QL 45 / 30 days insulin aspart INSULIN ASPART PENFILL 100 UNIT/ML SOLN CART Preferred QL 45 / 30 days insulin aspart INSULIN ASPART PROT & ASPART (70-30) 100 UNIT/ML SUSPENSION Preferred QL 40 / 30 days insulin aspart protamine & aspart (human) INSULIN LISPRO 100 UNIT/ML SOLUTION Preferred QL 40 / 30 days insulin lispro INSULIN LISPRO (1 UNIT DIAL) 100 UNIT/ML SOLN PEN Preferred QL 45 / 30 days insulin lispro INSULIN LISPRO JUNIOR KWIKPEN 100 UNIT/ML SOLN PEN Preferred insulin lispro

PAGE 177 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS INSULIN LISPRO PROT & LISPRO (75- 25) 100 UNIT/ML SUSP PEN Preferred insulin lispro protamine & lispro LANTUS 100 UNIT/ML SOLUTION Preferred QL 40 / 30 days insulin glargine LANTUS SOLOSTAR 100 UNIT/ML SOLN PEN Preferred QL 45 / 30 days insulin glargine LEVEMIR 100 UNIT/ML SOLUTION Preferred QL 40 / 30 days insulin detemir LEVEMIR FLEXTOUCH 100 UNIT/ML SOLN PEN Preferred QL 45 / 30 days insulin detemir LYUMJEV 100 UNIT/ML SOLUTION Non-Preferred insulin lispro-aabc LYUMJEV KWIKPEN 100 UNIT/ML SOLN PEN Non-Preferred insulin lispro-aabc LYUMJEV KWIKPEN 200 UNIT/ML SOLN PEN Non-Preferred insulin lispro-aabc NOVOLOG 100 UNIT/ML SOLUTION Preferred QL 40 / 30 days insulin aspart NOVOLOG FLEXPEN 100 UNIT/ML SOLN PEN Preferred QL 45 / 30 days insulin aspart NOVOLOG MIX 70/30 (70-30) 100 UNIT/ML SUSPENSION Preferred QL 40 / 30 days insulin aspart protamine & aspart (human) NOVOLOG MIX 70/30 FLEXPEN (70- 30) 100 UNIT/ML SUSP PEN Preferred QL 45 / 30 days insulin aspart protamine & aspart (human) NOVOLOG PENFILL 100 UNIT/ML SOLN CART Preferred QL 45 / 30 days insulin aspart SEMGLEE 100 UNIT/ML SOLN PEN Non-Preferred insulin glargine SEMGLEE 100 UNIT/ML SOLUTION Non-Preferred insulin glargine

PAGE 178 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SOLIQUA 100-33 UNT-MCG/ML SOLN PEN Non-Preferred QLC 18 mL/30 days insulin glargine-lixisenatide TOUJEO MAX SOLOSTAR 300 UNIT/ML SOLN PEN Non-Preferred QL 12 / 30 days insulin glargine TOUJEO SOLOSTAR 300 UNIT/ML SOLN PEN Non-Preferred QL 13.5 / 30 days insulin glargine TRESIBA 100 UNIT/ML SOLUTION Non-Preferred insulin degludec TRESIBA FLEXTOUCH 100 UNIT/ML SOLN PEN Non-Preferred insulin degludec TRESIBA FLEXTOUCH 200 UNIT/ML SOLN PEN Non-Preferred insulin degludec XULTOPHY 100-3.6 UNIT-MG/ML SOLN PEN Non-Preferred QLC 15 mL/30 days insulin degludec-liraglutide BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS

ANTICOAGULANTS

ARIXTRA 10 MG/0.8ML SOLUTION Non-Preferred fondaparinux sodium ARIXTRA 2.5 MG/0.5ML SOLUTION Non-Preferred fondaparinux sodium ARIXTRA 5 MG/0.4ML SOLUTION Non-Preferred fondaparinux sodium ARIXTRA 7.5 MG/0.6ML SOLUTION Non-Preferred fondaparinux sodium BEVYXXA 40 MG CAP Non-Preferred betrixaban maleate COUMADIN 1 MG TAB Non-Preferred warfarin sodium COUMADIN 10 MG TAB Non-Preferred warfarin sodium COUMADIN 2 MG TAB Non-Preferred warfarin sodium COUMADIN 2.5 MG TAB Non-Preferred warfarin sodium

PAGE 179 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS COUMADIN 3 MG TAB Non-Preferred warfarin sodium COUMADIN 4 MG TAB Non-Preferred warfarin sodium COUMADIN 5 MG TAB Non-Preferred warfarin sodium COUMADIN 6 MG TAB Non-Preferred warfarin sodium COUMADIN 7.5 MG TAB Non-Preferred warfarin sodium ELIQUIS 2.5 MG TAB Preferred QL 2 / 1 days apixaban ELIQUIS 5 MG TAB Preferred QL 4 / 1 days apixaban ELIQUIS DVT/PE STARTER PACK 5 MG TAB THPK Preferred apixaban

Up to a 180 day supply C every 365 days will be enoxaparin sodium inj 100 mg/ml Preferred allowed without PA QLC 2 mL/day

Up to a 180 day supply C every 365 days will be enoxaparin sodium inj 120 mg/0.8ml Preferred allowed without PA QLC 1.6 mL/day

Up to a 180 day supply C every 365 days will be enoxaparin sodium inj 150 mg/ml Preferred allowed without PA QLC 2 mL/day

Up to a 180 day supply C every 365 days will be enoxaparin sodium inj 30 mg/0.3ml Preferred allowed without PA QLC 0.6 mL/day

Up to a 180 day supply C every 365 days will be enoxaparin sodium inj 300 mg/3ml Preferred allowed without PA QLC 2 mL/day

Up to a 180 day supply C every 365 days will be enoxaparin sodium inj 40 mg/0.4ml Preferred allowed without PA QLC 0.8 mL/day

PAGE 180 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

Up to a 180 day supply C every 365 days will be enoxaparin sodium inj 60 mg/0.6ml Preferred allowed without PA QLC 1.2 mL/day

Up to a 180 day supply C every 365 days will be enoxaparin sodium inj 80 mg/0.8ml Preferred allowed without PA QLC 1.6 mL/day

fondaparinux sodium subcutaneous inj Non-Preferred 10 mg/0.8ml fondaparinux sodium subcutaneous inj Non-Preferred 2.5 mg/0.5ml fondaparinux sodium subcutaneous inj 5 Non-Preferred mg/0.4ml fondaparinux sodium subcutaneous inj Non-Preferred 7.5 mg/0.6ml FRAGMIN 10000 UNIT/ML SOLUTION Non-Preferred dalteparin sodium FRAGMIN 12500 UNIT/0.5ML SOLUTION Non-Preferred dalteparin sodium FRAGMIN 15000 UNIT/0.6ML SOLUTION Non-Preferred dalteparin sodium FRAGMIN 18000 UNT/0.72ML SOLUTION Non-Preferred dalteparin sodium FRAGMIN 2500 UNIT/0.2ML SOLUTION Non-Preferred dalteparin sodium FRAGMIN 5000 UNIT/0.2ML SOLUTION Non-Preferred dalteparin sodium FRAGMIN 7500 UNIT/0.3ML SOLUTION Non-Preferred dalteparin sodium FRAGMIN 95000 UNIT/3.8ML SOLUTION Non-Preferred dalteparin sodium heparin sodium (porcine) inj 1000 unit/ml Preferred heparin sodium (porcine) inj 10000 Preferred unit/ml

PAGE 181 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS heparin sodium (porcine) inj 20000 Preferred unit/ml heparin sodium (porcine) inj 5000 unit/ml Preferred heparin sodium (porcine) lock flush iv Preferred soln 10 unit/ml heparin sodium (porcine) lock flush iv Preferred soln 100 unit/ml

Up to a 180 day supply LOVENOX 100 MG/ML SOLUTION C every 365 days will be Non-Preferred enoxaparin sodium allowed without PA QLC 2 mL/day

Up to a 180 day supply LOVENOX 120 MG/0.8ML SOLUTION C every 365 days will be Non-Preferred enoxaparin sodium allowed without PA QLC 1.6 mL/day

Up to a 180 day supply LOVENOX 150 MG/ML SOLUTION C every 365 days will be Non-Preferred enoxaparin sodium allowed without PA QLC 2 mL/day

Up to a 180 day supply LOVENOX 30 MG/0.3ML SOLUTION C every 365 days will be Non-Preferred enoxaparin sodium allowed without PA QLC 0.6 mL/day

Up to a 180 day supply LOVENOX 300 MG/3ML SOLUTION C every 365 days will be Non-Preferred enoxaparin sodium allowed without PA QLC 2 mL/day

Up to a 180 day supply LOVENOX 40 MG/0.4ML SOLUTION C every 365 days will be Non-Preferred enoxaparin sodium allowed without PA QLC 0.8 mL/day

Up to a 180 day supply LOVENOX 60 MG/0.6ML SOLUTION C every 365 days will be Non-Preferred enoxaparin sodium allowed without PA QLC 1.2 mL/day

Up to a 180 day supply LOVENOX 80 MG/0.8ML SOLUTION C every 365 days will be Non-Preferred enoxaparin sodium allowed without PA QLC 1.6 mL/day

PRADAXA 110 MG CAP Preferred dabigatran etexilate mesylate

PAGE 182 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PRADAXA 150 MG CAP Preferred dabigatran etexilate mesylate PRADAXA 75 MG CAP Preferred dabigatran etexilate mesylate SAVAYSA 15 MG TAB Non-Preferred edoxaban tosylate SAVAYSA 30 MG TAB Non-Preferred edoxaban tosylate SAVAYSA 60 MG TAB Non-Preferred edoxaban tosylate warfarin sodium tab 1 mg Preferred warfarin sodium tab 1 mg Preferred warfarin sodium tab 10 mg Preferred warfarin sodium tab 10 mg Preferred warfarin sodium tab 2 mg Preferred warfarin sodium tab 2 mg Preferred warfarin sodium tab 2.5 mg Preferred warfarin sodium tab 2.5 mg Preferred warfarin sodium tab 3 mg Preferred warfarin sodium tab 3 mg Preferred warfarin sodium tab 4 mg Preferred warfarin sodium tab 4 mg Preferred warfarin sodium tab 5 mg Preferred warfarin sodium tab 5 mg Preferred warfarin sodium tab 6 mg Preferred warfarin sodium tab 6 mg Preferred warfarin sodium tab 7.5 mg Preferred warfarin sodium tab 7.5 mg Preferred XARELTO 10 MG TAB Preferred QL 1 / 1 days rivaroxaban XARELTO 15 MG TAB Preferred QL 2 / 1 days rivaroxaban XARELTO 2.5 MG TAB Preferred QL 2 / 1 days rivaroxaban

PAGE 183 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS XARELTO 20 MG TAB Preferred QL 1 / 1 days rivaroxaban XARELTO STARTER PACK 15 & 20 MG TAB THPK Preferred QL 51 / 1 years rivaroxaban ZONTIVITY 2.08 MG TAB Non-Preferred vorapaxar sulfate BLOOD FORMATION MODIFIERS

ARANESP (ALBUMIN FREE) 10 MCG/0.4ML SOLN PRSYR Non-Preferred darbepoetin alfa ARANESP (ALBUMIN FREE) 100 MCG/0.5ML SOLN PRSYR Non-Preferred darbepoetin alfa ARANESP (ALBUMIN FREE) 100 MCG/ML SOLUTION Non-Preferred darbepoetin alfa ARANESP (ALBUMIN FREE) 150 MCG/0.3ML SOLN PRSYR Non-Preferred darbepoetin alfa ARANESP (ALBUMIN FREE) 200 MCG/0.4ML SOLN PRSYR Non-Preferred darbepoetin alfa ARANESP (ALBUMIN FREE) 200 MCG/ML SOLUTION Non-Preferred darbepoetin alfa ARANESP (ALBUMIN FREE) 25 MCG/0.42ML SOLN PRSYR Non-Preferred darbepoetin alfa ARANESP (ALBUMIN FREE) 25 MCG/ML SOLUTION Non-Preferred darbepoetin alfa ARANESP (ALBUMIN FREE) 300 MCG/0.6ML SOLN PRSYR Non-Preferred darbepoetin alfa ARANESP (ALBUMIN FREE) 300 MCG/ML SOLUTION Non-Preferred darbepoetin alfa ARANESP (ALBUMIN FREE) 40 MCG/0.4ML SOLN PRSYR Non-Preferred darbepoetin alfa

PAGE 184 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ARANESP (ALBUMIN FREE) 40 MCG/ML SOLUTION Non-Preferred darbepoetin alfa ARANESP (ALBUMIN FREE) 500 MCG/ML SOLN PRSYR Non-Preferred darbepoetin alfa ARANESP (ALBUMIN FREE) 60 MCG/0.3ML SOLN PRSYR Non-Preferred darbepoetin alfa ARANESP (ALBUMIN FREE) 60 MCG/ML SOLUTION Non-Preferred darbepoetin alfa EPOGEN 10000 UNIT/ML SOLUTION Preferred PA epoetin alfa EPOGEN 2000 UNIT/ML SOLUTION Preferred PA epoetin alfa EPOGEN 20000 UNIT/ML SOLUTION Preferred PA epoetin alfa EPOGEN 3000 UNIT/ML SOLUTION Preferred PA epoetin alfa EPOGEN 4000 UNIT/ML SOLUTION Preferred PA epoetin alfa FULPHILA 6 MG/0.6ML SOLN PRSYR Preferred PA pegfilgrastim-jmdb GRANIX 300 MCG/0.5ML SOLN PRSYR Preferred PA tbo-filgrastim GRANIX 300 MCG/ML SOLUTION Preferred PA tbo-filgrastim GRANIX 480 MCG/0.8ML SOLN PRSYR Preferred PA tbo-filgrastim GRANIX 480 MCG/1.6ML SOLUTION Preferred PA tbo-filgrastim LEUKINE 250 MCG RECON SOLN Non-Preferred sargramostim MIRCERA 150 MCG/0.3ML SOLN PRSYR Non-Preferred methoxy polyethylene glycol-epoetin beta

PAGE 185 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NEULASTA 6 MG/0.6ML SOLN PRSYR Non-Preferred pegfilgrastim NEULASTA ONPRO 6 MG/0.6ML PREF SY KT Non-Preferred pegfilgrastim NEUPOGEN 300 MCG/0.5ML SOLN PRSYR Preferred PA filgrastim NEUPOGEN 300 MCG/ML SOLUTION Preferred PA filgrastim NEUPOGEN 480 MCG/0.8ML SOLN PRSYR Preferred PA filgrastim NEUPOGEN 480 MCG/1.6ML SOLUTION Preferred PA filgrastim NIVESTYM 300 MCG/0.5ML SOLN PRSYR Preferred PA filgrastim-aafi NIVESTYM 300 MCG/ML SOLUTION Preferred PA filgrastim-aafi NIVESTYM 480 MCG/0.8ML SOLN PRSYR Preferred PA filgrastim-aafi NIVESTYM 480 MCG/1.6ML SOLUTION Preferred PA filgrastim-aafi NPLATE 125 MCG RECON SOLN Preferred PA romiplostim NPLATE 250 MCG RECON SOLN Preferred PA romiplostim NPLATE 500 MCG RECON SOLN Preferred PA romiplostim NYVEPRIA 6 MG/0.6ML SOLN PRSYR Non-Preferred pegfilgrastim-apgf PROCRIT 10000 UNIT/ML SOLUTION Non-Preferred epoetin alfa PROCRIT 2000 UNIT/ML SOLUTION Non-Preferred epoetin alfa PROCRIT 20000 UNIT/ML SOLUTION Non-Preferred epoetin alfa

PAGE 186 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PROCRIT 3000 UNIT/ML SOLUTION Non-Preferred epoetin alfa PROCRIT 4000 UNIT/ML SOLUTION Non-Preferred epoetin alfa PROCRIT 40000 UNIT/ML SOLUTION Non-Preferred epoetin alfa PROMACTA 12.5 MG PACKET Preferred PA eltrombopag olamine PROMACTA 12.5 MG TAB Preferred PA eltrombopag olamine PROMACTA 25 MG PACKET Preferred PA eltrombopag olamine PROMACTA 25 MG TAB Preferred PA eltrombopag olamine PROMACTA 50 MG TAB Preferred PA eltrombopag olamine PROMACTA 75 MG TAB Preferred PA eltrombopag olamine RETACRIT 10000 UNIT/ML SOLUTION Preferred PA epoetin alfa-epbx RETACRIT 2000 UNIT/ML SOLUTION Preferred PA epoetin alfa-epbx RETACRIT 20000 UNIT/ML SOLUTION Preferred PA epoetin alfa-epbx RETACRIT 3000 UNIT/ML SOLUTION Preferred PA epoetin alfa-epbx RETACRIT 4000 UNIT/ML SOLUTION Preferred PA epoetin alfa-epbx RETACRIT 40000 UNIT/ML SOLUTION Preferred PA epoetin alfa-epbx TAVALISSE 100 MG TAB Non-Preferred fostamatinib disodium TAVALISSE 150 MG TAB Non-Preferred fostamatinib disodium UDENYCA 6 MG/0.6ML SOLN PRSYR Non-Preferred pegfilgrastim-cbqv ZARXIO 300 MCG/0.5ML SOLN PRSYR Non-Preferred filgrastim-sndz ZARXIO 480 MCG/0.8ML SOLN PRSYR Non-Preferred filgrastim-sndz

PAGE 187 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ZIEXTENZO 6 MG/0.6ML SOLN PRSYR Non-Preferred pegfilgrastim-bmez HEMOSTASIS AGENTS

ADVATE 1000 UNIT RECON SOLN antihemophilic factor (rcmb) Preferred PA plasma/albumin free (rahf-pfm) ADVATE 1500 UNIT RECON SOLN antihemophilic factor (rcmb) Preferred PA plasma/albumin free (rahf-pfm) ADVATE 2000 UNIT RECON SOLN antihemophilic factor (rcmb) Preferred PA plasma/albumin free (rahf-pfm) ADVATE 250 UNIT RECON SOLN antihemophilic factor (rcmb) Preferred PA plasma/albumin free (rahf-pfm) ADVATE 3000 UNIT RECON SOLN antihemophilic factor (rcmb) Preferred PA plasma/albumin free (rahf-pfm) ADVATE 4000 UNIT RECON SOLN antihemophilic factor (rcmb) Preferred PA plasma/albumin free (rahf-pfm) ADVATE 500 UNIT RECON SOLN antihemophilic factor (rcmb) Preferred PA plasma/albumin free (rahf-pfm) ADYNOVATE 1000 UNIT RECON SOLN Preferred PA antihemophilic factor (recombinant) pegylated ADYNOVATE 1500 UNIT RECON SOLN Preferred PA antihemophilic factor (recombinant) pegylated ADYNOVATE 2000 UNIT RECON SOLN Preferred PA antihemophilic factor (recombinant) pegylated ADYNOVATE 250 UNIT RECON SOLN antihemophilic factor (recombinant) Preferred PA pegylated ADYNOVATE 3000 UNIT RECON SOLN Preferred PA antihemophilic factor (recombinant) pegylated

PAGE 188 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ADYNOVATE 500 UNIT RECON SOLN antihemophilic factor (recombinant) Preferred PA pegylated ADYNOVATE 750 UNIT RECON SOLN antihemophilic factor (recombinant) Preferred PA pegylated AFSTYLA 1000 UNIT KIT antihemophilic factor (recombinant) Preferred PA single chain AFSTYLA 1500 UNIT KIT antihemophilic factor (recombinant) Preferred PA single chain AFSTYLA 2000 UNIT KIT antihemophilic factor (recombinant) Preferred PA single chain AFSTYLA 250 UNIT KIT antihemophilic factor (recombinant) Preferred PA single chain AFSTYLA 2500 UNIT KIT antihemophilic factor (recombinant) Preferred PA single chain AFSTYLA 3000 UNIT KIT antihemophilic factor (recombinant) Preferred PA single chain AFSTYLA 500 UNIT KIT antihemophilic factor (recombinant) Preferred PA single chain ALPHANATE 1000 UNIT RECON SOLN antihemophilic factor/von willebrand Preferred PA factor complex (human) ALPHANATE 1500 UNIT RECON SOLN antihemophilic factor/von willebrand Preferred PA factor complex (human) ALPHANATE 2000 UNIT RECON SOLN antihemophilic factor/von willebrand Preferred PA factor complex (human) ALPHANATE 250 UNIT RECON SOLN antihemophilic factor/von willebrand Preferred PA factor complex (human) ALPHANATE 500 UNIT RECON SOLN antihemophilic factor/von willebrand Preferred PA factor complex (human)

PAGE 189 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ALPHANATE/VWF COMPLEX/HUMAN 1000 UNIT RECON SOLN Preferred PA antihemophilic factor/von willebrand factor complex (human) ALPHANATE/VWF COMPLEX/HUMAN 1500 UNIT RECON SOLN Preferred PA antihemophilic factor/von willebrand factor complex (human) ALPHANATE/VWF COMPLEX/HUMAN 2000 UNIT RECON SOLN Preferred PA antihemophilic factor/von willebrand factor complex (human) ALPHANATE/VWF COMPLEX/HUMAN 250 UNIT RECON SOLN Preferred PA antihemophilic factor/von willebrand factor complex (human) ALPHANATE/VWF COMPLEX/HUMAN 500 UNIT RECON SOLN Preferred PA antihemophilic factor/von willebrand factor complex (human) ALPHANINE SD 1000 UNIT RECON SOLN Preferred PA coagulation factor ix ALPHANINE SD 1500 UNIT RECON SOLN Preferred PA coagulation factor ix ALPHANINE SD 500 UNIT RECON SOLN Preferred PA coagulation factor ix ALPROLIX 1000 UNIT RECON SOLN coagulation factor ix (recomb) fc fusion Preferred PA protein (rfixfc) ALPROLIX 2000 UNIT RECON SOLN coagulation factor ix (recomb) fc fusion Preferred PA protein (rfixfc) ALPROLIX 250 UNIT RECON SOLN coagulation factor ix (recomb) fc fusion Preferred PA protein (rfixfc) ALPROLIX 3000 UNIT RECON SOLN coagulation factor ix (recomb) fc fusion Preferred PA protein (rfixfc) ALPROLIX 4000 UNIT RECON SOLN coagulation factor ix (recomb) fc fusion Preferred PA protein (rfixfc)

PAGE 190 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ALPROLIX 500 UNIT RECON SOLN coagulation factor ix (recomb) fc fusion Preferred PA protein (rfixfc) aminocaproic acid oral soln 0.25 gm/ml Preferred aminocaproic acid tab 1000 mg Preferred aminocaproic acid tab 500 mg Preferred BENEFIX 1000 UNIT KIT Preferred PA coagulation factor ix (recombinant) BENEFIX 2000 UNIT KIT Preferred PA coagulation factor ix (recombinant) BENEFIX 250 UNIT KIT Preferred PA coagulation factor ix (recombinant) BENEFIX 3000 UNIT KIT Preferred PA coagulation factor ix (recombinant) BENEFIX 500 UNIT KIT Preferred PA coagulation factor ix (recombinant) ELOCTATE 1000 UNIT RECON SOLN antihemophilic factor (rcmb) fc fusion Preferred PA protein(bdd-rfviiifc) ELOCTATE 1500 UNIT RECON SOLN antihemophilic factor (rcmb) fc fusion Preferred PA protein(bdd-rfviiifc) ELOCTATE 2000 UNIT RECON SOLN antihemophilic factor (rcmb) fc fusion Preferred PA protein(bdd-rfviiifc) ELOCTATE 250 UNIT RECON SOLN antihemophilic factor (rcmb) fc fusion Preferred PA protein(bdd-rfviiifc) ELOCTATE 3000 UNIT RECON SOLN antihemophilic factor (rcmb) fc fusion Preferred PA protein(bdd-rfviiifc) ELOCTATE 4000 UNIT RECON SOLN antihemophilic factor (rcmb) fc fusion Preferred PA protein(bdd-rfviiifc) ELOCTATE 500 UNIT RECON SOLN antihemophilic factor (rcmb) fc fusion Preferred PA protein(bdd-rfviiifc) ELOCTATE 5000 UNIT RECON SOLN antihemophilic factor (rcmb) fc fusion Preferred PA protein(bdd-rfviiifc)

PAGE 191 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ELOCTATE 6000 UNIT RECON SOLN antihemophilic factor (rcmb) fc fusion Preferred PA protein(bdd-rfviiifc) ELOCTATE 750 UNIT RECON SOLN antihemophilic factor (rcmb) fc fusion Preferred PA protein(bdd-rfviiifc) ESPEROCT 1000 UNIT RECON SOLN antihemophilic factor (recombinant) Preferred PA glycopegylated-exei ESPEROCT 1500 UNIT RECON SOLN antihemophilic factor (recombinant) Preferred PA glycopegylated-exei ESPEROCT 2000 UNIT RECON SOLN antihemophilic factor (recombinant) Preferred PA glycopegylated-exei ESPEROCT 3000 UNIT RECON SOLN antihemophilic factor (recombinant) Preferred PA glycopegylated-exei ESPEROCT 500 UNIT RECON SOLN antihemophilic factor (recombinant) Preferred glycopegylated-exei FEIBA 1000 UNIT RECON SOLN Non-Preferred antiinhibitor coagulant complex FEIBA 2500 UNIT RECON SOLN Non-Preferred antiinhibitor coagulant complex FEIBA 500 UNIT RECON SOLN Non-Preferred antiinhibitor coagulant complex HELIXATE FS 1000 UNIT KIT Preferred PA antihemophilic factor (recombinant) HELIXATE FS 2000 UNIT KIT Preferred PA antihemophilic factor (recombinant) HELIXATE FS 250 UNIT KIT Preferred PA antihemophilic factor (recombinant) HELIXATE FS 3000 UNIT KIT Preferred PA antihemophilic factor (recombinant) HELIXATE FS 500 UNIT KIT Preferred PA antihemophilic factor (recombinant) HEMLIBRA 105 MG/0.7ML SOLUTION Preferred PA emicizumab-kxwh HEMLIBRA 150 MG/ML SOLUTION Preferred PA emicizumab-kxwh

PAGE 192 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS HEMLIBRA 30 MG/ML SOLUTION Preferred PA emicizumab-kxwh HEMLIBRA 60 MG/0.4ML SOLUTION Preferred PA emicizumab-kxwh HEMOFIL M 1000 UNIT RECON SOLN Preferred PA antihemophilic factor (human) HEMOFIL M 1700 UNIT RECON SOLN Preferred PA antihemophilic factor (human) HEMOFIL M 250 UNIT RECON SOLN Preferred PA antihemophilic factor (human) HEMOFIL M 500 UNIT RECON SOLN Preferred PA antihemophilic factor (human) HUMATE-P 1000-2400 UNIT RECON SOLN Preferred PA antihemophilic factor/von willebrand factor complex (human) HUMATE-P 250-600 UNIT RECON SOLN Preferred PA antihemophilic factor/von willebrand factor complex (human) HUMATE-P 500-1200 UNIT RECON SOLN Preferred PA antihemophilic factor/von willebrand factor complex (human) IDELVION 1000 UNIT RECON SOLN coagulation factor ix recomb albumin Non-Preferred fusion protein (rix-fp) IDELVION 2000 UNIT RECON SOLN coagulation factor ix recomb albumin Non-Preferred fusion protein (rix-fp) IDELVION 250 UNIT RECON SOLN coagulation factor ix recomb albumin Non-Preferred fusion protein (rix-fp) IDELVION 3500 UNIT RECON SOLN coagulation factor ix recomb albumin Non-Preferred fusion protein (rix-fp) IDELVION 500 UNIT RECON SOLN coagulation factor ix recomb albumin Non-Preferred fusion protein (rix-fp) IXINITY 1000 UNIT RECON SOLN Preferred PA coagulation factor ix (recombinant)

PAGE 193 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS IXINITY 1500 UNIT RECON SOLN Preferred PA coagulation factor ix (recombinant) IXINITY 2000 UNIT RECON SOLN Preferred PA coagulation factor ix (recombinant) IXINITY 250 UNIT RECON SOLN Preferred PA coagulation factor ix (recombinant) IXINITY 3000 UNIT RECON SOLN Preferred PA coagulation factor ix (recombinant) IXINITY 500 UNIT RECON SOLN Preferred PA coagulation factor ix (recombinant) JIVI 1000 UNIT RECON SOLN antihemophil fact(rcmb) pegylated-aucl Non-Preferred (bdd-rfviii peg-aucl) JIVI 2000 UNIT RECON SOLN antihemophil fact(rcmb) pegylated-aucl Non-Preferred (bdd-rfviii peg-aucl) JIVI 3000 UNIT RECON SOLN antihemophil fact(rcmb) pegylated-aucl Non-Preferred (bdd-rfviii peg-aucl) JIVI 500 UNIT RECON SOLN antihemophil fact(rcmb) pegylated-aucl Non-Preferred (bdd-rfviii peg-aucl) KOATE 1000 UNIT RECON SOLN Preferred PA antihemophilic factor (human) KOATE 250 UNIT RECON SOLN Preferred PA antihemophilic factor (human) KOATE 500 UNIT RECON SOLN Preferred PA antihemophilic factor (human) KOATE-DVI 1000 UNIT RECON SOLN Preferred PA antihemophilic factor (human) KOGENATE FS 1000 UNIT KIT Preferred PA antihemophilic factor (recombinant) KOGENATE FS 2000 UNIT KIT Preferred PA antihemophilic factor (recombinant) KOGENATE FS 250 UNIT KIT Preferred PA antihemophilic factor (recombinant) KOGENATE FS 3000 UNIT KIT Preferred PA antihemophilic factor (recombinant) KOGENATE FS 500 UNIT KIT Preferred PA antihemophilic factor (recombinant)

PAGE 194 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS KOGENATE FS BIO-SET 1000 UNIT KIT Preferred PA antihemophilic factor (recombinant) KOGENATE FS BIO-SET 2000 UNIT KIT Preferred PA antihemophilic factor (recombinant) KOGENATE FS BIO-SET 250 UNIT KIT Preferred PA antihemophilic factor (recombinant) KOGENATE FS BIO-SET 3000 UNIT KIT Preferred PA antihemophilic factor (recombinant) KOGENATE FS BIO-SET 500 UNIT KIT Preferred PA antihemophilic factor (recombinant) KOVALTRY 1000 UNIT RECON SOLN antihemophilic factor (rcmb) Non-Preferred plasma/albumin free (rahf-pfm) KOVALTRY 2000 UNIT RECON SOLN antihemophilic factor (rcmb) Non-Preferred plasma/albumin free (rahf-pfm) KOVALTRY 250 UNIT RECON SOLN antihemophilic factor (rcmb) Non-Preferred plasma/albumin free (rahf-pfm) KOVALTRY 3000 UNIT RECON SOLN antihemophilic factor (rcmb) Non-Preferred plasma/albumin free (rahf-pfm) KOVALTRY 500 UNIT RECON SOLN antihemophilic factor (rcmb) Non-Preferred plasma/albumin free (rahf-pfm) MONOCLATE-P 1000 UNIT KIT Preferred PA antihemophilic factor (human) MONOCLATE-P 1500 UNIT KIT Preferred PA antihemophilic factor (human) MONONINE 1000 UNIT RECON SOLN Preferred PA coagulation factor ix NOVOEIGHT 1000 UNIT RECON SOLN antihemophilic factor (rcmb) bd Preferred PA truncated (bd trunc-rfviii) NOVOEIGHT 1500 UNIT RECON SOLN antihemophilic factor (rcmb) bd Preferred PA truncated (bd trunc-rfviii) NOVOEIGHT 2000 UNIT RECON SOLN antihemophilic factor (rcmb) bd Preferred PA truncated (bd trunc-rfviii)

PAGE 195 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NOVOEIGHT 250 UNIT RECON SOLN antihemophilic factor (rcmb) bd Preferred PA truncated (bd trunc-rfviii) NOVOEIGHT 3000 UNIT RECON SOLN antihemophilic factor (rcmb) bd Preferred PA truncated (bd trunc-rfviii) NOVOEIGHT 500 UNIT RECON SOLN antihemophilic factor (rcmb) bd Preferred PA truncated (bd trunc-rfviii) NOVOSEVEN RT 1 MG RECON SOLN Non-Preferred coagulation factor viia (recombinant) NOVOSEVEN RT 2 MG RECON SOLN Non-Preferred coagulation factor viia (recombinant) NOVOSEVEN RT 5 MG RECON SOLN Non-Preferred coagulation factor viia (recombinant) NOVOSEVEN RT 8 MG RECON SOLN Non-Preferred coagulation factor viia (recombinant) NUWIQ 1000 UNIT KIT antihemophilic factor (rcmb) simoctocog Preferred PA alfa(bdd-rfviii,sim) NUWIQ 1000 UNIT RECON SOLN antihemophilic factor (rcmb) simoctocog Preferred PA alfa(bdd-rfviii,sim) NUWIQ 2000 UNIT KIT antihemophilic factor (rcmb) simoctocog Preferred PA alfa(bdd-rfviii,sim) NUWIQ 2000 UNIT RECON SOLN antihemophilic factor (rcmb) simoctocog Preferred PA alfa(bdd-rfviii,sim) NUWIQ 250 UNIT KIT antihemophilic factor (rcmb) simoctocog Preferred PA alfa(bdd-rfviii,sim) NUWIQ 250 UNIT RECON SOLN antihemophilic factor (rcmb) simoctocog Preferred PA alfa(bdd-rfviii,sim) NUWIQ 2500 UNIT KIT antihemophilic factor (rcmb) simoctocog Preferred PA alfa(bdd-rfviii,sim) NUWIQ 2500 UNIT RECON SOLN antihemophilic factor (rcmb) simoctocog Preferred PA alfa(bdd-rfviii,sim)

PAGE 196 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NUWIQ 3000 UNIT KIT antihemophilic factor (rcmb) simoctocog Preferred PA alfa(bdd-rfviii,sim) NUWIQ 3000 UNIT RECON SOLN antihemophilic factor (rcmb) simoctocog Preferred PA alfa(bdd-rfviii,sim) NUWIQ 4000 UNIT KIT antihemophilic factor (rcmb) simoctocog Preferred PA alfa(bdd-rfviii,sim) NUWIQ 4000 UNIT RECON SOLN antihemophilic factor (rcmb) simoctocog Preferred PA alfa(bdd-rfviii,sim) NUWIQ 500 UNIT KIT antihemophilic factor (rcmb) simoctocog Preferred PA alfa(bdd-rfviii,sim) NUWIQ 500 UNIT RECON SOLN antihemophilic factor (rcmb) simoctocog Preferred PA alfa(bdd-rfviii,sim) OBIZUR 500 UNIT RECON SOLN antihemophilic factor (recombinant Non-Preferred porcine) (rpfviii)

phytonadione tab 5 mg Preferred QL 5 / 1 days

PROFILNINE 1000 UNIT RECON SOLN Preferred PA factor ix complex PROFILNINE 1500 UNIT RECON SOLN Preferred PA factor ix complex PROFILNINE 500 UNIT RECON SOLN Preferred PA factor ix complex PROFILNINE SD 500 UNIT RECON SOLN Preferred PA factor ix complex REBINYN 1000 UNIT RECON SOLN coagulation factor ix (recombinant) Non-Preferred glycopegylated REBINYN 2000 UNIT RECON SOLN coagulation factor ix (recombinant) Non-Preferred glycopegylated REBINYN 500 UNIT RECON SOLN coagulation factor ix (recombinant) Non-Preferred glycopegylated RECOMBINATE 1241-1800 UNIT RECON SOLN Preferred PA antihemophilic factor (recombinant)

PAGE 197 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS RECOMBINATE 1801-2400 UNIT RECON SOLN Preferred PA antihemophilic factor (recombinant) RECOMBINATE 220-400 UNIT RECON SOLN Preferred PA antihemophilic factor (recombinant) RECOMBINATE 401-800 UNIT RECON SOLN Preferred PA antihemophilic factor (recombinant) RECOMBINATE 801-1240 UNIT RECON SOLN Preferred PA antihemophilic factor (recombinant) RIXUBIS 1000 UNIT RECON SOLN Preferred PA coagulation factor ix (recombinant) RIXUBIS 2000 UNIT RECON SOLN Preferred PA coagulation factor ix (recombinant) RIXUBIS 250 UNIT RECON SOLN Preferred PA coagulation factor ix (recombinant) RIXUBIS 3000 UNIT RECON SOLN Preferred PA coagulation factor ix (recombinant) RIXUBIS 500 UNIT RECON SOLN Preferred PA coagulation factor ix (recombinant) SEVENFACT 1 MG RECON SOLN coagulation factor viia (recombinant)- Non-Preferred jncw SEVENFACT 5 MG RECON SOLN coagulation factor viia (recombinant)- Non-Preferred jncw tranexamic acid tab 650 mg Preferred VONVENDI 1300 UNIT RECON SOLN Non-Preferred von willebrand factor (recombinant) VONVENDI 650 UNIT RECON SOLN Non-Preferred von willebrand factor (recombinant) WILATE 1000-1000 UNIT KIT antihemophilic factor/von willebrand Preferred PA factor complex (human) WILATE 500-500 UNIT KIT antihemophilic factor/von willebrand Preferred PA factor complex (human) XYNTHA 1000 UNIT KIT antihemophilic factor (rcmb) moroctocog Preferred PA alfa(bdd-rfviii,mor)

PAGE 198 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS XYNTHA 2000 UNIT KIT antihemophilic factor (rcmb) moroctocog Preferred PA alfa(bdd-rfviii,mor) XYNTHA 250 UNIT KIT antihemophilic factor (rcmb) moroctocog Preferred PA alfa(bdd-rfviii,mor) XYNTHA 500 UNIT KIT antihemophilic factor (rcmb) moroctocog Preferred PA alfa(bdd-rfviii,mor) XYNTHA SOLOFUSE 1000 UNIT KIT antihemophilic factor (rcmb) moroctocog Preferred PA alfa(bdd-rfviii,mor) XYNTHA SOLOFUSE 2000 UNIT KIT antihemophilic factor (rcmb) moroctocog Preferred PA alfa(bdd-rfviii,mor) XYNTHA SOLOFUSE 250 UNIT KIT antihemophilic factor (rcmb) moroctocog Preferred PA alfa(bdd-rfviii,mor) XYNTHA SOLOFUSE 3000 UNIT KIT antihemophilic factor (rcmb) moroctocog Preferred PA alfa(bdd-rfviii,mor) XYNTHA SOLOFUSE 500 UNIT KIT antihemophilic factor (rcmb) moroctocog Preferred PA alfa(bdd-rfviii,mor) PLATELET MODIFYING AGENTS

ADAKVEO 100 MG/10ML SOLUTION Non-Preferred crizanlizumab-tmca AGGRENOX 25-200 MG CAP ER 12H Preferred QL 60 / 30 days aspirin-dipyridamole aspirin-dipyridamole cap er 12hr 25-200 Preferred QL 60 / 30 days mg ASPIRIN-OMEPRAZOLE 81-40 MG TAB DR Non-Preferred aspirin-omeprazole BRILINTA 60 MG TAB Preferred QL 60 / 30 days ticagrelor BRILINTA 90 MG TAB Preferred QL 60 / 30 days ticagrelor

cilostazol tab 100 mg Preferred QL 2 / 1 days

cilostazol tab 50 mg Preferred QL 2 / 1 days

PAGE 199 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS clopidogrel bisulfate tab 300 mg (base Preferred equiv) clopidogrel bisulfate tab 75 mg (base Preferred QL 4 / 1 days equiv)

dipyridamole tab 25 mg Preferred QL 4 / 1 days

dipyridamole tab 50 mg Preferred QL 8 / 1 days

dipyridamole tab 75 mg Preferred QL 4 / 1 days

DOPTELET 20 MG TAB Non-Preferred avatrombopag maleate EFFIENT 10 MG TAB Non-Preferred QL 30 / 30 days prasugrel hcl EFFIENT 5 MG TAB Non-Preferred QL 30 / 30 days prasugrel hcl MULPLETA 3 MG TAB Non-Preferred lusutrombopag OXBRYTA 500 MG TAB Non-Preferred QL 90 / 30 days voxelotor PLAVIX 300 MG TAB Non-Preferred clopidogrel bisulfate PLAVIX 75 MG TAB Non-Preferred clopidogrel bisulfate

prasugrel hcl tab 10 mg (base equiv) Preferred QL 30 / 30 days

prasugrel hcl tab 5 mg (base equiv) Preferred QL 30 / 30 days

YOSPRALA 325-40 MG TAB DR Non-Preferred aspirin-omeprazole YOSPRALA 81-40 MG TAB DR Non-Preferred aspirin-omeprazole CARDIOVASCULAR AGENTS

ALPHA-ADRENERGIC AGONISTS

CATAPRES 0.1 MG TAB Non-Preferred clonidine hcl CATAPRES 0.2 MG TAB Non-Preferred clonidine hcl CATAPRES 0.3 MG TAB Non-Preferred clonidine hcl

PAGE 200 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CATAPRES-TTS-1 0.1 MG/24HR PATCH WK Non-Preferred clonidine CATAPRES-TTS-2 0.2 MG/24HR PATCH WK Non-Preferred clonidine CATAPRES-TTS-3 0.3 MG/24HR PATCH WK Non-Preferred clonidine

clonidine td patch weekly 0.1 mg/24hr Preferred QL 4 / 22 days

clonidine td patch weekly 0.2 mg/24hr Preferred QL 4 / 22 days

clonidine td patch weekly 0.3 mg/24hr Preferred QL 4 / 22 days

clonidine hcl tab 0.1 mg Preferred QL 8 / 1 days

clonidine hcl tab 0.2 mg Preferred QL 8 / 1 days

clonidine hcl tab 0.3 mg Preferred QL 8 / 1 days

guanfacine hcl tab 1 mg Preferred QL 90 / 30 days

guanfacine hcl tab 2 mg Preferred QL 60 / 30 days

methyldopa tab 250 mg Preferred QL 6 / 1 days

methyldopa tab 500 mg Preferred QL 6 / 1 days

midodrine hcl tab 10 mg Preferred QL 90 / 30 days

midodrine hcl tab 2.5 mg Preferred QL 90 / 30 days

midodrine hcl tab 5 mg Preferred QL 90 / 30 days

ALPHA-ADRENERGIC BLOCKING AGENTS

CARDURA 1 MG TAB Non-Preferred doxazosin mesylate CARDURA 2 MG TAB Non-Preferred doxazosin mesylate CARDURA 4 MG TAB Non-Preferred doxazosin mesylate CARDURA 8 MG TAB Non-Preferred doxazosin mesylate

doxazosin mesylate tab 1 mg Preferred QL 1 / 1 days

PAGE 201 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

doxazosin mesylate tab 2 mg Preferred QL 1 / 1 days

doxazosin mesylate tab 4 mg Preferred QL 1 / 1 days

doxazosin mesylate tab 8 mg Preferred QL 2 / 1 days

MINIPRESS 1 MG CAP Non-Preferred QL 120 / 30 days prazosin hcl MINIPRESS 2 MG CAP Non-Preferred QL 120 / 30 days prazosin hcl MINIPRESS 5 MG CAP Non-Preferred QL 120 / 30 days prazosin hcl

prazosin hcl cap 1 mg Preferred QL 120 / 30 days

prazosin hcl cap 2 mg Preferred QL 120 / 30 days

prazosin hcl cap 5 mg Preferred QL 120 / 30 days

terazosin hcl cap 1 mg (base equivalent) Preferred QL 2 / 1 days

terazosin hcl cap 10 mg (base Preferred QL 2 / 1 days equivalent)

terazosin hcl cap 2 mg (base equivalent) Preferred QL 2 / 1 days

terazosin hcl cap 5 mg (base equivalent) Preferred QL 2 / 1 days

ANGIOTENSIN II RECEPTOR ANTAGONISTS

ATACAND 16 MG TAB Non-Preferred candesartan cilexetil ATACAND 32 MG TAB Non-Preferred candesartan cilexetil ATACAND 4 MG TAB Non-Preferred candesartan cilexetil ATACAND 8 MG TAB Non-Preferred candesartan cilexetil AVAPRO 150 MG TAB Non-Preferred QL 60 / 30 days irbesartan AVAPRO 300 MG TAB Non-Preferred QL 30 / 30 days irbesartan AVAPRO 75 MG TAB Non-Preferred QL 30 / 30 days irbesartan BENICAR 20 MG TAB Non-Preferred QL 30 / 30 days olmesartan medoxomil

PAGE 202 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS BENICAR 40 MG TAB Non-Preferred QL 30 / 30 days olmesartan medoxomil BENICAR 5 MG TAB Non-Preferred QL 30 / 30 days olmesartan medoxomil candesartan cilexetil tab 16 mg Non-Preferred candesartan cilexetil tab 32 mg Non-Preferred candesartan cilexetil tab 4 mg Non-Preferred candesartan cilexetil tab 8 mg Non-Preferred COZAAR 100 MG TAB Non-Preferred QL 30 / 30 days losartan potassium COZAAR 25 MG TAB Non-Preferred QL 90 / 30 days losartan potassium COZAAR 50 MG TAB Non-Preferred QL 90 / 30 days losartan potassium DIOVAN 160 MG TAB Non-Preferred QL 60 / 30 days valsartan DIOVAN 320 MG TAB Non-Preferred QL 30 / 30 days valsartan DIOVAN 40 MG TAB Non-Preferred QL 60 / 30 days valsartan DIOVAN 80 MG TAB Non-Preferred QL 60 / 30 days valsartan EDARBI 40 MG TAB Non-Preferred azilsartan medoxomil EDARBI 80 MG TAB Non-Preferred azilsartan medoxomil EPROSARTAN MESYLATE 600 MG TAB Non-Preferred eprosartan mesylate

irbesartan tab 150 mg Preferred QL 60 / 30 days

irbesartan tab 300 mg Preferred QL 30 / 30 days

irbesartan tab 75 mg Preferred QL 30 / 30 days

losartan potassium tab 100 mg Preferred QL 30 / 30 days

losartan potassium tab 25 mg Preferred QL 90 / 30 days

losartan potassium tab 50 mg Preferred QL 90 / 30 days

PAGE 203 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MICARDIS 20 MG TAB Non-Preferred telmisartan MICARDIS 40 MG TAB Non-Preferred QL 2 / 1 days telmisartan MICARDIS 80 MG TAB Non-Preferred QL 1 / 1 days telmisartan

olmesartan medoxomil tab 20 mg Preferred QL 30 / 30 days

olmesartan medoxomil tab 40 mg Preferred QL 30 / 30 days

olmesartan medoxomil tab 5 mg Preferred QL 30 / 30 days

telmisartan tab 20 mg Non-Preferred QL 4 / 1 days

telmisartan tab 40 mg Non-Preferred QL 2 / 1 days

telmisartan tab 80 mg Non-Preferred QL 1 / 1 days

valsartan tab 160 mg Preferred QL 60 / 30 days

valsartan tab 320 mg Preferred QL 30 / 30 days

valsartan tab 40 mg Preferred QL 60 / 30 days

valsartan tab 80 mg Preferred QL 60 / 30 days

ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS

ACCUPRIL 10 MG TAB Non-Preferred QL 60 / 30 days quinapril hcl ACCUPRIL 20 MG TAB Non-Preferred QL 60 / 30 days quinapril hcl ACCUPRIL 40 MG TAB Non-Preferred QL 60 / 30 days quinapril hcl ACCUPRIL 5 MG TAB Non-Preferred QL 60 / 30 days quinapril hcl ALTACE 1.25 MG CAP Non-Preferred QL 60 / 30 days ramipril ALTACE 10 MG CAP Non-Preferred QL 60 / 30 days ramipril ALTACE 2.5 MG CAP Non-Preferred QL 60 / 30 days ramipril ALTACE 5 MG CAP Non-Preferred QL 60 / 30 days ramipril

PAGE 204 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

benazepril hcl tab 10 mg Preferred QL 2 / 1 days

benazepril hcl tab 20 mg Preferred QL 2 / 1 days

benazepril hcl tab 40 mg Preferred QL 2 / 1 days

benazepril hcl tab 5 mg Preferred QL 2 / 1 days

captopril tab 100 mg Preferred QL 3 / 1 days

captopril tab 12.5 mg Preferred QL 3 / 1 days

captopril tab 25 mg Preferred QL 3 / 1 days

captopril tab 50 mg Preferred QL 3 / 1 days

enalapril maleate tab 10 mg Preferred QL 2 / 1 days

enalapril maleate tab 2.5 mg Preferred QL 2 / 1 days

enalapril maleate tab 20 mg Preferred QL 2 / 1 days

enalapril maleate tab 5 mg Preferred QL 2 / 1 days

EPANED 1 MG/ML SOLUTION No PA required for Non-Preferred C enalapril maleate children under 9 years old

fosinopril sodium tab 10 mg Preferred QL 2 / 1 days

fosinopril sodium tab 20 mg Preferred QL 2 / 1 days

fosinopril sodium tab 40 mg Preferred QL 2 / 1 days

lisinopril tab 10 mg Preferred QL 60 / 30 days

lisinopril tab 2.5 mg Preferred QL 60 / 30 days

lisinopril tab 20 mg Preferred QL 60 / 30 days

lisinopril tab 30 mg Preferred QL 60 / 30 days

lisinopril tab 40 mg Preferred QL 60 / 30 days

lisinopril tab 5 mg Preferred QL 60 / 30 days

LOTENSIN 10 MG TAB Non-Preferred QL 2 / 1 days benazepril hcl LOTENSIN 20 MG TAB Non-Preferred QL 2 / 1 days benazepril hcl LOTENSIN 40 MG TAB Non-Preferred QL 2 / 1 days benazepril hcl

PAGE 205 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS moexipril hcl tab 15 mg Non-Preferred moexipril hcl tab 7.5 mg Non-Preferred perindopril erbumine tab 2 mg Non-Preferred perindopril erbumine tab 4 mg Non-Preferred perindopril erbumine tab 8 mg Non-Preferred PRINIVIL 10 MG TAB Non-Preferred QL 60 / 30 days lisinopril PRINIVIL 20 MG TAB Non-Preferred QL 60 / 30 days lisinopril PRINIVIL 5 MG TAB Non-Preferred QL 60 / 30 days lisinopril

QBRELIS 1 MG/ML SOLUTION No PA required for Non-Preferred C lisinopril children under 9 years old

quinapril hcl tab 10 mg Preferred QL 60 / 30 days

quinapril hcl tab 20 mg Preferred QL 60 / 30 days

quinapril hcl tab 40 mg Preferred QL 60 / 30 days

quinapril hcl tab 5 mg Preferred QL 60 / 30 days

ramipril cap 1.25 mg Preferred QL 60 / 30 days

ramipril cap 10 mg Preferred QL 60 / 30 days

ramipril cap 2.5 mg Preferred QL 60 / 30 days

ramipril cap 5 mg Preferred QL 60 / 30 days

trandolapril tab 1 mg Preferred trandolapril tab 2 mg Preferred trandolapril tab 4 mg Preferred VASOTEC 10 MG TAB Non-Preferred QL 2 / 1 days enalapril maleate VASOTEC 2.5 MG TAB Non-Preferred QL 2 / 1 days enalapril maleate VASOTEC 20 MG TAB Non-Preferred QL 2 / 1 days enalapril maleate VASOTEC 5 MG TAB Non-Preferred QL 2 / 1 days enalapril maleate

PAGE 206 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ZESTRIL 10 MG TAB Non-Preferred QL 60 / 30 days lisinopril ZESTRIL 2.5 MG TAB Non-Preferred QL 60 / 30 days lisinopril ZESTRIL 20 MG TAB Non-Preferred QL 60 / 30 days lisinopril ZESTRIL 30 MG TAB Non-Preferred QL 60 / 30 days lisinopril ZESTRIL 40 MG TAB Non-Preferred QL 60 / 30 days lisinopril ZESTRIL 5 MG TAB Non-Preferred QL 60 / 30 days lisinopril ANTIARRHYTHMICS

amiodarone hcl tab 200 mg Preferred QL 4 / 1 days

amiodarone hcl tab 200 mg Preferred QL 4 / 1 days

amiodarone hcl tab 400 mg Preferred QL 4 / 1 days

amiodarone hcl tab 400 mg Preferred QL 4 / 1 days

BETAPACE 120 MG TAB Non-Preferred QL 60 / 30 days sotalol hcl BETAPACE 160 MG TAB Non-Preferred QL 60 / 30 days sotalol hcl BETAPACE 80 MG TAB Non-Preferred QL 60 / 30 days sotalol hcl BETAPACE AF 120 MG TAB Non-Preferred QL 60 / 30 days sotalol hcl (afib/afl) BETAPACE AF 160 MG TAB Non-Preferred QL 60 / 30 days sotalol hcl (afib/afl) BETAPACE AF 80 MG TAB Non-Preferred QL 60 / 30 days sotalol hcl (afib/afl)

disopyramide phosphate cap 100 mg Preferred QL 480 / 30 days

disopyramide phosphate cap 150 mg Preferred QL 10 / 1 days

flecainide acetate tab 100 mg Preferred QL 3 / 1 days

flecainide acetate tab 150 mg Preferred QL 2 / 1 days

flecainide acetate tab 50 mg Preferred QL 3 / 1 days

PAGE 207 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

mexiletine hcl cap 150 mg Preferred QL 8 / 1 days

mexiletine hcl cap 200 mg Preferred QL 6 / 1 days

mexiletine hcl cap 250 mg Preferred QL 4 / 1 days

propafenone hcl tab 150 mg Preferred QL 3 / 1 days

propafenone hcl tab 225 mg Preferred QL 3 / 1 days

propafenone hcl tab 300 mg Preferred QL 3 / 1 days

quinidine sulfate tab 200 mg Preferred QL 6 / 1 days

quinidine sulfate tab 300 mg Preferred QL 6 / 1 days

sotalol hcl tab 120 mg Preferred QL 60 / 30 days

sotalol hcl tab 120 mg Preferred QL 60 / 30 days

sotalol hcl tab 160 mg Preferred QL 60 / 30 days

sotalol hcl tab 160 mg Preferred QL 60 / 30 days

sotalol hcl tab 240 mg Preferred QL 60 / 30 days

sotalol hcl tab 240 mg Preferred QL 60 / 30 days

sotalol hcl tab 80 mg Preferred QL 60 / 30 days

sotalol hcl tab 80 mg Preferred QL 60 / 30 days

sotalol hcl (afib/afl) tab 120 mg Preferred QL 60 / 30 days

sotalol hcl (afib/afl) tab 160 mg Preferred QL 60 / 30 days

sotalol hcl (afib/afl) tab 80 mg Preferred QL 60 / 30 days

SOTYLIZE 5 MG/ML SOLUTION Non-Preferred sotalol hcl BETA-ADRENERGIC BLOCKING AGENTS

acebutolol hcl cap 200 mg Preferred QL 3 / 1 days

acebutolol hcl cap 400 mg Preferred QL 3 / 1 days

atenolol tab 100 mg Preferred QL 2 / 1 days

atenolol tab 25 mg Preferred QL 2 / 1 days

atenolol tab 50 mg Preferred QL 2 / 1 days

PAGE 208 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

betaxolol hcl tab 10 mg Preferred QL 2 / 1 days

betaxolol hcl tab 20 mg Preferred QL 2 / 1 days

bisoprolol fumarate tab 10 mg Preferred QL 2 / 1 days

bisoprolol fumarate tab 5 mg Preferred QL 4 / 1 days

BYSTOLIC 10 MG TAB Non-Preferred nebivolol hcl BYSTOLIC 2.5 MG TAB Non-Preferred nebivolol hcl BYSTOLIC 20 MG TAB Non-Preferred nebivolol hcl BYSTOLIC 5 MG TAB Non-Preferred nebivolol hcl

carvedilol tab 12.5 mg Preferred QL 60 / 30 days

carvedilol tab 25 mg Preferred QL 120 / 30 days

carvedilol tab 3.125 mg Preferred QL 60 / 30 days

carvedilol tab 6.25 mg Preferred QL 60 / 30 days

carvedilol phosphate cap er 24hr 10 mg Non-Preferred carvedilol phosphate cap er 24hr 20 mg Non-Preferred carvedilol phosphate cap er 24hr 40 mg Non-Preferred carvedilol phosphate cap er 24hr 80 mg Non-Preferred COREG 12.5 MG TAB Non-Preferred QL 60 / 30 days carvedilol COREG 25 MG TAB Non-Preferred QL 120 / 30 days carvedilol COREG 3.125 MG TAB Non-Preferred QL 60 / 30 days carvedilol COREG 6.25 MG TAB Non-Preferred QL 60 / 30 days carvedilol COREG CR 10 MG CAP ER 24H Non-Preferred carvedilol phosphate COREG CR 20 MG CAP ER 24H Non-Preferred carvedilol phosphate COREG CR 40 MG CAP ER 24H Non-Preferred carvedilol phosphate

PAGE 209 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS COREG CR 80 MG CAP ER 24H Non-Preferred carvedilol phosphate CORGARD 20 MG TAB Non-Preferred nadolol CORGARD 40 MG TAB Non-Preferred nadolol CORGARD 80 MG TAB Non-Preferred nadolol INDERAL LA 120 MG CAP ER 24H Non-Preferred QL 1 / 1 days propranolol hcl INDERAL LA 160 MG CAP ER 24H Non-Preferred QL 1 / 1 days propranolol hcl INDERAL LA 60 MG CAP ER 24H Non-Preferred QL 1 / 1 days propranolol hcl INDERAL LA 80 MG CAP ER 24H Non-Preferred QL 1 / 1 days propranolol hcl INDERAL XL 120 MG CAP ER 24H Non-Preferred propranolol hcl sustained-release beads INDERAL XL 80 MG CAP ER 24H Non-Preferred propranolol hcl sustained-release beads INNOPRAN XL 120 MG CAP ER 24H Non-Preferred propranolol hcl sustained-release beads INNOPRAN XL 80 MG CAP ER 24H Non-Preferred propranolol hcl sustained-release beads KAPSPARGO SPRINKLE 100 MG CP24 SPRNK Non-Preferred metoprolol succinate KAPSPARGO SPRINKLE 200 MG CP24 SPRNK Non-Preferred metoprolol succinate KAPSPARGO SPRINKLE 25 MG CP24 SPRNK Non-Preferred metoprolol succinate KAPSPARGO SPRINKLE 50 MG CP24 SPRNK Non-Preferred metoprolol succinate

labetalol hcl tab 100 mg Preferred QL 14 / 1 days

labetalol hcl tab 200 mg Preferred QL 12 / 1 days

labetalol hcl tab 300 mg Preferred QL 8 / 1 days

PAGE 210 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS LOPRESSOR 100 MG TAB Non-Preferred QL 120 / 30 days metoprolol tartrate LOPRESSOR 50 MG TAB Non-Preferred QL 120 / 30 days metoprolol tartrate metoprolol succinate tab er 24hr 100 mg Preferred QL 60 / 30 days (tartrate equiv) metoprolol succinate tab er 24hr 200 mg Preferred QL 60 / 30 days (tartrate equiv) metoprolol succinate tab er 24hr 25 mg Preferred QL 60 / 30 days (tartrate equiv) metoprolol succinate tab er 24hr 50 mg Preferred QL 60 / 30 days (tartrate equiv)

metoprolol tartrate tab 100 mg Preferred QL 120 / 30 days

metoprolol tartrate tab 25 mg Preferred QL 120 / 30 days

metoprolol tartrate tab 37.5 mg Preferred

metoprolol tartrate tab 50 mg Preferred QL 120 / 30 days

metoprolol tartrate tab 75 mg Preferred

nadolol tab 20 mg Preferred QL 4 / 1 days

nadolol tab 40 mg Preferred QL 4 / 1 days

nadolol tab 80 mg Preferred QL 4 / 1 days

pindolol tab 10 mg Preferred QL 6 / 1 days

pindolol tab 5 mg Preferred QL 6 / 1 days

propranolol hcl cap er 24hr 120 mg Preferred QL 1 / 1 days

propranolol hcl cap er 24hr 160 mg Preferred QL 1 / 1 days

propranolol hcl cap er 24hr 60 mg Preferred QL 1 / 1 days

propranolol hcl cap er 24hr 80 mg Preferred QL 1 / 1 days

propranolol hcl oral soln 20 mg/5ml Preferred QL 80 / 1 days

propranolol hcl oral soln 40 mg/5ml Preferred QL 80 / 1 days

propranolol hcl tab 10 mg Preferred QL 8 / 1 days

propranolol hcl tab 20 mg Preferred QL 8 / 1 days

PAGE 211 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

propranolol hcl tab 40 mg Preferred QL 8 / 1 days

propranolol hcl tab 60 mg Preferred QL 8 / 1 days

propranolol hcl tab 80 mg Preferred QL 8 / 1 days

TENORMIN 100 MG TAB Non-Preferred QL 2 / 1 days atenolol TENORMIN 25 MG TAB Non-Preferred QL 2 / 1 days atenolol TENORMIN 50 MG TAB Non-Preferred QL 2 / 1 days atenolol

timolol maleate tab 10 mg Non-Preferred QL 3 / 1 days

timolol maleate tab 20 mg Non-Preferred QL 3 / 1 days

timolol maleate tab 5 mg Non-Preferred QL 3 / 1 days

TOPROL XL 100 MG TAB ER 24H Non-Preferred QL 60 / 30 days metoprolol succinate TOPROL XL 200 MG TAB ER 24H Non-Preferred QL 60 / 30 days metoprolol succinate TOPROL XL 25 MG TAB ER 24H Non-Preferred QL 60 / 30 days metoprolol succinate TOPROL XL 50 MG TAB ER 24H Non-Preferred QL 60 / 30 days metoprolol succinate CALCIUM CHANNEL BLOCKING AGENTS

ADALAT CC 30 MG TAB ER 24H Non-Preferred QL 2 / 1 days nifedipine ADALAT CC 60 MG TAB ER 24H Non-Preferred QL 2 / 1 days nifedipine ADALAT CC 90 MG TAB ER 24H Non-Preferred QL 2 / 1 days nifedipine amlodipine besylate tab 10 mg (base Preferred QL 2 / 1 days equivalent) amlodipine besylate tab 2.5 mg (base Preferred QL 2 / 1 days equivalent) amlodipine besylate tab 5 mg (base Preferred QL 2 / 1 days equivalent) CALAN 120 MG TAB Non-Preferred verapamil hcl

PAGE 212 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CALAN SR 120 MG TAB ER Non-Preferred QL 1 / 1 days verapamil hcl CALAN SR 180 MG TAB ER Non-Preferred QL 2 / 1 days verapamil hcl CALAN SR 240 MG TAB ER Non-Preferred QL 2 / 1 days verapamil hcl CARDIZEM 120 MG TAB Non-Preferred QL 2 / 1 days diltiazem hcl CARDIZEM 30 MG TAB Non-Preferred diltiazem hcl CARDIZEM 60 MG TAB Non-Preferred diltiazem hcl CARDIZEM CD 120 MG CAP ER 24H Non-Preferred QL 1 / 1 days diltiazem hcl coated beads CARDIZEM CD 180 MG CAP ER 24H Non-Preferred QL 1 / 1 days diltiazem hcl coated beads CARDIZEM CD 240 MG CAP ER 24H Non-Preferred QL 2 / 1 days diltiazem hcl coated beads CARDIZEM CD 300 MG CAP ER 24H Non-Preferred QL 1 / 1 days diltiazem hcl coated beads CARDIZEM CD 360 MG CAP ER 24H Non-Preferred QL 1 / 1 days diltiazem hcl coated beads CARDIZEM LA 120 MG TAB ER 24H Non-Preferred QL 1 / 1 days diltiazem hcl coated beads CARDIZEM LA 180 MG TAB ER 24H Non-Preferred QL 1 / 1 days diltiazem hcl coated beads CARDIZEM LA 240 MG TAB ER 24H Non-Preferred QL 1 / 1 days diltiazem hcl coated beads CARDIZEM LA 300 MG TAB ER 24H Non-Preferred QL 1 / 1 days diltiazem hcl coated beads CARDIZEM LA 360 MG TAB ER 24H Non-Preferred QL 1 / 1 days diltiazem hcl coated beads CARDIZEM LA 420 MG TAB ER 24H Non-Preferred QL 1 / 1 days diltiazem hcl coated beads CONJUPRI 2.5 MG TAB Non-Preferred levamlodipine maleate CONJUPRI 5 MG TAB Non-Preferred levamlodipine maleate

diltiazem hcl cap er 12hr 120 mg Non-Preferred QL 2 / 1 days

PAGE 213 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

diltiazem hcl cap er 12hr 60 mg Non-Preferred QL 2 / 1 days

diltiazem hcl cap er 12hr 90 mg Non-Preferred QL 2 / 1 days

diltiazem hcl cap er 24hr 120 mg Preferred QL 1 / 1 days

diltiazem hcl cap er 24hr 120 mg Preferred QL 1 / 1 days

diltiazem hcl cap er 24hr 180 mg Preferred QL 1 / 1 days

diltiazem hcl cap er 24hr 180 mg Preferred QL 1 / 1 days

diltiazem hcl cap er 24hr 240 mg Preferred QL 2 / 1 days

diltiazem hcl cap er 24hr 240 mg Preferred QL 2 / 1 days

diltiazem hcl tab 120 mg Preferred QL 2 / 1 days

diltiazem hcl tab 30 mg Preferred QL 4 / 1 days

diltiazem hcl tab 60 mg Preferred QL 4 / 1 days

diltiazem hcl tab 90 mg Preferred QL 3 / 1 days

diltiazem hcl coated beads cap er 24hr Preferred QL 1 / 1 days 120 mg diltiazem hcl coated beads cap er 24hr Preferred QL 1 / 1 days 120 mg diltiazem hcl coated beads cap er 24hr Preferred QL 1 / 1 days 180 mg diltiazem hcl coated beads cap er 24hr Preferred QL 30 / 30 days 180 mg diltiazem hcl coated beads cap er 24hr Preferred QL 2 / 1 days 240 mg diltiazem hcl coated beads cap er 24hr Preferred QL 60 / 30 days 240 mg diltiazem hcl coated beads cap er 24hr Preferred QL 1 / 1 days 300 mg diltiazem hcl coated beads cap er 24hr Preferred QL 1 / 1 days 300 mg diltiazem hcl coated beads cap er 24hr Preferred QL 1 / 1 days 360 mg diltiazem hcl coated beads tab er 24hr Non-Preferred QL 1 / 1 days 180 mg diltiazem hcl coated beads tab er 24hr Non-Preferred QL 1 / 1 days 180 mg

PAGE 214 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS diltiazem hcl coated beads tab er 24hr Non-Preferred QL 1 / 1 days 240 mg diltiazem hcl coated beads tab er 24hr Non-Preferred QL 1 / 1 days 240 mg diltiazem hcl coated beads tab er 24hr Non-Preferred QL 1 / 1 days 300 mg diltiazem hcl coated beads tab er 24hr Non-Preferred QL 1 / 1 days 300 mg diltiazem hcl coated beads tab er 24hr Non-Preferred QL 1 / 1 days 360 mg diltiazem hcl coated beads tab er 24hr Non-Preferred QL 1 / 1 days 360 mg diltiazem hcl coated beads tab er 24hr Non-Preferred QL 1 / 1 days 420 mg diltiazem hcl coated beads tab er 24hr Non-Preferred QL 1 / 1 days 420 mg diltiazem hcl extended release beads Preferred QL 1 / 1 days cap er 24hr 120 mg diltiazem hcl extended release beads Preferred QL 1 / 1 days cap er 24hr 120 mg diltiazem hcl extended release beads Preferred cap er 24hr 120 mg diltiazem hcl extended release beads Preferred QL 1 / 1 days cap er 24hr 180 mg diltiazem hcl extended release beads Preferred QL 1 / 1 days cap er 24hr 180 mg diltiazem hcl extended release beads Preferred cap er 24hr 180 mg diltiazem hcl extended release beads Preferred QL 2 / 1 days cap er 24hr 240 mg diltiazem hcl extended release beads Preferred QL 2 / 1 days cap er 24hr 240 mg diltiazem hcl extended release beads Preferred cap er 24hr 240 mg diltiazem hcl extended release beads Preferred QL 1 / 1 days cap er 24hr 300 mg diltiazem hcl extended release beads Preferred QL 1 / 1 days cap er 24hr 300 mg diltiazem hcl extended release beads Preferred cap er 24hr 300 mg

PAGE 215 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS diltiazem hcl extended release beads Preferred QL 1 / 1 days cap er 24hr 360 mg diltiazem hcl extended release beads Preferred QL 1 / 1 days cap er 24hr 360 mg diltiazem hcl extended release beads Preferred cap er 24hr 360 mg diltiazem hcl extended release beads Preferred QL 1 / 1 days cap er 24hr 420 mg diltiazem hcl extended release beads Preferred cap er 24hr 420 mg

felodipine tab er 24hr 10 mg Preferred QL 1 / 1 days

felodipine tab er 24hr 2.5 mg Preferred QL 1 / 1 days

felodipine tab er 24hr 5 mg Preferred QL 1 / 1 days

isradipine cap 2.5 mg Non-Preferred isradipine cap 5 mg Non-Preferred KATERZIA 1 MG/ML SUSPENSION Non-Preferred amlodipine benzoate

nicardipine hcl cap 20 mg Non-Preferred QL 6 / 1 days

nicardipine hcl cap 30 mg Non-Preferred QL 4 / 1 days

nifedipine cap 10 mg Preferred QL 4 / 1 days

nifedipine cap 20 mg Preferred QL 4 / 1 days

nifedipine tab er 24hr 30 mg Preferred QL 2 / 1 days

nifedipine tab er 24hr 60 mg Preferred QL 2 / 1 days

nifedipine tab er 24hr 90 mg Preferred QL 2 / 1 days

nifedipine tab er 24hr osmotic release 30 Preferred QL 2 / 1 days mg nifedipine tab er 24hr osmotic release 60 Preferred QL 2 / 1 days mg nifedipine tab er 24hr osmotic release 90 Preferred QL 2 / 1 days mg nimodipine cap 30 mg Preferred

nisoldipine tab er 24hr 17 mg Non-Preferred QL 1 / 1 days

PAGE 216 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

nisoldipine tab er 24hr 20 mg Non-Preferred QL 1 / 1 days

nisoldipine tab er 24hr 25.5 mg Non-Preferred QL 1 / 1 days

nisoldipine tab er 24hr 30 mg Non-Preferred QL 2 / 1 days

nisoldipine tab er 24hr 34 mg Non-Preferred QL 1 / 1 days

nisoldipine tab er 24hr 40 mg Non-Preferred QL 1 / 1 days

nisoldipine tab er 24hr 8.5 mg Non-Preferred QL 1 / 1 days

NORVASC 10 MG TAB Non-Preferred QL 2 / 1 days amlodipine besylate NORVASC 2.5 MG TAB Non-Preferred QL 2 / 1 days amlodipine besylate NORVASC 5 MG TAB Non-Preferred QL 2 / 1 days amlodipine besylate NYMALIZE 30 MG/10ML SOLUTION Non-Preferred nimodipine NYMALIZE 6 MG/ML SOLUTION Non-Preferred nimodipine NYMALIZE 60 MG/20ML SOLUTION Non-Preferred nimodipine PROCARDIA 10 MG CAP Non-Preferred nifedipine PROCARDIA XL 30 MG TAB ER 24H Non-Preferred QL 2 / 1 days nifedipine PROCARDIA XL 60 MG TAB ER 24H Non-Preferred QL 2 / 1 days nifedipine PROCARDIA XL 90 MG TAB ER 24H Non-Preferred QL 2 / 1 days nifedipine SULAR 17 MG TAB ER 24H Non-Preferred QL 1 / 1 days nisoldipine SULAR 34 MG TAB ER 24H Non-Preferred QL 1 / 1 days nisoldipine SULAR 8.5 MG TAB ER 24H Non-Preferred QL 1 / 1 days nisoldipine TIAZAC 120 MG CAP ER 24H Non-Preferred QL 1 / 1 days diltiazem hcl extended release beads TIAZAC 180 MG CAP ER 24H Non-Preferred QL 1 / 1 days diltiazem hcl extended release beads

PAGE 217 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TIAZAC 240 MG CAP ER 24H Non-Preferred QL 2 / 1 days diltiazem hcl extended release beads TIAZAC 300 MG CAP ER 24H Non-Preferred QL 1 / 1 days diltiazem hcl extended release beads TIAZAC 360 MG CAP ER 24H Non-Preferred QL 1 / 1 days diltiazem hcl extended release beads TIAZAC 420 MG CAP ER 24H Non-Preferred QL 1 / 1 days diltiazem hcl extended release beads verapamil hcl cap er 24hr 100 mg Preferred

verapamil hcl cap er 24hr 120 mg Preferred QL 2 / 1 days

verapamil hcl cap er 24hr 180 mg Preferred QL 2 / 1 days

verapamil hcl cap er 24hr 200 mg Preferred

verapamil hcl cap er 24hr 240 mg Preferred QL 2 / 1 days

verapamil hcl cap er 24hr 300 mg Preferred

verapamil hcl cap er 24hr 360 mg Preferred QL 1 / 1 days

verapamil hcl tab 120 mg Preferred QL 4 / 1 days

verapamil hcl tab 40 mg Preferred QL 3 / 1 days

verapamil hcl tab 80 mg Preferred QL 4 / 1 days

verapamil hcl tab er 120 mg Preferred QL 1 / 1 days

verapamil hcl tab er 180 mg Preferred QL 2 / 1 days

verapamil hcl tab er 240 mg Preferred QL 2 / 1 days

VERELAN 120 MG CAP ER 24H Non-Preferred QL 2 / 1 days verapamil hcl VERELAN 180 MG CAP ER 24H Non-Preferred QL 2 / 1 days verapamil hcl VERELAN 240 MG CAP ER 24H Non-Preferred QL 2 / 1 days verapamil hcl VERELAN 360 MG CAP ER 24H Non-Preferred QL 1 / 1 days verapamil hcl VERELAN PM 100 MG CAP ER 24H Non-Preferred verapamil hcl VERELAN PM 200 MG CAP ER 24H Non-Preferred verapamil hcl

PAGE 218 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VERELAN PM 300 MG CAP ER 24H Non-Preferred verapamil hcl CARDIOVASCULAR AGENTS, OTHER

ACCURETIC 10-12.5 MG TAB Non-Preferred quinapril-hydrochlorothiazide ACCURETIC 20-12.5 MG TAB Non-Preferred quinapril-hydrochlorothiazide ACCURETIC 20-25 MG TAB Non-Preferred quinapril-hydrochlorothiazide ALDACTAZIDE 50-50 MG TAB Preferred spironolactone & hydrochlorothiazide aliskiren fumarate tab 150 mg (base Non-Preferred equivalent) aliskiren fumarate tab 300 mg (base Non-Preferred equivalent) amiloride & hydrochlorothiazide tab 5-50 Preferred QL 2 / 1 days mg amlodipine besylate-atorvastatin calcium Non-Preferred tab 10-10 mg amlodipine besylate-atorvastatin calcium Non-Preferred tab 10-20 mg amlodipine besylate-atorvastatin calcium Non-Preferred tab 10-40 mg amlodipine besylate-atorvastatin calcium Non-Preferred tab 10-80 mg amlodipine besylate-atorvastatin calcium Non-Preferred tab 2.5-10 mg amlodipine besylate-atorvastatin calcium Non-Preferred tab 2.5-20 mg amlodipine besylate-atorvastatin calcium Non-Preferred tab 2.5-40 mg amlodipine besylate-atorvastatin calcium Non-Preferred tab 5-10 mg amlodipine besylate-atorvastatin calcium Non-Preferred tab 5-20 mg amlodipine besylate-atorvastatin calcium Non-Preferred tab 5-40 mg amlodipine besylate-atorvastatin calcium Non-Preferred tab 5-80 mg

PAGE 219 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS amlodipine besylate-benazepril hcl cap Preferred QL 1 / 1 days 10-20 mg amlodipine besylate-benazepril hcl cap Preferred QL 1 / 1 days 10-40 mg amlodipine besylate-benazepril hcl cap Preferred QL 1 / 1 days 2.5-10 mg amlodipine besylate-benazepril hcl cap Preferred QL 1 / 1 days 5-10 mg amlodipine besylate-benazepril hcl cap Preferred QL 1 / 1 days 5-20 mg amlodipine besylate-benazepril hcl cap Preferred QL 1 / 1 days 5-40 mg amlodipine besylate-olmesartan Non-Preferred medoxomil tab 10-20 mg amlodipine besylate-olmesartan Non-Preferred medoxomil tab 10-40 mg amlodipine besylate-olmesartan Non-Preferred medoxomil tab 5-20 mg amlodipine besylate-olmesartan Non-Preferred medoxomil tab 5-40 mg amlodipine besylate-valsartan tab 10- Preferred 160 mg amlodipine besylate-valsartan tab 10- Preferred 320 mg amlodipine besylate-valsartan tab 5-160 Preferred mg amlodipine besylate-valsartan tab 5-320 Preferred mg amlodipine-valsartan- Preferred hydrochlorothiazide tab 10-160-12.5 mg amlodipine-valsartan- Preferred hydrochlorothiazide tab 10-160-25 mg amlodipine-valsartan- Preferred hydrochlorothiazide tab 10-320-25 mg amlodipine-valsartan- Preferred hydrochlorothiazide tab 5-160-12.5 mg amlodipine-valsartan- Preferred hydrochlorothiazide tab 5-160-25 mg ATACAND HCT 16-12.5 MG TAB Non-Preferred candesartan cilexetil-hydrochlorothiazide

PAGE 220 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ATACAND HCT 32-12.5 MG TAB Non-Preferred candesartan cilexetil-hydrochlorothiazide ATACAND HCT 32-25 MG TAB Non-Preferred candesartan cilexetil-hydrochlorothiazide

atenolol & chlorthalidone tab 100-25 mg Preferred QL 1 / 1 days

atenolol & chlorthalidone tab 50-25 mg Preferred QL 2 / 1 days

AVALIDE 150-12.5 MG TAB Non-Preferred QL 30 / 30 days irbesartan-hydrochlorothiazide AVALIDE 300-12.5 MG TAB Non-Preferred QL 30 / 30 days irbesartan-hydrochlorothiazide AZOR 10-20 MG TAB amlodipine besylate-olmesartan Non-Preferred medoxomil AZOR 10-40 MG TAB amlodipine besylate-olmesartan Non-Preferred medoxomil AZOR 5-20 MG TAB amlodipine besylate-olmesartan Non-Preferred medoxomil AZOR 5-40 MG TAB amlodipine besylate-olmesartan Non-Preferred medoxomil benazepril & hydrochlorothiazide tab 10- Preferred 12.5 mg benazepril & hydrochlorothiazide tab 20- Preferred 12.5 mg benazepril & hydrochlorothiazide tab 20- Preferred 25 mg benazepril & hydrochlorothiazide tab 5- Preferred 6.25 mg BENICAR HCT 20-12.5 MG TAB olmesartan medoxomil- Non-Preferred QL 30 / 30 days hydrochlorothiazide BENICAR HCT 40-12.5 MG TAB olmesartan medoxomil- Non-Preferred QL 30 / 30 days hydrochlorothiazide BENICAR HCT 40-25 MG TAB olmesartan medoxomil- Non-Preferred QL 30 / 30 days hydrochlorothiazide

PAGE 221 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS BIDIL 20-37.5 MG TAB Non-Preferred isosorbide dinitrate-hydralazine hcl bisoprolol & hydrochlorothiazide tab 10- Preferred QL 60 / 30 days 6.25 mg bisoprolol & hydrochlorothiazide tab 2.5- Preferred QL 1 / 1 days 6.25 mg bisoprolol & hydrochlorothiazide tab 5- Preferred QL 1 / 1 days 6.25 mg CADUET 10-10 MG TAB Non-Preferred amlodipine besylate-atorvastatin calcium CADUET 10-20 MG TAB Non-Preferred amlodipine besylate-atorvastatin calcium CADUET 10-40 MG TAB Non-Preferred amlodipine besylate-atorvastatin calcium CADUET 10-80 MG TAB Non-Preferred amlodipine besylate-atorvastatin calcium CADUET 5-10 MG TAB Non-Preferred amlodipine besylate-atorvastatin calcium CADUET 5-20 MG TAB Non-Preferred amlodipine besylate-atorvastatin calcium CADUET 5-40 MG TAB Non-Preferred amlodipine besylate-atorvastatin calcium CADUET 5-80 MG TAB Non-Preferred amlodipine besylate-atorvastatin calcium candesartan cilexetil-hydrochlorothiazide Non-Preferred tab 16-12.5 mg candesartan cilexetil-hydrochlorothiazide Non-Preferred tab 32-12.5 mg candesartan cilexetil-hydrochlorothiazide Non-Preferred tab 32-25 mg captopril & hydrochlorothiazide tab 25- Non-Preferred QL 3 / 1 days 15 mg captopril & hydrochlorothiazide tab 25- Non-Preferred QL 2 / 1 days 25 mg captopril & hydrochlorothiazide tab 50- Non-Preferred QL 3 / 1 days 15 mg captopril & hydrochlorothiazide tab 50- Non-Preferred QL 2 / 1 days 25 mg CORZIDE 40-5 MG TAB Non-Preferred nadolol & bendroflumethiazide

PAGE 222 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CORZIDE 80-5 MG TAB Non-Preferred nadolol & bendroflumethiazide

digoxin oral soln 0.05 mg/ml Preferred QL 5 / 1 days

digoxin tab 125 mcg (0.125 mg) Preferred digoxin tab 125 mcg (0.125 mg) Preferred digoxin tab 125 mcg (0.125 mg) Preferred digoxin tab 250 mcg (0.25 mg) Preferred digoxin tab 250 mcg (0.25 mg) Preferred digoxin tab 250 mcg (0.25 mg) Preferred DIOVAN HCT 160-12.5 MG TAB Non-Preferred QL 60 / 30 days valsartan-hydrochlorothiazide DIOVAN HCT 160-25 MG TAB Non-Preferred QL 60 / 30 days valsartan-hydrochlorothiazide DIOVAN HCT 320-12.5 MG TAB Non-Preferred QL 30 / 30 days valsartan-hydrochlorothiazide DIOVAN HCT 320-25 MG TAB Non-Preferred QL 30 / 30 days valsartan-hydrochlorothiazide DIOVAN HCT 80-12.5 MG TAB Non-Preferred QL 60 / 30 days valsartan-hydrochlorothiazide EDARBYCLOR 40-12.5 MG TAB Non-Preferred azilsartan medoxomil-chlorthalidone EDARBYCLOR 40-25 MG TAB Non-Preferred azilsartan medoxomil-chlorthalidone enalapril maleate & hydrochlorothiazide Preferred QL 2 / 1 days tab 10-25 mg enalapril maleate & hydrochlorothiazide Preferred QL 1 / 1 days tab 5-12.5 mg ENTRESTO 24-26 MG TAB Preferred QL 60 / 30 days sacubitril-valsartan ENTRESTO 49-51 MG TAB Preferred QL 60 / 30 days sacubitril-valsartan ENTRESTO 97-103 MG TAB Preferred QL 60 / 30 days sacubitril-valsartan EXFORGE 10-160 MG TAB Non-Preferred amlodipine besylate-valsartan EXFORGE 10-320 MG TAB Non-Preferred amlodipine besylate-valsartan

PAGE 223 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS EXFORGE 5-160 MG TAB Non-Preferred amlodipine besylate-valsartan EXFORGE 5-320 MG TAB Non-Preferred amlodipine besylate-valsartan EXFORGE HCT 10-160-12.5 MG TAB amlodipine-valsartan- Non-Preferred hydrochlorothiazide EXFORGE HCT 10-160-25 MG TAB amlodipine-valsartan- Non-Preferred hydrochlorothiazide EXFORGE HCT 10-320-25 MG TAB amlodipine-valsartan- Non-Preferred hydrochlorothiazide EXFORGE HCT 5-160-12.5 MG TAB amlodipine-valsartan- Non-Preferred hydrochlorothiazide EXFORGE HCT 5-160-25 MG TAB amlodipine-valsartan- Non-Preferred hydrochlorothiazide fosinopril sodium & hydrochlorothiazide Preferred tab 10-12.5 mg fosinopril sodium & hydrochlorothiazide Preferred tab 20-12.5 mg HYZAAR 100-12.5 MG TAB losartan potassium & Non-Preferred QL 30 / 30 days hydrochlorothiazide HYZAAR 100-25 MG TAB losartan potassium & Non-Preferred QL 30 / 30 days hydrochlorothiazide HYZAAR 50-12.5 MG TAB losartan potassium & Non-Preferred QL 30 / 30 days hydrochlorothiazide irbesartan-hydrochlorothiazide tab 150- Preferred QL 30 / 30 days 12.5 mg irbesartan-hydrochlorothiazide tab 300- Preferred QL 30 / 30 days 12.5 mg lisinopril & hydrochlorothiazide tab 10- Preferred QL 30 / 30 days 12.5 mg lisinopril & hydrochlorothiazide tab 20- Preferred QL 60 / 30 days 12.5 mg lisinopril & hydrochlorothiazide tab 20-25 Preferred QL 60 / 30 days mg

PAGE 224 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS losartan potassium & Preferred QL 30 / 30 days hydrochlorothiazide tab 100-12.5 mg losartan potassium & Preferred QL 30 / 30 days hydrochlorothiazide tab 100-25 mg losartan potassium & Preferred QL 30 / 30 days hydrochlorothiazide tab 50-12.5 mg LOTENSIN HCT 10-12.5 MG TAB Non-Preferred benazepril & hydrochlorothiazide LOTENSIN HCT 20-12.5 MG TAB Non-Preferred benazepril & hydrochlorothiazide LOTENSIN HCT 20-25 MG TAB Non-Preferred benazepril & hydrochlorothiazide LOTREL 10-20 MG CAP Non-Preferred QL 1 / 1 days amlodipine besylate-benazepril hcl LOTREL 10-40 MG CAP Non-Preferred QL 1 / 1 days amlodipine besylate-benazepril hcl LOTREL 5-10 MG CAP Non-Preferred QL 1 / 1 days amlodipine besylate-benazepril hcl LOTREL 5-20 MG CAP Non-Preferred QL 1 / 1 days amlodipine besylate-benazepril hcl methyldopa & hydrochlorothiazide tab Non-Preferred 250-15 mg methyldopa & hydrochlorothiazide tab Non-Preferred 250-25 mg metoprolol & hydrochlorothiazide tab Non-Preferred QL 60 / 30 days 100-25 mg metoprolol & hydrochlorothiazide tab Non-Preferred QL 30 / 30 days 100-50 mg metoprolol & hydrochlorothiazide tab 50- Non-Preferred QL 60 / 30 days 25 mg MICARDIS HCT 40-12.5 MG TAB Non-Preferred telmisartan-hydrochlorothiazide MICARDIS HCT 80-12.5 MG TAB Non-Preferred telmisartan-hydrochlorothiazide MICARDIS HCT 80-25 MG TAB Non-Preferred telmisartan-hydrochlorothiazide moexipril-hydrochlorothiazide tab 15- Non-Preferred 12.5 mg moexipril-hydrochlorothiazide tab 15-25 Non-Preferred mg

PAGE 225 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS nadolol & bendroflumethiazide tab 80-5 Non-Preferred mg NADOLOL-BENDROFLUMETHIAZIDE 40-5 MG TAB Non-Preferred nadolol & bendroflumethiazide NEXLETOL 180 MG TAB Non-Preferred bempedoic acid olmesartan-amlodipine- Non-Preferred hydrochlorothiazide tab 20-5-12.5 mg olmesartan-amlodipine- Non-Preferred hydrochlorothiazide tab 40-10-12.5 mg olmesartan-amlodipine- Non-Preferred hydrochlorothiazide tab 40-10-25 mg olmesartan-amlodipine- Non-Preferred hydrochlorothiazide tab 40-5-12.5 mg olmesartan-amlodipine- Non-Preferred hydrochlorothiazide tab 40-5-25 mg olmesartan medoxomil- Preferred QL 30 / 30 days hydrochlorothiazide tab 20-12.5 mg olmesartan medoxomil- Preferred QL 30 / 30 days hydrochlorothiazide tab 40-12.5 mg olmesartan medoxomil- Preferred QL 30 / 30 days hydrochlorothiazide tab 40-25 mg

pentoxifylline tab er 400 mg Preferred QL 3 / 1 days

propranolol & hydrochlorothiazide tab Preferred QL 2 / 1 days 40-25 mg propranolol & hydrochlorothiazide tab Preferred QL 2 / 1 days 80-25 mg quinapril-hydrochlorothiazide tab 10- Preferred 12.5 mg quinapril-hydrochlorothiazide tab 20- Preferred 12.5 mg quinapril-hydrochlorothiazide tab 20-25 Preferred mg RANEXA 1000 MG TAB ER 12H Non-Preferred ranolazine RANEXA 500 MG TAB ER 12H Non-Preferred ranolazine

PAGE 226 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

ranolazine tab er 12hr 1000 mg Preferred PA

ranolazine tab er 12hr 500 mg Preferred PA

spironolactone & hydrochlorothiazide tab Preferred QL 8 / 1 days 25-25 mg TARKA 2-180 MG TAB ER Non-Preferred trandolapril-verapamil hcl TARKA 2-240 MG TAB ER Non-Preferred trandolapril-verapamil hcl TARKA 4-240 MG TAB ER Non-Preferred trandolapril-verapamil hcl TEKTURNA 150 MG TAB Non-Preferred aliskiren fumarate TEKTURNA 300 MG TAB Non-Preferred aliskiren fumarate TEKTURNA HCT 150-12.5 MG TAB Non-Preferred aliskiren-hydrochlorothiazide TEKTURNA HCT 150-25 MG TAB Non-Preferred aliskiren-hydrochlorothiazide TEKTURNA HCT 300-12.5 MG TAB Non-Preferred aliskiren-hydrochlorothiazide TEKTURNA HCT 300-25 MG TAB Non-Preferred aliskiren-hydrochlorothiazide telmisartan-amlodipine tab 40-10 mg Non-Preferred telmisartan-amlodipine tab 40-5 mg Non-Preferred telmisartan-amlodipine tab 80-10 mg Non-Preferred telmisartan-amlodipine tab 80-5 mg Non-Preferred telmisartan-hydrochlorothiazide tab 40- Non-Preferred 12.5 mg telmisartan-hydrochlorothiazide tab 80- Non-Preferred 12.5 mg telmisartan-hydrochlorothiazide tab 80- Non-Preferred 25 mg TENORETIC 100 100-25 MG TAB Non-Preferred QL 1 / 1 days atenolol & chlorthalidone TENORETIC 50 50-25 MG TAB Non-Preferred QL 2 / 1 days atenolol & chlorthalidone trandolapril-verapamil hcl tab er 1-240 Non-Preferred mg

PAGE 227 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS trandolapril-verapamil hcl tab er 2-180 Non-Preferred mg trandolapril-verapamil hcl tab er 2-240 Non-Preferred mg trandolapril-verapamil hcl tab er 4-240 Non-Preferred mg triamterene & hydrochlorothiazide cap Preferred QL 2 / 1 days 37.5-25 mg triamterene & hydrochlorothiazide tab Preferred QL 1 / 1 days 37.5-25 mg triamterene & hydrochlorothiazide tab Preferred QL 1 / 1 days 75-50 mg TRIBENZOR 20-5-12.5 MG TAB olmesartan medoxomil-amlodipine- Non-Preferred hydrochlorothiazide TRIBENZOR 40-10-12.5 MG TAB olmesartan medoxomil-amlodipine- Non-Preferred hydrochlorothiazide TRIBENZOR 40-10-25 MG TAB olmesartan medoxomil-amlodipine- Non-Preferred hydrochlorothiazide TRIBENZOR 40-5-12.5 MG TAB olmesartan medoxomil-amlodipine- Non-Preferred hydrochlorothiazide TRIBENZOR 40-5-25 MG TAB olmesartan medoxomil-amlodipine- Non-Preferred hydrochlorothiazide TWYNSTA 40-10 MG TAB Non-Preferred telmisartan-amlodipine TWYNSTA 40-5 MG TAB Non-Preferred telmisartan-amlodipine TWYNSTA 80-10 MG TAB Non-Preferred telmisartan-amlodipine TWYNSTA 80-5 MG TAB Non-Preferred telmisartan-amlodipine valsartan-hydrochlorothiazide tab 160- Preferred QL 60 / 30 days 12.5 mg valsartan-hydrochlorothiazide tab 160- Preferred QL 60 / 30 days 25 mg valsartan-hydrochlorothiazide tab 320- Preferred QL 30 / 30 days 12.5 mg

PAGE 228 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS valsartan-hydrochlorothiazide tab 320- Preferred QL 30 / 30 days 25 mg valsartan-hydrochlorothiazide tab 80- Preferred QL 60 / 30 days 12.5 mg VASERETIC 10-25 MG TAB Non-Preferred QL 2 / 1 days enalapril maleate & hydrochlorothiazide ZESTORETIC 10-12.5 MG TAB Non-Preferred QL 30 / 30 days lisinopril & hydrochlorothiazide ZESTORETIC 20-12.5 MG TAB Non-Preferred QL 60 / 30 days lisinopril & hydrochlorothiazide ZESTORETIC 20-25 MG TAB Non-Preferred QL 60 / 30 days lisinopril & hydrochlorothiazide ZIAC 10-6.25 MG TAB Non-Preferred QL 1 / 1 days bisoprolol & hydrochlorothiazide ZIAC 2.5-6.25 MG TAB Non-Preferred QL 1 / 1 days bisoprolol & hydrochlorothiazide ZIAC 5-6.25 MG TAB Non-Preferred QL 1 / 1 days bisoprolol & hydrochlorothiazide DIURETICS, CARBONIC ANHYDRASE INHIBITORS

acetazolamide cap er 12hr 500 mg Preferred QL 2 / 1 days

acetazolamide tab 125 mg Preferred QL 4 / 1 days

acetazolamide tab 250 mg Preferred QL 4 / 1 days

DIURETICS, LOOP

bumetanide tab 0.5 mg Preferred QL 5 / 1 days

bumetanide tab 1 mg Preferred QL 5 / 1 days

bumetanide tab 2 mg Preferred QL 5 / 1 days

furosemide oral soln 10 mg/ml Preferred QL 60 / 1 days

furosemide oral soln 8 mg/ml Preferred QL 75 / 1 days

furosemide tab 20 mg Preferred QL 15 / 1 days

furosemide tab 40 mg Preferred QL 15 / 1 days

furosemide tab 80 mg Preferred QL 7 / 1 days

torsemide tab 10 mg Preferred

PAGE 229 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS DIURETICS, POTASSIUM-SPARING

amiloride hcl tab 5 mg Preferred QL 4 / 1 days

spironolactone tab 100 mg Preferred QL 4 / 1 days

spironolactone tab 25 mg Preferred QL 2 / 1 days

spironolactone tab 50 mg Preferred QL 2 / 1 days

DIURETICS, THIAZIDE

chlorothiazide tab 250 mg Preferred QL 4 / 1 days

chlorothiazide tab 500 mg Preferred QL 4 / 1 days

chlorthalidone tab 25 mg Preferred QL 4 / 1 days

chlorthalidone tab 50 mg Preferred QL 4 / 1 days

DIURIL 250 MG/5ML SUSPENSION Preferred QL 40 / 1 days chlorothiazide

hydrochlorothiazide cap 12.5 mg Preferred QL 120 / 30 days

hydrochlorothiazide tab 12.5 mg Preferred QL 4 / 1 days

hydrochlorothiazide tab 25 mg Preferred QL 4 / 1 days

hydrochlorothiazide tab 50 mg Preferred QL 120 / 30 days

indapamide tab 1.25 mg Preferred QL 4 / 1 days

indapamide tab 2.5 mg Preferred QL 2 / 1 days

methyclothiazide tab 5 mg Preferred QL 2 / 1 days

metolazone tab 10 mg Preferred QL 2 / 1 days

metolazone tab 2.5 mg Preferred QL 2 / 1 days

metolazone tab 5 mg Preferred QL 2 / 1 days

DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES

ANTARA 30 MG CAP Non-Preferred fenofibrate micronized ANTARA 90 MG CAP Non-Preferred fenofibrate micronized choline fenofibrate cap dr 135 mg Preferred (fenofibric acid equiv)

PAGE 230 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS choline fenofibrate cap dr 45 mg Preferred (fenofibric acid equiv) fenofibrate cap 150 mg Non-Preferred fenofibrate cap 50 mg Non-Preferred fenofibrate tab 120 mg Non-Preferred

fenofibrate tab 145 mg Preferred QL 1 / 1 days

fenofibrate tab 160 mg Preferred QL 1 / 1 days

fenofibrate tab 40 mg Non-Preferred

fenofibrate tab 48 mg Preferred QL 1 / 1 days

fenofibrate tab 54 mg Preferred QL 1 / 1 days

fenofibrate micronized cap 130 mg Preferred

fenofibrate micronized cap 134 mg Preferred QL 1 / 1 days

fenofibrate micronized cap 134 mg Preferred QL 1 / 1 days

fenofibrate micronized cap 200 mg Preferred QL 1 / 1 days

fenofibrate micronized cap 200 mg Preferred QL 1 / 1 days

fenofibrate micronized cap 43 mg Preferred

fenofibrate micronized cap 67 mg Preferred QL 1 / 1 days

fenofibrate micronized cap 67 mg Preferred QL 1 / 1 days

FENOFIBRIC ACID 105 MG TAB Non-Preferred fenofibric acid FENOFIBRIC ACID 35 MG TAB Non-Preferred fenofibric acid fenofibric acid tab 105 mg Non-Preferred fenofibric acid tab 35 mg Non-Preferred FENOGLIDE 120 MG TAB Non-Preferred fenofibrate FENOGLIDE 40 MG TAB Non-Preferred fenofibrate FIBRICOR 105 MG TAB Non-Preferred fenofibric acid FIBRICOR 35 MG TAB Non-Preferred fenofibric acid

PAGE 231 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

gemfibrozil tab 600 mg Preferred QL 2 / 1 days

LIPOFEN 150 MG CAP Non-Preferred fenofibrate LIPOFEN 50 MG CAP Non-Preferred fenofibrate LOPID 600 MG TAB Non-Preferred QL 2 / 1 days gemfibrozil TRICOR 145 MG TAB Non-Preferred QL 1 / 1 days fenofibrate TRICOR 48 MG TAB Non-Preferred QL 1 / 1 days fenofibrate TRIGLIDE 160 MG TAB Non-Preferred QL 1 / 1 days fenofibrate TRILIPIX 135 MG CAP DR Non-Preferred choline fenofibrate TRILIPIX 45 MG CAP DR Non-Preferred choline fenofibrate DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS

ALTOPREV 20 MG TAB ER 24H Non-Preferred lovastatin ALTOPREV 40 MG TAB ER 24H Non-Preferred lovastatin ALTOPREV 60 MG TAB ER 24H Non-Preferred lovastatin atorvastatin calcium tab 10 mg (base Preferred QL 30 / 30 days equivalent) atorvastatin calcium tab 20 mg (base Preferred QL 30 / 30 days equivalent) atorvastatin calcium tab 40 mg (base Preferred QL 30 / 30 days equivalent) atorvastatin calcium tab 80 mg (base Preferred QL 30 / 30 days equivalent) CRESTOR 10 MG TAB Non-Preferred QL 1 / 1 days rosuvastatin calcium CRESTOR 20 MG TAB Non-Preferred QL 1 / 1 days rosuvastatin calcium CRESTOR 40 MG TAB Non-Preferred QL 1 / 1 days rosuvastatin calcium

PAGE 232 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CRESTOR 5 MG TAB Non-Preferred QL 1 / 1 days rosuvastatin calcium EZALLOR SPRINKLE 10 MG CAP SPRINK Non-Preferred rosuvastatin calcium EZALLOR SPRINKLE 20 MG CAP SPRINK Non-Preferred rosuvastatin calcium EZALLOR SPRINKLE 40 MG CAP SPRINK Non-Preferred rosuvastatin calcium EZALLOR SPRINKLE 5 MG CAP SPRINK Non-Preferred rosuvastatin calcium fluvastatin sodium cap 20 mg (base Non-Preferred QL 30 / 30 days equivalent) fluvastatin sodium cap 40 mg (base Non-Preferred QL 30 / 30 days equivalent) fluvastatin sodium tab er 24 hr 80 mg Non-Preferred (base equivalent) LESCOL XL 80 MG TAB ER 24H Non-Preferred fluvastatin sodium LIPITOR 10 MG TAB Non-Preferred QL 30 / 30 days atorvastatin calcium LIPITOR 20 MG TAB Non-Preferred QL 30 / 30 days atorvastatin calcium LIPITOR 40 MG TAB Non-Preferred QL 30 / 30 days atorvastatin calcium LIPITOR 80 MG TAB Non-Preferred QL 30 / 30 days atorvastatin calcium LIVALO 1 MG TAB Non-Preferred pitavastatin calcium LIVALO 2 MG TAB Non-Preferred pitavastatin calcium LIVALO 4 MG TAB Non-Preferred pitavastatin calcium

lovastatin tab 10 mg Preferred QL 1 / 1 days

lovastatin tab 20 mg Preferred QL 1 / 1 days

lovastatin tab 40 mg Preferred QL 2 / 1 days

PAGE 233 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PRAVACHOL 20 MG TAB Non-Preferred QL 1 / 1 days pravastatin sodium PRAVACHOL 40 MG TAB Non-Preferred QL 1 / 1 days pravastatin sodium PRAVACHOL 80 MG TAB Non-Preferred QL 1 / 1 days pravastatin sodium

pravastatin sodium tab 10 mg Preferred QL 1 / 1 days

pravastatin sodium tab 20 mg Preferred QL 1 / 1 days

pravastatin sodium tab 40 mg Preferred QL 1 / 1 days

pravastatin sodium tab 80 mg Preferred QL 1 / 1 days

rosuvastatin calcium tab 10 mg Preferred QL 1 / 1 days

rosuvastatin calcium tab 20 mg Preferred QL 1 / 1 days

rosuvastatin calcium tab 40 mg Preferred QL 1 / 1 days

rosuvastatin calcium tab 5 mg Preferred QL 1 / 1 days

SIMVASTATIN 20 MG/5ML SUSPENSION Non-Preferred simvastatin

simvastatin tab 10 mg Preferred QL 1 / 1 days

simvastatin tab 20 mg Preferred QL 1 / 1 days

simvastatin tab 40 mg Preferred QL 1 / 1 days

simvastatin tab 5 mg Preferred QL 1 / 1 days

simvastatin tab 80 mg Preferred QL 1 / 1 days

ZOCOR 10 MG TAB Non-Preferred QL 1 / 1 days simvastatin ZOCOR 20 MG TAB Non-Preferred QL 1 / 1 days simvastatin ZOCOR 40 MG TAB Non-Preferred QL 1 / 1 days simvastatin ZOCOR 80 MG TAB Non-Preferred QL 1 / 1 days simvastatin ZYPITAMAG 1 MG TAB Non-Preferred pitavastatin magnesium

PAGE 234 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ZYPITAMAG 2 MG TAB Non-Preferred pitavastatin magnesium ZYPITAMAG 4 MG TAB Non-Preferred pitavastatin magnesium DYSLIPIDEMICS, OTHER

cholestyramine powder 4 gm/dose Preferred QLC 54 grams/day

cholestyramine powder packets 4 gm Preferred QL 6 / 1 days

cholestyramine light powder 4 gm/dose Preferred QLC 54 grams/day

cholestyramine light powder 4 gm/dose Preferred QLC 54 grams/day

cholestyramine light powder packets 4 Preferred QL 6 / 1 days gm cholestyramine light powder packets 4 Preferred gm colesevelam hcl packet for susp 3.75 gm Non-Preferred colesevelam hcl tab 625 mg Non-Preferred COLESTID 1 GM TAB Non-Preferred colestipol hcl COLESTID 5 GM GRANULES Non-Preferred colestipol hcl COLESTID 5 GM PACKET Non-Preferred colestipol hcl COLESTID FLAVORED 5 GM GRANULES Non-Preferred colestipol hcl COLESTID FLAVORED 5 GM PACKET Non-Preferred colestipol hcl colestipol hcl granule packets 5 gm Non-Preferred colestipol hcl granules 5 gm Non-Preferred colestipol hcl tab 1 gm Preferred EVKEEZA 1200 MG/8ML SOLUTION Non-Preferred evinacumab-dgnb EVKEEZA 345 MG/2.3ML SOLUTION Non-Preferred evinacumab-dgnb

ezetimibe tab 10 mg Preferred QL 30 / 30 days

ezetimibe-simvastatin tab 10-10 mg Non-Preferred

PAGE 235 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ezetimibe-simvastatin tab 10-20 mg Non-Preferred ezetimibe-simvastatin tab 10-40 mg Non-Preferred ezetimibe-simvastatin tab 10-80 mg Non-Preferred icosapent ethyl cap 1 gm Non-Preferred JUXTAPID 10 MG CAP Non-Preferred lomitapide mesylate JUXTAPID 20 MG CAP Non-Preferred lomitapide mesylate JUXTAPID 30 MG CAP Non-Preferred lomitapide mesylate JUXTAPID 40 MG CAP Non-Preferred lomitapide mesylate JUXTAPID 5 MG CAP Non-Preferred lomitapide mesylate JUXTAPID 60 MG CAP Non-Preferred lomitapide mesylate LOVAZA 1 GM CAP Non-Preferred omega-3-acid ethyl esters NEXLIZET 180-10 MG TAB Non-Preferred bempedoic acid-ezetimibe niacin tab er 1000 mg Non-Preferred (antihyperlipidemic)

niacin tab er 500 mg (antihyperlipidemic) Non-Preferred QL 4 / 1 days

niacin tab er 750 mg (antihyperlipidemic) Non-Preferred NIACOR 500 MG TAB Non-Preferred niacin (antihyperlipidemic) NIASPAN 1000 MG TAB ER Non-Preferred niacin (antihyperlipidemic) NIASPAN 500 MG TAB ER Non-Preferred niacin (antihyperlipidemic) NIASPAN 750 MG TAB ER Non-Preferred niacin (antihyperlipidemic)

omega-3-acid ethyl esters cap 1 gm Preferred QL 4 / 1 days

PRALUENT 150 MG/ML SOLN A-INJ Non-Preferred QL 2 / 28 days alirocumab PRALUENT 75 MG/ML SOLN A-INJ Non-Preferred QL 2 / 28 days alirocumab

PAGE 236 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QUESTRAN 4 GM PACKET Non-Preferred cholestyramine QUESTRAN 4 GM/DOSE POWDER Non-Preferred cholestyramine QUESTRAN LIGHT 4 GM/DOSE POWDER Non-Preferred cholestyramine light REPATHA 140 MG/ML SOLN PRSYR Non-Preferred QL 3 / 28 days evolocumab REPATHA PUSHTRONEX SYSTEM 420 MG/3.5ML SOLN CART Non-Preferred evolocumab REPATHA SURECLICK 140 MG/ML SOLN A-INJ Non-Preferred QL 3 / 28 days evolocumab VASCEPA 0.5 GM CAP Non-Preferred icosapent ethyl VASCEPA 1 GM CAP Non-Preferred icosapent ethyl VYTORIN 10-10 MG TAB Non-Preferred ezetimibe-simvastatin VYTORIN 10-20 MG TAB Non-Preferred ezetimibe-simvastatin VYTORIN 10-40 MG TAB Non-Preferred ezetimibe-simvastatin VYTORIN 10-80 MG TAB Non-Preferred ezetimibe-simvastatin WELCHOL 3.75 GM PACKET Non-Preferred colesevelam hcl WELCHOL 625 MG TAB Non-Preferred colesevelam hcl ZETIA 10 MG TAB Non-Preferred QL 30 / 30 days ezetimibe VASODILATORS, DIRECT-ACTING ARTERIAL

hydralazine hcl tab 10 mg Preferred QL 4 / 1 days

hydralazine hcl tab 100 mg Preferred QL 3 / 1 days

hydralazine hcl tab 25 mg Preferred QL 4 / 1 days

hydralazine hcl tab 50 mg Preferred QL 4 / 1 days

PAGE 237 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

minoxidil tab 10 mg Preferred QL 10 / 1 days

minoxidil tab 2.5 mg Preferred QL 4 / 1 days

VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS

DILATRATE-SR 40 MG CAP ER Non-Preferred isosorbide dinitrate GONITRO 400 MCG PACKET Non-Preferred nitroglycerin ISORDIL TITRADOSE 40 MG TAB Non-Preferred isosorbide dinitrate ISORDIL TITRADOSE 5 MG TAB Non-Preferred isosorbide dinitrate

isosorbide dinitrate tab 10 mg Non-Preferred QL 8 / 1 days

isosorbide dinitrate tab 20 mg Non-Preferred QL 8 / 1 days

isosorbide dinitrate tab 30 mg Non-Preferred QL 8 / 1 days

isosorbide dinitrate tab 40 mg Non-Preferred

isosorbide dinitrate tab 5 mg Non-Preferred QL 8 / 1 days

isosorbide dinitrate tab er 40 mg Preferred QL 2 / 1 days

isosorbide mononitrate tab 10 mg Preferred QL 2 / 1 days

isosorbide mononitrate tab 20 mg Preferred QL 2 / 1 days

isosorbide mononitrate tab er 24hr 120 Preferred QL 2 / 1 days mg isosorbide mononitrate tab er 24hr 30 Preferred QL 3 / 1 days mg isosorbide mononitrate tab er 24hr 60 Preferred QL 2 / 1 days mg NITRO-BID 2 % OINTMENT Preferred nitroglycerin NITRO-DUR 0.1 MG/HR PATCH 24HR Non-Preferred QL 1 / 1 days nitroglycerin NITRO-DUR 0.2 MG/HR PATCH 24HR Non-Preferred QL 1 / 1 days nitroglycerin NITRO-DUR 0.3 MG/HR PATCH 24HR Non-Preferred nitroglycerin NITRO-DUR 0.4 MG/HR PATCH 24HR Non-Preferred QL 1 / 1 days nitroglycerin

PAGE 238 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NITRO-DUR 0.6 MG/HR PATCH 24HR Non-Preferred QL 1 / 1 days nitroglycerin NITRO-DUR 0.8 MG/HR PATCH 24HR Non-Preferred nitroglycerin

nitroglycerin cap er 2.5 mg Non-Preferred QL 4 / 1 days

nitroglycerin cap er 6.5 mg Non-Preferred QL 4 / 1 days

nitroglycerin sl tab 0.3 mg Preferred nitroglycerin sl tab 0.4 mg Preferred nitroglycerin sl tab 0.6 mg Preferred

nitroglycerin td patch 24hr 0.1 mg/hr Non-Preferred QL 1 / 1 days

nitroglycerin td patch 24hr 0.1 mg/hr Preferred QL 1 / 1 days

nitroglycerin td patch 24hr 0.2 mg/hr Non-Preferred QL 1 / 1 days

nitroglycerin td patch 24hr 0.2 mg/hr Preferred QL 1 / 1 days

nitroglycerin td patch 24hr 0.4 mg/hr Non-Preferred QL 1 / 1 days

nitroglycerin td patch 24hr 0.4 mg/hr Preferred QL 1 / 1 days

nitroglycerin td patch 24hr 0.6 mg/hr Non-Preferred QL 1 / 1 days

nitroglycerin td patch 24hr 0.6 mg/hr Preferred QL 1 / 1 days

nitroglycerin tl soln 0.4 mg/spray (400 Non-Preferred mcg/spray) NITROLINGUAL 0.4 MG/SPRAY SOLUTION Non-Preferred nitroglycerin NITROMIST 400 MCG/SPRAY AERO SOLN Non-Preferred nitroglycerin NITROSTAT 0.3 MG SL TAB Non-Preferred nitroglycerin NITROSTAT 0.4 MG SL TAB Non-Preferred nitroglycerin NITROSTAT 0.6 MG SL TAB Non-Preferred nitroglycerin

PAGE 239 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CENTRAL NERVOUS SYSTEM AGENTS

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES

QL 3 / 1 days ADDERALL 10 MG TAB Non-Preferred AL1 4 to 17 yrs old amphetamine-dextroamphetamine C Age restriction, clinical PA required

QL 3 / 1 days ADDERALL 12.5 MG TAB Non-Preferred AL1 4 to 17 yrs old amphetamine-dextroamphetamine C Age restriction, clinical PA required

QL 3 / 1 days ADDERALL 15 MG TAB Non-Preferred AL1 4 to 17 yrs old amphetamine-dextroamphetamine C Age restriction, clinical PA required

QL 3 / 1 days ADDERALL 20 MG TAB Non-Preferred AL1 4 to 17 yrs old amphetamine-dextroamphetamine C Age restriction, clinical PA required

QL 2 / 1 days ADDERALL 30 MG TAB Non-Preferred AL1 4 to 17 yrs old amphetamine-dextroamphetamine C Age restriction, clinical PA required

QL 120 / 30 days ADDERALL 5 MG TAB Non-Preferred AL1 4 to 17 yrs old amphetamine-dextroamphetamine C Age restriction, clinical PA required

QL 120 / 30 days ADDERALL 7.5 MG TAB Non-Preferred AL1 4 to 17 yrs old amphetamine-dextroamphetamine C Age restriction, clinical PA required

QL 1 / 1 days ADDERALL XR 10 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old amphetamine-dextroamphetamine C Age restriction, clinical PA required

QL 1 / 1 days ADDERALL XR 15 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old amphetamine-dextroamphetamine C Age restriction, clinical PA required

PAGE 240 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 1 / 1 days ADDERALL XR 20 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old amphetamine-dextroamphetamine C Age restriction, clinical PA required

QL 1 / 1 days ADDERALL XR 25 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old amphetamine-dextroamphetamine C Age restriction, clinical PA required

QL 1 / 1 days ADDERALL XR 30 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old amphetamine-dextroamphetamine C Age restriction, clinical PA required

QL 1 / 1 days ADDERALL XR 5 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old amphetamine-dextroamphetamine C Age restriction, clinical PA required

AL1 4 to 17 yrs old ADZENYS ER 1.25 MG/ML SUSP Non-Preferred amphetamine C Age restriction, clinical PA required

ADZENYS XR-ODT 12.5 MG TAB ER AL1 4 to 17 yrs old DISP Non-Preferred C Age restriction, clinical amphetamine PA required

ADZENYS XR-ODT 15.7 MG TAB ER AL1 4 to 17 yrs old DISP Non-Preferred C Age restriction, clinical amphetamine PA required

ADZENYS XR-ODT 18.8 MG TAB ER AL1 4 to 17 yrs old DISP Non-Preferred C Age restriction, clinical amphetamine PA required

ADZENYS XR-ODT 3.1 MG TAB ER AL1 4 to 17 yrs old DISP Non-Preferred C Age restriction, clinical amphetamine PA required

ADZENYS XR-ODT 6.3 MG TAB ER AL1 4 to 17 yrs old DISP Non-Preferred C Age restriction, clinical amphetamine PA required

ADZENYS XR-ODT 9.4 MG TAB ER AL1 4 to 17 yrs old DISP Non-Preferred C Age restriction, clinical amphetamine PA required AMPHETAMINE ER 1.25 MG/ML SUSP Non-Preferred amphetamine

PAGE 241 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

AL1 4 to 17 yrs old amphetamine sulfate tab 10 mg Non-Preferred C Age restriction, clinical PA required

AL1 4 to 17 yrs old amphetamine sulfate tab 5 mg Non-Preferred C Age restriction, clinical PA required

QL 30 / 30 days amphetamine-dextroamphetamine cap Preferred AL1 4 to 17 yrs old er 24hr 10 mg C Age restriction, clinical PA required

QL 30 / 30 days amphetamine-dextroamphetamine cap Preferred AL1 4 to 17 yrs old er 24hr 15 mg C Age restriction, clinical PA required

QL 30 / 30 days amphetamine-dextroamphetamine cap Preferred AL1 4 to 17 yrs old er 24hr 20 mg C Age restriction, clinical PA required

QL 30 / 30 days amphetamine-dextroamphetamine cap Preferred AL1 4 to 17 yrs old er 24hr 25 mg C Age restriction, clinical PA required

QL 30 / 30 days amphetamine-dextroamphetamine cap Preferred AL1 4 to 17 yrs old er 24hr 30 mg C Age restriction, clinical PA required

QL 30 / 30 days amphetamine-dextroamphetamine cap Preferred AL1 4 to 17 yrs old er 24hr 5 mg C Age restriction, clinical PA required

QL 90 / 30 days amphetamine-dextroamphetamine tab Preferred AL1 4 to 17 yrs old 10 mg C Age restriction, clinical PA required

QL 90 / 30 days amphetamine-dextroamphetamine tab Preferred AL1 4 to 17 yrs old 12.5 mg C Age restriction, clinical PA required

PAGE 242 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 90 / 30 days amphetamine-dextroamphetamine tab Preferred AL1 4 to 17 yrs old 15 mg C Age restriction, clinical PA required

QL 90 / 30 days amphetamine-dextroamphetamine tab Preferred AL1 4 to 17 yrs old 20 mg C Age restriction, clinical PA required

QL 60 / 30 days amphetamine-dextroamphetamine tab Preferred AL1 4 to 17 yrs old 30 mg C Age restriction, clinical PA required

QL 120 / 30 days amphetamine-dextroamphetamine tab 5 Preferred AL1 4 to 17 yrs old mg C Age restriction, clinical PA required

QL 120 / 30 days amphetamine-dextroamphetamine tab Preferred AL1 4 to 17 yrs old 7.5 mg C Age restriction, clinical PA required

AL1 4 to 17 yrs old DESOXYN 5 MG TAB Non-Preferred methamphetamine hcl C Age restriction, clinical PA required

QL 120 / 30 days DEXEDRINE 10 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old dextroamphetamine sulfate C Age restriction, clinical PA required

QL 120 / 30 days DEXEDRINE 15 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old dextroamphetamine sulfate C Age restriction, clinical PA required

QL 2 / 1 days DEXEDRINE 5 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old dextroamphetamine sulfate C Age restriction, clinical PA required

QL 120 / 30 days dextroamphetamine sulfate cap er 24hr Preferred AL1 4 to 17 yrs old 10 mg C Age restriction, clinical PA required

PAGE 243 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 120 / 30 days dextroamphetamine sulfate cap er 24hr Preferred AL1 4 to 17 yrs old 15 mg C Age restriction, clinical PA required

QL 2 / 1 days dextroamphetamine sulfate cap er 24hr Preferred AL1 4 to 17 yrs old 5 mg C Age restriction, clinical PA required

AL1 4 to 17 yrs old dextroamphetamine sulfate oral solution Non-Preferred 5 mg/5ml C Age restriction, clinical PA required

AL1 4 to 17 yrs old dextroamphetamine sulfate oral solution Non-Preferred 5 mg/5ml C Age restriction, clinical PA required

QL 120 / 30 days

dextroamphetamine sulfate tab 10 mg Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 120 / 30 days

dextroamphetamine sulfate tab 10 mg Non-Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 180 / 30 days

dextroamphetamine sulfate tab 5 mg Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 180 / 30 days

dextroamphetamine sulfate tab 5 mg Non-Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

AL1 4 to 17 yrs old DYANAVEL XR 2.5 MG/ML SUSP Non-Preferred amphetamine C Age restriction, clinical PA required

AL1 4 to 17 yrs old EVEKEO 10 MG TAB Non-Preferred amphetamine sulfate C Age restriction, clinical PA required

AL1 4 to 17 yrs old EVEKEO 5 MG TAB Non-Preferred amphetamine sulfate C Age restriction, clinical PA required

PAGE 244 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

AL1 4 to 17 yrs old EVEKEO ODT 10 MG TAB DISP Non-Preferred amphetamine sulfate C Age restriction, clinical PA required

AL1 4 to 17 yrs old EVEKEO ODT 15 MG TAB DISP Non-Preferred amphetamine sulfate C Age restriction, clinical PA required

AL1 4 to 17 yrs old EVEKEO ODT 20 MG TAB DISP Non-Preferred amphetamine sulfate C Age restriction, clinical PA required

AL1 4 to 17 yrs old EVEKEO ODT 5 MG TAB DISP Non-Preferred amphetamine sulfate C Age restriction, clinical PA required

AL1 4 to 17 yrs old methamphetamine hcl tab 5 mg Non-Preferred C Age restriction, clinical PA required

AL1 4 to 17 yrs old MYDAYIS 12.5 MG CAP ER 24H Non-Preferred amphetamine-dextroamphetamine C Age restriction, clinical PA required

AL1 4 to 17 yrs old MYDAYIS 25 MG CAP ER 24H Non-Preferred amphetamine-dextroamphetamine C Age restriction, clinical PA required

AL1 4 to 17 yrs old MYDAYIS 37.5 MG CAP ER 24H Non-Preferred amphetamine-dextroamphetamine C Age restriction, clinical PA required

AL1 4 to 17 yrs old MYDAYIS 50 MG CAP ER 24H Non-Preferred amphetamine-dextroamphetamine C Age restriction, clinical PA required

QL 1 / 1 days VYVANSE 10 MG CAP Preferred AL1 4 to 17 yrs old lisdexamfetamine dimesylate C Age restriction, clinical PA required

QL 30 / 30 days VYVANSE 10 MG CHEW TAB Non-Preferred AL1 4 to 17 yrs old lisdexamfetamine dimesylate C Age restriction, clinical PA required

QL 1 / 1 days VYVANSE 20 MG CAP Preferred AL1 4 to 17 yrs old lisdexamfetamine dimesylate C Age restriction, clinical PA required

PAGE 245 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 30 / 30 days VYVANSE 20 MG CHEW TAB Non-Preferred AL1 4 to 17 yrs old lisdexamfetamine dimesylate C Age restriction, clinical PA required

QL 1 / 1 days VYVANSE 30 MG CAP Preferred AL1 4 to 17 yrs old lisdexamfetamine dimesylate C Age restriction, clinical PA required

QL 30 / 30 days VYVANSE 30 MG CHEW TAB Non-Preferred AL1 4 to 17 yrs old lisdexamfetamine dimesylate C Age restriction, clinical PA required

QL 1 / 1 days VYVANSE 40 MG CAP Preferred AL1 4 to 17 yrs old lisdexamfetamine dimesylate C Age restriction, clinical PA required

QL 30 / 30 days VYVANSE 40 MG CHEW TAB Non-Preferred AL1 4 to 17 yrs old lisdexamfetamine dimesylate C Age restriction, clinical PA required

QL 1 / 1 days VYVANSE 50 MG CAP Preferred AL1 4 to 17 yrs old lisdexamfetamine dimesylate C Age restriction, clinical PA required

QL 30 / 30 days VYVANSE 50 MG CHEW TAB Non-Preferred AL1 4 to 17 yrs old lisdexamfetamine dimesylate C Age restriction, clinical PA required

QL 1 / 1 days VYVANSE 60 MG CAP Preferred AL1 4 to 17 yrs old lisdexamfetamine dimesylate C Age restriction, clinical PA required

QL 30 / 30 days VYVANSE 60 MG CHEW TAB Non-Preferred AL1 4 to 17 yrs old lisdexamfetamine dimesylate C Age restriction, clinical PA required

PAGE 246 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

AL1 4 to 17 yrs old ZENZEDI 15 MG TAB Non-Preferred dextroamphetamine sulfate C Age restriction, clinical PA required

AL1 4 to 17 yrs old ZENZEDI 2.5 MG TAB Non-Preferred dextroamphetamine sulfate C Age restriction, clinical PA required

AL1 4 to 17 yrs old ZENZEDI 20 MG TAB Non-Preferred dextroamphetamine sulfate C Age restriction, clinical PA required

AL1 4 to 17 yrs old ZENZEDI 30 MG TAB Non-Preferred dextroamphetamine sulfate C Age restriction, clinical PA required

AL1 4 to 17 yrs old ZENZEDI 7.5 MG TAB Non-Preferred dextroamphetamine sulfate C Age restriction, clinical PA required ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES

AL1 4 to 17 yrs old ADHANSIA XR 25 MG CAP ER 24H Non-Preferred methylphenidate hcl C Age restriction, clinical PA required

AL1 4 to 17 yrs old ADHANSIA XR 35 MG CAP ER 24H Non-Preferred methylphenidate hcl C Age restriction, clinical PA required

AL1 4 to 17 yrs old ADHANSIA XR 45 MG CAP ER 24H Non-Preferred methylphenidate hcl C Age restriction, clinical PA required

AL1 4 to 17 yrs old ADHANSIA XR 55 MG CAP ER 24H Non-Preferred methylphenidate hcl C Age restriction, clinical PA required

AL1 4 to 17 yrs old ADHANSIA XR 70 MG CAP ER 24H Non-Preferred methylphenidate hcl C Age restriction, clinical PA required

AL1 4 to 17 yrs old ADHANSIA XR 85 MG CAP ER 24H Non-Preferred methylphenidate hcl C Age restriction, clinical PA required

AL1 4 to 17 yrs old APTENSIO XR 10 MG CAP ER 24H Non-Preferred methylphenidate hcl C Age restriction, clinical PA required

AL1 4 to 17 yrs old APTENSIO XR 15 MG CAP ER 24H Non-Preferred methylphenidate hcl C Age restriction, clinical PA required

PAGE 247 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

AL1 4 to 17 yrs old APTENSIO XR 20 MG CAP ER 24H Non-Preferred methylphenidate hcl C Age restriction, clinical PA required

AL1 4 to 17 yrs old APTENSIO XR 30 MG CAP ER 24H Non-Preferred methylphenidate hcl C Age restriction, clinical PA required

AL1 4 to 17 yrs old APTENSIO XR 40 MG CAP ER 24H Non-Preferred methylphenidate hcl C Age restriction, clinical PA required

AL1 4 to 17 yrs old APTENSIO XR 50 MG CAP ER 24H Non-Preferred methylphenidate hcl C Age restriction, clinical PA required

AL1 4 to 17 yrs old APTENSIO XR 60 MG CAP ER 24H Non-Preferred methylphenidate hcl C Age restriction, clinical PA required

QL 2 / 1 days

atomoxetine hcl cap 10 mg (base equiv) Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 1 / 1 days atomoxetine hcl cap 100 mg (base Preferred AL1 4 to 17 yrs old equiv) C Age restriction, clinical PA required

QL 2 / 1 days

atomoxetine hcl cap 18 mg (base equiv) Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 2 / 1 days

atomoxetine hcl cap 25 mg (base equiv) Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 2 / 1 days

atomoxetine hcl cap 40 mg (base equiv) Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 1 / 1 days

atomoxetine hcl cap 60 mg (base equiv) Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

PAGE 248 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 1 / 1 days

atomoxetine hcl cap 80 mg (base equiv) Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

AL1 4 to 17 yrs old clonidine hcl tab er 12hr 0.1 mg Non-Preferred C Age restriction, clinical PA required

QL 30 / 30 days CONCERTA 18 MG TAB ER Non-Preferred AL1 4 to 17 yrs old methylphenidate hcl C Age restriction, clinical PA required

QL 30 / 30 days CONCERTA 27 MG TAB ER Non-Preferred AL1 4 to 17 yrs old methylphenidate hcl C Age restriction, clinical PA required

QL 60 / 30 days CONCERTA 36 MG TAB ER Non-Preferred AL1 4 to 17 yrs old methylphenidate hcl C Age restriction, clinical PA required

QL 30 / 30 days CONCERTA 54 MG TAB ER Non-Preferred AL1 4 to 17 yrs old methylphenidate hcl C Age restriction, clinical PA required

COTEMPLA XR-ODT 17.3 MG TAB ER AL1 4 to 17 yrs old DISP Non-Preferred C Age restriction, clinical methylphenidate PA required

COTEMPLA XR-ODT 25.9 MG TAB ER AL1 4 to 17 yrs old DISP Non-Preferred C Age restriction, clinical methylphenidate PA required

COTEMPLA XR-ODT 8.6 MG TAB ER AL1 4 to 17 yrs old DISP Non-Preferred C Age restriction, clinical methylphenidate PA required

AL1 4 to 17 yrs old DAYTRANA 10 MG/9HR PATCH Non-Preferred methylphenidate C Age restriction, clinical PA required

AL1 4 to 17 yrs old DAYTRANA 15 MG/9HR PATCH Non-Preferred methylphenidate C Age restriction, clinical PA required

PAGE 249 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

AL1 4 to 17 yrs old DAYTRANA 20 MG/9HR PATCH Non-Preferred methylphenidate C Age restriction, clinical PA required

AL1 4 to 17 yrs old DAYTRANA 30 MG/9HR PATCH Non-Preferred methylphenidate C Age restriction, clinical PA required

QL 2 / 1 days dexmethylphenidate hcl cap er 24 hr 10 Preferred AL1 4 to 17 yrs old mg C Age restriction, clinical PA required

QL 2 / 1 days dexmethylphenidate hcl cap er 24 hr 15 Preferred AL1 4 to 17 yrs old mg C Age restriction, clinical PA required

QL 2 / 1 days dexmethylphenidate hcl cap er 24 hr 20 Preferred AL1 4 to 17 yrs old mg C Age restriction, clinical PA required

QL 1 / 1 days dexmethylphenidate hcl cap er 24 hr 25 Preferred AL1 4 to 17 yrs old mg C Age restriction, clinical PA required

QL 1 / 1 days dexmethylphenidate hcl cap er 24 hr 30 Preferred AL1 4 to 17 yrs old mg C Age restriction, clinical PA required

QL 1 / 1 days dexmethylphenidate hcl cap er 24 hr 35 Preferred AL1 4 to 17 yrs old mg C Age restriction, clinical PA required

QL 1 / 1 days dexmethylphenidate hcl cap er 24 hr 40 Preferred AL1 4 to 17 yrs old mg C Age restriction, clinical PA required

QL 2 / 1 days dexmethylphenidate hcl cap er 24 hr 5 Preferred AL1 4 to 17 yrs old mg C Age restriction, clinical PA required

PAGE 250 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 2 / 1 days

dexmethylphenidate hcl tab 10 mg Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 2 / 1 days

dexmethylphenidate hcl tab 2.5 mg Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 2 / 1 days

dexmethylphenidate hcl tab 5 mg Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 2 / 1 days FOCALIN 10 MG TAB Non-Preferred AL1 4 to 17 yrs old dexmethylphenidate hcl C Age restriction, clinical PA required

QL 2 / 1 days FOCALIN 2.5 MG TAB Non-Preferred AL1 4 to 17 yrs old dexmethylphenidate hcl C Age restriction, clinical PA required

QL 2 / 1 days FOCALIN 5 MG TAB Non-Preferred AL1 4 to 17 yrs old dexmethylphenidate hcl C Age restriction, clinical PA required

QL 2 / 1 days FOCALIN XR 10 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old dexmethylphenidate hcl C Age restriction, clinical PA required

QL 2 / 1 days FOCALIN XR 15 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old dexmethylphenidate hcl C Age restriction, clinical PA required

QL 2 / 1 days FOCALIN XR 20 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old dexmethylphenidate hcl C Age restriction, clinical PA required

PAGE 251 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 1 / 1 days FOCALIN XR 30 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old dexmethylphenidate hcl C Age restriction, clinical PA required

QL 1 / 1 days FOCALIN XR 35 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old dexmethylphenidate hcl C Age restriction, clinical PA required

QL 1 / 1 days FOCALIN XR 40 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old dexmethylphenidate hcl C Age restriction, clinical PA required

QL 2 / 1 days FOCALIN XR 5 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old dexmethylphenidate hcl C Age restriction, clinical PA required

QL 60 / 30 days guanfacine hcl tab er 24hr 1 mg (base Preferred AL1 4 to 17 yrs old equiv) C Age restriction, clinical PA required

QL 60 / 30 days guanfacine hcl tab er 24hr 2 mg (base Preferred AL1 4 to 17 yrs old equiv) C Age restriction, clinical PA required

QL 60 / 30 days guanfacine hcl tab er 24hr 3 mg (base Preferred AL1 4 to 17 yrs old equiv) C Age restriction, clinical PA required

QL 30 / 30 days guanfacine hcl tab er 24hr 4 mg (base Preferred AL1 4 to 17 yrs old equiv) C Age restriction, clinical PA required

QL 60 / 30 days INTUNIV 1 MG TAB ER 24H Non-Preferred AL1 4 to 17 yrs old guanfacine hcl (adhd) C Age restriction, clinical PA required

PAGE 252 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 60 / 30 days INTUNIV 3 MG TAB ER 24H Non-Preferred AL1 4 to 17 yrs old guanfacine hcl (adhd) C Age restriction, clinical PA required

QL 30 / 30 days INTUNIV 4 MG TAB ER 24H Non-Preferred AL1 4 to 17 yrs old guanfacine hcl (adhd) C Age restriction, clinical PA required

AL1 4 to 17 yrs old JORNAY PM 100 MG CAP ER 24H Non-Preferred methylphenidate hcl C Age restriction, clinical PA required

AL1 4 to 17 yrs old JORNAY PM 20 MG CAP ER 24H Non-Preferred methylphenidate hcl C Age restriction, clinical PA required

AL1 4 to 17 yrs old JORNAY PM 40 MG CAP ER 24H Non-Preferred methylphenidate hcl C Age restriction, clinical PA required

AL1 4 to 17 yrs old JORNAY PM 60 MG CAP ER 24H Non-Preferred methylphenidate hcl C Age restriction, clinical PA required

AL1 4 to 17 yrs old JORNAY PM 80 MG CAP ER 24H Non-Preferred methylphenidate hcl C Age restriction, clinical PA required

AL1 4 to 17 yrs old KAPVAY 0.1 MG TAB ER 12H Non-Preferred clonidine hcl (adhd) C Age restriction, clinical PA required

AL1 4 to 17 yrs old METHYLIN 10 MG/5ML SOLUTION Non-Preferred methylphenidate hcl C Age restriction, clinical PA required

AL1 4 to 17 yrs old METHYLIN 5 MG/5ML SOLUTION Non-Preferred methylphenidate hcl C Age restriction, clinical PA required

QL 60 / 30 days

methylphenidate hcl cap er 10 mg (cd) Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days

methylphenidate hcl cap er 20 mg (cd) Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

PAGE 253 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 60 / 30 days methylphenidate hcl cap er 24hr 10 mg Preferred AL1 4 to 17 yrs old (la) C Age restriction, clinical PA required

AL1 4 to 17 yrs old methylphenidate hcl cap er 24hr 10 mg Non-Preferred (xr) C Age restriction, clinical PA required

AL1 4 to 17 yrs old methylphenidate hcl cap er 24hr 15 mg Non-Preferred (xr) C Age restriction, clinical PA required

QL 60 / 30 days methylphenidate hcl cap er 24hr 20 mg Preferred AL1 4 to 17 yrs old (la) C Age restriction, clinical PA required

AL1 4 to 17 yrs old methylphenidate hcl cap er 24hr 20 mg Non-Preferred (xr) C Age restriction, clinical PA required

QL 60 / 30 days methylphenidate hcl cap er 24hr 30 mg Preferred AL1 4 to 17 yrs old (la) C Age restriction, clinical PA required

AL1 4 to 17 yrs old methylphenidate hcl cap er 24hr 30 mg Non-Preferred (xr) C Age restriction, clinical PA required

QL 30 / 30 days methylphenidate hcl cap er 24hr 40 mg Preferred AL1 4 to 17 yrs old (la) C Age restriction, clinical PA required

AL1 4 to 17 yrs old methylphenidate hcl cap er 24hr 40 mg Non-Preferred (xr) C Age restriction, clinical PA required

AL1 4 to 17 yrs old methylphenidate hcl cap er 24hr 50 mg Non-Preferred (xr) C Age restriction, clinical PA required

QL 30 / 30 days methylphenidate hcl cap er 24hr 60 mg Preferred AL1 4 to 17 yrs old (la) C Age restriction, clinical PA required

PAGE 254 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

AL1 4 to 17 yrs old methylphenidate hcl cap er 24hr 60 mg Non-Preferred (xr) C Age restriction, clinical PA required

QL 60 / 30 days

methylphenidate hcl cap er 30 mg (cd) Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 30 / 30 days

methylphenidate hcl cap er 40 mg (cd) Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 30 / 30 days

methylphenidate hcl cap er 50 mg (cd) Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 30 / 30 days

methylphenidate hcl cap er 60 mg (cd) Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 180 / 30 days

methylphenidate hcl chew tab 10 mg Non-Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 120 / 30 days

methylphenidate hcl chew tab 2.5 mg Non-Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 120 / 30 days

methylphenidate hcl chew tab 5 mg Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

AL1 4 to 17 yrs old methylphenidate hcl soln 10 mg/5ml Preferred C Age restriction, clinical PA required

AL1 4 to 17 yrs old methylphenidate hcl soln 5 mg/5ml Preferred C Age restriction, clinical PA required

PAGE 255 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 90 / 30 days

methylphenidate hcl tab 20 mg Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 120 / 30 days

methylphenidate hcl tab 5 mg Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 90 / 30 days

methylphenidate hcl tab er 10 mg Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 90 / 30 days

methylphenidate hcl tab er 20 mg Non-Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 90 / 30 days

methylphenidate hcl tab er 20 mg Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 30 / 30 days

methylphenidate hcl tab er 24hr 18 mg Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 30 / 30 days

methylphenidate hcl tab er 24hr 27 mg Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 60 / 30 days

methylphenidate hcl tab er 24hr 36 mg Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

QL 30 / 30 days

methylphenidate hcl tab er 24hr 54 mg Preferred AL1 4 to 17 yrs old

C Age restriction, clinical PA required

PAGE 256 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 30 / 30 days methylphenidate hcl tab er osmotic Preferred AL1 4 to 17 yrs old release (osm) 27 mg C Age restriction, clinical PA required

QL 60 / 30 days methylphenidate hcl tab er osmotic Preferred AL1 4 to 17 yrs old release (osm) 36 mg C Age restriction, clinical PA required

QL 30 / 30 days methylphenidate hcl tab er osmotic Preferred AL1 4 to 17 yrs old release (osm) 54 mg C Age restriction, clinical PA required

METHYLPHENIDATE HCL ER 72 MG AL1 4 to 17 yrs old TAB ER Non-Preferred C Age restriction, clinical methylphenidate hcl PA required

AL1 4 to 17 yrs old QUILLICHEW ER 20 MG CHER Preferred methylphenidate hcl C Age restriction, clinical PA required

AL1 4 to 17 yrs old QUILLICHEW ER 30 MG CHER Preferred methylphenidate hcl C Age restriction, clinical PA required

AL1 4 to 17 yrs old QUILLICHEW ER 40 MG CHER Preferred methylphenidate hcl C Age restriction, clinical PA required

AL1 4 to 17 yrs old QUILLIVANT XR 25 MG/5ML SRER Preferred methylphenidate hcl C Age restriction, clinical PA required

AL1 4 to 17 yrs old RELEXXII 72 MG TAB ER Non-Preferred methylphenidate hcl C Age restriction, clinical PA required

QL 90 / 30 days RITALIN 10 MG TAB Non-Preferred AL1 4 to 17 yrs old methylphenidate hcl C Age restriction, clinical PA required

QL 90 / 30 days RITALIN 20 MG TAB Non-Preferred AL1 4 to 17 yrs old methylphenidate hcl C Age restriction, clinical PA required

PAGE 257 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 120 / 30 days RITALIN 5 MG TAB Non-Preferred AL1 4 to 17 yrs old methylphenidate hcl C Age restriction, clinical PA required

QL 60 / 30 days RITALIN LA 10 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old methylphenidate hcl C Age restriction, clinical PA required

QL 60 / 30 days RITALIN LA 20 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old methylphenidate hcl C Age restriction, clinical PA required

QL 60 / 30 days RITALIN LA 30 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old methylphenidate hcl C Age restriction, clinical PA required

QL 30 / 30 days RITALIN LA 40 MG CAP ER 24H Non-Preferred AL1 4 to 17 yrs old methylphenidate hcl C Age restriction, clinical PA required

QL 2 / 1 days STRATTERA 10 MG CAP Non-Preferred AL1 4 to 17 yrs old atomoxetine hcl C Age restriction, clinical PA required

QL 1 / 1 days STRATTERA 100 MG CAP Non-Preferred AL1 4 to 17 yrs old atomoxetine hcl C Age restriction, clinical PA required

QL 2 / 1 days STRATTERA 18 MG CAP Non-Preferred AL1 4 to 17 yrs old atomoxetine hcl C Age restriction, clinical PA required

QL 2 / 1 days STRATTERA 25 MG CAP Non-Preferred AL1 4 to 17 yrs old atomoxetine hcl C Age restriction, clinical PA required

PAGE 258 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 1 / 1 days STRATTERA 60 MG CAP Non-Preferred AL1 4 to 17 yrs old atomoxetine hcl C Age restriction, clinical PA required

QL 1 / 1 days STRATTERA 80 MG CAP Non-Preferred AL1 4 to 17 yrs old atomoxetine hcl C Age restriction, clinical PA required CENTRAL NERVOUS SYSTEM, OTHER

ALLZITAL 25-325 MG TAB Non-Preferred QLC Max 18 tabs/caps per butalbital-acetaminophen month AUSTEDO 12 MG TAB Preferred PA deutetrabenazine AUSTEDO 6 MG TAB Preferred PA deutetrabenazine AUSTEDO 9 MG TAB Preferred PA deutetrabenazine BUTALBITAL-ACETAMINOPHEN 25- 325 MG TAB Non-Preferred QLC Max 18 tabs/caps per butalbital-acetaminophen month BUTALBITAL-ACETAMINOPHEN 50- 300 MG CAP Non-Preferred QLC Max 18 tabs/caps per butalbital-acetaminophen month butalbital-acetaminophen cap 50-300 Non-Preferred QLC Max 18 tabs/caps per mg month

butalbital-acetaminophen tab 50-300 mg Non-Preferred QLC Max 18 tabs/caps per month

butalbital-acetaminophen tab 50-300 mg Non-Preferred QLC Max 18 tabs/caps per month

butalbital-acetaminophen tab 50-325 mg Non-Preferred QLC Max 18 tabs/caps per month

butalbital-acetaminophen tab 50-325 mg Non-Preferred QLC Max 18 tabs/caps per month butalbital-acetaminophen-caffeine cap Non-Preferred QLC Max 18 tabs/caps per 50-300-40 mg month butalbital-acetaminophen-caffeine cap Non-Preferred QLC Max 18 tabs/caps per 50-325-40 mg month butalbital-acetaminophen-caffeine cap Non-Preferred QLC Max 18 tabs/caps per 50-325-40 mg month

PAGE 259 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS butalbital-acetaminophen-caffeine cap Non-Preferred QLC Max 18 tabs/caps per 50-325-40 mg month butalbital-acetaminophen-caffeine soln Non-Preferred QLC 270 mL/30 days 50-325-40 mg/15ml butalbital-acetaminophen-caffeine soln Non-Preferred QLC 270 mL/30 days 50-325-40 mg/15ml

PA butalbital-acetaminophen-caffeine tab Preferred 50-325-40 mg QLC Max 18 tabs/caps per month

PA butalbital-acetaminophen-caffeine tab Preferred 50-325-40 mg QLC Max 18 tabs/caps per month ESGIC 50-325-40 MG TAB Non-Preferred QLC Max 18 tabs/caps per butalbital-acetaminophen-caffeine month FIORICET 50-300-40 MG CAP Non-Preferred QLC Max 18 tabs/caps per butalbital-acetaminophen-caffeine month HORIZANT 300 MG TAB ER Non-Preferred gabapentin enacarbil HORIZANT 600 MG TAB ER Non-Preferred gabapentin enacarbil INGREZZA 40 & 80 MG CAP THPK Preferred PA valbenazine tosylate

INGREZZA 40 MG CAP QL 30 / 30 days Preferred valbenazine tosylate PA

INGREZZA 80 MG CAP QL 1 / 1 days Preferred valbenazine tosylate PA

tetrabenazine tab 12.5 mg Preferred PA

tetrabenazine tab 25 mg Preferred PA

VTOL LQ 50-325-40 MG/15ML SOLUTION Non-Preferred QLC 270 mL/30 days butalbital-acetaminophen-caffeine XENAZINE 12.5 MG TAB Non-Preferred tetrabenazine XENAZINE 25 MG TAB Non-Preferred tetrabenazine

PAGE 260 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS FIBROMYALGIA AGENTS

CYMBALTA 20 MG CP DR PART Non-Preferred QL 2 / 1 days duloxetine hcl CYMBALTA 30 MG CP DR PART Non-Preferred QL 2 / 1 days duloxetine hcl CYMBALTA 60 MG CP DR PART Non-Preferred QL 2 / 1 days duloxetine hcl DRIZALMA SPRINKLE 20 MG CAP DR Non-Preferred duloxetine hcl DRIZALMA SPRINKLE 30 MG CAP DR Non-Preferred duloxetine hcl DRIZALMA SPRINKLE 40 MG CAP DR Non-Preferred duloxetine hcl DRIZALMA SPRINKLE 60 MG CAP DR Non-Preferred duloxetine hcl duloxetine hcl enteric coated pellets cap Preferred QL 2 / 1 days 20 mg (base eq) duloxetine hcl enteric coated pellets cap Preferred QL 2 / 1 days 30 mg (base eq) duloxetine hcl enteric coated pellets cap Non-Preferred QL 1 / 1 days 40 mg (base eq) duloxetine hcl enteric coated pellets cap Preferred QL 2 / 1 days 60 mg (base eq) LYRICA 100 MG CAP Non-Preferred QL 3 / 1 days pregabalin LYRICA 150 MG CAP Non-Preferred QL 3 / 1 days pregabalin LYRICA 20 MG/ML SOLUTION Non-Preferred QLC 30 mL/day pregabalin LYRICA 200 MG CAP Non-Preferred QL 3 / 1 days pregabalin LYRICA 225 MG CAP Non-Preferred QL 2 / 1 days pregabalin LYRICA 25 MG CAP Non-Preferred QL 3 / 1 days pregabalin LYRICA 300 MG CAP Non-Preferred QL 2 / 1 days pregabalin LYRICA 50 MG CAP Non-Preferred QL 3 / 1 days pregabalin

PAGE 261 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS LYRICA 75 MG CAP Non-Preferred QL 3 / 1 days pregabalin LYRICA CR 165 MG TAB ER 24H Non-Preferred QL 90 / 30 days pregabalin (once-daily) LYRICA CR 330 MG TAB ER 24H Non-Preferred QL 60 / 30 days pregabalin (once-daily) LYRICA CR 82.5 MG TAB ER 24H Non-Preferred QL 90 / 30 days pregabalin (once-daily)

pregabalin cap 100 mg Preferred QL 3 / 1 days

pregabalin cap 150 mg Preferred QL 3 / 1 days

pregabalin cap 200 mg Preferred QL 3 / 1 days

pregabalin cap 225 mg Preferred QL 2 / 1 days

pregabalin cap 25 mg Preferred QL 3 / 1 days

pregabalin cap 300 mg Preferred QL 2 / 1 days

pregabalin cap 50 mg Preferred QL 3 / 1 days

pregabalin cap 75 mg Preferred QL 3 / 1 days

pregabalin soln 20 mg/ml Preferred QLC 30 mL/day

SAVELLA 100 MG TAB Non-Preferred milnacipran hcl SAVELLA 12.5 MG TAB Non-Preferred milnacipran hcl SAVELLA 25 MG TAB Non-Preferred milnacipran hcl SAVELLA 50 MG TAB Non-Preferred milnacipran hcl SAVELLA TITRATION PACK 12.5 & 25 & 50 MG MISC Non-Preferred milnacipran hcl MULTIPLE SCLEROSIS AGENTS

AMPYRA 10 MG TAB ER 12H Non-Preferred QL 60 / 30 days dalfampridine

AUBAGIO 14 MG TAB QL 30 / 30 days Preferred teriflunomide PA

PAGE 262 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

AUBAGIO 7 MG TAB QL 30 / 30 days Preferred teriflunomide PA

AVONEX 30 MCG KIT Preferred interferon beta-1a AVONEX PEN 30 MCG/0.5ML AUT-IJ KIT Preferred interferon beta-1a AVONEX PREFILLED 30 MCG/0.5ML PREF SY KT Preferred interferon beta-1a BAFIERTAM 95 MG CAP DR Non-Preferred QL 120 / 30 days monomethyl fumarate BETASERON 0.3 MG KIT Preferred interferon beta-1b COPAXONE 20 MG/ML SOLN PRSYR Non-Preferred QL 30 / 30 days glatiramer acetate COPAXONE 40 MG/ML SOLN PRSYR Non-Preferred QL 12 / 28 days glatiramer acetate

QL 60 / 30 days dalfampridine tab er 12hr 10 mg Preferred PA

dimethyl fumarate capsule delayed Preferred PA release 120 mg dimethyl fumarate capsule delayed Preferred PA release 240 mg dimethyl fumarate capsule dr starter Preferred PA pack 120 mg & 240 mg EXTAVIA 0.3 MG KIT Non-Preferred interferon beta-1b GILENYA 0.25 MG CAP Preferred fingolimod hcl GILENYA 0.5 MG CAP Preferred PA fingolimod hcl glatiramer acetate soln prefilled syringe Preferred QL 30 / 30 days 20 mg/ml glatiramer acetate soln prefilled syringe Preferred QL 30 / 30 days 20 mg/ml glatiramer acetate soln prefilled syringe Preferred QL 12 / 28 days 40 mg/ml

PAGE 263 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS glatiramer acetate soln prefilled syringe Preferred QL 12 / 28 days 40 mg/ml KESIMPTA 20 MG/0.4ML SOLN A-INJ Non-Preferred ofatumumab (ms) LEMTRADA 12 MG/1.2ML SOLUTION Non-Preferred alemtuzumab (ms) MAVENCLAD (10 TABS) 10 MG TAB THPK Non-Preferred cladribine (multiple sclerosis) MAVENCLAD (4 TABS) 10 MG TAB THPK Non-Preferred cladribine (multiple sclerosis) MAVENCLAD (5 TABS) 10 MG TAB THPK Non-Preferred cladribine (multiple sclerosis) MAVENCLAD (6 TABS) 10 MG TAB THPK Non-Preferred cladribine (multiple sclerosis) MAVENCLAD (7 TABS) 10 MG TAB THPK Non-Preferred cladribine (multiple sclerosis) MAVENCLAD (8 TABS) 10 MG TAB THPK Non-Preferred cladribine (multiple sclerosis) MAVENCLAD (9 TABS) 10 MG TAB THPK Non-Preferred cladribine (multiple sclerosis) MAYZENT 0.25 MG TAB Non-Preferred QL 120 / 30 days siponimod fumarate MAYZENT 2 MG TAB Non-Preferred QL 30 / 30 days siponimod fumarate MAYZENT STARTER PACK 0.25 MG TAB THPK Non-Preferred QLC 1 fill per lifetime siponimod fumarate OCREVUS 300 MG/10ML SOLUTION Non-Preferred ocrelizumab PLEGRIDY 125 MCG/0.5ML SOLN PEN Non-Preferred peginterferon beta-1a PLEGRIDY 125 MCG/0.5ML SOLN PRSYR Non-Preferred peginterferon beta-1a

PAGE 264 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PLEGRIDY STARTER PACK 63 & 94 MCG/0.5ML SOLN PEN Non-Preferred peginterferon beta-1a PLEGRIDY STARTER PACK 63 & 94 MCG/0.5ML SOLN PRSYR Non-Preferred peginterferon beta-1a REBIF 22 MCG/0.5ML SOLN PRSYR Preferred interferon beta-1a REBIF 44 MCG/0.5ML SOLN PRSYR Preferred interferon beta-1a REBIF REBIDOSE 22 MCG/0.5ML SOLN A-INJ Preferred interferon beta-1a REBIF REBIDOSE 44 MCG/0.5ML SOLN A-INJ Preferred interferon beta-1a REBIF REBIDOSE TITRATION PACK 6X8.8 & 6X22 MCG SOLN A-INJ Preferred interferon beta-1a REBIF TITRATION PACK 6X8.8 & 6X22 MCG SOLN PRSYR Preferred interferon beta-1a TECFIDERA 120 & 240 MG MISC Non-Preferred dimethyl fumarate TECFIDERA 120 MG CAP DR Non-Preferred dimethyl fumarate TECFIDERA 240 MG CAP DR Non-Preferred dimethyl fumarate TYSABRI 300 MG/15ML CONC Preferred PA natalizumab VUMERITY 231 MG CAP DR Non-Preferred QL 120 / 30 days diroximel fumarate VUMERITY (STARTER) 231 MG CAP DR Non-Preferred QLC 1 fill per lifetime diroximel fumarate ZEPOSIA 0.92 MG CAP Non-Preferred QL 30 / 30 days ozanimod hcl ZEPOSIA 7-DAY STARTER PACK 4 X 0.23MG & 3 X 0.46MG CAP THPK Non-Preferred QLC 1 fill per lifetime ozanimod hcl ZEPOSIA STARTER KIT 0.23MG & 0.46MG & 0.92MG CAP THPK Non-Preferred QLC 1 fill per lifetime ozanimod hcl

PAGE 265 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS DENTAL AND ORAL AGENTS

chlorhexidine gluconate soln 0.12% Preferred QL 30 / 1 days

pilocarpine hcl tab 5 mg Preferred QL 4 / 1 days

pilocarpine hcl tab 7.5 mg Preferred QL 4 / 1 days

triamcinolone acetonide dental paste Preferred 0.1% triamcinolone acetonide dental paste Preferred 0.1% DERMATOLOGICAL AGENTS

ABSORICA 10 MG CAP Non-Preferred isotretinoin ABSORICA 20 MG CAP Non-Preferred isotretinoin ABSORICA 25 MG CAP Non-Preferred isotretinoin ABSORICA 30 MG CAP Non-Preferred isotretinoin ABSORICA 35 MG CAP Non-Preferred isotretinoin ABSORICA 40 MG CAP Non-Preferred isotretinoin ABSORICA LD 16 MG CAP Non-Preferred isotretinoin micronized ABSORICA LD 24 MG CAP Non-Preferred isotretinoin micronized ABSORICA LD 32 MG CAP Non-Preferred isotretinoin micronized ABSORICA LD 8 MG CAP Non-Preferred isotretinoin micronized ACANYA 1.2-2.5 % GEL Non-Preferred clindamycin phosphate-benzoyl peroxide acitretin cap 10 mg Non-Preferred acitretin cap 17.5 mg Non-Preferred acitretin cap 25 mg Non-Preferred ACZONE 5 % GEL Non-Preferred dapsone (topical)

PAGE 266 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ACZONE 7.5 % GEL Non-Preferred dapsone (topical)

AL1 Up to 20 yrs old ADAPALENE 0.1 % SOLUTION Non-Preferred adapalene C Age restriction, clinical PA required

QL 45 / 30 days

adapalene cream 0.1% Preferred AL1 Up to 20 yrs old

C Age restriction, clinical PA required

QL 45 / 30 days

adapalene gel 0.1% Preferred AL1 Up to 20 yrs old

C Age restriction, clinical PA required

AL1 Up to 20 yrs old adapalene gel 0.3% Preferred C Age restriction, clinical PA required

AL1 Up to 20 yrs old ADAPALENE 0.3 % GEL PUMP Non-Preferred C Age restriction, clinical PA required

AL1 Up to 20 yrs old adapalene-benzoyl peroxide gel 0.1- Preferred 2.5% C Age restriction, clinical PA required

AL1 Up to 20 yrs old AKLIEF 0.005 % CREAM Non-Preferred trifarotene C Age restriction, clinical PA required ALCORTIN A 1-2-1 % GEL iodoquinol-hydrocortisone-aloe Non-Preferred polysaccharide ALDARA 5 % CREAM Non-Preferred imiquimod

AL1 Up to 20 yrs old ALTRENO 0.05 % LOTION Non-Preferred tretinoin C Age restriction, clinical PA required ARAZLO 0.045 % LOTION Non-Preferred tazarotene (acne)

AL1 Up to 20 yrs old ATRALIN 0.05 % GEL Non-Preferred tretinoin C Age restriction, clinical PA required

AL1 Up to 20 yrs old AZELEX 20 % CREAM Non-Preferred azelaic acid (acne) C Age restriction, clinical PA required

PAGE 267 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS BENSAL HP 3-6 % OINTMENT Non-Preferred salicylic acid & benzoic acid BENZACLIN 1-5 % GEL Non-Preferred clindamycin phosphate-benzoyl peroxide BENZACLIN WITH PUMP 1-5 % GEL Non-Preferred clindamycin phosphate-benzoyl peroxide BENZEPRO 5.2 % FOAM Non-Preferred benzoyl peroxide BENZEPRO 5.8 % MISC Non-Preferred benzoyl peroxide benzoyl peroxide foam 9.8% Preferred BP CLEANSING WASH 10-4 % EMULSION Non-Preferred sulfacetamide sodium-sulfur in urea vehicle BPO 4 % GEL Non-Preferred benzoyl peroxide BPO 8 % GEL Non-Preferred benzoyl peroxide CALCIPOTRIENE 0.005 % FOAM Non-Preferred calcipotriene

calcipotriene cream 0.005% Preferred QL 60 / 30 days

calcipotriene oint 0.005% Preferred QL 60 / 30 days

calcipotriene oint 0.005% Non-Preferred calcipotriene soln 0.005% (50 mcg/ml) Preferred calcipotriene-betamethasone Non-Preferred dipropionate oint 0.005-0.064% calcipotriene-betamethasone Non-Preferred dipropionate susp 0.005-0.064% calcitriol oint 3 mcg/gm Non-Preferred CLINDAMYCIN PHOS-BENZOYL Non-Preferred PEROX 1-5 % GEL PUMP clindamycin phosphate foam 1% Non-Preferred clindamycin phosphate-benzoyl peroxide Preferred gel 1-5% clindamycin phosphate-benzoyl peroxide Non-Preferred gel 1.2-2.5%

PAGE 268 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS clindamycin phosph-benzoyl peroxide Preferred (refrig) gel 1.2 (1)-5% clindamycin phosph-benzoyl peroxide Non-Preferred (refrig) gel 1.2 (1)-5%

AL1 Up to 20 yrs old clindamycin phosphate-tretinoin gel 1.2- Non-Preferred 0.025% C Age restriction, clinical PA required clotrimazole w/ betamethasone cream 1- Preferred QL 45 / 28 days 0.05% clotrimazole w/ betamethasone lotion 1- Non-Preferred 0.05% CORTISPORIN 1 % OINTMENT Non-Preferred bacitracin-polymyxin-neomycin hc CORTISPORIN 3.5-10000-0.5 CREAM Non-Preferred neomycin-polymyxin-hc COSENTYX 150 MG/ML SOLN PRSYR Non-Preferred secukinumab COSENTYX (300 MG DOSE) 150 MG/ML SOLN PRSYR Non-Preferred secukinumab COSENTYX SENSOREADY (300 MG) 150 MG/ML SOLN A-INJ Non-Preferred secukinumab COSENTYX SENSOREADY PEN 150 MG/ML SOLN A-INJ Non-Preferred secukinumab dapsone gel 5% Non-Preferred dapsone gel 7.5% Non-Preferred

diclofenac sodium gel 1% Preferred QL 500 / 30 days

diclofenac sod soln 1.5% & capsaicin Non-Preferred cream 0.025% ther pack

QL 45 / 30 days DIFFERIN 0.1 % CREAM Preferred AL1 Up to 20 yrs old adapalene C Age restriction, clinical PA required

AL1 Up to 20 yrs old DIFFERIN 0.1 % LOTION Non-Preferred adapalene C Age restriction, clinical PA required

PAGE 269 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

AL1 Up to 20 yrs old DIFFERIN 0.3 % GEL Non-Preferred adapalene C Age restriction, clinical PA required DIPROLENE 0.05 % OINTMENT Non-Preferred QL 50 / 30 days betamethasone dipropionate augmented DOVONEX 0.005 % CREAM Non-Preferred QL 2 / 1 days calcipotriene DRYSOL 20 % SOLUTION Preferred aluminum chloride DUAC 1.2-5 % GEL clindamycin phosphate-benzoyl peroxide Non-Preferred (refrigerate) DUOBRII 0.01-0.045 % LOTION Non-Preferred halobetasol propionate-tazarotene DUPIXENT 200 MG/1.14ML SOLN PRSYR Non-Preferred QL 4.56 / 28 days dupilumab DUPIXENT 300 MG/2ML SOLN PEN Non-Preferred dupilumab DUPIXENT 300 MG/2ML SOLN PRSYR Non-Preferred QL 8 / 28 days dupilumab DUROLANE 60 MG/3ML PRSYR Preferred PA sodium hyaluronate (viscosupplement) ELIDEL 1 % CREAM Preferred QL 30 / 24 days pimecrolimus ENSTILAR 0.005-0.064 % FOAM calcipotriene-betamethasone Non-Preferred dipropionate

AL1 Up to 20 yrs old EPIDUO 0.1-2.5 % GEL Non-Preferred adapalene-benzoyl peroxide C Age restriction, clinical PA required

AL1 Up to 20 yrs old EPIDUO FORTE 0.3-2.5 % GEL Non-Preferred adapalene-benzoyl peroxide C Age restriction, clinical PA required EUCRISA 2 % OINTMENT Preferred PA crisaborole EVOCLIN 1 % FOAM Non-Preferred clindamycin phosphate (topical)

AL1 Up to 20 yrs old FABIOR 0.1 % FOAM Non-Preferred tazarotene (acne) C Age restriction, clinical PA required

PAGE 270 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS hydrocortisone perianal cream 1% Preferred hydrocortisone perianal cream 1% Preferred ILUMYA 100 MG/ML SOLN PRSYR Non-Preferred tildrakizumab-asmn imiquimod cream 3.75% Non-Preferred imiquimod cream 3.75% Non-Preferred

imiquimod cream 5% Preferred QL 48 / 365 days

iodoquinol-hc cream 1-1% Non-Preferred iodoquinol-hc cream 1-1% Non-Preferred *iodoquinol-hydrocortisone-aloe Non-Preferred polysaccharide gel 1-2-1%*** isotretinoin cap 10 mg Non-Preferred

isotretinoin cap 10 mg Preferred PA

isotretinoin cap 10 mg Non-Preferred isotretinoin cap 10 mg Non-Preferred

isotretinoin cap 10 mg Preferred PA

isotretinoin cap 10 mg Preferred PA

isotretinoin cap 20 mg Non-Preferred

isotretinoin cap 20 mg Preferred PA

isotretinoin cap 20 mg Non-Preferred isotretinoin cap 20 mg Non-Preferred

isotretinoin cap 20 mg Preferred PA

isotretinoin cap 20 mg Preferred PA

isotretinoin cap 30 mg Non-Preferred isotretinoin cap 30 mg Non-Preferred isotretinoin cap 30 mg Non-Preferred

isotretinoin cap 30 mg Preferred PA

isotretinoin cap 30 mg Preferred PA

isotretinoin cap 40 mg Non-Preferred

isotretinoin cap 40 mg Preferred PA

PAGE 271 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS isotretinoin cap 40 mg Non-Preferred isotretinoin cap 40 mg Non-Preferred

isotretinoin cap 40 mg Preferred PA

isotretinoin cap 40 mg Preferred PA

lactic acid (ammonium lactate) cream Preferred 12% lactic acid (ammonium lactate) lotion Preferred 12% LOTRISONE 1-0.05 % CREAM Non-Preferred clotrimazole w/ betamethasone LUXIQ 0.12 % FOAM Non-Preferred betamethasone valerate methoxsalen rapid cap 10 mg Non-Preferred

metronidazole cream 0.75% Preferred QL 45 / 26 days

metronidazole cream 0.75% Preferred QL 45 / 26 days

metronidazole gel 0.75% Preferred QL 45 / 26 days

metronidazole gel 0.75% Preferred QL 45 / 26 days

MICORT-HC 2.5 % CREAM Non-Preferred hydrocortisone acetate (topical) NEO-SYNALAR 0.5-0.025 % CREAM Non-Preferred neomycin sulfate-fluocinolone acetonide NEO-SYNALAR 0.5-0.025 % KIT Non-Preferred neomycin-fluocinolone & emollient NEUAC 1.2-5 % KIT clindamycin phosphate-benzoyl peroxide Non-Preferred & moisturizer ONEXTON 1.2-3.75 % GEL Non-Preferred clindamycin phosphate-benzoyl peroxide OXSORALEN ULTRA 10 MG CAP Non-Preferred methoxsalen rapid

pimecrolimus cream 1% Non-Preferred QL 30 / 24 days

PIMECROLIMUS 1 % CREAM Preferred QL 30 / 24 days (Oceanside [68682] labeler only) podofilox soln 0.5% Preferred

PAGE 272 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PROCTOCORT 1 % CREAM Non-Preferred hydrocortisone (rectal) PROCTOFOAM HC 1-1 % FOAM Preferred hydrocortisone acetate w/ pramoxine PROTOPIC 0.03 % OINTMENT Preferred QLC 30 grams per fill tacrolimus (topical) PROTOPIC 0.1 % OINTMENT Preferred QLC 30 grams per fill tacrolimus (topical)

QL 45 / 30 days RETIN-A 0.01 % GEL Preferred AL1 Up to 20 yrs old tretinoin C Age restriction, clinical PA required

QL 45 / 30 days RETIN-A 0.025 % CREAM Preferred AL1 Up to 20 yrs old tretinoin C Age restriction, clinical PA required

QL 45 / 30 days RETIN-A 0.025 % GEL Preferred AL1 Up to 20 yrs old tretinoin C Age restriction, clinical PA required

QL 45 / 30 days RETIN-A 0.05 % CREAM Preferred AL1 Up to 20 yrs old tretinoin C Age restriction, clinical PA required

QL 45 / 30 days RETIN-A 0.1 % CREAM Preferred AL1 Up to 20 yrs old tretinoin C Age restriction, clinical PA required

AL1 Up to 20 yrs old RETIN-A MICRO 0.04 % GEL Non-Preferred tretinoin microsphere C Age restriction, clinical PA required

AL1 Up to 20 yrs old RETIN-A MICRO 0.1 % GEL Non-Preferred tretinoin microsphere C Age restriction, clinical PA required

AL1 Up to 20 yrs old RETIN-A MICRO PUMP 0.04 % GEL Non-Preferred tretinoin microsphere C Age restriction, clinical PA required

AL1 Up to 20 yrs old RETIN-A MICRO PUMP 0.06 % GEL Non-Preferred tretinoin microsphere C Age restriction, clinical PA required

PAGE 273 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

AL1 Up to 20 yrs old RETIN-A MICRO PUMP 0.08 % GEL Non-Preferred tretinoin microsphere C Age restriction, clinical PA required

AL1 Up to 20 yrs old RETIN-A MICRO PUMP 0.1 % GEL Non-Preferred tretinoin microsphere C Age restriction, clinical PA required Max 60 days supply SANTYL 250 UNIT/GM OINTMENT C Preferred per 365 days collagenase QLC 120 grams/30 days

selenium sulfide lotion 2.5% Preferred SERNIVO 0.05 % EMULSION Non-Preferred betamethasone dipropionate (topical) SKYRIZI (150 MG DOSE) 75 MG/0.83ML PREF SY KT Non-Preferred risankizumab-rzaa SORIATANE 10 MG CAP Preferred acitretin SORIATANE 25 MG CAP Preferred acitretin SORILUX 0.005 % FOAM Non-Preferred calcipotriene SSS 10-5 10-5 % FOAM Non-Preferred sulfacetamide sodium w/ sulfur STELARA 130 MG/26ML SOLUTION Non-Preferred QLC 104 mL/56 days ustekinumab (iv) STELARA 45 MG/0.5ML SOLN PRSYR Non-Preferred QLC 0.5 mL/28 days ustekinumab STELARA 45 MG/0.5ML SOLUTION Non-Preferred QLC 0.5 mL/28 days ustekinumab STELARA 90 MG/ML SOLN PRSYR Non-Preferred QLC 1 mL/28 days ustekinumab sulfacetamide sodium liquid 10% Non-Preferred sulfacetamide sodium w/ sulfur cleanser Non-Preferred 10-2% sulfacetamide sodium w/ sulfur cleanser Non-Preferred 9.8-4.8% sulfacetamide sodium w/ sulfur Non-Preferred cleansing pad 10-4%

PAGE 274 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS sulfacetamide sodium w/ sulfur cream Non-Preferred 10-2% sulfacetamide sodium w/ sulfur cream Non-Preferred 10-5% sulfacetamide sodium w/ sulfur cream Non-Preferred 10-5% sulfacetamide sodium w/ sulfur cream Preferred 10-5% sulfacetamide sodium w/ sulfur cream Non-Preferred 10-5% sulfacetamide sodium w/ sulfur emulsion Non-Preferred 10-1% sulfacetamide sodium w/ sulfur emulsion Non-Preferred 10-5% sulfacetamide sodium w/ sulfur susp 8- Preferred 4% sulfacetamide sodium w/ sulfur wash 9- Non-Preferred 4% sulfacetamide sodium w/ sulfur wash 9- Non-Preferred 4% sulfacetamide sodium w/ sulfur wash 9- Preferred 4.5% sulfacetamide sodium w/ sulfur wash 9- Preferred 4.5% SUMADAN 9-4.5 % KIT sulfacetamide sodium-sulfur w/ skin Non-Preferred cleanser SUMADAN WASH 9-4.5 % LIQUID Non-Preferred sulfacetamide sodium w/ sulfur SUMADAN XLT 9-4.5 % KIT Non-Preferred sulfacetamide sodium-sulfur-sunscreen SUMAXIN 10-4 % PAD Non-Preferred sulfacetamide sodium w/ sulfur SUMAXIN CP 10-4 % KIT sulfacetamide sodium-sulfur w/ skin Non-Preferred cleanser SUMAXIN TS 8-4 % SUSPENSION Non-Preferred sulfacetamide sodium w/ sulfur SUMAXIN WASH 9-4 % LIQUID Non-Preferred sulfacetamide sodium w/ sulfur

PAGE 275 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TACLONEX 0.005-0.064 % OINTMENT calcipotriene-betamethasone Preferred dipropionate TACLONEX 0.005-0.064 % SUSPENSION Preferred calcipotriene-betamethasone dipropionate

tacrolimus oint 0.03% Preferred QLC 30 grams per fill

tacrolimus oint 0.1% Preferred QLC 30 grams per fill

TALTZ 80 MG/ML SOLN A-INJ Preferred PA ixekizumab TALTZ 80 MG/ML SOLN PRSYR Preferred PA ixekizumab

QL 30 / 30 days

tazarotene cream 0.1% Non-Preferred AL1 Up to 20 yrs old

C Age restriction, clinical PA required

QL 30 / 30 days TAZORAC 0.05 % CREAM Preferred AL1 Up to 20 yrs old tazarotene C Age restriction, clinical PA required

QL 30 / 30 days TAZORAC 0.05 % GEL Preferred AL1 Up to 20 yrs old tazarotene C Age restriction, clinical PA required

QL 30 / 30 days TAZORAC 0.1 % CREAM Preferred AL1 Up to 20 yrs old tazarotene C Age restriction, clinical PA required

QL 30 / 30 days TAZORAC 0.1 % GEL Preferred AL1 Up to 20 yrs old tazarotene C Age restriction, clinical PA required TOVET 0.05 % KIT clobetasol propionate emulsion foam w/ Non-Preferred moisturizing cream

QL 45 / 30 days

tretinoin cream 0.025% Preferred AL1 Up to 20 yrs old

C Age restriction, clinical PA required

PAGE 276 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 45 / 30 days

tretinoin cream 0.025% Preferred AL1 Up to 20 yrs old

C Age restriction, clinical PA required

QL 45 / 30 days

tretinoin cream 0.05% Preferred AL1 Up to 20 yrs old

C Age restriction, clinical PA required

QL 45 / 30 days

tretinoin cream 0.1% Preferred AL1 Up to 20 yrs old

C Age restriction, clinical PA required

QL 45 / 30 days

tretinoin gel 0.01% Preferred AL1 Up to 20 yrs old

C Age restriction, clinical PA required

QL 45 / 30 days

tretinoin gel 0.025% Preferred AL1 Up to 20 yrs old

C Age restriction, clinical PA required

QL 45 / 30 days

tretinoin gel 0.025% Preferred AL1 Up to 20 yrs old

C Age restriction, clinical PA required

AL1 Up to 20 yrs old tretinoin gel 0.05% Non-Preferred C Age restriction, clinical PA required

AL1 Up to 20 yrs old tretinoin microsphere gel 0.04% Non-Preferred C Age restriction, clinical PA required

AL1 Up to 20 yrs old tretinoin microsphere gel 0.04% Non-Preferred C Age restriction, clinical PA required

AL1 Up to 20 yrs old tretinoin microsphere gel 0.1% Non-Preferred C Age restriction, clinical PA required

AL1 Up to 20 yrs old tretinoin microsphere gel 0.1% Non-Preferred C Age restriction, clinical PA required

PAGE 277 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

urea lotion 40% Preferred QL 240 / 24 days

urea lotion 40% Preferred QL 240 / 24 days

VECTICAL 3 MCG/GM OINTMENT Non-Preferred calcitriol (topical) WINLEVI 1 % CREAM Non-Preferred clascoterone WYNZORA 0.005-0.064 % CREAM calcipotriene-betamethasone Non-Preferred dipropionate XEPI 1 % CREAM Non-Preferred ozenoxacin

AL1 Up to 20 yrs old ZIANA 1.2-0.025 % GEL Non-Preferred clindamycin phosphate-tretinoin C Age restriction, clinical PA required ZYCLARA 3.75 % CREAM Non-Preferred imiquimod ZYCLARA PUMP 2.5 % CREAM Non-Preferred imiquimod ZYCLARA PUMP 3.75 % CREAM Non-Preferred imiquimod ELECTROLYTES/MINERALS/METALS/VITAMINS

ELECTROLYTE/MINERAL REPLACEMENT

ACTIVE FE 75-1.25 MG TAB Non-Preferred fe carbonyl-fa-b complex-a-c-d-e-min ENDARI 5 GM PACKET Non-Preferred QL 180 / 30 days glutamine (sickle cell) *fe fum-iron polysacch complex-fa-b Non-Preferred cmplx-c-zn-mn-cu cap*** *fe fum-iron polysacch complex-fa-b Non-Preferred cmplx-c-zn-mn-cu cap*** fe fumarate-vit c-vit b12-fa cap 460 (151 Non-Preferred fe)-60-0.01-1 mg FERAHEME 510 MG/17ML SOLUTION Non-Preferred ferumoxytol FERIVA 21/7 75-1 MG TAB fe asparto gly-vit b12-fa-vit c-dss- Non-Preferred succinic acid-zinc

PAGE 278 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS FERIVAFA 110-1 MG CAP Non-Preferred iron-vit c-fa-b12-biotin-copper-docusate FERRALET 90 90-1 MG TAB fe carbonyl-fe gluconate-fa-vit b12-vit c- Non-Preferred docusate sodium FERRAPLUS 90 90-1 MG TAB iron-folic acid-vitamin b12-vitamin c- Non-Preferred docusate sodium FERRLECIT 12.5 MG/ML SOLUTION sodium ferric gluconate complex in Preferred sucrose *ferrous fumarate-fa-b complex-c-zn-mg- Non-Preferred mn-cu tab 106-1 mg*** *ferrous fumarate-fa-b complex-c-zn-mg- Preferred mn-cu tab 106-1 mg*** ferrous fumarate-folic acid tab 324-1 mg Non-Preferred ferrous fumarate-folic acid tab 324-1 mg Non-Preferred FOLIVANE-F 125-1 MG CAP ferrous fumarate-iron polysaccharide Preferred complex-folic acid-c-b3 FUSION PLUS CAP fe fum-iron polysacch complex-fa-b Non-Preferred cmplx-c-biotin-probiotic FUSION SPRINKLES 7-0.25-50-5 MG PACKET Non-Preferred ferrous fumarate-iron polysaccharide complex-fa-c-probiotic HEMATOGEN FA 200-250-0.01-1 MG CAP Non-Preferred fe fumarate-vitamin c-vitamin b12-folic acid HEMATOGEN FORTE 460-60-0.01-1 MG CAP Non-Preferred fe fumarate-vitamin c-vitamin b12-folic acid HEMETAB 22-6-1-0.025 MG TAB polysaccharide fe complex-fe heme Non-Preferred polypeptide-fa-vit b12 INFED 50 MG/ML SOLUTION Preferred iron dextran INJECTAFER 750 MG/15ML SOLUTION Non-Preferred ferric carboxymaltose

PAGE 279 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS INTEGRA F 125-1 MG CAP ferrous fumarate-iron polysaccharide Non-Preferred complex-folic acid-c-b3 iron polysacch complex-vit b12-fa cap Preferred 150-0.025-1 mg iron polysacch complex-vit b12-fa cap Non-Preferred 150-0.025-1 mg iron polysacch complex-vit b12-fa cap Non-Preferred 150-0.025-1 mg *iron-docusate-b12-folic acid-c-e-cu- Non-Preferred biotin tab 150-1 mg*** iron-folic acid-vit c-vit b6-vit b12-zinc tab Non-Preferred 150-1.25 mg IROSPAN 24/6 MISC fe bisglyc-fe polysaccharide-succ acd-b Non-Preferred complex-c-ca-fa levocarnitine oral soln 1 gm/10ml (10%) Preferred levocarnitine oral soln 1 gm/10ml (10%) Preferred MONOFERRIC 1000 MG/10ML SOLUTION Non-Preferred ferric derisomaltose MULTIGEN 70 MG TAB fe asparto gly-succin ac-c-threonic ac- Non-Preferred b12-des stom subst MULTIGEN FOLIC 70-150-2-1 MG TAB fe asparto gly-succinic acd-vit c-threonic Non-Preferred acd-vit b12-fa MULTIGEN PLUS 50-101-1 MG TAB fe asparto gly-fe fumarate-succ acd-c- Non-Preferred threonic acd-b12-fa NEPHRON FA TAB ferrous fumarate w/ fa-dss-b complex-vit Non-Preferred c

potassium bicarbonate effer tab 25 meq Preferred QL 4 / 1 days

potassium bicarbonate effer tab 25 meq Preferred QL 4 / 1 days

potassium bicarbonate effer tab 25 meq Preferred QL 4 / 1 days

potassium bicarbonate effer tab 25 meq Preferred QL 4 / 1 days

potassium chloride cap er 10 meq Preferred QL 5 / 1 days

PAGE 280 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

potassium chloride cap er 10 meq Preferred QL 5 / 1 days

potassium chloride cap er 8 meq Preferred potassium chloride cap er 8 meq Preferred potassium chloride oral soln 10% (20 Preferred QL 60 / 1 days meq/15ml) potassium chloride oral soln 20% (40 Preferred QL 60 / 1 days meq/15ml) potassium chloride powder packet 20 Preferred QL 5 / 1 days meq potassium chloride powder packet 20 Preferred QL 5 / 1 days meq

potassium chloride tab er 10 meq Preferred QL 5 / 1 days

potassium chloride tab er 10 meq Preferred QL 5 / 1 days

potassium chloride tab er 20 meq (1500 Preferred QL 5 / 1 days mg) potassium chloride tab er 8 meq (600 Preferred QL 5 / 1 days mg) potassium chloride tab er 8 meq (600 Preferred QL 5 / 1 days mg) potassium chloride microencapsulated Preferred QL 5 / 1 days crys er tab 10 meq potassium chloride microencapsulated Preferred QL 5 / 1 days crys er tab 10 meq potassium chloride microencapsulated Preferred QL 5 / 1 days crys er tab 20 meq potassium chloride microencapsulated Preferred QL 5 / 1 days crys er tab 20 meq sodium bicarbonate iv soln 8.4% Preferred sodium chloride irrigation soln 0.9% Preferred sod ferric gluc cmplx in sucrose iv soln Preferred 12.5 mg/ml (fe eq) sodium fluoride chew tab 0.25 mg f Preferred QL 4 / 1 days (from 0.55 mg naf) sodium fluoride chew tab 0.5 mg f (from Preferred QL 2 / 1 days 1.1 mg naf) sodium fluoride chew tab 1 mg f (from Preferred QL 1 / 1 days 2.2 mg naf)

PAGE 281 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS sodium fluoride soln 0.5 mg/ml f (from Preferred QL 50 / 30 days 1.1 mg/ml naf) TANDEM PLUS 162-115.2-1 MG CAP fe fum-iron polysacch complex-fa-b Non-Preferred complex-c-zn-mn-cu TARON FORTE CAP fe bisglycinate-fe polysaccharide-vit c-vit Non-Preferred b12-folic acid VENOFER 20 MG/ML SOLUTION Preferred iron sucrose ELECTROLYTE/MINERAL/METAL MODIFIERS

CHEMET 100 MG CAP Preferred succimer deferasirox granules packet 180 mg Preferred deferasirox granules packet 180 mg Preferred deferasirox granules packet 360 mg Preferred deferasirox granules packet 360 mg Preferred deferasirox granules packet 90 mg Preferred

deferasirox tab 180 mg Preferred PA

deferasirox tab 360 mg Preferred PA

deferasirox tab 90 mg Preferred PA

deferasirox tab for oral susp 125 mg Preferred PA

deferasirox tab for oral susp 250 mg Preferred PA

deferasirox tab for oral susp 500 mg Preferred PA

deferiprone tab 500 mg Non-Preferred EXJADE 125 MG TAB SOL Non-Preferred deferasirox EXJADE 250 MG TAB SOL Non-Preferred deferasirox EXJADE 500 MG TAB SOL Non-Preferred deferasirox FERRIPROX 100 MG/ML SOLUTION Non-Preferred deferiprone FERRIPROX 1000 MG TAB Non-Preferred deferiprone

PAGE 282 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS FERRIPROX 500 MG TAB Non-Preferred deferiprone FERRIPROX TWICE-A-DAY 1000 MG TAB Non-Preferred deferiprone JADENU 180 MG TAB Non-Preferred deferasirox JADENU 360 MG TAB Non-Preferred deferasirox JADENU 90 MG TAB Non-Preferred deferasirox JADENU SPRINKLE 180 MG PACKET Non-Preferred deferasirox JADENU SPRINKLE 360 MG PACKET Non-Preferred deferasirox JADENU SPRINKLE 90 MG PACKET Non-Preferred deferasirox

*sodium polystyrene sulfonate powder** Preferred QL 60 / 1 days

*sodium polystyrene sulfonate powder** Preferred QL 60 / 1 days

sodium polystyrene sulfonate oral susp Preferred QL 240 / 1 days 15 gm/60ml sodium polystyrene sulfonate oral susp Preferred QL 240 / 1 days 15 gm/60ml sodium polystyrene sulfonate rectal susp Preferred QL 480 / 1 days 30 gm/120ml sodium polystyrene sulfonate rectal susp Preferred QL 480 / 1 days 30 gm/120ml SPS 15 GM/60ML SUSPENSION Preferred QL 240 / 1 days sodium polystyrene sulfonate TRIFERIC 272 MG PACKET Non-Preferred ferric pyrophosphate citrate PHOSPHATE BINDERS

AURYXIA 1 GM 210 MG(FE) TAB Non-Preferred ferric citrate calcium acetate (phosphate binder) cap Preferred QL 12 / 1 days 667 mg (169 mg ca) calcium acetate (phosphate binder) tab Preferred QL 12 / 1 days 667 mg

PAGE 283 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS calcium acetate (phosphate binder) tab Preferred 667 mg FOSRENOL 1000 MG CHEW TAB Non-Preferred lanthanum carbonate FOSRENOL 1000 MG PACKET Non-Preferred lanthanum carbonate FOSRENOL 500 MG CHEW TAB Non-Preferred lanthanum carbonate FOSRENOL 750 MG CHEW TAB Non-Preferred lanthanum carbonate FOSRENOL 750 MG PACKET Non-Preferred lanthanum carbonate lanthanum carbonate chew tab 1000 mg Non-Preferred (elemental) lanthanum carbonate chew tab 500 mg Non-Preferred (elemental) lanthanum carbonate chew tab 750 mg Non-Preferred (elemental) PHOSLYRA 667 MG/5ML SOLUTION Preferred calcium acetate (phosphate binder) pot phos monobasic w/sod phos di & Preferred monobas tab 155-852-130mg pot phos monobasic w/sod phos di & Preferred monobas tab 155-852-130mg pot phos monobasic w/sod phos di & Preferred monobas tab 155-852-130mg RENAGEL 400 MG TAB Non-Preferred QL 16 / 1 days sevelamer hcl RENAGEL 800 MG TAB Non-Preferred QL 16 / 1 days sevelamer hcl RENVELA 0.8 GM PACKET Non-Preferred sevelamer carbonate RENVELA 2.4 GM PACKET Non-Preferred sevelamer carbonate RENVELA 800 MG TAB Non-Preferred QL 17 / 1 days sevelamer carbonate sevelamer carbonate packet 0.8 gm Non-Preferred sevelamer carbonate packet 2.4 gm Non-Preferred

PAGE 284 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

sevelamer carbonate tab 800 mg Preferred QL 17 / 1 days

SEVELAMER HCL 400 MG TAB Non-Preferred sevelamer hcl sevelamer hcl tab 800 mg Non-Preferred VELPHORO 500 MG CHEW TAB Non-Preferred sucroferric oxyhydroxide VELTASSA 16.8 GM PACKET Preferred PA patiromer sorbitex calcium VELTASSA 25.2 GM PACKET Preferred PA patiromer sorbitex calcium VELTASSA 8.4 GM PACKET Preferred PA patiromer sorbitex calcium VITAMINS

AZESCHEW PRENATAL/POSTNATAL 13-1 MG CHEW TAB Non-Preferred prenatal without a vit w/ fe fumarate-folic acid

*b-complex w/ c & folic acid cap 1 mg*** Preferred QL 1 / 1 days

*b-complex w/ c & folic acid cap 1 mg*** Preferred QL 1 / 1 days

*b-complex w/ c & folic acid cap 1 mg*** Preferred QL 1 / 1 days

*b-complex w/ c & folic acid tab 1 mg*** Preferred *b-complex w/ c & folic acid tab 1 mg*** Preferred *b-complex w/ c & folic acid tab 1 mg*** Preferred BP VIT 3 1 MG CAP folic acid-vitamin b6-vitamin b12-omega Non-Preferred 3 acids-phytosterols C-NATE DHA 28-1-200 MG CAP prenatal vit w/ ferrous fumarate-fa- Non-Preferred omega 3 fatty acids CENTRATEX 106-1 MG CAP ferrous fumarate-fa-b complex-c-zn-mg- Non-Preferred mn-cu CITRANATAL 90 DHA 90-1 & 300 MG MISC Non-Preferred prenatal w/o vit a w/ fe carbonyl-fe gluconate-dss-fa-dha

PAGE 285 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CITRANATAL B-CALM 20-1 MG & 2 X 25 MG MISC Non-Preferred prenatal w/o vit a w/ fe carbonyl-fe gluconate-fa & vit b6 CITRANATAL BLOOM 90-1 MG TAB prenatal vit w/ docusate-fe carbonyl-fe Non-Preferred gluconate-folic acid CITRANATAL DHA 27-1 & 250 MG MISC Non-Preferred prenatal w/o vit a w/ fe carbonyl-fe gluconate-dss-fa-dha CITRANATAL HARMONY 27-1-260 MG CAP Non-Preferred prenatal w/o vit a w/ fe fumarate-fe carbonyl-dss-fa-dha CITRANATAL RX 27-1 MG TAB prenatal without vit a w/ fe carbonyl-fe Non-Preferred gluc-docusate-fa COMPLETE NATAL DHA 29-1-200 & 250 MG MISC Preferred prenatal mv & min w/fe bisglyc-fe prot succ-fa-ca-omega 3 COMPLETENATE 29-1 MG CHEW TAB Non-Preferred prenatal vit w/ ferrous fumarate-folic acid CONCEPT DHA 53.5-38-1 MG CAP prenatal vit w/ fe fum-iron polysacch Non-Preferred complex -fa-omega 3 CONCEPT OB 130-92.4-1 MG CAP prenatal without a vit w/ fe fum-iron Non-Preferred polysacch complex -fa CORVITE 150 TAB Non-Preferred iron combinations CORVITE FE TAB Non-Preferred iron combinations cyanocobalamin inj 1000 mcg/ml Preferred ENBRACE HR CAP prenatal vit w/ fe glycine cysteinate-fa- Non-Preferred omega 3 fatty acids fe fumarate w/ b12-vit c-fa-ifc cap 110- Non-Preferred 0.015-75-0.5-240 mg fe fumarate w/ b12-vit c-fa-ifc cap 110- Non-Preferred 0.015-75-0.5-240 mg

PAGE 286 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

folic acid tab 1 mg Preferred QL 4 / 1 days

folic acid-pyridoxine-cyanocobalamin tab Preferred 2.5-25-2 mg folic acid-pyridoxine-cyanocobalamin tab Preferred 2.5-25-2 mg folic acid-vitamin b6-vitamin b12 tab 2.2- Preferred 25-0.5 mg folic acid-vitamin b6-vitamin b12 tab 2.2- Preferred 25-0.5 mg folic acid-vitamin b6-vitamin b12 tab 2.2- Non-Preferred 25-1 mg folic acid-vitamin b6-vitamin b12 tab 2.2- Preferred 25-1 mg folic acid-vitamin b6-vitamin b12 tab 2.2- Preferred 25-1 mg folic acid-vitamin b6-vitamin b12 tab 2.2- Non-Preferred 25-1 mg folic acid-vitamin b6-vitamin b12 tab 2.5- Non-Preferred 25-1 mg folic acid-vitamin b6-vitamin b12 tab 2.5- Non-Preferred 25-1 mg FOLITE TAB folic acid-vitamin d3-mag cit- Non-Preferred acetylcysteine-ca cit FOLIVANE-OB 130-92.4-1 MG CAP prenatal without a vit w/ fe fum-iron Non-Preferred polysacch complex -fa FOLIVANE-PLUS CAP fe fum-iron polysacch complex-fa-b Non-Preferred complex-c-biotin FOLTRATE 500-1 MCG-MG TAB Non-Preferred cobalamin combinations HEMOCYTE PLUS 106-1 MG CAP ferrous fumarate-fa-b complex-c-zn-mg- Non-Preferred mn-cu INTEGRA PLUS CAP fe fum-iron polysacch complex-fa-b Non-Preferred complex-c-biotin *iron combination cap*** Non-Preferred

PAGE 287 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS *iron combination cap*** Non-Preferred *iron w/ vitamin tab** Non-Preferred M-NATAL PLUS 27-1 MG TAB Preferred QL 1 / 1 days prenatal vit w/ ferrous fumarate-folic acid

*multiple vitamins w/ minerals tab** Preferred QL 1 / 1 days

*multiple vitamins w/ minerals tab** Preferred QL 1 / 1 days

*multiple vitamins w/ minerals tab** Preferred QL 1 / 1 days

MULTIVITAMIN/FLUORIDE 0.25 MG CHEW TAB Preferred QL 1 / 1 days pediatric multivitamins w/fl MULTIVITAMIN/FLUORIDE 0.5 MG CHEW TAB Preferred QL 1 / 1 days pediatric multivitamins w/fl MULTIVITAMIN/FLUORIDE 1 MG CHEW TAB Preferred QL 1 / 1 days pediatric multivitamins w/fl NESTABS 32-1 MG TAB prenatal vit without vit a w/ fe Non-Preferred bisglycinate-folic acid NESTABS DHA 32-1 MG MISC prenatal vit without vit a w/ fe Non-Preferred bisglycinate-fa-omeg 3 NESTABS ONE 38-1-225 MG CAP prenatal w/o a w/fe carbonyl-fe bisglyc-l Non-Preferred methylfol-dha NIFEREX TAB Non-Preferred iron combinations NIVA-PLUS 27-1 MG TAB Preferred QL 1 / 1 days prenatal vit w/ ferrous fumarate-folic acid NUFERA TAB Non-Preferred iron combinations O-CAL FA 27-1 MG TAB Preferred QL 1 / 1 days prenatal vit w/ ferrous fumarate-folic acid O-CAL PRENATAL TAB Non-Preferred prenatal vit w/ ferrous fumarate-folic acid OB COMPLETE 50-1.25 MG TAB Non-Preferred prenatal vit w/ iron carbonyl-folic acid OB COMPLETE ONE 50-1-476 MG CAP Non-Preferred prenatal w/o vit a w/ fe carbonyl-fe aspart glyc-fa-fish oil

PAGE 288 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS OB COMPLETE PETITE 35-5-1-200 MG CAP Non-Preferred prenatal w/o vit a w/ fe carbonyl-fe aspart glyc-fa-omega 3 OB COMPLETE PREMIER 30-20-1 MG TAB Non-Preferred prenatal vit w/ iron carbonyl-fe aspart glycinate-fa OB COMPLETE/DHA 30-10-1-200 MG CAP Non-Preferred prenat vit w/ iron carbonyl-fe asp glyc-fa- omega fatty acid *pediatric multiple vitamins w/ fl-fe drops Preferred 0.25-10 mg/ml** *pediatric multiple vitamins w/ fl-fe drops Preferred 0.25-10 mg/ml** *pediatric multiple vitamins w/ fl-fe drops Preferred 0.25-10 mg/ml** *pediatric multiple vitamins w/ fluoride Preferred QL 1 / 1 days chew tab 0.5 mg*** PNV PRENATAL PLUS MULTIVITAMIN 27-1 MG TAB Preferred prenatal vit w/ ferrous fumarate-folic acid PNV TABS 20-1 20-1 MG TAB prenatal vit w/ fe bisglycinate chelate- Non-Preferred folic acid PNV TABS 29-1 29-1 MG TAB Preferred QL 1 / 1 days prenatal vit w/ iron carbonyl-folic acid PNV-DHA+DOCUSATE 27-1.25-300 MG CAP Non-Preferred prenatal w/o vit a w/ fe fumarate-dss-fa- dha PNV-OMEGA 28-0.6-0.4-340 MG CAP prenatal without a w/ fe fumarate-l Non-Preferred methylfolate-fa-omega 3 PNV-SELECT 27-0.6-0.4 MG TAB prenatal vit w/ ferrous fumarate-l Non-Preferred methylfolate-folic acid PRENAISSANCE 29-1.25-325 MG CAP prenatal w/o vit a w/ fe fumarate-dss-fa- Non-Preferred dha

PAGE 289 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PRENATAL 27-1 MG TAB Preferred QL 1 / 1 days prenatal vit w/ ferrous fumarate-folic acid PRENATAL 19 CHEW TAB Non-Preferred prenatal vit w/ ferrous fumarate-folic acid *prenatal vit w/ iron carbonyl-fa tab 50- Non-Preferred 1.25 mg*** PRENATAL VITAMIN PLUS LOW IRON 27-1 MG TAB Preferred QL 1 / 1 days prenatal vit w/ ferrous fumarate-folic acid *prenat w/o a w/fefum-methfol-fa-dha Non-Preferred cap 27-0.6-0.4-300 mg** PRENATAL-U 106.5-1 MG CAP prenatal without a vit w/ fe fumarate-folic Preferred acid PRENATE 0.6-0.4 MG CHEW TAB prenatal multivitamins & minerals w/ l- Non-Preferred methylfolate-fa PRENATE AM 1 MG TAB prenatal w/ calcium-vit b6-vit b12-folic Non-Preferred acid-ginger PRENATE DHA 18-0.6-0.4-300 MG CAP Non-Preferred prenatal w/o a w/ fe asparto glyc-l methylfolate-fa-dha PRENATE ELITE 20-0.6-0.4 MG TAB prenatal w/ fe asparto glycinate-l Non-Preferred methylfolate-folic acid PRENATE ENHANCE 28-0.6-0.4-400 MG CAP Non-Preferred prenatal without a w/ fe fumarate-l methylfolate-fa-dha PRENATE ESSENTIAL 18-0.6-0.4-300 MG CAP Non-Preferred prenatal w/o a w/ fe asparto glyc-l methylfolate-fa-dha PRENATE MINI 18-0.6-0.4-350 MG CAP Non-Preferred prenatal w/o vit a w/ fe carbonyl-fe asp glyc-methfol-fa-dha PRENATE PIXIE 10-0.6-0.4-200 MG CAP Non-Preferred prenatal w/o a w/ fe asparto glyc-l methylfolate-fa-dha

PAGE 290 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PRENATE RESTORE 27-0.6-0.4-400 MG CAP Non-Preferred prenatal without a w/ fe fumarate-l methylfolate-fa-dha PRENATRIX 27-1 MG TAB Non-Preferred prenatal vit w/ ferrous fumarate-folic acid PRENATRYL 27-1 MG TAB Non-Preferred prenatal vit w/ ferrous fumarate-folic acid PREPLUS 27-1 MG TAB Preferred QL 1 / 1 days prenatal vit w/ ferrous fumarate-folic acid PRETAB 29-1 MG TAB Preferred prenatal vit w/ ferrous fumarate-folic acid PRIMACARE 30-1-470 MG CAP prenatal without a w/ fe asp glyc-l Non-Preferred methylfolate-fa-omega 3 PROVIDA DHA 16-16-1.25-110 MG CAP Non-Preferred prenatal without a w/fe fum-fe polysacch complex-fa-dha PROVIDA OB 20-20-1.25 MG CAP prenatal without a vit w/ fe fum-iron Non-Preferred polysacch complex -fa PUREFE OB PLUS 162-115.2-1 MG CAP Non-Preferred prenatal without a vit w/ fe fum-iron polysacch complex -fa SE-NATAL 19 29-1 MG CHEW TAB Non-Preferred prenatal vit w/ ferrous fumarate-folic acid SE-NATAL 19 29-1 MG TAB prenatal vit w/ docusate-fe fumarate-folic Non-Preferred acid SELECT-OB 29-0.6-0.4 MG CHEW TAB prenatal vit w/ iron polysaccharide Non-Preferred cmplx-l methylfolate-fa SELECT-OB 29-1 MG CHEW TAB prenatal vit w/ iron polysaccharide Non-Preferred complex-folic acid SELECT-OB+DHA 29-1 & 250 MG MISC Non-Preferred prenatal mv & min w/fe polysaccharide complex-fa-dha TARON-C DHA 53.5-38-1 MG CAP prenatal vit w/ fe fum-iron polysacch Non-Preferred complex -fa-omega 3

PAGE 291 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TARON-PREX 30-1.2-265 MG CAP prenatal w/o vit a w/ fe fumarate-dss-fa- Non-Preferred dha THRIVITE 19 1 MG TAB Non-Preferred multiple vitamins w/ minerals & folic acid THRIVITE RX 29-1 MG TAB Non-Preferred QL 1 / 1 days prenatal vit w/ iron carbonyl-folic acid TRICARE TAB Non-Preferred QL 1 / 1 days prenatal vit w/ ferrous fumarate-folic acid TRICARE PRENATAL DHA ONE 0.8 MG CAP Non-Preferred prenatal multivit-min w/fe-fa TRINATAL RX 1 60-1 MG TAB Preferred QL 1 / 1 days prenatal vit w/ ferrous fumarate-folic acid TRISTART DHA 31-0.6-0.4-200 MG CAP Non-Preferred prenatal without a w/ fe carbonyl-l methylfolate-fa-dha TRIVEEN-DUO DHA 29-1-200 & 400 MG MISC Preferred prenatal mv & min w/fe bisglyc-fe prot succ-fa-ca-omega 3 VINATE DHA RF 27-1.13 MG CAP prenatal without vit a w/ fe fumarate-l Non-Preferred methylfolate-omegas VINATE M 27-1 MG TAB prenatal vit w/ selenium-fe fumarate-folic Preferred acid VIRT NATE 28-1 MG TAB Non-Preferred prenatal vit w/ ferrous fumarate-folic acid VIRT-C DHA 53.5-38-1 MG CAP prenatal vit w/ fe fum-iron polysacch Non-Preferred complex -fa-omega 3 VIRT-FEFA PLUS CAP fe fum-iron polysacch complex-fa-b Non-Preferred complex-c-biotin VIRT-NATE DHA 28-1-200 MG CAP prenatal vit w/ ferrous fumarate-fa- Non-Preferred omega 3 fatty acids VIRT-PN 27-0.6-0.4 MG TAB prenatal vit w/ ferrous fumarate-l Non-Preferred methylfolate-folic acid

PAGE 292 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VIRT-PN DHA 27-0.6-0.4-300 MG CAP prenatal without a w/ fe fumarate-l Non-Preferred methylfolate-fa-dha VIRT-PN PLUS 28-0.6-0.4-340 MG CAP prenatal without a w/ fe fumarate-l Non-Preferred methylfolate-fa-omega 3 VIRT-SELECT 29-1.25-325 MG CAP prenatal w/o vit a w/ fe fumarate-dss-fa- Non-Preferred dha VIRTPREX 26-1.2-300 MG CAP prenatal w/o vit a w/ fe fumarate-dss-fa- Non-Preferred dha VITAFOL FE+ 90-0.6-0.4-200 MG CAP prenatal vit w/ fe polysacch complex-l Non-Preferred methylfolate-fa-dha VITAFOL FE+ 90-1-200 & 50 MG CAP THPK Non-Preferred prenatal vit w/ fe polysacch complex-l methylfol-fa-dha-dss VITAFOL GUMMIES 3.33-0.333-34.8 MG CHEW TAB Non-Preferred prenatal vit w/ ferric phosphate-fa- omega 3 fatty acids VITAFOL ULTRA 29-0.6-0.4-200 MG CAP Non-Preferred prenatal vit w/ fe polysacch complex-l methylfolate-fa-dha VITAFOL-NANO 18-0.6-0.4 MG TAB prenatal w/o a vit w/ fe fumarate-l Non-Preferred methylfolate-folic acid VITAFOL-OB TAB Non-Preferred prenatal vit w/ ferrous fumarate-folic acid VITAFOL-OB+DHA 65-1 & 250 MG MISC Non-Preferred prenatal mv & min w/fe fumarate-fa-dha VITAFOL-ONE 29-1-200 MG CAP prenatal mv & min w/fe polysaccharide Non-Preferred complex-fa-dha VOL-PLUS 27-1 MG TAB Preferred QL 1 / 1 days prenatal vit w/ ferrous fumarate-folic acid VP-PNV-DHA 28-1-215.8 MG CAP prenatal vit w/ ferrous fumarate-fa- Non-Preferred omega 3 fatty acids

PAGE 293 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS WESTAB PLUS 27-1 MG TAB Preferred prenatal vit w/ ferrous fumarate-folic acid WESTGEL DHA 31-0.6-0.4-200 MG CAP Non-Preferred prenatal without a w/ fe carbonyl-l methylfolate-fa-dha ZATEAN-PN DHA 27-0.6-0.4-300 MG CAP Non-Preferred prenatal without a w/ fe fumarate-l methylfolate-fa-dha ZATEAN-PN PLUS 28-0.6-0.4-340 MG CAP Non-Preferred prenatal without a w/ fe fumarate-l methylfolate-fa-omega 3 GASTROINTESTINAL AGENTS

ANTISPASMODICS, GASTROINTESTINAL

dicyclomine hcl cap 10 mg Preferred QL 8 / 1 days

dicyclomine hcl tab 20 mg Preferred QL 8 / 1 days

glycopyrrolate tab 1 mg Preferred QL 6 / 1 days

glycopyrrolate tab 2 mg Preferred QL 4 / 1 days

propantheline bromide tab 15 mg Preferred QL 5 / 1 days

GASTROINTESTINAL AGENTS, OTHER

ACTIGALL 300 MG CAP Non-Preferred QL 90 / 30 days ursodiol amoxicillin cap-clarithro tab-lansopraz Non-Preferred cap dr therapy pack CHENODAL 250 MG TAB Non-Preferred chenodiol diphenoxylate w/ atropine liq 2.5-0.025 Preferred QL 40 / 1 days mg/5ml diphenoxylate w/ atropine tab 2.5-0.025 Preferred QL 8 / 1 days mg HELIDAC THERAPY MISC metronidazole-tetracycline w/ bismuth Non-Preferred subsalicylate

loperamide hcl cap 2 mg Preferred QL 8 / 1 days

PAGE 294 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MOTEGRITY 1 MG TAB Non-Preferred QL 30 / 30 days prucalopride succinate MOTEGRITY 2 MG TAB Non-Preferred QL 30 / 30 days prucalopride succinate MOVANTIK 12.5 MG TAB Non-Preferred QL 1 / 1 days naloxegol oxalate MOVANTIK 25 MG TAB Non-Preferred QL 1 / 1 days naloxegol oxalate OMECLAMOX-PAK 500-500-20 MG MISC Non-Preferred amoxicillin-clarithromycin w/ omeprazole PYLERA 140-125-125 MG CAP bismuth subcitrate potassium- Non-Preferred metronidazole-tetracycline RELISTOR 12 MG/0.6ML SOLUTION Non-Preferred methylnaltrexone bromide RELISTOR 150 MG TAB Non-Preferred QL 90 / 30 days methylnaltrexone bromide RELISTOR 8 MG/0.4ML SOLUTION Non-Preferred methylnaltrexone bromide SYMPROIC 0.2 MG TAB Non-Preferred QL 30 / 30 days naldemedine tosylate TALICIA 250-12.5-10 MG CAP DR Non-Preferred amoxicillin-rifabutin-omeprazole URSO 250 250 MG TAB Non-Preferred ursodiol URSO FORTE 500 MG TAB Non-Preferred ursodiol

ursodiol cap 300 mg Preferred QL 90 / 30 days

ursodiol tab 250 mg Preferred ursodiol tab 500 mg Preferred HISTAMINE2 (H2) RECEPTOR ANTAGONISTS

cimetidine tab 200 mg Preferred QL 120 / 30 days

cimetidine tab 300 mg Preferred QL 8 / 1 days

cimetidine tab 400 mg Preferred QL 6 / 1 days

cimetidine tab 800 mg Preferred QL 90 / 30 days

PAGE 295 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

cimetidine hcl soln 300 mg/5ml Preferred QL 40 / 1 days

famotidine for susp 40 mg/5ml Preferred famotidine inj 20 mg/2ml Preferred famotidine inj 200 mg/20ml Preferred famotidine inj 40 mg/4ml Preferred

famotidine tab 20 mg Preferred QL 120 / 30 days

famotidine tab 40 mg Preferred QL 2 / 1 days

FAMOTIDINE PREMIXED 20-0.9 MG/50ML-% SOLUTION Preferred famotidine in nacl NIZATIDINE 15 MG/ML SOLUTION Preferred nizatidine NIZATIDINE 150 MG CAP Preferred nizatidine NIZATIDINE 300 MG CAP Preferred nizatidine nizatidine cap 150 mg Preferred nizatidine cap 300 mg Preferred PEPCID 20 MG TAB Non-Preferred famotidine PEPCID 40 MG TAB Non-Preferred QL 2 / 1 days famotidine RANITIDINE HCL 1000 MG/40ML SOLUTION Preferred ranitidine hcl

ranitidine hcl cap 150 mg Non-Preferred QL 4 / 1 days

ranitidine hcl cap 300 mg Non-Preferred QL 2 / 1 days

ranitidine hcl inj 150 mg/6ml (25 mg/ml) Preferred ranitidine hcl inj 50 mg/2ml (25 mg/ml) Preferred ranitidine hcl syrup 15 mg/ml (75 Preferred QL 40 / 1 days mg/5ml) ranitidine hcl syrup 15 mg/ml (75 Preferred QL 40 / 1 days mg/5ml) ranitidine hcl syrup 15 mg/ml (75 Preferred QL 40 / 1 days mg/5ml)

PAGE 296 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

ranitidine hcl tab 150 mg Preferred QL 120 / 30 days

ranitidine hcl tab 300 mg Preferred QL 2 / 1 days

ZANTAC 1000 MG/40ML SOLUTION Non-Preferred ranitidine hcl ZANTAC 150 MG/6ML SOLUTION Non-Preferred ranitidine hcl ZANTAC 50 MG/2ML SOLUTION Non-Preferred ranitidine hcl IRRITABLE BOWEL SYNDROME AGENTS

alosetron hcl tab 0.5 mg (base equiv) Non-Preferred alosetron hcl tab 1 mg (base equiv) Non-Preferred

AMITIZA 24 MCG CAP QL 60 / 30 days Preferred lubiprostone PA

AMITIZA 8 MCG CAP QL 60 / 30 days Preferred lubiprostone PA

LINZESS 145 MCG CAP QL 1 / 1 days Preferred linaclotide PA

LINZESS 290 MCG CAP QL 1 / 1 days Preferred linaclotide PA

LINZESS 72 MCG CAP Non-Preferred QL 1 / 1 days linaclotide LOTRONEX 0.5 MG TAB Non-Preferred alosetron hcl LOTRONEX 1 MG TAB Non-Preferred alosetron hcl LUBIPROSTONE 24 MCG CAP Non-Preferred QL 60 / 30 days lubiprostone LUBIPROSTONE 8 MCG CAP Non-Preferred QL 60 / 30 days lubiprostone VIBERZI 100 MG TAB Non-Preferred QL 60 / 30 days eluxadoline VIBERZI 75 MG TAB Non-Preferred QL 60 / 30 days eluxadoline ZELNORM 6 MG TAB Non-Preferred tegaserod maleate

PAGE 297 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS LAXATIVES

GOLYTELY 227.1 GM RECON SOLN peg 3350-kcl-sod bicarb-sod chloride- Preferred sod sulfate

lactulose solution 10 gm/15ml Preferred QL 120 / 1 days

lactulose solution 10 gm/15ml Preferred QL 120 / 1 days

lactulose solution 10 gm/15ml Preferred QL 120 / 1 days

lactulose (encephalopathy) solution 10 Preferred QL 120 / 1 days gm/15ml lactulose (encephalopathy) solution 10 Preferred QL 120 / 1 days gm/15ml lactulose (encephalopathy) solution 10 Preferred QL 120 / 1 days gm/15ml MOVIPREP 100 GM RECON SOLN peg 3350-kcl-nacl-na sulfate-na Preferred ascorbate-ascorbic acid peg 3350-kcl-nacl-na sulfate-na Preferred ascorbate-c for soln 100 gm peg 3350-kcl-nacl-na sulfate-na Preferred ascorbate-c for soln 100 gm peg 3350-kcl-na bicarb-nacl-na sulfate Preferred QL 4000 / 30 days for soln 236 gm peg 3350-kcl-na bicarb-nacl-na sulfate Preferred QL 4000 / 30 days for soln 236 gm peg 3350-kcl-na bicarb-nacl-na sulfate Preferred QL 4000 / 30 days for soln 240 gm peg 3350-kcl-na bicarb-nacl-na sulfate Preferred QL 4000 / 30 days for soln 240 gm peg 3350-kcl-sod bicarb-nacl for soln Preferred QL 4000 / 30 days 420 gm peg 3350-kcl-sod bicarb-nacl for soln Preferred QL 4000 / 30 days 420 gm peg 3350-kcl-sod bicarb-nacl for soln Preferred QL 4000 / 30 days 420 gm polyethylene glycol 3350 oral packet 17 Preferred QL 2 / 1 days gm polyethylene glycol 3350 oral powder 17 Preferred QLC 18 grams/day gm/scoop

PAGE 298 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TRULANCE 3 MG TAB Non-Preferred QL 30 / 30 days plecanatide PROTECTANTS

misoprostol tab 100 mcg Preferred QL 8 / 1 days

misoprostol tab 200 mcg Preferred QL 4 / 1 days

sucralfate susp 1 gm/10ml Preferred QL 40 / 1 days

sucralfate tab 1 gm Preferred QL 4 / 1 days

PROTON PUMP INHIBITORS

ACIPHEX 20 MG TAB DR Non-Preferred QL 30 / 30 days rabeprazole sodium ACIPHEX SPRINKLE 10 MG CAP SPRINK Non-Preferred rabeprazole sodium ACIPHEX SPRINKLE 5 MG CAP SPRINK Non-Preferred rabeprazole sodium DEXILANT 30 MG CAP DR Non-Preferred dexlansoprazole DEXILANT 60 MG CAP DR Non-Preferred dexlansoprazole

PA required for members under 6 esomeprazole magnesium cap delayed Preferred C years of age with a release 20 mg (base eq) history of 120 days supply in the previous 180 days PA required for members under 6 esomeprazole magnesium cap delayed Preferred C years of age with a release 40 mg (base eq) history of 120 days supply in the previous 180 days esomeprazole magnesium for delayed Non-Preferred release susp packet 10 mg esomeprazole magnesium for delayed Non-Preferred release susp packet 20 mg esomeprazole magnesium for delayed Non-Preferred release susp packet 40 mg ESOMEPRAZOLE STRONTIUM 49.3 MG CAP DR Non-Preferred esomeprazole strontium

PAGE 299 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

QL 60 / 30 days PA required for lansoprazole cap delayed release 15 mg Preferred members under 6 C years of age with a history of 120 days supply in the previous 180 days

QL 60 / 30 days PA required for lansoprazole cap delayed release 30 mg Preferred members under 6 C years of age with a history of 120 days supply in the previous 180 days

QL 60 / 30 days PA required for lansoprazole cap release 30 mg Preferred members under 6 C years of age with a history of 120 days supply in the previous 180 days lansoprazole tab delayed release orally Non-Preferred QL 30 / 30 days disintegrating 15 mg lansoprazole tab delayed release orally Non-Preferred QL 30 / 30 days disintegrating 30 mg

PA required for members under 6 NEXIUM 10 MG PACKET Preferred C years of age with a esomeprazole magnesium history of 120 days supply in the previous 180 days PA required for members under 6 NEXIUM 2.5 MG PACKET Preferred C years of age with a esomeprazole magnesium history of 120 days supply in the previous 180 days NEXIUM 20 MG CAP DR Non-Preferred esomeprazole magnesium

PA required for members under 6 NEXIUM 20 MG PACKET Preferred C years of age with a esomeprazole magnesium history of 120 days supply in the previous 180 days NEXIUM 40 MG CAP DR Non-Preferred esomeprazole magnesium

PAGE 300 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

PA required for members under 6 NEXIUM 5 MG PACKET Preferred C years of age with a esomeprazole magnesium history of 120 days supply in the previous 180 days

QL 60 / 30 days PA required for omeprazole cap delayed release 10 mg Preferred members under 6 C years of age with a history of 120 days supply in the previous 180 days

QL 60 / 30 days PA required for omeprazole cap delayed release 20 mg Preferred members under 6 C years of age with a history of 120 days supply in the previous 180 days

QL 60 / 30 days PA required for omeprazole cap delayed release 40 mg Preferred members under 6 C years of age with a history of 120 days supply in the previous 180 days omeprazole-sodium bicarbonate cap 20- Non-Preferred 1100 mg omeprazole-sodium bicarbonate cap 40- Non-Preferred 1100 mg omeprazole-sodium bicarbonate powd Non-Preferred pack for susp 20-1680 mg omeprazole-sodium bicarbonate powd Non-Preferred pack for susp 40-1680 mg

QL 60 / 30 days PA required for pantoprazole sodium ec tab 20 mg Preferred members under 6 (base equiv) C years of age with a history of 120 days supply in the previous 180 days

QL 60 / 30 days PA required for pantoprazole sodium ec tab 40 mg Preferred members under 6 (base equiv) C years of age with a history of 120 days supply in the previous 180 days

PAGE 301 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PREVACID 15 MG CAP DR Non-Preferred QL 60 / 30 days lansoprazole PREVACID 30 MG CAP DR Non-Preferred QL 60 / 30 days lansoprazole PREVACID SOLUTAB 15 MG TAB DR DISP Non-Preferred QL 30 / 30 days lansoprazole PREVACID SOLUTAB 30 MG TAB DR DISP Non-Preferred QL 30 / 30 days lansoprazole PRILOSEC 10 MG PACKET Preferred QL 60 / 30 days omeprazole magnesium PRILOSEC 2.5 MG PACKET Non-Preferred QL 2 / 1 days omeprazole magnesium PROTONIX 20 MG TAB DR Non-Preferred QL 2 / 1 days pantoprazole sodium PROTONIX 40 MG PACKET Non-Preferred pantoprazole sodium PROTONIX 40 MG TAB DR Non-Preferred QL 2 / 1 days pantoprazole sodium

rabeprazole sodium ec tab 20 mg Preferred QL 30 / 30 days

ZEGERID 20-1100 MG CAP Non-Preferred omeprazole-sodium bicarbonate ZEGERID 20-1680 MG PACKET Non-Preferred omeprazole-sodium bicarbonate ZEGERID 40-1100 MG CAP Non-Preferred omeprazole-sodium bicarbonate ZEGERID 40-1680 MG PACKET Non-Preferred omeprazole-sodium bicarbonate GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT

BUPHENYL 3 GM/TSP POWDER Preferred sodium phenylbutyrate BUPHENYL 500 MG TAB Preferred sodium phenylbutyrate CERDELGA 84 MG CAP Non-Preferred eliglustat tartrate CEREZYME 400 UNIT RECON SOLN Non-Preferred imiglucerase

PAGE 302 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CHOLBAM 250 MG CAP Preferred PA cholic acid CHOLBAM 50 MG CAP Preferred PA cholic acid CREON 12000 UNIT CP DR PART Preferred pancrelipase (lipase-protease-amylase) CREON 24000-76000 UNIT CP DR PART Preferred pancrelipase (lipase-protease-amylase) CREON 3000-9500 UNIT CP DR PART Preferred pancrelipase (lipase-protease-amylase) CREON 36000 UNIT CP DR PART Preferred pancrelipase (lipase-protease-amylase) CREON 6000 UNIT CP DR PART Preferred pancrelipase (lipase-protease-amylase) ELELYSO 200 UNIT RECON SOLN Preferred PA taliglucerase alfa miglustat cap 100 mg Non-Preferred OCALIVA 10 MG TAB Non-Preferred obeticholic acid OCALIVA 5 MG TAB Non-Preferred obeticholic acid PANCREAZE 10500 UNIT CP DR PART Non-Preferred pancrelipase (lipase-protease-amylase) PANCREAZE 16800 UNIT CP DR PART Non-Preferred pancrelipase (lipase-protease-amylase) PANCREAZE 21000 UNIT CP DR PART Non-Preferred pancrelipase (lipase-protease-amylase) PANCREAZE 2600 UNIT CP DR PART Non-Preferred pancrelipase (lipase-protease-amylase) PANCREAZE 4200 UNIT CP DR PART Non-Preferred pancrelipase (lipase-protease-amylase) PERTZYE 16000 UNIT CP DR PART Non-Preferred pancrelipase (lipase-protease-amylase) PERTZYE 24000-86250 UNIT CP DR PART Non-Preferred pancrelipase (lipase-protease-amylase)

PAGE 303 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PERTZYE 4000 UNIT CP DR PART Non-Preferred pancrelipase (lipase-protease-amylase) PERTZYE 8000 UNIT CP DR PART Non-Preferred pancrelipase (lipase-protease-amylase) RAVICTI 1.1 GM/ML LIQUID Non-Preferred glycerol phenylbutyrate sodium phenylbutyrate oral powder 3 Preferred gm/teaspoonful sodium phenylbutyrate tab 500 mg Preferred VIOKACE 10440 UNIT TAB Non-Preferred pancrelipase (lipase-protease-amylase) VIOKACE 20880 UNIT TAB Non-Preferred pancrelipase (lipase-protease-amylase) VPRIV 400 UNIT RECON SOLN Non-Preferred velaglucerase alfa ZAVESCA 100 MG CAP Preferred PA miglustat ZENPEP 10000-32000 UNIT CP DR PART Preferred pancrelipase (lipase-protease-amylase) ZENPEP 15000-47000 UNIT CP DR PART Preferred pancrelipase (lipase-protease-amylase) ZENPEP 20000-63000 UNIT CP DR PART Preferred pancrelipase (lipase-protease-amylase) ZENPEP 25000-79000 UNIT CP DR PART Preferred pancrelipase (lipase-protease-amylase) ZENPEP 3000-14000 UNIT CP DR PART Preferred pancrelipase (lipase-protease-amylase) ZENPEP 40000-126000 UNIT CP DR PART Preferred pancrelipase (lipase-protease-amylase) ZENPEP 5000-24000 UNIT CP DR PART Preferred pancrelipase (lipase-protease-amylase)

PAGE 304 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS GENITOURINARY AGENTS

ANTISPASMODICS, URINARY

darifenacin hydrobromide tab er 24hr 15 Non-Preferred mg (base equiv) darifenacin hydrobromide tab er 24hr 7.5 Non-Preferred mg (base equiv) DETROL 1 MG TAB Non-Preferred QL 2 / 1 days tolterodine tartrate DETROL 2 MG TAB Non-Preferred QL 2 / 1 days tolterodine tartrate DETROL LA 2 MG CAP ER 24H Non-Preferred QL 1 / 1 days tolterodine tartrate DETROL LA 4 MG CAP ER 24H Non-Preferred QL 1 / 1 days tolterodine tartrate DITROPAN XL 10 MG TAB ER 24H Non-Preferred QL 1 / 1 days oxybutynin chloride DITROPAN XL 5 MG TAB ER 24H Non-Preferred QL 1 / 1 days oxybutynin chloride ENABLEX 15 MG TAB ER 24H Non-Preferred darifenacin hydrobromide ENABLEX 7.5 MG TAB ER 24H Non-Preferred darifenacin hydrobromide flavoxate hcl tab 100 mg Non-Preferred GELNIQUE 10 % GEL Non-Preferred oxybutynin chloride GELNIQUE PUMP 10 % GEL Non-Preferred oxybutynin chloride GEMTESA 75 MG TAB Non-Preferred QL 30 / 30 days vibegron MYRBETRIQ 25 MG TAB ER 24H Non-Preferred mirabegron MYRBETRIQ 50 MG TAB ER 24H Non-Preferred mirabegron

oxybutynin chloride syrup 5 mg/5ml Preferred QL 20 / 1 days

oxybutynin chloride tab 5 mg Preferred QL 4 / 1 days

oxybutynin chloride tab er 24hr 10 mg Preferred QL 60 / 30 days

PAGE 305 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

oxybutynin chloride tab er 24hr 15 mg Preferred QL 60 / 30 days

oxybutynin chloride tab er 24hr 5 mg Preferred QL 30 / 30 days

OXYTROL 3.9 MG/24HR PATCH TW Non-Preferred oxybutynin solifenacin succinate tab 10 mg Preferred solifenacin succinate tab 5 mg Preferred

tolterodine tartrate cap er 24hr 2 mg Preferred QL 1 / 1 days

tolterodine tartrate cap er 24hr 4 mg Preferred QL 1 / 1 days

tolterodine tartrate tab 1 mg Preferred QL 2 / 1 days

tolterodine tartrate tab 2 mg Preferred QL 2 / 1 days

TOVIAZ 4 MG TAB ER 24H Non-Preferred fesoterodine fumarate TOVIAZ 8 MG TAB ER 24H Non-Preferred fesoterodine fumarate

trospium chloride cap er 24hr 60 mg Non-Preferred QL 1 / 1 days

trospium chloride tab 20 mg Preferred QL 60 / 30 days

VESICARE 10 MG TAB Non-Preferred solifenacin succinate VESICARE 5 MG TAB Non-Preferred solifenacin succinate VESICARE LS 5 MG/5ML SUSPENSION Non-Preferred solifenacin succinate BENIGN PROSTATIC HYPERTROPHY AGENTS

alfuzosin hcl tab er 24hr 10 mg Preferred QL 1 / 1 days

AVODART 0.5 MG CAP Non-Preferred QL 1 / 1 days dutasteride CARDURA XL 4 MG TAB ER 24H Non-Preferred doxazosin mesylate (bph) CARDURA XL 8 MG TAB ER 24H Non-Preferred doxazosin mesylate (bph) CIALIS 2.5 MG TAB Non-Preferred QL 30 / 30 days tadalafil CIALIS 5 MG TAB Non-Preferred QL 30 / 30 days tadalafil

PAGE 306 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

dutasteride cap 0.5 mg Preferred QL 1 / 1 days

dutasteride-tamsulosin hcl cap 0.5-0.4 Non-Preferred mg

finasteride tab 5 mg Preferred QL 1 / 1 days

FLOMAX 0.4 MG CAP Non-Preferred QL 2 / 1 days tamsulosin hcl JALYN 0.5-0.4 MG CAP Non-Preferred dutasteride-tamsulosin hcl PROSCAR 5 MG TAB Non-Preferred finasteride RAPAFLO 4 MG CAP Non-Preferred silodosin RAPAFLO 8 MG CAP Non-Preferred silodosin silodosin cap 4 mg Non-Preferred silodosin cap 8 mg Non-Preferred tadalafil tab 10 mg Non-Preferred

tadalafil tab 2.5 mg Non-Preferred QL 30 / 30 days

tadalafil tab 20 mg Non-Preferred

tadalafil tab 5 mg Non-Preferred QL 30 / 30 days

tamsulosin hcl cap 0.4 mg Preferred QL 2 / 1 days

GENITOURINARY AGENTS, OTHER

bethanechol chloride tab 10 mg Preferred QL 4 / 1 days

bethanechol chloride tab 25 mg Preferred QL 4 / 1 days

bethanechol chloride tab 5 mg Preferred QL 4 / 1 days

bethanechol chloride tab 50 mg Preferred QL 4 / 1 days

CIALIS 10 MG TAB Non-Preferred tadalafil CIALIS 20 MG TAB Non-Preferred tadalafil ELMIRON 100 MG CAP Preferred QL 3 / 1 days pentosan polysulfate sodium ORACIT 490-640 MG/5ML SOLUTION Preferred QL 120 / 1 days sodium citrate & citric acid

PAGE 307 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PARAGARD INTRAUTERINE COPPER IUD Preferred copper (iud) phenazopyridine hcl tab 100 mg Preferred phenazopyridine hcl tab 200 mg Preferred potassium citrate tab er 10 meq (1080 Preferred QL 10 / 1 days mg) potassium citrate tab er 15 meq (1620 Preferred mg)

potassium citrate tab er 5 meq (540 mg) Preferred QL 10 / 1 days

sodium citrate & citric acid soln 500-334 Preferred QL 120 / 1 days mg/5ml HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)

ALA SCALP 2 % LOTION Non-Preferred hydrocortisone (topical) alclometasone dipropionate cream Non-Preferred QL 1 / 1 days 0.05%

alclometasone dipropionate oint 0.05% Non-Preferred QL 60 / 24 days

ALKINDI SPRINKLE 0.5 MG CAP SPRINK Non-Preferred hydrocortisone ALKINDI SPRINKLE 1 MG CAP SPRINK Non-Preferred hydrocortisone ALKINDI SPRINKLE 2 MG CAP SPRINK Non-Preferred hydrocortisone ALKINDI SPRINKLE 5 MG CAP SPRINK Non-Preferred hydrocortisone amcinonide cream 0.1% Non-Preferred amcinonide lotion 0.1% Non-Preferred APEXICON E 0.05 % CREAM Non-Preferred diflorasone diacetate emollient base BESER 0.05 % KIT Non-Preferred fluticasone-emollient betamethasone dipropionate cream Preferred QL 45 / 28 days 0.05%

PAGE 308 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS betamethasone dipropionate lotion Preferred 0.05% betamethasone dipropionate oint 0.05% Preferred betamethasone dipropionate augmented Preferred QL 1 / 1 days cream 0.05% betamethasone dipropionate augmented Non-Preferred gel 0.05% betamethasone dipropionate augmented Non-Preferred lotion 0.05% betamethasone dipropionate augmented Non-Preferred QL 50 / 30 days oint 0.05% betamethasone valerate aerosol foam Non-Preferred 0.12% betamethasone valerate cream 0.1% Preferred QL 45 / 24 days (base equivalent) betamethasone valerate lotion 0.1% Preferred QL 60 / 27 days (base equivalent) betamethasone valerate oint 0.1% (base Preferred equivalent) BRYHALI 0.01 % LOTION Non-Preferred halobetasol propionate CAPEX 0.01 % SHAMPOO Non-Preferred fluocinolone acetonide

clobetasol propionate cream 0.05% Preferred QL 60 / 27 days

clobetasol propionate foam 0.05% Non-Preferred

clobetasol propionate gel 0.05% Non-Preferred QL 60 / 24 days

clobetasol propionate lotion 0.05% Non-Preferred

clobetasol propionate oint 0.05% Preferred QL 60 / 30 days

clobetasol propionate shampoo 0.05% Non-Preferred clobetasol propionate shampoo 0.05% Preferred

clobetasol propionate soln 0.05% Preferred QL 50 / 30 days

clobetasol propionate spray 0.05% Non-Preferred clobetasol propionate emollient base Non-Preferred cream 0.05% clobetasol propionate emollient base Non-Preferred cream 0.05%

PAGE 309 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS clobetasol propionate emulsion foam Non-Preferred 0.05% clobetasol propionate emulsion foam Non-Preferred 0.05% CLOBEX 0.05 % LOTION Non-Preferred clobetasol propionate CLOBEX 0.05 % SHAMPOO Non-Preferred clobetasol propionate CLOBEX SPRAY 0.05 % LIQUID Non-Preferred clobetasol propionate CLOCORTOLONE PIVALATE 0.1 % CREAM Non-Preferred clocortolone pivalate CLOCORTOLONE PIVALATE PUMP 0.1 % CREAM Non-Preferred clocortolone pivalate CLODAN 0.05 % KIT Non-Preferred clobetasol propionate & cleanser CLODERM 0.1 % CREAM Non-Preferred clocortolone pivalate CLODERM PUMP 0.1 % CREAM Non-Preferred clocortolone pivalate CORDRAN 4 MCG/SQCM TAPE Non-Preferred flurandrenolide CORTEF 10 MG TAB Non-Preferred hydrocortisone CORTEF 20 MG TAB Non-Preferred hydrocortisone CORTEF 5 MG TAB Non-Preferred hydrocortisone

cortisone acetate tab 25 mg Non-Preferred QL 12 / 1 days

CUTIVATE 0.05 % LOTION Non-Preferred fluticasone propionate DEPO-MEDROL 20 MG/ML SUSPENSION Preferred QL 8 / 1 days methylprednisolone acetate DERMA-SMOOTHE/FS BODY 0.01 % OIL Non-Preferred fluocinolone acetonide

PAGE 310 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS DERMA-SMOOTHE/FS SCALP 0.01 % OIL Non-Preferred fluocinolone acetonide DERMATOP 0.1 % OINTMENT Non-Preferred prednicarbate DESONATE 0.05 % GEL Non-Preferred desonide

desonide cream 0.05% Non-Preferred QL 120 / 24 days

desonide gel 0.05% Non-Preferred

desonide lotion 0.05% Non-Preferred QL 118 / 24 days

desonide oint 0.05% Non-Preferred QL 60 / 27 days

DESOWEN 0.05 % CREAM Non-Preferred desonide desoximetasone cream 0.05% Non-Preferred desoximetasone cream 0.25% Non-Preferred desoximetasone gel 0.05% Non-Preferred desoximetasone oint 0.05% Non-Preferred desoximetasone oint 0.25% Non-Preferred desoximetasone spray 0.25% Non-Preferred DEXABLISS 1.5 MG (39) TAB THPK Non-Preferred dexamethasone DEXAMETHASONE 1.5 MG (35) TAB THPK Non-Preferred dexamethasone DEXAMETHASONE 1.5 MG (51) TAB THPK Non-Preferred dexamethasone dexamethasone elixir 0.5 mg/5ml Non-Preferred dexamethasone elixir 0.5 mg/5ml Preferred dexamethasone soln 0.5 mg/5ml Preferred dexamethasone tab 0.5 mg Non-Preferred dexamethasone tab 0.5 mg Preferred dexamethasone tab 0.75 mg Non-Preferred dexamethasone tab 0.75 mg Preferred

PAGE 311 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS dexamethasone tab 1 mg Preferred dexamethasone tab 1.5 mg Preferred dexamethasone tab 2 mg Preferred dexamethasone tab 4 mg Non-Preferred dexamethasone tab 4 mg Preferred dexamethasone tab 6 mg Non-Preferred dexamethasone tab 6 mg Preferred dexamethasone tab therapy pack 1.5 Non-Preferred mg (21) dexamethasone tab therapy pack 1.5 Non-Preferred mg (21) dexamethasone tab therapy pack 1.5 Non-Preferred mg (21) dexamethasone tab therapy pack 1.5 Non-Preferred mg (21) dexamethasone tab therapy pack 1.5 Non-Preferred mg (35) dexamethasone tab therapy pack 1.5 Non-Preferred mg (51) DEXAMETHASONE INTENSOL 1 MG/ML CONC Preferred dexamethasone dexamethasone sodium phosphate inj Preferred 120 mg/30ml dexamethasone sodium phosphate inj Preferred 20 mg/5ml dexamethasone sodium phosphate inj 4 Preferred mg/ml diflorasone diacetate cream 0.05% Non-Preferred

diflorasone diacetate oint 0.05% Non-Preferred QL 60 / 27 days

DXEVO 11-DAY 1.5 MG TAB THPK Non-Preferred dexamethasone ELOCON 0.1 % CREAM Non-Preferred mometasone furoate EMFLAZA 18 MG TAB Non-Preferred deflazacort

PAGE 312 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS EMFLAZA 22.75 MG/ML SUSPENSION Non-Preferred deflazacort EMFLAZA 30 MG TAB Non-Preferred deflazacort EMFLAZA 36 MG TAB Non-Preferred deflazacort EMFLAZA 6 MG TAB Non-Preferred deflazacort

fludrocortisone acetate tab 0.1 mg Preferred QL 2 / 1 days

fluocinolone acetonide cream 0.01% Non-Preferred fluocinolone acetonide cream 0.025% Non-Preferred fluocinolone acetonide oil 0.01% (body Preferred oil) fluocinolone acetonide oil 0.01% (scalp Preferred oil)

fluocinolone acetonide oint 0.025% Preferred QL 60 / 30 days

fluocinolone acetonide soln 0.01% Preferred

fluocinonide cream 0.05% Preferred QL 120 / 24 days

fluocinonide cream 0.1% Non-Preferred

fluocinonide gel 0.05% Non-Preferred QL 60 / 24 days

fluocinonide oint 0.05% Preferred QL 60 / 24 days

fluocinonide soln 0.05% Preferred QL 60 / 24 days

fluocinonide emulsified base cream Non-Preferred QL 60 / 24 days 0.05% flurandrenolide cream 0.05% Non-Preferred flurandrenolide lotion 0.05% Non-Preferred flurandrenolide oint 0.05% Non-Preferred fluticasone propionate cream 0.05% Preferred fluticasone propionate lotion 0.05% Non-Preferred fluticasone propionate lotion 0.05% Non-Preferred

fluticasone propionate oint 0.005% Preferred QL 1 / 1 days

halcinonide cream 0.1% Non-Preferred

PAGE 313 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS HALOBETASOL PROPIONATE 0.05 % FOAM Non-Preferred halobetasol propionate

halobetasol propionate cream 0.05% Preferred QL 50 / 30 days

halobetasol propionate oint 0.05% Preferred QL 50 / 30 days

HALOG 0.1 % CREAM Non-Preferred halcinonide HALOG 0.1 % OINTMENT Non-Preferred halcinonide HALOG 0.1 % SOLUTION Non-Preferred halcinonide HEMADY 20 MG TAB Non-Preferred dexamethasone

hydrocortisone tab 10 mg Preferred QL 12 / 1 days

hydrocortisone tab 20 mg Preferred QL 12 / 1 days

hydrocortisone tab 5 mg Preferred QL 12 / 1 days

hydrocortisone perianal cream 2.5% Preferred hydrocortisone perianal cream 2.5% Preferred hydrocortisone perianal cream 2.5% Preferred hydrocortisone perianal cream 2.5% Preferred hydrocortisone cream 1% Non-Preferred

hydrocortisone cream 1% Preferred QL 60 / 30 days

hydrocortisone cream 2.5% Preferred

hydrocortisone lotion 2.5% Preferred QL 118 / 24 days

hydrocortisone oint 1% Preferred QL 30 / 7 days

hydrocortisone oint 1% Non-Preferred

hydrocortisone oint 2.5% Preferred QL 60 / 30 days

hydrocortisone butyrate cream 0.1% Non-Preferred hydrocortisone butyrate lotion 0.1% Non-Preferred hydrocortisone butyrate oint 0.1% Non-Preferred hydrocortisone butyrate soln 0.1% Non-Preferred hydrocortisone butyrate hydrophilic lipo Non-Preferred base cream 0.1%

PAGE 314 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

hydrocortisone valerate cream 0.2% Preferred QL 60 / 24 days

hydrocortisone valerate oint 0.2% Preferred QL 60 / 24 days

IMPEKLO 0.15 MG/ACT (0.05%) LOTION Non-Preferred clobetasol propionate KENALOG 0.147 MG/GM AERO SOLN Non-Preferred triamcinolone acetonide (topical) KENALOG 10 MG/ML SUSPENSION Preferred triamcinolone acetonide KENALOG 40 MG/ML SUSPENSION Preferred triamcinolone acetonide LEXETTE 0.05 % FOAM Non-Preferred halobetasol propionate LOCOID 0.1 % CREAM Non-Preferred hydrocortisone butyrate LOCOID 0.1 % LOTION Non-Preferred hydrocortisone butyrate LOCOID 0.1 % SOLUTION Non-Preferred hydrocortisone butyrate LOCOID LIPOCREAM 0.1 % CREAM hydrocortisone butyrate hydrophilic lipo Non-Preferred base MEDROL 16 MG TAB Non-Preferred methylprednisolone MEDROL 2 MG TAB Non-Preferred QL 4 / 1 days methylprednisolone MEDROL 32 MG TAB Non-Preferred QL 2 / 1 days methylprednisolone MEDROL 4 MG TAB Non-Preferred methylprednisolone MEDROL 4 MG TAB THPK Non-Preferred methylprednisolone MEDROL 8 MG TAB Non-Preferred methylprednisolone

methylprednisolone tab 16 mg Preferred QL 4 / 1 days

methylprednisolone tab 32 mg Preferred QL 2 / 1 days

methylprednisolone tab 4 mg Preferred QL 4 / 1 days

PAGE 315 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

methylprednisolone tab 8 mg Preferred QL 4 / 1 days

methylprednisolone tab therapy pack 4 Preferred mg (21) methylprednisolone acetate inj susp 40 Preferred QL 4 / 1 days mg/ml methylprednisolone acetate inj susp 80 Preferred QL 2 / 1 days mg/ml methylprednisolone sod succ for inj Preferred 1000 mg (base equiv) methylprednisolone sod succ for inj 40 Preferred mg (base equiv) methylprednisolone sod succ for inj 500 Preferred mg (base equiv) MILLIPRED 5 MG TAB Non-Preferred QL 12 / 1 days prednisolone MILLIPRED DP 5 MG (21) TAB THPK Non-Preferred prednisolone MILLIPRED DP 5 MG (48) TAB THPK Non-Preferred prednisolone

mometasone furoate cream 0.1% Preferred QL 45 / 30 days

mometasone furoate oint 0.1% Preferred QL 45 / 19 days

mometasone furoate solution 0.1% Preferred QL 30 / 14 days (lotion) OLUX 0.05 % FOAM Non-Preferred clobetasol propionate OLUX-E 0.05 % FOAM Non-Preferred clobetasol propionate emulsion ORAPRED ODT 10 MG TAB DISP Non-Preferred prednisolone sodium phosphate ORAPRED ODT 15 MG TAB DISP Non-Preferred prednisolone sodium phosphate ORAPRED ODT 30 MG TAB DISP Non-Preferred prednisolone sodium phosphate PANDEL 0.1 % CREAM Non-Preferred hydrocortisone probutate PEDIAPRED 6.7 (5 BASE) MG/5ML SOLUTION Non-Preferred prednisolone sodium phosphate

PAGE 316 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PREDNICARBATE 0.1 % CREAM Non-Preferred prednicarbate PREDNICARBATE 0.1 % OINTMENT Non-Preferred prednicarbate prednisolone syrup 15 mg/5ml (usp Preferred QL 20 / 1 days solution equivalent) prednisolone sod phos orally disintegr Non-Preferred tab 10 mg (base eq) prednisolone sod phos orally disintegr Non-Preferred tab 15 mg (base eq) prednisolone sod phos orally disintegr Non-Preferred tab 30 mg (base eq) prednisolone sod phosph oral soln 6.7 Preferred mg/5ml (5 mg/5ml base) prednisolone sod phosphate oral soln 10 Preferred mg/5ml (base equiv) prednisolone sod phosphate oral soln 15 Preferred QL 20 / 1 days mg/5ml (base equiv) prednisolone sod phosphate oral soln 20 Preferred mg/5ml (base equiv) prednisolone sodium phosphate oral Preferred soln 25 mg/5ml (base eq)

prednisone oral soln 5 mg/5ml Preferred QL 60 / 1 days

prednisone tab 1 mg Preferred QL 8 / 1 days

prednisone tab 10 mg Preferred QL 6 / 1 days

prednisone tab 2.5 mg Preferred QL 8 / 1 days

prednisone tab 20 mg Preferred QL 3 / 1 days

prednisone tab 5 mg Preferred QL 8 / 1 days

prednisone tab 50 mg Preferred QL 1 / 1 days

prednisone tab therapy pack 10 mg (21) Preferred prednisone tab therapy pack 10 mg (48) Preferred

prednisone tab therapy pack 5 mg (21) Preferred QL 8 / 1 days

prednisone tab therapy pack 5 mg (48) Preferred QL 8 / 1 days

PREDNISONE INTENSOL 5 MG/ML CONC Non-Preferred QL 12 / 1 days prednisone

PAGE 317 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PSORCON 0.05 % CREAM Non-Preferred diflorasone diacetate RAYOS 1 MG TAB DR Non-Preferred prednisone RAYOS 2 MG TAB DR Non-Preferred prednisone RAYOS 5 MG TAB DR Non-Preferred prednisone SILA III 0.1 % THER PACK Non-Preferred triamcinolone acetonide-silicone SOLU-CORTEF 100 MG RECON SOLN Preferred hydrocortisone sod succinate SOLU-MEDROL 40 MG RECON SOLN Preferred methylprednisolone sod succ SYNALAR 0.01 % SOLUTION Non-Preferred fluocinolone acetonide SYNALAR 0.025 % CREAM Non-Preferred fluocinolone acetonide SYNALAR 0.025 % OINTMENT Non-Preferred QL 60 / 30 days fluocinolone acetonide SYNALAR (CREAM) 0.025 % KIT Non-Preferred fluocinolone-emollient SYNALAR (OINTMENT) 0.025 % KIT Non-Preferred fluocinolone-emollient SYNALAR TS 0.01 % KIT Non-Preferred fluocinolone acetonide & cleanser TAPERDEX 12-DAY 1.5 MG (49) TAB THPK Non-Preferred dexamethasone TAPERDEX 7-DAY 1.5 MG (27) TAB THPK Non-Preferred dexamethasone TEMOVATE 0.05 % CREAM Non-Preferred clobetasol propionate TEMOVATE 0.05 % OINTMENT Non-Preferred QL 2 / 1 days clobetasol propionate TEXACORT 2.5 % SOLUTION Non-Preferred hydrocortisone (topical) TOPICORT 0.05 % CREAM Non-Preferred desoximetasone

PAGE 318 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TOPICORT 0.05 % GEL Non-Preferred desoximetasone TOPICORT 0.05 % OINTMENT Non-Preferred desoximetasone TOPICORT 0.25 % CREAM Non-Preferred desoximetasone TOPICORT 0.25 % OINTMENT Non-Preferred desoximetasone TOPICORT SPRAY 0.25 % LIQUID Non-Preferred desoximetasone triamcinolone acetonide inj susp 40 Preferred mg/ml triamcinolone acetonide aerosol soln Non-Preferred 0.147 mg/gm

triamcinolone acetonide cream 0.025% Preferred QL 456 / 24 days

triamcinolone acetonide cream 0.1% Preferred QL 456 / 24 days

triamcinolone acetonide cream 0.1% Non-Preferred

triamcinolone acetonide cream 0.5% Preferred QL 60 / 27 days

triamcinolone acetonide cream 0.5% Non-Preferred

triamcinolone acetonide lotion 0.025% Preferred QL 120 / 24 days

triamcinolone acetonide lotion 0.1% Preferred

triamcinolone acetonide oint 0.025% Preferred QL 456 / 24 days

triamcinolone acetonide oint 0.05% Preferred triamcinolone acetonide oint 0.05% Non-Preferred

triamcinolone acetonide oint 0.1% Preferred QL 456 / 24 days

triamcinolone acetonide oint 0.5% Preferred QL 30 / 24 days

ULTRAVATE 0.05 % CREAM Non-Preferred halobetasol propionate ULTRAVATE 0.05 % LOTION Non-Preferred halobetasol propionate ULTRAVATE 0.05 % OINTMENT Non-Preferred QL 50 / 30 days halobetasol propionate ULTRAVATE X (CREAM) 0.05 & 10 % KIT Non-Preferred halobetasol propionate & lactic acid

PAGE 319 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ULTRAVATE X (OINTMENT) 0.05 & 10 % KIT Non-Preferred halobetasol propionate & lactic acid VANOS 0.1 % CREAM Non-Preferred fluocinonide ZCORT 7-DAY 1.5 MG (25) TAB THPK Non-Preferred dexamethasone HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)

desmopressin acetate tab 0.1 mg Preferred QL 6 / 1 days

desmopressin acetate tab 0.2 mg Preferred QL 6 / 1 days

desmopressin acetate nasal spray soln Preferred QL 15 / 26 days 0.01% desmopressin acetate nasal spray soln Preferred QL 15 / 26 days 0.01% (refrigerated) GENOTROPIN 12 MG RECON SOLN Non-Preferred somatropin GENOTROPIN 5 MG RECON SOLN Non-Preferred somatropin GENOTROPIN MINIQUICK 0.2 MG RECON SOLN Non-Preferred somatropin GENOTROPIN MINIQUICK 0.4 MG RECON SOLN Non-Preferred somatropin GENOTROPIN MINIQUICK 0.6 MG RECON SOLN Non-Preferred somatropin GENOTROPIN MINIQUICK 0.8 MG RECON SOLN Non-Preferred somatropin GENOTROPIN MINIQUICK 1 MG RECON SOLN Non-Preferred somatropin GENOTROPIN MINIQUICK 1.2 MG RECON SOLN Non-Preferred somatropin GENOTROPIN MINIQUICK 1.4 MG RECON SOLN Non-Preferred somatropin

PAGE 320 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS GENOTROPIN MINIQUICK 1.6 MG RECON SOLN Non-Preferred somatropin GENOTROPIN MINIQUICK 1.8 MG RECON SOLN Non-Preferred somatropin GENOTROPIN MINIQUICK 2 MG RECON SOLN Non-Preferred somatropin HUMATROPE 12 MG RECON SOLN Non-Preferred somatropin HUMATROPE 24 MG RECON SOLN Non-Preferred somatropin HUMATROPE 6 MG RECON SOLN Non-Preferred somatropin NORDITROPIN FLEXPRO 10 MG/1.5ML SOLN PEN Preferred PA somatropin NORDITROPIN FLEXPRO 15 MG/1.5ML SOLN PEN Preferred PA somatropin NORDITROPIN FLEXPRO 30 MG/3ML SOLN PEN Preferred PA somatropin NORDITROPIN FLEXPRO 5 MG/1.5ML SOLN PEN Preferred PA somatropin NUTROPIN AQ NUSPIN 10 10 MG/2ML SOLN PEN Non-Preferred somatropin NUTROPIN AQ NUSPIN 20 20 MG/2ML SOLN PEN Non-Preferred somatropin NUTROPIN AQ NUSPIN 5 5 MG/2ML SOLN PEN Non-Preferred somatropin OMNITROPE 10 MG/1.5ML SOLN CART Preferred PA somatropin OMNITROPE 5 MG/1.5ML SOLN CART Preferred PA somatropin

PAGE 321 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS OMNITROPE 5.8 MG RECON SOLN Preferred PA somatropin ORIAHNN 300-1-0.5 & 300 MG CAP THPK QL 56 / 28 days Preferred elagolix sodium-estradiol-norethindrone PA acetate SAIZEN 5 MG RECON SOLN Non-Preferred somatropin (non-refrigerated) SAIZEN 8.8 MG RECON SOLN Non-Preferred somatropin (non-refrigerated) SAIZEN CLICK.EASY 8.8 MG RECON SOLN Non-Preferred somatropin (non-refrigerated) SAIZENPREP 8.8 MG RECON SOLN Non-Preferred somatropin (non-refrigerated) SEROSTIM 4 MG RECON SOLN Non-Preferred somatropin (non-refrigerated) SEROSTIM 5 MG RECON SOLN Non-Preferred somatropin (non-refrigerated) SEROSTIM 6 MG RECON SOLN Non-Preferred somatropin (non-refrigerated) STIMATE 1.5 MG/ML SOLUTION Preferred desmopressin acetate ZOMACTON 10 MG RECON SOLN Non-Preferred somatropin ZOMACTON 5 MG RECON SOLN Non-Preferred somatropin ZOMACTON (FOR ZOMA-JET 10) 10 MG RECON SOLN Non-Preferred somatropin ZORBTIVE 8.8 MG RECON SOLN Non-Preferred somatropin (non-refrigerated) HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)

ANABOLIC STEROIDS

ANADROL-50 50 MG TAB Non-Preferred oxymetholone

oxandrolone tab 10 mg Non-Preferred QL 2 / 1 days

oxandrolone tab 2.5 mg Non-Preferred QL 8 / 1 days

PAGE 322 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ANDROGENS

ANDRODERM 2 MG/24HR PATCH 24HR Non-Preferred testosterone ANDRODERM 4 MG/24HR PATCH 24HR Non-Preferred testosterone ANDROGEL 20.25 MG/1.25GM (1.62%) GEL Non-Preferred QL 150 / 30 days testosterone ANDROGEL 25 MG/2.5GM (1%) GEL Non-Preferred QL 300 / 30 days testosterone ANDROGEL 40.5 MG/2.5GM (1.62%) GEL Non-Preferred QL 150 / 30 days testosterone ANDROGEL 50 MG/5GM (1%) GEL Non-Preferred QL 300 / 30 days testosterone ANDROGEL PUMP 20.25 MG/ACT (1.62%) GEL Non-Preferred QL 150 / 30 days testosterone ANDROID 10 MG CAP Non-Preferred methyltestosterone AVEED 750 MG/3ML SOLUTION Non-Preferred testosterone undecanoate

DEPO-TESTOSTERONE 100 MG/ML QL 10 / 30 days SOLUTION Preferred testosterone cypionate PA

DEPO-TESTOSTERONE 200 MG/ML QL 10 / 30 days SOLUTION Preferred testosterone cypionate PA FORTESTA 10 MG/ACT (2%) GEL Non-Preferred QLC 3.51 grams/day testosterone JATENZO 158 MG CAP Non-Preferred testosterone undecanoate JATENZO 198 MG CAP Non-Preferred testosterone undecanoate JATENZO 237 MG CAP Non-Preferred testosterone undecanoate METHITEST 10 MG TAB Non-Preferred methyltestosterone

PAGE 323 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

methyltestosterone cap 10 mg Non-Preferred QL 5 / 1 days

NATESTO 5.5 MG/ACT GEL Non-Preferred testosterone STRIANT 30 MG MISC Non-Preferred testosterone TESTIM 50 MG/5GM (1%) GEL Non-Preferred QL 300 / 30 days testosterone TESTOPEL 75 MG PELLET Preferred PA testosterone TESTOSTERONE 100 MG PELLET Non-Preferred testosterone TESTOSTERONE 200 MG PELLET Non-Preferred testosterone

testosterone td gel 10mg/act (2%) Non-Preferred QLC 3.51 grams/day

testosterone td gel 12.5 mg/act (1%) Non-Preferred QL 150 / 30 days

testosterone td gel 20.25 mg/1.25gm Non-Preferred QL 150 / 30 days (1.62%)

testosterone td gel 25 mg/2.5gm (1%) Non-Preferred QL 300 / 30 days

testosterone td gel 40.5 mg/2.5gm Non-Preferred QL 150 / 30 days (1.62%)

testosterone td gel 50 mg/5gm (1%) Non-Preferred QL 300 / 30 days

testosterone td soln 30 mg/act Non-Preferred QLC 6 mL/day

testosterone cyp im or subcutaneous inj Preferred PA in oil 100 mg/ml testosterone cyp im or subcutaneous inj Preferred PA in oil 200 mg/ml

testosterone cypionate im inj in oil 100 QL 10 / 30 days Preferred mg/ml PA

testosterone cypionate im inj in oil 200 QL 10 / 30 days Preferred mg/ml PA

testosterone enanth im or subcutaneous Non-Preferred inj in oil 200 mg/ml testosterone enanthate im inj in oil 200 Non-Preferred QL 5 / 30 days mg/ml

PAGE 324 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

TESTOSTERONE TD GEL pump 20.25 QL 150 / 30 days Preferred MG/ACT (1.62%) PA

TESTOSTERONE TD GEL pump 20.25 QL 150 / 30 days Preferred MG/ACT (1.62%) PA

TESTRED 10 MG CAP Non-Preferred methyltestosterone VOGELXO 50 MG/5GM (1%) GEL Non-Preferred QL 300 / 30 days testosterone VOGELXO PUMP 12.5 MG/ACT (1%) GEL Non-Preferred QL 150 / 30 days testosterone XYOSTED 100 MG/0.5ML SOLN A-INJ Non-Preferred testosterone enanthate XYOSTED 50 MG/0.5ML SOLN A-INJ Non-Preferred testosterone enanthate XYOSTED 75 MG/0.5ML SOLN A-INJ Non-Preferred testosterone enanthate ESTROGENS

ACTIVELLA 0.5-0.1 MG TAB Non-Preferred estradiol & norethindrone acetate ACTIVELLA 1-0.5 MG TAB Non-Preferred estradiol & norethindrone acetate ALORA 0.025 MG/24HR PATCH TW Preferred estradiol ALORA 0.05 MG/24HR PATCH TW Preferred estradiol ALORA 0.075 MG/24HR PATCH TW Preferred estradiol ALORA 0.1 MG/24HR PATCH TW Preferred estradiol ANGELIQ 0.25-0.5 MG TAB Preferred drospirenone-estradiol ANGELIQ 0.5-1 MG TAB Preferred drospirenone-estradiol ANNOVERA 0.013-0.15 MG/24HR RING Non-Preferred segesterone acetate-ethinyl estradiol BALCOLTRA 0.1-20 MG-MCG(21) TAB levonorgestrel-ethinyl estradiol-ferrous Non-Preferred bisglycinate

PAGE 325 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS BEYAZ 3-0.02-0.451 MG TAB drospirenone-ethinyl estradiol- Non-Preferred levomefolate calcium BIJUVA 1-100 MG CAP Non-Preferred estradiol-progesterone CLIMARA 0.025 MG/24HR PATCH WK Non-Preferred estradiol CLIMARA 0.0375 MG/24HR PATCH WK Non-Preferred estradiol CLIMARA 0.05 MG/24HR PATCH WK Non-Preferred estradiol CLIMARA 0.06 MG/24HR PATCH WK Non-Preferred estradiol CLIMARA 0.075 MG/24HR PATCH WK Non-Preferred estradiol CLIMARA 0.1 MG/24HR PATCH WK Non-Preferred estradiol CLIMARA PRO 0.045-0.015 MG/DAY PATCH WK Preferred estradiol-levonorgestrel COMBIPATCH 0.05-0.14 MG/DAY PATCH TW Preferred estradiol & norethindrone acetate COMBIPATCH 0.05-0.25 MG/DAY PATCH TW Preferred estradiol & norethindrone acetate CYCLESSA 0.1/0.125/0.15 -0.025 MG TAB Non-Preferred desogestrel-ethinyl estradiol (triphasic) DELESTROGEN 10 MG/ML OIL Preferred estradiol valerate DELESTROGEN 20 MG/ML OIL Preferred estradiol valerate DELESTROGEN 40 MG/ML OIL Preferred estradiol valerate DEPO-ESTRADIOL 5 MG/ML OIL Preferred estradiol cypionate desogestrel & ethinyl estradiol tab 0.15 Preferred QL 1 / 1 days mg-30 mcg desogestrel & ethinyl estradiol tab 0.15 Preferred QL 1 / 1 days mg-30 mcg

PAGE 326 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS desogestrel & ethinyl estradiol tab 0.15 Preferred QL 1 / 1 days mg-30 mcg desogestrel & ethinyl estradiol tab 0.15 Preferred QL 28 / 28 days mg-30 mcg desogestrel & ethinyl estradiol tab 0.15 Preferred QL 28 / 28 days mg-30 mcg desogestrel & ethinyl estradiol tab 0.15 Preferred QL 1 / 1 days mg-30 mcg desogestrel & ethinyl estradiol tab 0.15 Preferred QL 1 / 1 days mg-30 mcg desogestrel & ethinyl estradiol tab 0.15 Preferred QL 1 / 1 days mg-30 mcg desogestrel & ethinyl estradiol tab 0.15 Preferred QL 28 / 28 days mg-30 mcg desogestrel & ethinyl estradiol tab 0.15 Preferred QL 1 / 1 days mg-30 mcg desogest-eth estrad & eth estrad tab Preferred QL 1 / 1 days 0.15-0.02/0.01 mg(21/5) desogest-eth estrad & eth estrad tab Preferred QL 1 / 1 days 0.15-0.02/0.01 mg(21/5) desogest-eth estrad & eth estrad tab Preferred QL 1 / 1 days 0.15-0.02/0.01 mg(21/5) desogest-eth estrad & eth estrad tab Preferred QL 1 / 1 days 0.15-0.02/0.01 mg(21/5) desogest-eth estrad & eth estrad tab Preferred QL 1 / 1 days 0.15-0.02/0.01 mg(21/5) desogest-eth estrad & eth estrad tab Preferred 0.15-0.02/0.01 mg(21/5) desogest-eth estrad & eth estrad tab Preferred QL 1 / 1 days 0.15-0.02/0.01 mg(21/5) desogest-eth estrad & eth estrad tab Preferred 0.15-0.02/0.01 mg(21/5) desogest-ethin est tab 0.1-0.025/0.125- Preferred QL 1 / 1 days 0.025/0.15-0.025mg-mg desogest-ethin est tab 0.1-0.025/0.125- Preferred QL 1 / 1 days 0.025/0.15-0.025mg-mg DIVIGEL 0.25 MG/0.25GM GEL Non-Preferred estradiol DIVIGEL 0.5 MG/0.5GM GEL Non-Preferred estradiol

PAGE 327 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS DIVIGEL 0.75 MG/0.75GM GEL Non-Preferred estradiol DIVIGEL 1 MG/GM GEL Non-Preferred estradiol DIVIGEL 1.25 MG/1.25GM GEL Non-Preferred estradiol drospirenone-ethinyl estradiol tab 3-0.02 Preferred QL 1 / 1 days mg drospirenone-ethinyl estradiol tab 3-0.02 Preferred QL 1 / 1 days mg drospirenone-ethinyl estradiol tab 3-0.02 Preferred QL 28 / 28 days mg drospirenone-ethinyl estradiol tab 3-0.02 Preferred mg drospirenone-ethinyl estradiol tab 3-0.02 Preferred QL 1 / 1 days mg drospirenone-ethinyl estradiol tab 3-0.02 Preferred QL 1 / 1 days mg drospirenone-ethinyl estradiol tab 3-0.03 Preferred QL 1 / 1 days mg drospirenone-ethinyl estradiol tab 3-0.03 Preferred QL 1 / 1 days mg drospirenone-ethinyl estradiol tab 3-0.03 Preferred QL 1 / 1 days mg drospirenone-ethinyl estradiol tab 3-0.03 Preferred QL 1 / 1 days mg drospirenone-ethinyl estradiol tab 3-0.03 Preferred mg drospirenone-ethinyl estrad- Non-Preferred levomefolate tab 3-0.02-0.451 mg drospirenone-ethinyl estrad- Non-Preferred levomefolate tab 3-0.03-0.451 mg drospirenone-ethinyl estrad- Non-Preferred levomefolate tab 3-0.03-0.451 mg ELESTRIN 0.52 MG/0.87 GM (0.06%) GEL Preferred estradiol esterified estrogens & Non-Preferred methyltestosterone tab 0.625-1.25 mg

PAGE 328 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS esterified estrogens & Non-Preferred methyltestosterone tab 0.625-1.25 mg esterified estrogens & Non-Preferred methyltestosterone tab 0.625-1.25 mg esterified estrogens & Non-Preferred methyltestosterone tab 1.25-2.5 mg esterified estrogens & Non-Preferred methyltestosterone tab 1.25-2.5 mg esterified estrogens & Non-Preferred methyltestosterone tab 1.25-2.5 mg esterified estrogens & Non-Preferred methyltestosterone tab 1.25-2.5 mg ESTRACE 0.1 MG/GM CREAM Non-Preferred QLC 42.5 grams/30 days estradiol vaginal ESTRACE 0.5 MG TAB Non-Preferred estradiol ESTRACE 1 MG TAB Non-Preferred QL 90 / 30 days estradiol ESTRACE 2 MG TAB Non-Preferred QL 90 / 30 days estradiol estradiol tab 0.5 mg Preferred

estradiol tab 1 mg Preferred QL 90 / 30 days

estradiol tab 2 mg Preferred QL 90 / 30 days

estradiol td patch twice weekly 0.025 Non-Preferred mg/24hr estradiol td patch twice weekly 0.025 Preferred QL 8 / 28 days mg/24hr estradiol td patch twice weekly 0.025 Non-Preferred mg/24hr estradiol td patch twice weekly 0.0375 Non-Preferred mg/24hr estradiol td patch twice weekly 0.0375 Preferred QL 8 / 28 days mg/24hr estradiol td patch twice weekly 0.0375 Non-Preferred mg/24hr estradiol td patch twice weekly 0.05 Non-Preferred mg/24hr

PAGE 329 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS estradiol td patch twice weekly 0.05 Preferred QL 8 / 28 days mg/24hr estradiol td patch twice weekly 0.05 Non-Preferred mg/24hr estradiol td patch twice weekly 0.075 Non-Preferred mg/24hr estradiol td patch twice weekly 0.075 Preferred QL 8 / 28 days mg/24hr estradiol td patch twice weekly 0.075 Non-Preferred mg/24hr estradiol td patch twice weekly 0.1 Non-Preferred mg/24hr estradiol td patch twice weekly 0.1 Preferred QL 8 / 28 days mg/24hr estradiol td patch twice weekly 0.1 Non-Preferred mg/24hr

estradiol td patch weekly 0.025 mg/24hr Preferred QL 4 / 28 days

estradiol td patch weekly 0.0375 Preferred QL 4 / 28 days mg/24hr (37.5 mcg/24hr)

estradiol td patch weekly 0.05 mg/24hr Preferred QL 4 / 28 days

estradiol td patch weekly 0.06 mg/24hr Preferred QL 4 / 28 days

estradiol td patch weekly 0.075 mg/24hr Preferred QL 4 / 28 days

estradiol td patch weekly 0.1 mg/24hr Preferred QL 4 / 28 days

estradiol & norethindrone acetate tab Non-Preferred 0.5-0.1 mg estradiol & norethindrone acetate tab Non-Preferred 0.5-0.1 mg estradiol & norethindrone acetate tab Non-Preferred 0.5-0.1 mg estradiol & norethindrone acetate tab Non-Preferred 0.5-0.1 mg estradiol & norethindrone acetate tab 1- Non-Preferred 0.5 mg estradiol & norethindrone acetate tab 1- Non-Preferred 0.5 mg estradiol & norethindrone acetate tab 1- Non-Preferred 0.5 mg

PAGE 330 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS estradiol & norethindrone acetate tab 1- Non-Preferred 0.5 mg

estradiol vaginal cream 0.1 mg/gm Preferred QLC 42.5 grams/30 days

estradiol vaginal tab 10 mcg Preferred estradiol vaginal tab 10 mcg Preferred estradiol valerate im in oil 20 mg/ml Preferred estradiol valerate im in oil 40 mg/ml Preferred ESTRING 2 MG RING Preferred estradiol vaginal ESTROGEL 0.75 MG/1.25 GM (0.06%) GEL Non-Preferred estradiol ESTROPIPATE 0.75 MG TAB Non-Preferred QL 1 / 1 days estropipate ESTROPIPATE 1.5 MG TAB Non-Preferred QL 1 / 1 days estropipate ESTROPIPATE 3 MG TAB Non-Preferred QL 3 / 1 days estropipate ESTROSTEP FE 1-20/1-30/1-35 MG- MCG TAB Non-Preferred QL 1 / 1 days norethindrone acetate-ethinyl estradiol- fe ethynodiol diacetate & ethinyl estradiol Preferred QL 1 / 1 days tab 1 mg-35 mcg ethynodiol diacetate & ethinyl estradiol Preferred QL 1 / 1 days tab 1 mg-35 mcg ethynodiol diacetate & ethinyl estradiol Preferred tab 1 mg-35 mcg ethynodiol diacetate & ethinyl estradiol Preferred QL 1 / 1 days tab 1 mg-35 mcg ethynodiol diacetate & ethinyl estradiol Preferred QL 28 / 28 days tab 1 mg-50 mcg ethynodiol diacetate & ethinyl estradiol Preferred QL 1 / 1 days tab 1 mg-50 mcg etonogestrel-ethinyl estradiol va ring Non-Preferred QL 1 / 28 days 0.120-0.015 mg/24hr etonogestrel-ethinyl estradiol va ring Non-Preferred QL 1 / 28 days 0.120-0.015 mg/24hr

PAGE 331 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS EVAMIST 1.53 MG/SPRAY SOLUTION Non-Preferred estradiol FEMHRT LOW DOSE 0.5-2.5 MG-MCG TAB Non-Preferred norethindrone acetate-ethinyl estradiol FEMRING 0.05 MG/24HR RING Preferred estradiol acetate vaginal FEMRING 0.1 MG/24HR RING Preferred estradiol acetate vaginal GENERESS FE 0.8-25 MG-MCG CHEW TAB Non-Preferred norethindrone & ethinyl estradiol-fe levonorgestrel & ethinyl estradiol tab 0.1 Preferred QL 28 / 28 days mg-20 mcg levonorgestrel & ethinyl estradiol tab 0.1 Preferred QL 1 / 1 days mg-20 mcg levonorgestrel & ethinyl estradiol tab 0.1 Preferred QL 1 / 1 days mg-20 mcg levonorgestrel & ethinyl estradiol tab 0.1 Preferred QL 1 / 1 days mg-20 mcg levonorgestrel & ethinyl estradiol tab 0.1 Preferred QL 1 / 1 days mg-20 mcg levonorgestrel & ethinyl estradiol tab 0.1 Preferred QL 1 / 1 days mg-20 mcg levonorgestrel & ethinyl estradiol tab 0.1 Preferred QL 1 / 1 days mg-20 mcg levonorgestrel & ethinyl estradiol tab 0.1 Preferred QL 28 / 28 days mg-20 mcg levonorgestrel & ethinyl estradiol tab 0.1 Preferred QL 1 / 1 days mg-20 mcg levonorgestrel & ethinyl estradiol tab 0.1 Preferred QL 28 / 28 days mg-20 mcg levonorgestrel & ethinyl estradiol tab 0.1 Preferred QL 1 / 1 days mg-20 mcg levonorgestrel & ethinyl estradiol tab 0.1 Preferred QL 1 / 1 days mg-20 mcg levonorgestrel & ethinyl estradiol tab Preferred QL 1 / 1 days 0.15 mg-30 mcg levonorgestrel & ethinyl estradiol tab Preferred QL 28 / 28 days 0.15 mg-30 mcg

PAGE 332 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS levonorgestrel & ethinyl estradiol tab Preferred QL 1 / 1 days 0.15 mg-30 mcg levonorgestrel & ethinyl estradiol tab Preferred QL 1 / 1 days 0.15 mg-30 mcg levonorgestrel & ethinyl estradiol tab Preferred QL 1 / 1 days 0.15 mg-30 mcg levonorgestrel & ethinyl estradiol tab Preferred QL 1 / 1 days 0.15 mg-30 mcg levonorgestrel & ethinyl estradiol tab Preferred QL 1 / 1 days 0.15 mg-30 mcg levonorgestrel & ethinyl estradiol tab Preferred QL 1 / 1 days 0.15 mg-30 mcg levonorgestrel & ethinyl estradiol tab Preferred QL 1 / 1 days 0.15 mg-30 mcg levonorgestrel & ethinyl estradiol tab Preferred QL 1 / 1 days 0.15 mg-30 mcg levonorgestrel-eth estra tab 0.05- Preferred QL 1 / 1 days 30/0.075-40/0.125-30mg-mcg levonorgestrel-eth estra tab 0.05- Preferred QL 1 / 1 days 30/0.075-40/0.125-30mg-mcg levonorgestrel-eth estra tab 0.05- Preferred QL 1 / 1 days 30/0.075-40/0.125-30mg-mcg levonorgestrel-eth estra tab 0.05- Preferred QL 1 / 1 days 30/0.075-40/0.125-30mg-mcg levonorgestrel-eth estra tab 0.05- Preferred QL 1 / 1 days 30/0.075-40/0.125-30mg-mcg levonor-eth est tab 0.15-0.02/0.025/0.03 Non-Preferred mg ð est 0.01 mg levonor-eth est tab 0.15-0.02/0.025/0.03 Non-Preferred mg ð est 0.01 mg levonor-eth est tab 0.15-0.02/0.025/0.03 Non-Preferred mg ð est 0.01 mg levonorg-eth est tab 0.1-0.02mg(84) & Non-Preferred eth est tab 0.01mg(7) levonorg-eth est tab 0.1-0.02mg(84) & Preferred eth est tab 0.01mg(7) levonorg-eth est tab 0.1-0.02mg(84) & Non-Preferred eth est tab 0.01mg(7) levonorg-eth est tab 0.1-0.02mg(84) & Non-Preferred eth est tab 0.01mg(7)

PAGE 333 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS levonorg-eth est tab 0.15-0.03mg(84) & Non-Preferred eth est tab 0.01mg(7) levonorg-eth est tab 0.15-0.03mg(84) & Non-Preferred eth est tab 0.01mg(7) levonorg-eth est tab 0.15-0.03mg(84) & Preferred eth est tab 0.01mg(7) levonorg-eth est tab 0.15-0.03mg(84) & Non-Preferred eth est tab 0.01mg(7) levonorg-eth est tab 0.15-0.03mg(84) & Non-Preferred eth est tab 0.01mg(7) levonorg-eth est tab 0.15-0.03mg(84) & Non-Preferred eth est tab 0.01mg(7) levonorg-eth est tab 0.15-0.03mg(84) & Non-Preferred eth est tab 0.01mg(7) levonorgestrel & ethinyl estradiol (91- Preferred day) tab 0.15-0.03 mg levonorgestrel & ethinyl estradiol (91- Preferred day) tab 0.15-0.03 mg levonorgestrel & ethinyl estradiol (91- Preferred day) tab 0.15-0.03 mg levonorgestrel & ethinyl estradiol (91- Preferred day) tab 0.15-0.03 mg levonorgestrel & ethinyl estradiol (91- Preferred day) tab 0.15-0.03 mg levonorgestrel-ethinyl estradiol Preferred QL 1 / 1 days (continuous) tab 90-20 mcg levonorgestrel-ethinyl estradiol Preferred QL 1 / 1 days (continuous) tab 90-20 mcg LO LOESTRIN FE 1 MG-10 MCG / 10 MCG TAB Non-Preferred norethindrone acetate-ethinyl estradiol- fe fum (biphasic) LOSEASONIQUE 0.1-0.02 & 0.01 MG TAB Non-Preferred levonorgestrel-ethinyl estradiol (91-day) MENEST 0.3 MG TAB Non-Preferred QL 1 / 1 days esterified estrogens MENEST 0.625 MG TAB Non-Preferred QL 1 / 1 days esterified estrogens

PAGE 334 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MENEST 1.25 MG TAB Non-Preferred QL 1 / 1 days esterified estrogens MENEST 2.5 MG TAB Non-Preferred esterified estrogens MENOSTAR 14 MCG/24HR PATCH WK Non-Preferred estradiol MINASTRIN 24 FE 1-20 MG-MCG(24) CHEW TAB Non-Preferred norethin acet & estrad-fe MINIVELLE 0.025 MG/24HR PATCH TW Non-Preferred estradiol MINIVELLE 0.0375 MG/24HR PATCH TW Non-Preferred estradiol MINIVELLE 0.05 MG/24HR PATCH TW Non-Preferred estradiol MINIVELLE 0.075 MG/24HR PATCH TW Non-Preferred estradiol MINIVELLE 0.1 MG/24HR PATCH TW Non-Preferred estradiol MIRCETTE 0.15-0.02/0.01 MG (21/5) TAB Non-Preferred QL 1 / 1 days desogestrel-ethinyl estradiol (biphasic) NATAZIA 3/2-2/2-3/1 MG TAB Non-Preferred estradiol valerate-dienogest norelgestromin-ethinyl estradiol td ptwk Preferred QL 3 / 28 days 150-35 mcg/24hr norethindrone ace & ethinyl estradiol-fe Preferred tab 1 mg-20 mcg norethindrone ace & ethinyl estradiol-fe Preferred QL 1 / 1 days tab 1 mg-20 mcg norethindrone ace & ethinyl estradiol-fe Preferred tab 1 mg-20 mcg norethindrone ace & ethinyl estradiol-fe Preferred QL 1 / 1 days tab 1 mg-20 mcg norethindrone ace & ethinyl estradiol-fe Preferred QL 1 / 1 days tab 1 mg-20 mcg norethindrone ace & ethinyl estradiol-fe Non-Preferred QL 1 / 1 days tab 1 mg-20 mcg

PAGE 335 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS norethindrone ace & ethinyl estradiol-fe Preferred QL 1 / 1 days tab 1 mg-20 mcg norethindrone ace & ethinyl estradiol-fe Preferred QL 1 / 1 days tab 1 mg-20 mcg norethindrone ace & ethinyl estradiol-fe Preferred QL 1 / 1 days tab 1 mg-20 mcg norethindrone ace & ethinyl estradiol-fe Preferred QL 1 / 1 days tab 1 mg-20 mcg norethindrone ace & ethinyl estradiol-fe Preferred tab 1.5 mg-30 mcg norethindrone ace & ethinyl estradiol-fe Preferred QL 28 / 28 days tab 1.5 mg-30 mcg norethindrone ace & ethinyl estradiol-fe Preferred tab 1.5 mg-30 mcg norethindrone ace & ethinyl estradiol-fe Preferred QL 1 / 1 days tab 1.5 mg-30 mcg norethindrone ace & ethinyl estradiol-fe Preferred QL 1 / 1 days tab 1.5 mg-30 mcg norethindrone ace & ethinyl estradiol-fe Non-Preferred QL 1 / 1 days tab 1.5 mg-30 mcg norethindrone ace & ethinyl estradiol-fe Preferred QL 28 / 28 days tab 1.5 mg-30 mcg norethindrone ace & ethinyl estradiol-fe Preferred tab 1.5 mg-30 mcg norethindrone ace-eth estradiol-fe chew Non-Preferred tab 1 mg-20 mcg (24) norethindrone ace-eth estradiol-fe chew Non-Preferred tab 1 mg-20 mcg (24) norethindrone ace-eth estradiol-fe chew Non-Preferred tab 1 mg-20 mcg (24) norethindrone ace-eth estradiol-fe chew Non-Preferred tab 1 mg-20 mcg (24) norethindrone ace-eth estradiol-fe chew Non-Preferred tab 1 mg-20 mcg (24) norethindrone ace-ethinyl estradiol-fe Non-Preferred cap 1 mg-20 mcg (24) norethindrone ace-ethinyl estradiol-fe Non-Preferred cap 1 mg-20 mcg (24) norethindrone ace-ethinyl estradiol-fe Non-Preferred tab 1 mg-20 mcg (24)

PAGE 336 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS norethindrone ace-ethinyl estradiol-fe Non-Preferred tab 1 mg-20 mcg (24) norethindrone ace-ethinyl estradiol-fe Non-Preferred tab 1 mg-20 mcg (24) norethindrone ace-ethinyl estradiol-fe Non-Preferred tab 1 mg-20 mcg (24) norethindrone ace-ethinyl estradiol-fe Non-Preferred tab 1 mg-20 mcg (24) norethindrone ace-ethinyl estradiol-fe Non-Preferred tab 1 mg-20 mcg (24) norethindrone ace-ethinyl estradiol-fe Non-Preferred tab 1 mg-20 mcg (24) norethindrone ace-ethinyl estradiol-fe Non-Preferred tab 1 mg-20 mcg (24) norethindrone & ethinyl estradiol tab 0.4 Preferred QL 1 / 1 days mg-35 mcg norethindrone & ethinyl estradiol tab 0.4 Preferred QL 1 / 1 days mg-35 mcg norethindrone & ethinyl estradiol tab 0.4 Preferred QL 1 / 1 days mg-35 mcg norethindrone & ethinyl estradiol tab 0.4 Preferred QL 1 / 1 days mg-35 mcg norethindrone & ethinyl estradiol tab 0.5 Preferred QL 1 / 1 days mg-35 mcg norethindrone & ethinyl estradiol tab 0.5 Preferred QL 1 / 1 days mg-35 mcg norethindrone & ethinyl estradiol tab 0.5 Preferred QL 1 / 1 days mg-35 mcg norethindrone & ethinyl estradiol tab 1 Preferred QL 1 / 1 days mg-35 mcg norethindrone & ethinyl estradiol tab 1 Preferred QL 1 / 1 days mg-35 mcg norethindrone & ethinyl estradiol tab 1 Preferred QL 1 / 1 days mg-35 mcg norethindrone & ethinyl estradiol tab 1 Preferred mg-35 mcg norethindrone & ethinyl estradiol tab 1 Preferred QL 1 / 1 days mg-35 mcg norethindrone & ethinyl estradiol tab 1 Preferred QL 1 / 1 days mg-35 mcg

PAGE 337 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS norethindrone & ethinyl estradiol-fe Non-Preferred QL 28 / 28 days chew tab 0.4 mg-35 mcg norethindrone & ethinyl estradiol-fe Non-Preferred QL 1 / 1 days chew tab 0.4 mg-35 mcg norethindrone & ethinyl estradiol-fe Non-Preferred chew tab 0.8 mg-25 mcg norethindrone & ethinyl estradiol-fe Non-Preferred chew tab 0.8 mg-25 mcg norethindrone & ethinyl estradiol-fe Non-Preferred chew tab 0.8 mg-25 mcg norethindrone ace & ethinyl estradiol tab Preferred 1 mg-20 mcg norethindrone ace & ethinyl estradiol tab Preferred QL 1 / 1 days 1 mg-20 mcg norethindrone ace & ethinyl estradiol tab Preferred QL 1 / 1 days 1 mg-20 mcg norethindrone ace & ethinyl estradiol tab Non-Preferred QL 1 / 1 days 1 mg-20 mcg norethindrone ace & ethinyl estradiol tab Preferred QL 1 / 1 days 1 mg-20 mcg norethindrone ace & ethinyl estradiol tab Preferred QL 1 / 1 days 1 mg-20 mcg norethindrone ace & ethinyl estradiol tab Preferred 1.5 mg-30 mcg norethindrone ace & ethinyl estradiol tab Preferred 1.5 mg-30 mcg norethindrone ace & ethinyl estradiol tab Preferred QL 1 / 1 days 1.5 mg-30 mcg norethindrone ace & ethinyl estradiol tab Preferred QL 1 / 1 days 1.5 mg-30 mcg norethindrone ace & ethinyl estradiol tab Non-Preferred QL 1 / 1 days 1.5 mg-30 mcg norethindrone ace & ethinyl estradiol tab Preferred QL 1 / 1 days 1.5 mg-30 mcg norethindrone ace & ethinyl estradiol tab Preferred QL 21 / 21 days 1.5 mg-30 mcg norethindrone acetate-ethinyl estradiol Preferred tab 0.5 mg-2.5 mcg norethindrone acetate-ethinyl estradiol Non-Preferred tab 0.5 mg-2.5 mcg

PAGE 338 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS norethindrone acetate-ethinyl estradiol Non-Preferred tab 0.5 mg-2.5 mcg norethindrone acetate-ethinyl estradiol Preferred tab 1 mg-5 mcg norethindrone acetate-ethinyl estradiol Preferred tab 1 mg-5 mcg norethindrone acetate-ethinyl estradiol Non-Preferred tab 1 mg-5 mcg norethindrone ac-ethinyl estrad-fe tab 1- Non-Preferred QL 1 / 1 days 20/1-30/1-35 mg-mcg norethindrone ac-ethinyl estrad-fe tab 1- Non-Preferred QL 1 / 1 days 20/1-30/1-35 mg-mcg norethindrone-eth estradiol tab 0.5- Preferred QL 28 / 28 days 35/0.75-35/1-35 mg-mcg norethindrone-eth estradiol tab 0.5- Preferred QL 28 / 28 days 35/0.75-35/1-35 mg-mcg norethindrone-eth estradiol tab 0.5- Preferred QL 28 / 28 days 35/0.75-35/1-35 mg-mcg norethindrone-eth estradiol tab 0.5- Preferred QL 28 / 28 days 35/0.75-35/1-35 mg-mcg norethindrone-eth estradiol tab 0.5- Preferred QL 28 / 28 days 35/0.75-35/1-35 mg-mcg norethindrone-eth estradiol tab 0.5- Preferred 35/0.75-35/1-35 mg-mcg norethindrone-eth estradiol tab 0.5- Preferred QL 28 / 28 days 35/0.75-35/1-35 mg-mcg norethindrone-eth estradiol tab 0.5-35/1- Preferred QL 1 / 1 days 35/0.5-35 mg-mcg norethindrone-eth estradiol tab 0.5-35/1- Preferred QL 1 / 1 days 35/0.5-35 mg-mcg norgestimate & ethinyl estradiol tab 0.25 Preferred QL 1 / 1 days mg-35 mcg norgestimate & ethinyl estradiol tab 0.25 Preferred QL 1 / 1 days mg-35 mcg norgestimate & ethinyl estradiol tab 0.25 Preferred QL 1 / 1 days mg-35 mcg norgestimate & ethinyl estradiol tab 0.25 Preferred QL 1 / 1 days mg-35 mcg norgestimate & ethinyl estradiol tab 0.25 Preferred QL 1 / 1 days mg-35 mcg

PAGE 339 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS norgestimate & ethinyl estradiol tab 0.25 Preferred QL 1 / 1 days mg-35 mcg norgestimate & ethinyl estradiol tab 0.25 Preferred mg-35 mcg norgestimate & ethinyl estradiol tab 0.25 Preferred QL 1 / 1 days mg-35 mcg norgestimate & ethinyl estradiol tab 0.25 Preferred QL 1 / 1 days mg-35 mcg norgestimate & ethinyl estradiol tab 0.25 Preferred QL 1 / 1 days mg-35 mcg norgestimate-eth estrad tab 0.18- Preferred QL 1 / 1 days 25/0.215-25/0.25-25 mg-mcg norgestimate-eth estrad tab 0.18- Preferred QL 1 / 1 days 25/0.215-25/0.25-25 mg-mcg norgestimate-eth estrad tab 0.18- Preferred QL 1 / 1 days 25/0.215-25/0.25-25 mg-mcg norgestimate-eth estrad tab 0.18- Preferred 25/0.215-25/0.25-25 mg-mcg norgestimate-eth estrad tab 0.18- Preferred QL 1 / 1 days 25/0.215-25/0.25-25 mg-mcg norgestimate-eth estrad tab 0.18- Preferred QL 1 / 1 days 25/0.215-25/0.25-25 mg-mcg norgestimate-eth estrad tab 0.18- Preferred QL 1 / 1 days 25/0.215-25/0.25-25 mg-mcg norgestimate-eth estrad tab 0.18- Preferred QL 1 / 1 days 35/0.215-35/0.25-35 mg-mcg norgestimate-eth estrad tab 0.18- Preferred QL 1 / 1 days 35/0.215-35/0.25-35 mg-mcg norgestimate-eth estrad tab 0.18- Preferred 35/0.215-35/0.25-35 mg-mcg norgestimate-eth estrad tab 0.18- Preferred QL 1 / 1 days 35/0.215-35/0.25-35 mg-mcg norgestimate-eth estrad tab 0.18- Preferred QL 1 / 1 days 35/0.215-35/0.25-35 mg-mcg norgestimate-eth estrad tab 0.18- Preferred 35/0.215-35/0.25-35 mg-mcg norgestimate-eth estrad tab 0.18- Preferred QL 1 / 1 days 35/0.215-35/0.25-35 mg-mcg norgestimate-eth estrad tab 0.18- Preferred QL 1 / 1 days 35/0.215-35/0.25-35 mg-mcg

PAGE 340 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS norgestimate-eth estrad tab 0.18- Preferred QL 1 / 1 days 35/0.215-35/0.25-35 mg-mcg norgestimate-eth estrad tab 0.18- Preferred QL 1 / 1 days 35/0.215-35/0.25-35 mg-mcg norgestrel & ethinyl estradiol tab 0.3 mg- Preferred QL 1 / 1 days 30 mcg norgestrel & ethinyl estradiol tab 0.3 mg- Preferred QL 1 / 1 days 30 mcg norgestrel & ethinyl estradiol tab 0.3 mg- Preferred QL 1 / 1 days 30 mcg norgestrel & ethinyl estradiol tab 0.5 mg- Non-Preferred QL 1 / 1 days 50 mcg NORINYL 1+35 (28) 1-35 MG-MCG TAB Non-Preferred norethindrone & eth estradiol NUVARING 0.12-0.015 MG/24HR RING Preferred QL 1 / 28 days etonogestrel-ethinyl estradiol ORTHO TRI-CYCLEN (28) 0.18/0.215/0.25 MG-35 MCG TAB Non-Preferred QL 28 / 28 days norgestimate-ethinyl estradiol (triphasic) ORTHO TRI-CYCLEN LO 0.18/0.215/0.25 MG-25 MCG TAB Non-Preferred QL 1 / 1 days norgestimate-ethinyl estradiol (triphasic) ORTHO-CYCLEN (28) 0.25-35 MG- MCG TAB Non-Preferred QL 28 / 28 days norgestimate-ethinyl estradiol ORTHO-NOVUM 1/35 (28) 1-35 MG- MCG TAB Non-Preferred QL 1 / 1 days norethindrone & eth estradiol ORTHO-NOVUM 7/7/7 (28) 0.5/0.75/1- 35 MG-MCG TAB Non-Preferred QL 28 / 28 days norethindrone-eth estradiol (triphasic) PREFEST 1/1-0.09 MG (15/15) TAB Non-Preferred estradiol-norgestimate PREMARIN 0.3 MG TAB Preferred QL 1 / 1 days estrogens, conjugated PREMARIN 0.45 MG TAB Preferred QL 1 / 1 days estrogens, conjugated PREMARIN 0.625 MG TAB Preferred QL 1 / 1 days estrogens, conjugated

PAGE 341 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PREMARIN 0.625 MG/GM CREAM Preferred estrogens, conjugated vaginal PREMARIN 0.9 MG TAB Preferred QL 1 / 1 days estrogens, conjugated PREMARIN 1.25 MG TAB Preferred estrogens, conjugated PREMARIN 25 MG RECON SOLN Non-Preferred estrogens, conjugated PREMPHASE 0.625-5 MG TAB conjugated estrogens- Preferred QL 1 / 1 days medroxyprogesterone acetate PREMPRO 0.3-1.5 MG TAB conjugated estrogens- Preferred QL 1 / 1 days medroxyprogesterone acetate PREMPRO 0.45-1.5 MG TAB conjugated estrogens- Preferred QL 1 / 1 days medroxyprogesterone acetate PREMPRO 0.625-2.5 MG TAB conjugated estrogens- Preferred QL 1 / 1 days medroxyprogesterone acetate PREMPRO 0.625-5 MG TAB conjugated estrogens- Preferred QL 1 / 1 days medroxyprogesterone acetate QUARTETTE 42-21-21-7 DAYS TAB Non-Preferred levonorgestrel-ethinyl estradiol (91-day) SAFYRAL 3-0.03-0.451 MG TAB drospirenone-ethinyl estradiol- Non-Preferred levomefolate calcium SEASONIQUE 0.15-0.03 &0.01 MG TAB Non-Preferred levonorgestrel-ethinyl estradiol (91-day) TAYTULLA 1-20 MG-MCG(24) CAP Non-Preferred norethin acet & estrad-fe TYBLUME 0.1-20 MG-MCG TAB Non-Preferred levonorgestrel & eth estradiol VAGIFEM 10 MCG TAB Preferred estradiol vaginal VIVELLE-DOT 0.025 MG/24HR PATCH TW Non-Preferred QL 8 / 28 days estradiol VIVELLE-DOT 0.0375 MG/24HR PATCH TW Non-Preferred QL 8 / 28 days estradiol

PAGE 342 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VIVELLE-DOT 0.05 MG/24HR PATCH TW Non-Preferred QL 8 / 28 days estradiol VIVELLE-DOT 0.075 MG/24HR PATCH TW Non-Preferred QL 8 / 28 days estradiol VIVELLE-DOT 0.1 MG/24HR PATCH TW Non-Preferred QL 8 / 28 days estradiol YASMIN 28 3-0.03 MG TAB Non-Preferred QL 1 / 1 days drospirenone-ethinyl estradiol YAZ 3-0.02 MG TAB Non-Preferred QL 1 / 1 days drospirenone-ethinyl estradiol PROGESTERONE AGONISTS/ANTAGONISTS

ELLA 30 MG TAB Preferred QL 1 / 1 fill ulipristal acetate PROGESTINS

AYGESTIN 5 MG TAB Non-Preferred QL 90 / 30 days norethindrone acetate CRINONE 4 % GEL Non-Preferred progesterone (vaginal) CRINONE 8 % GEL Non-Preferred progesterone (vaginal) DEPO-PROVERA 150 MG/ML SUSP PRSYR Non-Preferred medroxyprogesterone acetate (contraceptive) DEPO-PROVERA 150 MG/ML SUSPENSION Preferred medroxyprogesterone acetate (contraceptive) DEPO-PROVERA 400 MG/ML SUSPENSION Preferred medroxyprogesterone acetate (antineoplastic) DEPO-SUBQ PROVERA 104 104 MG/0.65ML SUSP PRSYR Preferred QL 1 / 84 days medroxyprogesterone acetate (contraceptive) HYDROXYPROGESTERONE CAPROATE 1.25 GM/5ML SOLUTION Preferred PA hydroxyprogesterone caproate (antineoplastic)

PAGE 343 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS hydroxyprogesterone caproate im in oil Preferred PA 250 mg/ml KYLEENA 19.5 MG IUD Preferred levonorgestrel (iud) LILETTA (52 MG) 19.5 MCG/DAY IUD Preferred levonorgestrel (iud) MAKENA 250 MG/ML OIL Non-Preferred PA hydroxyprogesterone caproate MAKENA 275 MG/1.1ML SOLN A-INJ Preferred PA hydroxyprogesterone caproate

medroxyprogesterone acetate tab 10 mg Preferred QL 3 / 1 days

medroxyprogesterone acetate tab 2.5 Preferred QL 1 / 1 days mg

medroxyprogesterone acetate tab 5 mg Preferred QL 3 / 1 days

medroxyprogesterone acetate im susp Preferred QL 1 / 84 days 150 mg/ml medroxyprogesterone acetate im susp Preferred QL 1 / 84 days prefilled syr 150 mg/ml megestrol acetate susp 40 mg/ml Preferred megestrol acetate susp 40 mg/ml Preferred

megestrol acetate tab 20 mg Preferred QL 8 / 1 days

megestrol acetate tab 40 mg Preferred QL 8 / 1 days

MIRENA (52 MG) 20 MCG/24HR IUD Preferred levonorgestrel (iud) NEXPLANON 68 MG IMPLANT Preferred etonogestrel

norethindrone tab 0.35 mg Preferred QL 1 / 1 days

norethindrone tab 0.35 mg Preferred QL 1 / 1 days

norethindrone tab 0.35 mg Preferred QL 1 / 1 days

norethindrone tab 0.35 mg Preferred QL 1 / 1 days

norethindrone tab 0.35 mg Preferred QL 1 / 1 days

norethindrone tab 0.35 mg Preferred QL 1 / 1 days

norethindrone tab 0.35 mg Preferred QL 1 / 1 days

PAGE 344 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS norethindrone tab 0.35 mg Preferred

norethindrone tab 0.35 mg Preferred QL 1 / 1 days

norethindrone tab 0.35 mg Preferred QL 1 / 1 days

norethindrone tab 0.35 mg Preferred QL 1 / 1 days

norethindrone tab 0.35 mg Preferred QL 1 / 1 days

norethindrone tab 0.35 mg Preferred QL 1 / 1 days

norethindrone tab 0.35 mg Preferred QL 1 / 1 days

norethindrone acetate tab 5 mg Preferred QL 90 / 30 days

ORTHO MICRONOR 0.35 MG TAB Preferred QL 1 / 1 days norethindrone (contraceptive) progesterone im in oil 50 mg/ml Preferred

progesterone micronized cap 100 mg Preferred QL 2 / 1 days

progesterone micronized cap 200 mg Preferred QL 2 / 1 days

PROMETRIUM 100 MG CAP Non-Preferred QL 2 / 1 days progesterone micronized PROMETRIUM 200 MG CAP Non-Preferred QL 2 / 1 days progesterone micronized PROVERA 10 MG TAB Non-Preferred QL 3 / 1 days medroxyprogesterone acetate PROVERA 2.5 MG TAB Non-Preferred medroxyprogesterone acetate PROVERA 5 MG TAB Non-Preferred QL 3 / 1 days medroxyprogesterone acetate SKYLA 13.5 MG IUD Preferred levonorgestrel (iud) SLYND 4 MG TAB Non-Preferred drospirenone SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS

DUAVEE 0.45-20 MG TAB Non-Preferred conjugated estrogens-bazedoxifene EVISTA 60 MG TAB Non-Preferred raloxifene hcl

raloxifene hcl tab 60 mg Non-Preferred QL 1 / 1 days

PAGE 345 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)

ARMOUR THYROID 120 MG TAB Preferred thyroid ARMOUR THYROID 15 MG TAB Preferred thyroid ARMOUR THYROID 180 MG TAB Preferred thyroid ARMOUR THYROID 240 MG TAB Preferred thyroid ARMOUR THYROID 30 MG TAB Preferred thyroid ARMOUR THYROID 300 MG TAB Preferred thyroid ARMOUR THYROID 60 MG TAB Preferred thyroid ARMOUR THYROID 90 MG TAB Preferred thyroid CYTOMEL 25 MCG TAB Preferred QL 3 / 1 days liothyronine sodium CYTOMEL 5 MCG TAB Preferred QL 4 / 1 days liothyronine sodium CYTOMEL 50 MCG TAB Preferred QL 2 / 1 days liothyronine sodium LEVOTHYROXINE SODIUM 100 MCG/5ML SOLUTION Non-Preferred levothyroxine sodium LEVOTHYROXINE SODIUM 200 MCG RECON SOLN Non-Preferred levothyroxine sodium levothyroxine sodium cap 100 mcg Non-Preferred levothyroxine sodium cap 112 mcg Non-Preferred levothyroxine sodium cap 125 mcg Non-Preferred levothyroxine sodium cap 13 mcg Non-Preferred levothyroxine sodium cap 137 mcg Non-Preferred levothyroxine sodium cap 150 mcg Non-Preferred levothyroxine sodium cap 175 mcg Non-Preferred levothyroxine sodium cap 200 mcg Non-Preferred

PAGE 346 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS levothyroxine sodium cap 25 mcg Non-Preferred levothyroxine sodium cap 50 mcg Non-Preferred levothyroxine sodium cap 75 mcg Non-Preferred levothyroxine sodium cap 88 mcg Non-Preferred levothyroxine sodium for iv inj 100 mcg Non-Preferred levothyroxine sodium for iv inj 200 mcg Non-Preferred levothyroxine sodium for iv inj 500 mcg Non-Preferred levothyroxine sodium tab 100 mcg Non-Preferred levothyroxine sodium tab 100 mcg Preferred levothyroxine sodium tab 100 mcg Preferred levothyroxine sodium tab 100 mcg Preferred levothyroxine sodium tab 100 mcg Non-Preferred levothyroxine sodium tab 112 mcg Non-Preferred levothyroxine sodium tab 112 mcg Preferred levothyroxine sodium tab 112 mcg Preferred levothyroxine sodium tab 112 mcg Preferred levothyroxine sodium tab 112 mcg Non-Preferred levothyroxine sodium tab 125 mcg Non-Preferred levothyroxine sodium tab 125 mcg Preferred levothyroxine sodium tab 125 mcg Preferred levothyroxine sodium tab 125 mcg Preferred levothyroxine sodium tab 125 mcg Non-Preferred levothyroxine sodium tab 137 mcg Non-Preferred levothyroxine sodium tab 137 mcg Preferred levothyroxine sodium tab 137 mcg Preferred levothyroxine sodium tab 137 mcg Preferred levothyroxine sodium tab 137 mcg Non-Preferred levothyroxine sodium tab 150 mcg Non-Preferred levothyroxine sodium tab 150 mcg Preferred levothyroxine sodium tab 150 mcg Preferred levothyroxine sodium tab 150 mcg Preferred

PAGE 347 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS levothyroxine sodium tab 150 mcg Non-Preferred levothyroxine sodium tab 175 mcg Non-Preferred levothyroxine sodium tab 175 mcg Preferred levothyroxine sodium tab 175 mcg Preferred levothyroxine sodium tab 175 mcg Preferred levothyroxine sodium tab 175 mcg Non-Preferred levothyroxine sodium tab 200 mcg Non-Preferred levothyroxine sodium tab 200 mcg Preferred levothyroxine sodium tab 200 mcg Preferred levothyroxine sodium tab 200 mcg Preferred levothyroxine sodium tab 200 mcg Non-Preferred levothyroxine sodium tab 25 mcg Non-Preferred levothyroxine sodium tab 25 mcg Preferred levothyroxine sodium tab 25 mcg Preferred levothyroxine sodium tab 25 mcg Preferred levothyroxine sodium tab 25 mcg Non-Preferred levothyroxine sodium tab 300 mcg Preferred levothyroxine sodium tab 300 mcg Preferred levothyroxine sodium tab 300 mcg Non-Preferred levothyroxine sodium tab 50 mcg Non-Preferred levothyroxine sodium tab 50 mcg Preferred levothyroxine sodium tab 50 mcg Preferred levothyroxine sodium tab 50 mcg Preferred levothyroxine sodium tab 50 mcg Non-Preferred levothyroxine sodium tab 75 mcg Non-Preferred levothyroxine sodium tab 75 mcg Preferred levothyroxine sodium tab 75 mcg Preferred levothyroxine sodium tab 75 mcg Preferred levothyroxine sodium tab 75 mcg Non-Preferred levothyroxine sodium tab 88 mcg Non-Preferred levothyroxine sodium tab 88 mcg Preferred

PAGE 348 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS levothyroxine sodium tab 88 mcg Preferred levothyroxine sodium tab 88 mcg Preferred levothyroxine sodium tab 88 mcg Non-Preferred liothyronine sodium iv soln 10 mcg/ml Non-Preferred

liothyronine sodium tab 25 mcg Preferred QL 3 / 1 days

liothyronine sodium tab 5 mcg Preferred QL 4 / 1 days

liothyronine sodium tab 50 mcg Preferred QL 2 / 1 days

SYNTHROID 100 MCG TAB Non-Preferred levothyroxine sodium SYNTHROID 112 MCG TAB Non-Preferred levothyroxine sodium SYNTHROID 125 MCG TAB Non-Preferred levothyroxine sodium SYNTHROID 137 MCG TAB Non-Preferred levothyroxine sodium SYNTHROID 150 MCG TAB Non-Preferred levothyroxine sodium SYNTHROID 175 MCG TAB Non-Preferred levothyroxine sodium SYNTHROID 200 MCG TAB Non-Preferred levothyroxine sodium SYNTHROID 25 MCG TAB Non-Preferred levothyroxine sodium SYNTHROID 300 MCG TAB Non-Preferred levothyroxine sodium SYNTHROID 50 MCG TAB Non-Preferred levothyroxine sodium SYNTHROID 75 MCG TAB Preferred levothyroxine sodium SYNTHROID 88 MCG TAB Non-Preferred levothyroxine sodium THYQUIDITY 100 MCG/5ML SOLUTION Non-Preferred levothyroxine sodium thyroid tab 120 mg (2 grain) Preferred thyroid tab 120 mg (2 grain) Preferred

PAGE 349 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS thyroid tab 15 mg (1/4 grain) Preferred thyroid tab 15 mg (1/4 grain) Preferred thyroid tab 30 mg (1/2 grain) Preferred thyroid tab 30 mg (1/2 grain) Preferred thyroid tab 60 mg (1 grain) Preferred thyroid tab 60 mg (1 grain) Preferred thyroid tab 90 mg (1 1/2 grain) Preferred thyroid tab 90 mg (1 1/2 grain) Preferred TIROSINT 100 MCG CAP Non-Preferred levothyroxine sodium TIROSINT 112 MCG CAP Non-Preferred levothyroxine sodium TIROSINT 125 MCG CAP Non-Preferred levothyroxine sodium TIROSINT 13 MCG CAP Non-Preferred levothyroxine sodium TIROSINT 137 MCG CAP Non-Preferred levothyroxine sodium TIROSINT 150 MCG CAP Non-Preferred levothyroxine sodium TIROSINT 175 MCG CAP Non-Preferred levothyroxine sodium TIROSINT 200 MCG CAP Non-Preferred levothyroxine sodium TIROSINT 25 MCG CAP Non-Preferred levothyroxine sodium TIROSINT 50 MCG CAP Non-Preferred levothyroxine sodium TIROSINT 75 MCG CAP Non-Preferred levothyroxine sodium TIROSINT 88 MCG CAP Non-Preferred levothyroxine sodium TIROSINT-SOL 100 MCG/ML SOLUTION Non-Preferred levothyroxine sodium TIROSINT-SOL 112 MCG/ML SOLUTION Non-Preferred levothyroxine sodium

PAGE 350 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TIROSINT-SOL 125 MCG/ML SOLUTION Non-Preferred levothyroxine sodium TIROSINT-SOL 13 MCG/ML SOLUTION Non-Preferred levothyroxine sodium TIROSINT-SOL 137 MCG/ML SOLUTION Non-Preferred levothyroxine sodium TIROSINT-SOL 150 MCG/ML SOLUTION Non-Preferred levothyroxine sodium TIROSINT-SOL 175 MCG/ML SOLUTION Non-Preferred levothyroxine sodium TIROSINT-SOL 200 MCG/ML SOLUTION Non-Preferred levothyroxine sodium TIROSINT-SOL 25 MCG/ML SOLUTION Non-Preferred levothyroxine sodium TIROSINT-SOL 50 MCG/ML SOLUTION Non-Preferred levothyroxine sodium TIROSINT-SOL 75 MCG/ML SOLUTION Non-Preferred levothyroxine sodium TIROSINT-SOL 88 MCG/ML SOLUTION Non-Preferred levothyroxine sodium TRIOSTAT 10 MCG/ML SOLUTION Non-Preferred liothyronine sodium HORMONAL AGENTS, SUPPRESSANT (PITUITARY)

cabergoline tab 0.5 mg Preferred QL 16 / 30 days

ELIGARD 22.5 MG KIT QL 1 / 90 days Preferred leuprolide acetate (3 month) PA

ELIGARD 30 MG KIT QL 1 / 120 days Preferred leuprolide acetate (4 month) PA

ELIGARD 45 MG KIT QL 1 / 180 days Preferred leuprolide acetate (6 month) PA

ELIGARD 7.5 MG KIT QL 1 / 30 days Preferred leuprolide acetate PA

PAGE 351 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS FENSOLVI (6 MONTH) 45 MG (PED) KIT Non-Preferred QL 1 / 180 days leuprolide acetate (cpp) (6 month)

QL 2 / 28 days leuprolide acetate inj kit 5 mg/ml Preferred PA

LUPANETA PACK 11.25 & 5 MG KIT QL 1 / 90 days leuprolide acetate & norethindrone Preferred acetate PA

LUPANETA PACK 3.75 & 5 MG KIT QL 1 / 30 days leuprolide acetate & norethindrone Preferred acetate PA

LUPRON DEPOT (1-MONTH) 3.75 MG QL 1 / 30 days KIT Preferred leuprolide acetate PA

LUPRON DEPOT (1-MONTH) 7.5 MG QL 1 / 30 days KIT Preferred leuprolide acetate PA

LUPRON DEPOT (3-MONTH) 11.25 MG QL 1 / 90 days KIT Preferred leuprolide acetate (3 month) PA

LUPRON DEPOT (3-MONTH) 22.5 MG QL 1 / 90 days KIT Preferred leuprolide acetate (3 month) PA

LUPRON DEPOT (4-MONTH) 30 MG QL 1 / 120 days KIT Preferred leuprolide acetate (4 month) PA

LUPRON DEPOT (6-MONTH) 45 MG QL 1 / 180 days KIT Preferred leuprolide acetate (6 month) PA

LUPRON DEPOT-PED (1-MONTH) QL 1 / 30 days 11.25 MG KIT Preferred leuprolide acetate (cpp) PA

LUPRON DEPOT-PED (1-MONTH) 15 QL 1 / 30 days MG KIT Preferred leuprolide acetate (cpp) PA

LUPRON DEPOT-PED (1-MONTH) 7.5 QL 1 / 30 days MG KIT Preferred leuprolide acetate (cpp) PA

LUPRON DEPOT-PED (3-MONTH) QL 1 / 90 days 11.25 MG (PED) KIT Preferred leuprolide acetate (cpp) (3 month) PA

PAGE 352 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

LUPRON DEPOT-PED (3-MONTH) 30 QL 1 / 90 days MG (PED) KIT Preferred leuprolide acetate (cpp) (3 month) PA ORGOVYX 120 MG TAB Non-Preferred QL 90 / 30 days relugolix

ORILISSA 150 MG TAB QL 1 / 1 days Preferred elagolix sodium PA

ORILISSA 200 MG TAB QL 2 / 1 days Preferred elagolix sodium PA

SUPPRELIN LA 50 MG KIT Non-Preferred histrelin acetate (cpp) SYNAREL 2 MG/ML SOLUTION Preferred PA nafarelin acetate TRELSTAR MIXJECT 11.25 MG RECON SUSP Non-Preferred triptorelin pamoate TRELSTAR MIXJECT 22.5 MG RECON SUSP Non-Preferred triptorelin pamoate TRELSTAR MIXJECT 3.75 MG RECON SUSP Non-Preferred triptorelin pamoate TRIPTODUR 22.5 MG SRER Preferred PA triptorelin pamoate (cpp) VANTAS 50 MG KIT Preferred PA histrelin acetate HORMONAL AGENTS, SUPPRESSANT (THYROID)

ANTITHYROID AGENTS

methimazole tab 10 mg Preferred QL 6 / 1 days

methimazole tab 5 mg Preferred QL 9 / 1 days

propylthiouracil tab 50 mg Preferred QL 9 / 1 days

IMMUNOLOGICAL AGENTS

ANGIOEDEMA AGENTS

BERINERT 500 UNIT KIT Preferred PA c1 esterase inhibitor (human)

PAGE 353 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CINRYZE 500 UNIT RECON SOLN Preferred PA c1 esterase inhibitor (human) FIRAZYR 30 MG/3ML SOLUTION Non-Preferred icatibant acetate HAEGARDA 2000 UNIT RECON SOLN Preferred PA c1 esterase inhibitor (human) HAEGARDA 3000 UNIT RECON SOLN Preferred PA c1 esterase inhibitor (human) icatibant acetate inj 30 mg/3ml (base Preferred PA equivalent) KALBITOR 10 MG/ML SOLUTION Preferred PA ecallantide ORLADEYO 110 MG CAP Non-Preferred berotralstat hcl ORLADEYO 150 MG CAP Non-Preferred berotralstat hcl RUCONEST 2100 UNIT RECON SOLN Preferred PA c1 esterase inhibitor (recombinant) TAKHZYRO 300 MG/2ML SOLUTION Preferred PA lanadelumab-flyo IMMUNE SUPPRESSANTS

ASTAGRAF XL 0.5 MG CAP ER 24H Non-Preferred tacrolimus ASTAGRAF XL 1 MG CAP ER 24H Non-Preferred tacrolimus ASTAGRAF XL 5 MG CAP ER 24H Non-Preferred tacrolimus AVSOLA 100 MG RECON SOLN Non-Preferred infliximab-axxq AZASAN 100 MG TAB Non-Preferred azathioprine AZASAN 75 MG TAB Non-Preferred azathioprine azathioprine tab 50 mg Preferred CELLCEPT 200 MG/ML RECON SUSP Preferred mycophenolate mofetil CELLCEPT 250 MG CAP Non-Preferred mycophenolate mofetil

PAGE 354 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CELLCEPT 500 MG TAB Non-Preferred mycophenolate mofetil CIMZIA 2 X 200 MG KIT Non-Preferred certolizumab pegol CIMZIA PREFILLED 2 X 200 MG/ML KIT Non-Preferred certolizumab pegol CIMZIA STARTER KIT 6 X 200 MG/ML KIT Non-Preferred QLC 1 starter pack/lifetime certolizumab pegol cyclosporine cap 100 mg Preferred cyclosporine cap 25 mg Preferred cyclosporine modified cap 100 mg Preferred cyclosporine modified cap 100 mg Non-Preferred cyclosporine modified cap 25 mg Preferred cyclosporine modified cap 25 mg Non-Preferred cyclosporine modified cap 50 mg Preferred cyclosporine modified oral soln 100 Preferred mg/ml cyclosporine modified oral soln 100 Non-Preferred mg/ml

ENBREL 25 MG RECON SOLN QL 8 / 28 days Preferred etanercept PA

ENBREL 25 MG/0.5ML SOLN PRSYR QL 4 / 28 days Preferred etanercept PA

ENBREL 25 MG/0.5ML SOLUTION Preferred PA etanercept

ENBREL 50 MG/ML SOLN PRSYR QL 8 / 28 days Preferred etanercept PA

ENBREL MINI 50 MG/ML SOLN CART QL 8 / 28 days Preferred etanercept PA

ENBREL SURECLICK 50 MG/ML SOLN QL 8 / 28 days A-INJ Preferred etanercept PA ENTYVIO 300 MG RECON SOLN Non-Preferred vedolizumab

PAGE 355 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ENVARSUS XR 0.75 MG TAB ER 24H Non-Preferred tacrolimus ENVARSUS XR 1 MG TAB ER 24H Non-Preferred tacrolimus ENVARSUS XR 4 MG TAB ER 24H Non-Preferred tacrolimus everolimus tab 0.25 mg Non-Preferred everolimus tab 0.5 mg Non-Preferred everolimus tab 0.75 mg Non-Preferred

HUMIRA 10 MG/0.1ML PREF SY KT QL 2 / 28 days Preferred adalimumab PA

HUMIRA 10 MG/0.2ML PREF SY KT QL 2 / 28 days Preferred adalimumab PA

HUMIRA 20 MG/0.2ML PREF SY KT QL 2 / 28 days Preferred adalimumab PA

HUMIRA 20 MG/0.4ML PREF SY KT QL 2 / 28 days Preferred adalimumab PA

HUMIRA 40 MG/0.4ML PREF SY KT QL 2 / 28 days Preferred adalimumab PA

HUMIRA 40 MG/0.8ML PREF SY KT QL 2 / 28 days Preferred adalimumab PA

HUMIRA 80 MG/0.8ML PEN KIT QL 3 / 28 days Preferred adalimumab PA

HUMIRA PEDIATRIC CROHNS START QL 6 / 28 days 40 MG/0.8ML PREF SY KT Preferred adalimumab PA HUMIRA PEDIATRIC CROHNS START 80 MG/0.8ML & 40MG/0.4ML PREF SY QL 2 / 28 days Preferred KT PA adalimumab

HUMIRA PEDIATRIC CROHNS START QL 3 / 28 days 80 MG/0.8ML PREF SY KT Preferred adalimumab PA

HUMIRA PEN 40 MG/0.4ML PEN KIT QL 2 / 28 days Preferred adalimumab PA

PAGE 356 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

HUMIRA PEN 40 MG/0.8ML PEN KIT QL 2 / 28 days Preferred adalimumab PA

HUMIRA PEN-CD/UC/HS STARTER 40 QL 6 / 28 days MG/0.8ML PEN KIT Preferred adalimumab PA

HUMIRA PEN-CD/UC/HS STARTER 80 QL 3 / 28 days MG/0.8ML PEN KIT Preferred adalimumab PA

HUMIRA PEN-PEDIATRIC UC START QL 3 / 28 days 80 MG/0.8ML PEN KIT Preferred adalimumab PA

HUMIRA PEN-PS/UV/ADOL HS START QL 4 / 35 days 40 MG/0.8ML PEN KIT Preferred adalimumab PA

HUMIRA PEN-PSOR/UVEIT STARTER QL 3 / 28 days 80 MG/0.8ML & 40MG/0.4ML PEN KIT Preferred adalimumab PA ILARIS 150 MG RECON SOLN Non-Preferred canakinumab IMURAN 50 MG TAB Non-Preferred azathioprine INFLECTRA 100 MG RECON SOLN Non-Preferred infliximab-dyyb KEVZARA 150 MG/1.14ML SOLN A-INJ Non-Preferred sarilumab KEVZARA 150 MG/1.14ML SOLN PRSYR Non-Preferred sarilumab KEVZARA 200 MG/1.14ML SOLN A-INJ Non-Preferred sarilumab KEVZARA 200 MG/1.14ML SOLN PRSYR Non-Preferred sarilumab KINERET 100 MG/0.67ML SOLN PRSYR Non-Preferred anakinra LUPKYNIS 7.9 MG CAP Non-Preferred QL 180 / 30 days voclosporin methotrexate sodium for inj 1 gm Preferred methotrexate sodium inj 250 mg/10ml Preferred (25 mg/ml)

PAGE 357 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS methotrexate sodium inj 50 mg/2ml (25 Preferred mg/ml) methotrexate sodium inj pf 1000 Preferred mg/40ml (25 mg/ml) methotrexate sodium inj pf 250 mg/10ml Preferred (25 mg/ml) methotrexate sodium inj pf 50 mg/2ml Preferred (25 mg/ml) methotrexate sodium tab 2.5 mg (base Preferred equiv) methotrexate sodium tab 2.5 mg (base Preferred equiv) mycophenolate mofetil cap 250 mg Preferred mycophenolate mofetil for oral susp 200 Non-Preferred mg/ml mycophenolate mofetil tab 500 mg Preferred mycophenolate sodium tab dr 180 mg Preferred QL 8 / 1 days (mycophenolic acid equiv) mycophenolate sodium tab dr 360 mg Preferred QL 120 / 30 days (mycophenolic acid equiv) MYFORTIC 180 MG TAB DR Non-Preferred QL 8 / 1 days mycophenolate sodium MYFORTIC 360 MG TAB DR Non-Preferred QL 120 / 30 days mycophenolate sodium NEORAL 100 MG CAP cyclosporine modified (for Non-Preferred microemulsion) NEORAL 100 MG/ML SOLUTION cyclosporine modified (for Non-Preferred microemulsion) NEORAL 25 MG CAP cyclosporine modified (for Non-Preferred microemulsion) OLUMIANT 1 MG TAB Non-Preferred baricitinib OLUMIANT 2 MG TAB Non-Preferred baricitinib ORENCIA 125 MG/ML SOLN PRSYR Non-Preferred QL 4 / 28 days abatacept

PAGE 358 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ORENCIA 250 MG RECON SOLN Non-Preferred abatacept ORENCIA 50 MG/0.4ML SOLN PRSYR Non-Preferred QL 1.6 / 28 days abatacept ORENCIA 87.5 MG/0.7ML SOLN PRSYR Non-Preferred QL 2.8 / 28 days abatacept ORENCIA CLICKJECT 125 MG/ML SOLN A-INJ Non-Preferred QL 4 / 28 days abatacept OTREXUP 10 MG/0.4ML SOLN A-INJ Non-Preferred methotrexate (antirheumatic) OTREXUP 12.5 MG/0.4ML SOLN A-INJ Non-Preferred methotrexate (antirheumatic) OTREXUP 15 MG/0.4ML SOLN A-INJ Non-Preferred methotrexate (antirheumatic) OTREXUP 17.5 MG/0.4ML SOLN A-INJ Non-Preferred methotrexate (antirheumatic) OTREXUP 20 MG/0.4ML SOLN A-INJ Non-Preferred methotrexate (antirheumatic) OTREXUP 22.5 MG/0.4ML SOLN A-INJ Non-Preferred methotrexate (antirheumatic) OTREXUP 25 MG/0.4ML SOLN A-INJ Non-Preferred methotrexate (antirheumatic) PROGRAF 0.2 MG PACKET Non-Preferred tacrolimus PROGRAF 0.5 MG CAP Non-Preferred tacrolimus PROGRAF 1 MG CAP Non-Preferred tacrolimus PROGRAF 1 MG PACKET Non-Preferred tacrolimus PROGRAF 5 MG CAP Non-Preferred tacrolimus RAPAMUNE 0.5 MG TAB Preferred sirolimus RAPAMUNE 1 MG TAB Preferred sirolimus RAPAMUNE 1 MG/ML SOLUTION Preferred sirolimus

PAGE 359 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS RAPAMUNE 2 MG TAB Preferred sirolimus RASUVO 10 MG/0.2ML SOLN A-INJ Non-Preferred methotrexate (antirheumatic) RASUVO 12.5 MG/0.25ML SOLN A-INJ Non-Preferred methotrexate (antirheumatic) RASUVO 15 MG/0.3ML SOLN A-INJ Non-Preferred methotrexate (antirheumatic) RASUVO 17.5 MG/0.35ML SOLN A-INJ Non-Preferred methotrexate (antirheumatic) RASUVO 20 MG/0.4ML SOLN A-INJ Non-Preferred methotrexate (antirheumatic) RASUVO 22.5 MG/0.45ML SOLN A-INJ Non-Preferred methotrexate (antirheumatic) RASUVO 25 MG/0.5ML SOLN A-INJ Non-Preferred methotrexate (antirheumatic) RASUVO 30 MG/0.6ML SOLN A-INJ Non-Preferred methotrexate (antirheumatic) RASUVO 7.5 MG/0.15ML SOLN A-INJ Non-Preferred methotrexate (antirheumatic) REDITREX 10 MG/0.4ML SOLN PRSYR Non-Preferred methotrexate (antirheumatic) REDITREX 12.5 MG/0.05ML SOLN PRSYR Non-Preferred methotrexate (antirheumatic) REDITREX 15 MG/0.6ML SOLN PRSYR Non-Preferred methotrexate (antirheumatic) REDITREX 17.5 MG/0.7ML SOLN PRSYR Non-Preferred methotrexate (antirheumatic) REDITREX 20 MG/0.8ML SOLN PRSYR Non-Preferred methotrexate (antirheumatic) REDITREX 22.5 MG/0.9ML SOLN PRSYR Non-Preferred methotrexate (antirheumatic) REDITREX 25 MG/ML SOLN PRSYR Non-Preferred methotrexate (antirheumatic)

PAGE 360 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS REDITREX 7.5 MG/0.3ML SOLN PRSYR Non-Preferred methotrexate (antirheumatic) REMICADE 100 MG RECON SOLN Non-Preferred infliximab RENFLEXIS 100 MG RECON SOLN Non-Preferred infliximab-abda RINVOQ 15 MG TAB ER 24H Non-Preferred QL 30 / 30 days upadacitinib SANDIMMUNE 100 MG CAP Non-Preferred cyclosporine SANDIMMUNE 100 MG/ML SOLUTION Preferred cyclosporine SANDIMMUNE 25 MG CAP Non-Preferred cyclosporine SILIQ 210 MG/1.5ML SOLN PRSYR Non-Preferred brodalumab SIMPONI 100 MG/ML SOLN A-INJ Non-Preferred golimumab SIMPONI 100 MG/ML SOLN PRSYR Non-Preferred golimumab SIMPONI 50 MG/0.5ML SOLN A-INJ Non-Preferred golimumab SIMPONI 50 MG/0.5ML SOLN PRSYR Non-Preferred golimumab SIMPONI ARIA 50 MG/4ML SOLUTION Non-Preferred golimumab sirolimus oral soln 1 mg/ml Non-Preferred sirolimus tab 0.5 mg Preferred sirolimus tab 1 mg Preferred sirolimus tab 2 mg Preferred tacrolimus cap 0.5 mg Preferred tacrolimus cap 1 mg Preferred tacrolimus cap 5 mg Preferred TREMFYA 100 MG/ML SOLN PEN Non-Preferred guselkumab TREMFYA 100 MG/ML SOLN PRSYR Non-Preferred guselkumab

PAGE 361 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TREXALL 10 MG TAB Non-Preferred methotrexate sodium TREXALL 15 MG TAB Non-Preferred methotrexate sodium TREXALL 5 MG TAB Non-Preferred methotrexate sodium TREXALL 7.5 MG TAB Non-Preferred methotrexate sodium XATMEP 2.5 MG/ML SOLUTION Non-Preferred methotrexate XELJANZ 1 MG/ML SOLUTION Non-Preferred tofacitinib citrate XELJANZ 10 MG TAB Non-Preferred QL 60 / 30 days tofacitinib citrate XELJANZ 5 MG TAB Non-Preferred QL 60 / 30 days tofacitinib citrate XELJANZ XR 11 MG TAB ER 24H Non-Preferred QL 30 / 30 days tofacitinib citrate XELJANZ XR 22 MG TAB ER 24H Non-Preferred QL 30 / 30 days tofacitinib citrate ZORTRESS 0.25 MG TAB Non-Preferred everolimus (immunosuppressant) ZORTRESS 0.5 MG TAB Non-Preferred everolimus (immunosuppressant) ZORTRESS 0.75 MG TAB Non-Preferred everolimus (immunosuppressant) ZORTRESS 1 MG TAB Non-Preferred everolimus (immunosuppressant) IMMUNIZING AGENTS, PASSIVE

HYPERRHO S/D 1500 UNIT SOLN PRSYR Preferred rho d immune globulin (human) RHOGAM ULTRA-FILTERED PLUS 1500 UNIT SOLN PRSYR Preferred rho d immune globulin (human) IMMUNOMODULATORS

ACTEMRA 162 MG/0.9ML SOLN PRSYR Non-Preferred tocilizumab

PAGE 362 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ACTEMRA 200 MG/10ML SOLUTION Non-Preferred tocilizumab ACTEMRA 400 MG/20ML SOLUTION Non-Preferred tocilizumab ACTEMRA 80 MG/4ML SOLUTION Non-Preferred tocilizumab ACTEMRA ACTPEN 162 MG/0.9ML SOLN A-INJ Non-Preferred tocilizumab ARCALYST 220 MG RECON SOLN Non-Preferred rilonacept CINQAIR 100 MG/10ML SOLUTION Non-Preferred reslizumab ILARIS 150 MG/ML SOLUTION Non-Preferred canakinumab

leflunomide tab 10 mg Preferred QL 1 / 1 days

leflunomide tab 20 mg Preferred QL 5 / 1 days

OTEZLA 10 & 20 & 30 MG TAB THPK Non-Preferred apremilast OTEZLA 30 MG TAB Non-Preferred QL 2 / 1 days apremilast VACCINES

ADACEL 5-2-15.5 LF-MCG/0.5 SUSPENSION Preferred tetanus toxoid-diphtheria-acellular pertussis adsorb (tdap) AFLURIA SUSPENSION Preferred influenza virus vaccine split AFLURIA PRESERVATIVE FREE 0.5 ML SUSP PRSYR Preferred influenza virus vaccine split preservative free AFLURIA QUADRIVALENT SUSPENSION Preferred influenza virus vaccine split quadrivalent AFLURIA QUADRIVALENT 0.25 ML SUSP PRSYR Preferred influenza virus vaccine split quadrivalent AFLURIA QUADRIVALENT 0.5 ML SUSP PRSYR Preferred influenza virus vaccine split quadrivalent

PAGE 363 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS BOOSTRIX 5-2.5-18.5 LF-MCG/0.5 SUSPENSION Preferred tetanus toxoid-diphtheria-acellular pertussis adsorb (tdap) ENGERIX-B 10 MCG/0.5ML SUSPENSION Preferred hepatitis b vaccine (recomb) ENGERIX-B 20 MCG/ML SUSPENSION Preferred hepatitis b vaccine (recomb) FLUAD 0.5 ML SUSP PRSYR influenza virus vaccine types a & b Preferred surface antigen adjuvant FLUARIX QUADRIVALENT 0.5 ML SUSP PRSYR Preferred influenza virus vaccine split quadrivalent FLUBLOK QUADRIVALENT 0.5 ML SOLN PRSYR Preferred influenza virus vac recomb hemagglutinin (ha) quadrivalent FLUCELVAX QUADRIVALENT SUSPENSION Preferred influenza virus vaccine tissue-cultured subunit quadrivalent FLUCELVAX QUADRIVALENT 0.5 ML SUSP PRSYR Preferred influenza virus vaccine tissue-cultured subunit quadrivalent FLULAVAL QUADRIVALENT SUSPENSION Preferred influenza virus vaccine split quadrivalent FLULAVAL QUADRIVALENT 0.5 ML SUSP PRSYR Preferred influenza virus vaccine split quadrivalent FLUZONE HIGH-DOSE 0.5 ML SUSP PRSYR Preferred influenza virus vaccine split high-dose preservative free FLUZONE QUADRIVALENT SUSPENSION Preferred influenza virus vaccine split quadrivalent FLUZONE QUADRIVALENT 0.25 ML SUSP PRSYR Preferred influenza virus vaccine split quadrivalent

PAGE 364 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS FLUZONE QUADRIVALENT 0.5 ML SUSP PRSYR Preferred influenza virus vaccine split quadrivalent FLUZONE QUADRIVALENT 0.5 ML SUSPENSION Preferred influenza virus vaccine split quadrivalent HAVRIX 1440 EL U/ML SUSPENSION Preferred hepatitis a vaccine HAVRIX 720 EL U/0.5ML SUSPENSION Preferred hepatitis a vaccine PNEUMOVAX 23 25 MCG/0.5ML INJECTABLE Preferred pneumococcal vac polyvalent PREVNAR 13 SUSPENSION pneumococcal 13-valent conjugate Preferred QL 1 / lifetime vaccine RECOMBIVAX HB 10 MCG/ML SUSPENSION Preferred hepatitis b vaccine (recomb) RECOMBIVAX HB 40 MCG/ML SUSPENSION Preferred hepatitis b vaccine (recomb) RECOMBIVAX HB 5 MCG/0.5ML SUSPENSION Preferred hepatitis b vaccine (recomb) SHINGRIX 50 MCG/0.5ML RECON SUSP Preferred QL 2 / lifetime zoster vaccine recombinant adjuvanted TWINRIX 720-20 ELU-MCG/ML SUSP PRSYR Preferred hepatitis a (inactivated)-hepatitis b (recombinant) vaccines VAQTA 25 UNIT/0.5ML SUSPENSION Preferred hepatitis a vaccine VAQTA 50 UNIT/ML SUSPENSION Preferred hepatitis a vaccine INFLAMMATORY BOWEL DISEASE AGENTS

AMINOSALICYLATES

APRISO 0.375 GM CAP ER 24H Preferred QL 120 / 30 days mesalamine

PAGE 365 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ASACOL HD 800 MG TAB DR Non-Preferred QL 6 / 1 days mesalamine AZULFIDINE 500 MG TAB Non-Preferred sulfasalazine AZULFIDINE EN-TABS 500 MG TAB DR Non-Preferred sulfasalazine

balsalazide disodium cap 750 mg Preferred QL 9 / 1 days

CANASA 1000 MG SUPPOS Non-Preferred QL 1 / 1 days mesalamine COLAZAL 750 MG CAP Non-Preferred balsalazide disodium DELZICOL 400 MG CAP DR Preferred QL 6 / 1 days mesalamine DIPENTUM 250 MG CAP Non-Preferred olsalazine sodium GIAZO 1.1 GM TAB Non-Preferred balsalazide disodium LIALDA 1.2 GM TAB DR Non-Preferred QL 4 / 1 days mesalamine

mesalamine cap dr 400 mg Preferred QL 6 / 1 days

mesalamine cap er 24hr 0.375 gm Non-Preferred QL 120 / 30 days

mesalamine enema 4 gm Preferred QL 60 / 1 days

mesalamine suppos 1000 mg Preferred QL 1 / 1 days

mesalamine tab delayed release 1.2 gm Preferred QL 4 / 1 days

mesalamine tab delayed release 800 mg Non-Preferred QL 6 / 1 days

*mesalamine rectal enema 4 gm & Preferred cleanser wipe kit** PENTASA 250 MG CAP ER Preferred QL 8 / 1 days mesalamine PENTASA 500 MG CAP ER Preferred QL 8 / 1 days mesalamine ROWASA 4 GM KIT Non-Preferred mesalamine w/ cleanser SFROWASA 4 GM/60ML ENEMA Non-Preferred mesalamine

PAGE 366 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

sulfasalazine tab 500 mg Preferred QL 12 / 1 days

sulfasalazine tab delayed release 500 Preferred QL 12 / 1 days mg GLUCOCORTICOIDS

budesonide delayed release particles Preferred cap 3 mg budesonide tab er 24hr 9 mg Preferred ENTOCORT EC 3 MG CP DR PART Non-Preferred budesonide

hydrocortisone enema 100 mg/60ml Preferred QL 240 / 1 days

hydrocortisone enema 100 mg/60ml Preferred QL 240 / 1 days

ORTIKOS 6 MG CAP ER 24H Non-Preferred budesonide ORTIKOS 9 MG CAP ER 24H Non-Preferred budesonide UCERIS 2 MG/ACT FOAM Non-Preferred budesonide (intrarectal) UCERIS 9 MG TAB ER 24H Non-Preferred budesonide METABOLIC BONE DISEASE AGENTS

ACTONEL 150 MG TAB Non-Preferred QL 1 / 28 days risedronate sodium ACTONEL 35 MG TAB Non-Preferred QL 4 / 28 days risedronate sodium ACTONEL 5 MG TAB Non-Preferred QL 30 / 30 days risedronate sodium alendronate sodium oral soln 70 Non-Preferred QL 10.7 / 1 days mg/75ml

alendronate sodium tab 10 mg Preferred QL 1 / 1 days

alendronate sodium tab 35 mg Preferred QL 4 / 28 days

alendronate sodium tab 40 mg Preferred QL 1 / 1 days

alendronate sodium tab 5 mg Preferred QL 1 / 1 days

alendronate sodium tab 70 mg Preferred QL 4 / 28 days

ATELVIA 35 MG TAB DR Non-Preferred risedronate sodium

PAGE 367 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS BINOSTO 70 MG EFFER TAB Non-Preferred alendronate sodium BONIVA 150 MG TAB Non-Preferred ibandronate sodium BONIVA 3 MG/3ML SOLUTION Non-Preferred ibandronate sodium calcitonin (salmon) nasal soln 200 Non-Preferred unit/act

calcitriol cap 0.25 mcg Preferred QL 4 / 1 days

calcitriol cap 0.5 mcg Preferred QL 4 / 1 days

CALCITRIOL INJ 1 MCG/ML Preferred

CALCITRIOL ORAL SOLN 1 MCG/ML Non-Preferred QL 60 / 30 days

cinacalcet hcl tab 30 mg (base equiv) Preferred QL 2 / 1 days

cinacalcet hcl tab 60 mg (base equiv) Preferred QL 2 / 1 days

cinacalcet hcl tab 90 mg (base equiv) Preferred QL 2 / 1 days

doxercalciferol cap 0.5 mcg Non-Preferred doxercalciferol cap 1 mcg Non-Preferred doxercalciferol cap 2.5 mcg Non-Preferred doxercalciferol inj 4 mcg/2ml (2 mcg/ml) Preferred

ergocalciferol cap 1.25 mg (50000 unit) Preferred QL 8 / 30 days

ergocalciferol cap 1.25 mg (50000 unit) Preferred QL 8 / 30 days

ETIDRONATE DISODIUM 200 MG TAB Non-Preferred etidronate disodium ETIDRONATE DISODIUM 400 MG TAB Non-Preferred etidronate disodium EVENITY 105 MG/1.17ML SOLN PRSYR Non-Preferred romosozumab-aqqg FORTEO 600 MCG/2.4ML SOLN PEN Non-Preferred teriparatide (recombinant) FOSAMAX 70 MG TAB Non-Preferred alendronate sodium FOSAMAX PLUS D 70-2800 MG-UNIT TAB Non-Preferred alendronate sodium-cholecalciferol

PAGE 368 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS FOSAMAX PLUS D 70-5600 MG-UNIT TAB Non-Preferred alendronate sodium-cholecalciferol HECTOROL 2 MCG/ML SOLUTION Preferred doxercalciferol HECTOROL 4 MCG/2ML SOLUTION Preferred doxercalciferol ibandronate sodium iv soln 3 mg/3ml Non-Preferred (base equivalent) ibandronate sodium tab 150 mg (base Preferred QL 1 / 30 days equivalent) MIACALCIN 200 UNIT/ML SOLUTION Non-Preferred calcitonin (salmon) PAMIDRONATE DISODIUM 30 MG RECON SOLN Preferred pamidronate disodium PAMIDRONATE DISODIUM 6 MG/ML SOLUTION Preferred pamidronate disodium PAMIDRONATE DISODIUM 90 MG RECON SOLN Preferred pamidronate disodium pamidronate disodium iv soln 3 mg/ml Preferred pamidronate disodium iv soln 9 mg/ml Preferred paricalcitol cap 1 mcg Non-Preferred paricalcitol cap 2 mcg Non-Preferred paricalcitol cap 4 mcg Non-Preferred paricalcitol iv soln 2 mcg/ml Preferred paricalcitol iv soln 5 mcg/ml Preferred PROLIA 60 MG/ML SOLN PRSYR Non-Preferred denosumab RAYALDEE 30 MCG CAP ER Non-Preferred calcifediol RECLAST 5 MG/100ML SOLUTION Non-Preferred zoledronic acid

risedronate sodium tab 150 mg Non-Preferred QL 1 / 28 days

risedronate sodium tab 30 mg Non-Preferred QL 30 / 30 days

PAGE 369 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

risedronate sodium tab 35 mg Non-Preferred QL 4 / 28 days

risedronate sodium tab 5 mg Non-Preferred QL 30 / 30 days

risedronate sodium tab delayed release Non-Preferred 35 mg risedronate sodium tab release 35 mg Non-Preferred ROCALTROL 0.25 MCG CAP Non-Preferred calcitriol ROCALTROL 0.5 MCG CAP Non-Preferred calcitriol ROCALTROL 1 MCG/ML SOLUTION Non-Preferred QL 60 / 30 days calcitriol TERIPARATIDE (RECOMBINANT) 620 MCG/2.48ML SOLN PEN Non-Preferred teriparatide (recombinant) TYMLOS 3120 MCG/1.56ML SOLN PEN Non-Preferred abaloparatide XGEVA 120 MG/1.7ML SOLUTION Non-Preferred denosumab ZEMPLAR 1 MCG CAP Non-Preferred paricalcitol ZEMPLAR 2 MCG CAP Non-Preferred paricalcitol ZEMPLAR 2 MCG/ML SOLUTION Non-Preferred paricalcitol ZEMPLAR 5 MCG/ML SOLUTION Non-Preferred paricalcitol ZOLEDRONIC ACID 4 MG RECON SOLN Preferred zoledronic acid ZOLEDRONIC ACID 4 MG/100ML SOLUTION Preferred zoledronic acid zoledronic acid inj conc for iv infusion 4 Preferred mg/5ml zoledronic acid iv soln 5 mg/100ml Preferred ZOMETA 4 MG/100ML SOLUTION Non-Preferred zoledronic acid

PAGE 370 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ZOMETA 4 MG/5ML CONC Non-Preferred zoledronic acid MISCELLANEOUS THERAPEUTIC AGENTS

AEROCHAMBER MV MISC Preferred spacer/aerosol-holding chambers AEROCHAMBER PLUS FLO-VU MISC Preferred spacer/aerosol-holding chambers AEROCHAMBER PLUS FLO-VU LARGE MISC Preferred spacer/aerosol-holding chambers AEROCHAMBER PLUS FLO-VU MEDIUM MISC Preferred spacer/aerosol-holding chambers AEROCHAMBER PLUS FLO-VU SMALL MISC Preferred spacer/aerosol-holding chambers AEROCHAMBER PLUS FLO-VU W/MASK MISC Preferred spacer/aerosol-holding chambers AEROCHAMBER PLUS FLOW VU MISC Preferred spacer/aerosol-holding chambers BD LUER-LOK SYRINGE 23G X 1" 3 ML MISC Preferred syringe/needle (disp) 3 ml COMP AIR COMPRESSOR NEBULIZER MISC Preferred nebulizers COMPACT SPACE CHAMBER/LG MASK DEVICE Preferred spacer/aerosol-holding chambers EASIVENT MISC Preferred spacer/aerosol-holding chambers EASIVENT MASK LARGE MISC Preferred spacer/aerosol-holding chambers EASIVENT MASK MEDIUM MISC Preferred spacer/aerosol-holding chambers EASIVENT MASK SMALL MISC Preferred spacer/aerosol-holding chambers

EUFLEXXA 20 MG/2ML SOLN PRSYR QL 12 / 180 days Preferred sodium hyaluronate (viscosupplement) PA

PAGE 371 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS FREESTYLE LIBRE 14 DAY READER DEVICE Preferred QL 1 / 365 days continuous blood glucose system receiver FREESTYLE LIBRE 14 DAY SENSOR MISC Preferred QL 3 / 30 days continuous blood glucose system sensor FREESTYLE LIBRE 2 READER DEVICE Preferred continuous blood glucose system receiver FREESTYLE LIBRE 2 SENSOR MISC Preferred continuous blood glucose system sensor FREESTYLE LIBRE READER DEVICE continuous blood glucose system Preferred QL 1 / 365 days receiver FREESTYLE LIBRE SENSOR SYSTEM MISC Preferred QL 3 / 30 days continuous blood glucose system sensor GEL-ONE 30 MG/3ML PRSYR Non-Preferred cross-linked hyaluronate GELSYN-3 16.8 MG/2ML SOLN PRSYR Preferred PA sodium hyaluronate (viscosupplement) GENVISC 850 25 MG/2.5ML SOLN PRSYR Non-Preferred sodium hyaluronate (viscosupplement) HYALGAN 20 MG/2ML SOLN PRSYR Preferred PA sodium hyaluronate (viscosupplement) HYALGAN 20 MG/2ML SOLUTION Preferred PA sodium hyaluronate (viscosupplement) HYMOVIS 24 MG/3ML SOLN PRSYR Non-Preferred hyaluronan INNOSPIRE ESSENCE NEBULIZER MISC Preferred nebulizers LOKELMA 10 GM PACKET Preferred PA sodium zirconium cyclosilicate LOKELMA 5 GM PACKET Preferred PA sodium zirconium cyclosilicate MONOJECT BLUNT CANNULA 18G X 1" MISC Preferred needle (disp) 18 g

PAGE 372 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MONOJECT HYPODERMIC NEEDLE 18G X 1" MISC Preferred needle (disp) 18 g MONOJECT MAGELLAN SAFETY NDL 18G X 1" MISC Preferred needle (disp) 18 g MONOJECT MAGELLAN SYRINGE 23G X 1" 3 ML MISC Preferred syringe/needle (disp) 3 ml MONOJECT SAFETY SYRINGE/SHIELD 23G X 1" 3 ML MISC Preferred syringe/needle (disp) 3 ml MONOJECT SYRINGE 23G X 1" 3 ML MISC Preferred syringe/needle (disp) 3 ml MONOVISC 88 MG/4ML SOLN PRSYR Non-Preferred hyaluronan OPTICHAMBER DIAMOND MISC Preferred spacer/aerosol-holding chambers OPTICHAMBER DIAMOND-LG MASK DEVICE Preferred spacer/aerosol-holding chambers OPTICHAMBER DIAMOND-MD MASK MISC Preferred spacer/aerosol-holding chambers OPTICHAMBER DIAMOND-SM MASK MISC Preferred spacer/aerosol-holding chambers ORTHOVISC 30 MG/2ML SOLN PRSYR Non-Preferred hyaluronan PROGESTERONE MICRONIZED POWDER Preferred progesterone micronized (bulk) PROGESTERONE ULTRA MICRONIZED POWDER Preferred progesterone micronized (bulk) SODIUM HYALURONATE 20 MG/2ML SOLN PRSYR Preferred PA sodium hyaluronate (viscosupplement) SUPARTZ FX 25 MG/2.5ML SOLN PRSYR Non-Preferred sodium hyaluronate (viscosupplement)

PAGE 373 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SYNVISC 16 MG/2ML SOLN PRSYR Non-Preferred hylan SYNVISC ONE 48 MG/6ML SOLN PRSYR Non-Preferred hylan TRILOCICLO 0.1 & 8 % KIT Non-Preferred triamcinolone acetonide-ciclopirox TRILURON 20 MG/2ML SOLN PRSYR Non-Preferred sodium hyaluronate (viscosupplement) TRIVISC 25 MG/2.5ML SOLN PRSYR Preferred PA sodium hyaluronate (viscosupplement) VALVED HOLDING CHAMBER DEVICE Preferred spacer/aerosol-holding chambers VIOS AEROSOL DELIVERY SYSTEM MISC Preferred nebulizers VISCO-3 25 MG/2.5ML SOLN PRSYR Preferred PA sodium hyaluronate (viscosupplement) water for irrigation, sterile irrigation soln Preferred water for irrigation, sterile irrigation soln Preferred OPHTHALMIC AGENTS

OPHTHALMIC AGENTS, OTHER

ATROPINE SULFATE 1 % SOLUTION Preferred QL 5 / 18 days atropine sulfate (ophthalmic) bacitracin-polymyxin-neomycin-hc ophth Preferred oint 1% bacitracin-polymyxin-neomycin-hc ophth Preferred oint 1%

bacitracin-polymyxin b ophth oint Preferred QL 7 / days

bacitracin-polymyxin b ophth oint Preferred QL 7 / 18 days

bacitracin-polymyxin b ophth oint Preferred BEOVU 6 MG/0.05ML SOLUTION Non-Preferred brolucizumab-dbll BLEPHAMIDE 10-0.2 % SUSPENSION Non-Preferred QL 1 / 1 days sulfacetamide sod-prednisolone BLEPHAMIDE S.O.P. 10-0.2 % OINTMENT Non-Preferred QL 7 / 18 days sulfacetamide sod-prednisolone

PAGE 374 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CEQUA 0.09 % SOLUTION Non-Preferred cyclosporine (ophth)

cyclopentolate hcl ophth soln 0.5% Preferred QL 15 / 30 days

cyclopentolate hcl ophth soln 1% Preferred QL 5 / 25 days

cyclopentolate hcl ophth soln 2% Preferred QL 15 / 30 days

EYLEA 2 MG/0.05ML SOLN PRSYR Preferred PA aflibercept EYLEA 2 MG/0.05ML SOLUTION Preferred PA aflibercept ISOPTO ATROPINE 1 % SOLUTION Preferred QL 5 / 18 days atropine sulfate (ophthalmic) LUCENTIS 0.3 MG/0.05ML SOLN PRSYR Preferred PA ranibizumab LUCENTIS 0.3 MG/0.05ML SOLUTION Preferred PA ranibizumab LUCENTIS 0.5 MG/0.05ML SOLN PRSYR Preferred PA ranibizumab LUCENTIS 0.5 MG/0.05ML SOLUTION Preferred PA ranibizumab MACUGEN 0.3 MG SOLUTION Preferred PA pegaptanib sodium MAXITROL 3.5-10000-0.1 OINTMENT Non-Preferred neomycin-polymy-dexameth MAXITROL 3.5-10000-0.1 SUSPENSION Non-Preferred neomycin-polymy-dexameth neomycin-bacitrac zn-polymyx 5(3.5)mg- Non-Preferred 400unt-10000unt op oin neomycin-bacitrac zn-polymyx 5(3.5)mg- Non-Preferred 400unt-10000unt op oin neomycin-bacitrac zn-polymyx 5(3.5)mg- Non-Preferred 400unt-10000unt op oin neomycin-polymyxin-dexamethasone Preferred ophth oint 0.1% neomycin-polymyxin-dexamethasone Preferred QL 5 / 18 days ophth susp 0.1%

PAGE 375 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS neomycin-polymy-gramicid op sol 1.75- Non-Preferred QL 10 / 15 days 10000-0.025mg-unt-mg/ml NEOMYCIN-POLYMYXIN-HC 3.5- Non-Preferred QL 10 / 15 days 10000-1 ophth SUSPENSION phenylephrine hcl ophth soln 2.5% Preferred polymyxin b-trimethoprim ophth soln Preferred QL 10 / 15 days 10000 unit/ml-0.1% POLYTRIM 10000-0.1 UNIT/ML-% SOLUTION Non-Preferred polymyxin b-trimethoprim PRED-G 0.3-1 % SUSPENSION Preferred gentamicin-prednisolone acetate PRED-G S.O.P. 0.3-0.6 % OINTMENT Preferred gentamicin-prednisolone acetate RESTASIS 0.05 % EMULSION Preferred QL 2 / 1 days cyclosporine (ophth) RESTASIS MULTIDOSE 0.05 % EMULSION Non-Preferred QL 5.5 / 28 days cyclosporine (ophth) sulfacetamide sodium-prednisolone Preferred QL 1 / 1 days ophth soln 10-0.23(0.25)% TOBRADEX 0.3-0.1 % OINTMENT Preferred QL 3.5 / 18 days tobramycin-dexamethasone TOBRADEX 0.3-0.1 % SUSPENSION Preferred QL 5 / 18 days tobramycin-dexamethasone TOBRADEX ST 0.3-0.05 % SUSPENSION Non-Preferred tobramycin-dexamethasone tobramycin-dexamethasone ophth susp Preferred QL 5 / 18 days 0.3-0.1%

tropicamide ophth soln 0.5% Preferred QL 15 / 18 days

tropicamide ophth soln 1% Preferred QL 15 / 18 days

VISUDYNE 15 MG RECON SOLN Preferred PA verteporfin XIIDRA 5 % SOLUTION Non-Preferred lifitegrast ZYLET 0.5-0.3 % SUSPENSION Preferred loteprednol etabonate-tobramycin

PAGE 376 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS OPHTHALMIC ANTI-ALLERGY AGENTS

ALOCRIL 2 % SOLUTION Non-Preferred QL 5 / 18 days nedocromil sodium (ophth) ALOMIDE 0.1 % SOLUTION Preferred QL 10 / 18 days lodoxamide tromethamine azelastine hcl ophth soln 0.05% Preferred BEPREVE 1.5 % SOLUTION Non-Preferred bepotastine besilate

cromolyn sodium ophth soln 4% Preferred QL 10 / 18 days

epinastine hcl ophth soln 0.05% Non-Preferred LASTACAFT 0.25 % SOLUTION Non-Preferred alcaftadine olopatadine hcl ophth soln 0.1% (base Preferred QL 5 / 25 days equivalent) olopatadine hcl ophth soln 0.2% (base Preferred QL 2.5 / 30 days equivalent) PATADAY 0.2 % SOLUTION Non-Preferred olopatadine hcl PATANOL 0.1 % SOLUTION Non-Preferred olopatadine hcl PAZEO 0.7 % SOLUTION Non-Preferred olopatadine hcl ZERVIATE 0.24 % SOLUTION Non-Preferred cetirizine hcl (ophth) OPHTHALMIC ANTI-INFLAMMATORIES

ACULAR 0.5 % SOLUTION Non-Preferred ketorolac tromethamine (ophth) ACULAR LS 0.4 % SOLUTION Non-Preferred ketorolac tromethamine (ophth) ACUVAIL 0.45 % SOLUTION Non-Preferred ketorolac tromethamine (ophth) ALREX 0.2 % SUSPENSION Preferred QL 5 / 18 days loteprednol etabonate bromfenac sodium ophth soln 0.09% Non-Preferred (base equiv) (once-daily) BROMSITE 0.075 % SOLUTION Non-Preferred bromfenac sodium (ophth)

PAGE 377 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS dexamethasone sodium phosphate Preferred QL 5 / 10 days ophth soln 0.1% DEXTENZA 0.4 MG INSERT Non-Preferred dexamethasone (ophth) DEXYCU 9 % SUSPENSION Non-Preferred dexamethasone (ophth) diclofenac sodium ophth soln 0.1% Non-Preferred DUREZOL 0.05 % EMULSION Preferred difluprednate EYSUVIS 0.25 % SUSPENSION Non-Preferred loteprednol etabonate FLAREX 0.1 % SUSPENSION Preferred QL 5 / 18 days fluorometholone acetate

fluorometholone ophth susp 0.1% Preferred QL 5 / 18 days

flurbiprofen sodium ophth soln 0.03% Preferred QL 5 / 10 days

FML 0.1 % OINTMENT Preferred QL 3.5 / 18 days fluorometholone (ophth) FML FORTE 0.25 % SUSPENSION Preferred QL 10 / 30 days fluorometholone (ophth) FML LIQUIFILM 0.1 % SUSPENSION Non-Preferred fluorometholone (ophth) ILEVRO 0.3 % SUSPENSION Preferred nepafenac ILUVIEN 0.19 MG IMPLANT Non-Preferred fluocinolone acetonide (ophth) INVELTYS 1 % SUSPENSION Non-Preferred loteprednol etabonate ketorolac tromethamine ophth soln 0.4% Preferred

ketorolac tromethamine ophth soln 0.5% Preferred QL 5 / 18 days

LOTEMAX 0.5 % GEL Non-Preferred loteprednol etabonate LOTEMAX 0.5 % OINTMENT Preferred loteprednol etabonate LOTEMAX 0.5 % SUSPENSION Non-Preferred loteprednol etabonate LOTEMAX SM 0.38 % GEL Non-Preferred loteprednol etabonate

PAGE 378 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS loteprednol etabonate ophth gel 0.5% Non-Preferred loteprednol etabonate ophth susp 0.5% Non-Preferred MAXIDEX 0.1 % SUSPENSION Preferred dexamethasone (ophth) NEVANAC 0.1 % SUSPENSION Preferred nepafenac OMNIPRED 1 % SUSPENSION Non-Preferred prednisolone acetate (ophth) OZURDEX 0.7 MG IMPLANT Non-Preferred dexamethasone (ophth) PRED FORTE 1 % SUSPENSION Non-Preferred prednisolone acetate (ophth) PRED MILD 0.12 % SUSPENSION Preferred QL 5 / 18 days prednisolone acetate (ophth)

prednisolone acetate ophth susp 1% Preferred QL 10 / 18 days

PREDNISOLONE SODIUM PHOSPHATE 1 % SOLUTION Preferred QL 10 / 18 days prednisolone sodium phosphate (ophth) PROLENSA 0.07 % SOLUTION Non-Preferred bromfenac sodium (ophth) RETISERT 0.59 MG IMPLANT Non-Preferred fluocinolone acetonide (ophth) TRIESENCE 40 MG/ML SUSPENSION Non-Preferred triamcinolone acetonide (ophth) YUTIQ 0.18 MG IMPLANT Non-Preferred fluocinolone acetonide (ophth) OPHTHALMIC ANTIGLAUCOMA AGENTS

ALPHAGAN P 0.1 % SOLUTION Preferred QL 15 / 26 days brimonidine tartrate ALPHAGAN P 0.15 % SOLUTION Preferred brimonidine tartrate apraclonidine hcl ophth soln 0.5% (base Non-Preferred equivalent) AZOPT 1 % SUSPENSION Non-Preferred QL 10 / 24 days brinzolamide betaxolol hcl ophth soln 0.5% Non-Preferred BETOPTIC-S 0.25 % SUSPENSION Non-Preferred betaxolol hcl (ophth)

PAGE 379 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

brimonidine tartrate ophth soln 0.15% Non-Preferred QL 15 / 26 days

brimonidine tartrate ophth soln 0.2% Preferred QL 5 / 18 days

carteolol hcl ophth soln 1% Preferred COMBIGAN 0.2-0.5 % SOLUTION Preferred brimonidine tartrate-timolol maleate COSOPT 22.3-6.8 MG/ML SOLUTION Non-Preferred dorzolamide hcl-timolol maleate COSOPT PF 2-0.5 % SOLUTION Non-Preferred dorzolamide hcl-timolol maleate

dorzolamide hcl ophth soln 2% Preferred QL 10 / 18 days

dorzolamide hcl-timolol maleate ophth Non-Preferred sol 22.3-6.8 mg/ml pf dorzolamide hcl-timolol maleate ophth Preferred QL 10 / 18 days soln 22.3-6.8 mg/ml IOPIDINE 0.5 % SOLUTION Non-Preferred apraclonidine hcl IOPIDINE 1 % SOLUTION Non-Preferred apraclonidine hcl ISOPTO CARPINE 1 % SOLUTION Non-Preferred pilocarpine hcl ISOPTO CARPINE 2 % SOLUTION Non-Preferred pilocarpine hcl ISOPTO CARPINE 4 % SOLUTION Non-Preferred pilocarpine hcl ISTALOL 0.5 % SOLUTION Non-Preferred timolol maleate (ophth)

levobunolol hcl ophth soln 0.5% Preferred QL 5 / 18 days

methazolamide tab 25 mg Preferred QL 4 / 1 days

methazolamide tab 50 mg Preferred QL 4 / 1 days

PHOSPHOLINE IODIDE 0.125 % RECON SOLN Non-Preferred echothiophate iodide

pilocarpine hcl ophth soln 1% Non-Preferred QL 15 / 18 days

pilocarpine hcl ophth soln 2% Non-Preferred QL 15 / 18 days

pilocarpine hcl ophth soln 4% Non-Preferred QL 15 / 18 days

PAGE 380 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS RHOPRESSA 0.02 % SOLUTION Non-Preferred netarsudil dimesylate ROCKLATAN 0.02-0.005 % SOLUTION Non-Preferred netarsudil dimesylate-latanoprost SIMBRINZA 1-0.2 % SUSPENSION Preferred QL 8 / 25 days brinzolamide-brimonidine tartrate timolol maleate ophth gel forming soln Non-Preferred QL 5 / 18 days 0.25% timolol maleate ophth gel forming soln Non-Preferred QL 5 / 18 days 0.5%

timolol maleate ophth soln 0.25% Preferred QL 5 / 18 days

timolol maleate ophth soln 0.5% Preferred QL 5 / 18 days

timolol maleate ophth soln 0.5% (once- Non-Preferred QL 5 / 18 days daily) timolol maleate preservative free ophth Non-Preferred soln 0.5% TIMOPTIC 0.25 % SOLUTION Non-Preferred timolol maleate (ophth) TIMOPTIC 0.5 % SOLUTION Non-Preferred timolol maleate (ophth) TIMOPTIC OCUDOSE 0.25 % SOLUTION Non-Preferred timolol maleate (ophth) TIMOPTIC OCUDOSE 0.5 % SOLUTION Non-Preferred timolol maleate (ophth) TIMOPTIC-XE 0.25 % GEL F SOLN Non-Preferred timolol maleate (ophth) TIMOPTIC-XE 0.5 % GEL F SOLN Non-Preferred timolol maleate (ophth) TRUSOPT 2 % SOLUTION Non-Preferred dorzolamide hcl VYZULTA 0.024 % SOLUTION Non-Preferred latanoprostene bunod OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS

bimatoprost ophth soln 0.03% Non-Preferred DURYSTA 10 MCG IMPLANT Non-Preferred bimatoprost

PAGE 381 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

latanoprost ophth soln 0.005% Preferred QL 2.5 / 18 days

LUMIGAN 0.01 % SOLUTION Non-Preferred bimatoprost TRAVATAN Z 0.004 % SOLUTION Non-Preferred QL 5 / 18 days travoprost travoprost ophth soln 0.004% Non-Preferred (benzalkonium free) (bak free) XALATAN 0.005 % SOLUTION Non-Preferred latanoprost XELPROS 0.005 % EMULSION Non-Preferred latanoprost ZIOPTAN 0.0015 % SOLUTION Non-Preferred tafluprost OTIC AGENTS

acetic acid otic soln 2% Preferred CIPRO HC 0.2-1 % SUSPENSION Preferred ciprofloxacin-hydrocortisone CIPRODEX 0.3-0.1 % SUSPENSION Preferred ciprofloxacin-dexamethasone CIPROFLOXACIN-FLUOCINOLONE PF 0.3-0.025 % SOLUTION Non-Preferred ciprofloxacin-fluocinolone acetonide COLY-MYCIN S 3.3-3-10-0.5 MG/ML SUSPENSION Preferred neomycin-colistin-hc-thonzonium CORTISPORIN-TC 3.3-3-10-0.5 MG/ML SUSPENSION Non-Preferred neomycin-colistin-hc-thonzonium

fluocinolone acetonide (otic) oil 0.01% Preferred QL 20 / 24 days

fluocinolone acetonide (otic) oil 0.01% Preferred QL 20 / 24 days

hydrocortisone w/ acetic acid otic soln 1- Preferred 2% hydrocortisone w/ acetic acid otic soln 1- Preferred 2% neomycin-polymyxin-hc otic soln 1% Preferred neomycin-polymyxin-hc otic soln 1% Preferred NEOMYCIN-POLYMYXIN-HC OTIC Preferred SUSP 3.5 MG/ML-10000 UNIT/ML-1%

PAGE 382 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS OTOVEL 0.3-0.025 % SOLUTION Non-Preferred ciprofloxacin-fluocinolone acetonide RESPIRATORY TRACT/PULMONARY AGENTS

ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS

ALVESCO 160 MCG/ACT AERO SOLN Non-Preferred ciclesonide ALVESCO 80 MCG/ACT AERO SOLN Non-Preferred ciclesonide ARMONAIR DIGIHALER 113 MCG/ACT AER POW BA Non-Preferred fluticasone propionate (inhalation) ARMONAIR DIGIHALER 232 MCG/ACT AER POW BA Non-Preferred fluticasone propionate (inhalation) ARMONAIR DIGIHALER 55 MCG/ACT AER POW BA Non-Preferred fluticasone propionate (inhalation) ARMONAIR RESPICLICK 232 232 MCG/ACT AER POW BA Non-Preferred fluticasone propionate (inhalation) ARMONAIR RESPICLICK 55 55 MCG/ACT AER POW BA Non-Preferred fluticasone propionate (inhalation) ARNUITY ELLIPTA 100 MCG/ACT AER POW BA Non-Preferred QL 30 / 30 days fluticasone furoate (inhalation) ARNUITY ELLIPTA 200 MCG/ACT AER POW BA Non-Preferred QL 30 / 30 days fluticasone furoate (inhalation) ARNUITY ELLIPTA 50 MCG/ACT AER POW BA Non-Preferred QL 30 / 30 days fluticasone furoate (inhalation) ASMANEX (120 METERED DOSES) 220 MCG/INH AER POW BA Preferred mometasone furoate (inhalation) ASMANEX (14 METERED DOSES) 220 MCG/INH AER POW BA Preferred mometasone furoate (inhalation) ASMANEX (30 METERED DOSES) 110 MCG/INH AER POW BA Preferred mometasone furoate (inhalation)

PAGE 383 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ASMANEX (30 METERED DOSES) 220 MCG/INH AER POW BA Preferred mometasone furoate (inhalation) ASMANEX (60 METERED DOSES) 220 MCG/INH AER POW BA Preferred mometasone furoate (inhalation) ASMANEX HFA 100 MCG/ACT AEROSOL Non-Preferred mometasone furoate (inhalation) ASMANEX HFA 200 MCG/ACT AEROSOL Non-Preferred mometasone furoate (inhalation) ASMANEX HFA 50 MCG/ACT AEROSOL Non-Preferred mometasone furoate (inhalation) BECONASE AQ 42 MCG/SPRAY SUSPENSION Non-Preferred beclomethasone diprop monohyd

budesonide inhalation susp 0.25 mg/2ml Preferred QL 8 / 1 days

budesonide inhalation susp 0.5 mg/2ml Preferred QL 4 / 1 days

budesonide inhalation susp 1 mg/2ml Non-Preferred QL 2 / 1 days

FLOVENT DISKUS 100 MCG/BLIST AER POW BA Preferred QL 60 / 30 days fluticasone propionate (inhalation) FLOVENT DISKUS 250 MCG/BLIST AER POW BA Preferred QL 60 / 30 days fluticasone propionate (inhalation) FLOVENT DISKUS 50 MCG/BLIST AER POW BA Preferred QL 60 / 30 days fluticasone propionate (inhalation) FLOVENT HFA 110 MCG/ACT AEROSOL Preferred QL 12 / 30 days fluticasone propionate hfa FLOVENT HFA 220 MCG/ACT AEROSOL Preferred QL 12 / 30 days fluticasone propionate hfa FLOVENT HFA 44 MCG/ACT AEROSOL Preferred QL 10.6 / 30 days fluticasone propionate hfa flunisolide nasal soln 25 mcg/act Preferred QL 0.84 / 1 days (0.025%)

PAGE 384 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS fluticasone propionate nasal susp 50 Preferred QL 16 / 20 days mcg/act Fluticasone Propionate 50 MCG/ACT Preferred QL 16 / 20 days SUSPENSION (Rx) mometasone furoate nasal susp 50 Non-Preferred mcg/act NASONEX 50 MCG/ACT SUSPENSION Non-Preferred mometasone furoate (nasal) OMNARIS 50 MCG/ACT SUSPENSION Non-Preferred ciclesonide (nasal) PULMICORT 0.25 MG/2ML SUSPENSION Non-Preferred budesonide (inhalation) PULMICORT 0.5 MG/2ML SUSPENSION Non-Preferred budesonide (inhalation) PULMICORT 1 MG/2ML SUSPENSION Non-Preferred QL 2 / 1 days budesonide (inhalation) PULMICORT FLEXHALER 180 MCG/ACT AER POW BA Preferred QL 1 / 30 days budesonide (inhalation) PULMICORT FLEXHALER 90 MCG/ACT AER POW BA Preferred QL 1 / 30 days budesonide (inhalation) QNASL 80 MCG/ACT AERO SOLN Non-Preferred beclomethasone dipropionate (nasal) QNASL CHILDRENS 40 MCG/ACT AERO SOLN Non-Preferred beclomethasone dipropionate (nasal) QVAR 40 MCG/ACT AERO SOLN Non-Preferred beclomethasone dipropionate QVAR 80 MCG/ACT AERO SOLN Non-Preferred beclomethasone dipropionate QVAR REDIHALER 40 MCG/ACT AERO BA Preferred QL 10.6 / 30 days beclomethasone dipropionate hfa QVAR REDIHALER 80 MCG/ACT AERO BA Preferred QL 10.6 / 30 days beclomethasone dipropionate hfa SINUVA 1350 MCG IMPLANT Non-Preferred mometasone furoate (nasal)

PAGE 385 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS XHANCE 93 MCG/ACT EXHU Non-Preferred fluticasone propionate (nasal) ZETONNA 37 MCG/ACT AERO SOLN Non-Preferred ciclesonide (nasal) ANTIHISTAMINES

ASTEPRO 0.15 % SOLUTION Non-Preferred azelastine hcl azelastine hcl nasal spray 0.1% (137 Preferred QL 30 / 24 days mcg/spray) azelastine hcl nasal spray 0.1% (137 Preferred QL 30 / 24 days mcg/spray) azelastine hcl nasal spray 0.15% (205.5 Non-Preferred mcg/spray) cetirizine hcl oral soln 1 mg/ml (5 Preferred QL 10 / 1 days mg/5ml) CLARINEX 0.5 MG/ML SYRUP Non-Preferred desloratadine CLARINEX 5 MG TAB Non-Preferred desloratadine

cyproheptadine hcl syrup 2 mg/5ml Preferred QL 30 / 1 days

cyproheptadine hcl tab 4 mg Preferred QL 8 / 1 days

desloratadine tab 5 mg Non-Preferred desloratadine tab orally disintegrating Non-Preferred 2.5 mg desloratadine tab orally disintegrating 5 Non-Preferred mg

diphenhydramine hcl elixir 12.5 mg/5ml Preferred QL 30 / 1 days

diphenhydramine hcl inj 50 mg/ml Preferred

hydroxyzine hcl syrup 10 mg/5ml Preferred QL 30 / 1 days

hydroxyzine hcl tab 10 mg Preferred QL 6 / 1 days

hydroxyzine hcl tab 25 mg Preferred QL 6 / 1 days

hydroxyzine hcl tab 50 mg Preferred QL 6 / 1 days

hydroxyzine pamoate cap 100 mg Preferred QL 6 / 1 days

hydroxyzine pamoate cap 25 mg Preferred QL 6 / 1 days

PAGE 386 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

hydroxyzine pamoate cap 50 mg Preferred QL 6 / 1 days

levocetirizine dihydrochloride soln 2.5 Non-Preferred mg/5ml (0.5 mg/ml)

levocetirizine dihydrochloride tab 5 mg Preferred QL 30 / 30 days

olopatadine hcl nasal soln 0.6% Non-Preferred PATANASE 0.6 % SOLUTION Non-Preferred olopatadine hcl (nasal)

AL1 At least 6 yrs old PHENERGAN 25 MG/ML SOLUTION Non-Preferred promethazine hcl C Age restriction, clinical PA required

AL1 At least 6 yrs old PHENERGAN 50 MG/ML SOLUTION Non-Preferred promethazine hcl C Age restriction, clinical PA required

AL1 At least 6 yrs old promethazine hcl inj 25 mg/ml Preferred C Age restriction, clinical PA required

AL1 At least 6 yrs old promethazine hcl inj 50 mg/ml Preferred C Age restriction, clinical PA required

AL1 At least 6 yrs old

promethazine hcl syrup 6.25 mg/5ml Preferred C Age restriction, clinical PA required QLC 30 mL/day

AL1 At least 6 yrs old

promethazine hcl syrup 6.25 mg/5ml Preferred C Age restriction, clinical PA required QLC 30 mL/day

QL 4 / 1 days

promethazine hcl tab 12.5 mg Preferred AL1 At least 6 yrs old

C Age restriction, clinical PA required

QL 4 / 1 days

promethazine hcl tab 25 mg Preferred AL1 At least 6 yrs old

C Age restriction, clinical PA required VISTARIL 25 MG CAP Non-Preferred hydroxyzine pamoate

PAGE 387 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VISTARIL 50 MG CAP Non-Preferred hydroxyzine pamoate ANTILEUKOTRIENES

ACCOLATE 10 MG TAB Non-Preferred zafirlukast ACCOLATE 20 MG TAB Non-Preferred zafirlukast montelukast sodium chew tab 4 mg Preferred QL 30 / 30 days (base equiv) montelukast sodium chew tab 5 mg Preferred QL 1 / 1 days (base equiv) montelukast sodium oral granules Preferred QL 30 / 30 days packet 4 mg (base equiv) montelukast sodium tab 10 mg (base Preferred QL 1 / 1 days equiv) SINGULAIR 10 MG TAB Non-Preferred QL 1 / 1 days montelukast sodium SINGULAIR 4 MG CHEW TAB Non-Preferred QL 1 / 1 days montelukast sodium SINGULAIR 4 MG PACKET Non-Preferred QL 30 / 30 days montelukast sodium SINGULAIR 5 MG CHEW TAB Non-Preferred QL 1 / 1 days montelukast sodium

zafirlukast tab 10 mg Non-Preferred QL 4 / 1 days

zafirlukast tab 20 mg Non-Preferred QL 2 / 1 days

zileuton tab er 12hr 600 mg Non-Preferred ZYFLO 600 MG TAB Non-Preferred zileuton ZYFLO CR 600 MG TAB ER 12H Non-Preferred zileuton BRONCHODILATORS, ANTICHOLINERGIC

ATROVENT HFA 17 MCG/ACT AERO SOLN Preferred QL 12.9 / 26 days ipratropium bromide hfa INCRUSE ELLIPTA 62.5 MCG/INH AER POW BA Non-Preferred QL 30 / 30 days umeclidinium bromide

PAGE 388 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

ipratropium bromide inhal soln 0.02% Preferred QL 10 / 1 days

ipratropium bromide nasal soln 0.03% Preferred (21 mcg/spray) ipratropium bromide nasal soln 0.06% Preferred (42 mcg/spray) LONHALA MAGNAIR REFILL KIT 25 MCG/ML SOLUTION Non-Preferred QL 2 / 1 days glycopyrrolate (inhalation) LONHALA MAGNAIR STARTER KIT 25 MCG/ML SOLUTION Non-Preferred QL 2 / 1 days glycopyrrolate (inhalation) SEEBRI NEOHALER 15.6 MCG CAP Non-Preferred glycopyrrolate (inhalation) SPIRIVA HANDIHALER 18 MCG CAP Preferred QL 30 / 30 days tiotropium bromide monohydrate SPIRIVA RESPIMAT 1.25 MCG/ACT AERO SOLN Preferred QL 4 / 30 days tiotropium bromide monohydrate SPIRIVA RESPIMAT 2.5 MCG/ACT AERO SOLN Preferred QL 4 / 30 days tiotropium bromide monohydrate TUDORZA PRESSAIR 400 MCG/ACT AER POW BA Non-Preferred aclidinium bromide YUPELRI 175 MCG/3ML SOLUTION Non-Preferred revefenacin BRONCHODILATORS, SYMPATHOMIMETIC

ALBUTEROL SULFATE (5 MG/ML) 0.5% NEBU SOLN Preferred albuterol sulfate albuterol sulfate inhal aero 108 mcg/act Preferred QLC 2 inhalers/month (90mcg base equiv) albuterol sulfate soln nebu 0.083% (2.5 Preferred mg/3ml) albuterol sulfate soln nebu 0.5% (5 Preferred mg/ml) albuterol sulfate soln nebu 0.5% (5 Preferred mg/ml) albuterol sulfate soln nebu 0.63 mg/3ml Preferred (base equiv)

PAGE 389 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS albuterol sulfate soln nebu 1.25 mg/3ml Preferred (base equiv)

albuterol sulfate syrup 2 mg/5ml Preferred QL 40 / 1 days

albuterol sulfate tab 2 mg Non-Preferred QL 4 / 1 days

albuterol sulfate tab 4 mg Non-Preferred QL 4 / 1 days

albuterol sulfate tab er 12hr 4 mg Non-Preferred QL 4 / 1 days

albuterol sulfate tab er 12hr 8 mg Non-Preferred QL 4 / 1 days

ARCAPTA NEOHALER 75 MCG CAP Non-Preferred indacaterol maleate BROVANA 15 MCG/2ML NEBU SOLN Non-Preferred QL 120 / 30 days arformoterol tartrate EPINEPHRINE 0.3 MG/0.3ML SOLN A- INJ Non-Preferred epinephrine (anaphylaxis) epinephrine solution auto-injector 0.15 Preferred mg/0.15ml (1:1000) epinephrine solution auto-injector 0.15 Preferred mg/0.3ml (1:2000) epinephrine solution auto-injector 0.3 Preferred mg/0.3ml (1:1000) EPIPEN 2-PAK 0.3 MG/0.3ML SOLN A- INJ Non-Preferred epinephrine (anaphylaxis) EPIPEN JR 2-PAK 0.15 MG/0.3ML SOLN A-INJ Preferred epinephrine (anaphylaxis) levalbuterol hcl soln nebu 0.31 mg/3ml Non-Preferred (base equiv) levalbuterol hcl soln nebu 0.63 mg/3ml Non-Preferred (base equiv) levalbuterol hcl soln nebu 1.25 mg/3ml Non-Preferred (base equiv) levalbuterol hcl soln nebu conc 1.25 Non-Preferred mg/0.5ml (base equiv) levalbuterol tartrate inhal aerosol 45 Preferred QL 30 / 30 days mcg/act (base equiv) METAPROTERENOL SULFATE 10 MG TAB Non-Preferred QL 4 / 1 days metaproterenol sulfate

PAGE 390 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS METAPROTERENOL SULFATE 20 MG TAB Non-Preferred QL 4 / 1 days metaproterenol sulfate

metaproterenol sulfate syrup 10 mg/5ml Non-Preferred QL 40 / 1 days

PERFOROMIST 20 MCG/2ML NEBU SOLN Non-Preferred QL 120 / 30 days formoterol fumarate PROAIR DIGIHALER 108 MCG/ACT AER POW BA Non-Preferred albuterol sulfate PROAIR HFA 108 (90 BASE) MCG/ACT AERO SOLN Preferred QLC 2 inhalers/month albuterol sulfate PROAIR RESPICLICK 108 (90 BASE) MCG/ACT AER POW BA Preferred albuterol sulfate PROVENTIL HFA 108 (90 BASE) MCG/ACT AERO SOLN Preferred QLC 2 inhalers/month albuterol sulfate

SEREVENT DISKUS 50 MCG/DOSE QL 60 / 30 days AER POW BA Preferred salmeterol xinafoate PA STRIVERDI RESPIMAT 2.5 MCG/ACT AERO SOLN Non-Preferred QL 4 / 30 days olodaterol hcl

terbutaline sulfate tab 2.5 mg Non-Preferred QL 3 / 1 days

terbutaline sulfate tab 5 mg Non-Preferred QL 3 / 1 days

VENTOLIN HFA 108 (90 BASE) MCG/ACT AERO SOLN Preferred QLC 2 inhalers/month albuterol sulfate XOPENEX 0.31 MG/3ML NEBU SOLN Non-Preferred levalbuterol hcl XOPENEX 0.63 MG/3ML NEBU SOLN Non-Preferred levalbuterol hcl XOPENEX 1.25 MG/3ML NEBU SOLN Non-Preferred levalbuterol hcl XOPENEX CONCENTRATE 1.25 MG/0.5ML NEBU SOLN Non-Preferred levalbuterol hcl XOPENEX HFA 45 MCG/ACT AEROSOL Preferred QL 30 / 30 days levalbuterol tartrate

PAGE 391 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CYSTIC FIBROSIS AGENTS

BETHKIS 300 MG/4ML NEBU SOLN Non-Preferred tobramycin CAYSTON 75 MG RECON SOLN Non-Preferred aztreonam lysine TOBI PODHALER 28 MG CAP Non-Preferred tobramycin tobramycin nebu soln 300 mg/4ml Non-Preferred MAST CELL STABILIZERS

cromolyn sodium soln nebu 20 mg/2ml Preferred QL 8 / 1 days

PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE

caffeine citrate oral soln 60 mg/3ml (10 Preferred mg/ml base equiv) caffeine citrate oral soln 60 mg/3ml (10 Preferred mg/ml base equiv) DALIRESP 250 MCG TAB Non-Preferred roflumilast DALIRESP 500 MCG TAB Non-Preferred roflumilast THEO-24 100 MG CAP ER 24H Preferred theophylline THEO-24 200 MG CAP ER 24H Preferred theophylline THEO-24 300 MG CAP ER 24H Preferred theophylline THEO-24 400 MG CAP ER 24H Preferred theophylline THEOCHRON 100 MG TAB ER 12H Preferred QL 4 / 1 days theophylline THEOCHRON 200 MG TAB ER 12H Preferred QL 3 / 1 days theophylline

theophylline soln 80 mg/15ml Preferred QL 75 / 1 days

theophylline tab er 12hr 100 mg Preferred QL 4 / 1 days

theophylline tab er 12hr 200 mg Preferred QL 3 / 1 days

theophylline tab er 12hr 300 mg Preferred QL 2 / 1 days

PAGE 392 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

theophylline tab er 12hr 450 mg Preferred QL 1 / 1 days

theophylline tab er 24hr 400 mg Preferred QL 1 / 1 days

theophylline tab er 24hr 600 mg Preferred QL 1 / 1 days

PULMONARY ANTIHYPERTENSIVES

ADCIRCA 20 MG TAB QL 60 / 30 days Non-Preferred tadalafil (pulmonary hypertension) PA

ADEMPAS 0.5 MG TAB Non-Preferred riociguat ADEMPAS 1 MG TAB Non-Preferred riociguat ADEMPAS 1.5 MG TAB Non-Preferred riociguat ADEMPAS 2 MG TAB Non-Preferred riociguat ADEMPAS 2.5 MG TAB Non-Preferred riociguat

ambrisentan tab 10 mg Preferred PA

ambrisentan tab 5 mg Preferred PA

bosentan tab 125 mg Non-Preferred bosentan tab 62.5 mg Non-Preferred LETAIRIS 10 MG TAB Non-Preferred ambrisentan LETAIRIS 5 MG TAB Non-Preferred ambrisentan OPSUMIT 10 MG TAB Non-Preferred macitentan ORENITRAM 0.125 MG TAB ER Non-Preferred treprostinil diolamine ORENITRAM 0.25 MG TAB ER Non-Preferred treprostinil diolamine ORENITRAM 1 MG TAB ER Non-Preferred treprostinil diolamine ORENITRAM 2.5 MG TAB ER Non-Preferred treprostinil diolamine ORENITRAM 5 MG TAB ER Non-Preferred treprostinil diolamine

PAGE 393 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS REVATIO 10 MG/ML RECON SUSP sildenafil citrate (pulmonary Preferred PA hypertension) REVATIO 20 MG TAB sildenafil citrate (pulmonary Non-Preferred QL 90 / 30 days hypertension) sildenafil citrate for suspension 10 mg/ml Non-Preferred

QL 90 / 30 days sildenafil citrate tab 20 mg Preferred PA

QL 60 / 30 days tadalafil tab 20 mg (pah) Non-Preferred PA

QL 60 / 30 days tadalafil tab 20 mg (pah) Preferred PA

TRACLEER 125 MG TAB Preferred PA bosentan TRACLEER 32 MG TAB SOL Non-Preferred bosentan TRACLEER 62.5 MG TAB Preferred PA bosentan TYVASO 0.6 MG/ML SOLUTION Preferred PA treprostinil TYVASO REFILL 0.6 MG/ML SOLUTION Preferred PA treprostinil TYVASO STARTER 0.6 MG/ML SOLUTION Preferred PA treprostinil UPTRAVI 1000 MCG TAB Non-Preferred selexipag UPTRAVI 1200 MCG TAB Non-Preferred selexipag UPTRAVI 1400 MCG TAB Non-Preferred selexipag UPTRAVI 1600 MCG TAB Non-Preferred selexipag UPTRAVI 200 & 800 MCG TAB THPK Non-Preferred selexipag UPTRAVI 200 MCG TAB Non-Preferred selexipag

PAGE 394 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS UPTRAVI 400 MCG TAB Non-Preferred selexipag UPTRAVI 600 MCG TAB Non-Preferred selexipag UPTRAVI 800 MCG TAB Non-Preferred selexipag VENTAVIS 10 MCG/ML SOLUTION Preferred PA iloprost VENTAVIS 20 MCG/ML SOLUTION Preferred PA iloprost PULMONARY FIBROSIS AGENTS

ESBRIET 267 MG CAP Preferred PA pirfenidone ESBRIET 267 MG TAB Preferred PA pirfenidone ESBRIET 801 MG TAB Preferred PA pirfenidone OFEV 100 MG CAP Preferred PA nintedanib esylate OFEV 150 MG CAP Preferred PA nintedanib esylate RESPIRATORY TRACT AGENTS, OTHER

acetylcysteine inhal soln 10% Preferred acetylcysteine inhal soln 20% Preferred ADVAIR DISKUS 100-50 MCG/DOSE AER POW BA Non-Preferred QL 60 / 30 days fluticasone-salmeterol ADVAIR DISKUS 250-50 MCG/DOSE AER POW BA Non-Preferred QL 60 / 30 days fluticasone-salmeterol ADVAIR DISKUS 500-50 MCG/DOSE AER POW BA Non-Preferred QL 60 / 30 days fluticasone-salmeterol ADVAIR HFA 115-21 MCG/ACT AEROSOL Preferred QL 12 / 30 days fluticasone-salmeterol ADVAIR HFA 230-21 MCG/ACT AEROSOL Preferred QL 12 / 30 days fluticasone-salmeterol

PAGE 395 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ADVAIR HFA 45-21 MCG/ACT AEROSOL Preferred QL 12 / 30 days fluticasone-salmeterol AIRDUO DIGIHALER 113-14 MCG/ACT AER POW BA Non-Preferred fluticasone-salmeterol AIRDUO DIGIHALER 232-14 MCG/ACT AER POW BA Non-Preferred fluticasone-salmeterol AIRDUO DIGIHALER 55-14 MCG/ACT AER POW BA Non-Preferred fluticasone-salmeterol AIRDUO RESPICLICK 113/14 113-14 MCG/ACT AER POW BA Non-Preferred fluticasone-salmeterol AIRDUO RESPICLICK 232/14 232-14 MCG/ACT AER POW BA Non-Preferred fluticasone-salmeterol AIRDUO RESPICLICK 55/14 55-14 MCG/ACT AER POW BA Non-Preferred fluticasone-salmeterol ANORO ELLIPTA 62.5-25 MCG/INH AER POW BA Preferred QL 60 / 30 days umeclidinium-vilanterol azelastine hcl-fluticasone prop nasal Non-Preferred spray 137-50 mcg/act

benzonatate cap 100 mg Preferred QL 3 / 1 days

benzonatate cap 200 mg Preferred QL 3 / 1 days

BEVESPI AEROSPHERE 9-4.8 MCG/ACT AEROSOL Preferred glycopyrrolate-formoterol fumarate BREO ELLIPTA 100-25 MCG/INH AER POW BA Non-Preferred QL 60 / 30 days fluticasone furoate-vilanterol BREO ELLIPTA 200-25 MCG/INH AER POW BA Non-Preferred QL 60 / 30 days fluticasone furoate-vilanterol BREZTRI AEROSPHERE 160-9-4.8 MCG/ACT AEROSOL Non-Preferred budesonide-glycopyrrolate-formoterol fumarate

PAGE 396 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS budesonide-formoterol fumarate dihyd Non-Preferred QL 10.2 / 30 days aerosol 160-4.5 mcg/act budesonide-formoterol fumarate dihyd Non-Preferred QL 10.2 / 30 days aerosol 80-4.5 mcg/act CLARINEX-D 12 HOUR 2.5-120 MG TAB ER 12H Non-Preferred desloratadine-pseudoephedrine COMBIVENT RESPIMAT 20-100 MCG/ACT AERO SOLN Preferred QL 4 / 20 days ipratropium-albuterol DUAKLIR PRESSAIR 400-12 MCG/ACT AER POW BA Non-Preferred aclidinium bromide-formoterol fumarate DULERA 100-5 MCG/ACT AEROSOL mometasone furoate-formoterol Preferred QL 13 / 30 days fumarate dihydrate DULERA 200-5 MCG/ACT AEROSOL mometasone furoate-formoterol Preferred QL 13 / 30 days fumarate dihydrate DULERA 50-5 MCG/ACT AEROSOL mometasone furoate-formoterol Preferred QL 13 / 30 days fumarate dihydrate DYMISTA 137-50 MCG/ACT SUSPENSION Non-Preferred azelastine hcl-fluticasone propionate FASENRA 30 MG/ML SOLN PRSYR Preferred PA benralizumab FASENRA PEN 30 MG/ML SOLN A-INJ Preferred PA benralizumab fluticasone-salmeterol aer powder ba Preferred QL 60 / 30 days 100-50 mcg/dose fluticasone-salmeterol aer powder ba Non-Preferred QL 60 / 30 days 100-50 mcg/dose fluticasone-salmeterol aer powder ba Preferred QL 1 / 30 days 113-14 mcg/act fluticasone-salmeterol aer powder ba Preferred QL 1 / 30 days 232-14 mcg/act fluticasone-salmeterol aer powder ba Preferred QL 60 / 30 days 250-50 mcg/dose fluticasone-salmeterol aer powder ba Non-Preferred QL 60 / 30 days 250-50 mcg/dose

PAGE 397 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS fluticasone-salmeterol aer powder ba Preferred QL 60 / 30 days 500-50 mcg/dose fluticasone-salmeterol aer powder ba Non-Preferred QL 60 / 30 days 500-50 mcg/dose fluticasone-salmeterol aer powder ba Preferred QL 1 / 30 days 55-14 mcg/act ipratropium-albuterol nebu soln 0.5- Preferred 2.5(3) mg/3ml KITABIS PAK 300 MG/5ML NEBU SOLN Preferred tobramycin NUCALA 100 MG RECON SOLN Preferred PA mepolizumab NUCALA 100 MG/ML SOLN A-INJ Preferred PA mepolizumab NUCALA 100 MG/ML SOLN PRSYR Preferred PA mepolizumab promethazine & phenylephrine syrup Preferred QL 6 / 1 days 6.25-5 mg/5ml promethazine & phenylephrine syrup Preferred QL 6 / 1 days 6.25-5 mg/5ml PROMETHAZINE-DM 6.25-15 MG/5ML SOLUTION Preferred promethazine-dm promethazine-dm syrup 6.25-15 mg/5ml Preferred pseudoephed-bromphen-dm syrup 30-2- Preferred 10 mg/5ml pseudoephed-bromphen-dm syrup 30-2- Preferred 10 mg/5ml SEMPREX-D 8-60 MG CAP Non-Preferred acrivastine & pseudoephedrine sodium chloride soln nebu 3% Preferred

sodium chloride soln nebu 7% Preferred QL 480 / 30 days

STIOLTO RESPIMAT 2.5-2.5 MCG/ACT AERO SOLN Non-Preferred QL 4 / 30 days tiotropium bromide-olodaterol hcl SYMBICORT 160-4.5 MCG/ACT AEROSOL Preferred QL 10.2 / 30 days budesonide-formoterol fumarate dihydrate

PAGE 398 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SYMBICORT 80-4.5 MCG/ACT AEROSOL Preferred QL 10.2 / 30 days budesonide-formoterol fumarate dihydrate TOBI 300 MG/5ML NEBU SOLN Non-Preferred tobramycin TOBRAMYCIN 300 MG/5ML NEBU SOLN Non-Preferred tobramycin tobramycin nebu soln 300 mg/5ml Preferred TRELEGY ELLIPTA 100-62.5-25 MCG/INH AER POW BA Non-Preferred QL 60 / 30 days fluticasone-umeclidinium-vilanterol TRELEGY ELLIPTA 200-62.5-25 MCG/INH AER POW BA Non-Preferred QL 60 / 30 days fluticasone-umeclidinium-vilanterol UTIBRON NEOHALER 27.5-15.6 MCG CAP Non-Preferred indacaterol maleate-glycopyrrolate XOLAIR 150 MG RECON SOLN Preferred PA omalizumab XOLAIR 150 MG/ML SOLN PRSYR Non-Preferred omalizumab XOLAIR 75 MG/0.5ML SOLN PRSYR Non-Preferred omalizumab SKELETAL MUSCLE RELAXANTS

AMRIX 15 MG CAP ER 24H Non-Preferred cyclobenzaprine hcl AMRIX 30 MG CAP ER 24H Non-Preferred cyclobenzaprine hcl carisoprodol tab 250 mg Non-Preferred

carisoprodol tab 350 mg Non-Preferred QL 4 / 1 days

carisoprodol tab 350 mg Non-Preferred CARISOPRODOL-ASPIRIN 200-325 MG TAB Non-Preferred QL 3 / 1 days carisoprodol w/ aspirin chlorzoxazone tab 375 mg Non-Preferred chlorzoxazone tab 375 mg Non-Preferred

PAGE 399 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

chlorzoxazone tab 500 mg Non-Preferred QL 6 / 1 days

chlorzoxazone tab 750 mg Non-Preferred chlorzoxazone tab 750 mg Non-Preferred cyclobenzaprine hcl cap er 24hr 15 mg Non-Preferred cyclobenzaprine hcl cap er 24hr 30 mg Non-Preferred

cyclobenzaprine hcl tab 10 mg Preferred QL 3 / 1 days

cyclobenzaprine hcl tab 5 mg Preferred QL 6 / 1 days

cyclobenzaprine hcl tab 7.5 mg Preferred DYSPORT 300 UNIT RECON SOLN Preferred PA abobotulinumtoxina DYSPORT 500 UNIT RECON SOLN Preferred PA abobotulinumtoxina FEXMID 7.5 MG TAB Non-Preferred cyclobenzaprine hcl metaxalone tab 400 mg Non-Preferred metaxalone tab 800 mg Non-Preferred metaxalone tab 800 mg Non-Preferred

methocarbamol tab 500 mg Preferred QL 16 / 1 days

methocarbamol tab 750 mg Preferred QL 10 / 1 days

MYOBLOC 10000 UNIT/2ML SOLUTION Non-Preferred rimabotulinumtoxinb MYOBLOC 2500 UNIT/0.5ML SOLUTION Non-Preferred rimabotulinumtoxinb MYOBLOC 5000 UNIT/ML SOLUTION Non-Preferred rimabotulinumtoxinb NORGESIC FORTE 50-770-60 MG TAB Non-Preferred orphenadrine w/ aspirin & caff

orphenadrine citrate tab er 12hr 100 mg Non-Preferred QL 2 / 1 days

orphenadrine w/ aspirin & caffeine tab Non-Preferred 50-770-60 mg orphenadrine w/ aspirin & caffeine tab Non-Preferred 50-770-60 mg

PAGE 400 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ROBAXIN-750 750 MG TAB Non-Preferred methocarbamol SKELAXIN 800 MG TAB Non-Preferred metaxalone SOMA 250 MG TAB Non-Preferred carisoprodol SOMA 350 MG TAB Non-Preferred carisoprodol SLEEP DISORDER AGENTS

GABA RECEPTOR MODULATORS

AMBIEN 10 MG TAB Non-Preferred QL 30 / 30 days zolpidem tartrate AMBIEN 5 MG TAB Non-Preferred QL 30 / 30 days zolpidem tartrate AMBIEN CR 12.5 MG TAB ER Non-Preferred QL 30 / 30 days zolpidem tartrate AMBIEN CR 6.25 MG TAB ER Non-Preferred QL 30 / 30 days zolpidem tartrate DORAL 15 MG TAB Non-Preferred quazepam EDLUAR 10 MG SL TAB Non-Preferred QL 30 / 30 days zolpidem tartrate EDLUAR 5 MG SL TAB Non-Preferred QL 30 / 30 days zolpidem tartrate

estazolam tab 1 mg Non-Preferred QL 1 / 1 days

estazolam tab 2 mg Non-Preferred QL 1 / 1 days

eszopiclone tab 1 mg Preferred QL 1 / 1 days

eszopiclone tab 2 mg Preferred QL 1 / 1 days

eszopiclone tab 3 mg Preferred QL 1 / 1 days

FLURAZEPAM HCL 15 MG CAP Non-Preferred QL 1 / 1 days flurazepam hcl FLURAZEPAM HCL 30 MG CAP Non-Preferred QL 1 / 1 days flurazepam hcl HALCION 0.25 MG TAB Non-Preferred triazolam

PAGE 401 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS INTERMEZZO 1.75 MG SL TAB Non-Preferred QL 30 / 30 days zolpidem tartrate INTERMEZZO 3.5 MG SL TAB Non-Preferred QL 30 / 30 days zolpidem tartrate LUNESTA 1 MG TAB Non-Preferred QL 1 / 1 days eszopiclone LUNESTA 2 MG TAB Non-Preferred QL 1 / 1 days eszopiclone LUNESTA 3 MG TAB Non-Preferred QL 1 / 1 days eszopiclone QUAZEPAM 15 MG TAB Non-Preferred quazepam RESTORIL 15 MG CAP Non-Preferred QL 30 / 30 days temazepam RESTORIL 22.5 MG CAP Non-Preferred temazepam RESTORIL 30 MG CAP Non-Preferred QL 30 / 30 days temazepam RESTORIL 7.5 MG CAP Non-Preferred temazepam

QL 30 / 30 days

temazepam cap 15 mg Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required temazepam cap 22.5 mg Non-Preferred

QL 30 / 30 days

temazepam cap 30 mg Preferred AL1 At least 21 yrs old

C Age restriction, clinical PA required temazepam cap 7.5 mg Non-Preferred

triazolam tab 0.125 mg Non-Preferred QL 60 / 30 days

triazolam tab 0.25 mg Non-Preferred QL 1 / 1 days

zaleplon cap 10 mg Preferred QL 2 / 1 days

zaleplon cap 5 mg Preferred QL 2 / 1 days

zolpidem tartrate sl tab 1.75 mg Non-Preferred QL 30 / 30 days

PAGE 402 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

zolpidem tartrate sl tab 3.5 mg Non-Preferred QL 30 / 30 days

zolpidem tartrate tab 10 mg Preferred QL 30 / 30 days

zolpidem tartrate tab 5 mg Preferred QL 30 / 30 days

zolpidem tartrate tab er 12.5 mg Non-Preferred QL 30 / 30 days

zolpidem tartrate tab er 6.25 mg Non-Preferred QL 30 / 30 days

ZOLPIMIST 5 MG/ACT SOLUTION Non-Preferred zolpidem tartrate SLEEP DISORDERS, OTHER

armodafinil tab 150 mg Preferred PA

armodafinil tab 200 mg Preferred PA

armodafinil tab 250 mg Preferred PA

armodafinil tab 50 mg Preferred PA

BELSOMRA 10 MG TAB Non-Preferred QL 1 / 1 days suvorexant BELSOMRA 15 MG TAB Non-Preferred QL 1 / 1 days suvorexant BELSOMRA 20 MG TAB Non-Preferred QL 1 / 1 days suvorexant BELSOMRA 5 MG TAB Non-Preferred QL 1 / 1 days suvorexant BUTISOL SODIUM 30 MG TAB Non-Preferred butabarbital sodium DAYVIGO 10 MG TAB Non-Preferred lemborexant DAYVIGO 5 MG TAB Non-Preferred lemborexant doxepin hcl (sleep) tab 3 mg (base Non-Preferred equiv) doxepin hcl (sleep) tab 6 mg (base Non-Preferred equiv) HETLIOZ 20 MG CAP Non-Preferred QL 30 / 30 days tasimelteon HETLIOZ LQ 4 MG/ML SUSPENSION Non-Preferred tasimelteon

PAGE 403 LAST UPDATED 03/2021 DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

modafinil tab 100 mg Preferred PA

modafinil tab 200 mg Preferred PA

NUVIGIL 150 MG TAB Non-Preferred armodafinil NUVIGIL 200 MG TAB Non-Preferred armodafinil NUVIGIL 250 MG TAB Non-Preferred armodafinil NUVIGIL 50 MG TAB Non-Preferred armodafinil PROVIGIL 100 MG TAB Non-Preferred modafinil PROVIGIL 200 MG TAB Non-Preferred modafinil ramelteon tab 8 mg Non-Preferred ROZEREM 8 MG TAB Non-Preferred ramelteon SECONAL 100 MG CAP Non-Preferred secobarbital sodium SILENOR 3 MG TAB Non-Preferred doxepin hcl (sleep) SILENOR 6 MG TAB Non-Preferred doxepin hcl (sleep) SUNOSI 150 MG TAB Non-Preferred solriamfetol hcl SUNOSI 75 MG TAB Non-Preferred solriamfetol hcl WAKIX 17.8 MG TAB Non-Preferred pitolisant hcl WAKIX 4.45 MG TAB Non-Preferred pitolisant hcl

PAGE 404 LAST UPDATED 03/2021 Category Listing ANALGESICS5 ANESTHETICS31 ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS33 ANTIBACTERIALS36 ANTICONVULSANTS53 ANTIDEMENTIA AGENTS67 ANTIDEPRESSANTS70 ANTIEMETICS81 ANTIFUNGALS86 ANTIGOUT AGENTS91 ANTIMIGRAINE AGENTS92 ANTIMYASTHENIC AGENTS96 ANTIMYCOBACTERIALS97 ANTINEOPLASTICS97 ANTIPARASITICS113 ANTIPARKINSON AGENTS114 ANTIPSYCHOTICS121 ANTISPASTICITY AGENTS144 ANTIVIRALS145 ANXIOLYTICS157 BIPOLAR AGENTS163 BLOOD GLUCOSE REGULATORS164 BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS179 CARDIOVASCULAR AGENTS200 CENTRAL NERVOUS SYSTEM AGENTS240 DENTAL AND ORAL AGENTS266 DERMATOLOGICAL AGENTS266 ELECTROLYTES/MINERALS/METALS/VITAMINS278 GASTROINTESTINAL AGENTS294 GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT302 GENITOURINARY AGENTS305 HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)308 HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)320 HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)322 HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)346 HORMONAL AGENTS, SUPPRESSANT (PITUITARY)351 HORMONAL AGENTS, SUPPRESSANT (THYROID)353 IMMUNOLOGICAL AGENTS353 INFLAMMATORY BOWEL DISEASE AGENTS365 METABOLIC BONE DISEASE AGENTS367 MISCELLANEOUS THERAPEUTIC AGENTS371 OPHTHALMIC AGENTS374 OTIC AGENTS382

PAGE 405 LAST UPDATED 03/2021 RESPIRATORY TRACT/PULMONARY AGENTS383 SKELETAL MUSCLE RELAXANTS399 SLEEP DISORDER AGENTS401

PAGE 406 LAST UPDATED 03/2021 Class Listing 1ST GENERATION/TYPICAL121 2ND GENERATION/ATYPICAL125 ALCOHOL DETERRENTS/ANTI-CRAVING33 ALKYLATING AGENTS97 ALPHA-ADRENERGIC AGONISTS200 ALPHA-ADRENERGIC BLOCKING AGENTS201 AMINOGLYCOSIDES36 AMINOSALICYLATES365 ANABOLIC STEROIDS322 ANDROGENS323 ANGIOEDEMA AGENTS353 ANGIOTENSIN II RECEPTOR ANTAGONISTS202 ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS204 ANTI-CYTOMEGALOVIRUS (CMV) AGENTS145 ANTI-HEPATITIS B (HBV) AGENTS145 ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING AGENTS146 ANTI-HEPATITIS C (HCV) AGENTS, OTHER147 ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)147 ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)148 ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)150 ANTI-HIV AGENTS, OTHER153 ANTI-HIV AGENTS, PROTEASE INHIBITORS153 ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS383 ANTI-INFLUENZA AGENTS155 ANTIANDROGENS98 ANTIANGIOGENIC AGENTS99 ANTIARRHYTHMICS207 ANTIBACTERIALS, OTHER37 ANTICHOLINERGICS114 ANTICOAGULANTS179 ANTICONVULSANTS, OTHER53 ANTIDEPRESSANTS, OTHER70 ANTIDIABETIC AGENTS164 ANTIEMETICS, OTHER81 ANTIESTROGENS/MODIFIERS99 ANTIHELMINTHICS113 ANTIHERPETIC AGENTS156 ANTIHISTAMINES386 ANTILEUKOTRIENES388 ANTIMETABOLITES100 ANTIMIGRAINE AGENTS, OTHER92 ANTIMYCOBACTERIALS, OTHER97 ANTINEOPLASTICS, OTHER101

PAGE 407 LAST UPDATED 03/2021 ANTIPARKINSON AGENTS, OTHER114 ANTIPROTOZOALS113 ANTISPASMODICS, GASTROINTESTINAL294 ANTISPASMODICS, URINARY305 ANTITHYROID AGENTS353 ANTITUBERCULARS97 ANXIOLYTICS, OTHER157 AROMATASE INHIBITORS, 3RD GENERATION104 ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES240 ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES247 BENIGN PROSTATIC HYPERTROPHY AGENTS306 BENZODIAZEPINES157 BETA-ADRENERGIC BLOCKING AGENTS208 BETA-LACTAM, CEPHALOSPORINS41 BETA-LACTAM, PENICILLINS43 BLOOD FORMATION MODIFIERS184 BRONCHODILATORS, ANTICHOLINERGIC388 BRONCHODILATORS, SYMPATHOMIMETIC389 CALCIUM CHANNEL BLOCKING AGENTS212 CALCIUM CHANNEL MODIFYING AGENTS55 CARDIOVASCULAR AGENTS, OTHER219 CENTRAL NERVOUS SYSTEM, OTHER259 CHOLINESTERASE INHIBITORS67 CYSTIC FIBROSIS AGENTS392 DIURETICS, CARBONIC ANHYDRASE INHIBITORS229 DIURETICS, LOOP229 DIURETICS, POTASSIUM-SPARING230 DIURETICS, THIAZIDE230 DOPAMINE AGONISTS116 DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS119 DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES230 DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS232 DYSLIPIDEMICS, OTHER235 ELECTROLYTE/MINERAL REPLACEMENT278 ELECTROLYTE/MINERAL/METAL MODIFIERS282 EMETOGENIC THERAPY ADJUNCTS84 ENZYME INHIBITORS104 ERGOT ALKALOIDS93 ESTROGENS325 FIBROMYALGIA AGENTS261 GABA RECEPTOR MODULATORS401 GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS55 GASTROINTESTINAL AGENTS, OTHER294 GENITOURINARY AGENTS, OTHER307 GLUCOCORTICOIDS367

PAGE 408 LAST UPDATED 03/2021 GLUTAMATE REDUCING AGENTS59 GLYCEMIC AGENTS175 HEMOSTASIS AGENTS188 HISTAMINE2 (H2) RECEPTOR ANTAGONISTS295 IMMUNE SUPPRESSANTS354 IMMUNIZING AGENTS, PASSIVE362 IMMUNOMODULATORS362 INSULINS175 IRRITABLE BOWEL SYNDROME AGENTS297 LAXATIVES298 LOCAL ANESTHETICS31 MACROLIDES45 MAST CELL STABILIZERS392 MOLECULAR TARGET INHIBITORS105 MONOAMINE OXIDASE B (MAO-B) INHIBITORS120 MONOAMINE OXIDASE INHIBITORS73 MOOD STABILIZERS163 MULTIPLE SCLEROSIS AGENTS262 N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST69 NONSTEROIDAL ANTI-INFLAMMATORY DRUGS5 OPHTHALMIC AGENTS, OTHER374 OPHTHALMIC ANTI-ALLERGY AGENTS377 OPHTHALMIC ANTI-INFLAMMATORIES377 OPHTHALMIC ANTIGLAUCOMA AGENTS379 OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS381 OPIOID ANALGESICS, LONG-ACTING10 OPIOID ANALGESICS, SHORT-ACTING21 OPIOID DEPENDENCE TREATMENTS34 OPIOID REVERSAL AGENTS35 PARASYMPATHOMIMETICS96 PEDICULICIDES/SCABICIDES114 PHOSPHATE BINDERS283 PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE392 PLATELET MODIFYING AGENTS199 PROGESTERONE AGONISTS/ANTAGONISTS343 PROGESTINS343 PROPHYLACTIC93 PROTECTANTS299 PROTON PUMP INHIBITORS299 PULMONARY ANTIHYPERTENSIVES393 PULMONARY FIBROSIS AGENTS395 QUINOLONES47 RESPIRATORY TRACT AGENTS, OTHER395 RETINOIDS112 SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS345

PAGE 409 LAST UPDATED 03/2021 SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS93 SLEEP DISORDERS, OTHER403 SMOKING CESSATION AGENTS36 SODIUM CHANNEL AGENTS64 SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITOR/SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITOR)73 SULFONAMIDES49 TETRACYCLINES50 TREATMENT-RESISTANT142 TRICYCLICS79 VACCINES363 VASODILATORS, DIRECT-ACTING ARTERIAL237 VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS238 VITAMINS285

PAGE 410 LAST UPDATED 03/2021 Index of covered drugs Actiq22 A ACTIQ22 ABACAVIR SULFATE150,152 Active FE278 ABACAVIR SULFATE-LAMIVUDINE150,151 Activella325 ABACAVIR SULFATE-LAMIVUDINE- Actonel367 ZIDOVUDINE150,151 Actoplus Met164 ABACAVIR-DOLUTEGRAVIR-LAMIVUDINE153 Actoplus met XR164 ABALOPARATIDE370 Actos164 ABATACEPT358,359 Acular377 ABEMACICLIB112 Acular LS377 Abilify125,126 Acuvail377 Abilify Maintena126 ACYCLOVIR156,157 Abilify MyCite126,127 ACYCLOVIR TOPICAL156,157 ABIRATERONE ACETATE98,99 ACYCLOVIR-HYDROCORTISONE157 ABOBOTULINUMTOXINA400 Aczone266,267 Absorica266 Adacel363 Absorica LD266 Adakveo199 Abstral21 Adalat CC212 ACALABRUTINIB105 ADALIMUMAB356,357 ACAMPROSATE CALCIUM33 ADAPALENE267,269,270 Acanya266 Adapalene267 ACARBOSE164,172 ADAPALENE-BENZOYL PEROXIDE267,270 Accolate388 Adasuve121 Accupril204 Adcirca393 Accuretic219 Adderall240 ACEBUTOLOL HCL208 Adderall XR240,241 ACETAMINOPHEN W/ CODEINE21,22,31 ADEFOVIR DIPIVOXIL145 ACETAMINOPHEN-CAFF-DIHYDROCOD22 Adempas393 ACETAZOLAMIDE229 Adhansia XR247 ACETIC ACID (OTIC)382 Adlyxin164 ACETYLCYSTEINE395 Adlyxin Starter Pack164 Aciphex299 Admelog175 AcipHex Sprinkle299 Admelog SoloStar175 ACITRETIN266,274 Advair Diskus395 ACLIDINIUM BROMIDE389 Advair HFA395,396 ACLIDINIUM BROMIDE-FORMOTEROL Advate188 FUMARATE397 Adynovate188,189 ACRIVASTINE & PSEUDOEPHEDRINE398 Adzenys ER241 Actemra362,363 Adzenys XR-ODT241 Actemra ACTPen363 AeroChamber MV371 Actigall294 AeroChamber Plus Flo-Vu371

PAGE 411 LAST UPDATED 03/2021 AeroChamber Plus Flo-Vu Large371 ALISKIREN FUMARATE219,227 AeroChamber Plus Flo-Vu Medium371 ALISKIREN-HYDROCHLOROTHIAZIDE227 AeroChamber Plus Flo-Vu Small371 Alkindi Sprinkle308 AeroChamber Plus Flo-Vu w/Mask371 ALLOPURINOL91,92 AeroChamber Plus Flow VU371 Allzital259 AFATINIB DIMALEATE106,107 ALMOTRIPTAN MALATE93 Afinitor105 Alocril377 Afinitor Disperz105 ALOGLIPTIN BENZOATE164,165,170 AFLIBERCEPT375 ALOGLIPTIN-METFORMIN HCL165,169 Afluria363 ALOGLIPTIN-PIOGLITAZONE165,171 Afluria Preservative Free363 Alomide377 Afluria Quadrivalent363 Alora325 Afrezza176 ALOSETRON HCL297 Afstyla189 Aloxi84 Aggrenox199 ALPELISIB110 Aimovig92 Alphagan P379 AirDuo Digihaler396 Alphanate189 AirDuo RespiClick 113/14396 Alphanate/VWF Complex/Human190 AirDuo RespiClick 232/14396 AlphaNine SD190 AirDuo RespiClick 55/14396 ALPRAZOLAM157,158,159,163 Ajovy92 ALPRAZolam Intensol159 Aklief267 Alprolix190,191 Akynzeo84 Alrex377 Ala Scalp308 Altace204 ALBIGLUTIDE173 Altoprev232 ALBUTEROL SULFATE389,390,391 Altreno267 Albuterol Sulfate389 ALUMINUM CHLORIDE270 ALCAFTADINE377 Alunbrig101 ALCLOMETASONE DIPROPIONATE308 Alvesco383 Alcortin A267 AMANTADINE HCL114,115 Aldactazide219 Amaryl165 Aldara267 Ambien401 Alecensa105 Ambien CR401 ALECTINIB HCL105 AMBRISENTAN393 ALEMTUZUMAB (MS)264 AMCINONIDE308 ALENDRONATE SODIUM367,368 Amerge93 ALENDRONATE SODIUM- AMIKACIN SULFATE LIPOSOME36 CHOLECALCIFEROL368,369 AMILORIDE & HYDROCHLOROTHIAZIDE219 ALFUZOSIN HCL306 AMILORIDE HCL230 Alinia113 AMINOCAPROIC ACID191 ALIROCUMAB236 AMIODARONE HCL207

PAGE 412 LAST UPDATED 03/2021 AMISULPRIDE (ANTIEMETIC)81 Anoro Ellipta396 Amitiza297 Antara230 AMITRIPTYLINE HCL79 ANTIHEMOPHIL FACT(RCMB) PEGYLATED-AUCL AMLODIPINE BENZOATE216 (BDD-RFVIII PEG-AUCL)194 AMLODIPINE BESYLATE212,217 ANTIHEMOPHILIC FACTOR (HUMAN)193,194,195 AMLODIPINE BESYLATE-ATORVASTATIN ANTIHEMOPHILIC FACTOR (RCMB) BD CALCIUM219,222 TRUNCATED (BD TRUNC-RFVIII)195,196 AMLODIPINE BESYLATE-BENAZEPRIL HCL220,225 ANTIHEMOPHILIC FACTOR (RCMB) FC FUSION AMLODIPINE BESYLATE-OLMESARTAN PROTEIN(BDD-RFVIIIFC)191,192 MEDOXOMIL220,221 ANTIHEMOPHILIC FACTOR (RCMB) AMLODIPINE BESYLATE-VALSARTAN220,223,224 MOROCTOCOG ALFA(BDD-RFVIII,MOR)198,199 AMLODIPINE-VALSARTAN- ANTIHEMOPHILIC FACTOR (RCMB) HYDROCHLOROTHIAZIDE220,224 PLASMA/ALBUMIN FREE (RAHF-PFM)188,195 AMOXAPINE79 ANTIHEMOPHILIC FACTOR (RCMB) SIMOCTOCOG AMOXICILLIN43,45 ALFA(BDD-RFVIII,SIM)196,197 AMOXICILLIN & POT CLAVULANATE43,44 ANTIHEMOPHILIC FACTOR (RECOMBINANT AMOXICILLIN-CLARITHROMYCIN W/ PORCINE) (RPFVIII)197 LANSOPRAZOLE294 ANTIHEMOPHILIC FACTOR AMOXICILLIN-CLARITHROMYCIN W/ (RECOMBINANT)192,194,195,197,198 OMEPRAZOLE295 ANTIHEMOPHILIC FACTOR (RECOMBINANT) AMOXICILLIN-RIFABUTIN-OMEPRAZOLE295 GLYCOPEGYLATED-EXEI192 AMPHETAMINE241,244 ANTIHEMOPHILIC FACTOR (RECOMBINANT) Amphetamine ER241 PEGYLATED188,189 AMPHETAMINE SULFATE242,244,245 ANTIHEMOPHILIC FACTOR (RECOMBINANT) AMPHETAMINE- SINGLE CHAIN189 DEXTROAMPHETAMINE240,241,242,243,245 ANTIHEMOPHILIC FACTOR/VON WILLEBRAND AMPICILLIN44 FACTOR COMPLEX (HUMAN)189,190,193,198 Ampyra262 ANTIINHIBITOR COAGULANT COMPLEX192 Amrix399 Anzemet84 Amzeeq50 Apadaz22 Anadrol-50322 APALUTAMIDE98 Anafranil79 APAP-Caff-Dihydrocodeine22 ANAKINRA357 ApexiCon E308 ANASTROZOLE104 Apidra176 Ancobon86 Apidra SoloStar176 Androderm323 APIXABAN180 AndroGel323 Aplenzin70 AndroGel Pump323 APOMORPHINE HYDROCHLORIDE116 Android323 APRACLONIDINE HCL379,380 Angeliq325 APREMILAST363 Annovera325 APREPITANT84,85

PAGE 413 LAST UPDATED 03/2021 Apriso365 Astagraf XL354 Aprizio Pak31 Astepro386 Aprizio Pak II31 Atacand202 Aptensio XR247,248 Atacand HCT220,221 Aptiom64 ATAZANAVIR SULFATE154,155 Aptivus153,154 ATAZANAVIR SULFATE-COBICISTAT154 Arakoda113 Atelvia367 Aranesp (Albumin Free)184,185 ATENOLOL208,212 Arazlo267 ATENOLOL & CHLORTHALIDONE221,227 Arcalyst363 Ativan159 Arcapta Neohaler390 ATOMOXETINE HCL248,249,258,259 ARFORMOTEROL TARTRATE390 ATORVASTATIN CALCIUM232,233 Aricept67 ATOVAQUONE-PROGUANIL HCL113 Arikayce36 Atralin267 Arimidex104 Atripla148 ARIPIPRAZOLE125,126,127,128 Atropine Sulfate374 ARIPIPRAZOLE LAUROXIL128 ATROPINE SULFATE (OPHTHALMIC)374,375 Aristada128 Atrovent HFA388 Aristada Initio128 Aubagio262,263 Arixtra179 Augmentin44 ARMODAFINIL403,404 Augmentin XR44 ArmonAir Digihaler383 Auryxia283 ArmonAir RespiClick 232383 Austedo259 ArmonAir RespiClick 55383 Avalide221 Armour Thyroid346 Avandia165 Arnuity Ellipta383 AVAPRITINIB101 Aromasin104 Avapro202 ARTEMETHER-LUMEFANTRINE113 AVATROMBOPAG MALEATE200 Arthrotec5 AVC Vaginal49 Arymo ER10 Aveed323 Asacol HD366 Avelox47 ASENAPINE138 Avodart306 ASENAPINE MALEATE128,129,138 Avonex263 Asmanex (120 Metered Doses)383 Avonex Pen263 Asmanex (14 Metered Doses)383 Avonex Prefilled263 Asmanex (30 Metered Doses)383,384 Avsola354 Asmanex (60 Metered Doses)384 AXITINIB108 Asmanex HFA384 Aygestin343 ASPIRIN-DIPYRIDAMOLE199 Ayvakit101 ASPIRIN-OMEPRAZOLE199,200 Azasan354 Aspirin-Omeprazole199 AzaSite45

PAGE 414 LAST UPDATED 03/2021 AZATHIOPRINE354,357 BECLOMETHASONE DIPROPIONATE385 AZELAIC ACID (ACNE)267 BECLOMETHASONE DIPROPIONATE (NASAL)385 AZELASTINE HCL386 BECLOMETHASONE DIPROPIONATE HFA385 AZELASTINE HCL (OPHTH)377 Beconase AQ384 AZELASTINE HCL-FLUTICASONE Belbuca10,11 PROPIONATE396,397 Belsomra403 Azelex267 BEMPEDOIC ACID226 AzesChew Prenatal/Postnatal285 BEMPEDOIC ACID-EZETIMIBE236 Azilect120 BENAZEPRIL & HYDROCHLOROTHIAZIDE221,225 AZILSARTAN MEDOXOMIL203 BENAZEPRIL HCL205 AZILSARTAN MEDOXOMIL-CHLORTHALIDONE223 BeneFIX191 AZITHROMYCIN45,47 Benicar202,203 AZITHROMYCIN (OPHTH)45 Benicar HCT221 Azopt379 BENRALIZUMAB397 Azor221 Bensal HP268 AZTREONAM LYSINE392 BenzaClin268 Azulfidine366 BenzaClin with Pump268 Azulfidine EN-tabs366 Benzamycin37 BenzePrO268 B BENZHYDROCODONE HCL- B-COMPLEX W/ C & FOLIC ACID285 ACETAMINOPHEN22,23 BACITRACIN (OPHTHALMIC)37 Benzhydrocodone-Acetaminophen22,23 BACITRACIN-POLY-NEOMYCIN-HC374 BENZONATATE396 BACITRACIN-POLYMYXIN B (OPHTH)374 BENZOYL PEROXIDE268 BACITRACIN-POLYMYXIN-NEOMYCIN HC269 BENZOYL PEROXIDE-ERYTHROMYCIN37 BACLOFEN144 BENZTROPINE MESYLATE114 Bafiertam263 Beovu374 Balcoltra325 BEPOTASTINE BESILATE377 BALOXAVIR MARBOXIL156 Bepreve377 BALSALAZIDE DISODIUM366 Berinert353 Balversa101 BEROTRALSTAT HCL354 Banzel64 Beser308 Baqsimi One Pack175 BESIFLOXACIN HCL47 Baqsimi Two Pack175 Besivance47 Baraclude145 BETAMETHASONE DIPROPIONATE Barhemsys81 (TOPICAL)274,308,309 BARICITINIB358 BETAMETHASONE DIPROPIONATE Basaglar KwikPen176 AUGMENTED270,309 Baxdela47 BETAMETHASONE VALERATE272,309 BD Luer-Lok Syringe371 Betapace207 BECLOMETHASONE DIPROP MONOHYD384 Betapace AF207

PAGE 415 LAST UPDATED 03/2021 Betaseron263 Breztri Aerosphere396 BETAXOLOL HCL209 BRIGATINIB101 BETAXOLOL HCL (OPHTH)379 Brilinta199 BETHANECHOL CHLORIDE307 BRIMONIDINE TARTRATE379,380 Bethkis392 BRIMONIDINE TARTRATE-TIMOLOL MALEATE380 Betoptic-S379 BRINZOLAMIDE379 BETRIXABAN MALEATE179 BRINZOLAMIDE-BRIMONIDINE TARTRATE381 Bevespi Aerosphere396 Brisdelle73 Bevyxxa179 BRIVARACETAM53 Beyaz326 Briviact53 BEZLOTOXUMAB41 BRODALUMAB361 BICALUTAMIDE98 BROLUCIZUMAB-DBLL374 Bicillin L-A44 BROMFENAC SODIUM (OPHTH)377,379 BICTEGRAVIR-EMTRICITABINE-TENOFOVIR BROMOCRIPTINE MESYLATE116,117 ALAFENAMIDE FUMARATE147 BromSite377 BiDil222 BROVANA390 Bijuva326 Brukinsa101 Biktarvy147 Bryhali309 BIMATOPROST381,382 BUDESONIDE367 BINIMETINIB110 BUDESONIDE (INHALATION)384,385 Binosto368 BUDESONIDE (INTRARECTAL)367 BISMUTH SUBCITRATE POTASSIUM- BUDESONIDE-FORMOTEROL FUMARATE METRONIDAZOLE-TETRACYCLINE295 DIHYDRATE397,398,399 BISOPROLOL & HYDROCHLOROTHIAZIDE222,229 BUDESONIDE-GLYCOPYRROLATE-FORMOTEROL BISOPROLOL FUMARATE209 FUMARATE396 Bleph-1049 BUMETANIDE229 Blephamide374 Bunavail34 Blephamide S.O.P.374 Buphenyl302 Boniva368 BUPRENORPHINE11,12,35 Bonjesta81 Buprenorphine11 Boostrix364 BUPRENORPHINE HCL10,11,34 BOSENTAN393,394 BUPRENORPHINE HCL-NALOXONE HCL Bosulif105 DIHYDRATE34,35 BOSUTINIB105 BUPROPION HCL70,72,73 Botox144 BUPROPION HCL (SMOKING DETERRENT)36 BP Cleansing Wash268 BUPROPION HYDROBROMIDE70 BP Vit 3285 BUSPIRONE HCL157 BPO268 BUSULFAN97 Braftovi105 BUTABARBITAL SODIUM403 Breo Ellipta396 BUTALBITAL-ACETAMINOPHEN259 BREXPIPRAZOLE135 Butalbital-Acetaminophen259

PAGE 416 LAST UPDATED 03/2021 BUTALBITAL-ACETAMINOPHEN-CAFFEINE259,260 Calquence105 BUTALBITAL-ACETAMINOPHEN-CAFFEINE W/ Cambia5 CODEINE23 CANAGLIFLOZIN168 BUTALBITAL-ASPIRIN-CAFFEINE5,25 CANAGLIFLOZIN-METFORMIN HCL168 Butalbital-Aspirin-Caffeine5 CANAKINUMAB357,363 BUTALBITAL-ASPIRIN-CAFFEINE W/COD23,25 Canasa366 BUTENAFINE HCL89 CANDESARTAN CILEXETIL202,203 Butisol Sodium403 CANDESARTAN CILEXETIL- BUTOCONAZOLE NITRATE (ONE DOSE)88 HYDROCHLOROTHIAZIDE220,221,222 BUTORPHANOL TARTRATE23 CANNABIDIOL54 Butrans11,12 CAPECITABINE100 Bydureon165 Capex309 Bydureon BCise165 Caplyta129 Byetta 10 MCG Pen165 CAPMATINIB HCL103 Byetta 5 MCG Pen165 Caprelsa105 Bystolic209 CAPSAICIN & CLEANSING GEL33 CAPTOPRIL205 C CAPTOPRIL & HYDROCHLOROTHIAZIDE222 C-Nate DHA285 CARBAMAZEPINE64,65,66 C1 ESTERASE INHIBITOR (HUMAN)353,354 CARBAMAZEPINE (ANTIPSYCHOTIC)163 C1 ESTERASE INHIBITOR (RECOMBINANT)354 Carbatrol65 Cabenuva153 CARBIDOPA119,120 CABERGOLINE351 CARBIDOPA-LEVODOPA119,120 Cabometyx105 CARBIDOPA-LEVODOPA-ENTACAPONE115,116 CABOTEGRAVIR & RILPIVIRINE153 Cardizem213 CABOTEGRAVIR SODIUM148 Cardizem CD213 CABOZANTINIB S-MALATE105,106 Cardizem LA213 Caduet222 Cardura201 Cafergot93 Cardura XL306 CAFFEINE CITRATE392 CARIPRAZINE HCL139,140 Calan212 CARISOPRODOL399,401 Calan SR213 CARISOPRODOL W/ ASPIRIN399 CALCIFEDIOL369 CARISOPRODOL W/ ASPIRIN & CODEINE23 CALCIPOTRIENE268,270,274 Carisoprodol-Aspirin399 Calcipotriene268 Carisoprodol-Aspirin-Codeine23 CALCIPOTRIENE-BETAMETHASONE CARTEOLOL HCL (OPHTH)380 DIPROPIONATE268,270,276,278 CARVEDILOL209 CALCITONIN (SALMON)368,369 CARVEDILOL PHOSPHATE209,210 CALCITRIOL368,370 Casodex98 CALCITRIOL (TOPICAL)268,278 Catapres200 CALCIUM ACETATE (PHOSPHATE BINDER)283,284 Catapres-TTS-1201

PAGE 417 LAST UPDATED 03/2021 Catapres-TTS-2201 CHLORAMBUCIL97 Catapres-TTS-3201 CHLORDIAZEPOXIDE HCL159 Cayston392 CHLORDIAZEPOXIDE-AMITRIPTYLINE70 CEFACLOR41 CHLORHEXIDINE GLUCONATE (MOUTH- Cefaclor41 THROAT)266 Cefaclor ER41 CHLOROQUINE PHOSPHATE113 CEFACLOR MONOHYDRATE41 CHLOROTHIAZIDE230 CEFADROXIL41 CHLORPROMAZINE HCL121 Cefadroxil41 CHLORPROPAMIDE165 CEFDINIR41 ChlorproPAMIDE165 CEFIXIME41,43 CHLORTHALIDONE230 CEFPODOXIME PROXETIL42 CHLORZOXAZONE399,400 CEFPROZIL42 Cholbam303 Ceftin42 CHOLESTYRAMINE235,237 CEFTRIAXONE SODIUM42 CHOLESTYRAMINE LIGHT235,237 CEFUROXIME AXETIL42 CHOLIC ACID303 CeleBREX5 CHOLINE FENOFIBRATE230,231,232 CELECOXIB5 Cialis306,307 CeleXA73 CICLESONIDE383 CellCept354,355 CICLESONIDE (NASAL)385,386 Celontin55 Ciclodan Cream87 CENOBAMATE64 Ciclodan Solution87 Centany37 CICLOPIROX87,89,90 Centany AT37 CICLOPIROX OLAMINE87,89 Centratex285 CICLOPIROX OLAMINE & CLEANSER87,89 CEPHALEXIN42,43 Ciclopirox Treatment87 Cephalexin42 CILOSTAZOL199 Cequa375 Ciloxan47,48 Cerdelga302 Cimduo150 Cerezyme302 CIMETIDINE295 CERITINIB112 CIMETIDINE HCL296 CERTOLIZUMAB PEGOL355 Cimzia355 Cesamet84 Cimzia Prefilled355 CETIRIZINE HCL386 Cimzia Starter Kit355 CETIRIZINE HCL (OPHTH)377 CINACALCET HCL368 Chantix36 Cinqair363 Chantix Continuing Month Pak36 Cinryze354 Chantix Starting Month Pak36 Cinvanti84 Chemet282 Cipro48 Chenodal294 Cipro HC382 CHENODIOL294 Ciprodex382

PAGE 418 LAST UPDATED 03/2021 CIPROFLOXACIN48 CLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE CIPROFLOXACIN (OTIC)49 & MOISTURIZER272 CIPROFLOXACIN HCL48 CLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE CIPROFLOXACIN HCL (OPHTH)47,48 (REFRIGERATE)269,270 CIPROFLOXACIN HCL (OTIC)48 CLINDAMYCIN PHOSPHATE-TRETINOIN269,278 Ciprofloxacin-Ciproflox HCl ER48 Clindesse38 CIPROFLOXACIN-CIPROFLOXACIN HCL48 CLOBAZAM55,58 CIPROFLOXACIN-DEXAMETHASONE382 CLOBETASOL PROPIONATE309,310,315,316,318 CIPROFLOXACIN-FLUOCINOLONE CLOBETASOL PROPIONATE & CLEANSER310 ACETONIDE382,383 CLOBETASOL PROPIONATE EMOLLIENT BASE309 Ciprofloxacin-Fluocinolone PF382 CLOBETASOL PROPIONATE EMULSION310,316 CIPROFLOXACIN-HYDROCORTISONE382 CLOBETASOL PROPIONATE EMULSION FOAM W/ CITALOPRAM HYDROBROMIDE73 MOISTURIZING CREAM276 CitraNatal 90 DHA285 Clobex310 CitraNatal Assure285 Clobex Spray310 CitraNatal B-Calm286 CLOCORTOLONE PIVALATE310 CitraNatal Bloom286 Clocortolone Pivalate310 CitraNatal DHA286 Clocortolone Pivalate Pump310 CitraNatal Harmony286 Clodan310 CitraNatal Rx286 Cloderm310 CLADRIBINE (MULTIPLE SCLEROSIS)264 Cloderm Pump310 Clarinex386 CLOMIPRAMINE HCL79 Clarinex-D 12 Hour397 CLONAZEPAM159,160,161 CLARITHROMYCIN45 CLONIDINE201 CLASCOTERONE278 CLONIDINE HCL200,201 Cleocin37 CLONIDINE HCL (ADHD)249,253 Cleocin-T37 CLOPIDOGREL BISULFATE200 Climara326 CLORAZEPATE DIPOTASSIUM160,162 Climara Pro326 CLOTRIMAZOLE87 Clindacin ETZ37 CLOTRIMAZOLE (TOPICAL)87 Clindacin Pac37 CLOTRIMAZOLE W/ BETAMETHASONE269,272 Clindagel37 CLOZAPINE142,143,144 CLINDAMYCIN HCL37,38 Clozaril143 CLINDAMYCIN PALMITATE HYDROCHLORIDE38 COAGULATION FACTOR IX190,195 CLINDAMYCIN PHOSPHATE & CLEANSER37 COAGULATION FACTOR IX (RECOMB) FC FUSION CLINDAMYCIN PHOSPHATE (ONE DOSE)38 PROTEIN (RFIXFC)190,191 CLINDAMYCIN PHOSPHATE COAGULATION FACTOR IX (TOPICAL)37,38,268,270 (RECOMBINANT)191,193,194,198 CLINDAMYCIN PHOSPHATE VAGINAL37,38 COAGULATION FACTOR IX (RECOMBINANT) CLINDAMYCIN PHOSPHATE-BENZOYL GLYCOPEGYLATED197 PEROXIDE266,268,272

PAGE 419 LAST UPDATED 03/2021 COAGULATION FACTOR IX RECOMB ALBUMIN CONTINUOUS BLOOD GLUCOSE SYSTEM FUSION PROTEIN (RIX-FP)193 RECEIVER372 COAGULATION FACTOR VIIA (RECOMBINANT)196 CONTINUOUS BLOOD GLUCOSE SYSTEM COAGULATION FACTOR VIIA (RECOMBINANT)- SENSOR372 JNCW198 ConZip12 Coartem113 Copaxone263 COBALAMIN COMBINATIONS287 Copiktra101 COBICISTAT153 COPPER (IUD)308 COBIMETINIB FUMARATE106 Cordran310 CODEINE SULFATE23,24 Coreg209 Codeine Sulfate23 Coreg CR209,210 Colazal366 Corgard210 COLCHICINE91,92 Cortef310 COLCHICINE W/ PROBENECID91 CORTISONE ACETATE310 Colcrys91 Cortisporin269 COLESEVELAM HCL235,237 Cortisporin-TC382 Colestid235 Corvite 150286 Colestid Flavored235 Corvite Fe286 COLESTIPOL HCL235 Corzide222,223 COLLAGENASE274 Cosentyx269 Coly-Mycin S382 Cosentyx (300 MG Dose)269 Combigan380 Cosentyx Sensoready (300 MG)269 CombiPatch326 Cosentyx Sensoready Pen269 Combivent Respimat397 Cosopt380 Combivir150 Cosopt PF380 Cometriq (100 mg Daily Dose)106 Cotellic106 Cometriq (140 mg Daily Dose)106 Cotempla XR-ODT249 Cometriq (60 mg Daily Dose)106 Coumadin179,180 Comp Air Compressor Nebulizer371 Cozaar203 Compact Space Chamber/Lg Mask371 Creon303 Complera148 Cresemba87 Complete Natal DHA286 Crestor232,233 CompleteNate286 Crinone343 Comtan115 CRISABOROLE270 Concept DHA286 Crixivan154 Concept OB286 CRIZANLIZUMAB-TMCA199 Concerta249 CRIZOTINIB112 CONJUGATED ESTROGENS-BAZEDOXIFENE345 CROMOLYN SODIUM392 CONJUGATED ESTROGENS- CROMOLYN SODIUM (OPHTH)377 MEDROXYPROGESTERONE ACETATE342 CROSS-LINKED HYALURONATE372 Conjupri213 CROTAMITON114

PAGE 420 LAST UPDATED 03/2021 Crotan114 Daypro5 Cutivate310 Daytrana249,250 CYANOCOBALAMIN286 DayVigo403 Cyclessa326 DECITABINE-CEDAZURIDINE102 CYCLOBENZAPRINE HCL399,400 DEFERASIROX282,283 CYCLOPENTOLATE HCL375 DEFERIPRONE282,283 CYCLOPHOSPHAMIDE97 DEFLAZACORT312,313 CYCLOSPORINE355,361 DELAFLOXACIN MEGLUMINE47 CYCLOSPORINE (OPHTH)375,376 DELAVIRDINE MESYLATE149 CYCLOSPORINE MODIFIED (FOR Delestrogen326 MICROEMULSION)355,358 Delstrigo148 Cymbalta261 Delzicol366 CYPROHEPTADINE HCL386 DEMECLOCYCLINE HCL50 Cytomel346 Demerol24 Denavir156 D DENOSUMAB369,370 D.H.E. 4593 Depakene55 DABIGATRAN ETEXILATE MESYLATE182,183 Depakote55 DABRAFENIB MESYLATE111 Depakote ER56 DACLATASVIR DIHYDROCHLORIDE146 Depakote Sprinkles56 DACOMITINIB103 Depo-Estradiol326 Daklinza146 DEPO-Medrol310 DALFAMPRIDINE262,263 Depo-Provera343 Daliresp392 Depo-SubQ Provera 104343 DALTEPARIN SODIUM181 Depo-Testosterone323 Dantrium144 Derma-Smoothe/FS Body310 DANTROLENE SODIUM144 Derma-Smoothe/FS Scalp311 DAPAGLIFLOZIN PROPANEDIOL166 Dermatop311 DAPAGLIFLOZIN-METFORMIN HCL174,175 Descovy153 DAPAGLIFLOZIN-SAXAGLIPTIN172 DESIPRAMINE HCL79,80 DAPSONE97 DESLORATADINE386 DAPSONE (TOPICAL)266,267,269 DESLORATADINE-PSEUDOEPHEDRINE397 DARBEPOETIN ALFA184,185 DESMOPRESSIN ACETATE320,322 DARIFENACIN HYDROBROMIDE305 DESMOPRESSIN ACETATE SPRAY320 DAROLUTAMIDE98 DESMOPRESSIN ACETATE SPRAY DARUNAVIR ETHANOLATE154,155 REFRIGERATED320 DARUNAVIR-COBICISTAT154 DESOGESTREL & ETHINYL ESTRADIOL326,327 DARUNAVIR-COBICISTAT-EMTRICITABINE- DESOGESTREL-ETHINYL ESTRADIOL TENOFOVIR ALAFENAMIDE155 (BIPHASIC)327,335 DASATINIB110 DESOGESTREL-ETHINYL ESTRADIOL Daurismo106 (TRIPHASIC)326,327

PAGE 421 LAST UPDATED 03/2021 Desonate311 DICLOFENAC SODIUM (TOPICAL)6,9,10,269 DESONIDE311 DICLOFENAC SODIUM-CAPSAICIN (TOPICAL)269 DesOwen311 DICLOFENAC W/ MISOPROSTOL5,6 DESOXIMETASONE311,318,319 DICLOXACILLIN SODIUM44 Desoxyn243 DICYCLOMINE HCL294 DESVENLAFAXINE73,74,75 DIDANOSINE150,152 Desvenlafaxine ER74 Differin269,270 DESVENLAFAXINE SUCCINATE74,77 Dificid46 Detrol305 DIFLORASONE DIACETATE312,318 Detrol LA305 DIFLORASONE DIACETATE EMOLLIENT BASE308 DEUTETRABENAZINE259 Diflucan87 Dexabliss311 DIFLUNISAL6 DEXAMETHASONE311,312,314,318,320 DIFLUPREDNATE378 Dexamethasone311 DIGOXIN223 DEXAMETHASONE (OPHTH)378,379 DIHYDROERGOTAMINE MESYLATE93 Dexamethasone Intensol312 Dilantin65 DEXAMETHASONE SODIUM PHOSPHATE312 Dilantin Infatabs65 DEXAMETHASONE SODIUM PHOSPHATE Dilatrate-SR238 (OPHTH)378 Dilaudid24 Dexedrine243 DILTIAZEM HCL213,214 Dexilant299 DILTIAZEM HCL COATED BEADS213,214,215 DEXLANSOPRAZOLE299 DILTIAZEM HCL EXTENDED RELEASE DEXMETHYLPHENIDATE HCL250,251,252 BEADS215,216,217,218 Dextenza378 DIMENHYDRINATE81 DEXTROAMPHETAMINE SULFATE243,244,247 DimenhyDRINATE81 Dexycu378 DIMETHYL FUMARATE263,265 Diacomit53 Diovan203 Diastat AcuDial56 Diovan HCT223 Diastat Pediatric56 Dipentum366 DIAZEPAM160,161 DIPHENHYDRAMINE HCL386 DiazePAM160,161 DIPHENOXYLATE W/ ATROPINE294 DIAZEPAM (ANTICONVULSANT)56,59 Diprolene270 Diclegis81 DIPYRIDAMOLE200 DICLOFENAC5,10 DIROXIMEL FUMARATE265 Diclofenac5 DISOPYRAMIDE PHOSPHATE207 DICLOFENAC EPOLAMINE5,6,7 DISULFIRAM33 Diclofenac Epolamine5 Ditropan XL305 DICLOFENAC POTASSIUM5,6,10 Diuril230 DICLOFENAC POTASSIUM (MIGRAINE)5 DIVALPROEX SODIUM55,56 DICLOFENAC SODIUM6 Divigel327,328 DICLOFENAC SODIUM (OPHTH)378 DOLASETRON MESYLATE84

PAGE 422 LAST UPDATED 03/2021 Dolophine12 Duavee345 DOLUTEGRAVIR SODIUM148 Duetact166 DOLUTEGRAVIR SODIUM-LAMIVUDINE153 Duexis6 DOLUTEGRAVIR SODIUM-RILPIVIRINE HCL153 DULAGLUTIDE174 DONEPEZIL HYDROCHLORIDE67 Dulera397 Doptelet200 DULOXETINE HCL261 Doral401 Duobrii270 DORAVIRINE149 Duopa119 DORAVIRINE-LAMIVUDINE-TENOFOVIR DUPILUMAB270 DISOPROXIL FUMARATE148 Dupixent270 Doryx50 Duragesic-10012 Doryx MPC50 Duragesic-1212 DORZOLAMIDE HCL380,381 Duragesic-2512 DORZOLAMIDE HCL-TIMOLOL MALEATE380 Duragesic-5012 Dovato153 Duragesic-7512 Dovonex270 Durezol378 DOXAZOSIN MESYLATE201,202 Durolane270 DOXAZOSIN MESYLATE (BPH)306 Durysta381 DOXEPIN HCL80 DUTASTERIDE306,307 DOXEPIN HCL (SLEEP)403,404 DUTASTERIDE-TAMSULOSIN HCL307 DOXERCALCIFEROL368,369 DUVELISIB101 Doxycycline50 Duzallo91 DOXYCYCLINE (MONOHYDRATE)50,51,53 Dxevo 11-Day312 DOXYCYCLINE (ROSACEA)50,52 Dyanavel XR244 DOXYCYCLINE CALCIUM53 Dymista397 DOXYCYCLINE HYCLATE50,51,53 Dysport400 Doxycycline Hyclate51 DOXYCYCLINE HYCLATE W/ CLEANSER52 E DOXYLAMINE-PYRIDOXINE81 E.E.S. Granules46 Drizalma Sprinkle261 EasiVent371 DRONABINOL84,85,86 EasiVent Mask Large371 DROSPIRENONE345 EasiVent Mask Medium371 DROSPIRENONE-ESTRADIOL325 EasiVent Mask Small371 DROSPIRENONE-ETHINYL ESTRADIOL328,343 ECALLANTIDE354 DROSPIRENONE-ETHINYL ESTRADIOL- ECHOTHIOPHATE IODIDE380 LEVOMEFOLATE CALCIUM326,328,342 ECONAZOLE NITRATE87 Droxia100 Edarbi203 Drysol270 Edarbyclor223 Dsuvia24 Edluar401 Duac270 EDOXABAN TOSYLATE183 Duaklir Pressair397 Edurant148

PAGE 423 LAST UPDATED 03/2021 EFAVIRENZ148,149 EMPAGLIFLOZIN-METFORMIN HCL173 EFAVIRENZ-EMTRICITABINE-TENOFOVIR Empricaine-II31 DISOPROXIL FUMARATE148,149 Emsam73 EFAVIRENZ-LAMIVUDINE-TENOFOVIR EMTRICITABINE150 DISOPROXIL FUMARATE149 EMTRICITABINE-RILPIVIRINE-TENOFOVIR Effexor XR74 ALAFENAMIDE FUMARATE149 Effient200 EMTRICITABINE-RILPIVIRINE-TENOFOVIR EFINACONAZOLE88 DISOPROXIL FUMARATE148 ELAGOLIX SODIUM353 EMTRICITABINE-TENOFOVIR ALAFENAMIDE ELAGOLIX SODIUM-ESTRADIOL-NORETHINDRONE FUMARATE153 ACETATE322 EMTRICITABINE-TENOFOVIR DISOPROXIL ELBASVIR-GRAZOPREVIR147 FUMARATE150,151,152 Elelyso303 Emtriva150 Elestrin328 Enablex305 ELETRIPTAN HYDROBROMIDE93,94 ENALAPRIL MALEATE205,206 Elidel270 ENALAPRIL MALEATE & Eligard351 HYDROCHLOROTHIAZIDE223,229 ELIGLUSTAT TARTRATE302 ENASIDENIB MESYLATE101 Elimite114 EnBrace HR286 Eliquis180 Enbrel355 Eliquis DVT/PE Starter Pack180 Enbrel Mini355 Ella343 Enbrel SureClick355 Elmiron307 ENCORAFENIB105 Elocon312 Endari278 Eloctate191,192 ENFUVIRTIDE153 ELTROMBOPAG OLAMINE187 Engerix-B364 ELUXADOLINE297 ENOXAPARIN SODIUM180,181,182 ELVITEGRAVIR-COBICISTAT-EMTRICITABINE- Enstilar270 TENOFOVIR ALAFENAMIDE148 ENTACAPONE115 ELVITEGRAVIR-COBICISTAT-EMTRICITABINE- ENTECAVIR145 TENOFOVIR DF148 Entocort EC367 Emcyt99 ENTRECTINIB102,103 Emend85 Entresto223 Emend Tri-Pack85 Entyvio355 Emflaza312,313 Envarsus XR356 Emgality92 ENZALUTAMIDE98 Emgality (300 MG Dose)92 Epaned205 EMICIZUMAB-KXWH192,193 Epclusa146 EMPAGLIFLOZIN169 Epidiolex54 EMPAGLIFLOZIN-LINAGLIPTIN168 Epiduo270 EMPAGLIFLOZIN-LINAGLIPTIN-METFORMIN174 Epiduo Forte270

PAGE 424 LAST UPDATED 03/2021 EPINASTINE HCL (OPHTH)377 ESLICARBAZEPINE ACETATE64 EPINEPHrine390 ESOMEPRAZOLE MAGNESIUM299,300,301 EPINEPHRINE (ANAPHYLAXIS)390 ESOMEPRAZOLE STRONTIUM299 EpiPen 2-Pak390 Esomeprazole Strontium299 EpiPen Jr 2-Pak390 Esperoct192 Epivir150,151 ESTAZOLAM401 Epivir HBV145 ESTERIFIED ESTROGENS334,335 EPOETIN ALFA185,186,187 ESTERIFIED ESTROGENS & EPOETIN ALFA-EPBX187 METHYLTESTOSTERONE328,329 Epogen185 Estrace329 EPROSARTAN MESYLATE203 ESTRADIOL325,326,327,328,329,330,331,332,335,34 Eprosartan Mesylate203 2,343 EPTINEZUMAB-JJMR93 ESTRADIOL & NORETHINDRONE Epzicom151 ACETATE325,326,330,331 Equetro163 ESTRADIOL ACETATE VAGINAL332 ERDAFITINIB101 ESTRADIOL CYPIONATE326 ERENUMAB-AOOE92 ESTRADIOL VAGINAL329,331,342 ERGOCALCIFEROL368 ESTRADIOL VALERATE326,331 Ergomar93 ESTRADIOL VALERATE-DIENOGEST335 ERGOTAMINE TARTRATE93 ESTRADIOL-LEVONORGESTREL326 ERGOTAMINE W/ CAFFEINE93 ESTRADIOL-NORGESTIMATE341 Erivedge106 ESTRADIOL-PROGESTERONE326 Erleada98 ESTRAMUSTINE PHOSPHATE SODIUM99 ERLOTINIB HCL106,111 Estring331 Ertaczo88 Estrogel331 ERTUGLIFLOZIN L-PYROGLUTAMIC ACID173 ESTROGENS, CONJUGATED341,342 ERTUGLIFLOZIN-METFORMIN HCL172 ESTROGENS, CONJUGATED VAGINAL342 ERTUGLIFLOZIN-SITAGLIPTIN173 ESTROPIPATE331 Erygel46 Estropipate331 EryPed 20046 Estrostep Fe331 EryPed 40046 ESZOPICLONE401,402 Erythrocin Stearate46 ETANERCEPT355 ERYTHROMYCIN (ACNE AID)46 ETHAMBUTOL HCL97 ERYTHROMYCIN (OPHTH)46 ETHOSUXIMIDE55 ERYTHROMYCIN BASE46,47 ETHOTOIN66 ERYTHROMYCIN ETHYLSUCCINATE46,47 ETHYNODIOL DIACET & ETH ESTRAD331 ERYTHROMYCIN STEARATE46 ETIDRONATE DISODIUM368 Esbriet395 Etidronate Disodium368 ESCITALOPRAM OXALATE74,75 ETODOLAC6 Esgic260 ETONOGESTREL344 ESKETAMINE HCL72 ETONOGESTREL-ETHINYL ESTRADIOL331,341

PAGE 425 LAST UPDATED 03/2021 ETOPOSIDE104 Famotidine Premixed296 Etoposide104 Fanapt129 ETRAVIRINE149 Fanapt Titration Pack129 Eucrisa270 Fareston99 Euflexxa371 Farxiga166 Eurax114 Farydak106 Evamist332 Fasenra397 Evekeo244 Fasenra Pen397 Evekeo ODT245 FazaClo143 Evenity368 FE ASPARTO GLY-FE FUMARATE-SUCC ACD-C- EVEROLIMUS105,106 THREONIC ACD-B12-FA280 EVEROLIMUS (IMMUNOSUPPRESSANT)356,362 FE ASPARTO GLY-SUCCIN AC-C-THREONIC AC- EVINACUMAB-DGNB235 B12-DES STOM SUBST280 Evista345 FE ASPARTO GLY-SUCCINIC ACD-VIT C- Evkeeza235 THREONIC ACD-VIT B12-FA280 Evoclin270 FE ASPARTO GLY-VIT B12-FA-VIT C-DSS- EVOLOCUMAB237 SUCCINIC ACID-ZINC278 Evotaz154 FE BISGLYC-FE POLYSACCHARIDE-SUCC ACD-B Exalgo12,13 COMPLEX-C-CA-FA280 Exelderm88 FE BISGLYCINATE-FE POLYSACCHARIDE-VIT C- Exelon67 VIT B12-FOLIC ACID282 EXEMESTANE104 FE CARBONYL-FA-B COMPLEX-A-C-D-E-MIN278 EXENATIDE165 FE CARBONYL-FE GLUCONATE-FA-VIT B12-VIT C- Exforge223,224 DOCUSATE SODIUM279 Exforge HCT224 FE FUM-IRON POLYSACCH COMPLEX-FA-B Exjade282 CMPLX-C-BIOTIN-PROBIOTIC279 Extavia263 FE FUM-IRON POLYSACCH COMPLEX-FA-B Extina88 COMPLEX-C-BIOTIN287,292 Eylea375 FE FUM-IRON POLYSACCH COMPLEX-FA-B Eysuvis378 COMPLEX-C-ZN-MN-CU278,282 Ezallor Sprinkle233 FE FUMARATE-VITAMIN C-VITAMIN B12-FOLIC EZETIMIBE235,237 ACID278,279 EZETIMIBE-SIMVASTATIN235,236,237 FEBUXOSTAT91,92 EZOGABINE54,55 FEDRATINIB HCL102 Feiba192 F FELBAMATE59 Fabior270 Felbatol59 FACTOR IX COMPLEX197 Feldene6 FAMCICLOVIR156 FELODIPINE216 FAMOTIDINE296 Femara104 FAMOTIDINE IN NACL296 Femhrt Low Dose332

PAGE 426 LAST UPDATED 03/2021 Femring332 Fiasp176 FENFLURAMINE HCL (ANTICONVULSANT)54 Fiasp FlexTouch176 FENOFIBRATE231,232 Fiasp PenFill176 FENOFIBRATE MICRONIZED230,231 Fibricor231 FENOFIBRIC ACID231 FIDAXOMICIN46 Fenofibric Acid231 FILGRASTIM186 Fenoglide231 FILGRASTIM-AAFI186 FENOPROFEN CALCIUM6,8 FILGRASTIM-SNDZ187 Fensolvi (6 Month)352 FINASTERIDE307 FENTANYL12,13,30 FINGOLIMOD HCL263 FENTANYL CITRATE21,22,24,25,26 Fintepla54 fentaNYL Citrate24 Fioricet260 Fentora24 Fiorinal25 FENTORA25 Fiorinal/Codeine #325 Feraheme278 Firazyr354 FeRiva 21/7278 Firvanq38 FeRivaFA279 Flagyl38 Ferralet 90279 Flarex378 FerraPlus 90279 FLAVOXATE HCL305 FERRIC CARBOXYMALTOSE279 FLECAINIDE ACETATE207 FERRIC CITRATE283 Flector6 FERRIC DERISOMALTOSE280 Flomax307 FERRIC PYROPHOSPHATE CITRATE283 Flovent Diskus384 Ferriprox282,283 Flovent HFA384 Ferriprox Twice-A-Day283 Fluad364 Ferrlecit279 Fluarix Quadrivalent364 FERROUS FUMARATE W/ B12-VIT C-FA-IFC286 Flublok Quadrivalent364 FERROUS FUMARATE W/ FA-DSS-B COMPLEX-VIT Flucelvax Quadrivalent364 C280 FLUCONAZOLE87,88 FERROUS FUMARATE-FA-B COMPLEX-C-ZN-MG- FLUCYTOSINE86,88 MN-CU279,285,287 FLUDROCORTISONE ACETATE313 FERROUS FUMARATE-FOLIC ACID279 Flulaval Quadrivalent364 FERROUS FUMARATE-IRON POLYSACCHARIDE Flumadine155 COMPLEX-FA-C-PROBIOTIC279 FLUNISOLIDE (NASAL)384 FERROUS FUMARATE-IRON POLYSACCHARIDE FLUOCINOLONE ACETONIDE309,310,311,313,318 COMPLEX-FOLIC ACID-C-B3279,280 FLUOCINOLONE ACETONIDE & CLEANSER318 FERUMOXYTOL278 FLUOCINOLONE ACETONIDE (OPHTH)378,379 FESOTERODINE FUMARATE306 FLUOCINOLONE ACETONIDE (OTIC)382 Fetzima74 FLUOCINOLONE-EMOLLIENT318 Fetzima Titration74 FLUOCINONIDE313,320 Fexmid400 FLUOCINONIDE EMULSIFIED BASE313

PAGE 427 LAST UPDATED 03/2021 FLUOROMETHOLONE (OPHTH)378 Folite287 FLUOROMETHOLONE ACETATE378 Folivane-F279 FLUOROURACIL (TOPICAL)100 Folivane-OB287 FLUOXETINE HCL74,75,77 Folivane-Plus287 FLUoxetine HCl74 Foltrate287 FLUOXETINE HCL (PMDD)75,77 FONDAPARINUX SODIUM179,181 FLUoxetine HCl (PMDD)75 Forfivo XL70 FLUPHENAZINE DECANOATE121 FORMOTEROL FUMARATE391 FLUPHENAZINE HCL121,122 Fortamet166 FLURANDRENOLIDE310,313 Forteo368 FLURAZEPAM HCL401 Fortesta323 Flurazepam HCl401 Fosamax368 FLURBIPROFEN6 Fosamax Plus D368,369 FLURBIPROFEN SODIUM378 FOSAMPRENAVIR CALCIUM154 FLUTAMIDE98 FOSAPREPITANT DIMEGLUMINE85 Flutamide98 Fosaprepitant Dimeglumine85 FLUTICASONE FUROATE (INHALATION)383 FOSFOMYCIN TROMETHAMINE38,39 FLUTICASONE FUROATE-VILANTEROL396 FOSINOPRIL SODIUM205 FLUTICASONE PROPIONATE310,313 FOSINOPRIL SODIUM & FLUTICASONE PROPIONATE (INHALATION)383,384 HYDROCHLOROTHIAZIDE224 FLUTICASONE PROPIONATE (NASAL)385,386 FOSNETUPITANT CHORIDE-PALONOSETRON FLUTICASONE PROPIONATE HFA384 HCL84 FLUTICASONE-EMOLLIENT308 Fosrenol284 FLUTICASONE-SALMETEROL395,396,397,398 FOSTAMATINIB DISODIUM187 FLUTICASONE-UMECLIDINIUM-VILANTEROL399 FOSTEMSAVIR TROMETHAMINE153 FLUVASTATIN SODIUM233 Fragmin181 FLUVOXAMINE MALEATE75 FreeStyle Libre 14 Day Reader372 Fluzone High-Dose364 FreeStyle Libre 14 Day Sensor372 Fluzone Quadrivalent364,365 FreeStyle Libre 2 Reader372 FML378 FreeStyle Libre 2 Sensor372 FML Forte378 FreeStyle Libre Reader372 FML Liquifilm378 FreeStyle Libre Sensor System372 Focalin251 FREMANEZUMAB-VFRM92 Focalin XR251,252 Frova93 FOLIC ACID287 FROVATRIPTAN SUCCINATE93 FOLIC ACID-PYRIDOXINE-CYANOCOBALAMIN287 Fulphila185 FOLIC ACID-VITAMIN B6-VITAMIN B12287 Furadantin38 FOLIC ACID-VITAMIN B6-VITAMIN B12-OMEGA 3 FUROSEMIDE229 ACIDS-PHYTOSTEROLS285 Fusion Plus279 FOLIC ACID-VITAMIN D3-MAG CIT- Fusion Sprinkles279 ACETYLCYSTEINE-CA CIT287 Fuzeon153

PAGE 428 LAST UPDATED 03/2021 Fycompa59,60 Gleevec107 GLIMEPIRIDE165,166 G GLIPIZIDE166,167 Gabapal56 GLIPIZIDE-METFORMIN HCL166 GABAPENTIN56,57 Gloperba92 GABAPENTIN & LIDOCAINE58 GlucaGen Diagnostic175 GABAPENTIN & LIDOCAINE-PRILOCAINE & GlucaGen HypoKit175 TRANSPARENT DRESSING57 GLUCAGON175 GABAPENTIN (ONCE-DAILY)57 GLUCAGON (RDNA)175 GABAPENTIN ENACARBIL260 Glucagon Emergency175 GABAPENTIN-LIDOCAINE-SILICONE56,57 GLUCAGON HCL (RDNA)175 Gabitril57 GLUCAGON HCL RDNA (DIAGNOSTIC)175 GALANTAMINE HYDROBROMIDE67,68 Glucophage166 GALCANEZUMAB-GNLM92 Glucophage XR167 GATIFLOXACIN (OPHTH)48,49 Glucotrol167 Gavreto106 Glucotrol XL167 GEFITINIB108 Glumetza167 Gel-One372 GLUTAMINE (SICKLE CELL)278 Gelnique305 GLYBURIDE167 Gelnique Pump305 GLYBURIDE MICRONIZED167 Gelsyn-3372 GLYBURIDE-METFORMIN167 GEMFIBROZIL232 GLYCEROL PHENYLBUTYRATE304 Gemtesa305 GLYCOPYRROLATE294 GEN7T PLUS31 GLYCOPYRROLATE (INHALATION)389 Generess FE332 GLYCOPYRROLATE-FORMOTEROL FUMARATE396 Genotropin320 Glynase167 Genotropin MiniQuick320,321 Glyset168 GENTAMICIN SULFATE (OPHTH)36 Glyxambi168 GENTAMICIN SULFATE (TOPICAL)36,37 Gocovri115 GENTAMICIN-PREDNISOLONE ACETATE376 GOLIMUMAB361 GenVisc 850372 Golytely298 Genvoya148 GoNitro238 Geodon130 GOSERELIN ACETATE104 Giazo366 Gralise57 Gilenya263 GRANISETRON86 Gilotrif106,107 GRANISETRON HCL85 GILTERITINIB FUMARATE103 Granix185 Gimoti81 GRISEOFULVIN MICROSIZE88 GLASDEGIB MALEATE106 GRISEOFULVIN ULTRAMICROSIZE88 GLATIRAMER ACETATE263,264 GUANFACINE HCL201 GLECAPREVIR-PIBRENTASVIR146 GUANFACINE HCL (ADHD)252,253

PAGE 429 LAST UPDATED 03/2021 GUSELKUMAB361 Hetlioz403 Gvoke HypoPen 1-Pack175 Hetlioz LQ403 Gvoke HypoPen 2-Pack175 Hiprex38 Gvoke PFS175 HISTRELIN ACETATE353 Gynazole-188 HISTRELIN ACETATE (CPP)353 Horizant260 H HumaLOG176 Haegarda354 HumaLOG Junior KwikPen176 HALCINONIDE313,314 HumaLOG KwikPen176 Halcion401 HumaLOG Mix 50/50177 Haldol122 HumaLOG Mix 50/50 KwikPen177 Haldol Decanoate122 HumaLOG Mix 75/25177 HALOBETASOL PROPIONATE309,314,315,319 HumaLOG Mix 75/25 KwikPen177 Halobetasol Propionate314 Humate-P193 HALOBETASOL PROPIONATE & LACTIC Humatrope321 ACID319,320 Humira356 HALOBETASOL PROPIONATE-TAZAROTENE270 Humira Pediatric Crohns Start356 Halog314 Humira Pen356,357 HALOPERIDOL122,123 Humira Pen-CD/UC/HS Starter357 HALOPERIDOL DECANOATE122,123 Humira Pen-Pediatric UC Start357 HALOPERIDOL LACTATE122,123 Humira Pen-Ps/UV/Adol HS Start357 Harvoni146 Humira Pen-Psor/Uveit Starter357 Havrix365 HumuLIN R U-500 (CONCENTRATED)177 Hectorol369 HumuLIN R U-500 KwikPen177 Helidac Therapy294 Hyalgan372 Helixate FS192 HYALURONAN372,373 Hemady314 HYDRALAZINE HCL237 Hemangeol101 Hydrea100 Hematogen FA279 HYDROCHLOROTHIAZIDE230 Hematogen Forte279 HYDROCODONE BITARTRATE13,14,20,21 HemeTab279 HYDROCODONE-ACETAMINOPHEN25,26,27 Hemlibra192,193 HYDROCODONE-IBUPROFEN26 Hemocyte Plus287 HYDROCORTISONE308,310,314 Hemofil M193 HYDROCORTISONE (INTRARECTAL)367 HEPARIN SODIUM (PORCINE)181,182 HYDROCORTISONE (RECTAL)271,273,314 HEPARIN SODIUM (PORCINE) LOCK FLUSH182 HYDROCORTISONE (TOPICAL)308,314,318 HEPATITIS A (INACTIVATED)-HEPATITIS B HYDROCORTISONE ACETATE (TOPICAL)272 (RECOMBINANT) VACCINES365 HYDROCORTISONE ACETATE W/ PRAMOXINE273 HEPATITIS A VACCINE365 HYDROCORTISONE BUTYRATE314,315 HEPATITIS B VACCINE (RECOMB)364,365 HYDROCORTISONE BUTYRATE HYDROPHILIC Hepsera145 LIPO BASE314,315

PAGE 430 LAST UPDATED 03/2021 HYDROCORTISONE PROBUTATE316 Iluvien378 HYDROCORTISONE SOD SUCCINATE318 IMATINIB MESYLATE107 HYDROCORTISONE VALERATE315 Imbruvica107,108 HYDROCORTISONE W/ACETIC ACID382 IMIGLUCERASE302 HYDROMORPHONE HCL12,13,14,24,26 IMIPRAMINE HCL80,81 HYDROmorphone HCl26 IMIPRAMINE PAMOATE80 HYDROXYCHLOROQUINE SULFATE113 IMIQUIMOD267,271,278 HYDROXYprogesterone Caproate343 Imitrex94 HYDROXYPROGESTERONE CAPROATE344 Imitrex STATdose Refill94 HYDROXYPROGESTERONE CAPROATE Imitrex STATdose System94 (ANTINEOPLASTIC)343 Impeklo315 HYDROXYUREA100 Imuran357 HYDROXYUREA (SICKLE CELL ANEMIA)100 Inbrija119 HYDROXYZINE HCL386 INCOBOTULINUMTOXINA144 HYDROXYZINE PAMOATE386,387,388 Incruse Ellipta388 HYLAN374 INDACATEROL MALEATE390 Hymovis372 INDACATEROL MALEATE-GLYCOPYRROLATE399 Hyophen38 INDAPAMIDE230 HyperRHO S/D362 Inderal LA210 Hysingla ER14 Inderal XL210 Hyzaar224 INDINAVIR SULFATE154 Indocin7 I INDOMETHACIN7,9 IBALIZUMAB-UIYK153 Indomethacin7 IBANDRONATE SODIUM368,369 Infed279 Ibrance107 Inflectra357 IBRUTINIB107,108 INFLIXIMAB361 Ibudone26 INFLIXIMAB-ABDA361 IBUPROFEN7 INFLIXIMAB-AXXQ354 IBUPROFEN-FAMOTIDINE6 INFLIXIMAB-DYYB357 ICATIBANT ACETATE354 INFLUENZA VIRUS VAC RECOMB Iclusig107 HEMAGGLUTININ (HA) QUADRIVALENT364 ICOSAPENT ETHYL236,237 INFLUENZA VIRUS VACCINE SPLIT363 IDELALISIB112 INFLUENZA VIRUS VACCINE SPLIT HIGH-DOSE Idelvion193 PRESERVATIVE FREE364 IDHIFA101 INFLUENZA VIRUS VACCINE SPLIT Ilaris357,363 PRESERVATIVE FREE363 Ilevro378 INFLUENZA VIRUS VACCINE SPLIT ILOPERIDONE129 QUADRIVALENT363,364,365 ILOPROST395 INFLUENZA VIRUS VACCINE TISSUE-CULTURED Ilumya271 SUBUNIT QUADRIVALENT364

PAGE 431 LAST UPDATED 03/2021 INFLUENZA VIRUS VACCINE TYPES A & B Invega Trinza131 SURFACE ANTIGEN ADJUVANT364 Inveltys378 Ingrezza260 Invirase154 Injectafer279 Invokamet168 Inlyta108 Invokamet XR168 InnoPran XL210 Invokana168 InnoSpire Essence Nebulizer372 IODOQUINOL-HC271 Inqovi102 IODOQUINOL-HYDROCORTISONE-ALOE Inrebic102 POLYSACCHARIDE267,271 Insulin Asp Prot & Asp FlexPen177 Iopidine380 INSULIN ASPART177,178 IPRATROPIUM BROMIDE389 Insulin Aspart177 IPRATROPIUM BROMIDE (NASAL)389 INSULIN ASPART (WITH NIACINAMIDE)176 IPRATROPIUM BROMIDE HFA388 Insulin Aspart FlexPen177 IPRATROPIUM-ALBUTEROL397,398 Insulin Aspart PenFill177 IRBESARTAN202,203 Insulin Aspart Prot & Aspart177 IRBESARTAN-HYDROCHLOROTHIAZIDE221,224 INSULIN ASPART PROTAMINE & ASPART Iressa108 (HUMAN)177,178 IRON COMBINATIONS286,287,288 INSULIN DEGLUDEC179 IRON DEXTRAN279 INSULIN DEGLUDEC-LIRAGLUTIDE179 IRON POLYSACCHARIDE COMPLEX-VIT B12-FOLIC INSULIN DETEMIR178 ACID280 INSULIN GLARGINE176,178,179 IRON SUCROSE282 INSULIN GLARGINE-LIXISENATIDE179 IRON W/ VITAMINS288 INSULIN GLULISINE176 IRON-DOCUSATE-B12-FOLIC ACID-VIT C-VIT E- INSULIN LISPRO175,176,177 COPPER-BIOTIN280 Insulin Lispro177 IRON-FOLIC ACID-VITAMIN B12-VITAMIN C- Insulin Lispro (1 Unit Dial)177 DOCUSATE SODIUM279 Insulin Lispro Junior KwikPen177 IRON-FOLIC ACID-VITAMIN C-VITAMIN B6-VITAMIN Insulin Lispro Prot & Lispro178 B12-ZINC280 INSULIN LISPRO PROTAMINE & LISPRO177,178 IRON-VIT C-FA-B12-BIOTIN-COPPER- INSULIN LISPRO-AABC178 DOCUSATE279 INSULIN REGULAR (HUMAN)176,177 Irospan 24/6280 Integra F280 ISAVUCONAZONIUM SULFATE87 Integra Plus287 Isentress148 Intelence149 Isentress HD148 INTERFERON BETA-1A263,265 ISOCARBOXAZID73 INTERFERON BETA-1B263 ISONIAZID97 Intermezzo402 Isopto Atropine375 Intuniv252,253 Isopto Carpine380 Invega130 Isordil Titradose238 Invega Sustenna130,131 ISOSORBIDE DINITRATE238

PAGE 432 LAST UPDATED 03/2021 ISOSORBIDE DINITRATE-HYDRALAZINE HCL222 Keflex43 ISOSORBIDE MONONITRATE238 Kenalog315 ISOTRETINOIN266,271,272 Keppra54 ISOTRETINOIN MICRONIZED266 Keppra XR54 ISRADIPINE216 Kerydin88 Istalol380 Kesimpta264 ISTRADEFYLLINE115 KETOCONAZOLE88 ITRACONAZOLE88,90,91 KETOCONAZOLE (TOPICAL)88,89 IVERMECTIN113 KETOPROFEN7 IVERMECTIN (PEDICULICIDE)113 Ketoprofen7 IVOSIDENIB103 KETOROLAC TROMETHAMINE7,9 IXAZOMIB CITRATE102 Ketorolac Tromethamine7 IXEKIZUMAB276 KETOROLAC TROMETHAMINE (OPHTH)377,378 Ixinity193,194 Kevzara357 Khedezla75 J Kineret357 Jadenu283 Kisqali (200 MG Dose)108 Jadenu Sprinkle283 Kisqali (400 MG Dose)108 Jakafi108 Kisqali (600 MG Dose)108 Jalyn307 Kisqali Femara (400 MG Dose)108 Janumet168 Kisqali Femara (600 MG Dose)108 Janumet XR169 Kisqali Femara(200 MG Dose)108 Januvia169 Kitabis Pak398 Jardiance169 Klaron49 Jatenzo323 KlonoPIN161 Jentadueto169 Koate194 Jentadueto XR169 Koate-DVI194 Jivi194 Kogenate FS194 Jornay PM253 Kogenate FS Bio-Set195 Jublia88 Kombiglyze XR170 Juluca153 Koselugo109 Juxtapid236 Kovaltry195 Krintafel113 K Krystexxa92 Kadian14,15 Kyleena344 Kalbitor354 Kynmobi116 Kaletra154 Kapspargo Sprinkle210 L Kapvay253 LABETALOL HCL210 Katerzia216 LACOSAMIDE67 Kazano169 LACTIC ACID (AMMONIUM LACTATE)272

PAGE 433 LAST UPDATED 03/2021 LACTULOSE298 LESINURAD92 LACTULOSE (ENCEPHALOPATHY)298 LESINURAD-ALLOPURINOL91 LaMICtal60 Letairis393 LaMICtal ODT60 LETERMOVIR145 LaMICtal Starter60,61 LETROZOLE104 LaMICtal XR61 LEUCOVORIN CALCIUM102 LAMIVUDINE150,151 Leukeran97 LAMIVUDINE (HBV)145,146 Leukine185 LAMIVUDINE-TENOFOVIR DISOPROXIL LEUPROLIDE ACETATE351,352 FUMARATE150,151 LEUPROLIDE ACETATE & NORETHINDRONE LAMIVUDINE-ZIDOVUDINE150,151 ACETATE352 LAMOTRIGINE60,61,62 LEUPROLIDE ACETATE (3 MONTH)351,352 LANADELUMAB-FLYO354 LEUPROLIDE ACETATE (4 MONTH)351,352 LANSOPRAZOLE300,302 LEUPROLIDE ACETATE (6 MONTH)351,352 LANTHANUM CARBONATE284 LEUPROLIDE ACETATE (CPP)352 Lantus178 LEUPROLIDE ACETATE (CPP) (3 MONTH)352,353 Lantus SoloStar178 LEUPROLIDE ACETATE (CPP) (6 MONTH)352 LAPATINIB DITOSYLATE109,111 LEVALBUTEROL HCL390,391 LAROTRECTINIB SULFATE103 LEVALBUTEROL TARTRATE390,391 LASMIDITAN SUCCINATE95 LEVAMLODIPINE MALEATE213 Lastacaft377 Levaquin48 LATANOPROST382 Levemir178 LATANOPROSTENE BUNOD381 Levemir FlexTouch178 Latuda131,132 LEVETIRACETAM54,55 Lazanda26 LEVOBUNOLOL HCL380 LEDIPASVIR-SOFOSBUVIR146 LEVOCARNITINE (METABOLIC MODIFIERS)280 Ledipasvir-Sofosbuvir146 LEVOCETIRIZINE DIHYDROCHLORIDE387 LEFLUNOMIDE363 LEVODOPA119 LEMBOREXANT403 LEVOFLOXACIN48,49 Lemtrada264 LEVOFLOXACIN (OPHTH)49 LENALIDOMIDE99 LEVOMILNACIPRAN HCL74 LENVATINIB MESYLATE109 LEVONORGESTREL & ETH ESTRADIOL332,333,342 Lenvima (10 MG Daily Dose)109 LEVONORGESTREL (IUD)344,345 Lenvima (12 MG Daily Dose)109 LEVONORGESTREL-ETH ESTRADIOL Lenvima (14 MG Daily Dose)109 (TRIPHASIC)333 Lenvima (18 MG Daily Dose)109 LEVONORGESTREL-ETHINYL ESTRADIOL (91- Lenvima (20 MG Daily Dose)109 DAY)333,334,342 Lenvima (24 MG Daily Dose)109 LEVONORGESTREL-ETHINYL ESTRADIOL Lenvima (4 MG Daily Dose)109 (CONTINUOUS)334 Lenvima (8 MG Daily Dose)109 LEVONORGESTREL-ETHINYL ESTRADIOL- Lescol XL233 FERROUS BISGLYCINATE325

PAGE 434 LAST UPDATED 03/2021 LEVORPHANOL TARTRATE26 Lo Loestrin Fe334 LEVOTHYROXINE SODIUM346,347,348,349,350,351 Locoid315 Levothyroxine Sodium346 Locoid Lipocream315 Lexapro75 Lodosyn120 Lexette315 LODOXAMIDE TROMETHAMINE377 Lexiva154 LOFEXIDINE HCL34 Lialda366 Lokelma372 Licart7 LOMITAPIDE MESYLATE236 LIDOCAINE31,33 Lonhala Magnair Refill Kit389 Lidocaine HCl31 Lonhala Magnair Starter Kit389 LIDOCAINE HCL31,32,33 Lonsurf102 LIDOCAINE HCL (LOCAL ANESTH.)32 LOPERAMIDE HCL294 LIDOCAINE HCL (MOUTH-THROAT)31,32 Lopid232 LIDOCAINE-MENTHOL31 LOPINAVIR-RITONAVIR154 LIDOCAINE-PRILOCAINE32,33 Lopressor211 LIDOCAINE-PRILOCAINE-TRANSPARENT Loprox89 DRESSING31,33 LORAZEPAM159,162 LIDOCAINE-TETRACAINE33 Lorbrena109 Lidocaine-Tetracaine33 LORLATINIB109 Lidoderm33 Lortab26 Lidotin57 LOSARTAN POTASSIUM203 Lidotral33 LOSARTAN POTASSIUM & LifEMS Naloxone35 HYDROCHLOROTHIAZIDE224,225 LIFITEGRAST376 LoSeasonique334 Liletta (52 MG)344 Lotemax378 LINACLOTIDE297 Lotemax SM378 LINAGLIPTIN174 Lotensin205 LINAGLIPTIN-METFORMIN HCL169 Lotensin HCT225 LINDANE114 LOTEPREDNOL ETABONATE377,378,379 Linzess297 LOTEPREDNOL ETABONATE-TOBRAMYCIN376 LIOTHYRONINE SODIUM346,349,351 Lotrel225 Lipitor233 Lotrisone272 Lipofen232 Lotronex297 Lipritin57 LOVASTATIN232,233 LIRAGLUTIDE174 Lovaza236 LISDEXAMFETAMINE DIMESYLATE245,246 Lovenox182 LISINOPRIL205,206,207 LOXAPINE121 LISINOPRIL & HYDROCHLOROTHIAZIDE224,229 LOXAPINE SUCCINATE123,124 LITHIUM CARBONATE163,164 LUBIPROSTONE297 Livalo233 Lubiprostone297 LIXISENATIDE164 Lucemyra34

PAGE 435 LAST UPDATED 03/2021 Lucentis375 Mavenclad (6 Tabs)264 LULICONAZOLE89 Mavenclad (7 Tabs)264 Luliconazole89 Mavenclad (8 Tabs)264 LUMATEPERONE TOSYLATE129 Mavenclad (9 Tabs)264 Lumigan382 Mavyret146 Lunesta402 Maxalt94 Lupaneta Pack352 Maxalt-MLT94 Lupkynis357 Maxidex379 Lupron Depot (1-Month)352 Maxitrol375 Lupron Depot (3-Month)352 Mayzent264 Lupron Depot (4-Month)352 Mayzent Starter Pack264 Lupron Depot (6-Month)352 MECLIZINE HCL82 Lupron Depot-Ped (1-Month)352 MECLOFENAMATE SODIUM7 Lupron Depot-Ped (3-Month)352,353 Medrol315 LURASIDONE HCL131,132 MEDROXYPROGESTERONE ACETATE344,345 LUSUTROMBOPAG200 MEDROXYPROGESTERONE ACETATE Luxiq272 (ANTINEOPLASTIC)343 Luzu89 MEDROXYPROGESTERONE ACETATE Lynparza109 (CONTRACEPTIVE)343,344 Lyrica261,262 MEFENAMIC ACID7 Lyrica CR262 MEFLOQUINE HCL113 Lysodren102 MEGESTROL ACETATE344 Lyumjev178 Mekinist109,110 Lyumjev KwikPen178 Mektovi110 MELOXICAM8,9,10 M MELPHALAN97 M-Natal Plus288 MEMANTINE HCL69,70 MACITENTAN393 MEMANTINE HCL-DONEPEZIL HCL68 Macrobid38 Menest334,335 Macrodantin38,39 Menostar335 Macugen375 Mentax89 Makena344 MEPERIDINE HCL24,27 Malarone113 Meperidine HCl27 MALATHION114 MEPOLIZUMAB398 MAPROTILINE HCL76 MEPROBAMATE157 MARAVIROC153 MERCAPTOPURINE100 Marinol85 MESALAMINE365,366 Marplan73 MESALAMINE W/ CLEANSER366 Mavenclad (10 Tabs)264 METAPROTERENOL SULFATE390,391 Mavenclad (4 Tabs)264 Metaproterenol Sulfate390,391 Mavenclad (5 Tabs)264 METAXALONE400,401

PAGE 436 LAST UPDATED 03/2021 METFORMIN HCL166,167,170,172 METOPROLOL SUCCINATE210,211,212 METHADONE HCL12,15 METOPROLOL TARTRATE211 Methadose15 MetroGel-Vaginal39 Methadose Sugar-Free15 METRONIDAZOLE38,39 METHAMPHETAMINE HCL243,245 METRONIDAZOLE (TOPICAL)272 METHAZOLAMIDE380 METRONIDAZOLE VAGINAL39,40 METHENAMINE HIPPURATE38,39 METRONIDAZOLE-TETRACYCLINE W/ BISMUTH METHENAMINE MANDELATE39 SUBSALICYLATE294 METHENAMINE-HYOSC-METHYLENE BLUE- MEXILETINE HCL208 BENZOIC ACID-PHENYL SAL38 Miacalcin369 METHENAMINE-HYOSC-METHYLENE BLUE-SOD Micardis204 PHOS-PHENYL SAL39,40 Micardis HCT225 METHENAMINE-HYOSCAMINE-METHYLENE BLUE- MICONAZOLE (MOUTH-THROAT)90 SODIUM PHOSPHATE39,40 Miconazole 389 METHIMAZOLE353 MICONAZOLE NITRATE VAGINAL89 Methitest323 Miconazole-Zinc Oxide-Petrolat89 METHOCARBAMOL400,401 MICONAZOLE-ZINC OXIDE-WHITE METHOTREXATE362 PETROLATUM89,91 METHOTREXATE (ANTIRHEUMATIC)359,360,361 MiCort-HC272 METHOTREXATE SODIUM357,358,362 MIDAZOLAM (ANTICONVULSANT)54 METHOXSALEN RAPID272 MIDAZOLAM HCL33 METHOXY POLYETHYLENE GLYCOL-EPOETIN MIDODRINE HCL201 BETA185 MIDOSTAURIN103 METHSUXIMIDE55 Migergot93 METHYCLOTHIAZIDE230 MIGLITOL168,170 METHYLDOPA201 MIGLUSTAT303,304 METHYLDOPA & HYDROCHLOROTHIAZIDE225 Migranal93 Methylin253 Millipred316 METHYLNALTREXONE BROMIDE295 Millipred DP316 METHYLPHENIDATE249,250 MILNACIPRAN HCL262 METHYLPHENIDATE Minastrin 24 Fe335 HCL247,248,249,253,254,255,256,257,258 Minipress202 Methylphenidate HCl ER257 Minivelle335 METHYLPREDNISOLONE315,316 Minocin51 METHYLPREDNISOLONE ACETATE310,316 MINOCYCLINE HCL51,52,53 METHYLPREDNISOLONE SOD SUCC316,318 Minocycline HCl ER52 METHYLTESTOSTERONE323,324,325 MINOCYCLINE HCL MICRONIZED (ACNE)50 METOCLOPRAMIDE HCL81,82,83,84 Minolira52 Metoclopramide HCl82 MINOXIDIL238 METOLAZONE230 MIRABEGRON305 METOPROLOL & HYDROCHLOROTHIAZIDE225 Mirapex116

PAGE 437 LAST UPDATED 03/2021 Mirapex ER117 MoviPrep298 Mircera185 Moxatag45 Mircette335 Moxeza49 Mirena (52 MG)344 MOXIFLOXACIN HCL47,49 MIRTAZAPINE70,71,72 MOXIFLOXACIN HCL (OPHTH)49 MISOPROSTOL299 MS Contin17 Mitigare92 Mulpleta200 MITOTANE102 Multigen280 Mobic8 Multigen Folic280 MODAFINIL404 Multigen Plus280 Moderiba (1200 MG Pack)147 MULTIPLE VITAMINS W/ MINERALS288 MOEXIPRIL HCL206 MULTIPLE VITAMINS W/ MINERALS & FOLIC MOEXIPRIL-HYDROCHLOROTHIAZIDE225 ACID292 MOLINDONE HCL124 Multivitamin/Fluoride288 MOMETASONE FUROATE312,316 MUPIROCIN37,40 MOMETASONE FUROATE (INHALATION)383,384 MUPIROCIN CALCIUM (TOPICAL)40 MOMETASONE FUROATE (NASAL)385 MYCOPHENOLATE MOFETIL354,355,358 MOMETASONE FUROATE-FORMOTEROL MYCOPHENOLATE SODIUM358 FUMARATE DIHYDRATE397 Mydayis245 Monoclate-P195 Myfortic358 Monoferric280 Myleran97 Monoject Blunt Cannula372 Myobloc400 Monoject Hypodermic Needle373 Myrbetriq305 Monoject Magellan Safety Ndl373 Mysoline57 Monoject Magellan Syringe373 Monoject Safety Syringe/Shield373 N Monoject Syringe373 NABILONE84 MONOMETHYL FUMARATE263 NABUMETONE8,9 Mononine195 NADOLOL210,211 Monovisc373 NADOLOL & BENDROFLUMETHIAZIDE222,223,226 MONTELUKAST SODIUM388 Nadolol-Bendroflumethiazide226 Monurol39 NAFARELIN ACETATE353 Morgidox52 NAFTIFINE HCL89 MorphaBond ER15,16 Naftin89 MORPHINE SULFATE10,14,15,16,17,27 NALDEMEDINE TOSYLATE295 Morphine Sulfate27 Nalfon8 MORPHINE SULFATE BEADS16,17 Nalocet27 Morphine Sulfate ER16 NALOXEGOL OXALATE295 Morphine Sulfate ER Beads16,17 NALOXONE HCL35,36 Motegrity295 Naloxone HCl35 Movantik295 NALTREXONE34

PAGE 438 LAST UPDATED 03/2021 NALTREXONE HCL33 Neoral358 Namenda69 NEPAFENAC378,379 Namenda Titration Pak69 Nephron FA280 Namenda XR69,70 NERATINIB MALEATE110 Namenda XR Titration Pack70 Nerlynx110 Namzaric68 Nesina170 Naprelan8 Nestabs288 NAPROXEN8 Nestabs DHA288 NAPROXEN SODIUM8,9 Nestabs One288 Naproxen Sodium ER9 NETARSUDIL DIMESYLATE381 NAPROXEN-ESOMEPRAZOLE MAGNESIUM9,10 NETARSUDIL DIMESYLATE-LATANOPROST381 NARATRIPTAN HCL93,94 NETUPITANT-PALONOSETRON84 Narcan36 Neuac272 Nardil73 Neulasta186 Nasonex385 Neulasta Onpro186 Natacyn89 Neupogen186 NATALIZUMAB265 Neupro117 NATAMYCIN89 Neurontin57 Natazia335 Nevanac379 NATEGLINIDE170,172,173 NEVIRAPINE149,150 Natesto324 NexAVAR110 Natroba113 NexIUM300,301 Nayzilam54 Nexletol226 NEBIVOLOL HCL209 Nexlizet236 NEBULIZERS371,372,374 Nexplanon344 NEDOCROMIL SODIUM (OPHTH)377 NIACIN (ANTIHYPERLIPIDEMIC)236 NEEDLE (DISP) 18 G372,373 Niacor236 NEFAZODONE HCL76 Niaspan236 NELFINAVIR MESYLATE155 NICARDIPINE HCL216 Neo-Synalar272 NICOTINE36 NEOMYCIN SULFATE37 Nicotrol36 NEOMYCIN SULFATE-FLUOCINOLONE Nicotrol NS36 ACETONIDE272 NIFEDIPINE212,216,217 NEOMYCIN-BACITRACIN ZN-POLYMYXIN375 Niferex288 NEOMYCIN-COLISTIN-HC-THONZONIUM382 NILOTINIB HCL111 NEOMYCIN-FLUOCINOLONE & EMOLLIENT272 NIMODIPINE216,217 NEOMYCIN-POLYMY-DEXAMETH375 Ninlaro102 NEOMYCIN-POLYMYXIN-GRAMICIDIN376 NINTEDANIB ESYLATE395 NEOMYCIN-POLYMYXIN-HC269 NIRAPARIB TOSYLATE112 NEOMYCIN-POLYMYXIN-HC (OPHTH)376 NISOLDIPINE216,217 NEOMYCIN-POLYMYXIN-HC (OTIC)382 NITAZOXANIDE113

PAGE 439 LAST UPDATED 03/2021 Nitro-Bid238 Norvir154 Nitro-Dur238,239 Nourianz115 NITROFURANTOIN38,40 Novoeight195,196 NITROFURANTOIN MACROCRYSTAL38,39,40 NovoLOG178 NITROFURANTOIN MONOHYD MACRO38,40 NovoLOG FlexPen178 NITROGLYCERIN238,239 NovoLOG Mix 70/30178 Nitrolingual239 NovoLOG Mix 70/30 FlexPen178 NitroMist239 NovoLOG PenFill178 Nitrostat239 NovoSeven RT196 Niva-Plus288 Noxafil89 Nivestym186 Nplate186 NIZATIDINE296 Nubeqa98 Nizatidine296 Nucala398 Nizoral89 Nucynta28 Norco27 Nucynta ER17 Norditropin FlexPro321 NuFera288 NORELGESTROMIN-ETHINYL ESTRADIOL335 Nuplazid132 NORETHIN ACET & ESTRAD-FE335,336,337,342 Nurtec92 NORETHINDRONE & ETH ESTRADIOL337,341 Nutropin AQ NuSpin 10321 NORETHINDRONE & ETHINYL ESTRADIOL- Nutropin AQ NuSpin 20321 FE332,338 Nutropin AQ NuSpin 5321 NORETHINDRONE (CONTRACEPTIVE)344,345 NuvaRing341 NORETHINDRONE ACET & ETH ESTRA338 Nuvessa40 NORETHINDRONE ACETATE343,345 Nuvigil404 NORETHINDRONE ACETATE-ETHINYL Nuwiq196,197 ESTRADIOL332,338,339 Nuzyra52 NORETHINDRONE ACETATE-ETHINYL Nymalize217 ESTRADIOL-FE331,339 NYSTATIN90 NORETHINDRONE ACETATE-ETHINYL NYSTATIN (MOUTH-THROAT)90 ESTRADIOL-FE FUM (BIPHASIC)334 NYSTATIN (TOPICAL)90 NORETHINDRONE-ETH ESTRADIOL NYSTATIN-TRIAMCINOLONE90 (TRIPHASIC)339,341 Nyvepria186 Norgesic Forte400 NORGESTIMATE-ETHINYL ESTRADIOL339,340,341 O NORGESTIMATE-ETHINYL ESTRADIOL O-Cal FA288 (TRIPHASIC)340,341 O-Cal Prenatal288 NORGESTREL & ETHINYL ESTRADIOL341 OB Complete288 Norinyl 1+35 (28)341 OB Complete One288 Norpramin80 OB Complete Petite289 NORTRIPTYLINE HCL80,81 OB Complete Premier289 Norvasc217 OB Complete/DHA289

PAGE 440 LAST UPDATED 03/2021 OBETICHOLIC ACID303 ONABOTULINUMTOXINA144 Obizur197 ONDANSETRON85,86 Ocaliva303 ONDANSETRON HCL85,86 OCRELIZUMAB264 Onexton272 Ocrevus264 Onfi58 Ocuflox49 Ongentys115 Odefsey149 Onglyza170,171 Odomzo110 Onmel90 OFATUMUMAB (MS)264 Onzetra Xsail94 Ofev395 Opana28 OFLOXACIN49 Opana ER18 OFLOXACIN (OPHTH)49 OPICAPONE115 OFLOXACIN (OTIC)49 Opsumit393 OLANZAPINE132,133,140,141,142 OptiChamber Diamond373 OLANZAPINE PAMOATE141 OptiChamber Diamond-Lg Mask373 OLANZAPINE-FLUOXETINE HCL71,72 OptiChamber Diamond-Md Mask373 OLAPARIB109 OptiChamber Diamond-Sm Mask373 OLMESARTAN MEDOXOMIL202,203,204 Oracea52 OLMESARTAN MEDOXOMIL-AMLODIPINE- Oracit307 HYDROCHLOROTHIAZIDE226,228 Orapred ODT316 OLMESARTAN MEDOXOMIL- Oravig90 HYDROCHLOROTHIAZIDE221,226 Orencia358,359 OLODATEROL HCL391 Orencia ClickJect359 OLOPATADINE HCL377 Orenitram393 OLOPATADINE HCL (NASAL)387 Orgovyx353 OLSALAZINE SODIUM366 Oriahnn322 Olumiant358 Orilissa353 Olux316 Orladeyo354 Olux-E316 ORPHENADRINE CITRATE400 OMADACYCLINE TOSYLATE52 ORPHENADRINE W/ ASPIRIN & CAFF400 OMALIZUMAB399 Ortho Micronor345 OMBITASVIR-PARITAPREVIR-RITONAVIR- Ortho Tri-Cyclen (28)341 DASABUVIR146 Ortho Tri-Cyclen Lo341 Omeclamox-Pak295 Ortho-Cyclen (28)341 OMEGA-3-ACID ETHYL ESTERS236 Ortho-Novum 1/35 (28)341 OMEPRAZOLE301 Ortho-Novum 7/7/7 (28)341 OMEPRAZOLE MAGNESIUM302 OrthoVisc373 OMEPRAZOLE-SODIUM BICARBONATE301,302 Ortikos367 Omnaris385 OSELTAMIVIR PHOSPHATE155,156 Omnipred379 Oseni171 Omnitrope321,322 OSIMERTINIB MESYLATE111

PAGE 441 LAST UPDATED 03/2021 Osmolex ER115 Pamelor80,81 Otezla363 PAMIDRONATE DISODIUM369 Otiprio49 Pamidronate Disodium369 Otovel383 Pancreaze303 Otrexup359 PANCRELIPASE (LIPASE-PROTEASE- Ovide114 AMYLASE)303,304 OXANDROLONE322 Pandel316 OXAPROZIN5,9 PANOBINOSTAT LACTATE106 Oxaydo28 PANTOPRAZOLE SODIUM301,302 OXAZEPAM162 Paragard Intrauterine Copper308 Oxbryta200 PARICALCITOL369,370 OXCARBAZEPINE65,66 Parlodel117 OXICONAZOLE NITRATE90 PAROMOMYCIN SULFATE37 Oxistat90 PAROXETINE HCL76 Oxsoralen Ultra272 PAROXETINE MESYLATE77 Oxtellar XR65,66 PAROXETINE MESYLATE (VASOMOTOR)73,76 OXYBUTYNIN306 Pataday377 OXYBUTYNIN CHLORIDE305,306 Patanase387 OXYCODONE20 Patanol377 OXYCODONE HCL18,19,28,30 PATIROMER SORBITEX CALCIUM285 oxyCODONE HCl ER18 Paxil76 OXYCODONE W/ ACETAMINOPHEN27,28,29,30 Paxil CR76 oxyCODONE-Acetaminophen29 Pazeo377 OXYCODONE-ASPIRIN29 PAZOPANIB HCL112 OXYCODONE-IBUPROFEN29 PED MULTIVITAMINS W/FL & IRON289 OxyCONTIN19 Pediapred316 OXYMETHOLONE322 PEDIATRIC MULTIVITAMINS W/FL288,289 OXYMORPHONE HCL18,19,28,29 PEG 3350-KCL-NACL-NA SULFATE-NA Oxytrol306 ASCORBATE-ASCORBIC ACID298 OZANIMOD HCL265 PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD Ozempic (0.25 or 0.5 MG/DOSE)171 SULFATE298 Ozempic (1 MG/DOSE)171 PEG 3350-POTASSIUM CHLORIDE-SOD OZENOXACIN278 BICARBONATE-SOD CHLORIDE298 Ozurdex379 Peganone66 PEGAPTANIB SODIUM375 P Pegasys147 PALBOCICLIB107 Pegasys ProClick147 PALIPERIDONE130,133 PEGFILGRASTIM186 PALIPERIDONE PALMITATE130,131 PEGFILGRASTIM-APGF186 PALONOSETRON HCL84,86 PEGFILGRASTIM-BMEZ188 Palonosetron HCl86 PEGFILGRASTIM-CBQV187

PAGE 442 LAST UPDATED 03/2021 PEGFILGRASTIM-JMDB185 Phoslyra284 PEGINTERFERON ALFA-2A147 Phospholine Iodide380 PEGINTERFERON ALFA-2B147 PHYTONADIONE197 PEGINTERFERON BETA-1A264,265 Pifeltro149 PegIntron147 PILOCARPINE HCL380 PEGLOTICASE92 PILOCARPINE HCL (ORAL)266 Pemazyre102 PIMAVANSERIN TARTRATE132 PEMIGATINIB102 PIMECROLIMUS270,272 PENCICLOVIR156 PIMOZIDE124 PENICILLIN G BENZATHINE44 PINDOLOL211 PENICILLIN G POTASSIUM45 PIOGLITAZONE HCL164,171 PENICILLIN G SODIUM45 PIOGLITAZONE HCL-GLIMEPIRIDE166,171 PENICILLIN V POTASSIUM45 PIOGLITAZONE HCL-METFORMIN HCL164,171 Penlac90 Piqray (200 MG Daily Dose)110 Pennsaid9 Piqray (250 MG Daily Dose)110 Pentasa366 Piqray (300 MG Daily Dose)110 PENTAZOCINE W/ NALOXONE29 PIRFENIDONE395 Pentican58 PIROXICAM6,9 PENTOSAN POLYSULFATE SODIUM307 PITAVASTATIN CALCIUM233 PENTOXIFYLLINE226 PITAVASTATIN MAGNESIUM234,235 Pepcid296 PITOLISANT HCL404 PERAMIVIR155 Plaquenil113 PERAMPANEL59,60 Plavix200 Percocet29 PLECANATIDE299 Perforomist391 Plegridy264 PERINDOPRIL ERBUMINE206 Plegridy Starter Pack265 PERMETHRIN114 Pliaglis33 PERPHENAZINE82 PNEUMOCOCCAL 13-VALENT CONJUGATE PERPHENAZINE-AMITRIPTYLINE71,72 VACCINE365 Perseris133,134 PNEUMOCOCCAL VAC POLYVALENT365 Pertzye303,304 Pneumovax 23365 Pexeva77 PNV Prenatal Plus Multivitamin289 PEXIDARTINIB HCL103 PNV Tabs 20-1289 PHENAZOPYRIDINE HCL308 PNV Tabs 29-1289 PHENELZINE SULFATE73 PNV-DHA+Docusate289 Phenergan387 PNV-Omega289 PHENOBARBITAL58 PNV-Select289 PHENYLEPHRINE HCL (MYDRIATIC)376 PODOFILOX272 Phenytek66 POLYETHYLENE GLYCOL 3350298 PHENYTOIN65,66 POLYMYXIN B-TRIMETHOPRIM376 PHENYTOIN SODIUM EXTENDED65,66

PAGE 443 LAST UPDATED 03/2021 POLYSACCHARIDE FE COMPLEX-FE HEME PREGABALIN261,262 POLYPEPTIDE-FA-VIT B12279 PREGABALIN (ONCE-DAILY)262 Polytrim376 Premarin341,342 POMALIDOMIDE99 Premphase342 Pomalyst99 Prempro342 PONATINIB HCL107 Prenaissance289 POSACONAZOLE89,90 Prenaissance Plus289 POT PHOSPHATE MONOBASIC W/ SOD PRENAT VIT W/ IRON CARBONYL-FE ASP GLYC- PHOSPHATE DIBASIC & MONOBASIC284 FA-OMEGA FATTY ACID289 POTASSIUM BICARBONATE280 Prenatal290 POTASSIUM CHLORIDE280,281 Prenatal 19290 POTASSIUM CHLORIDE MICROENCAPSULATED PRENATAL MULTIVIT-MIN W/FE-FA292 CRYSTALS ER281 PRENATAL MULTIVITAMINS & MINERALS W/ L- POTASSIUM CITRATE (ALKALINIZER)308 METHYLFOLATE-FA290 Potiga54,55 PRENATAL MV & MIN W/FE BISGLYC-FE PROT Pradaxa182,183 SUCC-FA-CA-OMEGA 3286,292 PRALSETINIB106 PRENATAL MV & MIN W/FE FUMARATE-FA-DHA293 Praluent236 PRENATAL MV & MIN W/FE POLYSACCHARIDE PRAMIPEXOLE DIHYDROCHLORIDE116,117,118 COMPLEX-FA-DHA291,293 PRAMLINTIDE ACETATE173 PRENATAL VIT W/ DOCUSATE-FE CARBONYL-FE Prandin171,172 GLUCONATE-FOLIC ACID286 PRASUGREL HCL200 PRENATAL VIT W/ DOCUSATE-FE FUMARATE- Pravachol234 FOLIC ACID291 PRAVASTATIN SODIUM234 PRENATAL VIT W/ FE BISGLYCINATE CHELATE- PRAZOSIN HCL202 FOLIC ACID289 Precose172 PRENATAL VIT W/ FE FUM-IRON POLYSACCH Pred Forte379 COMPLEX -FA-OMEGA 3286,291,292 Pred Mild379 PRENATAL VIT W/ FE GLYCINE CYSTEINATE-FA- Pred-G376 OMEGA 3 FATTY ACIDS286 Pred-G S.O.P.376 PRENATAL VIT W/ FE POLYSACCH COMPLEX-L PREDNICARBATE311,317 METHYLFOL-FA-DHA-DSS293 Prednicarbate317 PRENATAL VIT W/ FE POLYSACCH COMPLEX-L PREDNISOLONE316,317 METHYLFOLATE-FA-DHA293 PREDNISOLONE ACETATE (OPHTH)379 PRENATAL VIT W/ FERRIC PHOSPHATE-FA- PREDNISOLONE SODIUM PHOSPHATE316,317 OMEGA 3 FATTY ACIDS293 PrednisoLONE Sodium Phosphate379 PRENATAL VIT W/ FERROUS FUMARATE-FA- PREDNISOLONE SODIUM PHOSPHATE OMEGA 3 FATTY ACIDS285,292,293 (OPHTH)379 PRENATAL VIT W/ FERROUS FUMARATE-FOLIC PREDNISONE317,318 ACID286,288,289,290,291,292,293,294 PredniSONE Intensol317 PRENATAL VIT W/ FERROUS FUMARATE-L Prefest341 METHYLFOLATE-FOLIC ACID289,292

PAGE 444 LAST UPDATED 03/2021 PRENATAL VIT W/ IRON CARBONYL-FE ASPART PRENATAL WITHOUT A VIT W/ FE FUM-IRON GLYCINATE-FA289 POLYSACCH COMPLEX -FA286,287,291 PRENATAL VIT W/ IRON CARBONYL-FOLIC PRENATAL WITHOUT A VIT W/ FE FUMARATE- ACID288,289,290,292 FOLIC ACID285,290 PRENATAL VIT W/ IRON POLYSACCHARIDE PRENATAL WITHOUT A W/ FE ASP GLYC-L CMPLX-L METHYLFOLATE-FA291 METHYLFOLATE-FA-OMEGA 3291 PRENATAL VIT W/ IRON POLYSACCHARIDE PRENATAL WITHOUT A W/ FE CARBONYL-L COMPLEX-FOLIC ACID291 METHYLFOLATE-FA-DHA292,294 PRENATAL VIT W/ SELENIUM-FE FUMARATE- PRENATAL WITHOUT A W/ FE FUMARATE-L FOLIC ACID292 METHYLFOLATE-FA-DHA290,291,293,294 PRENATAL VIT WITHOUT VIT A W/ FE PRENATAL WITHOUT A W/ FE FUMARATE-L BISGLYCINATE-FA-OMEG 3288 METHYLFOLATE-FA-OMEGA 3289,293,294 PRENATAL VIT WITHOUT VIT A W/ FE PRENATAL WITHOUT A W/FE FUM-FE POLYSACCH BISGLYCINATE-FOLIC ACID288 COMPLEX-FA-DHA291 Prenatal Vitamin Plus Low Iron290 PRENATAL WITHOUT VIT A W/ FE CARBONYL-FE PRENATAL W/ CALCIUM-VIT B6-VIT B12-FOLIC GLUC-DOCUSATE-FA286 ACID-GINGER290 PRENATAL WITHOUT VIT A W/ FE FUMARATE-L PRENATAL W/ FE ASPARTO GLYCINATE-L METHYLFOLATE-OMEGAS292 METHYLFOLATE-FOLIC ACID290 Prenatal-U290 PRENATAL W/O A VIT W/ FE FUMARATE-L Prenate290 METHYLFOLATE-FOLIC ACID293 Prenate AM290 PRENATAL W/O A W/ FE ASPARTO GLYC-L Prenate DHA290 METHYLFOLATE-FA-DHA290 Prenate Elite290 PRENATAL W/O A W/FE CARBONYL-FE BISGLYC-L Prenate Enhance290 METHYLFOL-DHA288 Prenate Essential290 PRENATAL W/O VIT A W/ FE CARBONYL-DSS-FA- Prenate Mini290 DHA289 Prenate Pixie290 PRENATAL W/O VIT A W/ FE CARBONYL-FE ASP Prenate Restore291 GLYC-METHFOL-FA-DHA290 Prenatrix291 PRENATAL W/O VIT A W/ FE CARBONYL-FE Prenatryl291 ASPART GLYC-FA-FISH OIL288 PrePLUS291 PRENATAL W/O VIT A W/ FE CARBONYL-FE PreTAB291 ASPART GLYC-FA-OMEGA 3289 Prevacid302 PRENATAL W/O VIT A W/ FE CARBONYL-FE Prevacid SoluTab302 GLUCONATE-DSS-FA-DHA285,286 Prevnar 13365 PRENATAL W/O VIT A W/ FE CARBONYL-FE Prevymis145 GLUCONATE-FA & VIT B6286 Prezcobix154 PRENATAL W/O VIT A W/ FE FUMARATE-DSS-FA- Prezista154,155 DHA289,292,293 Prilo Patch II33 PRENATAL W/O VIT A W/ FE FUMARATE-FE PriLOSEC302 CARBONYL-DSS-FA-DHA286 Prilovixil33

PAGE 445 LAST UPDATED 03/2021 PrimaCare291 PROPRANOLOL & HYDROCHLOROTHIAZIDE226 PRIMAQUINE PHOSPHATE113,114 PROPRANOLOL HCL101,210,211,212 Primaquine Phosphate113 PROPRANOLOL HCL SUSTAINED-RELEASE PRIMIDONE57,58 BEADS210 Primlev29 PROPYLTHIOURACIL353 Prinivil206 Proscar307 Pristiq77 Protonix302 Prizopak II33 Protopic273 ProAir Digihaler391 PROTRIPTYLINE HCL81 ProAir HFA391 Proventil HFA391 ProAir RespiClick391 Provera345 PROBENECID92 Provida DHA291 Probuphine Implant Kit34 Provida OB291 Procardia217 Provigil404 Procardia XL217 PROzac77 PROCHLORPERAZINE82 PRUCALOPRIDE SUCCINATE295 PROCHLORPERAZINE EDISYLATE82 PSEUDOEPHED-BROMPHEN-DM398 PROCHLORPERAZINE MALEATE83 Psorcon318 Procrit186,187 Pulmicort385 Proctocort273 Pulmicort Flexhaler385 Proctofoam HC273 PureFe OB Plus291 Profilnine197 Pylera295 Profilnine SD197 PYRAZINAMIDE97 PROGESTERONE345 Pyrazinamide97 PROGESTERONE (VAGINAL)343 PYRIDOSTIGMINE BROMIDE96 PROGESTERONE MICRONIZED345 Progesterone Micronized373 Q PROGESTERONE MICRONIZED (BULK)373 Qbrelis206 Progesterone Ultra Micronized373 Qdolo30 Prograf359 Qinlock102 Prolate30 Qmiiz ODT9 Prolensa379 Qnasl385 Prolia369 Qnasl Childrens385 Promacta187 Qtern172 PROMETHAZINE & PHENYLEPHRINE398 Qualaquin114 PROMETHAZINE HCL83,387 Quartette342 PROMETHAZINE-DM398 QUAZEPAM401,402 Promethazine-DM398 Quazepam402 Prometrium345 Qudexy XR62,63 PROPAFENONE HCL208 Questran237 PROPANTHELINE BROMIDE294 Questran Light237

PAGE 446 LAST UPDATED 03/2021 QUETIAPINE FUMARATE134,135,138,139 Recombivax HB365 QuilliChew ER257 RediTrex360,361 Quillivant XR257 Reglan83,84 QUINAPRIL HCL204,206 REGORAFENIB110 QUINAPRIL-HYDROCHLOROTHIAZIDE219,226 Relafen DS9 QUINIDINE SULFATE208 Relenza Diskhaler155 QUININE SULFATE114 Relexxii257 Qutenza33 Relistor295 Qutenza (2 Patch)33 Relpax94 Qvar385 RELUGOLIX353 Qvar RediHaler385 Remeron72 Remeron SolTab72 R Remicade361 RABEPRAZOLE SODIUM299,302 Renagel284 RALOXIFENE HCL345 Renflexis361 RALTEGRAVIR POTASSIUM148 Renvela284 RAMELTEON404 REPAGLINIDE171,172 RAMIPRIL204,206 REPAGLINIDE-METFORMIN HCL172 Ranexa226 Repatha237 RANIBIZUMAB375 Repatha Pushtronex System237 RANITIDINE HCL296,297 Repatha SureClick237 raNITIdine HCl296 Requip118 RANOLAZINE226,227 Requip XL118 Rapaflo307 Rescriptor149 Rapamune359,360 RESLIZUMAB363 Rapivab155 Restasis376 RASAGILINE MESYLATE120 Restasis Multidose376 Rasuvo360 Restoril402 Ravicti304 Retacrit187 Rayaldee369 Retevmo102 Rayos318 Retin-A273 Razadyne68 Retin-A Micro273 Razadyne ER68 Retin-A Micro Pump273,274 Rebetol147 Retisert379 Rebif265 Retrovir151 Rebif Rebidose265 Revatio394 Rebif Rebidose Titration Pack265 REVEFENACIN389 Rebif Titration Pack265 Revlimid99 Rebinyn197 Rexulti135 Reclast369 Reyataz155 Recombinate197,198 Reyvow95

PAGE 447 LAST UPDATED 03/2021 RHO D IMMUNE GLOBULIN (HUMAN)362 ROMIPLOSTIM186 RhoGAM Ultra-Filtered Plus362 ROMOSOZUMAB-AQQG368 Rhopressa381 ROPINIROLE HYDROCHLORIDE118,119 Ribasphere147 ROSIGLITAZONE MALEATE165 Ribasphere RibaPak (1000 Pack)147 ROSUVASTATIN CALCIUM232,233,234 Ribasphere Ribapak (1200 Pack)147 ROTIGOTINE117 RIBAVIRIN (HEPATITIS C)147 Rowasa366 RIBOCICLIB SUCCINATE108 Roxicodone30 RIBOCICLIB SUCCINATE-LETROZOLE108 Rozerem404 RIFABUTIN97 Rozlytrek102,103 RIFAMPIN97 Rubraca103 RIFAXIMIN40,41 RUCAPARIB CAMSYLATE103 RILONACEPT363 Ruconest354 RILPIVIRINE HCL148 RUFINAMIDE64,66 RIMABOTULINUMTOXINB400 Rukobia153 RIMANTADINE HYDROCHLORIDE155,156 RUXOLITINIB PHOSPHATE108 RIMEGEPANT SULFATE92 Rybelsus172 Rinvoq361 Rydapt103 RIOCIGUAT393 Rytary120 Riomet172 Riomet ER172 S RIPRETINIB102 Sabril58 RISANKIZUMAB-RZAA274 SACUBITRIL-VALSARTAN223 RISEDRONATE SODIUM367,369,370 SAFINAMIDE MESYLATE120 RisperDAL135,136 Safyral342 RisperDAL Consta136 Saizen322 RISPERIDONE133,134,135,136,137,138 Saizen Click.Easy322 RISPERIDONE MICROSPHERES136 Saizenprep322 Ritalin257,258 SALICYLIC ACID & BENZOIC ACID268 Ritalin LA258 SALMETEROL XINAFOATE391 RITONAVIR154,155 SALSALATE9 RIVAROXABAN183,184 Sancuso86 RIVASTIGMINE67,68 SandIMMUNE361 RIVASTIGMINE TARTRATE68,69 Santyl274 Rixubis198 Saphris138 RIZATRIPTAN BENZOATE94,95 SAQUINAVIR MESYLATE154 Robaxin-750401 Sarafem77 Rocaltrol370 SARGRAMOSTIM185 rocklatan381 SARILUMAB357 ROFLUMILAST392 Savaysa183 ROLAPITANT HCL86 Savella262

PAGE 448 LAST UPDATED 03/2021 Savella Titration Pack262 Siklos100 SAXAGLIPTIN HCL170,171 Sila III318 SAXAGLIPTIN-METFORMIN HCL170 SILDENAFIL CITRATE (PULMONARY SCOPOLAMINE84 HYPERTENSION)394 Se-Natal 19291 Silenor404 Seasonique342 Siliq361 SECNIDAZOLE40 SILODOSIN307 SECOBARBITAL SODIUM404 SILVER SULFADIAZINE49 Seconal404 Simbrinza381 Secuado138 Simponi361 SECUKINUMAB269 Simponi Aria361 Seebri Neohaler389 SIMVASTATIN234 SEGESTERONE ACETATE-ETHINYL Simvastatin234 ESTRADIOL325 Sinemet120 Segluromet172 Sinemet CR120 Select-OB291 Singulair388 Select-OB+DHA291 Sinuva385 SELEGILINE73 SIPONIMOD FUMARATE264 SELEGILINE HCL120 SIROLIMUS359,360,361 SELENIUM SULFIDE274 SITAGLIPTIN PHOSPHATE169 SELEXIPAG394,395 SITAGLIPTIN-METFORMIN HCL168,169 SELINEXOR103,104 Sitavig156 SELPERCATINIB102 Skelaxin401 SELUMETINIB SULFATE109 Sklice113 Selzentry153 SkyaDerm-LP33 SEMAGLUTIDE171,172 Skyla345 Semglee178 Skyrizi (150 MG Dose)274 Semprex-D398 Slynd345 Serevent Diskus391 SODIUM BICARBONATE281 Sernivo274 SODIUM CHLORIDE (GU IRRIGANT)281 SEROquel138,139 SODIUM CHLORIDE (INHALANT)398 SEROquel XR139 SODIUM CITRATE & CITRIC ACID307,308 Serostim322 SODIUM FERRIC GLUCONATE COMPLEX IN SERTACONAZOLE NITRATE88 SUCROSE279,281 SERTRALINE HCL77,78,79 SODIUM FLUORIDE281,282 SEVELAMER CARBONATE284,285 Sodium Hyaluronate373 SEVELAMER HCL284,285 SODIUM HYALURONATE Sevelamer HCl285 (VISCOSUPPLEMENT)270,371,372,373,374 Sevenfact198 SODIUM PHENYLBUTYRATE302,304 SfRowasa366 SODIUM POLYSTYRENE SULFONATE283 Shingrix365 SODIUM ZIRCONIUM CYCLOSILICATE372

PAGE 449 LAST UPDATED 03/2021 SOFOSBUVIR146 Stalevo 125115 SOFOSBUVIR-VELPATASVIR146 Stalevo 150116 Sofosbuvir-Velpatasvir146 Stalevo 200116 SOFOSBUVIR-VELPATASVIR-VOXILAPREVIR147 Stalevo 50116 SOLIFENACIN SUCCINATE306 Stalevo 75116 Soliqua179 Starlix172,173 Solodyn52 STAVUDINE151,152 Solosec40 Stavudine151 SOLRIAMFETOL HCL404 Steglatro173 Soltamox100 Steglujan173 Solu-CORTEF318 Stelara274 SOLU-medrol318 Stimate322 Soma401 Stiolto Respimat398 SOMATROPIN320,321,322 STIRIPENTOL53 SOMATROPIN (NON-REFRIGERATED)322 Stivarga110 SONIDEGIB PHOSPHATE110 Strattera258,259 SORAFENIB TOSYLATE110 Striant324 Soriatane274 Stribild148 Sorilux274 Striverdi Respimat391 SOTALOL HCL207,208 Sublocade35 SOTALOL HCL (AFIB/AFL)207,208 Suboxone35 Sotylize208 Subsys30 Sovaldi146 SUCCIMER282 SPACER/AEROSOL-HOLDING SUCRALFATE299 CHAMBERS371,373,374 SUCROFERRIC OXYHYDROXIDE285 SPINOSAD113 SUFENTANIL CITRATE24 Spiriva HandiHaler389 Sular217 Spiriva Respimat389 SULCONAZOLE NITRATE88,90 SPIRONOLACTONE230 Sulconazole Nitrate90 SPIRONOLACTONE & SULFACETAMIDE SOD-PREDNISOLONE374,376 HYDROCHLOROTHIAZIDE219,227 SULFACETAMIDE SODIUM274 Sporanox90 SULFACETAMIDE SODIUM (ACNE)49 Sporanox Pulsepak90 SULFACETAMIDE SODIUM (OPHTH)49,50 Spravato (56 MG Dose)72 SULFACETAMIDE SODIUM W/ SULFUR274,275 Spravato (84 MG Dose)72 SULFACETAMIDE SODIUM-SULFUR IN UREA Spritam55 VEHICLE268 Sprix9 SULFACETAMIDE SODIUM-SULFUR W/ SKIN Sprycel110 CLEANSER275 SPS283 SULFACETAMIDE SODIUM-SULFUR- SSS 10-5274 SUNSCREEN275 Stalevo 100115 SULFADIAZINE50

PAGE 450 LAST UPDATED 03/2021 SulfADIAZINE50 Synera33 SULFAMETHOXAZOLE-TRIMETHOPRIM50 Synjardy173 SULFANILAMIDE VAGINAL49 Synjardy XR173 SULFASALAZINE366,367 Synthroid349 SULINDAC9 Synvisc374 Sumadan275 Synvisc One374 Sumadan Wash275 SYRINGE/NEEDLE (DISP) 3 ML371,373 Sumadan XLT275 SUMATRIPTAN94,95 T SUMATRIPTAN SUCCINATE94,95,96 Tabloid100 SUMATRIPTAN-NAPROXEN SODIUM95,96 Tabrecta103 Sumavel DosePro95 Taclonex276 Sumaxin275 TACROLIMUS354,356,359,361 Sumaxin CP275 TACROLIMUS (TOPICAL)273,276 Sumaxin TS275 TADALAFIL306,307 Sumaxin Wash275 TADALAFIL (PULMONARY HYPERTENSION)393,394 SUNITINIB MALATE110,111 TAFENOQUINE SUCCINATE113 Sunosi404 Tafinlar111 Supartz FX373 TAFLUPROST382 Supprelin LA353 Tagrisso111 Suprax43 Takhzyro354 Surmontil81 TALAZOPARIB TOSYLATE111 Sustiva149 Talicia295 Sustol86 TALIGLUCERASE ALFA303 Sutent110,111 Taltz276 SUVOREXANT403 Talzenna111 Symbicort398,399 Tamiflu156 Symbyax72 TAMOXIFEN CITRATE100 Symfi149 TAMSULOSIN HCL307 Symfi Lo149 Tandem Plus282 SymlinPen 120173 Tanzeum173 SymlinPen 60173 TAPENTADOL HCL17,28 Sympazan58 TaperDex 12-Day318 Symproic295 TaperDex 7-Day318 Symtuza155 Tarceva111 Synalar318 Tarka227 Synalar (Cream)318 Taron Forte282 Synalar (Ointment)318 Taron-C DHA291 Synalar TS318 Taron-Prex292 Synarel353 Tasigna111 Syndros86 TASIMELTEON403

PAGE 451 LAST UPDATED 03/2021 Tasmar116 Testosterone324 TAVABOROLE88,90 TESTOSTERONE CYPIONATE323,324 Tavalisse187 TESTOSTERONE ENANTHATE324,325 Taytulla342 TESTOSTERONE UNDECANOATE323 TAZAROTENE276 Testred325 TAZAROTENE (ACNE)267,270 TETANUS TOXOID-DIPHTHERIA-ACELLULAR TAZEMETOSTAT HBR103 PERTUSSIS ADSORB (TDAP)363,364 Tazorac276 TETRABENAZINE260 Tazverik103 TETRACYCLINE HCL53 TBO-FILGRASTIM185 Texacort318 Tecfidera265 THALIDOMIDE99 TEGASEROD MALEATE297 Thalomid99 TEGretol66 Theo-24392 TEGretol-XR66 Theochron392 Tekturna227 THEOPHYLLINE392,393 Tekturna HCT227 THIOGUANINE100 TELMISARTAN204 THIORIDAZINE HCL124 TELMISARTAN-AMLODIPINE227,228 THIOTHIXENE124,125 TELMISARTAN-HYDROCHLOROTHIAZIDE225,227 Thrivite 19292 TEMAZEPAM402 Thrivite Rx292 Temixys151 Thyquidity349 Temodar97,98 THYROID346,349,350 Temovate318 TIAGABINE HCL57,58,59 TEMOZOLOMIDE97,98 Tiazac217,218 TENOFOVIR ALAFENAMIDE FUMARATE146 Tibsovo103 TENOFOVIR DISOPROXIL FUMARATE151,152 TICAGRELOR199 Tenoretic 100227 Tigan84 Tenoretic 50227 TILDRAKIZUMAB-ASMN271 Tenormin212 TIMOLOL MALEATE212 Tepmetko111 TIMOLOL MALEATE (OPHTH)380,381 TEPOTINIB HCL111 Timoptic381 TERAZOSIN HCL202 Timoptic Ocudose381 TERBINAFINE HCL91 Timoptic-XE381 TERBUTALINE SULFATE391 Tindamax40 TERCONAZOLE VAGINAL91 TINIDAZOLE40 TERIFLUNOMIDE262,263 TIOTROPIUM BROMIDE MONOHYDRATE389 TERIPARATIDE (RECOMBINANT)368,370 TIOTROPIUM BROMIDE-OLODATEROL HCL398 Teriparatide (Recombinant)370 TIPRANAVIR153,154 Testim324 Tirosint350 Testopel324 Tirosint-SOL350,351 TESTOSTERONE323,324,325 Tivicay148

PAGE 452 LAST UPDATED 03/2021 Tivicay PD148 TRANDOLAPRIL206 Tivorbex9 TRANDOLAPRIL-VERAPAMIL HCL227,228 TIZANIDINE HCL144,145 TRANEXAMIC ACID198 Tobi399 Transderm-Scop (1.5 MG)84 Tobi Podhaler392 Tranxene-T162 TobraDex376 TRANYLCYPROMINE SULFATE73 TobraDex ST376 Travatan Z382 TOBRAMYCIN392,398,399 TRAVOPROST382 Tobramycin399 TRAZODONE HCL77 TOBRAMYCIN (OPHTH)37 Trelegy Ellipta399 TOBRAMYCIN-DEXAMETHASONE376 Trelstar Mixject353 Tobrex37 Tremfya361 TOCILIZUMAB362,363 TREPROSTINIL394 TOFACITINIB CITRATE362 TREPROSTINIL DIOLAMINE393 Tofranil81 Tresiba179 TOLAZAMIDE174 Tresiba FlexTouch179 TOLAZamide174 TRETINOIN267,273,276,277 TOLBUTAMIDE174 TRETINOIN (CHEMOTHERAPY)112 TOLCAPONE116 TRETINOIN MICROSPHERE273,274,277 TOLMETIN SODIUM9,10 Trexall362 Tolmetin Sodium9 Treximet96 Tolsura91 TRIAMCINOLONE ACETONIDE315,319 TOLTERODINE TARTRATE305,306 TRIAMCINOLONE ACETONIDE (MOUTH)266 Topamax63 TRIAMCINOLONE ACETONIDE (OPHTH)379 Topamax Sprinkle63 TRIAMCINOLONE ACETONIDE (TOPICAL)315,319 Topicort318,319 TRIAMCINOLONE ACETONIDE-CICLOPIROX374 Topicort Spray319 TRIAMCINOLONE ACETONIDE-SILICONE318 TOPIRAMATE62,63 TRIAMTERENE & HYDROCHLOROTHIAZIDE228 Toprol XL212 TRIAZOLAM401,402 TOREMIFENE CITRATE99,100 Tribenzor228 TORSEMIDE229 TriCare292 Tosymra95 TriCare Prenatal DHA ONE292 Toujeo Max SoloStar179 Tricor232 Toujeo SoloStar179 Triesence379 Tovet276 TRIFAROTENE267 Toviaz306 Triferic283 Tracleer394 TRIFLUOPERAZINE HCL125 Tradjenta174 TRIFLURIDINE156 TRAMADOL HCL12,19,20,30,31 TRIFLURIDINE-TIPIRACIL102 TRAMADOL-ACETAMINOPHEN30,31 Triglide232 TRAMETINIB DIMETHYL SULFOXIDE109,110 TRIHEXYPHENIDYL HCL114

PAGE 453 LAST UPDATED 03/2021 Trijardy XR174 Tyvaso Starter394 Trileptal66 Trilipix232 U Trilociclo374 Ubrelvy93 Triluron374 UBROGEPANT93 TRIMETHOBENZAMIDE HCL84 Uceris367 TRIMIPRAMINE MALEATE81 Udenyca187 Trinatal Rx 1292 Ukoniq111 Trintellix77,78 ULIPRISTAL ACETATE343 Triostat351 Uloric92 Triptodur353 Ultracet31 TRIPTORELIN PAMOATE353 Ultram31 TRIPTORELIN PAMOATE (CPP)353 Ultravate319 TriStart DHA292 Ultravate X (Cream)319 Triumeq153 Ultravate X (Ointment)320 Triveen-Duo DHA292 UMBRALISIB TOSYLATE111 TriVisc374 UMECLIDINIUM BROMIDE388 Trizivir151 UMECLIDINIUM-VILANTEROL396 Trogarzo153 UPADACITINIB361 Trokendi XR63 Uptravi394,395 TROPICAMIDE376 UREA278 TROSPIUM CHLORIDE306 Urimar-T40 Trulance299 Urogesic-Blue40 Trulicity174 Urso 250295 Trusopt381 Urso Forte295 Truvada151,152 URSODIOL294,295 TUCATINIB111 USTEKINUMAB274 Tudorza Pressair389 USTEKINUMAB (IV)274 Tukysa111 Utibron Neohaler399 Turalio103 Twinrix365 V Twynsta228 Vagifem342 Tyblume342 VALACYCLOVIR HCL156,157 Tybost153 VALBENAZINE TOSYLATE260 Tykerb111 Valcyte145 Tylenol with Codeine #331 VALGANCICLOVIR HCL145 Tylenol with Codeine #431 VALPROATE SODIUM55,59 Tymlos370 VALPROIC ACID55,59 Tysabri265 VALSARTAN203,204 Tyvaso394 VALSARTAN-HYDROCHLOROTHIAZIDE223,228,229 Tyvaso Refill394 Valtoco 10 MG Dose59

PAGE 454 LAST UPDATED 03/2021 Valtoco 15 MG Dose59 VIBEGRON305 Valtoco 20 MG Dose59 Viberzi297 Valtoco 5 MG Dose59 Vibramycin53 Valtrex156,157 Victoza174 Valved Holding Chamber374 Videx152 Vancocin40 Videx EC152 Vancocin HCl40 Viekira Pak146 VANCOMYCIN HCL38,40 VIGABATRIN58,59 Vancomycin HCl40 Vigamox49 VANDETANIB105 Viibryd78 Vanos320 Viibryd Starter Pack78 Vantas353 VILAZODONE HCL78 Vaqta365 Vimovo10 VARENICLINE TARTRATE36 Vimpat67 Varubi (180 MG Dose)86 Vinate DHA RF292 Vascepa237 Vinate M292 Vaseretic229 Viokace304 Vasotec206 Vios Aerosol Delivery System374 Vectical278 Viracept155 VEDOLIZUMAB355 Viramune150 VELAGLUCERASE ALFA304 Viramune XR150 Velphoro285 Viread152 Veltassa285 Virt Nate292 Vemlidy146 Virt-C DHA292 VEMURAFENIB112 Virt-FeFA Plus292 Venclexta111,112 Virt-Nate DHA292 Venclexta Starting Pack112 Virt-PN292 VENETOCLAX111,112 Virt-PN DHA293 VENLAFAXINE HCL74,78 Virt-PN Plus293 Venofer282 Virt-Select293 Ventavis395 VirtPrex293 Ventolin HFA391 Visco-3374 VERAPAMIL HCL212,213,218,219 VISMODEGIB106 Verelan218 Vistaril387,388 Verelan PM218,219 Visudyne376 Versacloz144 Vitafol FE+293 VERTEPORFIN376 Vitafol Gummies293 Verzenio112 Vitafol Ultra293 VESIcare306 Vitafol-Nano293 VESIcare LS306 Vitafol-OB293 Vfend91 Vitafol-OB+DHA293

PAGE 455 LAST UPDATED 03/2021 Vitafol-One293 WestGel DHA294 Vitrakvi103 Wilate198 Vivelle-Dot342,343 Winlevi278 Vivitrol34 Wynzora278 Vivlodex10 Vizimpro103 X Vocabria148 Xadago120 VOCLOSPORIN357 Xalatan382 Vogelxo325 Xalkori112 Vogelxo Pump325 Xanax163 Vol-Plus293 Xanax XR163 Voltaren10 Xarelto183,184 VON WILLEBRAND FACTOR (RECOMBINANT)198 Xarelto Starter Pack184 Vonvendi198 Xatmep362 VORAPAXAR SULFATE184 Xcopri64 VORICONAZOLE91 Xcopri (250 MG Daily Dose)64 VORINOSTAT104 Xcopri (350 MG Daily Dose)64 VORTIOXETINE HBR77,78 Xeljanz362 Vosevi147 Xeljanz XR362 Votrient112 Xeloda100 VOXELOTOR200 Xelpros382 VP-PNV-DHA293 Xenazine260 Vpriv304 Xeomin144 Vraylar139,140 Xepi278 Vtol LQ260 Xerese157 Vumerity265 Xgeva370 Vumerity (Starter)265 Xhance386 Vusion91 Xifaxan40,41 Vyepti93 Xigduo XR174,175 Vytorin237 Xiidra376 Vyvanse245,246 Ximino53 Vyzulta381 Xofluza (40 MG Dose)156 Xofluza (80 MG Dose)156 W Xolair399 Wakix404 Xopenex391 WARFARIN SODIUM179,180,183 Xopenex Concentrate391 WATER FOR IRRIGATION, STERILE374 Xopenex HFA391 Welchol237 Xospata103 Wellbutrin SR72,73 Xpovio (100 MG Once Weekly)103 Wellbutrin XL73 Xpovio (40 MG Once Weekly)104 WesTab Plus294 Xpovio (40 MG Twice Weekly)104

PAGE 456 LAST UPDATED 03/2021 Xpovio (60 MG Once Weekly)104 Zepatier147 Xpovio (60 MG Twice Weekly)104 Zeposia265 Xpovio (80 MG Once Weekly)104 Zeposia 7-Day Starter Pack265 Xpovio (80 MG Twice Weekly)104 Zeposia Starter Kit265 Xtampza ER20 Zerit152 Xtandi98 Zerviate377 Xultophy179 Zestoretic229 Xyntha198,199 Zestril207 Xyntha Solofuse199 Zetia237 Xyosted325 Zetonna386 Ziac229 Y Ziagen152 Yasmin 28343 Ziana278 YAZ343 ZIDOVUDINE151,152,153 Yonsa98 Ziextenzo188 Yosprala200 ZILEUTON388 Yupelri389 Zinplava41 Yutiq379 Zioptan382 ZIPRASIDONE HCL130,140 Z ZIPRASIDONE MESYLATE130,140 ZAFIRLUKAST388 Zipsor10 ZALEPLON402 Zithromax47 Zanaflex144,145 Zithromax Tri-Pak47 ZANAMIVIR155 Zithromax Z-Pak47 Zantac297 Zocor234 ZANUBRUTINIB101 Zofran86 Zarontin55 Zofran ODT86 Zarxio187 Zohydro ER20,21 Zatean-Pn DHA294 Zoladex104 Zatean-Pn Plus294 ZOLEDRONIC ACID369,370,371 Zavesca304 Zoledronic Acid370 ZCORT 7-Day320 Zolinza104 Zegerid302 ZOLMITRIPTAN96 Zejula112 ZOLMitriptan96 Zelapar120 Zoloft78,79 Zelboraf112 ZOLPIDEM TARTRATE401,402,403 Zelnorm297 Zolpimist403 Zembrace SymTouch96 Zomacton322 Zemplar370 Zomacton (for Zoma-Jet 10)322 Zenpep304 Zometa370,371 Zenzedi247 Zomig96

PAGE 457 LAST UPDATED 03/2021 Zomig ZMT96 ZONISAMIDE55 Zontivity184 Zorbtive322 Zortress362 Zorvolex10 ZOSTER VACCINE RECOMBINANT ADJUVANTED365 Zovirax157 ZTlido33 Zubsolv35 Zuplenz86 Zurampic92 Zyban36 Zyclara278 Zyclara Pump278 Zydelig112 Zyflo388 Zyflo CR388 Zykadia112 Zylet376 Zyloprim92 Zymaxid49 Zypitamag234,235 ZyPREXA140,141 ZyPREXA Relprevv141 ZyPREXA Zydis141,142 Zytiga99

PAGE 458 LAST UPDATED 03/2021