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VALUE Drug Formulary Updates

January, 2019

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2019 PHENERGAN promethazine hcl NEW AUTO RULE Non-formulary 01/01/2019 SEROPHENE clomiphene citrate NEW AUTO RULE Non-formulary 01/01/2019 cyproheptadine cyproheptadine hcl NEW AUTO RULE Tier 1 hcl 01/01/2019 cyproheptadine cyproheptadine hcl CHANGE TIER Tier 1 Non-formulary hcl 01/01/2020 omeppi omeprazole/sodium UM AUTO RULE: 1 cap/day bicarbonate QUANTITYCUSTOM 01/01/2020 LEVEMIR detemir NEW AUTO RULE Tier 2 01/01/2020 PRALUENT alirocumab TERM AUTO RULE SYRINGE 01/01/2020 salimez salicylic acid NEW AUTO RULE Non-Formulary 01/01/2020 genultimate test blood sugar diagnostic NEW AUTO RULE Non-formulary strip 01/01/2020 SYNAREL nafarelin acetate UM AUTO RULE: PA Applies AUTHORIZATION 01/01/2020 ROZLYTREK entrectinib UM AUTO RULE: CUSTOM Short Cycle 01/01/2020 clomiphene clomiphene citrate UM AUTO RULE: 10 tabs/28 days citrate QUANTITYCUSTOM 01/01/2020 LEVEMIR NEW AUTO RULE Tier 2 FLEXTOUCH 01/01/2020 RYBELSUS NEW AUTO RULE Tier 2 01/01/2020 SEROPHENE clomiphene citrate UM AUTO RULE: 10 tabs/28 days QUANTITYCUSTOM 01/01/2020 GONAL-F RFF follitropin alfa, recombinant NEW AUTO RULE NF specialty

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 1 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2020 valproic acid valproic acid (as sodium UM AUTO RULE: PA Applies salt) ( sodium) AUTHORIZATION 01/01/2020 UPTRAVI selexipag CHANGE UM: 2 tabs/day 140 tabs/180 QUANTITYCUSTOM days 01/01/2020 metoclopramide hcl ADD UM: AUTHORIZATION PA Applies hcl 01/01/2020 GONAL-F follitropin alfa, recombinant NEW AUTO RULE NF specialty 01/01/2020 GONAL-F RFF follitropin alfa, recombinant NEW AUTO RULE NF specialty REDI-JECT 01/01/2020 SENSIPAR cinacalcet hcl NEW AUTO RULE NF specialty 01/01/2020 RYBELSUS semaglutide TERM AUTO RULE 01/01/2020 GANIRELIX ganirelix acetate NEW AUTO RULE NF specialty ACETATE 01/01/2020 virtrate-2 citric acid/sodium citrate NEW AUTO RULE Non-formulary 01/01/2020 PERSANTINE dipyridamole TERM AUTO RULE 01/01/2020 XELJANZ tofacitinib citrate NEW AUTO RULE Tier 4 01/01/2020 abacavir- abacavir NEW AUTO RULE Tier 1 lamivudine- sulfate/lamivudine/zidovudin zidovudine e 01/01/2020 ALUNBRIG brigatinib UM AUTO RULE: CUSTOM Short Cycle 01/01/2020 KERALYT salicylic acid NEW AUTO RULE Non-Formulary 01/01/2020 PRALUENT PEN alirocumab TERM AUTO RULE 01/01/2020 urea urea NEW AUTO RULE Tier 1 01/01/2020 TRESIBA TERM AUTO RULE 01/01/2020 REPATHA evolocumab TERM AUTO RULE SYRINGE 01/01/2020 LEVEMIR insulin detemir TERM AUTO RULE FLEXTOUCH

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 2 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2020 LEVEMIR insulin detemir TERM AUTO RULE 01/01/2020 FULYZAQ crofelemer NEW AUTO RULE Non-formulary 01/01/2020 REGRANEX becaplermin NEW AUTO RULE NF specialty 01/01/2020 TASIGNA nilotinib hcl UM AUTO RULE: CUSTOM Short Cycle 01/01/2020 hydroxyzine hcl hydroxyzine hcl ADD UM: AUTHORIZATION PA Applies 01/01/2020 KERYDIN tavaborole NEW AUTO RULE NF specialty 01/01/2020 TRIUMEQ abacavir sulfate/dolutegravir NEW AUTO RULE Tier 3 sodium/lamivudine 01/01/2020 MENOPUR menotropins NEW AUTO RULE NF specialty 01/01/2020 REPATHA evolocumab TERM AUTO RULE SURECLICK 01/01/2020 easygluco plus blood sugar diagnostic NEW AUTO RULE Non-formulary 01/01/2020 ADVAIR HFA fluticasone NEW AUTO RULE Tier 2 propionate/salmeterol xinafoate 01/01/2020 SEROPHENE clomiphene citrate TERM AUTO RULE 01/01/2020 choicedm clarus blood sugar diagnostic NEW AUTO RULE Non-formulary test strips 01/01/2020 clomiphene clomiphene citrate TERM AUTO RULE citrate 01/01/2020 FOLLISTIM AQ follitropin beta,recombinant NEW AUTO RULE NF specialty 01/01/2020 VITRAKVI larotrectinib sulfate UM AUTO RULE: CUSTOM Short Cycle 01/01/2020 TRESIBA insulin degludec TERM AUTO RULE FLEXTOUCH U- 200 01/01/2020 TRESIBA insulin degludec NEW AUTO RULE Tier 2 FLEXTOUCH U- 100

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 3 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2020 OTEZLA apremilast NEW AUTO RULE Tier 4 01/01/2020 TALZENNA talazoparib tosylate UM AUTO RULE: CUSTOM Short Cycle 01/01/2020 theophylline theophylline anhydrous ADD UM: AUTHORIZATION PA Applies 01/01/2020 salicylic acid salicylic acid NEW AUTO RULE Non-Formulary 01/01/2020 simvastatin simvastatin UM AUTO RULE: 5 ml/day QUANTITYCUSTOM 01/01/2020 QUFLORA pediatric multivitamin no.157 NEW AUTO RULE Non-formulary with sodium fluoride 01/01/2020 erlotinib hcl erlotinib hcl TERM AUTO RULE 01/01/2020 TRESIBA insulin degludec NEW AUTO RULE Tier 2 01/01/2020 XELJANZ XR tofacitinib citrate NEW AUTO RULE Tier 4 01/01/2020 REPATHA evolocumab TERM AUTO RULE PUSHTRONEX 01/01/2020 NOVAREL chorionic gonadotropin, NEW AUTO RULE NF specialty human 01/01/2020 budesonide er budesonide UM AUTO RULE: 1 tab/day; not to QUANTITYCUSTOM exceed 60 days therapy/90 days 01/01/2020 bexarotene bexarotene TERM AUTO RULE 01/01/2020 deferasirox deferasirox UM AUTO RULE: CUSTOM Short Cycle 01/01/2020 CHORIONIC chorionic gonadotropin, NEW AUTO RULE NF specialty GONADOTROPI human N 01/01/2020 LORBRENA lorlatinib UM AUTO RULE: CUSTOM Short Cycle 01/01/2020 STELARA ustekinumab NEW AUTO RULE Tier 4 01/01/2020 CYMBALTA duloxetine hcl UM AUTO RULE: 2 caps/day QUANTITYCUSTOM

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 4 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2020 relion confirm- blood sugar diagnostic NEW AUTO RULE Non-formulary micro 01/01/2020 duloxetine hcl duloxetine hcl UM AUTO RULE: 2 caps/day QUANTITYCUSTOM 01/01/2020 TRESIBA insulin degludec TERM AUTO RULE FLEXTOUCH U- 100 01/01/2020 TRESIBA insulin degludec NEW AUTO RULE Tier 2 FLEXTOUCH U- 200 01/01/2020 microdot xtra blood sugar diagnostic NEW AUTO RULE Non-formulary 01/01/2020 ultima blood sugar diagnostic NEW AUTO RULE Non-formulary 01/01/2020 FIRAZYR acetate NEW AUTO RULE NF specialty 01/01/2020 ABSORICA isotretinoin UM AUTO RULE: PA Applies AUTHORIZATION 01/01/2020 td gold test strip blood sugar diagnostic NEW AUTO RULE Non-formulary 01/01/2020 NUBEQA darolutamide UM AUTO RULE: CUSTOM Short Cycle 01/01/2020 SKYRIZI (2 risankizumab-rzaa NEW AUTO RULE Tier 4 SYRINGES) KIT 01/01/2020 UCERIS budesonide UM AUTO RULE: 1 tab/day; not to QUANTITYCUSTOM exceed 60 days therapy/90 days 01/01/2020 BOSULIF bosutinib UM AUTO RULE: CUSTOM Short Cycle 01/01/2020 OVIDREL choriogonadotropin alfa NEW AUTO RULE NF specialty 01/01/2020 CETROTIDE cetrorelix acetate NEW AUTO RULE NF specialty 01/01/2020 VIZIMPRO dacomitinib UM AUTO RULE: CUSTOM Short Cycle 01/01/2020 PREGNYL chorionic gonadotropin, NEW AUTO RULE NF specialty human

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 5 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2020 ATRIPLA efavirenz/emtricitabine/tenof UM AUTO RULE: PA Applies ovir disoproxil fumarate AUTHORIZATION 01/01/2020 abacavir- abacavir sulfate/lamivudine NEW AUTO RULE Tier 1 lamivudine 01/01/2020 CABOMETYX cabozantinib s-malate UM AUTO RULE: CUSTOM Short Cycle 01/01/2020 TREMFYA guselkumab NEW AUTO RULE Tier 4 01/01/2020 genstrip blood sugar diagnostic NEW AUTO RULE Non-formulary 01/01/2021 ZYDELIG idelalisib TERM AUTO RULE 01/01/2021 TECHNIVIE ombitasvir/paritaprevir/ritona TERM AUTO RULE vir 01/01/2021 BYNFEZIA octreotide acetate TERM AUTO RULE 01/01/2021 hidex dexamethasone TERM AUTO RULE 01/01/2021 SYMPAZAN clobazam TERM AUTO RULE 01/01/2021 VIEKIRA PAK ombitasvir/paritaprevir/ritona TERM AUTO RULE vir/dasabuvir sodium 01/01/2021 prodigy no coding blood sugar diagnostic TERM AUTO RULE 01/01/2021 INVOKAMET XR canagliflozin/metformin hcl TERM AUTO RULE 01/01/2021 TANZEUM TERM AUTO RULE 01/01/2021 glucocard 01 blood sugar diagnostic TERM AUTO RULE sensor plus 01/01/2021 clobetasol clobetasol TERM AUTO RULE emollient propionate/emollient base 01/01/2021 LEUKINE sargramostim TERM AUTO RULE 01/01/2021 EDLUAR zolpidem tartrate TERM AUTO RULE 01/01/2021 CUVPOSA glycopyrrolate TERM AUTO RULE 01/01/2021 microdot blood sugar diagnostic TERM AUTO RULE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 6 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 CHORIONIC chorionic gonadotropin, REMOVE UM: PA Applies GONADOTROPI human AUTHORIZATION N 01/01/2021 PONSTEL mefenamic acid UM AUTO RULE: PA Applies AUTHORIZATION 01/01/2021 clever choice blood sugar diagnostic TERM AUTO RULE micro test strip 01/01/2021 VYNDAMAX tafamidis TERM AUTO RULE 01/01/2021 insulin lispro NEW AUTO RULE Non-formulary KWIKPEN U-100 01/01/2021 MEPRON atovaquone TERM AUTO RULE 01/01/2021 ZEBUTAL butalbital/acetaminophen/caf UM AUTO RULE: PA Applies feine AUTHORIZATION 01/01/2021 ZAVESCA miglustat TERM AUTO RULE 01/01/2021 SUBSYS fentanyl TERM AUTO RULE 01/01/2021 prednisolone prednisolone sodium TERM AUTO RULE sodium phos odt phosphate 01/01/2021 PARAFON chlorzoxazone TERM AUTO RULE FORTE DSC 01/01/2021 KUVAN sapropterin dihydrochloride TERM AUTO RULE 01/01/2021 APLENZIN bupropion hbr TERM AUTO RULE 01/01/2021 premium v10 blood sugar diagnostic TERM AUTO RULE 01/01/2021 D.H.E.45 mesylate TERM AUTO RULE 01/01/2021 AUVI-Q epinephrine TERM AUTO RULE 01/01/2021 ABSORICA LD isotretinoin, micronized TERM AUTO RULE 01/01/2021 smartest test blood sugar diagnostic TERM AUTO RULE 01/01/2021 fora tn'g voice blood sugar diagnostic TERM AUTO RULE test strips

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 7 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 hcl er clonidine hcl TERM AUTO RULE 01/01/2021 contour test strip blood sugar diagnostic TERM AUTO RULE 01/01/2021 easy plus ii blood sugar diagnostic TERM AUTO RULE 01/01/2021 LENVIMA lenvatinib mesylate TERM AUTO RULE 01/01/2021 chlorzoxazone chlorzoxazone TERM AUTO RULE 01/01/2021 BYDUREON microspheres TERM AUTO RULE BCISE 01/01/2021 OCALIVA obeticholic acid TERM AUTO RULE 01/01/2021 GONAL-F RFF follitropin alfa, recombinant TERM AUTO RULE 01/01/2021 DONNATAL phenobarbital/hyoscyamine NEW AUTO RULE Non-formulary sulf/atropine sulf/scopolamine hb 01/01/2021 PRALUENT PEN alirocumab TERM AUTO RULE 01/01/2021 infinity test strips blood sugar diagnostic TERM AUTO RULE 01/01/2021 SERNIVO betamethasone dipropionate TERM AUTO RULE 01/01/2021 NAPROSYN naproxen UM AUTO RULE: PA Applies AUTHORIZATION 01/01/2021 SABRIL vigabatrin TERM AUTO RULE 01/01/2021 LETAIRIS TERM AUTO RULE 01/01/2021 EMBEDA morphine sulfate/naltrexone TERM AUTO RULE hcl 01/01/2021 NOVOLIN 70-30 insulin nph human TERM AUTO RULE FLEXPEN isophane/insulin regular, human 01/01/2021 ZONALON doxepin hcl TERM AUTO RULE 01/01/2021 glucocard vital blood sugar diagnostic TERM AUTO RULE sensor

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 8 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 vicodin es hydrocodone TERM AUTO RULE bitartrate/acetaminophen 01/01/2021 ARAKODA tafenoquine succinate TERM AUTO RULE 01/01/2021 NUCYNTA tapentadol hcl TERM AUTO RULE 01/01/2021 QUILLIVANT XR methylphenidate hcl TERM AUTO RULE 01/01/2021 NUZYRA omadacycline tosylate TERM AUTO RULE 01/01/2021 v-go 20 sub-q insulin delivery TERM AUTO RULE device, 20 unit,disposable 01/01/2021 SUCRAID sacrosidase TERM AUTO RULE 01/01/2021 hydrocortisone hydrocortisone/mineral TERM AUTO RULE oil/petrolatum,white 01/01/2021 OFEV nintedanib esylate TERM AUTO RULE 01/01/2021 vicodin hp hydrocodone TERM AUTO RULE bitartrate/acetaminophen 01/01/2021 vigadrone vigabatrin TERM AUTO RULE 01/01/2021 CARAC fluorouracil TERM AUTO RULE 01/01/2021 LYRICA CR pregabalin TERM AUTO RULE 01/01/2021 glucocard shine blood sugar diagnostic TERM AUTO RULE 01/01/2021 ARANESP darbepoetin alfa in TERM AUTO RULE polysorbate 80 01/01/2021 fifty50 test strip blood sugar diagnostic TERM AUTO RULE 01/01/2021 BYDUREON exenatide microspheres TERM AUTO RULE PEN 01/01/2021 TIGLUTIK riluzole TERM AUTO RULE 01/01/2021 MENOPUR menotropins TERM AUTO RULE 01/01/2021 HALOG halcinonide NEW AUTO RULE NF specialty

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 9 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 butalb- butalbital/acetaminophen/caf UM AUTO RULE: PA Applies acetaminoph- feine/codeine phosphate AUTHORIZATION caff-codein 01/01/2021 morphine sulfate morphine sulfate TERM AUTO RULE er 01/01/2021 salicylic acid salicylic acid NEW AUTO RULE Tier 1 01/01/2021 MAKENA hydroxyprogesterone TERM AUTO RULE caproate/pf 01/01/2021 GENOTROPIN somatropin TERM AUTO RULE 01/01/2021 NERLYNX neratinib maleate TERM AUTO RULE 01/01/2021 NESINA alogliptin benzoate TERM AUTO RULE 01/01/2021 PRADAXA dabigatran etexilate TERM AUTO RULE mesylate 01/01/2021 easy gluco g2 blood sugar diagnostic TERM AUTO RULE 01/01/2021 FORTEO TERM AUTO RULE 01/01/2021 healthpro glucose blood sugar diagnostic TERM AUTO RULE test strips 01/01/2021 EVZIO naloxone hcl TERM AUTO RULE 01/01/2021 TREZIX acetaminophen/caffeine/dihy TERM AUTO RULE drocodeine bitartrate 01/01/2021 NOVOLOG MIX protamine TERM AUTO RULE 70-30 FLEXPEN human/insulin aspart 01/01/2021 ALLZITAL butalbital/acetaminophen TERM AUTO RULE 01/01/2021 SAIZEN- somatropin TERM AUTO RULE SAIZENPREP 01/01/2021 ergoloid ergoloid mesylates NEW AUTO RULE Tier 3 mesylates 01/01/2021 OLUMIANT baricitinib TERM AUTO RULE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 10 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 oxandrolone oxandrolone NEW AUTO RULE Tier 3 01/01/2021 zodex dexamethasone TERM AUTO RULE 01/01/2021 LAMICTAL ODT lamotrigine TERM AUTO RULE (ORANGE) 01/01/2021 INVOKAMET canagliflozin/metformin hcl TERM AUTO RULE 01/01/2021 SOLOSEC secnidazole TERM AUTO RULE 01/01/2021 TRADJENTA linagliptin TERM AUTO RULE 01/01/2021 ZYFLO CR zileuton TERM AUTO RULE 01/01/2021 ZEJULA niraparib tosylate TERM AUTO RULE 01/01/2021 NOVOLIN N insulin nph human isophane TERM AUTO RULE FLEXPEN 01/01/2021 glucocard blood sugar diagnostic TERM AUTO RULE expression 01/01/2021 TESTIM testosterone TERM AUTO RULE 01/01/2021 omnipod insulin pump cartridge TERM AUTO RULE 01/01/2021 vitamin d2 ergocalciferol (vitamin d2) NEW AUTO RULE Non-Formulary 01/01/2021 inpen (for insulin admin. supplies TERM AUTO RULE humalog) 01/01/2021 febuxostat febuxostat NEW AUTO RULE Non-formulary 01/01/2021 NATPARA TERM AUTO RULE 01/01/2021 VYNDAQEL tafamidis meglumine TERM AUTO RULE 01/01/2021 travoprost travoprost NEW AUTO RULE Tier 3 01/01/2021 DESONATE desonide TERM AUTO RULE 01/01/2021 KISQALI ribociclib succinate/letrozole TERM AUTO RULE FEMARA CO- PACK 01/01/2021 SUNOSI solriamfetol hcl TERM AUTO RULE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 11 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 lamotrigine odt lamotrigine TERM AUTO RULE 01/01/2021 OTREXUP methotrexate/pf TERM AUTO RULE 01/01/2021 BROMSITE bromfenac sodium TERM AUTO RULE 01/01/2021 LEVITRA vardenafil hcl TERM AUTO RULE 01/01/2021 DIFICID fidaxomicin TERM AUTO RULE 01/01/2021 ledipasvir- ledipasvir/sofosbuvir TERM AUTO RULE sofosbuvir 01/01/2021 MIGRANAL dihydroergotamine mesylate TERM AUTO RULE 01/01/2021 MAKENA hydroxyprogesterone TERM AUTO RULE caproate 01/01/2021 okebo doxycycline monohydrate TERM AUTO RULE 01/01/2021 pyrimethamine pyrimethamine NEW AUTO RULE Tier 4 01/01/2021 solifenacin solifenacin succinate NEW AUTO RULE Tier 2 succinate 01/01/2021 hydrocodone- guaifenesin/hydrocodone TERM AUTO RULE guaifenesin bitartrate 01/01/2021 REPATHA evolocumab TERM AUTO RULE SYRINGE 01/01/2021 PLEGRIDY PEN peginterferon beta-1a TERM AUTO RULE 01/01/2021 DEPEN penicillamine TERM AUTO RULE 01/01/2021 fora d15g blood sugar diagnostic TERM AUTO RULE 01/01/2021 FENORTHO fenoprofen calcium TERM AUTO RULE 01/01/2021 metronidazole metronidazole NEW AUTO RULE Non-formulary 01/01/2021 fioricet butalbital/acetaminophen/caf NEW AUTO RULE Non-formulary feine 01/01/2021 ONMEL itraconazole TERM AUTO RULE 01/01/2021 RHOPRESSA netarsudil mesylate TERM AUTO RULE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 12 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 TRINATE prenatal vits with calcium NEW AUTO RULE Tier 1 no.73/ferrous fumarate/folic acid 01/01/2021 REPATHA evolocumab NEW AUTO RULE Non-formulary PUSHTRONEX 01/01/2021 mondoxyne nl doxycycline monohydrate TERM AUTO RULE 01/01/2021 CLOBEX clobetasol propionate TERM AUTO RULE 01/01/2021 COTELLIC cobimetinib fumarate TERM AUTO RULE 01/01/2021 ESGIC butalbital/acetaminophen/caf TERM AUTO RULE feine 01/01/2021 DULERA mometasone TERM AUTO RULE furoate/formoterol fumarate 01/01/2021 VIEKIRA XR ombitasvir/paritaprevir/ritona TERM AUTO RULE vir/dasabuvir sodium 01/01/2021 test strips blood sugar diagnostic TERM AUTO RULE 01/01/2021 SENSIPAR cinacalcet hcl TERM AUTO RULE 01/01/2021 ZONALON doxepin hcl NEW AUTO RULE NF specialty 01/01/2021 INGREZZA valbenazine tosylate TERM AUTO RULE 01/01/2021 KADIAN morphine sulfate TERM AUTO RULE 01/01/2021 NAPRELAN naproxen sodium UM AUTO RULE: PA Applies AUTHORIZATION 01/01/2021 RAYOS prednisone TERM AUTO RULE 01/01/2021 ultima blood sugar diagnostic TERM AUTO RULE 01/01/2021 DARAPRIM pyrimethamine TERM AUTO RULE 01/01/2021 SANCUSO granisetron TERM AUTO RULE 01/01/2021 XHANCE fluticasone propionate TERM AUTO RULE 01/01/2021 ZIPSOR diclofenac potassium TERM AUTO RULE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 13 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 TIVORBEX indomethacin, TERM AUTO RULE submicronized 01/01/2021 VIZIMPRO dacomitinib TERM AUTO RULE 01/01/2021 LAMICTAL ODT lamotrigine TERM AUTO RULE (BLUE) 01/01/2021 embrace evo blood sugar diagnostic TERM AUTO RULE 01/01/2021 GALAFOLD migalastat hcl TERM AUTO RULE 01/01/2021 INSULIN insulin aspart REMOVE UM: PA Applies ASPART AUTHORIZATION 01/01/2021 MOTEGRITY prucalopride succinate TERM AUTO RULE 01/01/2021 AUSTEDO deutetrabenazine TERM AUTO RULE 01/01/2021 OPSUMIT TERM AUTO RULE 01/01/2021 OSPHENA ospemifene TERM AUTO RULE 01/01/2021 evencare blood sugar diagnostic TERM AUTO RULE 01/01/2021 omnipod dash 5 insulin pump cartridge TERM AUTO RULE pack pod 01/01/2021 dario blood blood sugar diagnostic TERM AUTO RULE glucose test strip 01/01/2021 metformin hcl metformin hcl TERM AUTO RULE 01/01/2021 delta d3 cholecalciferol (vitamin d3) TERM AUTO RULE 01/01/2021 SUMAXIN TS sulfacetamide sodium/sulfur TERM AUTO RULE 01/01/2021 ZELBORAF vemurafenib TERM AUTO RULE 01/01/2021 XULTOPHY 100- insulin degludec/ TERM AUTO RULE 3.6 01/01/2021 vgo 20 sub-q insulin delivery TERM AUTO RULE device, 20 unit,disposable 01/01/2021 oxycodone- oxycodone TERM AUTO RULE acetaminophen hcl/acetaminophen

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 14 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 FLUOROPLEX fluorouracil NEW AUTO RULE NF specialty 01/01/2021 VERZENIO abemaciclib TERM AUTO RULE 01/01/2021 SYMPROIC naldemedine tosylate TERM AUTO RULE 01/01/2021 TALTZ SYRINGE ixekizumab TERM AUTO RULE (3 PACK) 01/01/2021 INTERMEZZO zolpidem tartrate TERM AUTO RULE 01/01/2021 on call plus test blood sugar diagnostic TERM AUTO RULE strip 01/01/2021 NUEDEXTA dextromethorphan TERM AUTO RULE hbr/quinidine sulfate 01/01/2021 NORDITROPIN somatropin TERM AUTO RULE FLEXPRO 01/01/2021 QUDEXY XR TERM AUTO RULE 01/01/2021 XYREM sodium oxybate TERM AUTO RULE 01/01/2021 fluorouracil fluorouracil TERM AUTO RULE 01/01/2021 butalbital- butalbital/acetaminophen TERM AUTO RULE acetaminophen 01/01/2021 PROCRIT epoetin alfa TERM AUTO RULE 01/01/2021 premier test strip blood sugar diagnostic TERM AUTO RULE 01/01/2021 hydrocodone- hydrocodone REMOVE UM: PA Applies acetaminophen bitartrate/acetaminophen AUTHORIZATION 01/01/2021 JORNAY PM methylphenidate hcl TERM AUTO RULE 01/01/2021 accutrend blood sugar diagnostic TERM AUTO RULE glucose 01/01/2021 armodafinil armodafinil TERM AUTO RULE 01/01/2021 fluocinolone fluocinolone acetonide oil TERM AUTO RULE acetonide oil 01/01/2021 desonide desonide TERM AUTO RULE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 15 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 flurandrenolide flurandrenolide TERM AUTO RULE 01/01/2021 PLEXION sulfacetamide sodium/sulfur TERM AUTO RULE 01/01/2021 SORILUX calcipotriene TERM AUTO RULE 01/01/2021 glucose test strip blood sugar diagnostic TERM AUTO RULE 01/01/2021 tolcapone tolcapone NEW AUTO RULE NF specialty 01/01/2021 MAVENCLAD cladribine TERM AUTO RULE 01/01/2021 LORZONE chlorzoxazone TERM AUTO RULE 01/01/2021 YONSA abiraterone acetate, TERM AUTO RULE submicronized 01/01/2021 KOSELUGO selumetinib sulfate/vitamin e TERM AUTO RULE tpgs 01/01/2021 easy trak blood sugar diagnostic TERM AUTO RULE 01/01/2021 VERDESO desonide TERM AUTO RULE 01/01/2021 HARVONI ledipasvir/sofosbuvir TERM AUTO RULE 01/01/2021 butalb- butalbital/acetaminophen/caf TERM AUTO RULE acetaminoph- feine/codeine phosphate caff-codein 01/01/2021 panlor acetaminophen/caffeine/dihy TERM AUTO RULE drocodeine bitartrate 01/01/2021 DOPTELET avatrombopag maleate REMOVE UM: PA Applies AUTHORIZATION 01/01/2021 KISQALI ribociclib succinate TERM AUTO RULE 01/01/2021 fora v30a blood sugar diagnostic TERM AUTO RULE 01/01/2021 methylphenidate methylphenidate hcl NEW AUTO RULE Tier 2 er 01/01/2021 okebo doxycycline monohydrate UM AUTO RULE: PA Applies AUTHORIZATION 01/01/2021 AEMCOLO rifamycin sodium TERM AUTO RULE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 16 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 VIVLODEX meloxicam, submicronized TERM AUTO RULE 01/01/2021 OMNITROPE somatropin TERM AUTO RULE 01/01/2021 METOZOLV ODT metoclopramide hcl TERM AUTO RULE 01/01/2021 assure 4 blood sugar diagnostic TERM AUTO RULE 01/01/2021 precision xtra blood sugar diagnostic TERM AUTO RULE 01/01/2021 DICLEGIS doxylamine TERM AUTO RULE succinate/pyridoxine hcl (b6) 01/01/2021 DIACOMIT stiripentol TERM AUTO RULE 01/01/2021 CAPLYTA lumateperone tosylate TERM AUTO RULE 01/01/2021 ORAVIG miconazole TERM AUTO RULE 01/01/2021 kids vitamin d3 cholecalciferol (vitamin d3) NEW AUTO RULE Non-Formulary 01/01/2021 easymax 15 blood sugar diagnostic TERM AUTO RULE 01/01/2021 relion confirm- blood sugar diagnostic TERM AUTO RULE micro 01/01/2021 SUPRENZA ODT phentermine hcl TERM AUTO RULE 01/01/2021 OLUX clobetasol propionate TERM AUTO RULE 01/01/2021 AMICAR aminocaproic acid NEW AUTO RULE NF specialty 01/01/2021 EGRIFTA SV tesamorelin acetate TERM AUTO RULE 01/01/2021 doxylamine succ- doxylamine TERM AUTO RULE pyridoxine hcl succinate/pyridoxine hcl (b6) 01/01/2021 ACTEMRA tocilizumab TERM AUTO RULE 01/01/2021 FIORICET WITH butalbital/acetaminophen/caf UM AUTO RULE: PA Applies CODEINE feine/codeine phosphate AUTHORIZATION 01/01/2021 calcipotriene- calcipotriene/betamethason TERM AUTO RULE betamethasone e dipropionate dp

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 17 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 ESGIC butalbital/acetaminophen/caf UM AUTO RULE: PA Applies feine AUTHORIZATION 01/01/2021 TRACLEER TERM AUTO RULE 01/01/2021 easy talk blood sugar diagnostic TERM AUTO RULE 01/01/2021 EMGALITY -gnlm TERM AUTO RULE SYRINGE 01/01/2021 DUPIXENT dupilumab TERM AUTO RULE SYRINGE 01/01/2021 vicodin hydrocodone UM AUTO RULE: PA Applies bitartrate/acetaminophen AUTHORIZATION 01/01/2021 BETASERON interferon beta-1b TERM AUTO RULE 01/01/2021 PROCYSBI cysteamine bitartrate TERM AUTO RULE 01/01/2021 LEXETTE halobetasol propionate TERM AUTO RULE 01/01/2021 omeppi omeprazole/sodium TERM AUTO RULE bicarbonate 01/01/2021 verasens test blood sugar diagnostic TERM AUTO RULE strip 01/01/2021 gluco navii blood sugar diagnostic TERM AUTO RULE 01/01/2021 RHOFADE oxymetazoline hcl TERM AUTO RULE 01/01/2021 AJOVY -vfrm TERM AUTO RULE SYRINGE 01/01/2021 DOLOPHINE methadone hcl TERM AUTO RULE HCL 01/01/2021 KITABIS PAK tobramycin/nebulizer TERM AUTO RULE 01/01/2021 E.E.S. 200 erythromycin ethylsuccinate UM AUTO RULE: PA Applies AUTHORIZATION 01/01/2021 caresens n blood sugar diagnostic TERM AUTO RULE 01/01/2021 ABILIFY MYCITE aripiprazole TERM AUTO RULE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 18 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 CORDRAN flurandrenolide TERM AUTO RULE 01/01/2021 hydrocodone hydrocodone bitartrate TERM AUTO RULE bitartrate er 01/01/2021 alosetron hcl alosetron hcl NEW AUTO RULE Tier 4 01/01/2021 CONSENSI amlodipine TERM AUTO RULE besylate/celecoxib 01/01/2021 ISTURISA osilodrostat phosphate TERM AUTO RULE 01/01/2021 INBRIJA levodopa TERM AUTO RULE 01/01/2021 CONTRAVE naltrexone hcl/bupropion hcl TERM AUTO RULE 01/01/2021 TOBI tobramycin in 0.225 % TERM AUTO RULE sodium chloride 01/01/2021 atovaquone atovaquone NEW AUTO RULE Tier 3 01/01/2021 ORFADIN nitisinone TERM AUTO RULE 01/01/2021 AXIRON testosterone TERM AUTO RULE 01/01/2021 TACLONEX calcipotriene/betamethason TERM AUTO RULE e dipropionate 01/01/2021 ZIEXTENZO pegfilgrastim-bmez TERM AUTO RULE 01/01/2021 quintet blood sugar diagnostic TERM AUTO RULE 01/01/2021 TROKENDI XR topiramate TERM AUTO RULE 01/01/2021 TIROSINT-SOL levothyroxine sodium NEW AUTO RULE Non-formulary 01/01/2021 SOVALDI sofosbuvir TERM AUTO RULE 01/01/2021 PEMAZYRE pemigatinib TERM AUTO RULE 01/01/2021 emverm mebendazole TERM AUTO RULE 01/01/2021 taperdex dexamethasone REMOVE UM: PA Applies AUTHORIZATION 01/01/2021 KORLYM mifepristone TERM AUTO RULE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 19 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 EZALLOR rosuvastatin calcium TERM AUTO RULE SPRINKLE 01/01/2021 truetrack test blood sugar diagnostic TERM AUTO RULE strip 01/01/2021 ge100 blood blood sugar diagnostic TERM AUTO RULE glucose test strip 01/01/2021 CAVERJECT alprostadil TERM AUTO RULE 01/01/2021 novopen echo insulin admin. supplies TERM AUTO RULE 01/01/2021 INVELTYS loteprednol etabonate TERM AUTO RULE 01/01/2021 VENTOLIN HFA albuterol sulfate NEW AUTO RULE Non-formulary 01/01/2021 hydrocodone- hydrocodone TERM AUTO RULE acetaminophen bitartrate/acetaminophen 01/01/2021 KOMBIGLYZE saxagliptin hcl/metformin hcl TERM AUTO RULE XR 01/01/2021 dutasteride- dutasteride/tamsulosin hcl TERM AUTO RULE tamsulosin 01/01/2021 IMPOYZ clobetasol propionate TERM AUTO RULE 01/01/2021 SEGLUROMET ertugliflozin TERM AUTO RULE pidolate/metformin hcl 01/01/2021 MONODOX doxycycline monohydrate TERM AUTO RULE 01/01/2021 ZERVIATE cetirizine hcl TERM AUTO RULE 01/01/2021 CHOLBAM cholic acid TERM AUTO RULE 01/01/2021 SITAVIG acyclovir TERM AUTO RULE 01/01/2021 ONZETRA XSAIL succinate TERM AUTO RULE 01/01/2021 XCOPRI cenobamate TERM AUTO RULE 01/01/2021 true metrix blood sugar diagnostic TERM AUTO RULE glucose test strip 01/01/2021 ALINIA nitazoxanide TERM AUTO RULE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 20 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 ENSTILAR calcipotriene/betamethason TERM AUTO RULE e dipropionate 01/01/2021 choicedm clarus blood sugar diagnostic TERM AUTO RULE test strips 01/01/2021 INGREZZA valbenazine tosylate TERM AUTO RULE INITIATION PACK 01/01/2021 DAXBIA cephalexin TERM AUTO RULE 01/01/2021 precision pcx blood sugar diagnostic TERM AUTO RULE plus 01/01/2021 prednisolone prednisolone sodium UM AUTO RULE: PA Applies sodium phos odt phosphate AUTHORIZATION 01/01/2021 DURAGESIC fentanyl TERM AUTO RULE 01/01/2021 zolpidem tartrate zolpidem tartrate TERM AUTO RULE 01/01/2021 VUMERITY diroximel fumarate TERM AUTO RULE 01/01/2021 STEGLUJAN ertugliflozin TERM AUTO RULE pidolate/sitagliptin phosphate 01/01/2021 VIBERZI eluxadoline TERM AUTO RULE 01/01/2021 QBRELIS lisinopril TERM AUTO RULE 01/01/2021 ENDARI glutamine TERM AUTO RULE 01/01/2021 XARTEMIS XR oxycodone TERM AUTO RULE hcl/acetaminophen 01/01/2021 NUPLAZID pimavanserin tartrate TERM AUTO RULE 01/01/2021 ZORBTIVE somatropin TERM AUTO RULE 01/01/2021 HEMANGEOL hcl TERM AUTO RULE 01/01/2021 COLYTE WITH peg 3350/sod sulf/sod TERM AUTO RULE FLAVOR bicarb/sod PACKETS chloride/potassium chloride

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 21 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 DORYX doxycycline hyclate TERM AUTO RULE 01/01/2021 exemestane exemestane NEW AUTO RULE Tier 2 01/01/2021 BYDUREON exenatide microspheres TERM AUTO RULE 01/01/2021 KAZANO alogliptin TERM AUTO RULE benzoate/metformin hcl 01/01/2021 ROXYBOND oxycodone hcl TERM AUTO RULE 01/01/2021 SYMJEPI epinephrine TERM AUTO RULE 01/01/2021 PROMACTA eltrombopag olamine TERM AUTO RULE 01/01/2021 daptomycin daptomycin NEW AUTO RULE medical benefit drugs 01/01/2021 ERY-TAB erythromycin base TERM AUTO RULE 01/01/2021 NOVOLIN 70-30 insulin nph human TERM AUTO RULE isophane/insulin regular, human 01/01/2021 bupap butalbital/acetaminophen UM AUTO RULE: PA Applies AUTHORIZATION 01/01/2021 fora gd50 test blood sugar diagnostic TERM AUTO RULE strips 01/01/2021 ABSTRAL fentanyl citrate TERM AUTO RULE 01/01/2021 fora g20 blood sugar diagnostic TERM AUTO RULE 01/01/2021 NEXIUM esomeprazole magnesium TERM AUTO RULE 01/01/2021 quintet ac blood sugar diagnostic TERM AUTO RULE 01/01/2021 hcl nortriptyline hcl NEW AUTO RULE Tier 2 01/01/2021 clever choice test blood sugar diagnostic TERM AUTO RULE strips 01/01/2021 OSMOPREP sodium TERM AUTO RULE phosphate,monobasic/sodiu m phosphate,dibasic

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 22 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 trospium chloride trospium chloride NEW AUTO RULE Tier 1 01/01/2021 FIRAZYR icatibant acetate TERM AUTO RULE 01/01/2021 ADMELOG insulin lispro TERM AUTO RULE 01/01/2021 onetouch ultra blood sugar diagnostic TERM AUTO RULE blue test strp 01/01/2021 ORIAHNN elagolix TERM AUTO RULE sodium//norethindro ne acetate 01/01/2021 DAURISMO glasdegib maleate TERM AUTO RULE 01/01/2021 topotecan hcl topotecan hcl NEW AUTO RULE medical benefit drugs 01/01/2021 DORYX MPC doxycycline hyclate TERM AUTO RULE 01/01/2021 ZEGERID omeprazole/sodium TERM AUTO RULE bicarbonate 01/01/2021 ez smart blood sugar diagnostic TERM AUTO RULE 01/01/2021 clever choice talk blood sugar diagnostic TERM AUTO RULE 01/01/2021 premium blood blood sugar diagnostic TERM AUTO RULE glucose test 01/01/2021 NOXAFIL posaconazole TERM AUTO RULE 01/01/2021 BOSULIF bosutinib TERM AUTO RULE 01/01/2021 NOVOLIN R insulin regular, human TERM AUTO RULE 01/01/2021 evencare mini blood sugar diagnostic TERM AUTO RULE glucose test str 01/01/2021 aminophylline aminophylline NEW AUTO RULE medical benefit drugs 01/01/2021 CARBAGLU carglumic acid TERM AUTO RULE 01/01/2021 GLOPERBA colchicine TERM AUTO RULE 01/01/2021 CIALIS tadalafil TERM AUTO RULE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 23 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 AVAR sulfacetamide sodium/sulfur TERM AUTO RULE 01/01/2021 REBIF interferon beta-1a/albumin TERM AUTO RULE REBIDOSE human 01/01/2021 XERESE acyclovir/hydrocortisone TERM AUTO RULE 01/01/2021 CYSTAGON cysteamine bitartrate TERM AUTO RULE 01/01/2021 TAZVERIK tazemetostat hydrobromide TERM AUTO RULE 01/01/2021 VITRAKVI larotrectinib sulfate TERM AUTO RULE 01/01/2021 doxorubicin hcl doxorubicin hcl NEW AUTO RULE medical benefit drugs 01/01/2021 BUTRANS buprenorphine TERM AUTO RULE 01/01/2021 ADZENYS ER amphetamine TERM AUTO RULE 01/01/2021 ICLUSIG ponatinib hcl TERM AUTO RULE 01/01/2021 ofloxacin ofloxacin NEW AUTO RULE Tier 3 01/01/2021 MEKTOVI binimetinib TERM AUTO RULE 01/01/2021 CAMBIA diclofenac potassium TERM AUTO RULE 01/01/2021 DXEVO dexamethasone TERM AUTO RULE 01/01/2021 ACTEMRA tocilizumab TERM AUTO RULE ACTPEN 01/01/2021 sevelamer sevelamer carbonate NEW AUTO RULE Tier 2 carbonate 01/01/2021 ALTRENO tretinoin TERM AUTO RULE 01/01/2021 OXERVATE cenegermin-bkbj TERM AUTO RULE 01/01/2021 RAYOS prednisone NEW AUTO RULE NF specialty 01/01/2021 JATENZO testosterone undecanoate TERM AUTO RULE 01/01/2021 EMEND aprepitant TERM AUTO RULE 01/01/2021 ORAPRED ODT prednisolone sodium TERM AUTO RULE phosphate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 24 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 BUPHENYL sodium phenylbutyrate TERM AUTO RULE 01/01/2021 millipred dp prednisolone TERM AUTO RULE 01/01/2021 EVISTA raloxifene hcl TERM AUTO RULE 01/01/2021 MORPHABOND morphine sulfate TERM AUTO RULE ER 01/01/2021 vtol lq butalbital/acetaminophen/caf TERM AUTO RULE feine 01/01/2021 CORLANOR ivabradine hcl TERM AUTO RULE 01/01/2021 genstrip blood sugar diagnostic TERM AUTO RULE 01/01/2021 inpen (for insulin admin. supplies TERM AUTO RULE novolog or fiasp) 01/01/2021 chloramphenicol chloramphenicol sod NEW AUTO RULE medical benefit sod succinate succinate drugs 01/01/2021 DURLAZA aspirin TERM AUTO RULE 01/01/2021 RANEXA ranolazine TERM AUTO RULE 01/01/2021 CASODEX bicalutamide TERM AUTO RULE 01/01/2021 rightest gs300 blood sugar diagnostic TERM AUTO RULE test strips 01/01/2021 NUBEQA darolutamide TERM AUTO RULE 01/01/2021 ARIKAYCE amikacin sulfate liposomal TERM AUTO RULE with nebulizer accessories 01/01/2021 ez smart plus blood sugar diagnostic TERM AUTO RULE 01/01/2021 NAPRELAN naproxen sodium TERM AUTO RULE 01/01/2021 MAYZENT siponimod TERM AUTO RULE 01/01/2021 AKLIEF trifarotene TERM AUTO RULE 01/01/2021 PREGNYL chorionic gonadotropin, TERM AUTO RULE human

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 25 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 BEVYXXA betrixaban maleate TERM AUTO RULE 01/01/2021 aspirin- aspirin/omeprazole TERM AUTO RULE omeprazole 01/01/2021 SYNRIBO omacetaxine mepesuccinate TERM AUTO RULE 01/01/2021 rightest gs100 blood sugar diagnostic TERM AUTO RULE test strips 01/01/2021 ADHANSIA XR methylphenidate hcl TERM AUTO RULE 01/01/2021 LESCOL fluvastatin sodium TERM AUTO RULE 01/01/2021 MINOLIRA ER minocycline hcl TERM AUTO RULE 01/01/2021 RYDAPT midostaurin TERM AUTO RULE 01/01/2021 zalvit prenatal vitamins TERM AUTO RULE no.147/ferrous gluconate/folic acid 01/01/2021 RAVICTI glycerol phenylbutyrate TERM AUTO RULE 01/01/2021 potassium potassium chloride NEW AUTO RULE Tier 2 chloride 01/01/2021 OVIDREL choriogonadotropin alfa TERM AUTO RULE 01/01/2021 naproxen- naproxen/esomeprazole TERM AUTO RULE esomeprazole magnesium mag 01/01/2021 aminocaproic aminocaproic acid NEW AUTO RULE NF specialty acid 01/01/2021 budesonide- budesonide/formoterol TERM AUTO RULE formoterol fumarate fumarate 01/01/2021 ropinirole er ropinirole hcl NEW AUTO RULE Tier 1 01/01/2021 E.E.S. 400 erythromycin ethylsuccinate UM AUTO RULE: PA Applies AUTHORIZATION 01/01/2021 PALFORZIA peanut allergen powder-dnfp TERM AUTO RULE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 26 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 TUKYSA tucatinib TERM AUTO RULE 01/01/2021 TRIKAFTA elexacaftor/tezacaftor/ivacaft TERM AUTO RULE or 01/01/2021 hydromorphone hydromorphone hcl TERM AUTO RULE er 01/01/2021 vitamin d-400 cholecalciferol (vitamin d3) TERM AUTO RULE 01/01/2021 NOURIANZ istradefylline TERM AUTO RULE 01/01/2021 REPATHA evolocumab NEW AUTO RULE Non-formulary SYRINGE 01/01/2021 lamotrigine odt lamotrigine TERM AUTO RULE (orange) 01/01/2021 TABRECTA capmatinib hydrochloride TERM AUTO RULE 01/01/2021 methyltestosteron methyltestosterone TERM AUTO RULE e 01/01/2021 caretouch test blood sugar diagnostic TERM AUTO RULE strip 01/01/2021 fora d20 blood sugar diagnostic TERM AUTO RULE 01/01/2021 vicodin hp hydrocodone UM AUTO RULE: PA Applies bitartrate/acetaminophen AUTHORIZATION 01/01/2021 STAXYN vardenafil hcl TERM AUTO RULE 01/01/2021 fentanyl citrate fentanyl citrate TERM AUTO RULE 01/01/2021 RINVOQ upadacitinib TERM AUTO RULE 01/01/2021 RIBASPHERE ribavirin TERM AUTO RULE RIBAPAK 01/01/2021 phenobarbital- phenobarbital/hyoscyamine NEW AUTO RULE Non-formulary belladonna sulf/atropine sulf/scopolamine hb 01/01/2021 ANDROGEL testosterone TERM AUTO RULE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 27 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 PRUDOXIN doxepin hcl TERM AUTO RULE 01/01/2021 vicodin es hydrocodone UM AUTO RULE: PA Applies bitartrate/acetaminophen AUTHORIZATION 01/01/2021 erythromycin erythromycin ethylsuccinate TERM AUTO RULE ethylsuccinate 01/01/2021 candesartan candesartan cilexetil NEW AUTO RULE Tier 1 cilexetil 01/01/2021 CABOMETYX cabozantinib s-malate TERM AUTO RULE 01/01/2021 SOMAVERT pegvisomant TERM AUTO RULE 01/01/2021 megestrol megestrol acetate TERM AUTO RULE acetate 01/01/2021 oxymorphone hcl oxymorphone hcl TERM AUTO RULE 01/01/2021 rightest gs260 blood sugar diagnostic TERM AUTO RULE test strips 01/01/2021 assure prism blood sugar diagnostic TERM AUTO RULE multi 01/01/2021 levofloxacin levofloxacin NEW AUTO RULE Tier 2 01/01/2021 foracare gd40 blood sugar diagnostic TERM AUTO RULE 01/01/2021 EUCRISA crisaborole TERM AUTO RULE 01/01/2021 AVONEX interferon beta-1a/albumin TERM AUTO RULE human 01/01/2021 JADENU deferasirox TERM AUTO RULE SPRINKLE 01/01/2021 MOVIPREP peg 3350/sodium TERM AUTO RULE sulfate/sod chloride/kcl/ascorbate sod/vit c 01/01/2021 methazolamide methazolamide NEW AUTO RULE Tier 2 01/01/2021 foracare gd20 blood sugar diagnostic TERM AUTO RULE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 28 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 REGIMEX benzphetamine hcl TERM AUTO RULE 01/01/2021 assure platinum blood sugar diagnostic TERM AUTO RULE 01/01/2021 gatifloxacin gatifloxacin NEW AUTO RULE Tier 1 01/01/2021 amphetamine amphetamine TERM AUTO RULE 01/01/2021 NIVESTYM filgrastim-aafi TERM AUTO RULE 01/01/2021 anusol-hc hydrocortisone acetate TERM AUTO RULE 01/01/2021 STEGLATRO ertugliflozin pidolate TERM AUTO RULE 01/01/2021 OLYSIO simeprevir sodium TERM AUTO RULE 01/01/2021 pediatric vitamin cholecalciferol (vitamin d3) NEW AUTO RULE Non-Formulary d3 01/01/2021 optium blood sugar diagnostic TERM AUTO RULE 01/01/2021 NATESTO testosterone TERM AUTO RULE 01/01/2021 tetrabenazine tetrabenazine TERM AUTO RULE 01/01/2021 tolvaptan tolvaptan TERM AUTO RULE 01/01/2021 PROVIGIL modafinil TERM AUTO RULE 01/01/2021 CRESEMBA isavuconazonium sulfate TERM AUTO RULE 01/01/2021 fluvastatin fluvastatin sodium TERM AUTO RULE sodium 01/01/2021 ZOLPIMIST zolpidem tartrate TERM AUTO RULE 01/01/2021 fenoprofen fenoprofen calcium TERM AUTO RULE calcium 01/01/2021 minocycline hcl minocycline hcl TERM AUTO RULE er 01/01/2021 fioricet butalbital/acetaminophen/caf TERM AUTO RULE feine

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 29 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 ORALAIR grass pollen-orchard/sweet TERM AUTO RULE vernal/rye/kentucky/timothy, std. 01/01/2021 vitamin d-400 cholecalciferol (vitamin d3) NEW AUTO RULE Non-Formulary 01/01/2021 TALTZ ixekizumab TERM AUTO RULE AUTOINJECTOR 01/01/2021 ZOHYDRO ER hydrocodone bitartrate TERM AUTO RULE 01/01/2021 doxepin hcl doxepin hcl NEW AUTO RULE NF specialty 01/01/2021 ORILISSA elagolix sodium TERM AUTO RULE 01/01/2021 SIKLOS hydroxyurea TERM AUTO RULE 01/01/2021 plixda adapalene TERM AUTO RULE 01/01/2021 PARAFON chlorzoxazone NEW AUTO RULE NF specialty FORTE DSC 01/01/2021 XYOSTED testosterone enanthate TERM AUTO RULE 01/01/2021 BALCOLTRA levonorgestrel/ethinyl TERM AUTO RULE estradiol/ferrous bisglycinate 01/01/2021 FORTESTA testosterone TERM AUTO RULE 01/01/2021 ZYFLO zileuton TERM AUTO RULE 01/01/2021 lactulose lactulose TERM AUTO RULE 01/01/2021 ZUPLENZ ondansetron TERM AUTO RULE 01/01/2021 NOCTIVA desmopressin acetate TERM AUTO RULE 01/01/2021 OVACE PLUS sulfacetamide sodium REMOVE UM: PA Applies WASH AUTHORIZATION 01/01/2021 ADOXA doxycycline monohydrate UM AUTO RULE: PA Applies AUTHORIZATION 01/01/2021 adapalene adapalene TERM AUTO RULE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 30 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 butalbital- butalbital/acetaminophen/caf NEW AUTO RULE Non-formulary acetaminophen- feine caffe 01/01/2021 dalfampridine er dalfampridine TERM AUTO RULE 01/01/2021 MIRCERA methoxy polyethylene TERM AUTO RULE glycol-epoetin beta 01/01/2021 STENDRA avanafil TERM AUTO RULE 01/01/2021 embrace blood sugar diagnostic TERM AUTO RULE 01/01/2021 budesonide er budesonide TERM AUTO RULE 01/01/2021 naproxen sodium naproxen sodium TERM AUTO RULE cr 01/01/2021 cycloserine cycloserine NEW AUTO RULE Tier 3 01/01/2021 FOSRENOL lanthanum carbonate UM AUTO RULE: PA Applies AUTHORIZATION 01/01/2021 advanced blood sugar diagnostic TERM AUTO RULE glucose test strips 01/01/2021 vigabatrin vigabatrin TERM AUTO RULE 01/01/2021 SOLARAZE diclofenac sodium TERM AUTO RULE 01/01/2021 freestyle blood sugar diagnostic TERM AUTO RULE precision neo 01/01/2021 KRISTALOSE lactulose TERM AUTO RULE 01/01/2021 TARGADOX doxycycline hyclate TERM AUTO RULE 01/01/2021 LESCOL XL fluvastatin sodium TERM AUTO RULE 01/01/2021 VIMOVO naproxen/esomeprazole TERM AUTO RULE magnesium 01/01/2021 lamotrigine odt lamotrigine TERM AUTO RULE (green)

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 31 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 ZTLIDO lidocaine TERM AUTO RULE 01/01/2021 td gold test strip blood sugar diagnostic TERM AUTO RULE 01/01/2021 fenoprofen fenoprofen calcium NEW AUTO RULE NF specialty calcium 01/01/2021 easygluco test blood sugar diagnostic TERM AUTO RULE strips 01/01/2021 on call express blood sugar diagnostic TERM AUTO RULE test strip 01/01/2021 chlorzoxazone chlorzoxazone NEW AUTO RULE NF specialty 01/01/2021 ARYMO ER morphine sulfate TERM AUTO RULE 01/01/2021 SYNERA lidocaine/tetracaine TERM AUTO RULE 01/01/2021 advocate redi- blood sugar diagnostic TERM AUTO RULE code+ 01/01/2021 phrenilin forte butalbital/acetaminophen/caf UM AUTO RULE: PA Applies feine AUTHORIZATION 01/01/2021 nortriptyline hcl nortriptyline hcl REMOVE UM: PA Applies AUTHORIZATION 01/01/2021 CAROSPIR spironolactone TERM AUTO RULE 01/01/2021 naproxen sodium naproxen sodium TERM AUTO RULE er 01/01/2021 fora v10 blood sugar diagnostic TERM AUTO RULE 01/01/2021 fora v12 blood sugar diagnostic TERM AUTO RULE 01/01/2021 on call vivid test blood sugar diagnostic TERM AUTO RULE strip 01/01/2021 ANNOVERA segesterone acetate/ethinyl TERM AUTO RULE estradiol 01/01/2021 EMFLAZA deflazacort TERM AUTO RULE 01/01/2021 fora v20 blood sugar diagnostic TERM AUTO RULE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 32 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 albuterol sulfate albuterol sulfate REMOVE UM: PA Applies hfa AUTHORIZATION 01/01/2021 ENBREL MINI etanercept TERM AUTO RULE 01/01/2021 advocate test blood sugar diagnostic TERM AUTO RULE strip 01/01/2021 BRYHALI halobetasol propionate TERM AUTO RULE 01/01/2021 OLUX-E clobetasol TERM AUTO RULE propionate/emollient base 01/01/2021 CLOBEX clobetasol propionate UM AUTO RULE: PA Applies AUTHORIZATION 01/01/2021 WAKIX pitolisant hcl TERM AUTO RULE 01/01/2021 relexxii methylphenidate hcl NEW AUTO RULE Tier 2 01/01/2021 ZELNORM tegaserod hydrogen maleate TERM AUTO RULE 01/01/2021 NOVOLOG insulin aspart TERM AUTO RULE FLEXPEN 01/01/2021 PALYNZIQ pegvaliase-pqpz TERM AUTO RULE 01/01/2021 anusol-hc hydrocortisone acetate NEW AUTO RULE NF specialty 01/01/2021 evencare g3 blood sugar diagnostic TERM AUTO RULE 01/01/2021 evencare g2 blood sugar diagnostic TERM AUTO RULE 01/01/2021 LOKELMA sodium zirconium TERM AUTO RULE cyclosilicate 01/01/2021 ERYTHROCIN erythromycin stearate UM AUTO RULE: PA Applies STEARATE AUTHORIZATION 01/01/2021 VOGELXO testosterone TERM AUTO RULE 01/01/2021 vicodin hydrocodone TERM AUTO RULE bitartrate/acetaminophen 01/01/2021 QSYMIA phentermine hcl/topiramate TERM AUTO RULE 01/01/2021 PRUDOXIN doxepin hcl NEW AUTO RULE NF specialty

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 33 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 PRALUENT PEN alirocumab NEW AUTO RULE Non-formulary 01/01/2021 HORIZANT gabapentin enacarbil TERM AUTO RULE 01/01/2021 pharmacist blood sugar diagnostic TERM AUTO RULE choice 01/01/2021 ZIRGAN ganciclovir NEW AUTO RULE Non-formulary 01/01/2021 FENTORA fentanyl citrate TERM AUTO RULE 01/01/2021 ADZENYS XR- amphetamine TERM AUTO RULE ODT 01/01/2021 doxycycline ir-dr doxycycline monohydrate TERM AUTO RULE 01/01/2021 ORACEA doxycycline monohydrate TERM AUTO RULE 01/01/2021 phrenilin forte butalbital/acetaminophen/caf TERM AUTO RULE feine 01/01/2021 OXBRYTA voxelotor TERM AUTO RULE 01/01/2021 CETROTIDE cetrorelix acetate TERM AUTO RULE 01/01/2021 ACTHAR corticotropin REMOVE UM: PA Applies AUTHORIZATION 01/01/2021 SIMPONI golimumab TERM AUTO RULE 01/01/2021 butalbital- butalbital/acetaminophen/caf TERM AUTO RULE acetaminophen- feine caffe 01/01/2021 TIROSINT levothyroxine sodium NEW AUTO RULE Non-formulary 01/01/2021 PREVYMIS letermovir TERM AUTO RULE 01/01/2021 rightest gs550 blood sugar diagnostic TERM AUTO RULE test strips 01/01/2021 ERYPED 200 erythromycin ethylsuccinate TERM AUTO RULE 01/01/2021 repaglinide- repaglinide/metformin hcl NEW AUTO RULE Non-formulary metformin hcl 01/01/2021 ADEMPAS riociguat TERM AUTO RULE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 34 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 HALOG halcinonide TERM AUTO RULE 01/01/2021 zodex dexamethasone REMOVE UM: PA Applies AUTHORIZATION 01/01/2021 REYVOW succinate TERM AUTO RULE 01/01/2021 TALTZ SYRINGE ixekizumab TERM AUTO RULE (2 PACK) 01/01/2021 CAPEX fluocinolone acetonide TERM AUTO RULE SHAMPOO 01/01/2021 reveal test strip blood sugar diagnostic TERM AUTO RULE 01/01/2021 AMPYRA dalfampridine TERM AUTO RULE 01/01/2021 PLENVU peg 3350/sodium TERM AUTO RULE sulfate/sod chloride/kcl/ascorbate sod/vit c 01/01/2021 QUILLICHEW ER methylphenidate hcl TERM AUTO RULE 01/01/2021 GLUMETZA metformin hcl TERM AUTO RULE 01/01/2021 KAPVAY clonidine hcl TERM AUTO RULE 01/01/2021 RAYALDEE calcifediol TERM AUTO RULE 01/01/2021 ATRIPLA efavirenz/emtricitabine/tenof TERM AUTO RULE ovir disoproxil fumarate 01/01/2021 DOPTELET avatrombopag maleate TERM AUTO RULE 01/01/2021 easy touch test blood sugar diagnostic TERM AUTO RULE strip 01/01/2021 EPIDIOLEX cannabidiol (cbd) TERM AUTO RULE 01/01/2021 zileuton er zileuton TERM AUTO RULE 01/01/2021 acetamin-caff- acetaminophen/caffeine/dihy TERM AUTO RULE dihydrocodeine drocodeine bitartrate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 35 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 TREXIMET sumatriptan TERM AUTO RULE succinate/naproxen sodium 01/01/2021 FLUOROPLEX fluorouracil TERM AUTO RULE 01/01/2021 clovique trientine hcl TERM AUTO RULE 01/01/2021 MONODOX doxycycline monohydrate UM AUTO RULE: PA Applies AUTHORIZATION 01/01/2021 PENNSAID diclofenac sodium TERM AUTO RULE 01/01/2021 wavesense blood sugar diagnostic TERM AUTO RULE presto 01/01/2021 fora gtel glucose blood sugar diagnostic TERM AUTO RULE test strip 01/01/2021 LORZONE chlorzoxazone NEW AUTO RULE NF specialty 01/01/2021 SAXENDA liraglutide TERM AUTO RULE 01/01/2021 CEQUA cyclosporine TERM AUTO RULE 01/01/2021 DUEXIS ibuprofen/famotidine TERM AUTO RULE 01/01/2021 fora 6 connect blood sugar diagnostic TERM AUTO RULE glucose strip 01/01/2021 XERMELO telotristat etiprate TERM AUTO RULE 01/01/2021 IDHIFA enasidenib mesylate TERM AUTO RULE 01/01/2021 GOCOVRI amantadine hcl TERM AUTO RULE 01/01/2021 AMITIZA lubiprostone TERM AUTO RULE 01/01/2021 DUOBRII halobetasol TERM AUTO RULE propionate/tazarotene 01/01/2021 FORTAMET metformin hcl TERM AUTO RULE 01/01/2021 diclofenac diclofenac sodium TERM AUTO RULE sodium 01/01/2021 fluocinonide fluocinonide TERM AUTO RULE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 36 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 testosterone testosterone TERM AUTO RULE 01/01/2021 halobetasol halobetasol propionate TERM AUTO RULE propionate 01/01/2021 COTEMPLA XR- methylphenidate TERM AUTO RULE ODT 01/01/2021 posaconazole posaconazole TERM AUTO RULE 01/01/2021 CYCLOSET mesylate TERM AUTO RULE 01/01/2021 simvastatin simvastatin TERM AUTO RULE 01/01/2021 LONHALA glycopyrrolate/nebulizer and TERM AUTO RULE MAGNAIR accessories STARTER 01/01/2021 onetouch verio blood sugar diagnostic TERM AUTO RULE test strip 01/01/2021 BACTROBAN mupirocin calcium TERM AUTO RULE 01/01/2021 halcinonide halcinonide TERM AUTO RULE 01/01/2021 SECUADO asenapine TERM AUTO RULE 01/01/2021 AZESCO prenatal vitamins TERM AUTO RULE no.147/ferrous gluconate/folic acid 01/01/2021 AVONEX PEN interferon beta-1a TERM AUTO RULE 01/01/2021 ZOVIRAX acyclovir TERM AUTO RULE 01/01/2021 ACTIQ fentanyl citrate TERM AUTO RULE 01/01/2021 solus v2 test blood sugar diagnostic TERM AUTO RULE strips 01/01/2021 aminocaproic aminocaproic acid TERM AUTO RULE acid 01/01/2021 advocate redi- blood sugar diagnostic TERM AUTO RULE code

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 37 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 vgo 40 sub-q insulin delivery TERM AUTO RULE device, 40 unit, disposable 01/01/2021 trientine hcl trientine hcl TERM AUTO RULE 01/01/2021 v-go 40 sub-q insulin delivery TERM AUTO RULE device, 40 unit, disposable 01/01/2021 dvorah acetaminophen/caffeine/dihy TERM AUTO RULE drocodeine bitartrate 01/01/2021 doxycycline doxycycline monohydrate TERM AUTO RULE monohydrate 01/01/2021 erythromycin erythromycin base TERM AUTO RULE 01/01/2021 CRINONE , micronized TERM AUTO RULE 01/01/2021 calcipotriene calcipotriene TERM AUTO RULE 01/01/2021 SEROSTIM somatropin TERM AUTO RULE 01/01/2021 NYMALIZE nimodipine TERM AUTO RULE 01/01/2021 TALTZ ixekizumab TERM AUTO RULE AUTOINJECTOR (3 PACK) 01/01/2021 AFINITOR TERM AUTO RULE 01/01/2021 naproxen naproxen TERM AUTO RULE 01/01/2021 ALECENSA alectinib hcl TERM AUTO RULE 01/01/2021 ACTONEL risedronate sodium TERM AUTO RULE 01/01/2021 acyclovir acyclovir TERM AUTO RULE 01/01/2021 ZEPATIER elbasvir/grazoprevir TERM AUTO RULE 01/01/2021 naloxone hcl naloxone hcl TERM AUTO RULE 01/01/2021 pro voice v8-v9 blood sugar diagnostic TERM AUTO RULE test strip 01/01/2021 clobetasol clobetasol propionate TERM AUTO RULE propionate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 38 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 RENVELA sevelamer carbonate UM AUTO RULE: PA Applies AUTHORIZATION 01/01/2021 vivaguard ino test blood sugar diagnostic TERM AUTO RULE strip 01/01/2021 ZEBUTAL butalbital/acetaminophen/caf TERM AUTO RULE feine 01/01/2021 truetest test strips blood sugar diagnostic TERM AUTO RULE 01/01/2021 VYLEESI bremelanotide acetate TERM AUTO RULE 01/01/2021 ethacrynic acid ethacrynic acid TERM AUTO RULE 01/01/2021 RIOMET metformin hcl UM AUTO RULE: PA Applies AUTHORIZATION 01/01/2021 FORADIL formoterol fumarate TERM AUTO RULE 01/01/2021 xurea urea TERM AUTO RULE 01/01/2021 ROCKLATAN netarsudil TERM AUTO RULE mesylate/latanoprost 01/01/2021 CLINDAGEL clindamycin phosphate TERM AUTO RULE 01/01/2021 D-PENAMINE penicillamine TERM AUTO RULE 01/01/2021 HAEGARDA c1 esterase inhibitor TERM AUTO RULE 01/01/2021 VYZULTA latanoprostene bunod TERM AUTO RULE 01/01/2021 GLYCATE glycopyrrolate TERM AUTO RULE 01/01/2021 LONSURF trifluridine/tipiracil hcl TERM AUTO RULE 01/01/2021 sildenafil citrate sildenafil citrate TERM AUTO RULE 01/01/2021 CADUET amlodipine TERM AUTO RULE besylate/atorvastatin calcium 01/01/2021 MULPLETA lusutrombopag TERM AUTO RULE 01/01/2021 QINLOCK ripretinib TERM AUTO RULE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 39 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 methadone hcl methadone hcl TERM AUTO RULE 01/01/2021 tolmetin sodium tolmetin sodium TERM AUTO RULE 01/01/2021 lanthanum lanthanum carbonate TERM AUTO RULE carbonate 01/01/2021 SIVEXTRO tedizolid phosphate TERM AUTO RULE 01/01/2021 mefenamic acid mefenamic acid TERM AUTO RULE 01/01/2021 streptomycin streptomycin sulfate NEW AUTO RULE medical benefit sulfate drugs 01/01/2021 TARCEVA erlotinib hcl TERM AUTO RULE 01/01/2021 levorphanol levorphanol tartrate TERM AUTO RULE tartrate 01/01/2021 freestyle insulinx blood sugar diagnostic TERM AUTO RULE 01/01/2021 GONITRO nitroglycerin TERM AUTO RULE 01/01/2021 CYSTARAN cysteamine hcl TERM AUTO RULE 01/01/2021 HYSINGLA ER hydrocodone bitartrate TERM AUTO RULE 01/01/2021 SPRITAM levetiracetam TERM AUTO RULE 01/01/2021 exemestane exemestane TERM AUTO RULE 01/01/2021 DARAPRIM pyrimethamine NEW AUTO RULE NF specialty 01/01/2021 gojji lancet- lancets with blood glucose REMOVE UM: PA Applies glucose test strp test strips AUTHORIZATION 01/01/2021 FIRVANQ vancomycin hcl TERM AUTO RULE 01/01/2021 neostigmine neostigmine methylsulfate NEW AUTO RULE medical benefit methylsulfate drugs 01/01/2021 alosetron hcl alosetron hcl TERM AUTO RULE 01/01/2021 TERIPARATIDE teriparatide TERM AUTO RULE 01/01/2021 miglustat miglustat TERM AUTO RULE 01/01/2021 LAZANDA fentanyl citrate TERM AUTO RULE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 40 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 REXULTI brexpiprazole TERM AUTO RULE 01/01/2021 ORKAMBI lumacaftor/ivacaftor TERM AUTO RULE 01/01/2021 vanatol s butalbital/acetaminophen/caf TERM AUTO RULE feine 01/01/2021 ACZONE dapsone TERM AUTO RULE 01/01/2021 atovaquone atovaquone TERM AUTO RULE 01/01/2021 meclofenamate meclofenamate sodium TERM AUTO RULE sodium 01/01/2021 letrozole letrozole TERM AUTO RULE 01/01/2021 NEXLIZET bempedoic acid/ezetimibe TERM AUTO RULE 01/01/2021 millipred prednisolone UM AUTO RULE: PA Applies AUTHORIZATION 01/01/2021 glycopyrrolate glycopyrrolate TERM AUTO RULE 01/01/2021 doxepin hcl doxepin hcl TERM AUTO RULE 01/01/2021 locort dexamethasone TERM AUTO RULE 01/01/2021 APADAZ benzhydrocodone TERM AUTO RULE hcl/acetaminophen 01/01/2021 sodium sulfacetamide sodium TERM AUTO RULE sulfacetamide 01/01/2021 RAGWITEK allergenic extract-weed TERM AUTO RULE pollen-short ragweed 01/01/2021 ZONTIVITY vorapaxar sulfate TERM AUTO RULE 01/01/2021 MUSE alprostadil TERM AUTO RULE 01/01/2021 MEKINIST trametinib dimethyl sulfoxide TERM AUTO RULE 01/01/2021 NURTEC ODT sulfate TERM AUTO RULE 01/01/2021 ORENITRAM ER treprostinil diolamine TERM AUTO RULE 01/01/2021 XENICAL orlistat TERM AUTO RULE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 41 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 pentamidine pentamidine isethionate NEW AUTO RULE medical benefit isethionate drugs 01/01/2021 lamotrigine odt lamotrigine TERM AUTO RULE (blue) 01/01/2021 RIOMET metformin hcl TERM AUTO RULE 01/01/2021 EGRIFTA tesamorelin acetate TERM AUTO RULE 01/01/2021 fora d40-g31 test blood sugar diagnostic TERM AUTO RULE strips 01/01/2021 ure-k urea TERM AUTO RULE 01/01/2021 NOVOLOG insulin aspart TERM AUTO RULE 01/01/2021 CLENPIQ sodium TERM AUTO RULE picosulfate/magnesium oxide/citric acid 01/01/2021 optium ez blood sugar diagnostic TERM AUTO RULE 01/01/2021 smart sense test blood sugar diagnostic TERM AUTO RULE strips 01/01/2021 ultratrak blood sugar diagnostic TERM AUTO RULE 01/01/2021 ARMONAIR fluticasone propionate TERM AUTO RULE RESPICLICK 01/01/2021 E.E.S. 200 erythromycin ethylsuccinate TERM AUTO RULE 01/01/2021 AFINITOR everolimus TERM AUTO RULE DISPERZ 01/01/2021 PROGRAF tacrolimus TERM AUTO RULE 01/01/2021 LAMICTAL ODT lamotrigine TERM AUTO RULE (GREEN) 01/01/2021 SORILUX calcipotriene NEW AUTO RULE NF specialty 01/01/2021 OSENI alogliptin TERM AUTO RULE benzoate/pioglitazone hcl

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 42 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 rightest gs250s blood sugar diagnostic TERM AUTO RULE test strips 01/01/2021 JENTADUETO linagliptin/metformin hcl TERM AUTO RULE XR 01/01/2021 JYNARQUE tolvaptan TERM AUTO RULE 01/01/2021 BYETTA exenatide TERM AUTO RULE 01/01/2021 OZOBAX baclofen TERM AUTO RULE 01/01/2021 daunorubicin hcl daunorubicin hcl NEW AUTO RULE medical benefit drugs 01/01/2021 REPATHA evolocumab NEW AUTO RULE Non-formulary SURECLICK 01/01/2021 INVOKANA canagliflozin TERM AUTO RULE 01/01/2021 COPIKTRA duvelisib TERM AUTO RULE 01/01/2021 XENLETA lefamulin acetate TERM AUTO RULE 01/01/2021 raloxifene hcl raloxifene hcl TERM AUTO RULE 01/01/2021 clever choice blood sugar diagnostic TERM AUTO RULE voice+ tst strip 01/01/2021 bicalutamide bicalutamide TERM AUTO RULE 01/01/2021 irinotecan hcl irinotecan hcl NEW AUTO RULE medical benefit drugs 01/01/2021 oxycodone hcl er oxycodone hcl TERM AUTO RULE 01/01/2021 easygluco plus blood sugar diagnostic TERM AUTO RULE 01/01/2021 VEMLIDY tenofovir alafenamide TERM AUTO RULE 01/01/2021 AMICAR aminocaproic acid TERM AUTO RULE 01/01/2021 clever choice pro blood sugar diagnostic TERM AUTO RULE 01/01/2021 goodlife ac-302 blood sugar diagnostic TERM AUTO RULE test strip

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 43 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 ERYTHROCIN erythromycin stearate TERM AUTO RULE STEARATE 01/01/2021 ERYPED 400 erythromycin ethylsuccinate TERM AUTO RULE 01/01/2021 GRASTEK allergenic extract,grass TERM AUTO RULE pollen-timothy,standard 01/01/2021 delta d3 cholecalciferol (vitamin d3) NEW AUTO RULE Non-Formulary 01/01/2021 AVAR LS sulfacetamide sodium/sulfur TERM AUTO RULE 01/01/2021 RYCLORA dexchlorpheniramine TERM AUTO RULE maleate 01/01/2021 mondoxyne nl doxycycline monohydrate UM AUTO RULE: PA Applies AUTHORIZATION 01/01/2021 GLEEVEC imatinib mesylate TERM AUTO RULE 01/01/2021 TALZENNA talazoparib tosylate TERM AUTO RULE 01/01/2021 INSULIN insulin aspart protamine REMOVE UM: PA Applies ASPART PROT- human/insulin aspart AUTHORIZATION INSULN ASP 01/01/2021 pedia d-vite cholecalciferol (vitamin d3) NEW AUTO RULE Non-Formulary 01/01/2021 microdot xtra blood sugar diagnostic TERM AUTO RULE 01/01/2021 RASUVO methotrexate/pf TERM AUTO RULE 01/01/2021 TESTRED methyltestosterone TERM AUTO RULE 01/01/2021 ANADROL-50 oxymetholone TERM AUTO RULE 01/01/2021 sofosbuvir- sofosbuvir/velpatasvir TERM AUTO RULE velpatasvir 01/01/2021 FIORICET WITH butalbital/acetaminophen/caf TERM AUTO RULE CODEINE feine/codeine phosphate 01/01/2021 SILIQ brodalumab TERM AUTO RULE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 44 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 AZESCHEW prenatal vitamins TERM AUTO RULE no.165/ferrous fumarate/folic acid 01/01/2021 OXANDRIN oxandrolone TERM AUTO RULE 01/01/2021 element compact blood sugar diagnostic TERM AUTO RULE 01/01/2021 ADMELOG insulin lispro TERM AUTO RULE SOLOSTAR 01/01/2021 BELBUCA buprenorphine hcl TERM AUTO RULE 01/01/2021 ADCIRCA tadalafil TERM AUTO RULE 01/01/2021 klor-con potassium chloride NEW AUTO RULE Non-formulary 01/01/2021 AJOVY fremanezumab-vfrm TERM AUTO RULE AUTOINJECTOR 01/01/2021 JALYN dutasteride/tamsulosin hcl TERM AUTO RULE 01/01/2021 AROMASIN exemestane TERM AUTO RULE 01/01/2021 KINERET anakinra TERM AUTO RULE 01/01/2021 NOVOLIN N insulin nph human isophane TERM AUTO RULE 01/01/2021 iglucose test strip blood sugar diagnostic TERM AUTO RULE 01/01/2021 SIGNIFOR pasireotide diaspartate TERM AUTO RULE 01/01/2021 myglucohealth blood sugar diagnostic TERM AUTO RULE 01/01/2021 uredeb urea TERM AUTO RULE 01/01/2021 SPRIX ketorolac tromethamine TERM AUTO RULE 01/01/2021 ABSORICA isotretinoin TERM AUTO RULE 01/01/2021 FASENRA PEN benralizumab TERM AUTO RULE 01/01/2021 naproxen sodium naproxen sodium UM AUTO RULE: PA Applies er AUTHORIZATION 01/01/2021 RIOMET ER metformin hcl TERM AUTO RULE 01/01/2021 NORTHERA droxidopa TERM AUTO RULE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 45 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 GRALISE gabapentin TERM AUTO RULE 01/01/2021 candesartan- candesartan NEW AUTO RULE Tier 2 hydrochlorothiazi cilexetil/hydrochlorothiazide d 01/01/2021 naproxen sodium naproxen sodium UM AUTO RULE: PA Applies cr AUTHORIZATION 01/01/2021 XURIDEN uridine triacetate TERM AUTO RULE 01/01/2021 clobetasol clobetasol TERM AUTO RULE emulsion propionate/emollient base 01/01/2021 BAXDELA delafloxacin meglumine TERM AUTO RULE 01/01/2021 glucocard vital blood sugar diagnostic TERM AUTO RULE 01/01/2021 OPANA ER oxymorphone hcl TERM AUTO RULE 01/01/2021 sumatriptan succ- sumatriptan TERM AUTO RULE naproxen sod succinate/naproxen sodium 01/01/2021 PRALUENT alirocumab TERM AUTO RULE SYRINGE 01/01/2021 PLEGRIDY peginterferon beta-1a TERM AUTO RULE 01/01/2021 YOSPRALA aspirin/omeprazole TERM AUTO RULE 01/01/2021 CIMZIA certolizumab pegol TERM AUTO RULE 01/01/2021 BENLYSTA belimumab TERM AUTO RULE 01/01/2021 embrace talk test blood sugar diagnostic TERM AUTO RULE strip 01/01/2021 metoprolol metoprolol TERM AUTO RULE succinate er-hctz succinate/hydrochlorothiazid e 01/01/2021 infinity voice test blood sugar diagnostic TERM AUTO RULE strip 01/01/2021 NOVAREL chorionic gonadotropin, TERM AUTO RULE human

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 46 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 TEGSEDI inotersen sodium TERM AUTO RULE 01/01/2021 mupirocin mupirocin calcium NEW AUTO RULE Tier 3 01/01/2021 XELPROS latanoprost NEW AUTO RULE Non-formulary 01/01/2021 glucocom blood sugar diagnostic TERM AUTO RULE glucose 01/01/2021 UPTRAVI selexipag TERM AUTO RULE 01/01/2021 acetylcysteine acetylcysteine NEW AUTO RULE Tier 3 01/01/2021 freestyle lite test blood sugar diagnostic TERM AUTO RULE strip 01/01/2021 precision pcx blood sugar diagnostic TERM AUTO RULE 01/01/2021 NORITATE metronidazole TERM AUTO RULE 01/01/2021 ARIMIDEX anastrozole TERM AUTO RULE 01/01/2021 soloxide doxycycline hyclate TERM AUTO RULE 01/01/2021 bupap butalbital/acetaminophen TERM AUTO RULE 01/01/2021 INSULIN insulin aspart REMOVE UM: PA Applies ASPART AUTHORIZATION FLEXPEN 01/01/2021 ACTICLATE doxycycline hyclate TERM AUTO RULE 01/01/2021 alogliptin- alogliptin TERM AUTO RULE pioglitazone benzoate/pioglitazone hcl 01/01/2021 benzhydrocodon benzhydrocodone TERM AUTO RULE e-acetaminophen hcl/acetaminophen 01/01/2021 TUSSICAPS hydrocodone TERM AUTO RULE polistirex/chlorpheniramine polistirex 01/01/2021 freestyle test blood sugar diagnostic TERM AUTO RULE strips 01/01/2021 REVATIO sildenafil citrate TERM AUTO RULE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 47 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 VANOS fluocinonide TERM AUTO RULE 01/01/2021 moderiba ribavirin TERM AUTO RULE 01/01/2021 NOVOLOG MIX insulin aspart protamine TERM AUTO RULE 70-30 human/insulin aspart 01/01/2021 BETHKIS tobramycin TERM AUTO RULE 01/01/2021 cool glucose test blood sugar diagnostic TERM AUTO RULE strip 01/01/2021 primlev oxycodone TERM AUTO RULE hcl/acetaminophen 01/01/2021 LOTRONEX alosetron hcl TERM AUTO RULE 01/01/2021 moxifloxacin moxifloxacin hcl NEW AUTO RULE Non-formulary 01/01/2021 LYNPARZA olaparib TERM AUTO RULE 01/01/2021 ENTOCORT EC budesonide TERM AUTO RULE 01/01/2021 VFEND voriconazole TERM AUTO RULE 01/01/2021 millipred dp prednisolone UM AUTO RULE: PA Applies AUTHORIZATION 01/01/2021 easymax blood sugar diagnostic TERM AUTO RULE 01/01/2021 fortiscare glucose blood sugar diagnostic TERM AUTO RULE test strips 01/01/2021 harmony glucose blood sugar diagnostic TERM AUTO RULE test strip 01/01/2021 QBREXZA glycopyrronium tosylate TERM AUTO RULE 01/01/2021 paliperidone er paliperidone TERM AUTO RULE 01/01/2021 true metrix pro blood sugar diagnostic TERM AUTO RULE test strip 01/01/2021 micro blood sugar diagnostic TERM AUTO RULE 01/01/2021 VRAYLAR cariprazine hcl TERM AUTO RULE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 48 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 vitamin d3 cholecalciferol (vitamin d3) NEW AUTO RULE Non-Formulary 01/01/2021 RENACIDIN citric TERM AUTO RULE acid/gluconolactone/magnes ium carbonate 01/01/2021 DONNATAL phenobarbital/hyoscyamine TERM AUTO RULE sulf/atropine sulf/scopolamine hb 01/01/2021 ORENCIA abatacept TERM AUTO RULE CLICKJECT 01/01/2021 LUCEMYRA lofexidine hcl TERM AUTO RULE 01/01/2021 ZIOPTAN tafluprost/pf TERM AUTO RULE 01/01/2021 precision q-i-d blood sugar diagnostic TERM AUTO RULE 01/01/2021 ORAPRED ODT prednisolone sodium UM AUTO RULE: PA Applies phosphate AUTHORIZATION 01/01/2021 RELAFEN DS nabumetone TERM AUTO RULE 01/01/2021 MOZOBIL plerixafor TERM AUTO RULE 01/01/2021 OBREDON guaifenesin/hydrocodone TERM AUTO RULE bitartrate 01/01/2021 E.E.S. 400 erythromycin ethylsuccinate TERM AUTO RULE 01/01/2021 FERRIPROX deferiprone TERM AUTO RULE 01/01/2021 METHADOSE methadone hcl TERM AUTO RULE 01/01/2021 INREBIC fedratinib dihydrochloride TERM AUTO RULE 01/01/2021 REBIF interferon beta-1a/albumin TERM AUTO RULE human 01/01/2021 TRULANCE plecanatide TERM AUTO RULE 01/01/2021 unistrip1 blood sugar diagnostic TERM AUTO RULE 01/01/2021 SOTYLIZE sotalol hcl TERM AUTO RULE 01/01/2021 IRESSA gefitinib TERM AUTO RULE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 49 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 NUCYNTA ER tapentadol hcl TERM AUTO RULE 01/01/2021 fora g30-premium blood sugar diagnostic TERM AUTO RULE v10 test strp 01/01/2021 BRUKINSA zanubrutinib TERM AUTO RULE 01/01/2021 genultimate test blood sugar diagnostic TERM AUTO RULE strip 01/01/2021 RYVENT carbinoxamine maleate TERM AUTO RULE 01/01/2021 XTAMPZA ER oxycodone myristate TERM AUTO RULE 01/01/2021 phenobarbital- phenobarbital/hyoscyamine TERM AUTO RULE belladonna sulf/atropine sulf/scopolamine hb 01/01/2021 NEXLETOL bempedoic acid TERM AUTO RULE 01/01/2021 KATERZIA amlodipine benzoate TERM AUTO RULE 01/01/2021 ZONACORT dexamethasone TERM AUTO RULE 01/01/2021 NEO-SYNALAR neomycin TERM AUTO RULE sulfate/fluocinolone acetonide 01/01/2021 oxymorphone hcl oxymorphone hcl TERM AUTO RULE er 01/01/2021 UCERIS budesonide TERM AUTO RULE 01/01/2021 AFREZZA insulin regular, human TERM AUTO RULE 01/01/2021 BASAGLAR ,human TERM AUTO RULE KWIKPEN U-100 recombinant analog 01/01/2021 metoclopramide metoclopramide hcl TERM AUTO RULE hcl odt 01/01/2021 NEUPOGEN filgrastim TERM AUTO RULE 01/01/2021 clemastine clemastine fumarate NEW AUTO RULE Non-formulary fumarate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 50 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 nolix flurandrenolide TERM AUTO RULE 01/01/2021 ROZLYTREK entrectinib TERM AUTO RULE 01/01/2021 KARBINAL ER carbinoxamine maleate TERM AUTO RULE 01/01/2021 ADIPEX-P phentermine hcl TERM AUTO RULE 01/01/2021 ORENCIA abatacept TERM AUTO RULE 01/01/2021 neutek 2tek test blood sugar diagnostic TERM AUTO RULE strips 01/01/2021 ERIVEDGE vismodegib TERM AUTO RULE 01/01/2021 VIAGRA sildenafil citrate TERM AUTO RULE 01/01/2021 RENVELA sevelamer carbonate TERM AUTO RULE 01/01/2021 ketoprofen ketoprofen NEW AUTO RULE Non-formulary 01/01/2021 SOLIQUA 100-33 insulin glargine,human TERM AUTO RULE recombinant analog/ 01/01/2021 XIFAXAN rifaximin TERM AUTO RULE 01/01/2021 RECTIV nitroglycerin TERM AUTO RULE 01/01/2021 XOSPATA gilteritinib fumarate TERM AUTO RULE 01/01/2021 contour next test blood sugar diagnostic TERM AUTO RULE strip 01/01/2021 baciim bacitracin NEW AUTO RULE medical benefit drugs 01/01/2021 VENCLEXTA venetoclax TERM AUTO RULE STARTING PACK 01/01/2021 NUCALA mepolizumab TERM AUTO RULE 01/01/2021 PRALUENT alirocumab NEW AUTO RULE Non-formulary SYRINGE 01/01/2021 TARGRETIN bexarotene TERM AUTO RULE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 51 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 IMBRUVICA ibrutinib TERM AUTO RULE 01/01/2021 RIBATAB ribavirin TERM AUTO RULE 01/01/2021 diatrue plus blood sugar diagnostic TERM AUTO RULE 01/01/2021 XIMINO minocycline hcl TERM AUTO RULE 01/01/2021 TOLSURA itraconazole TERM AUTO RULE 01/01/2021 KEVZARA sarilumab TERM AUTO RULE 01/01/2021 ERYPED 200 erythromycin ethylsuccinate UM AUTO RULE: PA Applies AUTHORIZATION 01/01/2021 TAGRISSO osimertinib mesylate TERM AUTO RULE 01/01/2021 dexamethasone dexamethasone TERM AUTO RULE 01/01/2021 embrace pro test blood sugar diagnostic TERM AUTO RULE strip 01/01/2021 erythromycin erythromycin base UM AUTO RULE: PA Applies AUTHORIZATION 01/01/2021 buprenorphine buprenorphine TERM AUTO RULE 01/01/2021 FEMARA letrozole TERM AUTO RULE 01/01/2021 ultratrak ultimate blood sugar diagnostic TERM AUTO RULE 01/01/2021 PONSTEL mefenamic acid TERM AUTO RULE 01/01/2021 UBRELVY ubrogepant TERM AUTO RULE 01/01/2021 ZYKADIA ceritinib TERM AUTO RULE 01/01/2021 millipred prednisolone TERM AUTO RULE 01/01/2021 vancomycin hcl vancomycin hcl TERM AUTO RULE 01/01/2021 ADLYXIN lixisenatide TERM AUTO RULE 01/01/2021 FULYZAQ crofelemer TERM AUTO RULE 01/01/2021 fentanyl fentanyl TERM AUTO RULE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 52 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 vgo 30 sub-q insulin delivery TERM AUTO RULE device, 30 unit, disposable 01/01/2021 INSULIN insulin aspart REMOVE UM: PA Applies ASPART AUTHORIZATION PENFILL 01/01/2021 NUVIGIL armodafinil TERM AUTO RULE 01/01/2021 SYPRINE trientine hcl TERM AUTO RULE 01/01/2021 GONAL-F RFF follitropin alfa, recombinant TERM AUTO RULE REDI-JECT 01/01/2021 penicillamine penicillamine TERM AUTO RULE 01/01/2021 ZOMACTON somatropin TERM AUTO RULE 01/01/2021 YUPELRI revefenacin TERM AUTO RULE 01/01/2021 DEXPAK dexamethasone TERM AUTO RULE 01/01/2021 EPOGEN epoetin alfa TERM AUTO RULE 01/01/2021 naproxen naproxen UM AUTO RULE: PA Applies AUTHORIZATION 01/01/2021 ketorolac ketorolac tromethamine TERM AUTO RULE tromethamine 01/01/2021 AUBAGIO teriflunomide TERM AUTO RULE 01/01/2021 fora test strip blood sugar diagnostic TERM AUTO RULE 01/01/2021 hydroxyprogester hydroxyprogesterone TERM AUTO RULE one caproate caproate 01/01/2021 nova max blood sugar diagnostic TERM AUTO RULE glucose test strips 01/01/2021 ADDYI flibanserin TERM AUTO RULE 01/01/2021 NAPROSYN naproxen TERM AUTO RULE 01/01/2021 TAVALISSE fostamatinib disodium TERM AUTO RULE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 53 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 JENTADUETO linagliptin/metformin hcl TERM AUTO RULE 01/01/2021 vanatol lq butalbital/acetaminophen/caf TERM AUTO RULE feine 01/01/2021 carbinoxamine carbinoxamine maleate TERM AUTO RULE maleate 01/01/2021 OXYCONTIN oxycodone hcl TERM AUTO RULE 01/01/2021 RELISTOR methylnaltrexone bromide TERM AUTO RULE 01/01/2021 diclofenac diclofenac epolamine TERM AUTO RULE epolamine 01/01/2021 DRIZALMA duloxetine hcl TERM AUTO RULE SPRINKLE 01/01/2021 esomeprazole esomeprazole magnesium TERM AUTO RULE magnesium 01/01/2021 FOSRENOL lanthanum carbonate TERM AUTO RULE 01/01/2021 TURALIO pexidartinib hydrochloride TERM AUTO RULE 01/01/2021 DALIRESP roflumilast NEW AUTO RULE Tier 3 01/01/2021 ZIPSOR diclofenac potassium UM AUTO RULE: PA Applies AUTHORIZATION 01/01/2021 ONGLYZA saxagliptin hcl TERM AUTO RULE 01/01/2021 dapsone dapsone TERM AUTO RULE 01/01/2021 doxycycline doxycycline monohydrate UM AUTO RULE: PA Applies monohydrate AUTHORIZATION 01/01/2021 EXALGO hydromorphone hcl TERM AUTO RULE 01/01/2021 clindamycin clindamycin phosphate TERM AUTO RULE phosphate 01/01/2021 clobetasol clobetasol propionate UM AUTO RULE: PA Applies propionate AUTHORIZATION

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 54 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 sodium sodium phenylbutyrate TERM AUTO RULE phenylbutyrate 01/01/2021 PREPOPIK sodium TERM AUTO RULE picosulfate/magnesium oxide/citric acid 01/01/2021 evencare proview blood sugar diagnostic TERM AUTO RULE test strip 01/01/2021 ADOXA doxycycline monohydrate TERM AUTO RULE 01/01/2021 VENCLEXTA venetoclax TERM AUTO RULE 01/01/2021 GONAL-F follitropin alfa, recombinant TERM AUTO RULE 01/01/2021 RUBRACA rucaparib camsylate TERM AUTO RULE 01/01/2021 GANIRELIX ganirelix acetate TERM AUTO RULE ACETATE 01/01/2021 nitisinone nitisinone TERM AUTO RULE 01/01/2021 HUMATROPE somatropin TERM AUTO RULE 01/01/2021 MYTESI crofelemer TERM AUTO RULE 01/01/2021 STRIANT testosterone TERM AUTO RULE 01/01/2021 dexchlorphenira dexchlorpheniramine TERM AUTO RULE mine maleate maleate 01/01/2021 TRIJARDY XR empagliflozin/linagliptin/metf TERM AUTO RULE ormin hcl 01/01/2021 itraconazole itraconazole TERM AUTO RULE 01/01/2021 DISKETS methadone hcl TERM AUTO RULE 01/01/2021 sure-test blood sugar diagnostic TERM AUTO RULE easyplus mini 01/01/2021 metformin er metformin hcl TERM AUTO RULE gastric 01/01/2021 SAIZEN somatropin TERM AUTO RULE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 55 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 JUST D cholecalciferol (vitamin d3) NEW AUTO RULE Non-Formulary 01/01/2021 advanced blood sugar diagnostic TERM AUTO RULE glucose test strip 01/01/2021 DUTOPROL metoprolol TERM AUTO RULE succinate/hydrochlorothiazid e 01/01/2021 doxycycline doxycycline hyclate TERM AUTO RULE hyclate 01/01/2021 ketoprofen ketoprofen TERM AUTO RULE 01/01/2021 IMPAVIDO miltefosine TERM AUTO RULE 01/01/2021 TOBI tobramycin TERM AUTO RULE PODHALER 01/01/2021 DAKLINZA daclatasvir dihydrochloride TERM AUTO RULE 01/01/2021 BONJESTA doxylamine TERM AUTO RULE succinate/pyridoxine hcl (b6) 01/01/2021 anastrozole anastrozole TERM AUTO RULE 01/01/2021 DALIRESP roflumilast TERM AUTO RULE 01/01/2021 ANDRODERM testosterone TERM AUTO RULE 01/01/2021 VELTASSA patiromer calcium sorbitex TERM AUTO RULE 01/01/2021 element test blood sugar diagnostic TERM AUTO RULE strips 01/01/2021 ROSULA sulfacetamide sodium/sulfur TERM AUTO RULE 01/01/2021 d-vi-sol cholecalciferol (vitamin d3) TERM AUTO RULE 01/01/2021 nitroglycerin nitroglycerin NEW AUTO RULE Non-formulary 01/01/2021 calcipotriene- calcipotriene/betamethason NEW AUTO RULE NF specialty betamethasone e dipropionate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 56 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 GOLYTELY peg 3350/sod sulf/sod TERM AUTO RULE bicarb/sod chloride/potassium chloride 01/01/2021 INSULIN LISPRO insulin lispro NEW AUTO RULE Non-formulary 01/01/2021 AYVAKIT avapritinib TERM AUTO RULE 01/01/2021 pedia d-vite cholecalciferol (vitamin d3) TERM AUTO RULE 01/01/2021 ranolazine er ranolazine TERM AUTO RULE 01/01/2021 VALCHLOR mechlorethamine hcl TERM AUTO RULE 01/01/2021 XPOVIO selinexor TERM AUTO RULE 01/01/2021 blood glucose blood sugar diagnostic TERM AUTO RULE test strip 01/01/2021 FLOWTUSS guaifenesin/hydrocodone TERM AUTO RULE bitartrate 01/01/2021 TAKHZYRO lanadelumab-flyo TERM AUTO RULE 01/01/2021 progesterone progesterone NEW AUTO RULE Non-formulary 01/01/2021 optumrx blood sugar diagnostic TERM AUTO RULE 01/01/2021 freestyle insulinx blood sugar diagnostic TERM AUTO RULE test strips 01/01/2021 FLECTOR diclofenac epolamine TERM AUTO RULE 01/01/2021 FLOLIPID simvastatin TERM AUTO RULE 01/01/2021 XENAZINE tetrabenazine TERM AUTO RULE 01/01/2021 TASMAR tolcapone NEW AUTO RULE NF specialty 01/01/2021 FETZIMA levomilnacipran hcl TERM AUTO RULE 01/01/2021 ZYTIGA abiraterone acetate TERM AUTO RULE 01/01/2021 ZYVOX linezolid TERM AUTO RULE 01/01/2021 vitamin d3 cholecalciferol (vitamin d3) TERM AUTO RULE 01/01/2021 kids vitamin d3 cholecalciferol (vitamin d3) TERM AUTO RULE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 57 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 tadalafil tadalafil TERM AUTO RULE 01/01/2021 CHENODAL chenodiol TERM AUTO RULE 01/01/2021 REPATHA evolocumab TERM AUTO RULE PUSHTRONEX 01/01/2021 fora v10-v12-d10- blood sugar diagnostic TERM AUTO RULE d20 01/01/2021 LORBRENA lorlatinib TERM AUTO RULE 01/01/2021 NALFON fenoprofen calcium TERM AUTO RULE 01/01/2021 REBETOL ribavirin TERM AUTO RULE 01/01/2021 metformin er metformin hcl TERM AUTO RULE osmotic 01/01/2021 BALVERSA erdafitinib TERM AUTO RULE 01/01/2021 calcipotriene- calcipotriene/betamethason TERM AUTO RULE betamethasone e dipropionate 01/01/2021 vardenafil hcl vardenafil hcl TERM AUTO RULE 01/01/2021 TOSYMRA sumatriptan TERM AUTO RULE 01/01/2021 SPORANOX itraconazole TERM AUTO RULE 01/01/2021 FENORTHO fenoprofen calcium NEW AUTO RULE NF specialty 01/01/2021 MYDAYIS dextroamphetamine sulf- TERM AUTO RULE saccharate/amphetamine sulf-aspartate 01/01/2021 PROAIR albuterol sulfate TERM AUTO RULE DIGIHALER 01/01/2021 OSMOLEX ER amantadine hcl TERM AUTO RULE 01/01/2021 APLENZIN bupropion hbr NEW AUTO RULE NF specialty 01/01/2021 LONHALA glycopyrrolate/nebulizer TERM AUTO RULE MAGNAIR accessories REFILL

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 58 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 FOLLISTIM AQ follitropin beta,recombinant TERM AUTO RULE 01/01/2021 EDECRIN ethacrynic acid TERM AUTO RULE 01/01/2021 dexabliss dexamethasone TERM AUTO RULE 01/01/2021 INCRELEX TERM AUTO RULE 01/01/2021 ERYPED 400 erythromycin ethylsuccinate UM AUTO RULE: PA Applies AUTHORIZATION 01/01/2021 easy step blood sugar diagnostic TERM AUTO RULE 01/01/2021 PEXEVA paroxetine mesylate TERM AUTO RULE 01/01/2021 QTERN dapagliflozin TERM AUTO RULE propanediol/saxagliptin hcl 01/01/2021 ODACTRA allergenic extract, mite- TERM AUTO RULE d.farinae- d.pteronyssinus,standard 01/01/2021 v-go 30 sub-q insulin delivery TERM AUTO RULE device, 30 unit, disposable 01/01/2021 KENALOG-80 triamcinolone acetonide NEW AUTO RULE medical benefit drugs 01/01/2021 telcare blood sugar diagnostic TERM AUTO RULE 01/01/2021 wavesense jazz blood sugar diagnostic TERM AUTO RULE 01/01/2021 STRENSIQ asfotase alfa TERM AUTO RULE 01/01/2021 profeno fenoprofen calcium TERM AUTO RULE 01/01/2021 NOCDURNA desmopressin acetate TERM AUTO RULE 01/01/2021 indomethacin indomethacin, TERM AUTO RULE submicronized 01/01/2021 NOVOLIN R insulin regular, human TERM AUTO RULE FLEXPEN 01/01/2021 LAMICTAL ODT lamotrigine TERM AUTO RULE 01/01/2021 SANDOSTATIN octreotide acetate TERM AUTO RULE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 59 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 BRAFTOVI encorafenib TERM AUTO RULE 01/01/2021 INTRAROSA prasterone (dhea) TERM AUTO RULE 01/01/2021 DIBENZYLINE phenoxybenzamine hcl TERM AUTO RULE 01/01/2021 flac otic oil fluocinolone acetonide oil TERM AUTO RULE 01/01/2021 alogliptin alogliptin benzoate TERM AUTO RULE 01/01/2021 evolution test blood sugar diagnostic TERM AUTO RULE strips 01/01/2021 FARYDAK panobinostat lactate TERM AUTO RULE 01/01/2021 meclofenamate meclofenamate sodium UM AUTO RULE: PA Applies sodium AUTHORIZATION 01/01/2021 PHEXXI lactic acid/citric TERM AUTO RULE acid/potassium bitartrate 01/01/2021 PIQRAY alpelisib TERM AUTO RULE 01/01/2021 ENTRESTO /valsartan TERM AUTO RULE 01/01/2021 prolate oxycodone TERM AUTO RULE hcl/acetaminophen 01/01/2021 FULPHILA pegfilgrastim-jmdb TERM AUTO RULE 01/01/2021 JUXTAPID lomitapide mesylate TERM AUTO RULE 01/01/2021 agamatrix amp blood sugar diagnostic TERM AUTO RULE 01/01/2021 DENAVIR penciclovir TERM AUTO RULE 01/01/2021 erythromycin erythromycin ethylsuccinate UM AUTO RULE: PA Applies ethylsuccinate AUTHORIZATION 01/01/2021 gojji blood blood sugar diagnostic REMOVE UM: PA Applies glucose test strip AUTHORIZATION 01/01/2021 butalbital- butalbital/acetaminophen UM AUTO RULE: PA Applies acetaminophen AUTHORIZATION 01/01/2021 NITRO-BID nitroglycerin NEW AUTO RULE Tier 3

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 60 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 KERYDIN tavaborole TERM AUTO RULE 01/01/2021 TALTZ ixekizumab TERM AUTO RULE AUTOINJECTOR (2 PACK) 01/01/2021 tolmetin sodium tolmetin sodium UM AUTO RULE: PA Applies AUTHORIZATION 01/01/2021 AMZEEQ minocycline hcl TERM AUTO RULE 01/01/2021 AVONEX interferon beta-1a TERM AUTO RULE 01/01/2021 REPATHA evolocumab TERM AUTO RULE SURECLICK 01/01/2021 SYMLINPEN 120 acetate TERM AUTO RULE 01/01/2021 test n'go blood sugar diagnostic TERM AUTO RULE 01/01/2021 vitamin d2 ergocalciferol (vitamin d2) TERM AUTO RULE 01/01/2021 SAVAYSA edoxaban tosylate TERM AUTO RULE 01/01/2021 omeprazole- omeprazole/sodium TERM AUTO RULE sodium bicarbonate bicarbonate 01/01/2021 CALQUENCE acalabrutinib TERM AUTO RULE 01/01/2021 SYNDROS dronabinol TERM AUTO RULE 01/01/2021 RETEVMO selpercatinib TERM AUTO RULE 01/01/2021 ZEPOSIA ozanimod hydrochloride TERM AUTO RULE 01/01/2021 klofensaid ii diclofenac sodium TERM AUTO RULE 01/01/2021 SYLATRON peginterferon alfa-2b TERM AUTO RULE 01/01/2021 metformin hcl metformin hcl UM AUTO RULE: PA Applies AUTHORIZATION 01/01/2021 mefenamic acid mefenamic acid UM AUTO RULE: PA Applies AUTHORIZATION 01/01/2021 topiramate er topiramate TERM AUTO RULE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 61 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 repaglinide- repaglinide/metformin hcl TERM AUTO RULE metformin hcl 01/01/2021 precision point of blood sugar diagnostic TERM AUTO RULE care 01/01/2021 INLYTA axitinib TERM AUTO RULE 01/01/2021 NINLARO ixazomib citrate TERM AUTO RULE 01/01/2021 FIRDAPSE amifampridine phosphate TERM AUTO RULE 01/01/2021 INVEGA paliperidone TERM AUTO RULE 01/01/2021 d-vi-sol cholecalciferol (vitamin d3) NEW AUTO RULE Non-Formulary 01/01/2021 KEVEYIS dichlorphenamide TERM AUTO RULE 01/01/2021 LICART diclofenac epolamine TERM AUTO RULE 01/01/2021 SOLODYN minocycline hcl TERM AUTO RULE 01/01/2021 BACTROBAN mupirocin calcium UM AUTO RULE: PA Applies AUTHORIZATION 01/01/2021 KYNAMRO mipomersen sodium TERM AUTO RULE 01/01/2021 IMVEXXY estradiol TERM AUTO RULE 01/01/2021 alogliptin- alogliptin TERM AUTO RULE metformin benzoate/metformin hcl 01/01/2021 ALUNBRIG brigatinib TERM AUTO RULE 01/01/2021 TALTZ SYRINGE ixekizumab TERM AUTO RULE 01/01/2021 ODOMZO sonidegib phosphate TERM AUTO RULE 01/01/2021 hydroxyprogester hydroxyprogesterone TERM AUTO RULE one caproate caproate/pf 01/01/2021 SYMLINPEN 60 pramlintide acetate TERM AUTO RULE 01/01/2021 lanthanum lanthanum carbonate UM AUTO RULE: PA Applies carbonate AUTHORIZATION 01/01/2021 ANDROID methyltestosterone TERM AUTO RULE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 62 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 taperdex dexamethasone TERM AUTO RULE 01/01/2021 ERY-TAB erythromycin base UM AUTO RULE: PA Applies AUTHORIZATION 01/01/2021 assure platinum blood sugar diagnostic TERM AUTO RULE test strip 01/01/2021 SYMLINPEN 120 pramlintide acetate NEW AUTO RULE NF specialty 01/01/2021 agamatrix presto blood sugar diagnostic TERM AUTO RULE 01/01/2021 ZORVOLEX diclofenac submicronized TERM AUTO RULE 01/01/2021 QMIIZ ODT meloxicam TERM AUTO RULE 01/01/2021 EDEX alprostadil TERM AUTO RULE 01/01/2021 CUPRIMINE penicillamine TERM AUTO RULE 01/01/2021 gentamicin gentamicin sulfate in sodium NEW AUTO RULE medical benefit sulfate in ns chloride, iso-osmotic drugs 01/01/2021 coremino minocycline hcl TERM AUTO RULE 01/01/2021 hydrocodone- hydrocodone NEW AUTO RULE Non-formulary acetaminophen bitartrate/acetaminophen 01/01/2021 SYMLINPEN 60 pramlintide acetate NEW AUTO RULE NF specialty 01/01/2021 SEYSARA sarecycline hcl TERM AUTO RULE 01/01/2021 SAMSCA tolvaptan TERM AUTO RULE 01/01/2021 OPANA oxymorphone hcl TERM AUTO RULE 01/01/2021 PANDEL hydrocortisone probutate TERM AUTO RULE 01/01/2021 minocycline er minocycline hcl TERM AUTO RULE 01/01/2021 REGRANEX becaplermin TERM AUTO RULE 01/01/2021 JUST D cholecalciferol (vitamin d3) TERM AUTO RULE 01/01/2021 HETLIOZ tasimelteon TERM AUTO RULE 01/01/2021 INCRELEX mecasermin NEW AUTO RULE Tier 4

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 63 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 fluvastatin er fluvastatin sodium TERM AUTO RULE 01/01/2021 JUBLIA efinaconazole TERM AUTO RULE 01/01/2021 relion prime test blood sugar diagnostic TERM AUTO RULE strips 01/01/2021 MICORT-HC hydrocortisone acetate TERM AUTO RULE 01/01/2021 nalocet oxycodone TERM AUTO RULE hcl/acetaminophen 01/01/2021 OXAYDO oxycodone hcl TERM AUTO RULE 01/01/2021 refuah plus blood sugar diagnostic TERM AUTO RULE 01/03/2020 ABSORICA LD isotretinoin, micronized NEW AUTO RULE NF specialty 01/03/2020 ZIRABEV bevacizumab-bvzr NEW AUTO RULE Non-Formulary 01/03/2020 amifostine amifostine crystalline NEW AUTO RULE medical benefit drugs 01/03/2020 ETHYOL amifostine crystalline NEW AUTO RULE Non-Formulary 01/03/2020 ez-lets lancets NEW AUTO RULE Tier 2 01/03/2020 TAYTULLA norethindrone acetate- NEW AUTO RULE Non-formulary ethinyl estradiol/ferrous fumarate 01/03/2020 hypromellose hypromellose DRUG ATTR CHANGE Non-Formulary Non-Formulary OVERRIDE 01/03/2020 atropine sulfate atropine sulfate NEW AUTO RULE Non-Formulary 01/10/2020 fish oil omega-3 fatty acids/fish oil DRUG ATTR CHANGE Non-Formulary Non-Formulary OVERRIDE 01/10/2020 niva-fol cyanocobalamin/folic NEW AUTO RULE Non-Formulary acid/pyridoxine 01/10/2020 budesonide- budesonide/formoterol NEW AUTO RULE Non-formulary formoterol fumarate fumarate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 64 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/10/2020 HEMATEX iron polysaccharide complex NEW AUTO RULE Non-Formulary 01/10/2020 xeroform non- bismuth NEW AUTO RULE Non-Formulary occlusive tribromophenate/petrolatum, dressng white 01/10/2020 calcium acetate calcium acetate DRUG ATTR CHANGE Non-Formulary Non-Formulary OVERRIDE 01/10/2020 oral pain reliever benzocaine NEW AUTO RULE Non-Formulary 01/10/2020 aquacel ag burn silver/hydrocolloid dressing NEW AUTO RULE Non-Formulary 01/10/2020 methylcellulose methylcellulose 400cps DRUG ATTR CHANGE Non-Formulary Non-Formulary OVERRIDE 01/10/2020 benzodent benzocaine NEW AUTO RULE Non-Formulary 01/10/2020 blood pressure blood pressure test kit-wrist NEW AUTO RULE Non-Formulary monitor 01/10/2020 fish oil omega-3 fatty NEW AUTO RULE Non-Formulary acids/docosahexanoic acid/epa/fish oil 01/10/2020 VANACOF DMX guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary an hbr/phenylephrine 01/10/2020 autolet lancing lancing device NEW AUTO RULE Non-Formulary device 01/10/2020 fish oil omega-3 fatty DRUG ATTR CHANGE Non-Formulary Non-Formulary acids/docosahexanoic OVERRIDE acid/epa/fish oil 01/10/2020 BENZEPRO benzoyl peroxide NEW AUTO RULE Non-Formulary 01/10/2020 heparin sodium- heparin sodium,porcine in NEW AUTO RULE Non-Formulary 0.9% nacl 0.9 % sodium chloride/pf 01/10/2020 fungoid-d tolnaftate NEW AUTO RULE Non-Formulary 01/10/2020 fish oil omega-3 fatty acids/fish oil NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 65 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/10/2020 westab max cyanocobalamin/folic NEW AUTO RULE Non-Formulary acid/pyridoxine 01/10/2020 CALPHRON calcium acetate DRUG ATTR CHANGE Non-Formulary Non-Formulary OVERRIDE 01/10/2020 tolnaftate tolnaftate NEW AUTO RULE Non-Formulary 01/10/2020 calcium acetate calcium acetate NEW AUTO RULE Non-Formulary 01/10/2020 athlete's foot tolnaftate NEW AUTO RULE Non-Formulary 01/10/2020 ARTICADENT articaine hcl/epinephrine NEW AUTO RULE Non-Formulary DENTAL bitartrate 01/10/2020 almost naked aloe vera/xanthan gum/lactic NEW AUTO RULE Non-Formulary acid 01/10/2020 trinessa lo norgestimate-ethinyl NEW AUTO RULE Tier 1 estradiol 01/10/2020 ultra flo pen pen needle, diabetic NEW AUTO RULE Tier 2 needle 01/10/2020 series 400w bp blood pressure test kit-wrist NEW AUTO RULE Non-Formulary monitor 01/10/2020 OPTIRAY 300 ioversol NEW AUTO RULE Non-Formulary 01/10/2020 folbic cyanocobalamin/folic NEW AUTO RULE Non-Formulary acid/pyridoxine 01/10/2020 ethyl acetate ethyl acetate NEW AUTO RULE Non-Formulary 01/10/2020 dexamethasone dexamethasone sodium NEW AUTO RULE Non-Formulary sodium phosphate phosphate 01/10/2020 CALPHRON calcium acetate NEW AUTO RULE Non-Formulary 01/10/2020 antifungal cream tolnaftate NEW AUTO RULE Non-Formulary 01/10/2020 RECARBRIO imipenem/cilastatin NEW AUTO RULE Non-Formulary sodium/relebactam 01/10/2020 acetaminophen acetaminophen NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 66 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/10/2020 bardia red rubber catheter NEW AUTO RULE Non-Formulary catheter 01/10/2020 simvastatin simvastatin NEW AUTO RULE Non-formulary 01/10/2020 DIVIGEL estradiol NEW AUTO RULE Non-formulary 01/10/2020 ultra flo insulin syringe with NEW AUTO RULE Tier 2 syringe needle,insulin,0.3 ml 01/10/2020 wrist blood blood pressure test kit-wrist NEW AUTO RULE Non-Formulary pressure monitor 01/10/2020 omega-3 fish oil omega-3 fatty acids/fish oil NEW AUTO RULE Non-Formulary 01/10/2020 fish oil omega-3 omega-3 fatty acids/fish oil NEW AUTO RULE Non-Formulary 01/10/2020 ultiguard safe pen needle, diabetic, NEW AUTO RULE Non-Formulary pack remover and disposal unit 01/10/2020 penicillamine penicillamine NEW AUTO RULE Tier 4 01/10/2020 fish oil omega-3 fatty acids/fish oil NEW AUTO RULE Non-Formulary concentrate 01/10/2020 pen needle pen needle, diabetic NEW AUTO RULE Tier 2 01/15/2020 ciprofloxacin-d5w ciprofloxacin NEW AUTO RULE Non-Formulary lactate/dextrose 5 % in water 01/17/2020 acneclear benzoyl peroxide NEW AUTO RULE Non-Formulary 01/17/2020 glucagon hcl NEW AUTO RULE Tier 2 EMERGENCY KIT 01/17/2020 pure comfort alcohol antiseptic pads NEW AUTO RULE Non-Formulary alcohol pad 01/17/2020 XYLOCAINE- lidocaine hcl/pf NEW AUTO RULE Non-Formulary MPF 01/17/2020 acne treatment benzoyl peroxide NEW AUTO RULE Non-Formulary 01/17/2020 QUZYTTIR cetirizine hcl NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 67 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/17/2020 sodium chloride sodium chloride 3 % NEW AUTO RULE Non-Formulary 01/17/2020 CAFCIT caffeine citrate NEW AUTO RULE Non-Formulary 01/17/2020 bp benzoyl peroxide NEW AUTO RULE Non-Formulary 01/17/2020 AMINOACETIC glycine urologic solution NEW AUTO RULE Non-Formulary ACID 01/17/2020 enema sodium NEW AUTO RULE Non-Formulary disposable phosphate,monobasic/sodiu m phosphate,dibasic 01/17/2020 coenzyme q-10 ubidecarenone NEW AUTO RULE Non-Formulary 01/17/2020 AYVAKIT avapritinib NEW AUTO RULE NF specialty 01/17/2020 ACNE benzoyl peroxide NEW AUTO RULE Non-Formulary 01/17/2020 folivane-plus iron fumarate,polysac NEW AUTO RULE Non-Formulary cplex/folic acid/vitb comp with c no.9 01/17/2020 vitamin c ascorbic acid NEW AUTO RULE Non-Formulary 01/17/2020 daylogic acne benzoyl peroxide NEW AUTO RULE Non-Formulary treatment 01/17/2020 dextrose in water dextrose 70 % in water NEW AUTO RULE Non-Formulary 01/17/2020 bumetanide bumetanide NEW AUTO RULE Non-Formulary 01/17/2020 saline enema sodium NEW AUTO RULE Non-Formulary phosphate,monobasic/sodiu m phosphate,dibasic 01/17/2020 INTEGRA PLUS iron fumarate,polysac NEW AUTO RULE Non-Formulary cplex/folic acid/vitb comp with c no.9 01/17/2020 mannitol mannitol NEW AUTO RULE Non-Formulary 01/17/2020 benzoyl peroxide benzoyl peroxide NEW AUTO RULE Non-Formulary 01/17/2020 zinc sulfate zinc sulfate NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 68 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/17/2020 daunorubicin hcl daunorubicin hcl NEW AUTO RULE Non-Formulary 01/17/2020 pure and gentle sodium NEW AUTO RULE Non-Formulary saline enema phosphate,monobasic/sodiu m phosphate,dibasic 01/17/2020 pure comfort pen pen needle, diabetic NEW AUTO RULE Tier 2 needle 01/17/2020 XELJANZ XR tofacitinib citrate NEW AUTO RULE Tier 4 01/17/2020 CERASPORT sodium chloride/potassium NEW AUTO RULE Non-Formulary ENDURANCE chloride/sodium citrate/rice/whey 01/17/2020 VIRT-FEFA iron fumarate/polysac NEW AUTO RULE Non-Formulary PLUS complex/folic acid/vit b comp,c no.23 01/17/2020 indocyanine indocyanine green NEW AUTO RULE Non-Formulary green 01/17/2020 coenzyme q10 ubidecarenone NEW AUTO RULE Non-Formulary 01/17/2020 CALDOLOR ibuprofen NEW AUTO RULE Non-Formulary 01/17/2020 UBRELVY ubrogepant NEW AUTO RULE NF specialty 01/17/2020 VALTOCO diazepam NEW AUTO RULE Non-formulary 01/17/2020 caffeine citrate caffeine citrate NEW AUTO RULE Non-Formulary 01/17/2020 ganciclovir ganciclovir sodium NEW AUTO RULE Non-Formulary sodium 01/17/2020 glycine glycine urologic solution NEW AUTO RULE Non-Formulary 01/17/2020 naloxone hcl naloxone hcl NEW AUTO RULE Non-formulary 01/17/2020 gatifloxacin- gatifloxacin/dexamethasone NEW AUTO RULE Non-Formulary dexamethasone sodium phosphate 01/17/2020 coq-10 ubidecarenone NEW AUTO RULE Non-Formulary 01/17/2020 IC GREEN indocyanine green NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 69 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/17/2020 enema sodium NEW AUTO RULE Non-Formulary phosphate,monobasic/sodiu m phosphate,dibasic 01/17/2020 co q-10 ubidecarenone NEW AUTO RULE Non-Formulary 01/17/2020 virt-fefa plus iron fumarate,polysac NEW AUTO RULE Non-Formulary cplex/folic acid/vitb comp with c no.9 01/17/2020 prednisolone- prednisolone NEW AUTO RULE Non-Formulary bromfenac acetate/bromfenac sodium 01/17/2020 prednisolone prednisolone sodium NEW AUTO RULE Tier 1 sodium phosphate phosphate 01/17/2020 lidocaine hcl lidocaine hcl/pf NEW AUTO RULE Non-Formulary 01/17/2020 vitamin c ascorbic acid DRUG ATTR CHANGE Non-Formulary Non-Formulary OVERRIDE 01/17/2020 ESPEROCT antihemophilic factor (fviii) NEW AUTO RULE Non-Formulary rec, b-dom truncated peg- exei 01/17/2020 comfort shield diaper,brief,adult, NEW AUTO RULE Non-Formulary disposable 01/17/2020 OSMITROL mannitol NEW AUTO RULE Non-Formulary 01/17/2020 PERSA-GEL benzoyl peroxide NEW AUTO RULE Non-Formulary 01/24/2020 capsaicin hot capsaicin NEW AUTO RULE Non-Formulary patch 01/24/2020 COMPLEAT PED nutritional supplement/fiber NEW AUTO RULE Non-Formulary ORG BLEND CHICKEN 01/24/2020 TEPEZZA teprotumumab-trbw NEW AUTO RULE Non-Formulary 01/24/2020 ZITHROMAX azithromycin NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 70 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/24/2020 hydrocodone hydrocodone bitartrate NEW AUTO RULE Non-formulary bitartrate er 01/24/2020 CENTRUM multivitamin with NEW AUTO RULE Non-Formulary SILVER ULTRA minerals/folic MEN'S acid/lycopene/lutein 01/24/2020 calcipotriene- calcipotriene/betamethason NEW AUTO RULE Non-formulary betamethasone e dipropionate 01/24/2020 calcium antacid calcium carbonate NEW AUTO RULE Non-Formulary 01/24/2020 hyoscyamine hyoscyamine sulfate NEW AUTO RULE Non-Formulary sulfate 01/24/2020 ampicillin sodium ampicillin sodium NEW AUTO RULE Non-Formulary 01/24/2020 capsaicin capsaicin NEW AUTO RULE Non-Formulary 01/24/2020 ultra strength calcium carbonate NEW AUTO RULE Non-Formulary antacid 01/24/2020 CAPLYTA lumateperone tosylate NEW AUTO RULE NF specialty 01/24/2020 lidocaine hcl lidocaine hcl/pf NEW AUTO RULE Non-Formulary 01/24/2020 CENTRUM multivitamin with NEW AUTO RULE Non-Formulary SILVER MEN minerals/folic acid/lycopene/lutein 01/24/2020 COMPLEAT PED nutritional supplement/fiber NEW AUTO RULE Non-Formulary ORG BLENDS PLANT 01/24/2020 century ultimate multivitamin with NEW AUTO RULE Non-Formulary men's minerals/folic acid/lycopene/lutein 01/24/2020 ultimate men's multivitamin with NEW AUTO RULE Non-Formulary complete 50+ minerals/folic acid/lycopene/lutein 01/24/2020 a thru z select multivitamin with NEW AUTO RULE Non-Formulary minerals/folic acid/lycopene/lutein

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 71 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/24/2020 medicated heat capsaicin NEW AUTO RULE Non-Formulary patch 01/24/2020 calcium calcium carbonate NEW AUTO RULE Non-Formulary carbonate 01/24/2020 zinc stearate zinc stearate NEW AUTO RULE Non-Formulary 01/24/2020 triprolidine hcl triprolidine hcl NEW AUTO RULE Non-Formulary 01/24/2020 SALONPAS-HOT capsaicin NEW AUTO RULE Non-Formulary 01/24/2020 capsicum hot capsaicin NEW AUTO RULE Non-Formulary patch 01/24/2020 ensure plant- nutritional supplement/fiber NEW AUTO RULE Non-Formulary based protein 01/24/2020 triamcinolone triamcinolone acetonide NEW AUTO RULE Non-formulary acetonide 01/24/2020 spectravite ultra multivitamin with NEW AUTO RULE Non-Formulary men's minerals/folic acid/lycopene/lutein 01/24/2020 COMPLEAT nutritional supplement/fiber NEW AUTO RULE Non-Formulary ORGANIC BLEND CHICKEN 01/24/2020 core essentials nutritional supplement/fiber NEW AUTO RULE Non-Formulary ped standard 01/24/2020 spectravite ultra multivitamin with NEW AUTO RULE Non-Formulary men 50+ minerals/folic acid/lycopene/lutein 01/24/2020 core essentials nutritional supplement/fiber NEW AUTO RULE Non-Formulary ped peptid pls 01/24/2020 BLINK TEARS polyethylene glycol 400 NEW AUTO RULE Non-Formulary 01/24/2020 COMPLEAT nutritional supplement/fiber NEW AUTO RULE Non-Formulary ORGANIC BLENDS PLANT

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 72 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/24/2020 calcipotriene calcipotriene NEW AUTO RULE Non-formulary 01/24/2020 complete men 50 multivitamin with NEW AUTO RULE Non-Formulary plus minerals/folic acid/lycopene/lutein 01/27/2020 simvastatin simvastatin UM AUTO RULE: 5 ml/day QUANTITYCUSTOM 01/31/2020 hydromorphone hydromorphone hcl in sterile NEW AUTO RULE Non-Formulary hcl-water water/pf 01/31/2020 PEPTO-BISMOL bismuth subsalicylate NEW AUTO RULE Non-Formulary TO-GO 01/31/2020 daily fiber psyllium husk (with sugar) NEW AUTO RULE Non-Formulary 01/31/2020 B12 ACTIVE mecobalamin NEW AUTO RULE Non-Formulary 01/31/2020 children's diphenhydramine hcl NEW AUTO RULE Non-Formulary benadryl allergy 01/31/2020 bismuth bismuth subsalicylate NEW AUTO RULE Non-Formulary 01/31/2020 acetic acid acetic acid NEW AUTO RULE Non-Formulary 01/31/2020 triacetin triacetin NEW AUTO RULE Non-Formulary 01/31/2020 prilovixil lidocaine/prilocaine NEW AUTO RULE Non-Formulary 01/31/2020 pep-t-med bismuth subsalicylate NEW AUTO RULE Non-Formulary 01/31/2020 MONISTAT 3 miconazole nitrate/skin NEW AUTO RULE Non-Formulary cleanser no.17 on wipe 01/31/2020 pain relief methyl NEW AUTO RULE Non-Formulary salicylate/menthol/camphor 01/31/2020 psyllium psyllium husk NEW AUTO RULE Non-Formulary 01/31/2020 hydrocortisone hydrocortisone/aloe vera NEW AUTO RULE Non-Formulary plus 01/31/2020 cortizone-10 hydrocortisone/aloe vera NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 73 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/31/2020 dextrose 5%- dextrose 5 % and 0.9 % NEW AUTO RULE Non-Formulary 0.9% nacl sodium chloride 01/31/2020 MONISTAT 3 miconazole nitrate NEW AUTO RULE Non-Formulary 01/31/2020 PEPTO-BISMOL bismuth subsalicylate NEW AUTO RULE Non-Formulary 01/31/2020 RISPERDAL microspheres NEW AUTO RULE Non-Formulary CONSTA 01/31/2020 MARCAINE bupivacaine hcl in NEW AUTO RULE Non-Formulary SPINAL dextrose/pf 01/31/2020 BELEODAQ belinostat NEW AUTO RULE Non-Formulary 01/31/2020 vitamin b-12 cyanocobalamin (vitamin b- NEW AUTO RULE Non-Formulary 12) 01/31/2020 PHYSIOSOL physiological irrigating NEW AUTO RULE Non-Formulary solution no.1 01/31/2020 FORAXA lidocaine hcl/aloe NEW AUTO RULE Non-Formulary vera/,bovine 01/31/2020 lactated ringers ringer's solution,lactated NEW AUTO RULE Non-Formulary 01/31/2020 VEXASYN lidocaine hcl/aloe NEW AUTO RULE Non-Formulary vera/collagen,bovine 01/31/2020 intense hydration dimethicone NEW AUTO RULE Non-Formulary skin cream 01/31/2020 dextrose in water dextrose 25 % in water NEW AUTO RULE Non-Formulary 01/31/2020 tiadylt er diltiazem hcl NEW AUTO RULE Tier 1 01/31/2020 METAMUCIL psyllium husk NEW AUTO RULE Non-Formulary 01/31/2020 pain relieving methyl NEW AUTO RULE Non-Formulary salicylate/menthol/camphor 01/31/2020 pain-relief methyl NEW AUTO RULE Non-Formulary salicylate/menthol/camphor 01/31/2020 peptic relief bismuth subsalicylate NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 74 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/31/2020 PHYSIOLYTE physiological irrigating NEW AUTO RULE Non-Formulary solution no.1 01/31/2020 miconazole 3 miconazole nitrate NEW AUTO RULE Non-Formulary 01/31/2020 daily fiber psyllium husk NEW AUTO RULE Non-Formulary 01/31/2020 fiber psyllium husk NEW AUTO RULE Non-Formulary 01/31/2020 stomach relief bismuth subsalicylate NEW AUTO RULE Non-Formulary 01/31/2020 LIDOTREX lidocaine hcl/aloe NEW AUTO RULE Non-Formulary vera/collagen,bovine 01/31/2020 kionex sodium polystyrene NEW AUTO RULE Tier 1 sulfonate/sorbitol solution 01/31/2020 MEDERMA PM dimethicone NEW AUTO RULE Non-Formulary 01/31/2020 ketamine hcl- ketamine hcl in 0.9 % NEW AUTO RULE Non-Formulary 0.9% nacl sodium chloride 01/31/2020 digestive relief bismuth subsalicylate NEW AUTO RULE Non-Formulary 01/31/2020 dextrose 5%- dextrose 5 % and 0.3 % NEW AUTO RULE Non-Formulary 0.33% nacl sodium chloride 01/31/2020 dextrose 5%- dextrose 5 % and 0.3 % NEW AUTO RULE Non-Formulary 0.3% nacl sodium chloride 01/31/2020 ASMANEX HFA mometasone furoate NEW AUTO RULE Non-formulary 01/31/2020 bismatrol bismuth subsalicylate NEW AUTO RULE Non-Formulary 01/31/2020 DULERA mometasone NEW AUTO RULE Non-formulary furoate/formoterol fumarate 01/31/2020 sensorcaine with bupivacaine hcl in NEW AUTO RULE Non-Formulary dextrose dextrose/pf 01/31/2020 pain relieving rub methyl NEW AUTO RULE Non-Formulary salicylate/menthol/camphor 01/31/2020 diotame bismuth subsalicylate NEW AUTO RULE Non-Formulary 01/31/2020 RIOMET ER metformin hcl NEW AUTO RULE Non-formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 75 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/31/2020 muscle rub methyl NEW AUTO RULE Non-Formulary salicylate/menthol/camphor 01/31/2020 remifentanil hcl remifentanil hcl NEW AUTO RULE Non-Formulary 01/31/2020 hydroskin hydrocortisone/aloe vera NEW AUTO RULE Non-Formulary 01/31/2020 PROBICHEW bacillus coagulans/inulin NEW AUTO RULE Non-Formulary 01/31/2020 soothe bismuth subsalicylate NEW AUTO RULE Non-Formulary 01/31/2020 pink bismuth bismuth subsalicylate NEW AUTO RULE Non-Formulary 01/31/2020 ULTIVA remifentanil hcl NEW AUTO RULE Non-Formulary 01/31/2020 TAZVERIK tazemetostat hydrobromide NEW AUTO RULE NF specialty 01/31/2020 dextrose 5%- dextrose 5 % and 0.45 % NEW AUTO RULE Non-Formulary 0.45% nacl sodium chloride 01/31/2020 bupivacaine- bupivacaine hcl in NEW AUTO RULE Non-Formulary dextrose dextrose/pf 01/31/2020 RUXIENCE rituximab-pvvr NEW AUTO RULE Non-Formulary 01/31/2020 cbd-kings with lidocaine/methyl NEW AUTO RULE Non-Formulary lidocaine salicylate/menthol/camphor

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 76 UPDATED 12/2020 VALUE Drug Formulary Updates

February, 2020

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/01/2020 LUPRON DEPOT leuprolide acetate NEW AUTO RULE Non-Formulary 02/01/2020 OTREXUP methotrexate/pf NEW AUTO RULE NF specialty 02/01/2020 NUTROPIN AQ somatropin NEW AUTO RULE Tier 4 02/01/2020 UBRELVY ubrogepant UM AUTO RULE: 2 tabs/day; max QUANTITYCUSTOM 16 tabs/30 days 02/01/2020 NOVAREL chorionic gonadotropin, UM AUTO RULE: Specialty Drug human SPECIALTY 02/07/2020 antibiotic-pain neomycin sulf/bacitracin NEW AUTO RULE Non-Formulary relief zinc/polymyxin b sulf/pramoxine hcl 02/07/2020 effervescent multivit-minerals/vit NEW AUTO RULE Non-Formulary formula c/glutamine/lysine hcl/herbal no.124 02/07/2020 D3-50 cholecalciferol (vitamin d3) NEW AUTO RULE Non-Formulary 02/07/2020 healthpro glucose blood glucose calibration NEW AUTO RULE Non-Formulary control soln control high and low 02/07/2020 eye wash sodium borate/boric NEW AUTO RULE Non-Formulary acid/water/sodium chloride 02/07/2020 docetaxel docetaxel NEW AUTO RULE Non-Formulary 02/07/2020 anise oil anise oil NEW AUTO RULE Non-Formulary 02/07/2020 agamatrix control blood glucose calibration NEW AUTO RULE Non-Formulary solution control solution, high 02/07/2020 ROBITUSSIN dextromethorphan hbr NEW AUTO RULE Non-Formulary 02/07/2020 CHILDREN'S loratadine NEW AUTO RULE Non-Formulary CLARITIN 02/07/2020 tussin dm max guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary an hbr

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 77 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/07/2020 DESFERAL deferoxamine mesylate NEW AUTO RULE Non-Formulary MESYLATE 02/07/2020 anti-gas alpha-d-galactosidase NEW AUTO RULE Non-Formulary 02/07/2020 children's fever acetaminophen NEW AUTO RULE Non-Formulary reducer 02/07/2020 weekly-d cholecalciferol (vitamin d3) NEW AUTO RULE Non-Formulary 02/07/2020 triple antibiotic neomycin sulf/bacitracin NEW AUTO RULE Non-Formulary extra zinc/polymyxin b sulf/pramoxine hcl 02/07/2020 iron ferrous sulfate NEW AUTO RULE Non-Formulary 02/07/2020 NEOSPORIN- neomycin sulf/bacitracin NEW AUTO RULE Non-Formulary PAIN ITCH zinc/polymyxin b SCAR sulf/pramoxine hcl 02/07/2020 indomethacin indomethacin, NEW AUTO RULE Non-formulary submicronized 02/07/2020 airborne multivit-minerals/vit NEW AUTO RULE Non-Formulary c/glutamine/lysine hcl/herbal no.124 02/07/2020 REYVOW lasmiditan succinate NEW AUTO RULE NF specialty 02/07/2020 TAXOTERE docetaxel NEW AUTO RULE Non-Formulary 02/07/2020 collyrium sodium borate/boric NEW AUTO RULE Non-Formulary acid/water/sodium chloride 02/07/2020 TIVORBEX indomethacin, UM AUTO RULE: PA Applies submicronized AUTHORIZATION 02/07/2020 ferrousul ferrous sulfate NEW AUTO RULE Non-Formulary 02/07/2020 menstrual relief acetaminophen/pyrilamine NEW AUTO RULE Non-Formulary maleate/caffeine 02/07/2020 menstrual acetaminophen/pyrilamine NEW AUTO RULE Non-Formulary complete maleate/caffeine

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 78 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/07/2020 eye wash sodium borate/boric DRUG ATTR CHANGE Non-Formulary Non-Formulary acid/water/sodium chloride OVERRIDE 02/07/2020 FEVERALL acetaminophen NEW AUTO RULE Non-Formulary 02/07/2020 simethicone simethicone NEW AUTO RULE Non-Formulary 02/07/2020 agamatrix control blood glucose calibration NEW AUTO RULE Non-Formulary solution control solution, normal 02/07/2020 feosol ferrous sulfate NEW AUTO RULE Non-Formulary 02/07/2020 children's fever acetaminophen NEW AUTO RULE Non-Formulary reducing 02/07/2020 air protector multivit-minerals/vit NEW AUTO RULE Non-Formulary c/glutamine/lysine hcl/herbal no.124 02/07/2020 NEOSPORIN neomycin sulf/bacitracin NEW AUTO RULE Non-Formulary PLUS PAIN zinc/polymyxin b RELIEF sulf/pramoxine hcl 02/07/2020 pedia-lax glycerin NEW AUTO RULE Non-Formulary 02/07/2020 mi-acid simethicone NEW AUTO RULE Non-Formulary 02/07/2020 children's loratadine NEW AUTO RULE Non-Formulary loratadine 02/07/2020 children's allergy loratadine NEW AUTO RULE Non-Formulary relief 02/07/2020 cough control dextromethorphan hbr NEW AUTO RULE Non-Formulary 02/07/2020 deferoxamine deferoxamine mesylate NEW AUTO RULE Non-Formulary mesylate 02/07/2020 robafen cough dextromethorphan hbr NEW AUTO RULE Non-Formulary 02/07/2020 BIVIGAM immune NEW AUTO RULE Non-Formulary globulin,gamm(igg)/glycine/i ga greater than 50 mcg/ml 02/07/2020 acetaminophen acetaminophen NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 79 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/07/2020 healthpro glucose blood-glucose meter NEW AUTO RULE Non-Formulary monitor 02/07/2020 MEDIWASH sodium borate/boric NEW AUTO RULE Non-Formulary acid/water/sodium chloride 02/07/2020 MIDOL acetaminophen/pyrilamine NEW AUTO RULE Non-Formulary maleate/caffeine 02/07/2020 sterile eye wash sodium borate/boric NEW AUTO RULE Non-Formulary acid/water/sodium chloride 02/07/2020 optimal d3 cholecalciferol (vitamin d3) NEW AUTO RULE Non-Formulary 02/07/2020 ferosul ferrous sulfate NEW AUTO RULE Non-Formulary 02/07/2020 diazepam diazepam NEW AUTO RULE Non-Formulary 02/07/2020 decara cholecalciferol (vitamin d3) NEW AUTO RULE Non-Formulary 02/07/2020 ferro-time ferrous sulfate NEW AUTO RULE Non-Formulary 02/07/2020 MEDI-WASH sodium borate/boric NEW AUTO RULE Non-Formulary acid/water/sodium chloride 02/07/2020 first aid antibiotic- neomycin sulf/bacitracin NEW AUTO RULE Non-Formulary pain rlf zinc/polymyxin b sulf/pramoxine hcl 02/07/2020 antibiotic + pain neomycin sulf/bacitracin NEW AUTO RULE Non-Formulary relief zinc/polymyxin b sulf/pramoxine hcl 02/07/2020 gas relief simethicone NEW AUTO RULE Non-Formulary 02/07/2020 gas relief- alpha-d-galactosidase NEW AUTO RULE Non-Formulary prevention 02/07/2020 MIDOL acetaminophen/pyrilamine NEW AUTO RULE Non-Formulary COMPLETE maleate/caffeine 02/07/2020 wal-tussin cough dextromethorphan hbr NEW AUTO RULE Non-Formulary 02/07/2020 lidocaine- lidocaine/tetracaine NEW AUTO RULE Non-Formulary tetracaine

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 80 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/07/2020 ginkgo biloba ginkgo biloba leaf extract NEW AUTO RULE Non-Formulary 02/07/2020 PLIAGLIS lidocaine/tetracaine NEW AUTO RULE Non-Formulary 02/07/2020 tussin cough dextromethorphan hbr NEW AUTO RULE Non-Formulary 02/07/2020 AZO URINARY phenazopyridine hcl NEW AUTO RULE Non-Formulary PAIN RELIEF 02/07/2020 triple antibiotic neomycin sulf/bacitracin NEW AUTO RULE Non-Formulary plus zinc/polymyxin b sulf/pramoxine hcl 02/07/2020 SOLARAVIX diclofenac sodium/silicone, NEW AUTO RULE Non-Formulary adhesive 02/07/2020 little remedies simethicone NEW AUTO RULE Non-Formulary gas relief 02/07/2020 laxative glycerin NEW AUTO RULE Non-Formulary suppository 02/10/2020 AMZEEQ minocycline hcl UM AUTO RULE: 1 bottle/month QUANTITYCUSTOM 02/14/2020 SILA III triamcinolone NEW AUTO RULE Non-Formulary acetonide/gauze bandage/silicone, adhesive 02/14/2020 lidocaine hcl- lidocaine hcl/epinephrine NEW AUTO RULE Non-Formulary epinephrine 02/14/2020 duloxetine hcl duloxetine hcl UM AUTO RULE: 2 caps/day QUANTITYCUSTOM 02/14/2020 ketorolac ketorolac tromethamine NEW AUTO RULE NF specialty tromethamine 02/14/2020 clear fiber dextrin NEW AUTO RULE Non-Formulary 02/14/2020 magnesium oxide magnesium oxide NEW AUTO RULE Non-Formulary 02/14/2020 hypromellose hypromellose NEW AUTO RULE Non-Formulary 02/14/2020 cocaine hcl cocaine hcl NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 81 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/14/2020 carboplatin carboplatin NEW AUTO RULE Non-Formulary 02/14/2020 afrin oxymetazoline hcl NEW AUTO RULE Non-Formulary 02/14/2020 loratadine loratadine NEW AUTO RULE Non-Formulary 02/14/2020 no contact digital thermometer, infrared, non- NEW AUTO RULE Non-Formulary thermometer contact 02/14/2020 NUMBRINO cocaine hcl NEW AUTO RULE Non-Formulary 02/14/2020 allergy relief loratadine NEW AUTO RULE Non-Formulary 02/14/2020 HOMINEX-1 infant formula, special NEW AUTO RULE Non-Formulary metabolic, iron, - free 02/14/2020 duloxetine hcl duloxetine hcl TERM AUTO RULE 02/14/2020 magnesium magnesium oxide NEW AUTO RULE Non-Formulary 02/14/2020 KETONEX-1 infant formula with NEW AUTO RULE Non-Formulary iron,spec.metabolic,maple syrup urine dx 02/14/2020 GOPRELTO cocaine hcl NEW AUTO RULE Non-Formulary 02/14/2020 UBRELVY ubrogepant UM AUTO RULE: 2 tabs/day; max QUANTITYCUSTOM 16 tabs/30 days 02/14/2020 tramadol hcl tramadol hcl NEW AUTO RULE Tier 1 02/14/2020 methocel e 4 m hypromellose NEW AUTO RULE Non-Formulary 02/14/2020 allergy relief cetirizine hcl NEW AUTO RULE Non-Formulary 02/14/2020 easy touch safety pen needle, diabetic, safety NEW AUTO RULE Tier 2 pen needle 02/14/2020 new image ostomy supply NEW AUTO RULE Non-Formulary ceraplus skn barrier 02/14/2020 vtol lq butalbital/acetaminophen/caf NEW AUTO RULE NF specialty feine

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 82 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/14/2020 paraplatin carboplatin NEW AUTO RULE Non-Formulary 02/14/2020 XYLOCAINE lidocaine hcl/epinephrine NEW AUTO RULE Non-Formulary WITH EPINEPHRINE 02/14/2020 vanishpoint syringe with needle, insulin, NEW AUTO RULE Tier 2 insulin syringe safety, 1 ml 02/14/2020 ALAVERT loratadine NEW AUTO RULE Non-Formulary 02/14/2020 ALEVE PM naproxen NEW AUTO RULE Non-Formulary sodium/diphenhydramine hcl 02/14/2020 lidocaine hcl- lidocaine hcl/epinephrine/pf NEW AUTO RULE Non-Formulary epinephrine 02/14/2020 HALUCORT emollient combination NEW AUTO RULE Non-Formulary no.56/hyaluronic acid 02/14/2020 VOLUMEN barium sulfate NEW AUTO RULE Non-Formulary 02/14/2020 naproxen pm naproxen NEW AUTO RULE Non-Formulary sodium/diphenhydramine hcl 02/14/2020 dermaplex emollient combination NEW AUTO RULE Non-Formulary no.56/hyaluronic acid 02/14/2020 children's allergy cetirizine hcl NEW AUTO RULE Non-Formulary complete 02/14/2020 FETROJA cefiderocol sulfate tosylate NEW AUTO RULE Non-Formulary 02/14/2020 I-VALEX-1 infant formula,spec. NEW AUTO RULE Non-Formulary metabolic,isovaleric acidemia with iron 02/14/2020 PALFORZIA peanut allergen powder-dnfp NEW AUTO RULE Non-Formulary 02/18/2020 ZYVOX linezolid in dextrose 5 % in NEW AUTO RULE Non-Formulary water 02/18/2020 linezolid-d5w linezolid in dextrose 5 % in NEW AUTO RULE Non-Formulary water

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 83 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/21/2020 PROPIMEX-1 infant formula,spec. NEW AUTO RULE Non-Formulary metabolic, propionic acidemia,with iron 02/21/2020 ALOE VESTA petrolatum,white NEW AUTO RULE Non-Formulary 02/21/2020 ZORVOLEX diclofenac submicronized UM AUTO RULE: PA Applies AUTHORIZATION 02/21/2020 irinotecan hcl irinotecan hcl NEW AUTO RULE Non-Formulary 02/21/2020 selenium selenomethionine NEW AUTO RULE Non-Formulary 02/21/2020 syringe catheter syringe, disposable, 50 ml NEW AUTO RULE Non-Formulary tip 02/21/2020 PRO-PHREE infant formula, special NEW AUTO RULE Non-Formulary metabolic with iron 02/21/2020 ANGIOMAX bivalirudin NEW AUTO RULE Non-Formulary 02/21/2020 CYCLINEX-1 infant formula, special NEW AUTO RULE Non-Formulary metabolic, urea cycle disorder 02/21/2020 fish oil omega-3 fatty NEW AUTO RULE Non-Formulary acids/docosahexaenoic acid/epa/fish oil 02/21/2020 syringe slip tip syringe, disposable, 50 ml NEW AUTO RULE Non-Formulary non-sterile 02/21/2020 POLYSPORIN bacitracin zinc/polymyxin b NEW AUTO RULE Non-Formulary sulfate 02/21/2020 CHILDREN'S pediatric multivitamin no.120 NEW AUTO RULE Non-Formulary MULTIVITAMIN 02/21/2020 children's pediatric multivitamin no.119 NEW AUTO RULE Non-Formulary multivitamin 02/21/2020 bivalirudin bivalirudin NEW AUTO RULE Non-Formulary 02/21/2020 children's pediatric multivitamin no.101 NEW AUTO RULE Non-Formulary multivitamin

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 84 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/21/2020 PHENEX-1 infant formula for pku, iron, NEW AUTO RULE Non-Formulary no.2 02/21/2020 acetaminophen acetaminophen NEW AUTO RULE Non-Formulary 02/21/2020 mineral oil mineral oil NEW AUTO RULE Non-Formulary 02/21/2020 methyl salicylate methyl salicylate NEW AUTO RULE Non-Formulary 02/21/2020 syringe luer-lok syringe, disposable, 50 ml NEW AUTO RULE Non-Formulary sterile 02/21/2020 children's chew pediatric multivitamin no.17 NEW AUTO RULE Non-Formulary multivitamin 02/21/2020 TRAZIMERA trastuzumab-qyyp NEW AUTO RULE Non-Formulary 02/21/2020 TYREX-1 infant formula, special NEW AUTO RULE Non-Formulary metabolic, tyrosinemia, with iron 02/21/2020 PROCYSBI cysteamine bitartrate NEW AUTO RULE NF specialty 02/21/2020 poly bacitracin bacitracin zinc/polymyxin b NEW AUTO RULE Non-Formulary sulfate 02/21/2020 syringe luer-lok syringe, disposable, 50 ml NEW AUTO RULE Non-Formulary 02/21/2020 moxifloxacin moxifloxacin hcl NEW AUTO RULE Tier 3 02/21/2020 syringe catheter syringe, disposable, 50 ml NEW AUTO RULE Non-Formulary tip non-ster 02/21/2020 syringe slip tip syringe, disposable, 50 ml NEW AUTO RULE Non-Formulary 02/21/2020 uristat phenazopyridine hcl NEW AUTO RULE Non-Formulary 02/21/2020 oxycodone- oxycodone NEW AUTO RULE NF specialty acetaminophen hcl/acetaminophen 02/21/2020 syringe luer-lok syringe, disposable, 50 ml NEW AUTO RULE Non-Formulary non-sterile 02/21/2020 GLUTAREX-1 inf form, glutaric aciduria i NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 85 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/21/2020 AZO URINARY phenazopyridine hcl NEW AUTO RULE Non-Formulary PAIN RELIEF 02/21/2020 CHILDREN'S pyrilamine NEW AUTO RULE Non-Formulary DAYCLEAR maleate/chlophedianol hcl ALLERGY 02/21/2020 double antibiotic bacitracin zinc/polymyxin b NEW AUTO RULE Non-Formulary sulfate 02/21/2020 NORMOSOL-R electrolyte-r (ph 7.4) NEW AUTO RULE Non-Formulary PH 7.4 02/21/2020 pure comfort lancets NEW AUTO RULE Tier 2 lancets 02/21/2020 sorbitol-mannitol mannitol/sorbitol solution NEW AUTO RULE Non-Formulary 02/21/2020 pure comfort lancets NEW AUTO RULE Tier 2 safety lancets 02/21/2020 children's pediatric multivitamin no.73 NEW AUTO RULE Non-Formulary multivitamin 02/21/2020 children's pediatric multivitamin no.42 NEW AUTO RULE Non-Formulary multivitamin 02/21/2020 children's pediatric multivitamin no.17 NEW AUTO RULE Non-Formulary multivitamin 02/21/2020 mineral oil extra mineral oil NEW AUTO RULE Non-Formulary heavy 02/21/2020 mlc lidocaine/methyl NEW AUTO RULE Non-Formulary salicylate/camphor 02/21/2020 CAMPTOSAR irinotecan hcl NEW AUTO RULE Non-Formulary 02/22/2020 poly bacitracin bacitracin zinc/polymyxin b DRUG ATTR CHANGE Non-Formulary Non-Formulary sulfate OVERRIDE 02/22/2020 acetaminophen acetaminophen DRUG ATTR CHANGE Non-Formulary Non-Formulary OVERRIDE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 86 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/22/2020 methyl salicylate methyl salicylate DRUG ATTR CHANGE Non-Formulary Non-Formulary OVERRIDE 02/27/2020 TIVORBEX indomethacin, UM AUTO RULE: PA Applies submicronized AUTHORIZATION 02/28/2020 calcium 500-vit calcium NEW AUTO RULE Non-Formulary d3 carbonate/cholecalciferol (vitamin d3) 02/28/2020 COMPLEAT nutritional supplement/fiber NEW AUTO RULE Non-Formulary PEDIATRIC 1.5 02/28/2020 VITAFOL FE prenatal vits no.102/iron NEW AUTO RULE Non-formulary PLUS polysacch/folate no.1/dha 02/28/2020 glyceryl glyceryl monostearate NEW AUTO RULE Non-Formulary monostearate 02/28/2020 VB6 P5P pyridoxal phosphate NEW AUTO RULE Non-Formulary 02/28/2020 SIMILAC infant formula with NEW AUTO RULE Non-Formulary ADVANCE iron/docosahexanoic acid/arachidonic ac 02/28/2020 doxorubicin hcl doxorubicin hcl NEW AUTO RULE Non-Formulary 02/28/2020 ORABASE benzocaine NEW AUTO RULE Non-Formulary 02/28/2020 magnesium oxide magnesium oxide NEW AUTO RULE Non-Formulary 02/28/2020 calcium 500 + calcium NEW AUTO RULE Non-Formulary vitamin d carbonate/cholecalciferol (vitamin d3) 02/28/2020 laxative dietary magnesium oxide NEW AUTO RULE Non-Formulary supplement 02/28/2020 DELSYM dextromethorphan polistirex NEW AUTO RULE Non-Formulary 02/28/2020 phillips magnesium oxide NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 87 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/28/2020 CELESTONE betamethasone NEW AUTO RULE Non-Formulary acetate/betamethasone sodium phosphate 02/28/2020 children's dextromethorphan polistirex NEW AUTO RULE Non-Formulary robitussin er 02/28/2020 agamatrix presto blood sugar diagnostic NEW AUTO RULE Non-formulary 02/28/2020 gojji blood blood sugar diagnostic NEW AUTO RULE Non-formulary glucose test strip 02/28/2020 child's dibromm brompheniramine NEW AUTO RULE Non-Formulary cold-allergy maleate/phenylephrine hcl 02/28/2020 rynex pe brompheniramine NEW AUTO RULE Non-Formulary maleate/phenylephrine hcl 02/28/2020 dimetapp brompheniramine NEW AUTO RULE Non-Formulary maleate/phenylephrine hcl 02/28/2020 cough-cold chlorpheniramine NEW AUTO RULE Non-Formulary maleate/dextromethorphan hbr 02/28/2020 petrolatum petrolatum, yellow NEW AUTO RULE Non-Formulary 02/28/2020 DOTAREM gadoterate meglumine NEW AUTO RULE Non-Formulary 02/28/2020 butalbital- butalbital/acetaminophen NEW AUTO RULE NF specialty acetaminophen 02/28/2020 RECTICARE lidocaine NEW AUTO RULE Non-Formulary 02/28/2020 naproxen- naproxen/esomeprazole NEW AUTO RULE NF specialty esomeprazole magnesium mag 02/28/2020 acidophilus lactobacillus acidophilus NEW AUTO RULE Non-Formulary 02/28/2020 lc-5 lidocaine NEW AUTO RULE Non-Formulary 02/28/2020 CHILDREN'S dextromethorphan polistirex NEW AUTO RULE Non-Formulary DELSYM COUGH

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 88 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/28/2020 LMX 5 lidocaine NEW AUTO RULE Non-Formulary 02/28/2020 rectasmoothe lidocaine NEW AUTO RULE Non-Formulary 02/28/2020 cough-cold bp chlorpheniramine NEW AUTO RULE Non-Formulary maleate/dextromethorphan hbr 02/28/2020 abouttime pen pen needle, diabetic NEW AUTO RULE Tier 2 needle 02/28/2020 deferasirox deferasirox UM AUTO RULE: Limited Access LIMITEDACCESS 02/28/2020 COMPLEAT nutritional supplement/fiber NEW AUTO RULE Non-Formulary PEPTIDE 1.5 02/28/2020 children's cold- brompheniramine NEW AUTO RULE Non-Formulary allergy maleate/phenylephrine hcl 02/28/2020 dextrose in dextrose 5 % in lactated NEW AUTO RULE Non-Formulary lactated ringers ringers 02/28/2020 prodigy blood-glucose meter NEW AUTO RULE Non-Formulary 02/28/2020 ETOPOPHOS etoposide phosphate NEW AUTO RULE Non-Formulary 02/28/2020 robafen dm peak guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary cold an hbr 02/28/2020 wal-tap brompheniramine NEW AUTO RULE Non-Formulary maleate/phenylephrine hcl 02/28/2020 PROLEUKIN aldesleukin NEW AUTO RULE Non-Formulary 02/28/2020 precision xtra blood ketone and glucose NEW AUTO RULE Non-Formulary ketone-glucose monitor 02/28/2020 advantage infant formula with NEW AUTO RULE Non-Formulary iron/docosahexanoic acid/arachidonic ac 02/28/2020 cold-allergy brompheniramine NEW AUTO RULE Non-Formulary maleate/phenylephrine hcl

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 89 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/28/2020 dextrose 5%-ns- potassium chloride in NEW AUTO RULE Non-Formulary kcl dextrose 5 % and 0.9 % sodium chloride 02/28/2020 clever choice underpads NEW AUTO RULE Non-Formulary 02/28/2020 adjustable lancing device NEW AUTO RULE Non-Formulary lancing device 02/28/2020 phenobarbital phenobarbital sodium NEW AUTO RULE Non-Formulary sodium 02/28/2020 12-hour cough dextromethorphan polistirex NEW AUTO RULE Non-Formulary relief 02/28/2020 prolate oxycodone NEW AUTO RULE NF specialty hcl/acetaminophen 02/28/2020 witch hazel witch hazel NEW AUTO RULE Non-Formulary 02/28/2020 lancing device lancing device NEW AUTO RULE Non-Formulary 02/28/2020 gojji lancing lancing device NEW AUTO RULE Non-Formulary device 02/28/2020 child wal-tap brompheniramine NEW AUTO RULE Non-Formulary cold-allergy maleate/phenylephrine hcl 02/28/2020 primlev oxycodone NEW AUTO RULE NF specialty hcl/acetaminophen 02/28/2020 PURE BLISS infant formula with NEW AUTO RULE Non-Formulary NON-GMO iron/docosahexaenoic acid/arachidonic ac 02/28/2020 naproxen pm naproxen NEW AUTO RULE Non-Formulary sodium/diphenhydramine hcl 02/28/2020 ORAPEUTIC xylitol/pectin/acemannan/so NEW AUTO RULE Non-Formulary dium bicarbonate 02/28/2020 SIMILAC infant formula with NEW AUTO RULE Non-Formulary ADVANCE NON- iron/docosahexanoic GMO acid/arachidonic ac

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 90 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/28/2020 MCT OIL medium chain triglycerides NEW AUTO RULE Non-Formulary 02/28/2020 oral pain reliever benzocaine NEW AUTO RULE Non-Formulary 02/28/2020 droperidol droperidol NEW AUTO RULE Non-Formulary 02/28/2020 eucalyptus oil eucalyptus oil NEW AUTO RULE Non-Formulary 02/28/2020 oral anesthetic benzocaine NEW AUTO RULE Non-Formulary paste 02/28/2020 ALLZITAL butalbital/acetaminophen NEW AUTO RULE NF specialty 02/28/2020 anecream5 lidocaine NEW AUTO RULE Non-Formulary 02/28/2020 DOUBLE bacitracin zinc/polymyxin b NEW AUTO RULE Non-Formulary ANTIBIOTIC sulfate 02/28/2020 dextromethorpha dextromethorphan polistirex NEW AUTO RULE Non-Formulary n polistirex 02/28/2020 vitamin b-12 cyanocobalamin (vitamin b- NEW AUTO RULE Non-Formulary 12) 02/28/2020 dimaphen brompheniramine NEW AUTO RULE Non-Formulary maleate/phenylephrine hcl 02/28/2020 adriamycin doxorubicin hcl NEW AUTO RULE Non-Formulary 02/28/2020 LUVIRA omega-3 fatty NEW AUTO RULE Non-Formulary acids/docosahexaenoic acid/epa/fish oil 02/28/2020 child triaminic brompheniramine NEW AUTO RULE Non-Formulary cold-allergy maleate/phenylephrine hcl 02/28/2020 advantage with infant formula with NEW AUTO RULE Non-Formulary iron non-gmo iron/docosahexaenoic acid/arachidonic ac

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 91 UPDATED 12/2020 VALUE Drug Formulary Updates

March, 2019

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2019 ERYGEL erythromycin base in NEW AUTO RULE Non-formulary ethanol 03/01/2020 DENAVIR penciclovir UM AUTO RULE: 5 gm tube/fill; QUANTITYCUSTOM max 30 gm/year 03/01/2020 XERESE acyclovir/hydrocortisone UM AUTO RULE: 5 gm tube/fill; QUANTITYCUSTOM max 30 gm/year 03/01/2020 ENDOMETRIN progesterone, micronized NEW AUTO RULE Tier 3 03/01/2020 acyclovir acyclovir UM AUTO RULE: 5 gm tube/fill; QUANTITYCUSTOM max 30 gm/year 03/01/2020 ZOVIRAX acyclovir UM AUTO RULE: 5 gm tube/fill; QUANTITYCUSTOM max 30 gm/year 03/04/2020 PATANOL olopatadine hcl TERM AUTO RULE 03/04/2020 olopatadine hcl olopatadine hcl TERM AUTO RULE 03/04/2020 PATANOL olopatadine hcl NEW AUTO RULE Non-Formulary 03/04/2020 olopatadine hcl olopatadine hcl NEW AUTO RULE Non-Formulary 03/04/2020 PATADAY olopatadine hcl TERM AUTO RULE 03/04/2020 PATADAY olopatadine hcl NEW AUTO RULE Non-Formulary 03/06/2020 VYEPTI -jjmr NEW AUTO RULE Non-Formulary 03/06/2020 century multivitamin with NEW AUTO RULE Non-Formulary minerals/folic acid/lycopene/lutein 03/06/2020 multi-vitamin daily multivitamin NEW AUTO RULE Non-Formulary 03/06/2020 VITAMINS FOR multivitamin NEW AUTO RULE Non-Formulary HAIR

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 92 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/06/2020 a thru z select 50 multivitamin with NEW AUTO RULE Non-Formulary plus minerals/folic acid/lycopene/lutein 03/06/2020 one daily multivitamin NEW AUTO RULE Non-Formulary multivitamin 03/06/2020 once daily multivitamin NEW AUTO RULE Non-Formulary 03/06/2020 NEXLETOL bempedoic acid NEW AUTO RULE Non-formulary 03/06/2020 DAILY-VITE multivitamin NEW AUTO RULE Non-Formulary 03/06/2020 tc99m mertiatide kit for prep tc-99m/mertiatide NEW AUTO RULE Non-Formulary prep (betiatide) 03/06/2020 PEDIASURE pediatric nutrition, iron, NEW AUTO RULE Non-Formulary SIDEKICKS lactose free with fiber 03/06/2020 daily multiple multivitamin NEW AUTO RULE Non-Formulary vitamin 03/06/2020 KONSYL psyllium husk NEW AUTO RULE Non-Formulary 03/06/2020 CERTAVITE multivitamin with NEW AUTO RULE Non-Formulary SENIOR- minerals/folic ANTIOXIDANT acid/lycopene/lutein 03/06/2020 complete mv multivitamin with NEW AUTO RULE Non-Formulary adult 50 plus minerals/folic acid/lycopene/lutein 03/06/2020 sentry senior multivitamin with NEW AUTO RULE Non-Formulary minerals/folic acid/lycopene/lutein 03/06/2020 slow release iron ferrous sulfate NEW AUTO RULE Non-Formulary 03/06/2020 complete senior multivitamin with NEW AUTO RULE Non-Formulary minerals/folic acid/lycopene/lutein 03/06/2020 PEDIASURE pediatric nutrition, iron, NEW AUTO RULE Non-Formulary REDUCED lactose free with fiber CALORIE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 93 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/06/2020 ANIMAL pediatric multivitamin no.17 NEW AUTO RULE Non-Formulary SHAPES 03/06/2020 multivitamin multivitamin NEW AUTO RULE Non-Formulary 03/06/2020 daily value multivitamin NEW AUTO RULE Non-Formulary 03/06/2020 TAB-A-VITE multivitamin with folic acid NEW AUTO RULE Non-Formulary 03/06/2020 daily vitamin multivitamin NEW AUTO RULE Non-Formulary formula 03/06/2020 vitamin d3 cholecalciferol (vitamin d3) NEW AUTO RULE Non-Formulary 03/06/2020 SENSI-CARE zinc oxide/petrolatum,white NEW AUTO RULE Non-Formulary 03/06/2020 century mature multivitamin with NEW AUTO RULE Non-Formulary minerals/folic acid/lycopene/lutein 03/06/2020 multivitamins multivitamin NEW AUTO RULE Non-Formulary 03/06/2020 DAILY VITE multivitamin NEW AUTO RULE Non-Formulary 03/06/2020 SARCLISA isatuximab-irfc NEW AUTO RULE Non-Formulary 03/06/2020 BREVIBLOC esmolol hcl in sodium NEW AUTO RULE Non-Formulary chloride, iso-osmotic 03/06/2020 AMINOSYN-PF parenteral amino acid 10% NEW AUTO RULE Non-Formulary combination no.5 (pediatric) 03/06/2020 one daily multivitamin NEW AUTO RULE Non-Formulary essential 03/06/2020 co q10-black ubidecarenone (coenzyme NEW AUTO RULE Non-Formulary pepper q-10)/black pepper extract 03/06/2020 naproxen- naproxen/esomeprazole NEW AUTO RULE NF specialty esomeprazole magnesium mag 03/06/2020 natural fiber psyllium husk NEW AUTO RULE Non-Formulary supplement

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 94 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/06/2020 a thru z select multivitamin with NEW AUTO RULE Non-Formulary minerals/folic acid/lycopene/lutein 03/06/2020 midazolam hcl midazolam hcl/pf NEW AUTO RULE Non-Formulary 03/06/2020 SUPER multivitamin NEW AUTO RULE Non-Formulary MULTIVITAMIN 03/06/2020 one-daily multi- multivitamin NEW AUTO RULE Non-Formulary vitamin 03/06/2020 centrum silver multivitamin with NEW AUTO RULE Non-Formulary minerals/folic acid/lycopene/lutein 03/06/2020 ZERVIATE cetirizine hcl NEW AUTO RULE Non-formulary 03/06/2020 gas relief simethicone NEW AUTO RULE Non-Formulary 03/06/2020 NURTEC ODT rimegepant sulfate NEW AUTO RULE NF specialty 03/06/2020 multiple vitamins multivitamin NEW AUTO RULE Non-Formulary 03/06/2020 one-a-day multivitamin NEW AUTO RULE Non-Formulary essential 03/06/2020 MODULEN nutritional therapy for NEW AUTO RULE Non-Formulary impaired digestive function 03/06/2020 theratrum multivitamin with NEW AUTO RULE Non-Formulary complete 50 plus minerals/folic acid/lycopene/lutein 03/06/2020 IBRANCE palbociclib NEW AUTO RULE Tier 4 03/06/2020 PATADAY olopatadine hcl NEW AUTO RULE Non-Formulary 03/06/2020 senior tabs multivitamin with NEW AUTO RULE Non-Formulary minerals/folic acid/lycopene/lutein 03/06/2020 abc plus multivitamin with NEW AUTO RULE Non-Formulary minerals/folic acid/lycopene/lutein

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 95 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/06/2020 men's multi- multivitamin NEW AUTO RULE Non-Formulary vitamin 03/06/2020 centravites 50 multivitamin with NEW AUTO RULE Non-Formulary plus minerals/folic acid/lycopene/lutein 03/06/2020 compleat pediatric nutrition, iron, NEW AUTO RULE Non-Formulary pediatric reduced lactose free with fiber cal 03/06/2020 esmolol hcl- esmolol hcl in sodium NEW AUTO RULE Non-Formulary sodium chloride chloride, iso-osmotic 03/06/2020 PHAZYME simethicone NEW AUTO RULE Non-Formulary 03/06/2020 complete 50 plus multivitamin with NEW AUTO RULE Non-Formulary minerals/folic acid/lycopene/lutein 03/13/2020 AQUA-D cholecalciferol (vit NEW AUTO RULE Non-Formulary CONCENTRATE d3)/tocophersolan 03/13/2020 jaimiess levonorgestrel/ethinyl NEW AUTO RULE Tier 1 estradiol and ethinyl estradiol 03/13/2020 VISINE polyethylene glycol NEW AUTO RULE Non-Formulary 400/hypromellose/glycerin 03/13/2020 amethia lo levonorgestrel/ethinyl NEW AUTO RULE Tier 1 estradiol and ethinyl estradiol 03/13/2020 children's mapap acetaminophen NEW AUTO RULE Non-Formulary 03/13/2020 azelastine- azelastine hcl/fluticasone NEW AUTO RULE Non-formulary fluticasone propionate 03/13/2020 acetaminophen acetaminophen NEW AUTO RULE Non-Formulary 03/13/2020 melatonin melatonin NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 96 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/13/2020 omega-3 fish oil omega-3 fatty NEW AUTO RULE Non-Formulary acids/docosahexanoic acid/epa/fish oil 03/13/2020 liquid c ascorbic acid NEW AUTO RULE Non-Formulary 03/13/2020 ANTIOXIDANT beta-carotene/ascorbic NEW AUTO RULE Non-Formulary FORMULA acid/vite ac/selenium yeast 03/13/2020 volnea desogestrel-ethinyl NEW AUTO RULE Tier 1 estradiol/ethinyl estradiol 03/13/2020 advanced lactobacillus combo NEW AUTO RULE Non-Formulary probiotic no.37/bifido animalis/bifido longum 03/13/2020 fish oil omega-3 fatty NEW AUTO RULE Non-Formulary acids/docosahexaenoic acid/epa/fish oil 03/13/2020 omega-3 omega-3 fatty NEW AUTO RULE Non-Formulary acids/docosahexanoic acid/epa/fish oil 03/13/2020 lojaimiess levonorgestrel/ethinyl NEW AUTO RULE Tier 1 estradiol and ethinyl estradiol 03/13/2020 VISINE DRY polyethylene glycol NEW AUTO RULE Non-Formulary EYE RELIEF 400/hypromellose/glycerin 03/13/2020 MIRCETTE desogestrel-ethinyl NEW AUTO RULE Non-formulary estradiol/ethinyl estradiol 03/13/2020 pain reliever acetaminophen NEW AUTO RULE Non-Formulary junior strength 03/13/2020 camrese lo levonorgestrel/ethinyl NEW AUTO RULE Tier 1 estradiol and ethinyl estradiol 03/13/2020 unifine pen needle, diabetic NEW AUTO RULE Tier 2 safecontrol disposable, safety

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 97 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/13/2020 children's pain acetaminophen NEW AUTO RULE Non-Formulary relief 03/13/2020 GEODON ziprasidone mesylate NEW AUTO RULE Non-Formulary 03/13/2020 SCENESSE afamelanotide acetate NEW AUTO RULE Non-Formulary 03/13/2020 potassium potassium NEW AUTO RULE Non-Formulary phosphates phosphate,monobasic- dibasic 03/13/2020 TRIJARDY XR empagliflozin/linagliptin/metf NEW AUTO RULE Non-formulary ormin hcl 03/13/2020 children's tylenol acetaminophen NEW AUTO RULE Non-Formulary 03/13/2020 eye drop tears polyethylene glycol NEW AUTO RULE Non-Formulary 400/hypromellose/glycerin 03/13/2020 fish oil omega-3 fatty NEW AUTO RULE Non-Formulary acids/docosahexanoic acid/epa/fish oil 03/13/2020 gojji multi- blood ketone and glucose NEW AUTO RULE Non-Formulary functional meter monitor 03/13/2020 omega-3 omega-3 fatty NEW AUTO RULE Non-Formulary acids/docosahexaenoic acid/epa/fish oil 03/13/2020 paclitaxel paclitaxel NEW AUTO RULE Non-Formulary 03/13/2020 ziprasidone ziprasidone mesylate NEW AUTO RULE Non-Formulary mesylate 03/18/2020 LIBRAX chlordiazepoxide/clidinium UM AUTO RULE: 8 caps/day bromide QUANTITYCUSTOM 03/18/2020 CYCLOSET bromocriptine mesylate UM AUTO RULE: PA Applies AUTHORIZATION 03/18/2020 chlordiazepoxide- chlordiazepoxide/clidinium UM AUTO RULE: 8 caps/day clidinium bromide QUANTITYCUSTOM

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 98 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/20/2020 multi complete- multivitamin/ferrous NEW AUTO RULE Non-Formulary iron fumarate/folic acid 03/20/2020 MUCINEX FAST- diphenhydramine/phenyleph NEW AUTO RULE Non-Formulary MAX DAY-NITE rin/dextromethorph/acetamin COLD ophen/gg 03/20/2020 calcium calcium carbonate NEW AUTO RULE Non-Formulary carbonate 03/20/2020 everolimus everolimus NEW AUTO RULE NF specialty 03/20/2020 a thru z multivitamin/ferrous NEW AUTO RULE Non-Formulary advanced fumarate/folic acid formula 03/20/2020 etoposide etoposide NEW AUTO RULE Non-Formulary 03/20/2020 glucosamine glucosamine sulfate NEW AUTO RULE Non-Formulary sulfate 03/20/2020 AZO URINARY phenazopyridine hcl NEW AUTO RULE Non-Formulary PAIN RELIEF 03/20/2020 alum-mag magnesium NEW AUTO RULE Non-Formulary hydroxide- hydroxide/aluminum simethicone hydroxide/simethicone 03/20/2020 CEROVITE multivitamin/ferrous NEW AUTO RULE Non-Formulary ADVANCED fumarate/folic acid FORMULA 03/20/2020 daily multiple multivitamin/ferrous NEW AUTO RULE Non-Formulary fumarate/folic acid 03/20/2020 TAB-A-VITE multivitamin/ferrous NEW AUTO RULE Non-Formulary MULTIVIT WITH fumarate/folic acid IRON 03/20/2020 complete multi- multivitamin/ferrous NEW AUTO RULE Non-Formulary vit-mineral fumarate/folic acid 03/20/2020 intelligent mesh nebulizer NEW AUTO RULE Non-Formulary nebulizer

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 99 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/20/2020 synovacin glucosamine sulfate NEW AUTO RULE Non-Formulary 03/20/2020 glucose control blood glucose calibration NEW AUTO RULE Non-Formulary solution control solution, normal 03/20/2020 day-night severe dextromethorphan/phenylep NEW AUTO RULE Non-Formulary cold-flu hrine/acetaminophen/diphen hydramine 03/20/2020 complete multivitamin/ferrous NEW AUTO RULE Non-Formulary multivitamin fumarate/folic acid 03/20/2020 multi-day plus multivitamin/ferrous NEW AUTO RULE Non-Formulary iron fumarate/folic acid 03/20/2020 century ultimate multivitamin/ferrous NEW AUTO RULE Non-Formulary women's fumarate/folic acid 03/20/2020 ARAZLO tazarotene NEW AUTO RULE Non-formulary 03/20/2020 ketamine hcl- ketamine hcl in 0.9 % NEW AUTO RULE Non-Formulary 0.9% nacl sodium chloride 03/20/2020 centrum adults multivitamin/ferrous NEW AUTO RULE Non-Formulary fumarate/folic acid 03/20/2020 allergy-time chlorpheniramine maleate NEW AUTO RULE Non-Formulary 03/20/2020 mucinex fast-max phenylephrine NEW AUTO RULE Non-Formulary cold-flu hcl/dextromethorphan hbr/acetaminophen/guaifen 03/20/2020 wal-finate chlorpheniramine maleate NEW AUTO RULE Non-Formulary 03/20/2020 AQUA-K phytonadione (vitamin NEW AUTO RULE Non-Formulary CONCENTRATE k1)/vitamin e tpgs 03/20/2020 certavite- multivitamin/ferrous NEW AUTO RULE Non-Formulary antioxidant fumarate/folic acid 03/20/2020 AZO URINARY phenazopyridine hcl DRUG ATTR CHANGE Non-Formulary Non-Formulary PAIN RELIEF OVERRIDE 03/20/2020 one daily plus multivitamin/ferrous NEW AUTO RULE Non-Formulary iron fumarate/folic acid

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 100 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/20/2020 chlortabs chlorpheniramine maleate NEW AUTO RULE Non-Formulary 03/20/2020 one daily multivitamin/ferrous NEW AUTO RULE Non-Formulary multivitamin-iron fumarate/folic acid 03/20/2020 methotrexate methotrexate sodium/pf NEW AUTO RULE Non-Formulary 03/20/2020 complete women multivitamin/ferrous NEW AUTO RULE Non-Formulary fumarate/folic acid 03/20/2020 pyrimethamine pyrimethamine NEW AUTO RULE Tier 3 03/20/2020 cytra-k potassium citrate/citric acid NEW AUTO RULE Tier 1 03/20/2020 essentia multivitamin/ferrous NEW AUTO RULE Non-Formulary fumarate/folic acid 03/20/2020 allergy 4-hour chlorpheniramine maleate NEW AUTO RULE Non-Formulary 03/20/2020 gojji glucose blood glucose calibration NEW AUTO RULE Non-Formulary control solution control solution, normal 03/20/2020 spectravite ultra multivitamin/ferrous NEW AUTO RULE Non-Formulary women fumarate/folic acid 03/20/2020 CHLOR- chlorpheniramine maleate NEW AUTO RULE Non-Formulary TRIMETON 03/20/2020 co q-10 ubidecarenone NEW AUTO RULE Non-Formulary 03/20/2020 blood-glucose blood glucose calibration NEW AUTO RULE Non-Formulary control control solution, normal 03/20/2020 century multivitamin/ferrous NEW AUTO RULE Non-Formulary fumarate/folic acid 03/20/2020 yelets multivitamin/ferrous NEW AUTO RULE Non-Formulary fumarate/folic acid 03/20/2020 genicin glucosamine sulfate NEW AUTO RULE Non-Formulary 03/20/2020 CITRACAL-D3 calcium citrate/vit d3/zinc NEW AUTO RULE Non-Formulary MAXIMUM PLUS oxide/copper gluc/manganese gluc

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 101 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/20/2020 DARAPRIM pyrimethamine UM AUTO RULE: Limited Access LIMITEDACCESS 03/20/2020 daily vitamin multivitamin/ferrous NEW AUTO RULE Non-Formulary formula-iron fumarate/folic acid 03/20/2020 HYPERRAB rabies immune globulin/pf NEW AUTO RULE Non-Formulary 03/20/2020 allergy chlorpheniramine maleate NEW AUTO RULE Non-Formulary 03/20/2020 CERASPORT sodium chloride/potassium NEW AUTO RULE Non-Formulary chloride/sodium citrate/rice syrup 03/20/2020 cequr simplicity diabetic supplies,miscell NEW AUTO RULE Non-Formulary inserter 03/20/2020 TOBI tobramycin REMOVE FROM NF specialty Non-Formulary PODHALER FORMULARY 03/20/2020 chlorhist chlorpheniramine maleate NEW AUTO RULE Non-Formulary 03/20/2020 HERZUMA trastuzumab-pkrb NEW AUTO RULE Non-Formulary 03/20/2020 one-a-day teen multivitamin/ferrous NEW AUTO RULE Non-Formulary advantage fumarate/folic acid 03/20/2020 centrum multivitamin/ferrous NEW AUTO RULE Non-Formulary complete fumarate/folic acid 03/20/2020 spectravite multivitamin/ferrous NEW AUTO RULE Non-Formulary advanced fumarate/folic acid formula 03/20/2020 ALLER-CHLOR chlorpheniramine maleate NEW AUTO RULE Non-Formulary 03/20/2020 chlorpheniramine chlorpheniramine maleate NEW AUTO RULE Non-Formulary maleate 03/20/2020 toposar etoposide NEW AUTO RULE Non-Formulary 03/20/2020 centrum women multivitamin/ferrous NEW AUTO RULE Non-Formulary fumarate/folic acid

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 102 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/20/2020 GILTUSS chlorpheniramine NEW AUTO RULE Non-Formulary ALLERGY PLUS maleate/phenylephrine hcl/chlophedianol hcl 03/20/2020 sentry multivitamin/ferrous NEW AUTO RULE Non-Formulary fumarate/folic acid 03/20/2020 PHENAGIL CH chlorpheniramine NEW AUTO RULE Non-Formulary maleate/phenylephrine hcl/chlophedianol hcl 03/20/2020 q-sorb co q-10 ubidecarenone NEW AUTO RULE Non-Formulary 03/20/2020 giltuss diabetic guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary an hbr 03/20/2020 gojji blood ketone blood ketone test, strips NEW AUTO RULE Tier 2 test strip 03/20/2020 guardian sensor blood-glucose sensor NEW AUTO RULE Non-Formulary 3 03/20/2020 hypersoniq nebulizer accessories NEW AUTO RULE Non-Formulary nebulizer cartridge 03/20/2020 pharbechlor chlorpheniramine maleate NEW AUTO RULE Non-Formulary 03/23/2020 PULMICORT budesonide UM AUTO RULE: 4 ml/day QUANTITYCUSTOM 03/23/2020 NUVARING etonogestrel/ethinyl estradiol TERM AUTO RULE 03/25/2020 PLAQUENIL hydroxychloroquine sulfate UM AUTO RULE: 2 tabs/day QUANTITYCUSTOM 03/25/2020 ZITHROMAX azithromycin UM AUTO RULE: 12 tabs/30 days QUANTITYCUSTOM 03/25/2020 azithromycin azithromycin UM AUTO RULE: 12 tabs/30 days QUANTITYCUSTOM 03/25/2020 hydroxychloroqui hydroxychloroquine sulfate UM AUTO RULE: 2 tabs/day ne sulfate QUANTITYCUSTOM

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 103 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/25/2020 chloroquine chloroquine phosphate UM AUTO RULE: 25 tabs/30 days phosphate QUANTITYCUSTOM 03/26/2020 advocate lancet lancets UM AUTO RULE: 200 QUANTITYCUSTOM lancets/month 03/26/2020 advocate lancets lancets UM AUTO RULE: 200 QUANTITYCUSTOM lancets/month 03/27/2020 dextrose 5%- potassium chloride in NEW AUTO RULE Non-Formulary 0.45% nacl-kcl dextrose 5 %-0.45 % sodium chloride 03/27/2020 minocycline er minocycline hcl NEW AUTO RULE NF specialty 03/27/2020 baby oil mineral oil NEW AUTO RULE Non-Formulary 03/27/2020 GLYCINE SOYA soy protein NEW AUTO RULE Non-Formulary PROTEIN 03/27/2020 GILTUSS MULTI- dextromethorphan/phenylep NEW AUTO RULE Non-Formulary SYMPTOM hrine/acetaminophen/chlorp COLD-FLU heniramin 03/27/2020 50 plus adult eye vit c,e,zinc,copper NEW AUTO RULE Non-Formulary health 11/omega- 3/dha/epa/fish/lutein/zeaxant h 03/27/2020 theraflu phenylephrine NEW AUTO RULE Non-Formulary expressmax sv hcl/dextromethorphan cld-flu hbr/acetaminophen/guaifen 03/27/2020 mapo mineral oil NEW AUTO RULE Non-Formulary 03/27/2020 TEPADINA thiotepa NEW AUTO RULE Non-Formulary 03/27/2020 gencontuss chlorpheniramine NEW AUTO RULE Non-Formulary maleate/phenylephrine hcl/dextromethorphan 03/27/2020 pen needle pen needle, diabetic NEW AUTO RULE Tier 2

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 104 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/27/2020 PREVIDENT fluoride (sodium) NEW AUTO RULE Non-Formulary 5000 ORTHO DEFENSE 03/27/2020 vitamin c ascorbic acid NEW AUTO RULE Non-Formulary 03/27/2020 PENTACEL diphtheria,pertussis(acell),te NEW AUTO RULE Non-Formulary tanus,polio/haemophilus b/pf 03/27/2020 bio-rytuss chlorpheniramine NEW AUTO RULE Non-Formulary maleate/phenylephrine hcl/dextromethorphan 03/27/2020 minimed infusion set for insulin pump NEW AUTO RULE Non-Formulary silhouette 03/27/2020 quick-set infusion set for insulin pump NEW AUTO RULE Non-Formulary paradigm 03/27/2020 gojji lancet- lancets with blood glucose NEW AUTO RULE Non-formulary glucose test strp test strips 03/27/2020 biogil guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary an hbr/phenylephrine 03/27/2020 ANJESO meloxicam NEW AUTO RULE Non-Formulary 03/27/2020 CHILDRENS guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary GILTUSS an hbr/phenylephrine COUGH-COLD 03/27/2020 giltuss allergy chlorpheniramine NEW AUTO RULE Non-Formulary plus maleate/phenylephrine hcl/dextromethorphan 03/27/2020 unifine pen needle, diabetic NEW AUTO RULE Tier 2 safecontrol disposable, safety 03/27/2020 ORTHO-NOVUM norethindrone-ethinyl NEW AUTO RULE Non-formulary estradiol 03/27/2020 melatonin melatonin NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 105 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/27/2020 MUCINEX phenylephrine NEW AUTO RULE Non-Formulary JUNIOR COLD- hcl/dextromethorphan FLU hbr/acetaminophen/guaifen 03/27/2020 dexabliss dexamethasone NEW AUTO RULE Non-formulary 03/27/2020 balamine dm chlorpheniramine NEW AUTO RULE Non-Formulary maleate/phenylephrine hcl/dextromethorphan 03/27/2020 iliderm lidocaine hcl/palm oil NEW AUTO RULE Non-Formulary 03/27/2020 vicks dayquil phenylephrine NEW AUTO RULE Non-Formulary severe cold-flu hcl/dextromethorphan hbr/acetaminophen/guaifen 03/27/2020 TERIPARATIDE teriparatide NEW AUTO RULE NF specialty 03/27/2020 topical light mineral oil NEW AUTO RULE Non-Formulary mineral oil 03/27/2020 adult 50 plus eye vit c,e,zinc,copper NEW AUTO RULE Non-Formulary health 11/omega- 3/dha/epa/fish/lutein/zeaxant h 03/27/2020 thiotepa thiotepa NEW AUTO RULE Non-Formulary 03/27/2020 minimed sure t infusion set for insulin pump NEW AUTO RULE Non-Formulary 03/27/2020 mineral oil light mineral oil NEW AUTO RULE Non-Formulary 03/27/2020 HEMORRHOIDA phenylephrine NEW AUTO RULE Non-Formulary L hcl/hydrogenated vegetable SUPPOSITORY oil 03/27/2020 vitamin b-12 mecobalamin NEW AUTO RULE Non-Formulary 03/27/2020 esomeprazole esomeprazole magnesium NEW AUTO RULE Non-formulary magnesium 03/27/2020 magellan tb syringe,safety with needle,1 NEW AUTO RULE Non-Formulary safety syringe ml 03/27/2020 diazoxide diazoxide NEW AUTO RULE Non-formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 106 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/27/2020 brontuss sf guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary an hbr/phenylephrine 03/27/2020 eye health adult vit c,e,zinc,copper NEW AUTO RULE Non-Formulary 50 plus 11/omega- 3/dha/epa/fish/lutein/zeaxant h 03/27/2020 potassium potassium NEW AUTO RULE Non-Formulary phosphate phosphate,monobasic- dibasic 03/27/2020 minimed mio infusion set for insulin pump NEW AUTO RULE Non-Formulary 03/27/2020 XCOPRI cenobamate NEW AUTO RULE NF specialty 03/27/2020 LUGOL'S iodine/potassium iodide NEW AUTO RULE Non-Formulary 03/27/2020 rycontuss chlorpheniramine NEW AUTO RULE Non-Formulary maleate/phenylephrine hcl/dextromethorphan 03/27/2020 TYLENOL phenylephrine NEW AUTO RULE Non-Formulary COLD-FLU hcl/dextromethorphan SEVERE hbr/acetaminophen/guaifen 03/27/2020 PENTACEL diphther,pertus(acel),tetanus NEW AUTO RULE Non-Formulary DTAP-IPV ,polio vacc,component 1 of COMPONENT 2/pf 03/27/2020 MUCINEX triprolidine NEW AUTO RULE Non-Formulary NIGHTSHIFT hcl/phenylephrine/dextromet SINUS horphn/acetaminophen 03/27/2020 PREVIDENT fluoride (sodium) NEW AUTO RULE Non-Formulary 03/27/2020 b-complex thiamine NEW AUTO RULE Non-Formulary hcl/riboflavin/niacinamide/de xpanthenol/pyridoxine 03/27/2020 lobana bath oil mineral oil NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 107 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/27/2020 PROBIOTIC bacillus NEW AUTO RULE Non-Formulary coagulans/cholecalciferol (vit d3) 03/30/2020 INSULIN insulin aspart protamine DRUG ATTR CHANGE Non-formulary Non-formulary ASPART PROT- human/insulin aspart OVERRIDE INSULN ASP 03/30/2020 INSULIN insulin aspart DRUG ATTR CHANGE Non-formulary Non-formulary ASPART OVERRIDE 03/30/2020 CHORIONIC chorionic gonadotropin, DRUG ATTR CHANGE NF specialty NF specialty GONADOTROPI human OVERRIDE N 03/30/2020 INSULIN insulin aspart DRUG ATTR CHANGE Non-formulary Non-formulary ASPART OVERRIDE PENFILL 03/30/2020 INSULIN LISPRO insulin lispro DRUG ATTR CHANGE Non-formulary Non-formulary OVERRIDE 03/30/2020 INSULIN LISPRO insulin lispro DRUG ATTR CHANGE Tier 1 Tier 1 KWIKPEN U-100 OVERRIDE 03/30/2020 INSULIN insulin aspart DRUG ATTR CHANGE Non-formulary Non-formulary ASPART OVERRIDE FLEXPEN 03/31/2020 RUBRACA rucaparib camsylate UM AUTO RULE: 4 tabs/day QUANTITYCUSTOM

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 108 UPDATED 12/2020 VALUE Drug Formulary Updates

April, 2020

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/01/2020 NOVOLOG insulin aspart UM AUTO RULE: PA Applies FLEXPEN AUTHORIZATION 04/01/2020 NOVOLIN N insulin nph human isophane UM AUTO RULE: PA Applies AUTHORIZATION 04/01/2020 INSULIN LISPRO insulin lispro NEW AUTO RULE Tier 1 04/01/2020 NOVOLIN 70-30 insulin nph human UM AUTO RULE: PA Applies isophane/insulin regular, AUTHORIZATION human 04/01/2020 INSULIN LISPRO insulin lispro TERM AUTO RULE KWIKPEN U-100 04/01/2020 techlite pen pen needle, diabetic NEW AUTO RULE Tier 2 needle 04/01/2020 NOVOLOG MIX insulin aspart protamine UM AUTO RULE: PA Applies 70-30 human/insulin aspart AUTHORIZATION 04/01/2020 NOVOLIN 70-30 insulin nph human UM AUTO RULE: PA Applies FLEXPEN isophane/insulin regular, AUTHORIZATION human 04/01/2020 NOVOLIN R insulin regular, human UM AUTO RULE: PA Applies AUTHORIZATION 04/01/2020 INSULIN LISPRO insulin lispro TERM AUTO RULE 04/01/2020 abiraterone abiraterone acetate UM AUTO RULE: CUSTOM Short Cycle acetate 04/01/2020 INSULIN LISPRO insulin lispro NEW AUTO RULE Tier 1 KWIKPEN U-100 04/01/2020 NOVOLOG insulin aspart UM AUTO RULE: PA Applies AUTHORIZATION 04/01/2020 NOVOLOG MIX insulin aspart protamine UM AUTO RULE: PA Applies 70-30 FLEXPEN human/insulin aspart AUTHORIZATION

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 109 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/03/2020 GELX povidone/taurine/zinc NEW AUTO RULE Non-Formulary gluconate/peg-40 castor oil 04/03/2020 ONCASPAR pegaspargase NEW AUTO RULE Non-Formulary 04/03/2020 PROMACTA eltrombopag olamine NEW AUTO RULE NF specialty 04/03/2020 sochlor sodium chloride NEW AUTO RULE Non-Formulary 04/03/2020 lubricant eye mineral oil/petrolatum,white NEW AUTO RULE Non-Formulary 04/03/2020 AJOVY fremanezumab-vfrm NEW AUTO RULE Non-formulary AUTOINJECTOR 04/03/2020 muro-128 sodium chloride NEW AUTO RULE Non-Formulary 04/03/2020 hydrochloric acid hydrochloric acid NEW AUTO RULE Non-Formulary 04/03/2020 CARBOCAINE mepivacaine hcl/pf NEW AUTO RULE Non-Formulary 04/03/2020 CHOLECAL DF cholecalciferol (vit d3)/folic NEW AUTO RULE Non-Formulary acid 04/03/2020 sodium sodium bicarbonate NEW AUTO RULE Non-Formulary bicarbonate 04/03/2020 CHILD DELSYM acetaminophen/dextrometho NEW AUTO RULE Non-Formulary COUGH-SORE rphan hbr THROAT 04/03/2020 GLYCOSADE nutritional therapy for NEW AUTO RULE Non-Formulary glycogen storage disease (gsd) 04/03/2020 SYSTANE GEL hypromellose NEW AUTO RULE Non-Formulary 04/03/2020 standard 1.4 nutritional supplement/fiber NEW AUTO RULE Non-Formulary 04/03/2020 DELSYM acetaminophen/dextrometho NEW AUTO RULE Non-Formulary COUGH-SORE rphan hbr THROAT 04/03/2020 REFRESH P.M. mineral oil/petrolatum,white NEW AUTO RULE Non-Formulary 04/03/2020 sodium chloride sodium chloride NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 110 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/03/2020 polocaine-mpf mepivacaine hcl/pf NEW AUTO RULE Non-Formulary 04/03/2020 retaine nacl sodium chloride NEW AUTO RULE Non-Formulary 04/03/2020 PKU EXPLORE5 nutritional therapy for NEW AUTO RULE Non-Formulary phenylketonuria(pku) with iron no.52 04/03/2020 beanaid alpha-d-galactosidase NEW AUTO RULE Non-Formulary 04/03/2020 altachlore sodium chloride NEW AUTO RULE Non-Formulary 04/03/2020 restore pm mineral oil/petrolatum,white NEW AUTO RULE Non-Formulary 04/03/2020 lubricant pm mineral oil/petrolatum,white NEW AUTO RULE Non-Formulary 04/06/2020 PREVNAR 13 pneumococcal 13-valent NEW AUTO RULE Preventative conjugate vaccine Drugs (diphtheria crm)/pf 04/06/2020 PNEUMOVAX 23 pneumococcal 23-valent NEW AUTO RULE Preventative polysaccharide vaccine Drugs 04/10/2020 HIZENTRA immune globulin,gamma NEW AUTO RULE Non-Formulary (igg)/proline/iga 0 to 50 mcg/ml 04/10/2020 vitamin b- b-complex with vitamin c NEW AUTO RULE Non-Formulary complex with vit c 04/10/2020 allergy diphenhydramine hcl DRUG ATTR CHANGE Non-Formulary Non-Formulary OVERRIDE 04/10/2020 adult one daily multivitamin with NEW AUTO RULE Non-Formulary gummies minerals/folic acid 04/10/2020 ONE-A-DAY multivitamin with NEW AUTO RULE Non-Formulary VITACRAVES minerals/folic acid IMMUNITY 04/10/2020 men's daily multivitamin with NEW AUTO RULE Non-Formulary gummies minerals/folic acid

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 111 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/10/2020 advanced benzoyl peroxide NEW AUTO RULE Non-Formulary exfoliating cleanser 04/10/2020 superplex-t b-complex with vitamin c NEW AUTO RULE Non-Formulary 04/10/2020 INSULIN LISPRO insulin lispro protamine and NEW AUTO RULE Non-formulary PROTAMINE insulin lispro MIX 04/10/2020 women's multivitamin with NEW AUTO RULE Non-Formulary multivitamin minerals/folic acid 04/10/2020 allergy diphenhydramine hcl NEW AUTO RULE Non-Formulary 04/10/2020 PKU nutritional therapy for NEW AUTO RULE Non-Formulary EXPLORE10 phenylketonuria(pku) with iron no.52 04/10/2020 quintabs multivitamin with folic acid NEW AUTO RULE Non-Formulary 04/10/2020 total b with c b-complex with vitamin c NEW AUTO RULE Non-Formulary 04/10/2020 zinc sulfate zinc sulfate NEW AUTO RULE Non-Formulary 04/10/2020 super b complex- b-complex with vitamin c NEW AUTO RULE Non-Formulary vitamin c 04/10/2020 womens daily multivitamin with NEW AUTO RULE Non-Formulary gummies minerals/folic acid 04/10/2020 vitamin d3 cholecalciferol (vitamin d3) NEW AUTO RULE Non-Formulary 04/10/2020 bevacizumab bevacizumab NEW AUTO RULE Non-Formulary 04/10/2020 therems multivitamin with folic acid NEW AUTO RULE Non-Formulary multivitamin 04/10/2020 ONE-A-DAY multivitamin with NEW AUTO RULE Non-Formulary VITACRAVES minerals/folic acid SOUR 04/10/2020 b-complex plus b-complex with vitamin c NEW AUTO RULE Non-Formulary vitamin c

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 112 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/10/2020 EPINEPHRINE epinephrine NEW AUTO RULE Non-Formulary PROFESSIONAL KIT 04/10/2020 alpha lipoic acid alpha lipoic acid NEW AUTO RULE Non-Formulary 04/10/2020 benzoyl peroxide benzoyl peroxide NEW AUTO RULE Non-Formulary 04/10/2020 b-complex with b-complex with vitamin c NEW AUTO RULE Non-Formulary vitamin c 04/10/2020 simethicone simethicone NEW AUTO RULE Non-Formulary 04/10/2020 daily gummies multivitamin with NEW AUTO RULE Non-Formulary minerals/folic acid 04/10/2020 EPINEPHRINE epinephrine NEW AUTO RULE Non-Formulary PROFESSIONAL EMS 04/10/2020 ZINC-220 zinc sulfate NEW AUTO RULE Non-Formulary 04/10/2020 diaper rash zinc oxide NEW AUTO RULE Non-Formulary 04/10/2020 vitajoy adult multi multivitamin with NEW AUTO RULE Non-Formulary minerals/folic acid 04/10/2020 b-complex plus folic acid/vitamin b complex NEW AUTO RULE Non-Formulary vitamin c and vitamin c 04/10/2020 gas-x simethicone NEW AUTO RULE Non-Formulary 04/10/2020 bp wash benzoyl peroxide NEW AUTO RULE Non-Formulary 04/10/2020 MUCINEX triprolidine NEW AUTO RULE Non-Formulary NIGHTSHFT hcl/phenylephrine/dextromet COLD-FLU CLR horphn/acetaminophen 04/10/2020 vitamin b folic acid/vitamin b complex NEW AUTO RULE Non-Formulary complex-vitamin and vitamin c c 04/10/2020 bpo-5 benzoyl peroxide NEW AUTO RULE Non-Formulary 04/10/2020 esmolol hcl esmolol hcl NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 113 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/10/2020 vitamin b b-complex with vitamin c NEW AUTO RULE Non-Formulary complex-vitamin c 04/10/2020 secura dimethicone NEW AUTO RULE Non-Formulary dimethicone 04/10/2020 BREVIBLOC esmolol hcl NEW AUTO RULE Non-Formulary 04/10/2020 INSTA- dextrose/dextrin/maltose NEW AUTO RULE Non-Formulary GLUCOSE 04/10/2020 microdot insulin pen needle, diabetic NEW AUTO RULE Tier 2 pen needle 04/10/2020 potassium potassium chloride in NEW AUTO RULE Non-Formulary chloride in d5lr lactated ringers and 5 % dextrose 04/10/2020 thera multivitamin with folic acid NEW AUTO RULE Non-Formulary 04/10/2020 one daily multivitamin with folic acid NEW AUTO RULE Non-Formulary multivitamin 04/10/2020 gojji ketone blood-ketone control, normal NEW AUTO RULE Non-Formulary control solution 04/10/2020 centrum vitamints multivitamin with NEW AUTO RULE Non-Formulary minerals/folic acid 04/10/2020 ONE-A-DAY multivitamin with NEW AUTO RULE Non-Formulary MEN minerals/folic acid VITACRAVES 04/10/2020 ORAZINC zinc sulfate NEW AUTO RULE Non-Formulary 04/10/2020 MUCINEX FAST- triprolidine/phenylephrine/de NEW AUTO RULE Non-Formulary MAX xtromethorph/acetamin/guaif NIGHTSHFT enes CLR 04/10/2020 ONE-A-DAY multivitamin with NEW AUTO RULE Non-Formulary VITACRAVES minerals/folic acid

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 114 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/10/2020 MUCINEX triprolidine NEW AUTO RULE Non-Formulary NIGHTSHIFT hcl/dextromethorphan COLD-FLU hbr/acetaminophen 04/10/2020 pro comfort pen pen needle, diabetic NEW AUTO RULE Tier 2 needle 04/10/2020 adult multivitamin multivitamin with NEW AUTO RULE Non-Formulary extra d3 minerals/folic acid 04/10/2020 INSULIN LISPRO insulin lispro NEW AUTO RULE Non-formulary JUNIOR KWIKPEN 04/10/2020 b-complex with c b-complex with vitamin c NEW AUTO RULE Non-Formulary 04/10/2020 men's multivitamin with NEW AUTO RULE Non-Formulary multivitamin minerals/folic acid 04/10/2020 easy touch pen pen needle, diabetic NEW AUTO RULE Tier 2 needle 04/10/2020 ONE-A-DAY multivitamin with NEW AUTO RULE Non-Formulary WOMEN minerals/folic acid VITACRAVES 04/10/2020 gas relief simethicone NEW AUTO RULE Non-Formulary 04/10/2020 vita-bee with c folic acid/vitamin b complex NEW AUTO RULE Non-Formulary and vitamin c 04/13/2020 underwear diaper,brief,adult, NEW AUTO RULE Non-Formulary disposable 04/13/2020 underwear men- diaper,brief,adult, NEW AUTO RULE Non-Formulary women disposable 04/17/2020 DILUENT FOR diluent for rabies vaccine, NEW AUTO RULE Non-Formulary IMOVAX human diploid (sterile water) 04/17/2020 spirit style-3 catheter male,external NEW AUTO RULE Non-Formulary 04/17/2020 GILTUSS benzocaine/menthol/zinc NEW AUTO RULE Non-Formulary BUCALSEP chloride

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 115 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/17/2020 IMOVAX RABIES rabies vaccine, human NEW AUTO RULE Non-Formulary VACCINE diploid cell/pf 04/17/2020 DINO-LIFE multivitamin combination NEW AUTO RULE Non-Formulary MULTIVITAMIN no.56 04/17/2020 GELFOAM gelatin NEW AUTO RULE Non-Formulary sponge,absorbable/porcine skin 04/17/2020 ONTRUZANT trastuzumab-dttb NEW AUTO RULE Non-Formulary 04/17/2020 id now covid-19 covid-19 molecular nucleic NEW AUTO RULE Non-Formulary test kit acid test assay 04/17/2020 id now covid-19 covid-19 control swab kit NEW AUTO RULE Non-Formulary control kit 04/17/2020 surgifoam gelatin NEW AUTO RULE Non-Formulary sponge,absorbable/porcine skin 04/17/2020 giltuss hbp guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary an hbr 04/17/2020 fluconazole-nacl fluconazole in sodium NEW AUTO RULE Non-Formulary chloride, iso-osmotic 04/17/2020 butylated butylated hydroxytoluene NEW AUTO RULE Non-Formulary hydroxytoluene(b ht) 04/17/2020 KOSELUGO selumetinib sulfate/vitamin e NEW AUTO RULE NF specialty tpgs 04/17/2020 methylcobalamin mecobalamin NEW AUTO RULE Non-Formulary 04/17/2020 HONEY BEARS multivitamin combination NEW AUTO RULE Non-Formulary MULTIVITAMIN no.56 04/17/2020 ROMIDEPSIN romidepsin NEW AUTO RULE Non-Formulary 04/17/2020 dextrose in water dextrose 50 % in water NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 116 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/17/2020 onetouch verio blood-glucose meter NEW AUTO RULE Non-Formulary reflect meter 04/17/2020 PHENYLADE nutritional therapy for NEW AUTO RULE Non-Formulary GMP ULTRA phenylketonuria (pku) no.74 04/17/2020 rapid response covid-19 igg/igm test NEW AUTO RULE Non-Formulary covid-19 test cassette 04/17/2020 ISTURISA osilodrostat phosphate NEW AUTO RULE NF specialty 04/17/2020 DINO-LIFE multivitamin combination NEW AUTO RULE Non-Formulary EXTRA C no.55 MULTIVITAMIN 04/17/2020 fluconazole in fluconazole in sodium NEW AUTO RULE Non-Formulary saline chloride, iso-osmotic 04/22/2020 DESOXYN methamphetamine hcl UM AUTO RULE: AGE Up to 17 yrs old 04/22/2020 METADATE CD methylphenidate hcl UM AUTO RULE: AGE Up to 17 yrs old 04/22/2020 metadate er methylphenidate hcl UM AUTO RULE: AGE Up to 17 yrs old 04/22/2020 ZOLPIMIST zolpidem tartrate UM AUTO RULE: AGE Up to 64 yrs old 04/22/2020 clonidine hcl er clonidine hcl UM AUTO RULE: AGE Up to 17 yrs old 04/22/2020 SKELAXIN metaxalone UM AUTO RULE: AGE Up to 64 yrs old 04/22/2020 DEMEROL meperidine hcl UM AUTO RULE: AGE Up to 64 yrs old 04/22/2020 FEXMID cyclobenzaprine hcl UM AUTO RULE: AGE Up to 64 yrs old 04/22/2020 PROTOPIC tacrolimus UM AUTO RULE: AGE Up to 15 yrs old 04/22/2020 methylphenidate methylphenidate hcl UM AUTO RULE: AGE Up to 17 yrs old hcl cd 04/22/2020 PARAFON chlorzoxazone UM AUTO RULE: AGE Up to 64 yrs old FORTE DSC 04/22/2020 zaleplon zaleplon UM AUTO RULE: AGE Up to 64 yrs old 04/22/2020 meprobamate meprobamate UM AUTO RULE: AGE Up to 64 yrs old 04/22/2020 eszopiclone eszopiclone UM AUTO RULE: AGE Up to 64 yrs old

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 117 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/22/2020 dexmethylphenid dexmethylphenidate hcl UM AUTO RULE: AGE Up to 17 yrs old ate hcl er 04/22/2020 methylphenidate methylphenidate hcl UM AUTO RULE: AGE Up to 17 yrs old er (la) 04/22/2020 orphenadrine orphenadrine citrate UM AUTO RULE: AGE Up to 64 yrs old citrate er 04/22/2020 flurazepam hcl flurazepam hcl UM AUTO RULE: AGE Up to 64 yrs old 04/22/2020 dextroamphetami dextroamphetamine sulfate UM AUTO RULE: AGE Up to 17 yrs old ne sulfate er 04/22/2020 FOCALIN XR dexmethylphenidate hcl UM AUTO RULE: AGE Up to 17 yrs old 04/22/2020 APTENSIO XR methylphenidate hcl UM AUTO RULE: AGE Up to 17 yrs old 04/22/2020 chlorzoxazone chlorzoxazone UM AUTO RULE: AGE Up to 64 yrs old 04/22/2020 meperidine hcl meperidine hcl UM AUTO RULE: AGE Up to 64 yrs old 04/22/2020 DORAL quazepam UM AUTO RULE: AGE Up to 64 yrs old 04/22/2020 DYANAVEL XR amphetamine UM AUTO RULE: AGE Up to 17 yrs old 04/22/2020 carisoprodol carisoprodol UM AUTO RULE: AGE Up to 64 yrs old 04/22/2020 tacrolimus tacrolimus UM AUTO RULE: AGE Up to 15 yrs old 04/22/2020 AMBIEN zolpidem tartrate UM AUTO RULE: AGE Up to 64 yrs old 04/22/2020 metaxall metaxalone UM AUTO RULE: AGE Up to 64 yrs old 04/22/2020 RITALIN LA methylphenidate hcl UM AUTO RULE: AGE Up to 17 yrs old 04/22/2020 amphetamine amphetamine sulfate UM AUTO RULE: AGE Up to 17 yrs old sulfate 04/22/2020 carisoprodol- carisoprodol/aspirin/codeine UM AUTO RULE: AGE Up to 64 yrs old aspirin-codeine phosphate 04/22/2020 atomoxetine hcl atomoxetine hcl UM AUTO RULE: AGE Up to 17 yrs old 04/22/2020 STRATTERA atomoxetine hcl UM AUTO RULE: AGE Up to 17 yrs old 04/22/2020 INTUNIV guanfacine hcl UM AUTO RULE: AGE Up to 17 yrs old

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 118 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/22/2020 methocarbamol methocarbamol UM AUTO RULE: AGE Up to 64 yrs old 04/22/2020 dexchlorphenira dexchlorpheniramine UM AUTO RULE: AGE Up to 64 yrs old mine maleate maleate 04/22/2020 metaxalone metaxalone UM AUTO RULE: AGE Up to 64 yrs old 04/22/2020 JORNAY PM methylphenidate hcl UM AUTO RULE: AGE Up to 17 yrs old 04/22/2020 procentra dextroamphetamine sulfate UM AUTO RULE: AGE Up to 17 yrs old 04/22/2020 zolpidem tartrate zolpidem tartrate UM AUTO RULE: AGE Up to 64 yrs old 04/22/2020 CONCERTA methylphenidate hcl UM AUTO RULE: AGE Up to 17 yrs old 04/22/2020 INTERMEZZO zolpidem tartrate UM AUTO RULE: AGE Up to 64 yrs old 04/22/2020 ROBAXIN methocarbamol UM AUTO RULE: AGE Up to 64 yrs old 04/22/2020 digoxin digoxin UM AUTO RULE: AGE Up to 64 yrs old 04/22/2020 cyclobenzaprine cyclobenzaprine hcl UM AUTO RULE: AGE Up to 64 yrs old hcl 04/22/2020 dipyridamole dipyridamole UM AUTO RULE: AGE Up to 64 yrs old 04/22/2020 quazepam quazepam UM AUTO RULE: AGE Up to 64 yrs old 04/22/2020 carisoprodol carisoprodol/aspirin UM AUTO RULE: AGE Up to 64 yrs old compound 04/22/2020 QUILLICHEW ER methylphenidate hcl UM AUTO RULE: AGE Up to 17 yrs old 04/22/2020 digox digoxin UM AUTO RULE: AGE Up to 64 yrs old 04/22/2020 EDLUAR zolpidem tartrate UM AUTO RULE: AGE Up to 64 yrs old 04/22/2020 methamphetamin methamphetamine hcl UM AUTO RULE: AGE Up to 17 yrs old e hcl 04/22/2020 AMRIX cyclobenzaprine hcl UM AUTO RULE: AGE Up to 64 yrs old 04/22/2020 carisoprodol- carisoprodol/aspirin UM AUTO RULE: AGE Up to 64 yrs old aspirin 04/22/2020 methylphenidate methylphenidate hcl UM AUTO RULE: AGE Up to 17 yrs old hcl

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 119 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/22/2020 COTEMPLA XR- methylphenidate UM AUTO RULE: AGE Up to 17 yrs old ODT 04/22/2020 digitek digoxin UM AUTO RULE: AGE Up to 64 yrs old 04/22/2020 dexmethylphenid dexmethylphenidate hcl UM AUTO RULE: AGE Up to 17 yrs old ate hcl 04/22/2020 dextroamphetami dextroamphetamine sulfate UM AUTO RULE: AGE Up to 17 yrs old ne sulfate 04/22/2020 ADHANSIA XR methylphenidate hcl UM AUTO RULE: AGE Up to 17 yrs old 04/22/2020 ADDERALL dextroamphetamine sulf- UM AUTO RULE: AGE Up to 17 yrs old saccharate/amphetamine sulf-aspartate 04/22/2020 relexxii methylphenidate hcl UM AUTO RULE: AGE Up to 17 yrs old 04/22/2020 DEXEDRINE dextroamphetamine sulfate UM AUTO RULE: AGE Up to 17 yrs old 04/22/2020 dextroamphetami dextroamphetamine sulf- UM AUTO RULE: AGE Up to 17 yrs old ne-amphet er saccharate/amphetamine sulf-aspartate 04/22/2020 methylphenidate methylphenidate hcl UM AUTO RULE: AGE Up to 17 yrs old er 04/22/2020 dextroamphetami dextroamphetamine sulf- UM AUTO RULE: AGE Up to 17 yrs old ne-amphetamine saccharate/amphetamine sulf-aspartate 04/22/2020 FOCALIN dexmethylphenidate hcl UM AUTO RULE: AGE Up to 17 yrs old 04/22/2020 methylphenidate methylphenidate hcl UM AUTO RULE: AGE Up to 17 yrs old la 04/22/2020 guanfacine hcl er guanfacine hcl UM AUTO RULE: AGE Up to 17 yrs old 04/22/2020 METHYLIN methylphenidate hcl UM AUTO RULE: AGE Up to 17 yrs old 04/22/2020 KAPVAY clonidine hcl UM AUTO RULE: AGE Up to 17 yrs old 04/22/2020 zenzedi dextroamphetamine sulfate UM AUTO RULE: AGE Up to 17 yrs old 04/22/2020 LUNESTA eszopiclone UM AUTO RULE: AGE Up to 64 yrs old

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 120 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/22/2020 PERSANTINE dipyridamole UM AUTO RULE: AGE Up to 64 yrs old 04/22/2020 SOMA carisoprodol UM AUTO RULE: AGE Up to 64 yrs old 04/22/2020 RITALIN methylphenidate hcl UM AUTO RULE: AGE Up to 17 yrs old 04/22/2020 cyclobenzaprine cyclobenzaprine hcl UM AUTO RULE: AGE Up to 64 yrs old hcl er 04/22/2020 AMBIEN CR zolpidem tartrate UM AUTO RULE: AGE Up to 64 yrs old 04/22/2020 zolpidem tartrate zolpidem tartrate UM AUTO RULE: AGE Up to 64 yrs old er 04/22/2020 LANOXIN digoxin UM AUTO RULE: AGE Up to 64 yrs old 04/22/2020 RYCLORA dexchlorpheniramine UM AUTO RULE: AGE Up to 64 yrs old maleate 04/22/2020 ADDERALL XR dextroamphetamine sulf- UM AUTO RULE: AGE Up to 17 yrs old saccharate/amphetamine sulf-aspartate 04/22/2020 methylphenidate methylphenidate hcl UM AUTO RULE: AGE Up to 17 yrs old hcl er (cd) 04/22/2020 DAYTRANA methylphenidate UM AUTO RULE: AGE Up to 17 yrs old 04/22/2020 pentazocine- pentazocine hcl/naloxone UM AUTO RULE: AGE Up to 64 yrs old naloxone hcl hcl 04/22/2020 ROBAXIN-750 methocarbamol UM AUTO RULE: AGE Up to 64 yrs old 04/22/2020 VYVANSE lisdexamfetamine UM AUTO RULE: AGE Up to 17 yrs old dimesylate 04/22/2020 SONATA zaleplon UM AUTO RULE: AGE Up to 64 yrs old 04/23/2020 ATGAM lymphocyte immune NEW AUTO RULE Non-Formulary globulin,antithymocyte (equine) 04/23/2020 cefazolin sodium- cefazolin sodium/dextrose, NEW AUTO RULE Non-Formulary dextrose iso-osmotic 04/23/2020 ELELYSO taliglucerase alfa NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 121 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/23/2020 penicillin g penicillin g sodium NEW AUTO RULE Non-Formulary sodium 04/23/2020 BICILLIN C-R penicillin g NEW AUTO RULE Non-Formulary benzathine/penicillin g procaine 04/23/2020 foscarnet sodium foscarnet sodium NEW AUTO RULE Non-Formulary 04/23/2020 cefazolin sodium cefazolin sodium NEW AUTO RULE Non-Formulary 04/23/2020 LUMIZYME alglucosidase alfa NEW AUTO RULE Non-Formulary 04/23/2020 cefepime hcl cefepime hcl NEW AUTO RULE Non-Formulary 04/23/2020 INVANZ ertapenem sodium NEW AUTO RULE Non-Formulary 04/23/2020 FABRAZYME agalsidase beta NEW AUTO RULE Non-Formulary 04/23/2020 ALDURAZYME laronidase NEW AUTO RULE Non-Formulary 04/23/2020 piperacillin- piperacillin NEW AUTO RULE Non-Formulary tazobactam sodium/tazobactam sodium 04/23/2020 HYQVIA immune NEW AUTO RULE Non-Formulary globulin,gamma(igg) human/hyaluronidase, human recomb 04/23/2020 ceftriaxone ceftriaxone sodium NEW AUTO RULE Non-Formulary 04/23/2020 amifostine amifostine crystalline NEW AUTO RULE Non-Formulary 04/23/2020 BICILLIN L-A penicillin g benzathine NEW AUTO RULE Non-Formulary 04/23/2020 ALFERON N interferon alfa-n3 NEW AUTO RULE Non-Formulary 04/23/2020 TYSABRI natalizumab NEW AUTO RULE Non-Formulary 04/23/2020 ELAPRASE idursulfase NEW AUTO RULE Non-Formulary 04/23/2020 fludarabine fludarabine phosphate NEW AUTO RULE Non-Formulary phosphate 04/23/2020 BENLYSTA belimumab NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 122 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/23/2020 fosphenytoin fosphenytoin sodium NEW AUTO RULE Non-Formulary sodium 04/23/2020 ceftazidime ceftazidime NEW AUTO RULE Non-Formulary 04/23/2020 penicillin g penicillin g procaine NEW AUTO RULE Non-Formulary procaine 04/23/2020 cefotaxime cefotaxime sodium NEW AUTO RULE Non-Formulary sodium 04/23/2020 melphalan hcl melphalan hcl NEW AUTO RULE Non-Formulary 04/23/2020 meropenem meropenem NEW AUTO RULE Non-Formulary 04/23/2020 mitoxantrone hcl mitoxantrone hcl NEW AUTO RULE Non-Formulary 04/23/2020 BUSULFEX busulfan NEW AUTO RULE Non-Formulary 04/23/2020 ADAGEN pegademase bovine NEW AUTO RULE Non-Formulary 04/23/2020 penicillin g penicillin g potassium NEW AUTO RULE Non-Formulary potassium 04/23/2020 RITUXAN rituximab NEW AUTO RULE Non-Formulary 04/23/2020 ampicillin- ampicillin sodium/sulbactam NEW AUTO RULE Non-Formulary sulbactam sodium 04/23/2020 oxacillin sodium oxacillin sodium NEW AUTO RULE Non-Formulary 04/23/2020 BOTOX onabotulinumtoxina NEW AUTO RULE Non-Formulary 04/23/2020 REMICADE infliximab NEW AUTO RULE Non-Formulary 04/23/2020 CEREZYME imiglucerase NEW AUTO RULE Non-Formulary 04/23/2020 aztreonam aztreonam NEW AUTO RULE Non-Formulary 04/23/2020 nafcillin sodium nafcillin sodium NEW AUTO RULE Non-Formulary 04/23/2020 cidofovir cidofovir NEW AUTO RULE Non-Formulary 04/23/2020 cefoxitin sodium cefoxitin sodium/dextrose, NEW AUTO RULE Non-Formulary iso-osmotic 04/23/2020 REMODULIN treprostinil sodium NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 123 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/23/2020 ZOSYN piperacillin and tazobactam NEW AUTO RULE Non-Formulary in dextrose, iso-osmotic 04/23/2020 cefepime- cefepime hcl in dextrose 5 NEW AUTO RULE Non-Formulary dextrose % in water 04/23/2020 TORISEL NEW AUTO RULE Non-Formulary 04/23/2020 VPRIV velaglucerase alfa NEW AUTO RULE Non-Formulary 04/23/2020 cefepime cefepime hcl in iso-osmotic NEW AUTO RULE Non-Formulary dextrose 04/23/2020 cefotetan cefotetan disodium NEW AUTO RULE Non-Formulary 04/23/2020 cefoxitin cefoxitin sodium NEW AUTO RULE Non-Formulary 04/23/2020 imipenem- imipenem/cilastatin sodium NEW AUTO RULE Non-Formulary cilastatin sodium 04/23/2020 ORENCIA abatacept/maltose NEW AUTO RULE Non-Formulary 04/23/2020 NAGLAZYME galsulfase NEW AUTO RULE Non-Formulary 04/23/2020 ZOSYN piperacillin NEW AUTO RULE Non-Formulary sodium/tazobactam sodium 04/23/2020 UNASYN ampicillin sodium/sulbactam NEW AUTO RULE Non-Formulary sodium 04/23/2020 NULOJIX belatacept NEW AUTO RULE Non-Formulary 04/24/2020 potassium potassium chloride in water NEW AUTO RULE Non-Formulary chloride for injection, sterile 04/24/2020 eggs-apples-oats nutritional supplement/fiber NEW AUTO RULE Non-Formulary 04/24/2020 niacin niacinamide NEW AUTO RULE Non-Formulary 04/24/2020 SYSTANE propylene NEW AUTO RULE Non-Formulary glycol/polyethylene glycol 400/pf 04/24/2020 NOURISH nutritional supplement/fiber NEW AUTO RULE Non-Formulary ORIGINAL

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 124 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/24/2020 CARDENE I.V. nicardipine in sodium NEW AUTO RULE Non-Formulary chloride, iso-osmotic 04/24/2020 beef-potatoes- nutritional supplement/fiber NEW AUTO RULE Non-Formulary spinach 04/24/2020 hydromorphone hydromorphone hcl/pf NEW AUTO RULE Non-Formulary hcl 04/24/2020 esomeprazole esomeprazole strontium NEW AUTO RULE Non-formulary strontium 04/24/2020 dentagel fluoride (sodium) NEW AUTO RULE Non-Formulary 04/24/2020 SYSTANE propylene NEW AUTO RULE Non-Formulary ULTRA glycol/polyethylene glycol 400/pf 04/24/2020 DDAVP desmopressin acetate NEW AUTO RULE Non-Formulary 04/24/2020 sodium chloride sodium chloride NEW AUTO RULE Non-Formulary 04/24/2020 desmopressin desmopressin acetate NEW AUTO RULE Non-Formulary acetate 04/24/2020 epinephrine hcl- epinephrine hcl in 0.9 % NEW AUTO RULE Non-Formulary 0.9% nacl sodium chloride 04/24/2020 buprenorphine buprenorphine hcl NEW AUTO RULE Non-Formulary hcl 04/24/2020 triprolidine hcl triprolidine hcl NEW AUTO RULE Non-Formulary 04/24/2020 LIQUID HOPE nutritional supplement/fiber NEW AUTO RULE Non-Formulary ORIGINAL 04/24/2020 SYSTANE propylene NEW AUTO RULE Non-Formulary HYDRATION PF glycol/polyethylene glycol 400/pf 04/24/2020 easypoint needle needles, safety NEW AUTO RULE Non-Formulary 04/24/2020 salmon-oats- nutritional supplement/fiber NEW AUTO RULE Non-Formulary squash

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 125 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/24/2020 bpco balsam peru/castor oil NEW AUTO RULE Non-Formulary 04/24/2020 CHILD DELSYM diphenhydramine/phenyleph NEW AUTO RULE Non-Formulary COUGH PLUS rin/dextromethorph/acetamin DY-NT ophen/gg 04/24/2020 ringers injection ringer's solution NEW AUTO RULE Non-Formulary 04/24/2020 digestive saccharomyces boulardii NEW AUTO RULE Non-Formulary probiotic 04/24/2020 TUKYSA tucatinib NEW AUTO RULE NF specialty 04/24/2020 prevident fluoride (sodium) NEW AUTO RULE Non-Formulary 04/24/2020 sodium fluoride fluoride (sodium) NEW AUTO RULE Non-Formulary 04/24/2020 LIQUID HOPE nutritional supplement/fiber NEW AUTO RULE Non-Formulary PEPTIDE 04/24/2020 niacinamide niacinamide NEW AUTO RULE Non-Formulary 04/24/2020 TRODELVY sacituzumab govitecan-hziy NEW AUTO RULE Non-Formulary 04/24/2020 calcium calcium carbonate NEW AUTO RULE Non-Formulary 04/24/2020 super calcium calcium carbonate NEW AUTO RULE Non-Formulary 04/24/2020 nicardipine hcl- nicardipine in sodium NEW AUTO RULE Non-Formulary 0.9% nacl chloride, iso-osmotic 04/24/2020 quinoa-kale- nutritional supplement/fiber NEW AUTO RULE Non-Formulary hemp 04/24/2020 ALAHIST D phenylephrine NEW AUTO RULE Non-Formulary hcl/pheniramine maleate 04/24/2020 PEMAZYRE pemigatinib NEW AUTO RULE NF specialty 04/24/2020 NOURISH nutritional supplement/fiber NEW AUTO RULE Non-Formulary PEPTIDE 04/24/2020 KETO nutritional supplement/fiber NEW AUTO RULE Non-Formulary 04/24/2020 NEXAVIR liver extract (beef-pork) NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 126 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/24/2020 chloroprocaine chloroprocaine hcl/pf NEW AUTO RULE Non-Formulary hcl 04/24/2020 probiotic saccharomyces boulardii NEW AUTO RULE Non-Formulary 04/24/2020 saccharomyces saccharomyces boulardii NEW AUTO RULE Non-Formulary boulardii 04/24/2020 NESACAINE- chloroprocaine hcl/pf NEW AUTO RULE Non-Formulary MPF 04/24/2020 epinephrine-0.9% epinephrine hcl in 0.9 % NEW AUTO RULE Non-Formulary nacl sodium chloride 04/24/2020 PRAMOSONE hydrocortisone NEW AUTO RULE Non-Formulary acetate/pramoxine hcl 04/24/2020 AZESCHEW prenatal vitamins NEW AUTO RULE NF specialty no.165/ferrous fumarate/folic acid 04/24/2020 ANALPRAM HC hydrocortisone NEW AUTO RULE Non-Formulary acetate/pramoxine hcl 04/24/2020 FLORASTOR saccharomyces boulardii NEW AUTO RULE Non-Formulary 04/24/2020 MOUTHKOTE miscellaneous electrolyte NEW AUTO RULE Non-Formulary replacement/yerba santa 04/24/2020 orange chickn- nutritional supplement/fiber NEW AUTO RULE Non-Formulary carrot-brwn rice 04/24/2020 alfentanil hcl alfentanil hcl NEW AUTO RULE Non-Formulary 04/24/2020 gojji multi- blood ketone and glucose NEW AUTO RULE Non-Formulary functional meter monitor 04/24/2020 folic acid folic acid NEW AUTO RULE Non-Formulary 04/24/2020 sf fluoride (sodium) NEW AUTO RULE Non-Formulary 04/24/2020 allergy relief loratadine DRUG ATTR CHANGE Non-Formulary Non-Formulary OVERRIDE 04/27/2020 TARGRETIN bexarotene UM AUTO RULE: CUSTOM Short Cycle

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 127 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/27/2020 erlotinib hcl erlotinib hcl UM AUTO RULE: CUSTOM Short Cycle 04/27/2020 JADENU deferasirox UM AUTO RULE: CUSTOM Short Cycle SPRINKLE 04/27/2020 bexarotene bexarotene UM AUTO RULE: CUSTOM Short Cycle 04/27/2020 everolimus everolimus UM AUTO RULE: CUSTOM Short Cycle

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 128 UPDATED 12/2020 VALUE Drug Formulary Updates

May, 2020

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2020 zinc oxide zinc oxide NEW AUTO RULE Non-Formulary 05/01/2020 REPATHA evolocumab NEW AUTO RULE Tier 3 SYRINGE 05/01/2020 t:slim x2 control- subcutaneous insulin pump NEW AUTO RULE Non-Formulary iq 05/01/2020 nasal allergy triamcinolone acetonide NEW AUTO RULE Non-Formulary 05/01/2020 tussin cf guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary an hbr/phenylephrine 05/01/2020 omeprazole omeprazole magnesium NEW AUTO RULE Non-Formulary magnesium 05/01/2020 PRALUENT PEN alirocumab NEW AUTO RULE Tier 4 05/01/2020 benzoyl peroxide benzoyl peroxide NEW AUTO RULE Non-Formulary 05/01/2020 flu-severe cold- diphenhydramine NEW AUTO RULE Non-Formulary cough relief hcl/phenylephrine hcl/acetaminophen 05/01/2020 CHILDREN'S triamcinolone acetonide NEW AUTO RULE Non-Formulary NASACORT 05/01/2020 selsun blue pyrithione zinc NEW AUTO RULE Non-Formulary 05/01/2020 dobutamine hcl- dobutamine hcl in dextrose NEW AUTO RULE Non-Formulary d5w 5 % in water 05/01/2020 cough-cold guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary an hbr/phenylephrine 05/01/2020 dandruff pyrithione zinc NEW AUTO RULE Non-Formulary shampoo 05/01/2020 THERAFLU diphenhydramine NEW AUTO RULE Non-Formulary NIGHT SEVERE hcl/phenylephrine COLD-CGH hcl/acetaminophen

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 129 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2020 EMERPHED ephedrine sulfate NEW AUTO RULE Non-Formulary 05/01/2020 JELMYTO mitomycin NEW AUTO RULE Non-Formulary 05/01/2020 triamcinolone triamcinolone acetonide NEW AUTO RULE Non-Formulary acetonide 05/01/2020 desgen dm guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary an hbr/phenylephrine 05/01/2020 aller-cort triamcinolone acetonide NEW AUTO RULE Non-Formulary 05/01/2020 calcium 500-vit calcium NEW AUTO RULE Non-Formulary d3 carbonate/cholecalciferol (vitamin d3) 05/01/2020 polytoza silicone adhesive NEW AUTO RULE Non-Formulary 05/01/2020 oystercal-d calcium NEW AUTO RULE Non-Formulary carbonate/cholecalciferol (vitamin d3) 05/01/2020 ferrous sulfate ferrous sulfate NEW AUTO RULE Non-Formulary 05/01/2020 PROSOURCE TF amino acids/protein NEW AUTO RULE Non-Formulary hydrolysate 05/01/2020 NUVARING etonogestrel/ethinyl estradiol NEW AUTO RULE Non-formulary 05/01/2020 flu-severe cold- diphenhydramine NEW AUTO RULE Non-Formulary cough hcl/phenylephrine hcl/acetaminophen 05/01/2020 ZEMDRI plazomicin sulfate NEW AUTO RULE Non-Formulary 05/01/2020 MYCAMINE micafungin sodium NEW AUTO RULE Non-Formulary 05/01/2020 flu-severe cold- diphenhydramine NEW AUTO RULE Non-Formulary cough nitetime hcl/phenylephrine hcl/acetaminophen 05/01/2020 AFINITOR everolimus NEW AUTO RULE NF specialty 05/01/2020 PRILOSEC OTC omeprazole magnesium NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 130 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2020 severe cold diphenhydramine NEW AUTO RULE Non-Formulary cough-flu hcl/phenylephrine hcl/acetaminophen 05/01/2020 bp benzoyl peroxide NEW AUTO RULE Non-Formulary 05/01/2020 EMGALITY galcanezumab-gnlm NEW AUTO RULE NF specialty SYRINGE 05/01/2020 adult tussin multi- guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary symp cold an hbr/phenylephrine 05/01/2020 oyster shell calcium NEW AUTO RULE Non-Formulary calcium-vitamin d carbonate/cholecalciferol (vitamin d3) 05/01/2020 QUAD- l.acidophilus,paracasei/bifid NEW AUTO RULE Non-Formulary PROBIOTIC o animalis/strep thermophilus 05/01/2020 adlt wal-tussin guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary cough-cold cf an hbr/phenylephrine 05/01/2020 despec dm-g guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary an hbr/phenylephrine 05/01/2020 adult robitussin guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary peak cold m-s an hbr/phenylephrine 05/01/2020 DEPEN penicillamine NEW AUTO RULE NF specialty 05/01/2020 wal-flu severe diphenhydramine NEW AUTO RULE Non-Formulary cold-cough hcl/phenylephrine hcl/acetaminophen 05/01/2020 TRAVATAN Z travoprost NEW AUTO RULE Non-formulary 05/01/2020 CARAFATE sucralfate NEW AUTO RULE Non-formulary 05/01/2020 ULTRAM tramadol hcl UM AUTO RULE: 112 tabs/month QUANTITYCUSTOM 05/01/2020 PRALUENT PEN alirocumab CHANGE TIER Tier 4 Tier 3 05/01/2020 micafungin micafungin sodium NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 131 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2020 ACNE benzoyl peroxide NEW AUTO RULE Non-Formulary MEDICATION 05/01/2020 methylphenidate methylphenidate hcl NEW AUTO RULE Non-formulary er 05/01/2020 despec dm guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary an hbr/phenylephrine 05/01/2020 REPATHA evolocumab NEW AUTO RULE Tier 3 SURECLICK 05/01/2020 UPTRAVI selexipag UM AUTO RULE: pckg size #60= 2 QUANTITYCUSTOM tabs/day; pckg size #140= 140 tabs/6 months 05/01/2020 OS-CAL 500-VIT calcium NEW AUTO RULE Non-Formulary D3 carbonate/cholecalciferol (vitamin d3) 05/01/2020 wal-tussin cough- guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary cold cf an hbr/phenylephrine 05/01/2020 anastrozole anastrozole UM AUTO RULE: ACA Preventive Health 05/01/2020 NASACORT triamcinolone acetonide NEW AUTO RULE Non-Formulary 05/01/2020 2 in 1 dandruff pyrithione zinc NEW AUTO RULE Non-Formulary shampoo 05/01/2020 flu-severe cold- diphenhydramine NEW AUTO RULE Non-Formulary cough nightime hcl/phenylephrine hcl/acetaminophen 05/01/2020 REPATHA evolocumab NEW AUTO RULE Tier 3 PUSHTRONEX 05/01/2020 robafen cf guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary an hbr/phenylephrine 05/08/2020 stomach relief bismuth subsalicylate NEW AUTO RULE Non-Formulary 05/08/2020 clear bandages adhesive bandage NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 132 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/08/2020 doxycycline doxycycline hyclate NEW AUTO RULE Non-Formulary hyclate 05/08/2020 LORMATE mecobalamin/levomefolate NEW AUTO RULE Non-Formulary calcium/turmeric root extract 05/08/2020 lactose fast lactase NEW AUTO RULE Non-Formulary acting relief 05/08/2020 medicated foot menthol NEW AUTO RULE Non-Formulary 05/08/2020 melatonin melatonin NEW AUTO RULE Non-Formulary 05/08/2020 dairy digest lactase NEW AUTO RULE Non-Formulary 05/08/2020 daily acne wash salicylic acid NEW AUTO RULE Non-Formulary 05/08/2020 GOLD BOND menthol NEW AUTO RULE Non-Formulary MEDICATED FOOT 05/08/2020 cure chrome benzalkonium chloride NEW AUTO RULE Non-Formulary 05/08/2020 CITRACAL-D3 calcium NEW AUTO RULE Non-Formulary PETITES citrate/cholecalciferol (vitamin d3) 05/08/2020 DAYVIGO NEW AUTO RULE Non-formulary 05/08/2020 NYMALIZE nimodipine NEW AUTO RULE NF specialty 05/08/2020 digestive relief bismuth subsalicylate NEW AUTO RULE Non-Formulary 05/08/2020 pepto-bismol bismuth subsalicylate NEW AUTO RULE Non-Formulary 05/08/2020 lactase fast lactase NEW AUTO RULE Non-Formulary acting 05/08/2020 MULTIVITAMIN- b comp/c/folic acid/zinc NEW AUTO RULE Non-Formulary ZINC-STRESS sulfate/cupric sulfate/vitamin e ac 05/08/2020 NUFOLA pyridoxal NEW AUTO RULE Non-Formulary phosphate/levofolate calcium/mecobalamin/ala

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 133 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/08/2020 clear bandage adhesive bandage NEW AUTO RULE Non-Formulary 05/08/2020 heavy duty fabric benzalkonium chloride NEW AUTO RULE Non-Formulary antibac bndg 05/08/2020 compression compression socks, x-large NEW AUTO RULE Non-Formulary socks 05/08/2020 MONSEL'S ferric subsulfate NEW AUTO RULE Non-Formulary 05/08/2020 REFRESH PLUS carboxymethylcellulose NEW AUTO RULE Non-Formulary sodium 05/08/2020 citracal + d calcium NEW AUTO RULE Non-Formulary maximum citrate/cholecalciferol (vitamin d3) 05/08/2020 pink bismuth bismuth subsalicylate NEW AUTO RULE Non-Formulary 05/08/2020 vitamin e-oil vitamin e (dl-alpha NEW AUTO RULE Non-Formulary tocopheryl acetate) 05/08/2020 LACTAID FAST lactase NEW AUTO RULE Non-Formulary ACT 05/08/2020 ear drops for isopropyl alcohol in glycerin NEW AUTO RULE Non-Formulary swimmers 05/08/2020 SYSTANE propylene glycol NEW AUTO RULE Non-Formulary BALANCE 05/08/2020 heatwraps activated NEW AUTO RULE Non-Formulary charcoal/iron/sodium/water 05/08/2020 swim ear isopropyl alcohol in glycerin NEW AUTO RULE Non-Formulary 05/08/2020 instant cold pack cold-hot pack NEW AUTO RULE Non-Formulary 05/08/2020 compression compression socks, medium NEW AUTO RULE Non-Formulary socks 05/08/2020 CEPACOL SORE dextromethorphan NEW AUTO RULE Non-Formulary THROAT- hbr/benzocaine COUGH

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 134 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/08/2020 calcium citrate-vit calcium NEW AUTO RULE Non-Formulary d3 citrate/cholecalciferol (vitamin d3) 05/08/2020 calcium citrate-d calcium NEW AUTO RULE Non-Formulary citrate/cholecalciferol (vitamin d3) 05/08/2020 clearasil daily salicylic acid NEW AUTO RULE Non-Formulary clear 05/08/2020 ankle support leg brace NEW AUTO RULE Non-Formulary 05/08/2020 GVOKE PFS 2- glucagon DRUG ATTR CHANGE Non-formulary Non-formulary PACK SYRINGE OVERRIDE 05/08/2020 potassium potassium chloride in 0.45 NEW AUTO RULE Non-Formulary chloride-nacl % sodium chloride 05/08/2020 HALLS menthol NEW AUTO RULE Non-Formulary 05/08/2020 fast acting lactase NEW AUTO RULE Non-Formulary lactase 05/08/2020 dairy relief lactase NEW AUTO RULE Non-Formulary 05/08/2020 dobutamine hcl- dobutamine hcl in dextrose NEW AUTO RULE Non-Formulary d5w 5 % in water 05/08/2020 calcium citrate - calcium NEW AUTO RULE Non-Formulary vitamin d3 citrate/cholecalciferol (vitamin d3) 05/08/2020 ultra dairy lactase NEW AUTO RULE Non-Formulary digestive 05/08/2020 soothe bismuth subsalicylate NEW AUTO RULE Non-Formulary 05/08/2020 vitamin e vitamin e (dl-alpha NEW AUTO RULE Non-Formulary tocopheryl acetate) 05/08/2020 nitrile exam gloves NEW AUTO RULE Non-Formulary gloves

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 135 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/08/2020 mucus d guaifenesin/pseudoephedrin NEW AUTO RULE Non-Formulary e hcl 05/08/2020 citrus calcium + d calcium NEW AUTO RULE Non-Formulary citrate/cholecalciferol (vitamin d3) 05/08/2020 KAOPECTATE bismuth subsalicylate NEW AUTO RULE Non-Formulary 05/08/2020 vitamin d3 cholecalciferol (vitamin d3) NEW AUTO RULE Non-Formulary 05/08/2020 lubricating plus carboxymethylcellulose NEW AUTO RULE Non-Formulary sodium 05/08/2020 swimmer's instant isopropyl alcohol in glycerin NEW AUTO RULE Non-Formulary ear dry 05/08/2020 copper compress arm brace NEW AUTO RULE Non-Formulary sleeve elbow 05/08/2020 antacid ultra calcium carbonate NEW AUTO RULE Non-Formulary strength 05/08/2020 calcium citrate- calcium NEW AUTO RULE Non-Formulary vitamin d3 citrate/cholecalciferol (vitamin d3) 05/08/2020 adhesive tape adhesive tape NEW AUTO RULE Non-Formulary 05/08/2020 GVOKE PFS 1- glucagon DRUG ATTR CHANGE Non-formulary Non-formulary PACK SYRINGE OVERRIDE 05/08/2020 nicardipine hcl nicardipine hcl NEW AUTO RULE Non-Formulary 05/08/2020 DEFLUX dextranomer NEW AUTO RULE Non-Formulary microspheres/hyaluronate sod in 0.9 % sodium chl 05/08/2020 RICOLA menthol/herbal drugs NEW AUTO RULE Non-Formulary 05/08/2020 wrist support arm brace NEW AUTO RULE Non-Formulary 05/08/2020 ENFAMIL infant formula,soy,iron,lac- NEW AUTO RULE Non-Formulary PROSOBEE free/dha/arachidonic acid (ara)

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 136 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/08/2020 atropine sulfate atropine sulfate in 0.9 % NEW AUTO RULE Non-Formulary sodium chloride 05/08/2020 cicasil gel-matrix pad dressing, NEW AUTO RULE Non-Formulary silicone 05/08/2020 lactose fast lactase NEW AUTO RULE Non-Formulary acting 05/08/2020 dairy digestive lactase NEW AUTO RULE Non-Formulary 05/08/2020 cough drops menthol NEW AUTO RULE Non-Formulary 05/08/2020 tums ultra calcium carbonate NEW AUTO RULE Non-Formulary strength 05/08/2020 FENSOLVI leuprolide acetate NEW AUTO RULE Non-Formulary 05/08/2020 ear drying agent isopropyl alcohol in glycerin NEW AUTO RULE Non-Formulary 05/08/2020 finger injury kit finger splint NEW AUTO RULE Non-Formulary 05/08/2020 calcium citrate- calcium cit/vitamin NEW AUTO RULE Non-Formulary d3-magnesium d3/magnes ox/b6/zinc ox/copper/manganese 05/08/2020 citrus calcium- calcium NEW AUTO RULE Non-Formulary vitamin d3 citrate/cholecalciferol (vitamin d3) 05/08/2020 knee support leg brace NEW AUTO RULE Non-Formulary 05/08/2020 vitamin e oil vitamin e (dl-alpha NEW AUTO RULE Non-Formulary tocopheryl acetate) 05/08/2020 restore plus carboxymethylcellulose NEW AUTO RULE Non-Formulary sodium 05/08/2020 dextrose 5%- potassium chloride in NEW AUTO RULE Non-Formulary 1/2ns-kcl dextrose 5 %-0.45 % sodium chloride 05/08/2020 bismuth bismuth subsalicylate NEW AUTO RULE Non-Formulary 05/08/2020 HALOG halcinonide NEW AUTO RULE NF specialty

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 137 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/08/2020 DARZALEX daratumumab- NEW AUTO RULE Non-Formulary FASPRO hyaluronidase-fihj 05/08/2020 revive plus carboxymethylcellulose NEW AUTO RULE Non-Formulary sodium 05/08/2020 calcium citrate - calcium NEW AUTO RULE Non-Formulary vitamin d citrate/cholecalciferol (vitamin d3) 05/08/2020 lubricant eye propylene glycol NEW AUTO RULE Non-Formulary drop 05/08/2020 doxy 100 doxycycline hyclate NEW AUTO RULE Non-Formulary 05/08/2020 OIL-FREE ACNE salicylic acid NEW AUTO RULE Non-Formulary WASH 05/08/2020 merthiolate benzalkonium chloride NEW AUTO RULE Non-Formulary 05/08/2020 calcitrate + vit d calcium NEW AUTO RULE Non-Formulary citrate/cholecalciferol (vitamin d3) 05/15/2020 backache extra magnesium salicylate NEW AUTO RULE Non-Formulary strength 05/15/2020 EMERGEN-C ascorbic acid/multivit with NEW AUTO RULE Non-Formulary IMMUNE PLUS minerals 05/15/2020 midazolam hcl midazolam hcl/pf NEW AUTO RULE Non-Formulary 05/15/2020 VICKS NYQUIL dextromethorphan NEW AUTO RULE Non-Formulary hbr/acetaminophen/doxylam ine 05/15/2020 RETEVMO selpercatinib NEW AUTO RULE NF specialty 05/15/2020 child mucinex guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary freefrom day cgh an hbr 05/15/2020 coenzyme q10 ubidecarenone NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 138 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/15/2020 all-nite cold-flu dextromethorphan NEW AUTO RULE Non-Formulary relief hbr/acetaminophen/doxylam ine 05/15/2020 MUCINEX guaifenesin/phenylephrine NEW AUTO RULE Non-Formulary SINUS-MAX SEV hcl/acetaminophen CONGEST 05/15/2020 essence c ascorbic acid/multivit with NEW AUTO RULE Non-Formulary minerals 05/15/2020 CAMPTOSAR irinotecan hcl NEW AUTO RULE Non-Formulary 05/15/2020 heartburn relief cimetidine NEW AUTO RULE Non-Formulary 05/15/2020 atropine sulfate atropine sulfate NEW AUTO RULE Non-Formulary 05/15/2020 zinc sulfate zinc sulfate NEW AUTO RULE Non-Formulary 05/15/2020 oysco-500 calcium carbonate NEW AUTO RULE Non-Formulary 05/15/2020 nitetime cold-flu dextromethorphan NEW AUTO RULE Non-Formulary hbr/acetaminophen/doxylam ine 05/15/2020 CHILD MUCINEX triprolidine NEW AUTO RULE Non-Formulary FREEFROM NT hcl/phenylephrine/dextromet COLD horphn/acetaminophen 05/15/2020 backache relief magnesium salicylate NEW AUTO RULE Non-Formulary 05/15/2020 MUCINEX diphenhydramine NEW AUTO RULE Non-Formulary SINUS-MAX hcl/phenylephrine/acetamino DAY-NIGHT phen/guaifenesin 05/15/2020 vitamin c energy ascorbic acid/multivit with NEW AUTO RULE Non-Formulary booster minerals 05/15/2020 natural calcium calcium carbonate NEW AUTO RULE Non-Formulary 05/15/2020 CALTRATE calcium phosphate, NEW AUTO RULE Non-Formulary GUMMY BITES tribasic/cholecalciferol (vitamin d3)

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 139 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/15/2020 sure result tac triamcinolone NEW AUTO RULE Non-Formulary pak acetonide/dimethicone/silico ne, adhesive 05/15/2020 zionodil lidocaine hcl NEW AUTO RULE Non-Formulary 05/15/2020 dermawerx sds triamcinolone NEW AUTO RULE Non-Formulary acetonide/dimethicone/silico ne, adhesive 05/15/2020 reusable hot-cold cold-hot pack NEW AUTO RULE Non-Formulary wrap 05/15/2020 cleansing eyelid eyelid cleanser combination NEW AUTO RULE Non-Formulary pads no.8 05/15/2020 tri-sila triamcinolone NEW AUTO RULE Non-Formulary acetonide/dimethicone/silico ne, adhesive 05/15/2020 mucus relief cold guaifenesin/phenylephrine NEW AUTO RULE Non-Formulary & sinus hcl/acetaminophen 05/15/2020 lidocaine pain lidocaine NEW AUTO RULE Non-Formulary relief 05/15/2020 morphine sulfate- morphine sulfate in 0.9 % NEW AUTO RULE Non-Formulary 0.9% nacl sodium chloride 05/15/2020 probiotic bacillus coagulans/inulin NEW AUTO RULE Non-Formulary 05/15/2020 MUCINEX FAST- triprolidine/phenylephrine/de NEW AUTO RULE Non-Formulary MX CONG- xtromethorph/acetamin/guaif NIGHTSHFT enes 05/15/2020 BASADROX silver NEW AUTO RULE Non-Formulary 05/15/2020 rolled gauze gauze bandage NEW AUTO RULE Non-Formulary 05/15/2020 DERMACINRX triamcinolone NEW AUTO RULE Non-Formulary SILAPAK acetonide/dimethicone/silico ne, adhesive 05/15/2020 coenzyme q-10 ubidecarenone NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 140 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/15/2020 glucosa factor alpha lipoic acid/herbal NEW AUTO RULE Non-Formulary complex no.305 05/15/2020 robitussin cough- acetaminophen/dextrometho NEW AUTO RULE Non-Formulary sore throat rphan hbr 05/15/2020 DELSYM diphenhydramine/phenyleph NEW AUTO RULE Non-Formulary COUGH PLUS rin/dextromethorph/acetamin DAY-NIGHT ophen/gg 05/15/2020 MUCINEX triprolidine/phenylephrine/de NEW AUTO RULE Non-Formulary SINUS-MAX xtromethorph/acetamin/guaif NIGHTSHIFT enes 05/15/2020 calcium-vitamin calcium phosphate, NEW AUTO RULE Non-Formulary d3 tribasic/cholecalciferol (vitamin d3) 05/15/2020 sanadermrx triamcinolone NEW AUTO RULE Non-Formulary acetonide/dimethicone/silico ne, adhesive 05/15/2020 TAGAMET HB cimetidine NEW AUTO RULE Non-Formulary 05/15/2020 MUCINEX FAST- guaifenesin/phenylephrine NEW AUTO RULE Non-Formulary MAX CONG- hcl/acetaminophen HEADACHE 05/15/2020 EMERGEN-C ascorbic acid/multivit with NEW AUTO RULE Non-Formulary minerals 05/15/2020 coricidin hbp dextromethorphan NEW AUTO RULE Non-Formulary cold-multi sympt hbr/acetaminophen/doxylam ine 05/15/2020 trivix triamcinolone NEW AUTO RULE Non-Formulary acetonide/dimethicone/silico ne, adhesive 05/15/2020 cleansing eyelid eyelid cleanser combination NEW AUTO RULE Non-Formulary wipes no.8 05/15/2020 percogesic magnesium salicylate NEW AUTO RULE Non-Formulary backache relief

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 141 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/15/2020 severe guaifenesin/phenylephrine NEW AUTO RULE Non-Formulary congestion relief hcl/acetaminophen 05/15/2020 nite time cold-flu dextromethorphan NEW AUTO RULE Non-Formulary hbr/acetaminophen/doxylam ine 05/15/2020 ULTIMATE b. breve/b. bifidum/b. NEW AUTO RULE Non-Formulary FLORA BABY infantis/b. longum/l. PROBIOTIC rhamnosus 05/15/2020 dobutamine hcl- dobutamine hcl in dextrose NEW AUTO RULE Non-Formulary d5w 5 % in water 05/15/2020 premier urostomy urostomy pouch NEW AUTO RULE Non-Formulary pouch 05/15/2020 probiotic formula bacillus coagulans/inulin NEW AUTO RULE Non-Formulary 05/15/2020 DURYSTA bimatoprost NEW AUTO RULE Non-Formulary 05/15/2020 acid reducer cimetidine NEW AUTO RULE Non-Formulary 05/15/2020 sominex diphenhydramine hcl NEW AUTO RULE Non-Formulary 05/15/2020 zionodil-100 lidocaine hcl NEW AUTO RULE Non-Formulary 05/15/2020 co q-10 ubidecarenone NEW AUTO RULE Non-Formulary 05/15/2020 oyster shell calcium carbonate NEW AUTO RULE Non-Formulary calcium 05/15/2020 glucosamine glucosamine hcl/chondroitin NEW AUTO RULE Non-Formulary chondroitin sulf a/vitamin c/manganese/boron 05/15/2020 night time cold-flu dextromethorphan NEW AUTO RULE Non-Formulary hbr/acetaminophen/doxylam ine 05/15/2020 cimetidine cimetidine NEW AUTO RULE Non-Formulary 05/15/2020 calcium calcium carbonate NEW AUTO RULE Non-Formulary carbonate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 142 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/15/2020 calcium calcium carbonate NEW AUTO RULE Non-Formulary 05/15/2020 sinus relief max diphenhydramine NEW AUTO RULE Non-Formulary str day-night hcl/phenylephrine/acetamino phen/guaifenesin 05/15/2020 CHILD MUCINEX phenylephrine NEW AUTO RULE Non-Formulary FREEFROM DY hcl/dextromethorphan COLD hbr/acetaminophen/guaifen 05/15/2020 TABRECTA capmatinib hydrochloride NEW AUTO RULE NF specialty 05/15/2020 self-adherent elastic bandage NEW AUTO RULE Non-Formulary gentle wrap 05/20/2020 BELVIQ XR lorcaserin hcl NEW AUTO RULE Non-Formulary 05/20/2020 BELVIQ lorcaserin hcl TERM AUTO RULE 05/20/2020 BELVIQ lorcaserin hcl NEW AUTO RULE Non-Formulary 05/20/2020 BELVIQ XR lorcaserin hcl TERM AUTO RULE 05/22/2020 QINLOCK ripretinib NEW AUTO RULE NF specialty 05/22/2020 fentanyl- fentanyl citrate/ropivacaine NEW AUTO RULE Non-Formulary ropivacaine-0.9% hcl/sodium chloride 0.9%/pf nacl 05/22/2020 vitamin e vitamin e NEW AUTO RULE Non-Formulary 05/22/2020 INSULIN LISPRO insulin lispro NEW AUTO RULE Tier 1 05/22/2020 melatonin melatonin NEW AUTO RULE Non-Formulary 05/22/2020 JYNARQUE tolvaptan NEW AUTO RULE NF specialty 05/22/2020 vitamin b folic acid/vitamin b complex DRUG ATTR CHANGE Non-Formulary Non-Formulary complex-vitamin and vitamin c OVERRIDE c 05/22/2020 fentanyl- fentanyl citrate/bupivacaine NEW AUTO RULE Non-Formulary bupivacaine- hcl in 0.9 % sodium 0.9% nacl chloride/pf 05/22/2020 vitamin e vitamin e mixed NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 143 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/22/2020 omega-3 fish oil omega-3 fatty NEW AUTO RULE Non-Formulary acids/docosahexaenoic acid/epa/fish oil 05/22/2020 sleep time diphenhydramine hcl NEW AUTO RULE Non-Formulary 05/22/2020 tolvaptan tolvaptan NEW AUTO RULE NF specialty 05/22/2020 ADVIL JUNIOR ibuprofen NEW AUTO RULE Non-Formulary STRENGTH 05/22/2020 multivitamin with multivitamin with NEW AUTO RULE Non-Formulary minerals minerals/ferrous fumarate 05/22/2020 ENSURE CLEAR nutritional therapy for NEW AUTO RULE Non-Formulary impaired digestive function 05/22/2020 INSULIN LISPRO insulin lispro NEW AUTO RULE Tier 1 KWIKPEN U-100 05/22/2020 premier urostomy urostomy pouch NEW AUTO RULE Non-Formulary pouch 05/22/2020 urinary pain relief phenazopyridine hcl NEW AUTO RULE Non-Formulary 05/22/2020 medicated selenium sulfide NEW AUTO RULE Non-Formulary dandruff shampoo 05/22/2020 calcium 500 + vit calcium NEW AUTO RULE Non-Formulary d carbonate/cholecalciferol (vitamin d3) 05/22/2020 VITABEX IRON iron NEW AUTO RULE Non-Formulary bisglycinate/c/methylfolate/b 12/l. acidoph,plant/inulin 05/22/2020 selsun blue selenium sulfide NEW AUTO RULE Non-Formulary 05/22/2020 vitamin e vitamin e mixed DRUG ATTR CHANGE Non-Formulary Non-Formulary OVERRIDE 05/22/2020 vitamin e vitamin e acetate NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 144 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/22/2020 zoledronic acid zoledronic acid in mannitol NEW AUTO RULE Non-Formulary and water for injection 05/22/2020 glucosa immune herbal complex no.306 NEW AUTO RULE Non-Formulary booster 05/22/2020 DILAUDID hydromorphone hcl/pf NEW AUTO RULE Non-Formulary 05/22/2020 ZZZQUIL diphenhydramine hcl NEW AUTO RULE Non-Formulary 05/22/2020 BOTRYTIS allergenic extract-botrytis NEW AUTO RULE Non-Formulary CINEREA cinerea 05/22/2020 OSMOLEX ER amantadine hcl NEW AUTO RULE Non-formulary 05/22/2020 z-sleep diphenhydramine hcl NEW AUTO RULE Non-Formulary 05/22/2020 CEPACOL SORE benzocaine/menthol NEW AUTO RULE Non-Formulary THROAT 05/22/2020 fish oil omega-3 fatty NEW AUTO RULE Non-Formulary acids/docosahexaenoic acid/epa/fish oil 05/22/2020 unisom diphenhydramine hcl NEW AUTO RULE Non-Formulary 05/22/2020 ELECARE JR nutritional therapy for NEW AUTO RULE Non-Formulary impaired digestive function 05/22/2020 wal-sleep z diphenhydramine hcl NEW AUTO RULE Non-Formulary 05/22/2020 ENSURE CLEAR nutritional therapy for NEW AUTO RULE Non-Formulary THERAPEUTIC impaired digestive function 05/22/2020 equacare jr nutritional therapy for NEW AUTO RULE Non-Formulary impaired digestive function 05/22/2020 stresstabs energy vit b comp/vit c/folic NEW AUTO RULE Non-Formulary ac/arginine/glutamine/taurin e/ashwag 05/22/2020 anti-dandruff selenium sulfide NEW AUTO RULE Non-Formulary 05/22/2020 LICART diclofenac epolamine NEW AUTO RULE Non-formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 145 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/22/2020 dexmedetomidine dexmedetomidine hcl in 0.9 NEW AUTO RULE Non-Formulary -0.9% nacl % sodium chloride 05/22/2020 nighttime sleep diphenhydramine hcl NEW AUTO RULE Non-Formulary aid 05/22/2020 PKU SPHERE15 nutritional therapy for NEW AUTO RULE Non-Formulary phenylketonuria (pku) no.67 05/22/2020 META APPETITE psyllium husk NEW AUTO RULE Non-Formulary CONTROL 05/22/2020 PKU SPHERE20 nutritional therapy for NEW AUTO RULE Non-Formulary phenylketonuria (pku) no.67 05/29/2020 butterfly closures adhesive tape NEW AUTO RULE Non-Formulary 05/29/2020 mapap acetaminophen NEW AUTO RULE Non-Formulary 05/29/2020 lmc lidocaine/methyl NEW AUTO RULE Non-Formulary salicylate/camphor 05/29/2020 ALKALOL menthol/eucal/thymol/camph NEW AUTO RULE Non-Formulary NASAL WASH or/benz/sod chloride/pot chlorate 05/29/2020 AVSOLA infliximab-axxq NEW AUTO RULE Non-Formulary 05/29/2020 SODIUM DIURIL chlorothiazide sodium NEW AUTO RULE Non-Formulary 05/29/2020 norepinephrine norepinephrine bitartrate in NEW AUTO RULE Non-Formulary bitartrate-d5w 5 % dextrose in water 05/29/2020 succinylcholine succinylcholine chloride in NEW AUTO RULE Non-Formulary chloride-nacl sodium chloride,iso- osmotic/pf 05/29/2020 MARQIBO vincristine sulfate liposomal NEW AUTO RULE Non-Formulary 05/29/2020 ZEVALIN kit for prep yttrium- NEW AUTO RULE Non-Formulary 90/ibritumomab tiuxetan/albumin human 05/29/2020 transparent transparent dressing NEW AUTO RULE Non-Formulary mepitel film dress

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 146 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/29/2020 NEXLIZET bempedoic acid/ezetimibe NEW AUTO RULE Non-formulary 05/29/2020 DICLOVIX M diclofenac NEW AUTO RULE Non-Formulary sodium/menthol/kinesiology tape 05/29/2020 epi-clenz ethyl alcohol NEW AUTO RULE Non-Formulary 05/29/2020 MUCINEX FAST- triprolidine NEW AUTO RULE Non-Formulary MAX DM hcl/dextromethorphan/aceta NIGHTSHIFT minophen/guaifenesin 05/29/2020 OVEEZA folic NEW AUTO RULE Non-Formulary acid/b12/ala/ubiquinone/om ega-3/dha/epa 05/29/2020 SOVALDI sofosbuvir NEW AUTO RULE NF specialty 05/29/2020 cefuroxime cefuroxime sodium in 0.9 % NEW AUTO RULE Non-Formulary sodium-0.9% sodium chloride/pf nacl 05/29/2020 enovatizer ethyl alcohol NEW AUTO RULE Non-Formulary 05/29/2020 DIGESTIVE bacillus coagulans/calcium NEW AUTO RULE Non-Formulary ADVANTAGE carbonate PROBIOTIC 05/29/2020 acetaminophen acetaminophen NEW AUTO RULE Non-Formulary 05/29/2020 ESSENTIAL nut.tx.impaired digest NEW AUTO RULE Non-Formulary CARE JR fxn/fiber 05/29/2020 famotidine famotidine/pf NEW AUTO RULE Non-Formulary 05/29/2020 ZEPOSIA ozanimod hydrochloride NEW AUTO RULE NF specialty 05/29/2020 CLADOSPORIU allergenic extract- NEW AUTO RULE Non-Formulary M cladosporium CLADOSPORIOI cladosporioides DES 05/29/2020 TYR SPHERE20 nutritional therapy for NEW AUTO RULE Non-Formulary tyrosinemia with iron

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 147 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/29/2020 hand sanitizer ethyl alcohol NEW AUTO RULE Non-Formulary 05/29/2020 SUPLENA CARB nutritional therapy, impaired NEW AUTO RULE Non-Formulary STEADY renal function,lactose- reduced 05/29/2020 tylophen acetaminophen NEW AUTO RULE Non-Formulary 05/29/2020 HARVONI ledipasvir/sofosbuvir NEW AUTO RULE NF specialty 05/29/2020 chlorothiazide chlorothiazide sodium NEW AUTO RULE Non-Formulary sodium

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 148 UPDATED 12/2020 VALUE Drug Formulary Updates

June, 2020

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/03/2020 diclofenac diclofenac sodium NEW AUTO RULE Non-Formulary sodium 06/03/2020 ESGIC butalbital/acetaminophen/caf UM AUTO RULE: 6 caps/day; max feine QUANTITYCUSTOM 48 caps/30 days 06/03/2020 JADENU deferasirox UM AUTO RULE: PA Applies SPRINKLE AUTHORIZATION 06/03/2020 vanatol lq butalbital/acetaminophen/caf UM AUTO RULE: 90 ml/day; max feine QUANTITYCUSTOM 720 ml/30 days 06/03/2020 butalbital-aspirin- butalbital/aspirin/caffeine UM AUTO RULE: 6 caps/day; max caffeine QUANTITYCUSTOM 48 caps/30 days 06/03/2020 FIORINAL butalbital/aspirin/caffeine UM AUTO RULE: 6 caps/day; max QUANTITYCUSTOM 48 caps/30 days 06/03/2020 mesalamine mesalamine UM AUTO RULE: 1 suppository/day QUANTITYCUSTOM 06/03/2020 VOLTAREN diclofenac sodium NEW AUTO RULE Non-Formulary 06/03/2020 mesalamine dr mesalamine UM AUTO RULE: 6 caps/day QUANTITYCUSTOM 06/03/2020 ZEBUTAL butalbital/acetaminophen/caf UM AUTO RULE: 6 caps/day; max feine QUANTITYCUSTOM 48 caps/30 days 06/03/2020 fioricet butalbital/acetaminophen/caf UM AUTO RULE: 6 caps/day; max feine QUANTITYCUSTOM 48 caps/30 days 06/03/2020 CANASA mesalamine UM AUTO RULE: 1 suppository/day QUANTITYCUSTOM 06/03/2020 mesalamine er mesalamine NEW AUTO RULE Tier 2 06/03/2020 FLECTOR diclofenac epolamine UM AUTO RULE: 2 patches/day; QUANTITYCUSTOM max 30 patches/30 days

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 149 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/03/2020 tencon butalbital/acetaminophen UM AUTO RULE: 6 tabs/day; max QUANTITYCUSTOM 48 tabs/30 days 06/03/2020 bupap butalbital/acetaminophen UM AUTO RULE: 6 tabs/day; max QUANTITYCUSTOM 48 tabs/30 days 06/03/2020 DIPENTUM olsalazine sodium UM AUTO RULE: 4 caps/day QUANTITYCUSTOM 06/03/2020 VOLTAREN diclofenac sodium TERM AUTO RULE 06/03/2020 butalbital- butalbital/acetaminophen/caf UM AUTO RULE: 6 caps/day; max acetaminophen- feine QUANTITYCUSTOM 48 caps/30 days caffe 06/03/2020 vanatol s butalbital/acetaminophen/caf UM AUTO RULE: 90 ml/day; max feine QUANTITYCUSTOM 720 ml/30 days 06/03/2020 DELZICOL mesalamine UM AUTO RULE: 6 caps/day QUANTITYCUSTOM 06/03/2020 vtol lq butalbital/acetaminophen/caf UM AUTO RULE: 90 ml/day; max feine QUANTITYCUSTOM 720 ml/30 days 06/03/2020 diclofenac diclofenac sodium TERM AUTO RULE sodium 06/03/2020 butalbital- butalbital/acetaminophen UM AUTO RULE: 12 tabs/day; max acetaminophen QUANTITYCUSTOM 96 tabs/30 days 06/03/2020 diclofenac diclofenac epolamine UM AUTO RULE: 2 patches/day; epolamine QUANTITYCUSTOM max 30 patches/30 days 06/03/2020 phrenilin forte butalbital/acetaminophen/caf UM AUTO RULE: 6 caps/day; max feine QUANTITYCUSTOM 48 caps/30 days 06/03/2020 ALLZITAL butalbital/acetaminophen UM AUTO RULE: 12 tabs/day; max QUANTITYCUSTOM 96 tabs/30 days 06/04/2020 JADENU deferasirox TERM AUTO RULE SPRINKLE 06/05/2020 temsirolimus temsirolimus NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 150 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/05/2020 MUCOR allergenic extract-mucor NEW AUTO RULE Non-Formulary PLUMBEUS plumbeus 06/05/2020 I-VITE beta-carotene(a) w-c and NEW AUTO RULE Non-Formulary e/lutein/minerals 06/05/2020 arthritis hot pain methyl salicylate/menthol NEW AUTO RULE Non-Formulary relief 06/05/2020 COSAMIN glucosamine NEW AUTO RULE Non-Formulary AVOCA hcl/methylsulfonylmethane/b oswellia/herbal 182 06/05/2020 children's acetaminophen NEW AUTO RULE Non-Formulary acetaminophen 06/05/2020 acetaminophen acetaminophen NEW AUTO RULE Non-Formulary 06/05/2020 VICKS NYQUIL dextromethorphan NEW AUTO RULE Non-Formulary COUGH hbr/doxylamine succinate 06/05/2020 thiamine hcl thiamine hcl NEW AUTO RULE Non-Formulary 06/05/2020 night time cough dextromethorphan NEW AUTO RULE Non-Formulary hbr/doxylamine succinate 06/05/2020 blue-emu lidocaine NEW AUTO RULE Non-Formulary lidocaine patch 06/05/2020 MUCINEX phenylephrine NEW AUTO RULE Non-Formulary FREEFROM DAY hcl/dextromethorphan COLD-FLU hbr/acetaminophen/guaifen 06/05/2020 gojji lancing lancing device NEW AUTO RULE Non-Formulary device 06/05/2020 first aid antibiotic neomycin sulfate/bacitracin NEW AUTO RULE Non-Formulary zinc/polymyxin b 06/05/2020 antioxidant beta-carotene(a) w-c and NEW AUTO RULE Non-Formulary vitamins e/lutein/minerals 06/05/2020 nighttime cough dextromethorphan NEW AUTO RULE Non-Formulary hbr/doxylamine succinate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 151 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/05/2020 ocuvite with lutein beta-carotene(a) w-c and NEW AUTO RULE Non-Formulary e/lutein/minerals 06/05/2020 hailey fe norethindrone acetate- NEW AUTO RULE Tier 1 ethinyl estradiol/ferrous fumarate 06/05/2020 super calcium calcium NEW AUTO RULE Non-Formulary 600-vit d3 carbonate/cholecalciferol (vitamin d3) 06/05/2020 calcium 600-vit calcium NEW AUTO RULE Non-Formulary d3 carbonate/cholecalciferol (vitamin d3) 06/05/2020 healthy eyes beta-carotene(a) w-c and NEW AUTO RULE Non-Formulary e/lutein/minerals 06/05/2020 CLADOSPORIU allergenic extract- NEW AUTO RULE Non-Formulary M cladosporium CLADOSPORIOI cladosporioides DES 06/05/2020 epi-clenz ethyl alcohol NEW AUTO RULE Non-Formulary 06/05/2020 PHEXXI lactic acid/citric NEW AUTO RULE Non-formulary acid/potassium bitartrate 06/05/2020 STAHIST TP phenylephrine hcl/triprolidine NEW AUTO RULE Non-Formulary hcl 06/05/2020 MIDOL naproxen sodium NEW AUTO RULE Non-Formulary 06/05/2020 burn relief lidocaine hcl NEW AUTO RULE Non-Formulary 06/05/2020 TORISEL temsirolimus NEW AUTO RULE Non-Formulary 06/05/2020 potassium potassium chloride in 0.9 % NEW AUTO RULE Non-Formulary chloride-0.9% sodium chloride nacl 06/05/2020 VENOFER iron sucrose complex NEW AUTO RULE Non-Formulary 06/05/2020 gojji glucose blood glucose calibration NEW AUTO RULE Non-Formulary control solution control solution, normal

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 152 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/05/2020 MUCINEX triprolidine NEW AUTO RULE Non-Formulary FREEFROM NT hcl/phenylephrine/dextromet COLD-FLU horphn/acetaminophen 06/05/2020 premier drainable colostomy bags NEW AUTO RULE Non-Formulary pouch 06/05/2020 opti-vitamin beta-carotene(a) w-c and NEW AUTO RULE Non-Formulary e/lutein/minerals 06/05/2020 CAMPTOSAR irinotecan hcl NEW AUTO RULE Non-Formulary 06/05/2020 nighttime cough dextromethorphan NEW AUTO RULE Non-Formulary relief hbr/doxylamine succinate 06/05/2020 ORIAHNN elagolix NEW AUTO RULE NF specialty sodium/estradiol/norethindro ne acetate 06/05/2020 NORMOSOL-R electrolyte-r solution NEW AUTO RULE Non-Formulary 06/05/2020 nite time cough dextromethorphan NEW AUTO RULE Non-Formulary hbr/doxylamine succinate 06/06/2020 gojji glucose blood glucose calibration DRUG ATTR CHANGE Non-Formulary Non-Formulary control solution control solution, normal OVERRIDE 06/06/2020 gojji lancets lancets DRUG ATTR CHANGE Tier 2 Tier 2 OVERRIDE 06/06/2020 GVOKE glucagon DRUG ATTR CHANGE Non-formulary Non-formulary HYPOPEN 2- OVERRIDE PACK 06/06/2020 gojji lancet- lancets with blood glucose DRUG ATTR CHANGE Non-formulary Non-formulary glucose test strp test strips OVERRIDE 06/06/2020 gojji lancing lancing device DRUG ATTR CHANGE Non-Formulary Non-Formulary device OVERRIDE 06/06/2020 gojji blood blood sugar diagnostic DRUG ATTR CHANGE Non-formulary Non-formulary glucose test strip OVERRIDE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 153 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/06/2020 GVOKE glucagon DRUG ATTR CHANGE Non-formulary Non-formulary HYPOPEN 1- OVERRIDE PACK 06/06/2020 gojji blood ketone blood ketone test, strips DRUG ATTR CHANGE Tier 2 Tier 2 test strip OVERRIDE 06/08/2020 night time cold-flu dextromethorphan NEW AUTO RULE Non-Formulary hbr/acetaminophen/doxylam ine 06/08/2020 nighttime cold-flu dextromethorphan NEW AUTO RULE Non-Formulary hbr/acetaminophen/doxylam ine 06/08/2020 nighttime cold-flu dextromethorphan NEW AUTO RULE Non-Formulary relief hbr/acetaminophen/doxylam ine 06/10/2020 allergy loratadine NEW AUTO RULE Non-Formulary 06/10/2020 allergy relief loratadine NEW AUTO RULE Non-Formulary 06/12/2020 bp foam benzoyl peroxide NEW AUTO RULE Non-Formulary 06/12/2020 PRIZOTRAL-II lidocaine/prilocaine/lidocaine NEW AUTO RULE Non-Formulary hcl 06/12/2020 BENZEFOAM benzoyl peroxide NEW AUTO RULE Non-Formulary 06/12/2020 benzepro benzoyl peroxide NEW AUTO RULE Non-Formulary 06/12/2020 os-cal 500-vit d3 calcium NEW AUTO RULE Non-Formulary carbonate/cholecalciferol (vitamin d3) 06/12/2020 DIGESTIVE bacillus NEW AUTO RULE Non-Formulary ADVANTAGE coagulans/protease/amylase INT BOWEL /lipase 06/12/2020 fiber psyllium husk/aspartame NEW AUTO RULE Non-Formulary 06/12/2020 GERBER GOOD infant formula with iron/a2 NEW AUTO RULE Non-Formulary START A2 beta casein/dha/arach/l.reuteri

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 154 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/12/2020 META APPETITE psyllium husk/aspartame NEW AUTO RULE Non-Formulary CONTROL 06/12/2020 cleansing eyelid eyelid cleanser combination NEW AUTO RULE Non-Formulary wipes ext str no.10 06/12/2020 calcium 500-vit calcium NEW AUTO RULE Non-Formulary d3 carbonate/cholecalciferol (vitamin d3) 06/12/2020 GELUSIL magnesium NEW AUTO RULE Non-Formulary hydroxide/aluminum hydroxide/simethicone 06/12/2020 dextrose 5%-ns- potassium chloride in NEW AUTO RULE Non-Formulary kcl dextrose 5 % and 0.9 % sodium chloride 06/12/2020 KYNMOBI apomorphine hcl NEW AUTO RULE NF specialty 06/12/2020 ALKA-SELTZER doxylamine/phenylephrine/d NEW AUTO RULE Non-Formulary PLUS COLD extromethorphan/acetamino DAY-NT phen/gg 06/12/2020 fentanyl citrate fentanyl citrate/pf NEW AUTO RULE Non-Formulary 06/12/2020 ZILXI minocycline hcl NEW AUTO RULE Non-formulary 06/12/2020 decara cholecalciferol (vitamin d3) NEW AUTO RULE Non-Formulary 06/12/2020 probiotic bacillus coagulans NEW AUTO RULE Non-Formulary 06/12/2020 sodium fluoride sodium fluoride/potassium NEW AUTO RULE Non-Formulary sensitive nitrate 06/12/2020 NUVAKAAN-II lidocaine/prilocaine/silicone, NEW AUTO RULE Non-Formulary adhesive 06/12/2020 GERBER GOOD pediatric nut,milk NEW AUTO RULE Non-Formulary START A2 based,iron/a2 TODDLER casein/dha/ara/l. reuteri 06/12/2020 NAN PRO-1 infant formula with NEW AUTO RULE Non-Formulary INFANT iron/dha/ara/l. reuteri

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 155 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/12/2020 oysco 500-vit d3 calcium NEW AUTO RULE Non-Formulary carbonate/cholecalciferol (vitamin d3) 06/12/2020 SOOTHE XP light mineral oil/mineral oil/pf NEW AUTO RULE Non-Formulary 06/12/2020 potassium chl- potassium chloride in 0.9 % NEW AUTO RULE Non-Formulary normal saline sodium chloride 06/12/2020 LIPRITIN gabapentin/lidocaine/prilocai NEW AUTO RULE Non-Formulary ne/transparent dressing 06/12/2020 hi-cal calcium NEW AUTO RULE Non-Formulary carbonate/cholecalciferol (vitamin d3) 06/12/2020 PREVIDENT sodium fluoride/potassium NEW AUTO RULE Non-Formulary 5000 SENSITIVE nitrate 06/12/2020 DIGESTIVE bacillus coagulans NEW AUTO RULE Non-Formulary ADVANTAGE IMMUNE 06/12/2020 sodium fluoride fluoride (sodium) NEW AUTO RULE Non-Formulary 06/12/2020 minimed mio infusion set for insulin pump NEW AUTO RULE Non-Formulary advance 06/12/2020 mintox plus magnesium NEW AUTO RULE Non-Formulary hydroxide/aluminum hydroxide/simethicone 06/12/2020 is-d-10,000 cholecalciferol (vitamin d3) NEW AUTO RULE Non-Formulary 06/12/2020 droplet pen pen needle, diabetic NEW AUTO RULE Tier 2 needle 06/12/2020 FLORANEX lactobacillus NEW AUTO RULE Non-Formulary acidophilus/lactobacillus bulgaricus 06/12/2020 PREVIDENT sodium fluoride/potassium NEW AUTO RULE Non-Formulary 5000 ENAMEL nitrate PROTECT

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 156 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/12/2020 hailey fe norethindrone acetate- NEW AUTO RULE Tier 1 ethinyl estradiol/ferrous fumarate 06/12/2020 DIGESTIVE bacillus coagulans NEW AUTO RULE Non-Formulary ADVANTAGE PROBIOTIC 06/12/2020 empricaine-ii lidocaine/prilocaine NEW AUTO RULE Non-Formulary 06/12/2020 benzoyl peroxide benzoyl peroxide NEW AUTO RULE Non-Formulary 06/12/2020 iodides ammonium iodide/potassium NEW AUTO RULE Non-Formulary iodide 06/17/2020 ZOSTAVAX zoster vaccine live/pf UM AUTO RULE: AGE At least 50 yrs old 06/19/2020 hpr plus emollient combination no.53 NEW AUTO RULE Non-Formulary 06/19/2020 nivatopic plus emollient combination no.53 NEW AUTO RULE Non-Formulary 06/19/2020 IS-ZC 50 zinc oxide-zinc citrate NEW AUTO RULE Non-Formulary 06/19/2020 OPTIFLEX-G glucosamine sulfate NEW AUTO RULE Non-Formulary 06/19/2020 b-12 mecobalamin NEW AUTO RULE Non-Formulary 06/19/2020 GERBER LIL vit c/vit d3/vit e acet/choline NEW AUTO RULE Non-Formulary BRAINIES bit/omega 3,6,9 combo no.7 06/19/2020 LYUMJEV insulin lispro-aabc NEW AUTO RULE Non-formulary 06/19/2020 vitamin b-1 thiamine hcl NEW AUTO RULE Non-Formulary 06/19/2020 droplet micron pen needle, diabetic NEW AUTO RULE Tier 2 pen needle 06/19/2020 POLY-VI-SOL pediatric multivitamin NEW AUTO RULE Non-Formulary WITH IRON no.189/ferrous sulfate 06/19/2020 LYUMJEV insulin lispro-aabc NEW AUTO RULE Non-formulary KWIKPEN U-100 06/19/2020 PROPOVEN propofol in lipid emulsion NEW AUTO RULE Non-Formulary (EUA) mct/lct (1:1)/pf

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 157 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/19/2020 DIGESTIVE bacillus coagulans NEW AUTO RULE Non-Formulary ADVANTAGE PROBIO-PRE 06/19/2020 DONA glucosamine sulfate NEW AUTO RULE Non-Formulary 06/19/2020 eye drops tetrahydrozoline hcl/zinc NEW AUTO RULE Non-Formulary irritation relief sulfate 06/19/2020 blue tube lidocaine NEW AUTO RULE Non-Formulary 06/19/2020 airborne gummy multivitamin-minerals/vit NEW AUTO RULE Non-Formulary c/herbal no.124 06/19/2020 airborne multivitamin- NEW AUTO RULE Non-Formulary minerals/ascorbic acid/herbal no.124 06/19/2020 TIVICAY PD dolutegravir sodium NEW AUTO RULE Tier 3 06/19/2020 VISINE tetrahydrozoline hcl/zinc NEW AUTO RULE Non-Formulary ALLERGY sulfate RELIEF 06/19/2020 desonide desonide NEW AUTO RULE Non-formulary 06/19/2020 LYUMJEV insulin lispro-aabc NEW AUTO RULE Non-formulary KWIKPEN U-200 06/19/2020 HYLATOPICPLU emollient combination no.53 NEW AUTO RULE Non-Formulary S 06/19/2020 FLUOVIX PLUS fluocinonide/silicone, NEW AUTO RULE Non-Formulary adhesive 06/19/2020 hylaguard emollient combination no.53 NEW AUTO RULE Non-Formulary 06/19/2020 invigoflex d glucosamine sulfate NEW AUTO RULE Non-Formulary 06/19/2020 strataxrt gel dressing NEW AUTO RULE Non-Formulary 06/19/2020 NAN PRO pediatric nut,milk NEW AUTO RULE Non-Formulary TODDLER based,iron/lactobacillus reuteri

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 158 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/19/2020 DIGEST ADV bacillus coagulans/digestive NEW AUTO RULE Non-Formulary PROBIO PLUS enzymes combo no.10 GAS 06/19/2020 AQUANAZ PSE guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary an hbr/pseudoephedrine hcl 06/19/2020 stratactx gel dressing NEW AUTO RULE Non-Formulary 06/19/2020 atopaderm emollient combination no.53 NEW AUTO RULE Non-Formulary 06/19/2020 lc-4 lidocaine NEW AUTO RULE Non-Formulary 06/19/2020 airborne natural multivitamin- NEW AUTO RULE Non-Formulary energy minerals/ascorbic acid/herbal no.124 06/19/2020 airborne kids multivitamin-minerals/vit NEW AUTO RULE Non-Formulary c/herbal no.124 06/19/2020 astringent eye tetrahydrozoline hcl/zinc NEW AUTO RULE Non-Formulary drops sulfate 06/19/2020 airborne multivitamin-minerals/vit NEW AUTO RULE Non-Formulary c/herbal no.124 06/19/2020 niacin niacin NEW AUTO RULE Non-Formulary 06/19/2020 glucosamine glucosamine sulfate NEW AUTO RULE Non-Formulary sulfate 06/24/2020 hydrocortisone hydrocortisone UM AUTO RULE: STEP Commercial: use butyrate butyrate/emollient base two preferred topical steroids in the same potency class first 06/24/2020 LOPRESSOR metoprolol UM AUTO RULE: STEP Commercial: use HCT tartrate/hydrochlorothiazide 2 preferred beta- blocker agents first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 159 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 dextroamphetami dextroamphetamine sulf- UM AUTO RULE: STEP Commercial: use ne-amphet er saccharate/amphetamine one preferred sulf-aspartate extended-release ADHD agent first 06/24/2020 ketodan ketoconazole UM AUTO RULE: STEP Commercial: use econazole cream and one other preferred topical anti-fungal agent first 06/24/2020 ANAFRANIL clomipramine hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 carvedilol er carvedilol phosphate UM AUTO RULE: STEP Commercial: use 2 preferred beta- blocker agents first 06/24/2020 ciclopirox ciclopirox olamine UM AUTO RULE: STEP Commercial: use econazole cream and one other preferred topical anti-fungal agent first 06/24/2020 LOTRISONE clotrimazole/betamethasone UM AUTO RULE: STEP Commercial: use dipropionate econazole cream and one other preferred topical anti-fungal agent first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 160 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 BANZEL rufinamide UM AUTO RULE: STEP Commercial: use two of the following first: clonazepam, felbamate, lamotrigine, or topiramate 06/24/2020 PAXIL paroxetine hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 SPIRIVA tiotropium bromide UM AUTO RULE: STEP Commercial: use RESPIMAT Incruse Ellipta and Spiriva first 06/24/2020 ASMANEX HFA mometasone furoate UM AUTO RULE: STEP Commercial: use one preferred inhaled corticosteroid first 06/24/2020 entacapone entacapone UM AUTO RULE: STEP Commercial: use entacapone first 06/24/2020 URAMAXIN GT urea UM AUTO RULE: STEP Commercial: use two preferred urea products first 06/24/2020 zenzedi dextroamphetamine sulfate UM AUTO RULE: STEP Commercial: use one preferred immediate- release ADHD agent first 06/24/2020 glipizide er glipizide UM AUTO RULE: STEP Commercial: use metformin, glipizide, or glyburide first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 161 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 METHYLIN methylphenidate hcl UM AUTO RULE: STEP Commercial: use one preferred immediate- release ADHD agent first 06/24/2020 SINEMET CR carbidopa/levodopa UM AUTO RULE: STEP Commercial: use carbidopa/levodo pa er first 06/24/2020 sumatriptan sumatriptan UM AUTO RULE: STEP Commercial: use sumatriptan nasal first 06/24/2020 HALOG halcinonide UM AUTO RULE: STEP Commercial: use 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first 06/24/2020 MAXZIDE-25 MG triamterene/hydrochlorothiaz UM AUTO RULE: STEP Commercial: use ide amiloride, spironolactone, or triamterene/hctz first 06/24/2020 ABILIFY aripiprazole UM AUTO RULE: STEP Commercial: use aripiprazole, clozapine, olanzapine, quetiapine, risperidone, or ziprasidone first 06/24/2020 lactulose lactulose UM AUTO RULE: STEP Commercial: use lactulose first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 162 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 STRIVERDI olodaterol hcl UM AUTO RULE: STEP Commercial: use RESPIMAT Striverdi or Serevent first 06/24/2020 roweepra levetiracetam UM AUTO RULE: STEP Commercial: use levetiracetam first 06/24/2020 XADAGO safinamide mesylate UM AUTO RULE: STEP Commercial: use rasagiline first 06/24/2020 desvenlafaxine er desvenlafaxine UM AUTO RULE: STEP Commercial: use desvenlafaxine succinate er (Pristiq) first 06/24/2020 DEXEDRINE dextroamphetamine sulfate UM AUTO RULE: STEP Commercial: use one preferred extended-release ADHD agent first 06/24/2020 DIOVAN valsartan UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, , or thiazide diuretic 06/24/2020 URAMAXIN urea UM AUTO RULE: STEP Commercial: use two preferred urea products first 06/24/2020 tramadol hcl er tramadol hcl UM AUTO RULE: STEP Commercial: use tramadol [Ultram] ir or er first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 163 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 ZOMIG UM AUTO RULE: STEP Commercial: use sumatriptan nasal first 06/24/2020 aripiprazole odt aripiprazole UM AUTO RULE: STEP Commercial: use aripiprazole, clozapine, olanzapine, quetiapine, risperidone, or ziprasidone first 06/24/2020 VANOS fluocinonide UM AUTO RULE: STEP Commercial: use 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first 06/24/2020 losartan- losartan UM AUTO RULE: STEP Commercial: use hydrochlorothiazi potassium/hydrochlorothiazi an ARB and one de de agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 164 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 cartia xt diltiazem hcl UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 amcinonide amcinonide UM AUTO RULE: STEP Commercial: use one high potency topical corticosteroid AND desoximetasone 0.25% cream or ointment first 06/24/2020 ZOMIG ZMT zolmitriptan UM AUTO RULE: STEP Commercial: use two of the following first: , , sumatriptan or zolmitriptan 06/24/2020 pioglitazone hcl pioglitazone hcl UM AUTO RULE: STEP Commercial: use metformin or pioglitazone first 06/24/2020 ECOZA econazole nitrate UM AUTO RULE: STEP Commercial: use econazole cream and one other preferred topical anti-fungal agent first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 165 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 FLOVENT HFA fluticasone propionate UM AUTO RULE: STEP Commercial: use one preferred inhaled corticosteroid first 06/24/2020 UTIBRON indacaterol UM AUTO RULE: STEP Commercial: use NEOHALER maleate/glycopyrrolate Anoro Ellipta first 06/24/2020 JARDIANCE empagliflozin UM AUTO RULE: STEP Commercial: use metformin first 06/24/2020 TEKTURNA aliskiren hemifumarate UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 LAMICTAL ODT lamotrigine UM AUTO RULE: STEP Commercial: use (BLUE) two of the following first: clonazepam, felbamate, lamotrigine, or topiramate 06/24/2020 LOCOID hydrocortisone UM AUTO RULE: STEP Commercial: use LIPOCREAM butyrate/emollient base two preferred topical steroids in the same potency class first 06/24/2020 tolterodine tolterodine tartrate UM AUTO RULE: STEP Commercial: use tartrate er oxybutynin IR/ER or trospium IR/ER first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 166 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 olmesartan- olmesartan UM AUTO RULE: STEP Commercial: use amlodipine-hctz medoxomil/amlodipine an ARB and one besylate/hydrochlorothiazide agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 clobetasol clobetasol propionate UM AUTO RULE: STEP Commercial: use propionate 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first 06/24/2020 procentra dextroamphetamine sulfate UM AUTO RULE: STEP Commercial: use one preferred immediate- release ADHD agent first 06/24/2020 fluocinolone fluocinolone acetonide UM AUTO RULE: STEP Commercial: use acetonide 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first 06/24/2020 PAXIL CR paroxetine hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 167 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 ZIPSOR diclofenac potassium UM AUTO RULE: STEP Commercial: use two prescription strength NSAIDS, one being oral diclofenac first 06/24/2020 zolpidem tartrate zolpidem tartrate UM AUTO RULE: STEP Commercial: use er zolpidem immediate- release, zolpidem extended- release, eszopiclone, or zaleplon first 06/24/2020 ALTACE ramipril UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 ZURAMPIC lesinurad UM AUTO RULE: STEP Commercial: use Uloric or allopurinol first 06/24/2020 halobetasol halobetasol propionate UM AUTO RULE: STEP Commercial: use propionate 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 168 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 fluocinonide fluocinonide UM AUTO RULE: STEP Commercial: use 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first 06/24/2020 EQUETRO UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 ZOLOFT sertraline hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 metopic urea UM AUTO RULE: STEP Commercial: use two preferred urea products first 06/24/2020 gabapentin gabapentin UM AUTO RULE: STEP Commercial: use two of the following in 2 different drug classes including: TCA, SSRI, SNRI, tramadol, gabapentin, or cyclobenzaprine 06/24/2020 roweepra xr levetiracetam UM AUTO RULE: STEP Commercial: use levetiracetam first 06/24/2020 ACTONEL risedronate sodium UM AUTO RULE: STEP Commercial: use alendronate and ibandronate first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 169 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 cormax clobetasol propionate UM AUTO RULE: STEP Commercial: use 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first 06/24/2020 ATRALIN tretinoin UM AUTO RULE: STEP Commercial: use topical tretinoin and topical clindamycin first 06/24/2020 LOCOID hydrocortisone butyrate UM AUTO RULE: STEP Commercial: use 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first 06/24/2020 TEKTURNA HCT aliskiren UM AUTO RULE: STEP Commercial: use hemifumarate/hydrochlorothi an ARB and one azide agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 170 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 EXFORGE HCT amlodipine UM AUTO RULE: STEP Commercial: use besylate/valsartan/hydrochlo an ARB and one rothiazide agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 betamethasone betamethasone valerate UM AUTO RULE: STEP Commercial: use valerate 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first 06/24/2020 ALDACTAZIDE spironolactone/hydrochlorot UM AUTO RULE: STEP Commercial: use hiazide an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 TASMAR tolcapone UM AUTO RULE: STEP Commercial: use entacapone first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 171 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 MICARDIS telmisartan UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 enalapril- enalapril UM AUTO RULE: STEP Commercial: use hydrochlorothiazi maleate/hydrochlorothiazide an ARB and one de agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 GELNIQUE oxybutynin chloride UM AUTO RULE: STEP Commercial: use Vesicare or Myrbetriq AND either oxybutynin ir/er or trospium ir/er first 06/24/2020 ACCUPRIL quinapril hcl UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 172 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 glipizide xl glipizide UM AUTO RULE: STEP Commercial: use metformin, glipizide, or glyburide first 06/24/2020 VASOTEC enalapril maleate UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 captopril captopril UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 zolmitriptan odt zolmitriptan UM AUTO RULE: STEP Commercial: use two of the following first: naratriptan, rizatriptan, sumatriptan or zolmitriptan 06/24/2020 RIOMET ER metformin hcl UM AUTO RULE: STEP Commercial: use metformin, glipizide, or glyburide first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 173 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 SUMAVEL sumatriptan succinate UM AUTO RULE: STEP Commercial: use DOSEPRO sumatriptan vial, prefilled syringe, or prefilled cartridge first 06/24/2020 isradipine isradipine UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 GLUCOPHAGE metformin hcl UM AUTO RULE: STEP Commercial: use XR metformin first 06/24/2020 valsartan valsartan UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 VEREGEN sinecatechins UM AUTO RULE: STEP Commercial: use imiquimod, podofilox soln, Condylox gel, or Zyclara first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 174 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 halcinonide halcinonide UM AUTO RULE: STEP Commercial: use 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first 06/24/2020 glipizide- glipizide/metformin hcl UM AUTO RULE: STEP Commercial: use metformin metformin, glipizide, or glyburide first 06/24/2020 JANUMET XR sitagliptin UM AUTO RULE: STEP Commercial: use phosphate/metformin hcl metformin first 06/24/2020 IRENKA duloxetine hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 moexipril hcl moexipril hcl UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 MAXALT MLT rizatriptan benzoate UM AUTO RULE: STEP Commercial: use two of the following first: naratriptan, rizatriptan, sumatriptan or zolmitriptan

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 175 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 enalapril maleate enalapril maleate UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 nefazodone hcl nefazodone hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 alendronate alendronate sodium UM AUTO RULE: STEP Commercial: use sodium alendronate and ibandronate first 06/24/2020 darifenacin er darifenacin hydrobromide UM AUTO RULE: STEP Commercial: use oxybutynin IR/ER or trospium IR/ER first 06/24/2020 RITALIN methylphenidate hcl UM AUTO RULE: STEP Commercial: use one preferred immediate- release ADHD agent first 06/24/2020 venlafaxine hcl venlafaxine hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 KERAFOAM urea UM AUTO RULE: STEP Commercial: use two preferred urea products first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 176 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 XEPI ozenoxacin UM AUTO RULE: STEP Commercial: use mupirocin [Bactroban] ointment or cream first 06/24/2020 tranylcypromine tranylcypromine sulfate UM AUTO RULE: STEP Commercial: use sulfate 2 preferred antidepressants first 06/24/2020 SYNALAR fluocinolone acetonide UM AUTO RULE: STEP Commercial: use 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first 06/24/2020 eprosartan eprosartan mesylate UM AUTO RULE: STEP Commercial: use mesylate an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 bupropion hcl bupropion hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 azelastine hcl azelastine hcl UM AUTO RULE: STEP Commercial: use azelastine (Optivar) first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 177 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 XALATAN latanoprost UM AUTO RULE: STEP Commercial: use latanoprost first 06/24/2020 duloxetine hcl duloxetine hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 clozapine odt clozapine UM AUTO RULE: STEP Commercial: use aripiprazole, clozapine, olanzapine, quetiapine, risperidone, or ziprasidone first 06/24/2020 adapalene- adapalene/benzoyl peroxide UM AUTO RULE: STEP Commercial: use benzoyl peroxide adapalene or benzoyl peroxide containing product first 06/24/2020 risedronate risedronate sodium UM AUTO RULE: STEP Commercial: use sodium alendronate and ibandronate first 06/24/2020 imipramine pamoate UM AUTO RULE: STEP Commercial: use pamoate 2 preferred antidepressants first 06/24/2020 paroxetine hcl paroxetine hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 178 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 nifedipine nifedipine UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 amoxapine amoxapine UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 naftifine hcl naftifine hcl UM AUTO RULE: STEP Commercial: use econazole cream and one other preferred topical anti-fungal agent first 06/24/2020 ezetimibe- ezetimibe/simvastatin UM AUTO RULE: STEP Commercial: use simvastatin atorvastatin 80 mg or rosuvastatin 40 mg first 06/24/2020 nortriptyline hcl nortriptyline hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 RAPAFLO silodosin UM AUTO RULE: STEP Commercial: use tamsulosin [Flomax] first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 179 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 NAFTIN naftifine hcl UM AUTO RULE: STEP Commercial: use econazole cream and one other preferred topical anti-fungal agent first 06/24/2020 doxepin hcl doxepin hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 BENZAMYCIN erythromycin base/benzoyl UM AUTO RULE: STEP Commercial: use peroxide adapalene or benzoyl peroxide containing product first 06/24/2020 PRISTIQ desvenlafaxine succinate UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 ACEON perindopril erbumine UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 CLARINEX desloratadine UM AUTO RULE: STEP Commercial: use azelastine, flunisolide nasal, or fluticasone nasal first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 180 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 FEXMID cyclobenzaprine hcl UM AUTO RULE: STEP Commercial: use cyclobenzaprine [Flexeril] first 06/24/2020 EXFORGE amlodipine UM AUTO RULE: STEP Commercial: use besylate/valsartan an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 DUETACT pioglitazone hcl/glimepiride UM AUTO RULE: STEP Commercial: use pioglitazone or glimepiride first 06/24/2020 fluvoxamine fluvoxamine maleate UM AUTO RULE: STEP Commercial: use maleate 2 preferred antidepressants first 06/24/2020 trianex triamcinolone acetonide UM AUTO RULE: STEP Commercial: use one high potency topical corticosteroid AND desoximetasone 0.25% cream or ointment first 06/24/2020 metformin er metformin hcl UM AUTO RULE: STEP Commercial: use gastric metformin, glipizide, or glyburide first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 181 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 SONATA zaleplon UM AUTO RULE: STEP Commercial: use zolpidem immediate- release, zolpidem extended- release, eszopiclone, or zaleplon first 06/24/2020 irbesartan- irbesartan/hydrochlorothiazi UM AUTO RULE: STEP Commercial: use hydrochlorothiazi de an ARB and one de agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 diflorasone diflorasone diacetate UM AUTO RULE: STEP Commercial: use diacetate one high potency topical corticosteroid AND desoximetasone 0.25% cream or ointment first 06/24/2020 ATACAND HCT candesartan UM AUTO RULE: STEP Commercial: use cilexetil/hydrochlorothiazide an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 182 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 fenofibrate fenofibrate nanocrystallized UM AUTO RULE: STEP Commercial: use fenofibrate (generic Tricor or Lofibra) first 06/24/2020 levetiracetam er levetiracetam UM AUTO RULE: STEP Commercial: use levetiracetam first 06/24/2020 valsartan- valsartan/hydrochlorothiazid UM AUTO RULE: STEP Commercial: use hydrochlorothiazi e an ARB and one de agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 BACTROBAN mupirocin calcium UM AUTO RULE: STEP Commercial: use mupirocin [Bactroban] ointment or cream first 06/24/2020 betamethasone betamethasone dipropionate UM AUTO RULE: STEP Commercial: use diprop 2 preferred augmented medium potency topical corticosteroids; one of which is triamcinolone, first 06/24/2020 IMITREX sumatriptan succinate UM AUTO RULE: STEP Commercial: use two of the following first: naratriptan, rizatriptan, sumatriptan or zolmitriptan

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 183 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 COLAZAL balsalazide disodium UM AUTO RULE: STEP Commercial: use 2 of the following first: mesalamine er (Apriso), mesalamine (Lialda) or balsalazide (Colazal) 06/24/2020 almotriptan malate UM AUTO RULE: STEP Commercial: use malate two of the following first: naratriptan, rizatriptan, sumatriptan or zolmitriptan 06/24/2020 trimipramine trimipramine maleate UM AUTO RULE: STEP Commercial: use maleate 2 preferred antidepressants first 06/24/2020 chlordiazepoxide- UM AUTO RULE: STEP Commercial: use amitriptyline hcl/chlordiazepoxide 2 preferred antidepressants first 06/24/2020 SYMBYAX olanzapine/fluoxetine hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 184 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 CARDIZEM CD diltiazem hcl UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 captopril- captopril/hydrochlorothiazide UM AUTO RULE: STEP Commercial: use hydrochlorothiazi an ARB and one de agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 lofibra fenofibrate UM AUTO RULE: STEP Commercial: use fenofibrate (generic Tricor or Lofibra) first 06/24/2020 sertraline hcl sertraline hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 LUXIQ betamethasone valerate UM AUTO RULE: STEP Commercial: use two preferred topical steroids in the same potency class first 06/24/2020 SYNJARDY XR empagliflozin/metformin hcl UM AUTO RULE: STEP Commercial: use metformin first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 185 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 TOVIAZ fesoterodine fumarate UM AUTO RULE: STEP Commercial: use Vesicare or Myrbetriq AND either oxybutynin ir/er or trospium ir/er first 06/24/2020 VERELAN PM hcl UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 PROCARDIA nifedipine UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 VASERETIC enalapril UM AUTO RULE: STEP Commercial: use maleate/hydrochlorothiazide an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 186 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 BACTROBAN mupirocin UM AUTO RULE: STEP Commercial: use mupirocin [Bactroban] ointment or cream first 06/24/2020 triamterene- triamterene/hydrochlorothiaz UM AUTO RULE: STEP Commercial: use hydrochlorothiazi ide amiloride, d spironolactone, or triamterene/hctz first 06/24/2020 pindolol pindolol UM AUTO RULE: STEP Commercial: use 2 preferred beta- blocker agents first 06/24/2020 atenolol- atenolol/chlorthalidone UM AUTO RULE: STEP Commercial: use chlorthalidone 2 preferred beta- blocker agents first 06/24/2020 amitriptyline hcl amitriptyline hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 metoprolol metoprolol tartrate UM AUTO RULE: STEP Commercial: use tartrate 2 preferred beta- blocker agents first 06/24/2020 frovatriptan succinate UM AUTO RULE: STEP Commercial: use succinate two of the following first: naratriptan, rizatriptan, sumatriptan or zolmitriptan

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 187 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 TIAZAC diltiazem hcl UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 LEXAPRO escitalopram oxalate UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 diltiazem 24hr er diltiazem hcl UM AUTO RULE: STEP Commercial: use (cd) an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 RISPERDAL M- risperidone UM AUTO RULE: STEP Commercial: use TAB aripiprazole, clozapine, olanzapine, quetiapine, risperidone, or ziprasidone first 06/24/2020 CLODERM clocortolone pivalate UM AUTO RULE: STEP Commercial: use two preferred topical steroids in the same potency class first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 188 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 DIABETA glyburide UM AUTO RULE: STEP Commercial: use metformin, glipizide, or glyburide first 06/24/2020 AVITA tretinoin UM AUTO RULE: STEP Commercial: use topical tretinoin and topical clindamycin first 06/24/2020 naratriptan hcl naratriptan hcl UM AUTO RULE: STEP Commercial: use two of the following first: naratriptan, rizatriptan, sumatriptan or zolmitriptan 06/24/2020 FOSAMAX alendronate sodium UM AUTO RULE: STEP Commercial: use alendronate and ibandronate first 06/24/2020 QVAR beclomethasone UM AUTO RULE: STEP Commercial: use dipropionate one preferred inhaled corticosteroid first 06/24/2020 zolpidem tartrate zolpidem tartrate UM AUTO RULE: STEP Commercial: use zolpidem immediate- release, zolpidem extended- release, eszopiclone, or zaleplon first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 189 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 DIPROLENE AF betamethasone UM AUTO RULE: STEP Commercial: use dipropionate/propylene 2 preferred glycol medium potency topical corticosteroids; one of which is triamcinolone, first 06/24/2020 tacrolimus tacrolimus UM AUTO RULE: STEP Commercial: use tacrolimus IR first 06/24/2020 ZEMBRACE sumatriptan succinate UM AUTO RULE: STEP Commercial: use SYMTOUCH sumatriptan vial, prefilled syringe, or prefilled cartridge first 06/24/2020 VIIBRYD vilazodone hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 ciclopirox ciclopirox UM AUTO RULE: STEP Commercial: use econazole cream and one other preferred topical anti-fungal agent first 06/24/2020 acebutolol hcl acebutolol hcl UM AUTO RULE: STEP Commercial: use 2 preferred beta- blocker agents first 06/24/2020 fluvoxamine fluvoxamine maleate UM AUTO RULE: STEP Commercial: use maleate er 2 preferred antidepressants first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 190 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 desipramine hcl desipramine hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 ORTHO norethindrone UM AUTO RULE: STEP Commercial: use MICRONOR generic micronor first 06/24/2020 INTUNIV guanfacine hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 FAZACLO clozapine UM AUTO RULE: STEP Commercial: use aripiprazole, clozapine, olanzapine, quetiapine, risperidone, or ziprasidone first 06/24/2020 HYDRO 35 urea UM AUTO RULE: STEP Commercial: use two preferred urea products first 06/24/2020 lithium lithium citrate UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 propranolol hcl propranolol hcl UM AUTO RULE: STEP Commercial: use 2 preferred beta- blocker agents first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 191 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 hbr eletriptan hydrobromide UM AUTO RULE: STEP Commercial: use two of the following first: naratriptan, rizatriptan, sumatriptan or zolmitriptan 06/24/2020 pantoprazole pantoprazole sodium UM AUTO RULE: STEP Commercial: use sodium omeprazole, pantoprazole, rabeprazole or lansoprazole first 06/24/2020 ARICEPT donepezil hcl UM AUTO RULE: STEP Commercial: use donepezil 5mg or 10mg first 06/24/2020 HYDRO 40 urea UM AUTO RULE: STEP Commercial: use two preferred urea products first 06/24/2020 CALAN SR verapamil hcl UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 GEODON ziprasidone hcl UM AUTO RULE: STEP Commercial: use aripiprazole, clozapine, olanzapine, quetiapine, risperidone, or ziprasidone first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 192 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 AEROSPAN flunisolide UM AUTO RULE: STEP Commercial: use one preferred inhaled corticosteroid first 06/24/2020 ACTOPLUS MET pioglitazone hcl/metformin UM AUTO RULE: STEP Commercial: use hcl metformin or pioglitazone first 06/24/2020 spironolactone spironolactone UM AUTO RULE: STEP Commercial: use amiloride, spironolactone, or triamterene/hctz first 06/24/2020 VYVANSE lisdexamfetamine UM AUTO RULE: STEP Commercial: use dimesylate one preferred extended-release ADHD agent first 06/24/2020 STRATTERA atomoxetine hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 JANUMET sitagliptin UM AUTO RULE: STEP Commercial: use phosphate/metformin hcl metformin first 06/24/2020 DAYVIGO lemborexant UM AUTO RULE: STEP Commercial: use zolpidem ir, zolpidem er, eszopiclone, zaleplon, or rozerem first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 193 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 LAMICTAL ODT lamotrigine UM AUTO RULE: STEP Commercial: use (ORANGE) two of the following first: clonazepam, felbamate, lamotrigine, or topiramate 06/24/2020 NIZORAL ketoconazole UM AUTO RULE: STEP Commercial: use ketoconazole cream or shampoo first 06/24/2020 clindamycin clindamycin UM AUTO RULE: STEP Commercial: use phos-benzoyl phosphate/benzoyl peroxide adapalene or perox benzoyl peroxide containing product first 06/24/2020 nifedipine er nifedipine UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 SYNJARDY empagliflozin/metformin hcl UM AUTO RULE: STEP Commercial: use metformin first 06/24/2020 TOFRANIL imipramine hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 FLOMAX tamsulosin hcl UM AUTO RULE: STEP Commercial: use tamsulosin [Flomax] first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 194 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 FELBATOL felbamate UM AUTO RULE: STEP Commercial: use two of the following first: clonazepam, felbamate, lamotrigine, or topiramate 06/24/2020 TRIGLIDE fenofibrate nanocrystallized UM AUTO RULE: STEP Commercial: use fenofibrate (generic Tricor or Lofibra) first 06/24/2020 clodan clobetasol propionate UM AUTO RULE: STEP Commercial: use 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first 06/24/2020 methylphenidate methylphenidate hcl UM AUTO RULE: STEP Commercial: use er one preferred extended-release ADHD agent first 06/24/2020 clindacin etz clindamycin phosphate UM AUTO RULE: STEP Commercial: use topical tretinoin and topical clindamycin first 06/24/2020 SLYND drospirenone UM AUTO RULE: STEP Commercial: use generic micronor first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 195 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 nolix flurandrenolide UM AUTO RULE: STEP Commercial: use 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first 06/24/2020 donepezil hcl donepezil hcl UM AUTO RULE: STEP Commercial: use donepezil 5mg or 10mg first 06/24/2020 zolmitriptan zolmitriptan UM AUTO RULE: STEP Commercial: use two of the following first: naratriptan, rizatriptan, sumatriptan or zolmitriptan 06/24/2020 IMITREX sumatriptan UM AUTO RULE: STEP Commercial: use sumatriptan nasal first 06/24/2020 BENZACLIN clindamycin UM AUTO RULE: STEP Commercial: use phosphate/benzoyl peroxide adapalene or benzoyl peroxide containing product first 06/24/2020 LAMICTAL lamotrigine UM AUTO RULE: STEP Commercial: use (ORANGE) two of the following first: clonazepam, felbamate, lamotrigine, or topiramate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 196 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 miconazole-zinc miconazole nitrate/zinc UM AUTO RULE: STEP Commercial: use oxide-petroltm oxide/petrolatum,white econazole cream and one other preferred topical anti-fungal agent first 06/24/2020 MICARDIS HCT telmisartan/hydrochlorothiazi UM AUTO RULE: STEP Commercial: use de an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 DYRENIUM triamterene UM AUTO RULE: STEP Commercial: use amiloride, spironolactone, or triamterene/hctz first 06/24/2020 methylphenidate methylphenidate hcl UM AUTO RULE: STEP Commercial: use la one preferred extended-release ADHD agent first 06/24/2020 DETROL LA tolterodine tartrate UM AUTO RULE: STEP Commercial: use oxybutynin IR/ER or trospium IR/ER first 06/24/2020 sotalol af sotalol hcl UM AUTO RULE: STEP Commercial: use 2 preferred beta- blocker agents first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 197 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 DYANAVEL XR amphetamine UM AUTO RULE: STEP Commercial: use two preferred amphetamines first 06/24/2020 nadolol nadolol UM AUTO RULE: STEP Commercial: use 2 preferred beta- blocker agents first 06/24/2020 BETAPACE AF sotalol hcl UM AUTO RULE: STEP Commercial: use 2 preferred beta- blocker agents first 06/24/2020 ULTRACET tramadol hcl/acetaminophen UM AUTO RULE: STEP Commercial: use two of the following medications in 2 different drug classes including: TCA, SSRI, SNRI, tramadol, gabapentin, or cyclobenzaprine 06/24/2020 carvedilol carvedilol UM AUTO RULE: STEP Commercial: use 2 preferred beta- blocker agents first 06/24/2020 DEXILANT dexlansoprazole UM AUTO RULE: STEP Commercial: use omeprazole cap, lansoprazole cap and dexilant first 06/24/2020 esomeprazole esomeprazole magnesium UM AUTO RULE: STEP Commercial: use magnesium omeprazole cap and lansoprazole cap first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 198 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 dilt-xr diltiazem hcl UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 lithium carbonate lithium carbonate UM AUTO RULE: STEP Commercial: use er 2 preferred antidepressants first 06/24/2020 bisoprolol bisoprolol fumarate UM AUTO RULE: STEP Commercial: use fumarate 2 preferred beta- blocker agents first 06/24/2020 lansoprazole lansoprazole UM AUTO RULE: STEP Commercial: use omeprazole cap and lansoprazole cap first 06/24/2020 EVOCLIN clindamycin phosphate UM AUTO RULE: STEP Commercial: use topical tretinoin and topical clindamycin first 06/24/2020 sorine sotalol hcl UM AUTO RULE: STEP Commercial: use 2 preferred beta- blocker agents first 06/24/2020 propranolol hcl er propranolol hcl UM AUTO RULE: STEP Commercial: use 2 preferred beta- blocker agents first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 199 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 GLYXAMBI empagliflozin/linagliptin UM AUTO RULE: STEP Commercial: use metformin first 06/24/2020 metoprolol metoprolol succinate UM AUTO RULE: STEP Commercial: use succinate 2 preferred beta- blocker agents first 06/24/2020 erythromycin- erythromycin base/benzoyl UM AUTO RULE: STEP Commercial: use benzoyl peroxide peroxide adapalene or benzoyl peroxide containing product first 06/24/2020 ZIANA clindamycin UM AUTO RULE: STEP Commercial: use phosphate/tretinoin topical tretinoin and topical clindamycin first 06/24/2020 labetalol hcl labetalol hcl UM AUTO RULE: STEP Commercial: use 2 preferred beta- blocker agents first 06/24/2020 BYSTOLIC nebivolol hcl UM AUTO RULE: STEP Commercial: use 2 preferred beta- blocker agents first 06/24/2020 tolterodine tolterodine tartrate UM AUTO RULE: STEP Commercial: use tartrate oxybutynin IR/ER or trospium IR/ER first 06/24/2020 ACTOPLUS MET pioglitazone hcl/metformin UM AUTO RULE: STEP Commercial: use XR hcl metformin or pioglitazone first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 200 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 olanzapine odt olanzapine UM AUTO RULE: STEP Commercial: use aripiprazole, clozapine, olanzapine, quetiapine, risperidone, or ziprasidone first 06/24/2020 DIOVAN HCT valsartan/hydrochlorothiazid UM AUTO RULE: STEP Commercial: use e an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 solifenacin solifenacin succinate UM AUTO RULE: STEP Commercial: use succinate oxybutynin IR/ER or trospium IR/ER first 06/24/2020 imiquimod imiquimod UM AUTO RULE: STEP Commercial: use imiquimod 5% packets first 06/24/2020 maleate timolol maleate UM AUTO RULE: STEP Commercial: use 2 preferred beta- blocker agents first 06/24/2020 EMADINE emedastine difumarate UM AUTO RULE: STEP Commercial: use azelastine [Optivar] and Pataday first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 201 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 LOTREL amlodipine UM AUTO RULE: STEP Commercial: use besylate/benazepril hcl an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 betaxolol hcl betaxolol hcl UM AUTO RULE: STEP Commercial: use 2 preferred beta- blocker agents first 06/24/2020 LITHOBID lithium carbonate UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 diltiazem 24hr er diltiazem hcl UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 202 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 matzim la diltiazem hcl UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 PROZAC fluoxetine hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 relexxii methylphenidate hcl UM AUTO RULE: STEP Commercial: use one preferred extended-release ADHD agent first 06/24/2020 PREVACID lansoprazole UM AUTO RULE: STEP Commercial: use omeprazole cap and lansoprazole cap first 06/24/2020 VIMPAT lacosamide UM AUTO RULE: STEP Commercial: use two of the following first: clonazepam, felbamate, lamotrigine, or topiramate 06/24/2020 GLUMETZA metformin hcl UM AUTO RULE: STEP Commercial: use metformin, glipizide, or glyburide first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 203 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 bisoprolol- bisoprolol UM AUTO RULE: STEP Commercial: use hydrochlorothiazi fumarate/hydrochlorothiazid 2 preferred beta- de e blocker agents first 06/24/2020 tramadol hcl tramadol hcl UM AUTO RULE: STEP Commercial: use tramadol [Ultram] ir or er first 06/24/2020 PATANASE olopatadine hcl UM AUTO RULE: STEP Commercial: use azelastine 0.15% nasal or azelastine 0.1% nasal first 06/24/2020 KENALOG triamcinolone acetonide UM AUTO RULE: STEP Commercial: use 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first 06/24/2020 VENTOLIN HFA albuterol sulfate UM AUTO RULE: STEP Commercial: use Ventolin HFA, Generic Proventil HFA or generic Proair HFA first 06/24/2020 sumatriptan sumatriptan succinate UM AUTO RULE: STEP Commercial: use succinate sumatriptan vial, prefilled syringe, or prefilled cartridge first 06/24/2020 LAMICTAL XR lamotrigine UM AUTO RULE: STEP Commercial: use (GREEN) lamotrigine tabs first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 204 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 KAPVAY clonidine hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 CORGARD nadolol UM AUTO RULE: STEP Commercial: use 2 preferred beta- blocker agents first 06/24/2020 DESOXYN methamphetamine hcl UM AUTO RULE: STEP Commercial: use one preferred immediate- release ADHD agent first 06/24/2020 OXTELLAR XR UM AUTO RULE: STEP Commercial: use oxcarbazepine immediate release first 06/24/2020 pimecrolimus pimecrolimus UM AUTO RULE: STEP Commercial: use medium, high, or very high potency topical steroid first 06/24/2020 ULORIC febuxostat UM AUTO RULE: STEP Commercial: use allopurinol first 06/24/2020 FOCALIN dexmethylphenidate hcl UM AUTO RULE: STEP Commercial: use one preferred immediate- release ADHD agent first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 205 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 topiramate topiramate UM AUTO RULE: STEP Commercial: use two of the following first: clonazepam, felbamate, lamotrigine, or topiramate 06/24/2020 EPIDUO adapalene/benzoyl peroxide UM AUTO RULE: STEP Commercial: use adapalene or benzoyl peroxide containing product first 06/24/2020 fluocinonide-e fluocinonide/emollient base UM AUTO RULE: STEP Commercial: use 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first 06/24/2020 VELTIN clindamycin UM AUTO RULE: STEP Commercial: use phosphate/tretinoin topical tretinoin and topical clindamycin first 06/24/2020 ketoconazole ketoconazole UM AUTO RULE: STEP Commercial: use econazole cream and one other preferred topical anti-fungal agent first 06/24/2020 albuterol sulfate albuterol sulfate UM AUTO RULE: STEP Commercial: use hfa Ventolin HFA, Generic Proventil HFA or generic Proair HFA first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 206 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 clobazam clobazam UM AUTO RULE: STEP Commercial: use two of the following first: clonazepam, felbamate, lamotrigine, or topiramate 06/24/2020 guanfacine hcl er guanfacine hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 trazodone hcl trazodone hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 LATUDA lurasidone hcl UM AUTO RULE: STEP Commercial: use aripiprazole, clozapine, olanzapine, quetiapine, risperidone, or ziprasidone first 06/24/2020 ACTOS pioglitazone hcl UM AUTO RULE: STEP Commercial: use metformin or pioglitazone first 06/24/2020 maprotiline hcl maprotiline hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 atomoxetine hcl atomoxetine hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 207 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 CLOBEX clobetasol propionate UM AUTO RULE: STEP Commercial: use 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first 06/24/2020 TRETIN-X tretinoin UM AUTO RULE: STEP Commercial: use tretinoin [Retin-A] first 06/24/2020 diltiazem 12hr er diltiazem hcl UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 PAMELOR nortriptyline hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 LIPITOR atorvastatin calcium UM AUTO RULE: STEP Commercial: use atorvastatin 80 mg or rosuvastatin 40 mg first 06/24/2020 fluoxetine hcl fluoxetine hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 208 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 lamotrigine er lamotrigine UM AUTO RULE: STEP Commercial: use generic lamotrigine immediate- release first 06/24/2020 MYRBETRIQ mirabegron UM AUTO RULE: STEP Commercial: use oxybutynin IR/ER or trospium IR/ER first 06/24/2020 PENLAC ciclopirox UM AUTO RULE: STEP Commercial: use econazole cream and one other preferred topical anti-fungal agent first 06/24/2020 olanzapine- olanzapine/fluoxetine hcl UM AUTO RULE: STEP Commercial: use fluoxetine hcl 2 preferred antidepressants first 06/24/2020 imipramine hcl imipramine hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 econazole nitrate econazole nitrate UM AUTO RULE: STEP Commercial: use econazole cream and one other preferred topical anti-fungal agent first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 209 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 SEROQUEL quetiapine fumarate UM AUTO RULE: STEP Commercial: use aripiprazole, clozapine, olanzapine, quetiapine, risperidone, or ziprasidone first 06/24/2020 desloratadine desloratadine UM AUTO RULE: STEP Commercial: use azelastine, flunisolide nasal, or fluticasone nasal first 06/24/2020 flunisolide flunisolide UM AUTO RULE: STEP Commercial: use 2 of the following first: flunisolide, fluticasone, or mometasone 06/24/2020 ADALAT CC nifedipine UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 ACANYA clindamycin UM AUTO RULE: STEP Commercial: use phosphate/benzoyl peroxide adapalene or benzoyl peroxide containing product first 06/24/2020 clomipramine hcl clomipramine hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 210 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 DITROPAN XL oxybutynin chloride UM AUTO RULE: STEP Commercial: use oxybutynin IR/ER or trospium IR/ER first 06/24/2020 lithium carbonate lithium carbonate UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 GLYNASE glyburide,micronized UM AUTO RULE: STEP Commercial: use metformin, glipizide, or glyburide first 06/24/2020 fluticasone fluticasone propionate UM AUTO RULE: STEP Commercial: use propionate 2 of the following first: flunisolide, fluticasone, or mometasone 06/24/2020 SPIRIVA tiotropium bromide UM AUTO RULE: STEP Commercial: use Incruse Ellipta and Spiriva first 06/24/2020 luliconazole luliconazole UM AUTO RULE: STEP Commercial: use econazole cream and one other preferred topical anti-fungal agent first 06/24/2020 modafinil modafinil UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 APTENSIO XR methylphenidate hcl UM AUTO RULE: STEP Commercial: use one preferred extended-release methylphenidate first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 211 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 SARAFEM fluoxetine hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 SAVELLA milnacipran hcl UM AUTO RULE: STEP Commercial: use two of the following medications in 2 different drug classes including: TCA, SSRI, SNRI, tramadol, gabapentin, or cyclobenzaprine 06/24/2020 ALDARA imiquimod UM AUTO RULE: STEP Commercial: use imiquimod 5% packets first 06/24/2020 oxiconazole oxiconazole nitrate UM AUTO RULE: STEP Commercial: use nitrate econazole cream and one other preferred topical anti-fungal agent first 06/24/2020 CLARINEX-D 12 desloratadine/pseudoephedr UM AUTO RULE: STEP Commercial: use HOUR ine sulfate azelastine, flunisolide nasal, or fluticasone nasal first 06/24/2020 nystatin nystatin UM AUTO RULE: STEP Commercial: use econazole cream and one other preferred topical anti-fungal agent first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 212 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 EDARBYCLOR azilsartan UM AUTO RULE: STEP Commercial: use medoxomil/chlorthalidone two of the following: losartan, losartan/hctz, irbesartan, irbesartan/hctz, valsartan, or valsartan/hctz first 06/24/2020 fenofibrate fenofibrate,micronized UM AUTO RULE: STEP Commercial: use fenofibrate (generic Tricor or Lofibra) first 06/24/2020 TOPICORT desoximetasone UM AUTO RULE: STEP Commercial: use 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first 06/24/2020 verapamil sr verapamil hcl UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 bupropion xl bupropion hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 213 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 oxybutynin oxybutynin chloride UM AUTO RULE: STEP Commercial: use chloride oxybutynin IR/ER or trospium IR/ER first 06/24/2020 TEMOVATE clobetasol propionate UM AUTO RULE: STEP Commercial: use 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first 06/24/2020 ACCURETIC quinapril UM AUTO RULE: STEP Commercial: use hcl/hydrochlorothiazide an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 BEVESPI glycopyrrolate/formoterol UM AUTO RULE: STEP Commercial: use AEROSPHERE fumarate Anoro Ellipta first 06/24/2020 lamotrigine lamotrigine UM AUTO RULE: STEP Commercial: use (orange) two of the following first: clonazepam, felbamate, lamotrigine, or topiramate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 214 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 ENABLEX darifenacin hydrobromide UM AUTO RULE: STEP Commercial: use Vesicare or Myrbetriq AND either oxybutynin ir/er or trospium ir/er first 06/24/2020 DELZICOL mesalamine UM AUTO RULE: STEP Commercial: one of the following: mesalamine er capsule (Apriso), mesalamine dr tablet (Lialda), balsalazide (Colazal) 06/24/2020 carbidopa- carbidopa/levodopa UM AUTO RULE: STEP Commercial: use levodopa carbidopa/levodo pa er first 06/24/2020 clobetasol clobetasol UM AUTO RULE: STEP Commercial: use emulsion propionate/emollient base 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first 06/24/2020 SEEBRI glycopyrrolate UM AUTO RULE: STEP Commercial: use NEOHALER Spiriva or Incruse Ellipta first 06/24/2020 CLEOCIN T clindamycin phosphate UM AUTO RULE: STEP Commercial: use topical tretinoin and topical clindamycin first 06/24/2020 metformin hcl er metformin hcl UM AUTO RULE: STEP Commercial: use metformin first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 215 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 GLUCOVANCE glyburide/metformin hcl UM AUTO RULE: STEP Commercial: use metformin, glipizide, or glyburide first 06/24/2020 TRIBENZOR olmesartan UM AUTO RULE: STEP Commercial: use medoxomil/amlodipine an ARB and one besylate/hydrochlorothiazide agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 phenelzine phenelzine sulfate UM AUTO RULE: STEP Commercial: use sulfate 2 preferred antidepressants first 06/24/2020 BRIVIACT brivaracetam UM AUTO RULE: STEP Commercial: use levetiracetam first 06/24/2020 XOLEGEL ketoconazole UM AUTO RULE: STEP Commercial: use ketoconazole cream or shampoo first 06/24/2020 propranolol- propranolol UM AUTO RULE: STEP Commercial: use hydrochlorothiazi hcl/hydrochlorothiazide 2 preferred beta- d blocker agents first 06/24/2020 lamotrigine (blue) lamotrigine UM AUTO RULE: STEP Commercial: use two of the following first: clonazepam, felbamate, lamotrigine, or topiramate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 216 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 protriptyline hcl protriptyline hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 risedronate risedronate sodium UM AUTO RULE: STEP Commercial: use sodium dr alendronate and ibandronate first 06/24/2020 umecta urea UM AUTO RULE: STEP Commercial: use two preferred urea products first 06/24/2020 dextroamphetami dextroamphetamine sulfate UM AUTO RULE: STEP Commercial: use ne sulfate er one preferred extended-release ADHD agent first 06/24/2020 paroxetine cr paroxetine hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 LAMICTAL lamotrigine UM AUTO RULE: STEP Commercial: use generic lamotrigine immediate- release first 06/24/2020 paroxetine er paroxetine hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 AMRIX cyclobenzaprine hcl UM AUTO RULE: STEP Commercial: use cyclobenzaprine [Flexeril] first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 217 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 PROTONIX pantoprazole sodium UM AUTO RULE: STEP Commercial: use omeprazole, pantoprazole, rabeprazole or lansoprazole first 06/24/2020 CALAN verapamil hcl UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 ATACAND candesartan cilexetil UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 lamotrigine lamotrigine UM AUTO RULE: STEP Commercial: use (green) two of the following first: clonazepam, felbamate, lamotrigine, or topiramate 06/24/2020 escitalopram escitalopram oxalate UM AUTO RULE: STEP Commercial: use oxalate 2 preferred antidepressants first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 218 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 verapamil er verapamil hcl UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 ASMANEX mometasone furoate UM AUTO RULE: STEP Commercial: use one preferred inhaled corticosteroid first 06/24/2020 mirtazapine mirtazapine UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 TENORETIC 50 atenolol/chlorthalidone UM AUTO RULE: STEP Commercial: use 2 preferred beta- blocker agents first 06/24/2020 CARDIZEM diltiazem hcl UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 219 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 ACIPHEX rabeprazole sodium UM AUTO RULE: STEP Commercial: use SPRINKLE omeprazole, pantoprazole, rabeprazole or lansoprazole first 06/24/2020 LAMICTAL ODT lamotrigine UM AUTO RULE: STEP Commercial: use (GREEN) two of the following first: clonazepam, felbamate, lamotrigine, or topiramate 06/24/2020 LUNESTA eszopiclone UM AUTO RULE: STEP Commercial: use zolpidem immediate- release, zolpidem extended- release, eszopiclone, or zaleplon first 06/24/2020 lamotrigine lamotrigine UM AUTO RULE: STEP Commercial: use generic lamotrigine immediate- release first 06/24/2020 RYTARY carbidopa/levodopa UM AUTO RULE: STEP Commercial: use carbidopa/levodo pa er first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 220 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 ZESTORETIC lisinopril/hydrochlorothiazide UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 silodosin silodosin UM AUTO RULE: STEP Commercial: use tamsulosin [Flomax] first 06/24/2020 glimepiride glimepiride UM AUTO RULE: STEP Commercial: use pioglitazone or glimepiride first 06/24/2020 MAVIK trandolapril UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 DERMATOP prednicarbate UM AUTO RULE: STEP Commercial: use 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 221 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 nadolol- nadolol/bendroflumethiazide UM AUTO RULE: STEP Commercial: use bendroflumethiazi 2 preferred beta- de blocker agents first 06/24/2020 ANTARA fenofibrate,micronized UM AUTO RULE: STEP Commercial: use fenofibrate (generic Tricor or Lofibra) first 06/24/2020 glyburide- glyburide/metformin hcl UM AUTO RULE: STEP Commercial: use metformin hcl metformin, glipizide, or glyburide first 06/24/2020 PARNATE tranylcypromine sulfate UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 methylphenidate methylphenidate hcl UM AUTO RULE: STEP Commercial: use hcl cd one preferred extended-release ADHD agent first 06/24/2020 methylphenidate methylphenidate hcl UM AUTO RULE: STEP Commercial: use hcl er (cd) one preferred extended-release ADHD agent first 06/24/2020 omeprazole omeprazole UM AUTO RULE: STEP Commercial: use omeprazole cap and lansoprazole cap first 06/24/2020 WELLBUTRIN bupropion hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 XELPROS latanoprost UM AUTO RULE: STEP Commercial: use latanoprost first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 222 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 clobetasol clobetasol UM AUTO RULE: STEP Commercial: use emollient propionate/emollient base 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first 06/24/2020 EDARBI azilsartan medoxomil UM AUTO RULE: STEP Commercial: use two of the following: losartan, losartan/hctz, irbesartan, irbesartan/hctz, valsartan, or valsartan/hctz first 06/24/2020 CONDYLOX podofilox UM AUTO RULE: STEP Commercial: use imiquimod, podofilox soln, Condylox gel, or Zyclara first 06/24/2020 rosuvastatin rosuvastatin calcium UM AUTO RULE: STEP Commercial: use calcium atorvastatin 80 mg or rosuvastatin 40 mg first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 223 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 felodipine er felodipine UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 CLOZARIL clozapine UM AUTO RULE: STEP Commercial: use aripiprazole, clozapine, olanzapine, quetiapine, risperidone, or ziprasidone first 06/24/2020 metformin er metformin hcl UM AUTO RULE: STEP Commercial: use osmotic metformin, glipizide, or glyburide first 06/24/2020 atenolol atenolol UM AUTO RULE: STEP Commercial: use 2 preferred beta- blocker agents first 06/24/2020 methylphenidate methylphenidate hcl UM AUTO RULE: STEP Commercial: use er (la) one preferred extended-release ADHD agent first 06/24/2020 ZYPREXA olanzapine UM AUTO RULE: STEP Commercial: use aripiprazole, clozapine, olanzapine, quetiapine, risperidone, or ziprasidone first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 224 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 OXYTROL oxybutynin UM AUTO RULE: STEP Commercial: use Gelnique first 06/24/2020 clocortolone clocortolone pivalate UM AUTO RULE: STEP Commercial: use pivalate two preferred topical steroids in the same potency class first 06/24/2020 DIFFERIN adapalene UM AUTO RULE: STEP Commercial: use adapalene or benzoyl peroxide containing product first 06/24/2020 EVEKEO ODT amphetamine sulfate UM AUTO RULE: STEP Commercial: use one preferred immediate- release ADHD agent first 06/24/2020 CYMBALTA duloxetine hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 quetiapine quetiapine fumarate UM AUTO RULE: STEP Commercial: use fumarate er aripiprazole, clozapine, olanzapine, quetiapine, risperidone, or ziprasidone first 06/24/2020 fenofibrate fenofibrate UM AUTO RULE: STEP Commercial: use fenofibrate (generic Tricor or Lofibra) first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 225 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 DIPROLENE betamethasone UM AUTO RULE: STEP Commercial: use dipropionate/propylene 2 preferred glycol medium potency topical corticosteroids; one of which is triamcinolone, first 06/24/2020 tamsulosin hcl tamsulosin hcl UM AUTO RULE: STEP Commercial: use tamsulosin [Flomax] first 06/24/2020 ERTACZO sertaconazole nitrate UM AUTO RULE: STEP Commercial: use one preferred topical antifungal first 06/24/2020 trospium chloride trospium chloride UM AUTO RULE: STEP Commercial: use oxybutynin IR/ER or trospium IR/ER first 06/24/2020 LOPRESSOR metoprolol tartrate UM AUTO RULE: STEP Commercial: use 2 preferred beta- blocker agents first 06/24/2020 ALTABAX retapamulin UM AUTO RULE: STEP Commercial: use mupirocin [Bactroban] ointment or cream first 06/24/2020 LAMICTAL ODT lamotrigine UM AUTO RULE: STEP Commercial: use two of the following first: clonazepam, felbamate, lamotrigine, or topiramate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 226 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 AMBIEN CR zolpidem tartrate UM AUTO RULE: STEP Commercial: use zolpidem immediate- release, zolpidem extended- release, eszopiclone, or zaleplon first 06/24/2020 lofibra fenofibrate,micronized UM AUTO RULE: STEP Commercial: use fenofibrate (generic Tricor or Lofibra) first 06/24/2020 CLINDAGEL clindamycin phosphate UM AUTO RULE: STEP Commercial: use topical tretinoin and topical clindamycin first 06/24/2020 topiramate er topiramate UM AUTO RULE: STEP Commercial: use two of the following first: clonazepam, felbamate, lamotrigine, or topiramate 06/24/2020 KEPPRA levetiracetam UM AUTO RULE: STEP Commercial: use levetiracetam first 06/24/2020 cyclobenzaprine cyclobenzaprine hcl UM AUTO RULE: STEP Commercial: use hcl cyclobenzaprine [Flexeril] first 06/24/2020 urea urea UM AUTO RULE: STEP Commercial: use two preferred urea products first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 227 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 FENOGLIDE fenofibrate UM AUTO RULE: STEP Commercial: use fenofibrate (generic Tricor or Lofibra) first 06/24/2020 AVANDIA rosiglitazone maleate UM AUTO RULE: STEP Commercial: use pioglitazone first 06/24/2020 LOTENSIN HCT benazepril UM AUTO RULE: STEP Commercial: use hcl/hydrochlorothiazide an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 balsalazide balsalazide disodium UM AUTO RULE: STEP Commercial: use disodium 2 of the following first: mesalamine er (Apriso), mesalamine (Lialda) or balsalazide (Colazal) 06/24/2020 VICTOZA 3-PAK liraglutide UM AUTO RULE: STEP Commercial: use metformin first 06/24/2020 METADATE CD methylphenidate hcl UM AUTO RULE: STEP Commercial: use one preferred extended-release ADHD agent first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 228 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 APTIOM eslicarbazepine acetate UM AUTO RULE: STEP Commercial: use two of the following first: clonazepam, felbamate, lamotrigine, or topiramate 06/24/2020 spironolactone- spironolactone/hydrochlorot UM AUTO RULE: STEP Commercial: use hctz hiazide an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 carbidopa- carbidopa/levodopa UM AUTO RULE: STEP Commercial: use levodopa er carbidopa/levodo pa er first 06/24/2020 BONIVA ibandronate sodium UM AUTO RULE: STEP Commercial: use alendronate and ibandronate first 06/24/2020 LAMICTAL XR lamotrigine UM AUTO RULE: STEP Commercial: use generic lamotrigine immediate- release first 06/24/2020 TRULICITY UM AUTO RULE: STEP Commercial: use metformin first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 229 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 lisinopril lisinopril UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 OZEMPIC semaglutide UM AUTO RULE: STEP Commercial: use metformin first 06/24/2020 olmesartan- olmesartan UM AUTO RULE: STEP Commercial: use hydrochlorothiazi medoxomil/hydrochlorothiazi an ARB and one de de agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 metadate er methylphenidate hcl UM AUTO RULE: STEP Commercial: use one preferred extended-release ADHD agent first 06/24/2020 chlorothiazide chlorothiazide UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 230 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 rasagiline rasagiline mesylate UM AUTO RULE: STEP Commercial: use mesylate rasagiline first 06/24/2020 COMTAN entacapone UM AUTO RULE: STEP Commercial: use entacapone first 06/24/2020 dexmethylphenid dexmethylphenidate hcl UM AUTO RULE: STEP Commercial: use ate hcl er one preferred extended-release ADHD agent first 06/24/2020 olmesartan olmesartan medoxomil UM AUTO RULE: STEP Commercial: use medoxomil an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 rabeprazole rabeprazole sodium UM AUTO RULE: STEP Commercial: use sodium omeprazole cap and lansoprazole cap first 06/24/2020 QVAR beclomethasone UM AUTO RULE: STEP Commercial: use REDIHALER dipropionate one preferred inhaled corticosteroid first 06/24/2020 TENORMIN atenolol UM AUTO RULE: STEP Commercial: use 2 preferred beta- blocker agents first 06/24/2020 CARDURA XL doxazosin mesylate UM AUTO RULE: STEP Commercial: use tamsulosin [Flomax] first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 231 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 COREG CR carvedilol phosphate UM AUTO RULE: STEP Commercial: use 2 preferred beta- blocker agents first 06/24/2020 indapamide indapamide UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 DUAKLIR aclidinium UM AUTO RULE: STEP Commercial: use PRESSAIR bromide/formoterol fumarate Anoro Ellipta first 06/24/2020 INCRUSE umeclidinium bromide UM AUTO RULE: STEP Commercial: use ELLIPTA Incruse Ellipta and Spiriva first 06/24/2020 amlodipine- amlodipine UM AUTO RULE: STEP Commercial: use valsartan besylate/valsartan an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 EFFEXOR XR venlafaxine hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 constulose lactulose UM AUTO RULE: STEP Commercial: use lactulose first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 232 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 perphenazine- perphenazine/amitriptyline UM AUTO RULE: STEP Commercial: use amitriptyline hcl 2 preferred antidepressants first 06/24/2020 PROZAC fluoxetine hcl UM AUTO RULE: STEP Commercial: use WEEKLY 2 preferred antidepressants first 06/24/2020 TRICOR fenofibrate nanocrystallized UM AUTO RULE: STEP Commercial: use fenofibrate (generic Tricor or Lofibra) first 06/24/2020 hydrochlorothiazi hydrochlorothiazide UM AUTO RULE: STEP Commercial: use de an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 BENICAR olmesartan medoxomil UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 233 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 amlodipine- amlodipine UM AUTO RULE: STEP Commercial: use atorvastatin besylate/atorvastatin an ARB and one calcium agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 felbamate felbamate UM AUTO RULE: STEP Commercial: use two of the following first: clonazepam, felbamate, lamotrigine, or topiramate 06/24/2020 PULMICORT budesonide UM AUTO RULE: STEP Commercial: use FLEXHALER one preferred inhaled corticosteroid first 06/24/2020 bupropion hcl sr bupropion hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 tiadylt er diltiazem hcl UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 234 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 telmisartan telmisartan UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 FARXIGA dapagliflozin propanediol UM AUTO RULE: STEP Commercial: use metformin first 06/24/2020 CONCERTA methylphenidate hcl UM AUTO RULE: STEP Commercial: use one preferred extended-release ADHD agent first 06/24/2020 LUMIGAN bimatoprost UM AUTO RULE: STEP Commercial: use latanoprost first 06/24/2020 CONZIP tramadol hcl UM AUTO RULE: STEP Commercial: use tramadol ER first 06/24/2020 sotalol sotalol hcl UM AUTO RULE: STEP Commercial: use 2 preferred beta- blocker agents first 06/24/2020 benazepril- benazepril UM AUTO RULE: STEP Commercial: use hydrochlorothiazi hcl/hydrochlorothiazide an ARB and one de agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 235 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 ciclodan ciclopirox UM AUTO RULE: STEP Commercial: use econazole cream and one other preferred topical anti-fungal agent first 06/24/2020 rizatriptan rizatriptan benzoate UM AUTO RULE: STEP Commercial: use two of the following first: naratriptan, rizatriptan, sumatriptan or zolmitriptan 06/24/2020 ZYPITAMAG pitavastatin magnesium UM AUTO RULE: STEP Commercial: use atorvastatin 80 mg or rosuvastatin 40 mg first 06/24/2020 prednicarbate prednicarbate UM AUTO RULE: STEP Commercial: use 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first 06/24/2020 fosinopril- fosinopril UM AUTO RULE: STEP Commercial: use hydrochlorothiazi sodium/hydrochlorothiazide an ARB and one de agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 236 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 oxybutynin oxybutynin chloride UM AUTO RULE: STEP Commercial: use chloride er oxybutynin IR/ER or trospium IR/ER first 06/24/2020 MAXZIDE triamterene/hydrochlorothiaz UM AUTO RULE: STEP Commercial: use ide amiloride, spironolactone, or triamterene/hctz first 06/24/2020 dextroamphetami dextroamphetamine sulf- UM AUTO RULE: STEP Commercial: use ne-amphetamine saccharate/amphetamine one preferred sulf-aspartate immediate- release ADHD agent first 06/24/2020 ACIPHEX rabeprazole sodium UM AUTO RULE: STEP Commercial: use omeprazole, pantoprazole, rabeprazole or lansoprazole first 06/24/2020 FYCOMPA perampanel UM AUTO RULE: STEP Commercial: use two of the following first: clonazepam, felbamate, lamotrigine, or topiramate 06/24/2020 mometasone mometasone furoate UM AUTO RULE: STEP Commercial: use furoate 2 of the following first: flunisolide, fluticasone, or mometasone

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 237 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 nicardipine hcl nicardipine hcl UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 TRILEPTAL oxcarbazepine UM AUTO RULE: STEP Commercial: use oxcarbazepine immediate release first 06/24/2020 nimodipine nimodipine UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 ATELVIA risedronate sodium UM AUTO RULE: STEP Commercial: use alendronate and ibandronate first 06/24/2020 betamethasone betamethasone dipropionate UM AUTO RULE: STEP Commercial: use dipropionate 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 238 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 naratriptan naratriptan hcl UM AUTO RULE: STEP Commercial: use two of the following first: naratriptan, rizatriptan, sumatriptan or zolmitriptan 06/24/2020 TOPROL XL metoprolol succinate UM AUTO RULE: STEP Commercial: use 2 preferred beta- blocker agents first 06/24/2020 HYZAAR losartan UM AUTO RULE: STEP Commercial: use potassium/hydrochlorothiazi an ARB and one de agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 ZEBETA bisoprolol fumarate UM AUTO RULE: STEP Commercial: use 2 preferred beta- blocker agents first 06/24/2020 CADUET amlodipine UM AUTO RULE: STEP Commercial: use besylate/atorvastatin an ARB and one calcium agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 239 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 AVALIDE irbesartan/hydrochlorothiazi UM AUTO RULE: STEP Commercial: use de an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 APRISO mesalamine UM AUTO RULE: STEP Commercial: use 2 of the following first: mesalamine er (Apriso), mesalamine (Lialda) or balsalazide (Colazal) 06/24/2020 RISPERDAL risperidone UM AUTO RULE: STEP Commercial: use aripiprazole, clozapine, olanzapine, quetiapine, risperidone, or ziprasidone first 06/24/2020 mesalamine dr mesalamine UM AUTO RULE: STEP Commercial: one of the following: mesalamine er capsule (Apriso), mesalamine dr tablet (Lialda), balsalazide (Colazal) 06/24/2020 TUDORZA aclidinium bromide UM AUTO RULE: STEP Commercial: use PRESSAIR Incruse Ellipta and Spiriva first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 240 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 olopatadine hcl olopatadine hcl UM AUTO RULE: STEP Commercial: use azelastine 0.15% nasal or azelastine 0.1% nasal first 06/24/2020 DUZALLO lesinurad/allopurinol UM AUTO RULE: STEP Commercial: use allopurinol first 06/24/2020 AMBIEN zolpidem tartrate UM AUTO RULE: STEP Commercial: use zolpidem immediate- release, zolpidem extended- release, eszopiclone, or zaleplon first 06/24/2020 QUDEXY XR topiramate UM AUTO RULE: STEP Commercial: use two of the following first: clonazepam, felbamate, lamotrigine, or topiramate 06/24/2020 tramadol hcl- tramadol hcl/acetaminophen UM AUTO RULE: STEP Commercial: use acetaminophen two of the following medications in 2 different drug classes including: TCA, SSRI, SNRI, tramadol, gabapentin, or cyclobenzaprine

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 241 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 ZYPREXA ZYDIS olanzapine UM AUTO RULE: STEP Commercial: use aripiprazole, clozapine, olanzapine, quetiapine, risperidone, or ziprasidone first 06/24/2020 triderm triamcinolone acetonide UM AUTO RULE: STEP Commercial: use 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first 06/24/2020 CELEXA citalopram hydrobromide UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 travoprost travoprost UM AUTO RULE: STEP Commercial: use latanoprost first 06/24/2020 azelastine- azelastine hcl/fluticasone UM AUTO RULE: STEP Commercial: use fluticasone propionate azelastine 0.15% nasal or azelastine 0.1% nasal first 06/24/2020 SEREVENT salmeterol xinafoate UM AUTO RULE: STEP Commercial: use DISKUS Striverdi or Serevent first 06/24/2020 NEXIUM esomeprazole magnesium UM AUTO RULE: STEP Commercial: use omeprazole cap and lansoprazole cap first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 242 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 DYAZIDE triamterene/hydrochlorothiaz UM AUTO RULE: STEP Commercial: use ide amiloride, spironolactone, or triamterene/hctz first 06/24/2020 AZOR amlodipine UM AUTO RULE: STEP Commercial: use besylate/olmesartan an ARB and one medoxomil agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 KEPPRA XR levetiracetam UM AUTO RULE: STEP Commercial: use levetiracetam first 06/24/2020 INTERMEZZO zolpidem tartrate UM AUTO RULE: STEP Commercial: use zolpidem immediate- release, zolpidem extended- release, eszopiclone, or zaleplon first 06/24/2020 verapamil er pm verapamil hcl UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 243 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 glyburide glyburide,micronized UM AUTO RULE: STEP Commercial: use micronized metformin, glipizide, or glyburide first 06/24/2020 amphetamine amphetamine sulfate UM AUTO RULE: STEP Commercial: use sulfate one preferred immediate- release ADHD agent first 06/24/2020 ziprasidone hcl ziprasidone hcl UM AUTO RULE: STEP Commercial: use aripiprazole, clozapine, olanzapine, quetiapine, risperidone, or ziprasidone first 06/24/2020 ULTRAM tramadol hcl UM AUTO RULE: STEP Commercial: use tramadol IR first 06/24/2020 ANORO umeclidinium UM AUTO RULE: STEP Commercial: use ELLIPTA bromide/vilanterol trifenatate Anoro Ellipta first 06/24/2020 DESOWEN desonide UM AUTO RULE: STEP Commercial: use 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first 06/24/2020 naproxen sodium naproxen sodium UM AUTO RULE: STEP Commercial: use er two prescription strength NSAIDS; one of which is naproxen, first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 244 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 NAPRELAN naproxen sodium UM AUTO RULE: STEP Commercial: use two prescription strength NSAIDS; one of which is naproxen, first 06/24/2020 olanzapine olanzapine UM AUTO RULE: STEP Commercial: use aripiprazole, clozapine, olanzapine, quetiapine, risperidone, or ziprasidone first 06/24/2020 FLOVENT fluticasone propionate UM AUTO RULE: STEP Commercial: use DISKUS one preferred inhaled corticosteroid first 06/24/2020 tretinoin tretinoin microspheres UM AUTO RULE: STEP Commercial: use microsphere tretinoin [Retin-A] first 06/24/2020 RETIN-A MICRO tretinoin microspheres UM AUTO RULE: STEP Commercial: use PUMP tretinoin [Retin-A] first 06/24/2020 venlafaxine hcl er venlafaxine hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 PROGRAF tacrolimus UM AUTO RULE: STEP Commercial: use tacrolimus IR first 06/24/2020 BELSOMRA UM AUTO RULE: STEP Commercial: use zolpidem ir, zolpidem er, eszopiclone, zaleplon, or rozerem first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 245 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 AXERT almotriptan malate UM AUTO RULE: STEP Commercial: use two of the following first: naratriptan, rizatriptan, sumatriptan or zolmitriptan 06/24/2020 oxcarbazepine oxcarbazepine UM AUTO RULE: STEP Commercial: use oxcarbazepine immediate release first 06/24/2020 DAYTRANA methylphenidate UM AUTO RULE: STEP Commercial: use one preferred extended-release ADHD agent first 06/24/2020 naproxen sodium naproxen sodium UM AUTO RULE: STEP Commercial: use cr two prescription strength NSAIDS; one of which is naproxen, first 06/24/2020 TENORETIC 100 atenolol/chlorthalidone UM AUTO RULE: STEP Commercial: use 2 preferred beta- blocker agents first 06/24/2020 travoprost travoprost (benzalkonium) UM AUTO RULE: STEP Commercial: use latanoprost first 06/24/2020 quetiapine quetiapine fumarate UM AUTO RULE: STEP Commercial: use fumarate aripiprazole, clozapine, olanzapine, quetiapine, risperidone, or ziprasidone first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 246 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 SEROQUEL XR quetiapine fumarate UM AUTO RULE: STEP Commercial: use aripiprazole, clozapine, olanzapine, quetiapine, risperidone, or ziprasidone first 06/24/2020 lamotrigine odt lamotrigine UM AUTO RULE: STEP Commercial: use (blue) two of the following first: clonazepam, felbamate, lamotrigine, or topiramate 06/24/2020 PROAIR albuterol sulfate UM AUTO RULE: STEP Commercial: use RESPICLICK Ventolin HFA, generic Proventil HFA, or generic Proair HFA first 06/24/2020 clindamycin clindamycin UM AUTO RULE: STEP Commercial: use phos-tretinoin phosphate/tretinoin topical tretinoin and topical clindamycin first 06/24/2020 clonazepam clonazepam UM AUTO RULE: STEP Commercial: use two of the following first: clonazepam, felbamate, lamotrigine, or topiramate 06/24/2020 ALVESCO ciclesonide UM AUTO RULE: STEP Commercial: use one preferred inhaled corticosteroid first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 247 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 LOTENSIN benazepril hcl UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 ARNUITY fluticasone furoate UM AUTO RULE: STEP Commercial: use ELLIPTA one preferred inhaled corticosteroid first 06/24/2020 diltiazem 24hr er diltiazem hcl UM AUTO RULE: STEP Commercial: use (la) an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 norethindrone norethindrone UM AUTO RULE: STEP Commercial: use generic micronor first 06/24/2020 butalbital- butalbital/acetaminophen UM AUTO RULE: STEP Commercial: use acetaminophen generic butalbital 50 mg/apap 325 mg formulation first 06/24/2020 VESICARE solifenacin succinate UM AUTO RULE: STEP Commercial: use oxybutynin IR/ER or trospium IR/ER first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 248 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 lamotrigine odt lamotrigine UM AUTO RULE: STEP Commercial: use two of the following first: clonazepam, felbamate, lamotrigine, or topiramate 06/24/2020 aliskiren aliskiren hemifumarate UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 LUZU luliconazole UM AUTO RULE: STEP Commercial: use econazole cream and one other preferred topical anti-fungal agent first 06/24/2020 AMERGE naratriptan hcl UM AUTO RULE: STEP Commercial: use two of the following first: naratriptan, rizatriptan, sumatriptan or zolmitriptan 06/24/2020 INDERAL LA propranolol hcl UM AUTO RULE: STEP Commercial: use 2 preferred beta- blocker agents first 06/24/2020 latanoprost latanoprost UM AUTO RULE: STEP Commercial: use latanoprost first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 249 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 beser fluticasone propionate UM AUTO RULE: STEP Commercial: use two preferred topical steroids in the same potency class first (medium) 06/24/2020 clindamycin- clindamycin UM AUTO RULE: STEP Commercial: use benzoyl peroxide phosphate/benzoyl peroxide adapalene or benzoyl peroxide containing product first 06/24/2020 clotrimazole- clotrimazole/betamethasone UM AUTO RULE: STEP Commercial: use betamethasone dipropionate econazole cream and one other preferred topical anti-fungal agent first 06/24/2020 tolcapone tolcapone UM AUTO RULE: STEP Commercial: use entacapone first 06/24/2020 cyclobenzaprine cyclobenzaprine hcl UM AUTO RULE: STEP Commercial: use hcl er cyclobenzaprine [Flexeril] first 06/24/2020 MICROZIDE hydrochlorothiazide UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 250 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 BENICAR HCT olmesartan UM AUTO RULE: STEP Commercial: use medoxomil/hydrochlorothiazi an ARB and one de agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 JANUVIA sitagliptin phosphate UM AUTO RULE: STEP Commercial: use metformin first 06/24/2020 telmisartan- telmisartan/amlodipine UM AUTO RULE: STEP Commercial: use amlodipine besylate an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 PROVENTIL albuterol sulfate UM AUTO RULE: STEP Commercial: use HFA Ventolin HFA, Generic Proventil HFA or generic Proair HFA first 06/24/2020 pioglitazone- pioglitazone hcl/metformin UM AUTO RULE: STEP Commercial: use metformin hcl metformin or pioglitazone first 06/24/2020 pioglitazone- pioglitazone hcl/glimepiride UM AUTO RULE: STEP Commercial: use glimepiride pioglitazone or glimepiride first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 251 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 risperidone risperidone UM AUTO RULE: STEP Commercial: use aripiprazole, clozapine, olanzapine, quetiapine, risperidone, or ziprasidone first 06/24/2020 BINOSTO alendronate sodium UM AUTO RULE: STEP Commercial: use alendronate and ibandronate first 06/24/2020 apexicon e diflorasone UM AUTO RULE: STEP Commercial: use diacetate/emollient base one high potency topical corticosteroid AND desoximetasone 0.25% cream or ointment first 06/24/2020 amiloride hcl amiloride hcl UM AUTO RULE: STEP Commercial: use amiloride, spironolactone, or triamterene/hctz first 06/24/2020 clozapine clozapine UM AUTO RULE: STEP Commercial: use aripiprazole, clozapine, olanzapine, quetiapine, risperidone, or ziprasidone first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 252 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 CORDRAN flurandrenolide UM AUTO RULE: STEP Commercial: use 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first 06/24/2020 FETZIMA levomilnacipran hcl UM AUTO RULE: STEP Commercial: use two of the following medications in 2 different drug classes including: TCA, SSRI, SNRI, tramadol, gabapentin, or cyclobenzaprine 06/24/2020 LIALDA mesalamine UM AUTO RULE: STEP Commercial: use 2 of the following first: mesalamine er (Apriso), mesalamine (Lialda) or balsalazide (Colazal) 06/24/2020 lamotrigine odt lamotrigine UM AUTO RULE: STEP Commercial: use (orange) two of the following first: clonazepam, felbamate, lamotrigine, or topiramate 06/24/2020 ULTRAM ER tramadol hcl UM AUTO RULE: STEP Commercial: use tramadol IR first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 253 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 clindacin p clindamycin phosphate UM AUTO RULE: STEP Commercial: use topical tretinoin and topical clindamycin first 06/24/2020 neuac clindamycin UM AUTO RULE: STEP Commercial: use phosphate/benzoyl peroxide adapalene or benzoyl peroxide containing product first 06/24/2020 VERELAN verapamil hcl UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 OXISTAT oxiconazole nitrate UM AUTO RULE: STEP Commercial: use econazole cream and one other preferred topical anti-fungal agent first 06/24/2020 dextroamphetami dextroamphetamine sulfate UM AUTO RULE: STEP Commercial: use ne sulfate one preferred immediate- release ADHD agent first 06/24/2020 metoprolol- metoprolol UM AUTO RULE: STEP Commercial: use hydrochlorothiazi tartrate/hydrochlorothiazide 2 preferred beta- de blocker agents first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 254 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 KLONOPIN clonazepam UM AUTO RULE: STEP Commercial: use two of the following first: clonazepam, felbamate, lamotrigine, or topiramate 06/24/2020 SINEMET 25-250 carbidopa/levodopa UM AUTO RULE: STEP Commercial: use carbidopa/levodo pa er first 06/24/2020 methylphenidate methylphenidate hcl UM AUTO RULE: STEP Commercial: use hcl one preferred immediate- release ADHD agent first 06/24/2020 clonidine hcl er clonidine hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 AZILECT rasagiline mesylate UM AUTO RULE: STEP Commercial: use rasagiline first 06/24/2020 esomeprazole esomeprazole strontium UM AUTO RULE: STEP Commercial: use strontium the following: omeprazole, pantoprazole, rabeprazole, and lansoprazole first 06/24/2020 CRESTOR rosuvastatin calcium UM AUTO RULE: STEP Commercial: use atorvastatin 80 mg or rosuvastatin 40 mg first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 255 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 mesalamine er mesalamine UM AUTO RULE: STEP Commercial: use 2 of the following first: mesalamine er (Apriso), mesalamine (Lialda) or balsalazide (Colazal) 06/24/2020 ALDACTONE spironolactone UM AUTO RULE: STEP Commercial: use amiloride, spironolactone, or triamterene/hctz first 06/24/2020 aripiprazole aripiprazole UM AUTO RULE: STEP Commercial: use aripiprazole, clozapine, olanzapine, quetiapine, risperidone, or ziprasidone first 06/24/2020 DIURIL chlorothiazide UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 TRINTELLIX vortioxetine hydrobromide UM AUTO RULE: STEP Commercial: use two preferred antidepressants first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 256 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 ciclodan ciclopirox olamine UM AUTO RULE: STEP Commercial: use econazole cream and one other preferred topical anti-fungal agent first 06/24/2020 betamethasone betamethasone UM AUTO RULE: STEP Commercial: use diprop dipropionate/propylene 2 preferred augmented glycol medium potency topical corticosteroids; one of which is triamcinolone, first 06/24/2020 PENTASA mesalamine UM AUTO RULE: STEP Commercial: one of the following: mesalamine er capsule (Apriso), mesalamine dr tablet (Lialda), balsalazide (Colazal) 06/24/2020 OLUX-E clobetasol UM AUTO RULE: STEP Commercial: use propionate/emollient base 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 257 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 SULAR nisoldipine UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 ADDERALL XR dextroamphetamine sulf- UM AUTO RULE: STEP Commercial: use saccharate/amphetamine one preferred sulf-aspartate extended-release ADHD agent first 06/24/2020 KERALAC urea UM AUTO RULE: STEP Commercial: use two preferred urea products first 06/24/2020 febuxostat febuxostat UM AUTO RULE: STEP Commercial: use allopurinol first 06/24/2020 RETIN-A tretinoin UM AUTO RULE: STEP Commercial: use topical tretinoin and topical clindamycin first 06/24/2020 NARDIL phenelzine sulfate UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 FORFIVO XL bupropion hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 ENVARSUS XR tacrolimus UM AUTO RULE: STEP Commercial: use tacrolimus IR first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 258 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 clindamycin clindamycin phosphate UM AUTO RULE: STEP Commercial: use phosphate topical tretinoin and topical clindamycin first 06/24/2020 hydrocortisone hydrocortisone valerate UM AUTO RULE: STEP Commercial: use valerate 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first 06/24/2020 BYVALSON nebivolol hcl/valsartan UM AUTO RULE: STEP Commercial: use 2 preferred beta- blocker agents first 06/24/2020 GLUCOTROL glipizide UM AUTO RULE: STEP Commercial: use metformin, glipizide, or glyburide first 06/24/2020 TRAVATAN Z travoprost UM AUTO RULE: STEP Commercial: use latanoprost first 06/24/2020 EVEKEO amphetamine sulfate UM AUTO RULE: STEP Commercial: use one preferred immediate- release ADHD agent first 06/24/2020 LAMICTAL lamotrigine UM AUTO RULE: STEP Commercial: use (BLUE) two of the following first: clonazepam, felbamate, lamotrigine, or topiramate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 259 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 candesartan- candesartan UM AUTO RULE: STEP Commercial: use hydrochlorothiazi cilexetil/hydrochlorothiazide an ARB and one d agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 moexipril- moexipril UM AUTO RULE: STEP Commercial: use hydrochlorothiazi hcl/hydrochlorothiazide an ARB and one de agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 tencon butalbital/acetaminophen UM AUTO RULE: STEP Commercial: use generic butalbital 50 mg/apap 325 mg formulation first 06/24/2020 trandolapril trandolapril UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 260 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 verapamil hcl verapamil hcl UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 afeditab cr nifedipine UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 DRIZALMA duloxetine hcl UM AUTO RULE: STEP Commercial: use SPRINKLE two of the following medications in 2 different drug classes including: TCA, SSRI, SNRI, tramadol, gabapentin, or cyclobenzaprine 06/24/2020 CORZIDE nadolol/bendroflumethiazide UM AUTO RULE: STEP Commercial: use 2 preferred beta- blocker agents first 06/24/2020 RIOMET metformin hcl UM AUTO RULE: STEP Commercial: use metformin first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 261 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 desoximetasone desoximetasone UM AUTO RULE: STEP Commercial: use 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first 06/24/2020 fluoxetine dr fluoxetine hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 GLUCOTROL XL glipizide UM AUTO RULE: STEP Commercial: use metformin, glipizide, or glyburide first 06/24/2020 ure-k urea UM AUTO RULE: STEP Commercial: use two preferred urea products first 06/24/2020 RELPAX eletriptan hydrobromide UM AUTO RULE: STEP Commercial: use two of the following first: naratriptan, rizatriptan, sumatriptan or zolmitriptan 06/24/2020 XIGDUO XR dapagliflozin UM AUTO RULE: STEP Commercial: use propanediol/metformin hcl metformin first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 262 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 amlodipine- amlodipine UM AUTO RULE: STEP Commercial: use olmesartan besylate/olmesartan an ARB and one medoxomil agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 CUTIVATE fluticasone propionate UM AUTO RULE: STEP Commercial: use 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first 06/24/2020 atorvastatin atorvastatin calcium UM AUTO RULE: STEP Commercial: use calcium atorvastatin 80 mg or rosuvastatin 40 mg first 06/24/2020 ONEXTON clindamycin UM AUTO RULE: STEP Commercial: use phosphate/benzoyl peroxide clindamycin 1%/benzoyl peroxide 5% gel or clindamycin 1.2%/benzoyl peroxide 5% first 06/24/2020 FORTAMET metformin hcl UM AUTO RULE: STEP Commercial: use metformin, glipizide, or glyburide first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 263 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 ramipril ramipril UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 LAMICTAL lamotrigine UM AUTO RULE: STEP Commercial: use (GREEN) two of the following first: clonazepam, felbamate, lamotrigine, or topiramate 06/24/2020 perindopril perindopril erbumine UM AUTO RULE: STEP Commercial: use erbumine an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 glyburide glyburide UM AUTO RULE: STEP Commercial: use metformin, glipizide, or glyburide first 06/24/2020 allopurinol allopurinol UM AUTO RULE: STEP Commercial: use allopurinol first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 264 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 VYTORIN ezetimibe/simvastatin UM AUTO RULE: STEP Commercial: use atorvastatin 80 mg or rosuvastatin 40 mg first 06/24/2020 APLENZIN bupropion hbr UM AUTO RULE: STEP Commercial: use bupropion xl first 06/24/2020 irbesartan irbesartan UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 flurandrenolide flurandrenolide UM AUTO RULE: STEP Commercial: use 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first 06/24/2020 PRESTALIA perindopril UM AUTO RULE: STEP Commercial: use arginine/amlodipine besylate perindopril and amlodipine first 06/24/2020 triamcinolone triamcinolone acetonide UM AUTO RULE: STEP Commercial: use acetonide 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 265 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 glipizide glipizide UM AUTO RULE: STEP Commercial: use metformin, glipizide, or glyburide first 06/24/2020 SURMONTIL trimipramine maleate UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 nisoldipine nisoldipine UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 DIPENTUM olsalazine sodium UM AUTO RULE: STEP Commercial: one of the following: mesalamine er capsule (Apriso), mesalamine dr tablet (Lialda), balsalazide (Colazal) 06/24/2020 GLUCOPHAGE metformin hcl UM AUTO RULE: STEP Commercial: use metformin first 06/24/2020 ELOCON mometasone furoate UM AUTO RULE: STEP Commercial: use 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 266 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 fosinopril sodium fosinopril sodium UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 ZESTRIL lisinopril UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 subvenite lamotrigine UM AUTO RULE: STEP Commercial: use generic lamotrigine immediate- release first 06/24/2020 losartan losartan potassium UM AUTO RULE: STEP Commercial: use potassium an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 267 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 ADDERALL dextroamphetamine sulf- UM AUTO RULE: STEP Commercial: use saccharate/amphetamine one preferred sulf-aspartate immediate- release ADHD agent first 06/24/2020 LIVALO pitavastatin calcium UM AUTO RULE: STEP Commercial: use atorvastatin 80 mg or rosuvastatin 40 mg first 06/24/2020 amlodipine amlodipine besylate UM AUTO RULE: STEP Commercial: use besylate an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 nifedical xl nifedipine UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 nystatin- nystatin/triamcinolone UM AUTO RULE: STEP Commercial: use triamcinolone acetonide econazole cream and one other preferred topical anti-fungal agent first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 268 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 quinapril hcl quinapril hcl UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 NORVASC amlodipine besylate UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 TARKA trandolapril/verapamil hcl UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 trospium chloride trospium chloride UM AUTO RULE: STEP Commercial: use er oxybutynin IR/ER or trospium IR/ER first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 269 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 PEXEVA paroxetine mesylate UM AUTO RULE: STEP Commercial: use two of the following medications in 2 different drug classes including: TCA, SSRI, SNRI, tramadol, gabapentin, or cyclobenzaprine 06/24/2020 ONFI clobazam UM AUTO RULE: STEP Commercial: use two of the following first: clonazepam, felbamate, lamotrigine, or topiramate 06/24/2020 NEURONTIN gabapentin UM AUTO RULE: STEP Commercial: use two of the following medications in 2 different drug classes including: TCA, SSRI, SNRI, tramadol, gabapentin, or cyclobenzaprine 06/24/2020 ULTRAVATE halobetasol propionate UM AUTO RULE: STEP Commercial: use 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 270 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 PROVIGIL modafinil UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 chlorthalidone chlorthalidone UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 ALA-SCALP hydrocortisone UM AUTO RULE: STEP Commercial: use 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first 06/24/2020 GIAZO balsalazide disodium UM AUTO RULE: STEP Commercial: use balsalazide first 06/24/2020 amlodipine amlodipine UM AUTO RULE: STEP Commercial: use besylate- besylate/benazepril hcl an ARB and one benazepril agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 RYBELSUS semaglutide UM AUTO RULE: STEP Commercial: use metformin first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 271 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 FROVA frovatriptan succinate UM AUTO RULE: STEP Commercial: use two of the following first: naratriptan, rizatriptan, sumatriptan or zolmitriptan 06/24/2020 lamotrigine odt lamotrigine UM AUTO RULE: STEP Commercial: use (green) two of the following first: clonazepam, felbamate, lamotrigine, or topiramate 06/24/2020 KHEDEZLA desvenlafaxine UM AUTO RULE: STEP Commercial: use desvenlafaxine succinate er (Pristiq) first 06/24/2020 lisinopril- lisinopril/hydrochlorothiazide UM AUTO RULE: STEP Commercial: use hydrochlorothiazi an ARB and one de agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 WELLBUTRIN bupropion hcl UM AUTO RULE: STEP Commercial: use SR 2 preferred antidepressants first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 272 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 benazepril hcl benazepril hcl UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 REMERON mirtazapine UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 diltiazem hcl diltiazem hcl UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 AVAPRO irbesartan UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 273 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 methyclothiazide methyclothiazide UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 metolazone metolazone UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 WELLBUTRIN bupropion hcl UM AUTO RULE: STEP Commercial: use XL 2 preferred antidepressants first 06/24/2020 COREG carvedilol UM AUTO RULE: STEP Commercial: use 2 preferred beta- blocker agents first 06/24/2020 desonide desonide UM AUTO RULE: STEP Commercial: use 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 274 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 NORPRAMIN desipramine hcl UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 candesartan candesartan cilexetil UM AUTO RULE: STEP Commercial: use cilexetil an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 PRINIVIL lisinopril UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 hydrocortisone hydrocortisone butyrate UM AUTO RULE: STEP Commercial: use butyrate 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 275 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 CARDIZEM LA diltiazem hcl UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 LAMICTAL XR lamotrigine UM AUTO RULE: STEP Commercial: use (ORANGE) lamotrigine tabs first 06/24/2020 metformin hcl metformin hcl UM AUTO RULE: STEP Commercial: use metformin first 06/24/2020 NASONEX mometasone furoate UM AUTO RULE: STEP Commercial: use fluticasone or flunisolide first 06/24/2020 EXTINA ketoconazole UM AUTO RULE: STEP Commercial: use one preferred topical antifungal first 06/24/2020 psorcon diflorasone diacetate UM AUTO RULE: STEP Commercial: use one high potency topical corticosteroid AND desoximetasone 0.25% cream or ointment first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 276 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 taztia xt diltiazem hcl UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 ELIDEL pimecrolimus UM AUTO RULE: STEP Commercial: use medium, high, or very high potency topical steroid first 06/24/2020 quinapril- quinapril UM AUTO RULE: STEP Commercial: use hydrochlorothiazi hcl/hydrochlorothiazide an ARB and one de agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 RITALIN LA methylphenidate hcl UM AUTO RULE: STEP Commercial: use one preferred extended-release ADHD agent first 06/24/2020 desvenlafaxine desvenlafaxine succinate UM AUTO RULE: STEP Commercial: use succinate er 2 preferred antidepressants first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 277 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 ZIAC bisoprolol UM AUTO RULE: STEP Commercial: use fumarate/hydrochlorothiazid 2 preferred beta- e blocker agents first 06/24/2020 COZAAR losartan potassium UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 mesalamine mesalamine UM AUTO RULE: STEP Commercial: use 2 of the following first: mesalamine er (Apriso), mesalamine (Lialda) or balsalazide (Colazal) 06/24/2020 TWYNSTA telmisartan/amlodipine UM AUTO RULE: STEP Commercial: use besylate an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 278 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 OLUX clobetasol propionate UM AUTO RULE: STEP Commercial: use 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first 06/24/2020 PROCARDIA XL nifedipine UM AUTO RULE: STEP Commercial: use an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 RETIN-A MICRO tretinoin microspheres UM AUTO RULE: STEP Commercial: use tretinoin [Retin-A] first 06/24/2020 KRISTALOSE lactulose UM AUTO RULE: STEP Commercial: use lactulose first 06/24/2020 levetiracetam levetiracetam UM AUTO RULE: STEP Commercial: use levetiracetam first 06/24/2020 BETAPACE sotalol hcl UM AUTO RULE: STEP Commercial: use 2 preferred beta- blocker agents first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 279 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 diltiazem 24hr er diltiazem hcl UM AUTO RULE: STEP Commercial: use (xr) an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 ARCAPTA indacaterol maleate UM AUTO RULE: STEP Commercial: use NEOHALER Striverdi or Serevent first 06/24/2020 methamphetamin methamphetamine hcl UM AUTO RULE: STEP Commercial: use e hcl one preferred immediate- release ADHD agent first 06/24/2020 STIOLTO tiotropium UM AUTO RULE: STEP Commercial: use RESPIMAT bromide/olodaterol hcl Anoro Ellipta first 06/24/2020 PICATO ingenol mebutate UM AUTO RULE: STEP Commercial: use Picato first 06/24/2020 telmisartan- telmisartan/hydrochlorothiazi UM AUTO RULE: STEP Commercial: use hydrochlorothiazi de an ARB and one d agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 280 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 scalacort hydrocortisone UM AUTO RULE: STEP Commercial: use 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first 06/24/2020 ROZEREM ramelteon UM AUTO RULE: STEP Commercial: use zolpidem immediate- release, zolpidem extended- release, eszopiclone, or zaleplon first 06/24/2020 SECTRAL acebutolol hcl UM AUTO RULE: STEP Commercial: use 2 preferred beta- blocker agents first 06/24/2020 ZYCLARA imiquimod UM AUTO RULE: STEP Commercial: use imiquimod, podofilox soln, Condylox gel, or Zyclara first 06/24/2020 tretinoin tretinoin UM AUTO RULE: STEP Commercial: use topical tretinoin and topical clindamycin first 06/24/2020 EPIDUO FORTE adapalene/benzoyl peroxide UM AUTO RULE: STEP Commercial: use adapalene or benzoyl peroxide containing product first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 281 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 ramelteon ramelteon UM AUTO RULE: STEP Commercial: use zolpidem immediate- release, zolpidem extended- release, eszopiclone, or zaleplon first 06/24/2020 cem-urea urea UM AUTO RULE: STEP Commercial: use two preferred urea products first 06/24/2020 DYMISTA azelastine hcl/fluticasone UM AUTO RULE: STEP Commercial: use propionate azelastine 0.15% nasal or azelastine 0.1% nasal first 06/24/2020 VICTOZA 2-PAK liraglutide UM AUTO RULE: STEP Commercial: use metformin first 06/24/2020 citalopram hbr citalopram hydrobromide UM AUTO RULE: STEP Commercial: use 2 preferred antidepressants first 06/24/2020 dexmethylphenid dexmethylphenidate hcl UM AUTO RULE: STEP Commercial: use ate hcl one preferred immediate- release ADHD agent first 06/24/2020 clindamax clindamycin phosphate UM AUTO RULE: STEP Commercial: use topical tretinoin and topical clindamycin first 06/24/2020 AMARYL glimepiride UM AUTO RULE: STEP Commercial: use pioglitazone or glimepiride first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 282 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 ibandronate ibandronate sodium UM AUTO RULE: STEP Commercial: use sodium alendronate and ibandronate first 06/24/2020 FOCALIN XR dexmethylphenidate hcl UM AUTO RULE: STEP Commercial: use one preferred extended-release ADHD agent first 06/24/2020 ASACOL HD mesalamine UM AUTO RULE: STEP Commercial: use balsalazide (Colazal) or mesalamine (Lialda) first 06/24/2020 VUSION miconazole nitrate/zinc UM AUTO RULE: STEP Commercial: use oxide/petrolatum,white econazole cream and one other preferred topical anti-fungal agent first 06/24/2020 LAMICTAL XR lamotrigine UM AUTO RULE: STEP Commercial: use (BLUE) lamotrigine tabs first 06/24/2020 adapalene adapalene UM AUTO RULE: STEP Commercial: use adapalene or benzoyl peroxide containing product first 06/24/2020 DUAC clindamycin UM AUTO RULE: STEP Commercial: use phosphate/benzoyl peroxide adapalene or benzoyl peroxide containing product first 06/24/2020 DETROL tolterodine tartrate UM AUTO RULE: STEP Commercial: use oxybutynin IR/ER or trospium IR/ER first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 283 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 zaleplon zaleplon UM AUTO RULE: STEP Commercial: use zolpidem immediate- release, zolpidem extended- release, eszopiclone, or zaleplon first 06/24/2020 TOPAMAX topiramate UM AUTO RULE: STEP Commercial: use two of the following first: clonazepam, felbamate, lamotrigine, or topiramate 06/24/2020 amlodipine- amlodipine UM AUTO RULE: STEP Commercial: use valsartan-hctz besylate/valsartan/hydrochlo an ARB and one rothiazide agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic 06/24/2020 risperidone odt risperidone UM AUTO RULE: STEP Commercial: use aripiprazole, clozapine, olanzapine, quetiapine, risperidone, or ziprasidone first

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 284 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 tovet emollient clobetasol UM AUTO RULE: STEP Commercial: use propionate/emollient base 2 preferred medium potency topical corticosteroids; one of which is triamcinolone, first 06/24/2020 UTOPIC urea UM AUTO RULE: STEP Commercial: use two preferred urea products first 06/24/2020 MAXALT rizatriptan benzoate UM AUTO RULE: STEP Commercial: use two of the following first: naratriptan, rizatriptan, sumatriptan or zolmitriptan 06/24/2020 podofilox podofilox UM AUTO RULE: STEP Commercial: use imiquimod, podofilox soln, Condylox gel, or Zyclara first 06/24/2020 trandolapril- trandolapril/verapamil hcl UM AUTO RULE: STEP Commercial: use verapamil er an ARB and one agent from the following classes first: ACE- inhibitor, beta- blocker, calcium channel blocker, or thiazide diuretic

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 285 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/24/2020 eszopiclone eszopiclone UM AUTO RULE: STEP Commercial: use zolpidem immediate- release, zolpidem extended- release, eszopiclone, or zaleplon first 06/24/2020 LIPOFEN fenofibrate UM AUTO RULE: STEP Commercial: use fenofibrate (generic Tricor or Lofibra) first 06/24/2020 triamterene triamterene UM AUTO RULE: STEP Commercial: use amiloride, spironolactone, or triamterene/hctz first 06/24/2020 bimatoprost bimatoprost UM AUTO RULE: STEP Commercial: use latanoprost first 06/26/2020 covid19 test adm covid-19 test administered NEW AUTO RULE Non-Formulary by pharmacist by pharmacist 06/26/2020 MOVE FREE glucosamine/chondroitin/hya NEW AUTO RULE Non-Formulary JOINT HEALTH luronic acid/calcium fructoborate 06/26/2020 NOPIOID-TC KIT cyclobenzaprine NEW AUTO RULE Non-Formulary hcl/lidocaine/menthol 06/26/2020 yogurt plus calcium phosphate, NEW AUTO RULE Non-Formulary calcium tribasic/cholecalciferol (vitamin d3) 06/26/2020 FLUOPAR fluocinonide/dimethicone NEW AUTO RULE Non-Formulary 06/26/2020 BYNFEZIA octreotide acetate NEW AUTO RULE NF specialty

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 286 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2020 GERBER GROW pediatric multivitamin no.191 NEW AUTO RULE Non-Formulary MIGHTY 06/26/2020 ECONASIL econazole nitrate/gauze NEW AUTO RULE Non-Formulary bandage/silicone, adhesive 06/26/2020 GLYTACTIN nutritional therapy for NEW AUTO RULE Non-Formulary BURST 20-20 phenylketonuria (pku) no.75 06/26/2020 ENFAMIL A.R. infant formula with NEW AUTO RULE Non-Formulary iron/docosahexanoic acid/arachidonic ac 06/26/2020 ZEPZELCA lurbinectedin NEW AUTO RULE Non-Formulary 06/26/2020 airborne kids multivitamin-minerals/vit NEW AUTO RULE Non-Formulary c/herbal no.124 06/26/2020 ketamine hcl-nacl ketamine hcl in sodium NEW AUTO RULE Non-Formulary chloride, iso-osmotic 06/26/2020 UPLIZNA inebilizumab-cdon NEW AUTO RULE Non-Formulary 06/26/2020 XPOVIO selinexor NEW AUTO RULE NF specialty 06/26/2020 PKU SPHERE20 nutritional therapy for NEW AUTO RULE Non-Formulary phenylketonuria (pku) no.67 06/26/2020 ENFAMIL A.R. infant formula with NEW AUTO RULE Non-Formulary iron/docosahexaenoic acid/arachidonic ac 06/26/2020 helidac bismuth NEW AUTO RULE Non-Formulary subsalicylate/metronidazole/ tetracycline hcl 06/26/2020 vancomycin hcl- vancomycin in 0.9 % sodium NEW AUTO RULE Non-Formulary 0.9% nacl chloride 06/26/2020 probiotic lactobacillus acidophilus NEW AUTO RULE Non-Formulary 06/26/2020 airborne plus multivit-min/vitamin NEW AUTO RULE Non-Formulary probiotic c/bacillus coagulans/herbal no.124

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 287 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2020 yogurt+calcium calcium phosphate, NEW AUTO RULE Non-Formulary gummies tribasic/cholecalciferol (vitamin d3) 06/26/2020 vaseline white petrolatum,white NEW AUTO RULE Non-Formulary petroleum 06/26/2020 miclara lq triprolidine hcl NEW AUTO RULE Non-Formulary 06/26/2020 vanadom carisoprodol NEW AUTO RULE Tier 1 06/26/2020 MOVE FREE cartilage/collagen type NEW AUTO RULE Non-Formulary ULTRA TRIPLE ii/boron ACTION glycinate/hyaluronate sod 06/26/2020 probiotic l.acidoph,paracasei, b.lactis NEW AUTO RULE Non-Formulary 06/26/2020 DIGESTIVE l.acidoph,paracasei, b.lactis NEW AUTO RULE Non-Formulary ADVANTAGE ADVANCED 06/26/2020 lansoprazole lansoprazole UM AUTO RULE: STEP Commercial: use omeprazole, pantoprazole, rabeprazole or lansoprazole first 06/26/2020 GERBER GOOD infant formula with NEW AUTO RULE Non-Formulary START GENTLE iron/dha/ara/bifidobacterium NOGMO animalis 06/26/2020 covid19 covid-19 test specimen NEW AUTO RULE Non-Formulary specimen collect collection ncpdp 06/26/2020 DIGESTIVE bacillus coagulans/bacillus NEW AUTO RULE Non-Formulary ADVANTAG subtilis MULTISTRAIN 06/26/2020 GLYTACTIN nutritional therapy for NEW AUTO RULE Non-Formulary BURST 10-10 phenylketonuria (pku) no.75

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 288 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2020 PROMELLA lactobacillus NEW AUTO RULE Non-Formulary acidophilus/bifidobacterium animalis 06/26/2020 LIDOTIN gabapentin/lidocaine NEW AUTO RULE Non-Formulary hcl/silicone adhesive 06/26/2020 ALKA-SELTZER calcium phosphate, NEW AUTO RULE Non-Formulary PM tribasic/melatonin 06/30/2020 JADENU deferasirox UM AUTO RULE: PA Applies SPRINKLE AUTHORIZATION

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 289 UPDATED 12/2020 VALUE Drug Formulary Updates

July, 2020

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2020 deferasirox deferasirox NEW AUTO RULE Tier 4 07/03/2020 CENTRUM multivitamin with NEW AUTO RULE Non-Formulary ADULT 50 minerals/folic acid FRESH-FRUITY 07/03/2020 VOLTAREN diclofenac sodium NEW AUTO RULE Non-Formulary ARTHRITIS PAIN 07/03/2020 PHESGO pertuzumab-trastuzumab- NEW AUTO RULE Non-Formulary hyaluronidase-zzxf 07/03/2020 gas relief simethicone NEW AUTO RULE Non-Formulary 07/03/2020 freestyle libre 2 flash glucose sensor NEW AUTO RULE Non-Formulary sensor 07/03/2020 acne medication benzoyl peroxide NEW AUTO RULE Non-Formulary 07/03/2020 LIPRITIN II gabapentin/lidocaine/prilocai NEW AUTO RULE Non-Formulary ne/transparent dressing 07/03/2020 freestyle libre 2 flash glucose scanning NEW AUTO RULE Non-Formulary reader reader 07/03/2020 ULTIVA remifentanil hcl NEW AUTO RULE Non-Formulary 07/03/2020 chloroprocaine chloroprocaine hcl/pf NEW AUTO RULE Non-Formulary hcl 07/03/2020 remifentanil hcl remifentanil hcl NEW AUTO RULE Non-Formulary 07/03/2020 TWIRLA levonorgestrel/ethinyl NEW AUTO RULE Non-formulary estradiol 07/03/2020 FISH OIL omega-3 fatty NEW AUTO RULE Non-Formulary acids/dha/epa/other omega- 3s/fish oil 07/03/2020 GAS-X simethicone NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 290 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/03/2020 NESACAINE- chloroprocaine hcl/pf NEW AUTO RULE Non-Formulary MPF 07/03/2020 simethicone simethicone NEW AUTO RULE Non-Formulary 07/03/2020 benzoyl peroxide benzoyl peroxide NEW AUTO RULE Non-Formulary 07/03/2020 ENSURE CLEAR nutritional therapy for DRUG ATTR CHANGE Non-Formulary Non-Formulary THERAPEUTIC impaired digestive function OVERRIDE 07/03/2020 NULYTELY sodium chloride/sodium NEW AUTO RULE Non-formulary bicarbonate/potassium chloride/peg 07/03/2020 easy touch safety pen needle, diabetic, safety NEW AUTO RULE Tier 2 pen needle 07/10/2019 vitamin e vitamin e (dl-alpha NEW AUTO RULE Non-Formulary tocopheryl acetate) 07/10/2019 amphetamine amphetamine sulfate UM AUTO RULE: AGE Up to 17 yrs old sulfate 07/10/2019 NICORETTE nicotine polacrilex NEW AUTO RULE Preventative Drugs 07/10/2019 febuxostat febuxostat UM AUTO RULE: 1 tab/day QUANTITYCUSTOM 07/10/2020 TISSUEBLUE c.i. acid blue 90 NEW AUTO RULE Non-Formulary 07/10/2020 airborne ascorbic acid/vitamin NEW AUTO RULE Non-Formulary elderberry d3/vitamin e/zinc gummy gluconate/elderberry 07/10/2020 nasal four phenylephrine hcl NEW AUTO RULE Non-Formulary 07/10/2020 DUPIXENT PEN dupilumab NEW AUTO RULE NF specialty 07/10/2020 morphine sulfate morphine sulfate NEW AUTO RULE Non-Formulary 07/10/2020 dextrose 5%- potassium chloride in NEW AUTO RULE Non-Formulary 0.2% nacl-kcl dextrose 5 %-0.2 % sodium chloride

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 291 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/10/2020 FLULAVAL influenza virus vaccine TERM AUTO RULE QUAD 2018- quadrival 2018-2019(6 mos 2019 and up)/pf 07/10/2020 FLULAVAL influenza virus vaccine NEW AUTO RULE Preventative QUAD 2020- quadrival 2020-2021(6 mos Drugs 2021 and up)/pf 07/10/2020 AFLURIA QUAD influenza virus vaccine TERM AUTO RULE 2018-2019 quadrivalent 2018-19 (6 mos and up) 07/10/2020 AFLURIA QUAD influenza virus vaccine NEW AUTO RULE Non-Formulary 2018-2019 quadrival 2018-2019(6 mos and up)/pf 07/10/2020 sinus relief phenylephrine hcl NEW AUTO RULE Non-Formulary 07/10/2020 romidepsin romidepsin NEW AUTO RULE Non-Formulary 07/10/2020 topotecan hcl topotecan hcl NEW AUTO RULE Non-Formulary 07/10/2020 calcium citrate - calcium NEW AUTO RULE Non-Formulary vitamin d citrate/cholecalciferol (vitamin d3) 07/10/2020 DERMACINRX mupirocin/chlorhexidine NEW AUTO RULE Non-Formulary CLORHEXACIN glucon/dimethicone/silicone adhesive 07/10/2020 FLUBLOK QUAD influenza virus vaccine qv NEW AUTO RULE Non-Formulary 2018-2019 2018-19(18 yrs and older)rcmb/pf 07/10/2020 PENTICAN gabapentin/lidocaine NEW AUTO RULE Non-Formulary 07/10/2020 AFLURIA QUAD influenza virus vaccine UM AUTO RULE: 2 doses/year 2019-20 (3YR quadrivalent 2019-20 (36 QUANTITYCUSTOM UP) mos up)/pf 07/10/2020 AFLURIA QUAD influenza virus vaccine NEW AUTO RULE Non-Formulary 2018-2019 quadrivalent 2018-19 (6 mos and up)

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 292 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/10/2020 nusurgepak mupirocin/chlorhexidine NEW AUTO RULE Non-Formulary glucon/dimethicone/silicone adhesive 07/10/2020 FLUBLOK QUAD influenza virus vaccine qv NEW AUTO RULE Preventative 2020-2021 2020-21(18 yrs and Drugs older)rcmb/pf 07/10/2020 FLUZONE QUAD influenza virus vaccine NEW AUTO RULE Non-Formulary 2018-2019 quadrivalent 2018-19 (36 mos up)/pf 07/10/2020 airborne ascorbic acid/elderberry fruit NEW AUTO RULE Non-Formulary 07/10/2020 FLUZONE QUAD influenza virus vaccine NEW AUTO RULE Preventative 2020-2021 quadrival 2020-2021(6 mos Drugs and up)/pf 07/10/2020 DERMACINRX mupirocin/chlorhexidine NEW AUTO RULE Non-Formulary SURGICAL glucon/dimethicone/silicone PHARMAPAK adhesive 07/10/2020 germphobic ethyl alcohol NEW AUTO RULE Non-Formulary 07/10/2020 FLUZONE HIGH- influenza virus vaccine trival NEW AUTO RULE Non-Formulary DOSE 2018-2019 split 2018-2019(65 yr up)/pf 07/10/2020 FLUZONE QUAD influenza virus vaccine TERM AUTO RULE 2018-2019 quadrivalent 2018-19 (6 mos and up) 07/10/2020 ISTODAX romidepsin NEW AUTO RULE Non-Formulary 07/10/2020 LORTUSS LQ doxylamine NEW AUTO RULE Non-Formulary succinate/pseudoephedrine hcl 07/10/2020 dermawerx mupirocin/chlorhexidine NEW AUTO RULE Non-Formulary surgical plus pak glucon/dimethicone/silicone adhesive 07/10/2020 FINTEPLA fenfluramine hcl NEW AUTO RULE NF specialty

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 293 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/10/2020 FERRIPROX (2 deferiprone NEW AUTO RULE NF specialty TIMES A DAY) 07/10/2020 FLUZONE QUAD influenza virus vaccine TERM AUTO RULE 2018-2019 quadrivalent 2018-19 (36 mos up)/pf 07/10/2020 FLUZONE QUAD influenza virus vaccine NEW AUTO RULE Non-Formulary 2018-2019 quadrivalent 2018-19 (6 mos and up) 07/10/2020 PEDIA TRI-VITE vitamin a palmitate/ascorbic NEW AUTO RULE Non-Formulary acid/cholecalciferol (vit d3) 07/10/2020 nasal spray phenylephrine hcl NEW AUTO RULE Non-Formulary 07/10/2020 ZOMETA zoledronic acid NEW AUTO RULE Non-Formulary 07/10/2020 minimed infusion set for insulin pump NEW AUTO RULE Non-Formulary silhouette 07/10/2020 neo-synephrine phenylephrine hcl NEW AUTO RULE Non-Formulary 07/10/2020 FLULAVAL influenza virus vaccine NEW AUTO RULE Non-Formulary QUAD 2018- quadrivalent 2018-19 (6 mos 2019 and up) 07/10/2020 cerave itch relief pramoxine hcl NEW AUTO RULE Non-Formulary 07/10/2020 MOVE FREE krill oil/hyaluronic NEW AUTO RULE Non-Formulary ULTRA OMEGA acid/astaxanthin JNT PLUS 07/10/2020 FLUBLOK QUAD influenza virus vaccine qv TERM AUTO RULE 2018-2019 2018-19(18 yrs and older)rcmb/pf 07/10/2020 FLUZONE HIGH- influenza virus vaccine trival TERM AUTO RULE DOSE 2018-2019 split 2018-2019(65 yr up)/pf 07/10/2020 FLULAVAL influenza virus vaccine NEW AUTO RULE Non-Formulary QUAD 2018- quadrival 2018-2019(6 mos 2019 and up)/pf

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 294 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/10/2020 AFLURIA QUAD influenza virus vaccine TERM AUTO RULE 2018-2019 quadrival 2018-2019(6 mos and up)/pf 07/10/2020 RUKOBIA fostemsavir tromethamine NEW AUTO RULE Non-formulary 07/10/2020 wal-four phenylephrine hcl NEW AUTO RULE Non-Formulary 07/10/2020 FLUZONE QUAD influenza virus vaccine NEW AUTO RULE Preventative 2020-2021 quadrivalent 2020-21 (6 mos Drugs and up) 07/10/2020 move free ultra tamarindus indica NEW AUTO RULE Non-Formulary turmeric-tamar seed/turmeric root extract 07/10/2020 FLUZONE HIGH- influenza virus vaccine NEW AUTO RULE Preventative DOSE QUAD quadrival split 2020-21(65 yr Drugs 2020-21 up)/pf 07/10/2020 MEGARED omega-3 fatty NEW AUTO RULE Non-Formulary ADVANCED 4- acids/dha/epa/fish oil/krill oil IN-1 07/10/2020 4 way phenylephrine hcl NEW AUTO RULE Non-Formulary 07/10/2020 FLUARIX QUAD influenza virus vaccine NEW AUTO RULE Preventative 2020-2021 quadrival 2020-2021(6 mos Drugs and up)/pf 07/10/2020 FLUARIX QUAD influenza virus vaccine NEW AUTO RULE Non-Formulary 2018-2019 quadrival 2018-2019(6 mos and up)/pf 07/10/2020 airborne multivitamin- NEW AUTO RULE Non-Formulary elderberry minerals/ascorbic acid/elderberry/herb no.124 07/10/2020 GABAPAL gabapentin/lidocaine NEW AUTO RULE Non-Formulary hcl/gauze bandage/silicone adhesive 07/10/2020 MOVE FREE glucosamine/chondroitin/ms NEW AUTO RULE Non-Formulary PLUS MSM m/hyaluronic ac/calc fructoborate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 295 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/10/2020 FLUZONE QUAD influenza virus vaccine TERM AUTO RULE PEDI 2018-2019 quadrival 2018-19 (6 mos- 35 mos)/pf 07/10/2020 FLUAD QUAD influenza vaccine NEW AUTO RULE Preventative 2020-2021 quadrivalent 2020-21 (65 yr Drugs up)/mf59c.1/pf 07/10/2020 FLULAVAL influenza virus vaccine TERM AUTO RULE QUAD 2018- quadrivalent 2018-19 (6 mos 2019 and up) 07/10/2020 FLUARIX QUAD influenza virus vaccine TERM AUTO RULE 2018-2019 quadrival 2018-2019(6 mos and up)/pf 07/10/2020 BOOST nutritional tx. glucose NEW AUTO RULE Non-Formulary GLUCOSE intolerance,lactose- CONTROL free,soy/fiber 07/10/2020 atropine sulfate atropine sulfate in 0.9 % NEW AUTO RULE Non-Formulary sodium chloride 07/10/2020 FLUZONE QUAD influenza virus vaccine NEW AUTO RULE Non-Formulary PEDI 2018-2019 quadrival 2018-19 (6 mos- 35 mos)/pf 07/10/2020 dextrose 5%- potassium chloride in NEW AUTO RULE Non-Formulary 0.225% nacl-kcl dextrose 5 %-0.2 % sodium chloride 07/17/2019 LUGOL'S iodine/potassium iodide NEW AUTO RULE Non-Formulary 07/17/2019 perifresh skin cleanser NEW AUTO RULE Non-Formulary 07/17/2019 SIMILAC infant formula with NEW AUTO RULE Non-Formulary NEOSURE iron/docosahexanoic acid/arachidonic ac 07/17/2019 zinc oxide zinc oxide NEW AUTO RULE Non-Formulary 07/17/2019 cefazolin sodium- cefazolin sodium in 0.9 % NEW AUTO RULE Non-Formulary 0.9% nacl sodium chloride

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 296 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/17/2019 ephedrine ephedrine sulfate in 0.9 % NEW AUTO RULE Non-Formulary sulfate-0.9% nacl sodium chloride/pf 07/17/2019 polysorbate 80 polysorbate 80 NEW AUTO RULE Non-Formulary 07/17/2019 tincture iodine iodine/sodium iodide NEW AUTO RULE Non-Formulary 07/17/2019 geri-pectate bismuth subsalicylate NEW AUTO RULE Non-Formulary 07/17/2019 isopropanol isopropyl alcohol NEW AUTO RULE Non-Formulary 07/17/2019 wal-fex d 12 hour fexofenadine NEW AUTO RULE Non-Formulary hcl/pseudoephedrine hcl 07/17/2019 altacaine tetracaine hcl NEW AUTO RULE Non-Formulary 07/17/2019 saf-clens af skin cleanser NEW AUTO RULE Non-Formulary 07/17/2019 buffered lidocaine lidocaine hcl buffered with NEW AUTO RULE Non-Formulary 8.4 % sodium bicarbonate 07/17/2019 senna sennosides NEW AUTO RULE Non-Formulary 07/17/2019 RYCLORA dexchlorpheniramine NEW AUTO RULE NF specialty maleate 07/17/2019 citrate of magnesium citrate NEW AUTO RULE Non-Formulary magnesia 07/17/2019 cefazolin-d5w cefazolin sodium/dextrose 5 NEW AUTO RULE Non-Formulary % in water 07/17/2019 perianal skin cleanser NEW AUTO RULE Non-Formulary cleansing 07/17/2019 labetalol hcl labetalol hcl NEW AUTO RULE Non-Formulary 07/17/2019 lido-k lidocaine hcl NEW AUTO RULE Non-Formulary 07/17/2019 calcium calcium gluconate in 0.9 % NEW AUTO RULE Non-Formulary gluconate-0.9% sodium chloride nacl 07/17/2019 procare tens-ems transcutaneous electrical NEW AUTO RULE Non-Formulary nerve stimulators(tens)/electrodes

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 297 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/17/2019 vinyl gloves gloves NEW AUTO RULE Non-Formulary 07/17/2019 lidocaine hcl lidocaine hcl NEW AUTO RULE Non-Formulary 07/17/2019 mederma ag skin cleanser NEW AUTO RULE Non-Formulary 07/17/2019 CALCIUM calcium gluconate in sodium NEW AUTO RULE Non-Formulary GLUCONATE- chloride, iso-osmotic NACL 07/17/2019 peanut oil peanut oil NEW AUTO RULE Non-Formulary 07/17/2019 isopropyl alcohol isopropyl alcohol NEW AUTO RULE Non-Formulary 07/17/2019 fexofenadine-pse fexofenadine NEW AUTO RULE Non-Formulary er hcl/pseudoephedrine hcl 07/17/2019 cefazolin sodium- cefazolin sodium/dextrose 5 NEW AUTO RULE Non-Formulary d5w % in water 07/17/2019 cetaklenz skin cleanser NEW AUTO RULE Non-Formulary 07/17/2019 OCUVITE BLUE lutein/zeaxanthin NEW AUTO RULE Non-Formulary LIGHT 07/17/2019 lido-sorb lidocaine hcl NEW AUTO RULE Non-Formulary 07/17/2019 AFLURIA QUAD influenza virus vaccine NEW AUTO RULE Preventative 2019-20 (3YR quadrivalent 2019-20 (36 Drugs UP) mos up)/pf 07/17/2019 orphengesic forte orphenadrine NEW AUTO RULE Non-formulary citrate/aspirin/caffeine 07/17/2019 iodine iodine/potassium iodide NEW AUTO RULE Non-Formulary 07/17/2019 folvite-d cholecalciferol (vit d3)/folic NEW AUTO RULE Non-Formulary acid 07/17/2019 potassium cl- potassium chloride/lidocaine NEW AUTO RULE Non-Formulary lidocaine-ns hcl in 0.9 % sodium chloride 07/17/2019 rabeprazole rabeprazole sodium NEW AUTO RULE Non-formulary sodium

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 298 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/17/2019 cefazolin sodium- cefazolin sodium/water for NEW AUTO RULE Non-Formulary sterile water injection,sterile 07/17/2019 CITROMA magnesium citrate NEW AUTO RULE Non-Formulary 07/17/2019 dexchlorphenira dexchlorpheniramine NEW AUTO RULE NF specialty mine maleate maleate 07/17/2019 AFLURIA QUAD influenza virus vaccine NEW AUTO RULE Preventative 2019-2020 quadrivalent 2019-20 (6 mos Drugs and up) 07/17/2019 SYMJEPI epinephrine NEW AUTO RULE Non-formulary 07/17/2019 ondansetron hcl- ondansetron hcl in 0.9 % NEW AUTO RULE Non-Formulary 0.9% nacl sodium chloride 07/17/2019 heparin sodium- heparin sodium,porcine in NEW AUTO RULE Non-Formulary 0.9% nacl 0.9 % sodium chloride 07/17/2019 cetaphil skin cleanser NEW AUTO RULE Non-Formulary 07/17/2019 AFLURIA QUAD influenza virus vaccine NEW AUTO RULE Preventative 2019-20 (6- quadrival 2019-20 (6 mos- Drugs 35MO) 35 mos)/pf 07/17/2019 procare pediatric nebulizer and compressor NEW AUTO RULE Non-Formulary nebulizer 07/17/2019 ropivacaine hcl- ropivacaine hcl in 0.9 % NEW AUTO RULE Non-Formulary 0.9% nacl sodium chloride/pf 07/17/2019 THIOLA EC tiopronin NEW AUTO RULE Tier 4 07/17/2019 THIOLA tiopronin UM AUTO RULE: Limited Access LIMITEDACCESS 07/17/2019 FLUCELVAX flu vaccine quad 2019- NEW AUTO RULE Preventative QUAD 2019- 2020(4 years and older)cell Drugs 2020 derived/pf 07/17/2019 phenylephrine phenylephrine hcl in 0.9 % NEW AUTO RULE Non-Formulary hcl-0.9% nacl sodium chloride 07/17/2019 wintergreen oil methyl salicylate NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 299 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/17/2019 rubbing alcohol isopropyl alcohol NEW AUTO RULE Non-Formulary 07/17/2019 oxytocin-0.9% oxytocin in 0.9 % sodium NEW AUTO RULE Non-Formulary nacl chloride 07/17/2019 NORGESIC orphenadrine NEW AUTO RULE Non-formulary FORTE citrate/aspirin/caffeine 07/17/2019 SIMILAC infant formula with NEW AUTO RULE Non-Formulary ADVANCE iron/docosahexanoic acid/arachidonic ac 07/17/2019 DOPTELET avatrombopag maleate NEW AUTO RULE NF specialty 07/17/2019 hydroxypropylcell hydroxypropyl cellulose NEW AUTO RULE Non-Formulary ulose 07/17/2019 insulin syringe syringe with NEW AUTO RULE Tier 2 needle,disposable,insulin 1 ml 07/17/2019 FLUCELVAX flu vaccine quadriv 2019- NEW AUTO RULE Preventative QUAD 2019- 2020(4 years and older)cell Drugs 2020 derived 07/17/2019 isopropyl rubbing isopropyl alcohol NEW AUTO RULE Non-Formulary alcohol 07/17/2019 SITZMARKS radiopaque pvc NEW AUTO RULE Non-Formulary markers/barium sulfate 07/17/2019 amiodarone hcl- amiodarone hcl/dextrose 5 NEW AUTO RULE Non-Formulary d5w % in water 07/17/2019 ALLEGRA-D 12 fexofenadine NEW AUTO RULE Non-Formulary HOUR hcl/pseudoephedrine hcl 07/17/2019 carboprost carboprost tromethamine NEW AUTO RULE Non-Formulary tromethamine 07/17/2019 SLYND drospirenone NEW AUTO RULE Non-formulary 07/17/2019 bupivacaine hcl- bupivacaine hcl in 0.9 % NEW AUTO RULE Non-Formulary 0.9% nacl sodium chloride/pf

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 300 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/17/2019 tetcaine tetracaine hcl NEW AUTO RULE Non-Formulary 07/17/2019 premier compact blood-glucose meter NEW AUTO RULE Non-Formulary glucose meter 07/17/2019 lidozion lidocaine hcl NEW AUTO RULE Non-Formulary 07/17/2019 FLUAD 2019- influenza vaccine tvs 2019- NEW AUTO RULE Preventative 2020 20 (65 yr up)/adjuvant Drugs mf59c.1/pf 07/17/2019 methyl salicylate methyl salicylate NEW AUTO RULE Non-Formulary 07/17/2019 XPOVIO selinexor NEW AUTO RULE NF specialty 07/17/2019 pharmabase zinc oxide NEW AUTO RULE Non-Formulary barrier 07/17/2019 esmolol hcl esmolol hcl NEW AUTO RULE Non-Formulary 07/17/2019 cetaphil paraben/cetyl alcohol/stearyl NEW AUTO RULE Non-Formulary alc/prop gly/sod lauryl sulf 07/17/2019 z-clinz skin cleanser NEW AUTO RULE Non-Formulary 07/17/2019 guardian link 3 blood-glucose transmitter NEW AUTO RULE Non-Formulary 07/17/2020 TYLENOL chlorpheniram/phenyleph/de NEW AUTO RULE Non-Formulary COLD-FLU xtromethorphn/acetaminoph SEVERE DAY- en/guaifn NT 07/17/2020 FLUMIST QUAD influenza vaccine NEW AUTO RULE Non-Formulary 2018-2019 quadrivalent live 2018-2019 (2 yrs-49 yrs) 07/17/2020 assure id duo- pen needle, diabetic NEW AUTO RULE Tier 2 shield disposable, safety 07/17/2020 charlotte 24 fe norethindrone acetate- NEW AUTO RULE Tier 1 ethinyl estradiol/ferrous fumarate 07/17/2020 dacarbazine dacarbazine NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 301 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/17/2020 assure id insulin syringe with needle, insulin, NEW AUTO RULE Tier 2 safety safety, 0.5 ml 07/17/2020 assure id insulin syringe with needle, insulin, NEW AUTO RULE Tier 2 safety safety, 1 ml 07/17/2020 TRI-VI-SOL vitamin a palmitate/ascorbic NEW AUTO RULE Non-Formulary acid/cholecalciferol (vit d3) 07/17/2020 methylprednisolo methylprednisolone acetate NEW AUTO RULE Non-Formulary ne acetate 07/17/2020 FLUMIST QUAD influenza vaccine TERM AUTO RULE 2018-2019 quadrivalent live 2018-2019 (2 yrs-49 yrs) 07/17/2020 DEPO-MEDROL methylprednisolone acetate NEW AUTO RULE Non-Formulary 07/17/2020 effaclar adapalene NEW AUTO RULE Non-Formulary adapalene 07/17/2020 phenylephrine phenylephrine hcl in 0.9 % NEW AUTO RULE Non-Formulary hcl-0.9% nacl sodium chloride 07/17/2020 SIRTURO bedaquiline fumarate NEW AUTO RULE Non-Formulary 07/17/2020 adapalene adapalene NEW AUTO RULE Non-Formulary 07/17/2020 DOJOLVI triheptanoin NEW AUTO RULE Non-Formulary 07/17/2020 cerave psoriasis salicylic acid NEW AUTO RULE Non-Formulary 07/17/2020 MOVE FREE calcium fructoborate NEW AUTO RULE Non-Formulary ULTRA FASTER COMFORT 07/17/2020 cold-flu m- chlorpheniram/phenyleph/de NEW AUTO RULE Non-Formulary symptom day- xtromethorphn/acetaminoph night en/guaifn 07/17/2020 FLUMIST QUAD influenza vaccine NEW AUTO RULE Preventative 2020-2021 quadrivalent live 2020-2021 Drugs (2 yrs-49 yrs)

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 302 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/17/2020 helidac bismuth NEW AUTO RULE Non-formulary subsalicylate/metronidazole/ tetracycline hcl 07/17/2020 FLUAD 2020- influenza vaccine tvs 2020- NEW AUTO RULE Preventative 2021 21 (65 yr up)/adjuvant Drugs mf59c.1/pf 07/17/2020 aquacel-ag silver/hydrocolloid dressing NEW AUTO RULE Non-Formulary 07/17/2020 POLY-VI-SOL pediatric multivitamin no.192 NEW AUTO RULE Non-Formulary 07/17/2020 midazolam hcl- midazolam in sodium NEW AUTO RULE Non-Formulary 0.8% nacl chloride, iso-osmotic/pf 07/19/2019 ACTHAR corticotropin DRUG ATTR CHANGE NF specialty NF specialty OVERRIDE 07/22/2020 DOJOLVI triheptanoin NEW AUTO RULE NF specialty 07/24/2019 HERCEPTIN trastuzumab NEW AUTO RULE Non-Formulary 07/24/2019 ANNOVERA segesterone acetate/ethinyl NEW AUTO RULE Non-formulary estradiol 07/24/2019 FLUARIX QUAD influenza virus vaccine NEW AUTO RULE Preventative 2019-2020 quadrival 2019-2020(6 mos Drugs and up)/pf 07/24/2019 AVASTIN bevacizumab NEW AUTO RULE Non-Formulary 07/24/2019 SUDAFED 12- pseudoephedrine hcl NEW AUTO RULE Non-Formulary HOUR 07/24/2019 moxifloxacin moxifloxacin hcl in sodium NEW AUTO RULE Non-Formulary chloride,iso-osmotic/pf 07/24/2019 RITUXAN rituximab NEW AUTO RULE medical benefit drugs 07/24/2019 SUDAFED 12 pseudoephedrine hcl NEW AUTO RULE Non-Formulary HOUR 07/24/2019 isopropyl rubbing isopropyl alcohol NEW AUTO RULE Non-Formulary alcohol

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 303 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/24/2019 vitamin k1 phytonadione (vit k1) NEW AUTO RULE Non-Formulary 07/24/2019 surgiseal octyl 2-cyanoacrylate NEW AUTO RULE Non-Formulary teardrop 07/24/2019 FLULAVAL influenza virus vaccine NEW AUTO RULE Preventative QUAD 2019- quadrivalent 2019-20 (6 mos Drugs 2020 and up) 07/24/2019 calcium-vit d3-vit calcium NEW AUTO RULE Non-Formulary k1 carbonate/cholecalciferol (vit d3)/vit k1 07/24/2019 vancomycin hcl- vancomycin in 0.9 % sodium NEW AUTO RULE Non-Formulary 0.9% nacl chloride 07/24/2019 FLUZONE QUAD influenza virus vaccine NEW AUTO RULE Preventative 2019-2020 quadrivalent 2019-20 (6 mos Drugs and up) 07/24/2019 icatibant icatibant acetate NEW AUTO RULE Tier 4 07/24/2019 NATAVI PRIMA prenatal no.157/iron NEW AUTO RULE Non-Formulary fum/folic acid/omega- 3/dha/epa/fish oil 07/24/2019 FLULAVAL influenza virus vaccine NEW AUTO RULE Preventative QUAD 2019- quadrival 2019-2020(6 mos Drugs 2020 and up)/pf 07/24/2019 FLUBLOK QUAD influenza virus vaccine qv NEW AUTO RULE Preventative 2019-2020 2019-20(18 yrs and Drugs older)rcmb/pf 07/24/2019 severe cold-flu dextromethorphan NEW AUTO RULE Non-Formulary nighttime hbr/phenylephrine/acetamin ophen/doxylamine 07/24/2019 methylphenidate methylphenidate hcl UM AUTO RULE: AGE Up to 17 yrs old la 07/24/2019 isopropanol isopropyl alcohol NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 304 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/24/2019 FOLITE folic acid/calcium NEW AUTO RULE Non-Formulary citrate/vitamin d3/mag citrate/a-cysteine 07/24/2019 isopropyl alcohol isopropyl alcohol NEW AUTO RULE Non-Formulary 07/24/2019 BOOST lactose-reduced food NEW AUTO RULE Non-Formulary SOOTHE 07/24/2019 ZELNORM tegaserod hydrogen maleate NEW AUTO RULE Non-formulary 07/24/2019 FLUZONE QUAD influenza virus vaccine NEW AUTO RULE Preventative PEDI 2019-2020 quadrival 2019-20 (6 mos- Drugs 35 mos)/pf 07/24/2019 FLUZONE QUAD influenza virus vaccine NEW AUTO RULE Preventative 2019-2020 quadrival 2019-2020(6 mos Drugs and up)/pf 07/24/2019 DRAXIMAGE kit for the preparation of tc- NEW AUTO RULE Non-Formulary DTPA 99m/pentetic acid 07/24/2019 NATAVI PNV prenatal no.158/iron NEW AUTO RULE Non-Formulary fum/folic acid/omega- 3/dha/epa/fish oil 07/24/2019 magellan safety needles, safety NEW AUTO RULE Non-Formulary needle 07/24/2019 melatonin melatonin NEW AUTO RULE Non-Formulary 07/24/2019 SUDAFED pseudoephedrine hcl NEW AUTO RULE Non-Formulary 07/24/2019 child allergy plus phenylephrine NEW AUTO RULE Non-Formulary congestion hcl/diphenhydramine hcl 07/24/2019 nighttime severe dextromethorphan NEW AUTO RULE Non-Formulary cold-flu hbr/phenylephrine/acetamin ophen/doxylamine 07/24/2019 methylphenidate methylphenidate hcl UM AUTO RULE: AGE Up to 17 yrs old er (la) 07/24/2019 FLUZONE HIGH- influenza virus vaccine trival NEW AUTO RULE Preventative DOSE 2019-2020 split 2019-2020(65 yr up)/pf Drugs

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 305 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/24/2019 ENZADYNE lipase/protease/amylase NEW AUTO RULE Non-Formulary 07/24/2019 TRICARE prenatal vit NEW AUTO RULE Non-Formulary PRENATAL DHA no.156/iron/levomefolate/om ONE -3/dha/epa/fish oil 07/24/2019 ONEVITE multivit-minerals no.67/folic NEW AUTO RULE Non-Formulary acid/alpha lipoic acid/lutein 07/24/2019 heartburn relief magnesium NEW AUTO RULE Non-Formulary carbonate/aluminum hydroxide/alginic acid 07/24/2019 surgiseal twist octyl 2-cyanoacrylate NEW AUTO RULE Non-Formulary 07/24/2019 NEPTUNE ICE lidocaine/menthol/camphor/ NEW AUTO RULE Non-Formulary dimethicone 07/24/2019 nitetime severe dextromethorphan NEW AUTO RULE Non-Formulary cold & flu hbr/phenylephrine/acetamin ophen/doxylamine 07/24/2019 surgiseal stylus octyl 2-cyanoacrylate NEW AUTO RULE Non-Formulary 07/24/2019 chest rub eucalyptus NEW AUTO RULE Non-Formulary oil/menthol/camphor 07/24/2020 ZOLPAK econazole NEW AUTO RULE Non-Formulary nitrate/transparent dressing 07/24/2020 TASOPROL clobetasol propionate/gauze NEW AUTO RULE Non-Formulary bandage/silicone, adhesive 07/24/2020 FLUCELVAX flu vaccine quad 2020- NEW AUTO RULE Preventative QUAD 2020- 2021(4 years and older)cell Drugs 2021 derived/pf 07/24/2020 magnesium magnesium sulfate/dextrose NEW AUTO RULE Non-Formulary sulfate-d5w 5 % in water 07/24/2020 PREDIA magnesium oxide/chromium NEW AUTO RULE Non-Formulary picolinate/grape seed extract

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 306 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/24/2020 diclofenac diclofenac sodium NEW AUTO RULE Non-Formulary sodium 07/24/2020 CERAVE petrolatum,white NEW AUTO RULE Non-Formulary HEALING 07/24/2020 maxi-tuss tr triprolidine NEW AUTO RULE Non-Formulary hcl/pseudoephedrine hcl 07/24/2020 LIPIKAR colloidal oatmeal NEW AUTO RULE Non-Formulary ECZEMA 07/24/2020 BACICAP lactobacillus NEW AUTO RULE Non-Formulary acidophilus,paracasei,planta rum/b.animalis 07/24/2020 lidocaine hcl lidocaine hcl/pf NEW AUTO RULE Non-Formulary 07/24/2020 AFLURIA QUAD influenza virus vaccine NEW AUTO RULE Preventative 2020-2021 quadrivalent 2020-21 (6 mos Drugs and up) 07/24/2020 ritifed triprolidine NEW AUTO RULE Non-Formulary hcl/pseudoephedrine hcl 07/24/2020 virt-gard cyanocobalamin/folic NEW AUTO RULE Non-Formulary acid/pyridoxine 07/24/2020 aprizio pak ii lidocaine/prilocaine NEW AUTO RULE Non-Formulary 07/24/2020 CERAVE ACNE benzoyl peroxide NEW AUTO RULE Non-Formulary 07/24/2020 cerave itch relief pramoxine hcl NEW AUTO RULE Non-Formulary 07/24/2020 topotecan hcl topotecan hcl NEW AUTO RULE Non-Formulary 07/24/2020 ORTIKOS budesonide NEW AUTO RULE NF specialty 07/24/2020 FLUCELVAX flu vaccine quadriv 2020- NEW AUTO RULE Preventative QUAD 2020- 2021(4 years and older)cell Drugs 2021 derived 07/24/2020 eczema care colloidal oatmeal NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 307 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/24/2020 VICKS NYQUIL dextromethorphan NEW AUTO RULE Non-Formulary SEVERE COLD- hbr/phenylephrine/acetamin FLU ophen/doxylamine 07/24/2020 fabb cyanocobalamin/folic NEW AUTO RULE Non-Formulary acid/pyridoxine 07/24/2020 new skin benzethonium chloride NEW AUTO RULE Non-Formulary 07/24/2020 XYLOCAINE- lidocaine hcl/pf NEW AUTO RULE Non-Formulary MPF 07/24/2020 arctic relief menthol/camphor NEW AUTO RULE Non-Formulary 07/24/2020 FREEZE IT menthol/camphor NEW AUTO RULE Non-Formulary 07/24/2020 effaclar (salicylic salicylic acid NEW AUTO RULE Non-Formulary acid) 07/24/2020 prizopak ii lidocaine/prilocaine NEW AUTO RULE Non-Formulary 07/24/2020 AFLURIA QUAD influenza virus vaccine NEW AUTO RULE Preventative 2020-21 (3YR quadrivalent 2020-21 (36 Drugs UP) mos up)/pf 07/24/2020 AFLURIA QUAD influenza virus vaccine NEW AUTO RULE Preventative 2020-21 (6- quadrival 2020-21 (6 mos- Drugs 35MO) 35 mos)/pf 07/31/2019 secura antifungal miconazole nitrate NEW AUTO RULE Non-Formulary 07/31/2019 antacid extra calcium carbonate NEW AUTO RULE Non-Formulary strength 07/31/2019 evac-u-gen sennosides NEW AUTO RULE Non-Formulary 07/31/2019 KOVALTRY antihemophilic factor (fviii) NEW AUTO RULE Non-Formulary recombinant,full length 07/31/2019 vegetable sennosides NEW AUTO RULE Non-Formulary laxative 07/31/2019 dimenhydrinate dimenhydrinate NEW AUTO RULE Non-Formulary 07/31/2019 acetaminophen acetaminophen NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 308 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/31/2019 smooth antacid calcium carbonate NEW AUTO RULE Non-Formulary 07/31/2019 calcium calcium carbonate NEW AUTO RULE Non-Formulary carbonate 07/31/2019 leva set lidocaine/prilocaine NEW AUTO RULE Non-Formulary 07/31/2019 meclizine hcl meclizine hcl NEW AUTO RULE Non-Formulary 07/31/2019 allergy+congestio cetirizine NEW AUTO RULE Non-Formulary n relief-d hcl/pseudoephedrine hcl 07/31/2019 baza antifungal miconazole nitrate NEW AUTO RULE Non-Formulary 07/31/2019 dss docusate sodium NEW AUTO RULE Non-Formulary 07/31/2019 neosporin neomycin sulfate/bacitracin NEW AUTO RULE Non-Formulary zinc/polymyxin b 07/31/2019 ramelteon ramelteon NEW AUTO RULE Non-formulary 07/31/2019 DOK docusate sodium NEW AUTO RULE Non-Formulary 07/31/2019 pediacare fever acetaminophen NEW AUTO RULE Non-Formulary reducer 07/31/2019 micatin miconazole nitrate NEW AUTO RULE Non-Formulary 07/31/2019 CHILDREN'S diphenhydramine NEW AUTO RULE Non-Formulary MUCINEX hcl/phenylephrine hcl/acetaminophen 07/31/2019 banophen diphenhydramine hcl NEW AUTO RULE Non-Formulary 07/31/2019 hemorrhoidal witch hazel NEW AUTO RULE Non-Formulary hygiene 07/31/2019 stool softener sennosides/docusate NEW AUTO RULE Non-Formulary sodium 07/31/2019 dramamine less meclizine hcl NEW AUTO RULE Non-Formulary drowsy 07/31/2019 all day allergy-d cetirizine NEW AUTO RULE Non-Formulary hcl/pseudoephedrine hcl

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 309 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/31/2019 LANOLIN modified lanolin NEW AUTO RULE Non-Formulary 07/31/2019 ALKERAN melphalan hcl NEW AUTO RULE Non-Formulary 07/31/2019 one step pregnancy test kit NEW AUTO RULE Non-Formulary pregnancy test 07/31/2019 infants' fever-pain acetaminophen NEW AUTO RULE Non-Formulary reliever 07/31/2019 lidopril lidocaine/prilocaine NEW AUTO RULE Non-Formulary 07/31/2019 CHARCOCAPS activated charcoal NEW AUTO RULE Non-Formulary 07/31/2019 docusate sodium- sennosides/docusate NEW AUTO RULE Non-Formulary senna sodium 07/31/2019 ondansetron hcl ondansetron hcl NEW AUTO RULE Non-Formulary 07/31/2019 allergy complete- cetirizine NEW AUTO RULE Non-Formulary d hcl/pseudoephedrine hcl 07/31/2019 ropivacaine hcl- ropivacaine hcl in 0.9 % NEW AUTO RULE Non-Formulary 0.9% nacl sodium chloride/pf 07/31/2019 cold & flu relief diphenhydramine NEW AUTO RULE Non-Formulary hcl/phenylephrine hcl/acetaminophen 07/31/2019 infants' pain relief acetaminophen NEW AUTO RULE Non-Formulary 07/31/2019 leucovorin leucovorin calcium NEW AUTO RULE Non-Formulary calcium 07/31/2019 VAZCULEP phenylephrine hcl NEW AUTO RULE Non-Formulary 07/31/2019 nighttime allergy diphenhydramine hcl NEW AUTO RULE Non-Formulary relief 07/31/2019 foaming acne benzoyl peroxide NEW AUTO RULE Non-Formulary face wash 07/31/2019 ZOFRAN ondansetron hcl NEW AUTO RULE Non-Formulary 07/31/2019 b-1 thiamine hcl NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 310 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/31/2019 SENOKOT sennosides NEW AUTO RULE Non-Formulary 07/31/2019 non-aspirin acetaminophen NEW AUTO RULE Non-Formulary 07/31/2019 natural vegetable sennosides NEW AUTO RULE Non-Formulary laxative 07/31/2019 control phosphorated carbohydrate NEW AUTO RULE Non-Formulary (dextrose and fructose) 07/31/2019 bp wash benzoyl peroxide NEW AUTO RULE Non-Formulary 07/31/2019 dermacinrx lidocaine/prilocaine NEW AUTO RULE Non-Formulary prizopak 07/31/2019 CHILD DELSYM diphenhydramine NEW AUTO RULE Non-Formulary COUGH-COLD hcl/phenylephrine hcl/acetaminophen 07/31/2019 children's silapap acetaminophen NEW AUTO RULE Non-Formulary 07/31/2019 CHILDREN'S acetaminophen NEW AUTO RULE Non-Formulary TYLENOL 07/31/2019 herbiomed diphenhydramine NEW AUTO RULE Non-Formulary allergy cold-sinus hcl/phenylephrine hcl/acetaminophen 07/31/2019 noble formula pyrithione zinc NEW AUTO RULE Non-Formulary 07/31/2019 prikaan lite lidocaine/prilocaine NEW AUTO RULE Non-Formulary 07/31/2019 medi-meclizine meclizine hcl NEW AUTO RULE Non-Formulary 07/31/2019 wal-zyr d cetirizine NEW AUTO RULE Non-Formulary hcl/pseudoephedrine hcl 07/31/2019 allergy relief-d cetirizine NEW AUTO RULE Non-Formulary hcl/pseudoephedrine hcl 07/31/2019 ADVATE antihemophilic factor (fviii) NEW AUTO RULE Non-Formulary recombinant,full length 07/31/2019 KATERZIA amlodipine benzoate NEW AUTO RULE Non-formulary 07/31/2019 h2q ubidecarenone NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 311 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/31/2019 wal-dryl allergy diphenhydramine hcl NEW AUTO RULE Non-Formulary 07/31/2019 lido-prilo caine lidocaine/prilocaine NEW AUTO RULE Non-Formulary pack 07/31/2019 heartburn lansoprazole NEW AUTO RULE Non-Formulary treatment 24 hour 07/31/2019 dexamethasone- dexamethasone sod UM AUTO RULE: PA Applies moxifloxacin ph/moxifloxacin hcl in AUTHORIZATION nacl,iso-osmotic/pf 07/31/2019 PEPCID famotidine NEW AUTO RULE Tier 1 07/31/2019 hemorrhoidal witch hazel NEW AUTO RULE Non-Formulary pads 07/31/2019 caldyphen clear pramoxine hcl/zinc acetate NEW AUTO RULE Non-Formulary 07/31/2019 acne control benzoyl peroxide NEW AUTO RULE Non-Formulary cleanser 07/31/2019 smoothlax polyethylene glycol 3350 NEW AUTO RULE Non-Formulary 07/31/2019 MUCINEX FAST- diphenhydramine NEW AUTO RULE Non-Formulary MAX NITE hcl/phenylephrine COLD-FLU hcl/acetaminophen 07/31/2019 lice pyrinyl piperonyl NEW AUTO RULE Non-Formulary shampoo butoxide/pyrethrins 07/31/2019 multivitamin multivitamin- NEW AUTO RULE Non-Formulary women 50 plus minerals/ferrous fumarate/folic acid/lutein 07/31/2019 lice killing piperonyl NEW AUTO RULE Non-Formulary butoxide/pyrethrins 07/31/2019 SENOKOT-S sennosides/docusate NEW AUTO RULE Non-Formulary sodium 07/31/2019 TUMS calcium carbonate NEW AUTO RULE Non-Formulary SMOOTHIES 07/31/2019 DRAMAMINE dimenhydrinate NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 312 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/31/2019 spectravite ultra multivitamin- NEW AUTO RULE Non-Formulary women's minerals/ferrous fumarate/folic acid/lutein 07/31/2019 charcoal, activated charcoal NEW AUTO RULE Non-Formulary activated 07/31/2019 dermacinrx lidocaine/prilocaine NEW AUTO RULE Non-Formulary empricaine 07/31/2019 INFANTS' acetaminophen NEW AUTO RULE Non-Formulary TYLENOL 07/31/2019 fever reducer- acetaminophen NEW AUTO RULE Non-Formulary pain reliever 07/31/2019 allergy medicine diphenhydramine hcl NEW AUTO RULE Non-Formulary 07/31/2019 vitamin b-12 cyanocobalamin (vitamin b- NEW AUTO RULE Non-Formulary 12) 07/31/2019 benadryl allergy diphenhydramine hcl NEW AUTO RULE Non-Formulary 07/31/2019 TUMS calcium carbonate NEW AUTO RULE Non-Formulary 07/31/2019 little remedies acetaminophen NEW AUTO RULE Non-Formulary fever-pain 07/31/2019 vitamin b-1 thiamine mononitrate (vit b1) NEW AUTO RULE Non-Formulary 07/31/2019 iodine iodine/sodium iodide NEW AUTO RULE Non-Formulary 07/31/2019 diphenhist diphenhydramine hcl NEW AUTO RULE Non-Formulary 07/31/2019 acne foaming benzoyl peroxide NEW AUTO RULE Non-Formulary wash 07/31/2019 diphen diphenhydramine hcl NEW AUTO RULE Non-Formulary 07/31/2019 infant fever-pain acetaminophen NEW AUTO RULE Non-Formulary reliever 07/31/2019 col-rite docusate sodium NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 313 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/31/2019 CENTRUM multivitamin- NEW AUTO RULE Non-Formulary SILVER WOMEN minerals/ferrous fumarate/folic acid/lutein 07/31/2019 LODINE etodolac NEW AUTO RULE Non-formulary 07/31/2019 glycolax polyethylene glycol 3350 NEW AUTO RULE Non-Formulary 07/31/2019 bpo-10 benzoyl peroxide NEW AUTO RULE Non-Formulary 07/31/2019 allergy diphenhydramine hcl NEW AUTO RULE Non-Formulary medication 07/31/2019 premier urostomy urostomy pouch NEW AUTO RULE Non-Formulary pouch 07/31/2019 geri-dryl diphenhydramine hcl NEW AUTO RULE Non-Formulary 07/31/2019 aspirin- aspirin/omeprazole NEW AUTO RULE Non-formulary omeprazole 07/31/2019 travel-ease meclizine hcl NEW AUTO RULE Non-Formulary 07/31/2019 powderlax polyethylene glycol 3350 NEW AUTO RULE Non-Formulary 07/31/2019 children's non- acetaminophen NEW AUTO RULE Non-Formulary aspirin 07/31/2019 senexon sennosides NEW AUTO RULE Non-Formulary 07/31/2019 coq-10 ubidecarenone NEW AUTO RULE Non-Formulary 07/31/2019 insulin syringe syringe with NEW AUTO RULE Tier 2 needle,insulin,0.5 ml 07/31/2019 erythromycin erythromycin base NEW AUTO RULE Non-formulary 07/31/2019 infant pain-fever acetaminophen NEW AUTO RULE Non-Formulary 07/31/2019 clean-clear benzoyl peroxide NEW AUTO RULE Non-Formulary continuous control 07/31/2019 PREVACID lansoprazole NEW AUTO RULE Non-Formulary 24HR

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 314 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/31/2019 motion relief meclizine hcl NEW AUTO RULE Non-Formulary 07/31/2019 dexamethasone- dexamethasone sod TERM AUTO RULE moxifloxacin ph/moxifloxacin hcl in nacl,iso-osmotic/pf 07/31/2019 HELIXATE FS antihemophilic factor (fviii) NEW AUTO RULE Non-Formulary recombinant,full length 07/31/2019 nausea relief phosphorated carbohydrate NEW AUTO RULE Non-Formulary (dextrose and fructose) 07/31/2019 motion sickness meclizine hcl NEW AUTO RULE Non-Formulary relief 07/31/2019 aller-tec d cetirizine NEW AUTO RULE Non-Formulary hcl/pseudoephedrine hcl 07/31/2019 prikaan lidocaine/prilocaine NEW AUTO RULE Non-Formulary 07/31/2019 pain relief acetaminophen NEW AUTO RULE Non-Formulary 07/31/2019 calcium antacid calcium carbonate NEW AUTO RULE Non-Formulary 07/31/2019 wal-dram 2 meclizine hcl NEW AUTO RULE Non-Formulary 07/31/2019 century ultimate multivitamin- NEW AUTO RULE Non-Formulary women's minerals/ferrous fumarate/folic acid/lutein 07/31/2019 piperacillin- piperacillin NEW AUTO RULE Non-Formulary tazobactam sodium/tazobactam sodium 07/31/2019 heparin sodium heparin sodium,porcine/pf NEW AUTO RULE Non-Formulary 07/31/2019 lice treatment piperonyl NEW AUTO RULE Non-Formulary butoxide/pyrethrins 07/31/2019 PREVACID lansoprazole NEW AUTO RULE Non-Formulary 07/31/2019 itch relief pramoxine hcl/zinc acetate NEW AUTO RULE Non-Formulary 07/31/2019 premier urostomy ostomy supply NEW AUTO RULE Non-Formulary pouch 07/31/2019 gavilax polyethylene glycol 3350 NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 315 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/31/2019 COLACE 2-IN-1 sennosides/docusate NEW AUTO RULE Non-Formulary sodium 07/31/2019 CALADRYL pramoxine hcl/zinc acetate NEW AUTO RULE Non-Formulary CLEAR 07/31/2019 co q-10 ubidecarenone NEW AUTO RULE Non-Formulary 07/31/2019 daylogic acne benzoyl peroxide NEW AUTO RULE Non-Formulary foaming wash 07/31/2019 children's pain acetaminophen NEW AUTO RULE Non-Formulary relief 07/31/2019 ultimate women's multivitamin- NEW AUTO RULE Non-Formulary complete 50+ minerals/ferrous fumarate/folic acid/lutein 07/31/2019 motion sickness dimenhydrinate NEW AUTO RULE Non-Formulary 07/31/2019 orphenadrine- orphenadrine NEW AUTO RULE Non-formulary aspirin-caffeine citrate/aspirin/caffeine 07/31/2019 medicated pads witch hazel NEW AUTO RULE Non-Formulary 07/31/2019 purelax polyethylene glycol 3350 NEW AUTO RULE Non-Formulary 07/31/2019 early result pregnancy test kit NEW AUTO RULE Non-Formulary pregnancy test 07/31/2019 children's pain acetaminophen NEW AUTO RULE Non-Formulary and fever 07/31/2019 motion sickness meclizine hcl NEW AUTO RULE Non-Formulary 07/31/2019 antacid calcium carbonate NEW AUTO RULE Non-Formulary 07/31/2019 motion sickness ii meclizine hcl NEW AUTO RULE Non-Formulary 07/31/2019 complete allergy diphenhydramine hcl NEW AUTO RULE Non-Formulary 07/31/2019 BUSULFEX busulfan NEW AUTO RULE medical benefit drugs 07/31/2019 travel sickness dimenhydrinate NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 316 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/31/2019 laxacin sennosides/docusate NEW AUTO RULE Non-Formulary sodium 07/31/2019 panoxyl benzoyl peroxide NEW AUTO RULE Non-Formulary 07/31/2019 ZOSYN piperacillin NEW AUTO RULE medical benefit sodium/tazobactam sodium drugs 07/31/2019 allergy diphenhydramine hcl NEW AUTO RULE Non-Formulary 07/31/2019 aller-g-time diphenhydramine hcl NEW AUTO RULE Non-Formulary 07/31/2019 cetiri-d cetirizine NEW AUTO RULE Non-Formulary hcl/pseudoephedrine hcl 07/31/2019 q-sorb co q-10 ubidecarenone NEW AUTO RULE Non-Formulary 07/31/2019 gentlelax polyethylene glycol 3350 NEW AUTO RULE Non-Formulary 07/31/2019 emetrol phosphorated carbohydrate NEW AUTO RULE Non-Formulary (dextrose and fructose) 07/31/2019 b-12 cyanocobalamin (vitamin b- NEW AUTO RULE Non-Formulary 12) 07/31/2019 DORIBAX doripenem NEW AUTO RULE medical benefit drugs 07/31/2019 senna-time s sennosides/docusate NEW AUTO RULE Non-Formulary sodium 07/31/2019 ultracin m menthol NEW AUTO RULE Non-Formulary 07/31/2019 vancomycin hcl vancomycin hcl in water for NEW AUTO RULE Non-Formulary injection (peg-400, nada) 07/31/2019 medicated wipes glycerin/aloe vera/witch NEW AUTO RULE Non-Formulary hazel 07/31/2019 medicated wipes witch hazel NEW AUTO RULE Non-Formulary 07/31/2019 prilolid lidocaine/prilocaine NEW AUTO RULE Non-Formulary 07/31/2019 hemorrhoidal witch hazel NEW AUTO RULE Non-Formulary medicated wipes

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 317 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/31/2019 KANJINTI trastuzumab-anns NEW AUTO RULE Non-Formulary 07/31/2019 child fever acetaminophen NEW AUTO RULE Non-Formulary reducer-pain relvr 07/31/2019 TRICARE prenatal vit DRUG ATTR CHANGE Non-Formulary Non-Formulary PRENATAL DHA no.156/iron/levomefolate/om OVERRIDE ONE -3/dha/epa/fish oil 07/31/2019 benzoyl peroxide benzoyl peroxide NEW AUTO RULE Non-Formulary 07/31/2019 bed mat underpads NEW AUTO RULE Non-Formulary 07/31/2019 aprizio pak lidocaine/prilocaine NEW AUTO RULE Non-Formulary 07/31/2019 preparation h witch hazel NEW AUTO RULE Non-Formulary 07/31/2019 ketamine hcl ketamine hcl NEW AUTO RULE Non-Formulary 07/31/2019 preparation h witch hazel NEW AUTO RULE Non-Formulary totables 07/31/2019 tucks witch hazel NEW AUTO RULE Non-Formulary 07/31/2019 anodyne lpt lidocaine/prilocaine NEW AUTO RULE Non-Formulary 07/31/2019 p-col rite sennosides/docusate NEW AUTO RULE Non-Formulary sodium 07/31/2019 betatemp acetaminophen NEW AUTO RULE Non-Formulary 07/31/2019 anti-fungal cream miconazole nitrate NEW AUTO RULE Non-Formulary 07/31/2019 pregabalin pregabalin NEW AUTO RULE Non-formulary 07/31/2019 senno sennosides NEW AUTO RULE Non-Formulary 07/31/2019 antifungal cream miconazole nitrate NEW AUTO RULE Non-Formulary 07/31/2019 total allergy diphenhydramine hcl NEW AUTO RULE Non-Formulary 07/31/2019 melphalan hcl melphalan hcl NEW AUTO RULE medical benefit drugs 07/31/2019 natural laxative sennosides NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 318 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/31/2019 children's pain acetaminophen NEW AUTO RULE Non-Formulary reliever 07/31/2019 lanolin hydrous lanolin NEW AUTO RULE Non-Formulary 07/31/2019 KOGENATE FS antihemophilic factor (fviii) NEW AUTO RULE Non-Formulary recombinant,full length 07/31/2019 verticalm meclizine hcl NEW AUTO RULE Non-Formulary 07/31/2019 clear anti-itch pramoxine hcl/zinc acetate NEW AUTO RULE Non-Formulary 07/31/2019 children's acetaminophen NEW AUTO RULE Non-Formulary acetaminophen 07/31/2019 cetirizine- cetirizine NEW AUTO RULE Non-Formulary pseudoephedrine hcl/pseudoephedrine hcl er 07/31/2019 stool softener- sennosides/docusate NEW AUTO RULE Non-Formulary stimulant lax sodium 07/31/2019 JEUVEAU prabotulinumtoxina-xvfs NEW AUTO RULE Non-Formulary 07/31/2019 camphor camphor NEW AUTO RULE Non-Formulary 07/31/2019 nortemp acetaminophen NEW AUTO RULE Non-Formulary 07/31/2019 MUCINEX diphenhydramine NEW AUTO RULE Non-Formulary SINUS-MAX hcl/phenylephrine NITE CONGEST hcl/acetaminophen 07/31/2019 lax stool softener sennosides/docusate NEW AUTO RULE Non-Formulary with senna sodium 07/31/2019 miconazole miconazole nitrate NEW AUTO RULE Non-Formulary nitrate 07/31/2019 docusate sodium docusate sodium NEW AUTO RULE Non-Formulary 07/31/2019 vitamin b-1 thiamine hcl NEW AUTO RULE Non-Formulary 07/31/2019 DELSYM diphenhydramine NEW AUTO RULE Non-Formulary COUGH-COLD hcl/phenylephrine NIGHTTIME hcl/acetaminophen

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 319 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/31/2019 doripenem doripenem NEW AUTO RULE Non-Formulary 07/31/2019 formula em phosphorated carbohydrate NEW AUTO RULE Non-Formulary (dextrose and fructose) 07/31/2019 itch relief clear pramoxine hcl/zinc acetate NEW AUTO RULE Non-Formulary 07/31/2019 infant pain relief acetaminophen NEW AUTO RULE Non-Formulary 07/31/2019 smooth calcium carbonate NEW AUTO RULE Non-Formulary dissolving antacid 07/31/2019 prilovix lite plus lidocaine/prilocaine NEW AUTO RULE Non-Formulary 07/31/2019 sen-o-tab sennosides NEW AUTO RULE Non-Formulary 07/31/2019 inzo antifungal miconazole nitrate NEW AUTO RULE Non-Formulary 07/31/2019 central-vite multivitamin- NEW AUTO RULE Non-Formulary women's mature minerals/ferrous fumarate/folic acid/lutein 07/31/2019 mapap acetaminophen NEW AUTO RULE Non-Formulary 07/31/2019 lidopril xr lidocaine/prilocaine NEW AUTO RULE Non-Formulary 07/31/2019 senna laxative sennosides/docusate NEW AUTO RULE Non-Formulary sodium 07/31/2019 laxaclear polyethylene glycol 3350 NEW AUTO RULE Non-Formulary 07/31/2019 laxative peg 3350 polyethylene glycol 3350 NEW AUTO RULE Non-Formulary 07/31/2019 allergy d-12 cetirizine NEW AUTO RULE Non-Formulary hcl/pseudoephedrine hcl 07/31/2019 calamine clear pramoxine hcl/zinc acetate NEW AUTO RULE Non-Formulary 07/31/2019 calahist clear pramoxine hcl/zinc acetate NEW AUTO RULE Non-Formulary 07/31/2019 medi-laxx sennosides/docusate NEW AUTO RULE Non-Formulary sodium 07/31/2019 MVASI bevacizumab-awwb NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 320 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/31/2019 CHILD DELSYM diphenhydramine NEW AUTO RULE Non-Formulary COUGH+COLD hcl/phenylephrine hcl/acetaminophen 07/31/2019 anti-nausea phosphorated carbohydrate NEW AUTO RULE Non-Formulary (dextrose and fructose) 07/31/2019 dermazinc pyrithione zinc NEW AUTO RULE Non-Formulary 07/31/2019 TUMS X-STR calcium carbonate NEW AUTO RULE Non-Formulary 07/31/2019 rid piperonyl NEW AUTO RULE Non-Formulary butoxide/pyrethrins 07/31/2019 ed-apap acetaminophen NEW AUTO RULE Non-Formulary 07/31/2019 ZYRTEC-D cetirizine NEW AUTO RULE Non-Formulary hcl/pseudoephedrine hcl 07/31/2020 mapap cold dextromethorphan NEW AUTO RULE Non-Formulary formula hbr/phenylephrine hcl/acetaminophen 07/31/2020 atopavo emollient combination no.10 NEW AUTO RULE Non-Formulary 07/31/2020 SELRX selenium sulfide NEW AUTO RULE Non-Formulary 07/31/2020 FUSILEV levoleucovorin calcium NEW AUTO RULE Non-Formulary 07/31/2020 psoriasis salicylic acid NEW AUTO RULE Non-Formulary medicated 07/31/2020 daytime cold dextromethorphan NEW AUTO RULE Non-Formulary multi-symptom hbr/phenylephrine hcl/acetaminophen 07/31/2020 therapeutic salicylic acid NEW AUTO RULE Non-Formulary dandruff shampoo 07/31/2020 ed bron gp guaifenesin/phenylephrine NEW AUTO RULE Non-Formulary hcl 07/31/2020 dermarest salicylic acid NEW AUTO RULE Non-Formulary psoriasis

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 321 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/31/2020 children's cold- dextromethorphan NEW AUTO RULE Non-Formulary cough day hbr/phenylephrine hcl 07/31/2020 NICAZEL niacinamide/azelaic NEW AUTO RULE Non-Formulary acid/zinc oxide/vit b6/copper/fa 07/31/2020 diabetic siltussin- guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary dm max str an hbr 07/31/2020 adult wal-tussin guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary dm max an hbr 07/31/2020 adapalene adapalene NEW AUTO RULE Non-Formulary 07/31/2020 theraflu dextromethorphan NEW AUTO RULE Non-Formulary expressmax cold hbr/phenylephrine day hcl/acetaminophen 07/31/2020 selenium selenium NEW AUTO RULE Non-Formulary 07/31/2020 maxi-tuss pe brompheniramine NEW AUTO RULE Non-Formulary maleate/phenylephrine hcl 07/31/2020 avo cream emollient combination no.10 NEW AUTO RULE Non-Formulary 07/31/2020 PENICILLIUM allergenic extract-penicillium NEW AUTO RULE Non-Formulary NOTATUM notatum 07/31/2020 vita-bee with c folic acid/vitamin b complex DRUG ATTR CHANGE Non-Formulary Non-Formulary and vitamin c OVERRIDE 07/31/2020 sonafine emollient combination no.10 NEW AUTO RULE Non-Formulary 07/31/2020 maxi-tuss pe max guaifenesin/phenylephrine NEW AUTO RULE Non-Formulary hcl 07/31/2020 CINQAIR reslizumab NEW AUTO RULE Non-Formulary 07/31/2020 pancuronium pancuronium bromide NEW AUTO RULE Non-Formulary bromide 07/31/2020 maxi-tuss pe jr guaifenesin/phenylephrine NEW AUTO RULE Non-Formulary hcl

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 322 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/31/2020 cold relief multi- dextromethorphan NEW AUTO RULE Non-Formulary symptom hbr/phenylephrine hcl/acetaminophen 07/31/2020 MAXIPIME cefepime hcl NEW AUTO RULE Non-Formulary 07/31/2020 CARBOCAINE mepivacaine hcl/pf NEW AUTO RULE Non-Formulary 07/31/2020 pediacare multi- dextromethorphan NEW AUTO RULE Non-Formulary symptom cold hbr/phenylephrine hcl 07/31/2020 tussin dm max guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary an hbr 07/31/2020 sodium sodium bicarbonate NEW AUTO RULE Non-Formulary bicarbonate- water 07/31/2020 betasal salicylic acid NEW AUTO RULE Non-Formulary 07/31/2020 therapeutic t+plus salicylic acid NEW AUTO RULE Non-Formulary 07/31/2020 magnesium magnesium sulfate in sterile NEW AUTO RULE Non-Formulary sulfate water 07/31/2020 triaminic daytime dextromethorphan NEW AUTO RULE Non-Formulary cold-cough hbr/phenylephrine hcl 07/31/2020 hemorrhoidal lidocaine NEW AUTO RULE Non-Formulary relief 07/31/2020 MEGARED omega-3 fatty NEW AUTO RULE Non-Formulary ADVANCED 4- acids/docosahexaenoic IN-1 GUMMY acid/epa/fish oil 07/31/2020 maxi-tuss g guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary an hbr 07/31/2020 AZADROX silver/urea NEW AUTO RULE Non-Formulary 07/31/2020 adult cough guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary formula dm max an hbr 07/31/2020 AUREOBASIDIU allergenic extract- NEW AUTO RULE Non-Formulary M PULLULANS aureobasidium pullulans

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 323 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/31/2020 prutect emollient combination no.10 NEW AUTO RULE Non-Formulary 07/31/2020 selsun blue salicylic acid NEW AUTO RULE Non-Formulary naturals 07/31/2020 cold multi- dextromethorphan NEW AUTO RULE Non-Formulary symptom hbr/phenylephrine hcl/acetaminophen 07/31/2020 MEGARED KIDS omega-3 fatty NEW AUTO RULE Non-Formulary acids/docosahexaenoic acid/epa/fish oil 07/31/2020 MUCINEX guaifenesin/phenylephrine NEW AUTO RULE Non-Formulary SINUS-MAX hcl/acetaminophen CONGEST-PAIN 07/31/2020 MEGARED krill oil/hyaluronic NEW AUTO RULE Non-Formulary JOINT CARE acid/astaxanthin 07/31/2020 maxi-tuss jr dextromethorphan NEW AUTO RULE Non-Formulary hbr/phenylephrine hcl 07/31/2020 maxi-tuss gmx guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary an hbr 07/31/2020 MEGARED omega-3 fatty NEW AUTO RULE Non-Formulary ADVANCED acids/dha/epa/schizochytriu OMEGA-3 m algal oil ALGAE 07/31/2020 b-complex plus folic acid/vitamin b complex DRUG ATTR CHANGE Non-Formulary Non-Formulary vitamin c and vitamin c OVERRIDE 07/31/2020 DEMSER metyrosine UM AUTO RULE: 16 caps/day QUANTITYCUSTOM 07/31/2020 PRALUENT alirocumab TERM AUTO RULE SYRINGE 07/31/2020 tylenol cold max dextromethorphan NEW AUTO RULE Non-Formulary hbr/phenylephrine hcl/acetaminophen

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 324 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/31/2020 MEGARED krill oil/omega-3 fatty NEW AUTO RULE Non-Formulary OMEGA-3 KRILL acids/dha/epa/phospholipids OIL /astaxan 07/31/2020 BIAFINE emollient combination no.10 NEW AUTO RULE Non-Formulary 07/31/2020 PRALUENT alirocumab NEW AUTO RULE Non-Formulary SYRINGE 07/31/2020 GERBER GOOD infant formula with NEW AUTO RULE Non-Formulary START SOOTHE iron/dha/ara/l. reuteri NOGMO 07/31/2020 pixel covid19 covid-19 test specimen NEW AUTO RULE Non-Formulary home collect kit collection 07/31/2020 ASPERGILLUS allergenic extract-aspergillus NEW AUTO RULE Non-Formulary FUMIGATUS fumigatus 07/31/2020 TECARTUS brexucabtagene autoleucel NEW AUTO RULE Non-Formulary 07/31/2020 ULTRA prenatal vit no.166/iron/folic NEW AUTO RULE Non-Formulary PRENATAL acid/omega-3/dha/epa/fish PLUS DHA oil 07/31/2020 dhs sal salicylic acid NEW AUTO RULE Non-Formulary 07/31/2020 diabetic tussin guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary dm an hbr 07/31/2020 maxi-tuss ac codeine NEW AUTO RULE Tier 1 phosphate/guaifenesin 07/31/2020 child's sudafed dextromethorphan NEW AUTO RULE Non-Formulary pe cough-cold hbr/phenylephrine hcl 07/31/2020 metyrosine metyrosine NEW AUTO RULE NF specialty 07/31/2020 RESCON-GG guaifenesin/phenylephrine NEW AUTO RULE Non-Formulary hcl 07/31/2020 hydrocortisone hydrocortisone acetate NEW AUTO RULE Non-Formulary acetate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 325 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/31/2020 levoleucovorin levoleucovorin calcium NEW AUTO RULE Non-Formulary calcium 07/31/2020 selenium sulfide selenium sulfide NEW AUTO RULE Non-Formulary 07/31/2020 sodium chloride sodium chloride NEW AUTO RULE Non-Formulary 07/31/2020 selsun blue salicylic acid NEW AUTO RULE Non-Formulary 07/31/2020 polocaine-mpf mepivacaine hcl/pf NEW AUTO RULE Non-Formulary 07/31/2020 DERMACINRX capsicum oleoresin NEW AUTO RULE Non-Formulary PENETRAL 07/31/2020 ENBREL etanercept NEW AUTO RULE Tier 4 07/31/2020 cold head dextromethorphan NEW AUTO RULE Non-Formulary congestion hbr/phenylephrine hcl/acetaminophen 07/31/2020 ferrous sulfate ferrous sulfate NEW AUTO RULE Non-Formulary 07/31/2020 sodium sodium bicarbonate NEW AUTO RULE Non-Formulary bicarbonate 07/31/2020 SEA-OMEGA 30 omega-3 fatty NEW AUTO RULE Non-Formulary acids/docosahexaenoic acid/epa/fish oil 07/31/2020 tylenol cold multi- dextromethorphan NEW AUTO RULE Non-Formulary symptom hbr/phenylephrine hcl/acetaminophen

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 326 UPDATED 12/2020 VALUE Drug Formulary Updates

August, 2019

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/01/2019 FARESTON toremifene citrate NEW AUTO RULE NF specialty 08/01/2019 RAPAMUNE NEW AUTO RULE Non-formulary 08/01/2019 LETAIRIS ambrisentan NEW AUTO RULE NF specialty 08/01/2020 PRALUENT PEN alirocumab CHANGE TIER Tier 3 08/04/2020 TRUVADA emtricitabine/tenofovir UM AUTO RULE: ACA Preventive Health disoproxil fumarate 08/04/2020 nortriptyline hcl nortriptyline hcl CHANGE TIER Non-formulary 08/05/2020 MOXEZA moxifloxacin hcl NEW AUTO RULE Non-formulary 08/05/2020 TRUVADA emtricitabine/tenofovir UM AUTO RULE: 1 tab/day; PH disoproxil fumarate QUANTITYCUSTOM effective 1/1/2021 for IFP 08/05/2020 DARAPRIM pyrimethamine NEW AUTO RULE Non-formulary 08/07/2019 trusteel infusion infusion set for insulin pump NEW AUTO RULE Non-Formulary set 08/07/2019 renal vitamin folic acid/vitamin b complex NEW AUTO RULE Non-Formulary and vitamin c 08/07/2019 milk of magnesia magnesium hydroxide NEW AUTO RULE Non-Formulary 08/07/2019 KLARITY-L loteprednol NEW AUTO RULE Non-Formulary (LOTEPREDNOL etabonate/chondroitin -CHONDR) sulfate a sodium/pf 08/07/2019 vicks nyquil dextromethorphan NEW AUTO RULE Non-Formulary hbr/acetaminophen/doxylam ine 08/07/2019 ensure muscle lactose-reduced food NEW AUTO RULE Non-Formulary health 08/07/2019 simethicone simethicone NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 327 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/07/2019 EX-LAX sennosides NEW AUTO RULE Non-Formulary 08/07/2019 KLARITY-L loteprednol NEW AUTO RULE Non-Formulary (LOTEPREDNOL etabonate/chondroitin -CHONDR) sulfate a/pf 08/07/2019 diltiazem-d5w diltiazem hcl/dextrose 5 % in NEW AUTO RULE Non-Formulary water 08/07/2019 mucus relief sev phenylephrine NEW AUTO RULE Non-Formulary congest-cold hcl/dextromethorphan hbr/acetaminophen/guaifen 08/07/2019 capsule #2 gelatin capsules (empty) NEW AUTO RULE Non-Formulary 08/07/2019 capsule #5 gelatin capsules (empty) NEW AUTO RULE Non-Formulary 08/07/2019 capsule #4 gelatin capsules (empty) NEW AUTO RULE Non-Formulary 08/07/2019 capsule #7 gelatin capsules (empty) NEW AUTO RULE Non-Formulary 08/07/2019 little remedies sodium chloride NEW AUTO RULE Non-Formulary stuffy nose 08/07/2019 NATAVI mv-mins no.68/ferrous NEW AUTO RULE Non-Formulary LACTANT fum/folic ac/omega- 3/dha/epa/fish oil 08/07/2019 procare spacer inhaler,assist device with NEW AUTO RULE Tier 2 with adult mask large mask 08/07/2019 calagesic pramoxine hcl/calamine NEW AUTO RULE Non-Formulary 08/07/2019 lidocaine hcl lidocaine hcl NEW AUTO RULE Non-Formulary 08/07/2019 OCTAGAM immune NEW AUTO RULE Non-Formulary globulin,gamm(igg)/maltose/ iga greater than 50 mcg/ml 08/07/2019 capsule coni- gelatin capsules (empty) NEW AUTO RULE Non-Formulary snap 08/07/2019 NIZORAL A-D ketoconazole NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 328 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/07/2019 non-aspirin pm acetaminophen/diphenhydra NEW AUTO RULE Non-Formulary ex-strength mine hcl 08/07/2019 lipodox 50 doxorubicin hcl pegylated NEW AUTO RULE Non-Formulary liposomal 08/07/2019 NIGHT TIME dextromethorphan NEW AUTO RULE Non-Formulary COLD-FLU hbr/acetaminophen/doxylam RELIEF ine 08/07/2019 methadone hcl- methadone hydrochloride in NEW AUTO RULE Non-Formulary 0.9% nacl 0.9 % sodium chloride 08/07/2019 vitamin d3 cholecalciferol (vitamin d3) NEW AUTO RULE Non-Formulary 08/07/2019 laxative pills sennosides NEW AUTO RULE Non-Formulary 08/07/2019 mucinex fast-max phenylephrine NEW AUTO RULE Non-Formulary severe cold hcl/dextromethorphan hbr/acetaminophen/guaifen 08/07/2019 PERDIEM sennosides NEW AUTO RULE Non-Formulary 08/07/2019 DONNATAL phenobarbital/hyoscyamine NEW AUTO RULE NF specialty sulf/atropine sulf/scopolamine hb 08/07/2019 mucus relief phenylephrine NEW AUTO RULE Non-Formulary severe cold hcl/dextromethorphan hbr/acetaminophen/guaifen 08/07/2019 protein nutritional lactose-reduced food NEW AUTO RULE Non-Formulary shake 08/07/2019 CHILDREN'S guaifenesin/phenylephrine NEW AUTO RULE Non-Formulary MUCINEX hcl 08/07/2019 multi-symptom phenylephrine NEW AUTO RULE Non-Formulary cold hcl/dextromethorphan hbr/acetaminophen/guaifen 08/07/2019 high-protein lactose-reduced food NEW AUTO RULE Non-Formulary nutritional shake

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 329 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/07/2019 lipodox doxorubicin hcl pegylated NEW AUTO RULE Non-Formulary liposomal 08/07/2019 ropivacaine- ropivacaine/ketorolac/ketami NEW AUTO RULE Non-Formulary ketorolac- ne ketamine 08/07/2019 NUDERMRXPAK calcipotriene/dimethicone NEW AUTO RULE Non-Formulary 08/07/2019 OCEAN sodium chloride NEW AUTO RULE Non-Formulary 08/07/2019 rena-vite folic acid/vitamin b complex NEW AUTO RULE Non-Formulary and vitamin c 08/07/2019 potassium potassium chloride in water NEW AUTO RULE Non-Formulary chloride-water for injection, sterile 08/07/2019 NEPTUNE ICE lidocaine/menthol/camphor/ NEW AUTO RULE Non-Formulary dimethicone 08/07/2019 tylenol pm extra acetaminophen/diphenhydra NEW AUTO RULE Non-Formulary strength mine hcl 08/07/2019 nutritional shake lactose-reduced food NEW AUTO RULE Non-Formulary plus 08/07/2019 mucinex fast-max phenylephrine NEW AUTO RULE Non-Formulary cold-flu-thrt hcl/dextromethorphan hbr/acetaminophen/guaifen 08/07/2019 nutritional drink lactose-reduced food NEW AUTO RULE Non-Formulary plus 08/07/2019 capsule #11 gelatin capsules (empty) NEW AUTO RULE Non-Formulary 08/07/2019 capsule #10 gelatin capsules (empty) NEW AUTO RULE Non-Formulary 08/07/2019 capsule #00 gelatin capsules (empty) NEW AUTO RULE Non-Formulary 08/07/2019 BAQSIMI glucagon NEW AUTO RULE Tier 3 08/07/2019 hyaluronidase hyaluronidase in sodium NEW AUTO RULE Non-Formulary chloride, iso-osmotic/pf 08/07/2019 nutritional drink lactose-reduced food NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 330 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/07/2019 ensure max lactose-reduced food NEW AUTO RULE Non-Formulary protein 08/07/2019 fast mucus rlf phenylephrine NEW AUTO RULE Non-Formulary cold-flu-throat hcl/dextromethorphan hbr/acetaminophen/guaifen 08/07/2019 monoject prefill sodium chloride 0.9 % NEW AUTO RULE Non-Formulary advanced (flush) 08/07/2019 TYLENOL phenylephrine NEW AUTO RULE Non-Formulary COLD-FLU hcl/dextromethorphan SEVERE hbr/acetaminophen/guaifen 08/07/2019 children's saline sodium chloride NEW AUTO RULE Non-Formulary nasal spray 08/07/2019 ensure active lactose-reduced food NEW AUTO RULE Non-Formulary clear 08/07/2019 heparin sodium- heparin sodium,porcine in NEW AUTO RULE Non-Formulary 0.9% nacl 0.9 % sodium chloride 08/07/2019 ENBREL etanercept UM AUTO RULE: 4 ml/28 days QUANTITYCUSTOM 08/07/2019 saline nasal sodium chloride NEW AUTO RULE Non-Formulary spray 08/07/2019 headache pm acetaminophen/diphenhydra NEW AUTO RULE Non-Formulary formula mine hcl 08/07/2019 ensure active lactose-reduced food NEW AUTO RULE Non-Formulary light 08/07/2019 norepinephrine norepinephrine bitartrate in NEW AUTO RULE Non-Formulary bitar-0.9% nacl 0.9 % sodium chloride 08/07/2019 SYSTANE propylene NEW AUTO RULE Non-Formulary ULTRA glycol/polyethylene glycol 400 08/07/2019 skin protectant a vitamins a and d/white NEW AUTO RULE Non-Formulary and d petrolatum/lanolin

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 331 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/07/2019 DOXIL doxorubicin hcl pegylated NEW AUTO RULE Non-Formulary liposomal 08/07/2019 mapap pm acetaminophen/diphenhydra NEW AUTO RULE Non-Formulary mine hcl 08/07/2019 ensure active lactose-reduced food NEW AUTO RULE Non-Formulary high protein 08/07/2019 procare humidifier NEW AUTO RULE Non-Formulary humidifier 08/07/2019 ensure original lactose-reduced food NEW AUTO RULE Non-Formulary 08/07/2019 nutrition plus lactose-reduced food NEW AUTO RULE Non-Formulary 08/07/2019 nutritional shake lactose-reduced food NEW AUTO RULE Non-Formulary 08/07/2019 BOOST lactose-reduced food NEW AUTO RULE Non-Formulary COMPACT 08/07/2019 calamine pramoxine hcl/calamine NEW AUTO RULE Non-Formulary medicated 08/07/2019 pain relief pm acetaminophen/diphenhydra NEW AUTO RULE Non-Formulary mine hcl 08/07/2019 pharbetol acetaminophen NEW AUTO RULE Non-Formulary 08/07/2019 acetadryl acetaminophen/diphenhydra NEW AUTO RULE Non-Formulary mine hcl 08/07/2019 cold-flu severe phenylephrine NEW AUTO RULE Non-Formulary hcl/dextromethorphan hbr/acetaminophen/guaifen 08/07/2019 severe cold multi- phenylephrine NEW AUTO RULE Non-Formulary symptom hcl/dextromethorphan hbr/acetaminophen/guaifen 08/07/2019 cold head phenylephrine NEW AUTO RULE Non-Formulary congestion hcl/dextromethorphan hbr/acetaminophen/guaifen 08/07/2019 NEXIUM esomeprazole magnesium NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 332 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/07/2019 nutrafit lactose-reduced food NEW AUTO RULE Non-Formulary 08/07/2019 BOOST lactose-reduced food NEW AUTO RULE Non-Formulary CALORIE SMART 08/07/2019 CALADRYL pramoxine hcl/calamine NEW AUTO RULE Non-Formulary 08/07/2019 renal-vite folic acid/vitamin b complex NEW AUTO RULE Non-Formulary and vitamin c 08/07/2019 wal-nadol pm acetaminophen/diphenhydra NEW AUTO RULE Non-Formulary mine hcl 08/07/2019 AYR SALINE sodium chloride NEW AUTO RULE Non-Formulary 08/07/2019 lubricating eye carboxymethylcellulose NEW AUTO RULE Non-Formulary drops sodium/glycerin 08/07/2019 diclosaicin diclofenac sodium/capsicum NEW AUTO RULE Non-Formulary oleoresin 08/07/2019 doxorubicin hcl doxorubicin hcl pegylated NEW AUTO RULE Non-Formulary liposome liposomal 08/07/2019 NUBEQA darolutamide NEW AUTO RULE NF specialty 08/07/2019 acetaminophen acetaminophen/diphenhydra NEW AUTO RULE Non-Formulary pm xtra strength mine hcl 08/07/2019 severe cold phenylephrine NEW AUTO RULE Non-Formulary hcl/dextromethorphan hbr/acetaminophen/guaifen 08/07/2019 potassium potassium chloride in water NEW AUTO RULE Non-Formulary chloride for injection, sterile 08/07/2019 fast mucus relief phenylephrine NEW AUTO RULE Non-Formulary severe cold hcl/dextromethorphan hbr/acetaminophen/guaifen 08/07/2019 STAMARIL yellow fever vaccine live/pf NEW AUTO RULE Non-Formulary 08/07/2019 heparin flush heparin sodium,porcine/pf NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 333 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/07/2019 CHILD MUCINEX guaifenesin/phenylephrine NEW AUTO RULE Non-Formulary STUFFY NOSE- hcl CHST 08/07/2019 ultra lubricant eye propylene NEW AUTO RULE Non-Formulary glycol/polyethylene glycol 400 08/07/2019 cold relief head phenylephrine NEW AUTO RULE Non-Formulary congestion hcl/dextromethorphan hbr/acetaminophen/guaifen 08/07/2019 REFRESH carboxymethylcellulose NEW AUTO RULE Non-Formulary RELIEVA sodium/glycerin 08/07/2019 nite time cold-flu dextromethorphan NEW AUTO RULE Non-Formulary relief hbr/acetaminophen/doxylam ine 08/07/2019 PREPARATION phenylephrine hcl/cocoa NEW AUTO RULE Non-Formulary H butter 08/07/2019 pain & fever acetaminophen NEW AUTO RULE Non-Formulary 08/07/2019 ensure compact lactose-reduced food NEW AUTO RULE Non-Formulary 08/07/2019 bupivacaine- bupivacaine/ketorolac/ketam NEW AUTO RULE Non-Formulary ketorolac- ine ketamine 08/07/2019 NEPHRO-VITE folic acid/vitamin b complex NEW AUTO RULE Non-Formulary and vitamin c 08/07/2019 ensure active lactose-reduced food NEW AUTO RULE Non-Formulary protein-muscle 08/07/2019 west-vite with folic acid/vitamin b complex NEW AUTO RULE Non-Formulary folic acid and vitamin c 08/07/2019 normal saline sodium chloride 0.9 % NEW AUTO RULE Non-Formulary flush (flush)

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 334 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/07/2019 SYSTANE propylene NEW AUTO RULE Non-Formulary glycol/polyethylene glycol 400 08/07/2019 gas relief simethicone NEW AUTO RULE Non-Formulary 08/07/2019 KLARITY- azithromycin/chondroitin NEW AUTO RULE Non-Formulary A(AZITHROMYCI sulfate a sodium/pf N-CHONDR) 08/07/2019 ropivacaine- ropivacaine hcl/clonidine NEW AUTO RULE Non-Formulary clonidine-ketorolc hcl/ketorolac tromethamine 08/07/2019 nutri-drink lactose-reduced food NEW AUTO RULE Non-Formulary 08/07/2019 phenobarbital- phenobarbital/hyoscyamine NEW AUTO RULE NF specialty belladonna sulf/atropine sulf/scopolamine hb 08/07/2019 CEPACOL SORE benzocaine/menthol NEW AUTO RULE Non-Formulary THROAT 08/07/2019 saline mist sodium chloride NEW AUTO RULE Non-Formulary 08/07/2019 calamine plus pramoxine hcl/calamine NEW AUTO RULE Non-Formulary 08/07/2019 vitamin a and d vitamins a and d/white NEW AUTO RULE Non-Formulary grx petrolatum/lanolin 08/07/2019 gentamicin- gentamicin sulfate/sodium NEW AUTO RULE Non-Formulary sodium citrate citrate 08/07/2019 liquid nutrition lactose-reduced food NEW AUTO RULE Non-Formulary plus 08/07/2019 full spectrum b folic acid/vitamin b complex NEW AUTO RULE Non-Formulary and vitamin c 08/07/2019 dialyvite 800 folic acid/vitamin b complex NEW AUTO RULE Non-Formulary and vitamin c 08/07/2019 nasal sodium chloride NEW AUTO RULE Non-Formulary moisturizing

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 335 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/07/2019 children's stuffy guaifenesin/phenylephrine NEW AUTO RULE Non-Formulary nose-cold hcl 08/07/2019 cold multi- phenylephrine NEW AUTO RULE Non-Formulary symptom severe hcl/dextromethorphan hbr/acetaminophen/guaifen 08/07/2019 sore throat benzocaine/menthol NEW AUTO RULE Non-Formulary lozenge 08/07/2019 procare spacer inhaler,assist device with NEW AUTO RULE Tier 2 with child mask medium mask 08/07/2019 sodium citrate sodium citrate NEW AUTO RULE Non-Formulary 08/07/2019 NEXIUM 24HR esomeprazole magnesium NEW AUTO RULE Non-Formulary 08/07/2019 REFRESH carboxymethylcellulose NEW AUTO RULE Non-Formulary OPTIVE sodium/glycerin 08/07/2019 little remedies simethicone NEW AUTO RULE Non-Formulary gas relief 08/07/2019 REFRESH carboxymethylcellulose NEW AUTO RULE Non-Formulary REPAIR sodium/glycerin 08/07/2019 altamist sodium chloride NEW AUTO RULE Non-Formulary 08/07/2019 CULTURELLE lactobacillus rhamnosus NEW AUTO RULE Non-Formulary PRO-WELL 3-IN- gg/omega-3 fatty acids/fish 1 oil 08/07/2019 ranitidine hcl ranitidine hcl NEW AUTO RULE Non-Formulary 08/07/2019 acetaminophen acetaminophen NEW AUTO RULE Non-Formulary 08/07/2019 heparin lock heparin sodium,porcine/pf NEW AUTO RULE Non-Formulary 08/07/2019 eazzze the pain acetaminophen/diphenhydra NEW AUTO RULE Non-Formulary mine hcl 08/07/2019 lubricant eye carboxymethylcellulose NEW AUTO RULE Non-Formulary sodium/glycerin

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 336 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/07/2019 vicks dayquil phenylephrine NEW AUTO RULE Non-Formulary severe cold-flu hcl/dextromethorphan hbr/acetaminophen/guaifen 08/07/2019 PRE-ATTACHED lidocaine hcl NEW AUTO RULE Non-Formulary LTA KIT 08/07/2019 liquid nutrition lactose-reduced food NEW AUTO RULE Non-Formulary 08/07/2019 headache relief acetaminophen/diphenhydra NEW AUTO RULE Non-Formulary pm mine hcl 08/07/2019 vitamin a and d vitamins a and d/white NEW AUTO RULE Non-Formulary petrolatum/lanolin 08/07/2019 ensure active lactose-reduced food NEW AUTO RULE Non-Formulary muscle health 08/07/2019 mucus rlf cold-flu- phenylephrine NEW AUTO RULE Non-Formulary sore throat hcl/dextromethorphan hbr/acetaminophen/guaifen 08/07/2019 ENBREL MINI etanercept UM AUTO RULE: 4 ml/ 28 days QUANTITYCUSTOM 08/07/2019 pain reliever pm acetaminophen/diphenhydra NEW AUTO RULE Non-Formulary mine hcl 08/07/2019 shake that ache acetaminophen NEW AUTO RULE Non-Formulary 08/07/2019 laxative sennosides NEW AUTO RULE Non-Formulary 08/07/2019 capsule #000 gelatin capsules (empty) NEW AUTO RULE Non-Formulary 08/07/2019 nutrafit plus lactose-reduced food NEW AUTO RULE Non-Formulary 08/07/2019 anticoagulant sodium citrate NEW AUTO RULE Non-Formulary sodium citrate 08/07/2019 pain & sleep acetaminophen/diphenhydra NEW AUTO RULE Non-Formulary mine hcl 08/07/2019 ensure liquid lactose-reduced food NEW AUTO RULE Non-Formulary 08/07/2019 deep sea sodium chloride NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 337 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/07/2019 IONOSOL MB- electrolyte-mb NEW AUTO RULE Non-Formulary DEXTROSE 5% solution/dextrose 5 % in water 08/07/2019 a and d vitamins a and d/white NEW AUTO RULE Non-Formulary petrolatum/lanolin 08/07/2019 caldyphen pramoxine hcl/calamine NEW AUTO RULE Non-Formulary 08/07/2019 saline nose spray sodium chloride NEW AUTO RULE Non-Formulary 08/07/2019 little remedies sodium chloride NEW AUTO RULE Non-Formulary 08/07/2019 ensure active lactose-reduced food NEW AUTO RULE Non-Formulary heart health 08/07/2019 headache pm acetaminophen/diphenhydra NEW AUTO RULE Non-Formulary mine hcl 08/07/2019 ZANTAC ranitidine hcl NEW AUTO RULE Non-Formulary 08/07/2019 PHILLIPS' MILK magnesium hydroxide NEW AUTO RULE Non-Formulary OF MAGNESIA 08/07/2019 ENBREL etanercept UM AUTO RULE: 4 ml/28 days SURECLICK QUANTITYCUSTOM 08/07/2019 calahist pramoxine hcl/calamine NEW AUTO RULE Non-Formulary 08/07/2019 nite time dextromethorphan NEW AUTO RULE Non-Formulary hbr/acetaminophen/doxylam ine 08/07/2019 cold relief multi- phenylephrine NEW AUTO RULE Non-Formulary symptom hcl/dextromethorphan hbr/acetaminophen/guaifen 08/07/2019 acetaminophen- acetaminophen/diphenhydra NEW AUTO RULE Non-Formulary diphenhydramine mine hcl 08/07/2020 VAGISIL benzocaine/resorcinol NEW AUTO RULE Non-Formulary 08/07/2020 airborne multivit with NEW AUTO RULE Non-Formulary everyday stress minerals/ascorbic away acid/theanine/herb no.310

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 338 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/07/2020 vagicaine benzocaine/resorcinol NEW AUTO RULE Non-Formulary 08/07/2020 calcium 250-vit calcium NEW AUTO RULE Non-Formulary d3 carbonate/cholecalciferol (vitamin d3) 08/07/2020 pediatric comp- nebulizer and compressor NEW AUTO RULE Non-Formulary air compres neb 08/07/2020 VAGISIL benzocaine/resorcinol/aloe NEW AUTO RULE Non-Formulary vera/vitamin e acetate/vit a,d 08/07/2020 vagicaine benzocaine/resorcinol/aloe NEW AUTO RULE Non-Formulary vera/vitamin e acetate/vit a,d 08/07/2020 MOVE FREE cholecalciferol (vit NEW AUTO RULE Non-Formulary ULTRA- d3)/vitamin k2/calcium BORATE-K2-D3 fructoborate 08/07/2020 anti-itch vaginal benzocaine/resorcinol NEW AUTO RULE Non-Formulary 08/07/2020 uristat ultra phenazopyridine hcl NEW AUTO RULE Non-Formulary 08/07/2020 prosilk gel-matrix pad dressing, NEW AUTO RULE Non-Formulary silicone 08/07/2020 sofia sars antigen covid-19 antigen NEW AUTO RULE Non-Formulary fia immunoassay test 08/07/2020 airborne plus multivit with minerals/vitamin NEW AUTO RULE Non-Formulary good rest c/theanine/herb no.310 08/07/2020 MOVE FREE glucosamine/chondroitin/ms NEW AUTO RULE Non-Formulary PLUS MSM-VIT m/d3/hyaluronic acid/cal D3 borate 08/07/2020 oyster shell calcium NEW AUTO RULE Non-Formulary calcium-vit d3 carbonate/cholecalciferol (vitamin d3) 08/07/2020 oyster shell-d calcium NEW AUTO RULE Non-Formulary carbonate/cholecalciferol (vitamin d3)

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 339 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/07/2020 anti-itch vaginal benzocaine/resorcinol/aloe NEW AUTO RULE Non-Formulary max strength vera/vitamin e acetate/vit a,d 08/07/2020 vaginal itch benzocaine/resorcinol NEW AUTO RULE Non-Formulary cream 08/07/2020 EFFACLAR salicylic acid/benzoyl NEW AUTO RULE Non-Formulary ACNE SYSTEM peroxide (3 STEP) 08/07/2020 INVIGOFLEX GS glucosamine sulfate NEW AUTO RULE Non-Formulary dipotassium chlor/boswellia serrata ext 08/07/2020 anti-itch cream benzocaine/resorcinol NEW AUTO RULE Non-Formulary 08/07/2020 MAXIFED TR triprolidine NEW AUTO RULE Non-Formulary hcl/pseudoephedrine hcl 08/07/2020 vivaguard ino blood-glucose meter NEW AUTO RULE Non-Formulary smart gluc meter 08/10/2019 children's acetaminophen DRUG ATTR CHANGE Non-Formulary Non-Formulary acetaminophen OVERRIDE 08/10/2019 vitamin b-12 cyanocobalamin (vitamin b- DRUG ATTR CHANGE Non-Formulary Non-Formulary 12) OVERRIDE 08/14/2019 heartburn relief ranitidine hcl NEW AUTO RULE Non-Formulary 150 08/14/2019 COSMEGEN dactinomycin NEW AUTO RULE Non-Formulary 08/14/2019 lidocaine- lidocaine hcl/phenylephrine NEW AUTO RULE Non-Formulary phenylephrine- hcl/water for injection,sterile water 08/14/2019 children's acetaminophen NEW AUTO RULE Non-Formulary acetaminophen 08/14/2019 rocuronium rocuronium bromide NEW AUTO RULE Non-Formulary bromide 08/14/2019 hydromorphone hydromorphone hcl in 0.9 % NEW AUTO RULE Non-Formulary hcl-0.9% nacl sodium chloride/pf

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 340 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/14/2019 MUCINEX doxylamine/phenylephrine/d NEW AUTO RULE Non-Formulary SINUS-MAX DAY extromethorphan/acetamino NIGHT phen/gg 08/14/2019 phenylephrine- lidocaine hcl/phenylephrine NEW AUTO RULE Non-Formulary lidocaine-water hcl/water for injection,sterile 08/14/2019 non-drowsy loratadine NEW AUTO RULE Non-Formulary allergy 08/14/2019 norepinephrine norepinephrine bitartrate in NEW AUTO RULE Non-Formulary bitar-0.9% nacl 0.9 % sodium chloride 08/14/2019 TURALIO pexidartinib hydrochloride NEW AUTO RULE NF specialty 08/14/2019 FLUMIST QUAD influenza vaccine NEW AUTO RULE Preventative 2019-2020 quadrivalent live 2019-2020 Drugs (2 yrs-49 yrs) 08/14/2019 fentanyl citrate- fentanyl citrate in 0.9 % NEW AUTO RULE Non-Formulary 0.9% nacl sodium chloride/pf 08/14/2019 potassium potassium chloride NEW AUTO RULE Non-Formulary chloride 08/14/2019 XYLOCAINE lidocaine hcl/epinephrine NEW AUTO RULE Non-Formulary WITH EPINEPHRINE 08/14/2019 allerclear loratadine NEW AUTO RULE Non-Formulary 08/14/2019 DE3 DRY EYE omega-3/dha/epa/other NEW AUTO RULE Non-Formulary OMEGA omega-3s/fish oil/vitamin d3 BENEFITS 08/14/2019 wal-itin loratadine NEW AUTO RULE Non-Formulary 08/14/2019 wal-zan 150 ranitidine hcl NEW AUTO RULE Non-Formulary 08/14/2019 VYLEESI bremelanotide acetate NEW AUTO RULE NF specialty 08/14/2019 posaconazole posaconazole NEW AUTO RULE Non-formulary 08/14/2019 remedy miconazole nitrate NEW AUTO RULE Non-Formulary antifungal

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 341 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/14/2019 CHILDREN'S phenylephrine NEW AUTO RULE Non-Formulary MUCINEX hcl/dextromethorphan hbr/acetaminophen/guaifen 08/14/2019 lidocaine hcl- lidocaine hcl/epinephrine NEW AUTO RULE Non-Formulary epinephrine 08/14/2019 ALEVE naproxen sodium NEW AUTO RULE Non-Formulary 08/14/2019 child multi- phenylephrine NEW AUTO RULE Non-Formulary symptom cold- hcl/dextromethorphan fever hbr/acetaminophen/guaifen 08/14/2019 mediproxen naproxen sodium NEW AUTO RULE Non-Formulary 08/14/2019 LUTATHERA lutetium lu 177 dotatate NEW AUTO RULE Non-Formulary 08/14/2019 maxicomfort syringe with NEW AUTO RULE Tier 2 insulin syringe needle,insulin,0.5 ml 08/14/2019 desenex miconazole nitrate NEW AUTO RULE Non-Formulary 08/14/2019 daytime-cold doxylamine/phenylephrine/d NEW AUTO RULE Non-Formulary nighttime-cld-flu extromethorphan/acetamino phen/gg 08/14/2019 A AND D dimethicone/zinc NEW AUTO RULE Non-Formulary DIAPER RASH oxide/vitamins a and d/aloe vera extract 08/14/2019 all day relief naproxen sodium NEW AUTO RULE Non-Formulary 08/14/2019 quinosone mometasone NEW AUTO RULE Non-Formulary furoate/ammonium lactate 08/14/2019 flanax naproxen sodium NEW AUTO RULE Non-Formulary 08/14/2019 potassium potassium chloride NEW AUTO RULE Non-Formulary chloride proamp 08/14/2019 all day pain relief naproxen sodium NEW AUTO RULE Non-Formulary 08/14/2019 CLARITIN loratadine NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 342 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/14/2019 CHILD MUCINEX phenylephrine NEW AUTO RULE Non-Formulary COUGH-COLD- hcl/dextromethorphan FEVER hbr/acetaminophen/guaifen 08/14/2019 ENTEX T guaifenesin/pseudoephedrin NEW AUTO RULE Non-Formulary e hcl 08/14/2019 vitamin b-12 cyanocobalamin (vitamin b- NEW AUTO RULE Non-Formulary 12) 08/14/2019 ropivacaine hcl ropivacaine hcl/pf NEW AUTO RULE Non-Formulary 08/14/2019 IMPACT nutritional therapy, NEW AUTO RULE Non-Formulary ADVANCED compromised immune RECOVERY system, regular 08/14/2019 loradamed loratadine NEW AUTO RULE Non-Formulary 08/14/2019 remedy phytoplex miconazole nitrate NEW AUTO RULE Non-Formulary antifungal 08/14/2019 micro-guard miconazole nitrate NEW AUTO RULE Non-Formulary 08/14/2019 wal-proxen naproxen sodium NEW AUTO RULE Non-Formulary 08/14/2019 maxicomfort ii pen needle, diabetic NEW AUTO RULE Tier 2 pen needle 08/14/2019 MUCINEX FAST- doxylamine/phenylephrine/d NEW AUTO RULE Non-Formulary MAX DY-NT extromethorphan/acetamino CLD-FLU phen/gg 08/14/2019 childrn cold- phenylephrine NEW AUTO RULE Non-Formulary cough-sore throat hcl/dextromethorphan hbr/acetaminophen/guaifen 08/14/2019 athlete's foot miconazole nitrate NEW AUTO RULE Non-Formulary 08/14/2019 child cough-cold- phenylephrine NEW AUTO RULE Non-Formulary sore throat hcl/dextromethorphan hbr/acetaminophen/guaifen 08/14/2019 menthol-zinc menthol/zinc oxide NEW AUTO RULE Non-Formulary oxide

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 343 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/14/2019 NAROPIN ropivacaine hcl/pf NEW AUTO RULE Non-Formulary 08/14/2019 maxicomfort syringe with NEW AUTO RULE Tier 2 insulin syringe needle,disposable,insulin 1 ml 08/14/2019 KEYTRUDA pembrolizumab NEW AUTO RULE Non-Formulary 08/14/2019 ropivacaine hcl- ropivacaine hcl in 0.9 % NEW AUTO RULE Non-Formulary 0.9% nacl sodium chloride/pf 08/14/2019 wrist brace arm brace NEW AUTO RULE Non-Formulary 08/14/2019 band-aid adhesive bandage NEW AUTO RULE Non-Formulary 08/14/2019 zeasorb miconazole nitrate NEW AUTO RULE Non-Formulary 08/14/2019 ZANTAC ranitidine hcl NEW AUTO RULE Non-Formulary 08/14/2019 miconazorb af miconazole nitrate NEW AUTO RULE Non-Formulary 08/14/2019 phenohytro phenobarbital/hyoscyamine UM AUTO RULE: 40 ml/day sulf/atropine QUANTITYCUSTOM sulf/scopolamine hb 08/14/2019 phenobarbital- phenobarbital/hyoscyamine UM AUTO RULE: 40 ml/day belladonna sulf/atropine QUANTITYCUSTOM sulf/scopolamine hb 08/14/2019 b-12 cyanocobalamin (vitamin b- NEW AUTO RULE Non-Formulary 12) 08/14/2019 phenobarbital- phenobarbital/hyoscyamine UM AUTO RULE: 40 ml/day hyosc-atrop-scop sulf/atropine QUANTITYCUSTOM sulf/scopolamine hb 08/14/2019 heartburn relief ranitidine hcl NEW AUTO RULE Non-Formulary 08/14/2019 DONNATAL phenobarbital/hyoscyamine UM AUTO RULE: 40 ml/day sulf/atropine QUANTITYCUSTOM sulf/scopolamine hb 08/14/2019 AMELUZ aminolevulinic acid hcl NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 344 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/14/2019 robitussin cold-flu diphenhydramine NEW AUTO RULE Non-Formulary night hcl/phenylephrine hcl/acetaminophen 08/14/2020 CAPZASIN-HP capsaicin NEW AUTO RULE Non-Formulary 08/14/2020 TAB-A-VITE multivitamin with folic acid NEW AUTO RULE Non-Formulary 08/14/2020 BARHEMSYS amisulpride NEW AUTO RULE Non-Formulary 08/14/2020 folika probiotic lactobacillus NEW AUTO RULE Non-Formulary acidophilus/bifidobacterium animalis 08/14/2020 sesame oil sesame oil NEW AUTO RULE Non-Formulary 08/14/2020 melatin melatonin NEW AUTO RULE Non-Formulary 08/14/2020 multi-vitamin w- pediatric multivitamin NEW AUTO RULE Tier 1 fluoride-iron no.45/sodium fluoride/ferrous sulfate 08/14/2020 DERMACINRX cholecalciferol (vit d3)/folic NEW AUTO RULE Non-Formulary FOLIXAPURE acid 08/14/2020 MONJUVI tafasitamab-cxix NEW AUTO RULE Non-Formulary 08/14/2020 TRICHOPHYTO allergenic extract- NEW AUTO RULE Non-Formulary N trichophyton MENTAGROPHY mentagrophytes TES 08/14/2020 VASOSTRICT vasopressin NEW AUTO RULE Non-Formulary 08/14/2020 vitamin c with ascorbic acid NEW AUTO RULE Non-Formulary rose hips 08/14/2020 folika-nc vitamin b complex/folic NEW AUTO RULE Non-Formulary acid/ascorbic acid/biotin 08/14/2020 arthritis pain relief capsaicin NEW AUTO RULE Non-Formulary 08/14/2020 multivitamin-iron- pediatric multivitamin NEW AUTO RULE Tier 1 fluoride no.45/sodium fluoride/ferrous sulfate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 345 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/14/2020 c-1000 ascorbic acid NEW AUTO RULE Non-Formulary 08/14/2020 airborne multivitamin- NEW AUTO RULE Non-Formulary minerals/ascorbic acid/herbal no.124 08/14/2020 NORMOSOL-R electrolyte-r NEW AUTO RULE Non-Formulary AND DEXTROSE solution/dextrose 5 % in water 08/14/2020 bacitraycin plus bacitracin NEW AUTO RULE Non-Formulary 08/14/2020 DELFLEX-2.5% peritoneal dialysis no.21 NEW AUTO RULE Non-Formulary DEXTROSE with 2.5 % dextrose 08/14/2020 sufentanil citrate sufentanil citrate NEW AUTO RULE Non-Formulary 08/14/2020 HIGH POTENCY multivitamin with folic acid NEW AUTO RULE Non-Formulary MULTIVITAMIN 08/14/2020 tobramycin tobramycin sulfate NEW AUTO RULE Non-Formulary sulfate 08/14/2020 pantoprazole pantoprazole sodium NEW AUTO RULE Non-formulary sodium 08/14/2020 EVRYSDI risdiplam NEW AUTO RULE NF specialty 08/14/2020 CYCLOPHOSPH cyclophosphamide NEW AUTO RULE Non-Formulary AMIDE 08/14/2020 MYCAPSSA octreotide acetate NEW AUTO RULE NF specialty 08/14/2020 INQOVI decitabine/cedazuridine NEW AUTO RULE NF specialty 08/14/2020 methacholine methacholine chloride NEW AUTO RULE Non-Formulary chloride 08/14/2020 zostrix hp foot capsaicin NEW AUTO RULE Non-Formulary 08/14/2020 BREZTRI budesonide/glycopyrrolate/f NEW AUTO RULE Non-formulary AEROSPHERE ormoterol fumarate 08/14/2020 zostrix hp capsaicin NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 346 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/14/2020 moxifloxacin moxifloxacin hcl in sodium NEW AUTO RULE Non-Formulary chloride,iso-osmotic/pf 08/14/2020 vivaguard ino blood glucose calibration NEW AUTO RULE Non-Formulary control solution control solution, normal 08/14/2020 prosilk gel protectives combination no.6 NEW AUTO RULE Non-Formulary 08/14/2020 folixapure cholecalciferol (vit d3)/folic NEW AUTO RULE Non-Formulary acid 08/14/2020 PRODIGEN lactobacillus NEW AUTO RULE Non-Formulary acidophilus/bifidobacterium animalis 08/14/2020 BLENREP belantamab mafodotin-blmf NEW AUTO RULE Non-Formulary 08/14/2020 sod ferric sodium ferric gluconate NEW AUTO RULE Non-Formulary gluconate complex in sucrose complex 08/14/2020 BAFIERTAM monomethyl fumarate NEW AUTO RULE NF specialty 08/14/2020 vitasure vitamin b complex/folic NEW AUTO RULE Non-Formulary acid/ascorbic acid/biotin 08/14/2020 TRONVITE vitamin b complex/folic NEW AUTO RULE Non-Formulary acid/ascorbic acid/biotin 08/14/2020 mcl lidocaine/methyl NEW AUTO RULE Non-Formulary salicylate/camphor 08/14/2020 high potency capsaicin NEW AUTO RULE Non-Formulary capsaicin 08/14/2020 slo-niacin niacin NEW AUTO RULE Non-Formulary 08/14/2020 dulcolax magnesium hydroxide NEW AUTO RULE Non-Formulary 08/14/2020 NEO- phenylephrine hcl NEW AUTO RULE Non-Formulary SYNEPHRINE 08/14/2020 vitamin b-12 cyanocobalamin (vitamin b- NEW AUTO RULE Non-Formulary 12)

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 347 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/14/2020 xvite vitamin b complex/folic NEW AUTO RULE Non-Formulary acid/ascorbic acid/biotin 08/14/2020 vitamin c ascorbic acid NEW AUTO RULE Non-Formulary 08/14/2020 vivaguard ino blood glucose calibration NEW AUTO RULE Non-Formulary control solution control high and low 08/14/2020 folika-t vitamin b complex/folic NEW AUTO RULE Non-Formulary acid/ascorbic acid/biotin 08/14/2020 FERRLECIT sodium ferric gluconate NEW AUTO RULE Non-Formulary complex in sucrose 08/14/2020 c-1000 with rose ascorbic acid NEW AUTO RULE Non-Formulary hips 08/14/2020 ciprofloxacin- ciprofloxacin NEW AUTO RULE Tier 3 dexamethasone hcl/dexamethasone 08/14/2020 vitamin b6 pyridoxine hcl (vitamin b6) NEW AUTO RULE Non-Formulary 08/14/2020 DERMACINRX cholecalciferol (vit d3)/folic NEW AUTO RULE Non-Formulary PUREFOLIX acid 08/14/2020 TETRIX protectives combination no.2 NEW AUTO RULE Non-Formulary 08/14/2020 genicin vita-s vitamin b complex/folic NEW AUTO RULE Non-Formulary acid/ascorbic acid/biotin 08/14/2020 endur-acin niacin NEW AUTO RULE Non-Formulary 08/14/2020 UPNEEQ oxymetazoline hcl/pf NEW AUTO RULE Non-formulary 08/14/2020 nalbuphine hcl nalbuphine hcl NEW AUTO RULE Non-Formulary 08/14/2020 deferasirox deferasirox NEW AUTO RULE NF specialty 08/16/2019 halcinonide halcinonide NEW AUTO RULE Non-formulary 08/16/2019 DUOBRII halobetasol UM AUTO RULE: 200 gm/28 days propionate/tazarotene QUANTITYCUSTOM 08/20/2019 ARIXTRA fondaparinux sodium UM AUTO RULE: 1 syringe/day QUANTITYCUSTOM

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 348 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/20/2019 fondaparinux fondaparinux sodium UM AUTO RULE: 1 syringe/day sodium QUANTITYCUSTOM 08/20/2019 LOVENOX enoxaparin sodium UM AUTO RULE: 2 syringes/day QUANTITYCUSTOM 08/20/2019 enoxaparin enoxaparin sodium UM AUTO RULE: 2 syringes/day sodium QUANTITYCUSTOM 08/20/2019 tramadol hcl- tramadol hcl/acetaminophen UM AUTO RULE: 112 tabs/month acetaminophen QUANTITYCUSTOM 08/20/2019 FRAGMIN dalteparin sodium,porcine UM AUTO RULE: 2 syringes/day QUANTITYCUSTOM 08/20/2019 ULTRACET tramadol hcl/acetaminophen UM AUTO RULE: 112 tabs/month QUANTITYCUSTOM 08/20/2020 AFLURIA QUAD influenza virus vaccine TERM AUTO RULE 2019-20 (3YR quadrivalent 2019-20 (36 UP) mos up)/pf 08/20/2020 FLUCELVAX flu vaccine quadriv 2018- NEW AUTO RULE Non-Formulary QUAD 2018- 2019(4 years and older)cell 2019 derived 08/20/2020 FLUCELVAX flu vaccine quad 2018- NEW AUTO RULE Non-Formulary QUAD 2018- 2019(4 years and older)cell 2019 derived/pf 08/20/2020 FLUMIST QUAD influenza vaccine NEW AUTO RULE Non-Formulary 2019-2020 quadrivalent live 2019-2020 (2 yrs-49 yrs) 08/20/2020 FLUZONE QUAD influenza virus vaccine TERM AUTO RULE 2019-2020 quadrivalent 2019-20 (6 mos and up) 08/20/2020 FLUZONE QUAD influenza virus vaccine NEW AUTO RULE Non-Formulary PEDI 2019-2020 quadrival 2019-20 (6 mos- 35 mos)/pf

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 349 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/20/2020 FLUZONE QUAD influenza virus vaccine NEW AUTO RULE Non-Formulary 2019-2020 quadrivalent 2019-20 (6 mos and up) 08/20/2020 FLUAD 2018- influenza vaccine tvs 2018- NEW AUTO RULE Non-Formulary 2019 19 (65 yr up)/adjuvant mf59c.1/pf 08/20/2020 FLUCELVAX flu vaccine quadriv 2019- NEW AUTO RULE Non-Formulary QUAD 2019- 2020(4 years and older)cell 2020 derived 08/20/2020 FLUCELVAX flu vaccine quadriv 2018- TERM AUTO RULE QUAD 2018- 2019(4 years and older)cell 2019 derived 08/20/2020 FLUZONE QUAD influenza virus vaccine TERM AUTO RULE PEDI 2019-2020 quadrival 2019-20 (6 mos- 35 mos)/pf 08/20/2020 AFLURIA QUAD influenza virus vaccine TERM AUTO RULE 2019-20 (6- quadrival 2019-20 (6 mos- 35MO) 35 mos)/pf 08/20/2020 AFLURIA 2018- influenza virus vaccine TERM AUTO RULE 2019 trivalent 2018-19 (6 mos and older) 08/20/2020 FLUZONE QUAD influenza virus vaccine TERM AUTO RULE 2019-2020 quadrival 2019-2020(6 mos and up)/pf 08/20/2020 FLUMIST QUAD influenza vaccine TERM AUTO RULE 2019-2020 quadrivalent live 2019-2020 (2 yrs-49 yrs) 08/20/2020 FLUZONE QUAD influenza virus vaccine NEW AUTO RULE Non-Formulary 2019-2020 quadrival 2019-2020(6 mos and up)/pf 08/20/2020 FLUCELVAX flu vaccine quadriv 2019- TERM AUTO RULE QUAD 2019- 2020(4 years and older)cell 2020 derived

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 350 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/20/2020 FLUARIX QUAD influenza virus vaccine NEW AUTO RULE Non-Formulary 2019-2020 quadrival 2019-2020(6 mos and up)/pf 08/20/2020 FLUCELVAX flu vaccine quad 2019- NEW AUTO RULE Non-Formulary QUAD 2019- 2020(4 years and older)cell 2020 derived/pf 08/20/2020 FLUAD 2018- influenza vaccine tvs 2018- TERM AUTO RULE 2019 19 (65 yr up)/adjuvant mf59c.1/pf 08/20/2020 FLUAD 2019- influenza vaccine tvs 2019- TERM AUTO RULE 2020 20 (65 yr up)/adjuvant mf59c.1/pf 08/20/2020 FLULAVAL influenza virus vaccine NEW AUTO RULE Non-Formulary QUAD 2019- quadrivalent 2019-20 (6 mos 2020 and up) 08/20/2020 EZ FLU 2018- flu vaccine quad 2018- NEW AUTO RULE Non-Formulary 2019 2019(4 years and older)cell (FLUCELVAX) derived/pf 08/20/2020 FLUZONE HIGH- influenza virus vaccine trival NEW AUTO RULE Non-Formulary DOSE 2019-2020 split 2019-2020(65 yr up)/pf 08/20/2020 AFLURIA 2018- influenza virus vaccine NEW AUTO RULE Non-Formulary 2019 trivalent 2018-19 (6 mos and older) 08/20/2020 FLUZONE HIGH- influenza virus vaccine trival TERM AUTO RULE DOSE 2019-2020 split 2019-2020(65 yr up)/pf 08/20/2020 FLUBLOK QUAD influenza virus vaccine qv TERM AUTO RULE 2019-2020 2019-20(18 yrs and older)rcmb/pf 08/20/2020 FLUAD 2019- influenza vaccine tvs 2019- NEW AUTO RULE Non-Formulary 2020 20 (65 yr up)/adjuvant mf59c.1/pf

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 351 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/20/2020 AFLURIA 2018- influenza virus vaccine tvs TERM AUTO RULE 2019 2018-2019(6 months and older)/pf 08/20/2020 AFLURIA QUAD influenza virus vaccine NEW AUTO RULE Non-Formulary 2019-20 (6- quadrival 2019-20 (6 mos- 35MO) 35 mos)/pf 08/20/2020 AFLURIA QUAD influenza virus vaccine NEW AUTO RULE Non-Formulary 2019-20 (3YR quadrivalent 2019-20 (36 UP) mos up)/pf 08/20/2020 EZ FLU 2018- flu vaccine quad 2018- TERM AUTO RULE 2019 2019(4 years and older)cell (FLUCELVAX) derived/pf 08/20/2020 AFLURIA QUAD influenza virus vaccine NEW AUTO RULE Non-Formulary 2019-2020 quadrivalent 2019-20 (6 mos and up) 08/20/2020 AFLURIA 2018- influenza virus vaccine tvs NEW AUTO RULE Non-Formulary 2019 2018-2019(6 months and older)/pf 08/20/2020 FLUCELVAX flu vaccine quad 2019- TERM AUTO RULE QUAD 2019- 2020(4 years and older)cell 2020 derived/pf 08/20/2020 FLUARIX QUAD influenza virus vaccine TERM AUTO RULE 2019-2020 quadrival 2019-2020(6 mos and up)/pf 08/20/2020 FLUBLOK QUAD influenza virus vaccine qv NEW AUTO RULE Non-Formulary 2019-2020 2019-20(18 yrs and older)rcmb/pf 08/20/2020 AFLURIA QUAD influenza virus vaccine TERM AUTO RULE 2019-2020 quadrivalent 2019-20 (6 mos and up) 08/20/2020 FLULAVAL influenza virus vaccine TERM AUTO RULE QUAD 2019- quadrival 2019-2020(6 mos 2020 and up)/pf

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 352 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/20/2020 FLUCELVAX flu vaccine quad 2018- TERM AUTO RULE QUAD 2018- 2019(4 years and older)cell 2019 derived/pf 08/20/2020 FLULAVAL influenza virus vaccine NEW AUTO RULE Non-Formulary QUAD 2019- quadrival 2019-2020(6 mos 2020 and up)/pf 08/20/2020 FLULAVAL influenza virus vaccine TERM AUTO RULE QUAD 2019- quadrivalent 2019-20 (6 mos 2020 and up) 08/21/2019 VANACLEAR PD triprolidine hcl NEW AUTO RULE Non-Formulary 08/21/2019 DAKIN'S sodium hypochlorite NEW AUTO RULE Non-Formulary 08/21/2019 cold-allergy chlorpheniramine NEW AUTO RULE Non-Formulary maleate/phenylephrine hcl 08/21/2019 sosweet syrup compounding vehicle syrup NEW AUTO RULE Non-Formulary vehicle no.23 08/21/2019 eye drops tetrahydrozoline hcl/dextran NEW AUTO RULE Non-Formulary advanced relief 70/polyethylene gl 400/povidone 08/21/2019 l-arginine arginine NEW AUTO RULE Non-Formulary 08/21/2019 wal-dryl diphenhydramine hcl/zinc NEW AUTO RULE Non-Formulary acetate 08/21/2019 unisom diphenhydramine hcl NEW AUTO RULE Non-Formulary 08/21/2019 tusnel-ex guaifenesin NEW AUTO RULE Non-Formulary 08/21/2019 redness reliever tetrahydrozoline hcl NEW AUTO RULE Non-Formulary 08/21/2019 easypoint needle needles, safety NEW AUTO RULE Tier 2 08/21/2019 complete allergy diphenhydramine hcl NEW AUTO RULE Non-Formulary 08/21/2019 siladryl diphenhydramine hcl NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 353 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/21/2019 heartburn relief magnesium NEW AUTO RULE Non-Formulary carbonate/aluminum hydroxide 08/21/2019 diphedryl allergy diphenhydramine hcl NEW AUTO RULE Non-Formulary 08/21/2019 tussin guaifenesin NEW AUTO RULE Non-Formulary 08/21/2019 geri-dryl diphenhydramine hcl NEW AUTO RULE Non-Formulary 08/21/2019 m-dryl diphenhydramine hcl NEW AUTO RULE Non-Formulary 08/21/2019 ADRENALIN epinephrine NEW AUTO RULE Non-Formulary 08/21/2019 natural daily fiber psyllium husk (with sugar) NEW AUTO RULE Non-Formulary 08/21/2019 children's wal-dryl diphenhydramine hcl NEW AUTO RULE Non-Formulary allergy 08/21/2019 cough syrup guaifenesin NEW AUTO RULE Non-Formulary 08/21/2019 opti-clear tetrahydrozoline hcl NEW AUTO RULE Non-Formulary 08/21/2019 diabetic tussin ex guaifenesin NEW AUTO RULE Non-Formulary 08/21/2019 SCOT-TUSSIN guaifenesin NEW AUTO RULE Non-Formulary 08/21/2019 aa 3.5%-d10w-lo amino acid 3.5 % no.2 NEW AUTO RULE Non-Formulary calcium-heparn ped/dextrose 10 %/calcium gluc/heparin 08/21/2019 VANAHIST PD triprolidine hcl NEW AUTO RULE Non-Formulary 08/21/2019 siltussin sa guaifenesin NEW AUTO RULE Non-Formulary 08/21/2019 children's mucus guaifenesin NEW AUTO RULE Non-Formulary relief 08/21/2019 TYGACIL tigecycline NEW AUTO RULE Non-Formulary 08/21/2019 tussin honey guaifenesin NEW AUTO RULE Non-Formulary 08/21/2019 phenaseptic phenol NEW AUTO RULE Non-Formulary 08/21/2019 natural fiber psyllium husk (with sugar) NEW AUTO RULE Non-Formulary laxative

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 354 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/21/2019 CYSTEX PLUS methenamine/sodium NEW AUTO RULE Non-Formulary salicylate 08/21/2019 KLARITY- betamethasone sodium NEW AUTO RULE Non-Formulary B(BETAMETHAS phos/chondroitin sulfate a ONE-CHOND) sodium/pf 08/21/2019 robafen guaifenesin NEW AUTO RULE Non-Formulary 08/21/2019 konsyl psyllium husk (with sugar) NEW AUTO RULE Non-Formulary 08/21/2019 wal-som diphenhydramine hcl NEW AUTO RULE Non-Formulary 08/21/2019 throat spray phenol NEW AUTO RULE Non-Formulary 08/21/2019 diphedryl diphenhydramine hcl NEW AUTO RULE Non-Formulary 08/21/2019 sore throat spray phenol NEW AUTO RULE Non-Formulary 08/21/2019 sleep aid diphenhydramine hcl NEW AUTO RULE Non-Formulary 08/21/2019 webcol alcohol antiseptic pads NEW AUTO RULE Non-Formulary 08/21/2019 alcohol wipes alcohol antiseptic pads NEW AUTO RULE Non-Formulary 08/21/2019 suphedrine pe chlorpheniramine NEW AUTO RULE Non-Formulary sinus-allergy maleate/phenylephrine hcl 08/21/2019 zinc oxide zinc oxide NEW AUTO RULE Non-Formulary 08/21/2019 REGULOID psyllium husk (with sugar) NEW AUTO RULE Non-Formulary 08/21/2019 PEDIALYTE electrolytes/dextrose NEW AUTO RULE Non-Formulary ELECTROLYTE SINGLES 08/21/2019 cough drops menthol NEW AUTO RULE Non-Formulary 08/21/2019 PEDIACLEAR-8 pyrilamine maleate NEW AUTO RULE Non-Formulary 08/21/2019 azo urinary tract methenamine/sodium NEW AUTO RULE Non-Formulary defense salicylate 08/21/2019 dibucaine dibucaine NEW AUTO RULE Non-Formulary 08/21/2019 hailey norethindrone acetate- NEW AUTO RULE Tier 1 ethinyl estradiol

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 355 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/21/2019 fiber therapy psyllium husk (with sugar) NEW AUTO RULE Non-Formulary 08/21/2019 sure comfort alcohol antiseptic pads NEW AUTO RULE Non-Formulary alcohol 08/21/2019 atuss da brompheniramine NEW AUTO RULE Non-Formulary maleate/pseudoephedrine hcl/chlophedianol 08/21/2019 GAVISCON magnesium NEW AUTO RULE Non-Formulary carbonate/aluminum hydroxide 08/21/2019 droplet insulin syringe with NEW AUTO RULE Tier 2 syringe needle,disposable,insulin 1 ml 08/21/2019 wal-tussin guaifenesin NEW AUTO RULE Non-Formulary 08/21/2019 tussin chest guaifenesin NEW AUTO RULE Non-Formulary congestion 08/21/2019 benadryl itch diphenhydramine hcl/zinc NEW AUTO RULE Non-Formulary stopping acetate 08/21/2019 pip lancet lancets NEW AUTO RULE Tier 2 08/21/2019 single use swab alcohol antiseptic pads NEW AUTO RULE Non-Formulary 08/21/2019 easy touch alcohol antiseptic pads NEW AUTO RULE Non-Formulary alcohol prep pads 08/21/2019 child mucinex guaifenesin NEW AUTO RULE Non-Formulary chest congestion 08/21/2019 banophen anti- diphenhydramine hcl/zinc NEW AUTO RULE Non-Formulary itch acetate 08/21/2019 A AND D dimethicone/zinc NEW AUTO RULE Non-Formulary DIAPER RASH oxide/vitamins a and d/aloe vera extract 08/21/2019 microgestin norethindrone acetate- NEW AUTO RULE Tier 1 ethinyl estradiol

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 356 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/21/2019 ultilet alcohol alcohol antiseptic pads NEW AUTO RULE Non-Formulary swab 08/21/2019 KAMDOY lidocaine hcl/palm oil NEW AUTO RULE Non-Formulary 08/21/2019 ri-tussin guaifenesin NEW AUTO RULE Non-Formulary 08/21/2019 sleeping diphenhydramine hcl NEW AUTO RULE Non-Formulary 08/21/2019 geri-tussin guaifenesin NEW AUTO RULE Non-Formulary 08/21/2019 itch relief diphenhydramine hcl/zinc NEW AUTO RULE Non-Formulary acetate 08/21/2019 CORICIDIN HBP dextromethorphan NEW AUTO RULE Non-Formulary MAX STRENGTH hbr/acetaminophen/chlorphe FLU niramine maleate 08/21/2019 ADVIL ibuprofen NEW AUTO RULE Non-Formulary 08/21/2019 allergy diphenhydramine hcl NEW AUTO RULE Non-Formulary 08/21/2019 ed a-hist chlorpheniramine NEW AUTO RULE Non-Formulary maleate/phenylephrine hcl 08/21/2019 little remedies 0.9 % sodium chloride NEW AUTO RULE Non-Formulary sterile saline 08/21/2019 QUINIXIL mometasone NEW AUTO RULE Non-Formulary furoate/dimethicone 08/21/2019 vitamin b-12 cyanocobalamin (vitamin b- NEW AUTO RULE Non-Formulary 12) 08/21/2019 CORLANOR ivabradine hcl NEW AUTO RULE Non-formulary 08/21/2019 advanced tetrahydrozoline hcl/dextran NEW AUTO RULE Non-Formulary formula eye 70/polyethylene gl drops 400/povidone 08/21/2019 amino acid 3.5%- amino acid 3.5 % comb no.2 NEW AUTO RULE Non-Formulary d10w (pediatric) in 10 % dextrose 08/21/2019 VANAMINE PD diphenhydramine hcl NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 357 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/21/2019 ADVIL LIQUI- ibuprofen NEW AUTO RULE Non-Formulary GELS 08/21/2019 multihealth fiber psyllium husk (with sugar) NEW AUTO RULE Non-Formulary 08/21/2019 fiber psyllium husk (with sugar) NEW AUTO RULE Non-Formulary 08/21/2019 diphenhydramine diphenhydramine hcl NEW AUTO RULE Non-Formulary hcl 08/21/2019 curity alcohol alcohol antiseptic pads NEW AUTO RULE Non-Formulary preps 08/21/2019 sinus-allergy chlorpheniramine NEW AUTO RULE Non-Formulary maleate/phenylephrine hcl 08/21/2019 triprolidine hcl triprolidine hcl NEW AUTO RULE Non-Formulary 08/21/2019 alcohol pads alcohol antiseptic pads NEW AUTO RULE Non-Formulary 08/21/2019 banophen diphenhydramine hcl NEW AUTO RULE Non-Formulary 08/21/2019 metamucil psyllium husk (with sugar) NEW AUTO RULE Non-Formulary 08/21/2019 m-pap acetaminophen NEW AUTO RULE Non-Formulary 08/21/2019 amino acid 3.5%- amino acid 3.5 % no.2 NEW AUTO RULE Non-Formulary d10w-heparin pediatric/dextrose 10 %/heparin 08/21/2019 anti-itch diphenhydramine hcl/zinc NEW AUTO RULE Non-Formulary acetate 08/21/2019 aa 3%-d5w- amino acid 3 % comb NEW AUTO RULE Non-Formulary calcium-heparin no.2(pedi)/d5w/calcium gluconate/heparin 08/21/2019 chloraseptic phenol NEW AUTO RULE Non-Formulary 08/21/2019 eye drops tetrahydrozoline hcl/dextran NEW AUTO RULE Non-Formulary 70/polyethylene gl 400/povidone 08/21/2019 wal-mucil psyllium husk (with sugar) NEW AUTO RULE Non-Formulary 08/21/2019 wal-profen ibuprofen NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 358 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/21/2019 LMR PLUS lidocaine/menthol NEW AUTO RULE Non-Formulary 08/21/2019 vegetable lax- sennosides/docusate NEW AUTO RULE Non-Formulary stool softener sodium 08/21/2019 natural vegetable psyllium husk (with sugar) NEW AUTO RULE Non-Formulary powder 08/21/2019 children's allergy diphenhydramine hcl NEW AUTO RULE Non-Formulary relief 08/21/2019 oralyte electrolytes/dextrose NEW AUTO RULE Non-Formulary 08/21/2019 wal-dryl allergy diphenhydramine hcl NEW AUTO RULE Non-Formulary 08/21/2019 expectorant guaifenesin NEW AUTO RULE Non-Formulary 08/21/2019 iv prep wipes alcohol antiseptic pads NEW AUTO RULE Non-Formulary 08/21/2019 ora relief phenol NEW AUTO RULE Non-Formulary 08/21/2019 nighttime sleep diphenhydramine hcl NEW AUTO RULE Non-Formulary gel 08/21/2019 pro comfort alcohol antiseptic pads NEW AUTO RULE Non-Formulary alcohol pads 08/21/2019 diphenhist diphenhydramine hcl NEW AUTO RULE Non-Formulary 08/21/2019 expectorant guaifenesin NEW AUTO RULE Non-Formulary cough syrup 08/21/2019 natural fiber psyllium husk (with sugar) NEW AUTO RULE Non-Formulary 08/21/2019 allergy medicine diphenhydramine hcl NEW AUTO RULE Non-Formulary 08/21/2019 ceftriaxone ceftriaxone sodium NEW AUTO RULE medical benefit drugs 08/21/2019 PEDIACLEAR triprolidine hcl NEW AUTO RULE Non-Formulary ALLERGY 08/21/2019 lactated ringers ringer's solution,lactated NEW AUTO RULE Non-Formulary 08/21/2019 easy comfort pen pen needle, diabetic NEW AUTO RULE Tier 2 needle

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 359 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/21/2019 diabetic siltussin guaifenesin NEW AUTO RULE Non-Formulary das-na 08/21/2019 caretouch alcohol alcohol antiseptic pads NEW AUTO RULE Non-Formulary prep pad 08/21/2019 heartburn antacid magnesium NEW AUTO RULE Non-Formulary carbonate/aluminum hydroxide 08/21/2019 VAROPHEN diclofenac sodium/methyl NEW AUTO RULE Non-Formulary salicylate/menthol 08/21/2019 sinus pe plus chlorpheniramine NEW AUTO RULE Non-Formulary allergy maleate/phenylephrine hcl 08/21/2019 iv antiseptic alcohol antiseptic pads NEW AUTO RULE Non-Formulary wipes 08/21/2019 altazine tetrahydrozoline hcl NEW AUTO RULE Non-Formulary 08/21/2019 h-chlor 12 sodium hypochlorite NEW AUTO RULE Non-Formulary 08/21/2019 PEDIACLEAR diphenhydramine hcl NEW AUTO RULE Non-Formulary COUGH 08/21/2019 FERRIPROX deferiprone NEW AUTO RULE NF specialty 08/21/2019 guaifenesin guaifenesin NEW AUTO RULE Non-Formulary 08/21/2019 cardioplegia del cardioplegic solution no.16 NEW AUTO RULE Non-Formulary nido formula 08/21/2019 suphedrine pe chlorpheniramine NEW AUTO RULE Non-Formulary cold-allergy maleate/phenylephrine hcl 08/21/2019 dexamethasone dexamethasone sodium NEW AUTO RULE Non-Formulary sodium phosphate phosphate 08/21/2019 aa 3.5%-d10w- amino acid 3.5 % no.2 NEW AUTO RULE Non-Formulary calcium-heparin ped/dextrose 10 %/calcium gluc/heparin 08/21/2019 hydralazine hcl hydralazine hcl NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 360 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/21/2019 oral relief phenol NEW AUTO RULE Non-Formulary 08/21/2019 cardioplegia del cardioplegic solution no.25 NEW AUTO RULE Non-Formulary nido formula 08/21/2019 pseudoephedrine pseudoephedrine hcl NEW AUTO RULE Non-Formulary hcl 08/21/2019 antacid extra magnesium NEW AUTO RULE Non-Formulary strength carbonate/aluminum hydroxide 08/21/2019 alcohol prep pads alcohol antiseptic pads NEW AUTO RULE Non-Formulary 08/21/2019 lemon flavor lemon flavor extract NEW AUTO RULE Non-Formulary extract 08/21/2019 wal-phed pe chlorpheniramine NEW AUTO RULE Non-Formulary sinus-allergy maleate/phenylephrine hcl 08/21/2019 PEDIALYTE electrolytes/dextrose NEW AUTO RULE Non-Formulary 08/21/2019 sinus-allergy pe chlorpheniramine NEW AUTO RULE Non-Formulary maleate/phenylephrine hcl 08/21/2019 sterile eye drops tetrahydrozoline hcl NEW AUTO RULE Non-Formulary 08/21/2019 nighttime sleep diphenhydramine hcl NEW AUTO RULE Non-Formulary aid 08/21/2019 adult wal-tussin guaifenesin NEW AUTO RULE Non-Formulary 08/21/2019 PEDIALYTE electrolytes/dextrose NEW AUTO RULE Non-Formulary ADVANCED CARE 08/21/2019 VENLAFAXINE venlafaxine hcl NEW AUTO RULE Non-formulary HCL ER 08/21/2019 PEDIACLEAR triprolidine hcl NEW AUTO RULE Non-Formulary PD 08/21/2019 adult tussin chest guaifenesin NEW AUTO RULE Non-Formulary congestion

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 361 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/21/2019 ADVIL ibuprofen NEW AUTO RULE Non-Formulary 08/21/2019 m-hist pd triprolidine hcl NEW AUTO RULE Non-Formulary 08/21/2019 acid gone magnesium NEW AUTO RULE Non-Formulary carbonate/aluminum hydroxide 08/21/2019 HALLS menthol NEW AUTO RULE Non-Formulary 08/21/2019 y-tuss brompheniramine NEW AUTO RULE Non-Formulary maleate/pseudoephedrine hcl/chlophedianol 08/21/2019 ENFAMIL electrolytes/dextrose NEW AUTO RULE Non-Formulary ENFALYTE 08/21/2019 aa 3%-d5w-low amino acid 3 % comb NEW AUTO RULE Non-Formulary calcium-heparin no.2(pedi)/d5w/calcium gluconate/heparin 08/21/2019 daily fiber psyllium husk (with sugar) NEW AUTO RULE Non-Formulary 08/21/2019 allergy relief diphenhydramine hcl NEW AUTO RULE Non-Formulary 08/21/2019 sure-prep alcohol alcohol antiseptic pads NEW AUTO RULE Non-Formulary prep pads 08/21/2019 droplet insulin syringe with NEW AUTO RULE Tier 2 syringe needle,insulin,0.3 ml 08/21/2019 SCOT-TUSSIN guaifenesin NEW AUTO RULE Non-Formulary EXPECTORANT 08/21/2019 COMETRIQ cabozantinib s-malate UM AUTO RULE: Specialty Drug SPECIALTY 08/21/2019 droplet insulin syringe with needle,insulin NEW AUTO RULE Tier 2 syringe 0.5 ml (half unit mark) 08/21/2019 VISINE tetrahydrozoline hcl/dextran NEW AUTO RULE Non-Formulary ADVANCED 70/polyethylene gl 400/povidone

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 362 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/21/2019 tussin mucus- guaifenesin NEW AUTO RULE Non-Formulary chest congestion 08/21/2019 geri-mucil psyllium husk (with sugar) NEW AUTO RULE Non-Formulary 08/21/2019 COMETRIQ cabozantinib s-malate TERM AUTO RULE 08/21/2019 easy feed electric breast pump NEW AUTO RULE Non-Formulary breast pump 08/21/2019 wal-mucil natural psyllium husk (with sugar) NEW AUTO RULE Non-Formulary fiber lax 08/21/2019 pediatric freezer electrolytes/dextrose NEW AUTO RULE Non-Formulary pops 08/21/2019 visine tetrahydrozoline hcl NEW AUTO RULE Non-Formulary 08/21/2019 cold-allergy pe chlorpheniramine NEW AUTO RULE Non-Formulary maleate/phenylephrine hcl 08/21/2019 ropivacaine hcl- ropivacaine hcl in 0.9 % NEW AUTO RULE Non-Formulary 0.9% nacl sodium chloride/pf 08/21/2019 pediatric electrolytes/dextrose NEW AUTO RULE Non-Formulary electrolyte 08/21/2019 lidocaine lidocaine NEW AUTO RULE Non-Formulary 08/21/2019 incontrol alcohol alcohol antiseptic pads NEW AUTO RULE Non-Formulary pads 08/21/2020 c-500 ascorbic acid NEW AUTO RULE Non-Formulary 08/21/2020 dimethyl dimethyl fumarate NEW AUTO RULE NF specialty fumarate 08/21/2020 nitetime multi- dextromethorphan NEW AUTO RULE Non-Formulary symptom hbr/acetaminophen/doxylam ine 08/21/2020 FORTAZ ceftazidime NEW AUTO RULE Non-Formulary 08/21/2020 ultra b-100 vitamin b complex NEW AUTO RULE Non-Formulary complex

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 363 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/21/2020 nighttime cough dextromethorphan NEW AUTO RULE Non-Formulary & sore throat hbr/acetaminophen/doxylam ine 08/21/2020 ceftazidime ceftazidime NEW AUTO RULE Non-Formulary 08/21/2020 easy trak ii test blood sugar diagnostic NEW AUTO RULE Non-formulary strip 08/21/2020 contac cold-flu dextromethorphan NEW AUTO RULE Non-Formulary night hbr/acetaminophen/doxylam ine 08/21/2020 wal-flu severe dextromethorphan NEW AUTO RULE Non-Formulary cold-cough hbr/phenylephrine hcl/acetaminophen 08/21/2020 ENSPRYNG satralizumab-mwge NEW AUTO RULE NF specialty 08/21/2020 sure-test blood glucose calibration NEW AUTO RULE Non-Formulary easyplus mini control solution, normal 08/21/2020 cold-flu relief dextromethorphan NEW AUTO RULE Non-Formulary hbr/acetaminophen/doxylam ine 08/21/2020 cough & sore dextromethorphan NEW AUTO RULE Non-Formulary throat hbr/acetaminophen/doxylam ine 08/21/2020 mononessa norgestimate-ethinyl NEW AUTO RULE Tier 1 estradiol 08/21/2020 vitamin b vitamin b complex NEW AUTO RULE Non-Formulary complex 08/21/2020 VICKS dextromethorphan NEW AUTO RULE Non-Formulary DAYQUIL- hbr/phenylephrine/acetamin NYQUIL ophen/doxylamine 08/21/2020 inavix diclofenac sodium/capsaicin NEW AUTO RULE Non-Formulary 08/21/2020 EPICERAM emollient combination no.32 NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 364 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/21/2020 minimed quick infusion set for insulin pump NEW AUTO RULE Non-Formulary set 08/21/2020 b complex vitamin b complex NEW AUTO RULE Non-Formulary 08/21/2020 flu-severe cold- dextromethorphan NEW AUTO RULE Non-Formulary cough hbr/phenylephrine hcl/acetaminophen 08/21/2020 severe cold- dextromethorphan NEW AUTO RULE Non-Formulary cough-flu hbr/phenylephrine hcl/acetaminophen 08/21/2020 EPICOCCUM allergenic extract-epicoccum NEW AUTO RULE Non-Formulary NIGRUM nigrum 08/21/2020 glucose control blood glucose calibration NEW AUTO RULE Non-Formulary control solution, normal 08/21/2020 refissa tretinoin/emollient base NEW AUTO RULE Non-Formulary 08/21/2020 ZCORT dexamethasone NEW AUTO RULE Non-formulary 08/21/2020 night time cold-flu dextromethorphan NEW AUTO RULE Non-Formulary relief hbr/acetaminophen/doxylam ine 08/21/2020 vitamin c ascorbic acid/ascorbate NEW AUTO RULE Non-Formulary sodium 08/21/2020 easy trak ii blood glucose calibration NEW AUTO RULE Non-Formulary control solution control solution, normal 08/21/2020 vitamin c ascorbic acid NEW AUTO RULE Non-Formulary 08/21/2020 allergy & sinus phenylephrine NEW AUTO RULE Non-Formulary relief hcl/diphenhydramine hcl 08/21/2020 VILTEPSO viltolarsen NEW AUTO RULE Non-Formulary 08/21/2020 balanced b-50 vitamin b complex NEW AUTO RULE Non-Formulary 08/21/2020 BENADRYL phenylephrine NEW AUTO RULE Non-Formulary ALLERGY PLUS hcl/diphenhydramine hcl CONGEST

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 365 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/21/2020 COROMEGA fish oil/omega-3 fatty NEW AUTO RULE Non-Formulary acids/ascorbic acid/vitamin e 08/21/2020 glucocom control blood glucose calibration NEW AUTO RULE Non-Formulary solution control solution, normal 08/21/2020 flu-severe cold- dextromethorphan NEW AUTO RULE Non-Formulary cough daytime hbr/phenylephrine hcl/acetaminophen 08/21/2020 vitamin b-1 thiamine mononitrate (vit b1) NEW AUTO RULE Non-Formulary 08/21/2020 ASPERGILLUS allergenic extract-aspergillus NEW AUTO RULE Non-Formulary FUMIGATUS fumigatus 08/21/2020 NUDICLO diclofenac sodium/capsaicin NEW AUTO RULE Non-Formulary 08/21/2020 NESACAINE chloroprocaine hcl NEW AUTO RULE Non-Formulary 08/21/2020 BOTRYTIS allergenic extract-botrytis NEW AUTO RULE Non-Formulary CINEREA cinerea 08/21/2020 XYZMUNE vitamin c/d3/folic NEW AUTO RULE Non-Formulary acid/zinc/lysine/herbal complex no.312 08/21/2020 pro temp thermometer, electronic,oral NEW AUTO RULE Non-Formulary thermometer 08/21/2020 breeze 2 blood glucose calibration NEW AUTO RULE Non-Formulary control solution, normal 08/21/2020 flexipak diclofenac sodium/capsaicin NEW AUTO RULE Non-Formulary 08/21/2020 sevoflurane sevoflurane NEW AUTO RULE Non-Formulary 08/21/2020 nova max blood glucose calibration NEW AUTO RULE Non-Formulary glucose control control solution, normal soln 08/21/2020 vancomycin hcl vancomycin hcl in water for NEW AUTO RULE Non-Formulary injection (peg-400, nada) 08/21/2020 vitamin b-1 thiamine mononitrate (vit b1) DRUG ATTR CHANGE Non-Formulary Non-Formulary OVERRIDE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 366 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/21/2020 quick temp thermometer, infrared, non- NEW AUTO RULE Non-Formulary infrared thermom contact 08/21/2020 ULTANE sevoflurane NEW AUTO RULE Non-Formulary 08/21/2020 wal-dryl-d allery & phenylephrine NEW AUTO RULE Non-Formulary sinus hcl/diphenhydramine hcl 08/21/2020 tretinoin tretinoin/emollient base NEW AUTO RULE Non-Formulary 08/21/2020 antacid calcium NEW AUTO RULE Non-Formulary carbonate/magnesium hydroxide 08/21/2020 super quints vitamin b complex NEW AUTO RULE Non-Formulary 08/21/2020 microdot blood glucose calibration NEW AUTO RULE Non-Formulary control solution, normal 08/24/2019 STRENSIQ asfotase alfa DRUG ATTR CHANGE NF specialty NF specialty OVERRIDE 08/28/2019 ROZLYTREK entrectinib NEW AUTO RULE NF specialty 08/28/2019 aura portaneb nebulizer NEW AUTO RULE Non-Formulary 08/28/2019 BISAC-EVAC bisacodyl NEW AUTO RULE Non-Formulary 08/28/2019 child delsym guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary cough+chest dm an hbr 08/28/2019 CUVITRU immune NEW AUTO RULE Non-Formulary globulin,gamm(igg)/glycine/i ga greater than 50 mcg/ml 08/28/2019 epinephrine epinephrine REMOVE UM: 4 injections/fill; QUANTITYCUSTOM max 6 fills per year 08/28/2019 bupivacaine- bupivacaine NEW AUTO RULE Non-Formulary dexamethasone hcl/dexamethasone sodium sod phos in sterile water 08/28/2019 docuprene docusate sodium NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 367 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/28/2019 sarna sensitive pramoxine hcl NEW AUTO RULE Non-Formulary 08/28/2019 mucinex fast-max guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary dm max an hbr 08/28/2019 smoothlax polyethylene glycol 3350 NEW AUTO RULE Non-Formulary 08/28/2019 SURFAK docusate calcium NEW AUTO RULE Non-Formulary 08/28/2019 SARNA menthol/camphor NEW AUTO RULE Non-Formulary ORIGINAL 08/28/2019 BION TEARS dextran 70/hypromellose/pf NEW AUTO RULE Non-Formulary 08/28/2019 CULTURELLE lactobacillus rhamnosus gg NEW AUTO RULE Non-Formulary 08/28/2019 DURAMORPH morphine sulfate/pf NEW AUTO RULE Non-Formulary 08/28/2019 clearlax polyethylene glycol 3350 NEW AUTO RULE Non-Formulary 08/28/2019 magic bullet bisacodyl NEW AUTO RULE Non-Formulary 08/28/2019 mucus relief guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary cough an hbr 08/28/2019 sodium sodium bicarbonate NEW AUTO RULE Non-Formulary bicarbonate- water 08/28/2019 sensitive anti-itch pramoxine hcl NEW AUTO RULE Non-Formulary 08/28/2019 sodium sodium bicarbonate NEW AUTO RULE Non-Formulary bicarbonate 08/28/2019 cardioplegia cardioplegic solution no.17 NEW AUTO RULE Non-Formulary induction 4:1 (induction 4:1) 08/28/2019 nasal pseudoephedrine hcl NEW AUTO RULE Non-Formulary decongestant 08/28/2019 cardioplegia cardioplegic solution no.19 NEW AUTO RULE Non-Formulary maintenance 4:1 (maintenance 4:1) 08/28/2019 child chest guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary congestion-cough an hbr

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 368 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/28/2019 flavor chews calcium carbonate NEW AUTO RULE Non-Formulary antacid 08/28/2019 stool softener docusate sodium NEW AUTO RULE Non-Formulary 08/28/2019 HALOG halcinonide UM AUTO RULE: PA Applies AUTHORIZATION 08/28/2019 stomach relief bismuth subsalicylate NEW AUTO RULE Non-Formulary 08/28/2019 pink bismuth bismuth subsalicylate NEW AUTO RULE Non-Formulary 08/28/2019 anti-itch pramoxine hcl NEW AUTO RULE Non-Formulary 08/28/2019 RENOVA PUMP tretinoin/emollient base NEW AUTO RULE Non-Formulary 08/28/2019 DULCOLAX bisacodyl NEW AUTO RULE Non-Formulary 08/28/2019 suphedrine pseudoephedrine hcl NEW AUTO RULE Non-Formulary 08/28/2019 adult dm guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary maximum an hbr 08/28/2019 delsym guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary cough+chest an hbr congest dm 08/28/2019 MIRALAX polyethylene glycol 3350 NEW AUTO RULE Non-Formulary 08/28/2019 penicillin g penicillin g potassium NEW AUTO RULE medical benefit potassium drugs 08/28/2019 vitamin a and d vitamins a and d NEW AUTO RULE Non-Formulary 08/28/2019 pfizerpen penicillin g potassium NEW AUTO RULE Non-Formulary 08/28/2019 chld robitussin guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary cough-chest dm an hbr 08/28/2019 formula 3 tolnaftate NEW AUTO RULE Non-Formulary 08/28/2019 bevacizumab bevacizumab NEW AUTO RULE Non-Formulary 08/28/2019 RENOVA tretinoin/emollient base NEW AUTO RULE Non-Formulary 08/28/2019 docusate calcium docusate calcium NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 369 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/28/2019 tolnaftate tolnaftate NEW AUTO RULE Non-Formulary 08/28/2019 docusate sodium docusate sodium NEW AUTO RULE Non-Formulary 08/28/2019 vitamin d3 cholecalciferol (vitamin d3) NEW AUTO RULE Non-Formulary 08/28/2019 bisacodyl bisacodyl NEW AUTO RULE Non-Formulary 08/28/2019 d3-2000 cholecalciferol (vitamin d3) NEW AUTO RULE Non-Formulary 08/28/2019 glycerin glycerin NEW AUTO RULE Non-Formulary 08/28/2019 move it along docusate sodium NEW AUTO RULE Non-Formulary 08/28/2019 bismuth bismuth subsalicylate NEW AUTO RULE Non-Formulary maximum strength 08/28/2019 KAOPECTATE docusate calcium NEW AUTO RULE Non-Formulary 08/28/2019 TRI-MIX papaverine NEW AUTO RULE Non-Formulary (PAPVRN- hcl/phentolamine PHNTLMN- mesylate/alprostadil PGE1) 08/28/2019 blis-to-sol tolnaftate NEW AUTO RULE Non-Formulary 08/28/2019 PRAX pramoxine hcl NEW AUTO RULE Non-Formulary 08/28/2019 fiber therapy psyllium husk (with sugar) NEW AUTO RULE Non-Formulary 08/28/2019 2-in-1 lancet lancets NEW AUTO RULE Non-Formulary device 08/28/2019 XENLETA lefamulin acetate NEW AUTO RULE Non-Formulary 08/28/2019 kao-tin docusate calcium NEW AUTO RULE Non-Formulary 08/28/2019 bismatrol bismuth subsalicylate NEW AUTO RULE Non-Formulary 08/28/2019 suphedrine sinus pseudoephedrine hcl NEW AUTO RULE Non-Formulary congestion 08/28/2019 suphedrin pseudoephedrine hcl NEW AUTO RULE Non-Formulary 08/28/2019 children's cough guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary an hbr

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 370 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/28/2019 cough-chest guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary congestion dm an hbr 08/28/2019 promolaxin docusate sodium NEW AUTO RULE Non-Formulary 08/28/2019 artificial tears dextran 70/hypromellose/pf NEW AUTO RULE Non-Formulary 08/28/2019 RINVOQ upadacitinib NEW AUTO RULE NF specialty 08/28/2019 calcium calcium carbonate NEW AUTO RULE Non-Formulary carbonate 08/28/2019 LYRICA pregabalin TERM AUTO RULE 08/28/2019 child cough-chest guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary congest dm an hbr 08/28/2019 STRENSIQ asfotase alfa NEW AUTO RULE NF specialty 08/28/2019 curity gauze bandage NEW AUTO RULE Non-Formulary 08/28/2019 melatonin melatonin NEW AUTO RULE Non-Formulary 08/28/2019 pregabalin pregabalin NEW AUTO RULE Tier 2 08/28/2019 purelax polyethylene glycol 3350 NEW AUTO RULE Non-Formulary 08/28/2019 antacid calcium carbonate NEW AUTO RULE Non-Formulary 08/28/2019 TUMS calcium carbonate NEW AUTO RULE Non-Formulary FRESHERS 08/28/2019 kaopectate bismuth subsalicylate NEW AUTO RULE Non-Formulary 08/28/2019 children's guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary mucinex cough an hbr 08/28/2019 cal-gest calcium carbonate NEW AUTO RULE Non-Formulary 08/28/2019 ROBINUL glycopyrrolate NEW AUTO RULE Non-Formulary 08/28/2019 EUCERIN emollient combination NEW AUTO RULE Non-Formulary ADVANCED no.114 REPAIR

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 371 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/28/2019 CULTURELLE lactobacillus rhamnosus gg NEW AUTO RULE Non-Formulary HEALTH- WELLNESS 08/28/2019 biscolax bisacodyl NEW AUTO RULE Non-Formulary 08/28/2019 epinephrine epinephrine NEW AUTO RULE Tier 1 08/28/2019 dermasarra menthol/camphor NEW AUTO RULE Non-Formulary 08/28/2019 triamterene triamterene NEW AUTO RULE Non-formulary 08/28/2019 halcinonide halcinonide NEW AUTO RULE Non-formulary 08/28/2019 cardioplegia cardioplegic no.21 NEW AUTO RULE Non-Formulary reperfusate 4:1 (reperfusate 4:1) 08/28/2019 TUMS calcium carbonate NEW AUTO RULE Non-Formulary 08/28/2019 CLOLAR clofarabine NEW AUTO RULE Non-Formulary 08/28/2019 GENTEAL dextran 70/hypromellose/pf NEW AUTO RULE Non-Formulary TEARS 08/28/2019 child chest guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary congestion + an hbr cough 08/28/2019 ban-acid calcium carbonate NEW AUTO RULE Non-Formulary 08/28/2019 men-phor menthol/camphor NEW AUTO RULE Non-Formulary 08/28/2019 wal-phed pseudoephedrine hcl NEW AUTO RULE Non-Formulary 08/28/2019 PEPTO-BISMOL bismuth subsalicylate NEW AUTO RULE Non-Formulary 08/28/2019 cough-chest guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary congest dm an hbr 08/28/2019 tranexamic acid- tranexamic acid in sodium NEW AUTO RULE Non-Formulary nacl chloride,iso-osmotic 08/28/2019 ASTRAMORPH- morphine sulfate/pf NEW AUTO RULE Non-Formulary PF

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 372 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/28/2019 robitussin cough- guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary chest-cong dm an hbr 08/28/2019 pregabalin pregabalin TERM AUTO RULE 08/28/2019 INREBIC fedratinib dihydrochloride NEW AUTO RULE NF specialty 08/28/2020 AIRDUO fluticasone NEW AUTO RULE Non-formulary DIGIHALER propionate/salmeterol xinafoate 08/28/2020 lidocaine hcl- lidocaine hcl/epinephrine/pf NEW AUTO RULE Non-Formulary epinephrine 08/28/2020 KESIMPTA PEN ofatumumab NEW AUTO RULE NF specialty 08/28/2020 AZALGIA glucosamine/methylsulf/vit NEW AUTO RULE Non-Formulary c/folic ac/manganese/diet 29 08/28/2020 REFRESH carboxymethylcellulose NEW AUTO RULE Non-Formulary OPTIVE MEGA-3 sodium/glycerin/polysorbate 80/pf 08/28/2020 ADRENALIN epinephrine hcl NEW AUTO RULE Non-Formulary CHLORIDE 08/28/2020 elderberry ascorbic acid/elderberry fruit NEW AUTO RULE Non-Formulary extract-vitamin c 08/28/2020 melatonin melatonin NEW AUTO RULE Non-Formulary 08/28/2020 space chamber- inhaler,assist device with NEW AUTO RULE Tier 2 small mask small mask 08/28/2020 glostrips fluorescein sodium NEW AUTO RULE Non-Formulary 08/28/2020 REFRESH carboxymethylcellulose NEW AUTO RULE Non-Formulary DIGITAL sodium/glycerin/polysorbate 80 08/28/2020 spectravite multivitamin/ferrous NEW AUTO RULE Non-Formulary women fumarate/folic acid 08/28/2020 SACCHAROMYC allergenic extract- NEW AUTO RULE Non-Formulary ES CEREVISIAE saccharomyces cerevisiae

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 373 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/28/2020 I-VALEX-2 nutritional therapy for NEW AUTO RULE Non-Formulary isovaleric acidemia with iron 08/28/2020 lice killing permethrin NEW AUTO RULE Non-Formulary 08/28/2020 CERAVE ceramides 1,3,6- NEW AUTO RULE Non-Formulary FOAMING ii/niacinamide FACIAL 08/28/2020 lidocaine hcl- lidocaine hcl/epinephrine/pf DRUG ATTR CHANGE Non-Formulary Non-Formulary epinephrine OVERRIDE 08/28/2020 GLUTAREX-2 nutritional therapy, glutaric NEW AUTO RULE Non-Formulary aciduria type 1 08/28/2020 pentobarbital pentobarbital sodium NEW AUTO RULE Non-Formulary sodium 08/28/2020 FUL-GLO fluorescein sodium NEW AUTO RULE Non-Formulary 08/28/2020 PROPIMEX-2 nutritional therapy for NEW AUTO RULE Non-Formulary propionic acidemia with iron 08/28/2020 cerave daily ceramides 1,3,6-ii NEW AUTO RULE Non-Formulary moisturizing 08/28/2020 space chamber- inhaler,assist device with NEW AUTO RULE Tier 2 medium mask medium mask 08/28/2020 REFRESH carboxymethylcellulose NEW AUTO RULE Non-Formulary OPTIVE sodium/glycerin/polysorbate ADVANCED 80 08/28/2020 lice treatment permethrin NEW AUTO RULE Non-Formulary 08/28/2020 CYCLINEX-2 nutritional therapy, urea NEW AUTO RULE Non-Formulary cycle disorder 08/28/2020 TOTECT dexrazoxane hcl NEW AUTO RULE Non-Formulary 08/28/2020 VISTASEAL thrombin(human plasma NEW AUTO RULE Non-Formulary FIBRIN derived)/fibrinogen/calcium SEALANT chloride

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 374 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/28/2020 DICLOTREX diclofenac NEW AUTO RULE Non-Formulary sodium/menthol/camphor 08/28/2020 MEGARED omega-3 fatty NEW AUTO RULE Non-Formulary ADVANCED acids/dha/epa/fish TOTAL BODY oil/krill/lutein/zeaxanth 08/28/2020 NEMBUTAL pentobarbital sodium NEW AUTO RULE Non-Formulary SODIUM 08/28/2020 PHENEX-2 nutritional therapy for NEW AUTO RULE Non-Formulary phenylketonuria (pku) with iron no.1 08/28/2020 SIMILAC infant formula with NEW AUTO RULE Non-Formulary SPECIAL CARE iron/docosahexanoic 20 acid/arachidonic ac 08/28/2020 SIMILAC infant formula with NEW AUTO RULE Non-Formulary SPECIAL CARE iron/docosahexanoic 24 acid/arachidonic ac 08/28/2020 CORLOPAM fenoldopam mesylate NEW AUTO RULE Non-Formulary 08/28/2020 REFRESH carboxymethylcellulose NEW AUTO RULE Non-Formulary OPTIVE sodium/glycerin/polysorbate ADVANCED 80/pf 08/28/2020 TYREX-2 nutritional therapy for NEW AUTO RULE Non-Formulary tyrosinemia with iron 08/28/2020 moxifloxacin moxifloxacin hcl in sodium DRUG ATTR CHANGE Non-Formulary Non-Formulary chloride,iso-osmotic/pf OVERRIDE 08/28/2020 CERAVE ceramides 1,3,6-ii NEW AUTO RULE Non-Formulary HYDRATING FACIAL 08/28/2020 HOMINEX-2 nutritional therapy, NEW AUTO RULE Non-Formulary metabolic disorder, methionine-free 08/28/2020 CERAVE ceramides 1,3,6-ii NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 375 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/28/2020 REFRESH carboxymethylcellulose NEW AUTO RULE Non-Formulary DIGITAL PF sodium/glycerin/polysorbate 80/pf 08/28/2020 BRONKAID MAX ephedrine sulfate NEW AUTO RULE Non-Formulary 08/28/2020 NIX permethrin NEW AUTO RULE Non-Formulary 08/28/2020 DORYX doxycycline hyclate NEW AUTO RULE Non-formulary 08/28/2020 space chamber- inhaler,assist device with NEW AUTO RULE Tier 2 large mask large mask 08/28/2020 XYLOCAINE- lidocaine hcl/epinephrine/pf NEW AUTO RULE Non-Formulary MPF WITH EPINEPHRINE 08/28/2020 BACIGUENT bacitracin NEW AUTO RULE Non-formulary 08/28/2020 SIMILAC infant formula with NEW AUTO RULE Non-Formulary SPECIAL CARE iron/docosahexaenoic 24 acid/arachidonic ac

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 376 UPDATED 12/2020 VALUE Drug Formulary Updates

September, 2020

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/01/2020 FIASP insulin aspart (niacinamide) UM AUTO RULE: PA Applies FLEXTOUCH AUTHORIZATION 09/01/2020 azelaic acid azelaic acid NEW AUTO RULE Tier 2 09/01/2020 OXYTROL oxybutynin TERM AUTO RULE 09/01/2020 SOOLANTRA ivermectin UM AUTO RULE: PA Applies AUTHORIZATION 09/01/2020 TOVIAZ fesoterodine fumarate UM AUTO RULE: STEP Use myrbetriq first 09/01/2020 GELNIQUE oxybutynin chloride TERM AUTO RULE 09/01/2020 FIASP insulin aspart (niacinamide) UM AUTO RULE: PA Applies AUTHORIZATION 09/01/2020 GELNIQUE oxybutynin chloride UM AUTO RULE: STEP Use myrbetriq first 09/01/2020 OXYTROL oxybutynin UM AUTO RULE: STEP Use myrbetriq first 09/01/2020 ivermectin ivermectin UM AUTO RULE: PA Applies AUTHORIZATION 09/01/2020 TOVIAZ fesoterodine fumarate TERM AUTO RULE 09/01/2020 FIASP PENFILL insulin aspart (niacinamide) UM AUTO RULE: PA Applies AUTHORIZATION 09/03/2020 ROZEREM ramelteon NEW AUTO RULE Tier 2 09/03/2020 ramelteon ramelteon NEW AUTO RULE Tier 2 09/04/2019 ultra thin pen needle, diabetic NEW AUTO RULE Tier 2 09/04/2019 arthricream rub trolamine salicylate/aloe NEW AUTO RULE Non-Formulary vera 09/04/2019 cortisone hydrocortisone NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 377 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/04/2019 CLINOLIPID fat emulsions/olive NEW AUTO RULE Non-Formulary oil/soybean oil/phospholipids,egg 09/04/2019 caretouch ketone blood ketone test, strips NEW AUTO RULE Tier 2 test strip 09/04/2019 trolamine trolamine salicylate NEW AUTO RULE Non-Formulary salicylate 09/04/2019 children's allergy loratadine NEW AUTO RULE Non-Formulary relief 09/04/2019 phenylephrine phenylephrine hcl in 0.9 % NEW AUTO RULE Non-Formulary hcl-0.9% nacl sodium chloride 09/04/2019 sportscreme trolamine salicylate NEW AUTO RULE Non-Formulary 09/04/2019 allergy relief loratadine NEW AUTO RULE Non-Formulary 09/04/2019 easy comfort alcohol antiseptic pads NEW AUTO RULE Non-Formulary alcohol pad 09/04/2019 asper-flex trolamine salicylate NEW AUTO RULE Non-Formulary 09/04/2019 creme trolamine salicylate NEW AUTO RULE Non-Formulary 09/04/2019 loratadine loratadine NEW AUTO RULE Non-Formulary 09/04/2019 azo bladder pumpkin seed extract/soy NEW AUTO RULE Non-Formulary control-weight germ/cissus quadrangularis mgt extract 09/04/2019 ONE-A-DAY multivitamin,calcium,mineral NEW AUTO RULE Non-Formulary WOMEN'S 50 s/folic acid/phytonadione(vit PLUS k) 09/04/2019 hydrocortisone hydrocortisone NEW AUTO RULE Non-Formulary 09/04/2019 sports pain relief trolamine salicylate NEW AUTO RULE Non-Formulary 09/04/2019 VYNDAMAX tafamidis NEW AUTO RULE NF specialty 09/04/2019 cortizone-10 hydrocortisone NEW AUTO RULE Non-Formulary 09/04/2019 arthricream trolamine salicylate NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 378 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/04/2019 disposable probe thermometer probe covers NEW AUTO RULE Non-Formulary covers 09/04/2019 CHILDREN'S cetirizine hcl NEW AUTO RULE Non-Formulary ZYRTEC ALLERGY 09/04/2019 fentanyl citrate- fentanyl citrate in 0.9 % NEW AUTO RULE Non-Formulary 0.9% nacl sodium chloride/pf 09/04/2019 INTEGRILIN eptifibatide NEW AUTO RULE Non-Formulary 09/04/2019 thermometer thermometer probe covers NEW AUTO RULE Non-Formulary probe covers 09/04/2019 NUCARACLINPA clindamycin/octinoxate/octyl NEW AUTO RULE Non-Formulary K salicyl/octocryl/oxybenz/titan 09/04/2019 analgesic trolamine salicylate NEW AUTO RULE Non-Formulary 09/04/2019 arthricreme trolamine salicylate NEW AUTO RULE Non-Formulary 09/04/2019 NUCARARXPAK clindamycin/benzoyl/octinox/ NEW AUTO RULE Non-Formulary octyl/octocryl/oxyben/titaniu m 09/04/2019 ZYRTEC cetirizine hcl NEW AUTO RULE Non-Formulary 09/04/2019 anti-itch hydrocortisone NEW AUTO RULE Non-Formulary 09/04/2019 moxifloxacin hcl- moxifloxacin hcl in balanced NEW AUTO RULE Non-Formulary bss salt solution no.2/pf 09/04/2019 analgesic creme trolamine salicylate/aloe NEW AUTO RULE Non-Formulary vera 09/04/2019 cellpad gel-matrix pad dressing, NEW AUTO RULE Non-Formulary silicone 09/04/2019 wal-itin loratadine NEW AUTO RULE Non-Formulary 09/04/2019 MOBISYL trolamine salicylate NEW AUTO RULE Non-Formulary 09/04/2019 CLARITIN loratadine NEW AUTO RULE Non-Formulary 09/04/2019 aceso ag silver/silicone/foam bandage NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 379 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/04/2019 thermometer tip thermometer probe covers NEW AUTO RULE Non-Formulary covers 09/04/2020 ONGENTYS opicapone NEW AUTO RULE Non-formulary 09/04/2020 MONOFERRIC ferric derisomaltose NEW AUTO RULE Non-Formulary 09/04/2020 LANTUS insulin glargine,human UM AUTO RULE: 45 ml (15 pens)/ SOLOSTAR recombinant analog QUANTITYCUSTOM month 09/04/2020 calcium 600-vit calcium NEW AUTO RULE Non-Formulary d3 carbonate/cholecalciferol (vitamin d3) 09/04/2020 OCTAPLAS plasma human, blood group NEW AUTO RULE Non-Formulary ab 09/04/2020 glucosamine- glucosamine NEW AUTO RULE Non-Formulary msm-hyaluronic hcl/methylsulfonylmethane/h yaluronic acid 09/04/2020 lanolin anhydrous lanolin,anhydrous NEW AUTO RULE Non-Formulary 09/04/2020 bismuth bismuth subsalicylate NEW AUTO RULE Non-Formulary subsalicylate 09/04/2020 purecomfort peak peak flow meter NEW AUTO RULE Non-Formulary flow meter 09/04/2020 cold relief chlorpheniramine NEW AUTO RULE Non-Formulary maleate/phenylephrine bitartrate/aspirin 09/04/2020 MUTAMYCIN mitomycin NEW AUTO RULE Non-Formulary 09/04/2020 OCTAPLAS plasma human, blood group NEW AUTO RULE Non-Formulary o 09/04/2020 OCTAPLAS plasma human, blood group NEW AUTO RULE Non-Formulary a 09/04/2020 OCTAPLAS plasma human, blood group NEW AUTO RULE Non-Formulary b

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 380 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/04/2020 ashwagandha ashwagandha root extract NEW AUTO RULE Non-Formulary root extract 09/04/2020 REMDESIVIR remdesivir NEW AUTO RULE Non-Formulary (EUA) 09/04/2020 SEMGLEE insulin glargine,human NEW AUTO RULE Non-formulary recombinant analog 09/04/2020 red yeast rice red yeast rice NEW AUTO RULE Non-Formulary 09/04/2020 cold relief plus chlorpheniramine NEW AUTO RULE Non-Formulary maleate/phenylephrine bitartrate/aspirin 09/04/2020 AKYNZEO fosnetupitant chloride NEW AUTO RULE Non-Formulary hcl/palonosetron hcl 09/04/2020 BASAGLAR insulin glargine,human UM AUTO RULE: 45 ml (15 pens)/ KWIKPEN U-100 recombinant analog QUANTITYCUSTOM month 09/04/2020 NEUAC clindamycin NEW AUTO RULE Non-Formulary phosphate/benzoyl peroxide/emollient comb no.94 09/04/2020 ALKA-SELTZER chlorpheniramine NEW AUTO RULE Non-Formulary PLUS COLD maleate/phenylephrine bitartrate/aspirin 09/04/2020 VEKLURY remdesivir NEW AUTO RULE Non-Formulary 09/04/2020 heparin sodium heparin sodium,porcine/pf NEW AUTO RULE Non-Formulary 09/04/2020 SEMGLEE PEN insulin glargine,human NEW AUTO RULE Non-formulary recombinant analog 09/04/2020 SALONPAS methyl salicylate/menthol NEW AUTO RULE Non-Formulary 09/04/2020 hematex iron polysaccharide complex NEW AUTO RULE Non-Formulary 09/04/2020 emtricitabine emtricitabine NEW AUTO RULE Tier 2

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 381 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/04/2020 peg3350-sod sul- peg 3350/sodium NEW AUTO RULE Non-formulary nacl-kcl-asb-c sulfate/sod chloride/kcl/ascorbate sod/vit c 09/04/2020 RELAFEN nabumetone NEW AUTO RULE Non-formulary 09/04/2020 HEMADY dexamethasone NEW AUTO RULE Non-formulary 09/04/2020 LANTUS insulin glargine,human UM AUTO RULE: 4 vials (40ml)/ recombinant analog QUANTITYCUSTOM month 09/04/2020 ONUREG azacitidine NEW AUTO RULE NF specialty 09/05/2019 promethazine- promethazine hcl/codeine UM AUTO RULE: 30 ml/day; max 7 codeine QUANTITYCUSTOM days therapy/month 09/05/2019 promethazine- promethazine/phenylephrine UM AUTO RULE: 30 ml/day; max 7 phenyleph- hcl/codeine QUANTITYCUSTOM days codeine therapy/month 09/05/2019 codeine- codeine UM AUTO RULE: 60 ml/day; max 7 guaifenesin phosphate/guaifenesin QUANTITYCUSTOM days therapy/month 09/05/2019 tussigon hydrocodone UM AUTO RULE: 6 tabs/day; max 7 bitartrate/homatropine QUANTITYCUSTOM days methylbromide therapy/month 09/05/2019 epinephrine epinephrine UM AUTO RULE: 4 injections/fill; QUANTITYCUSTOM max 6 fills per year 09/05/2019 promethazine vc- promethazine/phenylephrine UM AUTO RULE: 30 ml/day; max 7 codeine hcl/codeine QUANTITYCUSTOM days therapy/month 09/05/2019 HYCOFENIX hydrocodone UM AUTO RULE: 40 ml/day; max 7 bitartrate/pseudoephedrine QUANTITYCUSTOM days hcl/guaifenesin therapy/month

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 382 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/05/2019 TUSSICAPS hydrocodone UM AUTO RULE: 2 caps/day; max polistirex/chlorpheniramine QUANTITYCUSTOM 7 days polistirex therapy/month 09/05/2019 guaifenesin- codeine UM AUTO RULE: 60 ml/day; max 7 codeine phosphate/guaifenesin QUANTITYCUSTOM days therapy/month 09/05/2019 VITUZ hydrocodone UM AUTO RULE: 20 ml/day; max 7 bitartrate/chlorpheniramine QUANTITYCUSTOM days maleate therapy/month 09/05/2019 TUSSIONEX hydrocodone UM AUTO RULE: 10 ml/day; max 7 polistirex/chlorpheniramine QUANTITYCUSTOM days polistirex therapy/month 09/05/2019 STRENSIQ asfotase alfa UM AUTO RULE: Limited Access LIMITEDACCESS 09/05/2019 hydrocodone- hydrocodone UM AUTO RULE: 10 ml/day; max 7 chlorpheniramne polistirex/chlorpheniramine QUANTITYCUSTOM days er polistirex therapy/month 09/05/2019 guaiatussin ac codeine UM AUTO RULE: 60 ml/day; max 7 phosphate/guaifenesin QUANTITYCUSTOM days therapy/month 09/05/2019 virtussin ac codeine UM AUTO RULE: 60 ml/day; max 7 phosphate/guaifenesin QUANTITYCUSTOM days therapy/month 09/05/2019 hydrocod-cpm- hydrocodone UM AUTO RULE: 20 ml/day; max 7 pseudoephedrine bitart/chlorpheniramine QUANTITYCUSTOM days maleate/pseudoephedrine therapy/month 09/05/2019 cheratussin ac codeine UM AUTO RULE: 60 ml/day; max 7 phosphate/guaifenesin QUANTITYCUSTOM days therapy/month 09/05/2019 TUZISTRA XR codeine UM AUTO RULE: 20 ml/day; max 7 polistirex/chlorpheniramine QUANTITYCUSTOM days polistirex therapy/month

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 383 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/05/2019 ZUTRIPRO hydrocodone UM AUTO RULE: 20 ml/day; max 7 bitart/chlorpheniramine QUANTITYCUSTOM days maleate/pseudoephedrine therapy/month 09/05/2019 robafen ac codeine UM AUTO RULE: 60 ml/day; max 7 phosphate/guaifenesin QUANTITYCUSTOM days therapy/month 09/05/2019 guaifenesin ac codeine UM AUTO RULE: 60 ml/day; max 7 phosphate/guaifenesin QUANTITYCUSTOM days therapy/month 09/05/2019 hydromet hydrocodone UM AUTO RULE: 30 ml/day; max 7 bitartrate/homatropine QUANTITYCUSTOM days methylbromide therapy/month 09/05/2019 hydrocodone- hydrocodone UM AUTO RULE: 30 ml/day; max 7 homatropine mbr bitartrate/homatropine QUANTITYCUSTOM days methylbromide therapy/month 09/05/2019 STRENSIQ asfotase alfa REMOVE UM: Limited Access LIMITEDACCESS 09/05/2019 g tussin ac codeine UM AUTO RULE: 60 ml/day; max 7 phosphate/guaifenesin QUANTITYCUSTOM days therapy/month 09/11/2019 soothing care hydrocortisone NEW AUTO RULE Non-Formulary 09/11/2019 SULFO LO sulfur NEW AUTO RULE Non-Formulary 09/11/2019 col-rite docusate sodium NEW AUTO RULE Non-Formulary 09/11/2019 hydromorphone hydromorphone hcl in sterile NEW AUTO RULE Non-Formulary hcl-water water/pf 09/11/2019 hydrocream hydrocortisone NEW AUTO RULE Non-Formulary 09/11/2019 sof-lax docusate sodium NEW AUTO RULE Non-Formulary 09/11/2019 e-200 vitamin e (dl-alpha NEW AUTO RULE Non-Formulary tocopheryl acetate) 09/11/2019 ENEMEEZ docusate sodium NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 384 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/11/2019 heartburn famotidine NEW AUTO RULE Non-Formulary prevention 09/11/2019 cortizone-10 hydrocortisone NEW AUTO RULE Non-Formulary 09/11/2019 XYLOCAINE lidocaine hcl/epinephrine NEW AUTO RULE Non-Formulary WITH EPINEPHRINE 09/11/2019 ALA-CORT hydrocortisone NEW AUTO RULE Non-Formulary 09/11/2019 sp antipruritic sod mg fluo/sodium NEW AUTO RULE Non-Formulary phos/nacl/hypochlorous acid/sod hypochlor 09/11/2019 caretouch safety lancets NEW AUTO RULE Tier 2 lancets 09/11/2019 periogard chlorhexidine gluconate NEW AUTO RULE Non-Formulary 09/11/2019 microgestin fe norethindrone acetate- NEW AUTO RULE Tier 1 ethinyl estradiol/ferrous fumarate 09/11/2019 LOESTRIN FE norethindrone acetate- NEW AUTO RULE Non-formulary ethinyl estradiol/ferrous fumarate 09/11/2019 CUBICIN daptomycin NEW AUTO RULE Non-Formulary 09/11/2019 doc-q-lace docusate sodium NEW AUTO RULE Non-Formulary 09/11/2019 CELACYN emollient combination no.60 NEW AUTO RULE Non-Formulary 09/11/2019 docusate sodium docusate sodium NEW AUTO RULE Non-Formulary 09/11/2019 adenosine adenosine NEW AUTO RULE Non-Formulary 09/11/2019 PROCTOCORT hydrocortisone NEW AUTO RULE Non-Formulary 09/11/2019 DOK docusate sodium NEW AUTO RULE Non-Formulary 09/11/2019 chlorhexidine chlorhexidine gluconate NEW AUTO RULE Non-Formulary gluconate 09/11/2019 procainamide hcl procainamide hcl NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 385 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/11/2019 FEIBA NF anti-inhibitor coagulant NEW AUTO RULE Non-Formulary complex 09/11/2019 CORTAID hydrocortisone NEW AUTO RULE Non-Formulary 09/11/2019 acid reducer famotidine NEW AUTO RULE Non-Formulary 09/11/2019 ADENOSCAN adenosine NEW AUTO RULE Non-Formulary 09/11/2019 lidocaine hcl- lidocaine hcl/epinephrine NEW AUTO RULE Non-Formulary epinephrine 09/11/2019 cortisone hydrocortisone NEW AUTO RULE Non-Formulary 09/11/2019 dulcolax stool docusate sodium NEW AUTO RULE Non-Formulary softener 09/11/2019 paroex chlorhexidine gluconate NEW AUTO RULE Non-Formulary 09/11/2019 caretouch insulin syringe with NEW AUTO RULE Tier 2 syringe needle,disposable,insulin 1 ml 09/11/2019 AMIDATE etomidate NEW AUTO RULE Non-Formulary 09/11/2019 PERIDEX chlorhexidine gluconate NEW AUTO RULE Non-Formulary 09/11/2019 esteem plus colostomy bag, non-sterile NEW AUTO RULE Non-Formulary drainable pouch 09/11/2019 heartburn relief famotidine NEW AUTO RULE Non-Formulary 09/11/2019 moxifloxacin moxifloxacin hcl in sodium NEW AUTO RULE Non-Formulary chloride,iso-osmotic/pf 09/11/2019 fosaprepitant fosaprepitant dimeglumine NEW AUTO RULE Non-Formulary dimeglumine 09/11/2019 dulcoease docusate sodium NEW AUTO RULE Non-Formulary 09/11/2019 CUBICIN RF daptomycin NEW AUTO RULE Non-Formulary 09/11/2019 phillips' laxative docusate sodium NEW AUTO RULE Non-Formulary 09/11/2019 skin success anti- sulfur NEW AUTO RULE Non-Formulary acne

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 386 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/11/2019 preparation h hydrocortisone NEW AUTO RULE Non-Formulary 09/11/2019 eczema anti-itch hydrocortisone NEW AUTO RULE Non-Formulary 09/11/2019 SOMATULINE lanreotide acetate NEW AUTO RULE Non-Formulary DEPOT 09/11/2019 restizan emollient combination no.60 NEW AUTO RULE Non-Formulary 09/11/2019 cortizone-10 plus hydrocortisone NEW AUTO RULE Non-Formulary 09/11/2019 INFLATHERM(DI diclofenac NEW AUTO RULE Non-Formulary CLOFENAC- sodium/menthol/camphor MENTHOL) 09/11/2019 caretouch blood ketone and glucose NEW AUTO RULE Non-Formulary ketone-glucose monitor sys 09/11/2019 PEPCID AC famotidine NEW AUTO RULE Non-Formulary 09/11/2019 LEVICYN sod mg fluo/sodium NEW AUTO RULE Non-Formulary phos/nacl/hypochlorous acid/sod hypochlor 09/11/2019 sp scar emollient combination no.60 NEW AUTO RULE Non-Formulary management 09/11/2019 SYSTANE mineral oil/petrolatum,white NEW AUTO RULE Non-Formulary 09/11/2019 docusil docusate sodium NEW AUTO RULE Non-Formulary 09/11/2019 ALEVICYN sod mg fluo/sodium NEW AUTO RULE Non-Formulary phos/nacl/hypochlorous acid/sod hypochlor 09/11/2019 COLACE docusate sodium NEW AUTO RULE Non-Formulary 09/11/2019 noble formula hc hydrocortisone NEW AUTO RULE Non-Formulary 09/11/2019 GENTEAL mineral oil/petrolatum,white NEW AUTO RULE Non-Formulary TEARS SEVERE 09/11/2019 MYXREDLIN insulin regular, human in 0.9 NEW AUTO RULE Non-Formulary % sodium chloride

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 387 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/11/2020 ENTERADE sodium chloride/sodium NEW AUTO RULE Non-Formulary ADVANCED cit/potassium/magnes/calc/a ONCOLOGY mino acid 09/11/2020 omega-3 fish oil omega-3 fatty NEW AUTO RULE Non-Formulary acids/docosahexanoic acid/epa/fish oil 09/11/2020 gel-one hyaluronate sod, cross- NEW AUTO RULE Non-Formulary linked 09/11/2020 GENADEK STEP multivit with minerals NEW AUTO RULE Non-Formulary 2 no.82/folic acid/vit k1/ubidecarenone 09/11/2020 chlorpromazine chlorpromazine hcl NEW AUTO RULE Non-Formulary hcl 09/11/2020 fentanyl- fentanyl citrate/ropivacaine NEW AUTO RULE Non-Formulary ropivacaine-0.9% hcl/sodium chloride 0.9%/pf nacl 09/11/2020 DAYTRANA methylphenidate TERM AUTO RULE 09/11/2020 band-aid adhesive bandage NEW AUTO RULE Non-Formulary 09/11/2020 fish oil omega-3 fatty NEW AUTO RULE Non-Formulary acids/docosahexaenoic acid/epa/fish oil 09/11/2020 CYSTADROPS cysteamine hcl NEW AUTO RULE NF specialty 09/11/2020 coconut oil coconut oil NEW AUTO RULE Non-Formulary 09/11/2020 TRULICITY dulaglutide NEW AUTO RULE Tier 2 09/11/2020 sanizen ethyl alcohol NEW AUTO RULE Non-Formulary 09/11/2020 GENADEK STEP multivit with minerals NEW AUTO RULE Non-Formulary 1 no.81/folic acid/vit k1/ubidecarenone 09/11/2020 REMEDY dimethicone NEW AUTO RULE Non-Formulary DIMETHICONE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 388 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/11/2020 THAM tromethamine NEW AUTO RULE Non-Formulary 09/11/2020 AMERISTORE petrolatum,white/water NEW AUTO RULE Non-Formulary 09/11/2020 fish oil omega-3 fatty NEW AUTO RULE Non-Formulary acids/docosahexanoic acid/epa/fish oil 09/11/2020 sapropterin sapropterin dihydrochloride NEW AUTO RULE NF specialty dihydrochloride 09/11/2020 CERAVE AM homosalate/meradimate/octi NEW AUTO RULE Non-Formulary noxate/octocrylene/zinc oxide 09/11/2020 dermacinrx skin dimethicone NEW AUTO RULE Non-Formulary repair complex 09/11/2020 calcium 600-vit calcium NEW AUTO RULE Non-Formulary d3 carbonate/cholecalciferol (vitamin d3) 09/11/2020 DESITIN MULTI- petrolatum,white NEW AUTO RULE Non-Formulary PURPOSE 09/11/2020 DAYTRANA methylphenidate UM AUTO RULE: STEP Commercial: use one preferred extended-release methylphenidate first 09/11/2020 SUPERSOFT petrolatum,white/water NEW AUTO RULE Non-Formulary 09/11/2020 mg217 psoriasis coal tar NEW AUTO RULE Non-Formulary 09/11/2020 TYPHIM VI typhoid vaccine vi capsular NEW AUTO RULE Non-Formulary polysaccharide 09/11/2020 SOOTHE & dimethicone NEW AUTO RULE Non-Formulary COOL INZO BARRIER 09/11/2020 GIMOTI metoclopramide hcl NEW AUTO RULE NF specialty

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 389 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/11/2020 omega-3 fish oil omega-3 fatty NEW AUTO RULE Non-Formulary acids/docosahexaenoic acid/epa/fish oil 09/11/2020 VIDAZA azacitidine NEW AUTO RULE Non-Formulary 09/11/2020 MENQUADFI meningococcal vaccine a,c,y NEW AUTO RULE Non-Formulary and w-135,conj tetanus toxoid/pf 09/11/2020 VANICREAM emollient combination NEW AUTO RULE Non-Formulary no.115 09/11/2020 EYE vit a, c, e/zinc oxide/sodium NEW AUTO RULE Non-Formulary MULTIVITAMIN selenate/cupric oxide/lutein WITH LUTEIN 09/11/2020 GAVRETO pralsetinib NEW AUTO RULE NF specialty 09/11/2020 athlete's foot clotrimazole DRUG ATTR CHANGE Non-Formulary Non-Formulary OVERRIDE 09/18/2019 ARTIFICIAL carboxymethylcellulose NEW AUTO RULE Non-Formulary TEARS sodium 09/18/2019 vitamin d3 cholecalciferol (vitamin d3) NEW AUTO RULE Non-Formulary 09/18/2019 NAYZILAM midazolam NEW AUTO RULE Non-formulary 09/18/2019 tropicamide- phenylephrine NEW AUTO RULE Non-Formulary phenylephrine hcl/tropicamide in sterile water 09/18/2019 BOROLEUM menthol/camphor/white NEW AUTO RULE Non-Formulary petrolatum 09/18/2019 pinworm pyrantel pamoate NEW AUTO RULE Non-Formulary treatment 09/18/2019 infants' mylicon simethicone NEW AUTO RULE Non-Formulary 09/18/2019 diaper rash zinc oxide/cod liver oil NEW AUTO RULE Non-Formulary ointment

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 390 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/18/2019 THERA M PLUS multivits with calcium and NEW AUTO RULE Non-Formulary minerals/iron fumarate/folic acid 09/18/2019 dextrose in water dextrose 10 % in water NEW AUTO RULE Non-Formulary 09/18/2019 therapeutic-m multivits with calcium and NEW AUTO RULE Non-Formulary minerals/iron fumarate/folic acid 09/18/2019 DILAUDID hydromorphone hcl/pf NEW AUTO RULE Non-Formulary 09/18/2019 CENTRUM KIDS pediatric multivitamin NEW AUTO RULE Non-Formulary no.180/iron,carbonyl/vit k1 09/18/2019 GVOKE PFS 2- glucagon NEW AUTO RULE Non-formulary PACK SYRINGE 09/18/2019 GVOKE PFS 1- glucagon NEW AUTO RULE Non-formulary PACK SYRINGE 09/18/2019 HISTATROL histamine phosphate NEW AUTO RULE Non-Formulary PERCUTANEOU S 09/18/2019 GVOKE glucagon NEW AUTO RULE Non-formulary HYPOPEN 1- PACK 09/18/2019 one-a-day teen multivits with calcium and NEW AUTO RULE Non-Formulary advantage minerals/iron fumarate/folic acid 09/18/2019 potassium potassium chloride in water NEW AUTO RULE Non-Formulary chloride for injection, sterile 09/18/2019 reese's pinworm pyrantel pamoate NEW AUTO RULE Non-Formulary 09/18/2019 PEDIASURE pediatric nutrition with iron, NEW AUTO RULE Non-Formulary lactose free 09/18/2019 BOUDREAUXS zinc oxide NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 391 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/18/2019 CULTURELLE lactobacillus rhamnosus gg NEW AUTO RULE Non-Formulary KIDS ULTIM BALANCE 09/18/2019 vancomycin hcl vancomycin hcl NEW AUTO RULE Non-formulary 09/18/2019 aminocaproic aminocaproic acid NEW AUTO RULE Non-formulary acid 09/18/2019 acid reducer omeprazole magnesium NEW AUTO RULE Non-Formulary 09/18/2019 THERA-M multivits with calcium and NEW AUTO RULE Non-Formulary minerals/iron fumarate/folic acid 09/18/2019 MAXIMUM D3 cholecalciferol (vitamin d3) NEW AUTO RULE Non-Formulary 09/18/2019 boost kid pediatric nutrition with iron, NEW AUTO RULE Non-Formulary essentials lactose free 09/18/2019 pediatric pediatric nutrition with iron, NEW AUTO RULE Non-Formulary balanced nutrition lactose free 09/18/2019 doxorubicin hcl doxorubicin hcl NEW AUTO RULE Non-Formulary 09/18/2019 diaper rash zinc oxide NEW AUTO RULE Non-Formulary ointment 09/18/2019 GVOKE glucagon NEW AUTO RULE Non-formulary HYPOPEN 2- PACK 09/18/2019 adriamycin doxorubicin hcl NEW AUTO RULE Non-Formulary 09/18/2019 FIRVANQ vancomycin hcl UM AUTO RULE: 450 ml/30 days QUANTITYCUSTOM 09/18/2019 pinworm pyrantel pamoate NEW AUTO RULE Non-Formulary medicine 09/18/2019 omeprazole omeprazole magnesium NEW AUTO RULE Non-Formulary magnesium 09/18/2019 cisatracurium cisatracurium besylate NEW AUTO RULE Non-Formulary besylate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 392 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/18/2019 ammonia n-13 ammonia n-13 NEW AUTO RULE Non-Formulary 09/18/2019 PEDIASURE pediatric nutrition with iron, NEW AUTO RULE Non-Formulary GROW-GAIN lactose free 09/18/2019 CULTURELLE pediatric multivitamin NEW AUTO RULE Non-Formulary KIDS no.181/lactobacillus COMPLETE MV rhamnosus gg 09/18/2019 NIMBEX cisatracurium besylate NEW AUTO RULE Non-Formulary 09/18/2019 pin-x pyrantel pamoate NEW AUTO RULE Non-Formulary 09/18/2019 testosterone testosterone propionate NEW AUTO RULE Non-Formulary propionate 09/18/2019 caretouch insulin syringe with NEW AUTO RULE Tier 2 syringe needle,disposable,insulin 1 ml 09/18/2020 ENSURE RAPID sodium/potassium/chloride/d NEW AUTO RULE Non-Formulary HYDRATION extrose 09/18/2020 SIMILAC infant formula with NEW AUTO RULE Non-Formulary ORGANIC A2 iron/docosahexaenoic MILK NO-GMO acid/arachidonic ac 09/18/2020 paper tape and adhesive tape NEW AUTO RULE Non-Formulary dispenser 09/18/2020 SIGNIFOR LAR pasireotide pamoate NEW AUTO RULE Non-Formulary 09/18/2020 LIDOMARK 2-5 lidocaine hcl/preservative NEW AUTO RULE Non-Formulary free/adhesive bandage 09/18/2020 SEVENFACT coagulation factor viia NEW AUTO RULE Non-Formulary recombinant-jncw 09/18/2020 tobramycin tobramycin NEW AUTO RULE NF specialty 09/18/2020 KENALOG-40 triamcinolone acetonide NEW AUTO RULE Non-Formulary 09/18/2020 KONSYL DAILY psyllium husk/sweetleaf NEW AUTO RULE Non-Formulary FIBER

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 393 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/18/2020 nasal relief sinus sodium chloride,sod bicarb NEW AUTO RULE Non-Formulary wash with neti pot nasal rinse device 09/18/2020 capsinac diclofenac sodium/capsicum NEW AUTO RULE Non-Formulary oleoresin 09/18/2020 diclofenac diclofenac submicronized NEW AUTO RULE Non-formulary 09/18/2020 PRECEDEX dexmedetomidine hcl in 0.9 NEW AUTO RULE Non-Formulary % sodium chloride 09/18/2020 SIMILAC infant formula with NEW AUTO RULE Non-Formulary ADVANCE iron/docosahexanoic ORGANIC acid/arachidonic ac 09/18/2020 sinus wash neti sodium chloride,sod bicarb NEW AUTO RULE Non-Formulary pot with neti pot nasal rinse device 09/18/2020 ayr saline nasal sodium chloride,sod bicarb NEW AUTO RULE Non-Formulary netirinse with neti pot nasal rinse device 09/18/2020 LAMPIT nifurtimox NEW AUTO RULE Non-formulary 09/18/2020 oxaliplatin oxaliplatin NEW AUTO RULE Non-Formulary 09/18/2020 paper tape adhesive tape NEW AUTO RULE Non-Formulary 09/18/2020 magnesium magnesium glycinate, NEW AUTO RULE Non-Formulary glycinate magnesium oxide 09/18/2020 acidophilus lactobacillus acidophilus NEW AUTO RULE Non-Formulary lactobacilli 09/18/2020 efavirenz-lamivu- efavirenz/lamivudine/tenofov NEW AUTO RULE Tier 2 tenofov disop ir disoproxil fumarate 09/18/2020 DETECTNET copper cu-64 dotatate NEW AUTO RULE Non-Formulary 09/18/2020 paper tape with adhesive tape NEW AUTO RULE Non-Formulary dispenser

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 394 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/18/2020 acidophilus lactobacillus acidophilus NEW AUTO RULE Non-Formulary probiotic 09/18/2020 NASAFLO sodium chloride,sod bicarb NEW AUTO RULE Non-Formulary PORCELAIN with neti pot nasal rinse device 09/18/2020 ONE-A-DAY prenatal vitamins NEW AUTO RULE Non-Formulary PRENATAL-1 no.168/iron/folic acid/omega-3/dha/epa 09/18/2020 tetracaine hcl tetracaine hcl/pf NEW AUTO RULE Non-Formulary 09/18/2020 ARMONAIR fluticasone propionate NEW AUTO RULE Non-formulary DIGIHALER 09/18/2020 NASAFLO sodium chloride,sod bicarb NEW AUTO RULE Non-Formulary with neti pot nasal rinse device 09/19/2019 TOUJEO MAX insulin glargine,human UM AUTO RULE: 6 pens/month SOLOSTAR recombinant analog QUANTITYCUSTOM 09/19/2019 TOUJEO insulin glargine,human UM AUTO RULE: 12 pens/month SOLOSTAR recombinant analog QUANTITYCUSTOM 09/20/2019 LUGOL'S iodine/potassium iodide DRUG ATTR CHANGE Non-Formulary Non-Formulary OVERRIDE 09/25/2019 SALONPAS methyl NEW AUTO RULE Non-Formulary salicylate/menthol/camphor 09/25/2019 antacid plus anti- magnesium NEW AUTO RULE Non-Formulary gas hydroxide/aluminum hydroxide/simethicone 09/25/2019 geri-lanta magnesium NEW AUTO RULE Non-Formulary hydroxide/aluminum hydroxide/simethicone 09/25/2019 utira-c methenamine/methylene NEW AUTO RULE Non-Formulary blue/sod phos/p.salicylate/hyoscyami ne

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 395 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/25/2019 TRISENOX arsenic trioxide NEW AUTO RULE Non-Formulary 09/25/2019 prednisolone- prednisolone NEW AUTO RULE Non-Formulary gatifloxacin acetate/gatifloxacin 09/25/2019 sinus nasal oxymetazoline hcl NEW AUTO RULE Non-Formulary 09/25/2019 prednisolone- prednisolone NEW AUTO RULE Non-Formulary gatiflox-bromfenc acetate/gatifloxacin/bromfen ac sodium 09/25/2019 COZIMA zinc oxide NEW AUTO RULE Non-Formulary 09/25/2019 sodium hyaluronate sodium NEW AUTO RULE Non-Formulary hyaluronate 09/25/2019 amikacin sulfate amikacin sulfate NEW AUTO RULE medical benefit drugs 09/25/2019 lidocaine- lidocaine hcl/epinephrine NEW AUTO RULE Non-Formulary epinephrine bitartrate 09/25/2019 original nasal oxymetazoline hcl NEW AUTO RULE Non-Formulary spray 09/25/2019 AFRIN oxymetazoline hcl NEW AUTO RULE Non-Formulary 09/25/2019 mylanta magnesium NEW AUTO RULE Non-Formulary maximum hydroxide/aluminum strength hydroxide/simethicone 09/25/2019 anefrin oxymetazoline hcl NEW AUTO RULE Non-Formulary 09/25/2019 liquid antacid magnesium NEW AUTO RULE Non-Formulary hydroxide/aluminum hydroxide/simethicone 09/25/2019 sinus relief oxymetazoline hcl NEW AUTO RULE Non-Formulary 09/25/2019 heparin sodium heparin sodium,porcine/pf NEW AUTO RULE Tier 1 09/25/2019 pain relief lidocaine NEW AUTO RULE Non-Formulary 09/25/2019 TOSYMRA sumatriptan NEW AUTO RULE Non-formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 396 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/25/2019 almacone-2 magnesium NEW AUTO RULE Non-Formulary hydroxide/aluminum hydroxide/simethicone 09/25/2019 ceftriaxone ceftriaxone sodium NEW AUTO RULE medical benefit drugs 09/25/2019 phosphasal methenamine/methylene NEW AUTO RULE Non-Formulary blue/sod phos/p.salicylate/hyoscyami ne 09/25/2019 nasal spray oxymetazoline hcl NEW AUTO RULE Non-Formulary 09/25/2019 advanced magnesium NEW AUTO RULE Non-Formulary antacid-antigas hydroxide/aluminum hydroxide/simethicone 09/25/2019 dr manzanilla dm triprolidine hcl/phenylephrine NEW AUTO RULE Non-Formulary hcl/dextromethorphan hbr 09/25/2019 histex-pe phenylephrine hcl/triprolidine NEW AUTO RULE Non-Formulary hcl 09/25/2019 URETRON D-S methenamine/methylene NEW AUTO RULE Non-Formulary blue/sod phos/p.salicylate/hyoscyami ne 09/25/2019 antacid with magnesium NEW AUTO RULE Non-Formulary simethicone hydroxide/aluminum hydroxide/simethicone 09/25/2019 medroxyprogeste medroxyprogesterone NEW AUTO RULE Non-Formulary rone acetate acetate 09/25/2019 lidocare lidocaine NEW AUTO RULE Non-Formulary 09/25/2019 no drip nasal oxymetazoline hcl NEW AUTO RULE Non-Formulary spray 09/25/2019 NICODERM CQ nicotine NEW AUTO RULE Preventative Drugs

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 397 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/25/2019 ur n-c methenamine/methylene NEW AUTO RULE Non-Formulary blue/sod phos/p.salicylate/hyoscyami ne 09/25/2019 long acting nasal oxymetazoline hcl NEW AUTO RULE Non-Formulary spray 09/25/2019 mi-acid magnesium NEW AUTO RULE Non-Formulary hydroxide/aluminum hydroxide/simethicone 09/25/2019 nasal relief oxymetazoline hcl NEW AUTO RULE Non-Formulary 09/25/2019 maalox maximum magnesium NEW AUTO RULE Non-Formulary strength hydroxide/aluminum hydroxide/simethicone 09/25/2019 EMLA lidocaine/prilocaine NEW AUTO RULE Non-formulary 09/25/2019 vicks sinex oxymetazoline hcl NEW AUTO RULE Non-Formulary 09/25/2019 TRILURON hyaluronate sodium NEW AUTO RULE Non-Formulary 09/25/2019 HISTEX PD triprolidine hcl NEW AUTO RULE Non-Formulary 09/25/2019 morphine sulfate- morphine sulfate in 0.9 % NEW AUTO RULE Non-Formulary 0.9% nacl sodium chloride/pf 09/25/2019 hematinic plus iron/folic acid/vitamin b NEW AUTO RULE Non-Formulary comp and c/minerals 09/25/2019 antacid maximum magnesium NEW AUTO RULE Non-Formulary strength hydroxide/aluminum hydroxide/simethicone 09/25/2019 MYLANTA calcium NEW AUTO RULE Non-Formulary TONIGHT carbonate/magnesium hydroxide/simethicone 09/25/2019 ACETADOTE acetylcysteine NEW AUTO RULE Non-Formulary 09/25/2019 ri-gel ii magnesium NEW AUTO RULE Non-Formulary hydroxide/aluminum hydroxide/simethicone

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 398 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/25/2019 antacid-gas relief magnesium NEW AUTO RULE Non-Formulary hydroxide/aluminum hydroxide/simethicone 09/25/2019 HISTEX triprolidine hcl NEW AUTO RULE Non-Formulary 09/25/2019 acetylcysteine acetylcysteine NEW AUTO RULE Non-Formulary 09/25/2019 oxymetazoline oxymetazoline hcl NEW AUTO RULE Non-Formulary hcl 09/25/2019 mag-al plus xs magnesium NEW AUTO RULE Non-Formulary hydroxide/aluminum hydroxide/simethicone 09/25/2019 urin d.s. methenamine/methylene NEW AUTO RULE Non-Formulary blue/sod phos/p.salicylate/hyoscyami ne 09/25/2019 nasal spray extra oxymetazoline hcl NEW AUTO RULE Non-Formulary moisturizing 09/25/2019 fentanyl- fentanyl citrate/ropivacaine NEW AUTO RULE Non-Formulary ropivacaine-0.9% hcl/sodium chloride 0.9%/pf nacl 09/25/2019 arsenic trioxide arsenic trioxide NEW AUTO RULE Non-Formulary 09/25/2019 XYLOCAINE lidocaine hcl/epinephrine NEW AUTO RULE Non-Formulary DENTAL- bitartrate EPINEPHRINE 09/25/2019 succinylcholine succinylcholine chloride NEW AUTO RULE Non-Formulary chloride 09/25/2019 antacid anti-gas magnesium NEW AUTO RULE Non-Formulary double str hydroxide/aluminum hydroxide/simethicone 09/25/2019 glycopyrrolate glycopyrrolate NEW AUTO RULE Non-Formulary 09/25/2019 protamine sulfate protamine sulfate NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 399 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/25/2019 masanti magnesium NEW AUTO RULE Non-Formulary hydroxide/aluminum hydroxide/simethicone 09/25/2019 XPHE nutritional therapy for NEW AUTO RULE Non-Formulary MAXAMUM phenylketonuria (pku) with iron no.6 09/25/2019 ferrocite plus iron/folic acid/vitamin b NEW AUTO RULE Non-Formulary comp and c/minerals 09/25/2019 mintox maximum magnesium NEW AUTO RULE Non-Formulary strength hydroxide/aluminum hydroxide/simethicone 09/25/2019 ASPERCREME lidocaine hcl NEW AUTO RULE Non-Formulary LIDOCAINE 09/25/2019 HISTEX-DM triprolidine hcl/phenylephrine NEW AUTO RULE Non-Formulary hcl/dextromethorphan hbr 09/25/2019 nasal oxymetazoline hcl NEW AUTO RULE Non-Formulary decongestant 09/25/2019 DEPO- medroxyprogesterone NEW AUTO RULE Non-Formulary PROVERA acetate 09/25/2019 dr manzanilla pe phenylephrine hcl/triprolidine NEW AUTO RULE Non-Formulary hcl 09/25/2019 EVISTA raloxifene hcl UM AUTO RULE: GENDER Female 09/25/2019 lidocaine pain lidocaine NEW AUTO RULE Non-Formulary relief 09/25/2019 sinus nasal spray oxymetazoline hcl NEW AUTO RULE Non-Formulary 09/25/2019 antacid magnesium NEW AUTO RULE Non-Formulary hydroxide/aluminum hydroxide/simethicone 09/25/2019 prednisolone prednisolone NEW AUTO RULE Non-Formulary acet-gatifloxacin acetate/gatifloxacin

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 400 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/25/2019 12 hour nasal oxymetazoline hcl NEW AUTO RULE Non-Formulary relief 09/25/2019 TNKASE tenecteplase NEW AUTO RULE Non-Formulary 09/25/2019 LIDOMD lidocaine/methyl NEW AUTO RULE Non-Formulary salicylate/capsaicin/menthol 09/25/2019 nasal spray sinus oxymetazoline hcl NEW AUTO RULE Non-Formulary 09/25/2019 dr manzanilla triprolidine hcl NEW AUTO RULE Non-Formulary infant 09/25/2019 antacid-antigas magnesium NEW AUTO RULE Non-Formulary hydroxide/aluminum hydroxide/simethicone 09/25/2019 ENSURE lactose-reduced food NEW AUTO RULE Non-Formulary ORIGINAL 09/25/2019 prilovix ultralite lidocaine/prilocaine NEW AUTO RULE Non-Formulary 09/25/2019 dr manzanilla triprolidine hcl NEW AUTO RULE Non-Formulary pediatric 09/25/2019 no drip oxymetazoline hcl NEW AUTO RULE Non-Formulary 09/25/2019 12 hour nasal oxymetazoline hcl NEW AUTO RULE Non-Formulary spray 09/25/2019 TRINAZ prenatal vitamins NEW AUTO RULE Non-Formulary no.162/ferrous gluconate/folic acid 09/25/2019 nutritional shake lactose-reduced food NEW AUTO RULE Non-Formulary 09/25/2019 transderm-iq lidocaine/methyl NEW AUTO RULE Non-Formulary salicylate/capsaicin/menthol 09/25/2019 prednisolone prednisolone NEW AUTO RULE Non-Formulary acet-gatiflo-brom acetate/gatifloxacin/bromfen ac sodium

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 401 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/25/2019 comfort gel magnesium NEW AUTO RULE Non-Formulary hydroxide/aluminum hydroxide/simethicone 09/25/2019 complete lactose-reduced food NEW AUTO RULE Non-Formulary nutritional 09/25/2019 CALTRATE 600 calcium NEW AUTO RULE Non-Formulary PLUS D3 carbonate/cholecalciferol (vitamin d3) 09/25/2020 magic3 catheter NEW AUTO RULE Non-Formulary intermittent catheter 09/25/2020 XYWAV sodium oxybate/calcium NEW AUTO RULE NF specialty oxybate/magnesium oxybate/pot oxybate 09/25/2020 POLIVY polatuzumab vedotin-piiq NEW AUTO RULE Non-Formulary 09/25/2020 CONJUPRI levamlodipine maleate NEW AUTO RULE Non-formulary 09/25/2020 PREVIDENT fluoride (sodium) NEW AUTO RULE Non-Formulary 09/25/2020 FOLIKA-MG multivit with min no.83/iron NEW AUTO RULE Non-Formulary bis-glycinate/folate no.10 09/25/2020 ARESTIN minocycline hcl NEW AUTO RULE Non-Formulary microspheres 09/25/2020 ciferex cholecalciferol (vit d3)/folic NEW AUTO RULE Non-Formulary acid 09/25/2020 folic d3 cholecalciferol (vit d3)/folic NEW AUTO RULE Non-Formulary acid 09/25/2020 fluorouracil fluorouracil NEW AUTO RULE Non-Formulary 09/25/2020 DURACHOL cholecalciferol (vit d3)/folic NEW AUTO RULE Non-Formulary acid 09/25/2020 CIFRAZOL cholecalciferol (vit d3)/folic NEW AUTO RULE Non-Formulary acid

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 402 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/25/2020 deferiprone deferiprone NEW AUTO RULE NF specialty 09/25/2020 ROBAXIN methocarbamol NEW AUTO RULE Non-Formulary 09/25/2020 t:slim x2 with subcutaneous insulin pump NEW AUTO RULE Non-Formulary basal-iq 09/25/2020 ortho df cholecalciferol (vit d3)/folic NEW AUTO RULE Non-Formulary acid 09/27/2019 sulfamethoxazole sulfamethoxazole/trimethopr ADD UM: AUTHORIZATION PA Applies -trimethoprim im 09/27/2019 SULFATRIM sulfamethoxazole/trimethopr ADD UM: AUTHORIZATION PA Applies im 09/27/2019 eptifibatide eptifibatide DRUG ATTR CHANGE Non-Formulary Non-Formulary OVERRIDE 09/29/2020 ORALAIR grass pollen-orchard/sweet TERM AUTO RULE vernal/rye/kentucky/timothy, std. 09/29/2020 HYCAMTIN topotecan hcl TERM AUTO RULE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 403 UPDATED 12/2020 VALUE Drug Formulary Updates

October, 2020

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 MYCAPSSA octreotide acetate UM AUTO RULE: Limited Access LIMITEDACCESS 10/01/2020 MYCAPSSA octreotide acetate TERM AUTO RULE 10/01/2020 ferrous sulfate ferrous sulfate NEW AUTO RULE Non-Formulary 10/01/2020 amitriptyline hcl amitriptyline hcl UM AUTO RULE: STEP Commercial: use two preferred antidepressants first 10/01/2020 elavil amitriptyline hcl ADD TO FORMULARY Non-Formulary Non-formulary 10/02/2019 ICAPS AREDS2 vitamin c/vit e/zinc NEW AUTO RULE Non-Formulary oxide/copper citrate/lutein/zeaxanthin 10/02/2019 acid reducer famotidine NEW AUTO RULE Non-Formulary 10/02/2019 lidall lidocaine/menthol NEW AUTO RULE Non-Formulary 10/02/2019 ADVIL ibuprofen NEW AUTO RULE Non-Formulary 10/02/2019 TEMIXYS lamivudine/tenofovir NEW AUTO RULE Tier 2 disoproxil fumarate 10/02/2019 nulido lidocaine/menthol NEW AUTO RULE Non-Formulary 10/02/2019 WAKIX pitolisant hcl NEW AUTO RULE NF specialty 10/02/2019 FIASP PENFILL insulin aspart (niacinamide) NEW AUTO RULE Non-formulary 10/02/2019 nitisinone nitisinone NEW AUTO RULE NF specialty 10/02/2019 acid controller famotidine NEW AUTO RULE Non-Formulary 10/02/2019 lidopin lidocaine hcl NEW AUTO RULE Non-Formulary 10/02/2019 sensorcaine-mpf bupivacaine NEW AUTO RULE Non-Formulary epinephrine hcl/epinephrine/pf

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 404 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/02/2019 OPTIMAL D3 M cholecalciferol (vitamin d3) NEW AUTO RULE Non-Formulary 10/02/2019 hydromorphone hydromorphone hcl in 0.9 % NEW AUTO RULE Non-Formulary hcl-0.9% nacl sodium chloride/pf 10/02/2019 menthol-camphor menthol/camphor NEW AUTO RULE Non-Formulary 10/02/2019 icy hot lidocaine/menthol NEW AUTO RULE Non-Formulary 10/02/2019 sodium sulfacetamide NEW AUTO RULE Non-Formulary sulfacetamide- sodium/sulfur/avobenzone/o sulfur ctinoxate/octyl sal 10/02/2019 heartburn relief famotidine NEW AUTO RULE Non-Formulary 10/02/2019 cidaleaze lidocaine hcl NEW AUTO RULE Non-Formulary 10/02/2019 LIDOPATCH lidocaine/menthol NEW AUTO RULE Non-Formulary 10/02/2019 SUMADAN XLT sulfacetamide NEW AUTO RULE Non-Formulary sodium/sulfur/avobenzone/o ctinoxate/octyl sal 10/02/2019 lidocaine hcl lidocaine hcl NEW AUTO RULE Non-Formulary 10/02/2019 RYBELSUS semaglutide NEW AUTO RULE Non-formulary 10/02/2019 DEPO- medroxyprogesterone NEW AUTO RULE Non-Formulary PROVERA acetate 10/02/2019 bead back wrap cold-hot pack NEW AUTO RULE Non-Formulary 10/02/2019 pepcid famotidine NEW AUTO RULE Non-Formulary 10/02/2019 ICAPS AREDS2 vit c/vit e ace/zinc NEW AUTO RULE Non-Formulary oxide/copper hvp chel/lutein/zeaxanthin 10/02/2019 DUAKLIR aclidinium NEW AUTO RULE NF specialty PRESSAIR bromide/formoterol fumarate 10/02/2019 eptifibatide eptifibatide NEW AUTO RULE Non-Formulary 10/02/2019 heartburn famotidine NEW AUTO RULE Non-Formulary prevention

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 405 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/02/2019 cold and hot pain lidocaine/menthol NEW AUTO RULE Non-Formulary relief 10/02/2019 MARCAINE- bupivacaine NEW AUTO RULE Non-Formulary EPINEPHRINE hcl/epinephrine/pf 10/02/2019 bupivacaine hcl- bupivacaine NEW AUTO RULE Non-Formulary epinephrine hcl/epinephrine/pf 10/02/2019 NOURIANZ istradefylline NEW AUTO RULE NF specialty 10/02/2019 XYLOCAINE lidocaine hcl NEW AUTO RULE Non-Formulary 10/02/2019 valproic acid valproic acid (as sodium ADD UM: AUTHORIZATION PA Applies salt) (valproate sodium) 10/02/2019 famotidine famotidine NEW AUTO RULE Non-Formulary 10/02/2019 hot and cold pain lidocaine/menthol NEW AUTO RULE Non-Formulary relief 10/02/2020 CERAVE ceramides 1,3,6-ii NEW AUTO RULE Non-Formulary MOISTURIZING 10/02/2020 ENSURE nutritional NEW AUTO RULE Non-Formulary HARVEST supplement,special formula,lactose free,iron/soy 10/02/2020 maximum naphazoline NEW AUTO RULE Non-Formulary redness relief hcl/hypromellose 10/02/2020 MEGARED ADV omega-3 fatty NEW AUTO RULE Non-Formulary TOTAL BODY acids/dha/epa/fish REFRESH oil/krill/lutein/zeaxanth 10/02/2020 anu-med phenylephrine hcl NEW AUTO RULE Non-Formulary 10/02/2020 VISTASEAL thrombin(human plasma NEW AUTO RULE Non-Formulary FIBRIN derived)/fibrinogen/calcium SEALANT chloride 10/02/2020 alocane lidocaine hcl NEW AUTO RULE Non-Formulary emergency burn 10/02/2020 lapatinib lapatinib ditosylate NEW AUTO RULE Tier 3

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 406 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/02/2020 cognitive health citicoline NEW AUTO RULE Non-Formulary 10/02/2020 cranberry cranberry fruit NEW AUTO RULE Non-Formulary 10/02/2020 dimethyl dimethyl fumarate TERM AUTO RULE fumarate 10/02/2020 CERAVE ceramides 1,3,6-ii NEW AUTO RULE Non-Formulary 10/02/2020 ADVANCED EYE naphazoline NEW AUTO RULE Non-Formulary RELIEF hcl/hypromellose REDNESS 10/02/2020 CERAVE PM ceramides 1,3,6- NEW AUTO RULE Non-Formulary ii/niacinamide/hyaluronic acid 10/02/2020 hemorrhoidal phenylephrine hcl NEW AUTO RULE Non-Formulary suppository 10/02/2020 RHEUMATE levomefolate NEW AUTO RULE Non-Formulary calcium/mecobalamin/herbal complex no.236 10/02/2020 TUSNEL-DM guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary PEDIATRIC an hbr/phenylephrine 10/02/2020 dimethyl dimethyl fumarate NEW AUTO RULE NF specialty fumarate 10/02/2020 tropic- tropicamide/proparacaine/ph NEW AUTO RULE Non-Formulary proparacaine-pe- enylephrine/ketorolac in ketorlc water 10/02/2020 TENDER CARE lanolin NEW AUTO RULE Non-Formulary LANOLIN 10/02/2020 XERAVA eravacycline di- NEW AUTO RULE Non-Formulary hydrochloride 10/02/2020 RISAQUAD l. acidophilus/l. paracasei/b. NEW AUTO RULE Non-Formulary bifidum/s. thermophilus 10/02/2020 lubricant redness naphazoline NEW AUTO RULE Non-Formulary eye drops hcl/hypromellose

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 407 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/02/2020 FOLIKA-CI multivitamin with mineral NEW AUTO RULE Non-Formulary no.84/ferrous gluconate/folic acid 10/02/2020 ATIVAN lorazepam NEW AUTO RULE Non-Formulary 10/02/2020 HEMORRHOIDA phenylephrine hcl NEW AUTO RULE Non-Formulary L 10/08/2020 LOPROX ciclopirox olamine NEW AUTO RULE Non-formulary 10/09/2019 ear drops carbamide peroxide NEW AUTO RULE Non-Formulary 10/09/2019 diltiazem hcl- diltiazem hcl in 0.9 % NEW AUTO RULE Non-Formulary 0.7% nacl sodium chloride 10/09/2019 epinephrine-0.9% epinephrine hcl in 0.9 % NEW AUTO RULE Non-Formulary nacl sodium chloride 10/09/2019 child's mucus guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary relief m-s cold an hbr/phenylephrine 10/09/2019 carbamoxide carbamide peroxide NEW AUTO RULE Non-Formulary 10/09/2019 diltiazem hcl- diltiazem hcl in 0.9 % NEW AUTO RULE Non-Formulary 0.9% nacl sodium chloride 10/09/2019 non-aspirin extra acetaminophen NEW AUTO RULE Non-Formulary strength 10/09/2019 nighttime sleep- doxylamine succinate NEW AUTO RULE Non-Formulary aid 10/09/2019 fast mucus rlf guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary congest-cough an hbr/phenylephrine 10/09/2019 diphen diphenhydramine hcl NEW AUTO RULE Non-Formulary 10/09/2019 g-tron guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary an hbr 10/09/2019 adult tussin guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary cough congest an hbr dm

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 408 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/09/2019 epinephrine hcl- epinephrine hcl in 0.9 % NEW AUTO RULE Non-Formulary 0.9% nacl sodium chloride 10/09/2019 child mucinex oxymetazoline hcl NEW AUTO RULE Non-Formulary stuffy nose spry 10/09/2019 norethindron- norethindrone acetate- NEW AUTO RULE Tier 1 ethinyl estradiol ethinyl estradiol 10/09/2019 MKO midazolam/ketamine NEW AUTO RULE Non-Formulary (MIDAZOLAM- hcl/ondansetron hcl KETAMINE- ONDAN) 10/09/2019 UNISOM SLEEP doxylamine succinate NEW AUTO RULE Non-Formulary AID 10/09/2019 ultra sleep doxylamine succinate NEW AUTO RULE Non-Formulary 10/09/2019 UNISOM doxylamine succinate NEW AUTO RULE Non-Formulary 10/09/2019 cold-flu-sore phenylephrine NEW AUTO RULE Non-Formulary throat hcl/dextromethorphan hbr/acetaminophen/guaifen 10/09/2019 mucus relief guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary congest-cough an hbr/phenylephrine 10/09/2019 CHILD MUCINEX guaifenesin NEW AUTO RULE Non-Formulary CHEST MINI- MELTS 10/09/2019 RELAFEN DS nabumetone NEW AUTO RULE NF specialty 10/09/2019 dextrose 5%- dextrose 5 % and 0.2 % NEW AUTO RULE Non-Formulary 0.2% nacl sodium chloride 10/09/2019 diabetic tussin guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary dm an hbr 10/09/2019 adult robitussin guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary peak cold dm an hbr 10/09/2019 KIVIK palm oil/benzoyl peroxide NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 409 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/09/2019 morphine sulfate- morphine sulfate in 0.9 % NEW AUTO RULE Non-Formulary 0.9% nacl sodium chloride/pf 10/09/2019 PAIN & FEVER acetaminophen NEW AUTO RULE Non-Formulary 10/09/2019 herbiomed phenylephrine NEW AUTO RULE Non-Formulary severe cold-flu hcl/dextromethorphan m-s hbr/acetaminophen/guaifen 10/09/2019 ultra dm free & guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary clear an hbr 10/09/2019 tusnel diabetic guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary an hbr 10/09/2019 guaifenesin- guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary dextromethorpha an hbr n 10/09/2019 children's multi- guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary symptom cold an hbr/phenylephrine 10/09/2019 mucus relief phenylephrine NEW AUTO RULE Non-Formulary severe cold hcl/dextromethorphan hbr/acetaminophen/guaifen 10/09/2019 OZOBAX baclofen NEW AUTO RULE NF specialty 10/09/2019 KETODAN ketoconazole/skin cleanser NEW AUTO RULE Non-Formulary combination no.28 10/09/2019 rompe pecho phenylephrine NEW AUTO RULE Non-Formulary max multi hcl/dextromethorphan symptoms hbr/acetaminophen/guaifen 10/09/2019 DRIZALMA duloxetine hcl NEW AUTO RULE Non-formulary SPRINKLE 10/09/2019 MUCINEX FAST- phenylephrine NEW AUTO RULE Non-Formulary MAX COLD-FLU hcl/dextromethorphan hbr/acetaminophen/guaifen 10/09/2019 safetussin dm guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary an hbr

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 410 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/09/2019 curity sodium chloride irrigating NEW AUTO RULE Non-Formulary solution 10/09/2019 CHILD MUCINEX guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary COUGH MINI- an hbr MELTS 10/09/2019 CHILDREN'S guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary MUCINEX an hbr/phenylephrine FREEFROM 10/09/2019 acetaminophen acetaminophen NEW AUTO RULE Non-Formulary 10/09/2019 clindamycin clindamycin phosphate NEW AUTO RULE Non-Formulary phosphate 10/09/2019 murine ear wax carbamide peroxide NEW AUTO RULE Non-Formulary removal system 10/09/2019 PREGENNA prenatal vitamins NEW AUTO RULE Non-Formulary no.163/iron bis- glycinate/folate no.10 10/09/2019 mucus rlf cold-flu- phenylephrine NEW AUTO RULE Non-Formulary sore throat hcl/dextromethorphan hbr/acetaminophen/guaifen 10/09/2019 diphenhydramine diphenhydramine hcl NEW AUTO RULE Non-Formulary hcl 10/09/2019 tovet emollient clobetasol NEW AUTO RULE Tier 1 propionate/emollient base 10/09/2019 ropivacaine hcl- ropivacaine hcl in 0.9 % NEW AUTO RULE Non-Formulary 0.9% nacl sodium chloride/pf 10/09/2019 CHILD MUCINEX guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary COUGH- an hbr/phenylephrine CONGEST 10/09/2019 dextrose 5%- dextrose 5 % and 0.2 % NEW AUTO RULE Non-Formulary 0.225% nacl sodium chloride 10/09/2019 pain relief adult acetaminophen NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 411 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/09/2019 CYTOVENE ganciclovir sodium NEW AUTO RULE Non-Formulary 10/09/2019 pain relief acetaminophen NEW AUTO RULE Non-Formulary 10/09/2019 pain reliever adult acetaminophen NEW AUTO RULE Non-Formulary 10/09/2019 mucinex sinus- oxymetazoline hcl NEW AUTO RULE Non-Formulary max 10/09/2019 DEBROX carbamide peroxide NEW AUTO RULE Non-Formulary 10/09/2019 severe cough- guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary congestion an hbr/phenylephrine 10/09/2019 aqua care sodium chloride irrigating NEW AUTO RULE Non-Formulary sodium chloride solution 10/09/2019 wal-som doxylamine succinate NEW AUTO RULE Non-Formulary 10/09/2019 children's allergy diphenhydramine hcl NEW AUTO RULE Non-Formulary 10/09/2019 guaiasorb dm guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary an hbr 10/09/2019 antiseptic povidone-iodine NEW AUTO RULE Non-Formulary 10/09/2019 mapap acetaminophen NEW AUTO RULE Non-Formulary 10/09/2019 MUCINEX FAST- phenylephrine NEW AUTO RULE Non-Formulary MAX SEVERE hcl/dextromethorphan COLD hbr/acetaminophen/guaifen 10/09/2019 ASPARLAS calaspargase pegol-mknl NEW AUTO RULE Non-Formulary 10/09/2019 geri-tussin dm guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary an hbr 10/09/2019 CYTOGAM cytomegalovirus immune NEW AUTO RULE Non-Formulary globulin (human) 10/09/2019 sodium chloride sodium chloride irrigating NEW AUTO RULE Non-Formulary solution 10/09/2019 DACOGEN decitabine NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 412 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/09/2019 EARWAX carbamide peroxide NEW AUTO RULE Non-Formulary TREATMENT DROPS 10/09/2019 siltussin dm das guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary an hbr 10/09/2019 sebex salicylic acid/sulfur NEW AUTO RULE Non-Formulary 10/09/2019 CLEOCIN clindamycin phosphate NEW AUTO RULE Non-Formulary PHOSPHATE 10/09/2019 MUCINEX FAST- guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary MAX CONGEST- an hbr/phenylephrine COUGH 10/09/2019 sorbugen nr guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary an hbr 10/09/2019 tussin cf max phenylephrine NEW AUTO RULE Non-Formulary severe m-s cold hcl/dextromethorphan hbr/acetaminophen/guaifen 10/09/2019 ear system carbamide peroxide NEW AUTO RULE Non-Formulary 10/09/2019 tussin cough guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary an hbr 10/09/2019 CHILDREN'S guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary MUCINEX an hbr/phenylephrine 10/09/2019 BETADINE povidone-iodine NEW AUTO RULE Non-Formulary 10/09/2019 diabetic siltussin- guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary dm an hbr 10/09/2019 biocotron guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary an hbr 10/09/2019 MURINE EAR carbamide peroxide NEW AUTO RULE Non-Formulary DROPS 10/09/2020 freestyle libre 14 flash glucose sensor NEW AUTO RULE Non-Formulary day sensor

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 413 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/09/2020 stool softener docusate sodium NEW AUTO RULE Non-Formulary 10/09/2020 re-gen nutritional supplement NEW AUTO RULE Non-Formulary 10/09/2020 enlite glucose blood-glucose sensor NEW AUTO RULE Non-Formulary sensor 10/09/2020 CERAVE SA ceramides (1,3,6-ii)/salicylic NEW AUTO RULE Non-Formulary acid/niacinamide 10/09/2020 RESOURCE 2.0 nutritional supplement NEW AUTO RULE Non-Formulary 10/09/2020 altachlore sodium chloride NEW AUTO RULE Non-Formulary 10/09/2020 CERAVE ceramides 1,3,6- DRUG ATTR CHANGE Non-Formulary Non-Formulary FOAMING ii/niacinamide OVERRIDE FACIAL 10/09/2020 MURO-128 sodium chloride NEW AUTO RULE Non-Formulary 10/09/2020 sof-sensor blood-glucose sensor NEW AUTO RULE Non-Formulary 10/09/2020 REGIOCIT (EUA) sodium chloride/sodium NEW AUTO RULE Non-Formulary citrate 10/09/2020 hand sanitizer ethyl alcohol NEW AUTO RULE Non-Formulary 10/09/2020 TAB-A-VITE multivitamin with folic acid DRUG ATTR CHANGE Non-Formulary Non-Formulary OVERRIDE 10/09/2020 giltuss cough- guaifenesin/dextromethorph NEW AUTO RULE Non-Formulary congestion an hbr 10/09/2020 vitamin e vitamin e (dl-alpha NEW AUTO RULE Non-Formulary tocopheryl acetate) 10/09/2020 nootropic coffee- coffee extract/phosphatidyl NEW AUTO RULE Non-Formulary ps serine 10/09/2020 eversense smart blood-glucose transmitter NEW AUTO RULE Non-Formulary transmitter 10/09/2020 omega-3 fish oil omega-3 fatty NEW AUTO RULE Non-Formulary acids/docosahexaenoic acid/epa/fish oil

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 414 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/09/2020 germ-x ethyl alcohol NEW AUTO RULE Non-Formulary 10/09/2020 norepinephrine norepinephrine bitartrate in NEW AUTO RULE Non-Formulary bitar-0.9% nacl 0.9 % sodium chloride 10/09/2020 DIOCTO docusate sodium NEW AUTO RULE Non-Formulary 10/09/2020 INVIGOFLEX glucosamine dipot NEW AUTO RULE Non-Formulary AMPM chl/chondroitin sul a na/boswell/turmeric 10/09/2020 prenatal prenatal vits with calcium NEW AUTO RULE Non-Formulary 95/ferrous fumarate/folic acid 10/09/2020 freestyle libre 10 flash glucose sensor NEW AUTO RULE Non-Formulary day sensor 10/09/2020 LIMENCIN lidocaine/menthol NEW AUTO RULE Non-Formulary 10/09/2020 dexcom g6 blood-glucose sensor NEW AUTO RULE Non-Formulary 10/09/2020 freestyle blood-glucose sensor NEW AUTO RULE Non-Formulary navigator 10/09/2020 lidocaine-menthol lidocaine/menthol NEW AUTO RULE Non-Formulary 10/09/2020 TEROCIN lidocaine/menthol NEW AUTO RULE Non-Formulary 10/09/2020 retaine nacl sodium chloride NEW AUTO RULE Non-Formulary 10/09/2020 total care incontinence pad,liner,disp NEW AUTO RULE Non-Formulary underpads 10/09/2020 diphen diphenhydramine hcl NEW AUTO RULE Non-Formulary 10/09/2020 aphen acetaminophen NEW AUTO RULE Non-Formulary 10/09/2020 hi-cal nutritional supplement NEW AUTO RULE Non-Formulary 10/09/2020 magic3 go catheter NEW AUTO RULE Non-Formulary intermit catheter 10/09/2020 docusate sodium docusate sodium NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 415 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/09/2020 PALYNZIQ pegvaliase-pqpz UM AUTO RULE: 3 syringes/day QUANTITYCUSTOM 10/09/2020 nasal spray oxymetazoline hcl DRUG ATTR CHANGE Non-Formulary Non-Formulary OVERRIDE 10/09/2020 docu liquid docusate sodium NEW AUTO RULE Non-Formulary 10/09/2020 senna sennosides NEW AUTO RULE Non-Formulary 10/09/2020 eo28 splash nutritional supplement NEW AUTO RULE Non-Formulary 10/09/2020 ephedrine ephedrine sulfate in 0.9 % NEW AUTO RULE Non-Formulary sulfate-nacl sodium chloride/pf 10/09/2020 SILACE docusate sodium NEW AUTO RULE Non-Formulary 10/09/2020 liquituss gg guaifenesin NEW AUTO RULE Non-Formulary 10/09/2020 ephedrine ephedrine sulfate in 0.9 % NEW AUTO RULE Non-Formulary sulfate-0.9% nacl sodium chloride/pf 10/09/2020 efavirenz-emtric- efavirenz/emtricitabine/tenof NEW AUTO RULE Non-formulary tenofov disop ovir disoproxil fumarate 10/09/2020 dexcom g6 blood-glucose transmitter NEW AUTO RULE Non-Formulary 10/09/2020 dexcom g5 blood-glucose transmitter NEW AUTO RULE Non-Formulary 10/09/2020 dexcom g4 blood-glucose transmitter NEW AUTO RULE Non-Formulary 10/09/2020 wal-dram dimenhydrinate NEW AUTO RULE Non-Formulary 10/09/2020 omega-3 fish oil omega-3 fatty NEW AUTO RULE Non-Formulary acids/docosahexanoic acid/epa/fish oil 10/09/2020 giltuss ex guaifenesin NEW AUTO RULE Non-Formulary 10/09/2020 sodium chloride sodium chloride NEW AUTO RULE Non-Formulary 10/09/2020 minimed 770g subcutaneous insulin pump NEW AUTO RULE Non-Formulary 10/09/2020 glucosamine glucosamine sulfate NEW AUTO RULE Non-Formulary sulfate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 416 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/09/2020 MONUROL fosfomycin tromethamine UM AUTO RULE: 1 packet/30 days QUANTITYCUSTOM 10/09/2020 emtricitabine- emtricitabine/tenofovir NEW AUTO RULE Tier 2 tenofovir disop disoproxil fumarate 10/09/2020 prenatal formula prenatal vits with calcium NEW AUTO RULE Non-Formulary 95/ferrous fumarate/folic acid 10/09/2020 magnesium magnesium sulfate NEW AUTO RULE Non-Formulary sulfate 10/09/2020 fish oil omega-3 fatty NEW AUTO RULE Non-Formulary acids/docosahexanoic acid/epa/fish oil 10/09/2020 TRELEGY fluticasone NEW AUTO RULE Tier 2 ELLIPTA furoate/umeclidinium bromide/vilanterol trifenat 10/09/2020 BREEZA sorbitol/mannitol/xanthan NEW AUTO RULE Non-Formulary NEUTRAL AB- gum PELVIC IMAGE 10/09/2020 fludarabine fludarabine phosphate NEW AUTO RULE Non-Formulary phosphate 10/09/2020 surgiflo gelatin sponge,absorbable NEW AUTO RULE Non-Formulary 10/09/2020 gelrite ethyl alcohol NEW AUTO RULE Non-Formulary 10/09/2020 valerian root- valerian root extract/hops NEW AUTO RULE Non-Formulary hops 10/09/2020 lenzapro lidocaine/menthol NEW AUTO RULE Non-Formulary 10/09/2020 phenylephrine phenylephrine hcl in 0.9 % NEW AUTO RULE Non-Formulary hcl-0.9% nacl sodium chloride 10/09/2020 MULTI PRO multivit-mins no.85/iron/folic NEW AUTO RULE Non-Formulary acid/dha/lactobacillus casei 10/09/2020 elbow arm brace NEW AUTO RULE Non-Formulary compression

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 417 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/09/2020 clear tape adhesive tape NEW AUTO RULE Non-Formulary 10/09/2020 CERAVE ceramides 1,3,6- NEW AUTO RULE Non-Formulary FOAMING ii/niacinamide FACIAL 10/09/2020 PEDIASURE nutritional NEW AUTO RULE Non-Formulary HARVEST supplement,special formula,lactose free,iron/soy 10/09/2020 dexcom g5-g4 blood-glucose sensor NEW AUTO RULE Non-Formulary sensor 10/09/2020 fosfomycin fosfomycin tromethamine NEW AUTO RULE Tier 3 tromethamine 10/09/2020 alocane lidocaine hcl NEW AUTO RULE Non-Formulary emergency burn 10/14/2020 TRUVADA emtricitabine/tenofovir TERM AUTO RULE disoproxil fumarate 10/16/2019 antacid calcium calcium carbonate NEW AUTO RULE Non-Formulary 10/16/2019 ELIGARD leuprolide acetate NEW AUTO RULE Non-Formulary 10/16/2019 prilovix ultralite lidocaine/prilocaine NEW AUTO RULE Non-Formulary plus 10/16/2019 PREPARATION phenylephrine NEW AUTO RULE Non-Formulary H hcl/pramoxine hcl/glycerin/white petrolatum 10/16/2019 poly-iron iron polysaccharide complex NEW AUTO RULE Non-Formulary 10/16/2019 daytime-cold diphenhydramine/phenyleph NEW AUTO RULE Non-Formulary nighttime-cld-flu rin/dextromethorph/acetamin ophen/gg 10/16/2019 warm steam vaporizer NEW AUTO RULE Non-Formulary vaporizer 10/16/2019 wal-dryl diphenhydramine hcl/zinc NEW AUTO RULE Non-Formulary acetate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 418 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/16/2019 xurea urea NEW AUTO RULE NF specialty 10/16/2019 sinus phenylephrine hcl NEW AUTO RULE Non-Formulary decongestant 10/16/2019 BETADINE povidone-iodine NEW AUTO RULE Non-Formulary 10/16/2019 polysaccharide iron polysaccharide complex NEW AUTO RULE Non-Formulary iron 10/16/2019 ferric x-150 iron polysaccharide complex NEW AUTO RULE Non-Formulary 10/16/2019 mucinex sinus- dextromethorphan NEW AUTO RULE Non-Formulary max congest-pain hbr/phenylephrine hcl/acetaminophen 10/16/2019 ketodan ketoconazole NEW AUTO RULE Non-formulary 10/16/2019 alert aid caffeine NEW AUTO RULE Non-Formulary 10/16/2019 men's 50 plus multivitamin with NEW AUTO RULE Non-Formulary daily formula minerals/folic acid/vitamin k1/lycopene 10/16/2019 XEMBIFY immune globulin,gamma NEW AUTO RULE Non-Formulary (igg)-klhw human 10/16/2019 white petrolatum petrolatum,white NEW AUTO RULE Non-Formulary 10/16/2019 sodium chloride sodium chloride 0.45 % NEW AUTO RULE Non-Formulary 10/16/2019 GLUCERNA nutritional therapy, glucose NEW AUTO RULE Non-Formulary SNACK BAR intolerance,soy 10/16/2019 antacid & pain aspirin/sodium NEW AUTO RULE Non-Formulary relief bicarbonate/citric acid 10/16/2019 rubbing alcohol ethyl alcohol NEW AUTO RULE Non-Formulary 10/16/2019 wal-sporin bacitracin zinc/polymyxin b NEW AUTO RULE Non-Formulary sulfate 10/16/2019 AKLIEF trifarotene NEW AUTO RULE Non-formulary 10/16/2019 calcium antacid calcium carbonate NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 419 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/16/2019 suphedrine pe phenylephrine hcl NEW AUTO RULE Non-Formulary 10/16/2019 mucinex sinus- phenylephrine NEW AUTO RULE Non-Formulary max pressure- hcl/dextromethorphan cgh hbr/acetaminophen/guaifen 10/16/2019 sinus pressure- phenylephrine hcl NEW AUTO RULE Non-Formulary cong relief pe 10/16/2019 petroleum jelly petrolatum,white NEW AUTO RULE Non-Formulary 10/16/2019 MERREM meropenem NEW AUTO RULE Non-Formulary 10/16/2019 MENOSTAR estradiol UM AUTO RULE: 4 patches/28 QUANTITYCUSTOM days 10/16/2019 MSUD EASY nutritional ther.msud(maple NEW AUTO RULE Non-Formulary syrup urine disease)without iron 10/16/2019 thermoscan-3 thermometer for the ear, NEW AUTO RULE Non-Formulary electronic 10/16/2019 VIVARIN caffeine NEW AUTO RULE Non-Formulary 10/16/2019 scot-tussin dextromethorphan hbr NEW AUTO RULE Non-Formulary diabetes 10/16/2019 iferex 150 iron polysaccharide complex NEW AUTO RULE Non-Formulary 10/16/2019 NU-IRON 150 iron polysaccharide complex NEW AUTO RULE Non-Formulary 10/16/2019 effervescent aspirin/sodium NEW AUTO RULE Non-Formulary antacid-pain rlf bicarbonate/citric acid 10/16/2019 fentanyl citrate fentanyl citrate/pf NEW AUTO RULE Non-Formulary 10/16/2019 antacid calcium carbonate NEW AUTO RULE Non-Formulary 10/16/2019 PRIALT ziconotide acetate NEW AUTO RULE Non-Formulary 10/16/2019 alertness aid caffeine NEW AUTO RULE Non-Formulary 10/16/2019 senna sennosides NEW AUTO RULE Non-Formulary 10/16/2019 panoxyl benzoyl peroxide NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 420 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/16/2019 myferon 150 iron polysaccharide complex NEW AUTO RULE Non-Formulary 10/16/2019 MUCINEX FAST- diphenhydramine/phenyleph NEW AUTO RULE Non-Formulary MAX DAY-NITE rin/dextromethorph/acetamin COLD ophen/gg 10/16/2019 b-12 cyanocobalamin (vitamin b- NEW AUTO RULE Non-Formulary 12) 10/16/2019 miconazole-7 miconazole nitrate NEW AUTO RULE Non-Formulary 10/16/2019 poly bacitracin bacitracin zinc/polymyxin b NEW AUTO RULE Non-Formulary sulfate 10/16/2019 white petroleum petrolatum,white NEW AUTO RULE Non-Formulary 10/16/2019 HEPLISAV-B hepatitis b vaccine NEW AUTO RULE Non-Formulary recombinant/vaccine adjuvant cpg 1018/pf 10/16/2019 slow release iron ferrous sulfate, dried NEW AUTO RULE Non-Formulary 10/16/2019 ICAPS AREDS2 vitamin c/vit e/zinc NEW AUTO RULE Non-Formulary oxide/copper citrate/lutein/zeaxanthin 10/16/2019 acetaminophen acetaminophen NEW AUTO RULE Non-Formulary 10/16/2019 b-12 dots cyanocobalamin (vitamin b- NEW AUTO RULE Non-Formulary 12) 10/16/2019 nasal phenylephrine hcl NEW AUTO RULE Non-Formulary decongestant pe 10/16/2019 cefazolin sodium cefazolin sodium NEW AUTO RULE medical benefit drugs 10/16/2019 ALKA-SELTZER aspirin/sodium NEW AUTO RULE Non-Formulary ORIGINAL bicarbonate/citric acid 10/16/2019 petroleum jelly lip petrolatum,white NEW AUTO RULE Non-Formulary treatment

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 421 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/16/2019 hemorrhoidal phenylephrine NEW AUTO RULE Non-Formulary cream hcl/pramoxine hcl/glycerin/white petrolatum 10/16/2019 SUDAFED PE phenylephrine hcl NEW AUTO RULE Non-Formulary 10/16/2019 one daily men's multivitamin with NEW AUTO RULE Non-Formulary 50 plus d3 minerals/folic acid/vitamin k1/lycopene 10/16/2019 ENFAMIL infant formula with NEW AUTO RULE Non-Formulary ENFACARE iron/docosahexanoic acid/arachidonic ac 10/16/2019 BEOVU brolucizumab-dbll NEW AUTO RULE Non-Formulary 10/16/2019 ONE-A-DAY multivitamin with NEW AUTO RULE Non-Formulary MEN'S 50 PLUS minerals/folic acid/vitamin k1/lycopene 10/16/2019 effervescent pain aspirin/sodium NEW AUTO RULE Non-Formulary relief bicarbonate/citric acid 10/16/2019 miconazole 7 miconazole nitrate NEW AUTO RULE Non-Formulary 10/16/2019 METRO IV metronidazole in sodium NEW AUTO RULE Non-Formulary chloride 10/16/2019 uredeb urea NEW AUTO RULE NF specialty 10/16/2019 SOVALDI sofosbuvir NEW AUTO RULE NF specialty 10/16/2019 one daily men's multivitamin with NEW AUTO RULE Non-Formulary 50 plus minerals/folic acid/vitamin k1/lycopene 10/16/2019 vitamin b-12 cyanocobalamin (vitamin b- NEW AUTO RULE Non-Formulary 12) 10/16/2019 meropenem meropenem NEW AUTO RULE medical benefit drugs 10/16/2019 FASENRA PEN benralizumab NEW AUTO RULE NF specialty 10/16/2019 wal-phed phenylephrine hcl NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 422 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/16/2019 stay awake caffeine NEW AUTO RULE Non-Formulary 10/16/2019 PROTONIX IV pantoprazole sodium NEW AUTO RULE Non-Formulary 10/16/2019 caffeine caffeine NEW AUTO RULE Non-Formulary 10/16/2019 men 50 plus multivitamin with NEW AUTO RULE Non-Formulary advanced one minerals/folic acid/vitamin daily k1/lycopene 10/16/2019 creamy acne face benzoyl peroxide NEW AUTO RULE Non-Formulary 10/16/2019 father john's dextromethorphan hbr NEW AUTO RULE Non-Formulary cough suppressnt 10/16/2019 miconazole miconazole nitrate NEW AUTO RULE Non-Formulary nitrate 10/16/2019 vaporizer vaporizer NEW AUTO RULE Non-Formulary 10/16/2019 pantoprazole pantoprazole sodium NEW AUTO RULE Non-Formulary sodium 10/16/2019 testosterone testosterone NEW AUTO RULE Non-Formulary 10/16/2019 awake caffeine NEW AUTO RULE Non-Formulary 10/16/2019 SCOT-TUSSIN dextromethorphan hbr NEW AUTO RULE Non-Formulary 10/16/2019 panoxyl-4 benzoyl peroxide NEW AUTO RULE Non-Formulary 10/16/2019 metronidazole metronidazole in sodium NEW AUTO RULE Non-Formulary chloride 10/16/2019 itch relief diphenhydramine hcl/zinc NEW AUTO RULE Non-Formulary acetate 10/16/2019 ferrex 150 iron polysaccharide complex NEW AUTO RULE Non-Formulary 10/16/2019 MONISTAT 7 miconazole nitrate NEW AUTO RULE Non-Formulary 10/16/2019 MYLANTA GAS simethicone NEW AUTO RULE Non-Formulary MINIS 10/16/2019 BENADRYL diphenhydramine hcl/zinc NEW AUTO RULE Non-Formulary acetate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 423 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/16/2019 anti-itch diphenhydramine hcl/zinc NEW AUTO RULE Non-Formulary acetate 10/16/2019 HARVONI ledipasvir/sofosbuvir NEW AUTO RULE Tier 4 10/16/2020 testosterone testosterone NEW AUTO RULE Non-Formulary 10/16/2020 CERAVE SA salicylic acid/ceramides NEW AUTO RULE Non-Formulary 1,3,6-ii 10/16/2020 sleep aid diphenhydramine hcl NEW AUTO RULE Non-Formulary 10/16/2020 lutein-zeaxanthin lutein/zeaxanthin NEW AUTO RULE Non-Formulary 10/16/2020 ez nite sleep diphenhydramine hcl NEW AUTO RULE Non-Formulary 10/16/2020 wal-sleep z diphenhydramine hcl NEW AUTO RULE Non-Formulary 10/16/2020 sleep-aid diphenhydramine hcl NEW AUTO RULE Non-Formulary 10/16/2020 XYNTHA antihemophilic factor (factor NEW AUTO RULE Non-Formulary SOLOFUSE viii) recomb,b-domain deleted 10/16/2020 arthritis pain diclofenac sodium NEW AUTO RULE Non-Formulary 10/16/2020 CLOBETAVIX clobetasol NEW AUTO RULE Non-Formulary propionate/hydrocolloid dressing 10/16/2020 sleep time diphenhydramine hcl NEW AUTO RULE Non-Formulary 10/16/2020 epinephrine epinephrine hcl NEW AUTO RULE Non-Formulary chloride 10/16/2020 arthritis pain diclofenac sodium NEW AUTO RULE Non-Formulary reliever 10/16/2020 lofric primo catheter NEW AUTO RULE Non-Formulary nelaton 10/16/2020 lutrish dietary supplement NEW AUTO RULE Non-Formulary 10/16/2020 magnesium magnesium chloride NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 424 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/16/2020 ONE-A-DAY multivit with calcium- NEW AUTO RULE Non-Formulary WOMEN'S mins/iron fumarate/folic COMPLETE acid/vit k 10/16/2020 cml lidocaine/methyl NEW AUTO RULE Non-Formulary salicylate/camphor 10/16/2020 lotrimin af miconazole nitrate NEW AUTO RULE Non-Formulary 10/16/2020 z-sleep diphenhydramine hcl NEW AUTO RULE Non-Formulary 10/16/2020 laxative sennosides NEW AUTO RULE Non-Formulary 10/16/2020 ALKINDI hydrocortisone NEW AUTO RULE NF specialty SPRINKLE 10/16/2020 ZZZQUIL diphenhydramine hcl NEW AUTO RULE Non-Formulary 10/16/2020 CERAVE SA ceramides (1,3,6-ii)/salicylic NEW AUTO RULE Non-Formulary acid/niacinamide 10/16/2020 tolvaptan tolvaptan NEW AUTO RULE NF specialty 10/16/2020 athlete's foot miconazole nitrate NEW AUTO RULE Non-Formulary 10/16/2020 sinus wash sodium chloride/sodium NEW AUTO RULE Non-Formulary bicarbonate 10/16/2020 OCUVITE lutein/zeaxanthin NEW AUTO RULE Non-Formulary LUTEIN 25 10/16/2020 nighttime sleep diphenhydramine hcl NEW AUTO RULE Non-Formulary aid 10/18/2019 virt-phos 250 sodium DRUG ATTR CHANGE Tier 1 Tier 1 neutral phosphate,dibasic/pot OVERRIDE phos,monob/sod phosphate mono 10/18/2019 multivitamins with pediatric multivitamin no.82 DRUG ATTR CHANGE Tier 1 Tier 1 fluoride with sodium fluoride OVERRIDE 10/18/2019 QUFLORA FE pediatric multivitamin DRUG ATTR CHANGE Non-formulary Non-formulary no.142/iron,carbonyl/sodium OVERRIDE fluoride

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 425 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/18/2019 vitasure vitamin b complex/folic DRUG ATTR CHANGE Non-Formulary Non-Formulary acid/ascorbic acid/biotin OVERRIDE 10/18/2019 vinate-m prenatal vits with calcium DRUG ATTR CHANGE Tier 1 Tier 1 136/ferrous fumarate/folic OVERRIDE acid 10/18/2019 sodium citrate- citric acid/sodium citrate DRUG ATTR CHANGE Non-formulary Non-formulary citric acid OVERRIDE 10/18/2019 ESCAVITE pediatric multivitamin DRUG ATTR CHANGE Non-formulary Non-formulary no.47/ferrous fumarate/sod OVERRIDE fluoride 10/18/2019 tri-vite with pediatric multivit with a,c,d3 DRUG ATTR CHANGE Tier 1 Tier 1 fluoride no.21/sodium fluoride OVERRIDE 10/18/2019 TEXAVITE LQ pediatric multivitamin DRUG ATTR CHANGE Non-Formulary Non-Formulary no.108/iron fumarate/sodium OVERRIDE fluoride 10/18/2019 folic-k vitamin e/b1/b6/folic DRUG ATTR CHANGE Non-Formulary Non-Formulary acid/b12/alpha lipoic OVERRIDE ac/coenzyme q10 10/18/2019 hylavite folic acid/vitamin b complex DRUG ATTR CHANGE Non-Formulary Non-Formulary and vitamin c OVERRIDE 10/18/2019 QUFLORA pediatric multivitamin no.83 DRUG ATTR CHANGE Non-formulary Non-formulary with sodium fluoride OVERRIDE 10/18/2019 genicin vita-q folic DRUG ATTR CHANGE Non-Formulary Non-Formulary acid/b1/b6/b12/c/d3/nadh OVERRIDE sodium/coenzyme q10 10/18/2019 hydroxypropylcell hydroxypropyl cellulose DRUG ATTR CHANGE Non-Formulary Non-Formulary ulose OVERRIDE 10/18/2019 ludent fluoride fluoride (sodium) DRUG ATTR CHANGE Preventative Preventative OVERRIDE Drugs Drugs 10/18/2019 VINATE CARE multivitamin combination DRUG ATTR CHANGE Tier 1 Tier 1 no.43/ferrous fumarate/folic OVERRIDE acid

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 426 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/18/2019 xvite vitamin b complex/folic DRUG ATTR CHANGE Non-Formulary Non-Formulary acid/ascorbic acid/biotin OVERRIDE 10/18/2019 vitamins a,c,d pediatric multivit with a,c,d3 DRUG ATTR CHANGE Non-Formulary Non-Formulary and fluoride no.21/sodium fluoride OVERRIDE 10/18/2019 ENZADYNE lipase/protease/amylase DRUG ATTR CHANGE Non-Formulary Non-Formulary OVERRIDE 10/18/2019 tri-vit with fluoride/iron/vitamins a,c,and DRUG ATTR CHANGE Tier 1 Tier 1 fluoride-iron d OVERRIDE 10/18/2019 ESCAVITE LQ pediatric multivitamin no.86 DRUG ATTR CHANGE Non-formulary Non-formulary with iron and sodium fluoride OVERRIDE 10/18/2019 FLORIVA pediatric multivitamin no.85 DRUG ATTR CHANGE Non-formulary Non-formulary with sodium fluoride OVERRIDE 10/18/2019 multi-vitamin w- pediatric multivitamin DRUG ATTR CHANGE Tier 1 Tier 1 fluoride-iron no.45/sodium OVERRIDE fluoride/ferrous sulfate 10/18/2019 CADEAU DHA prenatal vitamins no.83/iron DRUG ATTR CHANGE Non-formulary Non-formulary fumarate/folate combo OVERRIDE no.6/dha 10/18/2019 potass cit-sod cit- sodium/potassium/potassiu DRUG ATTR CHANGE Non-formulary Non-formulary citric acid m citrate/sodium citrate/cit OVERRIDE ac 10/18/2019 potassium citrate- potassium citrate/citric acid DRUG ATTR CHANGE Tier 1 Tier 1 citric acid OVERRIDE 10/18/2019 multivitamin with pediatric multivitamins no.17 DRUG ATTR CHANGE Tier 1 Tier 1 fluoride with sodium fluoride OVERRIDE 10/18/2019 QUFLORA FE pediatric multivitamin DRUG ATTR CHANGE Non-formulary Non-formulary no.151/ferrous sulfate/sod OVERRIDE fluoride 10/18/2019 multivitamins w- pediatric multivitamin DRUG ATTR CHANGE Preventive Health Preventive Health fluoride-iron no.45/sodium OVERRIDE fluoride/ferrous sulfate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 427 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/18/2019 KETOVIE 3:1 nutritional tx, DRUG ATTR CHANGE Non-Formulary Non-Formulary ketogenic,whey OVERRIDE 10/18/2019 FLUORABON fluoride (sodium) DRUG ATTR CHANGE Preventative Preventative OVERRIDE Drugs Drugs 10/18/2019 flura-drops fluoride (sodium) DRUG ATTR CHANGE Preventative Preventative OVERRIDE Drugs Drugs 10/18/2019 folvite-d cholecalciferol (vit d3)/folic DRUG ATTR CHANGE Non-Formulary Non-Formulary acid OVERRIDE 10/18/2019 TOBAKIENT vit b2/vit b6/folic acid/vit DRUG ATTR CHANGE Non-Formulary Non-Formulary c/d3/glutathione/astaxanthin OVERRIDE 10/18/2019 FOLITE folic acid/calcium DRUG ATTR CHANGE Non-Formulary Non-Formulary citrate/vitamin d3/mag OVERRIDE citrate/a-cysteine 10/18/2019 multivitamin-iron- pediatric multivitamin DRUG ATTR CHANGE Tier 1 Tier 1 fluoride no.45/sodium OVERRIDE fluoride/ferrous sulfate 10/18/2019 polysorbate 80 polysorbate 80 DRUG ATTR CHANGE Non-Formulary Non-Formulary OVERRIDE 10/18/2019 activite folic acid/vitamin b complex DRUG ATTR CHANGE Non-Formulary Non-Formulary and vitamin c OVERRIDE 10/18/2019 TRINAZ prenatal vitamins DRUG ATTR CHANGE Non-Formulary Non-Formulary no.162/ferrous OVERRIDE gluconate/folic acid 10/18/2019 fluoride fluoride (sodium) DRUG ATTR CHANGE Preventative Preventative OVERRIDE Drugs Drugs 10/18/2019 VIRT-FEFA iron fumarate/polysac DRUG ATTR CHANGE Non-Formulary Non-Formulary PLUS complex/folic acid/vit b OVERRIDE comp,c no.23 10/18/2019 MVC-FLUORIDE pediatric multivitamin no.12 DRUG ATTR CHANGE Non-formulary Non-formulary with sodium fluoride OVERRIDE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 428 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/18/2019 multivitamin with pediatric multivitamin DRUG ATTR CHANGE Tier 1 Tier 1 fluoride no.16/sodium fluoride OVERRIDE 10/18/2019 FLUORITAB fluoride (sodium) DRUG ATTR CHANGE Preventative Preventative OVERRIDE Drugs Drugs 10/18/2019 multivitamin and pediatric multivitamin DRUG ATTR CHANGE Preventive Health Preventive Health fluoride no.2/sodium fluoride OVERRIDE 10/18/2019 FLORIVA sodium DRUG ATTR CHANGE Preventative Preventative fluoride/cholecalciferol OVERRIDE Drugs Drugs (vitamin d3) 10/18/2019 LUGOL'S iodine/potassium iodide DRUG ATTR CHANGE Non-Formulary Non-Formulary OVERRIDE 10/18/2019 multivitamins with pediatric multivitamin DRUG ATTR CHANGE Preventive Health Preventive Health fluoride no.2/sodium fluoride OVERRIDE 10/18/2019 QUFLORA pediatric multivitamin no.84 DRUG ATTR CHANGE Non-formulary Non-formulary with sodium fluoride OVERRIDE 10/18/2019 microcrystalline cellulose DRUG ATTR CHANGE Non-Formulary Non-Formulary cellulose OVERRIDE 10/18/2019 sodium fluoride fluoride (sodium) DRUG ATTR CHANGE Preventative Preventative OVERRIDE Drugs Drugs 10/18/2019 ONEVITE multivit-minerals no.67/folic DRUG ATTR CHANGE Non-Formulary Non-Formulary acid/alpha lipoic acid/lutein OVERRIDE 10/18/2019 ESCAVITE D pediatric multivitamin no.78 DRUG ATTR CHANGE Non-formulary Non-formulary with iron and sodium fluoride OVERRIDE 10/18/2019 methocel e 4 m hypromellose DRUG ATTR CHANGE Non-Formulary Non-Formulary OVERRIDE 10/18/2019 O-CAL FA multivitamin with minerals DRUG ATTR CHANGE Non-Formulary Non-Formulary no.61/ferrous fumarate/folic OVERRIDE acid 10/18/2019 tricitrates sodium/potassium/potassiu DRUG ATTR CHANGE Tier 1 Tier 1 m citrate/sodium citrate/cit OVERRIDE ac

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 429 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/18/2019 nicazyme niacinamide/fa/b6/copper/zin DRUG ATTR CHANGE Non-Formulary Non-Formulary c oxide/baikal OVERRIDE skullcap/catechu 10/18/2019 PREGENNA prenatal vitamins DRUG ATTR CHANGE Non-Formulary Non-Formulary no.163/iron bis- OVERRIDE glycinate/folate no.10 10/18/2019 multivitamin with pediatric multivitamin no.150 DRUG ATTR CHANGE Preventive Health Preventive Health fluoride with sodium fluoride OVERRIDE 10/18/2019 tri-vitamin with pediatric multivit with a,c,d3 DRUG ATTR CHANGE Tier 1 Tier 1 fluoride no.21/sodium fluoride OVERRIDE 10/18/2019 multivitamin with pediatric multivitamin DRUG ATTR CHANGE Tier 1 Tier 1 fluoride no.2/sodium fluoride OVERRIDE 10/18/2019 virtrate-k potassium citrate/citric acid DRUG ATTR CHANGE Tier 1 Tier 1 OVERRIDE 10/18/2019 phospha 250 sodium DRUG ATTR CHANGE Tier 1 Tier 1 neutral phosphate,dibasic/pot OVERRIDE phos,monob/sod phosphate mono 10/18/2019 completenate prenatal vitamins DRUG ATTR CHANGE Tier 1 Tier 1 no.14/ferrous fumarate/folic OVERRIDE acid 10/18/2019 QUFLORA pediatric multivitamin no.63 DRUG ATTR CHANGE Non-formulary Non-formulary with sodium fluoride OVERRIDE 10/18/2019 niva-plus multivitamin-minerals DRUG ATTR CHANGE Non-Formulary Non-Formulary no.60/ferrous fumarate/folic OVERRIDE acid 10/18/2019 genicin vita-s vitamin b complex/folic DRUG ATTR CHANGE Non-Formulary Non-Formulary acid/ascorbic acid/biotin OVERRIDE 10/18/2019 vinate one prenatal vitamin 27 with DRUG ATTR CHANGE Tier 1 Tier 1 calcium/ferrous OVERRIDE fumarate/folic acid

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 430 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/18/2019 virtrate-3 sodium/potassium/potassiu DRUG ATTR CHANGE Non-formulary Non-formulary m citrate/sodium citrate/cit OVERRIDE ac 10/18/2019 genicin vita-d cholecalciferol (vit d3)/folic DRUG ATTR CHANGE Non-Formulary Non-Formulary acid OVERRIDE 10/18/2019 FLORIVA PLUS pediatric multivitamin DRUG ATTR CHANGE Non-formulary Non-formulary no.130/sodium fluoride OVERRIDE 10/18/2019 PEDIASURE pediatric nutrition with iron, DRUG ATTR CHANGE Non-Formulary Non-Formulary GROW-GAIN lactose free OVERRIDE 10/18/2019 virtrate-2 citric acid/sodium citrate DRUG ATTR CHANGE Non-formulary Non-formulary OVERRIDE 10/18/2019 hematinic plus iron/folic acid/vitamin b DRUG ATTR CHANGE Non-Formulary Non-Formulary comp and c/minerals OVERRIDE 10/18/2019 multivitamins w- pediatric multivitamin DRUG ATTR CHANGE Tier 1 Tier 1 fluoride-iron no.75/sodium OVERRIDE fluoride/ferrous sulfate 10/18/2019 K-PHOS sodium DRUG ATTR CHANGE Non-formulary Non-formulary NEUTRAL phosphate,dibasic/pot OVERRIDE phos,monob/sod phosphate mono 10/18/2019 FOLIKA-V folic DRUG ATTR CHANGE Non-Formulary Non-Formulary acid/b1/b6/b12/c/d3/nadh OVERRIDE sodium/coenzyme q10 10/18/2019 multivitamins with pediatric multivitamin DRUG ATTR CHANGE Preventive Health Preventive Health fluoride no.16/sodium fluoride OVERRIDE 10/19/2020 dimethyl dimethyl fumarate UM AUTO RULE: 2 tabs/day; 1 fumarate QUANTITYCUSTOM pack/month; MADD, 30DS 10/23/2019 ephedrine ephedrine sulfate in 0.9 % NEW AUTO RULE Non-Formulary sulfate-nacl sodium chloride/pf 10/23/2019 waltz free benzalkonium chloride NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 431 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/23/2019 GAS-X ULTRA simethicone NEW AUTO RULE Non-Formulary STRENGTH 10/23/2019 PEDIASURE pediatric nutrition with iron, NEW AUTO RULE Non-Formulary ENTERAL lactose free 10/23/2019 ENFAMIL infant form.iron, NEW AUTO RULE Non-Formulary NEURO lact.reduced/dha/arachidoni SENSITIVE c acid (ara) NONGMO 10/23/2019 NEOSPORIN benzalkonium chloride NEW AUTO RULE Non-Formulary 10/23/2019 bupivacaine hcl- bupivacaine hcl/epinephrine NEW AUTO RULE Non-Formulary epinephrine 10/23/2019 CHILD MUCINEX diphenhydramine/phenyleph NEW AUTO RULE Non-Formulary M-S COLD DAY- rin/dextromethorph/acetamin NTE ophen/gg 10/23/2019 ephedrine ephedrine sulfate in 0.9 % NEW AUTO RULE Non-Formulary sulfate-0.9% nacl sodium chloride/pf 10/23/2019 simethicone simethicone NEW AUTO RULE Non-Formulary 10/23/2019 pentamidine pentamidine isethionate NEW AUTO RULE Non-Formulary isethionate 10/23/2019 midazolam hcl midazolam hcl NEW AUTO RULE Non-Formulary 10/23/2019 senna plus sennosides/docusate NEW AUTO RULE Non-Formulary sodium 10/23/2019 INFASURF calfactant NEW AUTO RULE Non-Formulary 10/23/2019 bevacizumab bevacizumab NEW AUTO RULE Non-Formulary 10/23/2019 TOVET KIT clobetasol NEW AUTO RULE Non-Formulary propionate/emollient combination no.65 10/23/2019 MARCAINE- bupivacaine hcl/epinephrine NEW AUTO RULE Non-Formulary EPINEPHRINE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 432 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/23/2019 CLEOCIN clindamycin phosphate NEW AUTO RULE Non-Formulary PHOSPHATE 10/23/2019 children's m-s diphenhydramine/phenyleph NEW AUTO RULE Non-Formulary cold day-night rin/dextromethorph/acetamin ophen/gg 10/23/2019 clm patch lidocaine/methyl NEW AUTO RULE Non-Formulary salicylate/camphor 10/23/2019 VIVA PATCH lidocaine/methyl NEW AUTO RULE Non-Formulary salicylate/camphor 10/23/2019 MUCINEX FAST- phenylephrine NEW AUTO RULE Non-Formulary MAX COLD-FLU- hcl/dextromethorphan THRT hbr/acetaminophen/guaifen 10/23/2019 levocarnitine sf levocarnitine NEW AUTO RULE Non-formulary 10/23/2019 ropivacaine hcl ropivacaine hcl/pf NEW AUTO RULE Non-Formulary 10/23/2019 sensorcaine- bupivacaine hcl/epinephrine NEW AUTO RULE Non-Formulary epinephrine 10/23/2019 QUELICIN succinylcholine chloride NEW AUTO RULE Non-Formulary 10/23/2019 easy comfort syringe with NEW AUTO RULE Tier 2 insulin syringe needle,insulin,0.5 ml 10/23/2019 PHAZYME simethicone NEW AUTO RULE Non-Formulary 10/23/2019 MUCINEX FAST- phenylephrine NEW AUTO RULE Non-Formulary MAX COLD-FLU hcl/dextromethorphan hbr/acetaminophen/guaifen 10/23/2019 hydrocortisone hydrocortisone acetate NEW AUTO RULE Non-Formulary 10/23/2019 anti-gas simethicone NEW AUTO RULE Non-Formulary 10/23/2019 vancomycin hcl vancomycin hcl in water for NEW AUTO RULE Non-Formulary injection (peg-400, nada) 10/23/2019 ivermectin ivermectin NEW AUTO RULE Non-formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 433 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/23/2019 pain relieving methyl NEW AUTO RULE Non-Formulary patch salicylate/menthol/camphor 10/23/2019 CATHFLO alteplase NEW AUTO RULE Non-Formulary ACTIVASE 10/23/2019 LACTO-PECTIN l.acidophilus,casei,plantariu NEW AUTO RULE Non-Formulary m,rhamnosus gg/b.breve/b.longum 10/23/2019 PROAIR albuterol sulfate NEW AUTO RULE Non-formulary DIGIHALER 10/23/2019 microair mesh nebulizer NEW AUTO RULE Non-Formulary nebulizer 10/23/2019 PEDIASURE pediatric nutrition with iron, NEW AUTO RULE Non-Formulary GROW-GAIN lactose free 10/23/2019 NUTRAMIGEN infant NEW AUTO RULE Non-Formulary TODDLER formula,iron,spec.metabol,la ENFLORA-LGG ctose free/l.rhamnosus gg 10/23/2019 PEDIZOL PAK ketoconazole/miconazole NEW AUTO RULE Non-Formulary nitrate 10/23/2019 PHENERGAN promethazine hcl NEW AUTO RULE Tier 2 10/23/2019 HAIR, SKIN AND ascorbic acid/vitamin e NEW AUTO RULE Non-Formulary NAILS-BIOTIN acetate (dl- alpha,tocopheryl)/biotin 10/23/2019 ENFAMIL infant formula w- NEW AUTO RULE Non-Formulary REGULINE iron/dha/ara/polydextrose/go s 10/23/2019 stool softener- sennosides/docusate NEW AUTO RULE Non-Formulary stimulant lax sodium 10/23/2019 REFRESH carboxymethylcellulose NEW AUTO RULE Non-Formulary CELLUVISC sodium 10/23/2019 thera tears carboxymethylcellulose NEW AUTO RULE Non-Formulary sodium

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 434 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/23/2019 ribavirin ribavirin NEW AUTO RULE Non-Formulary 10/23/2019 clindamycin clindamycin phosphate NEW AUTO RULE Non-Formulary phosphate 10/23/2019 germ bloc benzalkonium chloride NEW AUTO RULE Non-Formulary 10/23/2019 gallium citrate ga- gallium-67 citrate NEW AUTO RULE Non-Formulary 67 10/23/2019 BALANCED B-50 vitamin b complex/folic acid NEW AUTO RULE Non-Formulary COMPLEX 10/23/2019 NEBUPENT pentamidine isethionate NEW AUTO RULE Non-Formulary 10/23/2019 VIRAZOLE ribavirin NEW AUTO RULE Non-Formulary 10/23/2020 cefotetan cefotetan disodium NEW AUTO RULE Non-Formulary 10/23/2020 anti-diarrheal- loperamide hcl/simethicone NEW AUTO RULE Non-Formulary anti-gas 10/23/2020 famotidine famotidine NEW AUTO RULE Non-Formulary 10/23/2020 tavaborole tavaborole NEW AUTO RULE NF specialty 10/23/2020 KERYDIN tavaborole UM AUTO RULE: 10 ml/30 days QUANTITYCUSTOM 10/23/2020 non-aspirin acetaminophen NEW AUTO RULE Non-Formulary 10/23/2020 POLYSPORIN bacitracin zinc/polymyxin b NEW AUTO RULE Non-Formulary sulfate 10/23/2020 certavite- multivitamin/ferrous NEW AUTO RULE Non-Formulary antioxidant fumarate/folic acid 10/23/2020 pod-care 100c betamethasone NEW AUTO RULE Non-Formulary acetate/betamethasone sodium phosphate 10/23/2020 SIMILAC bifidobacterium NEW AUTO RULE Non-Formulary PROBIOTIC TRI- animlis/bifidobacterium BLEND infantis/s. thermoph

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 435 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/23/2020 menthol- capsaicin/menthol NEW AUTO RULE Non-Formulary capsaicin 10/23/2020 CEFOTAN cefotetan disodium NEW AUTO RULE Non-Formulary 10/23/2020 MENCAPS capsaicin/menthol NEW AUTO RULE Non-Formulary 10/23/2020 AMINOSYN II parenteral amino acid 10 % NEW AUTO RULE Non-Formulary combination no.1 10/23/2020 vitamin b-12 cyanocobalamin (vitamin b- NEW AUTO RULE Non-Formulary 12) 10/23/2020 sweet cheeks dextrose NEW AUTO RULE Non-Formulary 10/23/2020 BETA 1 betamethasone NEW AUTO RULE Non-Formulary acetate/betamethasone sodium phosphate 10/23/2020 BSP 0820 betamethasone NEW AUTO RULE Non-Formulary acetate/betamethasone sodium phosphate 10/23/2020 EPCLUSA sofosbuvir/velpatasvir NEW AUTO RULE Tier 4 10/23/2020 quick temp pro thermometer, infrared, non- NEW AUTO RULE Non-Formulary thermometer contact 10/23/2020 atrantil tannic acid/horse chestnut NEW AUTO RULE Non-Formulary seed xt/peppermint leaf xt 10/23/2020 IMODIUM loperamide hcl/simethicone NEW AUTO RULE Non-Formulary MULTI- SYMPTOM RELIEF 10/23/2020 readysharp betamethasone NEW AUTO RULE Non-Formulary betamethasone acetate/betamethasone sodium phosphate 10/23/2020 poly-vita with iron pediatric multivitamin NEW AUTO RULE Non-Formulary no.160/ferrous sulfate 10/23/2020 children's pain acetaminophen NEW AUTO RULE Non-Formulary relief

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 436 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/23/2020 dr manzanilla phenylephrine NEW AUTO RULE Non-Formulary cough-cold hcl/diphenhydramine hcl 10/23/2020 POLYSPORIN bacitracin zinc/polymyxin b DRUG ATTR CHANGE Non-Formulary Non-Formulary sulfate OVERRIDE 10/23/2020 new image skin ostomy supply NEW AUTO RULE Non-Formulary barrier-flange 10/23/2020 westab mini cyanocobalamin/folic NEW AUTO RULE Non-Formulary acid/pyridoxine 10/23/2020 nalbuphine hcl nalbuphine hcl NEW AUTO RULE Non-Formulary 10/23/2020 olopatadine hcl olopatadine hcl NEW AUTO RULE Non-Formulary 10/23/2020 ULTOMIRIS ravulizumab-cwvz NEW AUTO RULE Non-Formulary 10/23/2020 ENVIVE l.acidoph,paracasei, b.lactis NEW AUTO RULE Non-Formulary 10/23/2020 poly-vita pediatric multivitamin no.171 NEW AUTO RULE Non-Formulary 10/23/2020 milrinone in 5% milrinone lactate/dextrose 5 NEW AUTO RULE Non-Formulary dextrose % in water 10/23/2020 PKU EASY nutritional therapy for NEW AUTO RULE Non-Formulary phenylketonuria(pku) no.56 10/23/2020 child benadryl phenylephrine NEW AUTO RULE Non-Formulary plus congestion hcl/diphenhydramine hcl 10/23/2020 PEDIA POLY- pediatric multivitamin NEW AUTO RULE Non-Formulary VITE WITH IRON no.160/ferrous sulfate 10/23/2020 5-htp cr 5-hydroxytryptophan (5-htp) NEW AUTO RULE Non-Formulary 10/23/2020 new image skin ostomy supply NEW AUTO RULE Non-Formulary barrier 10/25/2019 atropine sulfate atropine sulfate NEW AUTO RULE Non-Formulary 10/25/2019 TOSYMRA sumatriptan UM AUTO RULE: 12 bottles/30 QUANTITYCUSTOM days

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 437 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/25/2019 FLUCELVAX flu vaccine quad 2019- UM AUTO RULE: 2 doses/year QUAD 2019- 2020(4 years and older)cell QUANTITYCUSTOM 2020 derived/pf 10/25/2019 TURALIO pexidartinib hydrochloride UM AUTO RULE: 4 caps/day QUANTITYCUSTOM 10/25/2019 FLUAD 2019- influenza vaccine tvs 2019- UM AUTO RULE: 2 doses/year 2020 20 (65 yr up)/adjuvant QUANTITYCUSTOM mf59c.1/pf 10/25/2019 FLUCELVAX flu vaccine quadriv 2019- UM AUTO RULE: 2 doses/year QUAD 2019- 2020(4 years and older)cell QUANTITYCUSTOM 2020 derived 10/26/2020 tramadol hcl er tramadol hcl UM AUTO RULE: PA Applies AUTHORIZATION 10/26/2020 tramadol hcl er tramadol hcl TERM AUTO RULE 10/28/2019 ADDERALL dextroamphetamine sulf- REMOVE UM: AGE At least 18 yrs saccharate/amphetamine old sulf-aspartate 10/28/2019 ADDERALL dextroamphetamine sulf- TERM AUTO RULE saccharate/amphetamine sulf-aspartate 10/30/2019 kaopectate bismuth subsalicylate NEW AUTO RULE Non-Formulary 10/30/2019 OCEAN salt irrigation solution no.1 NEW AUTO RULE Non-Formulary COMPLETE 10/30/2019 sinus pe phenylephrine NEW AUTO RULE Non-Formulary pressure-pain- hcl/dextromethorphan cold hbr/acetaminophen/guaifen 10/30/2019 ALBURX albumin human NEW AUTO RULE Non-Formulary 10/30/2019 congestion relief ibuprofen/phenylephrine hcl NEW AUTO RULE Non-Formulary 10/30/2019 kao-tin bismuth subsalicylate NEW AUTO RULE Non-Formulary 10/30/2019 curity water for irrigation,sterile NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 438 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/30/2019 trueplus glucose dextrose NEW AUTO RULE Non-Formulary 10/30/2019 cold-cough sinus phenylephrine NEW AUTO RULE Non-Formulary relief pe hcl/dextromethorphan hbr/acetaminophen/guaifen 10/30/2019 HECTOROL doxercalciferol NEW AUTO RULE Non-Formulary 10/30/2019 vitamin b vitamin b complex/folic acid NEW AUTO RULE Non-Formulary complex 10/30/2019 soothe bismuth subsalicylate NEW AUTO RULE Non-Formulary 10/30/2019 XYZAL levocetirizine NEW AUTO RULE Non-Formulary dihydrochloride 10/30/2019 balance b-50 vitamin b complex/folic acid NEW AUTO RULE Non-Formulary 10/30/2019 sudafed pe head ibuprofen/phenylephrine hcl NEW AUTO RULE Non-Formulary congestn-pain 10/30/2019 balance b-100 vitamin b complex/folic acid NEW AUTO RULE Non-Formulary 10/30/2019 aqua care sterile water for irrigation,sterile NEW AUTO RULE Non-Formulary water irrig 10/30/2019 SUDAFED PE phenylephrine NEW AUTO RULE Non-Formulary PRESSURE+PAI hcl/dextromethorphan N+COLD hbr/acetaminophen/guaifen 10/30/2019 super quints vitamin b complex/folic acid NEW AUTO RULE Non-Formulary 10/30/2019 bismatrol bismuth subsalicylate NEW AUTO RULE Non-Formulary 10/30/2019 VITAL AF 1.2 nut.tx.impaired digest NEW AUTO RULE Non-Formulary CAL fxn/fiber 10/30/2019 GLUCERNA nutritional therapy, glucose NEW AUTO RULE Non-Formulary HUNGER intolerance,lactose-free,soy SMART 10/30/2019 digestive relief bismuth subsalicylate NEW AUTO RULE Non-Formulary 10/30/2019 AMVISC PLUS hyaluronate sodium NEW AUTO RULE Non-Formulary 10/30/2019 PLASBUMIN-25 albumin human NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 439 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/30/2019 wal-phed pe cold- phenylephrine NEW AUTO RULE Non-Formulary cough hcl/dextromethorphan hbr/acetaminophen/guaifen 10/30/2019 BLOXIVERZ neostigmine methylsulfate NEW AUTO RULE Non-Formulary 10/30/2019 peptic relief bismuth subsalicylate NEW AUTO RULE Non-Formulary 10/30/2019 balanced b-100 vitamin b complex/folic acid NEW AUTO RULE Non-Formulary 10/30/2019 stomach relief bismuth subsalicylate NEW AUTO RULE Non-Formulary original 10/30/2019 OXYTROL FOR oxybutynin NEW AUTO RULE Non-Formulary WOMEN 10/30/2019 methylprednisolo methylprednisolone sodium NEW AUTO RULE Non-Formulary ne sodium succ succinate 10/30/2019 bismuth bismuth subsalicylate NEW AUTO RULE Non-Formulary 10/30/2019 ALBUTEIN albumin human NEW AUTO RULE Non-Formulary 10/30/2019 b complex vitamin b complex/folic acid NEW AUTO RULE Non-Formulary number 1 10/30/2019 GLUCERNA nutritional therapy, glucose NEW AUTO RULE Non-Formulary ADVANCE intolerance,lactose-free,soy 10/30/2019 MAGOX 400 magnesium oxide NEW AUTO RULE Non-Formulary 10/30/2019 vitamin b-100 vitamin b complex/folic acid NEW AUTO RULE Non-Formulary complex 10/30/2019 ALBUMINAR-25 albumin human NEW AUTO RULE Non-Formulary 10/30/2019 SUDAFED PE guaifenesin/phenylephrine NEW AUTO RULE Non-Formulary HEAD hcl/acetaminophen CONGESTN- MUCUS 10/30/2019 SOLU-MEDROL methylprednisolone sodium NEW AUTO RULE Non-Formulary succinate 10/30/2019 dex4 glucose dextrose NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 440 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/30/2019 super b maxi vitamin b complex/folic acid NEW AUTO RULE Non-Formulary complex 10/30/2019 mgo magnesium oxide NEW AUTO RULE Non-Formulary 10/30/2019 TYLENOL acetaminophen NEW AUTO RULE Non-Formulary 10/30/2019 DELTASONE prednisone NEW AUTO RULE Non-formulary 10/30/2019 sodium sodium bicarbonate NEW AUTO RULE Non-Formulary bicarbonate 10/30/2019 XYLOCAINE lidocaine hcl/epinephrine NEW AUTO RULE Non-Formulary DENTAL- bitartrate EPINEPHRINE 10/30/2019 levocetirizine levocetirizine NEW AUTO RULE Non-Formulary dihydrochloride dihydrochloride 10/30/2019 clovique trientine hcl NEW AUTO RULE NF specialty 10/30/2019 acetaminophen acetaminophen NEW AUTO RULE Non-Formulary 10/30/2019 all day allergy cetirizine hcl NEW AUTO RULE Non-Formulary 10/30/2019 children's allergy cetirizine hcl NEW AUTO RULE Non-Formulary relief 10/30/2019 SUDAFED PE phenylephrine NEW AUTO RULE Non-Formulary HEAD hcl/dextromethorphan CONGESTION- hbr/acetaminophen/guaifen FLU 10/30/2019 baciim bacitracin NEW AUTO RULE Non-Formulary 10/30/2019 PEPTO-BISMOL bismuth subsalicylate NEW AUTO RULE Non-Formulary 10/30/2019 VAXCHORA cholera vaccine, live NEW AUTO RULE Non-Formulary VACCINE 10/30/2019 stomach relief bismuth subsalicylate NEW AUTO RULE Non-Formulary 10/30/2019 estroven cmplt rhubarb root extract NEW AUTO RULE Non-Formulary menopause rlf 10/30/2019 k-pec bismuth subsalicylate NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 441 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/30/2019 morphine sulfate- morphine sulfate in 0.9 % NEW AUTO RULE Non-Formulary 0.9% nacl sodium chloride 10/30/2019 ADDERALL dextroamphetamine sulf- UM AUTO RULE: AGE Up to 18 yrs old saccharate/amphetamine sulf-aspartate 10/30/2019 b-complex vitamin b complex/folic acid NEW AUTO RULE Non-Formulary 10/30/2019 KEDBUMIN albumin human NEW AUTO RULE Non-Formulary 10/30/2019 XYLOCAINE- lidocaine hcl/epinephrine/pf NEW AUTO RULE Non-Formulary MPF WITH EPINEPHRINE 10/30/2019 kobee vitamin b complex/folic acid NEW AUTO RULE Non-Formulary 10/30/2019 water water for irrigation,sterile NEW AUTO RULE Non-Formulary 10/30/2019 children's wal-zyr cetirizine hcl NEW AUTO RULE Non-Formulary 10/30/2019 children's all day cetirizine hcl NEW AUTO RULE Non-Formulary allergy 10/30/2019 wal-phed pe phenylephrine NEW AUTO RULE Non-Formulary pressure+pain+c hcl/dextromethorphan old hbr/acetaminophen/guaifen 10/30/2019 GLUCERNA nutritional therapy, glucose NEW AUTO RULE Non-Formulary intolerance,lactose-free,soy 10/30/2019 saccharin saccharin NEW AUTO RULE Non-Formulary 10/30/2019 doxercalciferol doxercalciferol NEW AUTO RULE Non-Formulary 10/30/2019 pressure-pain pe phenylephrine NEW AUTO RULE Non-Formulary plus cold hcl/dextromethorphan hbr/acetaminophen/guaifen 10/30/2019 cetirizine hcl cetirizine hcl NEW AUTO RULE Non-Formulary 10/30/2019 CHILDREN'S cetirizine hcl NEW AUTO RULE Non-Formulary ZYRTEC 10/30/2019 pink bismuth bismuth subsalicylate NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 442 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/30/2019 anti-diarrheal bismuth subsalicylate NEW AUTO RULE Non-Formulary 10/30/2019 TRIKAFTA elexacaftor/tezacaftor/ivacaft NEW AUTO RULE NF specialty or 10/30/2019 glytrol nutritional therapy, glucose NEW AUTO RULE Non-Formulary intolerance,lactose-free,soy 10/30/2019 sodium fluoride fluoride (sodium) NEW AUTO RULE Non-Formulary 10/30/2019 dometuss g phenylephrine NEW AUTO RULE Non-Formulary hcl/dextromethorphan hbr/acetaminophen/guaifen 10/30/2019 diarrhea relief bismuth subsalicylate NEW AUTO RULE Non-Formulary 10/30/2019 wal-zyr cetirizine hcl NEW AUTO RULE Non-Formulary 10/30/2019 vitamin b-50 vitamin b complex/folic acid NEW AUTO RULE Non-Formulary complex 10/30/2020 ULTRA beta-carotene(vit a) with NEW AUTO RULE Non-Formulary ANTIOXIDANT vitamins c and e/selenium 10/30/2020 CHILD MUCINEX triprolidine/phenylephrine/de NEW AUTO RULE Non-Formulary FREEFROM MS xtromethorph/acetamin/guaif D-N enes 10/30/2020 PLEGISOL cardioplegic solution no.1 NEW AUTO RULE Non-Formulary 10/30/2020 vision beta-carotene (vitamin a) NEW AUTO RULE Non-Formulary with vitamins c and e/minerals 10/30/2020 ONE-A-DAY multivitamin,calcium,mineral NEW AUTO RULE Non-Formulary MEN'S s/folic acid/vitamin COMPLETE k1/lycopene 10/30/2020 CLINIMIX amino acid 6 % in dextrose NEW AUTO RULE Non-Formulary 5 % water 10/30/2020 hematogen forte ferrous fumarate/ascorbic NEW AUTO RULE Non-Formulary acid/cyanocobalamin/folic acid

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 443 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/30/2020 ocutabs beta-carotene (vitamin a) NEW AUTO RULE Non-Formulary with vitamins c and e/minerals 10/30/2020 ICY HOT menthol NEW AUTO RULE Non-Formulary 10/30/2020 CLINIMIX E amino acid 8 % comb NEW AUTO RULE Non-Formulary no.3/d10w/parenteral electrolytes no.37 10/30/2020 vitamin d3- calcium phosphate, NEW AUTO RULE Non-Formulary calcium- dibasic/cholecalciferol phosphorus (vitamin d3) 10/30/2020 cardioplegic cardioplegic solution no.1 NEW AUTO RULE Non-Formulary 10/30/2020 REMDESIVIR remdesivir NEW AUTO RULE Non-Formulary (EUA) 10/30/2020 oxaliplatin oxaliplatin NEW AUTO RULE Non-Formulary 10/30/2020 SAVISION beta-carotene(a) w-c and NEW AUTO RULE Non-Formulary e/zinc/copper 10/30/2020 kinderlyte electrolytes/dextrose NEW AUTO RULE Non-Formulary 10/30/2020 ASPERCREME menthol NEW AUTO RULE Non-Formulary MAX 10/30/2020 TYBLUME levonorgestrel/ethinyl NEW AUTO RULE Non-formulary estradiol 10/30/2020 CLINIMIX amino acids 8 % in dextrose NEW AUTO RULE Non-Formulary 14% water 10/30/2020 ADRENAMAX tyrosine/acetylcysteine NEW AUTO RULE Non-Formulary 10/30/2020 stratagrt gel dressing NEW AUTO RULE Non-Formulary 10/30/2020 ALKA-SELTZER doxylamine NEW AUTO RULE Non-Formulary PLUS NIGHT succinate/phenylephrine/dex tromethorphan hbr/asa

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 444 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/30/2020 trigels-f forte ferrous fumarate/ascorbic NEW AUTO RULE Non-Formulary acid/cyanocobalamin/folic acid 10/30/2020 LIDOMARK 1-5 lidocaine hcl/preservative NEW AUTO RULE Non-Formulary free/adhesive bandage 10/30/2020 super antioxidant beta-carotene(vit a) with NEW AUTO RULE Non-Formulary vitamins c and e/selenium 10/30/2020 cool 'n heat menthol NEW AUTO RULE Non-Formulary 10/30/2020 BENZEPRO benzoyl peroxide micronized NEW AUTO RULE Non-Formulary 10/30/2020 ICY HOT NO menthol NEW AUTO RULE Non-Formulary MESS 10/30/2020 QDOLO tramadol hcl NEW AUTO RULE NF specialty 10/30/2020 glucosamine- glucosamine hcl/hyaluronic NEW AUTO RULE Non-Formulary hyaluronic acid acid 10/30/2020 THROMBIN-JMI thrombin (bovine) NEW AUTO RULE Non-Formulary 10/30/2020 CLINIMIX E amino acid 8 % comb NEW AUTO RULE Non-Formulary no.3/d14w/parenteral electrolytes no.37 10/30/2020 antioxidant beta-carotene(vit a) with NEW AUTO RULE Non-Formulary vitamins c and e/selenium 10/30/2020 CLINIMIX amino acids 8 % in dextrose NEW AUTO RULE Non-Formulary 10% water 10/30/2020 PERIOMED stannous fluoride NEW AUTO RULE Non-Formulary 10/30/2020 ACTIDOSE- activated charcoal NEW AUTO RULE Non-Formulary AQUA 10/30/2020 REMDESIVIR remdesivir DRUG ATTR CHANGE Non-Formulary Non-Formulary (EUA) OVERRIDE 10/30/2020 insta-char activated charcoal NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 445 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/30/2020 sofia2 flu-sars covid-19, influenza a, NEW AUTO RULE Non-Formulary antigen fia influenza b antigen immunoassay test 10/30/2020 CHILD MUCINEX diphenhydramine NEW AUTO RULE Non-Formulary M-S COLD hcl/phenylephrine hcl/acetaminophen

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 446 UPDATED 12/2020 VALUE Drug Formulary Updates

November, 2020

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/03/2020 ascorbic acid ascorbic acid NEW AUTO RULE Non-Formulary 11/03/2020 nasal spray oxymetazoline hcl NEW AUTO RULE Non-Formulary 11/03/2020 nasal spray oxymetazoline hcl NEW AUTO RULE Non-Formulary original 11/03/2020 TAB-A-VITE multivitamin with folic acid NEW AUTO RULE Non-Formulary 11/03/2020 prenatal prenatal vits with calcium NEW AUTO RULE Non-Formulary multivitamin 95/ferrous fumarate/folic acid 11/03/2020 CHEST guaifenesin NEW AUTO RULE Non-Formulary CONGESTION RELIEF 11/03/2020 giltuss severe oxymetazoline hcl NEW AUTO RULE Non-Formulary sinus 11/03/2020 prenatal prenatal vitamins NEW AUTO RULE Non-Formulary multivitamin no.121/ferrous fumarate/folic acid 11/03/2020 vitamin c ascorbic acid NEW AUTO RULE Non-Formulary 11/03/2020 pureair mini nebulizer and compressor NEW AUTO RULE Non-Formulary nebulizer 11/04/2019 VENLAFAXINE venlafaxine hcl NEW AUTO RULE Non-formulary HCL ER 11/04/2020 granisetron hcl granisetron hcl UM AUTO RULE: 12 tabs/fill QUANTITYCUSTOM 11/06/2019 bupivacaine hcl- bupivacaine hcl in 0.9 % NEW AUTO RULE Non-Formulary 0.9% nacl sodium chloride/pf 11/06/2019 sodium sodium bicarbonate in NEW AUTO RULE Non-Formulary bicarbonate-d5w dextrose 5%-water

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 447 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/06/2019 daytime cold-flu dextromethorphan NEW AUTO RULE Non-Formulary hbr/phenylephrine hcl/acetaminophen 11/06/2019 severe cold and dextromethorphan NEW AUTO RULE Non-Formulary flu daytime hbr/phenylephrine hcl/acetaminophen 11/06/2019 HYCET hydrocodone UM AUTO RULE: 90 ml/day; max bitartrate/acetaminophen QUANTITYCUSTOM 1260 ml/30 days 11/06/2019 diapers diaper/brief,infant-toddler, NEW AUTO RULE Non-Formulary disposable 11/06/2019 ENFAGROW pediatric nutrition,milk NEW AUTO RULE Non-Formulary TODLR NXT STP based,iron/docosahexanoic NON-GMO acid 11/06/2019 girls training diaper/brief,infant-toddler, NEW AUTO RULE Non-Formulary pants disposable 11/06/2019 fentanyl citrate- fentanyl citrate in dextrose NEW AUTO RULE Non-Formulary d5w 5% in water/pf 11/06/2019 midazolam hcl- midazolam hcl in dextrose NEW AUTO RULE Non-Formulary d5w 5% in water 11/06/2019 ENFAGROW infant formula with NEW AUTO RULE Non-Formulary TODLR iron/docosahexanoic TRANSITN acid/arachidonic ac NONGMO 11/06/2019 day time cold-flu dextromethorphan NEW AUTO RULE Non-Formulary hbr/phenylephrine hcl/acetaminophen 11/06/2019 mucus d guaifenesin/pseudoephedrin NEW AUTO RULE Non-Formulary e hcl 11/06/2019 sheer adhesive adhesive bandage NEW AUTO RULE Non-Formulary bandages

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 448 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/06/2019 flu-severe cold dextromethorphan NEW AUTO RULE Non-Formulary hbr/phenylephrine hcl/acetaminophen 11/06/2019 aa 3%-d10w- amino acid 3 % no.2 NEW AUTO RULE Non-Formulary calcium-heparin pedi/dextrose 10 %/calcium gluc/heparin 11/06/2019 oxytocin-0.9% oxytocin in 0.9 % sodium NEW AUTO RULE Non-Formulary nacl chloride 11/06/2019 aa 2.5%-d10w- amino acid 2.5 % no.2 NEW AUTO RULE Non-Formulary calcium-heparin ped/dextrose 10 %/calcium gluc/heparin 11/06/2019 guaifenesin- guaifenesin/pseudoephedrin NEW AUTO RULE Non-Formulary pseudoephedrine e hcl er 11/06/2019 aa 2%-d10w- amino acid 2 % no.1 NEW AUTO RULE Non-Formulary calcium-heparin ped/dextrose 10 %/calcium gluc/heparin 11/06/2019 sheer bandage adhesive bandage NEW AUTO RULE Non-Formulary 11/06/2019 flu relief therapy dextromethorphan NEW AUTO RULE Non-Formulary daytime hbr/phenylephrine hcl/acetaminophen 11/06/2019 diphenhydramine diphenhydramine hcl in 0.9 NEW AUTO RULE Non-Formulary -0.9% nacl % sodium chloride 11/06/2019 hydromorphone hydromorphone hcl in 0.9 % NEW AUTO RULE Non-Formulary hcl-0.9% nacl sodium chloride/pf 11/06/2019 GLOPERBA colchicine NEW AUTO RULE NF specialty 11/06/2019 DIMENTHO diclofenac NEW AUTO RULE Non-Formulary sodium/menthol/kinesiology tape 11/06/2019 transparent i.v. transparent dressing NEW AUTO RULE Non-Formulary site dressing

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 449 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/06/2019 hydromorphone hydromorphone hcl in NEW AUTO RULE Non-Formulary hcl-d5w dextrose 5 %-water/pf 11/06/2019 KANJINTI trastuzumab-anns NEW AUTO RULE Non-Formulary 11/06/2019 potassium potassium phosphate in 0.9 NEW AUTO RULE Non-Formulary phosphate-0.9% % sodium chloride nacl 11/06/2019 sinus 12 hour pseudoephedrine hcl NEW AUTO RULE Non-Formulary 11/06/2019 chlorhexidine chlorhexidine gluconate NEW AUTO RULE Non-Formulary gluconate 11/06/2019 ephedrine sulfate ephedrine sulfate NEW AUTO RULE Non-Formulary 11/06/2019 omeprazole omeprazole NEW AUTO RULE Non-Formulary 11/06/2019 midazolam hcl midazolam hcl NEW AUTO RULE Non-Formulary 11/06/2019 biofreeze menthol NEW AUTO RULE Non-Formulary 11/06/2019 ENFAGROW pediatric nutrition,milk NEW AUTO RULE Non-Formulary TODDLER NEXT based,iron/docosahexaenoic STEP acid 11/06/2019 sinus 12-hour pseudoephedrine hcl NEW AUTO RULE Non-Formulary 11/06/2019 aa 4%-d10w- amino acid 4 % no.2 NEW AUTO RULE Non-Formulary calcium-heparin pedi/dextrose 10 %/calcium gluc/heparin 11/06/2019 TYLENOL COLD dextromethorphan NEW AUTO RULE Non-Formulary MULTI- hbr/phenylephrine SYMPTOM hcl/acetaminophen 11/06/2019 oxytocin-lactated oxytocin/ringer's NEW AUTO RULE Non-Formulary ringers solution,lactated 11/06/2019 LMX 4 lidocaine NEW AUTO RULE Non-Formulary 11/06/2019 children's diphenhydramine hcl NEW AUTO RULE Non-Formulary aurodryl allergy 11/06/2019 TARCEVA erlotinib hcl NEW AUTO RULE NF specialty

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 450 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/06/2019 ciprofloxacin hcl- ciprofloxacin hcl/fluocinolone NEW AUTO RULE Non-formulary fluocinolone acetonide 11/06/2019 long acting nasal pseudoephedrine hcl NEW AUTO RULE Non-Formulary decongestant 11/06/2019 CULTURELLE bacillus subtilis/inulin NEW AUTO RULE Non-Formulary GUMMY 11/06/2019 fentanyl- fentanyl citrate/bupivacaine NEW AUTO RULE Non-Formulary bupivacaine- hcl in 0.9 % sodium 0.9% nacl chloride/pf 11/06/2019 aa 2%-d10w-low amino acid 2 % no.1 NEW AUTO RULE Non-Formulary calcium-heparin ped/dextrose 10 %/calcium gluc/heparin 11/06/2019 sensorcaine- bupivacaine hcl/epinephrine NEW AUTO RULE Non-Formulary epinephrine 11/06/2019 oxytocin-d5- oxytocin in dextrose 5 %- NEW AUTO RULE Non-Formulary lactated ringers lactated ringers 11/06/2019 phenylephrine phenylephrine hcl in 0.9 % NEW AUTO RULE Non-Formulary hcl-0.9% nacl sodium chloride 11/06/2019 revonto dantrolene sodium NEW AUTO RULE Non-Formulary 11/06/2019 belted shields diaper,brief,adult, NEW AUTO RULE Non-Formulary disposable 11/06/2019 DANTRIUM dantrolene sodium NEW AUTO RULE Non-Formulary 11/06/2019 dantrolene dantrolene sodium NEW AUTO RULE Non-Formulary sodium 11/06/2019 lidocaine hcl lidocaine hcl/pf NEW AUTO RULE Non-Formulary 11/06/2019 children's acetaminophen NEW AUTO RULE Non-Formulary aurophen pain- fever 11/06/2019 selenium sulfide selenium sulfide NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 451 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/06/2019 transparent transparent dressing NEW AUTO RULE Non-Formulary dressing 11/06/2019 UDENYCA pegfilgrastim-cbqv NEW AUTO RULE Tier 4 11/06/2019 AKOVAZ ephedrine sulfate NEW AUTO RULE Non-Formulary 11/06/2019 TRACLEER bosentan NEW AUTO RULE NF specialty 11/06/2019 children's profen ibuprofen NEW AUTO RULE Non-Formulary ib 11/06/2019 nasal pseudoephedrine hcl NEW AUTO RULE Non-Formulary decongestant 11/06/2019 COOL THERAPY menthol NEW AUTO RULE Non-Formulary 11/06/2019 nicoderm cq nicotine NEW AUTO RULE Preventative Drugs 11/06/2019 fentanyl citrate fentanyl citrate/pf NEW AUTO RULE Non-Formulary 11/06/2019 aa 3%-d10w-low amino acid 3 % no.2 NEW AUTO RULE Non-Formulary calcium-heparin pedi/dextrose 10 %/calcium gluc/heparin 11/06/2019 wal-phed 12 hour pseudoephedrine hcl NEW AUTO RULE Non-Formulary 11/06/2019 XYLOCAINE- lidocaine hcl/pf NEW AUTO RULE Non-Formulary MPF 11/06/2019 morphine sulfate- morphine sulfate in 0.9 % NEW AUTO RULE Non-Formulary 0.9% nacl sodium chloride 11/06/2019 tromethamine- tromethamine in sterile NEW AUTO RULE Non-Formulary sterile water water for injection 11/06/2019 poison ivy wash pramoxine hcl NEW AUTO RULE Non-Formulary 11/06/2019 boys training diaper/brief,infant-toddler, NEW AUTO RULE Non-Formulary pants disposable 11/06/2019 children's ibuprofen NEW AUTO RULE Non-Formulary profenib

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 452 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/06/2019 theraflu dextromethorphan NEW AUTO RULE Non-Formulary expressmax cold- hbr/phenylephrine cough hcl/acetaminophen 11/06/2019 vicks dayquil dextromethorphan NEW AUTO RULE Non-Formulary hbr/phenylephrine hcl/acetaminophen 11/06/2019 suphedrine 12- pseudoephedrine hcl NEW AUTO RULE Non-Formulary hour 11/06/2019 hydrocodone- hydrocodone UM AUTO RULE: 90 ml/day; max acetaminophen bitartrate/acetaminophen QUANTITYCUSTOM 1260 ml/30 days 11/06/2019 cold-flu relief dextromethorphan NEW AUTO RULE Non-Formulary hbr/phenylephrine hcl/acetaminophen 11/06/2019 fentanyl citrate- fentanyl citrate in 0.9 % NEW AUTO RULE Non-Formulary 0.9% nacl sodium chloride/pf 11/06/2019 12 hour pseudoephedrine hcl NEW AUTO RULE Non-Formulary decongestant 11/06/2019 MUCINEX D guaifenesin/pseudoephedrin NEW AUTO RULE Non-Formulary e hcl 11/06/2019 MARCAINE- bupivacaine hcl/epinephrine NEW AUTO RULE Non-Formulary EPINEPHRINE 11/06/2019 anecream lidocaine NEW AUTO RULE Non-Formulary 11/06/2019 heparin sodium- heparin sodium,porcine in NEW AUTO RULE Non-Formulary 0.9% nacl 0.9 % sodium chloride 11/06/2019 plastic adhesive adhesive bandage NEW AUTO RULE Non-Formulary bandages 11/06/2019 CHILDREN'S ibuprofen NEW AUTO RULE Non-Formulary ADVIL 11/06/2019 bupivacaine hcl- bupivacaine hcl/epinephrine NEW AUTO RULE Non-Formulary epinephrine

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 453 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/06/2019 ENFAGROW infant formula with NEW AUTO RULE Non-Formulary TODDLER iron/docosahexaenoic TRANSITIONS acid/arachidonic ac 11/06/2019 REMEDIENT multivitamin with NEW AUTO RULE Non-Formulary minerals/iron succinyl- protein/folic acid 11/06/2020 studio 35 glycerin/dimethicone/petrolat NEW AUTO RULE Non-Formulary moisturizing skin um,white/water 11/06/2020 fish oil omega-3 fatty NEW AUTO RULE Non-Formulary acids/dha/epa/other omega- 3s/fish oil 11/06/2020 CETAPHIL cetyl alcohol/stearyl NEW AUTO RULE Non-Formulary alcohol/prop gly/sodium lauryl sulfate 11/06/2020 finger cream emollient base NEW AUTO RULE Non-Formulary 11/06/2020 GADAVIST gadobutrol NEW AUTO RULE Non-Formulary 11/06/2020 dermabase emollient base NEW AUTO RULE Non-Formulary 11/06/2020 TINACTIN tolnaftate NEW AUTO RULE Non-Formulary 11/06/2020 NORWEGIAN glycerin NEW AUTO RULE Non-Formulary FORMULA 11/06/2020 OLINVYK oliceridine fumarate NEW AUTO RULE Non-Formulary 11/06/2020 antifungal tolnaftate NEW AUTO RULE Non-Formulary 11/06/2020 iron glycinate ferrous bis-glycinate chelate NEW AUTO RULE Non-Formulary 11/06/2020 ABREVA docosanol NEW AUTO RULE Non-Formulary 11/06/2020 SOOTHE & vitamins a and d/aloe vera NEW AUTO RULE Non-Formulary COOL SKIN CREAM 11/06/2020 EMOLLIA emollient combination no.39 NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 454 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/06/2020 clindamycin clindamycin palmitate hcl NEW AUTO RULE Tier 1 pediatric 11/06/2020 pyridoxine hcl pyridoxine hcl (vitamin b6) NEW AUTO RULE Non-Formulary 11/06/2020 ACTIDOSE- activated charcoal NEW AUTO RULE Non-Formulary AQUA 11/06/2020 EUCERIN SKIN emollient combination no.69 NEW AUTO RULE Non-Formulary CALMING 11/06/2020 moisturizing glycerin/dimethicone/petrolat NEW AUTO RULE Non-Formulary cream um,white/water 11/06/2020 HYDRASYN25 urea/alpha hydroxy acids NEW AUTO RULE Non-Formulary 11/06/2020 rufinamide rufinamide NEW AUTO RULE Non-formulary 11/06/2020 insta-char activated charcoal NEW AUTO RULE Non-Formulary 11/06/2020 NIVEA SOFT emollient combination no.67 NEW AUTO RULE Non-Formulary 11/06/2020 COMPLEX 15 lecithin/glycerin/dimethicone NEW AUTO RULE Non-Formulary 11/06/2020 valerian root- valerian/passion NEW AUTO RULE Non-Formulary herbal blend flower/hops/lemon balm 11/06/2020 contour next link blood-glucose meter, NEW AUTO RULE Non-Formulary 2.4 wireless 11/06/2020 PEN-KERA emollient combination no.58 NEW AUTO RULE Non-Formulary 11/06/2020 microgestin 24 fe norethindrone acetate- ADD TO FORMULARY Non-Formulary Tier 1 ethinyl estradiol/ferrous fumarate 11/06/2020 LANTISEPTIC lanolin NEW AUTO RULE Non-Formulary 11/06/2020 athlete's foot tolnaftate NEW AUTO RULE Non-Formulary 11/06/2020 VELVACHOL mineral oil/white NEW AUTO RULE Non-Formulary pet/cetyl,stearyl alcohol/sls/cholesterol

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 455 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/06/2020 microgestin 24 fe norethindrone acetate- ADD UM: ACA Preventive Health ethinyl estradiol/ferrous fumarate 11/06/2020 calcidol ergocalciferol (vitamin d2) NEW AUTO RULE Non-Formulary 11/06/2020 COCONUT OIL emollient combination no.61 NEW AUTO RULE Non-Formulary CREAM 11/06/2020 NUTRASEB emollient combination NEW AUTO RULE Non-Formulary no.107 11/06/2020 NOPIOID-LMC cyclobenzaprine NEW AUTO RULE Non-Formulary KIT hcl/lidocaine/menthol 11/06/2020 LACTINOL HX lactic acid NEW AUTO RULE Non-Formulary 11/06/2020 fish oil omega-3 fatty acids/fish oil NEW AUTO RULE Non-Formulary 11/06/2020 calcium- calcium NEW AUTO RULE Non-Formulary magnesium-zinc carbonate/magnesium oxide/copper/zinc oxide 11/06/2020 KELARX dimethicone/dimethicone NEW AUTO RULE Non-Formulary crosspolymer/trimethylsiloxy silicate 11/06/2020 KERADAN emollient combination no.65 NEW AUTO RULE Non-Formulary 11/06/2020 vanicream emollient base NEW AUTO RULE Non-Formulary 11/06/2020 BETA XMA aloe vera/dimethicone NEW AUTO RULE Non-Formulary 11/06/2020 clindamycin clindamycin palmitate hcl NEW AUTO RULE Tier 1 (pediatric) 11/06/2020 IBUPAK ibuprofen/glycerin NEW AUTO RULE Non-Formulary 11/06/2020 aqua glycolic emollient base NEW AUTO RULE Non-Formulary 11/06/2020 sorbolene glycerin/mineral NEW AUTO RULE Non-Formulary oil/petrolatum,white/cetostea ryl alc/water

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 456 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/06/2020 clindamycin clindamycin palmitate hcl DRUG ATTR CHANGE Tier 1 Tier 1 (pediatric) OVERRIDE 11/06/2020 vitamin b- b-complex with vitamin c NEW AUTO RULE Non-Formulary complex & c 11/06/2020 ORAMAGICRX potassium NEW AUTO RULE Non-Formulary sorbate/maltodextrin/aloe vera/mann ps 11/06/2020 therapeutic mineral oil/petrolatum,white NEW AUTO RULE Non-Formulary moisturizing 11/06/2020 miclara dm triprolidine hcl/phenylephrine NEW AUTO RULE Non-Formulary hcl/dextromethorphan hbr 11/06/2020 icosapent ethyl icosapent ethyl NEW AUTO RULE Tier 3 11/06/2020 mag-g magnesium gluconate NEW AUTO RULE Non-Formulary 11/06/2020 type ii collagen- cartilage/collagen type NEW AUTO RULE Non-Formulary ha-boron ii/boron glycinate/hyaluronate sod 11/06/2020 IMPEKLO clobetasol propionate NEW AUTO RULE Non-formulary 11/06/2020 CETAPHIL glycerin/dimethicone/shea NEW AUTO RULE Non-Formulary tree/stearyl alcohol 11/06/2020 child cough-sore acetaminophen/dextrometho NEW AUTO RULE Non-Formulary throat rphan hbr 11/06/2020 turmeric-tamarind tamarindus indica NEW AUTO RULE Non-Formulary blend seed/turmeric root extract 11/06/2020 k2-45 vitamin k2 NEW AUTO RULE Non-Formulary 11/06/2020 EUCERIN emollient combination no.73 NEW AUTO RULE Non-Formulary INTENSIVE REPAIR 11/06/2020 DML FORTE pantothenic NEW AUTO RULE Non-Formulary acid/glycerin/petrolatum,hyd rophilic

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 457 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/06/2020 TRINAZ prenatal vitamins NEW AUTO RULE NF specialty no.162/ferrous gluconate/folic acid 11/06/2020 DIGESTIVE bacillus coagulans NEW AUTO RULE Non-Formulary ADVANTAGE KID PROBIO 11/06/2020 NIVEA emollient combination no.66 NEW AUTO RULE Non-Formulary 11/06/2020 pretty feet & emollient base NEW AUTO RULE Non-Formulary hands 11/06/2020 beta care cetyl alcohol/stearyl NEW AUTO RULE Non-Formulary alcohol/prop gly/sodium lauryl sulfate 11/08/2019 AZESCO prenatal vitamins NEW AUTO RULE NF specialty no.147/ferrous gluconate/folic acid 11/08/2019 MEDI-PADS witch hazel DRUG ATTR CHANGE Non-Formulary Non-Formulary OVERRIDE 11/09/2020 dimethyl dimethyl fumarate UM AUTO RULE: 2 tabs/day; max 1 fumarate QUANTITYCUSTOM pack/month 11/09/2020 microgestin norethindrone acetate- NEW AUTO RULE Tier 1 ethinyl estradiol 11/13/2019 PEDIASURE pediatric nutrition with iron, NEW AUTO RULE Non-Formulary GROW-GAIN lactose free ORGANIC 11/13/2019 central-vite multivitamin with NEW AUTO RULE Non-Formulary minerals/ferrous fumarate/folic acid/vit k 11/13/2019 compoz diphenhydramine hcl NEW AUTO RULE Non-Formulary 11/13/2019 epinephrine hcl- epinephrine hcl in dextrose NEW AUTO RULE Non-Formulary d5w 5 % in water

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 458 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/13/2019 wal-flu night diphenhydramine NEW AUTO RULE Non-Formulary severe cold hcl/phenylephrine hcl/acetaminophen 11/13/2019 DIPRIVAN propofol NEW AUTO RULE Non-Formulary 11/13/2019 SUDAFED 24- pseudoephedrine hcl NEW AUTO RULE Non-Formulary HOUR 11/13/2019 MIXED VESPID allergenic extract-venom- NEW AUTO RULE Non-Formulary VENOM mixed vespid protein PROTEIN 11/13/2019 MULTI-DAY multivitamin with NEW AUTO RULE Non-Formulary PLUS minerals/ferrous MINERALS fumarate/folic acid/vit k 11/13/2019 SUDAFED PE phenylephrine NEW AUTO RULE Non-Formulary SINUS hcl/acetaminophen PRESSURE 11/13/2019 sinus pain- phenylephrine NEW AUTO RULE Non-Formulary congestion hcl/acetaminophen 11/13/2019 restfully sleep diphenhydramine hcl NEW AUTO RULE Non-Formulary 11/13/2019 fiber laxative calcium polycarbophil NEW AUTO RULE Non-Formulary 11/13/2019 theraflu diphenhydramine NEW AUTO RULE Non-Formulary expressmax cold hcl/phenylephrine night hcl/acetaminophen 11/13/2019 cefotaxime cefotaxime sodium NEW AUTO RULE medical benefit sodium drugs 11/13/2019 MEDI-PADS witch hazel NEW AUTO RULE Non-Formulary 11/13/2019 LIVETROL zinc oxide/herbal complex NEW AUTO RULE Non-Formulary no.303 11/13/2019 chest rub eucalyptus NEW AUTO RULE Non-Formulary oil/menthol/camphor 11/13/2019 sinus pain relief phenylephrine NEW AUTO RULE Non-Formulary hcl/acetaminophen

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 459 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/13/2019 methylcellulose methylcellulose 400cps NEW AUTO RULE Non-Formulary 11/13/2019 artificial tears polyvinyl alcohol/povidone NEW AUTO RULE Non-Formulary 11/13/2019 sleep aid diphenhydramine hcl NEW AUTO RULE Non-Formulary 11/13/2019 flu & severe cold diphenhydramine NEW AUTO RULE Non-Formulary hcl/phenylephrine hcl/acetaminophen 11/13/2019 sinus maximum phenylephrine NEW AUTO RULE Non-Formulary strength hcl/acetaminophen 11/13/2019 konsyl fiber calcium polycarbophil NEW AUTO RULE Non-Formulary 11/13/2019 OLUMIANT baricitinib NEW AUTO RULE NF specialty 11/13/2019 CLAFORAN cefotaxime sodium NEW AUTO RULE Non-Formulary 11/13/2019 guaifenesin- guaifenesin/pseudoephedrin NEW AUTO RULE Non-Formulary pseudoephedrine e hcl 11/13/2019 alka-seltzer plus diphenhydramine hcl NEW AUTO RULE Non-Formulary allergy 11/13/2019 IMODIUM A-D loperamide hcl NEW AUTO RULE Non-Formulary 11/13/2019 SUDAFED PE phenylephrine NEW AUTO RULE Non-Formulary PRESSURE- hcl/acetaminophen PAIN 11/13/2019 ULTRA B-100 vit b complex/folic NEW AUTO RULE Non-Formulary COMPLEX acid/choline bitartrate/inositol/herbs 11/13/2019 flu relief diphenhydramine NEW AUTO RULE Non-Formulary hcl/phenylephrine hcl/acetaminophen 11/13/2019 vitamin b-12 cyanocobalamin (vitamin b- NEW AUTO RULE Non-Formulary 12) 11/13/2019 one daily multivitamin with NEW AUTO RULE Non-Formulary women's minerals/ferrous multivitamin fumarate/folic acid/vit k

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 460 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/13/2019 suphedrine pe phenylephrine NEW AUTO RULE Non-Formulary sinus headache hcl/acetaminophen 11/13/2019 fiber-lax calcium polycarbophil NEW AUTO RULE Non-Formulary 11/13/2019 loperamide loperamide hcl NEW AUTO RULE Non-Formulary 11/13/2019 VUMERITY diroximel fumarate NEW AUTO RULE NF specialty 11/13/2019 severe cold-flu diphenhydramine NEW AUTO RULE Non-Formulary night hcl/phenylephrine hcl/acetaminophen 11/13/2019 chorionic chorionic gonadotropin, NEW AUTO RULE Non-Formulary gonadotropin human 11/13/2019 zalvit prenatal vitamins NEW AUTO RULE NF specialty no.147/ferrous gluconate/folic acid 11/13/2019 fiber tabs calcium polycarbophil NEW AUTO RULE Non-Formulary 11/13/2019 SUDAFED PE phenylephrine NEW AUTO RULE Non-Formulary DAY-NIGHT hcl/diphenhydramine hcl 11/13/2019 PRIALT ziconotide acetate NEW AUTO RULE Non-Formulary 11/13/2019 wal-phed pe phenylephrine NEW AUTO RULE Non-Formulary sinus headache hcl/acetaminophen 11/13/2019 testosterone testosterone cypionate NEW AUTO RULE Non-Formulary cypionate 11/13/2019 sinus relief phenylephrine NEW AUTO RULE Non-Formulary hcl/acetaminophen 11/13/2019 nytol quickcaps diphenhydramine hcl NEW AUTO RULE Non-Formulary 11/13/2019 children's l.acidophilus,casei,rhamnos NEW AUTO RULE Non-Formulary probiotic us/b.longum,breve 11/13/2019 fiber calcium polycarbophil NEW AUTO RULE Non-Formulary 11/13/2019 vitamin e vitamin e mixed NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 461 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/13/2019 hair, skin and multivitamin with NEW AUTO RULE Non-Formulary nails minerals/folic acid/biotin 11/13/2019 pain relief sinus phenylephrine NEW AUTO RULE Non-Formulary pe hcl/acetaminophen 11/13/2019 anti-diarrhea loperamide hcl NEW AUTO RULE Non-Formulary 11/13/2019 flu relief therapy diphenhydramine NEW AUTO RULE Non-Formulary nighttime hcl/phenylephrine hcl/acetaminophen 11/13/2019 dexamethasone dexamethasone sodium NEW AUTO RULE Non-Formulary sodium phosphate/pf phosphate 11/13/2019 sleep tablet diphenhydramine hcl NEW AUTO RULE Non-Formulary 11/13/2019 simply sleep diphenhydramine hcl NEW AUTO RULE Non-Formulary 11/13/2019 sinus pressure- phenylephrine NEW AUTO RULE Non-Formulary pain hcl/acetaminophen 11/13/2019 fiber-tabs calcium polycarbophil NEW AUTO RULE Non-Formulary 11/13/2019 FIBERCON calcium polycarbophil NEW AUTO RULE Non-Formulary 11/13/2019 sleep ii diphenhydramine hcl NEW AUTO RULE Non-Formulary 11/13/2019 fiber lax calcium polycarbophil NEW AUTO RULE Non-Formulary 11/13/2019 arthritis wonder menthol NEW AUTO RULE Non-Formulary 11/13/2019 OGIVRI trastuzumab-dkst NEW AUTO RULE Non-Formulary 11/13/2019 sleep tabs diphenhydramine hcl NEW AUTO RULE Non-Formulary 11/13/2019 7T GUMMY ES acetaminophen NEW AUTO RULE Non-Formulary 11/13/2019 fiber therapy calcium polycarbophil NEW AUTO RULE Non-Formulary 11/13/2019 sinus congestion- phenylephrine NEW AUTO RULE Non-Formulary pain hcl/acetaminophen 11/13/2019 BIORPHEN phenylephrine hcl NEW AUTO RULE Non-Formulary 11/13/2019 water water for injection,sterile NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 462 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/13/2019 clever choice peak flow meter NEW AUTO RULE Non-Formulary peak flow meter 11/13/2019 centravites adults multivitamin with NEW AUTO RULE Non-Formulary minerals/ferrous fumarate/folic acid/vit k 11/13/2019 excel-gel pantothenic acid/aloe vera NEW AUTO RULE Non-Formulary 11/13/2019 calcium calcium polycarbophil NEW AUTO RULE Non-Formulary polycarbophil 11/13/2019 diamode loperamide hcl NEW AUTO RULE Non-Formulary 11/13/2019 ultra a-d loperamide hcl NEW AUTO RULE Non-Formulary 11/13/2019 OCTREOSCAN indium-111 NEW AUTO RULE Non-Formulary chloride/pentetreotide 11/13/2019 nighttime sleep diphenhydramine hcl NEW AUTO RULE Non-Formulary aid 11/13/2019 one daily multivitamin with NEW AUTO RULE Non-Formulary women's formula minerals/ferrous fumarate/folic acid/vit k 11/13/2019 mapap sinus phenylephrine NEW AUTO RULE Non-Formulary hcl/acetaminophen 11/13/2019 flu relief therapy diphenhydramine NEW AUTO RULE Non-Formulary hcl/phenylephrine hcl/acetaminophen 11/13/2020 complete famotidine/calcium NEW AUTO RULE Non-Formulary carbonate/magnesium hydroxide 11/13/2020 MG217 COAL coal tar NEW AUTO RULE Non-Formulary TAR 11/13/2020 gemmily norethindrone acetate- NEW AUTO RULE Non-formulary ethinyl estradiol/ferrous fumarate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 463 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/13/2020 ADRENAL multivitamin with NEW AUTO RULE Non-Formulary MANAGER minerals/herbal complex no.315 11/13/2020 turmeric turmeric/turmeric root NEW AUTO RULE Non-Formulary extract 11/13/2020 tums dual action famotidine/calcium NEW AUTO RULE Non-Formulary carbonate/magnesium hydroxide 11/13/2020 BAMLANIVIMAB bamlanivimab NEW AUTO RULE Non-Formulary (EUA) 11/13/2020 first aid abx pain neomycin sulfate/polymyxin NEW AUTO RULE Non-Formulary relief b sulfate/pramoxine 11/13/2020 motrin pm ibuprofen/diphenhydramine NEW AUTO RULE Non-Formulary citrate 11/13/2020 l-lysine lysine hcl NEW AUTO RULE Non-Formulary 11/13/2020 k2-d3 10,000 cholecalciferol (vit NEW AUTO RULE Non-Formulary d3)/vitamin k2 11/13/2020 TRAVEL meclizine hcl NEW AUTO RULE Non-Formulary SICKNESS 11/13/2020 NICORETTE nicotine polacrilex UM AUTO RULE: ACA Preventive Health 11/13/2020 multi antibiotic neomycin sulfate/polymyxin NEW AUTO RULE Non-Formulary plus b sulfate/pramoxine 11/13/2020 VISTASEAL thrombin(human plasma NEW AUTO RULE Non-Formulary FIBRIN derived)/fibrinogen/calcium SEALANT chloride 11/13/2020 melatonin melatonin NEW AUTO RULE Non-Formulary 11/13/2020 KONSYL psyllium husk NEW AUTO RULE Non-Formulary 11/13/2020 motion sickness meclizine hcl NEW AUTO RULE Non-Formulary relief 11/13/2020 ibuprofen ibuprofen NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 464 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/13/2020 meclizine hcl meclizine hcl NEW AUTO RULE Non-Formulary 11/13/2020 succinylcholine succinylcholine chloride in NEW AUTO RULE Non-Formulary chloride-nacl sodium chloride,iso- osmotic/pf 11/13/2020 vivaguard thermometer, infrared, non- NEW AUTO RULE Non-Formulary infrared contact thermometer 11/13/2020 stratatriz dimethicone NEW AUTO RULE Non-Formulary 11/13/2020 POLY-VI-SOL pediatric multivitamin no.192 DRUG ATTR CHANGE Non-Formulary Non-Formulary OVERRIDE 11/13/2020 amiodarone hcl amiodarone hcl NEW AUTO RULE Non-Formulary 11/13/2020 PFIZER covid-19 vaccine, mrna, NEW AUTO RULE Non-Formulary COVID19 VACC bnt162b2, lnp-s (pfizer)/pf (UNAPPROV) 11/13/2020 first aid antibiotic- neomycin sulfate/polymyxin NEW AUTO RULE Non-Formulary pain rlf b sulfate/pramoxine 11/13/2020 MODERNA covid-19 vaccine, mrna- NEW AUTO RULE Non-Formulary COVID19 1273, lnp-s (moderna)/pf VACC(UNAPPR OV) 11/13/2020 MYCAPSSA octreotide acetate UM AUTO RULE: 4 caps/day QUANTITYCUSTOM 11/13/2020 azo cranberry cranberry fruit NEW AUTO RULE Non-Formulary extract/ascorbic acid 11/13/2020 antibiotic plus neomycin sulfate/polymyxin NEW AUTO RULE Non-Formulary pain relief b sulfate/pramoxine 11/13/2020 PEPCID famotidine/calcium NEW AUTO RULE Non-Formulary COMPLETE carbonate/magnesium hydroxide 11/13/2020 motion-time meclizine hcl NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 465 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/13/2020 double antibiotic- neomycin sulfate/polymyxin NEW AUTO RULE Non-Formulary pain relief b sulfate/pramoxine 11/13/2020 lidocaine- lidocaine hcl/hydrocortisone NEW AUTO RULE Non-Formulary hydrocortisone acetate 11/13/2020 vitamin k2 vitamin k2 NEW AUTO RULE Non-Formulary 11/13/2020 antibiotic plus neomycin sulfate/polymyxin NEW AUTO RULE Non-Formulary b sulfate/pramoxine 11/13/2020 magnesium magnesium citrate NEW AUTO RULE Non-Formulary citrate 11/13/2020 l-theanine theanine NEW AUTO RULE Non-Formulary 11/13/2020 lidocort lidocaine hcl/hydrocortisone NEW AUTO RULE Non-Formulary acetate 11/13/2020 stratamark dimethicone NEW AUTO RULE Non-Formulary 11/13/2020 norethin-eth norethindrone acetate- NEW AUTO RULE Non-formulary estra-ferrous fum ethinyl estradiol/ferrous fumarate 11/13/2020 NEOSPORIN neomycin sulfate/polymyxin NEW AUTO RULE Non-Formulary PLUS PAIN b sulfate/pramoxine RELIEF 11/13/2020 vitajoy melatonin melatonin NEW AUTO RULE Non-Formulary 11/13/2020 timolol maleate timolol maleate/pf NEW AUTO RULE Non-formulary 11/13/2020 acid controller famotidine/calcium NEW AUTO RULE Non-Formulary complete carbonate/magnesium hydroxide 11/13/2020 PEPCID AC famotidine NEW AUTO RULE Non-Formulary 11/13/2020 ADVIL PM ibuprofen/diphenhydramine NEW AUTO RULE Non-Formulary citrate 11/13/2020 contour next link blood-glucose meter, NEW AUTO RULE Non-Formulary 2.4 wireless

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 466 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/13/2020 k-mg citrate magnesium NEW AUTO RULE Non-Formulary citrate/potassium citrate 11/13/2020 NEULUMEX barium sulfate NEW AUTO RULE Non-Formulary 11/13/2020 clearshield sodium chloride 0.9 % NEW AUTO RULE Non-Formulary sodium chlor (flush) flush 11/13/2020 krill-fish oil blend omega-3 fatty NEW AUTO RULE Non-Formulary acids/dha/epa/fish oil/krill oil 11/13/2020 glucosamine- glucosamine NEW AUTO RULE Non-Formulary vitamin d3-ha hcl/cholecalciferol (vit d3)/hyaluronic acid 11/13/2020 NEOSPORIN + neomycin sulfate/polymyxin NEW AUTO RULE Non-Formulary PAIN RELIEF b sulfate/pramoxine 11/20/2019 BENZEFOAM benzoyl peroxide NEW AUTO RULE Non-Formulary ULTRA 11/20/2019 daylogic petrolatum,white NEW AUTO RULE Non-Formulary advanced healing 11/20/2019 ALEVE SINUS naproxen NEW AUTO RULE Non-Formulary AND HEADACHE sodium/pseudoephedrine hcl 11/20/2019 sudafed sinus naproxen NEW AUTO RULE Non-Formulary 12hr pressr-pain sodium/pseudoephedrine hcl 11/20/2019 benzepro benzoyl peroxide NEW AUTO RULE Non-Formulary 11/20/2019 unifine pentips pen needle, diabetic NEW AUTO RULE Tier 2 maxflow 11/20/2019 ADVANCED lactobacillus combo NEW AUTO RULE Non-Formulary PROBIOTIC-10 no.41/bifidobacterium bifidum, animalis 11/20/2019 DRISTAN oxymetazoline hcl NEW AUTO RULE Non-Formulary 11/20/2019 TRUXIMA rituximab-abbs NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 467 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/20/2019 ALEVE-D SINUS naproxen NEW AUTO RULE Non-Formulary AND COLD sodium/pseudoephedrine hcl 11/20/2019 entrust plus diaper,brief,adult, NEW AUTO RULE Non-Formulary disposable 11/20/2019 UP4 lactobacillus combination NEW AUTO RULE Non-Formulary PROBIOTICS no.51/bifidobacterium ULTRA combo no.4 11/20/2019 PRETOMANID pretomanid NEW AUTO RULE Non-formulary 11/20/2019 dry skin petrolatum,white NEW AUTO RULE Non-Formulary treatment 11/20/2019 thallous chloride thallous chloride tl-201 NEW AUTO RULE Non-Formulary tl-201 11/20/2019 calcium acetate calcium acetate NEW AUTO RULE Non-Formulary 11/20/2019 clariscan gadoterate meglumine NEW AUTO RULE Non-Formulary 11/20/2019 benzoyl peroxide benzoyl peroxide NEW AUTO RULE Non-Formulary 11/20/2019 morphine sulfate morphine sulfate NEW AUTO RULE Non-Formulary 11/20/2019 AQUAPHOR petrolatum,white NEW AUTO RULE Non-Formulary 11/20/2019 UP4 l.acidophilus/l.gasseri/l.plant/ NEW AUTO RULE Non-Formulary PROBIOTICS l.rham/b.animalis/cranberry WOMEN'S 11/20/2019 children's acetaminophen NEW AUTO RULE Non-Formulary acetaminophen 11/20/2019 hydroxypropylcell hydroxypropyl cellulose NEW AUTO RULE Non-Formulary ulose 11/20/2019 UP4 bacillus coagulans/bacillus NEW AUTO RULE Non-Formulary PROBIOTICS- subtilis/inulin/ascorbic acid PREBIOTIC

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 468 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/20/2019 AZO COMPLETE lactobacillus crispatus/l. NEW AUTO RULE Non-Formulary FEMININE gasseri/l. jensenii/l. BALANCE rhamnosus 11/20/2019 enzoclear benzoyl peroxide NEW AUTO RULE Non-Formulary 11/20/2019 sinus and cold-d naproxen NEW AUTO RULE Non-Formulary sodium/pseudoephedrine hcl 11/20/2019 REBLOZYL luspatercept-aamt NEW AUTO RULE Non-Formulary 11/20/2019 afrin oxymetazoline hcl NEW AUTO RULE Non-Formulary 11/20/2019 vicks qlearquil oxymetazoline hcl NEW AUTO RULE Non-Formulary 11/20/2019 ENFAGROW infant formula with NEW AUTO RULE Non-Formulary GENTLEASE iron/soy/dha/arachidonic FORMULA acid 11/20/2019 vicks sinex oxymetazoline hcl NEW AUTO RULE Non-Formulary 11/20/2019 toddler-infant infant formula with NEW AUTO RULE Non-Formulary formula iron/soy/dha/arachidonic acid 11/20/2019 CHILD MUCINEX phenylephrine NEW AUTO RULE Non-Formulary MS COLD- hcl/dextromethorphan THROAT hbr/acetaminophen/guaifen 11/20/2019 REUMAKEND EF methyl NEW AUTO RULE Non-Formulary salicylate/levomenthol 11/20/2019 unifine pentips pen needle, diabetic NEW AUTO RULE Tier 2 plus maxflow 11/20/2019 ANTISEPTIC chlorhexidine gluconate NEW AUTO RULE Non-Formulary SKIN CLEANSER 11/20/2019 mucus-er max guaifenesin NEW AUTO RULE Non-Formulary 11/20/2019 ZIEXTENZO pegfilgrastim-bmez NEW AUTO RULE NF specialty 11/20/2019 advanced healing petrolatum,white NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 469 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/20/2019 easy comfort syringe with NEW AUTO RULE Tier 2 insulin syringe needle,disposable,insulin 1 ml 11/20/2019 anefrin oxymetazoline hcl NEW AUTO RULE Non-Formulary 11/20/2019 sinus relief oxymetazoline hcl NEW AUTO RULE Non-Formulary 11/20/2019 bp foam benzoyl peroxide NEW AUTO RULE Non-Formulary 11/20/2019 all day pain relief naproxen NEW AUTO RULE Non-Formulary sodium/pseudoephedrine hcl 11/20/2019 ALEVE COLD naproxen NEW AUTO RULE Non-Formulary AND SINUS sodium/pseudoephedrine hcl 11/20/2019 ALEVE-D SINUS naproxen NEW AUTO RULE Non-Formulary AND HEADACHE sodium/pseudoephedrine hcl 11/20/2019 baby buddha breast pump NEW AUTO RULE Non-Formulary breast pump 11/20/2019 HECTOROL doxercalciferol NEW AUTO RULE Non-Formulary 11/20/2020 levothyroxine levothyroxine sodium NEW AUTO RULE Non-formulary 11/20/2020 CEPACOL benzocaine/menthol NEW AUTO RULE Non-Formulary INSTAMAX SORE THROAT 11/20/2020 OFIRMEV acetaminophen NEW AUTO RULE Non-Formulary 11/20/2020 fentanyl- fentanyl citrate/bupivacaine NEW AUTO RULE Non-Formulary bupivacaine- hcl in 0.9 % sodium 0.9% nacl chloride/pf 11/20/2020 SODIUM ethacrynate sodium NEW AUTO RULE Non-Formulary EDECRIN 11/20/2020 SUTAB sodium sulfate/potassium NEW AUTO RULE Non-formulary chloride/magnesium sulfate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 470 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/20/2020 MEGARED krill oil/omega-3 fatty NEW AUTO RULE Non-Formulary OMEGA-3 KRILL acids/dha/epa/phospholipids OIL /astaxan 11/20/2020 prumyx emollient combination no.35 NEW AUTO RULE Non-Formulary 11/20/2020 ethyl alcohol ethyl alcohol NEW AUTO RULE Non-Formulary 11/20/2020 ginkgo biloba ginkgo biloba NEW AUTO RULE Non-Formulary 11/20/2020 thermacare activated NEW AUTO RULE Non-Formulary charcoal/iron/sodium/water 11/20/2020 MINERAL OIL mineral oil NEW AUTO RULE Non-Formulary HEAVY 11/20/2020 pedia iron ferrous sulfate NEW AUTO RULE Non-Formulary 11/20/2020 pediatric tri- vitamin a palmitate/ascorbic NEW AUTO RULE Non-Formulary vitamin acid/cholecalciferol (vit d3) 11/20/2020 CULTURELLE lactobacillus rhamnosus NEW AUTO RULE Non-Formulary DIGESTIVE gg/inulin 11/20/2020 curad stretch gauze bandage NEW AUTO RULE Non-Formulary gauze bandage 11/20/2020 mineral oil mineral oil NEW AUTO RULE Non-Formulary 11/20/2020 ALOPRIM allopurinol sodium NEW AUTO RULE Non-Formulary 11/20/2020 ANTARCTIC krill oil/omega-3 fatty NEW AUTO RULE Non-Formulary KRILL OIL acids/dha/epa/phospholipids /astaxan 11/20/2020 children's iron ferrous sulfate NEW AUTO RULE Non-Formulary 11/20/2020 MAGNESIUM magnesium NEW AUTO RULE Non-Formulary COMPLEX carb,citrate,oxide 11/20/2020 SALJET SALINE sodium chloride NEW AUTO RULE Non-Formulary 11/20/2020 LIPOTROPIX inositol/choline/methionine/t NEW AUTO RULE Non-Formulary aurine/herbal no.317

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 471 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/20/2020 phosphorous sodium NEW AUTO RULE Non-Formulary phosphate/potassium phosphates, monobasic and bibasic 11/20/2020 AZO vit NEW AUTO RULE Non-Formulary HORMONAL b1/b6/calcium/magnesium HLTH HAPPY oxide/chaste CYCLE tree/ashwagandha 11/20/2020 heat wraps activated NEW AUTO RULE Non-Formulary charcoal/iron/sodium/water 11/20/2020 heat therapy activated NEW AUTO RULE Non-Formulary patches charcoal/iron/sodium/water 11/20/2020 PKU GO nutritional therapy for NEW AUTO RULE Non-Formulary phenylketonuria(pku) with iron no.60 11/20/2020 biotin-vitamin c vitamin a/ascorbic NEW AUTO RULE Non-Formulary acid/biotin/zinc/selenomethi onine 11/20/2020 eucalyptus oil eucalyptus oil NEW AUTO RULE Non-Formulary 11/20/2020 CULTURELLE lactobacillus rhamnosus NEW AUTO RULE Non-Formulary DIGESTIVE gg/inulin HEALTH 11/20/2020 VENOFER iron sucrose complex NEW AUTO RULE Non-Formulary 11/20/2020 heatwraps heating pad NEW AUTO RULE Non-Formulary 11/20/2020 PHOS-NAK sodium NEW AUTO RULE Non-Formulary phosphate/potassium phosphates, monobasic and bibasic 11/20/2020 MIMYX emollient combination no.35 NEW AUTO RULE Non-Formulary 11/20/2020 FER-IN-SOL ferrous sulfate NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 472 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/20/2020 allopurinol allopurinol sodium NEW AUTO RULE Non-Formulary sodium 11/20/2020 SALJET SALINE sodium chloride NEW AUTO RULE Non-Formulary RINSE 11/20/2020 ADRENALIV ascorbic acid/calcium NEW AUTO RULE Non-Formulary pant/pyridoxal phosphate/herbal no.316 11/20/2020 morphine sulfate morphine sulfate NEW AUTO RULE Non-Formulary 11/20/2020 hydroquinone hydroquinone microspheres NEW AUTO RULE Non-Formulary 11/20/2020 zovia 1-35 ethynodiol diacetate-ethinyl NEW AUTO RULE Tier 1 estradiol 11/20/2020 LIVER acetylcysteine/alpha NEW AUTO RULE Non-Formulary PROTECT lipoic/milk thistle/selenomethionine 11/20/2020 ethacrynate ethacrynate sodium NEW AUTO RULE Non-Formulary sodium 11/20/2020 TAB-A-VITE multivitamin/ferrous NEW AUTO RULE Non-Formulary MULTIVIT WITH sulfate/folic acid IRON 11/20/2020 pediatric poly- pediatric multivitamin no.171 NEW AUTO RULE Non-Formulary vitamin 11/20/2020 lyllana estradiol NEW AUTO RULE Tier 1 11/22/2019 ENFAGROW pediatric nutrition,milk DRUG ATTR CHANGE Non-Formulary Non-Formulary TODLR NXT STP based,iron/docosahexanoic OVERRIDE NON-GMO acid 11/22/2019 cleocin clindamycin phosphate DRUG ATTR CHANGE Non-Formulary Non-Formulary phosphate OVERRIDE 11/22/2019 ENFAGROW infant formula with DRUG ATTR CHANGE Non-Formulary Non-Formulary TODLR iron/docosahexanoic OVERRIDE TRANSITN acid/arachidonic ac NONGMO

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 473 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/27/2019 BRUKINSA zanubrutinib NEW AUTO RULE NF specialty 11/27/2019 bortezomib bortezomib NEW AUTO RULE Non-Formulary 11/27/2019 dialyvite vitamin d cholecalciferol (vitamin d3) NEW AUTO RULE Non-Formulary 11/27/2019 ASCENIV immune globulin,gamma NEW AUTO RULE Non-Formulary (igg)-slra human 11/27/2019 sensorcaine-mpf bupivacaine hcl/pf DRUG ATTR CHANGE Non-Formulary Non-Formulary OVERRIDE 11/27/2019 autosoft xc infusion set for insulin pump NEW AUTO RULE Non-Formulary 11/27/2019 ENFAMIL infant formula with NEW AUTO RULE Non-Formulary ENSPIRE iron/docosahexanoic INFANT acid/arachidonic ac FORMULA 11/27/2019 AMZEEQ minocycline hcl NEW AUTO RULE Non-formulary 11/27/2019 premier urostomy urostomy pouch NEW AUTO RULE Non-Formulary pouch 11/27/2019 phenylephrine phenylephrine hcl in 0.9 % NEW AUTO RULE Non-Formulary hcl-0.9% nacl sodium chloride 11/27/2019 mycophenolate mycophenolate mofetil hcl NEW AUTO RULE Non-Formulary mofetil 11/27/2019 ESTROVEN soy isoflavone/black cohosh NEW AUTO RULE Non-Formulary WEIGHT root ext/cissus quadrangular MANAGEMENT ext 11/27/2019 GLUCERNA nutritional therapy, glucose NEW AUTO RULE Non-Formulary SNACK BAR intolerance,soy 11/27/2019 PRISMASOL bicarbonate dialysis solution NEW AUTO RULE Non-Formulary no.14 without calcium 11/27/2019 potassium potassium chloride in water NEW AUTO RULE Non-Formulary chloride for injection, sterile 11/27/2019 CELLCEPT mycophenolate mofetil hcl NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 474 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/27/2019 NPLATE romiplostim NEW AUTO RULE Non-Formulary 11/27/2019 UP4 lactobacillus acidophilus/l. NEW AUTO RULE Non-Formulary PROBIOTICS plantarum/bifido no.7 ADULT 11/27/2019 ADAKVEO crizanlizumab-tmca NEW AUTO RULE Non-Formulary 11/27/2019 dextrose in water dextrose 20 % in water NEW AUTO RULE Non-Formulary 11/27/2019 UP4 bacillus coagulans/bacillus NEW AUTO RULE Non-Formulary PROBIOTICS- subtilis/inulin/ascorbic acid PREBIOTIC KIDS 11/27/2019 infant formula infant formula with NEW AUTO RULE Non-Formulary with iron iron/docosahexanoic acid/arachidonic ac 11/27/2019 ENFAMIL infant formula with NEW AUTO RULE Non-Formulary NEWBORN iron/docosahexanoic NON-GMO acid/arachidonic ac 11/27/2019 QUTENZA capsaicin/skin cleanser NEW AUTO RULE Non-Formulary 11/27/2019 tiadylt er diltiazem hcl NEW AUTO RULE Tier 1 11/27/2019 hyophen methenamine/methylene NEW AUTO RULE Non-Formulary blue/benzoic acid/salicylat/hyoscyamin 11/27/2019 t:slim x2 insulin pump cartridge NEW AUTO RULE Non-Formulary 11/27/2019 CULTURELLE bacillus subtilis/inulin NEW AUTO RULE Non-Formulary KIDS GUMMY 11/27/2019 SOLU-MEDROL methylprednisolone sodium NEW AUTO RULE Non-Formulary succinate 11/27/2019 ENFAMIL infant formula with NEW AUTO RULE Non-Formulary NEWBORN iron/docosahexanoic acid/arachidonic ac

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 475 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/27/2019 PEDIALYTE sodium/potassium/chloride/d NEW AUTO RULE Non-Formulary SPARKLING extrose RUSH 11/27/2019 sulfamethoxazole sulfamethoxazole/trimethopr NEW AUTO RULE Non-Formulary -trimethoprim im 11/27/2019 premium infant infant formula with NEW AUTO RULE Non-Formulary formula iron/docosahexanoic acid/arachidonic ac 11/29/2019 sensorcaine-mpf bupivacaine hcl/pf DRUG ATTR CHANGE Non-Formulary Non-Formulary OVERRIDE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 476 UPDATED 12/2020 VALUE Drug Formulary Updates

December, 2019

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/01/2019 JAKAFI ruxolitinib phosphate NEW AUTO RULE Tier 4 12/01/2019 TYKERB lapatinib ditosylate UM AUTO RULE: 6 tabs/day QUANTITYCUSTOM 12/01/2020 LOKELMA sodium zirconium TERM AUTO RULE cyclosilicate 12/01/2020 SELZENTRY maraviroc TERM AUTO RULE 12/01/2020 LESCOL fluvastatin sodium TERM AUTO RULE 12/01/2020 GOLYTELY peg 3350/sod sulf/sod TERM AUTO RULE bicarb/sod chloride/potassium chloride 12/01/2020 fluvastatin fluvastatin sodium TERM AUTO RULE sodium 12/01/2020 GOLYTELY peg 3350/sod sulf/sod NEW AUTO RULE Tier 3 bicarb/sod chloride/potassium chloride 12/01/2020 fluvastatin fluvastatin sodium NEW AUTO RULE Tier 2 sodium 12/01/2020 SYMBICORT budesonide/formoterol NEW AUTO RULE Tier 2 fumarate 12/01/2020 LOKELMA sodium zirconium NEW AUTO RULE Tier 3 cyclosilicate 12/01/2020 TRUVADA emtricitabine/tenofovir UM AUTO RULE: 1 tab/day disoproxil fumarate QUANTITYCUSTOM 12/04/2019 RECOTHROM thrombin (recombinant) NEW AUTO RULE Non-Formulary 12/04/2019 fitted briefs diaper,brief,adult, NEW AUTO RULE Non-Formulary disposable 12/04/2019 CALPHRON calcium acetate NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 477 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/04/2019 lidocaine lidocaine NEW AUTO RULE Non-Formulary 12/04/2019 white wax beeswax NEW AUTO RULE Non-Formulary 12/04/2019 nighttime diaper,brief,youth,disposabl NEW AUTO RULE Non-Formulary underpants e 12/04/2019 sensorcaine-mpf bupivacaine hcl/pf NEW AUTO RULE Non-Formulary 12/04/2019 UP4 lactobacillus acidophilus/l. NEW AUTO RULE Non-Formulary PROBIOTICS plantarum/bifido no.7 ADULT 50 PLUS 12/04/2019 BLOXIVERZ neostigmine methylsulfate NEW AUTO RULE Non-Formulary 12/04/2019 beeswax white beeswax NEW AUTO RULE Non-Formulary 12/04/2019 redness relief naphazoline hcl/glycerin NEW AUTO RULE Non-Formulary 12/04/2019 beeswax yellow beeswax NEW AUTO RULE Non-Formulary 12/04/2019 potassium potassium chloride in water NEW AUTO RULE Non-Formulary chloride for injection, sterile 12/04/2019 CLEAR EYES naphazoline hcl/glycerin NEW AUTO RULE Non-Formulary REDNESS RELIEF 12/04/2019 lidocaine pain lidocaine NEW AUTO RULE Non-Formulary relief 12/04/2019 GABACAINE gabapentin/lidocaine NEW AUTO RULE Non-Formulary 12/04/2019 eliphos calcium acetate NEW AUTO RULE Non-Formulary 12/04/2019 fitted brief diaper,brief,adult, NEW AUTO RULE Non-Formulary disposable 12/04/2019 deferasirox deferasirox NEW AUTO RULE NF specialty 12/04/2019 GIVLAARI givosiran sodium NEW AUTO RULE Non-Formulary 12/06/2019 burn relief lidocaine/aloe vera NEW AUTO RULE Non-Formulary 12/06/2019 allergy relief d loratadine/pseudoephedrine NEW AUTO RULE Non-Formulary sulfate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 478 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/06/2019 allergy medicine diphenhydramine hcl NEW AUTO RULE Non-Formulary 12/06/2019 severe allergy- diphenhydramine NEW AUTO RULE Non-Formulary sinus headache hcl/phenylephrine hcl/acetaminophen 12/06/2019 DERMAL benzethonium chloride NEW AUTO RULE Non-Formulary WOUND CLEANSER 12/06/2019 thick and easy starch NEW AUTO RULE Non-Formulary 12/06/2019 ENFAMIL infant formula with NEW AUTO RULE Non-Formulary NEURO iron/docosahexaenoic GENTLEASE acid/arachidonic ac NONGMO 12/06/2019 DIPHENHIST diphenhydramine hcl NEW AUTO RULE Non-Formulary 12/06/2019 wal-dryl diphenhydramine hcl NEW AUTO RULE Non-Formulary 12/06/2019 BENADRYL diphenhydramine hcl NEW AUTO RULE Non-Formulary 12/06/2019 allergy- loratadine/pseudoephedrine NEW AUTO RULE Non-Formulary congestion relief- sulfate d 12/06/2019 xenon xe-133 xenon 133 in carbon dioxide NEW AUTO RULE Non-Formulary 12/06/2019 cold-hot pain menthol NEW AUTO RULE Non-Formulary relief 12/06/2019 ENFAMIL infant formula with NEW AUTO RULE Non-Formulary ENSPIRE iron/docosahexanoic GENTLEASE acid/arachidonic ac 12/06/2019 OXBRYTA voxelotor NEW AUTO RULE NF specialty 12/06/2019 bengay ultra menthol NEW AUTO RULE Non-Formulary strength 12/06/2019 GEN7T PLUS lidocaine/menthol NEW AUTO RULE Non-Formulary 12/06/2019 allergy relief diphenhydramine hcl NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 479 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/06/2019 wal-itin d 12 hour loratadine/pseudoephedrine NEW AUTO RULE Non-Formulary sulfate 12/06/2019 alavert loratadine/pseudoephedrine NEW AUTO RULE Non-Formulary sulfate 12/06/2019 allergy- loratadine/pseudoephedrine NEW AUTO RULE Non-Formulary congestion 12hr sulfate 12/06/2019 hydrocerin lanolin alcohols/mineral NEW AUTO RULE Non-Formulary oil/petrolatum,white/ceresin 12/06/2019 EUCERIN lanolin alcohols/mineral NEW AUTO RULE Non-Formulary oil/petrolatum,white/ceresin 12/06/2019 unispend compound vehicle NEW AUTO RULE Non-Formulary anhydrous sweet suspension sugar-free no.24 12/06/2019 diphenhydramine diphenhydramine hcl NEW AUTO RULE Non-Formulary hcl 12/06/2019 aloe burn relief lidocaine/aloe vera NEW AUTO RULE Non-Formulary 12/06/2019 SOLARCAINE lidocaine/aloe vera NEW AUTO RULE Non-Formulary COOL ALOE 12/06/2019 acetone acetone NEW AUTO RULE Non-Formulary 12/06/2019 wal-phed pe diphenhydramine NEW AUTO RULE Non-Formulary nighttime cold hcl/phenylephrine hcl/acetaminophen 12/06/2019 SECURA benzethonium chloride NEW AUTO RULE Non-Formulary MOISTURIZING 12/06/2019 ENFAMIL FOR infant formula with NEW AUTO RULE Non-Formulary SUPPLEMENTIN iron/docosahexanoic G acid/arachidonic ac 12/06/2019 FLOXIN ofloxacin NEW AUTO RULE Non-formulary 12/06/2019 allergy plus- diphenhydramine NEW AUTO RULE Non-Formulary severe sinus ha hcl/phenylephrine hcl/acetaminophen

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 480 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/06/2019 burn relief w-aloe lidocaine/aloe vera NEW AUTO RULE Non-Formulary 12/06/2019 allergy relief-d loratadine/pseudoephedrine NEW AUTO RULE Non-Formulary sulfate 12/06/2019 sucralfate sucralfate NEW AUTO RULE Tier 3 12/06/2019 allergy- loratadine/pseudoephedrine NEW AUTO RULE Non-Formulary congestion relief sulfate 12hr 12/06/2019 UP4 lactobacillus NEW AUTO RULE Non-Formulary PROBIOTICS acidophilus/bifidobacterium KIDS CUBES animalis/vit d2 12/06/2019 aler-caps diphenhydramine hcl NEW AUTO RULE Non-Formulary 12/06/2019 ALIVE WOMEN'S multivit with minerals/folic/vit NEW AUTO RULE Non-Formulary 50 PLUS k/lutein/herbal complex 293 12/06/2019 allergy diphenhydramine hcl NEW AUTO RULE Non-Formulary 12/06/2019 diphedryl diphenhydramine hcl NEW AUTO RULE Non-Formulary 12/06/2019 ENFAMIL infant formula with NEW AUTO RULE Non-Formulary GENTLEASE iron/docosahexanoic NON-GMO acid/arachidonic ac 12/06/2019 wal-dryl severe diphenhydramine NEW AUTO RULE Non-Formulary allergy-sinus hcl/phenylephrine hcl/acetaminophen 12/06/2019 cool-heat menthol NEW AUTO RULE Non-Formulary 12/06/2019 vitamin e vitamin e (dl-alpha DRUG ATTR CHANGE Non-Formulary Non-Formulary tocopheryl acetate) OVERRIDE 12/06/2019 allergy relief-d12 loratadine/pseudoephedrine NEW AUTO RULE Non-Formulary sulfate 12/06/2019 allerclear d-12hr loratadine/pseudoephedrine NEW AUTO RULE Non-Formulary sulfate 12/06/2019 complete allergy diphenhydramine hcl NEW AUTO RULE Non-Formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 481 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/06/2019 SECURA benzethonium chloride NEW AUTO RULE Non-Formulary 12/06/2019 saline wound benzethonium chloride NEW AUTO RULE Non-Formulary wash 12/06/2019 PRILO PATCH lidocaine/prilocaine NEW AUTO RULE Non-Formulary 12/06/2019 icy hot menthol NEW AUTO RULE Non-Formulary 12/06/2019 premier lock n roll ostomy supply NEW AUTO RULE Non-Formulary 12/06/2019 lido king lidocaine NEW AUTO RULE Non-Formulary 12/06/2019 allergy relief d-12 loratadine/pseudoephedrine NEW AUTO RULE Non-Formulary sulfate 12/06/2019 EYLEA aflibercept NEW AUTO RULE Non-Formulary 12/06/2019 aloe vera burn lidocaine/aloe vera NEW AUTO RULE Non-Formulary relief 12/06/2019 vitamin e vitamin e (dl-alpha NEW AUTO RULE Non-Formulary tocopheryl acetate) 12/06/2019 ENFAMIL infant formula with NEW AUTO RULE Non-Formulary NEURO iron/docosahexanoic GENTLEASE acid/arachidonic ac NONGMO 12/06/2019 fentanyl- fentanyl citrate/bupivacaine NEW AUTO RULE Non-Formulary bupivacaine- hcl in 0.9 % sodium 0.9% nacl chloride/pf 12/06/2019 gianvi ethinyl NEW AUTO RULE Tier 1 estradiol/drospirenone 12/06/2019 XYZAL levocetirizine NEW AUTO RULE Non-Formulary dihydrochloride 12/06/2019 cold-hot extra menthol NEW AUTO RULE Non-Formulary strength 12/06/2019 loratadine-d loratadine/pseudoephedrine NEW AUTO RULE Non-Formulary sulfate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 482 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/06/2019 dry skin therapy lanolin alcohols/mineral NEW AUTO RULE Non-Formulary oil/petrolatum,white/ceresin 12/06/2019 mesalamine er mesalamine NEW AUTO RULE Non-formulary 12/06/2019 vol-nate prenatal vits with calcium NEW AUTO RULE Tier 1 no.73/ferrous fumarate/folic acid 12/06/2019 thritex menthol NEW AUTO RULE Non-Formulary 12/06/2019 allergy diphenhydramine hcl NEW AUTO RULE Non-Formulary medication 12/06/2019 SIMILAC PRO- infant formula with NEW AUTO RULE Non-Formulary SENSITIVE iron/docosahexanoic NON-GMO acid/arachidonic ac 12/06/2019 pharbedryl diphenhydramine hcl NEW AUTO RULE Non-Formulary 12/06/2019 PROMISEB emollient combination no.43 NEW AUTO RULE Non-Formulary 12/12/2019 FENORTHO fenoprofen calcium UM AUTO RULE: 8 caps/day QUANTITYCUSTOM 12/12/2019 fenoprofen fenoprofen calcium UM AUTO RULE: 8 caps/day calcium QUANTITYCUSTOM 12/13/2019 sinus congestion phenylephrine NEW AUTO RULE Non-Formulary & pain hcl/acetaminophen/chlorphe niramine 12/13/2019 sinutrol pe phenylephrine NEW AUTO RULE Non-Formulary hcl/acetaminophen/chlorphe niramine 12/13/2019 EGRIFTA SV tesamorelin acetate NEW AUTO RULE NF specialty 12/13/2019 cequr simplicity subcutaneous bolus insulin NEW AUTO RULE Non-Formulary patch pump, 200 unit, disposable 12/13/2019 allergy relief phenylephrine NEW AUTO RULE Non-Formulary hcl/acetaminophen/chlorphe niramine

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 483 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/13/2019 SE-NATAL-19 prenatal vitamins NEW AUTO RULE Non-formulary no.119/iron fumarate/folic acid 12/13/2019 XYLOCAINE lidocaine hcl/epinephrine/pf NEW AUTO RULE Non-Formulary WITH EPINEPHRINE 12/13/2019 ultiguard safe pen needle, diabetic, NEW AUTO RULE Non-Formulary pack remover and disposal unit 12/13/2019 INSULIN insulin aspart NEW AUTO RULE Non-formulary ASPART 12/13/2019 severe cold & flu doxylamine/phenylephrine/d NEW AUTO RULE Non-Formulary extromethorphan/acetamino phen/gg 12/13/2019 INSULIN insulin aspart NEW AUTO RULE Non-formulary ASPART PENFILL 12/13/2019 NEPHRON FA vit b complex and vit c NEW AUTO RULE Non-Formulary no.24/ferrous fumarate/folic acid 12/13/2019 GEN7T lidocaine NEW AUTO RULE Non-Formulary 12/13/2019 alpha lipoic acid alpha lipoic acid NEW AUTO RULE Non-Formulary 12/13/2019 multi-symptom phenylephrine NEW AUTO RULE Non-Formulary allergy relief hcl/acetaminophen/chlorphe niramine 12/13/2019 INSULIN insulin aspart protamine NEW AUTO RULE Non-formulary ASPART PROT- human/insulin aspart INSULN ASP 12/13/2019 neostigmine- neostigmine methylsulfate in NEW AUTO RULE Non-Formulary sterile water sterile water for injection 12/13/2019 medicidin-d phenylephrine NEW AUTO RULE Non-Formulary hcl/acetaminophen/chlorphe niramine

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 484 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/13/2019 allergy multi- phenylephrine NEW AUTO RULE Non-Formulary symptom hcl/acetaminophen/chlorphe niramine 12/13/2019 allergy sinus pe phenylephrine NEW AUTO RULE Non-Formulary hcl/acetaminophen/chlorphe niramine 12/13/2019 tylenol cold-flu- doxylamine/phenylephrine/d NEW AUTO RULE Non-Formulary cough day-nt extromethorphan/acetamino phen/gg 12/13/2019 DRISTAN COLD phenylephrine NEW AUTO RULE Non-Formulary hcl/acetaminophen/chlorphe niramine 12/13/2019 sinus relief- phenylephrine NEW AUTO RULE Non-Formulary congestion & hcl/acetaminophen/chlorphe pain niramine 12/13/2019 INSULIN insulin aspart NEW AUTO RULE Non-formulary ASPART FLEXPEN 12/13/2019 UNASYN ampicillin sodium/sulbactam NEW AUTO RULE medical benefit sodium drugs 12/13/2019 cladribine cladribine NEW AUTO RULE Non-Formulary 12/13/2019 pain relief allergy phenylephrine NEW AUTO RULE Non-Formulary hcl/acetaminophen/chlorphe niramine 12/13/2019 VICKS doxylamine/phenylephrine/d NEW AUTO RULE Non-Formulary DAYQUIL- extromethorphan/acetamino NYQUIL phen/gg SEVERE 12/13/2019 everolimus everolimus NEW AUTO RULE Tier 4 12/20/2019 sulconazole sulconazole nitrate NEW AUTO RULE Non-formulary nitrate 12/20/2019 dapsone dapsone NEW AUTO RULE Non-formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 485 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/20/2019 LIDOVIX diclofenac sodium/lidocaine NEW AUTO RULE Non-Formulary 12/20/2019 KETALAR ketamine hcl NEW AUTO RULE Non-Formulary 12/20/2019 REFRESH carboxymethylcellulose NEW AUTO RULE Non-Formulary RELIEVA PF sodium/glycerin/pf 12/20/2019 westab one cyanocobalamin/folic NEW AUTO RULE Non-Formulary acid/pyridoxine 12/20/2019 JATENZO testosterone undecanoate NEW AUTO RULE Non-formulary 12/20/2019 VYONDYS-53 golodirsen NEW AUTO RULE Non-Formulary 12/20/2019 NITROPRESS nitroprusside sodium NEW AUTO RULE Non-Formulary 12/20/2019 LANOXIN digoxin NEW AUTO RULE Non-Formulary PEDIATRIC 12/20/2019 LOESTRIN FE norethindrone acetate- NEW AUTO RULE Non-formulary ethinyl estradiol/ferrous fumarate 12/20/2019 gerber good start lactobacillus reuteri NEW AUTO RULE Non-Formulary grow kids 12/20/2019 MICROVIX LP lidocaine/prilocaine/benzalk NEW AUTO RULE Non-Formulary onium chloride/dressing 12/20/2019 pedia-lax lactobacillus reuteri NEW AUTO RULE Non-Formulary probiotic yums 12/20/2019 biogaia lactobacillus reuteri NEW AUTO RULE Non-Formulary 12/20/2019 vitamin b-6 pyridoxine hcl (vitamin b6) NEW AUTO RULE Non-Formulary 12/20/2019 LANOXIN digoxin NEW AUTO RULE Non-Formulary 12/20/2019 FERIVA 21-7 iron asp gly/ascorbic NEW AUTO RULE Non-Formulary acid/folate no.1/vit b12/zinc/succinic 12/20/2019 FERIVA FA iron NEW AUTO RULE Non-Formulary bisgly,aspart,fumarate/vit c/folate/b12/biotin/cupric

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 486 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/20/2019 etonogestrel- etonogestrel/ethinyl estradiol NEW AUTO RULE Tier 2 ethinyl estradiol 12/20/2019 microgestin fe norethindrone acetate- NEW AUTO RULE Tier 1 ethinyl estradiol/ferrous fumarate 12/20/2019 ketamine hcl ketamine hcl NEW AUTO RULE Non-Formulary 12/20/2019 oxytocin oxytocin NEW AUTO RULE Non-Formulary 12/20/2019 VENLAFAXINE venlafaxine hcl NEW AUTO RULE Non-formulary HCL ER 12/20/2019 norethindrone-eth norethindrone acetate- NEW AUTO RULE Tier 1 estradiol-fe ethinyl estradiol/ferrous fumarate 12/20/2019 IMODIUM A-D loperamide hcl NEW AUTO RULE Non-Formulary 12/20/2019 folbee cyanocobalamin/folic NEW AUTO RULE Non-Formulary acid/pyridoxine 12/20/2019 sodium tetradecyl sodium tetradecyl sulfate NEW AUTO RULE Non-Formulary sulfate 12/20/2019 CONSENSI amlodipine NEW AUTO RULE NF specialty besylate/celecoxib 12/20/2019 eluryng etonogestrel/ethinyl estradiol NEW AUTO RULE Tier 2 12/20/2019 PREPIDIL dinoprostone NEW AUTO RULE Non-Formulary 12/20/2019 SOTRADECOL sodium tetradecyl sulfate NEW AUTO RULE Non-Formulary 12/20/2019 HEALON GV hyaluronate sodium NEW AUTO RULE Non-Formulary PRO 12/20/2019 travoprost travoprost NEW AUTO RULE Tier 2 12/20/2019 PITOCIN oxytocin NEW AUTO RULE Non-Formulary 12/20/2019 CLOZARIL clozapine NEW AUTO RULE Non-formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 487 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/20/2019 ABC COMPLETE multivit-calc-min/ferrous NEW AUTO RULE Non-Formulary SENIOR fumarate/folic acid/vit WOMEN'S k1/lutein 12/20/2019 sodium nitroprusside sodium NEW AUTO RULE Non-Formulary nitroprusside 12/20/2019 isosorbide isosorbide dinitrate NEW AUTO RULE Tier 1 dinitrate 12/20/2019 SECUADO asenapine NEW AUTO RULE NF specialty 12/20/2019 virt-vite cyanocobalamin/folic NEW AUTO RULE Non-Formulary acid/pyridoxine 12/22/2020 INBRIJA levodopa TERM AUTO RULE 12/22/2020 INBRIJA levodopa UM AUTO RULE: Limited Access LIMITEDACCESS 12/26/2019 hydrocodone hydrocodone bitartrate NEW AUTO RULE Non-formulary bitartrate er 12/26/2019 GERBER GOOD lactobacillus reuteri NEW AUTO RULE Non-Formulary START GROW TODDLER 12/26/2019 TALICIA omeprazole NEW AUTO RULE Non-formulary magnesium/amoxicillin trihydrate/rifabutin 12/26/2019 ENHERTU fam-trastuzumab NEW AUTO RULE Non-Formulary deruxtecan-nxki 12/26/2019 NOVOLIN N insulin nph human isophane NEW AUTO RULE Non-formulary FLEXPEN 12/26/2019 EVOMELA melphalan hcl/betadex NEW AUTO RULE Non-Formulary sulfobutyl ether sodium 12/26/2019 NOVOLIN R insulin regular, human NEW AUTO RULE Non-formulary FLEXPEN 12/26/2019 amphetamine amphetamine NEW AUTO RULE Non-formulary

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 488 UPDATED 12/2020 VALUE Drug Formulary Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/26/2019 PADCEV enfortumab vedotin-ejfv NEW AUTO RULE Non-Formulary 12/26/2019 TRIDESILON desonide NEW AUTO RULE Non-formulary 12/26/2019 doxepin hcl doxepin hcl NEW AUTO RULE Non-formulary 12/26/2019 peppermint oil peppermint oil NEW AUTO RULE Non-Formulary 12/26/2019 ciprofloxacin-d5w ciprofloxacin NEW AUTO RULE Non-Formulary lactate/dextrose 5 % in water 12/26/2019 deferasirox deferasirox NEW AUTO RULE NF specialty 12/26/2019 CIPRO I.V. ciprofloxacin NEW AUTO RULE Non-Formulary lactate/dextrose 5 % in water

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 489 UPDATED 12/2020