2020 Comprehensive Formulary

Jan. 1, 2020 – Dec. 31, 2020

888-645-6025 | TTY 711 Seven Days a Week, 8 A.M. to 8 P.M. (Oct. 1, 2019 to Mar. 31, 2020) Monday-Friday, 8 A.M. to 8 P.M. (All Other Times)

(PDP)

12783M-2020 BlueCross Rx Value

2020 Formulary

(List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

HPMS Approved Formulary File Submission ID 00020198, Version Number 10

This formulary was updated on 12/03/2019. For more recent information or other questions, please contact BlueCross Rx Value at 1-888-645-6025, or, for TTY users 711, 8 a.m. to 8 p.m., Eastern Time, Monday through Friday. Our automated telephone system handles calls received after 8 p.m. and on Saturdays, Sundays and holidays. From October 1, 2019 to March 31, 2020, we are available 8 a.m. to 8 p.m. Eastern Time, seven days a week. Or visit www.SCBluesMedAdvantage.com/marx20. Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to “we,” “us”, or “our,” it means BlueCross BlueShield of South Carolina. When it refers to “plan” or “our plan,” it means BlueCross Rx Value. This document includes a list of the drugs (formulary) for our plan which is current as of 12/03/2019. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2021, and from time to time during the year. What is the BlueCross Rx Value Formulary? A formulary is a list of covered drugs selected by our plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. BlueCross Rx Value will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a BlueCross Rx Value network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Most changes in drug coverage happen on January 1, but BlueCross Rx Value may add or remove drugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow Medicare rules in making these changes. Changes that can affect you this year: In the below cases, you will be affected by coverage changes during the year: • New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made.

o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the BlueCross Rx Value Formulary?” • Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. • Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. If we remove drugs from our ii formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 30-day supply of the drug.

o If we make these other changes, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the BlueCross Rx Value Formulary?” Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2020 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2020 coverage year except as described above. This means these drugs will remain available at the same cost-sharing and with no new restrictions for those members taking them for the remainder of the coverage year. The enclosed formulary is current as of 12/03/2019. To get updated information about the drugs covered by BlueCross Rx Value, please contact us. Our contact information appears on the front and back cover pages. We will update our printed formularies each month, and they will be available on www.SCBluesMedAdvantage.com/marx20.

How do I use the Formulary? There are two ways to find your drug within the formulary:

Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular. If you know what your drug is used for, look for the category name in the list that begins on page number 1. Then look under the category name for your drug.

Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 65. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs? BlueCross Rx Value covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: iii

• Prior Authorization: BlueCross Rx Value requires you [or your physician] to get prior authorization for certain drugs. This means that you will need to get approval from BlueCross Rx Value before you fill your prescriptions. If you don’t get approval, BlueCross Rx Value may not cover the drug. • Quantity Limits: For certain drugs, BlueCross Rx Value limits the amount of the drug that BlueCross Rx Value will cover. For example, BlueCross Rx Value provides 30 tablets per 30 days for CABLIVI. This may be in addition to a standard one-month or three-month supply. • Step Therapy: In some cases, BlueCross Rx Value requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, BlueCross Rx Value may not cover Drug B unless you try Drug A first. If Drug A does not work for you, BlueCross Rx Value will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask BlueCross Rx Value to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the BlueCross Rx Value’s formulary?” on page v for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. If you learn that BlueCross Rx Value does not cover your drug, you have two options: • You can ask Customer Service for a list of similar drugs that are covered by BlueCross Rx Value. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by BlueCross Rx Value. • You can ask BlueCross Rx Value to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the BlueCross Rx Value Formulary? You can ask BlueCross Rx Value to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. • You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. • You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, our plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

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Generally, BlueCross Rx Value will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception. During a level-of-care change in which the member changes from one treatment setting to another, drugs may be prescribed that are not covered by the plan. If this happens, you and your doctor must use the plan’s coverage determination request process. To prevent a gap in care when you are discharged, you may get a full outpatient supply that will allow therapy to continue once the limited discharge supply is gone. This outpatient supply is available before discharge from a Medicare Part A stay. When you are admitted to or discharged from an LTC facility, you may not have access to the drugs you were previously given. You may, however, get a refill upon admission or discharge.

For more information For more detailed information about your BlueCross Rx Value prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about BlueCross Rx Value, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800- MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

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BlueCross Rx Value’s Formulary The formulary that begins on page 1 provides coverage information about the drugs covered by BlueCross Rx Value. If you have trouble finding your drug in the list, turn to the Index that begins on page 65. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., JANUVIA) and generic drugs are listed in lower-case italics (e.g., lisinopril). The information in the Requirements/Limits column tells you if BlueCross Rx Value has any special requirements for coverage of your drug. The information in the Drug Tier column tells you what tier each drug is in. The table below describes your share of the cost when you receive a covered Part D prescription drug for a 30-day or 90-day supply from a standard in-network retail pharmacy, or a 90-day supply through a standard mail-order pharmacy. BlueCross Rx Value $195 Annual Deductible

30-Day 90-Day 90-Day Drug Tiers and Standard Standard Standard Tier Names Retail Supply Retail Supply Mail Order Tier 1: Preferred $5 copay $15 copay $12.50 copay Generic Tier 2: Generic $20 copay $60 copay $50 copay Tier 3: Preferred $47 copay $141 copay $117.50 copay Brand Tier 4: Non- 50% 50% 50% Preferred Drug coinsurance coinsurance coinsurance Tier 5: Specialty 29% 29% 29% Tier coinsurance coinsurance coinsurance

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and copayments/coinsurance may change on January 1 of each year.

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2020 Dosage Abbreviation Key AEPB Aerosol Powder-Breath Activated NEBU Nebulization Solution AERO Aerosol OINT Ointment AERP Aerosol, Powder POWD Powder AERS Aerosol, Solution PTCH Patch CAPS Capsule PTTW Patch Twice Weekly CART Cartridge PTWK Patch Weekly CHEW Tablet, chewable SHAM Shampoo CONC Concentrate SOAJ Solution Auto-Injector CPCR Capsule Extended Release SOCT Solution Cartridge CPCW Capsule Chewable SOLG Gel Forming Solution CPDR Capsule-Delayed Release SOLN Solution CPEP Capsule Delayed Release Particles SOLR Solution Reconstituted CPPK Capsule Therapy Pack SOPN Solution Pen-Injector

CPSP Capsule Sprinkle SOSY Solution Prefilled Syringe Capsule Extended Release 12 Hour Reconstituted Susp that Releases Dose CP12 SRER Over Extended Time CP24 Capsule Extended Release 24 Hour SUBL Tablet, Sublingual CREA Cream SUPN Suspension Pen-Injector Capsule Designed to Delay Release Until Suppository CSDR Specific Area of GI Tract SUPP ELIX Elixir SUSP Suspension EMUL Emulsion SUSR Suspension Reconstituted ENEM Enema SYRP Syrup FILM Film TABS Tablet GEL Gel TB12 Tablet Extended Release 12 Hour GRAN Granules TB24 Tablet Extended Release 24 Hour INHA Inhaler TB3D Tablet Disintegrating Soluble INJ Injectable TB3E Tablet Disintegrating Soluble ER KIT Kit TDCR Tablet Extended Release LIQD Liquid TBDP Tablet Dispersible LOTN Lotion TBEC Tablet Delayed Release LOZG Lozenge TBPK Tablet Therapy Pack LPOP Lozenge on a Handle TBSO Tablet Soluble NDS Non-Extended Day Supply TROC Troche

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Drug Tiers

Every drug on the plan’s Drug List is in one of five cost-sharing tiers. In general, the higher the cost- sharing tier, the higher your cost for the drug: • Cost-Sharing Tier 1: Preferred Generic – Tier 1 is the lowest tier and includes preferred generic drugs. • Cost-Sharing Tier 2: Generic – Tier 2 includes generic drugs. • Cost-Sharing Tier 3: Preferred Brand – Tier 3 includes preferred brand drugs and non-preferred generic drugs. • Cost-Sharing Tier 4: Non-Preferred Drug – Tier 4 includes non-preferred brand drugs and non- preferred generic drugs. • Cost-Sharing Tier 5: Specialty Tier – Tier 5 is the highest tier. It contains very high-cost brand and generic drugs that may require special handling and/or close monitoring.

Requirements/Limits Key

B/D = Drug that may be covered under Medicare Part B or Medicare Part D, depending on the indication, where and how the drug was administered and by whom. The plan must first conduct a review to determine the correct coverage (B or D). PA = Prior Authorization QL = Quantity Limits NDS = Non-Extended Day Supply. This prescription drug is not available for an extended days' supply. ST = Step Therapy LA = Limited Access Drug. This prescription may be available only at certain pharmacies. For more Information, consult your Pharmacy Directory or call Customer Service at 1-888-645-6025, 8 a.m. to 8 p.m. Eastern Time, Monday through Friday. Our automated telephone system handles calls received after 8 p.m. and on Saturdays, Sundays and holidays. From October 1, 2019, to March 31, 2020, we are available 8 a.m. to 8 p.m. Eastern Time, seven days a week. TTY users should call 711.

viii Drug Drug Name Tier Requirements/Limits Analgesics Nonsteroidal Anti-inflammatory Drugs diclofenac potassium 4 diclofenac sodium dr 4 diclofenac sodium er 4 diclofenac sodium xr 4 diclofenac sodium gel 3% 4 diclofenac sodium gel 1% 4 QL (1000 GM per 30 days) diflunisal tabs 500mg 4 etodolac tabs 2 etodolac caps 4 flurbiprofen tabs 2 ibuprofen susp 2 ibuprofen tabs 400mg, 600mg, 800mg ibu tabs 600mg, 800mg 1 indomethacin caps 4 ketoprofen caps 50mg, 75mg 2 ketorolac tromethamine inj 15mg/ml, 30mg/ml 4 ketorolac tromethamine tabs 10mg 4 QL (20 EA per 30 days) meloxicam tabs 1 nabumetone tabs 2 naproxen dr 2 naproxen sodium tabs 275mg, 550mg 4 naproxen tabs 1 naproxen susp 4 oxaprozin 4 SPRIX 5 QL (5 EA per 30 days) sulindac tabs 2 Opioid Analgesics, Long-acting EMBEDA 3 NDS fentanyl pt72 100mcg/hr, 12mcg/hr, 25mcg/hr, 50mcg/hr, 4 NDS 75mcg/hr hydromorphone hcl er t24a 16mg 4 NDS hydromorphone hcl er t24a 32mg 5 NDS hydromorphone hydrochloride er 5 NDS INFUMORPH 200 4 NDS INFUMORPH 500 4 NDS methadone hcl intensol 2 NDS methadone hcl conc, oral soln, tabs 2 NDS methadone hcl inj 4 NDS methadose sugar-free 2 NDS methadose conc 10mg/ml 2 NDS mitigo 2 NDS morphine sulfate er tbcr 2 NDS XTAMPZA ER 3 NDS Opioid Analgesics, Short-acting ABSTRAL 4 PA NDS

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 1 of 88 Drug Drug Name Tier Requirements/Limits acetaminophen/codeine 2 NDS butorphanol tartrate inj 4 NDS codeine sulfate tabs 4 NDS endocet tabs 325mg; 5mg 2 NDS endocet tabs 325mg; 10mg, 325mg; 2.5mg, 325mg; 7.5mg 4 NDS fentanyl citrate oral transmucosal 5 PA NDS fentanyl citrate tabs 4 PA fentanyl citrate inj 1000mcg/20ml, 100mcg/2ml, 4 B/D NDS 2500mcg/50ml, 250mcg/5ml, 500mcg/10ml hydrocodone bitartrate/acetaminophen soln 325mg/15ml; 4 NDS 7.5mg/15ml hydrocodone bitartrate/acetaminophen tabs 300mg; 10mg, 4 NDS 300mg; 5mg, 300mg; 7.5mg, 325mg; 2.5mg hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 5mg, 4 NDS 325mg; 7.5mg hydromorphone hcl dosette 4 NDS hydromorphone hcl tabs 2 NDS hydromorphone hcl liqd 4 NDS hydromorphone hcl inj 10mg/ml, 1mg/ml, 2mg/ml, 4mg/ml, 4 NDS 50mg/5ml hydromorphone hydrochloride inj 1mg/ml 4 LAZANDA 4 PA NDS lorcet 4 NDS lorcet hd 4 NDS lorcet plus tabs 325mg; 7.5mg 4 NDS morphine sulfate tabs 2 NDS morphine sulfate oral soln 4 NDS morphine sulfate inj 15mg/ml, 8mg/ml 4 morphine sulfate inj 10mg/ml, 150mg/30ml, 1mg/ml, 4mg/ml, 4 B/D NDS 5mg/ml, 8mg/ml morphine sulfate inj 0.5mg/ml, 10mg/ml, 1mg/ml, 2mg/ml, 4 NDS 4mg/ml, 5mg/ml, 8mg/ml nalbuphine hcl inj 10mg/ml, 20mg/ml 4 NDS OXAYDO 5 NDS oxycodone hcl caps, conc 4 NDS oxycodone hcl tabs 10mg, 20mg, 30mg, 5mg 2 NDS oxycodone hydrochloride soln 4 NDS oxycodone hydrochloride tabs 15mg 2 NDS oxycodone/acetaminophen soln 2 NDS oxycodone/acetaminophen tabs 325mg; 5mg 2 NDS oxycodone/acetaminophen tabs 325mg; 10mg, 325mg; 2.5mg, 4 NDS 325mg; 7.5mg oxycodone/aspirin tabs 325mg; 4.835mg 4 NDS tramadol hcl tabs 2 NDS tramadol hydrochloride/acetaminophen 2 NDS vicodin es tabs 300mg; 7.5mg 4 NDS vicodin hp tabs 300mg; 10mg 4 NDS

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 2 of 88 Drug Drug Name Tier Requirements/Limits vicodin tabs 300mg; 5mg 4 NDS Anesthetics Local Anesthetics 7t lido gel 3 QL (30 GM per 30 days) PA chloroprocaine hydrochloride 4 glydo 3 QL (30 ML per 30 days) PA lidocaine hcl jelly gel 3 QL (30 ML per 30 days) PA lidocaine hcl inj 0.5%, 1%, 1.5%, 2%, 4% 2 lidocaine hcl prsy 2% 3 QL (30 ML per 30 days) PA lidocaine hcl external soln 4% 4 QL (250 ML per 30 days) PA lidocaine hydrochloride inj 1% 2 lidocaine-prilocaine-cream base crea 3 QL (30 GM per 30 days) PA lidocaine/epinephrine 1 lidocaine/prilocaine crea 3 QL (30 GM per 30 days) PA lidocaine ptch 4 PA lidocaine oint 4 QL (150 GM per 30 days) PA polocaine-mpf 4 polocaine inj 1%, 2% 4 xylocaine dental inj 1 Anti-Addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-craving acamprosate calcium dr 4 disulfiram tabs 3 VIVITROL 5 Opioid Dependence Treatments buprenorphine hcl/naloxone hcl subl 2mg; 0.5mg 1 QL (360 EA per 30 days) buprenorphine hcl/naloxone hcl subl 8mg; 2mg 1 QL (90 EA per 30 days) buprenorphine hcl subl 2 buprenorphine hydrochloride/naloxone hydrochloride film 2 QL (60 EA per 30 days) 12mg; 3mg, 4mg; 1mg buprenorphine hydrochloride/naloxone hydrochloride film 2 QL (90 EA per 30 days) 2mg; 0.5mg, 8mg; 2mg BUPRENORPHINE HYDROCHLORIDE/NALOXONE 1 QL (360 EA per 30 days) HYDROCHLORIDE SUBL 2MG; 0.5MG naltrexone hcl tabs 2 Opioid Reversal Agents naloxone hcl inj 0.4mg/ml, 2mg/2ml, 4mg/10ml 2 NARCAN LIQD 4 Smoking Cessation Agents bupropion hydrochloride er (sr) tb12 150mg 2 QL (60 EA per 30 days) CHANTIX CONTINUING MONTH PAK 4 QL (504 EA per 365 days) CHANTIX STARTING MONTH PAK 4 QL (504 EA per 365 days) CHANTIX TABS 0.5MG, 1MG 4 QL (504 EA per 365 days) NICOTROL INHALER 4 QL (2688 EA per 365 days) NICOTROL NS 3 QL (360 ML per 365 days) Anti-inflammatory Agents Glucocorticoids

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 3 of 88 Drug Drug Name Tier Requirements/Limits hydrocortisone rectal crea 1%, 2.5% 2 procto-med hc 2 procto-pak 2 proctosol hc 2 proctozone-hc 2 Antibacterials Aminoglycosides gentak oint 4 gentamicin sulfate/0.9% sodium chloride inj 1.2mg/ml; 0.9%, 4 1.6mg/ml; 0.9%, 1mg/ml; 0.9% gentamicin sulfate crea, external oint, ophthalmic oint, 2 ophthalmic soln gentamicin sulfate inj 40mg/ml 4 neomycin sulfate 3 neomycin/polymyxin b sulfates 2 paromomycin sulfate 4 streptomycin sulfate inj 1gm 4 tobramycin sulfate ophthalmic soln 2 tobramycin sulfate inj 3 TOBREX OINT 4 Antibacterials, Other baciim 3 bacitracin inj 3 bacitracin oint 4 chloramphenicol sodium succinate 4 CLEOCIN SUPP 4 clindamycin 3 clindamycin hcl caps 300mg, 75mg 2 clindamycin hydrochloride caps 150mg 2 clindamycin palmitate hcl 2 clindamycin phosphate add-vantage 3 clindamycin phosphate in d5w 4 clindamycin phosphate external soln, swab 2 clindamycin phosphate inj 3 clindamycin phosphate crea, gel, lotn 4 clindamycin/sodium chloride 3 colistimethate sodium 4 DAPTOMYCIN INJ 350MG 5 daptomycin inj 500mg 5 IMPAVIDO 5 linezolid tabs 4 QL (56 EA per 28 days) linezolid susr 5 QL (1800 ML per 28 days) linezolid inj 600mg/300ml 5 MAFENIDE ACETATE PACK 4 methenamine hippurate 4 metronidazole in nacl 0.79% 3 metronidazole vaginal 4

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 4 of 88 Drug Drug Name Tier Requirements/Limits metronidazole inj 5mg/ml 3 metronidazole tabs 250mg, 500mg 2 mupirocin oint 2 nitrofurantoin macrocrystals 4 nitrofurantoin monohydrate 2 nitrofurantoin monohydrate/macrocrystals 2 nitrofurantoin susp 4 PRIMSOL 4 silver sulfadiazine crea 2 SIVEXTRO TABS 5 QL (6 EA per 30 days) ssd 2 trimethoprim tabs 2 TRIMPEX SOLN 4 vancomycin hcl inj 100gm, 10gm, 1gm, 5gm 3 vancomycin hydrochloride/dextrose inj 5%; 1gm/200ml, 5%; 3 500mg/100ml vancomycin hydrochloride caps 125mg 4 QL (120 EA per 30 days) vancomycin hydrochloride caps 250mg 5 QL (240 EA per 30 days) vancomycin hydrochloride inj 1.25gm, 1.5gm, 250mg, 500mg, 3 5gm, 750mg vandazole 4 XENLETA 5 XIFAXAN 5 PA Beta-lactam, Cephalosporins cefaclor er tb12 500mg 4 cefaclor caps 4 cefadroxil caps, susr 2 cefazolin sodium/dextrose inj 1gm; 4%, 2gm; 3% 3 cefazolin sodium inj 100gm, 10gm, 1gm/50ml; 4%, 1gm, 3 20gm, 300gm, 500mg cefazolin inj 2gm/100ml; 4% 3 cefdinir 2 CEFDITOREN PIVOXIL TABS 200MG 4 cefditoren pivoxil tabs 400mg 4 cefepime inj 1gm, 2gm 3 cefixime caps 3 cefixime susr 4 cefotaxime sodium 3 cefotetan 3 cefotetan/dextrose 3 cefoxitin sodium 3 cefpodoxime proxetil susr 2 cefpodoxime proxetil tabs 4 cefprozil 2 ceftazidime/dextrose 3 ceftazidime inj 1gm, 2gm, 6gm 3 ceftibuten susr 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 5 of 88 Drug Drug Name Tier Requirements/Limits ceftriaxone in iso-osmotic dextrose 3 ceftriaxone sodium inj 3 ceftriaxone/dextrose 3 cefuroxime axetil tabs 2 cefuroxime sodium inj 1.5gm, 7.5gm, 750mg, 75gm 3 cephalexin caps 250mg, 500mg 2 cephalexin susr 2 SUPRAX CHEW 3 SUPRAX SUSR 500MG/5ML 5 tazicef inj 1gm, 2gm, 6gm 3 TEFLARO 5 Beta-lactam, Other AZACTAM IN ISO-OSMOTIC DEXTROSE INJ 4 1GM/50ML; 0, 2GM/50ML; 0 aztreonam inj 1gm 4 aztreonam inj 2gm 5 DORIPENEM INJ 500MG 4 ertapenem 3 ertapenem sodium 3 imipenem/cilastatin 3 meropenem 3 Beta-lactam, Penicillins amoxicillin/clavulanate potassium 2 amoxicillin/clavulanate potassium er 2 amoxicillin chew 125mg, 250mg 2 amoxicillin caps, susr, tabs 2 ampicillin 2 ampicillin sodium inj 4 ampicillin-sulbactam 3 AUGMENTIN SUSR 125MG/5ML; 31.25MG/5ML 5 BICILLIN C-R INJ 300000UNIT/ML; 300000UNIT/ML, 4 900000UNIT/2ML; 300000UNIT/2ML BICILLIN L-A INJ 1200000UNIT/2ML, 4 2400000UNIT/4ML, 600000UNIT/ML dicloxacillin sodium 2 nafcillin sodium inj 10gm, 1gm, 2gm 4 PENICILLIN G POTASSIUM IN ISO-OSMOTIC 4 DEXTROSE penicillin g potassium inj 20000000unit, 5000000unit 4 penicillin g sodium 4 penicillin v potassium 2 piperacillin sodium/ tazobactam sodium 3 piperacillin sodium/tazobactam 3 piperacillin sodium/tazobactam sodium inj 2gm; 0.25gm, 3 4gm; 0.5gm piperacillin/tazobactam 3 Macrolides

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 6 of 88 Drug Drug Name Tier Requirements/Limits AZASITE 4 azithromycin susr, tabs 2 azithromycin pack 4 azithromycin inj 500mg 3 clarithromycin er 2 clarithromycin susr, tabs 2 DIFICID 5 ery 4 ERY-TAB 3 ERYTHROCIN STEARATE TABS 250MG 4 erythromycin base 4 erythromycin dr 2 erythromycin ethylsuccinate tabs 4 erythromycin ethylsuccinate susr 400mg/5ml 4 erythromycin oint 2 erythromycin cpep, gel, pads 4 erythromycin soln 2% 2 Quinolones BESIVANCE 4 ciprofloxacin er 4 ciprofloxacin hcl tabs 750mg 2 ciprofloxacin hcl tabs 100mg 4 ciprofloxacin hydrochloride tabs 2 ciprofloxacin hydrochloride soln 4 ciprofloxacin i.v.-in d5w 3 ciprofloxacin otic soln 2 ciprofloxacin inj 3 ciprofloxacin susr 250mg/5ml, 500mg/5ml 2 gatifloxacin 4 levofloxacin in d5w 3 levofloxacin tabs 2 levofloxacin ophthalmic soln 3 levofloxacin inj, oral soln 4 moxifloxacin hydrochloride/sodium hydrochloride 4 moxifloxacin hcl inj 4 moxifloxacin hydrochloride tabs 2 moxifloxacin hydrochloride soln 3 ofloxacin otic soln 2 ofloxacin ophthalmic soln 3 ofloxacin tabs 300mg, 400mg 2 Sulfonamides sulfacetamide sodium oint, soln 3 sulfadiazine tabs 4 sulfamethoxazole/trimethoprim ds 2 sulfamethoxazole/trimethoprim susp, tabs 2 sulfamethoxazole/trimethoprim inj 3 sulfatrim pediatric 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 7 of 88 Drug Drug Name Tier Requirements/Limits Tetracyclines demeclocycline hcl tabs 2 demeclocycline hydrochloride tabs 300mg 2 doxy 100 4 doxycycline hyclate dr tbec 150mg 4 doxycycline hyclate inj 4 doxycycline hyclate tabs 100mg, 20mg 2 doxycycline monohydrate caps 100mg, 50mg 2 doxycycline monohydrate tabs 50mg 2 MINOCIN INJ 4 minocycline hcl caps 75mg 2 minocycline hcl tabs 2 minocycline hydrochloride caps 100mg, 50mg 2 mondoxyne nl caps 100mg, 50mg 2 NUZYRA TABS 5 okebo caps 100mg 2 SEYSARA 5 soloxide 4 tetracycline hydrochloride caps 2 VIBRAMYCIN SYRP 4 Anticonvulsants Anticonvulsants, Other APTIOM 4 BRIVIACT 5 PA EPIDIOLEX 5 PA FYCOMPA 4 levetiracetam er 2 levetiracetam/sodium chloride 4 levetiracetam oral soln, tabs 2 levetiracetam inj 4 phenobarbital sodium inj 130mg/ml, 65mg/ml 2 PA phenobarbital elix 20mg/5ml 4 PA POTIGA 5 roweepra 2 roweepra xr 2 SPRITAM 4 Calcium Channel Modifying Agents CELONTIN CAPS 300MG 4 ethosuximide 4 LYRICA SOLN 3 QL (900 ML per 30 days) LYRICA CAPS 300MG 3 QL (60 EA per 30 days) LYRICA CAPS 100MG, 150MG, 200MG, 225MG, 25MG, 3 QL (90 EA per 30 days) 50MG, 75MG pregabalin caps 300mg 2 QL (60 EA per 30 days) pregabalin caps 100mg, 150mg, 200mg, 225mg, 25mg, 50mg, 2 QL (90 EA per 30 days) 75mg pregabalin soln 2 QL (900 ML per 30 days)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 8 of 88 Drug Drug Name Tier Requirements/Limits zonisamide 2 Gamma-aminobutyric Acid (GABA) Augmenting Agents clobazam 4 clonazepam odt tbdp 2mg 4 QL (300 EA per 30 days) clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg, 1mg 4 QL (90 EA per 30 days) clonazepam tabs 2mg 2 QL (300 EA per 30 days) clonazepam tabs 0.5mg, 1mg 2 QL (90 EA per 30 days) DIASTAT ACUDIAL 4 DIASTAT PEDIATRIC GEL 2.5MG 4 diazepam rectal gel 4 diazepam gel 10mg, 2.5mg, 20mg 4 divalproex sodium dr 2 divalproex sodium er 2 divalproex sodium csdr 3 gabapentin caps 400mg 2 QL (270 EA per 30 days) gabapentin caps 100mg, 300mg 2 QL (360 EA per 30 days) gabapentin soln 4 QL (2160 ML per 30 days) gabapentin tabs 800mg 2 QL (150 EA per 30 days) gabapentin tabs 600mg 2 QL (180 EA per 30 days) phenobarbital tabs 100mg, 15mg, 16.2mg, 30mg, 32.4mg, 4 PA 60mg, 64.8mg, 97.2mg primidone tabs 2 SYMPAZAN FILM 5MG 4 SYMPAZAN FILM 10MG, 20MG 5 tiagabine hydrochloride 4 valproate sodium inj 100mg/ml 2 valproic acid caps, soln 2 vigabatrin 5 PA vigadrone 5 PA Glutamate Reducing Agents felbamate tabs 4 felbamate susp 5 lamotrigine starter kit/blue 4 lamotrigine starter kit/green 4 lamotrigine starter kit/orange 4 lamotrigine titration kit 0 4 lamotrigine titration kit 0 5 lamotrigine chew, tabs 2 subvenite 2 subvenite starter kit/blue 4 subvenite starter kit/green 4 subvenite starter kit/orange 4 topiramate cpsp, tabs 2 Sodium Channel Agents BANZEL 5 carbamazepine er 4 carbamazepine chew, susp, tabs 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 9 of 88 Drug Drug Name Tier Requirements/Limits DILANTIN CAPS 30MG 4 epitol 2 fosphenytoin sodium 2 oxcarbazepine tabs 2 oxcarbazepine susp 4 PEGANONE TABS 250MG 4 phenytoin sodium extended 4 phenytoin chew, susp 2 VIMPAT INJ, ORAL SOLN 4 VIMPAT TABS 50MG 4 VIMPAT TABS 100MG, 150MG, 200MG 5 Antidementia Agents Antidementia Agents, Other ergoloid mesylates tabs 3 Cholinesterase Inhibitors donepezil hcl tbdp 2 donepezil hcl tabs 10mg 2 donepezil hydrochloride 2 galantamine hydrobromide er 4 galantamine hydrobromide soln, tabs 4 rivastigmine tartrate 4 rivastigmine transdermal system 4 N-methyl-D-aspartate (NMDA) Receptor Antagonist memantine hcl 2 memantine hcl titration pak 2 memantine hydrochloride er 4 QL (30 EA per 30 days) memantine hydrochloride soln 4 Antidepressants Antidepressants, Other bupropion hcl tabs 100mg 2 bupropion hydrochloride er (sr) tb12 150mg, 200mg 2 QL (60 EA per 30 days) bupropion hydrochloride er (sr) tb12 100mg 2 QL (90 EA per 30 days) bupropion hydrochloride er (xl) tb24 300mg 2 QL (30 EA per 30 days) bupropion hydrochloride er (xl) tb24 150mg 2 QL (90 EA per 30 days) bupropion hydrochloride tabs 75mg 2 mirtazapine odt 2 mirtazapine tabs 2 Monoamine Oxidase Inhibitors EMSAM 5 QL (30 EA per 30 days) ST MARPLAN 4 phenelzine sulfate 3 tranylcypromine sulfate 4 SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitor citalopram hydrobromide 2 DESVENLAFAXINE ER TB24 100MG 4 QL (120 EA per 30 days) ST DESVENLAFAXINE ER TB24 50MG 4 QL (30 EA per 30 days) ST

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 10 of 88 Drug Drug Name Tier Requirements/Limits desvenlafaxine er tb24 100mg 4 QL (120 EA per 30 days) desvenlafaxine er tb24 25mg, 50mg 4 QL (30 EA per 30 days) DRIZALMA SPRINKLE CSDR 20MG, 60MG 4 QL (60 EA per 30 days) DRIZALMA SPRINKLE CSDR 30MG, 40MG 4 QL (90 EA per 30 days) duloxetine hcl cpep 20mg 2 QL (60 EA per 30 days) duloxetine hydrochloride cpep 60mg 2 QL (60 EA per 30 days) duloxetine hydrochloride cpep 30mg 2 QL (90 EA per 30 days) escitalopram oxalate 2 FETZIMA 4 QL (30 EA per 30 days) ST FETZIMA TITRATION PACK 4 QL (56 EA per 365 days) ST fluoxetine 2 fluoxetine hcl caps 20mg, 40mg 2 fluoxetine hydrochloride caps 10mg 2 fluoxetine hydrochloride soln 2 fluvoxamine maleate 2 maprotiline hcl 4 nefazodone hcl tabs 100mg, 150mg 4 nefazodone hydrochloride tabs 200mg, 250mg, 50mg 4 paroxetine hcl er 4 paroxetine hcl tabs 10mg, 30mg, 40mg 4 paroxetine hydrochloride tabs 20mg 4 PAXIL SUSP 4 sertraline hcl conc 4 sertraline hcl tabs 25mg, 50mg 2 sertraline hydrochloride tabs 100mg 2 trazodone hydrochloride tabs 100mg, 150mg, 50mg 2 TRINTELLIX 4 QL (30 EA per 30 days) venlafaxine hcl 2 venlafaxine hcl er cp24 2 VIIBRYD STARTER PACK 4 QL (60 EA per 365 days) VIIBRYD TABS 4 QL (30 EA per 30 days) Tricyclics amitriptyline hcl tabs 100mg, 150mg, 25mg, 75mg 4 PA amitriptyline hydrochloride tabs 10mg, 50mg 4 PA amoxapine 4 clomipramine hcl caps 4 desipramine hcl tabs 4 doxepin hcl caps 100mg, 10mg, 150mg, 50mg, 75mg 4 PA doxepin hcl conc 4 PA doxepin hydrochloride caps 25mg 4 PA imipramine hcl tabs 25mg, 50mg 4 imipramine hydrochloride tabs 10mg 4 nortriptyline hcl caps 10mg, 25mg, 75mg 2 nortriptyline hcl soln 2 nortriptyline hydrochloride caps 50mg 2 protriptyline hcl 4 trimipramine maleate caps 4

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 11 of 88 Drug Drug Name Tier Requirements/Limits Antiemetics Antiemetics, Other AKYNZEO 4 QL (2 EA per 30 days) B/D compro 4 doxylamine succinate/pyridoxine hydrochloride 4 QL (120 EA per 30 days) droperidol inj 2 meclizine hcl tabs 4 prochlorperazine edisylate inj 10mg/2ml 4 prochlorperazine maleate tabs 2 prochlorperazine supp 25mg 4 promethazine hcl plain 4 PA promethazine hcl inj 25mg/ml 4 PA promethazine hcl tabs 12.5mg 4 PA promethazine hydrochloride inj 4 PA promethazine hydrochloride tabs 25mg, 50mg 4 PA scopolamine 4 Emetogenic Therapy Adjuncts ANZEMET TABS 50MG 4 QL (5 EA per 30 days) B/D ANZEMET TABS 100MG 5 QL (5 EA per 30 days) B/D aprepitant caps 40mg 4 QL (1 EA per 30 days) B/D aprepitant caps 125mg 4 QL (2 EA per 30 days) B/D aprepitant caps 0 4 QL (6 EA per 30 days) B/D aprepitant caps 80mg 4 QL (8 EA per 30 days) B/D CINVANTI 4 dronabinol 4 QL (60 EA per 30 days) PA EMEND SUSR 4 QL (6 EA per 30 days) B/D granisetron hcl tabs 4 QL (30 EA per 30 days) B/D granisetron hcl inj 0.1mg/ml, 1mg/ml 2 granisetron hydrochloride 2 ondansetron hcl soln 2 QL (450 ML per 30 days) B/D ondansetron hcl tabs 24mg 2 QL (14 EA per 28 days) B/D ondansetron hydrochloride inj 2 ondansetron hydrochloride tabs 2 B/D ondansetron odt 2 B/D palonosetron hydrochloride 2 SANCUSO 5 QL (2 EA per 30 days) SYNDROS 5 QL (120 ML per 30 days) PA Antifungals Antifungals ABELCET 5 B/D AMBISOME 5 B/D amphotericin b inj 4 B/D caspofungin acetate 5 ciclodan crea 2 ciclodan soln 2 PA ciclopirox nail lacquer 2 PA ciclopirox olamine crea 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 12 of 88 Drug Drug Name Tier Requirements/Limits ciclopirox gel 2 ciclopirox sham, susp 4 clotrimazole/betamethasone dipropionate crea 2 clotrimazole/betamethasone dipropionate lotn 4 clotrimazole crea, soln 2 clotrimazole lozg 4 econazole nitrate crea 2 fluconazole in nacl 3 fluconazole susr, tabs 2 flucytosine caps 5 griseofulvin microsize 4 griseofulvin ultramicrosize tabs 125mg, 250mg 4 itraconazole caps 4 PA itraconazole soln 5 PA JUBLIA 4 ketoconazole sham 2 ketoconazole crea, tabs 4 miconazole 3 supp 4 NATACYN 4 NOXAFIL SUSP, TBEC 5 nyamyc 2 nyata powd 2 nystatin/triamcinolone 4 nystatin crea, oint, powd 2 nystatin susp, tabs 4 nystop 2 ONMEL 5 PA oxiconazole nitrate 4 posaconazole dr 5 terbinafine hcl tabs 2 QL (84 EA per 180 days) terconazole crea 0.4% 2 terconazole crea 0.8% 4 terconazole supp 4 voriconazole inj, susr, tabs 5 zazole crea 0.8% 2 zazole supp 4 Antigout Agents Antigout Agents allopurinol sodium 4 allopurinol tabs 2 COLCHICINE CAPS 3 COLCHICINE TABS 0.6MG 3 febuxostat 2 KRYSTEXXA 5 PA probenecid/colchicine 4 probenecid tabs 4 ULORIC 3 ST

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 13 of 88 Drug Drug Name Tier Requirements/Limits Antimigraine Agents Ergot Alkaloids dihydroergotamine mesylate inj 5 dihydroergotamine mesylate nasal soln 5 QL (8 ML per 30 days) ERGOMAR 3 ergotamine tartrate/caffeine 3 Prophylactic AIMOVIG INJ 140MG/ML 4 QL (1 ML per 30 days) PA AIMOVIG INJ 70MG/ML 4 QL (2 ML per 30 days) PA EMGALITY INJ 120MG/ML 4 QL (1 ML per 30 days) PA EMGALITY INJ 100MG/ML 4 QL (3 ML per 30 days) PA timolol maleate tabs 10mg, 20mg, 5mg 3 Serotonin (5-HT) 1b/1d Receptor Agonists frovatriptan succinate 4 QL (12 EA per 30 days) naratriptan hcl 2 QL (9 EA per 30 days) rizatriptan benzoate 2 QL (18 EA per 30 days) rizatriptan benzoate odt 2 QL (18 EA per 30 days) sumatriptan succinate refill inj 6mg/0.5ml 4 QL (5 ML per 30 days) sumatriptan succinate refill inj 4mg/0.5ml 4 QL (8 ML per 30 days) sumatriptan succinate tabs 2 QL (9 EA per 30 days) sumatriptan succinate inj 6mg/0.5ml 4 QL (5 ML per 30 days) sumatriptan succinate inj 4mg/0.5ml 4 QL (8 ML per 30 days) sumatriptan/naproxen sodium 4 QL (9 EA per 30 days) sumatriptan soln 4 QL (12 EA per 30 days) zolmitriptan tabs 4 QL (12 EA per 30 days) Antimyasthenic Agents Parasympathomimetics guanidine hcl 4 pyridostigmine bromide er 4 pyridostigmine bromide soln 5 pyridostigmine bromide tabs 60mg 3 regonol inj 10mg/2ml 4 Antimycobacterials Antimycobacterials, Other dapsone tabs 100mg, 25mg 3 rifabutin 4 Antituberculars CAPASTAT SULFATE 4 cycloserine 4 ethambutol hcl tabs 100mg 4 ethambutol hydrochloride 4 isoniazid syrp, tabs 2 isoniazid inj 4 paser 4 PRIFTIN 4 pyrazinamide tabs 2 rifampin caps, inj 4

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 14 of 88 Drug Drug Name Tier Requirements/Limits RIFATER 4 SIRTURO 5 TRECATOR 4 Antineoplastics Alkylating Agents BELRAPZO 5 bendamustine hydrochloride 5 BENDEKA 5 BICNU 5 busulfan 5 carboplatin inj 150mg/15ml, 450mg/45ml, 50mg/5ml, 4 600mg/60ml carmustine 5 cisplatin inj 100mg/100ml, 200mg/200ml, 50mg/50ml 4 cyclophosphamide caps 3 B/D cyclophosphamide inj 5 dacarbazine inj 100mg, 200mg 4 EVOMELA 5 GLEOSTINE 4 HEXALEN 5 ifosfamide 4 KISQALI FEMARA 200 DOSE 5 PA KISQALI FEMARA 400 DOSE 5 PA KISQALI FEMARA 600 DOSE 5 PA LEUKERAN 5 MATULANE 5 melphalan hydrochloride 5 MUSTARGEN 5 oxaliplatin inj 100mg/20ml, 50mg/10ml 4 oxaliplatin inj 100mg, 50mg 5 TEMODAR INJ 4 TEPADINA INJ 100MG 5 thiotepa inj 15mg 5 TREANDA INJ 100MG, 25MG 5 VALCHLOR 5 PA YONDELIS 5 ZANOSAR 5 Antiandrogens abiraterone acetate 5 PA bicalutamide 2 ERLEADA 5 PA flutamide 4 nilutamide 5 NUBEQA 5 PA XTANDI 5 PA Antiangiogenic Agents POMALYST 5 PA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 15 of 88 Drug Drug Name Tier Requirements/Limits REVLIMID 5 PA THALOMID 5 PA Antiestrogens/Modifiers EMCYT 5 FASLODEX INJ 250MG/5ML 5 fulvestrant 5 SOLTAMOX 5 tamoxifen citrate tabs 2 toremifene citrate 5 Antimetabolites ALIMTA 5 ARRANON 5 cladribine 5 B/D clofarabine 5 cytarabine aqueous 2 B/D cytarabine inj 100mg/ml, 20mg/ml 2 B/D DEPOCYT 5 DROXIA 4 floxuridine inj 5 B/D fluorouracil crea 5% 4 fluorouracil crea 0.5% 5 fluorouracil external soln 4 fluorouracil inj 1gm/20ml, 2.5gm/50ml, 500mg/10ml, 4 5gm/100ml FOLOTYN 5 PA gemcitabine 5 gemcitabine hcl 4 GEMCITABINE HYDROCHLORIDE INJ 1.5GM/15ML, 5 1GM/10ML, 200MG/2ML, 2GM/20ML gemcitabine hydrochloride inj 1gm, 200mg 4 gemcitabine hydrochloride inj 1gm/26.3ml, 200mg/5.26ml, 5 2gm/52.6ml hydroxyurea caps 2 LONSURF 5 PA mercaptopurine tabs 2 NIPENT 5 PURIXAN 5 SIKLOS TABS 100MG 4 PA SIKLOS TABS 1000MG 5 PA TABLOID 4 VYXEOS 5 PA Antineoplastics, Other ABRAXANE 5 adriamycin inj 10mg, 2mg/ml, 50mg 5 amifostine 5 arsenic trioxide inj 10mg/10ml 2 arsenic trioxide inj 12mg/6ml 5

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 16 of 88 Drug Drug Name Tier Requirements/Limits azacitidine 5 BELEODAQ 5 PA bleomycin 2 B/D bleomycin sulfate 2 B/D BORTEZOMIB 5 PA BRAFTOVI 5 PA CISPLATIN INJ 50MG 4 COPIKTRA 5 PA COTELLIC 5 PA dactinomycin 5 daunorubicin hcl inj 20mg/4ml 4 daunorubicin hydrochloride inj 20mg/4ml 4 DAURISMO 5 PA decitabine 5 PA docetaxel inj 160mg/16ml, 160mg/8ml, 200mg/10ml, 5 20mg/2ml, 20mg/ml, 80mg/4ml, 80mg/8ml doxorubicin hcl inj 10mg, 2mg/ml, 50mg 5 doxorubicin hydrochloride liposomal 5 doxorubicin hydrochloride liposome 5 ELZONRIS 5 PA epirubicin hcl inj 200mg/100ml, 50mg/25ml 5 ERWINAZE 5 FARYDAK 5 PA fludarabine phosphate inj 50mg 4 HALAVEN 5 PA IBRANCE 5 PA idarubicin hcl 5 idarubicin hydrochloride 5 INREBIC 5 PA ISTODAX (OVERFILL) 5 PA IXEMPRA KIT INJ 45MG 5 JEVTANA 5 PA KISQALI 5 PA leucovorin calcium tabs 3 levoleucovorin calcium 5 LEVOLEUCOVORIN INJ 175MG 5 levoleucovorin inj 50mg 5 lipodox 50 5 LORBRENA 5 PA LYNPARZA 5 PA MARQIBO 5 MEKTOVI 5 PA mitomycin inj 20mg, 40mg, 5mg 5 mitoxantrone hcl inj 2mg/ml 4 mutamycin 5 NERLYNX 5 QL (180 EA per 30 days) PA NINLARO 5 PA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 17 of 88 Drug Drug Name Tier Requirements/Limits ONCASPAR 5 paclitaxel inj 100mg/16.7ml, 150mg/25ml, 300mg/50ml, 4 30mg/5ml PIQRAY 200MG DAILY DOSE 5 PA PIQRAY 250MG DAILY DOSE 5 PA PIQRAY 300MG DAILY DOSE 5 PA PROLEUKIN 5 romidepsin 5 PA ROZLYTREK 5 PA RYDAPT 5 PA SYLATRON 5 PA SYNRIBO 5 PA TALZENNA 5 PA TENIPOSIDE 5 THERACYS INJ 81MG/VIAL 5 TICE BCG 4 TRISENOX INJ 10MG/10ML 4 TRISENOX INJ 12MG/6ML 5 valrubicin 5 VELCADE 5 PA VERZENIO 5 PA vinblastine sulfate inj 1mg/ml 4 VINCASAR PFS 4 vincristine sulfate 4 VITRAKVI 5 PA XPOVIO 100 MG ONCE WEEKLY 5 PA XPOVIO 60 MG ONCE WEEKLY 5 PA XPOVIO 80 MG ONCE WEEKLY 5 PA XPOVIO 80 MG TWICE WEEKLY 5 PA ZALTRAP 5 PA ZOLINZA 5 PA ZYKADIA TABS 150MG 5 PA Aromatase Inhibitors, 3rd Generation anastrozole tabs 2 exemestane 4 letrozole 2 Enzyme Inhibitors BALVERSA 5 PA etoposide inj 100mg/5ml, 1gm/50ml, 500mg/25ml 4 irinotecan hcl 2 irinotecan hydrochloride inj 100mg/5ml 2 irinotecan inj 100mg/5ml 2 KYPROLIS 5 PA ONIVYDE 5 topotecan hcl 5 topotecan hydrochloride 5 ZYDELIG 5 PA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 18 of 88 Drug Drug Name Tier Requirements/Limits Molecular Target Inhibitors AFINITOR 5 QL (30 EA per 30 days) PA AFINITOR DISPERZ 5 PA ALECENSA 5 PA ALIQOPA 5 PA ALUNBRIG TBPK 5 QL (60 EA per 365 days) PA ALUNBRIG TABS 30MG 5 QL (120 EA per 30 days) PA ALUNBRIG TABS 180MG, 90MG 5 QL (30 EA per 30 days) PA BOSULIF 5 PA CABOMETYX 5 PA CALQUENCE 5 PA CAPRELSA TABS 300MG 5 PA CAPRELSA TABS 100MG 5 QL (60 EA per 30 days) PA COMETRIQ 5 PA ERIVEDGE 5 PA erlotinib hydrochloride 5 PA GILOTRIF 5 QL (30 EA per 30 days) PA ICLUSIG TABS 45MG 5 PA ICLUSIG TABS 15MG 5 QL (60 EA per 30 days) PA IDHIFA 5 QL (30 EA per 30 days) PA imatinib mesylate 5 PA IMBRUVICA 5 PA INLYTA 5 PA IRESSA 5 PA JAKAFI TABS 15MG, 20MG, 25MG, 5MG 5 PA JAKAFI TABS 10MG 5 QL (60 EA per 30 days) PA LENVIMA 10 MG DAILY DOSE 5 PA LENVIMA 12MG DAILY DOSE 5 PA LENVIMA 14 MG DAILY DOSE 5 PA LENVIMA 18 MG DAILY DOSE 5 PA LENVIMA 20 MG DAILY DOSE 5 PA LENVIMA 24 MG DAILY DOSE 5 PA LENVIMA 4 MG DAILY DOSE 5 PA LENVIMA 8 MG DAILY DOSE 5 PA MEKINIST 5 PA NEXAVAR 5 PA ODOMZO 5 PA RUBRACA 5 PA SPRYCEL 5 PA STIVARGA 5 PA SUTENT 5 PA TAFINLAR 5 PA TAGRISSO TABS 80MG 5 PA TAGRISSO TABS 40MG 5 QL (30 EA per 30 days) PA TASIGNA 5 PA temsirolimus 5 TIBSOVO 5 PA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 19 of 88 Drug Drug Name Tier Requirements/Limits TORISEL 5 TURALIO 5 PA TYKERB 5 PA VENCLEXTA STARTING PACK 5 PA VENCLEXTA TABS 10MG, 50MG 3 PA VENCLEXTA TABS 100MG 5 PA VIZIMPRO 5 PA VOTRIENT 5 PA XALKORI 5 PA XOSPATA 5 PA ZEJULA 5 PA ZELBORAF 5 PA ZYKADIA CAPS 150MG 5 PA Monoclonal Antibody/Antibody-Drug Conjugate ARZERRA 5 PA AVASTIN 5 BAVENCIO 5 PA BESPONSA 5 PA BLINCYTO 5 PA CYRAMZA 5 PA DARZALEX 5 PA EMPLICITI 5 PA ERBITUX 5 PA GAZYVA 5 PA HERCEPTIN 5 PA IMFINZI 5 PA KADCYLA 5 PA KEYTRUDA INJ 100MG/4ML 5 PA LARTRUVO 5 PA LIBTAYO 5 PA LUMOXITI 5 PA MYLOTARG 5 PA OPDIVO 5 PA PERJETA 5 PA POLIVY 5 PA PORTRAZZA 5 PA POTELIGEO 5 PA RITUXAN 5 PA RITUXAN HYCELA 5 PA TECENTRIQ INJ 1200MG/20ML 5 PA UNITUXIN 5 VECTIBIX INJ 100MG/5ML, 400MG/20ML 5 YERVOY 5 PA ZEVALIN Y-90 5 Retinoids bexarotene 5 PA PANRETIN 5

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 20 of 88 Drug Drug Name Tier Requirements/Limits TARGRETIN GEL 5 PA tretinoin caps 10mg 5 Treatment Adjuncts dexrazoxane 5 KHAPZORY 5 mesna 4 MESNEX TABS 5 Antiparasitics Anthelmintics albendazole tabs 5 BENZNIDAZOLE 3 ivermectin tabs 2 praziquantel tabs 4 Antiprotozoals ALINIA 5 atovaquone 5 atovaquone/proguanil hcl 2 chloroquine phosphate tabs 2 COARTEM 4 DARAPRIM 5 PA hydroxychloroquine sulfate tabs 2 mefloquine hcl 4 NEBUPENT 4 B/D PENTAM 300 4 pentamidine isethionate 4 primaquine phosphate tabs 4 quinine sulfate caps 324mg 2 PA tinidazole tabs 2 Pediculicides/Scabicides crotan 4 lindane sham 4 malathion 4 permethrin crea 3 ULESFIA 4 Antiparkinson Agents Anticholinergics benztropine mesylate inj, tabs 2 trihexyphenidyl hcl soln 2 trihexyphenidyl hydrochloride 4 Antiparkinson Agents, Other entacapone 3 tolcapone 5 Dopamine Agonists APOKYN INJ 30MG/3ML 5 QL (90 ML per 30 days) PA bromocriptine mesylate caps, tabs 4 NEUPRO 4 ST pramipexole dihydrochloride 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 21 of 88 Drug Drug Name Tier Requirements/Limits ropinirole hcl tabs 0.5mg, 1mg, 2mg, 4mg, 5mg 2 ropinirole hydrochloride tabs 0.25mg, 3mg 2 Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors carbidopa/levodopa 2 carbidopa/levodopa er 2 carbidopa/levodopa odt 4 carbidopa tabs 5 RYTARY 4 ST Monoamine Oxidase B (MAO-B) Inhibitors rasagiline mesylate tabs 4 selegiline hcl tabs 2 selegiline hcl caps 4 Antipsychotics 1st Generation/Typical chlorpromazine hcl inj 2 chlorpromazine hcl tabs 4 fluphenazine decanoate inj 4 fluphenazine hcl tabs 2 fluphenazine hcl conc, inj 4 fluphenazine hydrochloride 2 haloperidol decanoate inj 4 haloperidol lactate 4 haloperidol conc, tabs 2 loxapine succinate caps 25mg, 50mg, 5mg 4 loxapine caps 10mg 4 molindone hydrochloride 4 perphenazine tabs 4 pimozide 4 thioridazine hcl tabs 100mg, 10mg, 25mg, 50mg 4 PA thiothixene caps 10mg, 1mg, 2mg, 5mg 4 trifluoperazine hcl tabs 4 2nd Generation/Atypical ABILIFY MAINTENA 5 ABILIFY MYCITE 5 QL (30 EA per 30 days) ST aripiprazole odt 5 QL (60 EA per 30 days) aripiprazole tabs 4 QL (30 EA per 30 days) aripiprazole soln 4 QL (750 ML per 30 days) ARISTADA 5 ARISTADA INITIO 5 FANAPT TITRATION PACK 4 QL (8 EA per 180 days) ST FANAPT TABS 1MG, 2MG, 4MG 4 QL (60 EA per 30 days) ST FANAPT TABS 10MG, 12MG, 6MG, 8MG 5 QL (60 EA per 30 days) ST GEODON INJ 4 QL (60 EA per 30 days) INVEGA SUSTENNA INJ 39MG/0.25ML 4 INVEGA SUSTENNA INJ 117MG/0.75ML, 156MG/ML, 5 234MG/1.5ML, 78MG/0.5ML INVEGA TRINZA 5

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 22 of 88 Drug Drug Name Tier Requirements/Limits LATUDA TABS 120MG, 20MG, 40MG, 60MG 5 QL (30 EA per 30 days) LATUDA TABS 80MG 5 QL (60 EA per 30 days) NUPLAZID 5 PA olanzapine odt 4 QL (30 EA per 30 days) olanzapine tabs 2 QL (30 EA per 30 days) olanzapine inj 4 paliperidone er tb24 1.5mg, 3mg 4 QL (30 EA per 30 days) paliperidone er tb24 6mg 4 QL (60 EA per 30 days) paliperidone er tb24 9mg 5 QL (30 EA per 30 days) PERSERIS 5 quetiapine fumarate er tb24 150mg, 300mg, 400mg, 50mg 4 QL (60 EA per 30 days) quetiapine fumarate er tb24 200mg 4 QL (90 EA per 30 days) quetiapine fumarate tabs 300mg, 400mg 2 QL (60 EA per 30 days) quetiapine fumarate tabs 100mg, 200mg, 25mg, 50mg 2 QL (90 EA per 30 days) REXULTI 5 QL (30 EA per 30 days) RISPERDAL CONSTA INJ 12.5MG, 25MG 4 RISPERDAL CONSTA INJ 37.5MG, 50MG 5 risperidone odt 4 QL (60 EA per 30 days) risperidone soln 2 QL (240 ML per 30 days) risperidone tabs 2 QL (60 EA per 30 days) SAPHRIS 5 QL (60 EA per 30 days) VRAYLAR CPPK 4 QL (14 EA per 365 days) ST VRAYLAR CAPS 5 QL (30 EA per 30 days) ST ziprasidone hcl 2 QL (60 EA per 30 days) ZYPREXA RELPREVV INJ 210MG 4 ZYPREXA RELPREVV INJ 300MG, 405MG 5 Treatment-Resistant clozapine odt tbdp 150mg 4 QL (180 EA per 30 days) clozapine odt tbdp 100mg, 25mg 4 QL (270 EA per 30 days) clozapine odt tbdp 12.5mg 4 QL (90 EA per 30 days) clozapine odt tbdp 200mg 5 QL (120 EA per 30 days) clozapine tabs 200mg 3 QL (120 EA per 30 days) clozapine tabs 50mg 3 QL (180 EA per 30 days) clozapine tabs 100mg, 25mg 3 QL (270 EA per 30 days) VERSACLOZ 5 QL (540 ML per 30 days) Antispasticity Agents Antispasticity Agents baclofen tabs 2 baclofen inj 2 B/D BOTOX 4 PA dantrolene sodium caps 4 GABLOFEN INJ 10000MCG/20ML, 20000MCG/20ML, 4 B/D 50MCG/ML GABLOFEN INJ 40000MCG/20ML 5 B/D LIORESAL INTRATHECAL INJ 0.05MG/ML, 10MG/20ML 4 B/D LIORESAL INTRATHECAL INJ 10MG/5ML, 40MG/20ML 5 B/D tizanidine hcl tabs 2mg 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 23 of 88 Drug Drug Name Tier Requirements/Limits tizanidine hydrochloride tabs 2 Antivirals Anti-cytomegalovirus (CMV) Agents cidofovir 5 ganciclovir inj 500mg/10ml, 500mg 3 B/D valganciclovir 5 valganciclovir hydrochlorde 5 ZIRGAN 3 Anti-hepatitis B (HBV) Agents adefovir dipivoxil 5 BARACLUDE SOLN 5 QL (600 ML per 30 days) entecavir 4 QL (30 EA per 30 days) EPIVIR HBV SOLN 4 INTRON A 5 PA INTRON A W/DILUENT INJ 10MU 5 PA lamivudine tabs 100mg 3 VEMLIDY 5 Anti-hepatitis C (HCV) Agents, Direct Acting Agents MAVYRET 5 QL (336 EA per 365 days) PA SOFOSBUVIR/VELPATASVIR 5 QL (84 EA per 365 days) PA VOSEVI 5 QL (84 EA per 365 days) PA Anti-hepatitis C (HCV) Agents, Other moderiba tbpk 5 PEGASYS 5 PA PEGASYS PROCLICK 5 PA PEGINTRON INJ 50MCG/0.5ML 5 PA ribasphere tabs 200mg 3 ribasphere tabs 400mg, 600mg 5 ribavirin tabs 200mg 3 Anti-HIV Agents, Integrase Inhibitors (INSTI) BIKTARVY 5 QL (30 EA per 30 days) DELSTRIGO 5 QL (30 EA per 30 days) DOVATO 5 QL (30 EA per 30 days) GENVOYA 5 QL (30 EA per 30 days) ISENTRESS CHEW 25MG 3 ISENTRESS CHEW 100MG 5 ISENTRESS PACK 100MG 5 JULUCA 5 QL (30 EA per 30 days) STRIBILD 5 QL (30 EA per 30 days) TIVICAY TABS 10MG 4 TIVICAY TABS 25MG, 50MG 5 TRIUMEQ 5 QL (30 EA per 30 days) VITEKTA 5 Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) ATRIPLA 5 QL (30 EA per 30 days) COMPLERA 5 QL (30 EA per 30 days)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 24 of 88 Drug Drug Name Tier Requirements/Limits EDURANT 5 efavirenz caps 50mg 4 efavirenz caps 200mg 5 efavirenz tabs 5 INTELENCE TABS 25MG 4 INTELENCE TABS 100MG, 200MG 5 nevirapine 2 nevirapine er 4 ODEFSEY 5 QL (30 EA per 30 days) PIFELTRO 5 RESCRIPTOR 4 SYMFI 5 QL (30 EA per 30 days) SYMFI LO 5 QL (30 EA per 30 days) Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) abacavir 4 abacavir sulfate/lamivudine 4 QL (30 EA per 30 days) abacavir sulfate/lamivudine/zidovudine 5 QL (60 EA per 30 days) CIMDUO 5 QL (30 EA per 30 days) DESCOVY 5 QL (30 EA per 30 days) didanosine cpdr 200mg, 250mg, 400mg 2 EMTRIVA 4 lamivudine/zidovudine 4 QL (60 EA per 30 days) lamivudine soln 10mg/ml 4 lamivudine tabs 150mg, 300mg 4 RETROVIR IV INFUSION 4 stavudine caps 4 TEMIXYS 5 QL (30 EA per 30 days) TENOFOVIR DISOPROXIL FUMARATE 4 TRUVADA 5 QL (30 EA per 30 days) VIDEX EC CPDR 125MG 4 VIDEX PEDIATRIC 4 VIREAD POWD 5 VIREAD TABS 150MG, 200MG, 250MG 5 ZERIT SOLR 4 zidovudine 3 Anti-HIV Agents, Other FUZEON 5 QL (60 EA per 30 days) ISENTRESS HD 5 ISENTRESS TABS 400MG 5 SELZENTRY SOLN 5 SELZENTRY TABS 25MG 4 SELZENTRY TABS 150MG, 300MG, 75MG 5 TROGARZO 5 TYBOST 3 Anti-HIV Agents, Protease Inhibitors APTIVUS 5

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 25 of 88 Drug Drug Name Tier Requirements/Limits atazanavir sulfate 5 CRIXIVAN CAPS 200MG, 400MG 3 EVOTAZ 5 QL (30 EA per 30 days) fosamprenavir calcium 5 INVIRASE 5 KALETRA TABS 100MG; 25MG 4 KALETRA TABS 200MG; 50MG 5 LEXIVA SUSP 4 lopinavir/ritonavir 5 NORVIR PACK 3 NORVIR CAPS, SOLN 4 PREZCOBIX 5 QL (30 EA per 30 days) PREZISTA SUSP 5 PREZISTA TABS 150MG, 75MG 4 PREZISTA TABS 600MG, 800MG 5 REYATAZ PACK 5 ritonavir 2 SYMTUZA 5 QL (30 EA per 30 days) VIRACEPT 5 Anti-influenza Agents amantadine hcl syrp 2 amantadine hcl caps, tabs 4 oseltamivir phosphate caps 75mg 2 QL (110 EA per 365 days) oseltamivir phosphate caps 30mg 2 QL (168 EA per 365 days) oseltamivir phosphate caps 45mg 2 QL (84 EA per 365 days) oseltamivir phosphate susr 2 QL (1080 ML per 365 days) RELENZA DISKHALER 4 QL (240 EA per 365 days) rimantadine hcl 3 XOFLUZA 3 QL (4 EA per 365 days) Antiherpetic Agents ACYCLOVIR SODIUM INJ 1000MG 4 B/D acyclovir sodium inj 500mg, 50mg/ml 4 B/D acyclovir caps, susp, tabs 2 acyclovir crea, oint 4 famciclovir tabs 2 trifluridine 3 valacyclovir hcl tabs 1gm 2 QL (120 EA per 30 days) valacyclovir hydrochloride tabs 500mg 2 QL (120 EA per 30 days) Anxiolytics Anxiolytics, Other buspirone hcl tabs 15mg, 30mg 2 buspirone hydrochloride tabs 10mg, 5mg, 7.5mg 2 hydroxyzine hcl syrp 4 PA hydroxyzine hcl inj 25mg/ml 4 PA hydroxyzine hcl tabs 25mg, 50mg 4 PA hydroxyzine hydrochloride inj 4 PA hydroxyzine hydrochloride tabs 10mg 4 PA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 26 of 88 Drug Drug Name Tier Requirements/Limits Benzodiazepines alprazolam tabs 0.25mg, 0.5mg, 1mg 2 QL (120 EA per 30 days) PA alprazolam tabs 2mg 2 QL (150 EA per 30 days) PA clorazepate dipotassium tabs 15mg 4 QL (180 EA per 30 days) clorazepate dipotassium tabs 7.5mg 4 QL (360 EA per 30 days) clorazepate dipotassium tabs 3.75mg 4 QL (720 EA per 30 days) diazepam conc 5mg/ml 4 diazepam inj 5mg/ml 4 diazepam oral soln 5mg/5ml 4 diazepam tabs 10mg 2 QL (120 EA per 30 days) diazepam tabs 5mg 2 QL (240 EA per 30 days) diazepam tabs 2mg 2 QL (300 EA per 30 days) lorazepam intensol 2 PA lorazepam conc 2 PA lorazepam inj 2mg/ml, 4mg/ml 2 PA lorazepam tabs 2mg 2 QL (150 EA per 30 days) PA lorazepam tabs 0.5mg, 1mg 2 QL (90 EA per 30 days) PA midazolam hcl inj 10mg/10ml, 10mg/2ml, 25mg/5ml, 2mg/2ml,1 50mg/10ml, 5mg/5ml, 5mg/ml midazolam hydrochloride inj 2mg/2ml, 50mg/10ml, 5mg/5ml 1 temazepam caps 15mg, 30mg 2 QL (30 EA per 30 days) PA Bipolar Agents Mood Stabilizers EQUETRO 4 lithium 2 lithium carbonate er 2 lithium carbonate caps, tabs 2 Blood Glucose Regulators Antidiabetic Agents acarbose tabs 2 BYDUREON 4 QL (4 EA per 28 days) BYDUREON BCISE 4 QL (3.4 ML per 28 days) BYDUREON PEN 4 QL (4 EA per 28 days) glimepiride 1 glipizide er 1 glipizide xl 1 glipizide/metformin hydrochloride 1 glipizide tabs 1 glyburide micronized tabs 3mg, 6mg 2 glyburide/metformin hydrochloride 2 glyburide tabs 2 GLYXAMBI 3 ST INVOKAMET 3 ST INVOKAMET XR 3 ST INVOKANA 3 ST JANUMET 3 ST JANUMET XR 3 ST

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 27 of 88 Drug Drug Name Tier Requirements/Limits JANUVIA 3 ST JARDIANCE 3 ST JENTADUETO 3 ST JENTADUETO XR 3 ST KOMBIGLYZE XR 4 ST metformin hydrochloride er tb24 500mg, 750mg 1 metformin hydrochloride tabs 1 metformin hydrochloride soln 2 nateglinide 1 ONGLYZA 4 ST OZEMPIC INJ 2MG/1.5ML 3 QL (1.5 ML per 28 days) OZEMPIC INJ 2MG/1.5ML 3 QL (3 ML per 28 days) pioglitazone hcl-glimepiride 4 pioglitazone hcl/metformin hcl 2 pioglitazone hcl tabs 45mg 1 pioglitazone hydrochloride tabs 15mg, 30mg 1 repaglinide 1 repaglinide/metformin hydrochloride 2 SYNJARDY 3 ST SYNJARDY XR 3 ST TRADJENTA 3 ST TRULICITY 3 QL (2 ML per 28 days) VICTOZA 3 QL (9 ML per 30 days) Glycemic Agents GLUCAGEN HYPOKIT 4 GLUCAGON EMERGENCY KIT 3 PROGLYCEM 5 Insulins HUMALOG 3 HUMALOG JUNIOR KWIKPEN 3 HUMALOG KWIKPEN 3 HUMALOG MIX 50/50 3 HUMALOG MIX 50/50 KWIKPEN 3 HUMALOG MIX 75/25 3 HUMALOG MIX 75/25 KWIKPEN 3 HUMULIN 70/30 3 HUMULIN 70/30 KWIKPEN 3 HUMULIN N 3 HUMULIN N KWIKPEN 3 HUMULIN R 3 HUMULIN R U-500 (CONCENTRATED) 3 HUMULIN R U-500 KWIKPEN 3 INSULIN LISPRO 3 INSULIN LISPRO KWIKPEN 3 LANTUS 3 LANTUS SOLOSTAR 3 LEVEMIR 3

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 28 of 88 Drug Drug Name Tier Requirements/Limits LEVEMIR FLEXTOUCH 3 TOUJEO MAX SOLOSTAR 3 TOUJEO SOLOSTAR 3 TRESIBA 3 TRESIBA FLEXTOUCH 3 Blood Products/Modifiers/Volume Expanders Anticoagulants argatroban inj 125mg/125ml; 0.9%, 250mg/2.5ml, 5 250mg/250ml; 0.9%, 50mg/50ml ELIQUIS STARTER PACK 3 QL (148 EA per 365 days) ELIQUIS TABS 2.5MG 3 QL (60 EA per 30 days) ELIQUIS TABS 5MG 3 QL (90 EA per 30 days) enoxaparin sodium inj 30mg/0.3ml 4 QL (10.5 ML per 90 days) enoxaparin sodium inj 300mg/3ml 4 QL (105 ML per 90 days) enoxaparin sodium inj 40mg/0.4ml 4 QL (14 ML per 90 days) enoxaparin sodium inj 60mg/0.6ml 4 QL (21 ML per 90 days) enoxaparin sodium inj 120mg/0.8ml, 80mg/0.8ml 4 QL (28 ML per 90 days) enoxaparin sodium inj 100mg/ml, 150mg/ml 4 QL (35 ML per 90 days) fondaparinux sodium inj 2.5mg/0.5ml 4 QL (17.5 ML per 90 days) fondaparinux sodium inj 5mg/0.4ml 5 QL (14 ML per 90 days) fondaparinux sodium inj 7.5mg/0.6ml 5 QL (21 ML per 90 days) fondaparinux sodium inj 10mg/0.8ml 5 QL (28 ML per 90 days) FRAGMIN INJ 2500UNIT/0.2ML, 5000UNIT/0.2ML 4 QL (7 ML per 90 days) FRAGMIN INJ 7500UNIT/0.3ML 5 QL (10.5 ML per 90 days) FRAGMIN INJ 12500UNIT/0.5ML 5 QL (17.5 ML per 90 days) FRAGMIN INJ 15000UNIT/0.6ML 5 QL (21 ML per 90 days) FRAGMIN INJ 95000UNIT/3.8ML 5 QL (22.8 ML per 90 days) FRAGMIN INJ 18000UNT/0.72ML 5 QL (25.3 ML per 90 days) FRAGMIN INJ 10000UNIT/ML 5 QL (35 ML per 90 days) heparin sodium/d5w inj 5%; 40unit/ml 2 heparin sodium/nacl 0.45% inj 12500unit/250ml; 0.45%, 2 25000unit/250ml; 0.45%, 25000unit/500ml; 0.45% heparin sodium/nacl 0.9% inj 1000unit/500ml; 0.9% 2 heparin sodium/sodium chloride 0.9% premix inj 2 1000unit/500ml; 0.9%, 2000unit/l; 0.9% heparin sodium/sodium chloride 0.9% inj 1000unit/500ml; 2 0.9%, 2000unit/l; 0.9% heparin sodium/sodium chloride inj 1000unit/500ml; 0.9%, 2 25000unit/500ml; 0.45% heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 2 5000unit/0.5ml, 5000unit/ml jantoven 2 PRADAXA 4 QL (60 EA per 30 days) warfarin sodium tabs 2 XARELTO STARTER PACK 3 QL (102 EA per 365 days) XARELTO TABS 10MG, 20MG 3 QL (30 EA per 30 days) XARELTO TABS 15MG, 2.5MG 3 QL (60 EA per 30 days)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 29 of 88 Drug Drug Name Tier Requirements/Limits Blood Formation Modifiers anagrelide hydrochloride 3 ARANESP ALBUMIN FREE INJ 10MCG/0.4ML, 4 PA 25MCG/0.42ML, 25MCG/ML, 40MCG/0.4ML, 40MCG/ML, 60MCG/0.3ML ARANESP ALBUMIN FREE INJ 100MCG/0.5ML, 5 PA 100MCG/ML, 150MCG/0.3ML, 200MCG/0.4ML, 200MCG/ML, 300MCG/0.6ML, 300MCG/ML, 500MCG/ML, 60MCG/ML MOZOBIL 5 QL (38.4 ML per 365 days) PA NEULASTA 5 PA NEULASTA ONPRO KIT 5 PA NEUPOGEN 5 ST NIVESTYM 5 ST NPLATE 5 PA PROMACTA 5 PA UDENYCA 5 PA ZARXIO 5 Blood Products/Modifiers/Volume Expanders SOLIRIS 5 PA ULTOMIRIS 5 PA Hemostasis Agents aminocaproic acid inj, tabs 4 RETACRIT INJ 10000UNIT/ML, 2000UNIT/ML, 4 PA 3000UNIT/ML, 4000UNIT/ML RETACRIT INJ 40000UNIT/ML 5 PA tranexamic acid inj 2 tranexamic acid tabs 3 Platelet Modifying Agents ASPIRIN/DIPYRIDAMOLE 4 BRILINTA 4 CABLIVI 5 QL (30 EA per 30 days) PA cilostazol 2 clopidogrel 2 prasugrel 4 Cardiovascular Agents Alpha-adrenergic Agonists clonidine hcl ptwk 0.1mg/24hr, 0.2mg/24hr, 0.3mg/24hr 4 clonidine hcl tabs 0.1mg, 0.3mg 2 clonidine hydrochloride tabs 0.2mg 2 CLORPRES 4 guanfacine hcl 4 methyldopa tabs 250mg, 500mg 4 midodrine hcl 2 phenylephrine hydrochloride inj 10mg/ml 4 Alpha-adrenergic Blocking Agents phenoxybenzamine hydrochloride 5

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 30 of 88 Drug Drug Name Tier Requirements/Limits prazosin hcl caps 1mg, 5mg 2 prazosin hydrochloride caps 2mg 2 Angiotensin II Receptor Antagonists candesartan cilexetil 2 candesartan cilexetil/hydrochlorothiazide 2 eprosartan mesylate 4 irbesartan 1 irbesartan/hydrochlorothiazide 1 losartan potassium 1 losartan potassium/hydrochlorothiazide 1 olmesartan medoxomil/hydrochlorothiazide 2 olmesartan medoxomil tabs 2 telmisartan 2 telmisartan/hydrochlorothiazide 2 valsartan 2 valsartan/hydrochlorothiazide 1 Angiotensin-converting Enzyme (ACE) Inhibitors benazepril hcl/hydrochlorothiazide 1 benazepril hcl tabs 10mg, 40mg, 5mg 1 benazepril hydrochloride tabs 20mg 1 captopril/hydrochlorothiazide 1 captopril tabs 1 enalapril maleate/hydrochlorothiazide 1 enalapril maleate tabs 1 EPANED SOLR 4 EPANED SOLN 5 fosinopril sodium 1 fosinopril sodium/hydrochlorothiazide 1 lisinopril/hydrochlorothiazide 1 lisinopril tabs 1 moexipril hcl 1 moexipril/hydrochlorothiazide 1 perindopril erbumine 1 quinapril hcl tabs 20mg, 40mg, 5mg 1 quinapril hydrochloride tabs 10mg 1 quinapril/hydrochlorothiazide 1 ramipril 1 trandolapril 1 Antiarrhythmics amiodarone hcl inj 50mg/ml, 900mg/18ml 2 amiodarone hcl tabs 200mg 2 amiodarone hcl tabs 400mg 4 amiodarone hydrochloride inj 2 amiodarone hydrochloride tabs 100mg 4 disopyramide phosphate caps 4 dofetilide 4 flecainide acetate 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 31 of 88 Drug Drug Name Tier Requirements/Limits ibutilide fumarate 4 lidocaine hcl inj 100mg/5ml, 50mg/5ml 2 mexiletine hcl 4 NORPACE CR 4 pacerone tabs 200mg 2 pacerone tabs 100mg, 400mg 4 procainamide hcl inj 2 procainamide hydrochloride 2 propafenone hcl 2 propafenone hydrochloride er 4 quinidine gluconate cr 4 quinidine gluconate er 4 quinidine gluconate inj 2 quinidine sulfate tabs 2 sorine 2 sotalol hcl 2 sotalol hcl (af) tabs 120mg, 80mg 2 sotalol hcl af 2 sotalol hydrochloride (af) 2 sotalol hydrochloride af 2 sotalol hydrochloride tabs 2 sotalol hydrochloride inj 5 Beta-adrenergic Blocking Agents acebutolol hcl caps 2 atenolol/chlorthalidone 2 atenolol tabs 1 betaxolol hcl tabs 10mg, 20mg 4 bisoprolol fumarate 2 bisoprolol fumarate/hydrochlorothiazide 1 BYSTOLIC 3 carvedilol 2 esmolol hcl inj 100mg/10ml 4 ESMOLOL HYDROCHLORIDE IN WATER 4 ESMOLOL HYDROCHLORIDE IN WATER DOUBLE 4 STRENGTH esmolol hydrochloride/sodium chloride 2 labetalol hydrochloride tabs 2 metoprolol succinate er 2 metoprolol tartrate tabs 100mg, 25mg, 50mg 1 metoprolol/hydrochlorothiazide 4 nadolol tabs 20mg, 40mg, 80mg 4 pindolol tabs 4 propranolol hcl er cp24 120mg, 160mg, 60mg 4 propranolol hcl inj 2 propranolol hcl oral soln 4 propranolol hcl tabs 40mg, 80mg 2 propranolol hydrochloride er 4

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 32 of 88 Drug Drug Name Tier Requirements/Limits propranolol hydrochloride tabs 10mg, 20mg, 60mg 2 propranolol/hydrochlorothiazide 4 Calcium Channel Blocking Agents afeditab cr 4 amlodipine besylate/atorvastatin calcium 4 amlodipine besylate/benazepril hydrochloride 1 amlodipine besylate/valsartan 1 amlodipine besylate tabs 1 cartia xt 2 dilt-xr 2 diltiazem cd cp24 120mg 2 diltiazem hcl cd 2 diltiazem hcl er cp24 2 diltiazem hcl er cp12, tb24 4 diltiazem hcl tabs 2 diltiazem hcl inj 100mg, 125mg/25ml, 25mg/5ml, 50mg/10ml 2 diltiazem hydrochloride er 2 felodipine er 2 matzim la 4 nifedipine er 4 nimodipine caps 5 nisoldipine er 4 NYMALIZE 5 taztia xt 2 verapamil hcl er tbcr 2 verapamil hcl er cp24 4 verapamil hcl sr cp24 4 verapamil hcl tabs 40mg, 80mg 2 verapamil hydrochloride inj, tabs 2 Cardiovascular Agents, Other atropine sulfate inj 8mg/20ml 2 CORLANOR TABS 4 QL (60 EA per 30 days) PA DEMSER 5 digitek 2 digox 2 digoxin oral soln 4 digoxin inj 0.25mg/ml 4 digoxin tabs 125mcg, 250mcg 2 dobutamine hcl/d5w inj 5%; 1mg/ml 2 B/D dobutamine hcl inj 250mg/20ml, 500mg/40ml 4 B/D dobutamine hydrochloride/dextrose 2 B/D dobutamine/dextrose 5% inj 5%; 2mg/ml, 5%; 4mg/ml 2 B/D dopamine hcl 2 B/D dopamine hydrochloride/dextrose 2 B/D dopamine/d5w inj 5%; 3.2mg/ml 2 B/D ENTRESTO 3 QL (60 EA per 30 days) LANOXIN TABS 187.5MCG, 62.5MCG 4

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 33 of 88 Drug Drug Name Tier Requirements/Limits mannitol inj 20%, 25% 2 milrinone in dextrose inj 5%; 20mg/100ml, 5%; 40mg/200ml 4 B/D milrinone lactate inj 10mg/10ml, 20mg/20ml, 50mg/50ml 4 B/D norepinephrine bitartrate 2 NORTHERA 5 PA osmitrol viaflex 2 pentoxifylline er 4 ranolazine er 4 REPATHA 4 QL (3 ML per 28 days) PA REPATHA PUSHTRONEX SYSTEM 4 QL (3.5 ML per 28 days) PA REPATHA SURECLICK 4 QL (3 ML per 28 days) PA TAKHZYRO 5 PA VYNDAMAX 5 QL (30 EA per 30 days) PA VYNDAQEL 5 QL (120 EA per 30 days) PA Diuretics, Carbonic Anhydrase Inhibitors acetazolamide sodium 5 Diuretics, Loop bumetanide inj, tabs 2 ethacrynic acid tabs 5 furosemide inj, oral soln, tabs 2 torsemide tabs 2 Diuretics, Potassium-sparing ALDACTAZIDE TABS 50MG; 50MG 4 amiloride hcl tabs 2 amiloride/hydrochlorothiazide 4 eplerenone 4 spironolactone/hydrochlorothiazide 4 spironolactone tabs 2 triamterene/hydrochlorothiazide 2 Diuretics, Thiazide chlorothiazide 2 chlorothiazide sodium 4 chlorthalidone tabs 25mg, 50mg 4 hydrochlorothiazide caps, tabs 1 indapamide tabs 2 methyclothiazide tabs 4 metolazone 4 Dyslipidemics, Fibric Acid Derivatives fenofibrate micronized 2 fenofibrate caps 134mg, 200mg, 67mg 2 fenofibrate caps 43mg 4 fenofibrate tabs 145mg, 160mg, 48mg, 54mg 2 fenofibric acid dr 4 gemfibrozil tabs 2 Dyslipidemics, HMG CoA Reductase Inhibitors atorvastatin calcium 1 fluvastatin 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 34 of 88 Drug Drug Name Tier Requirements/Limits fluvastatin sodium er 4 LIVALO 4 ST lovastatin 1 pravastatin sodium 1 rosuvastatin calcium 1 simvastatin tabs 1 Dyslipidemics, Other cholestyramine light 4 cholestyramine pack, powd 4 colesevelam hydrochloride tabs 4 colestipol hcl 4 ezetimibe 2 ezetimibe/simvastatin 2 JUXTAPID 5 QL (30 EA per 30 days) PA niacin er 4 omega-3-acid ethyl esters 4 prevalite 4 triklo 4 VASCEPA 4 Vasodilators, Direct-acting Arterial/Venous DILATRATE SR 4 ISORDIL TITRADOSE TABS 40MG 5 isosorbide dinitrate er 4 isosorbide dinitrate tabs 10mg, 20mg, 30mg, 5mg 4 isosorbide mononitrate 2 isosorbide mononitrate er 2 minitran 2 NITRO-BID 4 NITRO-DUR PT24 0.3MG/HR, 0.8MG/HR 4 nitroglycerin in 5% dextrose 2 nitroglycerin in dextrose 5% 2 nitroglycerin transdermal 2 nitroglycerin subl 0.3mg, 0.4mg, 0.6mg 2 Vasodilators, Direct-acting Arterial hydralazine hcl tabs 10mg 2 hydralazine hydrochloride tabs 100mg, 25mg, 50mg 2 minoxidil tabs 4 Central Nervous System Agents Attention Deficit Hyperactivity Disorder Agents, Amphetamines amphetamine/dextroamphetamine tabs 3 QL (90 EA per 30 days) PA amphetamine/dextroamphetamine cp24 4 QL (30 EA per 30 days) PA dexedrine tabs 10mg 4 QL (180 EA per 30 days) PA dexedrine tabs 5mg 4 QL (90 EA per 30 days) PA dextroamphetamine sulfate er cp24 15mg 4 QL (120 EA per 30 days) PA dextroamphetamine sulfate er cp24 10mg 4 QL (180 EA per 30 days) PA dextroamphetamine sulfate er cp24 5mg 4 QL (60 EA per 30 days) PA dextroamphetamine sulfate soln 4 QL (1800 ML per 30 days) PA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 35 of 88 Drug Drug Name Tier Requirements/Limits dextroamphetamine sulfate tabs 10mg 4 QL (180 EA per 30 days) PA dextroamphetamine sulfate tabs 5mg 4 QL (90 EA per 30 days) PA ZENZEDI TABS 10MG 4 QL (180 EA per 30 days) PA ZENZEDI TABS 5MG 4 QL (90 EA per 30 days) PA Attention Deficit Hyperactivity Disorder Agents, Non- amphetamines atomoxetine caps 100mg, 18mg, 25mg, 40mg, 60mg, 80mg 4 QL (30 EA per 30 days) atomoxetine caps 10mg 4 QL (60 EA per 30 days) dexmethylphenidate hcl 4 QL (60 EA per 30 days) PA guanfacine er 4 metadate er tbcr 20mg 4 QL (90 EA per 30 days) PA methylphenidate hydrochloride er tbcr 10mg 4 QL (180 EA per 30 days) PA methylphenidate hydrochloride er tbcr 20mg 4 QL (90 EA per 30 days) PA methylphenidate hydrochloride chew 10mg 4 QL (180 EA per 30 days) PA methylphenidate hydrochloride chew 2.5mg, 5mg 4 QL (90 EA per 30 days) PA methylphenidate hydrochloride tabs 2 QL (90 EA per 30 days) PA methylphenidate hydrochloride soln 4 PA Central Nervous System, Other AUSTEDO 5 QL (120 EA per 30 days) PA caffeine citrate 4 clonidine hcl inj 100mcg/ml, 500mcg/ml 4 B/D NUEDEXTA 4 PA RADICAVA 5 PA riluzole 3 PA tetrabenazine 5 PA TIGLUTIK 5 PA Fibromyalgia Agents SAVELLA 3 QL (60 EA per 30 days) SAVELLA TITRATION PACK 3 QL (110 EA per 365 days) Multiple Sclerosis Agents AVONEX 5 QL (4 EA per 28 days) PA AVONEX PEN 5 QL (4 EA per 28 days) PA BETASERON 5 QL (15 EA per 30 days) PA dalfampridine er 5 QL (60 EA per 30 days) PA GILENYA 5 QL (30 EA per 30 days) PA glatiramer acetate inj 40mg/ml 5 QL (12 ML per 28 days) PA glatiramer acetate inj 20mg/ml 5 QL (30 ML per 30 days) PA glatopa inj 40mg/ml 5 QL (12 ML per 28 days) PA glatopa inj 20mg/ml 5 QL (30 ML per 30 days) PA MAVENCLAD 5 PA MAYZENT STARTER PACK 5 QL (24 EA per 365 days) PA MAYZENT TABS 0.25MG 5 QL (120 EA per 30 days) PA MAYZENT TABS 2MG 5 QL (30 EA per 30 days) PA PLEGRIDY 5 QL (1 ML per 28 days) PA PLEGRIDY STARTER PACK INJ 0 5 QL (2 ML per 365 days) PA PLEGRIDY STARTER PACK INJ 0 5 QL (4 ML per 365 days) PA REBIF 5 QL (6 ML per 28 days) PA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 36 of 88 Drug Drug Name Tier Requirements/Limits REBIF REBIDOSE 5 QL (6 ML per 28 days) PA REBIF REBIDOSE TITRATION PACK 5 QL (8.4 ML per 365 days) PA REBIF TITRATION PACK 5 QL (8.4 ML per 365 days) PA TECFIDERA 5 QL (60 EA per 30 days) PA TECFIDERA STARTER PACK 5 QL (120 EA per 365 days) PA TYSABRI 5 PA Dental and Oral Agents Dental and Oral Agents chlorhexidine gluconate soln 2 lidocaine hcl mouth/throat soln 4% 4 lidocaine viscous 4 oralone dental paste 4 paroex 2 periogard 2 pilocarpine hcl tabs 7.5mg 4 pilocarpine hydrochloride tabs 5mg 4 triamcinolone acetonide dental paste 4 Dermatological Agents Dermatological Agents acitretin caps 10mg, 25mg 4 acitretin caps 17.5mg 5 ammonium lactate crea, lotn 3 amnesteem 4 PA avita 4 PA azelaic acid 4 calcipotriene crea, oint 2 QL (120 GM per 30 days) calcipotriene soln 2 QL (60 ML per 30 days) calcitrene 2 QL (120 GM per 30 days) claravis 4 PA clindamycin phosphate/benzoyl peroxide gel 5%; 1.2% 4 clindamycin/benzoyl peroxide 4 COSENTYX 5 PA COSENTYX SENSOREADY PEN 5 PA dapsone gel 5% 4 diclofenac sodium transdermal soln 1.5% 4 PA erythromycin/benzoyl peroxide 4 EUCRISA 4 PA FINACEA FOAM 4 ILUMYA 4 PA imiquimod pump 5 imiquimod crea 3 isotretinoin caps 4 PA methoxsalen caps 5 metronidazole crea 0.75% 4 metronidazole gel 0.75%, 1% 4 metronidazole lotn 0.75% 4 myorisan 4 PA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 37 of 88 Drug Drug Name Tier Requirements/Limits PICATO 5 pimecrolimus 4 podofilox soln 4 RECTIV 4 rosadan 4 SANTYL 4 selenium sulfide lotn 2 STELARA INJ 45MG/0.5ML, 90MG/ML 4 PA tacrolimus oint 0.03%, 0.1% 4 TALTZ 4 PA tazarotene crea 4 TREMFYA 4 PA tretinoin crea 0.025%, 0.05%, 0.1% 2 PA tretinoin gel 0.01%, 0.025%, 0.05% 4 PA UVADEX 4 zenatane 4 PA Electrolytes/Minerals/Metals/Vitamins Electrolyte/Mineral Replacement AMINOSYN 7%/ELECTROLYTES INJ 124MEQ/L; 4 B/D 900MG/100ML; 690MG/100ML; 96MEQ/L; 900MG/100ML; 210MG/100ML; 510MG/100ML; 660MG/100ML; 510MG/100ML; 10MEQ/L; 280MG/100ML; 310MG/100ML; 30MMOLE/L; 65MEQ/L; 610MG/100ML; 300MG/100ML; 65MEQ/L; 370MG/100ML; 120MG/100ML; 44MG/100ML; 560MG/100ML aminosyn 8.5%/electrolytes inj 142meq/l; 1100mg/100ml; 4 B/D 850mg/100ml; 98meq/l; 1100mg/100ml; 260mg/100ml; 620mg/100ml; 810mg/100ml; 624mg/100ml; 10meq/l; 340mg/100ml; 380mg/100ml; 30meq/l; 65meq/l; 750mg/100ml; 370mg/100ml; 65meq/l; 460mg/100ml; 150mg/100ml; 44mg/100ml; 680mg/100ml aminosyn ii 8.5%/electrolytes 4 B/D AMINOSYN M INJ 65MEQ/L; 448MG/100ML; 4 B/D 343MG/100ML; 40MEQ/L; 448MG/100ML; 105MG/100ML; 252MG/100ML; 329MG/100ML; 252MG/100ML; 3MEQ/L; 140MG/100ML; 154MG/100ML; 3.5MMOLE/L; 13MEQ/L; 300MG/100ML; 147MG/100ML; 40MEQ/L; 182MG/100ML; 56MG/100ML; 31MG/100ML; 280MG/100ML calcium gluconate/sodium chloride inj 1gm/50ml; 0.675% 2 calcium gluconate inj 10% 2 CARBAGLU 5 CLINIMIX 2.75%/DEXTROSE 5% 4 B/D CLINIMIX 4.25%/DEXTROSE 10% 4 B/D CLINIMIX 4.25%/DEXTROSE 20% 4 B/D CLINIMIX 4.25%/DEXTROSE 25% 4 B/D CLINIMIX 4.25%/DEXTROSE 5% 4 B/D CLINIMIX 5%/DEXTROSE 15% 4 B/D

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 38 of 88 Drug Drug Name Tier Requirements/Limits CLINIMIX 5%/DEXTROSE 20% 4 B/D CLINIMIX 5%/DEXTROSE 25% 4 B/D CLINIMIX E 2.75%/DEXTROSE 10% INJ 570MG/100ML; 4 B/D 317MG/100ML; 33MG/100ML; 10GM/100ML; 283MG/100ML; 132MG/100ML; 165MG/100ML; 201MG/100ML; 159MG/100ML; 51MG/100ML; 110MG/100ML; 454MG/100ML; 154MG/100ML; 261MG/100ML; 187MG/100ML; 138MG/100ML; 217MG/100ML; 112MG/100ML; 116MG/100ML; 50MG/100ML; 11MG/100ML; 160MG/100ML CLINIMIX E 2.75%/DEXTROSE 5% 4 B/D CLINIMIX E 4.25%/DEXTROSE 10% 4 B/D CLINIMIX E 4.25%/DEXTROSE 25% 4 B/D CLINIMIX E 4.25%/DEXTROSE 5% 4 B/D CLINIMIX E 5%/DEXTROSE 15% 4 B/D CLINIMIX E 5%/DEXTROSE 20% 4 B/D CLINIMIX E 5%/DEXTROSE 25% 4 B/D CLINIMIX N14G30E 4 B/D CLINIMIX N9G15E 4 B/D CLINIMIX N9G20E 4 B/D dextrose 10%/nacl 0.45% 2 dextrose 10% 2 dextrose 10%/nacl 0.2% 2 dextrose 2.5%/nacl 0.45% 2 dextrose 20% 2 dextrose 25% inj 250mg/ml 2 dextrose 30% 2 dextrose 40% 2 dextrose 5% 2 dextrose 5%/lactated ringers 2 dextrose 5%/nacl 0.2% 2 dextrose 5%/nacl 0.225% 2 dextrose 5%/nacl 0.3% 2 dextrose 5%/nacl 0.33% 2 dextrose 5%/nacl 0.45% 2 dextrose 5%/nacl 0.9% 2 dextrose 50% 2 dextrose 70% 2 dextrose inj 2 glucose 5% 2 IONOSOL-B/DEXTROSE 5% 4 IONOSOL-MB/DEXTROSE 5% 4 ISOLYTE-P/DEXTROSE 5% 4 ISOLYTE-S 4 ISOLYTE-S PH 7.4 4 kcl 0.075%/d5w/nacl 0.45% 2 kcl 0.15%/d5w/nacl 0.2% 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 39 of 88 Drug Drug Name Tier Requirements/Limits kcl 0.15%/d5w/nacl 0.225% inj 5%; 20meq/l; 0.225% 2 kcl 0.15%/d5w/nacl 0.45% 2 kcl 0.15%/d5w/nacl 0.9% 2 kcl 0.3%/d5w/nacl 0.45% 2 kcl 0.3%/d5w/nacl 0.9% 2 klor-con 4 klor-con 10 2 klor-con 8 2 klor-con m10 2 klor-con m15 2 klor-con m20 2 klor-con sprinkle 2 lactated ringers viaflex 2 lactated ringers inj 2.7meq/l; 109meq/l; 28meq/l; 4meq/l; 2 130meq/l, 3meq/l; 109meq/l; 28meq/l; 4meq/l; 130meq/l magnesium sulfate in d5w inj 5%; 1gm/100ml 2 magnesium sulfate inj 20gm/500ml, 2gm/50ml, 40gm/1000ml, 4 4gm/100ml, 4gm/50ml, 50% NORMOSOL -R 4 NORMOSOL-M IN D5W 4 NORMOSOL-R 4 NORMOSOL-R IN D5W 4 PLASMA-LYTE A 4 PLASMA-LYTE-148 4 PLASMA-LYTE-56/D5W 4 potassium chloride cr tbcr 10meq, 20meq 2 potassium chloride er cpcr 2 potassium chloride er tbcr 10meq, 20meq, 8meq 2 potassium chloride sr tbcr 8meq 2 potassium chloride/dextrose/lactated ringers 2 potassium chloride/dextrose/sodium chloride 2 potassium chloride/dextrose inj 5%; 20meq/l, 5%; 40meq/l 2 potassium chloride/sodium chloride inj 20meq/l; 0.45%, 2 20meq/l; 0.9%, 40meq/l; 0.9% potassium chloride pack, oral soln 4 potassium chloride inj 20meq/100ml 1 potassium chloride inj 10meq/50ml, 20meq/50ml 2 potassium citrate er tbcr 1080mg, 540mg 4 PROCALAMINE 4 B/D ringers injection inj 4.5meq/l; 156meq/l; 4meq/l; 147meq/l 2 sodium acetate inj 2meq/ml 2 sodium bicarbonate inj 8.4% 2 sodium chloride 0.45% inj 2 sodium chloride inj 0.45%, 0.9%, 2.5meq/ml, 3%, 5% 2 sodium fluoride tabs 1mg 2 Electrolyte/Mineral/Metal Modifiers d-penamine 5

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 40 of 88 Drug Drug Name Tier Requirements/Limits deferasirox 5 PA DEPEN TITRATABS 4 FERRIPROX 5 PA JADENU 5 PA JADENU SPRINKLE 5 PA kionex 3 LOKELMA 4 QL (90 EA per 30 days) sodium polystyrene sulfonate 3 sps 3 trientine hydrochloride 5 PA veltassa 5 Phosphate Binders AURYXIA 5 PA calcium acetate caps 4 calcium acetate tabs 667mg 2 lanthanum carbonate 5 sevelamer carbonate tabs 4 sevelamer carbonate pack 5 sevelamer hydrochloride 4 Vitamins RAYALDEE 5 vp-pnv-dha 2 Gastrointestinal Agents Antispasmodics, Gastrointestinal dicyclomine hcl inj, oral soln 4 dicyclomine hydrochloride caps, tabs 2 dicyclomine hydrochloride inj 4 glycate 4 glycopyrrolate tabs 1mg, 2mg 2 glycopyrrolate tabs 1.5mg 4 methscopolamine bromide tabs 4 Gastrointestinal Agents, Other CHENODAL 5 CHOLBAM 5 PA cromolyn sodium conc 100mg/5ml 2 diphenoxylate/atropine tabs 2 GATTEX 5 PA loperamide hcl caps 2 metoclopramide hcl inj, oral soln 2 metoclopramide hcl tabs 5mg 2 metoclopramide hydrochloride tabs 2 opium 4 opium tincture tinc 1% 4 RELISTOR TABS 5 QL (90 EA per 30 days) ST RELISTOR INJ 8MG/0.4ML 5 QL (12 ML per 30 days) ST RELISTOR INJ 12MG/0.6ML 5 QL (18 ML per 30 days) ST ursodiol tabs 250mg 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 41 of 88 Drug Drug Name Tier Requirements/Limits ursodiol tabs 500mg 4 Histamine2 (H2) Receptor Antagonists famotidine susr 4 famotidine tabs 20mg, 40mg 2 ranitidine hcl syrp 2 ranitidine hcl tabs 150mg, 300mg 2 ranitidine hydrochloride inj 1000mg/40ml 4 Irritable Bowel Syndrome Agents alosetron hydrochloride 5 PA AMITIZA 3 QL (60 EA per 30 days) LINZESS 3 QL (30 EA per 30 days) Laxatives CLENPIQ 3 constulose 2 enulose 2 gavilyte-c 2 gavilyte-g 2 gavilyte-h 4 gavilyte-n/flavor pack 2 generlac 2 KRISTALOSE PACK 20GM 4 lactulose soln 2 lactulose pack 4 peg 3350/electrolytes 2 peg-3350/electrolytes 2 peg-3350/nacl/na bicarbonate/kcl 2 polyethylene glycol 3350 pack, powd 2 SUPREP BOWEL PREP KIT 3 trilyte 2 Protectants misoprostol 2 sucralfate tabs 2 Proton Pump Inhibitors esomeprazole magnesium 4 QL (60 EA per 30 days) lansoprazole odt 4 QL (30 EA per 30 days) lansoprazole cpdr 2 QL (60 EA per 30 days) lansoprazole tbdd 4 QL (60 EA per 30 days) omeprazole cpdr 2 QL (60 EA per 30 days) pantoprazole sodium inj 2 pantoprazole sodium tbec 2 QL (60 EA per 30 days) rabeprazole sodium 2 QL (60 EA per 30 days) Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment ADAGEN 5 ALDURAZYME 5 PA CERDELGA 5 PA CEREZYME 5 PA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 42 of 88 Drug Drug Name Tier Requirements/Limits CREON CPEP 120000UNIT; 24000UNIT; 76000UNIT, 3 15000UNIT; 3000UNIT; 9500UNIT, 180000UNIT; 36000UNIT; 114000UNIT, 30000UNIT; 6000UNIT; 19000UNIT, 60000UNIT; 12000UNIT; 38000UNIT CYSTAGON 4 ELAPRASE 5 PA EXONDYS 51 5 PA FABRAZYME INJ 35MG 5 PA GALAFOLD 5 QL (14 EA per 28 days) PA KANUMA 5 PA KUVAN 5 PA LUMIZYME 5 PA miglustat 5 PA NAGLAZYME 5 PA nitisinone 5 ORFADIN 5 PROCYSBI 5 PA RAVICTI 5 PA sodium phenylbutyrate powd 5 STRENSIQ 5 PA VIMIZIM 5 PA VPRIV 5 PA XIAFLEX 5 PA ZENPEP CPEP 105000UNIT; 25000UNIT; 79000UNIT, 3 14000UNIT; 3000UNIT; 10000UNIT, 168000UNIT; 40000UNIT; 126000UNIT, 24000UNIT; 5000UNIT; 17000UNIT, 42000UNIT; 10000UNIT; 32000UNIT, 63000UNIT; 15000UNIT; 47000UNIT, 84000UNIT; 20000UNIT; 63000UNIT Genitourinary Agents Antispasmodics, Urinary darifenacin hydrobromide er 4 flavoxate hcl 4 MYRBETRIQ 3 oxybutynin chloride er 2 oxybutynin chloride syrp, tabs 2 tolterodine tartrate 4 tolterodine tartrate er 4 trospium chloride 2 Benign Prostatic Hypertrophy Agents alfuzosin hcl er 2 doxazosin mesylate 2 dutasteride caps 4 finasteride tabs 5mg 2 silodosin 3 tamsulosin hydrochloride 2 terazosin hcl caps 10mg, 1mg, 5mg 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 43 of 88 Drug Drug Name Tier Requirements/Limits terazosin hydrochloride caps 2mg 2 Genitourinary Agents, Other acetic acid 0.25% 1 bethanechol chloride tabs 3 ELMIRON 4 THIOLA EC 5 Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) ala-cort crea 2.5% 2 alclometasone dipropionate 3 augmented betamethasone dipropionate crea 2 augmented betamethasone dipropionate lotn, oint 4 betamethasone dipropionate crea, lotn 3 betamethasone dipropionate oint 4 betamethasone valerate crea, lotn, oint 3 clobetasol propionate e 4 clobetasol propionate emollient 4 clobetasol propionate crea, foam, gel, liqd, lotn, oint, sham, 4 soln clodan 4 cormax scalp application 4 CORTIFOAM FOAM 10% 4 cortisone acetate tabs 25mg 2 deltasone tabs 20mg 2 DEPO-MEDROL INJ 20MG/ML 4 desonide crea, lotn, oint 4 dexamethasone 10-day dose pack 4 dexamethasone 13-day dose pack 4 dexamethasone 6-day dose pack 4 dexamethasone intensol 2 dexamethasone sodium phosphate inj 100mg/10ml, 10mg/ml, 2 120mg/30ml, 20mg/5ml, 4mg/ml dexamethasone elix 2 dexamethasone tabs 0.5mg, 0.75mg, 1.5mg, 1mg, 2mg, 4mg, 2 6mg fludrocortisone acetate tabs 2 fluocinolone acetonide crea 0.01%, 0.025% 4 fluocinolone acetonide oint 0.025% 4 fluocinolone acetonide soln 0.01% 4 fluocinonide emulsified base 3 fluocinonide crea 0.05% 3 fluocinonide crea 0.1% 3 QL (120 GM per 30 days) fluocinonide gel, oint, soln 3 fluticasone propionate crea 0.05% 3 fluticasone propionate oint 0.005% 3 halcinonide 4 halobetasol propionate oint 4

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 44 of 88 Drug Drug Name Tier Requirements/Limits halobetasol propionate foam 5 hydrocortisone butyrate crea, oint, soln 4 hydrocortisone valerate oint 3 hydrocortisone valerate crea 3 QL (60 GM per 30 days) hydrocortisone external crea 2.5% 2 hydrocortisone lotn 2.5% 2 hydrocortisone oint 2.5% 2 hydrocortisone tabs 10mg, 20mg, 5mg 2 KENALOG-10 4 KENALOG-40 4 LEXETTE 5 lokara 4 methylprednisolone dose pack tbpk 2 methylprednisolone sodium succinate inj 500mg 2 methylprednisolone tabs 2 MILLIPRED DP 4 mometasone furoate crea 0.1% 2 mometasone furoate oint 0.1% 2 mometasone furoate soln 0.1% 3 prednicarbate oint 4 prednisolone sodium phosphate oral soln 15mg/5ml 2 prednisolone soln 2 prednisone intensol 2 prednisone soln, tbpk 2 prednisone tabs 10mg, 1mg, 2.5mg, 20mg, 50mg, 5mg 2 SOLU-CORTEF 4 SOLU-MEDROL INJ 2GM 4 tovet 4 triamcinolone acetonide crea 0.025%, 0.1%, 0.5% 2 triamcinolone acetonide inj 40mg/ml 2 triamcinolone acetonide lotn 0.025%, 0.1% 2 triamcinolone acetonide oint 0.025%, 0.1%, 0.5% 2 triderm 2 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) chorionic gonadotropin 4 PA desmopressin acetate tabs 3 desmopressin acetate inj, nasal soln 4 GENOTROPIN 5 PA GENOTROPIN MINIQUICK INJ 0.2MG 4 PA GENOTROPIN MINIQUICK INJ 0.4MG, 0.6MG, 0.8MG, 5 PA 1.2MG, 1.4MG, 1.6MG, 1.8MG, 1MG, 2MG INCRELEX 5 PA NOVAREL INJ 5000UNIT 4 PA novarel inj 10000unit 4 PA NUTROPIN AQ NUSPIN 10 5 PA NUTROPIN AQ NUSPIN 20 5 PA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 45 of 88 Drug Drug Name Tier Requirements/Limits NUTROPIN AQ NUSPIN 5 5 PA pregnyl w/diluent benzyl alcohol/nacl 4 PA STIMATE SOLN 5 ZORBTIVE 5 PA Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) KORLYM 5 QL (120 EA per 30 days) PA Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) Anabolic Steroids ANADROL-50 5 PA oxandrolone tabs 2.5mg 3 QL (240 EA per 30 days) PA oxandrolone tabs 10mg 5 QL (60 EA per 30 days) PA Androgens ANDRODERM PT24 2MG/24HR, 4MG/24HR 3 PA androxy 4 PA danazol caps 4 testosterone cypionate inj 100mg/ml, 200mg/ml 4 PA testosterone enanthate inj 4 PA TESTOSTERONE PUMP GEL 1% 4 PA testosterone pump gel 1.62% 4 PA testosterone topical solution 4 PA TESTOSTERONE GEL 25MG/2.5GM, 50MG/5GM 4 PA testosterone gel 1.62%, 20.25mg/1.25gm, 40.5mg/2.5gm 4 PA testosterone soln 4 PA Estrogens altavera 2 alyacen 1/35 2 alyacen 7/7/7 2 amethia 4 QL (91 EA per 91 days) amethia lo 4 QL (91 EA per 91 days) apri 2 aranelle 4 ashlyna 4 QL (91 EA per 91 days) aubra 2 aviane 2 balziva 2 bekyree 2 blisovi 24 fe 4 blisovi fe 1.5/30 2 blisovi fe 1/20 2 briellyn 2 camrese 4 QL (91 EA per 91 days) camrese lo 4 QL (91 EA per 91 days) caziant 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 46 of 88 Drug Drug Name Tier Requirements/Limits chateal 2 CLIMARA PRO 4 cryselle-28 2 cyclafem 1/35 2 cyclafem 7/7/7 2 cyred 2 dasetta 1/35 2 dasetta 7/7/7 2 daysee 4 QL (91 EA per 91 days) delyla 2 desogestrel/ethinyl estradiol 2 dotti 4 drospirenone/ethinyl estradiol 2 drospirenone/ethinyl estradiol/levomefolate calcium tabs 3mg; 2 0.03mg; 0.451mg ELESTRIN 4 elinest 2 emoquette 2 enpresse-28 2 enskyce 2 estarylla 2 estradiol valerate inj 20mg/ml, 40mg/ml 4 estradiol crea, pttw, ptwk, oral tabs, vaginal tabs 4 ESTRING 4 QL (1 EA per 90 days) estropipate tabs 4 ethynodiol diacetate/ethinyl estradiol 2 falmina 2 femynor 2 fyavolv 4 gianvi 2 gildagia 2 hailey 1.5/30 2 hailey 24 fe 4 IMVEXXY MAINTENANCE PACK 3 PA IMVEXXY STARTER PACK 3 PA introvale 4 QL (91 EA per 91 days) isibloom 2 jevantique lo 4 jinteli 4 jolessa 4 QL (91 EA per 91 days) juleber 2 junel 1.5/30 2 junel 1/20 2 junel fe 1.5/30 2 junel fe 1/20 2 junel fe 24 4 kariva 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 47 of 88 Drug Drug Name Tier Requirements/Limits kelnor 1/35 2 kelnor 1/50 2 kimidess 2 kurvelo 2 larin 1.5/30 2 larin 1/20 2 larin 24 fe 4 larin fe 1.5/30 2 larin fe 1/20 2 larissia 2 leena 4 lessina 2 levonest 2 levonorgestrel and ethinyl estradiol tabs 0; 0 4 QL (91 EA per 91 days) levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0, 2 20mcg; 0.1mg levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0 4 QL (91 EA per 91 days) levora 0.15/30-28 2 LO LOESTRIN FE 4 loryna 2 low-ogestrel 2 lutera 2 marlissa 2 microgestin 1.5/30 2 microgestin 1/20 2 microgestin 24 fe 4 microgestin fe 2 microgestin fe 1.5/30 2 mili 2 mono-linyah 2 mononessa 2 myzilra 2 necon 0.5/35-28 2 necon 1/35 2 necon 1/50-28 2 necon 10/11-28 2 necon 7/7/7 2 nikki 2 norethindrone acetate/ethinyl estradiol/ferrous fumarate tabs 2 20mcg; 75mg; 1mg norethindrone acetate/ethinyl estradiol/ferrous fumarate tabs 4 20mcg; 75mg; 1mg norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg 2 norethindrone acetate/ethinyl estradiol tabs 2.5mcg; 0.5mg, 4 5mcg; 1mg norgestimate/ethinyl estradiol 2 nortrel 0.5/35 (28) 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 48 of 88 Drug Drug Name Tier Requirements/Limits nortrel 1/35 2 nortrel 7/7/7 2 ocella 2 orsythia 2 philith 2 pimtrea 2 pirmella 1/35 2 pirmella 7/7/7 2 portia-28 2 PREMARIN CREA 4 PREMARIN TABS 0.3MG 3 PREMARIN TABS 0.45MG, 0.625MG, 0.9MG, 1.25MG 4 PREMPHASE 4 PREMPRO 4 previfem 2 quasense 4 QL (91 EA per 91 days) rajani 2 reclipsen 2 setlakin 4 QL (91 EA per 91 days) sprintec 28 2 sronyx 2 syeda 2 tarina 24 fe 4 tarina fe 1/20 2 tri-estarylla 2 tri-legest fe 4 tri-linyah 2 tri-lo-estarylla 2 tri-lo-marzia 2 tri-lo-sprintec 2 tri-mili 2 tri-previfem 2 tri-sprintec 2 tri-vylibra 2 trinessa 2 trinessa lo 2 trivora-28 2 velivet 2 vienva 2 viorele 2 vyfemla 2 vylibra 2 wera 2 xulane 4 yuvafem 4 zarah 2 zenchent 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 49 of 88 Drug Drug Name Tier Requirements/Limits zenchent fe 2 zovia 1/35e 2 zovia 1/50e 2 zumandimine 2 Progesterone Agonists/Antagonists ELLA 3 Progestins camila 2 deblitane 2 DEPO-PROVERA INJ 400MG/ML 4 QL (10 ML per 28 days) errin 2 heather 2 HYDROXYPROGESTERONE CAPROATE INJ 250MG/ML 5 PA hydroxyprogesterone caproate inj 1.25gm/5ml 5 PA incassia 2 jencycla 2 jolivette 2 levonorgestrel tabs 1.5mg 2 lyza 2 MAKENA INJ 275MG/1.1ML 5 PA medroxyprogesterone acetate tabs 2 medroxyprogesterone acetate inj 4 QL (1 ML per 90 days) megestrol acetate susp, tabs 4 PA my way 2 nora-be 2 norethindrone acetate tabs 2 norethindrone tabs 2 norlyroc 2 progesterone inj 2 sharobel 2 tulana 2 Selective Estrogen Receptor Modifying Agents OSPHENA 3 QL (30 EA per 30 days) PA raloxifene hydrochloride 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) levothyroxine sodium tabs 2 levothyroxine sodium inj 5 LEVOXYL TABS 100MCG, 112MCG, 125MCG, 137MCG, 4 150MCG, 175MCG, 200MCG, 25MCG, 50MCG, 75MCG, 88MCG liothyronine sodium tabs 3 liothyronine sodium inj 4 Hormonal Agents, Suppressant (Adrenal) Hormonal Agents, Suppressant (Adrenal) LYSODREN 3 Hormonal Agents, Suppressant (Pituitary)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 50 of 88 Drug Drug Name Tier Requirements/Limits Hormonal Agents, Suppressant (Pituitary) cabergoline 4 FIRMAGON INJ 80MG 4 QL (1 EA per 28 days) PA FIRMAGON INJ 120MG 5 QL (4 EA per 365 days) PA leuprolide acetate inj 5 PA LUPRON DEPOT (1-MONTH) 5 QL (1 EA per 28 days) PA LUPRON DEPOT (3-MONTH) 5 QL (1 EA per 84 days) PA LUPRON DEPOT (4-MONTH) 5 QL (1 EA per 112 days) PA LUPRON DEPOT (6-MONTH) 5 QL (1 EA per 168 days) PA LUPRON DEPOT-PED (1-MONTH) 5 QL (1 EA per 28 days) PA LUPRON DEPOT-PED (3-MONTH) 5 QL (1 EA per 84 days) PA octreotide acetate inj 100mcg/ml, 200mcg/ml, 50mcg/ml 3 PA octreotide acetate inj 1000mcg/ml, 500mcg/ml 5 PA ORILISSA TABS 150MG 5 QL (30 EA per 30 days) PA ORILISSA TABS 200MG 5 QL (60 EA per 30 days) PA SIGNIFOR 5 QL (60 ML per 30 days) PA SOMATULINE DEPOT 5 PA SOMAVERT 5 PA SUPPRELIN LA 5 QL (1 EA per 365 days) PA SYNAREL 5 TRELSTAR MIXJECT INJ 22.5MG 5 QL (1 EA per 168 days) PA TRELSTAR MIXJECT INJ 3.75MG 5 QL (1 EA per 28 days) PA TRELSTAR MIXJECT INJ 11.25MG 5 QL (1 EA per 84 days) PA TRELSTAR INJ 3.75MG 5 QL (1 EA per 28 days) PA TRELSTAR INJ 11.25MG 5 QL (1 EA per 84 days) PA TRIPTODUR 5 QL (1 EA per 168 days) PA ZOLADEX INJ 3.6MG 4 QL (1 EA per 28 days) Hormonal Agents, Suppressant (Thyroid) Antithyroid Agents methimazole tabs 10mg, 5mg 2 propylthiouracil tabs 3 Immunological Agents Angioedema Agents BERINERT 5 PA FIRAZYR 5 PA icatibant acetate 5 PA KALBITOR 5 PA RUCONEST 5 PA Immune Suppressants AZASAN 4 B/D azathioprine inj 2 B/D azathioprine tabs 3 B/D BENLYSTA 5 PA cyclosporine modified 3 B/D cyclosporine inj 2 cyclosporine caps 4 B/D ENBREL 5 PA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 51 of 88 Drug Drug Name Tier Requirements/Limits ENBREL MINI 5 PA ENBREL SURECLICK 5 PA gengraf 3 B/D HUMIRA 5 PA HUMIRA PEDIATRIC CROHNS DISEASE STARTER 5 PA PACK HUMIRA PEN 5 PA HUMIRA PEN-CD/UC/HS STARTER 5 PA HUMIRA PEN-PS/UV STARTER 5 PA INFLECTRA 5 PA methotrexate sodium inj 1gm/40ml, 250mg/10ml, 50mg/2ml 2 methotrexate tabs 2 methotrexate inj 50mg/2ml 2 mycophenolate mofetil inj 2 B/D mycophenolate mofetil caps, tabs 3 B/D mycophenolate mofetil susr 5 B/D mycophenolic acid dr 4 B/D NULOJIX 5 PA ORENCIA 5 PA ORENCIA CLICKJECT 5 QL (4 ML per 28 days) PA PROGRAF INJ 4 PROGRAF PACK 5 B/D RASUVO INJ 7.5MG/0.15ML 4 QL (0.6 ML per 28 days) PA RASUVO INJ 10MG/0.2ML 4 QL (0.8 ML per 28 days) PA RASUVO INJ 12.5MG/0.25ML 4 QL (1 ML per 28 days) PA RASUVO INJ 15MG/0.3ML 4 QL (1.2 ML per 28 days) PA RASUVO INJ 17.5MG/0.35ML 4 QL (1.4 ML per 28 days) PA RASUVO INJ 20MG/0.4ML 4 QL (1.6 ML per 28 days) PA RASUVO INJ 22.5MG/0.45ML 4 QL (1.8 ML per 28 days) PA RASUVO INJ 25MG/0.5ML 4 QL (2 ML per 28 days) PA RASUVO INJ 27.5MG/0.55ML 4 QL (2.2 ML per 28 days) PA RASUVO INJ 30MG/0.6ML 4 QL (2.4 ML per 28 days) PA RENFLEXIS 5 PA SANDIMMUNE SOLN 4 B/D SIMPONI 5 PA sirolimus soln 5 B/D sirolimus tabs 0.5mg, 1mg 4 B/D sirolimus tabs 2mg 5 B/D SKYRIZI 5 PA tacrolimus caps 0.5mg, 1mg 2 B/D tacrolimus caps 5mg 4 B/D TREXALL 4 XATMEP 4 ZORTRESS 5 PA Immunizing Agents, Passive ATGAM 5 BIVIGAM 5 PA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 52 of 88 Drug Drug Name Tier Requirements/Limits carimune nanofiltered inj 12gm, 6gm 5 PA CUVITRU 5 PA FLEBOGAMMA DIF 5 PA GAMASTAN 3 PA GAMASTAN S/D 3 PA GAMMAGARD LIQUID INJ 30GM/300ML 5 PA gammagard liquid inj 10gm/100ml, 1gm/10ml, 2.5gm/25ml, 5 PA 20gm/200ml, 5gm/50ml GAMMAGARD S/D IGA LESS THAN 1MCG/ML 5 PA GAMMAKED 5 PA GAMMAPLEX INJ 10GM/100ML, 10GM/200ML, 5 PA 20GM/200ML, 20GM/400ML, 5GM/100ML, 5GM/50ML GAMUNEX-C 5 PA HEPAGAM B 5 B/D HIZENTRA 5 PA HYPERHEP B S/D 5 B/D HYPERRAB 3 B/D HYPERRHO S/D MINI-DOSE 4 HYPERRHO S/D INJ 1500UNIT 4 MICRHOGAM ULTRA-FILTERED PLUS 4 NABI-HB 5 B/D OCTAGAM 5 PA PANZYGA 5 PA PRIVIGEN 5 PA RHOGAM ULTRA-FILTERED PLUS 4 RHOPHYLAC 4 SYNAGIS INJ 100MG/ML, 50MG/0.5ML 5 PA XEMBIFY 5 PA Immunomodulators ACTEMRA ACTPEN 4 PA ACTEMRA INJ 162MG/0.9ML 4 QL (3.6 ML per 28 days) PA ACTIMMUNE 5 PA ARCALYST 5 PA ENTYVIO 5 PA GAMIFANT 5 PA ILARIS INJ 150MG 5 QL (2 EA per 28 days) PA ILARIS INJ 150MG/ML 5 QL (2 ML per 28 days) PA leflunomide tabs 3 LEMTRADA 5 PA OLUMIANT 4 PA RINVOQ 5 PA SIMPONI ARIA 5 PA SYLVANT 5 PA XELJANZ 5 PA XELJANZ XR 5 PA Vaccines ACTHIB INJ 0 3

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 53 of 88 Drug Drug Name Tier Requirements/Limits ADACEL 3 BCG VACCINE 3 BEXSERO 3 BOOSTRIX 3 DAPTACEL INJ 23MCG/0.5ML; 15LF/0.5ML; 5LF/0.5ML 3 diphtheria/tetanus toxoids adsorbed pediatric 3 ENGERIX-B 3 B/D GARDASIL 3 GARDASIL 9 3 HAVRIX INJ 1440ELU/ML, 720ELU/0.5ML 3 HEPLISAV-B 3 B/D HIBERIX 3 IMOVAX RABIES (H.D.C.V.) 3 B/D INFANRIX 3 IPOL INACTIVATED IPV 3 IXIARO 3 KINRIX 3 M-M-R II 3 MENACTRA 3 MENHIBRIX 3 MENOMUNE-A/C/Y/W-135 3 MENVEO 3 PEDIARIX 3 PEDVAX HIB INJ 7.5MCG/0.5ML 3 PENTACEL 3 PROQUAD 3 QUADRACEL 3 RABAVERT 3 B/D RECOMBIVAX HB 3 B/D ROTARIX 3 ROTATEQ SOLN 3 SHINGRIX 3 STAMARIL 3 TDVAX 3 TENIVAC 3 TRUMENBA 3 TWINRIX 3 TYPHIM VI 3 VAQTA 3 VARIVAX 3 YF-VAX 3 ZOSTAVAX 3 Inflammatory Bowel Disease Agents Aminosalicylates APRISO 3 balsalazide disodium 4 MESALAMINE DR TBEC 800MG 3

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 54 of 88 Drug Drug Name Tier Requirements/Limits mesalamine dr tbec 1.2gm 3 mesalamine enem, kit 4 mesalamine supp 5 SFROWASA 4 Glucocorticoids BUDESONIDE ER 5 budesonide cpep 3mg 4 colocort 4 hydrocortisone enem 100mg/60ml 4 Sulfonamides sulfasalazine tabs, tbec 2 Metabolic Bone Disease Agents Metabolic Bone Disease Agents alendronate sodium soln 4 alendronate sodium tabs 10mg, 35mg, 5mg 2 alendronate sodium tabs 70mg 2 QL (4 EA per 28 days) alendronate sodium tabs 40mg 4 calcitonin-salmon soln 2 QL (3.7 ML per 30 days) calcitriol caps 2 calcitriol oral soln 4 calcitriol inj 1mcg/ml 2 doxercalciferol caps 4 etidronate disodium 4 FORTEO INJ 600MCG/2.4ML 5 PA ibandronate sodium tabs 2 QL (1 EA per 28 days) MIACALCIN INJ 5 NATPARA 5 QL (2 EA per 28 days) PA pamidronate disodium 2 paricalcitol caps 4 PARICALCITOL INJ 5MCG/ML 4 paricalcitol inj 2mcg/ml 4 PROLIA 4 QL (2 ML per 365 days) TYMLOS 5 PA XGEVA 5 PA zoledronic acid inj 4mg/100ml, 4mg/5ml 2 zoledronic acid inj 5mg/100ml 4 zoledronic acid inj 4mg 5 Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ALCOHOL PREP PADS 3 alcohol preps pads 70% 3 amino acid 4 B/D

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 55 of 88 Drug Drug Name Tier Requirements/Limits AMINOSYN II INJ 50.3MEQ/L; 695MG/100ML; 4 B/D 713MG/100ML; 490MG/100ML; 517MG/100ML; 350MG/100ML; 210MG/100ML; 462MG/100ML; 700MG/100ML; 735MG/100ML; 120MG/100ML; 209MG/100ML; 505MG/100ML; 371MG/100ML; 31.3MEQ/L; 280MG/100ML; 140MG/100ML; 189MG/100ML; 350MG/100ML, 71.8MEQ/L; 993MG/100ML; 1018MG/100ML; 700MG/100ML; 738MG/100ML; 500MG/100ML; 300MG/100ML; 660MG/100ML; 1000MG/100ML; 1050MG/100ML; 172MG/100ML; 298MG/100ML; 722MG/100ML; 530MG/100ML; 38MEQ/L; 400MG/100ML; 200MG/100ML; 270MG/100ML; 500MG/100ML AMINOSYN-HBC INJ 7.1MEQ/100ML; 660MG/100ML; 4 B/D 507MG/100ML; 660MG/100ML; 154MG/100ML; 789MG/100ML; 1576MG/100ML; 265MG/100ML; 206MG/100ML; 1.12GM/100ML; 228MG/100ML; 448MG/100ML; 221MG/100ML; 272MG/100ML; 88MG/100ML; 33MG/100ML; 789MG/100ML AMINOSYN-PF 7% 4 B/D AMINOSYN-PF INJ 46MEQ/L; 698MG/100ML; 4 B/D 1227MG/100ML; 527MG/100ML; 820MG/100ML; 385MG/100ML; 312MG/100ML; 760MG/100ML; 1200MG/100ML; 677MG/100ML; 180MG/100ML; 427MG/100ML; 812MG/100ML; 495MG/100ML; 3.4MEQ/L; 70MG/100ML; 512MG/100ML; 180MG/100ML; 44MG/100ML; 673MG/100ML AMINOSYN-RF INJ 113MEQ/L; 600MG/100ML; 4 B/D 429MG/100ML; 462MG/100ML; 726MG/100ML; 535MG/100ML; 726MG/100ML; 726MG/100ML; 330MG/100ML; 165MG/100ML; 528MG/100ML AMINOSYN INJ 148MEQ/L; 1280MG/100ML; 4 B/D 980MG/100ML; 1280MG/100ML; 300MG/100ML; 720MG/100ML; 940MG/100ML; 720MG/100ML; 400MG/100ML; 440MG/100ML; 860MG/100ML; 420MG/100ML; 520MG/100ML; 160MG/100ML; 44MG/100ML; 800MG/100ML ASSURE ID SAFETY PEN NEEDLES 30G X 3/16" 3 QL (200 EA per 30 days) ASSURE ID SAFETY PEN NEEDLES 30G X 5/16" 3 QL (200 EA per 30 days) ASSURE ID SAFETY PEN NEEDLES 31G X 3/16" 3 QL (200 EA per 30 days) B-D INSULIN SYRINGE ULTRAFINE II/0.3ML/31G X 3 QL (200 EA per 30 days) 5/16" BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2" 3 QL (200 EA per 30 days) BD INSULIN SYRINGE ULTRA-FINE/0.5ML/30G X 3 QL (200 EA per 30 days) 12.7MM BD INSULIN SYRINGE ULTRA-FINE/1ML/31G X 8MM 3 QL (200 EA per 30 days) BD INSULIN SYRINGE/0.3ML/29G X 12.7MM 3 QL (200 EA per 30 days)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 56 of 88 Drug Drug Name Tier Requirements/Limits BD INSULIN SYRINGE/0.5ML/29G X 12.7MM 3 QL (200 EA per 30 days) BD INSULIN SYRINGE/1ML/27G X 12.7MM 3 QL (200 EA per 30 days) BD INSULIN SYRINGE/1ML/29G X 12.7MM 3 QL (200 EA per 30 days) BD INSULIN SYRINGE/U-500/0.5ML/31G X 6MM 3 QL (200 EA per 30 days) BD PEN NEEDLE/ORIGINAL/ULTRA-FINE/29G X 3 QL (200 EA per 30 days) 12.7MM BD SAFETYGLIDE INSULIN SYRINGE/1ML/31G X 3 QL (200 EA per 30 days) 15/64" BD VEO INSULIN SYRINGE ULTRA-AFINE/0.3ML/31G 3 QL (200 EA per 30 days) X 6MM BD VEO INSULIN SYRINGE ULTRA-FINE/0.5ML/31G X 3 QL (200 EA per 30 days) 6MM BD VEO INSULIN SYRINGE ULTRA-FINE/1ML/31G X 3 QL (200 EA per 30 days) 6MM CINRYZE 5 PA CLINOLIPID 5 B/D CURITY GAUZE PADS 2"X2" 3 deferoxamine mesylate 4 B/D DROPSAFE SAFETY PEN NEEDLES/31G X 5/16" 3 QL (200 EA per 30 days) DROPSAFE SAFTEY PEN NEEDLES/31G X 1/4" 3 QL (200 EA per 30 days) EASY COMFORT INSULIN SYRINGE/1ML/32GX5/16" 3 QL (200 EA per 30 days) EASY COMFORT INSULIN SYRINGES/0.5ML/32GX5/16" 3 QL (200 EA per 30 days) EASY GLIDE PEN NEEDLES 33G X 5/32" 3 QL (200 EA per 30 days) ENDARI 5 PA EXEL COMFORT POINT INSULIN SYRINGE/1ML/29G X 3 QL (200 EA per 30 days) 1/2" FIRDAPSE 5 QL (240 EA per 30 days) PA FREAMINE HBC 6.9% 4 B/D FREAMINE III INJ 89MEQ/L; 710MG/100ML; 4 B/D 950MG/100ML; 3MEQ/L; 24MG/100ML; 1400MG/100ML; 280MG/100ML; 690MG/100ML; 910MG/100ML; 730MG/100ML; 530MG/100ML; 560MG/100ML; 10MMOLE/L; 120MG/100ML; 1120MG/100ML; 590MG/100ML; 10MEQ/L; 400MG/100ML; 150MG/100ML; 660MG/100ML HAEGARDA 5 PA hepatamine 4 B/D INSULIN SYRINGE/NEEDLE 0.3ML/30G X 5/16" 3 QL (200 EA per 30 days) INSULIN SYRINGE/NEEDLE 0.3ML/31G X 5/16" 3 QL (200 EA per 30 days) INSULIN SYRINGE/NEEDLE 0.5ML/29G X 1/2" 3 QL (200 EA per 30 days) INSULIN SYRINGE/NEEDLE 0.5ML/30G X 5/16" 3 QL (200 EA per 30 days) INSULIN SYRINGE/NEEDLE 0.5ML/31G X 5/16" 3 QL (200 EA per 30 days) INSULIN SYRINGE/NEEDLE 1ML/31G X 5/16" 3 QL (200 EA per 30 days) intralipid inj 20gm/100ml 4 B/D lactated ringers irrigation 2 levocarnitine soln, tabs 4 methergine tabs 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 57 of 88 Drug Drug Name Tier Requirements/Limits methylergonovine maleate tabs 2 MYALEPT 5 PA NEPHRAMINE 4 B/D nutrilipid 4 B/D OMNIPOD 10 PACK 3 QL (30 EA per 30 days) OMNIPOD 5 PACK 3 QL (30 EA per 30 days) OMNIPOD DASH 5 PACK 3 QL (30 EA per 30 days) OMNIPOD DASH SYSTEM 3 QL (1 EA per 365 days) OMNIPOD STARTER KIT 3 QL (1 EA per 365 days) PHYSIOLYTE 4 PHYSIOSOL IRRIGATION 4 PREMASOL INJ 52MEQ/L; 1760MG/100ML; 4 B/D 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML; 152MG/100ML premasol inj 56meq/l; 320mg/100ml; 730mg/100ml; 4 B/D 190mg/100ml; 3meq/l; 20mg/100ml; 300mg/100ml; 220mg/100ml; 290mg/100ml; 490mg/100ml; 840mg/100ml; 490mg/100ml; 200mg/100ml; 290mg/100ml; 410mg/100ml; 230mg/100ml; 5meq/l; 15mg/100ml; 250mg/100ml; 120mg/100ml; 140mg/100ml; 470mg/100ml PROSOL 4 B/D ringers irrigation 2 RUZURGI 5 QL (300 EA per 30 days) PA sodium chloride 0.9% 2 sodium chloride 0.9% 2 sodium phenylacetate/sodium benzoate 5 SPINRAZA 5 PA sterile water irrigation 2 sterile water irrigation plastic bottle 2 sterile water irrigation w/hanger 2 SYNTHAMIN 17 4 B/D tis-u-sol 2 TRAVASOL INJ 52MEQ/L; 1760MG/100ML; 4 B/D 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 500MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML; 152MG/100ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 58 of 88 Drug Drug Name Tier Requirements/Limits TROPHAMINE INJ 97MEQ/L; 0.54GM/100ML; 4 B/D 1.2GM/100ML; 0.32GM/100ML; 0; 0; 0.5GM/100ML; 0.36GM/100ML; 0.48GM/100ML; 0.82GM/100ML; 1.4GM/100ML; 1.2GM/100ML; 0.34GM/100ML; 0.48GM/100ML; 0.68GM/100ML; 0.38GM/100ML; 5MEQ/L; 0.025GM/100ML; 0.42GM/100ML; 0.2GM/100ML; 0.24GM/100ML; 0.78GM/100ML ULTICARE MICRO PEN NEEDLES/31G X 1/4" 3 QL (200 EA per 30 days) ULTICARE MICRO PEN NEEDLES/31G X 5/16" 3 QL (200 EA per 30 days) ULTILET INSULIN SYRINGE/SHORT/0.3ML/31G X 5/16" 3 QL (200 EA per 30 days) ULTILET INSULIN SYRINGE/SHORT/1ML/31G X 5/16" 3 QL (200 EA per 30 days) UNIFINE PENTIPS 33GX4MM 3 QL (200 EA per 30 days) UNIFINE PENTIPS PLUS 33GX4MM 3 QL (200 EA per 30 days) V-GO 20 3 V-GO 30 3 V-GO 40 3 VISTOGARD 5 Ophthalmic Agents Ophthalmic Prostaglandin and Prostamide Analogs bimatoprost 3 QL (5 ML per 30 days) latanoprost soln 1 LUMIGAN 3 QL (2.5 ML per 25 days) VYZULTA 4 QL (5 ML per 25 days) ZIOPTAN 4 QL (30 EA per 30 days) Ophthalmic Agents, Other atropine sulfate ophthalmic soln 1% 3 bacitracin/polymyxin b 4 cyclopentolate hcl 2 cyclopentolate hydrochloride 2 CYSTARAN 5 QL (60 ML per 28 days) PA EYLEA 5 PA neo-polycin 3 neomycin/bacitracin/polymyxin 3 neomycin/polymyxin/bacitracin oint 400unit/gm; 3.5mg/gm; 3 10000unit/gm neomycin/polymyxin/gramicidin 3 OXERVATE 5 QL (56 ML per 28 days) PA polycin 4 polymyxin b sulfate/trimethoprim sulfate 2 proparacaine hcl 3 RESTASIS 3 RHOPRESSA 3 QL (2.5 ML per 25 days) ST XIIDRA 4 QL (60 EA per 30 days) Ophthalmic Anti-allergy Agents azelastine hcl ophthalmic soln 0.05% 2 BEPREVE 4 cromolyn sodium soln 4% 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 59 of 88 Drug Drug Name Tier Requirements/Limits epinastine hcl 3 olopatadine hcl ophthalmic soln 0.1% 3 olopatadine hydrochloride soln 0.2% 3 PAZEO 4 Ophthalmic Anti-inflammatories ALREX 4 BLEPHAMIDE 4 BLEPHAMIDE S.O.P. 4 bromfenac 2 dexamethasone sodium phosphate ophthalmic soln 0.1% 3 diclofenac sodium ophthalmic soln 0.1% 4 DUREZOL 3 FLAREX 3 flurbiprofen sodium 2 FML FORTE 3 INVELTYS 4 ketorolac tromethamine ophthalmic soln 0.5% 2 ketorolac tromethamine ophthalmic soln 0.4% 3 LOTEMAX SM 4 QL (20 GM per 365 days) LOTEMAX OINT 4 QL (14 GM per 365 days) LOTEMAX GEL 4 QL (20 GM per 365 days) loteprednol etabonate 2 neo-polycin hc 3 neomycin/polymyxin/bacitracin/hydrocortisone 3 neomycin/polymyxin/dexamethasone 2 neomycin/polymyxin/hydrocortisone ophthalmic susp 1%; 4 3.5mg/ml; 10000unit/ml prednisolone acetate 4 prednisolone acetate p-f 4 prednisolone sodium phosphate ophthalmic soln 1% 3 PROLENSA 4 QL (12 ML per 365 days) sulfacetamide sodium/prednisolone sodium phosphate 2 TOBRADEX ST 4 TOBRADEX OINT 4 tobramycin/dexamethasone 4 TRIESENCE 4 ZYLET 4 Ophthalmic Antiglaucoma Agents acetazolamide er 4 acetazolamide tabs 2 ALPHAGAN P SOLN 0.1% 3 apraclonidine 3 AZOPT 3 betaxolol hcl soln 0.5% 3 BETIMOL 4 brimonidine tartrate soln 0.2% 3 brimonidine tartrate soln 0.15% 4

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 60 of 88 Drug Drug Name Tier Requirements/Limits carteolol hcl 4 COMBIGAN 3 dorzolamide hcl 3 dorzolamide hcl/timolol maleate 3 dorzolamide hydrochloride/timolol maleate pf 3 levobunolol hcl soln 0.5% 2 methazolamide tabs 4 metipranolol 3 PHOSPHOLINE IODIDE SOLR 0.125% 4 pilocarpine hcl soln 1%, 2%, 4% 4 ROCKLATAN 3 QL (2.5 ML per 25 days) SIMBRINZA 4 timolol maleate ophthalmic gel forming 4 timolol maleate soln 0.25%, 0.5% 2 timolol maleate soln 0.5% 4 Otic Agents Otic Agents acetic acid 2 acetic acid/aluminum acetate soln 2%; 0 2 CIPRODEX 4 flac 4 fluocinolone acetonide ear drops 4 fluocinolone acetonide oil 0.01% 4 neomycin/polymyxin/hc 4 neomycin/polymyxin/hydrocortisone otic susp 1%; 3.5mg/ml; 4 10000unit/ml Respiratory Tract/Pulmonary Agents Anti-inflammatories, Inhaled Corticosteroids ASMANEX HFA 4 QL (26 GM per 30 days) ASMANEX TWISTHALER 120 METERED DOSES 4 QL (1 EA per 30 days) ASMANEX TWISTHALER 14 METERED DOSES 4 QL (1 EA per 30 days) ASMANEX TWISTHALER 30 METERED DOSES 4 QL (1 EA per 30 days) ASMANEX TWISTHALER 60 METERED DOSES 4 QL (1 EA per 30 days) ASMANEX TWISTHALER 7 METERED DOSES 4 QL (1 EA per 30 days) BREO ELLIPTA 3 QL (60 EA per 30 days) budesonide susp 0.25mg/2ml, 0.5mg/2ml, 1mg/2ml 4 QL (120 ML per 30 days) B/D DYMISTA 4 QL (23 GM per 30 days) FLOVENT DISKUS AEPB 250MCG/BLIST 3 QL (240 EA per 30 days) FLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/BLIST 3 QL (60 EA per 30 days) FLOVENT HFA AERO 44MCG/ACT 3 QL (21.2 GM per 30 days) FLOVENT HFA AERO 110MCG/ACT, 220MCG/ACT 3 QL (24 GM per 30 days) flunisolide soln 0.025% 4 QL (50 ML per 30 days) fluticasone propionate susp 50mcg/act 2 mometasone furoate susp 50mcg/act 4 QL (34 GM per 30 days) QVAR REDIHALER 3 QL (21.2 GM per 30 days) triamcinolone acetonide aero 55mcg/act 2 Antihistamines

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 61 of 88 Drug Drug Name Tier Requirements/Limits azelastine hcl nasal soln 0.15% 2 QL (60 ML per 30 days) azelastine hydrochloride 2 QL (60 ML per 30 days) cetirizine hydrochloride soln 1mg/ml 2 cyproheptadine hcl tabs 4 PA dexchlorpheniramine maleate syrp 4 PA diphenhydramine hcl inj 50mg/ml 2 diphenhydramine hydrochloride inj 2 hydroxyzine pamoate caps 4 PA levocetirizine dihydrochloride tabs 2 olopatadine hcl nasal soln 0.6% 4 QL (30.5 GM per 30 days) Antileukotrienes montelukast sodium chew, tabs 2 montelukast sodium pack 4 zafirlukast 4 Bronchodilators, Anticholinergic ATROVENT HFA 4 QL (25.8 GM per 30 days) COMBIVENT RESPIMAT 3 QL (8 GM per 30 days) ipratropium bromide/albuterol sulfate 2 QL (540 ML per 30 days) B/D ipratropium bromide inhalation soln 2 QL (312.5 ML per 30 days) B/D ipratropium bromide nasal soln 4 LONHALA MAGNAIR REFILL KIT 5 QL (60 ML per 30 days) SPIRIVA HANDIHALER 3 QL (30 EA per 30 days) SPIRIVA RESPIMAT 3 QL (8 GM per 28 days) Bronchodilators, Sympathomimetic albuterol sulfate syrp, tabs 4 albuterol sulfate nebu 0.5% 2 QL (100 EA per 30 days) B/D albuterol sulfate nebu 0.63mg/3ml, 1.25mg/3ml 2 QL (375 ML per 30 days) B/D albuterol sulfate nebu 0.083% 2 QL (525 ML per 30 days) B/D aliskiren 2 EPINEPHRINE INJ 0.15MG/0.3ML 3 epinephrine inj 0.3mg/0.3ml 3 EPIPEN 2-PAK 3 EPIPEN-JR 2-PAK 3 isoproterenol hydrochloride 4 levalbuterol hcl nebu 1.25mg/3ml 4 QL (270 ML per 30 days) B/D levalbuterol hcl nebu 0.31mg/3ml, 0.63mg/3ml 4 QL (540 ML per 30 days) B/D levalbuterol hydrochloride nebu 1.25mg/3ml 4 QL (270 ML per 30 days) B/D levalbuterol hydrochloride nebu 0.31mg/3ml, 0.63mg/3ml 4 QL (540 ML per 30 days) B/D levalbuterol tartrate hfa 3 QL (30 GM per 30 days) levalbuterol nebu 4 QL (90 EA per 30 days) B/D metaproterenol sulfate syrp, tabs 4 PERFOROMIST 4 QL (120 ML per 30 days) B/D PROAIR DIGIHALER 3 PROAIR HFA 3 QL (17 GM per 30 days) PROAIR RESPICLICK 3 QL (2 EA per 30 days) SEREVENT DISKUS 3 QL (60 EA per 30 days) Cystic Fibrosis Agents

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 62 of 88 Drug Drug Name Tier Requirements/Limits CAYSTON 5 PA KALYDECO 5 PA ORKAMBI TABS 5 QL (112 EA per 28 days) PA ORKAMBI PACK 5 QL (56 EA per 28 days) PA PULMOZYME 5 PA SYMDEKO TBPK 75MG; 50MG 5 QL (56 EA per 28 days) PA TOBI PODHALER 5 QL (224 EA per 56 days) tobramycin 5 B/D Mast Cell Stabilizers cromolyn sodium nebu 20mg/2ml 3 B/D Phosphodiesterase Inhibitors, Airways Disease aminophylline inj 2 DALIRESP 4 PA theophylline anhydrous cr tb12 300mg 3 theophylline cr tb12 100mg, 200mg 3 theophylline er tb24 4 theophylline er tb12 300mg, 450mg 3 theophylline/d5w inj 5%; 0.8mg/ml 2 Pulmonary Antihypertensives ADEMPAS 5 QL (90 EA per 30 days) PA alyq 5 QL (60 EA per 30 days) PA ambrisentan 5 QL (30 EA per 30 days) PA epoprostenol sodium 5 PA OPSUMIT 5 QL (30 EA per 30 days) PA ORENITRAM TBCR 0.125MG 4 PA ORENITRAM TBCR 0.25MG, 1MG, 2.5MG, 5MG 5 PA sildenafil citrate tabs 3 QL (90 EA per 30 days) PA sildenafil inj 5 PA tadalafil 5 QL (60 EA per 30 days) PA TREPROSTINIL 5 PA VELETRI 5 PA VENTAVIS 5 QL (270 ML per 30 days) PA Pulmonary Fibrosis Agents ESBRIET TABS 267MG, 801MG 5 PA Respiratory Tract Agents, Other acetylcysteine soln 4 B/D ADVAIR DISKUS 3 QL (60 EA per 30 days) ADVAIR HFA 3 QL (24 GM per 30 days) ANORO ELLIPTA 3 QL (60 EA per 30 days) ARALAST NP INJ 1000MG, 500MG 5 PA DULERA 4 QL (17.6 GM per 30 days) ESBRIET CAPS 267MG 5 PA fluticasone propionate/salmeterol diskus 3 QL (60 EA per 30 days) NUCALA INJ 100MG/ML 5 QL (3 ML per 28 days) PA OFEV 5 PA PROLASTIN-C INJ 1000MG 5 PA STIOLTO RESPIMAT 3 QL (24 GM per 30 days)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 63 of 88 Drug Drug Name Tier Requirements/Limits SYMBICORT AERO 160MCG/ACT; 4.5MCG/ACT 3 QL (12 GM per 30 days) SYMBICORT AERO 80MCG/ACT; 4.5MCG/ACT 3 QL (13.8 GM per 30 days) TRELEGY ELLIPTA 3 QL (60 EA per 30 days) wixela inhub 3 QL (60 EA per 30 days) XOLAIR 5 PA ZEMAIRA 5 PA Skeletal Muscle Relaxants Skeletal Muscle Relaxants chlorzoxazone tabs 500mg 4 PA chlorzoxazone tabs 250mg 5 PA cyclobenzaprine hydrochloride tabs 10mg, 5mg 2 PA succinylcholine chloride inj 20mg/ml 2 Sleep Disorder Agents GABA Receptor Modulators zaleplon caps 5mg 4 QL (30 EA per 30 days) zaleplon caps 10mg 4 QL (60 EA per 30 days) zolpidem tartrate tabs 3 QL (30 EA per 30 days) Sleep Disorders, Other BELSOMRA 3 QL (30 EA per 30 days) HETLIOZ 5 QL (30 EA per 30 days) PA modafinil 4 QL (30 EA per 30 days) PA pentobarbital sodium inj 4 PA ramelteon 2 QL (30 EA per 30 days) XYREM 4 QL (540 ML per 30 days) PA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 64 of 88 Drug Name Page # alcohol preps 55 Index of Drugs ALDACTAZIDE 34 Drug Name Page # ALDURAZYME 42 7t lido gel 3 ALECENSA 19 abacavir 25 alendronate sodium 55 abacavir sulfate/lamivudine 25 alfuzosin hcl er 43 abacavir sulfate/lamivudine/zidovudine 25 ALIMTA 16 ABELCET 12 ALINIA 21 ABILIFY MAINTENA 22 ALIQOPA 19 ABILIFY MYCITE 22 aliskiren 62 abiraterone acetate 15 allopurinol 13 ABRAXANE 16 allopurinol sodium 13 ABSTRAL 1 alosetron hydrochloride 42 acamprosate calcium dr 3 ALPHAGAN P 60 acarbose 27 alprazolam 27 acebutolol hcl 32 ALREX 60 acetaminophen/codeine 2 altavera 46 acetazolamide 60 ALUNBRIG 19 acetazolamide er 60 alyacen 1/35 46 acetazolamide sodium 34 alyacen 7/7/7 46 acetic acid 61 alyq 63 acetic acid 0.25% 44 amantadine hcl 26 acetic acid/aluminum acetate 61 AMBISOME 12 acetylcysteine 63 ambrisentan 63 acitretin 37 amethia 46 ACTEMRA 53 amethia lo 46 ACTEMRA ACTPEN 53 amifostine 16 ACTHIB 53 amiloride hcl 34 ACTIMMUNE 53 amiloride/hydrochlorothiazide 34 acyclovir 26 amino acid 55 ACYCLOVIR SODIUM 26 aminocaproic acid 30 ADACEL 54 aminophylline 63 ADAGEN 42 AMINOSYN 56 adefovir dipivoxil 24 AMINOSYN 7%/ELECTROLYTES 38 ADEMPAS 63 aminosyn 8.5%/electrolytes 38 adriamycin 16 AMINOSYN II 56 ADVAIR DISKUS 63 aminosyn ii 8.5%/electrolytes 38 ADVAIR HFA 63 AMINOSYN M 38 afeditab cr 33 AMINOSYN-HBC 56 AFINITOR 19 AMINOSYN-PF 56 AFINITOR DISPERZ 19 AMINOSYN-PF 7% 56 AIMOVIG 14 AMINOSYN-RF 56 AKYNZEO 12 amiodarone hcl 31 ala-cort 44 amiodarone hydrochloride 31 albendazole 21 AMITIZA 42 albuterol sulfate 62 amitriptyline hcl 11 alclometasone dipropionate 44 amitriptyline hydrochloride 11 ALCOHOL PREP PADS 55 amlodipine besylate 33 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 65 of 88 Drug Name Page # Drug Name Page # amlodipine besylate/atorvastatin calcium 33 ASMANEX TWISTHALER 30 METERED 61 amlodipine besylate/benazepril 33 DOSES hydrochloride ASMANEX TWISTHALER 60 METERED 61 amlodipine besylate/valsartan 33 DOSES ammonium lactate 37 ASMANEX TWISTHALER 7 METERED 61 amnesteem 37 DOSES amoxapine 11 ASPIRIN/DIPYRIDAMOLE 30 amoxicillin 6 ASSURE ID SAFETY PEN NEEDLES 56 amoxicillin/clavulanate potassium 6 30G X 3/16" amoxicillin/clavulanate potassium er 6 ASSURE ID SAFETY PEN NEEDLES 56 amphetamine/dextroamphetamine 35 30G X 5/16" amphotericin b 12 ASSURE ID SAFETY PEN NEEDLES 56 ampicillin 6 31G X 3/16" ampicillin sodium 6 atazanavir sulfate 26 ampicillin-sulbactam 6 atenolol 32 ANADROL-50 46 atenolol/chlorthalidone 32 anagrelide hydrochloride 30 ATGAM 52 anastrozole 18 atomoxetine 36 ANDRODERM 46 atorvastatin calcium 34 androxy 46 atovaquone 21 ANORO ELLIPTA 63 atovaquone/proguanil hcl 21 ANZEMET 12 ATRIPLA 24 APOKYN 21 atropine sulfate 33 apraclonidine 60 atropine sulfate 59 aprepitant 12 ATROVENT HFA 62 apri 46 aubra 46 APRISO 54 augmented betamethasone dipropionate 44 APTIOM 8 AUGMENTIN 6 APTIVUS 25 AURYXIA 41 ARALAST NP 63 AUSTEDO 36 aranelle 46 AVASTIN 20 ARANESP ALBUMIN FREE 30 aviane 46 ARCALYST 53 avita 37 argatroban 29 AVONEX 36 aripiprazole 22 AVONEX PEN 36 aripiprazole odt 22 azacitidine 17 ARISTADA 22 AZACTAM IN ISO-OSMOTIC 6 ARISTADA INITIO 22 DEXTROSE ARRANON 16 AZASAN 51 arsenic trioxide 16 AZASITE 7 ARZERRA 20 azathioprine 51 ashlyna 46 azelaic acid 37 ASMANEX HFA 61 azelastine hcl 59 ASMANEX TWISTHALER 120 61 azelastine hcl 62 METERED DOSES azelastine hydrochloride 62 ASMANEX TWISTHALER 14 METERED 61 azithromycin 7 DOSES AZOPT 60 aztreonam 6

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 66 of 88 Drug Name Page # Drug Name Page # baciim 4 BENLYSTA 51 bacitracin 4 BENZNIDAZOLE 21 bacitracin/polymyxin b 59 benztropine mesylate 21 baclofen 23 BEPREVE 59 balsalazide disodium 54 BERINERT 51 BALVERSA 18 BESIVANCE 7 balziva 46 BESPONSA 20 BANZEL 9 betamethasone dipropionate 44 BARACLUDE 24 betamethasone valerate 44 BAVENCIO 20 BETASERON 36 BCG VACCINE 54 betaxolol hcl 32 BD INSULIN SYRINGE 56 betaxolol hcl 60 SAFETYGLIDE/1ML/29G X 1/2" bethanechol chloride 44 B-D INSULIN SYRINGE ULTRAFINE 56 BETIMOL 60 II/0.3ML/31G X 5/16" bexarotene 20 BD INSULIN SYRINGE ULTRA- 56 BEXSERO 54 FINE/0.5ML/30G X 12.7MM bicalutamide 15 BD INSULIN SYRINGE ULTRA- 56 BICILLIN C-R 6 FINE/1ML/31G X 8MM BICILLIN L-A 6 BD INSULIN SYRINGE/0.3ML/29G X 56 BICNU 15 12.7MM BIKTARVY 24 BD INSULIN SYRINGE/0.5ML/29G X 57 bimatoprost 59 12.7MM bisoprolol fumarate 32 BD INSULIN SYRINGE/1ML/27G X 57 bisoprolol fumarate/hydrochlorothiazide 32 12.7MM BIVIGAM 52 BD INSULIN SYRINGE/1ML/29G X 57 bleomycin 17 12.7MM bleomycin sulfate 17 BD INSULIN SYRINGE/U- 57 BLEPHAMIDE 60 500/0.5ML/31G X 6MM BLEPHAMIDE S.O.P. 60 BD PEN NEEDLE/ORIGINAL/ULTRA- 57 BLINCYTO 20 FINE/29G X 12.7MM blisovi 24 fe 46 BD SAFETYGLIDE INSULIN 57 blisovi fe 1.5/30 46 SYRINGE/1ML/31G X 15/64" blisovi fe 1/20 46 BD VEO INSULIN SYRINGE ULTRA- 57 BOOSTRIX 54 AFINE/0.3ML/31G X 6MM BORTEZOMIB 17 BD VEO INSULIN SYRINGE ULTRA- 57 BOSULIF 19 FINE/0.5ML/31G X 6MM BOTOX 23 BD VEO INSULIN SYRINGE ULTRA- 57 BRAFTOVI 17 FINE/1ML/31G X 6MM BREO ELLIPTA 61 bekyree 46 briellyn 46 BELEODAQ 17 BRILINTA 30 BELRAPZO 15 brimonidine tartrate 60 BELSOMRA 64 BRIVIACT 8 benazepril hcl 31 bromfenac 60 benazepril hcl/hydrochlorothiazide 31 bromocriptine mesylate 21 benazepril hydrochloride 31 budesonide 55 bendamustine hydrochloride 15 budesonide 61 BENDEKA 15 BUDESONIDE ER 55

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 67 of 88 Drug Name Page # Drug Name Page # bumetanide 34 carmustine 15 buprenorphine hcl 3 carteolol hcl 61 buprenorphine hcl/naloxone hcl 3 cartia xt 33 buprenorphine hydrochloride/naloxone 3 carvedilol 32 hydrochloride caspofungin acetate 12 bupropion hcl 10 CAYSTON 63 bupropion hydrochloride 10 caziant 46 bupropion hydrochloride er (sr) 3 cefaclor 5 bupropion hydrochloride er (sr) 10 cefaclor er 5 bupropion hydrochloride er (xl) 10 cefadroxil 5 buspirone hcl 26 cefazolin 5 buspirone hydrochloride 26 cefazolin sodium 5 busulfan 15 cefazolin sodium/dextrose 5 butorphanol tartrate 2 cefdinir 5 BYDUREON 27 CEFDITOREN PIVOXIL 5 BYDUREON BCISE 27 cefepime 5 BYDUREON PEN 27 cefixime 5 BYSTOLIC 32 cefotaxime sodium 5 cabergoline 51 cefotetan 5 CABLIVI 30 cefotetan/dextrose 5 CABOMETYX 19 cefoxitin sodium 5 caffeine citrate 36 cefpodoxime proxetil 5 calcipotriene 37 cefprozil 5 calcitonin-salmon 55 ceftazidime 5 calcitrene 37 ceftazidime/dextrose 5 calcitriol 55 ceftibuten 5 calcium acetate 41 ceftriaxone in iso-osmotic dextrose 6 calcium gluconate 38 ceftriaxone sodium 6 calcium gluconate/sodium chloride 38 ceftriaxone/dextrose 6 CALQUENCE 19 cefuroxime axetil 6 camila 50 cefuroxime sodium 6 camrese 46 CELONTIN 8 camrese lo 46 cephalexin 6 candesartan cilexetil 31 CERDELGA 42 candesartan cilexetil/hydrochlorothiazide 31 CEREZYME 42 CAPASTAT SULFATE 14 cetirizine hydrochloride 62 CAPRELSA 19 CHANTIX 3 captopril 31 CHANTIX CONTINUING MONTH PAK 3 captopril/hydrochlorothiazide 31 CHANTIX STARTING MONTH PAK 3 CARBAGLU 38 chateal 47 carbamazepine 9 CHENODAL 41 carbamazepine er 9 chloramphenicol sodium succinate 4 carbidopa 22 chlorhexidine gluconate 37 carbidopa/levodopa 22 chloroprocaine hydrochloride 3 carbidopa/levodopa er 22 chloroquine phosphate 21 carbidopa/levodopa odt 22 chlorothiazide 34 carboplatin 15 chlorothiazide sodium 34 carimune nanofiltered 53 chlorpromazine hcl 22

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 68 of 88 Drug Name Page # Drug Name Page # chlorthalidone 34 CLINIMIX 5%/DEXTROSE 25% 39 chlorzoxazone 64 CLINIMIX E 2.75%/DEXTROSE 10% 39 CHOLBAM 41 CLINIMIX E 2.75%/DEXTROSE 5% 39 cholestyramine 35 CLINIMIX E 4.25%/DEXTROSE 10% 39 cholestyramine light 35 CLINIMIX E 4.25%/DEXTROSE 25% 39 chorionic gonadotropin 45 CLINIMIX E 4.25%/DEXTROSE 5% 39 ciclodan 12 CLINIMIX E 5%/DEXTROSE 15% 39 ciclopirox 13 CLINIMIX E 5%/DEXTROSE 20% 39 ciclopirox nail lacquer 12 CLINIMIX E 5%/DEXTROSE 25% 39 ciclopirox olamine 12 CLINIMIX N14G30E 39 cidofovir 24 CLINIMIX N9G15E 39 cilostazol 30 CLINIMIX N9G20E 39 CIMDUO 25 CLINOLIPID 57 CINRYZE 57 clobazam 9 CINVANTI 12 clobetasol propionate 44 CIPRODEX 61 clobetasol propionate e 44 ciprofloxacin 7 clobetasol propionate emollient 44 ciprofloxacin er 7 clodan 44 ciprofloxacin hcl 7 clofarabine 16 ciprofloxacin hydrochloride 7 clomipramine hcl 11 ciprofloxacin i.v.-in d5w 7 clonazepam 9 cisplatin 15 clonazepam odt 9 CISPLATIN 17 clonidine hcl 30 citalopram hydrobromide 10 clonidine hcl 36 cladribine 16 clonidine hydrochloride 30 claravis 37 clopidogrel 30 clarithromycin 7 clorazepate dipotassium 27 clarithromycin er 7 CLORPRES 30 CLENPIQ 42 clotrimazole 13 CLEOCIN 4 clotrimazole/betamethasone dipropionate 13 CLIMARA PRO 47 clozapine 23 clindamycin 4 clozapine odt 23 clindamycin hcl 4 COARTEM 21 clindamycin hydrochloride 4 codeine sulfate 2 clindamycin palmitate hcl 4 COLCHICINE 13 clindamycin phosphate 4 colesevelam hydrochloride 35 clindamycin phosphate add-vantage 4 colestipol hcl 35 clindamycin phosphate in d5w 4 colistimethate sodium 4 clindamycin phosphate/benzoyl peroxide 37 colocort 55 clindamycin/benzoyl peroxide 37 COMBIGAN 61 clindamycin/sodium chloride 4 COMBIVENT RESPIMAT 62 CLINIMIX 2.75%/DEXTROSE 5% 38 COMETRIQ 19 CLINIMIX 4.25%/DEXTROSE 10% 38 COMPLERA 24 CLINIMIX 4.25%/DEXTROSE 20% 38 compro 12 CLINIMIX 4.25%/DEXTROSE 25% 38 constulose 42 CLINIMIX 4.25%/DEXTROSE 5% 38 COPIKTRA 17 CLINIMIX 5%/DEXTROSE 15% 38 CORLANOR 33 CLINIMIX 5%/DEXTROSE 20% 39 cormax scalp application 44

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 69 of 88 Drug Name Page # Drug Name Page # CORTIFOAM 44 daysee 47 cortisone acetate 44 deblitane 50 COSENTYX 37 decitabine 17 COSENTYX SENSOREADY PEN 37 deferasirox 41 COTELLIC 17 deferoxamine mesylate 57 CREON 43 DELSTRIGO 24 CRIXIVAN 26 deltasone 44 cromolyn sodium 41 delyla 47 cromolyn sodium 59 demeclocycline hcl 8 cromolyn sodium 63 demeclocycline hydrochloride 8 crotan 21 DEMSER 33 cryselle-28 47 DEPEN TITRATABS 41 CURITY GAUZE PADS 2"X2" 57 DEPOCYT 16 CUVITRU 53 DEPO-MEDROL 44 cyclafem 1/35 47 DEPO-PROVERA 50 cyclafem 7/7/7 47 DESCOVY 25 cyclobenzaprine hydrochloride 64 desipramine hcl 11 cyclopentolate hcl 59 desmopressin acetate 45 cyclopentolate hydrochloride 59 desogestrel/ethinyl estradiol 47 cyclophosphamide 15 desonide 44 cycloserine 14 DESVENLAFAXINE ER 10 cyclosporine 51 dexamethasone 44 cyclosporine modified 51 dexamethasone 10-day dose pack 44 cyproheptadine hcl 62 dexamethasone 13-day dose pack 44 CYRAMZA 20 dexamethasone 6-day dose pack 44 cyred 47 dexamethasone intensol 44 CYSTAGON 43 dexamethasone sodium phosphate 44 CYSTARAN 59 dexamethasone sodium phosphate 60 cytarabine 16 dexchlorpheniramine maleate 62 cytarabine aqueous 16 dexedrine 35 dacarbazine 15 dexmethylphenidate hcl 36 dactinomycin 17 dexrazoxane 21 dalfampridine er 36 dextroamphetamine sulfate 35 DALIRESP 63 dextroamphetamine sulfate er 35 danazol 46 dextrose 39 dantrolene sodium 23 dextrose 10%/nacl 0.45% 39 dapsone 14 dextrose 10% 39 dapsone 37 dextrose 10%/nacl 0.2% 39 DAPTACEL 54 dextrose 2.5%/nacl 0.45% 39 DAPTOMYCIN 4 dextrose 20% 39 DARAPRIM 21 dextrose 25% 39 darifenacin hydrobromide er 43 dextrose 30% 39 DARZALEX 20 dextrose 40% 39 dasetta 1/35 47 dextrose 5% 39 dasetta 7/7/7 47 dextrose 5%/lactated ringers 39 daunorubicin hcl 17 dextrose 5%/nacl 0.2% 39 daunorubicin hydrochloride 17 dextrose 5%/nacl 0.225% 39 DAURISMO 17 dextrose 5%/nacl 0.3% 39

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 70 of 88 Drug Name Page # Drug Name Page # dextrose 5%/nacl 0.33% 39 dobutamine/dextrose 5% 33 dextrose 5%/nacl 0.45% 39 docetaxel 17 dextrose 5%/nacl 0.9% 39 dofetilide 31 dextrose 50% 39 donepezil hcl 10 dextrose 70% 39 donepezil hydrochloride 10 DIASTAT ACUDIAL 9 dopamine hcl 33 DIASTAT PEDIATRIC 9 dopamine hydrochloride/dextrose 33 diazepam 9 dopamine/d5w 33 diazepam 27 DORIPENEM 6 diazepam rectal gel 9 dorzolamide hcl 61 diclofenac potassium 1 dorzolamide hcl/timolol maleate 61 diclofenac sodium 1 dorzolamide hydrochloride/timolol maleate 61 diclofenac sodium 37 pf diclofenac sodium 60 dotti 47 diclofenac sodium dr 1 DOVATO 24 diclofenac sodium er 1 doxazosin mesylate 43 diclofenac sodium xr 1 doxepin hcl 11 dicloxacillin sodium 6 doxepin hydrochloride 11 dicyclomine hcl 41 doxercalciferol 55 dicyclomine hydrochloride 41 doxorubicin hcl 17 didanosine 25 doxorubicin hydrochloride liposomal 17 DIFICID 7 doxorubicin hydrochloride liposome 17 diflunisal 1 doxy 100 8 digitek 33 doxycycline hyclate 8 digox 33 doxycycline hyclate dr 8 digoxin 33 doxycycline monohydrate 8 dihydroergotamine mesylate 14 doxylamine succinate/pyridoxine 12 DILANTIN 10 hydrochloride DILATRATE SR 35 d-penamine 40 diltiazem cd 33 DRIZALMA SPRINKLE 11 diltiazem hcl 33 dronabinol 12 diltiazem hcl cd 33 droperidol 12 diltiazem hcl er 33 DROPSAFE SAFETY PEN 57 diltiazem hydrochloride er 33 NEEDLES/31G X 5/16" dilt-xr 33 DROPSAFE SAFTEY PEN 57 diphenhydramine hcl 62 NEEDLES/31G X 1/4" diphenhydramine hydrochloride 62 drospirenone/ethinyl estradiol 47 diphenoxylate/atropine 41 drospirenone/ethinyl estradiol/levomefolate 47 diphtheria/tetanus toxoids adsorbed 54 calcium pediatric DROXIA 16 disopyramide phosphate 31 DULERA 63 disulfiram 3 duloxetine hcl 11 divalproex sodium 9 duloxetine hydrochloride 11 divalproex sodium dr 9 DUREZOL 60 divalproex sodium er 9 dutasteride 43 dobutamine hcl 33 DYMISTA 61 dobutamine hcl/d5w 33 EASY COMFORT INSULIN 57 dobutamine hydrochloride/dextrose 33 SYRINGE/1ML/32GX5/16"

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 71 of 88 Drug Name Page # Drug Name Page # EASY COMFORT INSULIN 57 eplerenone 34 SYRINGES/0.5ML/32GX5/16" epoprostenol sodium 63 EASY GLIDE PEN NEEDLES 33G X 57 eprosartan mesylate 31 5/32" EQUETRO 27 econazole nitrate 13 ERBITUX 20 EDURANT 25 ergoloid mesylates 10 efavirenz 25 ERGOMAR 14 ELAPRASE 43 ergotamine tartrate/caffeine 14 ELESTRIN 47 ERIVEDGE 19 elinest 47 ERLEADA 15 ELIQUIS 29 erlotinib hydrochloride 19 ELIQUIS STARTER PACK 29 errin 50 ELLA 50 ertapenem 6 ELMIRON 44 ertapenem sodium 6 ELZONRIS 17 ERWINAZE 17 EMBEDA 1 ery 7 EMCYT 16 ERY-TAB 7 EMEND 12 ERYTHROCIN STEARATE 7 EMGALITY 14 erythromycin 7 emoquette 47 erythromycin base 7 EMPLICITI 20 erythromycin dr 7 EMSAM 10 erythromycin ethylsuccinate 7 EMTRIVA 25 erythromycin/benzoyl peroxide 37 enalapril maleate 31 ESBRIET 63 enalapril maleate/hydrochlorothiazide 31 ESBRIET 63 ENBREL 51 escitalopram oxalate 11 ENBREL MINI 52 esmolol hcl 32 ENBREL SURECLICK 52 ESMOLOL HYDROCHLORIDE IN 32 ENDARI 57 WATER endocet 2 ESMOLOL HYDROCHLORIDE IN 32 ENGERIX-B 54 WATER DOUBLE STRENGTH enoxaparin sodium 29 esmolol hydrochloride/sodium chloride 32 enpresse-28 47 esomeprazole magnesium 42 enskyce 47 estarylla 47 entacapone 21 estradiol 47 entecavir 24 estradiol valerate 47 ENTRESTO 33 ESTRING 47 ENTYVIO 53 estropipate 47 enulose 42 ethacrynic acid 34 EPANED 31 ethambutol hcl 14 EPIDIOLEX 8 ethambutol hydrochloride 14 epinastine hcl 60 ethosuximide 8 EPINEPHRINE 62 ethynodiol diacetate/ethinyl estradiol 47 EPIPEN 2-PAK 62 etidronate disodium 55 EPIPEN-JR 2-PAK 62 etodolac 1 epirubicin hcl 17 etoposide 18 epitol 10 EUCRISA 37 EPIVIR HBV 24 EVOMELA 15

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 72 of 88 Drug Name Page # Drug Name Page # EVOTAZ 26 fluocinolone acetonide 44 EXEL COMFORT POINT INSULIN 57 fluocinolone acetonide 61 SYRINGE/1ML/29G X 1/2" fluocinolone acetonide ear drops 61 exemestane 18 fluocinonide 44 EXONDYS 51 43 fluocinonide emulsified base 44 EYLEA 59 fluorouracil 16 ezetimibe 35 fluoxetine 11 ezetimibe/simvastatin 35 fluoxetine hcl 11 FABRAZYME 43 fluoxetine hydrochloride 11 falmina 47 fluphenazine decanoate 22 famciclovir 26 fluphenazine hcl 22 famotidine 42 fluphenazine hydrochloride 22 FANAPT 22 flurbiprofen 1 FANAPT TITRATION PACK 22 flurbiprofen sodium 60 FARYDAK 17 flutamide 15 FASLODEX 16 fluticasone propionate 44 febuxostat 13 fluticasone propionate 61 felbamate 9 fluticasone propionate/salmeterol diskus 63 felodipine er 33 fluvastatin 34 femynor 47 fluvastatin sodium er 35 fenofibrate 34 fluvoxamine maleate 11 fenofibrate micronized 34 FML FORTE 60 fenofibric acid dr 34 FOLOTYN 16 fentanyl 1 fondaparinux sodium 29 fentanyl citrate 2 FORTEO 55 fentanyl citrate oral transmucosal 2 fosamprenavir calcium 26 FERRIPROX 41 fosinopril sodium 31 FETZIMA 11 fosinopril sodium/hydrochlorothiazide 31 FETZIMA TITRATION PACK 11 fosphenytoin sodium 10 FINACEA 37 FRAGMIN 29 finasteride 43 FREAMINE HBC 6.9% 57 FIRAZYR 51 FREAMINE III 57 FIRDAPSE 57 frovatriptan succinate 14 FIRMAGON 51 fulvestrant 16 flac 61 furosemide 34 FLAREX 60 FUZEON 25 flavoxate hcl 43 fyavolv 47 FLEBOGAMMA DIF 53 FYCOMPA 8 flecainide acetate 31 gabapentin 9 FLOVENT DISKUS 61 GABLOFEN 23 FLOVENT HFA 61 GALAFOLD 43 floxuridine 16 galantamine hydrobromide 10 fluconazole 13 galantamine hydrobromide er 10 fluconazole in nacl 13 GAMASTAN 53 flucytosine 13 GAMASTAN S/D 53 fludarabine phosphate 17 GAMIFANT 53 fludrocortisone acetate 44 GAMMAGARD LIQUID 53 flunisolide 61

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 73 of 88 Drug Name Page # Drug Name Page # GAMMAGARD S/D IGA LESS THAN 53 glydo 3 1MCG/ML GLYXAMBI 27 GAMMAKED 53 granisetron hcl 12 GAMMAPLEX 53 granisetron hydrochloride 12 GAMUNEX-C 53 griseofulvin microsize 13 ganciclovir 24 griseofulvin ultramicrosize 13 GARDASIL 54 guanfacine er 36 GARDASIL 9 54 guanfacine hcl 30 gatifloxacin 7 guanidine hcl 14 GATTEX 41 HAEGARDA 57 gavilyte-c 42 hailey 1.5/30 47 gavilyte-g 42 hailey 24 fe 47 gavilyte-h 42 HALAVEN 17 gavilyte-n/flavor pack 42 halcinonide 44 GAZYVA 20 halobetasol propionate 44 gemcitabine 16 haloperidol 22 gemcitabine hcl 16 haloperidol decanoate 22 GEMCITABINE HYDROCHLORIDE 16 haloperidol lactate 22 gemfibrozil 34 HAVRIX 54 generlac 42 heather 50 gengraf 52 HEPAGAM B 53 GENOTROPIN 45 heparin sodium 29 GENOTROPIN MINIQUICK 45 heparin sodium/d5w 29 gentak 4 heparin sodium/nacl 0.45% 29 gentamicin sulfate 4 heparin sodium/nacl 0.9% 29 gentamicin sulfate/0.9% sodium chloride 4 heparin sodium/sodium chloride 29 GENVOYA 24 heparin sodium/sodium chloride 0.9% 29 GEODON 22 heparin sodium/sodium chloride 0.9% 29 gianvi 47 premix gildagia 47 hepatamine 57 GILENYA 36 HEPLISAV-B 54 GILOTRIF 19 HERCEPTIN 20 glatiramer acetate 36 HETLIOZ 64 glatopa 36 HEXALEN 15 GLEOSTINE 15 HIBERIX 54 glimepiride 27 HIZENTRA 53 glipizide 27 HUMALOG 28 glipizide er 27 HUMALOG JUNIOR KWIKPEN 28 glipizide xl 27 HUMALOG KWIKPEN 28 glipizide/metformin hydrochloride 27 HUMALOG MIX 50/50 28 GLUCAGEN HYPOKIT 28 HUMALOG MIX 50/50 KWIKPEN 28 GLUCAGON EMERGENCY KIT 28 HUMALOG MIX 75/25 28 glucose 5% 39 HUMALOG MIX 75/25 KWIKPEN 28 glyburide 27 HUMIRA 52 glyburide micronized 27 HUMIRA PEDIATRIC CROHNS 52 glyburide/metformin hydrochloride 27 DISEASE STARTER PACK glycate 41 HUMIRA PEN 52 glycopyrrolate 41 HUMIRA PEN-CD/UC/HS STARTER 52

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 74 of 88 Drug Name Page # Drug Name Page # HUMIRA PEN-PS/UV STARTER 52 IMBRUVICA 19 HUMULIN 70/30 28 IMFINZI 20 HUMULIN 70/30 KWIKPEN 28 imipenem/cilastatin 6 HUMULIN N 28 imipramine hcl 11 HUMULIN N KWIKPEN 28 imipramine hydrochloride 11 HUMULIN R 28 imiquimod 37 HUMULIN R U-500 (CONCENTRATED) 28 imiquimod pump 37 HUMULIN R U-500 KWIKPEN 28 IMOVAX RABIES (H.D.C.V.) 54 hydralazine hcl 35 IMPAVIDO 4 hydralazine hydrochloride 35 IMVEXXY MAINTENANCE PACK 47 hydrochlorothiazide 34 IMVEXXY STARTER PACK 47 hydrocodone bitartrate/acetaminophen 2 incassia 50 hydrocodone/acetaminophen 2 INCRELEX 45 hydrocortisone 4 indapamide 34 hydrocortisone 45 indomethacin 1 hydrocortisone 55 INFANRIX 54 hydrocortisone butyrate 45 INFLECTRA 52 hydrocortisone valerate 45 INFUMORPH 200 1 hydromorphone hcl 2 INFUMORPH 500 1 hydromorphone hcl dosette 2 INLYTA 19 hydromorphone hcl er 1 INREBIC 17 hydromorphone hydrochloride 2 INSULIN LISPRO 28 hydromorphone hydrochloride er 1 INSULIN LISPRO KWIKPEN 28 hydroxychloroquine sulfate 21 INSULIN SYRINGE/NEEDLE 0.3ML/30G 57 HYDROXYPROGESTERONE 50 X 5/16" CAPROATE INSULIN SYRINGE/NEEDLE 0.3ML/31G 57 hydroxyurea 16 X 5/16" hydroxyzine hcl 26 INSULIN SYRINGE/NEEDLE 0.5ML/29G 57 hydroxyzine hydrochloride 26 X 1/2" hydroxyzine pamoate 62 INSULIN SYRINGE/NEEDLE 0.5ML/30G 57 HYPERHEP B S/D 53 X 5/16" HYPERRAB 53 INSULIN SYRINGE/NEEDLE 0.5ML/31G 57 HYPERRHO S/D 53 X 5/16" HYPERRHO S/D MINI-DOSE 53 INSULIN SYRINGE/NEEDLE 1ML/31G 57 ibandronate sodium 55 X 5/16" IBRANCE 17 INTELENCE 25 ibu 1 intralipid 57 ibuprofen 1 INTRON A 24 ibutilide fumarate 32 INTRON A W/DILUENT 24 icatibant acetate 51 introvale 47 ICLUSIG 19 INVEGA SUSTENNA 22 idarubicin hcl 17 INVEGA TRINZA 22 idarubicin hydrochloride 17 INVELTYS 60 IDHIFA 19 INVIRASE 26 ifosfamide 15 INVOKAMET 27 ILARIS 53 INVOKAMET XR 27 ILUMYA 37 INVOKANA 27 imatinib mesylate 19 IONOSOL-B/DEXTROSE 5% 39

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 75 of 88 Drug Name Page # Drug Name Page # IONOSOL-MB/DEXTROSE 5% 39 JULUCA 24 IPOL INACTIVATED IPV 54 junel 1.5/30 47 ipratropium bromide 62 junel 1/20 47 ipratropium bromide/albuterol sulfate 62 junel fe 1.5/30 47 irbesartan 31 junel fe 1/20 47 irbesartan/hydrochlorothiazide 31 junel fe 24 47 IRESSA 19 JUXTAPID 35 irinotecan 18 KADCYLA 20 irinotecan hcl 18 KALBITOR 51 irinotecan hydrochloride 18 KALETRA 26 ISENTRESS 24 KALYDECO 63 ISENTRESS 25 KANUMA 43 ISENTRESS HD 25 kariva 47 isibloom 47 kcl 0.075%/d5w/nacl 0.45% 39 ISOLYTE-P/DEXTROSE 5% 39 kcl 0.15%/d5w/nacl 0.2% 39 ISOLYTE-S 39 kcl 0.15%/d5w/nacl 0.225% 40 ISOLYTE-S PH 7.4 39 kcl 0.15%/d5w/nacl 0.45% 40 isoniazid 14 kcl 0.15%/d5w/nacl 0.9% 40 isoproterenol hydrochloride 62 kcl 0.3%/d5w/nacl 0.45% 40 ISORDIL TITRADOSE 35 kcl 0.3%/d5w/nacl 0.9% 40 isosorbide dinitrate 35 kelnor 1/35 48 isosorbide dinitrate er 35 kelnor 1/50 48 isosorbide mononitrate 35 KENALOG-10 45 isosorbide mononitrate er 35 KENALOG-40 45 isotretinoin 37 ketoconazole 13 ISTODAX (OVERFILL) 17 ketoprofen 1 itraconazole 13 ketorolac tromethamine 1 ivermectin 21 ketorolac tromethamine 60 IXEMPRA KIT 17 KEYTRUDA 20 IXIARO 54 KHAPZORY 21 JADENU 41 kimidess 48 JADENU SPRINKLE 41 KINRIX 54 JAKAFI 19 kionex 41 jantoven 29 KISQALI 17 JANUMET 27 KISQALI FEMARA 200 DOSE 15 JANUMET XR 27 KISQALI FEMARA 400 DOSE 15 JANUVIA 28 KISQALI FEMARA 600 DOSE 15 JARDIANCE 28 klor-con 40 jencycla 50 klor-con 10 40 JENTADUETO 28 klor-con 8 40 JENTADUETO XR 28 klor-con m10 40 jevantique lo 47 klor-con m15 40 JEVTANA 17 klor-con m20 40 jinteli 47 klor-con sprinkle 40 jolessa 47 KOMBIGLYZE XR 28 jolivette 50 KORLYM 46 JUBLIA 13 KRISTALOSE 42 juleber 47 KRYSTEXXA 13

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 76 of 88 Drug Name Page # Drug Name Page # kurvelo 48 levalbuterol 62 KUVAN 43 levalbuterol hcl 62 KYPROLIS 18 levalbuterol hydrochloride 62 labetalol hydrochloride 32 levalbuterol tartrate hfa 62 lactated ringers 40 LEVEMIR 28 lactated ringers irrigation 57 LEVEMIR FLEXTOUCH 29 lactated ringers viaflex 40 levetiracetam 8 lactulose 42 levetiracetam er 8 lamivudine 24 levetiracetam/sodium chloride 8 lamivudine 25 levobunolol hcl 61 lamivudine/zidovudine 25 levocarnitine 57 lamotrigine 9 levocetirizine dihydrochloride 62 lamotrigine starter kit/blue 9 levofloxacin 7 lamotrigine starter kit/green 9 levofloxacin in d5w 7 lamotrigine starter kit/orange 9 LEVOLEUCOVORIN 17 lamotrigine titration 9 levoleucovorin calcium 17 LANOXIN 33 levonest 48 lansoprazole 42 levonorgestrel 50 lansoprazole odt 42 levonorgestrel and ethinyl estradiol 48 lanthanum carbonate 41 levonorgestrel/ethinyl estradiol 48 LANTUS 28 levora 0.15/30-28 48 LANTUS SOLOSTAR 28 levothyroxine sodium 50 larin 1.5/30 48 LEVOXYL 50 larin 1/20 48 LEXETTE 45 larin 24 fe 48 LEXIVA 26 larin fe 1.5/30 48 LIBTAYO 20 larin fe 1/20 48 lidocaine 3 larissia 48 lidocaine hcl 3 LARTRUVO 20 lidocaine hcl 32 latanoprost 59 lidocaine hcl 37 LATUDA 23 lidocaine hcl jelly 3 LAZANDA 2 lidocaine hydrochloride 3 leena 48 lidocaine viscous 37 leflunomide 53 lidocaine/epinephrine 3 LEMTRADA 53 lidocaine/prilocaine 3 LENVIMA 10 MG DAILY DOSE 19 lidocaine-prilocaine-cream base 3 LENVIMA 12MG DAILY DOSE 19 lindane 21 LENVIMA 14 MG DAILY DOSE 19 linezolid 4 LENVIMA 18 MG DAILY DOSE 19 LINZESS 42 LENVIMA 20 MG DAILY DOSE 19 LIORESAL INTRATHECAL 23 LENVIMA 24 MG DAILY DOSE 19 liothyronine sodium 50 LENVIMA 4 MG DAILY DOSE 19 lipodox 50 17 LENVIMA 8 MG DAILY DOSE 19 lisinopril 31 lessina 48 lisinopril/hydrochlorothiazide 31 letrozole 18 lithium 27 leucovorin calcium 17 lithium carbonate 27 LEUKERAN 15 lithium carbonate er 27 leuprolide acetate 51 LIVALO 35

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 77 of 88 Drug Name Page # Drug Name Page # LO LOESTRIN FE 48 matzim la 33 lokara 45 MAVENCLAD 36 LOKELMA 41 MAVYRET 24 LONHALA MAGNAIR REFILL KIT 62 MAYZENT 36 LONSURF 16 MAYZENT STARTER PACK 36 loperamide hcl 41 meclizine hcl 12 lopinavir/ritonavir 26 medroxyprogesterone acetate 50 lorazepam 27 mefloquine hcl 21 lorazepam intensol 27 megestrol acetate 50 LORBRENA 17 MEKINIST 19 lorcet 2 MEKTOVI 17 lorcet hd 2 meloxicam 1 lorcet plus 2 melphalan hydrochloride 15 loryna 48 memantine hcl 10 losartan potassium 31 memantine hcl titration pak 10 losartan potassium/hydrochlorothiazide 31 memantine hydrochloride 10 LOTEMAX 60 memantine hydrochloride er 10 LOTEMAX SM 60 MENACTRA 54 loteprednol etabonate 60 MENHIBRIX 54 lovastatin 35 MENOMUNE-A/C/Y/W-135 54 low-ogestrel 48 MENVEO 54 loxapine 22 mercaptopurine 16 loxapine succinate 22 meropenem 6 LUMIGAN 59 mesalamine 55 LUMIZYME 43 MESALAMINE DR 54 LUMOXITI 20 mesna 21 LUPRON DEPOT (1-MONTH) 51 MESNEX 21 LUPRON DEPOT (3-MONTH) 51 metadate er 36 LUPRON DEPOT (4-MONTH) 51 metaproterenol sulfate 62 LUPRON DEPOT (6-MONTH) 51 metformin hydrochloride 28 LUPRON DEPOT-PED (1-MONTH) 51 metformin hydrochloride er 28 LUPRON DEPOT-PED (3-MONTH) 51 methadone hcl 1 lutera 48 methadone hcl intensol 1 LYNPARZA 17 methadose 1 LYRICA 8 methadose sugar-free 1 LYSODREN 50 methazolamide 61 lyza 50 methenamine hippurate 4 MAFENIDE ACETATE 4 methergine 57 magnesium sulfate 40 methimazole 51 magnesium sulfate in d5w 40 methotrexate 52 MAKENA 50 methotrexate sodium 52 malathion 21 methoxsalen 37 mannitol 34 methscopolamine bromide 41 maprotiline hcl 11 methyclothiazide 34 marlissa 48 methyldopa 30 MARPLAN 10 methylergonovine maleate 58 MARQIBO 17 methylphenidate hydrochloride 36 MATULANE 15 methylphenidate hydrochloride er 36

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 78 of 88 Drug Name Page # Drug Name Page # methylprednisolone 45 mometasone furoate 45 methylprednisolone dose pack 45 mometasone furoate 61 methylprednisolone sodium succinate 45 mondoxyne nl 8 metipranolol 61 mono-linyah 48 metoclopramide hcl 41 mononessa 48 metoclopramide hydrochloride 41 montelukast sodium 62 metolazone 34 morphine sulfate 2 metoprolol succinate er 32 morphine sulfate er 1 metoprolol tartrate 32 moxifloxacin hydrochloride/sodium 7 metoprolol/hydrochlorothiazide 32 hydrochloride metronidazole 5 moxifloxacin hcl 7 metronidazole 37 moxifloxacin hydrochloride 7 metronidazole in nacl 0.79% 4 MOZOBIL 30 metronidazole vaginal 4 mupirocin 5 mexiletine hcl 32 MUSTARGEN 15 MIACALCIN 55 mutamycin 17 miconazole 3 13 my way 50 MICRHOGAM ULTRA-FILTERED PLUS 53 MYALEPT 58 microgestin 1.5/30 48 mycophenolate mofetil 52 microgestin 1/20 48 mycophenolic acid dr 52 microgestin 24 fe 48 MYLOTARG 20 microgestin fe 48 myorisan 37 microgestin fe 1.5/30 48 MYRBETRIQ 43 midazolam hcl 27 myzilra 48 midazolam hydrochloride 27 NABI-HB 53 midodrine hcl 30 nabumetone 1 miglustat 43 nadolol 32 mili 48 nafcillin sodium 6 MILLIPRED DP 45 NAGLAZYME 43 milrinone in dextrose 34 nalbuphine hcl 2 milrinone lactate 34 naloxone hcl 3 minitran 35 naltrexone hcl 3 MINOCIN 8 naproxen 1 minocycline hcl 8 naproxen dr 1 minocycline hydrochloride 8 naproxen sodium 1 minoxidil 35 naratriptan hcl 14 mirtazapine 10 NARCAN 3 mirtazapine odt 10 NATACYN 13 misoprostol 42 nateglinide 28 mitigo 1 NATPARA 55 mitomycin 17 NEBUPENT 21 mitoxantrone hcl 17 necon 0.5/35-28 48 M-M-R II 54 necon 1/35 48 modafinil 64 necon 1/50-28 48 moderiba 24 necon 10/11-28 48 moexipril hcl 31 necon 7/7/7 48 moexipril/hydrochlorothiazide 31 nefazodone hcl 11 molindone hydrochloride 22 nefazodone hydrochloride 11

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 79 of 88 Drug Name Page # Drug Name Page # neomycin sulfate 4 norethindrone acetate/ethinyl estradiol 48 neomycin/bacitracin/polymyxin 59 norethindrone acetate/ethinyl 48 neomycin/polymyxin b sulfates 4 estradiol/ferrous fumarate neomycin/polymyxin/bacitracin 59 norgestimate/ethinyl estradiol 48 neomycin/polymyxin/bacitracin/hydrocortis 60 norlyroc 50 one NORMOSOL -R 40 neomycin/polymyxin/dexamethasone 60 NORMOSOL-M IN D5W 40 neomycin/polymyxin/gramicidin 59 NORMOSOL-R 40 neomycin/polymyxin/hc 61 NORMOSOL-R IN D5W 40 neomycin/polymyxin/hydrocortisone 60 NORPACE CR 32 neomycin/polymyxin/hydrocortisone 61 NORTHERA 34 neo-polycin 59 nortrel 0.5/35 (28) 48 neo-polycin hc 60 nortrel 1/35 49 NEPHRAMINE 58 nortrel 7/7/7 49 NERLYNX 17 nortriptyline hcl 11 NEULASTA 30 nortriptyline hydrochloride 11 NEULASTA ONPRO KIT 30 NORVIR 26 NEUPOGEN 30 NOVAREL 45 NEUPRO 21 NOXAFIL 13 nevirapine 25 NPLATE 30 nevirapine er 25 NUBEQA 15 NEXAVAR 19 NUCALA 63 niacin er 35 NUEDEXTA 36 NICOTROL INHALER 3 NULOJIX 52 NICOTROL NS 3 NUPLAZID 23 nifedipine er 33 nutrilipid 58 nikki 48 NUTROPIN AQ NUSPIN 10 45 nilutamide 15 NUTROPIN AQ NUSPIN 20 45 nimodipine 33 NUTROPIN AQ NUSPIN 5 46 NINLARO 17 NUZYRA 8 NIPENT 16 nyamyc 13 nisoldipine er 33 nyata 13 nitisinone 43 NYMALIZE 33 NITRO-BID 35 nystatin 13 NITRO-DUR 35 nystatin/triamcinolone 13 nitrofurantoin 5 nystop 13 nitrofurantoin macrocrystals 5 ocella 49 nitrofurantoin monohydrate 5 OCTAGAM 53 nitrofurantoin monohydrate/macrocrystals 5 octreotide acetate 51 nitroglycerin 35 ODEFSEY 25 nitroglycerin in 5% dextrose 35 ODOMZO 19 nitroglycerin in dextrose 5% 35 OFEV 63 nitroglycerin transdermal 35 ofloxacin 7 NIVESTYM 30 okebo 8 nora-be 50 olanzapine 23 norepinephrine bitartrate 34 olanzapine odt 23 norethindrone 50 olmesartan medoxomil 31 norethindrone acetate 50 olmesartan medoxomil/hydrochlorothiazide 31

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 80 of 88 Drug Name Page # Drug Name Page # olopatadine hcl 60 paclitaxel 18 olopatadine hcl 62 paliperidone er 23 olopatadine hydrochloride 60 palonosetron hydrochloride 12 OLUMIANT 53 pamidronate disodium 55 omega-3-acid ethyl esters 35 PANRETIN 20 omeprazole 42 pantoprazole sodium 42 OMNIPOD 10 PACK 58 PANZYGA 53 OMNIPOD 5 PACK 58 paricalcitol 55 OMNIPOD DASH 5 PACK 58 paroex 37 OMNIPOD DASH SYSTEM 58 paromomycin sulfate 4 OMNIPOD STARTER KIT 58 paroxetine hcl 11 ONCASPAR 18 paroxetine hcl er 11 ondansetron hcl 12 paroxetine hydrochloride 11 ondansetron hydrochloride 12 paser 14 ondansetron odt 12 PAXIL 11 ONGLYZA 28 PAZEO 60 ONIVYDE 18 PEDIARIX 54 ONMEL 13 PEDVAX HIB 54 OPDIVO 20 peg 3350/electrolytes 42 opium 41 peg-3350/electrolytes 42 opium tincture 41 peg-3350/nacl/na bicarbonate/kcl 42 OPSUMIT 63 PEGANONE 10 oralone dental paste 37 PEGASYS 24 ORENCIA 52 PEGASYS PROCLICK 24 ORENCIA CLICKJECT 52 PEGINTRON 24 ORENITRAM 63 penicillin g potassium 6 ORFADIN 43 PENICILLIN G POTASSIUM IN ISO- 6 ORILISSA 51 OSMOTIC DEXTROSE ORKAMBI 63 penicillin g sodium 6 orsythia 49 penicillin v potassium 6 oseltamivir phosphate 26 PENTACEL 54 osmitrol viaflex 34 PENTAM 300 21 OSPHENA 50 pentamidine isethionate 21 oxaliplatin 15 pentobarbital sodium 64 oxandrolone 46 pentoxifylline er 34 oxaprozin 1 PERFOROMIST 62 OXAYDO 2 perindopril erbumine 31 oxcarbazepine 10 periogard 37 OXERVATE 59 PERJETA 20 oxiconazole nitrate 13 permethrin 21 oxybutynin chloride 43 perphenazine 22 oxybutynin chloride er 43 PERSERIS 23 oxycodone hcl 2 phenelzine sulfate 10 oxycodone hydrochloride 2 phenobarbital 8 oxycodone/acetaminophen 2 phenobarbital 9 oxycodone/aspirin 2 phenobarbital sodium 8 OZEMPIC 28 phenoxybenzamine hydrochloride 30 pacerone 32 phenylephrine hydrochloride 30

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 81 of 88 Drug Name Page # Drug Name Page # phenytoin 10 potassium chloride/dextrose 40 phenytoin sodium extended 10 potassium chloride/dextrose/lactated 40 philith 49 ringers PHOSPHOLINE IODIDE 61 potassium chloride/dextrose/sodium 40 PHYSIOLYTE 58 chloride PHYSIOSOL IRRIGATION 58 potassium chloride/sodium chloride 40 PICATO 38 potassium citrate er 40 PIFELTRO 25 POTELIGEO 20 pilocarpine hcl 37 POTIGA 8 pilocarpine hcl 61 PRADAXA 29 pilocarpine hydrochloride 37 pramipexole dihydrochloride 21 pimecrolimus 38 prasugrel 30 pimozide 22 pravastatin sodium 35 pimtrea 49 praziquantel 21 pindolol 32 prazosin hcl 31 pioglitazone hcl 28 prazosin hydrochloride 31 pioglitazone hcl/metformin hcl 28 prednicarbate 45 pioglitazone hcl-glimepiride 28 prednisolone 45 pioglitazone hydrochloride 28 prednisolone acetate 60 piperacillin sodium/ tazobactam sodium 6 prednisolone acetate p-f 60 piperacillin sodium/tazobactam 6 prednisolone sodium phosphate 45 piperacillin sodium/tazobactam sodium 6 prednisolone sodium phosphate 60 piperacillin/tazobactam 6 prednisone 45 PIQRAY 200MG DAILY DOSE 18 prednisone intensol 45 PIQRAY 250MG DAILY DOSE 18 pregabalin 8 PIQRAY 300MG DAILY DOSE 18 pregnyl w/diluent benzyl alcohol/nacl 46 pirmella 1/35 49 PREMARIN 49 pirmella 7/7/7 49 PREMASOL 58 PLASMA-LYTE A 40 PREMPHASE 49 PLASMA-LYTE-148 40 PREMPRO 49 PLASMA-LYTE-56/D5W 40 prevalite 35 PLEGRIDY 36 previfem 49 PLEGRIDY STARTER PACK 36 PREZCOBIX 26 podofilox 38 PREZISTA 26 POLIVY 20 PRIFTIN 14 polocaine 3 primaquine phosphate 21 polocaine-mpf 3 primidone 9 polycin 59 PRIMSOL 5 polyethylene glycol 3350 42 PRIVIGEN 53 polymyxin b sulfate/trimethoprim sulfate 59 PROAIR DIGIHALER 62 POMALYST 15 PROAIR HFA 62 portia-28 49 PROAIR RESPICLICK 62 PORTRAZZA 20 probenecid 13 posaconazole dr 13 probenecid/colchicine 13 potassium chloride 40 procainamide hcl 32 potassium chloride cr 40 procainamide hydrochloride 32 potassium chloride er 40 PROCALAMINE 40 potassium chloride sr 40 prochlorperazine 12

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 82 of 88 Drug Name Page # Drug Name Page # prochlorperazine edisylate 12 RABAVERT 54 prochlorperazine maleate 12 rabeprazole sodium 42 procto-med hc 4 RADICAVA 36 procto-pak 4 rajani 49 proctosol hc 4 raloxifene hydrochloride 50 proctozone-hc 4 ramelteon 64 PROCYSBI 43 ramipril 31 progesterone 50 ranitidine hcl 42 PROGLYCEM 28 ranitidine hydrochloride 42 PROGRAF 52 ranolazine er 34 PROLASTIN-C 63 rasagiline mesylate 22 PROLENSA 60 RASUVO 52 PROLEUKIN 18 RAVICTI 43 PROLIA 55 RAYALDEE 41 PROMACTA 30 REBIF 36 promethazine hcl 12 REBIF REBIDOSE 37 promethazine hcl plain 12 REBIF REBIDOSE TITRATION PACK 37 promethazine hydrochloride 12 REBIF TITRATION PACK 37 propafenone hcl 32 reclipsen 49 propafenone hydrochloride er 32 RECOMBIVAX HB 54 proparacaine hcl 59 RECTIV 38 propranolol hcl 32 regonol 14 propranolol hcl er 32 RELENZA DISKHALER 26 propranolol hydrochloride 33 RELISTOR 41 propranolol hydrochloride er 32 RENFLEXIS 52 propranolol/hydrochlorothiazide 33 repaglinide 28 propylthiouracil 51 repaglinide/metformin hydrochloride 28 PROQUAD 54 REPATHA 34 PROSOL 58 REPATHA PUSHTRONEX SYSTEM 34 protriptyline hcl 11 REPATHA SURECLICK 34 PULMOZYME 63 RESCRIPTOR 25 PURIXAN 16 RESTASIS 59 pyrazinamide 14 RETACRIT 30 pyridostigmine bromide 14 RETROVIR IV INFUSION 25 pyridostigmine bromide er 14 REVLIMID 16 QUADRACEL 54 REXULTI 23 quasense 49 REYATAZ 26 quetiapine fumarate 23 RHOGAM ULTRA-FILTERED PLUS 53 quetiapine fumarate er 23 RHOPHYLAC 53 quinapril hcl 31 RHOPRESSA 59 quinapril hydrochloride 31 ribasphere 24 quinapril/hydrochlorothiazide 31 ribavirin 24 quinidine gluconate 32 rifabutin 14 quinidine gluconate cr 32 rifampin 14 quinidine gluconate er 32 RIFATER 15 quinidine sulfate 32 riluzole 36 quinine sulfate 21 rimantadine hcl 26 QVAR REDIHALER 61 ringers injection 40

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 83 of 88 Drug Name Page # Drug Name Page # ringers irrigation 58 SIGNIFOR 51 RINVOQ 53 SIKLOS 16 RISPERDAL CONSTA 23 sildenafil 63 risperidone 23 sildenafil citrate 63 risperidone odt 23 silodosin 43 ritonavir 26 silver sulfadiazine 5 RITUXAN 20 SIMBRINZA 61 RITUXAN HYCELA 20 SIMPONI 52 rivastigmine tartrate 10 SIMPONI ARIA 53 rivastigmine transdermal system 10 simvastatin 35 rizatriptan benzoate 14 sirolimus 52 rizatriptan benzoate odt 14 SIRTURO 15 ROCKLATAN 61 SIVEXTRO 5 romidepsin 18 SKYRIZI 52 ropinirole hcl 22 sodium acetate 40 ropinirole hydrochloride 22 sodium bicarbonate 40 rosadan 38 sodium chloride 40 rosuvastatin calcium 35 sodium chloride 0.9% 58 ROTARIX 54 sodium chloride 0.45% 40 ROTATEQ 54 sodium chloride 0.9% 58 roweepra 8 sodium fluoride 40 roweepra xr 8 sodium phenylacetate/sodium benzoate 58 ROZLYTREK 18 sodium phenylbutyrate 43 RUBRACA 19 sodium polystyrene sulfonate 41 RUCONEST 51 SOFOSBUVIR/VELPATASVIR 24 RUZURGI 58 SOLIRIS 30 RYDAPT 18 soloxide 8 RYTARY 22 SOLTAMOX 16 SANCUSO 12 SOLU-CORTEF 45 SANDIMMUNE 52 SOLU-MEDROL 45 SANTYL 38 SOMATULINE DEPOT 51 SAPHRIS 23 SOMAVERT 51 SAVELLA 36 sorine 32 SAVELLA TITRATION PACK 36 sotalol hcl 32 scopolamine 12 sotalol hcl (af) 32 selegiline hcl 22 sotalol hcl af 32 selenium sulfide 38 sotalol hydrochloride 32 SELZENTRY 25 sotalol hydrochloride (af) 32 SEREVENT DISKUS 62 sotalol hydrochloride af 32 sertraline hcl 11 SPINRAZA 58 sertraline hydrochloride 11 SPIRIVA HANDIHALER 62 setlakin 49 SPIRIVA RESPIMAT 62 sevelamer carbonate 41 spironolactone 34 sevelamer hydrochloride 41 spironolactone/hydrochlorothiazide 34 SEYSARA 8 sprintec 28 49 SFROWASA 55 SPRITAM 8 sharobel 50 SPRIX 1 SHINGRIX 54 SPRYCEL 19

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 84 of 88 Drug Name Page # Drug Name Page # sps 41 SYNAREL 51 sronyx 49 SYNDROS 12 ssd 5 SYNJARDY 28 STAMARIL 54 SYNJARDY XR 28 stavudine 25 SYNRIBO 18 STELARA 38 SYNTHAMIN 17 58 sterile water irrigation 58 TABLOID 16 sterile water irrigation plastic bottle 58 tacrolimus 38 sterile water irrigation w/hanger 58 tacrolimus 52 STIMATE 46 tadalafil 63 STIOLTO RESPIMAT 63 TAFINLAR 19 STIVARGA 19 TAGRISSO 19 STRENSIQ 43 TAKHZYRO 34 streptomycin sulfate 4 TALTZ 38 STRIBILD 24 TALZENNA 18 subvenite 9 tamoxifen citrate 16 subvenite starter kit/blue 9 tamsulosin hydrochloride 43 subvenite starter kit/green 9 TARGRETIN 21 subvenite starter kit/orange 9 tarina 24 fe 49 succinylcholine chloride 64 tarina fe 1/20 49 sucralfate 42 TASIGNA 19 sulfacetamide sodium 7 tazarotene 38 sulfacetamide sodium/prednisolone sodium 60 tazicef 6 phosphate taztia xt 33 sulfadiazine 7 TDVAX 54 sulfamethoxazole/trimethoprim 7 TECENTRIQ 20 sulfamethoxazole/trimethoprim ds 7 TECFIDERA 37 sulfasalazine 55 TECFIDERA STARTER PACK 37 sulfatrim pediatric 7 TEFLARO 6 sulindac 1 telmisartan 31 sumatriptan 14 telmisartan/hydrochlorothiazide 31 sumatriptan succinate 14 temazepam 27 sumatriptan succinate refill 14 TEMIXYS 25 sumatriptan/naproxen sodium 14 TEMODAR 15 SUPPRELIN LA 51 temsirolimus 19 SUPRAX 6 TENIPOSIDE 18 SUPREP BOWEL PREP KIT 42 TENIVAC 54 SUTENT 19 TENOFOVIR DISOPROXIL FUMARATE 25 syeda 49 TEPADINA 15 SYLATRON 18 terazosin hcl 43 SYLVANT 53 terazosin hydrochloride 44 SYMBICORT 64 terbinafine hcl 13 SYMDEKO 63 terconazole 13 SYMFI 25 TESTOSTERONE 46 SYMFI LO 25 testosterone cypionate 46 SYMPAZAN 9 testosterone enanthate 46 SYMTUZA 26 TESTOSTERONE PUMP 46 SYNAGIS 53 testosterone topical solution 46

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 85 of 88 Drug Name Page # Drug Name Page # tetrabenazine 36 tranylcypromine sulfate 10 tetracycline hydrochloride 8 TRAVASOL 58 THALOMID 16 trazodone hydrochloride 11 theophylline anhydrous cr 63 TREANDA 15 theophylline cr 63 TRECATOR 15 theophylline er 63 TRELEGY ELLIPTA 64 theophylline/d5w 63 TRELSTAR 51 THERACYS 18 TRELSTAR MIXJECT 51 THIOLA EC 44 TREMFYA 38 thioridazine hcl 22 TREPROSTINIL 63 thiotepa 15 TRESIBA 29 thiothixene 22 TRESIBA FLEXTOUCH 29 tiagabine hydrochloride 9 tretinoin 21 TIBSOVO 19 tretinoin 38 TICE BCG 18 TREXALL 52 TIGLUTIK 36 triamcinolone acetonide 45 timolol maleate 14 triamcinolone acetonide 61 timolol maleate 61 triamcinolone acetonide dental paste 37 timolol maleate ophthalmic gel forming 61 triamterene/hydrochlorothiazide 34 tinidazole 21 triderm 45 tis-u-sol 58 trientine hydrochloride 41 TIVICAY 24 TRIESENCE 60 tizanidine hcl 23 tri-estarylla 49 tizanidine hydrochloride 24 trifluoperazine hcl 22 TOBI PODHALER 63 trifluridine 26 TOBRADEX 60 trihexyphenidyl hcl 21 TOBRADEX ST 60 trihexyphenidyl hydrochloride 21 tobramycin 63 triklo 35 tobramycin sulfate 4 tri-legest fe 49 tobramycin/dexamethasone 60 tri-linyah 49 TOBREX 4 tri-lo-estarylla 49 tolcapone 21 tri-lo-marzia 49 tolterodine tartrate 43 tri-lo-sprintec 49 tolterodine tartrate er 43 trilyte 42 topiramate 9 trimethoprim 5 topotecan hcl 18 tri-mili 49 topotecan hydrochloride 18 trimipramine maleate 11 toremifene citrate 16 TRIMPEX 5 TORISEL 20 trinessa 49 torsemide 34 trinessa lo 49 TOUJEO MAX SOLOSTAR 29 TRINTELLIX 11 TOUJEO SOLOSTAR 29 tri-previfem 49 tovet 45 TRIPTODUR 51 TRADJENTA 28 TRISENOX 18 tramadol hcl 2 tri-sprintec 49 tramadol hydrochloride/acetaminophen 2 TRIUMEQ 24 trandolapril 31 trivora-28 49 tranexamic acid 30 tri-vylibra 49

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 86 of 88 Drug Name Page # Drug Name Page # TROGARZO 25 VECTIBIX 20 TROPHAMINE 59 VELCADE 18 trospium chloride 43 VELETRI 63 TRULICITY 28 velivet 49 TRUMENBA 54 veltassa 41 TRUVADA 25 VEMLIDY 24 tulana 50 VENCLEXTA 20 TURALIO 20 VENCLEXTA STARTING PACK 20 TWINRIX 54 venlafaxine hcl 11 TYBOST 25 venlafaxine hcl er 11 TYKERB 20 VENTAVIS 63 TYMLOS 55 verapamil hcl 33 TYPHIM VI 54 verapamil hcl er 33 TYSABRI 37 verapamil hcl sr 33 UDENYCA 30 verapamil hydrochloride 33 ULESFIA 21 VERSACLOZ 23 ULORIC 13 VERZENIO 18 ULTICARE MICRO PEN NEEDLES/31G 59 V-GO 20 59 X 1/4" V-GO 30 59 ULTICARE MICRO PEN NEEDLES/31G 59 V-GO 40 59 X 5/16" VIBRAMYCIN 8 ULTILET INSULIN 59 vicodin 3 SYRINGE/SHORT/0.3ML/31G X 5/16" vicodin es 2 ULTILET INSULIN 59 vicodin hp 2 SYRINGE/SHORT/1ML/31G X 5/16" VICTOZA 28 ULTOMIRIS 30 VIDEX EC 25 UNIFINE PENTIPS 33GX4MM 59 VIDEX PEDIATRIC 25 UNIFINE PENTIPS PLUS 33GX4MM 59 vienva 49 UNITUXIN 20 vigabatrin 9 ursodiol 41 vigadrone 9 UVADEX 38 VIIBRYD 11 valacyclovir hcl 26 VIIBRYD STARTER PACK 11 valacyclovir hydrochloride 26 VIMIZIM 43 VALCHLOR 15 VIMPAT 10 valganciclovir 24 vinblastine sulfate 18 valganciclovir hydrochlorde 24 VINCASAR PFS 18 valproate sodium 9 vincristine sulfate 18 valproic acid 9 viorele 49 valrubicin 18 VIRACEPT 26 valsartan 31 VIREAD 25 valsartan/hydrochlorothiazide 31 VISTOGARD 59 vancomycin hcl 5 VITEKTA 24 vancomycin hydrochloride 5 VITRAKVI 18 vancomycin hydrochloride/dextrose 5 VIVITROL 3 vandazole 5 VIZIMPRO 20 VAQTA 54 voriconazole 13 VARIVAX 54 VOSEVI 24 VASCEPA 35 VOTRIENT 20

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 87 of 88 Drug Name Page # Drug Name Page # vp-pnv-dha 41 ZELBORAF 20 VPRIV 43 ZEMAIRA 64 VRAYLAR 23 zenatane 38 vyfemla 49 zenchent 49 vylibra 49 zenchent fe 50 VYNDAMAX 34 ZENPEP 43 VYNDAQEL 34 ZENZEDI 36 VYXEOS 16 ZERIT 25 VYZULTA 59 ZEVALIN Y-90 20 warfarin sodium 29 zidovudine 25 wera 49 ZIOPTAN 59 wixela inhub 64 ziprasidone hcl 23 XALKORI 20 ZIRGAN 24 XARELTO 29 ZOLADEX 51 XARELTO STARTER PACK 29 zoledronic acid 55 XATMEP 52 ZOLINZA 18 XELJANZ 53 zolmitriptan 14 XELJANZ XR 53 zolpidem tartrate 64 XEMBIFY 53 zonisamide 9 XENLETA 5 ZORBTIVE 46 XGEVA 55 ZORTRESS 52 XIAFLEX 43 ZOSTAVAX 54 XIFAXAN 5 zovia 1/35e 50 XIIDRA 59 zovia 1/50e 50 XOFLUZA 26 zumandimine 50 XOLAIR 64 ZYDELIG 18 XOSPATA 20 ZYKADIA 18 XPOVIO 100 MG ONCE WEEKLY 18 ZYKADIA 20 XPOVIO 60 MG ONCE WEEKLY 18 ZYLET 60 XPOVIO 80 MG ONCE WEEKLY 18 ZYPREXA RELPREVV 23 XPOVIO 80 MG TWICE WEEKLY 18 XTAMPZA ER 1 XTANDI 15 xulane 49 xylocaine dental 3 XYREM 64 YERVOY 20 YF-VAX 54 YONDELIS 15 yuvafem 49 zafirlukast 62 zaleplon 64 ZALTRAP 18 ZANOSAR 15 zarah 49 ZARXIO 30 zazole 13 ZEJULA 20

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Page 88 of 88 Non-Discrimination Statement and Foreign Language Access

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اﮔﺮ ﺷﻤﺎ ﯾﺎ ﻓﺮدی ﮐﮫ ﺑﮫ او ﮐﻤﮏ ﻣﯽ ﮐﻨﯿﺪ ﺳﺆاﻻﺗﯽ در ﺑﺎرهی اﯾﻦ ﺑﺮﻧﺎﻣﮫی ﺑﮭﺪاﺷﺘﯽ داﺷﺘﮫ ﺑﺎﺷﯿﺪ، ﺣﻖ اﯾﻦ را دارﯾﺪ ﮐﮫ ﮐﻤﮏ و اﻃﻼﻋﺎت ﺑﮫ زﺑﺎن ﺧﻮد را ﺑﮫ ﻃﻮر راﯾﮕﺎن درﯾﺎﻓﺖ ﮐﻨﯿﺪ. ﺑﺮای ﺻﺤﺒﺖ ﮐﺮدن ﺑﺎ ﻣﺘﺮﺟﻢ، ﻟﻄﻔﺎً ﺑﺎ ﺷﻤﺎرهی 6233-398-844-1 ﺗﻤﺎس ﺣﺎﺻﻞ ﻧﻤﺎﯾﯿﺪ. (Persian-Farsi) This formulary was updated on 12/03/2019. For more recent information or other questions, please contact BlueCross Rx Value at 1-888-645-6025, or, for TTY users 711, 8 a.m. to 8 p.m., Eastern Time, Monday through Friday. Our automated telephone system handles calls received after 8 p.m. and on Saturdays, Sundays and holidays. From October 1, 2019 to March 31, 2020, we are available 8 a.m. to 8 p.m. Eastern Time, seven days a week. Or visit www.SCBluesMedAdvantage.com/marx20.

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