Formulary (List of Covered Drugs)

Home , Acidifier, Diphenylbutylpiperidine

3ODQ

202 Formulary (List of Covered Drugs)

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

$0 Cost Share AI/AN HMO Minimum Coverage HMO Silver 70 HMO Active Choice PPO Silver Opal 25 Gold HMO Silver 70 OFF Exchange HMO Amber 50 HMO Silver Opal 50 Silver HMO Silver 73 HMO Bronze 60 HDHP HMO Platinum 90 HMO Silver 87 HMO Bronze 60 HMO Ruby 10 Platinum HMO Silver 94 HMO Gold 80 HMO Ruby 20 Platinum HMO Jade 15 HMO Ruby 40 Platinum HMO

This formulary was last updated on8//20. This formulary is VXEMHFWto change and all previous versions of the formulary no longer apply. For more recent information or other questions, please contact Chinese Community Health Plan Member Services at 1-888-775-7888 or, for TTY users, 1-877-681-8898, seven days a week from 8:00 a.m. to 8:00 p.m., or visit www.cchphealthplan.com/family-member -,-ϭ -,-ϭ " &* !# " +

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O Table of Contents Informational Section ...... 3 Analgesic, Anti-inflammatory or Antipyretic - Drugs for Pain and Fever ...... 1 Anesthetics - Drugs for Pain and Fever ...... 8 Anorectal Preparations - Rectal Preparations ...... 9 Antidotes and other Reversal Agents - Drugs for Overdose or Poisoning ...... 9 Anti-Infective Agents - Drugs for Infections ...... 10 Antineoplastics - Drugs for Cancer ...... 22 Antiseptics and Disinfectants - Antiseptics and Disinfectants ...... 29 Biologicals - Biological Agents ...... 30 Cardiovascular Therapy Agents - Drugs for the Heart ...... 32 Central Nervous System Agents - Drugs for the Nervous System ...... 41 Chemical Dependency, Agents to Treat - Drugs for Addiction ...... 56 Chemicals-Pharmaceutical Adjuvants ...... 57 Cognitive Disorder Therapy - Drugs for the Nervous System ...... 57 Contraceptives - Drugs for Women ...... 58 Dermatological - Drugs for the Skin ...... 70 Diagnostic Agents ...... 81 Drugs to treat Erectile Dysfunction - Drugs for the Urinary System ...... 82 Eating Disorder Therapy - Drugs for Eating Disorders ...... 82 Electrolyte Balance-Nutritional Products - Drugs for Nutrition ...... 82 Endocrine - Hormones ...... 96 Gastrointestinal Therapy Agents - Drugs for the Stomach ...... 107 Genitourinary Therapy - Drugs for the Urinary System ...... 113 Gout and Hyperuricemia Therapy - Drugs for Pain and Fever ...... 116 Hematological Agents - Drugs for the Blood ...... 116 Immunosuppressive Agents - Drugs for Organ Transplants ...... 119 Locomotor System - Drugs for Muscles, Ligaments, Tendons, and Bones ...... 120 Medical Supplies and Durable Medical Equipment (DME) - Medical Supplies and Durable Medical Equipment ...... 121 Medical Supply, FDB Superset ...... 172 Metabolic Modifiers - Drugs that Alter Metabolism ...... 208 Mouth-Throat-Dental - Preparations - Drugs for the Mouth and Throat ...... 208 Multiple Sclerosis Agents - Drugs for the Nervous System ...... 209 Ophthalmic Agents - Drugs for the Eye ...... 211 Otic (Ear) - Drugs for the Ear ...... 218 Respiratory Therapy Agents - Drugs for the Lungs...... 219 TOC-1 Vaginal Products - Drugs for Women ...... 226

TOC-2 Informational Section

Coverage Prescription Drug Name Drug Tier Requirements and Limits Analgesic, Anti-inflammatory or Antipyretic - Drugs for Pain and Fever Analgesic Opioid Agonists - Arthritis and Pain Drugs codeine sulfate oral tablet 15 mg, 30 mg, 60 mg Tier 1 fentanyl citrate buccal lozenge on a handle 1,200 mcg, PA; QL (120 EA per 30 Tier 1 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg days) fentanyl transdermal patch 72 hour 100 mcg/hr, 12 Tier 1 QL (10 EA per 30 days) mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr FENTORA BUCCAL TABLET, EFFERVESCENT 100 MCG, PA; QL (120 EA per 30 200 MCG, 400 MCG, 600 MCG, 800 MCG (fentanyl Tier 2 days) citrate) hydromorphone oral tablet 2 mg, 4 mg, 8 mg Tier 1 hydromorphone rectal suppository 3 mg Tier 1 HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.24 HR 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 Tier 3 QL (1 EA per 1 day) MG (hydrocodone bitartrate) levorphanol tartrate oral tablet 2 mg Tier 2 meperidine oral tablet 50 mg Tier 1 methadone hcl (Methadone Intensol Oral Concentrate 10 Tier 1 Mg/Ml) methadone oral concentrate 10 mg/ml Tier 1 methadone oral solution 10 mg/5 ml, 5 mg/5 ml Tier 1 methadone oral tablet 10 mg, 5 mg Tier 1 methadone oral tablet,soluble 40 mg Tier 1 methadone hcl (Methadose Oral Tablet,Soluble 40 Mg) Tier 1 morphine concentrate oral solution 100 mg/5 ml (20 Tier 1 mg/ml) morphine oral capsule,extend.release pellets 10 mg, Tier 1 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg morphine oral solution 10 mg/5 ml, 20 mg/5 ml (4 Tier 1 mg/ml) morphine oral tablet 15 mg, 30 mg Tier 1 morphine oral tablet extended release 100 mg, 15 mg, Tier 1 200 mg, 30 mg, 60 mg morphine rectal suppository 10 mg, 20 mg, 30 mg, 5 mg Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 5 Coverage Prescription Drug Name Drug Tier Requirements and Limits NSAID Analgesics (COX Non-Specific) - Other - Arthritis and Pain Drugs ketorolac oral tablet 10 mg Tier 1 QL (20 EA per 5 days) nabumetone oral tablet 500 mg, 750 mg Tier 1 sulindac oral tablet 150 mg, 200 mg Tier 1 tolmetin oral tablet 200 mg Tier 3 NSAID Analgesics (COX Non-Specific) - Oxicam Derivatives - Arthritis and Pain Drugs meloxicam oral tablet 15 mg, 7.5 mg Tier 1 piroxicam oral capsule 10 mg, 20 mg Tier 1 NSAID Analgesics (COX Non-Specific) - Phenylacetic Acid Derivatives - Arthritis and Pain Drugs diclofenac potassium oral tablet 50 mg Tier 1 diclofenac sodium oral tablet extended release 24 hr Tier 1 100 mg diclofenac sodium oral tablet,delayed release (dr/ec) 25 Tier 1 mg, 50 mg, 75 mg NSAID Analgesics (COX Non-Specific) - Propionic Acid Derivatives - Arthritis and Pain Drugs ALEVE ORAL TABLET 220 MG (naproxen sodium) Tier 1 ALL DAY PAIN RELIEF ORAL TABLET 220 MG (naproxen Tier 1 sodium) ALL DAY RELIEF ORAL TABLET 220 MG (naproxen Tier 1 sodium) CHILDREN'S IBUPROFEN ORAL SUSPENSION 100 MG/5 Tier 1 ML (ibuprofen) CHILDREN'S PROFEN IB ORAL SUSPENSION 100 MG/5 Tier 1 ML (ibuprofen) EC-NAPROXEN ORAL TABLET,DELAYED RELEASE Tier 1 (DR/EC) 375 MG, 500 MG (naproxen) FLANAX (NAPROXEN) ORAL TABLET 220 MG (naproxen Tier 1 sodium) flurbiprofen oral tablet 100 mg Tier 1 ibuprofen (Ibu Oral Tablet 400 Mg, 600 Mg, 800 Mg) Tier 1 ibuprofen oral drops,suspension 50 mg/1.25 ml Tier 1 ibuprofen oral suspension 100 mg/5 ml Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 6 Coverage Prescription Drug Name Drug Tier Requirements and Limits ibuprofen oral tablet 400 mg, 600 mg, 800 mg Tier 1 INFANT'S ADVIL ORAL DROPS,SUSPENSION 50 Tier 1 MG/1.25 ML (ibuprofen) INFANT'S IBUPROFEN ORAL DROPS,SUSPENSION 50 Tier 1 MG/1.25 ML (ibuprofen) INFANT'S MOTRIN ORAL DROPS,SUSPENSION 50 Tier 1 MG/1.25 ML (ibuprofen) INFANTS PROFENIB ORAL DROPS,SUSPENSION 50 Tier 1 MG/1.25 ML (ibuprofen) MEDIPROXEN ORAL TABLET 220 MG (naproxen Tier 1 sodium) naproxen oral suspension 125 mg/5 ml Tier 1 naproxen oral tablet 250 mg, 375 mg, 500 mg Tier 1 naproxen oral tablet,delayed release (dr/ec) 375 mg, 500 Tier 1 mg naproxen sodium oral tablet 220 mg, 275 mg Tier 1 WAL-PROXEN ORAL TABLET 220 MG (naproxen Tier 1 sodium) NSAID Analgesics, (COX Non-specific) - Indole Acetic Acid Derivatives - Arthritis and Pain Drugs etodolac oral capsule 200 mg, 300 mg Tier 1 etodolac oral tablet 400 mg, 500 mg Tier 1 etodolac oral tablet extended release 24 hr 400 mg, 500 Tier 1 mg, 600 mg INDOCIN ORAL SUSPENSION 25 MG/5 ML Tier 2 (indomethacin) INDOCIN RECTAL SUPPOSITORY 50 MG Tier 2 (indomethacin) indomethacin oral capsule 25 mg, 50 mg Tier 1 indomethacin oral capsule, extended release 75 mg Tier 1 Salicylate Analgesics - Arthritis and Pain Drugs ADULT ASPIRIN REGIMEN ORAL TABLET,DELAYED EHB; AG: IF MALE, 45-79 $0 RELEASE (DR/EC) 81 MG (aspirin) YEARS ADULT LOW DOSE ASPIRIN ORAL TABLET,DELAYED EHB; AG: IF MALE, 45-79 $0 RELEASE (DR/EC) 81 MG (aspirin) YEARS

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 8 Coverage Prescription Drug Name Drug Tier Requirements and Limits Anorectal Preparations - Rectal Preparations Anorectal - Glucocorticoids - Rectal Preparations ANUCORT-HC RECTAL SUPPOSITORY 25 MG Tier 2 (hydrocortisone acetate) hydrocortisone acetate rectal suppository 25 mg Tier 2 hydrocortisone topical cream with perineal applicator 1 Tier 1 %, 2.5 % hydrocortisone (Procto-Med Hc Topical Cream With Tier 1 Perineal Applicator 2.5 %) hydrocortisone (Procto-Pak Topical Cream With Perineal Tier 1 Applicator 1 %) hydrocortisone (Proctosol Hc Topical Cream With Perineal Tier 1 Applicator 2.5 %) hydrocortisone (Proctozone-Hc Topical Cream With Tier 1 Perineal Applicator 2.5 %) Anorectal - Hemorrhoidal Rectal Glucocorticoid-Local Anesthetic Comb - Rectal Preparations lidocaine hcl-hydrocortison ac rectal cream 3-0.5 % Tier 1 lidocaine hcl-hydrocortison ac rectal kit 3-0.5 % Tier 1 hydrocortisone acetate/pramoxine hcl (Proctofoam Hc Tier 2 Rectal Foam 1-1 %) Antidotes and other Reversal Agents - Drugs for Overdose or Poisoning Antidote Others - Drugs for Overdose or Poisoning GALZIN ORAL CAPSULE 25 MG (ZINC), 50 MG (ZINC) Tier 2 (zinc acetate) WILZIN ORAL CAPSULE 25 MG (ZINC) (zinc acetate) Tier 2 Chelating Agents - Copper - Drugs for Overdose or Poisoning penicillamine oral tablet 250 mg Tier 3 SP Chelating Agents - Iron - Drugs for Overdose or Poisoning deferasirox oral tablet 180 mg, 360 mg, 90 mg Tier 4 PA; SP deferasirox oral tablet, dispersible 125 mg, 250 mg, 500 Tier 4 PA; SP mg Chelating Agents - Lead Poisoning - Drugs for Overdose or Poisoning CHEMET ORAL CAPSULE 100 MG (succimer) Tier 2

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 9 Coverage Prescription Drug Name Drug Tier Requirements and Limits Mu-Opioid Receptor Antagonists, Peripherally-Acting - Drugs for Overdose or Poisoning RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6 ML Tier 4 PA (methylnaltrexone bromide) RELISTOR SUBCUTANEOUS SYRINGE 12 MG/0.6 ML, 8 Tier 4 PA MG/0.4 ML (methylnaltrexone bromide) Opioid Reversal Agents - Opioid Antagonists - Drugs for Overdose or Poisoning naloxone injection syringe 1 mg/ml Tier 1 naltrexone oral tablet 50 mg Tier 1 NARCAN NASAL SPRAY,NON-AEROSOL 4 Tier 2 MG/ACTUATION (naloxone hcl) Anti-Infective Agents - Drugs for Infections Amebicides - Drugs for Parasites paromomycin oral capsule 250 mg Tier 1 Aminoglycoside Antibiotic - Antibiotics neomycin oral tablet 500 mg Tier 1 Aminopenicillin Antibiotic - Antibiotics amoxicillin oral capsule 250 mg, 500 mg Tier 1 amoxicillin oral suspension for reconstitution 125 mg/5 Tier 1 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg Tier 1 amoxicillin oral tablet,chewable 125 mg, 250 mg Tier 1 ampicillin oral capsule 250 mg, 500 mg Tier 1 Aminopenicillin Antibiotic - Beta-lactamase Inhibitor Combinations - Antibiotics amoxicillin-pot clavulanate oral suspension for reconstitution 200-28.5 mg/5 ml, 250-62.5 mg/5 ml, 400- Tier 1 57 mg/5 ml, 600-42.9 mg/5 ml amoxicillin-pot clavulanate oral tablet 250-125 mg, 500- Tier 1 125 mg, 875-125 mg amoxicillin-pot clavulanate oral tablet extended release Tier 1 12 hr 1,000-62.5 mg amoxicillin-pot clavulanate oral tablet,chewable 200- Tier 1 28.5 mg, 400-57 mg Anthelmintic Agents - Benzimidazole Derivatives - Drugs for Parasites

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 10 Coverage Prescription Drug Name Drug Tier Requirements and Limits albendazole oral tablet 200 mg Tier 2 Anthelmintic Agents - Macrocyclic Lactones - Drugs for Parasites ivermectin oral tablet 3 mg Tier 1 Antibacterial Folate Antagonist - Other Combinations - Antibiotics sulfamethoxazole-trimethoprim oral suspension 200-40 Tier 1 mg/5 ml sulfamethoxazole-trimethoprim oral tablet 400-80 mg, Tier 1 800-160 mg SULFATRIM ORAL SUSPENSION 200-40 MG/5 ML Tier 1 (sulfamethoxazole/trimethoprim) Antibacterial Folate Antagonist Others - Antibiotics trimethoprim oral tablet 100 mg Tier 1 Antifungal - Allylamines - Drugs for Fungus terbinafine hcl oral tablet 250 mg Tier 1 Antifungal - Amphoteric Polyene Macrolides - Drugs for Fungus nystatin oral tablet 500,000 unit Tier 1 Antifungal - Fluorinated Pyrimidine-type Agents - Drugs for Fungus flucytosine oral capsule 250 mg, 500 mg Tier 1 Antifungal - Imidazoles - Drugs for Fungus ketoconazole oral tablet 200 mg Tier 1 Antifungal - Triazoles - Drugs for Fungus fluconazole oral suspension for reconstitution 10 Tier 1 mg/ml, 40 mg/ml fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg Tier 1 itraconazole oral capsule 100 mg Tier 1 PA NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML) Tier 3 QL (240 ML per 30 days) (posaconazole) posaconazole oral tablet,delayed release (dr/ec) 100 mg Tier 3 QL (93 EA per 30 days) PR: RESTRICTED TO voriconazole oral suspension for reconstitution 200 Tier 3 INFECTIOUS DISEASE mg/5 ml (40 mg/ml) SPECIALIST PR: RESTRICTED TO voriconazole oral tablet 200 mg, 50 mg Tier 3 INFECTIOUS DISEASE SPECIALIST

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 11 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antifungal other - Drugs for Fungus griseofulvin microsize oral suspension 125 mg/5 ml Tier 1 griseofulvin microsize oral tablet 500 mg Tier 1 griseofulvin ultramicrosize oral tablet 125 mg, 250 mg Tier 1 Antileprotic - Immunomodulators - Antibiotics THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, Tier 4 PA; SP 50 MG (thalidomide) Antileprotic - Sulfone Agents - Antibiotics dapsone oral tablet 100 mg, 25 mg Tier 1 Antimalarial Combinations - Drugs for Parasites atovaquone-proguanil oral tablet 250-100 mg, 62.5-25 Tier 1 mg COARTEM ORAL TABLET 20-120 MG Tier 1 (artemether/lumefantrine) Antimalarials - Drugs for Parasites chloroquine phosphate oral tablet 250 mg Tier 1 chloroquine phosphate oral tablet 500 mg Tier 1 hydroxychloroquine oral tablet 200 mg Tier 1 mefloquine oral tablet 250 mg Tier 1 primaquine oral tablet 26.3 mg Tier 2 pyrimethamine oral tablet 25 mg Tier 4 PA; SP quinine sulfate oral capsule 324 mg Tier 1 Antiprotozoal Agents - Other - Drugs for Parasites atovaquone oral suspension 750 mg/5 ml Tier 1 Antiprotozoal Agents (antiparasitic) - 5-Nitrothiazolyl Derivatives - Drugs for Parasites ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 Tier 2 MG/5 ML (nitazoxanide) nitazoxanide oral tablet 500 mg Tier 2 QL (6 EA per 1 FILL) Antiprotozoal-Antibacterial 1st Generation 2-methyl-5-nitroimidazole - Drugs for Infections metronidazole oral capsule 375 mg Tier 1 metronidazole oral tablet 250 mg, 500 mg Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 12 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antiprotozoal-Antibacterial 2nd Generation 2-methyl-5-nitroimidazole - Drugs for Infections tinidazole oral tablet 250 mg, 500 mg Tier 1 Antiretroviral - CCR5 Co-Receptor Antagonist - Drugs for Viral Infections SELZENTRY ORAL TABLET 150 MG, 25 MG, 300 MG, 75 Tier 4 MG (maraviroc) Antiretroviral - CD4 Attachment Inhibitors - Drugs for Viral Infections RUKOBIA ORAL TABLET EXTENDED RELEASE 12 HR Tier 4 PA; QL (60 EA per 30 days) 600 MG (fostemsavir tromethamine) Antiretroviral - HIV-1 Fusion Inhibitors - Drugs for Viral Infections FUZEON SUBCUTANEOUS RECON SOLN 90 MG Tier 4 (enfuvirtide) Antiretroviral - HIV-1 Integrase Strand Transfer Inhibitors - Drugs for Viral Infections ISENTRESS HD ORAL TABLET 600 MG (raltegravir Tier 2 potassium) ISENTRESS ORAL POWDER IN PACKET 100 MG Tier 2 (raltegravir potassium) ISENTRESS ORAL TABLET 400 MG (raltegravir Tier 2 potassium) ISENTRESS ORAL TABLET,CHEWABLE 100 MG, 25 MG Tier 2 (raltegravir potassium) TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG Tier 2 QL (2 EA per 1 day) (dolutegravir sodium) TIVICAY PD ORAL TABLET FOR SUSPENSION 5 MG Tier 2 QL (180 EA per 30 days) (dolutegravir sodium) Antiretroviral - Integrase Inhibitor and NNRTI Combinations - Drugs for Viral Infections JULUCA ORAL TABLET 50-25 MG (dolutegravir Tier 4 QL (30 EA per 30 days) sodium/rilpivirine hcl) Antiretroviral - Integrase Inhibitor and NRTI Combinations - Drugs for Viral Infections DOVATO ORAL TABLET 50-300 MG (dolutegravir Tier 4 QL (1 EA per 1 day) sodium/lamivudine)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 15 Coverage Prescription Drug Name Drug Tier Requirements and Limits lamivudine-zidovudine oral tablet 150-300 mg Tier 1 Antiretroviral-Nucleoside, Nucleotide Analogs and Non-Nucleoside RTI - Drugs for Viral Infections COMPLERA ORAL TABLET 200-25-300 MG (emtricitabine/rilpivirine hcl/tenofovir disoproxil Tier 4 QL (1 EA per 1 day) fumarate) efavirenz-emtricitabin-tenofov oral tablet 600-200-300 Tier 4 QL (1 EA per 1 day) mg ODEFSEY ORAL TABLET 200-25-25 MG (emtricitabine/rilpivirine hcl/tenofovir alafenamide Tier 4 QL (1 EA per 1 day) fumarate) Antitubercular - Isonicotinic Acid Derivatives - Antibiotics isoniazid oral solution 50 mg/5 ml Tier 1 isoniazid oral tablet 100 mg, 300 mg Tier 1 Antitubercular - Niacinamide Derivatives - Antibiotics pyrazinamide oral tablet 500 mg Tier 1 Antitubercular - Rifamycin and Derivatives - Antibiotics PRIFTIN ORAL TABLET 150 MG (rifapentine) Tier 2 rifabutin oral capsule 150 mg Tier 1 rifampin oral capsule 150 mg, 300 mg Tier 1 Antitubercular Agents Other - Antibiotics ethambutol oral tablet 100 mg, 400 mg Tier 1 TRECATOR ORAL TABLET 250 MG (ethionamide) Tier 3 Cephalosporin Antibiotics - 1st Generation - Antibiotics cefadroxil oral capsule 500 mg Tier 1 cefadroxil oral suspension for reconstitution 250 mg/5 Tier 1 ml, 500 mg/5 ml cefadroxil oral tablet 1 gram Tier 1 cephalexin oral capsule 250 mg, 500 mg, 750 mg Tier 1 cephalexin oral suspension for reconstitution 125 mg/5 Tier 1 ml, 250 mg/5 ml cephalexin oral tablet 250 mg, 500 mg Tier 1 Cephalosporin Antibiotics - 2nd Generation - Antibiotics cefaclor oral capsule 250 mg, 500 mg Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 16 Coverage Prescription Drug Name Drug Tier Requirements and Limits cefprozil oral suspension for reconstitution 125 mg/5 Tier 1 ml, 250 mg/5 ml cefprozil oral tablet 250 mg, 500 mg Tier 1 cefuroxime axetil oral tablet 250 mg, 500 mg Tier 1 Cephalosporin Antibiotics - 3rd Generation - Antibiotics cefdinir oral capsule 300 mg Tier 1 cefdinir oral suspension for reconstitution 125 mg/5 ml, Tier 1 250 mg/5 ml cefixime oral suspension for reconstitution 100 mg/5 Tier 1 ml, 200 mg/5 ml cefpodoxime oral suspension for reconstitution 100 Tier 1 mg/5 ml, 50 mg/5 ml cefpodoxime oral tablet 100 mg, 200 mg Tier 1 SUPRAX ORAL SUSPENSION FOR RECONSTITUTION Tier 3 500 MG/5 ML (cefixime) CMV Antiviral Agent - Nucleoside Analogs - Drugs for Viral Infections valganciclovir oral recon soln 50 mg/ml Tier 1 valganciclovir oral tablet 450 mg Tier 1 CMV Antiviral Agent - Terminase Complex Inhibitors - Drugs for Viral Infections PREVYMIS ORAL TABLET 240 MG, 480 MG (letermovir) Tier 4 PA; QL (1 EA per 1 day) Fluoroquinolone Antibiotics - Antibiotics CIPRO ORAL SUSPENSION,MICROCAPSULE RECON Tier 3 250 MG/5 ML, 500 MG/5 ML (ciprofloxacin) CIPRO XR ORAL TABLET, ER MULTIPHASE 24 HR 1,000 Tier 3 MG, 500 MG (ciprofloxacin/ciprofloxacin hcl) ciprofloxacin hcl oral tablet 100 mg Tier 3 ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg Tier 1 ciprofloxacin oral suspension,microcapsule recon 250 Tier 1 mg/5 ml, 500 mg/5 ml FACTIVE ORAL TABLET 320 MG (gemifloxacin Tier 4 mesylate) levofloxacin oral solution 250 mg/10 ml Tier 1 levofloxacin oral tablet 250 mg, 500 mg, 750 mg Tier 1 moxifloxacin oral tablet 400 mg Tier 1 ofloxacin oral tablet 300 mg, 400 mg Tier 1 PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 17 Coverage Prescription Drug Name Drug Tier Requirements and Limits Glycopeptide Antibiotics - Antibiotics vancomycin oral capsule 125 mg, 250 mg Tier 4 QL (56 EA per 1 FILL) Hepatitis B Treatment- Nucleoside Analogs (Antiviral) - Drugs for Viral Infections entecavir oral tablet 0.5 mg, 1 mg Tier 1 EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML) Tier 4 PA (lamivudine) lamivudine oral tablet 100 mg Tier 1 Hepatitis B Treatment- Nucleotide Analogs (Antiviral) - Drugs for Viral Infections adefovir oral tablet 10 mg Tier 4 PA; SP VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG Tier 4 PA (tenofovir disoproxil fumarate) Hepatitis C - Interferons - Drugs for Viral Infections PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML Tier 4 PA; SP (peginterferon alfa-2a) PEGASYS SUBCUTANEOUS SYRINGE 180 MCG/0.5 ML Tier 4 PA; SP (peginterferon alfa-2a) Hepatitis C - NS5A, NS3/4A Protease, Nucleo.NS5B Polymerase Inhib Comb - Drugs for Viral Infections VOSEVI ORAL TABLET 400-100-100 MG Tier 4 PA; QL (28 EA per 28 days) (sofosbuvir/velpatasvir/voxilaprevir) Hepatitis C - NS5B Polymerase and NS5A Inhibitor Combinations - Drugs for Viral Infections EPCLUSA ORAL TABLET 200-50 MG Tier 4 PA; QL (28 EA per 28 days) (sofosbuvir/velpatasvir) EPCLUSA ORAL TABLET 400-100 MG Tier 4 PA; QL (1 EA per 1 day) (sofosbuvir/velpatasvir) HARVONI ORAL PELLETS IN PACKET 33.75-150 MG PA; SP; QL (28 EA per 28 Tier 4 (ledipasvir/sofosbuvir) days) HARVONI ORAL PELLETS IN PACKET 45-200 MG PA; SP; QL (56 EA per 28 Tier 4 (ledipasvir/sofosbuvir) days) HARVONI ORAL TABLET 45-200 MG PA; SP; QL (60 EA per 30 Tier 4 (ledipasvir/sofosbuvir) days) Hepatitis C - Nucleoside Analogs - Drugs for Viral Infections ribavirin oral capsule 200 mg Tier 1 ribavirin oral tablet 200 mg Tier 1 PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 18 Coverage Prescription Drug Name Drug Tier Requirements and Limits Herpes Antiviral Agent - Purine Analogs - Drugs for Viral Infections acyclovir oral capsule 200 mg Tier 1 acyclovir oral suspension 200 mg/5 ml Tier 1 acyclovir oral tablet 400 mg, 800 mg Tier 1 valacyclovir oral tablet 1 gram, 500 mg Tier 1 Herpes Antiviral Agent - Thymidine Analogs - Drugs for Viral Infections famciclovir oral tablet 125 mg, 250 mg, 500 mg Tier 1 Influenza Antiviral Agents - Neuraminidase Inhibitors - Drugs for Viral Infections oseltamivir oral capsule 30 mg Tier 1 QL (20 EA per 1 FILL) oseltamivir oral capsule 45 mg, 75 mg Tier 1 QL (10 EA per 1 FILL) oseltamivir oral suspension for reconstitution 6 mg/ml Tier 2 QL (250 ML per 1 FILL) RELENZA DISKHALER INHALATION BLISTER WITH Tier 2 QL (20 EA per 1 FILL) DEVICE 5 MG/ACTUATION (zanamivir) Influenza-A Antiviral Agents - Drugs for Viral Infections rimantadine oral tablet 100 mg Tier 1 Lincosamide Antibiotics - Antibiotics clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg Tier 1 clindamycin palmitate hcl (Clindamycin Pediatric Oral Tier 1 Recon Soln 75 Mg/5 Ml) Macrolide Antibiotics - Antibiotics azithromycin oral suspension for reconstitution 100 Tier 1 mg/5 ml, 200 mg/5 ml azithromycin oral tablet 250 mg, 500 mg, 600 mg Tier 1 clarithromycin oral suspension for reconstitution 125 Tier 1 mg/5 ml, 250 mg/5 ml clarithromycin oral tablet 250 mg, 500 mg Tier 1 clarithromycin oral tablet extended release 24 hr 500 Tier 1 mg ST: Prior prescription for Vancomycin HCL in 120 DIFICID ORAL TABLET 200 MG (fidaxomicin) Tier 3 days; QL (20 EA per 30 days) erythromycin ethylsuccinate (E.E.S. 400 Oral Tablet 400 Tier 1 Mg)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 19 Coverage Prescription Drug Name Drug Tier Requirements and Limits erythromycin base (Ery-Tab Oral Tablet,Delayed Release Tier 1 (Dr/Ec) 250 Mg, 500 Mg) erythromycin stearate (Erythrocin (As Stearate) Oral Tier 1 Tablet 250 Mg) erythromycin ethylsuccinate oral suspension for Tier 1 reconstitution 200 mg/5 ml erythromycin ethylsuccinate oral suspension for Tier 3 reconstitution 400 mg/5 ml erythromycin ethylsuccinate oral tablet 400 mg Tier 1 erythromycin oral capsule,delayed release(dr/ec) 250 Tier 1 mg erythromycin oral tablet 250 mg, 500 mg Tier 3 erythromycin oral tablet,delayed release (dr/ec) 250 mg, Tier 1 333 mg, 500 mg Misc Anti-Infective - Drugs for Infections methenamine hippurate oral tablet 1 gram Tier 1 methenamine mandelate oral tablet 1 gram Tier 1 NEBUPENT INHALATION RECON SOLN 300 MG Tier 2 (pentamidine isethionate) Oxazolidinone Antibiotics - Antibiotics PR: RESTRICTED TO linezolid oral suspension for reconstitution 100 mg/5 ml Tier 4 INFECTIOUS DISEASE SPECIALIST PR: RESTRICTED TO linezolid oral tablet 600 mg Tier 4 INFECTIOUS DISEASE SPECIALIST PR: RESTRICTED TO INFECTIOUS DISEASE SIVEXTRO ORAL TABLET 200 MG (tedizolid phosphate) Tier 2 SPECIALIST; QL (6 EA per 1 FILL) Penicillin Antibiotic - Natural - Antibiotics penicillin v potassium oral recon soln 125 mg/5 ml, 250 Tier 1 mg/5 ml penicillin v potassium oral tablet 250 mg, 500 mg Tier 1 Penicillin Antibiotic - Penicillinase-resistant - Antibiotics dicloxacillin oral capsule 250 mg, 500 mg Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 20 Coverage Prescription Drug Name Drug Tier Requirements and Limits Protease Inhibitors (Non-Peptidic) Antiretroviral - Drugs for Viral Infections APTIVUS ORAL CAPSULE 250 MG (tipranavir) Tier 4 PREZCOBIX ORAL TABLET 800-150 MG-MG (darunavir Tier 4 ethanolate/cobicistat) PREZISTA ORAL SUSPENSION 100 MG/ML (darunavir Tier 4 ethanolate) PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 Tier 4 MG (darunavir ethanolate) Protease Inhibitors (Peptidic) Antiretroviral - Drugs for Viral Infections atazanavir oral capsule 150 mg, 200 mg, 300 mg Tier 4 EVOTAZ ORAL TABLET 300-150 MG (atazanavir Tier 4 sulfate/cobicistat) fosamprenavir oral tablet 700 mg Tier 2 INVIRASE ORAL TABLET 500 MG (saquinavir mesylate) Tier 4 LEXIVA ORAL SUSPENSION 50 MG/ML (fosamprenavir Tier 4 calcium) NORVIR ORAL SOLUTION 80 MG/ML (ritonavir) Tier 2 REYATAZ ORAL POWDER IN PACKET 50 MG Tier 4 (atazanavir sulfate) ritonavir oral tablet 100 mg Tier 2 VIRACEPT ORAL TABLET 250 MG, 625 MG (nelfinavir Tier 4 mesylate) Rifamycins and Related Derivative Antibiotics - Antibiotics rifabutin oral capsule 150 mg Tier 1 Sulfonamide Antibiotic - Antibiotics sulfadiazine oral tablet 500 mg Tier 1 Tetracycline Antibiotics - Antibiotics demeclocycline oral tablet 150 mg, 300 mg Tier 1 doxycycline hyclate oral capsule 100 mg, 50 mg Tier 1 doxycycline hyclate oral tablet 100 mg Tier 1 doxycycline monohydrate oral capsule 100 mg, 50 mg Tier 1 doxycycline monohydrate oral suspension for Tier 1 reconstitution 25 mg/5 ml doxycycline monohydrate oral tablet 100 mg, 50 mg, 75 Tier 1 mg PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 21 Coverage Prescription Drug Name Drug Tier Requirements and Limits minocycline oral capsule 100 mg, 50 mg, 75 mg Tier 1 minocycline oral tablet 100 mg, 50 mg, 75 mg Tier 1 doxycycline monohydrate (Mondoxyne Nl Oral Capsule Tier 1 100 Mg) tetracycline oral capsule 250 mg, 500 mg Tier 3 Antineoplastics - Drugs for Cancer ANP - Human Vascular Endothelial Growth Factor Inhib Rec-MC Antibody - Drugs for Cancer AVASTIN INTRAVENOUS SOLUTION 25 MG/ML Tier 4 PA; SP (bevacizumab) Antineoplasic-Epiderm.Growth Factor-EGFR (ErbB1),HER-2 (ErbB2)R.Inhib - Drugs for Cancer PA; SP; OCH; QL (180 EA lapatinib oral tablet 250 mg Tier 4 per 30 days) Antineoplastic - 1st generation EGFR tyrosine kinase inhibitor - Drugs for Cancer erlotinib oral tablet 100 mg, 150 mg, 25 mg Tier 4 PA; SP; OCH IRESSA ORAL TABLET 250 MG (gefitinib) Tier 4 PA; SP; OCH Antineoplastic - 3rd generation EGFR tyrosine kinase inhibitor - Drugs for Cancer TAGRISSO ORAL TABLET 40 MG, 80 MG (osimertinib PA; SP; OCH; QL (1 EA per Tier 4 mesylate) 1 day) Antineoplastic - Alkylating Agent - Alkyl Sulfonates - Drugs for Cancer MYLERAN ORAL TABLET 2 MG (busulfan) Tier 4 SP; OCH Antineoplastic - Alkylating Agent - Methylhydrazines - Drugs for Cancer MATULANE ORAL CAPSULE 50 MG (procarbazine hcl) Tier 2 SP; OCH Antineoplastic - Alkylating Agent - Nitrogen Mustards - Drugs for Cancer cyclophosphamide oral capsule 25 mg, 50 mg Tier 2 SP; OCH cyclophosphamide oral tablet 25 mg, 50 mg Tier 1 SP; OCH LEUKERAN ORAL TABLET 2 MG (chlorambucil) Tier 2 SP; OCH melphalan oral tablet 2 mg Tier 2 OCH Antineoplastic - Alkylating Agent - Nitrosoureas - Drugs for Cancer GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG Tier 3 SP; OCH (lomustine) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 22 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antineoplastic - Alkylating Agent - Triazenes - Drugs for Cancer temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 Tier 4 SP; OCH mg, 250 mg, 5 mg Antineoplastic - Anaplastic Lymphoma Kinase (ALK) Inhibitors - Drugs for Cancer PA; SP; OCH; QL (8 EA per ALECENSA ORAL CAPSULE 150 MG (alectinib hcl) Tier 4 1 day) ALUNBRIG ORAL TABLET 180 MG, 30 MG, 90 MG PA; SP; OCH; QL (6 EA per Tier 4 (brigatinib) 1 day) ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 180 PA; SP; OCH; QL (6 EA per Tier 4 MG (23) (brigatinib) 1 day) XALKORI ORAL CAPSULE 200 MG, 250 MG (crizotinib) Tier 4 PA; SP; OCH Antineoplastic - Antiandrogens - Drugs for Cancer PA; SP; OCH; QL (4 EA per abiraterone oral tablet 250 mg Tier 3 1 day) bicalutamide oral tablet 50 mg Tier 1 OCH flutamide oral capsule 125 mg Tier 1 OCH nilutamide oral tablet 150 mg Tier 4 SP; OCH PA; SP; OCH; QL (120 EA NUBEQA ORAL TABLET 300 MG (darolutamide) Tier 4 per 30 days) PA; SP; OCH; QL (4 EA per XTANDI ORAL CAPSULE 40 MG (enzalutamide) Tier 4 1 day) Antineoplastic - Antimetabolite - Folic Acid Analogs - Drugs for Cancer methotrexate sodium (pf) injection recon soln 1 gram Tier 1 methotrexate sodium (pf) injection solution 25 mg/ml Tier 1 TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG Tier 2 OCH (methotrexate sodium) Antineoplastic - Antimetabolite - Purine Analogs - Drugs for Cancer mercaptopurine oral tablet 50 mg Tier 1 OCH TABLOID ORAL TABLET 40 MG (thioguanine) Tier 2 SP; OCH Antineoplastic - Antimetabolite - Pyrimidine Analogs - Drugs for Cancer capecitabine oral tablet 150 mg, 500 mg Tier 4 SP; OCH Antineoplastic - Antimetabolite - Urea Derivatives - Drugs for Cancer hydroxyurea oral capsule 500 mg Tier 1 OCH

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 26 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antineoplastic - Mutant Isocitrate Dehydrogenase 2 (mIDH2) Inhibitors - Drugs for Cancer PA; SP; OCH; QL (1 EA per IDHIFA ORAL TABLET 100 MG (enasidenib mesylate) Tier 4 1 day) PA; SP; OCH; QL (2 EA per IDHIFA ORAL TABLET 50 MG (enasidenib mesylate) Tier 4 1 day) Antineoplastic - Phosphatidylinositol 3-Kinase (PI3K) Inhibitors - Drugs for Cancer ZYDELIG ORAL TABLET 100 MG, 150 MG (idelalisib) Tier 4 PA; SP; OCH Antineoplastic - PI3K-alpha Inhibitors - Drugs for Cancer PIQRAY ORAL TABLET 200 MG/DAY (200 MG X 1) PA; SP; OCH; QL (28 EA Tier 4 (alpelisib) per 28 days) PIQRAY ORAL TABLET 250 MG/DAY (200 MG X1-50 MG PA; SP; OCH; QL (56 EA Tier 4 X1), 300 MG/DAY (150 MG X 2) (alpelisib) per 28 days) Antineoplastic - PI3K-delta Inhibitors - Drugs for Cancer ZYDELIG ORAL TABLET 100 MG, 150 MG (idelalisib) Tier 4 PA; SP; OCH Antineoplastic - Poly (ADP-ribose) polymerase (PARP) inhibitors - Drugs for Cancer LYNPARZA ORAL TABLET 100 MG, 150 MG (olaparib) Tier 4 PA; SP; OCH RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG PA; SP; OCH; QL (4 EA per Tier 4 (rucaparib camsylate) 1 day) Antineoplastic - Progestins - Drugs for Cancer megestrol oral tablet 20 mg, 40 mg Tier 1 OCH Antineoplastic - Proteasome Enzyme Inhibitors - Drugs for Cancer NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG Tier 4 PA; SP; OCH (ixazomib citrate) Antineoplastic - Protein-Tyrosine Kinase Inhibitors - Drugs for Cancer BOSULIF ORAL TABLET 100 MG, 500 MG (bosutinib) Tier 4 PA; SP; OCH PA; SP; OCH; QL (60 EA CALQUENCE ORAL CAPSULE 100 MG (acalabrutinib) Tier 4 per 30 days) CAPRELSA ORAL TABLET 100 MG, 300 MG (vandetanib) Tier 4 PA; SP; OCH imatinib oral tablet 100 mg, 400 mg Tier 4 PA; SP; OCH PA; SP; OCH; QL (4 EA per IMBRUVICA ORAL CAPSULE 140 MG, 70 MG (ibrutinib) Tier 4 1 day)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 30 Coverage Prescription Drug Name Drug Tier Requirements and Limits ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-(2.5-5-3-5 MCG)- Tier 3 QL (1 ML per 300 days) 5LF/0.5 ML (diphtheria,pertussis(acellular),tetanus vaccine/pf) BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION 2.5- 8-5 LF-MCG-LF/0.5ML Tier 3 QL (1 ML per 300 days) (diphtheria,pertussis(acellular),tetanus vaccine) BOOSTRIX TDAP INTRAMUSCULAR SYRINGE 2.5-8-5 LF-MCG-LF/0.5ML Tier 3 QL (1 ML per 300 days) (diphtheria,pertussis(acellular),tetanus vaccine) Vaccine Bacterial - Gram Positive Cocci - Vaccines PNEUMOVAX-23 INJECTION SOLUTION 25 MCG/0.5 ML Tier 3 QL (1 ML per 365 days) (pneumococcal 23-valent polysaccharide vaccine) PNEUMOVAX-23 INJECTION SYRINGE 25 MCG/0.5 ML Tier 3 QL (1 ML per 365 days) (pneumococcal 23-valent polysaccharide vaccine) Vaccine Viral - COVID-19 (SARS-CoV-2) - Vaccines ASTRAZENECA COVID19 VAC(UNAPP) INTRAMUSCULAR SUSPENSION 0.5 ML (covid-19 Tier 3 $0 COPAY vaccine, azd-1222 (astrazeneca)/pf) JANSSEN COVID-19 VACCINE (EUA) INTRAMUSCULAR $0 COPAY; QL (0.5 ML per SUSPENSION 0.5 ML (covid-19 vac, ad26.cov2.s Tier 3 365 days); Age (Min 18 (janssen)/pf) Years) MODERNA COVID-19 VACCINE (EUA) INTRAMUSCULAR $0 COPAY; QL (0.5 ML per SUSPENSION 100 MCG/0.5 ML (covid-19 vaccine, mrna, Tier 3 24 days); Age (Min 18 cx-024414, lnp-s (moderna)/pf) Years) NOVAVAX COVID19 VAC,ADJ(UNAPP) INTRAMUSCULAR SUSPENSION 5 MCG/0.5 ML (covid- Tier 3 $0 COPAY 19 vaccine, nvx-cov2373 (novavax)/adjuvant-matrix/pf) PFIZER COVID-19 VACCINE (EUA) INTRAMUSCULAR $0 COPAY; QL (0.3 ML per SUSPENSION FOR RECONSTITUTION 30 MCG/0.3 ML Tier 3 17 days); Age (Min 12 (covid-19 vaccine, mrna, bnt162b2, lnp-s (pfizer)/pf) Years) Vaccine Viral - Varicella - Vaccines SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR EHB; QL (2 EA per 365 RECONSTITUTION 50 MCG/0.5 ML (varicella-zoster $0 days); Age (Min 50 Years) virus glycoprotein e,rec/as01b adjuvant/pf) SHINGRIX GE ANTIGEN COMPONENT INTRAMUSCULAR SUSPENSION FOR EHB; QL (2 EA per 365 $0 RECONSTITUTION 50 MCG (varicella-zoster virus days); Age (Min 50 Years) glycoprotein e,rec,component 2 of 2) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 31 Coverage Prescription Drug Name Drug Tier Requirements and Limits Cardiovascular Therapy Agents - Drugs for the Heart ACE Inhibitor and Calcium Channel Blocker Combinations - Drugs for High Blood Pressure amlodipine-benazepril oral capsule 10-20 mg, 10-40 mg, Tier 1 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg trandolapril-verapamil oral tablet, ir - er, biphasic 24hr Tier 1 1-240 mg, 2-180 mg, 2-240 mg, 4-240 mg ACE Inhibitor and Diuretic Combinations - Drugs for High Blood Pressure benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, Tier 1 20-12.5 mg, 20-25 mg, 5-6.25 mg captopril-hydrochlorothiazide oral tablet 25-15 mg, 25- Tier 1 25 mg, 50-15 mg, 50-25 mg enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5- Tier 1 12.5 mg fosinopril-hydrochlorothiazide oral tablet 10-12.5 mg, Tier 1 20-12.5 mg lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20- Tier 1 12.5 mg, 20-25 mg quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20- Tier 1 12.5 mg, 20-25 mg ACE Inhibitors - Drugs for High Blood Pressure benazepril oral tablet 10 mg, 20 mg, 40 mg, 5 mg Tier 1 captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg Tier 1 enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg Tier 1 EPANED ORAL SOLUTION 1 MG/ML (enalapril maleate) Tier 3 PA fosinopril oral tablet 10 mg, 20 mg, 40 mg Tier 1 lisinopril oral tablet 10 mg Tier 2 lisinopril oral tablet 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg Tier 1 moexipril oral tablet 15 mg, 7.5 mg Tier 1 perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg Tier 1 quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg Tier 1 ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg Tier 1 trandolapril oral tablet 1 mg, 2 mg, 4 mg Tier 1 Aldosterone Receptor Antagonists - Drugs for High Blood Pressure eplerenone oral tablet 25 mg, 50 mg Tier 1 PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 32 Coverage Prescription Drug Name Drug Tier Requirements and Limits spironolactone oral tablet 100 mg, 25 mg, 50 mg Tier 1 Alpha-Beta Blockers - Drugs for High Blood Pressure carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg Tier 1 labetalol oral tablet 100 mg, 200 mg, 300 mg Tier 1 Angiotensin II Receptor Blocker (ARB)-Calcium Channel Blocker Comb. - Drugs for High Blood Pressure amlodipine-valsartan oral tablet 10-160 mg, 10-320 mg, Tier 1 5-160 mg, 5-320 mg Angiotensin II Receptor Blocker (ARB)-Calcium Channel Blocker-Diuretic - Drugs for High Blood Pressure amlodipine-valsartan-hcthiazid oral tablet 10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160- Tier 1 25 mg Angiotensin II Receptor Blocker (ARB)-Diuretic Combinations - Drugs for High Blood Pressure candesartan-hydrochlorothiazid oral tablet 16-12.5 mg, Tier 1 32-12.5 mg, 32-25 mg irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, Tier 1 300-12.5 mg losartan-hydrochlorothiazide oral tablet 100-12.5 mg, Tier 1 100-25 mg, 50-12.5 mg valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, Tier 1 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg Angiotensin II Receptor Blocker-Neprilysin Inhibitor Comb. (ARNi) - Drugs for High Blood Pressure ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 Tier 2 PA MG (sacubitril/valsartan) Angiotensin II Receptor Blockers (ARBs) - Drugs for High Blood Pressure candesartan oral tablet 16 mg, 32 mg, 4 mg, 8 mg Tier 1 irbesartan oral tablet 150 mg, 300 mg, 75 mg Tier 1 losartan oral tablet 100 mg, 25 mg, 50 mg Tier 1 valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg Tier 1 Antianginal - Coronary Vasodilators (Nitrates) - Drugs for Angina isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 Tier 1 mg PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 33 Coverage Prescription Drug Name Drug Tier Requirements and Limits isosorbide mononitrate oral tablet 10 mg, 20 mg Tier 1 isosorbide mononitrate oral tablet extended release 24 Tier 1 hr 120 mg, 30 mg, 60 mg nitroglycerin (Minitran Transdermal Patch 24 Hour 0.1 Tier 1 Mg/Hr, 0.2 Mg/Hr, 0.4 Mg/Hr, 0.6 Mg/Hr) NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 Tier 2 MG/HR, 0.8 MG/HR (nitroglycerin) nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 0.6 mg Tier 1 nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 Tier 1 mg/hr, 0.4 mg/hr, 0.6 mg/hr NITRO-TIME ORAL CAPSULE, EXTENDED RELEASE 2.5 Tier 1 MG, 6.5 MG, 9 MG (nitroglycerin) Antianginal and Anti-ischemic Agents, Non-hemodynamic - Drugs for Angina ranolazine oral tablet extended release 12 hr 1,000 mg, Tier 1 500 mg Antiarrhythmic - Class Ia - Drugs for Abnormal Heart Rhythms disopyramide phosphate oral capsule 100 mg, 150 mg Tier 1 NORPACE CR ORAL CAPSULE, EXTENDED RELEASE Tier 2 100 MG, 150 MG (disopyramide phosphate) quinidine gluconate oral tablet extended release 324 mg Tier 1 quinidine sulfate oral tablet 200 mg, 300 mg Tier 1 Antiarrhythmic - Class Ib - Drugs for Abnormal Heart Rhythms mexiletine oral capsule 150 mg, 200 mg, 250 mg Tier 1 Antiarrhythmic - Class Ic - Drugs for Abnormal Heart Rhythms flecainide oral tablet 100 mg, 150 mg, 50 mg Tier 1 propafenone oral capsule,extended release 12 hr 225 Tier 1 mg, 325 mg, 425 mg propafenone oral tablet 150 mg, 225 mg, 300 mg Tier 1 Antiarrhythmic - Class II - Drugs for Abnormal Heart Rhythms sotalol hcl (Sorine Oral Tablet 120 Mg, 160 Mg, 240 Mg, Tier 1 80 Mg) sotalol hcl (Sotalol Af Oral Tablet 120 Mg, 160 Mg, 80 Mg) Tier 1 sotalol oral tablet 120 mg, 160 mg, 240 mg, 80 mg Tier 1 Antiarrhythmic - Class III - Drugs for Abnormal Heart Rhythms amiodarone oral tablet 100 mg, 200 mg, 400 mg Tier 1 PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 34 Coverage Prescription Drug Name Drug Tier Requirements and Limits dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg Tier 1 MULTAQ ORAL TABLET 400 MG (dronedarone hcl) Tier 2 amiodarone hcl (Pacerone Oral Tablet 100 Mg, 200 Mg, Tier 1 400 Mg) Antiarrhythmic - Class IV - Drugs for Abnormal Heart Rhythms verapamil oral tablet 120 mg, 40 mg, 80 mg Tier 1 Antihyperlipidemic - ATP-Citrate Lyase (ACLY) Inhibitor - Drugs for Cholesterol NEXLETOL ORAL TABLET 180 MG (bempedoic acid) Tier 3 PA; QL (30 EA per 30 days) Antihyperlipidemic - Bile Acid Sequestrants - Drugs for Cholesterol cholestyramine (with sugar) oral powder 4 gram Tier 1 cholestyramine (with sugar) oral powder in packet 4 Tier 1 gram cholestyramine/aspartame (Cholestyramine Light Oral Tier 1 Powder 4 Gram) cholestyramine/aspartame (Cholestyramine Light Oral Tier 1 Powder In Packet 4 Gram) colesevelam oral powder in packet 3.75 gram Tier 2 colesevelam oral tablet 625 mg Tier 2 COLESTID FLAVORED ORAL PACKET 7.5 GRAM Tier 3 (colestipol hcl) colestipol oral granules 5 gram Tier 1 colestipol oral packet 5 gram Tier 1 colestipol oral tablet 1 gram Tier 1 cholestyramine/aspartame (Prevalite Oral Powder 4 Tier 1 Gram) cholestyramine/aspartame (Prevalite Oral Powder In Tier 1 Packet 4 Gram) Antihyperlipidemic - Fibric Acid Derivatives - Drugs for Cholesterol fenofibrate micronized oral capsule 130 mg, 134 mg, Tier 1 200 mg, 43 mg, 67 mg fenofibrate nanocrystallized oral tablet 145 mg, 48 mg Tier 1 fenofibrate oral tablet 120 mg, 160 mg, 40 mg, 54 mg Tier 1 fenofibric acid (choline) oral capsule,delayed Tier 1 release(dr/ec) 135 mg, 45 mg gemfibrozil oral tablet 600 mg Tier 1 PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 35 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antihyperlipidemic - HMG CoA Reductase Inhibitors (statins) - Drugs for Cholesterol atorvastatin oral tablet 10 mg, 20 mg $0 EHB atorvastatin oral tablet 40 mg, 80 mg Tier 1 fluvastatin oral tablet extended release 24 hr 80 mg Tier 1 PA lovastatin oral tablet 10 mg, 20 mg, 40 mg $0 EHB pravastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg $0 EHB rosuvastatin oral tablet 10 mg, 5 mg $0 EHB; QL (1 EA per 1 day) rosuvastatin oral tablet 20 mg, 40 mg Tier 1 QL (1 EA per 1 day) simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg $0 EHB Antihyperlipidemic - Nicotinic Acid Derivatives - Drugs for Cholesterol niacin oral tablet extended release 24 hr 1,000 mg, 500 Tier 2 mg, 750 mg niacin (Niacor Oral Tablet 500 Mg) Tier 1 Antihyperlipidemic - Omega-3 Fatty Acid Type - Drugs for Cholesterol PA; QL (120 EA per 30 icosapent ethyl oral capsule 1 gram Tier 3 days) omega-3 acid ethyl esters oral capsule 1 gram Tier 1 PA; QL (240 EA per 30 VASCEPA ORAL CAPSULE 0.5 GRAM (icosapent ethyl) Tier 3 days) Antihyperlipidemic - PCSK9 Inhibitors - Drugs for Cholesterol REPATHA SURECLICK SUBCUTANEOUS PEN Tier 4 PA; QL (3 ML per 28 days) INJECTOR 140 MG/ML (evolocumab) REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 Tier 4 PA; QL (3 ML per 28 days) MG/ML (evolocumab) Antihyperlipidemic - Selective Cholesterol Absorption Inhibitor - Drugs for Cholesterol ezetimibe oral tablet 10 mg Tier 2 QL (1 EA per 1 day) Antihyperlipidemic- ATP-Citrate Lyase and Cholesterol Absorption Inhib - Drugs for Cholesterol NEXLIZET ORAL TABLET 180-10 MG (bempedoic Tier 3 PA; QL (30 EA per 30 days) acid/ezetimibe) Antihyperlipidemic HMG CoA Reduct Inhib and Calcium Channel Blocker - Drugs for Cholesterol

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 36 Coverage Prescription Drug Name Drug Tier Requirements and Limits amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5- Tier 3 10 mg, 5-20 mg, 5-40 mg, 5-80 mg Beta Blockers Cardiac Selective - Drugs for High Blood Pressure atenolol oral tablet 100 mg, 25 mg, 50 mg Tier 1 betaxolol oral tablet 10 mg, 20 mg Tier 1 bisoprolol fumarate oral tablet 10 mg, 5 mg Tier 1 BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG Tier 2 (nebivolol hcl) metoprolol succinate oral tablet extended release 24 hr Tier 1 100 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 100 mg, 50 mg Tier 1 metoprolol tartrate oral tablet 25 mg Tier 1 Beta Blockers Cardiac Selective, Intrinsic Sympathomimetic Activity - Drugs for High Blood Pressure acebutolol oral capsule 200 mg, 400 mg Tier 1 Beta Blockers Non-Cardiac Selective - Drugs for High Blood Pressure INDERAL XL ORAL CAPSULE,EXTENDED RELEASE Tier 1 24HR 120 MG, 80 MG (propranolol hcl) INNOPRAN XL ORAL CAPSULE,EXTENDED RELEASE Tier 1 24HR 120 MG, 80 MG (propranolol hcl) propranolol oral capsule,extended release 24 hr 120 Tier 1 mg, 160 mg, 60 mg, 80 mg propranolol oral solution 20 mg/5 ml (4 mg/ml), 40 mg/5 Tier 1 ml (8 mg/ml) propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 Tier 1 mg Calcium Channel Blockers - Benzothiazepines - Drugs for High Blood Pressure diltiazem hcl (Cartia Xt Oral Capsule,Extended Release Tier 1 24Hr 120 Mg, 180 Mg, 240 Mg, 300 Mg) diltiazem hcl oral capsule,ext.rel 24h degradable 120 Tier 1 mg, 180 mg, 240 mg diltiazem hcl oral capsule,extended release 12 hr 120 Tier 1 mg, 60 mg, 90 mg diltiazem hcl oral capsule,extended release 24 hr 120 Tier 1 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 37 Coverage Prescription Drug Name Drug Tier Requirements and Limits diltiazem hcl oral capsule,extended release 24hr 120 Tier 1 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg Tier 1 diltiazem hcl oral tablet extended release 24 hr 180 mg, Tier 1 240 mg, 300 mg, 360 mg, 420 mg DILT-XR ORAL CAPSULE,EXT.REL 24H DEGRADABLE Tier 1 120 MG, 180 MG, 240 MG (diltiazem hcl) diltiazem hcl (Matzim La Oral Tablet Extended Release 24 Tier 1 Hr 180 Mg, 240 Mg, 300 Mg, 360 Mg, 420 Mg) diltiazem hcl (Taztia Xt Oral Capsule,Extended Release 24 Tier 1 Hr 120 Mg, 180 Mg, 240 Mg, 300 Mg, 360 Mg) diltiazem hcl (Tiadylt Er Oral Capsule,Extended Release Tier 1 24 Hr 120 Mg, 180 Mg, 240 Mg, 300 Mg, 360 Mg, 420 Mg) Calcium Channel Blockers - Dihydropyridines - Cerebrovascular Specific - Drugs for High Blood Pressure nimodipine oral capsule 30 mg Tier 1 Calcium Channel Blockers - Dihydropyridines - Drugs for High Blood Pressure amlodipine oral tablet 10 mg, 2.5 mg, 5 mg Tier 1 felodipine oral tablet extended release 24 hr 10 mg, 2.5 Tier 1 mg, 5 mg isradipine oral capsule 2.5 mg, 5 mg Tier 1 nicardipine oral capsule 20 mg, 30 mg Tier 1 nifedipine oral capsule 10 mg, 20 mg Tier 1 nifedipine oral tablet extended release 24hr 30 mg, 60 Tier 1 mg, 90 mg nifedipine oral tablet extended release 30 mg, 60 mg, 90 Tier 1 mg nisoldipine oral tablet extended release 24 hr 17 mg, 20 Tier 1 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg Calcium Channel Blockers - Phenylakylamines - Drugs for High Blood Pressure verapamil oral capsule, 24 hr er pellet ct 100 mg, 300 Tier 2 mg verapamil oral capsule, 24 hr er pellet ct 200 mg Tier 1 verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 Tier 1 mg, 240 mg, 360 mg

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 38 Coverage Prescription Drug Name Drug Tier Requirements and Limits verapamil oral tablet extended release 120 mg, 180 mg, Tier 1 240 mg Cardiac Selective Beta Blocker-Thiazide Diuretic and Related Comb. - Drugs for High Blood Pressure atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg Tier 1 bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, Tier 1 2.5-6.25 mg, 5-6.25 mg DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HR 100-12.5 MG, 25-12.5 MG, 50-12.5 MG (metoprolol Tier 2 succinate/hydrochlorothiazide) metoprolol ta-hydrochlorothiaz oral tablet 100-25 mg, Tier 1 100-50 mg, 50-25 mg Cardiovascular Sympathomimetic - Anaphylaxis Therapy Single Agents - Drugs for Serious Allergic Reaction epinephrine injection auto-injector 0.15 mg/0.15 ml, 0.15 Tier 2 QL (2 EA per 1 FILL) mg/0.3 ml, 0.3 mg/0.3 ml Cardiovascular Sympathomimetics - Drugs for Serious Allergic Reaction midodrine oral tablet 10 mg, 2.5 mg, 5 mg Tier 1 Central Alpha-2 Agonists-Thiazide Diuretic and Related Comb. - Drugs for High Blood Pressure methyldopa-hydrochlorothiazide oral tablet 250-15 mg, Tier 1 250-25 mg Central Alpha-2 Receptor Agonists - Drugs for High Blood Pressure clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg Tier 1 clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 Tier 1 mg/24 hr, 0.3 mg/24 hr guanfacine oral tablet 1 mg, 2 mg Tier 1 methyldopa oral tablet 250 mg, 500 mg Tier 1 Digitalis Glycosides - Drugs for the Heart digoxin (Digitek Oral Tablet 125 Mcg (0.125 Mg), 250 Mcg Tier 1 (0.25 Mg)) digoxin (Digox Oral Tablet 125 Mcg (0.125 Mg), 250 Mcg Tier 1 (0.25 Mg)) digoxin oral solution 50 mcg/ml (0.05 mg/ml) Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 39 Coverage Prescription Drug Name Drug Tier Requirements and Limits digoxin oral tablet 125 mcg (0.125 mg), 250 mcg (0.25 Tier 1 mg) Direct Acting Vasodilators - Drugs for High Blood Pressure hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg Tier 1 minoxidil oral tablet 10 mg, 2.5 mg Tier 1 Diuretic - Carbonic Anhydrase Inhibitors - Drugs for High Blood Pressure acetazolamide oral capsule, extended release 500 mg Tier 1 acetazolamide oral tablet 125 mg, 250 mg Tier 1 methazolamide oral tablet 25 mg, 50 mg Tier 1 Diuretic - Loop - Drugs for High Blood Pressure bumetanide oral tablet 0.5 mg, 1 mg, 2 mg Tier 1 ethacrynic acid oral tablet 25 mg Tier 1 furosemide oral solution 10 mg/ml Tier 1 furosemide oral solution 40 mg/5 ml (8 mg/ml) Tier 1 furosemide oral tablet 20 mg, 40 mg, 80 mg Tier 1 torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg Tier 1 Diuretic - Potassium Sparing - Drugs for High Blood Pressure amiloride oral tablet 5 mg Tier 1 triamterene oral capsule 100 mg, 50 mg Tier 2 Diuretic - Potassium Sparing-Thiazide and Related Combinations - Drugs for High Blood Pressure amiloride-hydrochlorothiazide oral tablet 5-50 mg Tier 1 spironolacton-hydrochlorothiaz oral tablet 25-25 mg Tier 1 triamterene-hydrochlorothiazid oral capsule 37.5-25 mg Tier 1 triamterene-hydrochlorothiazid oral tablet 37.5-25 mg, Tier 1 75-50 mg Diuretic - Thiazides and Related - Drugs for High Blood Pressure chlorthalidone oral tablet 25 mg, 50 mg Tier 1 DIURIL ORAL SUSPENSION 250 MG/5 ML Tier 2 (chlorothiazide) hydrochlorothiazide oral capsule 12.5 mg Tier 1 hydrochlorothiazide oral tablet 12.5 mg Tier 1 hydrochlorothiazide oral tablet 25 mg, 50 mg Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 41 Coverage Prescription Drug Name Drug Tier Requirements and Limits alprazolam oral tablet extended release 24 hr 0.5 mg, 1 Tier 1 mg, 2 mg, 3 mg alprazolam oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 Tier 1 mg, 2 mg chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg Tier 1 clonazepam oral tablet 0.5 mg, 1 mg, 2 mg Tier 1 clonazepam oral tablet,disintegrating 0.125 mg, 0.25 Tier 1 mg, 0.5 mg, 1 mg, 2 mg clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 Tier 1 mg diazepam (Diazepam Intensol Oral Concentrate 5 Mg/Ml) Tier 1 diazepam oral concentrate 5 mg/ml Tier 1 diazepam oral solution 5 mg/5 ml (1 mg/ml) Tier 1 diazepam oral tablet 10 mg, 2 mg, 5 mg Tier 1 lorazepam (Lorazepam Intensol Oral Concentrate 2 Mg/Ml) Tier 1 lorazepam oral concentrate 2 mg/ml Tier 1 lorazepam oral tablet 0.5 mg, 1 mg, 2 mg Tier 1 oxazepam oral capsule 10 mg, 15 mg, 30 mg Tier 1 Antianxiety Agent - Dicarbamate Type - Drugs for Anxiety meprobamate oral tablet 200 mg, 400 mg Tier 1 Antianxiety Agent - Non-Benzodiazepine - Drugs for Anxiety buspirone oral tablet 10 mg, 15 mg, 5 mg, 7.5 mg Tier 1 Anticonvulsant - Barbiturates and Derivatives - Drugs for Seizures /Personality Disorder/Nerve Pain MYSOLINE ORAL TABLET 250 MG, 50 MG (primidone) Tier 3 primidone oral tablet 250 mg, 50 mg Tier 1 Anticonvulsant - Benzodiazepines - Drugs for Seizures /Personality Disorder/Nerve Pain clobazam oral suspension 2.5 mg/ml Tier 1 clobazam oral tablet 10 mg, 20 mg Tier 1 SYMPAZAN ORAL FILM 10 MG, 20 MG, 5 MG (clobazam) Tier 2 PA Anticonvulsant - Carbamates - Drugs for Seizures /Personality Disorder/Nerve Pain felbamate oral suspension 600 mg/5 ml Tier 2 PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 42 Coverage Prescription Drug Name Drug Tier Requirements and Limits felbamate oral tablet 400 mg, 600 mg Tier 2 FELBATOL ORAL SUSPENSION 600 MG/5 ML Tier 3 (felbamate) FELBATOL ORAL TABLET 400 MG, 600 MG (felbamate) Tier 2 Anticonvulsant - Carboxylic Acid Derivatives - Drugs for Seizures /Personality Disorder/Nerve Pain divalproex oral capsule, delayed rel sprinkle 125 mg Tier 1 divalproex oral tablet extended release 24 hr 250 mg, Tier 1 500 mg divalproex oral tablet,delayed release (dr/ec) 125 mg, Tier 1 250 mg, 500 mg valproic acid oral capsule 250 mg Tier 1 Anticonvulsant - GABA Analogs - Drugs for Seizures /Personality Disorder/Nerve Pain gabapentin oral capsule 100 mg, 300 mg, 400 mg Tier 1 gabapentin oral solution 250 mg/5 ml Tier 1 gabapentin oral solution 250 mg/5 ml (5 ml), 300 mg/6 Tier 1 ml (6 ml) gabapentin oral tablet 600 mg, 800 mg Tier 1 pregabalin oral capsule 100 mg, 150 mg, 200 mg, 225 Tier 1 mg, 25 mg, 300 mg, 50 mg, 75 mg pregabalin oral solution 20 mg/ml Tier 2 Anticonvulsant - GABA Re-uptake Inhibitor, Nipecotic Acid Derivatives - Drugs for Seizures /Personality Disorder/Nerve Pain GABITRIL ORAL TABLET 12 MG, 16 MG, 2 MG, 4 MG Tier 3 (tiagabine hcl) tiagabine oral tablet 12 mg, 16 mg, 2 mg, 4 mg Tier 2 Anticonvulsant - GABA Transaminase (GABA-T) Inhibitor - Drugs for Seizures /Personality Disorder/Nerve Pain vigabatrin oral powder in packet 500 mg Tier 4 PA; SP Anticonvulsant - Hydantoins - Drugs for Seizures /Personality Disorder/Nerve Pain phenytoin sodium extended (Dilantin Extended Oral Tier 3 Capsule 100 Mg) phenytoin (Dilantin Infatabs Oral Tablet,Chewable 50 Mg) Tier 3 PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 43 Coverage Prescription Drug Name Drug Tier Requirements and Limits DILANTIN ORAL CAPSULE 30 MG (phenytoin sodium Tier 3 extended) DILANTIN-125 ORAL SUSPENSION 125 MG/5 ML Tier 3 (phenytoin) phenytoin sodium extended (Phenytek Oral Capsule 200 Tier 3 Mg, 300 Mg) phenytoin oral suspension 100 mg/4 ml Tier 1 phenytoin oral suspension 125 mg/5 ml Tier 1 phenytoin oral tablet,chewable 50 mg Tier 1 phenytoin sodium extended oral capsule 100 mg, 200 Tier 1 mg, 300 mg Anticonvulsant - Iminostilbene Derivatives - Drugs for Seizures /Personality Disorder/Nerve Pain carbamazepine oral capsule, er multiphase 12 hr 100 Tier 1 mg, 200 mg, 300 mg carbamazepine oral suspension 100 mg/5 ml Tier 1 carbamazepine oral tablet 200 mg Tier 1 carbamazepine oral tablet extended release 12 hr 100 Tier 1 mg, 200 mg, 400 mg carbamazepine oral tablet,chewable 100 mg Tier 1 CARBATROL ORAL CAPSULE, ER MULTIPHASE 12 HR Tier 3 100 MG, 200 MG, 300 MG (carbamazepine) carbamazepine (Epitol Oral Tablet 200 Mg) Tier 1 EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 Tier 2 MG, 300 MG (carbamazepine) EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 200 Tier 3 MG (carbamazepine) oxcarbazepine oral suspension 300 mg/5 ml (60 mg/ml) Tier 1 oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg Tier 1 TEGRETOL ORAL SUSPENSION 100 MG/5 ML Tier 3 (carbamazepine) TEGRETOL ORAL TABLET 200 MG (carbamazepine) Tier 3 TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 Tier 3 HR 100 MG, 200 MG, 400 MG (carbamazepine) Anticonvulsant - Monosaccharide Derivatives - Drugs for Seizures /Personality Disorder/Nerve Pain PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 44 Coverage Prescription Drug Name Drug Tier Requirements and Limits topiramate oral capsule, sprinkle 15 mg, 25 mg Tier 1 topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg Tier 1 Anticonvulsant - Phenyltriazine Derivatives - Drugs for Seizures /Personality Disorder/Nerve Pain LAMICTAL ODT ORAL TABLET,DISINTEGRATING 100 Tier 3 MG, 200 MG, 25 MG, 50 MG (lamotrigine) LAMICTAL ORAL TABLET 100 MG, 150 MG, 200 MG, 25 Tier 3 MG (lamotrigine) LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 25 Tier 3 MG, 5 MG (lamotrigine) LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24HR 100 MG, 200 MG, 25 MG, 300 MG, 50 MG Tier 3 (lamotrigine) LAMICTAL XR ORAL TABLET EXTENDED RELEASE Tier 4 24HR 250 MG (lamotrigine) lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg Tier 1 lamotrigine oral tablet extended release 24hr 100 mg, Tier 2 200 mg, 25 mg, 50 mg lamotrigine oral tablet extended release 24hr 250 mg Tier 4 lamotrigine oral tablet extended release 24hr 300 mg Tier 3 lamotrigine oral tablet, chewable dispersible 25 mg, 5 Tier 1 mg lamotrigine oral tablet,disintegrating 100 mg, 200 mg, Tier 1 25 mg, 50 mg lamotrigine (Subvenite Oral Tablet 100 Mg, 150 Mg, 200 Tier 1 Mg, 25 Mg) Anticonvulsant - Pyrrolidine Derivatives - Drugs for Seizures /Personality Disorder/Nerve Pain levetiracetam oral solution 100 mg/ml Tier 1 levetiracetam oral solution 500 mg/5 ml (5 ml) Tier 1 levetiracetam oral tablet 1,000 mg, 250 mg, 500 mg, 750 Tier 1 mg levetiracetam oral tablet extended release 24 hr 500 mg, Tier 1 750 mg Anticonvulsant - Succinimides - Drugs for Seizures /Personality Disorder/Nerve Pain

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 46 Coverage Prescription Drug Name Drug Tier Requirements and Limits fluoxetine oral solution 20 mg/5 ml (4 mg/ml) Tier 1 fluoxetine oral tablet 10 mg, 20 mg Tier 1 ST: At least 2 prior prescriptions for Citalopram Hydrobromide, Escitalopram fluvoxamine oral capsule,extended release 24hr 100 Tier 1 Oxalate, Fluoxetine HCL, mg, 150 mg Fluvoxamine Maleate, Paroxetine HCL, Paxil, or Sertraline HCL in 120 days fluvoxamine oral tablet 100 mg, 25 mg, 50 mg Tier 1 paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg Tier 1 paroxetine hcl oral tablet extended release 24 hr 12.5 Tier 1 mg, 25 mg, 37.5 mg sertraline oral concentrate 20 mg/ml Tier 1 sertraline oral tablet 100 mg, 25 mg, 50 mg Tier 1 Antidepressant - Serotonin-2 Antagonist-Reuptake Inhibitors (SARIs) - Drugs for Depression nefazodone oral tablet 100 mg, 150 mg, 200 mg, 250 mg, Tier 1 50 mg trazodone oral tablet 100 mg, 150 mg, 50 mg Tier 1 Antidepressant - Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) - Drugs for Depression duloxetine oral capsule,delayed release(dr/ec) 20 mg, Tier 1 QL (2 EA per 1 day) 30 mg, 60 mg FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK Tier 3 PA; QL (1 EA per 1 day) 20 MG (2)- 40 MG (26) (levomilnacipran hcl) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR Tier 3 PA; QL (1 EA per 1 day) 120 MG, 20 MG, 40 MG, 80 MG (levomilnacipran hcl) SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 Tier 2 QL (2 EA per 1 day) MG (milnacipran hcl) SAVELLA ORAL TABLETS,DOSE PACK 12.5 MG (5)-25 Tier 2 MG(8)-50 MG(42) (milnacipran hcl) venlafaxine oral capsule,extended release 24hr 150 mg, Tier 1 37.5 mg, 75 mg venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, Tier 1 75 mg

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 47 Coverage Prescription Drug Name Drug Tier Requirements and Limits venlafaxine oral tablet extended release 24hr 150 mg, Tier 1 225 mg, 37.5 mg, 75 mg Antidepressant - SSRI and Serotonin (5-HT) Receptor Modulator - Drugs for Depression TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG Tier 3 PA; QL (1 EA per 1 day) (vortioxetine hydrobromide) Antidepressant - Tricyclic and Antipsychotic, Phenothiazine Comb - Drugs for Depression perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, Tier 1 4-10 mg, 4-25 mg, 4-50 mg Antidepressant - Tricyclic-Benzodiazepine Combinations - Drugs for Depression amitriptyline-chlordiazepoxide oral tablet 12.5-5 mg, 25- Tier 1 10 mg Antidepressant-Norepinephrine and Dopamine Reuptake Inhibitors (NDRIs) - Drugs for Depression bupropion hcl oral tablet 100 mg, 75 mg Tier 1 bupropion hcl oral tablet extended release 24 hr 150 Tier 1 mg, 300 mg bupropion hcl oral tablet sustained-release 12 hr 100 Tier 1 mg, 150 mg, 200 mg Antidepressant-Tricyclics and Related (Non-Select Reuptake Inhibitors) - Drugs for Depression amitriptyline oral tablet 10 mg, 100 mg, 150 mg, 25 mg, Tier 1 50 mg, 75 mg amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg Tier 1 clomipramine oral capsule 25 mg, 50 mg, 75 mg Tier 1 desipramine oral tablet 10 mg, 100 mg, 150 mg, 25 mg, Tier 1 50 mg, 75 mg doxepin oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 Tier 1 mg, 75 mg doxepin oral concentrate 10 mg/ml Tier 1 imipramine hcl oral tablet 10 mg, 25 mg, 50 mg Tier 1 imipramine pamoate oral capsule 100 mg, 125 mg, 150 Tier 1 mg, 75 mg maprotiline oral tablet 25 mg, 50 mg, 75 mg Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 48 Coverage Prescription Drug Name Drug Tier Requirements and Limits nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75 mg Tier 1 nortriptyline oral solution 10 mg/5 ml Tier 1 protriptyline oral tablet 10 mg, 5 mg Tier 1 trimipramine oral capsule 100 mg, 25 mg, 50 mg Tier 1 Antiparkinson - Dopaminergic-Periph COMT-Dopa-decarboxylase Inhib Comb - Drugs for Parkinson carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, Tier 2 37.5-150-200 mg, 50-200-200 mg Antiparkinson - Dopaminerg-Peripheral Dopa-decarboxylase Inhibit Comb - Drugs for Parkinson carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, Tier 1 25-250 mg carbidopa-levodopa oral tablet extended release 25-100 Tier 1 mg, 50-200 mg carbidopa-levodopa oral tablet,disintegrating 10-100 Tier 1 mg, 25-100 mg, 25-250 mg RYTARY ORAL CAPSULE, EXTENDED RELEASE 23.75- ST: Prior prescription for 95 MG, 36.25-145 MG, 48.75-195 MG, 61.25-245 MG Tier 3 Carbidopa/levodopa or (carbidopa/levodopa) Rytary in 120 days Antiparkinson Adjuvant - Peripheral COMT Inhibitors - Drugs for Parkinson entacapone oral tablet 200 mg Tier 2 Antiparkinson Adjuvant - Peripheral Dopa-decarboxylase Inhibitors - Drugs for Parkinson carbidopa oral tablet 25 mg Tier 1 Antiparkinson Therapy - Anticholinergic Agents - Drugs for Parkinson benztropine oral tablet 0.5 mg, 1 mg, 2 mg Tier 1 trihexyphenidyl oral elixir 0.4 mg/ml Tier 1 trihexyphenidyl oral tablet 2 mg, 5 mg Tier 1 Antiparkinson Therapy - Ergot Alkaloids and Derivatives - Drugs for Parkinson bromocriptine oral capsule 5 mg Tier 2 bromocriptine oral tablet 2.5 mg Tier 2 Antiparkinson Therapy - Monoamine Oxidase Inhibitor(MAO-B) - Drugs for Parkinson

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 49 Coverage Prescription Drug Name Drug Tier Requirements and Limits rasagiline oral tablet 0.5 mg, 1 mg Tier 2 selegiline hcl oral capsule 5 mg Tier 1 selegiline hcl oral tablet 5 mg Tier 1 Antiparkinson Therapy - Non-ergot Dopamine Agonist Agents - Drugs for Parkinson amantadine hcl oral capsule 100 mg Tier 1 amantadine hcl oral solution 50 mg/5 ml Tier 1 NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, Tier 4 PA 6 MG/24 HOUR, 8 MG/24 HOUR (rotigotine) pramipexole oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 Tier 1 mg, 1 mg, 1.5 mg pramipexole oral tablet extended release 24 hr 0.375 Tier 2 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, Tier 1 4 mg, 5 mg ropinirole oral tablet extended release 24 hr 12 mg, 2 Tier 2 mg, 4 mg, 6 mg, 8 mg Antipsychotic - Atypical Dopamine-Serotonin Antag- Benzisoxazole Deriv - Drugs for Severe Mental Disorders paliperidone oral tablet extended release 24hr 1.5 mg, 3 Tier 3 QL (30 EA per 30 days) mg, 6 mg, 9 mg risperidone oral solution 1 mg/ml Tier 1 risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 Tier 1 mg, 4 mg risperidone oral tablet,disintegrating 0.25 mg Tier 1 risperidone oral tablet,disintegrating 0.5 mg, 1 mg, 2 Tier 1 mg, 3 mg, 4 mg Antipsychotic - Atypical Dopamine-Serotonin Antag-Dibenzodiazepine Der - Drugs for Severe Mental Disorders clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg Tier 1 clozapine oral tablet,disintegrating 100 mg, 25 mg Tier 1 clozapine oral tablet,disintegrating 12.5 mg, 150 mg, Tier 2 200 mg Antipsychotic - Butyrophenone Derivatives - Drugs for Severe Mental Disorders

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 50 Coverage Prescription Drug Name Drug Tier Requirements and Limits haloperidol lactate oral concentrate 2 mg/ml Tier 1 haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 Tier 1 mg, 5 mg Antipsychotic - Dibenzoxazepine Derivatives - Drugs for Severe Mental Disorders loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 Tier 1 mg Antipsychotic - Diphenylbutylpiperidine Derivatives - Drugs for Severe Mental Disorders pimozide oral tablet 1 mg, 2 mg Tier 1 Antipsychotic - Phenothiazines, Aliphatic - Drugs for Severe Mental Disorders chlorpromazine oral tablet 10 mg, 100 mg, 200 mg, 25 Tier 1 mg, 50 mg Antipsychotic - Phenothiazines, Piperazine - Drugs for Severe Mental Disorders fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg Tier 1 perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg Tier 1 prochlorperazine maleate oral tablet 10 mg, 5 mg Tier 1 trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5 mg Tier 1 Antipsychotic - Phenothiazines, Piperidine - Drugs for Severe Mental Disorders thioridazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg Tier 1 Antipsychotic - Thioxanthenes - Drugs for Severe Mental Disorders thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg Tier 1 Attention Deficit-Hyperact. Disorder (ADHD)- alpha-2 Receptor Agonist - Drugs for Attention Deficit Disorder guanfacine oral tablet extended release 24 hr 1 mg, 2 Tier 1 mg, 3 mg, 4 mg Attention Deficit-Hyperactivity (ADHD) Therapy, Stimulant-Type - Drugs for Attention Deficit Disorder dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5 mg Tier 1 methylphenidate hcl (Metadate Er Oral Tablet Extended Tier 1 Release 20 Mg) methylphenidate hcl oral capsule, er biphasic 30-70 10 Tier 1 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 51 Coverage Prescription Drug Name Drug Tier Requirements and Limits methylphenidate hcl oral capsule,er biphasic 50-50 20 Tier 1 mg, 30 mg, 40 mg methylphenidate hcl oral solution 10 mg/5 ml, 5 mg/5 ml Tier 1 methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg Tier 1 methylphenidate hcl oral tablet extended release 10 mg, Tier 1 20 mg methylphenidate hcl oral tablet extended release 24hr Tier 1 18 mg, 27 mg, 36 mg, 54 mg VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG (lisdexamfetamine Tier 2 dimesylate) Attention Deficit-Hyperactivity Disorder (ADHD) Therapy, NRI-Type - Drugs for Attention Deficit Disorder atomoxetine oral capsule 10 mg, 100 mg, 18 mg, 25 mg, Tier 2 40 mg, 60 mg, 80 mg Benzodiazepines - Drugs for Seizures /Personality Disorder/Nerve Pain diazepam (Diazepam Intensol Oral Concentrate 5 Mg/Ml) Tier 1 diazepam oral concentrate 5 mg/ml Tier 1 diazepam oral solution 5 mg/5 ml (1 mg/ml) Tier 1 flurazepam oral capsule 15 mg, 30 mg Tier 1 lorazepam (Lorazepam Intensol Oral Concentrate 2 Mg/Ml) Tier 1 Bipolar Therapy Agents - Anticonvulsant Type - Drugs for Seizures /Personality Disorder/Nerve Pain CARBATROL ORAL CAPSULE, ER MULTIPHASE 12 HR Tier 3 100 MG, 200 MG, 300 MG (carbamazepine) carbamazepine (Epitol Oral Tablet 200 Mg) Tier 1 EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 Tier 2 MG, 300 MG (carbamazepine) EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 200 Tier 3 MG (carbamazepine) LAMICTAL ODT ORAL TABLET,DISINTEGRATING 100 Tier 3 MG, 200 MG, 25 MG, 50 MG (lamotrigine) TEGRETOL ORAL SUSPENSION 100 MG/5 ML Tier 3 (carbamazepine) TEGRETOL ORAL TABLET 200 MG (carbamazepine) Tier 3

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 53 Coverage Prescription Drug Name Drug Tier Requirements and Limits CNS Stimulant - Amphetamines - Drugs for Attention Deficit Disorder dextroamphetamine oral capsule, extended release 10 Tier 1 mg, 15 mg, 5 mg dextroamphetamine oral solution 5 mg/5 ml Tier 1 dextroamphetamine oral tablet 10 mg, 5 mg Tier 1 methamphetamine oral tablet 5 mg Tier 1 dextroamphetamine sulfate (Zenzedi Oral Tablet 10 Mg, 5 Tier 1 Mg) CNS Stimulant - Analeptics, methylxanthine-type - Drugs for the Nervous System caffeine citrate oral solution 60 mg/3 ml (20 mg/ml) Tier 1 Age (Max 1 Years) Fibromyalgia Agents - Serotonin-Norepinephrine Reuptake-Inhib (SNRIs) - Drugs for Seizures /Personality Disorder/Nerve Pain SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 Tier 2 QL (2 EA per 1 day) MG (milnacipran hcl) SAVELLA ORAL TABLETS,DOSE PACK 12.5 MG (5)-25 Tier 2 MG(8)-50 MG(42) (milnacipran hcl) Hypnotics - Melatonin M1/M2 Receptor Agonists - Drugs for Insomnia ramelteon oral tablet 8 mg Tier 2 PA; QL (1 EA per 1 day) Migraine Therapy - Ergot Alkaloids and Derivatives - Drugs for Migraine Headaches dihydroergotamine injection solution 1 mg/ml Tier 1 ERGOMAR SUBLINGUAL TABLET 2 MG (ergotamine Tier 3 tartrate) Migraine Therapy - Ergot Combinations - Drugs for Migraine Headaches MIGERGOT RECTAL SUPPOSITORY 2-100 MG Tier 2 (ergotamine tartrate/caffeine) Migraine Therapy - Selective Serotonin Agonists 5-HT(1) - Drugs for Migraine Headaches naratriptan oral tablet 1 mg, 2.5 mg Tier 1 QL (9 EA per 1 FILL) rizatriptan oral tablet 10 mg, 5 mg Tier 1 QL (12 EA per 1 FILL) rizatriptan oral tablet,disintegrating 10 mg, 5 mg Tier 1 QL (12 EA per 1 FILL) sumatriptan nasal spray,non-aerosol 20 mg/actuation, 5 Tier 1 QL (6 EA per 1 FILL) mg/actuation sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg Tier 1 QL (9 EA per 1 FILL)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 54 Coverage Prescription Drug Name Drug Tier Requirements and Limits sumatriptan succinate subcutaneous cartridge 4 mg/0.5 Tier 3 QL (2 ML per 1 FILL) ml, 6 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 4 Tier 1 QL (2 ML per 1 FILL) mg/0.5 ml, 6 mg/0.5 ml sumatriptan succinate subcutaneous solution 6 mg/0.5 Tier 1 QL (2.5 ML per 1 FILL) ml zolmitriptan oral tablet 2.5 mg, 5 mg Tier 1 QL (9 EA per 1 FILL) zolmitriptan oral tablet,disintegrating 2.5 mg, 5 mg Tier 1 QL (9 EA per 1 FILL) Migraine Therapy - Selective Serotonin Agonists 5-HT(1F) - Drugs for Migraine Headaches REYVOW ORAL TABLET 100 MG, 50 MG (lasmiditan Tier 4 PA; QL (9 EA per 30 days) succinate) Movement Disorder Drug Therapy - Drugs for the Nervous System tetrabenazine oral tablet 12.5 mg, 25 mg Tier 4 PA; SP Narcolepsy Therapy Agents - Non-Sympathomimetic - Drugs for Sleep Disorder modafinil oral tablet 100 mg, 200 mg Tier 1 PA; QL (2 EA per 1 day) Pseudobulbar Affect (PBA) Agents, NMDA antagonists type - Drugs for Severe Mental Disorders NUEDEXTA ORAL CAPSULE 20-10 MG Tier 2 QL (2 EA per 1 day) (dextromethorphan hbr/quinidine sulfate) Sedative-Hypnotic - Antihistamines - Drugs for Insomnia NIGHTIME SLEEP ORAL CAPSULE 50 MG Tier 1 (diphenhydramine hcl) NIGHTTIME SLEEP AID (DIPHEN) ORAL CAPSULE 50 Tier 1 MG (diphenhydramine hcl) SLEEP AID (DIPHENHYDRAMINE) ORAL CAPSULE 50 Tier 1 MG (diphenhydramine hcl) SLEEP AID MAX STR (DIPHENHYDR) ORAL CAPSULE Tier 1 50 MG (diphenhydramine hcl) SLEEPING ORAL CAPSULE 50 MG (diphenhydramine Tier 1 hcl) UNISOM SLEEPGELS ORAL CAPSULE 50 MG Tier 1 (diphenhydramine hcl) WAL-SOM (DIPHENHYDRAMINE) ORAL CAPSULE 50 Tier 1 MG (diphenhydramine hcl) Sedative-Hypnotic - Barbiturates - Drugs for Insomnia PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 55 Coverage Prescription Drug Name Drug Tier Requirements and Limits phenobarbital oral elixir 20 mg/5 ml (4 mg/ml) Tier 1 phenobarbital oral tablet 100 mg, 16.2 mg, 32.4 mg, 64.8 Tier 1 mg, 97.2 mg phenobarbital oral tablet 15 mg, 30 mg, 60 mg Tier 1 SECONAL SODIUM ORAL CAPSULE 100 MG Tier 2 (secobarbital sodium) Sedative-Hypnotic - Benzodiazepines - Drugs for Insomnia estazolam oral tablet 1 mg, 2 mg Tier 1 flurazepam oral capsule 15 mg, 30 mg Tier 1 temazepam oral capsule 15 mg, 22.5 mg, 30 mg, 7.5 mg Tier 1 triazolam oral tablet 0.125 mg, 0.25 mg Tier 1 Sedative-Hypnotic - GABA-Receptor Modulators - Drugs for Insomnia eszopiclone oral tablet 1 mg, 2 mg, 3 mg Tier 2 zaleplon oral capsule 10 mg, 5 mg Tier 1 zolpidem oral tablet 10 mg, 5 mg Tier 1 QL (1 EA per 1 day) Chemical Dependency, Agents to Treat - Drugs for Addiction Agents for Opioid Withdrawal, Opioid-Type - Drugs for Opioid Addiction buprenorphine-naloxone sublingual film 12-3 mg, 2-0.5 Tier 2 mg, 4-1 mg, 8-2 mg buprenorphine-naloxone sublingual tablet 2-0.5 mg, 8-2 Tier 1 mg Alcohol Abstinence Therapy - Glutamate and GABA System Type - Drugs for Alcohol Addiction acamprosate oral tablet,delayed release (dr/ec) 333 mg Tier 1 Alcohol Deterrents - Drugs for Alcohol Addiction disulfiram oral tablet 250 mg, 500 mg Tier 1 Smoking Deterrents - NE and Dopamine Reuptake Inhibitor (NDRI)-Type - Drugs for Smoking Addiction bupropion hcl (smoking deter) oral tablet extended EHB; QL (180 EA per 365 $0 release 12 hr 150 mg days) Smoking Deterrents - Nicotine-Type - Drugs for Smoking Addiction EHB; QL (180 EA per 365 nicotine (polacrilex) buccal gum 2 mg $0 days) nicotine (polacrilex) buccal gum 4 mg $0 EHB PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 56 Coverage Prescription Drug Name Drug Tier Requirements and Limits nicotine (polacrilex) buccal lozenge 2 mg, 4 mg $0 EHB nicotine (polacrilex) buccal mini lozenge 2 mg, 4 mg $0 EHB nicotine transdermal patch 24 hour 14 mg/24 hr, 21 $0 EHB mg/24 hr, 7 mg/24 hr nicotine transdermal patch, td daily, sequential 21-14-7 $0 EHB mg/24 hr NICOTROL INHALATION CARTRIDGE 10 MG (nicotine) $0 EHB NICOTROL NS NASAL SPRAY,NON-AEROSOL 10 $0 EHB MG/ML (nicotine) EHB; QL (180 EA per 365 QUIT 2 BUCCAL GUM 2 MG (nicotine polacrilex) $0 days) QUIT 2 BUCCAL LOZENGE 2 MG (nicotine polacrilex) $0 EHB QUIT 4 BUCCAL GUM 4 MG (nicotine polacrilex) $0 EHB QUIT 4 BUCCAL LOZENGE 4 MG (nicotine polacrilex) $0 EHB STOP SMOKING AID BUCCAL LOZENGE 2 MG, 4 MG $0 EHB (nicotine polacrilex) Smoking Deterrents - Nicotinic Receptor Partial Agonist, alpha4beta2 - Drugs for Smoking Addiction CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 $0 EHB MG (varenicline tartrate) CHANTIX ORAL TABLET 0.5 MG, 1 MG (varenicline $0 EHB tartrate) CHANTIX STARTING MONTH BOX ORAL EHB; QL (180 EA per 365 TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42) $0 days) (varenicline tartrate) Chemicals-Pharmaceutical Adjuvants Pharmaceutical Adjuvant - Inhalation Vehicles HYPER-SAL INHALATION SOLUTION FOR Tier 2 NEBULIZATION 3.5 % (sodium chloride for inhalation) NEBUSAL INHALATION SOLUTION FOR NEBULIZATION Tier 1 3 % (sodium chloride for inhalation) NEBUSAL INHALATION SOLUTION FOR NEBULIZATION Tier 2 6 % (sodium chloride for inhalation) sodium chloride inhalation solution for nebulization 0.9 Tier 1 %, 10 %, 3 %, 7 % Cognitive Disorder Therapy - Drugs for the Nervous System PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 57 Coverage Prescription Drug Name Drug Tier Requirements and Limits Alzheimer's Disease Therapy - Cholinesterase Inhibitors - Drugs for Alzheimer's Disease donepezil oral tablet 10 mg, 5 mg Tier 1 QL (2 EA per 1 day) donepezil oral tablet 23 mg Tier 1 QL (1 EA per 1 day) donepezil oral tablet,disintegrating 10 mg, 5 mg Tier 1 QL (1 EA per 1 day) galantamine oral capsule,ext rel. pellets 24 hr 16 mg, 24 Tier 2 mg, 8 mg galantamine oral solution 4 mg/ml Tier 2 galantamine oral tablet 12 mg, 4 mg, 8 mg Tier 2 rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, Tier 1 6 mg ST: Prior prescription for Donepezil HCL, rivastigmine transdermal patch 24 hour 13.3 mg/24 Tier 2 Galantamine HBR, or hour, 4.6 mg/24 hour, 9.5 mg/24 hour Rivastigmine Tartrate in 120 days; QL (1 EA per 1 day) Alzheimer's Disease Therapy - NMDA Receptor Antagonists - Drugs for Alzheimer's Disease memantine oral capsule,sprinkle,er 24hr 14 mg, 21 mg, Tier 2 28 mg, 7 mg memantine oral solution 2 mg/ml Tier 1 memantine oral tablet 10 mg, 5 mg Tier 1 memantine oral tablets,dose pack 5-10 mg Tier 1 Cognitive Disorder Therapy - Cerebral Vasodilators - Drugs for Alzheimer's Disease ergoloid oral tablet 1 mg Tier 1 Contraceptives - Drugs for Women Contraceptive Injectable - Progestin - Birth Control Pills DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SYRINGE CT; EHB; QL (1 ML per 90 $0 104 MG/0.65 ML (medroxyprogesterone acetate) days) medroxyprogesterone intramuscular suspension 150 CT; EHB; QL (1 ML per 90 $0 mg/ml days) CT; EHB; QL (1 ML per 90 medroxyprogesterone intramuscular syringe 150 mg/ml $0 days) Contraceptive Oral - Biphasic - Birth Control Pills

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 58 Coverage Prescription Drug Name Drug Tier Requirements and Limits levonorgestrel/ethinyl estradiol and ethinyl estradiol (Amethia Oral Tablets,Dose Pack,3 Month 0.15 Mg-30 Mcg $0 CT; EHB (84)/10 Mcg (7)) levonorgestrel/ethinyl estradiol and ethinyl estradiol (Ashlyna Oral Tablets,Dose Pack,3 Month 0.15 Mg-30 Mcg $0 CT; EHB (84)/10 Mcg (7)) desogestrel-ethinyl estradiol/ethinyl estradiol (Azurette $0 CT; EHB (28) Oral Tablet 0.15-0.02 Mgx21 /0.01 Mg X 5) desogestrel-ethinyl estradiol/ethinyl estradiol (Bekyree $0 CT; EHB (28) Oral Tablet 0.15-0.02 Mgx21 /0.01 Mg X 5) CAMRESE LO ORAL TABLETS,DOSE PACK,3 MONTH 0.10 MG-20 MCG (84)/10 MCG (7) (levonorgestrel/ethinyl $0 CT; EHB estradiol and ethinyl estradiol) CAMRESE ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (84)/10 MCG (7) (levonorgestrel/ethinyl $0 CT; EHB estradiol and ethinyl estradiol) levonorgestrel/ethinyl estradiol and ethinyl estradiol (Daysee Oral Tablets,Dose Pack,3 Month 0.15 Mg-30 Mcg $0 CT; EHB (84)/10 Mcg (7)) desog-e.estradiol/e.estradiol oral tablet 0.15-0.02 mgx21 $0 CT; EHB /0.01 mg x 5 levonorgestrel/ethinyl estradiol and ethinyl estradiol (Jaimiess Oral Tablets,Dose Pack,3 Month 0.15 Mg-30 Mcg $0 CT; EHB (84)/10 Mcg (7)) desogestrel-ethinyl estradiol/ethinyl estradiol (Kariva $0 CT; EHB (28) Oral Tablet 0.15-0.02 Mgx21 /0.01 Mg X 5) l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7), 0.15 mg-30 mcg $0 CT; EHB (84)/10 mcg (7) LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG (24)/10 MCG (2) (norethindrone acetate-ethinyl $0 CT; EHB estradiol/ferrous fumarate) levonorgestrel/ethinyl estradiol and ethinyl estradiol (Lojaimiess Oral Tablets,Dose Pack,3 Month 0.10 Mg-20 $0 CT; EHB Mcg (84)/10 Mcg (7)) desogestrel-ethinyl estradiol/ethinyl estradiol (Pimtrea $0 CT; EHB (28) Oral Tablet 0.15-0.02 Mgx21 /0.01 Mg X 5) desogestrel-ethinyl estradiol/ethinyl estradiol (Simliya $0 CT; EHB (28) Oral Tablet 0.15-0.02 Mgx21 /0.01 Mg X 5)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 59 Coverage Prescription Drug Name Drug Tier Requirements and Limits levonorgestrel/ethinyl estradiol and ethinyl estradiol (Simpesse Oral Tablets,Dose Pack,3 Month 0.15 Mg-30 $0 CT; EHB Mcg (84)/10 Mcg (7)) desogestrel-ethinyl estradiol/ethinyl estradiol (Viorele $0 CT; EHB (28) Oral Tablet 0.15-0.02 Mgx21 /0.01 Mg X 5) desogestrel-ethinyl estradiol/ethinyl estradiol (Volnea $0 CT; EHB (28) Oral Tablet 0.15-0.02 Mgx21 /0.01 Mg X 5) Contraceptive Oral - Monophasic - Birth Control Pills levonorgestrel/ethinyl estradiol (Afirmelle Oral Tablet 0.1- $0 CT; EHB 20 Mg-Mcg) levonorgestrel/ethinyl estradiol (Altavera (28) Oral Tablet $0 CT; EHB 0.15-0.03 Mg) norethindrone-ethinyl estradiol (Alyacen 1/35 (28) Oral $0 CT; EHB Tablet 1-35 Mg-Mcg) desogestrel-ethinyl estradiol (Apri Oral Tablet 0.15-0.03 $0 CT; EHB Mg) levonorgestrel/ethinyl estradiol (Aubra Eq Oral Tablet $0 CT; EHB 0.1-20 Mg-Mcg) levonorgestrel/ethinyl estradiol (Aubra Oral Tablet 0.1-20 $0 CT; EHB Mg-Mcg) norethindrone acetate-ethinyl estradiol (Aurovela 1.5/30 $0 CT; EHB (21) Oral Tablet 1.5-30 Mg-Mcg) norethindrone acetate-ethinyl estradiol (Aurovela 1/20 $0 CT; EHB (21) Oral Tablet 1-20 Mg-Mcg) norethindrone acetate-ethinyl estradiol/ferrous fumarate (Aurovela 24 Fe Oral Tablet 1 Mg-20 Mcg (24)/75 $0 CT; EHB Mg (4)) norethindrone acetate-ethinyl estradiol/ferrous fumarate (Aurovela Fe 1.5/30 (28) Oral Tablet 1.5 Mg-30 $0 CT; EHB Mcg (21)/75 Mg (7)) norethindrone acetate-ethinyl estradiol/ferrous fumarate (Aurovela Fe 1-20 (28) Oral Tablet 1 Mg-20 Mcg $0 CT; EHB (21)/75 Mg (7)) levonorgestrel/ethinyl estradiol (Aviane Oral Tablet 0.1- $0 CT; EHB 20 Mg-Mcg) levonorgestrel/ethinyl estradiol (Ayuna Oral Tablet 0.15- $0 CT; EHB 0.03 Mg)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 60 Coverage Prescription Drug Name Drug Tier Requirements and Limits norethindrone-ethinyl estradiol (Balziva (28) Oral Tablet $0 CT; EHB 0.4-35 Mg-Mcg) norethindrone acetate-ethinyl estradiol/ferrous fumarate (Blisovi 24 Fe Oral Tablet 1 Mg-20 Mcg (24)/75 $0 CT; EHB Mg (4)) norethindrone acetate-ethinyl estradiol/ferrous fumarate (Blisovi Fe 1.5/30 (28) Oral Tablet 1.5 Mg-30 Mcg $0 CT; EHB (21)/75 Mg (7)) norethindrone acetate-ethinyl estradiol/ferrous fumarate (Blisovi Fe 1/20 (28) Oral Tablet 1 Mg-20 Mcg $0 CT; EHB (21)/75 Mg (7)) norethindrone-ethinyl estradiol (Briellyn Oral Tablet 0.4- $0 CT; EHB 35 Mg-Mcg) levonorgestrel/ethinyl estradiol (Chateal (28) Oral Tablet $0 CT; EHB 0.15-0.03 Mg) levonorgestrel/ethinyl estradiol (Chateal Eq (28) Oral $0 CT; EHB Tablet 0.15-0.03 Mg) norgestrel-ethinyl estradiol (Cryselle (28) Oral Tablet 0.3- $0 CT; EHB 30 Mg-Mcg) norethindrone-ethinyl estradiol (Cyclafem 1/35 (28) Oral $0 CT; EHB Tablet 1-35 Mg-Mcg) desogestrel-ethinyl estradiol (Cyred Eq Oral Tablet 0.15- $0 CT; EHB 0.03 Mg) desogestrel-ethinyl estradiol (Cyred Oral Tablet 0.15-0.03 $0 CT; EHB Mg) norethindrone-ethinyl estradiol (Dasetta 1/35 (28) Oral $0 CT; EHB Tablet 1-35 Mg-Mcg) desogestrel-ethinyl estradiol oral tablet 0.15-0.03 mg $0 CT; EHB drospirenone-e.estradiol-lm.fa oral tablet 3-0.02-0.451 $0 CT; EHB mg (24) (4) drospirenone-ethinyl estradiol oral tablet 3-0.02 mg, 3- $0 CT; EHB 0.03 mg norgestrel-ethinyl estradiol (Elinest Oral Tablet 0.3-30 $0 CT; EHB Mg-Mcg) desogestrel-ethinyl estradiol (Emoquette Oral Tablet $0 CT; EHB 0.15-0.03 Mg) desogestrel-ethinyl estradiol (Enskyce Oral Tablet 0.15- $0 CT; EHB 0.03 Mg)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 64 Coverage Prescription Drug Name Drug Tier Requirements and Limits norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg $0 CT; EHB (21)/75 mg (7), 1.5 mg-30 mcg (21)/75 mg (7) norgestimate-ethinyl estradiol oral tablet 0.25-35 mg- $0 CT; EHB mcg norethindrone-ethinyl estradiol (Nortrel 0.5/35 (28) Oral $0 CT; EHB Tablet 0.5-35 Mg-Mcg) NORTREL 1/35 (21) ORAL TABLET 1-35 MG-MCG (21) $0 CT; EHB (norethindrone-ethinyl estradiol) norethindrone-ethinyl estradiol (Nortrel 1/35 (28) Oral $0 CT; EHB Tablet 1-35 Mg-Mcg) norgestimate-ethinyl estradiol (Nymyo Oral Tablet 0.25- $0 CT; EHB 35 Mg-Mcg) OCELLA ORAL TABLET 3-0.03 MG (ethinyl $0 CT; EHB estradiol/drospirenone) levonorgestrel/ethinyl estradiol (Orsythia Oral Tablet 0.1- $0 CT; EHB 20 Mg-Mcg) norethindrone-ethinyl estradiol (Philith Oral Tablet 0.4-35 $0 CT; EHB Mg-Mcg) norethindrone-ethinyl estradiol (Pirmella Oral Tablet 1-35 $0 CT; EHB Mg-Mcg) levonorgestrel/ethinyl estradiol (Portia 28 Oral Tablet $0 CT; EHB 0.15-0.03 Mg) norgestimate-ethinyl estradiol (Previfem Oral Tablet 0.25- $0 CT; EHB 35 Mg-Mcg) desogestrel-ethinyl estradiol (Reclipsen (28) Oral Tablet $0 CT; EHB 0.15-0.03 Mg) levonorgestrel/ethinyl estradiol (Setlakin Oral $0 CT; EHB Tablets,Dose Pack,3 Month 0.15 Mg-30 Mcg (91)) norgestimate-ethinyl estradiol (Sprintec (28) Oral Tablet $0 CT; EHB 0.25-35 Mg-Mcg) levonorgestrel/ethinyl estradiol (Sronyx Oral Tablet 0.1- $0 CT; EHB 20 Mg-Mcg) ethinyl estradiol/drospirenone (Syeda Oral Tablet 3-0.03 $0 CT; EHB Mg) norethindrone acetate-ethinyl estradiol/ferrous fumarate (Tarina 24 Fe Oral Tablet 1 Mg-20 Mcg (24)/75 $0 CT; EHB Mg (4))

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 65 Coverage Prescription Drug Name Drug Tier Requirements and Limits norethindrone acetate-ethinyl estradiol/ferrous fumarate (Tarina Fe 1/20 (28) Oral Tablet 1 Mg-20 Mcg $0 CT; EHB (21)/75 Mg (7)) norethindrone acetate-ethinyl estradiol/ferrous fumarate (Tarina Fe 1-20 Eq (28) Oral Tablet 1 Mg-20 Mcg $0 CT; EHB (21)/75 Mg (7)) TYBLUME ORAL TABLET,CHEWABLE 0.1 MG- 20 MCG $0 CT; EHB (levonorgestrel/ethinyl estradiol) ethinyl estradiol/drospirenone (Vestura (28) Oral Tablet $0 CT; EHB 3-0.02 Mg) levonorgestrel/ethinyl estradiol (Vienva Oral Tablet 0.1- $0 CT; EHB 20 Mg-Mcg) norethindrone-ethinyl estradiol (Vyfemla (28) Oral Tablet $0 CT; EHB 0.4-35 Mg-Mcg) norgestimate-ethinyl estradiol (Vylibra Oral Tablet 0.25- $0 CT; EHB 35 Mg-Mcg) norethindrone-ethinyl estradiol (Wera (28) Oral Tablet $0 CT; EHB 0.5-35 Mg-Mcg) norethindrone-ethinyl estradiol/ferrous fumarate (Wymzya Fe Oral Tablet,Chewable 0.4Mg-35Mcg(21) And $0 CT; EHB 75 Mg (7)) ethinyl estradiol/drospirenone (Zarah Oral Tablet 3-0.03 $0 CT; EHB Mg) ethynodiol diacetate-ethinyl estradiol (Zovia 1/35E (28) $0 CT; EHB Oral Tablet 1-35 Mg-Mcg) ethynodiol diacetate-ethinyl estradiol (Zovia 1-35 (28) $0 CT; EHB Oral Tablet 1-35 Mg-Mcg) ethinyl estradiol/drospirenone (Zumandimine (28) Oral $0 CT; EHB Tablet 3-0.03 Mg) Contraceptive Oral - Progestin - Birth Control Pills norethindrone (Camila Oral Tablet 0.35 Mg) $0 CT; EHB norethindrone (Deblitane Oral Tablet 0.35 Mg) $0 CT; EHB norethindrone (Errin Oral Tablet 0.35 Mg) $0 CT; EHB norethindrone (Heather Oral Tablet 0.35 Mg) $0 CT; EHB norethindrone (Incassia Oral Tablet 0.35 Mg) $0 CT; EHB norethindrone (Jencycla Oral Tablet 0.35 Mg) $0 CT; EHB norethindrone (Lyleq Oral Tablet 0.35 Mg) $0 CT; EHB PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 66 Coverage Prescription Drug Name Drug Tier Requirements and Limits norethindrone (Lyza Oral Tablet 0.35 Mg) $0 CT; EHB NORA-BE ORAL TABLET 0.35 MG (norethindrone) $0 CT; EHB norethindrone (contraceptive) oral tablet 0.35 mg $0 CT; EHB norethindrone (Norlyda Oral Tablet 0.35 Mg) $0 CT; EHB norethindrone (Sharobel Oral Tablet 0.35 Mg) $0 CT; EHB norethindrone (Tulana Oral Tablet 0.35 Mg) $0 CT; EHB Contraceptive Oral - Triphasic - Birth Control Pills norethindrone-ethinyl estradiol (Alyacen 7/7/7 (28) Oral $0 CT; EHB Tablet 0.5/0.75/1 Mg- 35 Mcg) norethindrone-ethinyl estradiol (Aranelle (28) Oral Tablet $0 CT; EHB 0.5/1/0.5-35 Mg-Mcg) desogestrel-ethinyl estradiol (Caziant (28) Oral Tablet $0 CT; EHB 0.1/.125/.15-25 Mg-Mcg) norethindrone-ethinyl estradiol (Cyclafem 7/7/7 (28) Oral $0 CT; EHB Tablet 0.5/0.75/1 Mg- 35 Mcg) norethindrone-ethinyl estradiol (Dasetta 7/7/7 (28) Oral $0 CT; EHB Tablet 0.5/0.75/1 Mg- 35 Mcg) levonorgestrel/ethinyl estradiol (Enpresse Oral Tablet 50- $0 CT; EHB 30 (6)/75-40 (5)/125-30(10)) LEENA 28 ORAL TABLET 0.5/1/0.5-35 MG-MCG $0 CT; EHB (norethindrone-ethinyl estradiol) levonorgestrel/ethinyl estradiol (Levonest (28) Oral $0 CT; EHB Tablet 50-30 (6)/75-40 (5)/125-30(10)) levonorg-eth estrad triphasic oral tablet 50-30 (6)/75-40 $0 CT; EHB (5)/125-30(10) norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 $0 CT; EHB mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg (28) norethindrone-ethinyl estradiol (Nortrel 7/7/7 (28) Oral $0 CT; EHB Tablet 0.5/0.75/1 Mg- 35 Mcg) norethindrone-ethinyl estradiol (Nylia 7/7/7 (28) Oral $0 CT; EHB Tablet 0.5/0.75/1 Mg- 35 Mcg) norethindrone-ethinyl estradiol (Pirmella Oral Tablet $0 CT; EHB 0.5/0.75/1 Mg- 35 Mcg) norethindrone acetate-ethinyl estradiol/ferrous fumarate (Tilia Fe Oral Tablet 1-20(5)/1-30(7) /1Mg-35Mcg $0 CT; EHB (9))

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 67 Coverage Prescription Drug Name Drug Tier Requirements and Limits norgestimate-ethinyl estradiol (Tri Femynor Oral Tablet $0 CT; EHB 0.18/0.215/0.25 Mg-35 Mcg (28)) norgestimate-ethinyl estradiol (Tri-Estarylla Oral Tablet $0 CT; EHB 0.18/0.215/0.25 Mg-35 Mcg (28)) norethindrone acetate-ethinyl estradiol/ferrous fumarate (Tri-Legest Fe Oral Tablet 1-20(5)/1-30(7) /1Mg- $0 CT; EHB 35Mcg (9)) norgestimate-ethinyl estradiol (Tri-Linyah Oral Tablet $0 CT; EHB 0.18/0.215/0.25 Mg-35 Mcg (28)) norgestimate-ethinyl estradiol (Tri-Lo-Estarylla Oral $0 CT; EHB Tablet 0.18/0.215/0.25 Mg-25 Mcg) norgestimate-ethinyl estradiol (Tri-Lo-Marzia Oral Tablet $0 CT; EHB 0.18/0.215/0.25 Mg-25 Mcg) norgestimate-ethinyl estradiol (Tri-Lo-Mili Oral Tablet $0 CT; EHB 0.18/0.215/0.25 Mg-25 Mcg) norgestimate-ethinyl estradiol (Tri-Lo-Sprintec Oral $0 CT; EHB Tablet 0.18/0.215/0.25 Mg-25 Mcg) norgestimate-ethinyl estradiol (Tri-Mili Oral Tablet $0 CT; EHB 0.18/0.215/0.25 Mg-35 Mcg (28)) norgestimate-ethinyl estradiol (Tri-Nymyo Oral Tablet $0 CT; EHB 0.18/0.215/0.25 Mg-35 Mcg (28)) norgestimate-ethinyl estradiol (Tri-Previfem (28) Oral $0 CT; EHB Tablet 0.18/0.215/0.25 Mg-35 Mcg (28)) norgestimate-ethinyl estradiol (Tri-Sprintec (28) Oral $0 CT; EHB Tablet 0.18/0.215/0.25 Mg-35 Mcg (28)) levonorgestrel/ethinyl estradiol (Trivora (28) Oral Tablet $0 CT; EHB 50-30 (6)/75-40 (5)/125-30(10)) norgestimate-ethinyl estradiol (Tri-Vylibra Lo Oral Tablet $0 CT; EHB 0.18/0.215/0.25 Mg-25 Mcg) norgestimate-ethinyl estradiol (Tri-Vylibra Oral Tablet $0 CT; EHB 0.18/0.215/0.25 Mg-35 Mcg (28)) desogestrel-ethinyl estradiol (Velivet Triphasic Regimen $0 CT; EHB (28) Oral Tablet 0.1/.125/.15-25 Mg-Mcg) Contraceptive Transdermal Combinations - Estrogen and Progestin Comb. - Birth Control Pills XULANE TRANSDERMAL PATCH WEEKLY 150-35 $0 CT; EHB MCG/24 HR (norelgestromin/ethinyl estradiol)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 68 Coverage Prescription Drug Name Drug Tier Requirements and Limits norelgestromin/ethinyl estradiol (Zafemy Transdermal $0 CT; EHB Patch Weekly 150-35 Mcg/24 Hr) Contraceptives - Intravaginal, Systemic - Estrogen and Progestin Comb. - Birth Control Pills etonogestrel/ethinyl estradiol (Eluryng Vaginal Ring 0.12- $0 CT; EHB 0.015 Mg/24 Hr) etonogestrel-ethinyl estradiol vaginal ring 0.12-0.015 $0 CT; EHB mg/24 hr Emergency Contraceptives - Birth Control Pills AFTERA ORAL TABLET 1.5 MG (levonorgestrel) $0 CT; EHB ECONTRA EZ ORAL TABLET 1.5 MG (levonorgestrel) $0 CT; EHB ECONTRA ONE-STEP ORAL TABLET 1.5 MG $0 CT; EHB (levonorgestrel) ELLA ORAL TABLET 30 MG (ulipristal acetate) $0 CT; EHB levonorgestrel oral tablet 1.5 mg $0 CT; EHB MY CHOICE ORAL TABLET 1.5 MG (levonorgestrel) $0 CT; EHB MY WAY ORAL TABLET 1.5 MG (levonorgestrel) $0 CT; EHB NEW DAY ORAL TABLET 1.5 MG (levonorgestrel) $0 CT; EHB OPCICON ONE-STEP ORAL TABLET 1.5 MG $0 CT; EHB (levonorgestrel) OPTION-2 ORAL TABLET 1.5 MG (levonorgestrel) $0 CT; EHB TAKE ACTION ORAL TABLET 1.5 MG (levonorgestrel) $0 CT; EHB Emergency Contraceptives - Progestin Type - Birth Control Pills AFTERA ORAL TABLET 1.5 MG (levonorgestrel) $0 CT; EHB MY CHOICE ORAL TABLET 1.5 MG (levonorgestrel) $0 CT; EHB MY WAY ORAL TABLET 1.5 MG (levonorgestrel) $0 CT; EHB NEW DAY ORAL TABLET 1.5 MG (levonorgestrel) $0 CT; EHB OPCICON ONE-STEP ORAL TABLET 1.5 MG $0 CT; EHB (levonorgestrel) OPTION-2 ORAL TABLET 1.5 MG (levonorgestrel) $0 CT; EHB TAKE ACTION ORAL TABLET 1.5 MG (levonorgestrel) $0 CT; EHB Spermicides - Birth Control Pills GYNOL II VAGINAL GEL 3 % (nonoxynol 9) $0 CT; EHB

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 77 Coverage Prescription Drug Name Drug Tier Requirements and Limits fluocinonide topical solution 0.05 % Tier 1 fluocinonide/emollient base (Fluocinonide-E Topical Tier 1 QL (30 GM per 1 FILL) Cream 0.05 %) fluocinonide-emollient topical cream 0.05 % Tier 1 QL (30 GM per 1 FILL) fluticasone propionate topical cream 0.05 % Tier 1 fluticasone propionate topical ointment 0.005 % Tier 1 halobetasol propionate topical cream 0.05 % Tier 2 PA; QL (50 GM per 1 FILL) halobetasol propionate topical ointment 0.05 % Tier 2 PA; QL (50 GM per 1 FILL) hydrocortisone acetate topical cream 0.5 %, 1 % Tier 1 hydrocortisone acetate topical ointment 1 % Tier 1 HYDROCORTISONE PLUS TOPICAL CREAM 1 % Tier 1 (hydrocortisone/aloe vera) hydrocortisone topical cream 0.5 %, 1 %, 2.5 % Tier 1 hydrocortisone topical cream with perineal applicator 1 Tier 1 %, 2.5 % hydrocortisone topical lotion 1 %, 2.5 % Tier 1 hydrocortisone topical ointment 0.5 %, 1 %, 2.5 % Tier 1 HYDROCREAM TOPICAL CREAM 1 % (hydrocortisone) Tier 1 mometasone topical cream 0.1 % Tier 1 mometasone topical ointment 0.1 % Tier 1 mometasone topical solution 0.1 % Tier 1 NOBLE FORMULA HC TOPICAL CREAM 1 % Tier 1 (hydrocortisone) prednicarbate topical cream 0.1 % Tier 1 prednicarbate topical ointment 0.1 % Tier 1 PREPARATION H HYDROCORTISONE TOPICAL CREAM Tier 1 1 % (hydrocortisone) hydrocortisone (Procto-Med Hc Topical Cream With Tier 1 Perineal Applicator 2.5 %) hydrocortisone (Procto-Pak Topical Cream With Perineal Tier 1 Applicator 1 %) hydrocortisone (Proctosol Hc Topical Cream With Perineal Tier 1 Applicator 2.5 %) SOOTHING CARE (HYDROCORTISONE) TOPICAL Tier 1 CREAM 1 % (hydrocortisone)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 78 Coverage Prescription Drug Name Drug Tier Requirements and Limits triamcinolone acetonide topical cream 0.025 %, 0.1 %, Tier 1 0.5 % triamcinolone acetonide topical lotion 0.025 %, 0.1 % Tier 1 triamcinolone acetonide topical ointment 0.025 %, 0.1 Tier 1 %, 0.5 % triamcinolone acetonide (Triderm Topical Cream 0.1 %, Tier 1 0.5 %) VANICREAM HC TOPICAL CREAM 1 % (hydrocortisone Tier 1 acetate) Dermatological - Glucocorticoid-Emollient Combinations - Drugs for the Skin ANTI-ITCH PLUS TOPICAL CREAM 1 % Tier 1 (hydrocortisone/aloe vera/vit e acet/vitamins a and d) ANTI-ITCH(HYDROCORTISONE)-ALOE TOPICAL CREAM Tier 1 1 % (hydrocortisone/aloe vera) AVEENO ANTI-ITCH (HYDROCORTSN) TOPICAL CREAM Tier 1 1 % (hydrocortisone/colloidal oatmeal/aloe/vitamin e) CORTISONE WITH ALOE TOPICAL CREAM 1 % Tier 1 (hydrocortisone/aloe vera) CORTIZONE-10 WITH ALOE TOPICAL CREAM 1 % Tier 1 (hydrocortisone/aloe vera) hydrocortisone-aloe vera topical cream 1 % Tier 1 Dermatological - Glucocorticoid-Local Anesthetic Combinations - Drugs for the Skin EPIFOAM TOPICAL FOAM 1-1 % (hydrocortisone Tier 2 acetate/pramoxine hcl) lidocaine hcl-hydrocortison ac topical cream 3-0.5 % Tier 1 PRAMOSONE TOPICAL CREAM 1-1 % (hydrocortisone Tier 2 acetate/pramoxine hcl) PRAMOSONE TOPICAL OINTMENT 1-1 %, 2.5-1 % Tier 2 (hydrocortisone acetate/pramoxine hcl) Dermatological - Immunomodulator - Imidazoquinolinamines - Drugs for the Skin imiquimod topical cream in packet 5 % Tier 1 Dermatological - Keratolytic-Antimitotic Single Agents - Drugs for the Skin PODOCON TOPICAL LIQUID 25 % (podophyllum resin) Tier 2 podofilox topical solution 0.5 % Tier 1 salicylic acid topical shampoo 6 % Tier 1 PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 79 Coverage Prescription Drug Name Drug Tier Requirements and Limits Dermatological - Local Anesthetic Combinations - Drugs for the Skin BURN RELIEF WITH ALOE TOPICAL GEL 0.5 % Tier 1 (lidocaine/aloe vera) lidocaine-aloe vera topical gel 0.5 % Tier 1 lidocaine-prilocaine topical cream 2.5-2.5 % Tier 1 Dermatological - NSAID Single Agents - Drugs for the Skin ARTHRITIS PAIN (DICLOFENAC) TOPICAL GEL 1 % Tier 1 QL (500 GM per 1 FILL) (diclofenac sodium) diclofenac sodium topical gel 1 % Tier 1 QL (500 GM per 1 FILL) Dermatological - Rosacea Therapy, Topical - Drugs for the Skin CLEANSING WASH TOPICAL CLEANSER 10-4-10 % Tier 1 (sulfacetamide sodium/sulfur/urea) metronidazole topical cream 0.75 % Tier 1 metronidazole topical gel 0.75 %, 1 % Tier 1 metronidazole topical gel with pump 1 % Tier 1 metronidazole topical lotion 0.75 % Tier 1 metronidazole (Rosadan Topical Cream 0.75 %) Tier 1 sulfacetamide sod-sulfur-urea topical cleanser 10-5-10 Tier 1 % Dermatological - Topical Local Anesthetic Amides - Drugs for the Skin ASPERCREME (LIDOCAINE) TOPICAL ADHESIVE Tier 2 PA; QL (1 EA per 1 day) PATCH,MEDICATED 4 % (lidocaine) ASPERFLEX TOPICAL ADHESIVE PATCH,MEDICATED 4 Tier 2 PA; QL (1 EA per 1 day) % (lidocaine) BLUE-EMU LIDOCAINE PATCH TOPICAL ADHESIVE Tier 2 PA; QL (1 EA per 1 day) PATCH,MEDICATED 4 % (lidocaine) lidocaine hcl (Glydo Mucous Membrane Jelly In Applicator Tier 1 2 %) LIDO KING TOPICAL ADHESIVE PATCH,MEDICATED 4 Tier 2 PA; QL (1 EA per 1 day) % (lidocaine) lidocaine hcl mucous membrane jelly 2 % Tier 1 lidocaine hcl mucous membrane jelly in applicator 2 % Tier 1 lidocaine hcl topical cream 3 % Tier 1 LIDOCAINE PAIN RELIEF TOPICAL ADHESIVE Tier 2 PA; QL (1 EA per 1 day) PATCH,MEDICATED 4 % (lidocaine)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 80 Coverage Prescription Drug Name Drug Tier Requirements and Limits lidocaine topical adhesive patch,medicated 4 %, 5 % Tier 2 PA; QL (1 EA per 1 day) LIDOCARE TOPICAL ADHESIVE PATCH,MEDICATED 4 Tier 2 PA; QL (1 EA per 1 day) % (lidocaine) REGENECARE HA TOPICAL GEL 2 % (lidocaine Tier 1 hcl/hyaluronic acid/aloe vera/collagen) SALONPAS (LIDOCAINE) TOPICAL ADHESIVE Tier 2 PA; QL (1 EA per 1 day) PATCH,MEDICATED 4 % (lidocaine) Scabicide and Pediculicide Single Agents - Drugs for the Skin EURAX TOPICAL CREAM 10 % (crotamiton) Tier 2 lindane topical shampoo 1 % Tier 1 malathion topical lotion 0.5 % Tier 1 QL (118 ML per 1 FILL) permethrin topical cream 5 % Tier 1 spinosad topical suspension 0.9 % Tier 2 QL (120 ML per 1 FILL) Wound Care - Growth Factor Agents - Drugs for the Skin REGRANEX TOPICAL GEL 0.01 % (becaplermin) Tier 2 DD; QL (30 GM per 1 FILL) Diagnostic Agents Diagnostic - Blood Test Others PRECISION XTRA B-KETONE STRIP (blood ketone test, Tier 2 strips) Diagnostic - Multiple Urine Tests CHEK-STIX CONTROL STRIP (urine multiple test strips) Tier 1 CHEMSTRIP 10 MD STRIP (urine multiple test strips) Tier 1 CHEMSTRIP 10/SG STRIP (urine multiple test strips) Tier 1 CHEMSTRIP 2 GP STRIP (urine multiple test strips) Tier 1 CHEMSTRIP 50B STRIP (urine multiple test strips) Tier 1 CHEMSTRIP 7 STRIP (urine multiple test strips) Tier 1 CHEMSTRIP 9 STRIP (urine multiple test strips) Tier 1 COMBISTIX REAGENT STRIP (urine multiple test strips) Tier 1 HEMA-COMBISTIX STRIP (urine multiple test strips) Tier 1 LABSTIX REAGENT STRIP (urine multiple test strips) Tier 1 MULTISTIX 10 SG STRIP (urine multiple test strips) Tier 1 MULTISTIX 5 STRIP (urine multiple test strips) Tier 1 MULTISTIX 7 STRIP (urine multiple test strips) Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 81 Coverage Prescription Drug Name Drug Tier Requirements and Limits MULTISTIX 8 SG STRIP (urine multiple test strips) Tier 1 MULTISTIX 9 SG STRIP (urine multiple test strips) Tier 1 MULTISTIX 9 STRIP (urine multiple test strips) Tier 1 MULTISTIX STRIP (urine multiple test strips) Tier 1 URISTIX 4 STRIP (urine multiple test strips) Tier 1 URISTIX REAGENT STRIP (urine multiple test strips) Tier 1 Drugs to treat Erectile Dysfunction - Drugs for the Urinary System Erectile Dysfunction (ED) Drugs-Sel.cGMP Phosphodiesterase Type5 Inhib - Drugs for Erectile Dysfunction tadalafil oral tablet 5 mg Tier 4 PA Eating Disorder Therapy - Drugs for Eating Disorders Appetite Stimulants - Progestin Hormone Type - Drugs for Eating Disorders megestrol oral suspension 400 mg/10 ml (10 ml) Tier 1 megestrol oral suspension 400 mg/10 ml (40 mg/ml) Tier 1 Electrolyte Balance-Nutritional Products - Drugs for Nutrition Amino Acid - Carnitine Derivatives - Drugs for Nutrition levocarnitine oral tablet 330 mg Tier 1 B-Complex Vitamin Combinations - Drugs for Nutrition VIRT-VITE PLUS ORAL TABLET 5 MG (folic acid/vitamin Tier 1 b complex with vitamin c no.17) B-Complex Vitamins - Drugs for Nutrition BALANCED B-50 ORAL TABLET (vitamin b complex) Tier 1 Dietary Product - Dietary Supplements - Drugs for Nutrition NIACIN-AZE AC-TURMER-FA-B6-ZN ORAL TABLET 700- 500-8-12 MG-MCG-MG-MG (niacinamide/azelaic Tier 1 ac/quercet/turmer/fa/b6/zinc ox/copper) Electrolyte Depleters - Ion Exchange Resin - Drugs for Nutrition sodium polystyrene sulfonate oral powder Tier 1 sodium polystyrene sulfonate/sorbitol solution (Sps Tier 1 (With Sorbitol) Oral Suspension 15-20 Gram/60 Ml) SPS (WITH SORBITOL) RECTAL ENEMA 30-40 GRAM/120 ML (sodium polystyrene sulfonate/sorbitol Tier 1 solution)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 91 Coverage Prescription Drug Name Drug Tier Requirements and Limits PRETAB ORAL TABLET 29-1 MG (prenatal vits with Tier 1 calcium no.78/ferrous fumarate/folic acid) PROVIDA OB ORAL CAPSULE 40 MG IRON- 1.25 MG (prenatal vits no.65/iron fumarate,polysac complex/folic Tier 3 acid) R-NATAL OB ORAL CAPSULE 20 MG IRON- 1 MG-320 MG (prenatal vitamins no.66/iron,carbonyl/folic Tier 3 acid/dha) SELECT-OB (FOLIC ACID) ORAL TABLET,CHEWABLE 29 MG IRON- 1 MG (prenatal vit no.128/iron polysaccharide Tier 3 complex/folic acid) SELECT-OB + DHA ORAL COMBO PACK 29 MG IRON-1 MG -250 MG (prenatal vitamins no.33/iron polysach Tier 3 complex/folic acid/dha) SELECT-OB ORAL TABLET,CHEWABLE 29 MG IRON- 1 MG (prenatal vitamin no.13/iron polysaccharides/folate Tier 3 comb no.1) SE-NATAL 19 CHEWABLE ORAL TABLET,CHEWABLE 29 MG IRON- 1 MG (prenatal vits with calcium 118/ferrous Tier 3 fumarate/folic acid) SE-NATAL-19 ORAL TABLET 29 MG IRON- 1 MG Tier 3 (prenatal vitamins no.119/iron fumarate/folic acid) SIMILAC PRENATAL ORAL COMBO PACK 27 MG IRON- 800 MCG-200 MG (prenatal vits, calcium no.102/ferrous Tier 3 fum/folic acid/dha/lut) STUART ONE ORAL CAPSULE 27 MG IRON- 800 MCG- 200 MG (prenatal vitamins no.63/iron,carbonyl/folic Tier 3 acid/dha) TARON-PREX PRENATAL-DHA ORAL CAPSULE 30 MG IRON-1.2 MG-55 MG-265 MG (multivitamin no.53/ferrous Tier 3 fum/folic acid/docusate/dha) TENDERA-OB ORAL CAPSULE 27 MG IRON-1 MG -205 MG (prenatal vitamins no.148/iron, carbonyl/folate Tier 3 comb no.6/dha) THERANATAL COMPLETE ORAL COMBO PACK 27 MG IRON- 1 MG-150 MG (prenatal vitamins no.32/ferrous Tier 3 fumarate/folic acid/dha) THERANATAL ONE ORAL CAPSULE 27 MG IRON-1000 MCG-300 MG (prenatal vitamins no.100/iron Tier 3 fumarate/folic acid/dha/epa) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 92 Coverage Prescription Drug Name Drug Tier Requirements and Limits THERANATAL ORAL TABLET 27 MG IRON- 1 MG Tier 1 (prenatal vitamins no.28/ferrous fumarate/folic acid) THERANATAL OVAVITE ORAL COMBO PACK 18-1-125 MG-MG-UNIT (prenatal vitamins no.74/ferrous Tier 3 fumarate/folic acid/coq10) THERANATAL PLUS ORAL COMBO PACK 27 MG IRON- 1 MG-300 MG (prenatal vitamins no.74/ferrous Tier 3 fumarate/folic acid/dha) THRIVITE RX ORAL TABLET 29 MG IRON- 1 MG (prenatal vitamin with calcium no.76/iron,carbonyl/folic Tier 3 acid) THRIVITE-19 ORAL TABLET 29 MG IRON-1 MG -25 MG (multivit-mins no.59/ferrous fumarate/folic Tier 3 acid/docusate sod) TRICARE ORAL TABLET 27 MG IRON- 1 MG (prenatal Tier 1 vits with calcium 103/ferrous fumarate/folic acid) TRINATE ORAL TABLET 28 MG IRON- 1 MG (prenatal Tier 1 vits with calcium no.73/ferrous fumarate/folic acid) TRIVEEN-DUO DHA ORAL COMBO PACK 29-1-400 MG (prenatal vit with calcium 53/iron bis,s-p/folic Tier 3 acid/omega-3) TRIVEEN-PRX RNF ORAL CAPSULE 26-1.2-55-300 MG (prenatal vits,calcium no.66/iron fum/folic Tier 3 acid/docusate/dha) ULTRA PRENATAL PLUS DHA ORAL CAPSULE 27 MG- 800 MCG- 250 MG-200 MG (prenatal vit no.166/iron/folic Tier 3 acid/omega-3/dha/epa/fish oil) VENA-BAL DHA ORAL COMBO PACK,TABLET AND CAP,DR 27-1-430 MG (prenatal vit no.81/sod.feredetate- Tier 3 iron ps/folic acid/omega-3) VINATE GT ORAL TABLET 90-1-50 MG (prenatal vit with Tier 3 calcium 16/iron/folic acid/docusate sodium) VINATE II ORAL TABLET 29 MG IRON- 1 MG (prenatal Tier 3 vitamins with calcium/iron fum,b-g/folic acid) VINATE ULTRA ORAL TABLET 90-1-50 MG (prenatal vit Tier 3 with calcium 18/iron/folic acid/docusate sodium) VIRT-NATE DHA ORAL CAPSULE 28 MG IRON-1 MG - 200 MG (prenatal vitamins no.11/ferrous fumarate/folic Tier 3 acid/omega-3)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 97 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Prior prescription for Glipizide/Metformin HCL, XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10- Glyburide/Metformin HCL, 1,000 MG, 10-500 MG, 2.5-1,000 MG, 5-1,000 MG, 5-500 Tier 2 Metformin HCL, Pioglitazone MG (dapagliflozin propanediol/metformin hcl) HCL/Metformin HCL, or Riomet ER in 120 days; QL (1 EA per 1 day) Antihyperglycemic - Sodium Glucose Cotransporter-2 (SGLT2) Inhibitors - Drugs for Diabetes DD; ST: Prior prescription for Glipizide/Metformin HCL, Glyburide/Metformin HCL, FARXIGA ORAL TABLET 10 MG, 5 MG (dapagliflozin Tier 2 Metformin HCL, Pioglitazone propanediol) HCL/Metformin HCL, or Riomet ER in 120 days; QL (1 EA per 1 day) DD; ST: Prior prescription for Glipizide/Metformin HCL, Glyburide/Metformin HCL, JARDIANCE ORAL TABLET 10 MG, 25 MG Tier 2 Metformin HCL, Pioglitazone (empagliflozin) HCL/Metformin HCL, or Riomet ER in 120 days; QL (1 EA per 1 day) Antihyperglycemic - Sulfonylurea and Biguanide Combinations - Drugs for Diabetes glipizide-metformin oral tablet 2.5-250 mg, 2.5-500 mg, Tier 1 DD 5-500 mg glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 Tier 1 DD mg, 5-500 mg Antihyperglycemic - Sulfonylurea Derivatives - Drugs for Diabetes glimepiride oral tablet 1 mg, 2 mg, 4 mg Tier 1 DD glipizide oral tablet 10 mg, 5 mg Tier 1 DD glipizide oral tablet extended release 24hr 10 mg, 2.5 Tier 1 DD mg, 5 mg glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg Tier 1 DD glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg Tier 1 DD Antihyperglycemic - Thiazolidinedione and Biguanide Combinations - Drugs for Diabetes

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 98 Coverage Prescription Drug Name Drug Tier Requirements and Limits pioglitazone-metformin oral tablet 15-500 mg, 15-850 Tier 1 DD mg Antihyperglycemic - Thiazolidinedione and Sulfonylurea Combinations - Drugs for Diabetes pioglitazone-glimepiride oral tablet 30-2 mg, 30-4 mg Tier 1 DD Antihyperglycemic, Incretin Mimetic,GLP-1 Receptor Agonist Analog-Type - Drugs for Diabetes DD; ST: Prior prescription for Glipizide/Metformin HCL, TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 Glyburide/Metformin HCL, MG/0.5 ML, 1.5 MG/0.5 ML, 3 MG/0.5 ML, 4.5 MG/0.5 ML Tier 2 Metformin HCL, Pioglitazone (dulaglutide) HCL/Metformin HCL, or Riomet ER in 120 days; QL (2 ML per 28 days) DD; ST: Prior prescription for Glipizide/Metformin HCL, Glyburide/Metformin HCL, VICTOZA 2-PAK SUBCUTANEOUS PEN INJECTOR 0.6 Tier 2 Metformin HCL, Pioglitazone MG/0.1 ML (18 MG/3 ML) (liraglutide) HCL/Metformin HCL, or Riomet ER in 120 days; QL (9 ML per 30 days) DD; ST: Prior prescription for Glipizide/Metformin HCL, Glyburide/Metformin HCL, VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR 0.6 Tier 2 Metformin HCL, Pioglitazone MG/0.1 ML (18 MG/3 ML) (liraglutide) HCL/Metformin HCL, or Riomet ER in 120 days; QL (9 ML per 30 days) Antihyperglycemic-Dipeptidyl Peptidase-4(DPP-4)Inhibitor and Biguanide - Drugs for Diabetes DD; ST: Prior prescription for Glipizide/Metformin HCL, Glyburide/Metformin HCL, JANUMET ORAL TABLET 50-1,000 MG, 50-500 MG Tier 2 Metformin HCL, Pioglitazone (sitagliptin phosphate/metformin hcl) HCL/Metformin HCL, or Riomet ER in 120 days; QL (2 EA per 1 day)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 99 Coverage Prescription Drug Name Drug Tier Requirements and Limits DD; ST: Prior prescription for Glipizide/Metformin HCL, Glyburide/Metformin HCL, JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR Tier 2 Metformin HCL, Pioglitazone 100-1,000 MG (sitagliptin phosphate/metformin hcl) HCL/Metformin HCL, or Riomet ER in 120 days; QL (1 EA per 1 day) DD; ST: Prior prescription for Glipizide/Metformin HCL, JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR Glyburide/Metformin HCL, 50-1,000 MG, 50-500 MG (sitagliptin Tier 2 Metformin HCL, Pioglitazone phosphate/metformin hcl) HCL/Metformin HCL, or Riomet ER in 120 days; QL (2 EA per 1 day) Antithyroid Agents, Thionamides - Imidazole Derivatives - Drugs for Thyroid methimazole oral tablet 10 mg, 5 mg Tier 1 Antithyroid Agents, Thionamides - Thiouracil Derivatives - Drugs for Thyroid propylthiouracil oral tablet 50 mg Tier 1 Bone Formation Stimulating Agents - Parathyroid Hormone-Type - Drugs for Menopause and Bone Loss FORTEO SUBCUTANEOUS PEN INJECTOR 20 PA; SP; QL (2.4 ML per 28 Tier 4 MCG/DOSE (620MCG/2.48ML) (teriparatide) days) teriparatide subcutaneous pen injector 20 mcg/dose PA; SP; QL (2.48 ML per 28 Tier 4 (620mcg/2.48ml) days) Bone Resorption Inhibitors - Bisphosphonates - Drugs for Menopause and Bone Loss alendronate oral tablet 10 mg, 35 mg, 5 mg, 70 mg Tier 1 etidronate disodium oral tablet 200 mg Tier 1 ibandronate oral tablet 150 mg Tier 1 risedronate oral tablet 150 mg, 30 mg, 35 mg, 5 mg Tier 1 Calcimimetic, Parathyroid Calcium Receptor Sensitivity Enhancer - Drugs for Menopause and Bone Loss cinacalcet oral tablet 30 mg, 60 mg, 90 mg Tier 4 SP; QL (2 EA per 1 day) Calcitonins - Drugs for Menopause and Bone Loss calcitonin (salmon) nasal spray,non-aerosol 200 Tier 1 unit/actuation

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 100 Coverage Prescription Drug Name Drug Tier Requirements and Limits Estrogen and Selective Estrogen Receptor Modulator (SERM) Combinations - Drugs for Women DUAVEE ORAL TABLET 0.45-20 MG (estrogens, Tier 2 conjugated/bazedoxifene acetate) Estrogen-Progestin - Drugs for Women estradiol/norethindrone acetate (Amabelz Oral Tablet Tier 1 0.5-0.1 Mg, 1-0.5 Mg) COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY 0.05-0.14 MG/24 HR, 0.05-0.25 MG/24 HR Tier 3 (estradiol/norethindrone acetate) estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 Tier 1 mg norethindrone acetate-ethinyl estradiol (Fyavolv Oral Tier 1 Tablet 0.5-2.5 Mg-Mcg, 1-5 Mg-Mcg) norethindrone acetate-ethinyl estradiol (Jinteli Oral Tier 1 Tablet 1-5 Mg-Mcg) estradiol/norethindrone acetate (Mimvey Oral Tablet 1- Tier 1 0.5 Mg) norethindrone ac-eth estradiol oral tablet 0.5-2.5 mg- Tier 1 mcg, 1-5 mg-mcg PREMPHASE ORAL TABLET 0.625 MG (14)/ 0.625MG- 5MG(14) (estrogens, conjugated/medroxyprogesterone Tier 2 acetate) PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG (estrogens, Tier 2 conjugated/medroxyprogesterone acetate) Estrogens - Drugs for Women ALORA TRANSDERMAL PATCH SEMIWEEKLY 0.025 MG/24 HR, 0.05 MG/24 HR, 0.075 MG/24 HR, 0.1 MG/24 Tier 3 HR (estradiol) estradiol (Dotti Transdermal Patch Semiweekly 0.025 Mg/24 Hr, 0.0375 Mg/24 Hr, 0.05 Mg/24 Hr, 0.075 Mg/24 Tier 1 Hr, 0.1 Mg/24 Hr) estradiol oral tablet 0.5 mg, 1 mg, 2 mg Tier 1 estradiol transdermal patch semiweekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1 Tier 1 mg/24 hr

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 101 Coverage Prescription Drug Name Drug Tier Requirements and Limits estradiol transdermal patch weekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, 0.075 Tier 1 mg/24 hr, 0.1 mg/24 hr estradiol (Lyllana Transdermal Patch Semiweekly 0.025 Mg/24 Hr, 0.0375 Mg/24 Hr, 0.05 Mg/24 Hr, 0.075 Mg/24 Tier 1 Hr, 0.1 Mg/24 Hr) PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, Tier 2 0.9 MG, 1.25 MG (estrogens, conjugated) Glucocorticoids - Drugs for Inflammation dexamethasone (Decadron Oral Tablet 0.5 Mg, 0.75 Mg, 4 Tier 1 Mg, 6 Mg) DEXAMETHASONE INTENSOL ORAL DROPS 1 MG/ML Tier 1 (dexamethasone) dexamethasone oral elixir 0.5 mg/5 ml Tier 1 dexamethasone oral solution 0.5 mg/5 ml Tier 1 dexamethasone oral tablet 0.5 mg, 0.75 mg, 1.5 mg, 4 Tier 1 mg, 6 mg dexamethasone oral tablet 1 mg, 2 mg Tier 1 hydrocortisone oral tablet 10 mg, 20 mg, 5 mg Tier 1 MEDROL ORAL TABLET 2 MG (methylprednisolone) Tier 1 methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 Tier 1 mg methylprednisolone oral tablets,dose pack 4 mg Tier 1 prednisolone oral solution 15 mg/5 ml Tier 1 prednisolone sodium phosphate oral solution 10 mg/5 ml, 15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4 mg/ml), 5 mg Tier 1 base/5 ml (6.7 mg/5 ml) prednisolone sodium phosphate oral Tier 1 tablet,disintegrating 10 mg, 15 mg, 30 mg prednisone oral solution 5 mg/5 ml Tier 1 prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 Tier 1 mg, 50 mg prednisone oral tablets,dose pack 10 mg, 5 mg Tier 2 Gonadotropin Inhibitor Pituitary Suppressants - Drugs for Women danazol oral capsule 100 mg, 200 mg, 50 mg Tier 2 Growth Hormone Receptor Antagonists - Drugs for Growth PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 102 Coverage Prescription Drug Name Drug Tier Requirements and Limits SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG, 15 Tier 4 PA; SP MG, 20 MG, 25 MG, 30 MG (pegvisomant) Growth Hormones - Drugs for Growth NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 Tier 4 PA; SP MG/ML), 30 MG/3 ML (10 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) (somatropin) Human Insulins - Fixed Combinations - Drugs for Diabetes HUMULIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) (insulin nph human Tier 3 DD isophane/insulin regular, human) HUMULIN 70/30 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) (insulin nph human Tier 3 DD isophane/insulin regular, human) NOVOLIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) (insulin nph human Tier 2 DD isophane/insulin regular, human) NOVOLIN 70-30 FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) (insulin nph human Tier 2 DD isophane/insulin regular, human) Human Insulins - Intermediate Acting - Drugs for Diabetes HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) (insulin nph human Tier 3 DD isophane) HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (insulin nph human Tier 3 DD isophane) NOVOLIN N FLEXPEN SUBCUTANEOUS INSULIN PEN Tier 2 DD 100 UNIT/ML (3 ML) (insulin nph human isophane) NOVOLIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (insulin nph human Tier 2 DD isophane) Human Insulins - Short Acting - Drugs for Diabetes HUMULIN R REGULAR U-100 INSULN INJECTION Tier 3 DD SOLUTION 100 UNIT/ML (insulin regular, human) HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS Tier 2 DD SOLUTION 500 UNIT/ML (insulin regular, human)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 105 Coverage Prescription Drug Name Drug Tier Requirements and Limits cabergoline oral tablet 0.5 mg Tier 1 Selective Estrogen Receptor Modulators (SERMs) - Drugs for Menopause and Bone Loss $0 COPAY IF FEMALE 35 raloxifene oral tablet 60 mg Tier 1 YEARS OF AGE OR OLDER Somatostatic Agents - Drugs for Growth octreotide acetate injection solution 1,000 mcg/ml, 100 Tier 4 SP mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml octreotide acetate injection syringe 100 mcg/ml (1 ml), Tier 4 SP 50 mcg/ml (1 ml), 500 mcg/ml (1 ml) SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML) (pasireotide Tier 4 PA; SP; QL (2 ML per 1 day) diaspartate) Thyroid Hormone Combinations - Synthetic T3 and T4 - Drugs for Thyroid THYROLAR-1 ORAL TABLET 12.5-50 MCG (liotrix) Tier 2 THYROLAR-1/2 ORAL TABLET 6.25-25 MCG (liotrix) Tier 2 THYROLAR-1/4 ORAL TABLET 3.1-12.5 MCG (liotrix) Tier 2 THYROLAR-2 ORAL TABLET 25-100 MCG (liotrix) Tier 2 THYROLAR-3 ORAL TABLET 37.5-150 MCG (liotrix) Tier 2 Thyroid Hormones - Animal Source (Porcine) - Drugs for Thyroid ARMOUR THYROID ORAL TABLET 120 MG, 15 MG, 180 MG, 240 MG, 30 MG, 300 MG, 60 MG, 90 MG Tier 1 (thyroid,pork) NP THYROID ORAL TABLET 15 MG, 30 MG, 60 MG, 90 Tier 1 MG (thyroid,pork) WESTHROID ORAL TABLET 130 MG, 195 MG, 32.5 MG, Tier 1 65 MG, 97.5 MG (thyroid,pork) Thyroid Hormones - Synthetic T3 (Triiodothyronine) - Drugs for Thyroid liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg Tier 1 Thyroid Hormones - Synthetic T4 (Thyroxine) - Drugs for Thyroid EUTHYROX ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, Tier 1 50 MCG, 75 MCG, 88 MCG (levothyroxine sodium)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 106 Coverage Prescription Drug Name Drug Tier Requirements and Limits levothyroxine oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, Tier 1 50 mcg, 75 mcg, 88 mcg Gastrointestinal Therapy Agents - Drugs for the Stomach Antidiarrheal - Antiperistaltic Agents - Drugs for Diarrhea opium tincture oral tincture 10 mg/ml (morphine) Tier 1 Antidiarrheal Antiperistaltic-Anticholinergic Combinations - Drugs for Diarrhea diphenoxylate-atropine oral liquid 2.5-0.025 mg/5 ml Tier 1 diphenoxylate-atropine oral tablet 2.5-0.025 mg Tier 1 Antiemetic - Anticholinergics - Drugs for Vomiting and Nausea scopolamine base transdermal patch 3 day 1 mg over 3 Tier 3 days Antiemetic - Antihistamines - Drugs for Vomiting and Nausea DRAMAMINE LESS DROWSY ORAL TABLET 25 MG Tier 1 (meclizine hcl) meclizine oral tablet 25 mg Tier 1 MEDI-MECLIZINE ORAL TABLET 25 MG (meclizine hcl) Tier 1 MOTION SICKNESS (MECLIZINE) ORAL TABLET 25 MG Tier 1 (meclizine hcl) MOTION SICKNESS RELIEF(MECLIZ) ORAL TABLET 25 Tier 1 MG (meclizine hcl) TRAVEL-EASE (MECLIZINE) ORAL TABLET 25 MG Tier 1 (meclizine hcl) VERTICALM ORAL TABLET 25 MG (meclizine hcl) Tier 1 WAL-DRAM 2 ORAL TABLET 25 MG (meclizine hcl) Tier 1 Antiemetic - Cannabinoid Type - Drugs for Vomiting and Nausea dronabinol oral capsule 10 mg, 2.5 mg, 5 mg Tier 1 Antiemetic - Dopamine (D2)/5-HT3 Antagonists - Drugs for Vomiting and Nausea trimethobenzamide oral capsule 300 mg Tier 1 Antiemetic - Phenothiazines - Drugs for Vomiting and Nausea prochlorperazine (Compro Rectal Suppository 25 Mg) Tier 1 prochlorperazine rectal suppository 25 mg Tier 1 promethazine rectal suppository 50 mg Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 107 Coverage Prescription Drug Name Drug Tier Requirements and Limits promethazine hcl (Promethegan Rectal Suppository 25 Tier 1 Mg) Antiemetic - Selective Serotonin 5-HT3 Antagonists - Drugs for Vomiting and Nausea granisetron hcl oral tablet 1 mg Tier 1 QL (9 EA per 1 FILL) ondansetron hcl oral solution 4 mg/5 ml Tier 1 ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg Tier 1 ondansetron oral tablet,disintegrating 4 mg, 8 mg Tier 1 Antiemetic - Substance P-Neurokinin 1 (NK1) Receptor Antagonists - Drugs for Vomiting and Nausea aprepitant oral capsule 125 mg, 40 mg, 80 mg Tier 2 QL (2 EA per 21 days) aprepitant oral capsule,dose pack 125 mg (1)- 80 mg (2) Tier 2 QL (3 EA per 21 days) PR: RESTRICTED TO ONCOLOGIST OR VARUBI ORAL TABLET 90 MG (rolapitant hcl) Tier 2 HEMATOLOGIST; QL (2 EA per 1 day) Antiemetic - Substance P-Neurokinin 1 and 5-HT3 Recept Antagonist Comb - Drugs for Vomiting and Nausea PR: RESTRICTED TO AKYNZEO (NETUPITANT) ORAL CAPSULE 300-0.5 MG ONCOLOGIST OR Tier 2 (netupitant/palonosetron hcl) HEMATOLOGIST; QL (1 EA per 1 FILL) Colonic Acidifier (Ammonia Inhibitor) - Drugs for the Stomach lactulose (Enulose Oral Solution 10 Gram/15 Ml) Tier 1 lactulose (Generlac Oral Solution 10 Gram/15 Ml) Tier 1 lactulose oral solution 10 gram/15 ml (15 ml) Tier 1 Digestive Enzyme Mixtures - Drugs for the Stomach CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000 -60,000 UNIT, 24,000-76,000 -120,000 UNIT, 3,000-9,500- 15,000 UNIT, 36,000-114,000- 180,000 Tier 2 UNIT, 6,000-19,000 -30,000 UNIT (lipase/protease/amylase) PANCREAZE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,500-35,500- 61,500 UNIT, 16,800- 56,800- 98,400 UNIT, 2,600-8,800- 15,200 UNIT, 21,000- Tier 2 54,700- 83,900 UNIT, 4,200-14,200- 24,600 UNIT (lipase/protease/amylase) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 108 Coverage Prescription Drug Name Drug Tier Requirements and Limits Gallstone Solubilizing (Litholysis) Agents - Drugs for the Stomach ursodiol oral capsule 300 mg Tier 1 ursodiol oral tablet 250 mg, 500 mg Tier 1 Gastric Acid Secretion Reducers - Histamine H2-Receptor Antagonists - Drugs for Ulcers and Stomach Acid ACID CONTROLLER ORAL TABLET 10 MG, 20 MG Tier 1 (famotidine) ACID REDUCER (CIMETIDINE) ORAL TABLET 200 MG Tier 1 (cimetidine) ACID REDUCER (FAMOTIDINE) ORAL TABLET 10 MG, Tier 1 20 MG (famotidine) ACID-PEP ORAL TABLET 20 MG (famotidine) Tier 1 cimetidine hcl oral solution 300 mg/5 ml Tier 1 cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg Tier 1 famotidine oral suspension 40 mg/5 ml (8 mg/ml) Tier 1 famotidine oral tablet 10 mg, 20 mg, 40 mg Tier 1 HEARTBURN PREVENTION ORAL TABLET 10 MG, 20 Tier 1 MG (famotidine) HEARTBURN RELIEF (CIMETIDINE) ORAL TABLET 200 Tier 1 MG (cimetidine) HEARTBURN RELIEF (FAMOTIDINE) ORAL TABLET 10 Tier 1 MG, 20 MG (famotidine) nizatidine oral capsule 150 mg, 300 mg Tier 1 nizatidine oral solution 150 mg/10 ml Tier 1 ZANTAC-360 (FAMOTIDINE) ORAL TABLET 20 MG Tier 1 (famotidine) Gastric Acid Secretion Reducing Agents - Proton Pump Inhibitors (PPIs) - Drugs for Ulcers and Stomach Acid lansoprazole oral capsule,delayed release(dr/ec) 15 mg, Tier 1 30 mg lansoprazole oral tablet,disintegrat, delay rel 15 mg, 30 Tier 2 mg omeprazole oral capsule,delayed release(dr/ec) 10 mg, Tier 1 20 mg, 40 mg pantoprazole oral tablet,delayed release (dr/ec) 20 mg, Tier 1 40 mg PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 109 Coverage Prescription Drug Name Drug Tier Requirements and Limits Gastric Mucosa - Cytoprotective Prostaglandin Analogs - Drugs for Ulcers and Stomach Acid misoprostol oral tablet 100 mcg, 200 mcg Tier 1 Gastrointestinal Prokinetic Agents - D2 Antagonist/5-HT4 Agonists - Drugs for the Stomach metoclopramide hcl oral solution 5 mg/5 ml Tier 1 metoclopramide hcl oral tablet 10 mg, 5 mg Tier 1 GI Antispasmodic - Belladonna Alkaloids - Drugs for Stomach Cramps ED-SPAZ ORAL TABLET,DISINTEGRATING 0.125 MG Tier 1 (hyoscyamine sulfate) hyoscyamine sulfate oral drops 0.125 mg/ml Tier 1 hyoscyamine sulfate oral elixir 0.125 mg/5 ml Tier 1 hyoscyamine sulfate oral tablet 0.125 mg Tier 1 hyoscyamine sulfate oral tablet extended release 12 hr Tier 1 0.375 mg hyoscyamine sulfate oral tablet,disintegrating 0.125 mg Tier 1 hyoscyamine sulfate sublingual tablet 0.125 mg Tier 1 HYOSYNE ORAL DROPS 0.125 MG/ML (hyoscyamine Tier 1 sulfate) HYOSYNE ORAL ELIXIR 0.125 MG/5 ML (hyoscyamine Tier 1 sulfate) methscopolamine oral tablet 2.5 mg, 5 mg Tier 1 OSCIMIN ORAL TABLET 0.125 MG (hyoscyamine Tier 1 sulfate) OSCIMIN SL SUBLINGUAL TABLET 0.125 MG Tier 1 (hyoscyamine sulfate) OSCIMIN SR ORAL TABLET EXTENDED RELEASE 12 Tier 1 HR 0.375 MG (hyoscyamine sulfate) GI Antispasmodic - Quaternary Ammonium Compounds - Drugs for Stomach Cramps glycopyrrolate oral tablet 1 mg, 2 mg Tier 1 GI Antispasmodic - Synthetic Tertiary Amines - Drugs for Stomach Cramps dicyclomine oral capsule 10 mg Tier 1 dicyclomine oral solution 10 mg/5 ml Tier 1 dicyclomine oral tablet 20 mg Tier 1 PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 110 Coverage Prescription Drug Name Drug Tier Requirements and Limits GI Antispasmodic Combinations Other - Drugs for Stomach Cramps belladonna alkaloids-opium rectal suppository 16.2-30 Tier 2 mg, 16.2-60 mg IBS Agent - Gastrointestinal Chloride Channel Activator Agents - Drugs for Irritable Bowel Syndrome lubiprostone oral capsule 24 mcg, 8 mcg Tier 2 PA; QL (60 EA per 30 days) IBS Agent - Guanylate Cyclase-C (GC-C) Agonists - Drugs for Irritable Bowel Syndrome LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG Tier 2 PA; QL (1 EA per 1 day) (linaclotide) Inflammatory Bowel Agent - Aminosalicylates and Related Agents - Drugs for Inflammatory Bowel Disease balsalazide oral capsule 750 mg Tier 1 mesalamine oral capsule (with del rel tablets) 400 mg Tier 2 mesalamine oral capsule,extended release 24hr 0.375 Tier 2 gram mesalamine oral tablet,delayed release (dr/ec) 1.2 gram, Tier 2 800 mg mesalamine rectal enema 4 gram/60 ml Tier 1 mesalamine rectal suppository 1,000 mg Tier 1 sulfasalazine oral tablet 500 mg Tier 1 sulfasalazine oral tablet,delayed release (dr/ec) 500 mg Tier 1 Inflammatory Bowel Agent - Glucocorticoids - Drugs for Inflammatory Bowel Disease budesonide oral capsule,delayed,extend.release 3 mg Tier 2 budesonide oral tablet,delayed and ext.release 9 mg Tier 2 hydrocortisone rectal enema 100 mg/60 ml Tier 1 Inflammatory Bowel Agent - Tumor Necrosis Factor Alpha Blockers - Drugs for Inflammatory Bowel Disease CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT Tier 4 PA; SP 400 MG (200 MG X 2 VIALS) (certolizumab pegol) CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT Tier 4 PA; SP 400 MG/2 ML (200 MG/ML X 2) (certolizumab pegol) CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML Tier 4 PA; SP (200 MG/ML X 2) (certolizumab pegol) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 111 Coverage Prescription Drug Name Drug Tier Requirements and Limits HUMIRA PEN CROHNS-UC-HS START SUBCUTANEOUS PA; SP; QL (2 EA per 28 Tier 4 PEN INJECTOR KIT 40 MG/0.8 ML (adalimumab) days) HUMIRA PEN PSOR-UVEITS-ADOL HS PA; SP; QL (2 EA per 28 SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML Tier 4 days) (adalimumab) HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 PA; SP; QL (2 EA per 28 Tier 4 MG/0.8 ML (adalimumab) days) HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML PA; SP; QL (2 EA per 28 Tier 4 (adalimumab) days) HUMIRA(CF) PEDI CROHNS STARTER PA; SP; QL (3 EA per 28 SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML Tier 4 days) (adalimumab) HUMIRA(CF) PEDI CROHNS STARTER PA; SP; QL (2 EA per 28 SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML-40 MG/0.4 Tier 4 days) ML (adalimumab) HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS PA; SP; QL (3 EA per 28 Tier 4 PEN INJECTOR KIT 80 MG/0.8 ML (adalimumab) days) HUMIRA(CF) PEN PSOR-UV-ADOL HS SUBCUTANEOUS PA; SP; QL (3 EA per 28 PEN INJECTOR KIT 80 MG/0.8 ML-40 MG/0.4 ML Tier 4 days) (adalimumab) HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT PA; SP; QL (2 EA per 28 Tier 4 40 MG/0.4 ML (adalimumab) days) HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT PA; SP; QL (3 EA per 28 Tier 4 80 MG/0.8 ML (adalimumab) days) HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 20 MG/0.2 PA; SP; QL (2 EA per 28 Tier 4 ML, 40 MG/0.4 ML (adalimumab) days) Irritable Bowel Syndrome (IBS) Agents - Drugs for Irritable Bowel Syndrome alosetron oral tablet 0.5 mg Tier 3 QL (60 EA per 30 days) lubiprostone oral capsule 24 mcg, 8 mcg Tier 2 PA; QL (60 EA per 30 days) Laxative - Saline and Osmotic - Drugs to Prevent Constipation lactulose (Constulose Oral Solution 10 Gram/15 Ml) Tier 1 lactulose oral solution 10 gram/15 ml Tier 1 lactulose oral solution 20 gram/30 ml Tier 1 Laxative - Saline/Osmotic Mixtures - Drugs to Prevent Constipation GAVILYTE-C ORAL RECON SOLN 240-22.72-6.72 -5.84 $0 COPAY IF AGE 50-75 GRAM (peg 3350/sod sulf/sod bicarb/sod Tier 1 YEARS chloride/potassium chloride) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 112 Coverage Prescription Drug Name Drug Tier Requirements and Limits peg 3350/sod sulf/sod bicarb/sod chloride/potassium $0 COPAY IF AGE 50-75 chloride (Gavilyte-G Oral Recon Soln 236-22.74-6.74 -5.86 Tier 1 YEARS Gram) sodium chloride/sodium bicarbonate/potassium $0 COPAY IF AGE 50-75 Tier 1 chloride/peg (Gavilyte-N Oral Recon Soln 420 Gram) YEARS OSMOPREP ORAL TABLET 1.5 GRAM (sodium Tier 3 phosphate,monobasic/sodium phosphate,dibasic) peg 3350-electrolytes oral recon soln 236-22.74-6.74 - $0 COPAY IF AGE 50-75 Tier 1 5.86 gram YEARS $0 COPAY IF AGE 50-75 peg-electrolyte soln oral recon soln 420 gram Tier 1 YEARS sodium chloride/sodium bicarbonate/potassium $0 COPAY IF AGE 50-75 chloride/peg (Trilyte With Flavor Packets Oral Recon Soln Tier 1 YEARS 420 Gram) Peptic Ulcer - Gastric Lumen Adherent Cytoprotectives - Drugs for Ulcers and Stomach Acid sucralfate oral suspension 100 mg/ml Tier 3 sucralfate oral tablet 1 gram Tier 1 Peptic Ulcer-Treatment H. Pylori-Proton Pump Inhibitor and Antibiotics - Drugs for Ulcers and Stomach Acid amoxicil-clarithromy-lansopraz oral combo pack 500- Tier 1 500-30 mg Genitourinary Therapy - Drugs for the Urinary System BPH Agent- 5-alpha Reductase Inhib and alpha-1 Adrenoceptor Antag Comb - Drugs for the Prostate dutasteride-tamsulosin oral capsule, er multiphase 24 Tier 1 hr 0.5-0.4 mg Cystinosis Therapy (Cystine Depleting Agents) - Drugs for the Urinary System PROCYSBI ORAL GRANULES DEL RELEASE IN PACKET Tier 4 PA; SP 300 MG, 75 MG (cysteamine bitartrate) G.U. Irrigants - Drugs for the Urinary System SEA-CLENS WOUND CLEANSER IRRIGATION SOLUTION (sodium chloride irrigation soln/decyl Tier 1 glucoside) Interstitial Cystitis Agents - Drugs for the Urinary System

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 114 Coverage Prescription Drug Name Drug Tier Requirements and Limits Urinary Alkalinizer - Citrates - Drugs for Infections ORACIT ORAL SOLUTION 490-640 MG/5 ML (citric Tier 1 acid/sodium citrate) potassium citrate oral tablet extended release 10 meq Tier 1 (1,080 mg), 15 meq, 5 meq (540 mg) Urinary Analgesics - Drugs for Infections AZO URINARY PAIN RELIEF ORAL TABLET 95 MG Tier 1 (phenazopyridine hcl) phenazopyridine oral tablet 100 mg, 200 mg Tier 1 URINARY PAIN RELIEF ORAL TABLET 95 MG, 97.5 MG Tier 1 (phenazopyridine hcl) Urinary Antibacterial - Nitrofuran Derivatives - Drugs for Infections nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, Tier 1 50 mg nitrofurantoin monohyd/m-cryst oral capsule 100 mg Tier 1 nitrofurantoin oral suspension 25 mg/5 ml Tier 1 Urinary Antibacterial - Quinolones - Drugs for Infections CIPRO XR ORAL TABLET, ER MULTIPHASE 24 HR 1,000 Tier 3 MG, 500 MG (ciprofloxacin/ciprofloxacin hcl) Urinary Antispasmodic - Antichol., M(3) Muscarinic Selective (Bladder) - Drugs for the Bladder solifenacin oral tablet 10 mg, 5 mg Tier 2 Urinary Antispasmodic - Anticholinergics, Non-Selective - Drugs for the Bladder ED-SPAZ ORAL TABLET,DISINTEGRATING 0.125 MG Tier 1 (hyoscyamine sulfate) HYOSYNE ORAL DROPS 0.125 MG/ML (hyoscyamine Tier 1 sulfate) HYOSYNE ORAL ELIXIR 0.125 MG/5 ML (hyoscyamine Tier 1 sulfate) OSCIMIN ORAL TABLET 0.125 MG (hyoscyamine Tier 1 sulfate) OSCIMIN SL SUBLINGUAL TABLET 0.125 MG Tier 1 (hyoscyamine sulfate) OSCIMIN SR ORAL TABLET EXTENDED RELEASE 12 Tier 1 HR 0.375 MG (hyoscyamine sulfate)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 115 Coverage Prescription Drug Name Drug Tier Requirements and Limits Urinary Antispasmodic - Smooth Muscle Relaxants - Drugs for the Bladder oxybutynin chloride oral syrup 5 mg/5 ml Tier 1 oxybutynin chloride oral tablet 5 mg Tier 1 oxybutynin chloride oral tablet extended release 24hr Tier 1 10 mg, 15 mg, 5 mg tolterodine oral capsule,extended release 24hr 2 mg, 4 Tier 1 mg tolterodine oral tablet 1 mg, 2 mg Tier 1 TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR 4 Tier 2 MG, 8 MG (fesoterodine fumarate) trospium oral capsule,extended release 24hr 60 mg Tier 1 trospium oral tablet 20 mg Tier 1 Urinary Retention Therapy - Parasympathomimetic Agents - Drugs for the Bladder bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 Tier 1 mg Gout and Hyperuricemia Therapy - Drugs for Pain and Fever Gout Acute Therapy - Antimitotics - Gout Drugs colchicine oral capsule 0.6 mg Tier 1 Gout and Hyperuricemia - Antimitotic-Uricosuric Combinations - Gout Drugs probenecid-colchicine oral tablet 500-0.5 mg Tier 1 Hyperuricemia Therapy - Uricosurics - Gout Drugs probenecid oral tablet 500 mg Tier 1 Hyperuricemia Therapy - Xanthine Oxidase Inhibitors - Gout Drugs allopurinol oral tablet 100 mg, 300 mg Tier 1 febuxostat oral tablet 40 mg, 80 mg Tier 2 PA; QL (30 EA per 30 days) Hematological Agents - Drugs for the Blood Anticoagulants - Coumarin - Drugs to Prevent Blood Clots warfarin sodium (Jantoven Oral Tablet 1 Mg, 10 Mg, 2 Mg, Tier 1 2.5 Mg, 3 Mg, 4 Mg, 5 Mg, 6 Mg, 7.5 Mg) warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 Tier 1 mg, 5 mg, 6 mg, 7.5 mg C1 Esterase Inhibitor Agents - Drugs for the Blood

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 117 Coverage Prescription Drug Name Drug Tier Requirements and Limits Granulocyte-Macrophage Colony-Stimulating Factor (GM-CSF) - Drugs for the Blood LEUKINE INJECTION RECON SOLN 250 MCG Tier 4 SP (sargramostim) Hematorheologic Agents - Drugs for the Blood pentoxifylline oral tablet extended release 400 mg Tier 1 Hemostatic Systemic - Antifibrinolytic Agents - Drugs to Prevent Bleeding aminocaproic acid oral solution 250 mg/ml (25 %) Tier 1 aminocaproic acid oral tablet 1,000 mg, 500 mg Tier 1 tranexamic acid oral tablet 650 mg Tier 1 Indirect Factor Xa Inhibitors - Drugs to Prevent Blood Clots fondaparinux subcutaneous syringe 10 mg/0.8 ml, 2.5 Tier 2 PA mg/0.5 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml Low Molecular Weight Heparins - Drugs to Prevent Blood Clots enoxaparin subcutaneous solution 300 mg/3 ml Tier 2 enoxaparin subcutaneous syringe 100 mg/ml, 120 mg/0.8 ml, 150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 Tier 2 mg/0.6 ml, 80 mg/0.8 ml Platelet Aggregation Inhib - Cyclopentyl-triazolo-pyrimidines (CPTPs) - Drugs for the Blood BRILINTA ORAL TABLET 60 MG, 90 MG (ticagrelor) Tier 3 Platelet Aggregation Inhibitor Combinations - Drugs for the Blood aspirin-dipyridamole oral capsule, er multiphase 12 hr Tier 2 25-200 mg Platelet Aggregation Inhibitors - Phosphodiesterase III Inhibitors - Drugs for the Blood cilostazol oral tablet 100 mg, 50 mg Tier 1 Platelet Aggregation Inhibitors - Quinazoline Agents - Drugs for the Blood anagrelide oral capsule 0.5 mg, 1 mg Tier 1 Platelet Aggregation Inhibitors - Salicylates - Drugs for the Blood ADULT LOW DOSE ASPIRIN ORAL TABLET,DELAYED EHB; AG: IF MALE, 45-79 $0 RELEASE (DR/EC) 81 MG (aspirin) YEARS ASPIRIN CHILDRENS ORAL TABLET,CHEWABLE 81 MG EHB; AG: IF MALE, 45-79 $0 (aspirin) YEARS

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 120 Coverage Prescription Drug Name Drug Tier Requirements and Limits Skeletal Muscle Relaxant - Analgesic Salicylate Combinations - Drugs for Muscles, Ligaments, Tendons, and Bones carisoprodol-aspirin oral tablet 200-325 mg Tier 1 orphenadrine-asa-caffeine oral tablet 50-770-60 mg Tier 3 orphenadrine citrate/aspirin/caffeine (Orphengesic Forte Tier 3 Oral Tablet 50-770-60 Mg) Skeletal Muscle Relaxant - Central Muscle Relaxants - Drugs for Muscles, Ligaments, Tendons, and Bones baclofen oral tablet 10 mg, 20 mg Tier 1 carisoprodol oral tablet 350 mg Tier 1 cyclobenzaprine oral tablet 10 mg, 5 mg Tier 1 methocarbamol oral tablet 500 mg, 750 mg Tier 1 tizanidine oral tablet 2 mg Tier 1 Skeletal Muscle Relaxant - Direct Muscle Relaxants - Drugs for Muscles, Ligaments, Tendons, and Bones dantrolene oral capsule 25 mg Tier 2 Skeletal Muscle Relaxant - Opioid Analgesic Combinations - Drugs for Muscles, Ligaments, Tendons, and Bones carisoprodol-aspirin-codeine oral tablet 200-325-16 mg Tier 1 Skeletal Muscle Relaxant, Salicylate, and Opioid Analgesic Comb. - Drugs for Muscles, Ligaments, Tendons, and Bones carisoprodol-aspirin-codeine oral tablet 200-325-16 mg Tier 1 Medical Supplies and Durable Medical Equipment (DME) - Medical Supplies and Durable Medical Equipment Medical Supplies and DME - Blood Glucose Tests - Medical Supplies and Durable Medical Equipment FREESTYLE INSULINX STRIP (blood sugar diagnostic) $0 DD; EHB FREESTYLE INSULINX TEST STRIPS STRIP (blood $0 DD; EHB sugar diagnostic) FREESTYLE LITE STRIPS STRIP (blood sugar $0 DD; EHB diagnostic) FREESTYLE PRECISION NEO STRIPS STRIP (blood $0 DD; EHB sugar diagnostic) FREESTYLE TEST STRIP (blood sugar diagnostic) $0 DD; EHB

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 121 Coverage Prescription Drug Name Drug Tier Requirements and Limits PRECISION XTRA TEST STRIP (blood sugar diagnostic) $0 DD; EHB Medical Supplies and DME - Cervical Caps - Medical Supplies and Durable Medical Equipment FEMCAP VAGINAL DEVICE 22 MM, 26 MM, 30 MM $0 CT; EHB (cervical cap) Medical Supplies and DME - Diaphragms - Medical Supplies and Durable Medical Equipment CAYA CONTOURED VAGINAL DIAPHRAGM 65-80 MM $0 CT; EHB (diaphragms, contoured) WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 60 $0 CT; EHB MM (diaphragms, wide seal) WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM 65 $0 CT; EHB MM (diaphragms, wide seal) WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM 70 $0 CT; EHB MM (diaphragms, wide seal) WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM 75 $0 CT; EHB MM (diaphragms, wide seal) WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM 80 $0 CT; EHB MM (diaphragms, wide seal) WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM 85 $0 CT; EHB MM (diaphragms, wide seal) WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM 90 $0 CT; EHB MM (diaphragms, wide seal) WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM 95 $0 CT; EHB MM (diaphragms, wide seal) Medical Supplies and DME - Equipment Cleaning Agents - Medical Supplies and Durable Medical Equipment ALCOH-GLOVE TOWELETTE 70 % (isopropyl alcohol) Tier 1 ALCOH-WIPE TOWELETTE 70 % (isopropyl alcohol) Tier 1 Medical Supplies and DME - Female Condoms - Medical Supplies and Durable Medical Equipment FC2 FEMALE CONDOM (condoms, female) $0 CT; EHB Medical Supplies and DME - Glucose Monitoring Test Supplies - Medical Supplies and Durable Medical Equipment 1ST TIER UNILET COMFORTOUCH 28 GAUGE, 30 Tier 1 DD GAUGE (lancets) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 122 Coverage Prescription Drug Name Drug Tier Requirements and Limits 2TEK CONTROL (HIGH-NORMAL) SOLUTION (blood Tier 1 DD glucose calibration control solution, high and normal) ACCU-CHEK AVIVA CONTROL SOLN SOLUTION (blood Tier 1 DD glucose calibration control high and low) ACCU-CHEK FASTCLIX LANCET DRUM (lancets) Tier 1 DD ACCU-CHEK FASTCLIX LANCING DEV KIT (lancing Tier 1 DD device/lancets) ACCU-CHEK GUIDE L1-L2 CTRL SOL SOLUTION (blood Tier 1 DD glucose calibration control high and low) ACCU-CHEK MULTICLIX LANCET (lancets) Tier 1 DD ACCU-CHEK MULTICLIX LANCET KIT (lancing Tier 1 DD device/lancets) ACCU-CHEK SAFE-T-PRO 23 GAUGE (lancets) Tier 1 DD ACCU-CHEK SAFE-T-PRO PLUS 23 GAUGE (lancets) Tier 1 DD ACCU-CHEK SMARTVIEW CONTRL SOL SOLUTION Tier 1 DD (blood glucose calibration control solution, normal) ACCU-CHEK SOFT DEV LANCETS KIT (lancing Tier 1 DD device/lancets) ACCU-CHEK SOFTCLIX LANCETS (lancets) Tier 1 DD ACCUTREND GLUCOSE CONTROL SOLUTION (blood Tier 1 DD glucose calibration control high and low) ACTI-LANCE LANCETS 17 GAUGE, 23 GAUGE, 28 Tier 1 DD GAUGE (lancets) ADJUSTABLE LANCING DEVICE (lancing device) Tier 1 DD ADVANCED LANCING DEVICE KIT (lancing Tier 1 DD device/lancets) ADVANCED TRAVEL LANCETS 28 GAUGE, 30 GAUGE Tier 1 DD (lancets) ADVOCATE CONTROL SOLUTION HIGH SOLUTION Tier 1 DD (blood glucose calibration control solution, high) ADVOCATE LANCET 26 GAUGE, 30 GAUGE (lancets) Tier 1 DD ADVOCATE LANCING DEVICE (lancing device) Tier 1 DD ADVOCATE LOW CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, low) ADVOCATE RAPID-SAFE LANCING (lancing device) Tier 1 DD ADVOCATE REDI-CODE+ CTRL HIGH SOLUTION (blood Tier 1 DD glucose calibration control solution, high) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 123 Coverage Prescription Drug Name Drug Tier Requirements and Limits ADVOCATE REDI-CODE+ CTRL LOW SOLUTION (blood Tier 1 DD glucose calibration control solution, low) AGAMATRIX CONTROL HIGH SOLUTION (blood glucose Tier 1 DD calibration control solution, high) AGAMATRIX CONTROL NORM-HI SOLUTION (blood Tier 1 DD glucose calibration control solution, high and normal) AGAMATRIX CONTROL SOLN-LEVEL 2 SOLUTION Tier 1 DD (blood glucose calibration control solution, normal) AGAMATRIX CONTROL SOLN-LEVEL 4 SOLUTION Tier 1 DD (blood glucose calibration control solution, high) ALTERNATE SITE LANCET 26 GAUGE (lancets) Tier 1 DD ALTERNATE SITE LANCING DEVICE (lancing device) Tier 1 DD AQUA LANCE LANCING DEVICE (lancing device) Tier 1 DD ASSURE 4 CONTROL SOLUTION COMBO PACK (blood- Tier 1 DD glucose calib. control) ASSURE DOSE NORMAL CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) ASSURE DOSE NORM-HI CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, high and normal) ASSURE HAEMOLANCE PLUS 1.2 MM (blade lancet, Tier 1 DD safety) ASSURE HAEMOLANCE PLUS 18 GAUGE, 21 GAUGE, Tier 1 DD 25 GAUGE, 28 GAUGE (lancets) ASSURE LANCE 25 GAUGE, 28 GAUGE (lancets) Tier 1 DD ASSURE LANCE PLUS 21 GAUGE, 25 GAUGE, 30 Tier 1 DD GAUGE (lancets) ASSURE PRISM CONTROL 1-2 SOLN SOLUTION (blood Tier 1 DD glucose calibration control solution, high and normal) AUTO-LANCET MINI (lancing device) Tier 1 DD AUTOLET IMPRESSION LANC DEV KIT (lancing Tier 1 DD device/lancets) AUTOLET LANCING DEVICE (lancing device) Tier 1 DD AUTOLET PLUS LANCING DEVICE (lancing device) Tier 1 DD BD MICROTAINER LANCET 1.5 X 2 MM (blade lancet, Tier 1 DD safety) BD MICROTAINER LANCET 21 GAUGE, 30 GAUGE Tier 1 DD (lancets) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 124 Coverage Prescription Drug Name Drug Tier Requirements and Limits BD ULTRA FINE LANCETS 33 GAUGE (lancets) Tier 1 DD BD ULTRA-FINE II LANCETS 30 GAUGE (lancets) Tier 1 DD blood glucose contrl hi,normal solution Tier 1 DD blood glucose control, normal solution Tier 1 DD blood glucose ctl high,nml,low solution Tier 1 DD BREEZE 2 CONTROL SOLUTION, LOW SOLUTION Tier 1 DD (blood glucose calibration control solution, low) BREEZE 2 CONTROL SOLUTION, NML SOLUTION Tier 1 DD (blood glucose calibration control solution, normal) BREEZE 2 CONTROL SOLUTION,HIGH SOLUTION Tier 1 DD (blood glucose calibration control solution, high) BULLSEYE MINI SAFETY LANCETS 21 GAUGE, 25 Tier 1 DD GAUGE, 28 GAUGE (lancets) BUTTERFLY TOUCH LANCET 30 GAUGE (lancets) Tier 1 DD CAREONE LANCING DEVICE (lancing device) Tier 1 DD CAREONE THIN LANCET (lancets) Tier 1 DD CAREONE ULTRA THIN LANCET (lancets) Tier 1 DD CARESENS CONTROL A AND B SOLUTION (blood Tier 1 DD glucose calibration control solution, high and normal) CARESENS CONTROL A NORMAL SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) CARESENS LANCETS 30 GAUGE (lancets) Tier 1 DD CARETOUCH LANCING DEVICE (lancing device) Tier 1 DD CARETOUCH SAFETY LANCETS 26 GAUGE, 28 GAUGE Tier 1 DD (lancets) CARETOUCH TWIST LANCET 28 GAUGE, 30 GAUGE, 33 Tier 1 DD GAUGE (lancets) CHOICE DM CLARUS NORM CONTROL SOLUTION Tier 1 DD (blood glucose calibration control solution, normal) CLEVER CHEK LANCETS 30 GAUGE (lancets) Tier 1 DD CLEVER CHOICE LEVEL 1 CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, low) CLEVER CHOICE LEVEL 2 CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) CLEVER CHOICE LEVEL 3 CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, high)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 127 Coverage Prescription Drug Name Drug Tier Requirements and Limits EASYMAX NORMAL CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) ELEMENT COMPACT HIGH CONTROL SOLUTION Tier 1 DD (blood glucose calibration control solution, high) ELEMENT COMPACT NORMAL CONTROL SOLUTION Tier 1 DD (blood glucose calibration control solution, normal) ELEMENT HIGH CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, high) ELEMENT LOW CONTROL SOLUTION (blood glucose Tier 1 DD calibration control solution, low) ELEMENT NORMAL CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, normal) EMBRACE EVO LEVEL 1 SOLUTION (blood glucose Tier 1 DD calibration control solution, low) EMBRACE GLUCOSE CONTROL HIGH SOLUTION Tier 1 DD (blood glucose calibration control solution, high) EMBRACE GLUCOSE CONTROL LOW SOLUTION (blood Tier 1 DD glucose calibration control solution, low) EMBRACE LANCETS 30 GAUGE (lancets) Tier 1 DD EMBRACE PRO SOLUTION (blood glucose calibration Tier 1 DD control solution, high and normal) EMBRACE TALK CONTROL-HIGH (L2) SOLUTION (blood Tier 1 DD glucose calibration control solution, high) EMBRACE TALK CONTROL-LOW (L1) SOLUTION (blood Tier 1 DD glucose calibration control solution, low) EVENCARE G2 SOLUTION (blood glucose calibration Tier 1 DD control high and low) EVENCARE G3 CONTROL SOLUTION (blood glucose Tier 1 DD calibration control high and low) EVENCARE MINI GLUCOSE CONTROL SOLUTION Tier 1 DD (blood glucose calibration control solution, normal) EVENCARE PROVIEW CONTROL-L2,L3 SOLUTION Tier 1 DD (blood glucose calibration control high and low) EVENCARE SOLUTION (blood glucose calibration Tier 1 DD control high and low) EVOLUTION NORMAL CONTROL SOLUTION (blood Tier 1 DD glucose calibration control solution, normal)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 144 Coverage Prescription Drug Name Drug Tier Requirements and Limits EASY TOUCH UNI-SLIP SYRINGE 1 ML (syringe without Tier 2 DD needle,insulin disposible, 1 ml) EXEL INSULIN SYRINGE 0.3 ML 29 GAUGE X 1/2" Tier 2 DD (syringe with needle,insulin,0.3 ml) EXEL INSULIN SYRINGE 0.5 ML 30 GAUGE X 5/16", 1/2 Tier 2 DD ML 28 GAUGE X 1/2" (syringe with needle,insulin,0.5 ml) EXEL INSULIN SYRINGE 1 ML 30 GAUGE X 5/16 Tier 2 DD (syringe with needle,disposable,insulin 1 ml) FREESTYLE PRECISION SYRINGE 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16" (syringe with Tier 2 DD needle,insulin,0.5 ml) FREESTYLE PRECISION SYRINGE 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 (syringe with Tier 2 DD needle,disposable,insulin 1 ml) HEALTHWISE INSULIN SYRINGE SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16" (syringe with Tier 2 DD needle,insulin,0.3 ml) HEALTHWISE INSULIN SYRINGE SYRINGE 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16" (syringe with Tier 2 DD needle,insulin,0.5 ml) HEALTHWISE INSULIN SYRINGE SYRINGE 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 (syringe with Tier 2 DD needle,disposable,insulin 1 ml) HEALTHWISE PEN NEEDLE NEEDLE 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32" (pen needle, Tier 2 DD diabetic) HEALTHY ACCENTS UNIFINE PENTIP NEEDLE 29 Tier 2 DD GAUGE X 1/2" (pen needle, diabetic, safety) HEALTHY ACCENTS UNIFINE PENTIP NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 Tier 2 DD GAUGE X 5/32" (pen needle, diabetic) INCONTROL PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", Tier 2 DD 32 GAUGE X 5/32" (pen needle, diabetic) insulin syr/ndl u100 half mark syringe 0.3 ml 31 gauge x Tier 2 DD 1/4" INSULIN SYRINGE MICROFINE SYRINGE 1 ML 27 GAUGE X 5/8" (syringe with needle,disposable,insulin 1 Tier 2 DD ml)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 158 Coverage Prescription Drug Name Drug Tier Requirements and Limits MINI WRIGHT PEAK FLOW METER DEVICE (peak flow Tier 1 meter) PEAK AIR PEAK FLOW METER DEVICE (peak flow Tier 1 meter) PERSONAL BEST FULL RANGE DEVICE (peak flow Tier 1 meter) PERSONAL BEST LOW RANGE DEVICE (peak flow Tier 1 meter) PIKO 1 DEVICE (peak flow meter) Tier 1 POCKET PEAK FLOW METER DEVICE (peak flow meter) Tier 1 PURECOMFORT PEAK FLOW METER DEVICE (peak Tier 1 flow meter) TRUZONE PEAK FLOW METER DEVICE (peak flow Tier 1 meter) Medical Supplies and DME - Respiratory Therapy Supplies - Medical Supplies and Durable Medical Equipment A.I.R.S NEBULIZER REPLACEMENT KIT (nebulizer Tier 2 accessories) ACE AEROSOL CLOUD ENHANCER SPACER (inhaler, Tier 2 assist devices) ADULT AEROSOL MASK (nebulizer accessories) Tier 2 ADULT DISPOSABLE MOUTHPIECE (nebulizer Tier 2 accessories) AEROCHAMBER MINI SPACER (inhaler, assist devices) Tier 2 AEROCHAMBER MV SPACER (inhaler, assist devices) Tier 2 AEROCHAMBER PLUS FLOW-VU SPACER (inhaler, Tier 2 assist devices) AEROCHAMBER PLUS FLOW-VU,L MSK SPACER Tier 2 (inhaler,assist device with large mask) AEROCHAMBER PLUS FLOW-VU,M MSK SPACER Tier 2 (inhaler,assist device with medium mask) AEROCHAMBER PLUS FLOW-VU,S MSK SPACER Tier 2 (inhaler,assist device with small mask) AEROCHAMBER PLUS Z STAT LG MSK SPACER Tier 2 (inhaler,assist device with large mask) AEROCHAMBER PLUS Z STAT MD MSK SPACER Tier 2 (inhaler,assist device with medium mask) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 159 Coverage Prescription Drug Name Drug Tier Requirements and Limits AEROCHAMBER PLUS Z STAT SM MSK SPACER Tier 2 (inhaler,assist device with small mask) AEROCHAMBER PLUS Z STAT SPACER (inhaler, assist Tier 2 devices) AEROCHAMBER WITH FLOWSIGNAL SPACER (inhaler, Tier 2 assist devices) AEROCHAMBER Z-STAT PLUS-FLW SG SPACER Tier 2 (inhaler, assist devices) AERONEB GO (nebulizer accessories) Tier 2 AEROTRACH PLUS SPACER (inhaler, assist devices) Tier 2 AEROVENT PLUS SPACER (inhaler, assist devices) Tier 2 AIR TUBE WITH AIR PLUGS (nebulizer accessories) Tier 2 AIRS ADULT AEROSOL MASK (nebulizer accessories) Tier 2 ALL FLOW 1000 KIT (nebulizer accessories) Tier 2 ALL FLOW 1000 PFT FILTER (nebulizer accessories) Tier 2 ALL FLOW 3000 KIT (nebulizer accessories) Tier 2 ALL FLOW 3000 PFT FILTER (nebulizer accessories) Tier 2 ALL FLOW 4000 KIT (nebulizer accessories) Tier 2 ALL FLOW 4000 PFT FILTER (nebulizer accessories) Tier 2 ALL FLOW 5000 KIT (nebulizer accessories) Tier 2 ALL FLOW 5000 PFT FILTER (nebulizer accessories) Tier 2 ALL FLOW 6000 PFT FILTER (nebulizer accessories) Tier 2 BREATHERITE MDI SPACER SPACER (inhaler, assist Tier 2 devices) BREATHERITE SPACER-MASK, NEO. SPACER Tier 2 (inhaler,assist device with small mask) BREATHERITE SPACER-MASK,ADULT SPACER Tier 2 (inhaler,assist device with large mask) BREATHERITE SPACER-MASK,CHILD SPACER Tier 2 (inhaler,assist device with medium mask) BREATHERITE SPACER-MASK,INFANT SPACER Tier 2 (inhaler,assist device with small mask) BREATHERITE SPACER-MASK,S.CHLD SPACER Tier 2 (inhaler,assist device with small mask) BREATHERITE VALVED MDI CHAMBER SPACER Tier 2 (inhaler, assist devices) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 160 Coverage Prescription Drug Name Drug Tier Requirements and Limits BREATHERITE VALVED MDI SPACER SPACER (inhaler, Tier 2 assist devices) BUBBLES THE FISH PEDI MASK (nebulizer accessories) Tier 2 CLEVER CHOICE CHAMBER-LRG MASK SPACER Tier 2 (inhaler,assist device with large mask) CLEVER CHOICE CHAMBER-MED MASK SPACER Tier 2 (inhaler,assist device with medium mask) CLEVER CHOICE CHAMBER-SM MASK SPACER Tier 2 (inhaler,assist device with small mask) CLEVER CHOICE NEBULIZER DEVICE (nebulizer and Tier 2 compressor) CLEVER CHOICE WHISPER AIRE PED DEVICE Tier 2 (nebulizer and compressor) COMPACT SPACE CHAMBER PLUS SPACER (inhaler, Tier 2 assist devices) COMPACT SPACE CHAMBER SPACER (inhaler, assist Tier 2 devices) COMPACT SPACE CHAMBER-LRG MASK SPACER Tier 2 (inhaler,assist device with large mask) COMPACT SPACE CHAMBER-MED MASK SPACER Tier 2 (inhaler,assist device with medium mask) COMPACT SPACE CHAMBER-SM MASK SPACER Tier 2 (inhaler,assist device with small mask) COMP-AIR NEBULIZER COMPRESSOR DEVICE Tier 2 (nebulizer and compressor) DEVILBISS PULMO-AIDE COMPRESSR DEVICE Tier 2 (compressor, for nebulizer) DEVILBISS PULMOMATE COMPRESSOR DEVICE Tier 2 (compressor, for nebulizer) DEVILBISS PULMONEB LT COMP-NEB DEVICE Tier 2 (nebulizer and compressor) DEVILBISS TRAVELER COMPRESSOR DEVICE Tier 2 (nebulizer and compressor) EASIVENT HOLDING CHAMBER SPACER (inhaler, Tier 2 assist devices) EASIVENT MASK LARGE DEVICE (inhaler, assist Tier 2 devices, accessories)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 162 Coverage Prescription Drug Name Drug Tier Requirements and Limits INSPIRACHAMBER WITH MASK-MED SPACER Tier 2 (inhaler,assist device with medium mask) INSPIRACHAMBER WITH MASK-SMALL SPACER Tier 2 (inhaler,assist device with small mask) INSPIRATION ELITE FILTER (nebulizer accessories) Tier 2 LITE TOUCH-MEDIUM MASK DEVICE (inhaler, assist Tier 2 devices, accessories) LITEAIRE MDI CHAMBER SPACER (inhaler, assist Tier 2 devices) LITETOUCH-LARGE MASK DEVICE (inhaler, assist Tier 2 devices, accessories) LITETOUCH-SMALL MASK DEVICE (inhaler, assist Tier 2 devices, accessories) MICRO ELITE REPLACEMENT FILTER (nebulizer Tier 2 accessories) MICROCHAMBER SPACER (inhaler, assist devices) Tier 2 MICROSPACER SPACER (inhaler, assist devices) Tier 2 MINI ELITE FILTER REPLACEMENT (nebulizer Tier 2 accessories) MISTASSIST DEVICE (spirometers and accessories) Tier 2 MISTASSIST KIT DEVICE (spirometer with drug delivery Tier 2 adapters) MOUTHPIECE DEVICE (inhaler, assist devices, Tier 2 accessories) nebulizer and compressor device Tier 2 NOSE CLIP (nebulizer accessories) Tier 2 OMBRA COMPRESSOR SYSTEM DEVICE (nebulizer and Tier 2 compressor) ONE WAY VALVED MOUTHPIECE DEVICE (inhaler, Tier 2 assist devices, accessories) OPTICHAMBER ADULT MASK-LARGE DEVICE (inhaler, Tier 2 assist devices, accessories) OPTICHAMBER DIAMOND LG MASK SPACER Tier 2 (inhaler,assist device with large mask) OPTICHAMBER DIAMOND VHC SPACER (inhaler, assist Tier 2 devices)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 164 Coverage Prescription Drug Name Drug Tier Requirements and Limits PFLEX INSPIRATORY TRAINER DEVICE (spirometers Tier 2 and accessories) PILLOW MASK CHILD (nebulizer accessories) Tier 2 PILLOW MASK PEDIATRIC (nebulizer accessories) Tier 2 POCKET CHAMBER SPACER (inhaler, assist devices) Tier 2 PORTABLE NEBULIZER SYSTEM DEVICE (nebulizer Tier 2 and compressor) PRIMEAIRE SPACER (inhaler, assist devices) Tier 2 PRO COMFORT SPACER-ADULT MASK SPACER Tier 2 (inhaler,assist device with large mask) PRO COMFORT SPACER-CHILD MASK SPACER Tier 2 (inhaler,assist device with small mask) PROCARE COMPRESSOR NEBULIZER DEVICE Tier 2 (nebulizer and compressor) PROCARE PEDIATRIC NEBULIZER DEVICE (nebulizer Tier 2 and compressor) PROCARE SPACER WITH ADULT MASK SPACER Tier 2 (inhaler,assist device with large mask) PROCARE SPACER WITH CHILD MASK SPACER Tier 2 (inhaler,assist device with medium mask) PROCHAMBER SPACER (inhaler, assist devices) Tier 2 PRONEB ULTRA FILTER SET (nebulizer accessories) Tier 2 PRONEB ULTRA II FILTER ASSEM (nebulizer Tier 2 accessories) PULMO-AIDE COMPRESSOR DEVICE (compressor, for Tier 2 nebulizer) PULMONEB LT COMPRESSOR NEBUL DEVICE Tier 2 (nebulizer and compressor) PUREAIR MINI NEBULIZER DEVICE (nebulizer and Tier 2 compressor) REUSABLE NEBULIZER KIT KIT (nebulizer accessories) Tier 2 RITEFLO AEROCHAMBER SPACER (inhaler, assist Tier 2 devices) RUBBER MOUTHPIECE (nebulizer accessories) Tier 2 SAMI THE SEAL DEVICE (nebulizer and compressor) Tier 2 SAMI THE SEAL FILTER (nebulizer accessories) Tier 2

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 165 Coverage Prescription Drug Name Drug Tier Requirements and Limits SAMI THE SEAL MASK (nebulizer accessories) Tier 2 SIDESTREAM ADULT FACE MASK (nebulizer Tier 2 accessories) SIDESTREAM MASK (nebulizer accessories) Tier 2 SIDESTREAM PEDIATRIC FACE MASK DEVICE (inhaler, Tier 2 assist devices, accessories) SILICONE MASK (nebulizer accessories) Tier 2 SILICONE MASK - INFANT DEVICE (inhaler, assist Tier 2 devices, accessories) SILICONE MASK - PEDIATRIC DEVICE (inhaler, assist Tier 2 devices, accessories) SINUSTAR AEROSOL DEVICE (nebulizer and Tier 2 compressor) SOOTHENEB COMPRESSOR NEBULIZER DEVICE Tier 2 (nebulizer and compressor) SOOTHENEB NBL100 ADULT MASK (nebulizer Tier 2 accessories) SOOTHENEB NBL100 CHILD MASK (nebulizer Tier 2 accessories) SOOTHENEB NBL100 MED CUP (nebulizer accessories) Tier 2 SOOTHENEB NBL100 MESH CAP (nebulizer Tier 2 accessories) SPACE CHAMBER PLUS SPACER (inhaler, assist Tier 2 devices) SPACE CHAMBER SPACER (inhaler, assist devices) Tier 2 SPACE CHAMBER WITH LARGE MASK SPACER Tier 2 (inhaler,assist device with large mask) SPACE CHAMBER WITH MEDIUM MASK SPACER Tier 2 (inhaler,assist device with medium mask) SPACE CHAMBER WITH SMALL MASK SPACER Tier 2 (inhaler,assist device with small mask) SUNRISE COMPRESSOR-NEBULIZER DEVICE Tier 2 (compressor, for nebulizer) THRESHOLD IMT TRAINER DEVICE (spirometers and Tier 2 accessories) THRESHOLD PEP DEVICE DEVICE (spirometers and Tier 2 accessories)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 168 Coverage Prescription Drug Name Drug Tier Requirements and Limits CURITY 8000 URINE MTR FLY TRAY TRAY , 16 FR, 18 Tier 2 FR (catheterization tray) CURITY BEDSIDE DRAINAGE SET TRAY Tier 2 (catheterization tray) CURITY BEDSIDE-MONO-FLO DRANGE TRAY Tier 2 (catheterization tray) CURITY FOLEY CATHETER KIT KIT (catheter) Tier 2 CURITY PREMIUM CATHETER TRAY TRAY 16 FR, 18 FR Tier 2 (catheterization tray) CURITY STRMLIN CATH - MONO-FLO TRAY 14 FR Tier 2 (catheterization tray) CURITY ULTRAMER 2-W CATH LAT/T 16 FR, 18 FR, 20 Tier 2 FR, 24 FR, 26 FR, 30 FR (catheter) CURITY ULTRAMER 2-W CATH TEFLN 28 FR (catheter) Tier 2 CURITY ULTRAMER 2-WAY CATHETER 12 FR, 14 FR, 16 FR, 18 FR, 20 FR, 22 FR, 24 FR, 26 FR, 28 FR, 30 FR Tier 2 (catheter) CURITY ULTRAMER IRRG 3WAY CATH 18 FR, 20 FR, 22 Tier 2 FR, 24 FR, 26 FR (catheter) CURITY ULTRAMER URETHRAL CATH 12 FR, 14 FR, 16 Tier 2 FR, 18 FR, 20 FR, 22 FR, 24 FR (catheter) CURITY UNIVERSAL - NO DRAINAGE TRAY 16 FR, 18 Tier 2 FR (catheterization tray) CURITY URETH CATH CLOSED SYSTM TRAY Tier 2 (catheterization tray) CURITY URETH CATH OPEN SYSTEM TRAY Tier 2 (catheterization tray) CURITY URETHRAL CATHETER 14 FR (catheter) Tier 2 DAVOL C.S. FOLEY CATHETER TRAY TRAY 16 FR, 18 Tier 2 FR (catheterization tray) DAVOL COMPLETE FOLEY KIT (catheter) Tier 2 DAVOL FOLEY CATH INSERT TRAY TRAY Tier 2 (catheterization tray) DAVOL SILICONE FOLEY CATHETER 14 FR, 16 FR, 18 Tier 2 FR, 20 FR, 22 FR, 24 FR (catheter) DAVOL UNIVERSAL CATH TRAY TRAY (catheterization Tier 2 tray)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 171 Coverage Prescription Drug Name Drug Tier Requirements and Limits Medical Supplies and DME - Vaporizers - Medical Supplies and Durable Medical Equipment vaporizers Tier 2 VICKS WARM STEAM VAPORIZER (vaporizer) Tier 2 WARM STEAM VAPORIZER (vaporizer) Tier 2 Medical Supply, FDB Superset Medical Supply, FDB Superset A.I.R.S NEBULIZER REPLACEMENT KIT (nebulizer Tier 2 accessories) ABOUTTIME PEN NEEDLE NEEDLE 30 GAUGE X 5/16", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X Tier 2 DD 5/32" (pen needle, diabetic) ACCU-CHEK AVIVA CONTROL SOLN SOLUTION (blood Tier 1 DD glucose calibration control high and low) ACCU-CHEK FASTCLIX LANCET DRUM (lancets) Tier 1 DD ACCU-CHEK FASTCLIX LANCING DEV KIT (lancing Tier 1 DD device/lancets) ACCU-CHEK MULTICLIX LANCET KIT (lancing Tier 1 DD device/lancets) ACCU-CHEK SAFE-T-PRO PLUS 23 GAUGE (lancets) Tier 1 DD ACCU-CHEK SMARTVIEW CONTRL SOL SOLUTION Tier 1 DD (blood glucose calibration control solution, normal) ACCU-CHEK SOFT DEV LANCETS KIT (lancing Tier 1 DD device/lancets) ACCUTREND GLUCOSE CONTROL SOLUTION (blood Tier 1 DD glucose calibration control high and low) ACE AEROSOL CLOUD ENHANCER SPACER (inhaler, Tier 2 assist devices) ADD-A-FOLEY CATH-MONO-FLO DRNG TRAY Tier 2 (catheterization tray) ADULT AEROSOL MASK (nebulizer accessories) Tier 2 ADULT DISPOSABLE MOUTHPIECE (nebulizer Tier 2 accessories) ADVANCE PLUS INTERMITTENT 10 FR, 10-16 FR-", 12 Tier 2 FR, 6-16 FR-", 8-16 FR-" (catheter) ADVANCED TRAVEL LANCETS 30 GAUGE (lancets) Tier 1 DD

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 188 Coverage Prescription Drug Name Drug Tier Requirements and Limits INSPIRACHAMBER WITH MASK-MED SPACER Tier 2 (inhaler,assist device with medium mask) INSPIRACHAMBER WITH MASK-SMALL SPACER Tier 2 (inhaler,assist device with small mask) INSPIRATION ELITE FILTER (nebulizer accessories) Tier 2 insulin syr/ndl u100 half mark syringe 0.3 ml 31 gauge x Tier 2 DD 1/4" INSULIN SYRINGE MICROFINE SYRINGE 1 ML 27 GAUGE X 5/8" (syringe with needle,disposable,insulin 1 Tier 2 DD ml) INSULIN SYRINGE MICROFINE SYRINGE 1/2 ML 28 Tier 2 DD GAUGE X 1/2" (syringe with needle,insulin,0.5 ml) insulin syringe needleless syringe 1 ml Tier 2 DD INSULIN SYRINGE SYRINGE 1 ML 29 GAUGE X 1/2" Tier 2 DD (syringe with needle,disposable,insulin 1 ml) insulin syringe-needle u-100 syringe 0.3 ml 31 gauge x 1/4", 1 ml 28 gauge, 1 ml 29 gauge x 7/16", 1 ml 30 Tier 2 DD gauge x 3/8", 1 ml 31 gauge x 1/4", 1/2 ml 28 gauge, 1/2 ml 31 gauge x 1/4" INSUPEN NEEDLE 30 GAUGE X 5/16", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 32 GAUGE X 1/4", 32 GAUGE X 5/16", Tier 2 DD 33 GAUGE X 5/32" (pen needle, diabetic) INSYTE IV CATHETER INFUSION SET 14 X 1.75 ", 20 X Tier 2 1.16 " (intravenous catheter) INTELLIGENT MESH NEBULIZER (nebulizer) Tier 2 INTROSYTE AUTOGUARD INFUSION SET 16 GAUGE X 5 FR, 18 GAUGE X 4 FR, 20 GAUGE X 3 FR (intravenous Tier 2 catheter kit/intravenous catheter kit accessory) INVACARE LANCETS 30 GAUGE (lancets) Tier 1 DD KENGUARD FOLEY CATHETER 18-16 FR-" (catheter) Tier 2 KENGUARD FOLEY CATHETER TRAY (catheterization Tier 2 tray) KENLINE ADD-A-FOLEY TRAY 30CC TRAY Tier 2 (catheterization tray) KETONE CARE STRIP (urine acetone test,strips) Tier 1 DD KETONE URINE TEST STRIP (urine acetone test,strips) Tier 1 DD KETOSTIX STRIP (urine acetone test,strips) Tier 1 DD

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 189 Coverage Prescription Drug Name Drug Tier Requirements and Limits LABSTIX REAGENT STRIP (urine multiple test strips) Tier 1 LANCETS, SUPER THIN (lancets) Tier 1 DD LANCETS,THIN 28 GAUGE (lancets) Tier 1 DD LANCETS,ULTRA THIN (lancets) Tier 1 DD LANCING SYSTEM (lancing device) Tier 1 DD LANZO LANCING DEVICE KIT (lancing device/lancets) Tier 1 DD LC PLUS NEBULIZER-PED MASK (nebulizer) Tier 2 LITE TOUCH INSULIN PEN NEEDLES NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 Tier 2 DD GAUGE X 5/16" (pen needle, diabetic) LITE TOUCH INSULIN SYRINGE SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 1/2 ML 28 Tier 2 DD GAUGE, 1/2 ML 28 GAUGE X 1/2", 1/2 ML 29 , 1/2 ML 30 GAUGE (syringe with needle,insulin,0.5 ml) LITE TOUCH INSULIN SYRINGE SYRINGE 1 ML 28 GAUGE, 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE, 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 30 Tier 2 DD GAUGE X 7/16", 1 ML 31 GAUGE X 5/16 (syringe with needle,disposable,insulin 1 ml) LITE TOUCH LANCETS 28 GAUGE, 30 GAUGE, 33 Tier 1 DD GAUGE (lancets) LITE TOUCH LANCING DEVICE (lancing device) Tier 1 DD LITE TOUCH-MEDIUM MASK DEVICE (inhaler, assist Tier 2 devices, accessories) LITEAIRE MDI CHAMBER SPACER (inhaler, assist Tier 2 devices) LITETOUCH-LARGE MASK DEVICE (inhaler, assist Tier 2 devices, accessories) LITETOUCH-SMALL MASK DEVICE (inhaler, assist Tier 2 devices, accessories) LOFRIC 12-16 FR-", 14-16 FR-" (catheter) Tier 2 LOFRIC ORIGO 14-16 FR-" (catheter) Tier 2 MAGELLAN INSULIN SAFETY SYRNG SYRINGE 0.3 ML Tier 2 DD 29 X 1/2" (syringe with needle, insulin, safety, 0.3 ml) MAGELLAN INSULIN SAFETY SYRNG SYRINGE 0.5 ML 29 GAUGE X 1/2" (syringe with needle, insulin, safety, Tier 2 DD 0.5 ml)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 199 Coverage Prescription Drug Name Drug Tier Requirements and Limits SOOTHENEB NBL100 CHILD MASK (nebulizer Tier 2 accessories) SOOTHENEB NBL100 MED CUP (nebulizer accessories) Tier 2 SOOTHENEB NBL100 MESH CAP (nebulizer Tier 2 accessories) SPACE CHAMBER PLUS SPACER (inhaler, assist Tier 2 devices) SPACE CHAMBER SPACER (inhaler, assist devices) Tier 2 SPACE CHAMBER WITH LARGE MASK SPACER Tier 2 (inhaler,assist device with large mask) SPACE CHAMBER WITH MEDIUM MASK SPACER Tier 2 (inhaler,assist device with medium mask) SPACE CHAMBER WITH SMALL MASK SPACER Tier 2 (inhaler,assist device with small mask) SPEEDICATH (FEMALE) 16 FR (catheter) Tier 2 SPEEDICATH (MALE) 12 FR (catheter) Tier 2 SPIRIT EXT CATHETER TYPE 3 32 MM (catheter Tier 2 male,external) SPIRIT STYLE-3 29 MM (catheter male,external) Tier 2 STERILANCE TL 30 GAUGE, 32 GAUGE (lancets) Tier 1 DD SUNRISE COMPRESSOR-NEBULIZER DEVICE Tier 2 (compressor, for nebulizer) SUPER THIN LANCETS (lancets) Tier 1 DD SURE COMFORT INS. SYR. U-100 SYRINGE 0.5 ML 29 Tier 2 DD GAUGE X 1/2" (syringe with needle,insulin,0.5 ml) SURE COMFORT INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 1/2", 0.3 ML 30 Tier 2 DD GAUGE X 5/16", 0.3 ML 31 GAUGE X 1/4" (syringe with needle,insulin,0.3 ml) SURE COMFORT INSULIN SYRINGE SYRINGE 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 Tier 2 DD GAUGE X 5/16", 1/2 ML 28 GAUGE X 1/2", 1/2 ML 31 GAUGE X 1/4" (syringe with needle,insulin,0.5 ml) SURE COMFORT INSULIN SYRINGE SYRINGE 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 1/4", 1 Tier 2 DD ML 31 GAUGE X 5/16 (syringe with needle,disposable,insulin 1 ml) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 200 Coverage Prescription Drug Name Drug Tier Requirements and Limits SURE COMFORT LANCETS 18 GAUGE, 21 GAUGE, 23 Tier 1 DD GAUGE, 28 GAUGE (lancets) SURE COMFORT LANCING PEN (lancing device) Tier 1 DD SURE COMFORT PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 30 GAUGE X 5/16", 31 GAUGE X 3/16", 31 GAUGE X Tier 2 DD 5/16", 32 GAUGE X 1/4", 32 GAUGE X 5/32" (pen needle, diabetic) SURE COMFORT SAFETY PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 32 GAUGE X 5/32" (pen needle, diabetic, Tier 2 DD safety) SUREFLEX DEVICE WITH LANCETS KIT (lancing Tier 1 DD device/lancets) SUREFLEX LANCING DEVICE (lancing device) Tier 1 DD SURE-JECT INSULIN SYRINGE SYRINGE 0.3 ML 31 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin,0.3 ml) SURE-JECT INSULIN SYRINGE SYRINGE 0.5 ML 31 Tier 2 DD GAUGE X 5/16" (syringe with needle,insulin,0.5 ml) SURE-JECT INSULIN SYRINGE SYRINGE 1 ML 31 GAUGE X 5/16 (syringe with needle,disposable,insulin 1 Tier 2 DD ml) SURE-LANCE 26 GAUGE (lancets) Tier 1 DD SURE-TOUCH LANCET (lancets) Tier 1 DD TELCARE CONTROL SOLUTION (blood glucose Tier 1 DD calibration control high and low) TELCARE LANCETS 30 GAUGE (lancets) Tier 1 DD TERUMO INSULIN SYRINGE SYRINGE 0.3 ML 30 X 3/8" Tier 2 DD (syringe with needle,insulin,0.3 ml) TERUMO INSULIN SYRINGE SYRINGE 0.5 ML 29 GAUGE X 1/2", 1/2 ML 27 GAUGE X 1/2", 1/2 ML 28 Tier 2 DD GAUGE X 1/2", 1/2 ML 30 X 3/8" (syringe with needle,insulin,0.5 ml) TERUMO INSULIN SYRINGE SYRINGE 1 ML 27 GAUGE X 1/2", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2" Tier 2 DD (syringe with needle,disposable,insulin 1 ml) THINPRO INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 X 3/8", 0.3 ML 31 X 3/8" Tier 2 DD (syringe with needle,insulin,0.3 ml)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 212 Coverage Prescription Drug Name Drug Tier Requirements and Limits neomycin sulfate/bacitracin zinc/polymyxin b/hydrocortisone (Neo-Polycin Hc Ophthalmic (Eye) Tier 1 Ointment 3.5-400-10,000 Mg-Unit/G-1%) PRED-G OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3- Tier 2 1 % (gentamicin sulfate/prednisolone acetate) sulfacetamide-prednisolone ophthalmic (eye) drops 10 Tier 1 %-0.23 % (0.25 %) TOBRADEX OPHTHALMIC (EYE) OINTMENT 0.3-0.1 % Tier 2 (tobramycin/dexamethasone) tobramycin-dexamethasone ophthalmic (eye) Tier 1 drops,suspension 0.3-0.1 % ZYLET OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3- Tier 2 QL (5 ML per 1 FILL) 0.5 % (tobramycin/loteprednol etabonate) Ophthalmic - Anticholinergics - Drugs for the Eye atropine ophthalmic (eye) drops 1 % Tier 1 atropine ophthalmic (eye) ointment 1 % Tier 1 cyclopentolate ophthalmic (eye) drops 0.5 %, 1 %, 2 % Tier 1 HOMATROPAIRE OPHTHALMIC (EYE) DROPS 5 % Tier 1 (homatropine hbr) tropicamide ophthalmic (eye) drops 0.5 %, 1 % Tier 1 Ophthalmic - Antihistamines - Drugs for Itchy Eye ALAWAY OPHTHALMIC (EYE) DROPS 0.025 % (0.035 %) EHB; QL (10 ML per 30 $0 (ketotifen fumarate) days) ALLERGY EYE (KETOTIFEN) OPHTHALMIC (EYE) EHB; QL (10 ML per 30 $0 DROPS 0.025 % (0.035 %) (ketotifen fumarate) days) azelastine ophthalmic (eye) drops 0.05 % Tier 1 CHILDREN'S ALAWAY OPHTHALMIC (EYE) DROPS EHB; QL (10 ML per 30 $0 0.025 % (0.035 %) (ketotifen fumarate) days) ST: At least 2 prior prescriptions for Azelastine epinastine ophthalmic (eye) drops 0.05 % Tier 2 HCL, Ketotifen Fumarate or Olopatadine HCL in 120 days

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 213 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: At least 2 prior prescriptions for Azelastine EYE ALLERGY ITCH RELIEF OPHTHALMIC (EYE) HCL, Ketotifen Fumarate or Tier 2 DROPS 0.2 % (olopatadine hcl) Olopatadine HCL in 120 days; QL (2.5 ML per 30 days) ST: Prior prescription for Azelastine HCL, Ketotifen EYE ALLERGY ITCH-REDNESS RLF OPHTHALMIC (EYE) Tier 2 Fumarate, or Olopatadine DROPS 0.1 % (olopatadine hcl) HCL in 120 days; QL (2.5 ML per 30 days) EYE ITCH RELIEF OPHTHALMIC (EYE) DROPS 0.025 % EHB; QL (10 ML per 30 $0 (0.035 %) (ketotifen fumarate) days) ITCHY EYE DROPS OPHTHALMIC (EYE) DROPS 0.025 EHB; QL (10 ML per 30 $0 % (0.035 %) (ketotifen fumarate) days) ketotifen fumarate ophthalmic (eye) drops 0.025 % EHB; QL (10 ML per 30 $0 (0.035 %) days) ST: Prior prescription for Azelastine HCL, Ketotifen olopatadine ophthalmic (eye) drops 0.1 % Tier 2 Fumarate, or Olopatadine HCL in 120 days; QL (2.5 ML per 30 days) ST: At least 2 prior prescriptions for Azelastine HCL, Ketotifen Fumarate or olopatadine ophthalmic (eye) drops 0.2 % Tier 2 Olopatadine HCL in 120 days; QL (2.5 ML per 30 days) WAL-ZYR (KETOTIFEN) OPHTHALMIC (EYE) DROPS EHB; QL (10 ML per 30 $0 0.025 % (0.035 %) (ketotifen fumarate) days) Ophthalmic - Anti-Inflammatory, Glucocorticoids - Anti-Infective/Anti- Inflammatories dexamethasone sodium phosphate ophthalmic (eye) Tier 1 drops 0.1 % fluorometholone ophthalmic (eye) drops,suspension Tier 1 0.1 % loteprednol etabonate ophthalmic (eye) Tier 3 drops,suspension 0.5 % MAXIDEX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 Tier 2 % (dexamethasone) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 214 Coverage Prescription Drug Name Drug Tier Requirements and Limits prednisolone acetate ophthalmic (eye) Tier 1 drops,suspension 1 % prednisolone sodium phosphate ophthalmic (eye) Tier 2 drops 1 % Ophthalmic - Anti-Inflammatory, Immunomodulators - Anti-Infective/Anti- Inflammatories PR: RESTRICTED TO RESTASIS MULTIDOSE OPHTHALMIC (EYE) DROPS OPHTHALMOLOGY OR Tier 3 0.05 % (cyclosporine) OPTOMETRY SPECIALIST; QL (60 ML per 30 days) PR: RESTRICTED TO RESTASIS OPHTHALMIC (EYE) DROPPERETTE 0.05 % OPHTHALMOLOGY OR Tier 3 (cyclosporine) OPTOMETRY SPECIALIST; QL (60 EA per 30 days) Ophthalmic - Anti-inflammatory, NSAIDs - Anti-Infective/Anti-Inflammatories bromfenac ophthalmic (eye) drops 0.09 % Tier 1 QL (2.5 ML per 1 FILL) BROMSITE OPHTHALMIC (EYE) DROPS 0.075 % Tier 2 QL (5 ML per 1 FILL) (bromfenac sodium) diclofenac sodium ophthalmic (eye) drops 0.1 % Tier 1 flurbiprofen sodium ophthalmic (eye) drops 0.03 % Tier 1 ILEVRO OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3 Tier 2 QL (3 ML per 1 FILL) % (nepafenac) ketorolac ophthalmic (eye) drops 0.4 %, 0.5 % Tier 1 NEVANAC OPHTHALMIC (EYE) DROPS,SUSPENSION Tier 2 0.1 % (nepafenac) ST: Prior prescription for PROLENSA OPHTHALMIC (EYE) DROPS 0.07 % Tier 3 Bromfenac Sodium in 120 (bromfenac sodium) days; QL (3 ML per 1 FILL) Ophthalmic - Beta blockers-Carbonic Anhydrase Inhibitor Combinations - Drugs for Glaucoma dorzolamide-timolol ophthalmic (eye) drops 22.3-6.8 Tier 1 mg/ml Ophthalmic - Carbonic Anhydrase Inhibitors - Drugs for Glaucoma dorzolamide ophthalmic (eye) drops 2 % Tier 1 Ophthalmic - Decongestants - Drugs for Itchy Eye phenylephrine hcl ophthalmic (eye) drops 10 %, 2.5 % Tier 1

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 215 Coverage Prescription Drug Name Drug Tier Requirements and Limits Ophthalmic - Intraocular Pressure Reducing Agents, Beta-blockers - Drugs for Glaucoma betaxolol ophthalmic (eye) drops 0.5 % Tier 2 carteolol ophthalmic (eye) drops 1 % Tier 1 levobunolol ophthalmic (eye) drops 0.5 % Tier 1 metipranolol ophthalmic (eye) drops 0.3 % Tier 1 timolol maleate ophthalmic (eye) drops 0.25 %, 0.5 % Tier 1 timolol maleate ophthalmic (eye) gel forming solution Tier 3 0.25 % Ophthalmic - Local Anesthetic Esters - Drugs for the Eye proparacaine hcl (Alcaine Ophthalmic (Eye) Drops 0.5 %) Tier 1 proparacaine ophthalmic (eye) drops 0.5 % Tier 1 Ophthalmic - Mast Cell Stabilizers - Drugs for Itchy Eye ALOCRIL OPHTHALMIC (EYE) DROPS 2 % (nedocromil Tier 2 sodium) ALOMIDE OPHTHALMIC (EYE) DROPS 0.1 % Tier 2 (lodoxamide tromethamine) cromolyn ophthalmic (eye) drops 4 % Tier 1 Ophthalmic Antibacterial Mixtures - Anti-Infective/Anti-Inflammatories bacitracin/polymyxin b sulfate (Ak-Poly-Bac Ophthalmic Tier 1 (Eye) Ointment 500-10,000 Unit/Gram) bacitracin-polymyxin b ophthalmic (eye) ointment 500- Tier 1 10,000 unit/gram neomycin-bacitracin-polymyxin ophthalmic (eye) Tier 1 ointment 3.5-400-10,000 mg-unit-unit/g neomycin-polymyxin-gramicidin ophthalmic (eye) drops Tier 1 1.75 mg-10,000 unit-0.025mg/ml neomycin sulfate/bacitracin/polymyxin b (Neo-Polycin Tier 1 Ophthalmic (Eye) Ointment 3.5-400-10,000 Mg-Unit-Unit/G) bacitracin/polymyxin b sulfate (Polycin Ophthalmic (Eye) Tier 1 Ointment 500-10,000 Unit/Gram) polymyxin b sulf-trimethoprim ophthalmic (eye) drops Tier 1 10,000 unit- 1 mg/ml Ophthalmic Antibiotic - Aminoglycosides - Anti-Infective/Anti-Inflammatories

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 216 Coverage Prescription Drug Name Drug Tier Requirements and Limits gentamicin sulfate (Gentak Ophthalmic (Eye) Ointment 0.3 Tier 1 % (3 Mg/Gram)) gentamicin ophthalmic (eye) drops 0.3 % Tier 1 tobramycin ophthalmic (eye) drops 0.3 % Tier 1 Ophthalmic Antibiotic - Dehydropeptidase Inhibitors - Anti-Infective/Anti- Inflammatories bacitracin ophthalmic (eye) ointment 500 unit/gram Tier 2 Ophthalmic Antibiotic - Fluoroquinolones - Anti-Infective/Anti-Inflammatories ciprofloxacin hcl ophthalmic (eye) drops 0.3 % Tier 1 ST: Prior prescription for Ciprofloxacin HCL, gatifloxacin ophthalmic (eye) drops 0.5 % Tier 1 Levofloxacin, Moxifloxacin HCL, or Ofloxacin in 120 days levofloxacin ophthalmic (eye) drops 0.5 % Tier 1 moxifloxacin ophthalmic (eye) drops 0.5 % Tier 2 QL (3 ML per 1 FILL) moxifloxacin ophthalmic (eye) drops, viscous 0.5 % Tier 2 QL (3 ML per 1 FILL) ofloxacin ophthalmic (eye) drops 0.3 % Tier 1 Ophthalmic Antibiotic - Macrolides - Anti-Infective/Anti-Inflammatories AZASITE OPHTHALMIC (EYE) DROPS 1 % Tier 2 QL (2.5 ML per 1 FILL) (azithromycin) erythromycin ophthalmic (eye) ointment 5 mg/gram (0.5 Tier 1 %) Ophthalmic Antibiotic - Sulfonamides - Anti-Infective/Anti-Inflammatories sulfacetamide sodium (Bleph-10 Ophthalmic (Eye) Drops Tier 1 10 %) sulfacetamide sodium ophthalmic (eye) drops 10 % Tier 1 Ophthalmic Antivirals - Anti-Infective/Anti-Inflammatories trifluridine ophthalmic (eye) drops 1 % Tier 1 ZIRGAN OPHTHALMIC (EYE) GEL 0.15 % (ganciclovir) Tier 2 Ophthalmic-Intraocular Press. Reducing, Sel. Alpha Adrenergic Agonists - Drugs for Glaucoma

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 218 Coverage Prescription Drug Name Drug Tier Requirements and Limits fluocinolone acetonide oil otic (ear) drops 0.01 % Tier 1 hydrocortisone-acetic acid otic (ear) drops 1-2 % Tier 1 Respiratory Therapy Agents - Drugs for the Lungs 1st Generation Antihistamine-Decongestant Combinations - Drugs for Cough and Cold phenylephrine hcl/promethazine hcl (Promethazine Vc Tier 1 Oral Syrup 6.25-5 Mg/5 Ml) promethazine-phenylephrine oral syrup 6.25-5 mg/5 ml Tier 1 Antihistamine - 1st Generation - Ethanolamines - Drugs for Allergies BANOPHEN ORAL CAPSULE 50 MG (diphenhydramine Tier 1 hcl) carbinoxamine maleate oral liquid 4 mg/5 ml Tier 1 carbinoxamine maleate oral tablet 4 mg Tier 1 diphenhydramine hcl oral capsule 50 mg Tier 1 PHARBEDRYL ORAL CAPSULE 50 MG Tier 1 (diphenhydramine hcl) Antihistamine - 1st Generation - Phenothiazines - Drugs for Allergies promethazine oral syrup 6.25 mg/5 ml Tier 1 promethazine oral tablet 12.5 mg, 25 mg, 50 mg Tier 1 promethazine rectal suppository 12.5 mg, 25 mg, 50 mg Tier 1 promethazine hcl (Promethegan Rectal Suppository 12.5 Tier 1 Mg, 25 Mg, 50 Mg) Antihistamine - 1st Generation - Piperidines - Drugs for Allergies cyproheptadine oral syrup 2 mg/5 ml Tier 1 cyproheptadine oral tablet 4 mg Tier 1 Antihistamines - 1st Generation - Drugs for Allergies carbinoxamine maleate oral liquid 4 mg/5 ml Tier 1 NIGHTIME SLEEP ORAL CAPSULE 50 MG Tier 1 (diphenhydramine hcl) promethazine rectal suppository 50 mg Tier 1 promethazine hcl (Promethegan Rectal Suppository 25 Tier 1 Mg) Antitussives - Non-Opioid - Drugs for Allergies benzonatate oral capsule 100 mg, 200 mg Tier 1 PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 219 Coverage Prescription Drug Name Drug Tier Requirements and Limits benzonatate oral capsule 150 mg Tier 3 Asthma Therapy - Inhaled Corticosteroids (Glucocorticoids) - Drugs for Asthma/COPD ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 200 MCG/ACTUATION, 50 Tier 2 MCG/ACTUATION (fluticasone furoate) budesonide inhalation suspension for nebulization 0.25 Tier 1 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 250 MCG/ACTUATION, 50 Tier 2 MCG/ACTUATION (fluticasone propionate) FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION, 44 Tier 2 MCG/ACTUATION (fluticasone propionate) Asthma Therapy - Leukotriene Receptor Antagonists - Drugs for Asthma/COPD montelukast oral granules in packet 4 mg Tier 1 montelukast oral tablet 10 mg Tier 1 montelukast oral tablet,chewable 4 mg, 5 mg Tier 1 zafirlukast oral tablet 10 mg, 20 mg Tier 1 Asthma Therapy - Mast Cell Stabilizers - Drugs for Asthma/COPD cromolyn inhalation solution for nebulization 20 mg/2 Tier 1 ml Asthma Therapy - Xanthines - Drugs for Asthma/COPD theophylline anhydrous (Elixophyllin Oral Elixir 80 Mg/15 Tier 2 Ml) THEOCHRON ORAL TABLET EXTENDED RELEASE 12 Tier 1 HR 100 MG, 200 MG, 300 MG (theophylline anhydrous) theophylline oral elixir 80 mg/15 ml Tier 1 theophylline oral solution 80 mg/15 ml Tier 1 theophylline oral tablet extended release 12 hr 300 mg, Tier 1 450 mg theophylline oral tablet extended release 24 hr 400 mg, Tier 1 600 mg Asthma Therapy- Monoclonal Antibody - Interleukin-5 (IL-5) Antagonists - Drugs for Asthma/COPD

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 222 Coverage Prescription Drug Name Drug Tier Requirements and Limits SP; PR: RESTRICTED TO tobramycin in 0.225 % nacl inhalation solution for INFECTIOUS DISEASE OR Tier 4 nebulization 300 mg/5 ml PULMONOLOGY SPECIALIST SP; PR: RESTRICTED TO tobramycin inhalation solution for nebulization 300 INFECTIOUS DISEASE OR Tier 4 mg/4 ml PULMONOLOGY SPECIALIST SP; PR: RESTRICTED TO tobramycin with nebulizer inhalation solution for INFECTIOUS DISEASE OR Tier 4 nebulization 300 mg/5 ml PULMONOLOGY SPECIALIST Cystic Fibrosis - Inhaled Monobactams - Drugs for Cystic Fibrosis SP; PR: RESTRICTED TO CAYSTON INHALATION SOLUTION FOR NEBULIZATION INFECTIOUS DISEASE OR Tier 4 75 MG/ML (aztreonam lysine) PULMONOLOGY SPECIALIST Cystic Fibrosis-Transmembrane Conductance Regulator (CFTR) Potentiator - Drugs for Cystic Fibrosis KALYDECO ORAL GRANULES IN PACKET 50 MG, 75 MG Tier 4 PA; SP; QL (2 EA per 1 day) (ivacaftor) KALYDECO ORAL TABLET 150 MG (ivacaftor) Tier 4 PA; SP; QL (2 EA per 1 day) Cystic Fib-Transmemb Conduct. Reg.(CFTR) Potentiator and Corrector Cmb - Drugs for Cystic Fibrosis ORKAMBI ORAL GRANULES IN PACKET 100-125 MG, Tier 4 PA; SP; QL (4 EA per 1 day) 150-188 MG (lumacaftor/ivacaftor) ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG Tier 4 PA; SP; QL (4 EA per 1 day) (lumacaftor/ivacaftor) SYMDEKO ORAL TABLETS, SEQUENTIAL 100-150 MG Tier 4 PA; SP; QL (2 EA per 1 day) (D)/ 150 MG (N) (tezacaftor/ivacaftor) Mucolytics - Drugs for the Lungs acetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 Tier 1 %) PULMOZYME INHALATION SOLUTION 1 MG/ML Tier 4 SP (dornase alfa) Nasal Anticholinergics - Allergy

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 223 Coverage Prescription Drug Name Drug Tier Requirements and Limits ipratropium bromide nasal spray,non-aerosol 21 mcg Tier 1 (0.03 %), 42 mcg (0.06 %) Nasal Antihistamines - Allergy azelastine nasal aerosol,spray 137 mcg (0.1 %) Tier 1 azelastine nasal spray,non-aerosol 205.5 mcg (0.15 %) Tier 1 olopatadine nasal spray,non-aerosol 0.6 % Tier 1 Nasal Corticosteroids - Allergy 24 HOUR ALLERGY RELIEF NASAL SPRAY,SUSPENSION 50 MCG/ACTUATION (fluticasone Tier 1 QL (31.6 ML per 1 FILL) propionate) 24 HOUR NASAL ALLERGY NASAL AEROSOL,SPRAY 55 Tier 1 QL (33.8 ML per 1 FILL) MCG (triamcinolone acetonide) ALLER-CORT NASAL AEROSOL,SPRAY 55 MCG Tier 1 QL (33.8 ML per 1 FILL) (triamcinolone acetonide) ALLER-FLO NASAL SPRAY,SUSPENSION 50 Tier 1 QL (31.6 ML per 1 FILL) MCG/ACTUATION (fluticasone propionate) ALLERGY RELIEF (FLUTICASONE) NASAL SPRAY,SUSPENSION 50 MCG/ACTUATION (fluticasone Tier 1 QL (31.6 ML per 1 FILL) propionate) budesonide nasal spray,non-aerosol 32 mcg/actuation Tier 2 ST: Prior prescription for Children's Nasacort, CHILDREN'S FLONASE SENSIMIST NASAL Flunisolide, Fluticasone SPRAY,SUSPENSION 27.5 MCG/ACTUATION Tier 3 Propionate, Mometasone (fluticasone furoate) Furoate, or Triamcinolone Acetonide in 120 days; QL (31.6 ML per 1 FILL) CLARISPRAY NASAL SPRAY,SUSPENSION 50 Tier 1 QL (31.6 ML per 1 FILL) MCG/ACTUATION (fluticasone propionate) ST: Prior prescription for Children's Nasacort, Flunisolide, Fluticasone FLONASE SENSIMIST NASAL SPRAY,SUSPENSION 27.5 Tier 3 Propionate, Mometasone MCG/ACTUATION (fluticasone furoate) Furoate, or Triamcinolone Acetonide in 120 days; QL (31.6 ML per 1 FILL) flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) Tier 1 QL (50 ML per 1 FILL)

PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit | SP = Specialty Drug | EHB = USPSTF A & B Drug | DD = Diabetes Drug or Device| CT = Contraceptive | OCH = Oral Anti-Cancer Drug 224 Coverage Prescription Drug Name Drug Tier Requirements and Limits fluticasone propionate nasal spray,suspension 50 Tier 1 QL: 2 BOTTLES PER FILL mcg/actuation mometasone nasal spray,non-aerosol 50 mcg/actuation Tier 1 QL (34 GM per 1 FILL) NASAL ALLERGY NASAL AEROSOL,SPRAY 55 MCG Tier 1 QL (33.8 ML per 1 FILL) (triamcinolone acetonide) triamcinolone acetonide nasal aerosol,spray 55 mcg Tier 1 QL (33.8 ML per 1 FILL) Nasal Sympathomimetic Decongestants (Intranasal) - Allergy TYZINE NASAL DROPS 0.1 % (tetrahydrozoline hcl) Tier 3 TYZINE NASAL SPRAY,NON-AEROSOL 0.1 % Tier 3 (tetrahydrozoline hcl) Non-Opioid Antitussive-Antihistamine Combinations - Drugs for Cough and Cold promethazine-dm oral syrup 6.25-15 mg/5 ml Tier 1 Opioid Antitussive-1st Generation Antihistamine Combinations - Drugs for Cough and Cold hydrocodone-chlorpheniramine oral Tier 1 QL (120 ML per 1 FILL) suspension,extended rel 12 hr 10-8 mg/5 ml promethazine-codeine oral syrup 6.25-10 mg/5 ml Tier 1 Age (Min 18 Years) Opioid Antitussive-1st Generation Antihistamine-Decongestant Comb. - Drugs for Cough and Cold promethazine/phenylephrine hcl/codeine (Promethazine Tier 1 Age (Min 18 Years) Vc-Codeine Oral Syrup 6.25-5-10 Mg/5 Ml) promethazine-phenyleph-codeine oral syrup 6.25-5-10 Tier 1 Age (Min 18 Years) mg/5 ml RYDEX ORAL LIQUID 1.3-10-6.3 MG/5 ML (brompheniramine maleate/pseudoephedrine Tier 1 hcl/codeine phosphat) Opioid Antitussive-Anticholinergic Combinations - Drugs for Cough and Cold hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml Tier 1 hydrocodone-homatropine oral tablet 5-1.5 mg Tier 1 hydrocodone bitartrate/homatropine methylbromide Tier 1 (Hydromet Oral Syrup 5-1.5 Mg/5 Ml) Opioid Antitussive-Expectorant Combinations - Drugs for Cough and Cold codeine-guaifenesin oral liquid 10-100 mg/5 ml Tier 1 QL (240 ML per 1 FILL) G TUSSIN AC ORAL LIQUID 10-100 MG/5 ML (codeine Tier 1 QL (240 ML per 1 FILL) phosphate/guaifenesin)

1 ACCUTREND GLUCOSE ADVOCATE CONTROL 1ST TIER UNIFINE CONTROL ...... 123, 172 SOLUTION HIGH 123, 173 PENTIPS ...... 138 ACE AEROSOL CLOUD ADVOCATE LANCET ..... 123 1ST TIER UNIFINE ENHANCER ...... 159, 172 ADVOCATE LANCING PENTIPS PLUS ...... 138 acebutolol ...... 37 DEVICE ...... 123, 173 1ST TIER UNILET acetaminophen-codeine ...... 2 ADVOCATE LOW COMFORTOUCH ...... 122 acetazolamide ...... 40 CONTROL ...... 123, 173 2 acetic acid ...... 218 ADVOCATE PEN NEEDLE 24 HOUR ALLERGY RELIEF acetylcysteine ...... 223 ...... 139, 173 ...... 224 ACID CONTROLLER ...... 109 ADVOCATE RAPID-SAFE 24 HOUR NASAL ALLERGY ACID REDUCER LANCING ...... 123, 173 ...... 224 (CIMETIDINE) ...... 109 ADVOCATE REDI-CODE+ 2TEK CONTROL (HIGH- ACID REDUCER CTRL HIGH ...... 123, 173 NORMAL) ...... 123 (FAMOTIDINE) ...... 109 ADVOCATE REDI-CODE+ A ACID-PEP ...... 109 CTRL LOW ...... 124, 173 A.I.R.S NEBULIZER acitretin ...... 74 ADVOCATE SYRINGES 139, REPLACEMENT .. 159, 172 ACNE MEDICATION ...... 72 173 abacavir ...... 14 ACTI-LANCE LANCETS . 123 AEROCHAMBER MINI ... 159, abacavir-lamivudine ...... 15 ACTIVE CATH ...... 167 173 abacavir-lamivudine- acyclovir ...... 19, 75 AEROCHAMBER MV ..... 159, zidovudine ...... 15 ADACEL(TDAP 173 abiraterone ...... 23 ADOLESN/ADULT)(PF) 30, AEROCHAMBER PLUS ABOUTTIME PEN NEEDLE 31 FLOW-VU ...... 159 ...... 138, 172 adapalene ...... 72 AEROCHAMBER PLUS acamprosate ...... 56 ADD-A-FOLEY CATH- FLOW-VU,L MSK ...... 159 acarbose ...... 97 MONO-FLO DRNG ..... 167, AEROCHAMBER PLUS ACCU-CHEK AVIVA 172 FLOW-VU,M MSK ...... 159 CONTROL SOLN 123, 172 ADD-A-FOLEY CATH-PRE- AEROCHAMBER PLUS ACCU-CHEK FASTCLIX FILL SYRN ...... 167 FLOW-VU,S MSK ...... 159 LANCET DRUM ... 123, 172 ADD-A-FOLEY TRAY...... 167 AEROCHAMBER PLUS Z ACCU-CHEK FASTCLIX adefovir ...... 18 STAT ...... 160, 173 LANCING DEV .... 123, 172 ADJUSTABLE LANCING AEROCHAMBER PLUS Z ACCU-CHEK GUIDE L1-L2 DEVICE ...... 123 STAT LG MSK ..... 159, 173 CTRL SOL ...... 123 ADULT AEROSOL MASK AEROCHAMBER PLUS Z ACCU-CHEK MULTICLIX ...... 159, 172 STAT MD MSK .... 159, 173 LANCET ...... 123, 172 ADULT ASPIRIN REGIMEN 7 AEROCHAMBER PLUS Z ACCU-CHEK SAFE-T-PRO ADULT DISPOSABLE STAT SM MSK .... 160, 173 ...... 123 MOUTHPIECE ..... 159, 172 AEROCHAMBER WITH ACCU-CHEK SAFE-T-PRO ADULT LOW DOSE FLOWSIGNAL ..... 160, 173 PLUS ...... 123, 172 ASPIRIN ...... 7, 118 AEROCHAMBER Z-STAT ACCU-CHEK SMARTVIEW ADVAIR DISKUS ...... 222 PLUS-FLW SG .... 160, 173 CONTRL SOL ...... 123, 172 ADVAIR HFA ...... 222 AEROECLIPSE II ACCU-CHEK SOFT DEV ADVANCE PLUS NEBULIZER...... 157, 173 LANCETS ...... 123, 172 INTERMITTENT .. 168, 172 AEROGEAR ACTION ACCU-CHEK SOFTCLIX ADVANCED LANCING ASTHMA KIT ...... 158, 174 LANCETS ...... 123 DEVICE ...... 123 AERONEB GO ...... 160 Accutane ...... 70 ADVANCED TRAVEL AERONEB GO NEBULIZER LANCETS ...... 123, 172 ...... 157

227 AEROTRACH PLUS 160, 174 ALL FLOW 1000 PFT amitriptyline-chlordiazepoxide AEROVENT PLUS .. 160, 174 FILTER ...... 160 ...... 48 AFINITOR ...... 26 ALL FLOW 3000 KIT ...... 160 amlodipine ...... 38 AFINITOR DISPERZ ...... 26 ALL FLOW 3000 PFT amlodipine-atorvastatin ..... 37 Afirmelle ...... 60 FILTER ...... 160 amlodipine-benazepril ...... 32 AFTERA ...... 69 ALL FLOW 4000 KIT ...... 160 amlodipine-valsartan ...... 33 AGAMATRIX CONTROL ALL FLOW 4000 PFT amlodipine-valsartan- HIGH ...... 124, 174 FILTER ...... 160 hcthiazid ...... 33 AGAMATRIX CONTROL ALL FLOW 5000 KIT ...... 160 ammonium lactate ...... 76 NORM-HI ...... 124, 174 ALL FLOW 5000 PFT Amnesteem ...... 70 AGAMATRIX CONTROL FILTER ...... 160 amoxapine ...... 48 SOLN-LEVEL 2 ... 124, 174 ALL FLOW 6000 PFT amoxicil-clarithromy- AGAMATRIX CONTROL FILTER ...... 160 lansopraz ...... 113 SOLN-LEVEL 4 ... 124, 174 ALLER-CORT ...... 224 amoxicillin ...... 10 AIR TUBE WITH AIR PLUGS ALLER-FLO ...... 224 amoxicillin-pot clavulanate 10 ...... 160, 174 ALLERGY EYE ampicillin ...... 10 AIRS ADULT AEROSOL (KETOTIFEN) ...... 213 anagrelide ...... 118 MASK ...... 160, 174 ALLERGY RELIEF anastrozole ...... 24 AIRS DISPOSABLE (FLUTICASONE) ...... 224 ANGIOCATH AUTOGUARD NEBULIZER ...... 157, 174 allopurinol ...... 116 IV CATH ...... 156, 174 AIRZONE AND ALOCRIL ...... 216 ANORO ELLIPTA ...... 222 MINIWRIGHT AFS ..... 156, ALOMIDE ...... 216 ANTI-DANDRUFF ...... 75 174 ALORA ...... 101 ANTI-DANDRUFF WITH AIRZONE PEAK FLOW alosetron ...... 112 MENTHOL ...... 75 METER ...... 158, 174 ALPHAGAN P ...... 218 ANTI-EMBOLISM Ak-Poly-Bac ...... 216 alprazolam ...... 41, 42 STOCKINGS...... 157, 174 AKYNZEO (NETUPITANT) Altavera (28) ...... 60 ANTI-ITCH (HC) ...... 76 ...... 108 ALTERA NEBULIZER .... 157, ANTI-ITCH PLUS ...... 79 Ala-Cort ...... 76 174 ANTI- Ala-Scalp ...... 76 ALTERA NEBULIZER ITCH(HYDROCORTISON ALAWAY ...... 213 SYSTEM ...... 157, 174 E)-ALOE ...... 79 albendazole ...... 11 ALTERNATE SITE LANCET ANUCORT-HC ...... 9 albuterol sulfate ...... 221, 222 ...... 124, 174 APOGEE HC INTERMIT Alcaine ...... 216 ALTERNATE SITE LANCING CATHETER ...... 168 alclometasone ...... 76 DEVICE ...... 124, 174 APOGEE IC INTERMIT ALCOH-GLOVE ...... 30, 122 ALUNBRIG ...... 23 CATHETER ...... 168, 174 ALCOHOL PADS ...... 29 Alyacen 1/35 (28) ...... 60 apraclonidine ...... 218 ALCOHOL PREP PADS ... 29 Alyacen 7/7/7 (28) ...... 67 aprepitant ...... 108 alcohol swabs ...... 29 Alyq ...... 41 Apri ...... 60 ALCOHOL WIPES ...... 29 Amabelz ...... 101 APTIVUS ...... 21 ALCOH-WIPE ...... 30, 122 amantadine hcl ...... 50 AQUA CARE SODIUM ALECENSA ...... 23 Amethia ...... 59 CHLORIDE ...... 83 alendronate ...... 100 AMIELLE VAGINAL AQUA LANCE LANCING ALEVE ...... 6 TRAINER ...... 157 DEVICE ...... 124, 174 alfuzosin ...... 114 amiloride ...... 40 AQUANIL HC ...... 76 ALINIA ...... 12 amiloride-hydrochlorothiazide AQUAPHOR ITCH RELIEF ALIVE PRENATAL ...... 95 ...... 40 ...... 76 ALL DAY PAIN RELIEF ...... 6 aminocaproic acid ...... 118 Aranelle (28) ...... 67 ALL DAY RELIEF ...... 6 amiodarone ...... 34 ARANESP (IN ALL FLOW 1000 KIT ...... 160 amitriptyline ...... 48 POLYSORBATE) ...... 117

228 ARGYLE TROCAR . 168, 174 atropine ...... 213 BARD CATHETER STRAP aripiprazole...... 53 ATROVENT HFA ...... 221 ...... 157, 175 ARMOUR THYROID ...... 106 AUBAGIO ...... 211 BARD CLEAN-CATH ..... 168, ARNUITY ELLIPTA ...... 220 Aubra...... 60 175 ARTHRITIS PAIN Aubra Eq ...... 60 BARD COUDE TIP (DICLOFENAC) ...... 80 AURA PORTANEB . 157, 175 CATHETER ...... 168, 175 ARTIFICIAL TEARS Aurovela 1.5/30 (21) ...... 60 BARD FEMALE (POLYVIN ALC) ...... 212 Aurovela 1/20 (21) ...... 60 INTERMITTENT CATH ARTIFICIAL Aurovela 24 Fe ...... 60 ...... 168, 175 TEARS(GLYCERIN-PEG) Aurovela Fe 1.5/30 (28) ..... 60 BARD INFECT CONT TRAY- ...... 211 Aurovela Fe 1-20 (28) ...... 60 NO CATH ...... 168, 175 Ashlyna ...... 59 AURYXIA ...... 83, 114 BARD LUBRICATH FOLEY ASPERCREME AUTODROP ...... 157, 175 CATHETER ...... 168, 175 (LIDOCAINE) ...... 80 AUTO-LANCET MINI ..... 124, BARD LUBRICATH FOLEY ASPERFLEX ...... 80 175 TRAY ...... 168, 175 aspirin ...... 8 AUTOLET IMPRESSION BARD LUBRICATH FOLEY ASPIRIN CHILDRENS 8, 118 LANC DEV ...... 124 TRAY 18FR ...... 168, 175 ASPIRIN LOW DOSE ...... 8 AUTOLET LANCING BARD RUBBER UTILITY aspirin-dipyridamole ...... 118 DEVICE ...... 124 CATHETER ...... 168, 175 ASPIR-TRIN ...... 8, 119 AUTOLET PLUS LANCING BARD UNIVERSAL FOLEY ASSURE 4 CONTROL DEVICE ...... 124 CATH TRAY ...... 168 SOLUTION ...... 124 AUTOSQUEEZE ..... 157, 175 BARD URETHRAL ASSURE DOSE NORMAL AVASTIN ...... 22 CATHETER TRAY ...... 168, CONTROL ...... 124 AVEENO ANTI-ITCH 175 ASSURE DOSE NORM-HI (HYDROCORTSN) ...... 79 BARDEX ALL-SILICONE CONTROL ...... 124 Aviane ...... 60 FOLEY CATH ...... 168, 175 ASSURE HAEMOLANCE AVITA ...... 72 BARDEX CLOSED SYSTEM PLUS ...... 124 AVONEX ...... 210 CATH TRAY ...... 168, 175 ASSURE ID INSULIN Ayuna ...... 60 BARDEX LUBRICATH SAFETY...... 139, 174 AZASITE ...... 217 FOLEY CATH ...... 168, 175 ASSURE ID PEN NEEDLE azathioprine ...... 120 BARDEX URETHRAL ...... 139 azelaic acid ...... 70 CATHETERTRAY 168, 175 ASSURE LANCE ...... 124 azelastine ...... 213, 224 BARDIA RED RUBBER ASSURE LANCE PLUS .. 124 azithromycin ...... 19 CATHETER ...... 168, 175 ASSURE PRISM CONTROL AZO URINARY PAIN BD ALCOHOL SWABS ..... 29 1-2 SOLN...... 124 RELIEF ...... 115 BD ANGIOCATH IV ASTHMA CHECK METER Azurette (28) ...... 59 CATHETER ...... 156, 175 ...... 158, 175 B BD AUTOSHIELD DUO PEN ASTHMAPACK CHILDREN'S bacitracin ...... 217 NEEDLE ...... 139, 176 ...... 158, 175 bacitracin-polymyxin b ..... 216 BD ECLIPSE LUER-LOK 139, ASTRAZENECA COVID19 baclofen ...... 121 176 VAC(UNAPP) ...... 31 BALANCED B-50 ...... 82 BD INSULIN SYRINGE .. 139, ATABEX OB ...... 85 BAL-CARE DHA ...... 85 140, 176 atazanavir...... 21 BAL-CARE DHA ESSENTIAL BD INSULIN SYRINGE atenolol ...... 37 ...... 85 (HALF UNIT) ...... 139 atenolol-chlorthalidone ...... 39 balsalazide ...... 111 BD INSULIN SYRINGE atomoxetine...... 52 Balziva (28) ...... 61 MICRO-FINE ...... 139, 176 atorvastatin...... 36 BANOPHEN ...... 219 BD INSULIN SYRINGE atovaquone ...... 12 BANZEL ...... 46 SAFETY-LOK ...... 139, 176 atovaquone-proguanil ...... 12 BAQSIMI ...... 96

229 BD INSULIN SYRINGE SLIP BETA-HC ...... 76 BREEZE 2 CONTROL TIP ...... 139, 176 betamethasone dipropionate SOLUTION, LOW 125, 177 BD INSULIN SYRINGE U- ...... 76 BREEZE 2 CONTROL 500 ...... 140, 176 betamethasone valerate .... 76 SOLUTION, NML . 125, 177 BD INSULIN SYRINGE betamethasone, augmented BREEZE 2 CONTROL ULTRA-FINE ...... 140 ...... 76, 77 SOLUTION,HIGH 125, 177 BD INSYTE AUTOGUARD betaxolol ...... 37, 216 BREO ELLIPTA ...... 222 ...... 156, 176 bethanechol chloride ...... 116 Briellyn ...... 61 BD LO-DOSE MICRO-FINE bexarotene ...... 28 BRILINTA ...... 118 IV ...... 140, 176 bicalutamide ...... 23 brimonidine ...... 218 BD LO-DOSE ULTRA-FINE BIKTARVY ...... 15 bromfenac ...... 215 ...... 140, 176 bimatoprost ...... 218 bromocriptine ...... 49 BD MICROTAINER LANCET bisoprolol fumarate ...... 37 BROMSITE ...... 215 ...... 124, 176 bisoprolol- BUBBLES THE FISH PEDI BD NANO 2ND GEN PEN hydrochlorothiazide...... 39 MASK ...... 161, 177 NEEDLE ...... 140, 176 Bleph-10 ...... 217 budesonide ...... 111, 220, 224 BD SAFETYGLIDE INSULIN BLEPHAMIDE ...... 212 BULLSEYE MINI SAFETY SYRINGE ... 140, 141, 176, Blisovi 24 Fe ...... 61 LANCETS ...... 125 177 Blisovi Fe 1.5/30 (28) ...... 61 bumetanide ...... 40 BD SAFETYGLIDE Blisovi Fe 1/20 (28) ...... 61 buprenorphine ...... 3 SYRINGE ...... 141, 177 blood glucose contrl buprenorphine-naloxone ... 56 BD SAF-T-INTIMA .. 156, 177 hi,normal ...... 125, 177 bupropion hcl ...... 48 BD ULTRA FINE LANCETS blood glucose control, normal bupropion hcl (smoking ...... 125, 177 ...... 125 deter) ...... 56 BD ULTRA-FINE II blood glucose ctl BURN RELIEF WITH ALOE LANCETS ...... 125 high,nml,low ...... 125, 177 ...... 80 BD ULTRA-FINE MICRO BLUE-EMU LIDOCAINE buspirone ...... 42 PEN NEEDLE ...... 141, 177 PATCH ...... 80 butorphanol ...... 3 BD ULTRA-FINE MINI PEN BOOSTRIX TDAP ...... 31 BUTTERFLY TOUCH NEEDLE ...... 141 BOSULIF ...... 27 LANCET ...... 125, 177 BD ULTRA-FINE NANO PEN BP 10-1 ...... 71 BYSTOLIC ...... 37 NEEDLE ...... 141 BRAFTOVI ...... 24 C BD ULTRA-FINE ORIG PEN BRAINSTRONG PRENATAL cabergoline ...... 106 NEEDLE ...... 141 ...... 85 CABOMETYX ...... 26 BD ULTRA-FINE SHORT BREATHERITE MDI CADEAU DHA ...... 85 PEN NEEDLE ...... 141 SPACER ...... 160 caffeine citrate ...... 54 BD VEO INSULIN SYR BREATHERITE SPACER- calcipotriene ...... 75 (HALF UNIT) ...... 141 MASK, NEO...... 160 calcipotriene-betamethasone BD VEO INSULIN SYRINGE BREATHERITE SPACER- ...... 72 UF ...... 141 MASK,ADULT ...... 160 calcitonin (salmon) ...... 100 Bekyree (28)...... 59 BREATHERITE SPACER- calcitriol ...... 75, 95 belladonna alkaloids-opium MASK,CHILD ...... 160 calcium acetate ...... 83 ...... 111 BREATHERITE SPACER- calcium acetate(phosphat benazepril...... 32 MASK,INFANT ...... 160 bind) ...... 114 benazepril- BREATHERITE SPACER- CALCIUM PNV ...... 84 hydrochlorothiazide ...... 32 MASK,S.CHLD ...... 160 CALPHRON ...... 83 benzonatate ...... 219, 220 BREATHERITE VALVED CALQUENCE ...... 24, 27 benzoyl peroxide ...... 72 MDI CHAMBER ...... 160 Camila ...... 66 benztropine ...... 49 BREATHERITE VALVED CAMRESE ...... 59 BERINERT ...... 117 MDI SPACER ...... 161 CAMRESE LO ...... 59

230 candesartan ...... 33 CAYA CONTOURED ..... 122, ciclopirox ...... 73 candesartan- 178 cilostazol ...... 118 hydrochlorothiazid ...... 33 CAYSTON ...... 223 cimetidine ...... 109 capecitabine ...... 23 Caziant (28) ...... 67 cimetidine hcl ...... 109 CAPRELSA ...... 27 cefaclor ...... 16 CIMZIA ...... 3, 4, 111 captopril ...... 32 cefadroxil ...... 16 CIMZIA POWDER FOR captopril-hydrochlorothiazide cefdinir ...... 17 RECONST ...... 3, 4, 111 ...... 32 cefixime ...... 17 CIMZIA STARTER KIT ... 3, 4, carbamazepine ...... 44 cefpodoxime ...... 17 111 CARBATROL ...... 44, 52 cefprozil ...... 17 cinacalcet ...... 100 carbidopa ...... 49 cefuroxime axetil ...... 17 CIPRO ...... 17 carbidopa-levodopa ...... 49 celecoxib ...... 5 CIPRO XR ...... 17, 115 carbidopa-levodopa- CELONTIN ...... 46 ciprofloxacin ...... 17 entacapone ...... 49 cephalexin ...... 16 ciprofloxacin hcl . 17, 217, 218 carbinoxamine maleate ... 219 CERTAIN DRI ...... 74 ciprofloxacin-dexamethasone CAREFINE PEN NEEDLE cevimeline ...... 209 ...... 218 ...... 141, 177 CHANTIX ...... 57 citalopram ...... 46 CAREONE LANCING CHANTIX CONTINUING CITRANATAL (DUAL-IRON) DEVICE ...... 125, 177 MONTH BOX ...... 57 ...... 85 CAREONE THIN LANCET CHANTIX STARTING CITRANATAL 90 DHA ...... 125, 178 MONTH BOX ...... 57 (ALGAL OIL) ...... 85 CAREONE ULTRA THIN Chateal (28) ...... 61 CITRANATAL ASSURE .... 85 LANCET ...... 125 Chateal Eq (28) ...... 61 CITRANATAL DHA (ALGAL CARESENS CONTROL A CHEK-STIX CONTROL.... 81, OIL) ...... 85 AND B ...... 125, 178 171, 178 CITRANATAL HARMONY CARESENS CONTROL A CHEMET ...... 9 (IRON FUM)...... 85 NORMAL ...... 125, 178 CHEMSTRIP 10 MD.. 81, 178 Claravis ...... 70 CARESENS LANCETS .. 125, CHEMSTRIP 10/SG .. 81, 178 CLARISPRAY ...... 224 178 CHEMSTRIP 2 GP .... 81, 178 clarithromycin ...... 19 CARETOUCH ALCOHOL CHEMSTRIP 50B ...... 81, 178 CLEANSING WASH .... 71, 80 PREP PAD ...... 29 CHEMSTRIP 7 ...... 81, 178 CLEAR ADVANTAGE ..... 168 CARETOUCH INSULIN CHEMSTRIP 9 ...... 81, 178 CLEVER CHEK LANCETS SYRINGE ...... 141, 178 CHILDREN'S ALAWAY ... 213 ...... 125 CARETOUCH LANCING CHILDREN'S ASPIRIN ...... 8 CLEVER CHOICE DEVICE ...... 125, 178 CHILDREN'S FLONASE CHAMBER-LRG MASK161 CARETOUCH PEN NEEDLE SENSIMIST ...... 224 CLEVER CHOICE ...... 142, 178 CHILDREN'S IBUPROFEN . 6 CHAMBER-MED MASK CARETOUCH SAFETY CHILDREN'S IRON ...... 83 ...... 161 LANCETS ...... 125, 178 CHILDREN'S PROFEN IB... 6 CLEVER CHOICE CARETOUCH TWIST chlordiazepoxide hcl ...... 42 CHAMBER-SM MASK . 161 LANCET ...... 125, 178 chlorhexidine gluconate... 209 CLEVER CHOICE LEVEL 1 carisoprodol...... 121 chloroquine phosphate ...... 12 CONTROL ...... 125, 179 carisoprodol-aspirin ...... 121 chlorpromazine ...... 51 CLEVER CHOICE LEVEL 2 carisoprodol-aspirin-codeine chlorthalidone ...... 40 CONTROL ...... 125, 179 ...... 121 CHOICE DM CLARUS CLEVER CHOICE LEVEL 3 carteolol ...... 216 NORM CONTROL 125, 178 CONTROL ...... 125, 179 Cartia Xt ...... 37 cholecalciferol (vitamin d3) 95 CLEVER CHOICE carvedilol ...... 33 cholestyramine (with sugar) NEBULIZER...... 161, 179 CATH-SECURE TUBE ...... 35 CLEVER CHOICE PEAK HOLDER...... 138, 178 Cholestyramine Light...... 35 FLOW METER ..... 158, 179

231 CLEVER CHOICE WHISPER COMFORT TOUCH ULT CORTIZONE-10 WITH ALOE AIRE PED ...... 161, 179 THIN LANCETS ... 126, 179 ...... 79 CLICKFINE PEN NEEDLE COMPACT COMPRESSOR COSENTYX ...... 72 ...... 142 NEBULIZER ...... 157, 179 COSENTYX (2 SYRINGES) clindamycin hcl ...... 19 COMPACT SPACE ...... 72 Clindamycin Pediatric ...... 19 CHAMBER ...... 161, 180 COSENTYX PEN ...... 72 clindamycin phosphate ..... 70, COMPACT SPACE COSENTYX PEN (2 PENS) 226 CHAMBER PLUS 161, 180 ...... 72 clindamycin-benzoyl peroxide COMPACT SPACE COTELLIC ...... 26 ...... 71 CHAMBER-LRG MASK161 CREON ...... 108 clindamycin-tretinoin ...... 71 COMPACT SPACE cromolyn ...... 26, 216, 220 CLINPRO 5000 ...... 208 CHAMBER-MED MASK Cryselle (28) ...... 61 clobazam ...... 42 ...... 161 CURITY 8000 URINE MTR clobetasol ...... 77 COMPACT SPACE FLY TRAY ...... 169, 180 clobetasol-emollient ...... 77 CHAMBER-SM MASK . 161 CURITY ALCOHOL SWABS clomipramine ...... 48 COMPACT ULTRASONIC ...... 29 clonazepam ...... 42 NEBULIZER ...... 157, 180 CURITY BEDSIDE clonidine ...... 39 COMP-AIR NEBULIZER DRAINAGE SET .. 169, 180 clonidine hcl ...... 39 COMPRESSOR ... 161, 180 CURITY BEDSIDE-MONO- clopidogrel ...... 119 COMPETE ...... 84 FLO DRANGE ..... 169, 180 clorazepate dipotassium ... 42 COMPLERA ...... 16 CURITY FOLEY CATHETER clotrimazole ...... 209 COMPLETE ...... 83 KIT ...... 169 clotrimazole-betamethasone COMPLETE NATAL DHA . 86 CURITY PREMIUM ...... 74 COMPLETENATE ...... 86 CATHETER TRAY ...... 169 clozapine ...... 50 Compro ...... 107 CURITY STRMLIN CATH - C-NATE DHA ...... 85 Constulose ...... 112 MONO-FLO ...... 169, 180 COAGUCHEK LANCETS CONTOUR CONTROL CURITY ULTRAMER 2-W ...... 126, 179 SOLUTION, HIGH 126, 180 CATH LAT/T ...... 169, 180 COARTEM ...... 12 CONTOUR CONTROL CURITY ULTRAMER 2-W codeine sulfate ...... 1 SOLUTION, LOW 126, 180 CATH TEFLN...... 169, 180 codeine-guaifenesin ...... 225 CONTOUR CONTROL CURITY ULTRAMER 2-WAY colchicine ...... 116 SOLUTION, NML . 126, 180 CATHETER ...... 169, 180 colesevelam ...... 35 CONTOUR NEXT LEV 1 CURITY ULTRAMER IRRG COLESTID FLAVORED .... 35 CONTROL SOL ... 126, 180 3WAY CATH ...... 169, 180 colestipol ...... 35 CONTOUR NEXT LEV 2 CURITY ULTRAMER COLOR LANCETS .. 126, 179 CONTROL SOL ... 126, 180 URETHRAL CATH ...... 169, COMBIPATCH ...... 101 COOL CONTROL A 180 COMBISTIX REAGENT ... 81, SOLUTION ...... 126, 180 CURITY UNIVERSAL - NO 179 COOL CONTROL B DRAINAGE ...... 169, 181 COMBIVENT RESPIMAT 222 SOLUTION ...... 126, 180 CURITY URETH CATH COMFORT EZ INSULIN COOL MIST HUMIDIFIER CLOSED SYSTM ...... 169 SYRINGE ...... 142, 179 ...... 138 CURITY URETH CATH COMFORT EZ LANCETS 126 CORLANOR ...... 41 OPEN SYSTEM ...... 169 COMFORT EZ PEN CORTAID ...... 77 CURITY URETHRAL NEEDLES ...... 142, 179 CORTISONE CATHETER ...... 169, 181 COMFORT LANCETS .... 126 (HYDROCORTISONE) .. 77 cyanocobalamin (vitamin b- COMFORT TOUCH PEN CORTISONE WITH ALOE 79 12) ...... 95 NEEDLE ...... 142, 179 CORTISPORIN-TC ...... 218 Cyclafem 1/35 (28) ...... 61 COMFORT TOUCH PLUS CORTIZONE-10 ...... 77 Cyclafem 7/7/7 (28) ...... 67 SAFETY LANC .... 126, 179 CORTIZONE-10 PLUS ...... 77 cyclobenzaprine ...... 121

232 CYCLOMYDRIL ...... 212 DERMACINRX PRENATRIX DIFICID ...... 19 cyclopentolate ...... 213 ...... 86 diflorasone ...... 77 cyclophosphamide ...... 22 DERMACINRX PRENATRYL diflunisal ...... 8 cyclosporine ...... 5, 119, 120 ...... 86 Digitek ...... 39 cyclosporine modified ...... 119 DERMAREST ECZEMA Digox ...... 39 cyproheptadine ...... 219 (HYDROCORT) ...... 77 digoxin ...... 39, 40 Cyred ...... 61 DESCOVY ...... 14 dihydroergotamine ...... 54 Cyred Eq ...... 61 desipramine ...... 48 DILANTIN ...... 44 D desmopressin ...... 96, 97 Dilantin Extended ...... 43 dalfampridine ...... 210 desog-e.estradiol/e.estradiol Dilantin Infatabs...... 43 danazol ...... 102 ...... 59 DILANTIN-125 ...... 44 DANDRUFF SHAMPOO desogestrel-ethinyl estradiol diltiazem hcl ...... 37, 38 (SELEN-ALOE) ...... 75 ...... 61 DILT-XR ...... 38 DANDRUFF SHAMPOO desoximetasone ...... 77 dimethyl fumarate ...... 210 (SELENIUM) ...... 75 DEVILBISS DISPOSABLE diphenhydramine hcl ...... 219 DANDRUFF SHAMPOO- NEBULIZER ...... 157, 181 diphenoxylate-atropine .... 107 MENTHOL ...... 75 DEVILBISS PULMO-AIDE dipyridamole ...... 119 dantrolene ...... 121 COMPRESSR ..... 161, 181 disopyramide phosphate ... 34 dapsone ...... 12 DEVILBISS PULMOMATE DISPOSABLE PAPER Dasetta 1/35 (28) ...... 61 COMPRESSOR ... 161, 181 MOUTHPIECE ...... 157 Dasetta 7/7/7 (28) ...... 67 DEVILBISS PULMONEB LT disulfiram ...... 56 DAVOL C.S. FOLEY COMP-NEB ...... 161, 181 DIURIL ...... 40 CATHETER TRAY ...... 169, DEVILBISS TRAVELER divalproex ...... 43 181 COMPRESSOR ...... 161 dofetilide ...... 35 DAVOL COMPLETE FOLEY dexamethasone ...... 102 donepezil ...... 58 ...... 169 DEXAMETHASONE dorzolamide ...... 215 DAVOL FOLEY CATH INTENSOL ...... 102 dorzolamide-timolol ...... 215 INSERT TRAY ...... 169 dexamethasone sodium Dotti ...... 101 DAVOL SILICONE FOLEY phosphate ...... 214 DOVATO ...... 13 CATHETER ...... 169, 181 dexmethylphenidate ...... 51 DOVER CATHETER 170, 181 DAVOL UNIVERSAL CATH dextroamphetamine ...... 54 DOVER FOLEY CATHETER TRAY ...... 169 dextroamphetamine- ...... 170, 181 DAVOL URETHRAL amphetamine ...... 53 DOVER LATEX FOLEY CATHETER TRAY ...... 170, DIACOMIT ...... 46 CATHETER ...... 170, 181 181 DIASTIX ...... 171 DOVER RED RUBBER DAVOL URETHRAL DIATRUE CONTROL SOLN ROBINSON CATH ...... 170, CATHTRAY (W/O) ...... 170, NORMAL ...... 126, 181 181 181 DIATRUE CONTROL DOVER TEXAS MALE Daysee ...... 59 SOLUTION HIGH 126, 181 EXTERNAL CATH ...... 170 DDAVP ...... 96 DIATRUE CONTROL DOVER UNIVERSAL ..... 170, Deblitane ...... 66 SOLUTION LOW . 126, 181 181 Decadron ...... 102 diazepam ...... 42, 52 DOVER URI-DRAIN MALE deferasirox ...... 9 Diazepam Intensol ...... 42, 52 EXT CATH ...... 170 demeclocycline ...... 21 diclofenac potassium ...... 6 doxazosin ...... 41 DENAVIR ...... 75 diclofenac sodium .. 6, 74, 80, doxepin ...... 48 DENTA 5000 PLUS ...... 208 215 doxercalciferol ...... 208 DENTAGEL ...... 208 diclofenac-misoprostol...... 5 doxycycline hyclate ... 21, 209 DEPO-SUBQ PROVERA 104 dicloxacillin ...... 20 doxycycline monohydrate .. 21 ...... 58 dicyclomine ...... 110 DRAMAMINE LESS didanosine ...... 14 DROWSY ...... 107

233 dronabinol ...... 107 EASY GLIDE INSULIN EASY TOUCH DROPLET INSULIN SYRINGE ...... 143, 182 SHEATHLOCK INSULIN SYR(HALF UNIT) 142, 181 EASY GLIDE PEN NEEDLE ...... 144, 184 DROPLET INSULIN ...... 143, 183 EASY TOUCH TWIST SYRINGE ... 142, 143, 181, EASY MINI EJECT LANCETS ...... 127, 184 182 LANCING DEVICE ..... 126, EASY TOUCH UNI-SLIP . 145 DROPLET LANCETS ...... 126 183 EASY TRAK HIGH DROPLET LANCING EASY NEB COMPRESSOR CONTROL ...... 127, 184 DEVICE ...... 126, 182 NEBULIZER ...... 162, 183 EASY TRAK II CTRL SOLN- DROPLET MICRON PEN EASY PLUS II HIGH NORMAL ...... 127, 184 NEEDLE ...... 143, 182 CONTROL ...... 126, 183 EASY TRAK LOW DROPLET PEN NEEDLE EASY PLUS II LOW CONTROL ...... 127, 184 ...... 143, 182 CONTROL ...... 126, 183 EASY TWIST AND CAP DROPSAFE PEN NEEDLE EASY STEP HIGH LANCETS ...... 127, 184 ...... 143, 182 CONTROL SOLN 127, 183 EASYAIR COMPRESSOR drospirenone-e.estradiol- EASY STEP LOW NEBULIZER...... 162, 184 lm.fa ...... 61 CONTROL SOLUTION EASYGLUCO PLUS drospirenone-ethinyl estradiol ...... 127, 183 NORMAL CONTROL .. 127, ...... 61 EASY STEP NORMAL 184 DROXIA ...... 119 CONTROL SOLN 127, 183 EASYMAX 15 LEVEL 1 .. 127, DRYSOL ...... 74 EASY TALK HIGH 184 DRYSOL DAB-O-MATIC ... 74 CONTROL ...... 127, 183 EASYMAX 15 LEVEL 2 .. 127, DUAVEE ...... 101 EASY TALK LOW CONTROL 184 DUET DHA BALANCED ... 86 ...... 127, 183 EASYMAX LOW CONTROL DUET DHA WITH OMEGA-3 EASY TOUCH ...... 144 ...... 127 ...... 86 EASY TOUCH ALCOHOL EASYMAX NORMAL duloxetine ...... 47 PREP PADS ...... 29 CONTROL ...... 128 DUPIXENT PEN ...... 73 EASY TOUCH BLU CTRL EBASE CONTROLLER .. 162, DUPIXENT SYRINGE ...... 73 SOLN-L1,L3 ...... 127, 183 184 dutasteride ...... 114 EASY TOUCH FLIPLOCK EC-NAPROXEN ...... 6 dutasteride-tamsulosin .... 113 INSULIN ...... 144, 183 econazole ...... 73 DUTOPROL ...... 39 EASY TOUCH HIGH-LOW ECONTRA EZ ...... 69 E CONTROL ...... 127 ECONTRA ONE-STEP ..... 69 E.E.S. 400 ...... 19 EASY TOUCH INSULIN ECOTRIN ...... 8 EASIVENT HOLDING SAFETY SYR ...... 144, 183 ED-SPAZ ...... 110, 115 CHAMBER ...... 161 EASY TOUCH INSULIN EDURANT ...... 14 EASIVENT MASK LARGE SYRINGE ...... 144 efavirenz ...... 14 ...... 161, 182 EASY TOUCH LANCETS efavirenz-emtricitabin-tenofov EASIVENT MASK MEDIUM ...... 127, 183 ...... 16 ...... 162, 182 EASY TOUCH LANCING EFFACLAR ADAPALENE . 72 EASIVENT MASK SMALL DEVICE ...... 127, 183 EFFER-K ...... 83 ...... 162, 182 EASY TOUCH LUER LOCK ELEMENT COMPACT HIGH EASY COMFORT ALCOHOL INSULIN ...... 144, 183 CONTROL ...... 128, 184 PAD ...... 29 EASY TOUCH PEN NEEDLE ELEMENT COMPACT EASY COMFORT INSULIN ...... 144, 183 NORMAL CONTROL .. 128, SYRINGE ...... 143, 182 EASY TOUCH SAFETY 184 EASY COMFORT LANCETS LANCETS ...... 127, 184 ELEMENT HIGH CONTROL ...... 126 EASY TOUCH SAFETY PEN ...... 128, 184 EASY COMFORT PEN NEEDLE ...... 144, 184 ELEMENT LOW CONTROL NEEDLES ...... 143, 182 ...... 128, 184

234 ELEMENT NORMAL EPIVIR HBV ...... 18 everolimus CONTROL ...... 128, 185 eplerenone ...... 32 (immunosuppressive) .. 120 Elinest ...... 61 EPOGEN ...... 117 EVOLUTION NORMAL ELIQUIS ...... 117 EQUETRO ...... 44, 52 CONTROL ...... 128, 185 ELIQUIS DVT-PE TREAT ergocalciferol (vitamin d2) . 95 EVOTAZ ...... 15, 21 30D START ...... 117 ergoloid ...... 58 EXEL INSULIN ...... 145 Elixophyllin ...... 220 ERGOMAR ...... 54 exemestane ...... 24 ELLA ...... 69 ERIVEDGE ...... 25 EXPECTA PRENATAL ...... 86 ELMIRON ...... 114 erlotinib ...... 22 EXPIRATORY Eluryng ...... 69 Errin...... 66 MOUTHPIECE ..... 162, 185 EMBRACE EVO LEVEL 1 ERY PADS ...... 70 EXTAVIA ...... 210 ...... 128, 185 Ery-Tab ...... 20 external catheter, male ... 170, EMBRACE GLUCOSE Erythrocin (As Stearate) .... 20 185 CONTROL HIGH . 128, 185 erythromycin ...... 20, 217 EXTRA-VIRT PLUS DHA .. 86 EMBRACE GLUCOSE erythromycin ethylsuccinate EYE ALLERGY ITCH CONTROL LOW .. 128, 185 ...... 20 RELIEF ...... 214 EMBRACE LANCETS .... 128, erythromycin with ethanol .. 70 EYE ALLERGY ITCH- 185 erythromycin-benzoyl REDNESS RLF ...... 214 EMBRACE PRO ...... 128, 185 peroxide ...... 71 EYE ITCH RELIEF ...... 214 EMBRACE TALK ESBRIET ...... 226 E-Z JECT LANCETS 129, 185 CONTROL-HIGH (L2) 128, escitalopram oxalate ...... 46 E-Z JECT THIN LANCETS 185 Estarylla ...... 62 ...... 129 EMBRACE TALK estazolam ...... 56 EZ SMART CONTROL .... 129 CONTROL-LOW (L1) . 128, estradiol ...... 101, 102, 226 EZ SMART LANCETS .... 129, 185 estradiol-norethindrone acet 185 EMCYT ...... 25 ...... 101 ezetimibe ...... 36 Emoquette ...... 61 ESTRING ...... 226 EZ-LETS ...... 129, 185 emtricitabine ...... 14 eszopiclone ...... 56 F emtricitabine-tenofovir (tdf) 14 ethacrynic acid ...... 40 FACE SPLASH SHIELD, EMTRIVA ...... 14 ethambutol ...... 16 FULL ...... 157, 185 enalapril maleate ...... 32 ethosuximide ...... 46 FACE SPLASH SHIELD, enalapril-hydrochlorothiazide ethynodiol diac-eth estradiol SHORT ...... 157, 185 ...... 32 ...... 62 FACTIVE ...... 17 ENBREL ...... 4 etidronate disodium ...... 100 Falmina (28) ...... 62 ENBREL SURECLICK ...... 4 etodolac ...... 7 famciclovir ...... 19 Endocet ...... 3 etonogestrel-ethinyl estradiol famotidine ...... 109 ENGERIX-B (PF) ...... 30 ...... 69 FARXIGA ...... 98 enoxaparin ...... 118 etoposide ...... 25 FARYDAK ...... 25 Enpresse ...... 67 EURAX ...... 81 FC2 FEMALE CONDOM 122, Enskyce ...... 61 EUTHYROX ...... 106 185 entacapone ...... 49 EVENCARE ...... 128, 185 febuxostat ...... 116 entecavir ...... 18 EVENCARE G2 ...... 128 felbamate ...... 42, 43 ENTRESTO...... 33 EVENCARE G3 CONTROL FELBATOL ...... 43 Enulose ...... 108 ...... 128 felodipine ...... 38 EPANED ...... 32 EVENCARE MINI GLUCOSE FEMALE CATHETER ..... 170, EPCLUSA ...... 18 CONTROL ...... 128, 185 185 EPIFOAM ...... 79 EVENCARE PROVIEW FEMALE SPECIMEN epinastine ...... 213 CONTROL-L2,L3 . 128, 185 CATHETER ...... 170, 185 epinephrine ...... 39 everolimus (antineoplastic) 26 FEMCAP ...... 122, 186 Epitol ...... 44, 52 Femynor ...... 62

235 fenofibrate ...... 35 flurazepam ...... 52, 56 FREESTYLE LITE METER fenofibrate micronized ...... 35 flurbiprofen ...... 6 ...... 130, 187 fenofibrate nanocrystallized flurbiprofen sodium ...... 215 FREESTYLE LITE STRIPS ...... 35 flutamide ...... 23 ...... 121 fenofibric acid (choline) ..... 35 fluticasone propionate 78, 225 FREESTYLE PRECISION fentanyl ...... 1 fluvastatin ...... 36 ...... 145, 187 fentanyl citrate ...... 1 fluvoxamine ...... 47 FREESTYLE PRECISION FENTORA ...... 1 FLYP NEBULIZER ...... 157 NEO STRIPS ...... 121 ferrous sulfate ...... 83 FOLET ONE ...... 84, 86 FREESTYLE TEST ...... 121 FETZIMA ...... 47 FOLEY CATHETER 170, 186 FREESTYLE UNISTIK 2 130, FIFTY50 SAFETY SEAL FOLEY CATHETER TRAY 187 LANCETS ...... 129 ...... 170, 186 furosemide ...... 40 FILTERED MOUTHPIECE folic acid ...... 96 FUZEON ...... 13 ATTACHMENT .... 157, 186 fondaparinux ...... 118 Fyavolv ...... 101 finasteride...... 114 FORA HIGH CONTROL . 129, G FINE 30 UNIVERSAL 186 G TUSSIN AC ...... 225 LANCETS ...... 129 FORA LANCING DEVICE 129 gabapentin ...... 43 FINGERSTIX LANCETS 129, FORA LOW CONTROL.. 129, GABITRIL ...... 43 186 186 galantamine ...... 58 FLANAX (NAPROXEN) ...... 6 FORA NORMAL CONTROL GALZIN ...... 9 flecainide ...... 34 ...... 129 gatifloxacin ...... 217 FLEXICHAMBER .... 162, 186 FORACARE GDH HIGH GAVILYTE-C ...... 112 FLEXICHAMBER-LG CHILD CONTROL ...... 129, 186 Gavilyte-G ...... 113 MASK ...... 162, 186 FORACARE GDH LOW Gavilyte-N ...... 113 FLEXICHAMBER-SM ADULT CONTROL ...... 129, 186 GE100 CONTROL MASK ...... 162, 186 FORACARE GDH NORMAL SOLUTION NORMAL .. 130 FLEXICHAMBER-SM CHILD CONTROL ...... 129, 186 GE333 CONTROL MASK ...... 162, 186 FORACARE LANCETS .. 129, SOLUTION NORMAL . 130, FLONASE SENSIMIST ... 224 186 187 FLOVENT DISKUS ...... 220 FORTEO ...... 100 gemfibrozil ...... 35 FLOVENT HFA ...... 220 FORTISCARE HIGH 129, 186 Generlac ...... 108 fluconazole ...... 11 FORTISCARE LOW 129, 186 Gengraf ...... 5, 120 flucytosine ...... 11 FORTISCARE NORMAL 129, Gentak ...... 217 fludrocortisone ...... 105 186 gentamicin ...... 73, 217 flunisolide ...... 224 fosamprenavir ...... 21 GENTEAL TEARS fluocinolone ...... 77 fosinopril ...... 32 MODERATE (PF) ...... 211 fluocinolone acetonide oil 219 fosinopril-hydrochlorothiazide GENTLECATH ...... 170, 187 fluocinolone and shower cap ...... 32 GENVOYA ...... 15 ...... 77 FOSRENOL ...... 114 GILENYA ...... 211 fluocinonide ...... 77, 78 FREEDOM CATH ...... 170 GIZMO ...... 170 Fluocinonide-E ...... 78 FREESTYLE CONTROL . 129 glatiramer ...... 210 fluocinonide-emollient ...... 78 FREESTYLE FREEDOM Glatopa ...... 210 fluoride (sodium) ...... 208 LITE ...... 129, 186 GLEOSTINE ...... 22 FLUORIDEX DAILY FREESTYLE INSULINX . 121, glimepiride ...... 98 DEFENSE ...... 208 129, 186 glipizide ...... 98 fluorometholone ...... 214 FREESTYLE INSULINX glipizide-metformin ...... 98 FLUOROPLEX ...... 74 TEST STRIPS ..... 121, 186 Glucagon Emergency Kit fluorouracil...... 74 FREESTYLE LANCETS . 129, (Human) ...... 96 fluoxetine ...... 46, 47 186 GLUCOCARD 01 HI- fluphenazine hcl ...... 51 NORMAL CONTROL ... 130

236 GLUCOCARD 01 NORMAL HEALTHY ACCENTS HUMULIN R REGULAR U- CONTROL ...... 130 UNIFINE PENTIP 145, 188 100 INSULN...... 103 GLUCOCARD EXPRESSION HEALTHY ACCENTS HUMULIN R U-500 (CONC) ...... 130 UNILET LANCET ...... 130 INSULIN ...... 103 GLUCOCARD SHINE ..... 130 HEARTBURN PREVENTION HUMULIN R U-500 (CONC) GLUCOCOM CONTROL ...... 109 KWIKPEN ...... 104 HIGH ...... 130, 187 HEARTBURN RELIEF HYCAMTIN ...... 28 GLUCOCOM CONTROL (CIMETIDINE) ...... 109 hydralazine ...... 40 NORMAL ...... 130, 187 HEARTBURN RELIEF hydrochlorothiazide ...... 40 GLUCOCOM LANCETS 130, (FAMOTIDINE) ...... 109 hydrocodone-acetaminophen 187 Heather ...... 66 ...... 2 GLUCOSE CONTROL .... 130 HEMA-COMBISTIX ... 81, 188 hydrocodone- GLUCOSE KETONE HIZENTRA ...... 30 chlorpheniramine ...... 225 CONTROL SOLN ...... 130 HOMATROPAIRE ...... 213 hydrocodone-homatropine glyburide ...... 98 HOME NEBULIZER PLUS ...... 225 glyburide micronized ...... 98 SIDESTREAM ...... 162 hydrocodone-ibuprofen ...... 2 glyburide-metformin ...... 98 HUMALOG KWIKPEN hydrocortisone ...... 9, 78, 102, glycopyrrolate ...... 110 INSULIN ...... 105 111 Glydo ...... 80 HUMALOG MIX 50-50 hydrocortisone acetate .. 9, 78 GOJJI GLUCOSE CNTRL INSULN U-100 ...... 104 HYDROCORTISONE PLUS SOL-NORMAL ..... 130, 187 HUMALOG MIX 50-50 ...... 78 GOJJI LANCETS .... 130, 187 KWIKPEN ...... 104 hydrocortisone-acetic acid granisetron hcl ...... 108 HUMALOG MIX 75-25(U- ...... 219 griseofulvin microsize ...... 12 100)INSULN ...... 104 hydrocortisone-aloe vera ... 79 griseofulvin ultramicrosize . 12 HUMALOG U-100 INSULIN HYDROCREAM ...... 78 GUAIATUSSIN AC ...... 226 ...... 105 Hydromet ...... 225 GUAIFENESIN AC ...... 226 humidifiers ...... 138 hydromorphone ...... 1 guanfacine...... 39, 51 HUMIRA ...... 3, 4, 112 hydroxychloroquine ...... 12 GYNOL II...... 69 HUMIRA PEN ...... 112 hydroxyurea ...... 23 H HUMIRA PEN CROHNS-UC- hydroxyzine hcl...... 41 Hailey ...... 62 HS START ...... 3, 4, 112 hydroxyzine pamoate ...... 41 Hailey 24 Fe ...... 62 HUMIRA PEN PSOR- hyoscyamine sulfate ...... 110 Hailey Fe 1.5/30 (28) ...... 62 UVEITS-ADOL HS ...... 3, 4, HYOSYNE ...... 110, 115 Hailey Fe 1/20 (28) ...... 62 112 HYPER-SAL ...... 57 HAIR,SKIN AND NAILS .... 84 HUMIRA(CF) ...... 4, 5, 112 HYPERSONIQ NEBULIZER halobetasol propionate ...... 78 HUMIRA(CF) PEDI CROHNS CARTRIDGE...... 162, 188 haloperidol...... 51 STARTER ...... 3, 4, 112 HYPOLANCE AST LANCING haloperidol lactate ...... 51 HUMIRA(CF) PEN ...... 112 ...... 130, 188 HARMONY CONTROL L1,L3 HUMIRA(CF) PEN HYSINGLA ER ...... 1 ...... 130, 187 CROHNS-UC-HS..... 4, 112 I HARVONI ...... 18 HUMIRA(CF) PEN PSOR- ibandronate ...... 100 HEALTHMIST ...... 138, 187 UV-ADOL HS ...... 4, 5, 112 IBRANCE ...... 24 HEALTHPRO HIGH-LOW HUMULIN 70/30 U-100 Ibu ...... 6 CONTROL ...... 130 INSULIN ...... 103 ibuprofen ...... 6, 7 HEALTHWISE INSULIN HUMULIN 70/30 U-100 Iclevia ...... 62 SYRINGE ...... 145, 187 KWIKPEN ...... 103 icosapent ethyl ...... 36 HEALTHWISE PEN NEEDLE HUMULIN N NPH INSULIN IDHIFA ...... 27 ...... 145, 187 KWIKPEN ...... 103 ILEVRO ...... 215 HEALTHY ACCENTS HUMULIN N NPH U-100 imatinib ...... 27 AUTOLET ...... 130, 187 INSULIN ...... 103 IMBRUVICA ...... 24, 27, 28

237 imipramine hcl ...... 48 INNOSPIRE GO ITCHY EYE DROPS ...... 214 imipramine pamoate ...... 48 NEBULIZER ...... 157, 188 itraconazole ...... 11 imiquimod ...... 79 INNOSPIRE MINI ...... 162 IV PREP WIPES...... 29 INCARE INVIEW INNOSPIRE ivermectin ...... 11 CATHETER ...... 170 REPLACEMENT FILTER J Incassia ...... 66 ...... 162, 188 Jaimiess ...... 59 IN-CHECK DIAL TRAINING INSPIRACHAMBER 162, 188 JAKAFI ...... 25 DEVICE ...... 162, 188 INSPIRACHAMBER WITH JANSSEN COVID-19 IN-CHECK NASAL WITH MASK-LARGE ..... 162, 188 VACCINE (EUA) ...... 31 MASK ...... 158, 188 INSPIRACHAMBER WITH Jantoven ...... 116 IN-CHECK ORAL FLOW MASK-MED ...... 163, 189 JANUMET ...... 99 METER ...... 158, 188 INSPIRACHAMBER WITH JANUMET XR ...... 100 INCONTROL ALCOHOL MASK-SMALL ..... 163, 189 JANUVIA ...... 97 PADS ...... 29 INSPIRATION ELITE FILTER JARDIANCE ...... 98 INCONTROL LANCING ...... 163, 189 Jasmiel (28) ...... 62 DEVICE ...... 130, 188 insulin syr/ndl u100 half mark Jencycla ...... 66 INCONTROL PEN NEEDLE ...... 145, 189 Jinteli ...... 101 ...... 145, 188 INSULIN SYRINGE . 146, 189 JOLESSA ...... 62 INCONTROL SUPER THIN INSULIN SYRINGE Juleber ...... 62 LANCETS ...... 131, 188 MICROFINE 145, 146, 189 JULUCA ...... 13 INCONTROL ULTRA THIN insulin syringe needleless Junel 1.5/30 (21) ...... 62 LANCETS ...... 131, 188 ...... 146, 189 Junel 1/20 (21) ...... 62 INCRELEX ...... 105 insulin syringe-needle u-100 Junel Fe 1.5/30 (28) ...... 62 INCRUSE ELLIPTA ...... 221 ...... 146, 189 Junel Fe 1/20 (28) ...... 62 indapamide...... 41 INSUPEN ...... 146, 189 Junel Fe 24 ...... 63 INDERAL XL ...... 37 INSYTE IV CATHETER .. 156, K INDOCIN ...... 7 189 Kaitlib Fe ...... 63 indomethacin ...... 7 INTELENCE ...... 14 KALETRA ...... 15 INFANT'S ADVIL ...... 7 INTELLIGENT MESH Kalliga ...... 63 INFANT'S IBUPROFEN ...... 7 NEBULIZER ...... 158, 189 KALYDECO ...... 223 INFANT'S MOTRIN ...... 7 INTRON A ...... 25 Kariva (28) ...... 59 INFANTS PROFENIB ...... 7 INTROSYTE AUTOGUARD Kelnor 1/35 (28)...... 63 INFINITY CONTROL ...... 156, 189 Kelnor 1-50 (28) ...... 63 SOLUTION HIGH 131, 188 INVACARE LANCETS ... 131, KENGUARD FOLEY INFINITY CONTROL 189 CATHETER ...... 170, 189 SOLUTION LOW . 131, 188 INVIRASE ...... 21 KENLINE ADD-A-FOLEY INFINITY CONTROL ipratropium bromide 221, 224 TRAY 30CC ...... 170, 189 SOLUTION NORM ..... 131, ipratropium-albuterol ...... 222 ketoconazole ...... 11, 73 188 irbesartan ...... 33 KETO-DIASTIX ...... 171 INFINITY VOICE CTRL irbesartan- KETONE CARE...... 171, 189 SOLN-LVL 2 ...... 131, 188 hydrochlorothiazide...... 33 KETONE URINE TEST ... 189 INJECT EASE LANCETS IRESSA ...... 22 ketorolac ...... 6, 215 ...... 131, 188 ISENTRESS ...... 13 KETOSTIX ...... 189 INLYTA ...... 28 ISENTRESS HD ...... 13 ketotifen fumarate...... 214 INNOPRAN XL ...... 37 Isibloom ...... 62 KINERET ...... 5 INNOSPIRE DELUXE .... 162, isoniazid ...... 16 KISQALI ...... 24, 25 188 isosorbide dinitrate ...... 33 KISQALI FEMARA CO-PACK INNOSPIRE ELEGANCE 162 isosorbide mononitrate ...... 34 ...... 26 INNOSPIRE ESSENCE .. 162 isotretinoin ...... 70 Klor-Con M10 ...... 83 isradipine ...... 38 Klor-Con M15 ...... 83

238 Klor-Con M20 ...... 83 LENVIMA ...... 28 LITEAIRE MDI CHAMBER K-PHOS ORIGINAL ...... 114 Lessina ...... 63 ...... 163, 190 KPN ...... 86 letrozole ...... 24 LITETOUCH-LARGE MASK Kurvelo (28)...... 63 leucovorin calcium ...... 29 ...... 163, 190 L LEUKERAN ...... 22 LITETOUCH-SMALL MASK l norgest/e.estradiol-e.estrad LEUKINE ...... 118 ...... 163, 190 ...... 59 levalbuterol hcl ...... 221 lithium carbonate ...... 53 labetalol ...... 33 levetiracetam ...... 45 lithium citrate ...... 53 LABSTIX REAGENT . 81, 190 levobunolol ...... 216 LITHOBID ...... 53 LACRISERT ...... 212 levocarnitine ...... 82, 208 LO LOESTRIN FE ...... 59 lactulose ...... 108, 112 levocarnitine (with sugar) 208 LO-DOSE ASPIRIN ..... 8, 119 LAMICTAL...... 45 levofloxacin ...... 17, 217 LOFRIC ...... 170, 190 LAMICTAL ODT ...... 45, 52 Levonest (28) ...... 67 LOFRIC ORIGO ...... 170, 190 LAMICTAL XR ...... 45 levonorgestrel ...... 69 LOFRIC PRIMO NELATON lamivudine ...... 14, 18 levonorgestrel-ethinyl estrad CATHETER ...... 170 lamivudine-zidovudine ...... 16 ...... 63 Lojaimiess ...... 59 lamotrigine...... 45 levonorg-eth estrad triphasic LONSURF ...... 24 lancets ...... 131 ...... 67 lopinavir-ritonavir ...... 15 LANCETS, SUPER THIN 131, Levora-28 ...... 63 lorazepam ...... 42 190 levorphanol tartrate ...... 1 Lorazepam Intensol ..... 42, 52 LANCETS,THIN ...... 131, 190 levothyroxine ...... 107 Loryna (28) ...... 64 LANCETS,ULTRA THIN 131, LEXIVA ...... 21 losartan ...... 33 190 LIDO KING ...... 80 losartan-hydrochlorothiazide lancing device ...... 131 lidocaine ...... 8, 81 ...... 33 lancing device with lancets lidocaine hcl ...... 8, 80, 209 loteprednol etabonate ...... 214 ...... 131 lidocaine hcl-hydrocortison ac lovastatin ...... 36 LANCING DEVICE WITH ...... 9, 79 Low-Ogestrel (28) ...... 64 LANCETS ...... 131 LIDOCAINE PAIN RELIEF 80 loxapine succinate ...... 51 LANCING SYSTEM 131, 190 Lidocaine Viscous ...... 209 Lo-Zumandimine (28) ...... 64 lansoprazole ...... 109 lidocaine-aloe vera ...... 80 lubiprostone ...... 111, 112 lanthanum ...... 114 lidocaine-prilocaine ...... 80 LUBRICANT EYE (CMC- LANTUS SOLOSTAR U-100 LIDOCARE ...... 81 GLYCERIN) ...... 211 INSULIN ...... 104 Lillow (28) ...... 64 LUBRICATING DROPS .. 211 LANTUS U-100 INSULIN 104 lindane...... 81 Lutera (28) ...... 64 LANZO LANCING DEVICE linezolid ...... 20 Lyleq ...... 66 ...... 131, 190 LINZESS ...... 111 Lyllana ...... 102 lapatinib ...... 22 liothyronine ...... 106 LYNPARZA ...... 27 Larin 1.5/30 (21) ...... 63 lisinopril ...... 32 Lyza ...... 67 Larin 1/20 (21) ...... 63 lisinopril-hydrochlorothiazide M Larin 24 Fe ...... 63 ...... 32 MAGELLAN INSULIN Larin Fe 1.5/30 (28) ...... 63 LITE TOUCH INSULIN PEN SAFETY SYRNG 147, 190, Larin Fe 1/20 (28) ...... 63 NEEDLES ...... 146, 190 191 Larissia ...... 63 LITE TOUCH INSULIN MAGELLAN SYRINGE ... 147, latanoprost ...... 218 SYRINGE ...... 146, 190 191 LAYOLIS FE...... 63 LITE TOUCH LANCETS 131, MAGIC3 GO INTERMIT LC PLUS ...... 158 190 CATHETER ...... 170, 191 LC PLUS NEBULIZER-PED LITE TOUCH LANCING MAGIC3 INTERMITTENT MASK ...... 158, 190 DEVICE ...... 131, 190 CATHETER ...... 171, 191 LEENA 28 ...... 67 LITE TOUCH-MEDIUM malathion ...... 81 leflunomide ...... 5 MASK ...... 163, 190 maprotiline ...... 48

239 Marlissa (28) ...... 64 MEDISENSE THIN metoprolol ta- MARNATAL-F ...... 86 LANCETS ...... 131 hydrochlorothiaz ...... 39 MARPLAN ...... 46 MEDLANCE PLUS metoprolol tartrate ...... 37 MATULANE...... 22 LANCETS ...... 132 metronidazole ...... 12, 80, 226 Matzim La...... 38 MEDLANCE PLUS SPECIAL mexiletine ...... 34 MAVENCLAD (10 TABLET BLADE ...... 132 MICRO ELITE PACK) ...... 211 MEDPOINT NORMAL REPLACEMENT FILTER MAVENCLAD (4 TABLET CONTROL ...... 132, 191 ...... 163, 191 PACK) ...... 211 MEDROL ...... 102 MICRO THIN LANCETS . 132 MAVENCLAD (5 TABLET medroxyprogesterone 58, 105 MICROAIR MESH PACK) ...... 211 mefloquine ...... 12 NEBULIZER...... 158 MAVENCLAD (6 TABLET megestrol ...... 27, 82 MICROCHAMBER ...... 163 PACK) ...... 211 MEKINIST ...... 26 MICRODOT HIGH-LOW MAVENCLAD (7 TABLET MEKTOVI ...... 26 CONTROL ...... 132, 191 PACK) ...... 211 meloxicam ...... 6 MICRODOT INSULIN PEN MAVENCLAD (8 TABLET melphalan ...... 22 NEEDLE ...... 147, 191 PACK) ...... 211 memantine ...... 58 MICRODOT NORMAL MAVENCLAD (9 TABLET meperidine ...... 1 CONTROL ...... 132, 191 PACK) ...... 211 meprobamate ...... 42 Microgestin 1.5/30 (21) ...... 64 MAXICOMFORT II PEN mercaptopurine ...... 23 Microgestin 1/20 (21) ...... 64 NEEDLE ...... 147, 191 mesalamine ...... 111 Microgestin 24 Fe ...... 64 MAXICOMFORT INSULIN MESNEX ...... 29 Microgestin Fe 1.5/30 (28) 64 SYRINGE ...... 147, 191 Metadate Er ...... 51 Microgestin Fe 1/20 (28) ... 64 MAXI-COMFORT INSULIN metaproterenol ...... 222 MICROLET 2 LANCING SYRINGE ...... 147 METER-CHECK ...... 132 DEVICE ...... 132, 191 MAXI-COMFORT INSULIN metformin ...... 105 MICROLET LANCET ...... 132 SYRINGE ...... 147 methadone ...... 1 MICROLET NEXT LANCING MAXI-COMFORT INSULIN Methadone Intensol ...... 1 DEVICE ...... 132, 192 SYRINGE ...... 191 Methadose ...... 1 MICROLIFE PEAK FLOW MAXI-COMFORT INSULIN methamphetamine ...... 54 METER ...... 158, 192 SYRINGE ...... 191 methazolamide ...... 40 MICROSPACER...... 163 MAXICOMFORT SAFETY methenamine hippurate..... 20 midodrine ...... 39 PEN NEEDLE ...... 147 methenamine mandelate ... 20 MIGERGOT ...... 54 MAXIDEX ...... 214 methimazole ...... 100 Mili ...... 64 MAXIMUM DAILY GREEN 84 methocarbamol ...... 121 Mimvey ...... 101 MAXI-TUSS AC ...... 226 methotrexate sodium ...... 5 MINI ELITE FILTER MAYZENT ...... 211 methotrexate sodium (pf) .. 23 REPLACEMENT .. 163, 192 MAYZENT STARTER PACK methoxsalen ...... 74 MINI LANCING DEVICE 132, ...... 211 methscopolamine ...... 110 192 M-CLEAR WC ...... 226 methyldopa ...... 39 MINI PLUS NEBULIZER 158, meclizine ...... 107 methyldopa- 192 MEDI-MECLIZINE ...... 107 hydrochlorothiazide...... 39 MINI PRENATAL ...... 86 MEDIPROXEN ...... 7 methylergonovine ...... 105 MINI ULTRA-THIN II 147, 192 MEDISENSE ...... 131 methylphenidate hcl .... 51, 52 MINI WRIGHT PEAK FLOW MEDISENSE CONTROLS 1- methylprednisolone ...... 102 METER ...... 159 HI 1-LO ...... 131, 191 methyltestosterone ...... 96 Minitran ...... 34 MEDISENSE GLUCOSE metipranolol ...... 216 minocycline ...... 22 KETONE ...... 131 metoclopramide hcl ...... 110 minoxidil ...... 40 MEDISENSE MID CONTROL metolazone ...... 41 mirtazapine ...... 46 ...... 131 metoprolol succinate ...... 37 misoprostol ...... 110

240 MISTASSIST ...... 163, 192 MYGLUCOHEALTH Neuac ...... 71 MISTASSIST KIT .... 163, 192 CONTROL SOLUTION NEULASTA ...... 117 M-NATAL PLUS ...... 86 ...... 132, 193 NEULASTA ONPRO ...... 117 modafinil ...... 55 MYGLUCOHEALTH NEUPRO ...... 50 MODERNA COVID-19 LANCETS ...... 132, 193 NEVANAC ...... 215 VACCINE (EUA) ...... 31 MYLERAN ...... 22 nevirapine ...... 14 moexipril ...... 32 MYNATAL ...... 87 NEW DAY ...... 69 mometasone ...... 78, 225 MYNATAL ADVANCE ...... 87 NEWGEN ...... 87 Mondoxyne Nl ...... 22 MYNATAL PLUS ...... 87 NEXA PLUS ...... 87 MONOJECT INSULIN MYNATAL-Z ...... 87 NEXAVAR ...... 26 SAFETY SYRING147, 148, MYNATE 90 PLUS ...... 87 NEXIVA ...... 156, 193 192 Myorisan ...... 70 NEXLETOL ...... 35 MONOJECT INSULIN MYSOLINE ...... 42 NEXLIZET ...... 36 SYRINGE ...... 148, 192 N niacin ...... 36 MONOJECT SYRINGE .. 148, nabumetone ...... 6 NIACIN-AZE AC-TURMER- 192 naftifine ...... 73 FA-B6-ZN ...... 82 MONOJECT ULTRA naloxone ...... 10 Niacor ...... 36 COMFORT INSULIN .. 148, naltrexone ...... 10 nicardipine ...... 38 192 naproxen ...... 7 nicotine ...... 57 MONOLET LANCETS ..... 132 naproxen sodium ...... 7 nicotine (polacrilex) ..... 56, 57 MONOLET THIN LANCETS naratriptan ...... 54 NICOTROL ...... 57 ...... 132, 192 NARCAN ...... 10 NICOTROL NS ...... 57 Mono-Linyah ...... 64 NASAL ALLERGY ...... 225 nifedipine ...... 38 montelukast ...... 220 NATACHEW (FE BIS- NIGHTIME SLEEP .... 55, 219 morphine ...... 1 GLYCINATE) ...... 87 NIGHTTIME SLEEP AID morphine concentrate ...... 1 NATAVI PNV ...... 87 (DIPHEN) ...... 55 MOTION SICKNESS NATAVI PRIMA ...... 95 Nikki (28) ...... 64 (MECLIZINE) ...... 107 nateglinide ...... 97 nilutamide ...... 23 MOTION SICKNESS nebulizer and compressor nimodipine ...... 38 RELIEF(MECLIZ) ...... 107 ...... 163, 193 NINLARO ...... 27 MOUTHPIECE ...... 163, 192 NEBUPENT ...... 20 nisoldipine ...... 38 moxifloxacin ...... 17, 217 NEBUSAL ...... 57 nitazoxanide ...... 12 MULTAQ ...... 35 Necon 0.5/35 (28) ...... 64 NITRO-DUR ...... 34 MULTI-LANCET DEVICE 2 nefazodone ...... 47 nitrofurantoin ...... 115 ...... 132, 192 neomycin ...... 10 nitrofurantoin macrocrystal MULTISTIX ...... 82, 193 neomycin-bacitracin-poly-hc ...... 115 MULTISTIX 10 SG .... 81, 193 ...... 212 nitrofurantoin monohyd/m- MULTISTIX 5 ...... 81, 193 neomycin-bacitracin- cryst ...... 115 MULTISTIX 7 ...... 81, 193 polymyxin ...... 216 nitroglycerin ...... 34 MULTISTIX 8 SG ...... 82, 193 neomycin-polymyxin b- NITRO-TIME ...... 34 MULTISTIX 9 ...... 82, 193 dexameth ...... 212 nizatidine ...... 109 MULTISTIX 9 SG ...... 82, 193 neomycin-polymyxin- NOBLE FORMULA HC ..... 78 MULTI-VIT WITH gramicidin ...... 216 NORA-BE ...... 67 FLUORIDE-IRON .... 84, 85 neomycin-polymyxin-hc .. 212, NORDITROPIN FLEXPRO mupirocin ...... 73 218 ...... 103 mupirocin calcium ...... 73 NEONATAL-DHA ...... 87 noreth-ethinyl estradiol-iron MY CHOICE ...... 69 Neo-Polycin ...... 216 ...... 64 MY WAY ...... 69 Neo-Polycin Hc ...... 213 norethindrone (contraceptive) mycophenolate mofetil .... 120 NESTABS ABC ...... 87 ...... 67 mycophenolate sodium ... 120 NESTABS DHA ...... 87 norethindrone acetate ..... 105

241 norethindrone ac-eth NOVOLOG U-100 INSULIN ON CALL VIVID CONTROL estradiol ...... 64, 101 ASPART ...... 105 ...... 133, 194 norethindrone-e.estradiol-iron NOVOTWIST ...... 148, 193 ondansetron ...... 108 ...... 65 NOXAFIL ...... 11 ondansetron hcl ...... 108 norgestimate-ethinyl estradiol NP THYROID ...... 106 ONE DAILY PRENATAL ... 88 ...... 65, 67 NUBEQA ...... 23 ONE WAY VALVED Norlyda ...... 67 NUCALA ...... 221 MOUTHPIECE ...... 163 NORPACE CR ...... 34 NUCYNTA ER ...... 2 ONE-A-DAY PRENATAL-1 88 Nortrel 0.5/35 (28) ...... 65 NUEDEXTA ...... 55 ONETOUCH DELICA LANC NORTREL 1/35 (21) ...... 65 Nyamyc ...... 73 DEVICE ...... 133, 194 Nortrel 1/35 (28) ...... 65 Nylia 7/7/7 (28) ...... 67 ONETOUCH DELICA Nortrel 7/7/7 (28) ...... 67 Nymyo ...... 65 LANCETS ...... 133, 194 nortriptyline...... 49 nystatin ...... 11, 73, 209 ONETOUCH DELICA PLUS NORVIR ...... 21 nystatin-triamcinolone ...... 74 LANCET ...... 133, 194 NOSE CLIP ...... 163, 193 Nystop ...... 73 ONETOUCH SURESOFT NO-STICK GLUCOSE ... 171, O LANCING DEV .... 133, 194 193 OB COMPLETE PREMIER 87 ONETOUCH ULTRA NOVA MAX GLUCOSE OB COMPLETE WITH DHA CONTROL ...... 133 CONTROL ...... 132, 193 ...... 88 ONETOUCH ULTRASOFT NOVA SAFETY LANCETS OBSTETRIX DHA ...... 88 LANCETS ...... 133, 194 ...... 132 OBSTETRIX EC ...... 88 ONETOUCH VERIO HIGH NOVA SUREFLEX OBSTETRIX ONE ...... 84 CONTROL ...... 133, 194 LANCETS ...... 132, 193 OBTREX DHA (WITH ONETOUCH VERIO MID NOVAMAX PLUS GLU-KET QUATREFOLIC) ...... 88 CONTROL ...... 133, 194 ...... 132, 193 O-CAL PRENATAL ...... 88 ON-THE-GO LANCETS .. 133 NOVAVAX COVID19 OCELLA ...... 65 OPCICON ONE-STEP ...... 69 VAC,ADJ(UNAPP) ...... 31 octreotide acetate ...... 106 opium tincture ...... 107 NOVOFINE 32 ...... 148, 193 ODEFSEY ...... 16 OPSUMIT ...... 41 NOVOFINE AUTOCOVER ODOMZO ...... 25 OPTICHAMBER ADULT ...... 148, 193 OFEV ...... 28, 226 MASK-LARGE ..... 163, 194 NOVOFINE PLUS ... 148, 193 ofloxacin ...... 17, 217, 218 OPTICHAMBER DIAMOND NOVOLIN 70/30 U-100 olanzapine ...... 53 LG MASK ...... 163, 194 INSULIN ...... 103 olanzapine-fluoxetine ...... 53 OPTICHAMBER DIAMOND NOVOLIN 70-30 FLEXPEN olopatadine ...... 214, 224 VHC ...... 163, 194 U-100 ...... 103 OMBRA COMPRESSOR OPTICHAMBER DIAMOND- NOVOLIN N FLEXPEN ... 103 SYSTEM ...... 163, 193 MED MSK ...... 164, 194 NOVOLIN N NPH U-100 omega-3 acid ethyl esters . 36 OPTICHAMBER DIAMOND- INSULIN ...... 103 omeprazole ...... 109 SML MASK ...... 164, 194 NOVOLIN R FLEXPEN ... 104 ON CALL EXPRESS OPTION-2 ...... 69 NOVOLIN R REGULAR U- CONTROL ...... 132, 193 OPTUMRX ...... 133, 194 100 INSULN ...... 104 ON CALL LANCET .. 132, 193 ORACIT ...... 115 NOVOLOG FLEXPEN U-100 ON CALL LANCING DEVICE Oralone ...... 209 INSULIN ...... 105 ...... 132, 193 ORKAMBI ...... 223 NOVOLOG MIX 70-30 U-100 ON CALL PLUS CONTROL orphenadrine-asa-caffeine INSULN ...... 104 ...... 133, 194 ...... 121 NOVOLOG MIX 70- ON CALL PLUS LANCET Orphengesic Forte ...... 121 30FLEXPEN U-100 ..... 104 ...... 133, 194 Orsythia ...... 65 NOVOLOG PENFILL U-100 ON CALL PLUS LANCING OSCIMIN ...... 110, 115 INSULIN ...... 105 DEVICE ...... 133, 194 OSCIMIN SL ...... 110, 115 OSCIMIN SR ...... 110, 115

242 oseltamivir ...... 19 PEDIATRIC DINOSAUR phenytoin ...... 44 OSMOPREP ...... 113 NEBULIZER ...... 164, 195 phenytoin sodium extended OVACE PLUS SHAMPOO 75 PEDIATRIC DOG ...... 44 oxandrolone ...... 96 NEBULIZER ...... 164, 195 Philith ...... 65 oxazepam...... 42 PEDIATRIC FE-VITE ...... 83 PHOSLYRA ...... 114 oxcarbazepine ...... 44 PEDIATRIC FROG phytonadione (vitamin k1) . 96 oxiconazole ...... 74 NEBULIZER ...... 164, 195 PIKO 1 ...... 159, 196 OXISTAT ...... 74 PEDIATRIC MEDIUM MASK PILLOW MASK CHILD ... 165, oxybutynin chloride ...... 116 ...... 164, 195 196 oxycodone ...... 2 PEDIATRIC MOUTHPIECES PILLOW MASK PEDIATRIC oxycodone-acetaminophen . 3 ...... 157, 195 ...... 165, 196 oxycodone-aspirin ...... 3 PEDIATRIC PANDA MASK pilocarpine hcl ...... 209, 212 OXYCONTIN ...... 2 ...... 164, 195 pimecrolimus ...... 76 P PEDIATRIC SMALL MASK pimozide ...... 51 Pacerone ...... 35 ...... 164, 195 Pimtrea (28) ...... 59 paliperidone...... 50 PEDIATRIC-SMALL MOUTH pioglitazone ...... 105 PANCREAZE ...... 108 ADAPTOR ...... 157 pioglitazone-glimepiride ..... 99 PANDA MASK ...... 164 peg 3350-electrolytes ...... 113 pioglitazone-metformin ...... 99 pantoprazole ...... 109 PEGASYS ...... 18 PIP LANCET ...... 133, 196 PARI BABY CONV KIT - peg-electrolyte soln ...... 113 PIP PEN NEEDLE ... 149, 196 SIZE 1 ...... 164, 194 PEN NEEDLE ...... 148 PIQRAY ...... 27 PARI BABY CONV KIT - pen needle, diabetic 148, 195 Pirmella ...... 65, 67 SIZE 2 ...... 164, 194 penicillamine ...... 9 piroxicam ...... 6 PARI BABY CONV KIT - penicillin v potassium ...... 20 PLEGRIDY ...... 210 SIZE 3 ...... 164, 194 pentazocine-naloxone ...... 3 PNEUMOVAX-23 ...... 31 PARI LC SPRINT PENTIPS ...... 148 PNV 29-1 ...... 88 NEBULIZER SET 158, 194 pentoxifylline ...... 118 pnv cmb#95-ferrous PARI LC SPRINT SINUS 158, perindopril erbumine ...... 32 fumarate-fa ...... 88 195 Periogard ...... 209 PNV-DHA + DOCUSATE .. 88 PARI SINUS AEROSOL permethrin ...... 81 PNV-FERROUS SYSTEM ...... 164, 195 perphenazine ...... 51 FUMARATE-DOCU-FA . 88 PARI TREK S COMBO perphenazine-amitriptyline 48 PNV-SELECT ...... 88 PACK ...... 164, 195 PERRY PRENATAL ...... 88 POCKET CHAMBER ...... 165 PARI TREK S COMPACT PERSONAL BEST FULL POCKET PEAK FLOW COMPRESSOR ... 164, 195 RANGE ...... 159, 195 METER ...... 159, 196 PARI TREK S PORTABLE PERSONAL BEST LOW PODOCON ...... 79 PWR KIT...... 164, 195 RANGE ...... 159, 195 podofilox ...... 79 paricalcitol ...... 208 PERSONAL CATHETER Polycin ...... 216 Paroex Oral Rinse ...... 209 INTERMITTENT .. 171, 196 polymyxin b sulf-trimethoprim paromomycin ...... 10 PFIZER COVID-19 VACCINE ...... 216 paroxetine hcl ...... 47 (EUA) ...... 31 polyvinyl alcohol ...... 212 PEAK AIR PEAK FLOW PFLEX INSPIRATORY PORTABLE NEBULIZER METER ...... 159, 195 TRAINER ...... 165, 196 SYSTEM ...... 165, 196 PEDIA IRON ...... 83 PHARBEDRYL ...... 219 Portia 28 ...... 65 PEDIATRIC AEROSOL phenazopyridine ...... 115 posaconazole ...... 11 MASK ...... 164, 195 phenelzine ...... 46 potassium chloride ...... 84 PEDIATRIC BEAR phenobarbital ...... 56 potassium citrate ...... 115 NEBULIZER ...... 164, 195 phenoxybenzamine ...... 41 PR NATAL 400 ...... 89 PEDIATRIC COMP-AIR phenylephrine hcl ...... 215 PR NATAL 400 EC ...... 88 COMPRES NEB .. 164, 195 Phenytek ...... 44 PR NATAL 430 ...... 89

243 PR NATAL 430 EC ...... 89 PRENATAL MULTI-DHA PRO COMFORT SPACER- PRADAXA ...... 119 (ALGAL OIL) ...... 90 ADULT MASK ...... 165, 197 pramipexole...... 50 PRENATAL MULTI- PRO COMFORT SPACER- PRAMOSONE ...... 79 DHA(WITH VIT K)...... 90 CHILD MASK ...... 165, 197 prasugrel ...... 119 PRENATAL probenecid ...... 116 pravastatin...... 36 MULTIVITAMINS ...... 90 probenecid-colchicine ...... 116 prazosin ...... 41 PRENATAL ONE DAILY ... 90 PROCARE COMPRESSOR PRECISION GLUCOSE PRENATAL PLUS ...... 91 NEBULIZER...... 165, 197 CONTROL SOLN 133, 196 PRENATAL PLUS PROCARE HUMIDIFIER 138, PRECISION (CALCIUM CARB) ...... 91 197 GLUCOSE/KETONE PRENATAL PLUS DHA .... 91 PROCARE PEDIATRIC CONTR ...... 133, 196 PRENATAL TABLET ...... 91 NEBULIZER...... 165 PRECISION XTRA B- PRENATAL VITAMIN ...... 91 PROCARE SPACER WITH KETONE ...... 81, 196 PRENATAL VITAMIN PLUS ADULT MASK ...... 165, 197 PRECISION XTRA LOW IRON ...... 91 PROCARE SPACER WITH MONITOR ...... 133, 196 PRENATAL VITAMIN WITH CHILD MASK ...... 165, 197 PRECISION XTRA TEST 122 MINERALS ...... 91 PROCHAMBER...... 165, 197 PRED-G ...... 213 prenatal vit-iron fum-folic ac prochlorperazine...... 107 prednicarbate ...... 78 ...... 91 prochlorperazine maleate .. 51 prednisolone...... 102 prenatal vits96-iron fum-folic Proctofoam Hc...... 9 prednisolone acetate ...... 215 ...... 91 Procto-Med Hc ...... 9, 78 prednisolone sodium PRENATAL WITH DHA- Procto-Pak ...... 9, 78 phosphate ...... 102, 215 FOLIC ACID ...... 91 Proctosol Hc ...... 9, 78 prednisone ...... 102 PRENATE ELITE ...... 91 Proctozone-Hc...... 9 pregabalin ...... 43 PREPARATION H PROCYSBI ...... 113 PREGEN DHA ...... 89 HYDROCORTISONE .... 78 PRODIGY CONTROL PREMARIN ...... 102, 226 PREPLUS ...... 91 SOLUTION, LOW ...... 133 PREMPHASE ...... 101 PRESSURE ACTIVATED PRODIGY CONTROL PREMPRO ...... 101 LANCETS ...... 133, 196 SOLUTION,HIGH 134, 197 PRENA1 CHEW ...... 89 PRETAB ...... 92 PRODIGY INSULIN PRENA1 PEARL ...... 89 Prevalite ...... 35 SYRINGE ...... 149, 197 PRENA1 TRUE ...... 89 PREVENT DROPSAFE PEN PRODIGY LANCETS ..... 134, PRENAISSANCE ...... 89 NEEDLE ...... 149, 196 197 PRENAISSANCE PLUS .... 89 PREVIDENT ...... 208 PRODIGY LANCING PRENATA ...... 89 Previfem ...... 65 DEVICE ...... 134, 197 PRENATABS FA ...... 89 PREVYMIS ...... 17 PRODIGY MINI-MIST PRENATABS RX ...... 89 PREZCOBIX ...... 15, 21 NEBULIZER...... 158 PRENATAL ...... 90, 91, 95 PREZISTA ...... 21 PRODIGY TWIST TOP PRENATAL + DHA...... 89 PRIFTIN ...... 16 LANCET ...... 134 PRENATAL 19 ...... 90 primaquine ...... 12 progesterone micronized . 105 PRENATAL 19 (WITH PRIMEAIRE ...... 165, 196 PROGRAF ...... 120 DOCUSATE) ...... 90 primidone ...... 42 PROLENSA ...... 215 PRENATAL COMPLETE .. 90 PRO COMFORT ALCOHOL PROLEUKIN ...... 25 PRENATAL FORMULA ..... 90 PADS ...... 29 PROMACTA ...... 119 PRENATAL FORMULA-DHA PRO COMFORT INSULIN promethazine ...... 107, 219 ...... 90 SYRINGE ...... 149, 196 Promethazine Vc ...... 219 PRENATAL GUMMIES ..... 95 PRO COMFORT LANCET Promethazine Vc-Codeine PRENATAL LOW IRON .... 90 ...... 133, 196 ...... 225 PRENATAL MULTI ...... 90 PRO COMFORT PEN promethazine-codeine ..... 225 NEEDLE ...... 149, 196 promethazine-dm ...... 225

244 promethazine-phenyleph- QUIT 2 ...... 57 RESTASIS MULTIDOSE . 215 codeine ...... 225 QUIT 4 ...... 57 RETACRIT ...... 117 promethazine-phenylephrine R RETRACTED PENIS ...... 219 raloxifene ...... 106 POUCH ...... 171 Promethegan ...... 108, 219 ramelteon ...... 54 REUSABLE NEBULIZER KIT PRONEB ULTRA FILTER ramipril ...... 32 ...... 165 SET ...... 165, 197 ranolazine ...... 34 REVLIMID ...... 28 PRONEB ULTRA II FILTER rasagiline ...... 50 REYATAZ ...... 21 ASSEM ...... 165, 197 READYLANCE SAFETY REYVOW ...... 55 propafenone ...... 34 LANCETS ...... 134, 198 ribavirin ...... 18 proparacaine ...... 216 REBIF (WITH ALBUMIN) 210 RIDAURA ...... 5 propranolol ...... 37 REBIF REBIDOSE ...... 210 rifabutin ...... 16, 21 propranolol- REBIF TITRATION PACK 210 rifampin ...... 16 hydrochlorothiazid ...... 41 Reclipsen (28) ...... 65 RIGHTEST CONTROL propylthiouracil ...... 100 RECOMBIVAX HB (PF) .... 30 SOLUTION HIGH 134, 198 protriptyline...... 49 REFRESH DIGITAL PF ... 211 RIGHTEST CONTROL PROVIDA OB ...... 92 REFRESH OPTIVE SOLUTION NORM ..... 134, PULMO-AIDE ADVANCED (PF) ...... 212 198 COMPRESSOR ...... 165 REFRESH OPTIVE MEGA-3 RIGHTEST GC250S CNTRL PULMONEB LT (PF) ...... 212 SOL NORM...... 134, 198 COMPRESSOR NEBUL REFRESH OPTIVE RIGHTEST GC700 LEV 2 ...... 165, 197 SENSITIVE (PF) ...... 212 CTRL SOLN...... 134, 198 PULMOZYME ...... 223 REFRESH RELIEVA ...... 212 RIGHTEST GD500 PURE COMFORT ALCOHOL REFUAH PLUS GLUCOSE LANCING DEVICE ..... 134, PADS ...... 29 CONTROL ...... 134, 198 198 PURE COMFORT REGENECARE HA ...... 81 RIGHTEST GL300 HUMIDIFIER ...... 138, 197 REGRANEX ...... 81 LANCETS ...... 134, 198 PURE COMFORT LANCETS RELENZA DISKHALER .... 19 RIGHTEST GT333 LEV 2 ...... 134 RELIAMED LANCET ...... 134, CTRL SOLN...... 134, 198 PURE COMFORT PEN 198 riluzole ...... 120 NEEDLE ...... 149, 197 RELIAMED MINI LANCING rimantadine ...... 19 PURE COMFORT SAFETY DEVICE ...... 134, 198 RINVOQ ...... 5 LANCETS ...... 134, 197 RELIAMED SAFETY SEAL risedronate ...... 100 PUREAIR MINI NEBULIZER LANCETS ...... 134, 198 risperidone ...... 50 ...... 165, 197 RELIAMED TWIST AND RITEFLO AEROCHAMBER PURECOMFORT PEAK CAP LANCET ...... 134, 198 ...... 165, 198 FLOW METER ...... 159 RELION NEEDLES . 149, 198 ritonavir ...... 21 PUSH BUTTON SAFETY RELION PEN NEEDLES 149, rivastigmine ...... 58 LANCETS ...... 134, 197 198 rivastigmine tartrate ...... 58 pyrazinamide ...... 16 RELION THIN LANCETS134, rizatriptan ...... 54 pyridostigmine bromide ... 120 198 R-NATAL OB ...... 92 pyrimethamine ...... 12 RELION ULTRA THIN PLUS ROBINSON CLEAR VINYL Q LANCETS ...... 134, 198 CATHETER ...... 171, 198 quetiapine ...... 53 RELISTOR ...... 10 ROB-NEL URETHRAL quinapril ...... 32 repaglinide ...... 97 CATHETER ...... 171, 198 quinapril-hydrochlorothiazide REPATHA SURECLICK .... 36 ropinirole ...... 50 ...... 32 REPATHA SYRINGE ...... 36 Rosadan ...... 80 quinidine gluconate ...... 34 REPLACEMENT J-4 ROSANIL ...... 71 quinidine sulfate ...... 34 CANNULA ...... 157, 198 ROSULA CLEANSING quinine sulfate ...... 12 RESTASIS ...... 215 CLOTHS ...... 71

245 rosuvastatin ...... 36 SEMGLEE U-100 INSULIN SLEEP AID RUBBER MOUTHPIECE 165, ...... 104 (DIPHENHYDRAMINE) . 55 198 SE-NATAL 19 CHEWABLE SLEEP AID MAX STR RUBRACA...... 27 ...... 92 (DIPHENHYDR) ...... 55 rufinamide ...... 46 SE-NATAL-19 ...... 92 SLEEPING ...... 55 RUKOBIA ...... 13 SEREVENT DISKUS...... 221 SMART SENSE LANCETS RYDEX ...... 225 sertraline ...... 47 ...... 135, 199 RYTARY ...... 49 Setlakin ...... 65 SMARTDIABETES S sevelamer carbonate ...... 114 VANTAGE ...... 135, 199 SAFELET IV CATHETER 156 sevelamer hcl ...... 114 SMARTEST CONTROL . 135, SAFESNAP INSULIN SF ...... 209 199 SYRINGE ...... 149 SF 5000 PLUS ...... 209 SMARTEST LANCET ..... 135, SAFETY LANCETS . 134, 198 Sharobel ...... 67 199 SAFETY PEN NEEDLE .. 149 SHINGRIX (PF) ...... 31 sodium chloride ...... 57, 83 SAFETY SEAL LANCETS SHINGRIX GE ANTIGEN SODIUM FLUORIDE 5000 ...... 135 COMPONENT ...... 31 DRY MOUTH ...... 209 SAFETY-LET LANCETS 135, SIDESTREAM ...... 158 SODIUM FLUORIDE 5000 199 SIDESTREAM ADULT FACE PLUS ...... 209 salicylic acid ...... 79 MASK ...... 166, 199 sodium phenylbutyrate .... 208 SALONPAS (LIDOCAINE) 81 SIDESTREAM MASK ...... 166 sodium polystyrene sulfonate salsalate ...... 8 SIDESTREAM NEBULIZER ...... 82 SAMI THE SEAL ..... 165, 199 ...... 158 SOFT TOUCH LANCETS SAMI THE SEAL FILTER SIDESTREAM PEDIATRIC ...... 135, 199 ...... 165, 199 FACE MASK ...... 166 solifenacin ...... 115 SAMI THE SEAL MASK . 166, SIDESTREAM PLUS...... 158, SOLUS V2 CONTROL 199 199 SOLUTION, LOW 135, 199 SANDIMMUNE ...... 5, 120 SIGNIFOR ...... 106 SOLUS V2 CONTROL SANTYL ...... 76 SILASTIC FOLEY SOLUTION,HIGH 135, 199 SAVELLA ...... 47, 54 CATHETER ...... 171, 199 SOLUS V2 LANCETS .... 135, scopolamine base ...... 107 sildenafil (pulm.hypertension) 199 SEA-CLENS WOUND ...... 41 SOLUS V2 LANCING CLEANSER ...... 113 SILICONE MASK ...... 166 DEVICE ...... 135, 199 SECONAL SODIUM ...... 56 SILICONE MASK - INFANT SOMAVERT ...... 103 SECURESAFE PEN ...... 166, 199 SOOTHENEB NEEDLE ...... 150 SILICONE MASK - COMPRESSOR SELECT-OB ...... 92 PEDIATRIC ...... 166, 199 NEBULIZER...... 166, 199 SELECT-OB (FOLIC ACID) silver sulfadiazine ...... 76 SOOTHENEB MESH ...... 92 SIMILAC PRENATAL ...... 92 NEBULIZER...... 158, 199 SELECT-OB + DHA ...... 92 Simliya (28) ...... 59 SOOTHENEB NBL100 selegiline hcl...... 50 Simpesse ...... 60 ADULT MASK ...... 166, 199 selenium sulfide ...... 75 simvastatin ...... 36 SOOTHENEB NBL100 SELF-CATH ...... 171, 199 SINGLE-LET ...... 135, 199 CHILD MASK ...... 166, 200 SELF-CATH 10 ...... 171 SINUSTAR AEROSOL .... 166 SOOTHENEB NBL100 MED SELF-CATHETER, FEMALE SINUSTAR NEBULIZER 158, CUP ...... 166, 200 ...... 171, 199 199 SOOTHENEB NBL100 SELSUN BLUE ...... 75 sirolimus ...... 120 MESH CAP ...... 166, 200 SELSUN BLUE 2-IN-1 ...... 75 SIVEXTRO ...... 20 SOOTHING CARE SELSUN BLUE SKIN TREATMENT ...... 76 (HYDROCORTISONE) .. 78 MOISTURIZING ...... 75 SKYRIZI ...... 72 Sorine ...... 34 SELZENTRY ...... 13 sotalol ...... 34

246 Sotalol Af ...... 34 sulfacetamide sodium-sulfur SURE-TOUCH LANCET 135, SPACE CHAMBER . 166, 200 ...... 71 201 SPACE CHAMBER PLUS sulfacetamide sod-sulfur-urea SUTENT ...... 28 ...... 166, 200 ...... 71, 80 Syeda ...... 65 SPACE CHAMBER WITH sulfacetamide-prednisolone SYMDEKO ...... 223 LARGE MASK ..... 166, 200 ...... 213 SYMPAZAN ...... 42 SPACE CHAMBER WITH SULFACLEANSE 8-4 ...... 71 SYNAREL ...... 105 MEDIUM MASK ... 166, 200 sulfadiazine ...... 21 SYNJARDY ...... 97 SPACE CHAMBER WITH sulfamethoxazole- SYNJARDY XR ...... 97 SMALL MASK ...... 166, 200 trimethoprim ...... 11 T SPEEDICATH (FEMALE) SULFAMYLON ...... 76 TABLOID ...... 23 ...... 171, 200 sulfasalazine ...... 111 tacrolimus ...... 76, 120 SPEEDICATH (MALE) ... 171, SULFATRIM ...... 11 tadalafil ...... 82 200 sulindac ...... 6 tadalafil (pulm. hypertension) spinosad ...... 81 sumatriptan ...... 54 ...... 41 SPIRIT EXT CATHETER sumatriptan succinate . 54, 55 TAFINLAR ...... 24 TYPE 3 ...... 171, 200 SUNRISE COMPRESSOR- TAGRISSO ...... 22 SPIRIT STYLE-3 ..... 171, 200 NEBULIZER ...... 166, 200 TAKE ACTION ...... 69 SPIRIVA RESPIMAT ...... 221 SUPER THIN LANCETS 135, tamoxifen ...... 28 SPIRIVA WITH 200 tamsulosin ...... 114 HANDIHALER ...... 221 SUPRAX ...... 17 TARGRETIN ...... 74 spironolactone ...... 33 SURE COMFORT ALCOHOL Tarina 24 Fe ...... 65 spironolacton- PREP PADS ...... 29 Tarina Fe 1/20 (28) ...... 66 hydrochlorothiaz ...... 40 SURE COMFORT INS. SYR. Tarina Fe 1-20 Eq (28) ...... 66 SPLASH SHIELD FLEX .. 157 U-100 ...... 150, 200 TARON-PREX PRENATAL- Sprintec (28)...... 65 SURE COMFORT INSULIN DHA ...... 84, 92 SPRYCEL ...... 28 SYRINGE ...... 150, 200 TASIGNA ...... 28 Sps (With Sorbitol) ...... 82 SURE COMFORT LANCETS Taztia Xt ...... 38 SPS (WITH SORBITOL) ... 82 ...... 135, 201 TD GOLD LEVEL 1 Sronyx ...... 65 SURE COMFORT LANCING CONTROL ...... 135 SSD ...... 76 PEN ...... 135, 201 TD GOLD LEVEL 2 SSKI ...... 83 SURE COMFORT PEN CONTROL ...... 135 SSS 10-5 ...... 71 NEEDLE ...... 150, 201 TD GOLD LEVEL 3 ST JOSEPH ASPIRIN ...... 8 SURE COMFORT SAFETY CONTROL ...... 136 ST. JOSEPH ASPIRIN ...... 8 PEN NEEDLE ...... 150, 201 TECHLITE INSULIN stavudine ...... 14 SURE-FINE PEN NEEDLES SYRINGE ...... 151 STERILANCE TL .... 135, 200 ...... 150 TECHLITE INSULN STERILE SALINE ...... 83 SUREFLEX DEVICE WITH SYR(HALF UNIT) ...... 151 STIOLTO RESPIMAT ..... 222 LANCETS ...... 135, 201 TECHLITE LANCETS ..... 136 STIVARGA ...... 26 SUREFLEX LANCING TECHLITE PEN NEEDLE 151 STOP SMOKING AID ...... 57 DEVICE ...... 135, 201 TEGRETOL ...... 44, 52 STRIBILD ...... 15 SURE-JECT INSULIN TEGRETOL XR ...... 44, 53 STRIVERDI RESPIMAT .. 221 SYRINGE ...... 150, 201 TELCARE CONTROL .... 136, STUART ONE ...... 92 SURE-LANCE ...... 135, 201 201 Subvenite ...... 45 SURE-LANCE ULTRA THIN TELCARE LANCETS ..... 136, sucralfate ...... 113 ...... 135 201 sulfacetamide sodium 75, 217 SURE-PREP ALCOHOL temazepam ...... 56 sulfacetamide sodium (acne) PREP PADS ...... 29 temozolomide ...... 23 ...... 70 SURE-TEST EASYPLUS TENDERA-OB ...... 92 MINI ...... 135

247 tenofovir disoproxil fumarate tobramycin in 0.225 % nacl trifluridine ...... 217 ...... 15 ...... 223 trihexyphenidyl ...... 49 terazosin ...... 41 tobramycin with nebulizer 223 Tri-Legest Fe ...... 68 terbinafine hcl ...... 11 tobramycin-dexamethasone Tri-Linyah ...... 68 terbutaline ...... 222 ...... 213 Tri-Lo-Estarylla ...... 68 terconazole...... 226 TODAY CONTRACEPTIVE Tri-Lo-Marzia ...... 68 teriparatide ...... 100 SPONGE ...... 70 Tri-Lo-Mili ...... 68 TERUMO INSULIN TOLAK ...... 74 Tri-Lo-Sprintec...... 68 SYRINGE ...... 151, 201 tolmetin ...... 6 Trilyte With Flavor Packets testosterone ...... 96 tolterodine ...... 116 ...... 113 testosterone cypionate ...... 96 TOPCARE CLICKFINE .. 151, trimethobenzamide ...... 107 tetrabenazine ...... 55 202 trimethoprim ...... 11 tetracycline ...... 22 TOPCARE ULTRA Tri-Mili ...... 68 THALOMID...... 12, 28 COMFORT ...... 152, 202 trimipramine ...... 49 THEOCHRON ...... 220 TOPCARE UNIVERSAL1 TRINATE ...... 93 theophylline ...... 220 LANCET ...... 136, 202 TRINTELLIX ...... 48 THERANATAL ...... 93 topiramate ...... 45 Tri-Nymyo ...... 68 THERANATAL COMPLETE toremifene ...... 28 TRIPLE ANTIBIOTIC PLUS ...... 92 torsemide ...... 40 ...... 73 THERANATAL ONE ...... 92 TOUCH-TROL ...... 171, 202 Tri-Previfem (28) ...... 68 THERANATAL OVAVITE .. 93 TOUJEO MAX U-300 Tri-Sprintec (28) ...... 68 THERANATAL PLUS ...... 93 SOLOSTAR ...... 104 TRIUMEQ ...... 15 THIN LANCETS ...... 136 TOUJEO SOLOSTAR U-300 TRIVEEN-DUO DHA ...... 93 THINPRO INSULIN INSULIN ...... 104 TRIVEEN-PRX RNF ...... 93 SYRINGE .... 151, 201, 202 TOVIAZ ...... 116 Trivora (28) ...... 68 thioridazine ...... 51 tramadol ...... 2 Tri-Vylibra ...... 68 thiothixene ...... 51 tramadol-acetaminophen ..... 3 Tri-Vylibra Lo ...... 68 THRESHOLD IMT TRAINER trandolapril ...... 32 tropicamide ...... 213 ...... 166, 202 trandolapril-verapamil ...... 32 trospium ...... 116 THRESHOLD PEP DEVICE tranexamic acid ...... 118 TRUE COMFORT ALCOHOL ...... 166, 202 tranylcypromine ...... 46 PADS ...... 30 THRIVITE RX ...... 93 TRAVEL-EASE (MECLIZINE) TRUE COMFORT INSULIN THRIVITE-19 ...... 84, 93 ...... 107 SYRINGE ...... 152, 202 THYROLAR-1 ...... 106 travoprost ...... 218 TRUE COMFORT LANCET THYROLAR-1/2 ...... 106 trazodone ...... 47 ...... 136, 202 THYROLAR-1/4 ...... 106 TRECATOR ...... 16 TRUE COMFORT PEN THYROLAR-2 ...... 106 tretinoin ...... 72 NEEDLE ...... 152, 202 THYROLAR-3 ...... 106 tretinoin (antineoplastic) .... 28 TRUE METRIX LEVEL 1 . 136 Tiadylt Er ...... 38 TREXALL ...... 5, 23 TRUE METRIX LEVEL 2 . 136 tiagabine ...... 43 Tri Femynor ...... 68 TRUE METRIX LEVEL 3 . 136 TIBSOVO ...... 26 triamcinolone acetonide ... 79, TRUECONTROL LEVEL 0 Tilia Fe ...... 67 209, 225 ...... 136, 202 timolol maleate ...... 216 triamterene ...... 40 TRUECONTROL LEVEL 1 tinidazole ...... 13 triamterene- ...... 136, 202 TIVICAY ...... 13 hydrochlorothiazid ...... 40 TRUEDRAW LANCING TIVICAY PD ...... 13 triazolam ...... 56 DEVICE ...... 136, 202 tizanidine ...... 121 TRICARE ...... 93 TRUEPLUS INSULIN ...... 152 TOBI PODHALER ...... 222 Triderm ...... 79 TRUEPLUS KETONE ..... 203 TOBRADEX ...... 213 Tri-Estarylla ...... 68 TRUEPLUS LANCETS ... 136, tobramycin...... 217, 223 trifluoperazine ...... 51 203

248 TRUEPLUS PEN NEEDLE ULTRA FLO PEN NEEDLE UNILET EXCELITE LANCET ...... 152 ...... 154, 204 ...... 137 TRULICITY...... 99 ULTRA PRENATAL PLUS UNILET GP LANCET ...... 137 TRUNEB NEBULIZER ... 158, DHA ...... 93 UNILET LANCET ...... 137 203 ULTRA THIN II LANCETS UNILET LANCETS ...... 137 TRUZONE PEAK FLOW ...... 136, 204 UNILET SUPER THIN METER ...... 159, 203 ULTRA THIN LANCETS . 136, LANCETS ...... 137 TUKYSA ...... 25 204 UNISOM SLEEPGELS ...... 55 Tulana ...... 67 ULTRA THIN PEN NEEDLE UNISTIK 2 NORMAL TWIST LANCETS ...... 136 ...... 154, 204 LANCET,DEVICE 137, 205 TYBLUME ...... 66 ULTRA THIN PLUS UNISTIK 3 COMFORT TYZINE ...... 225 LANCETS ...... 137, 204 LANCET ...... 137, 205 U ULTRA TLC LANCETS ... 137 UNISTIK 3 EXTRA LANCET ULTICARE ...... 153 ULTRACARE INSULIN ...... 137 ULTICARE INSULIN SYRINGE .... 154, 155, 204 UNISTIK 3 GENTLE ...... 137 SYRINGE ...... 152 ULTRA-CARE LANCETS UNISTIK 3 LANCETS ..... 137, ULTICARE INSULN ...... 137, 204 205 SYR(HALF UNIT) ...... 152 ULTRACARE PEN NEEDLE UNISTIK 3 NORMAL ULTICARE PEN NEEDLE ...... 155, 205 LANCET ...... 137, 205 ...... 153 ULTRALANCE LANCETS UNISTIK CZT LANCET .. 137, ULTICARE SAFETY PEN ...... 137, 205 205 NEEDLE ...... 153, 203 ULTRA-THIN II (SHORT) INS UNISTIK PRO LANCET . 137, ULTIGUARD SAFEPACK- SYR ...... 155, 205 206 INSULIN SYR ...... 153, 203 ULTRA-THIN II (SHORT) UNISTIK SAFETY ... 137, 206 ULTIGUARD SAFEPACK- PEN NDL ...... 155, 205 UNISTIK TOUCH LANCETS PEN NEEDLE ...... 153, 203 ULTRA-THIN II INS PEN ...... 137, 206 ULTI-LANCE ...... 136, 203 NEEDLES ...... 155, 205 UNISTRIP HIGH CONTROL ULTILET ALCOHOL SWAB ULTRA-THIN II INSULIN ...... 137, 206 ...... 30 SYRINGE ...... 155, 205 UNISTRIP LOW CONTROL ULTILET BASIC LANCETS ULTRA-THIN II LANCETS ...... 138, 206 ...... 136, 203 ...... 137, 205 UNIVERSAL 1 LANCETS 138 ULTILET CLASSIC ULTRATRAK HIGH-LOW URETHRAL CATHETER 171, LANCETS ...... 136, 203 CONTROL ...... 137 206 ULTILET INSULIN SYRINGE ULTRATRAK NORMAL URINARY PAIN RELIEF . 115 ...... 153, 203 CONTROL ...... 137 URISTIX 4 ...... 82, 206 ULTILET LANCETS 136, 203 ULTRATRAK ULTIMATE 137, URISTIX REAGENT .. 82, 206 ULTILET PEN NEEDLE . 153, 205 URO-SAN PLUS ...... 171 203 ULTRAVATE ...... 75 ursodiol ...... 109 ULTILET SAFETY LANCETS UNIFINE PEN NEEDLE . 155, V ...... 136, 203 205 VAGINAL CONTRACEPTIVE ULTRA CMFT INS SYR UNIFINE PENTIPS . 155, 205 FILM ...... 70 (HALF UNIT) ...... 154, 204 UNIFINE PENTIPS VAGINAL CONTRACEPTIVE ULTRA COMFORT INSULIN MAXFLOW ...... 155 FOAM ...... 70 SYRINGE ...... 154, 204 UNIFINE PENTIPS PLUS 155 valacyclovir ...... 19 ULTRA FINE LANCETS . 136, UNIFINE PENTIPS PLUS valganciclovir ...... 17 204 MAXFLOW ...... 155 valproic acid ...... 43 ULTRA FLO INSUL UNILET COMFORTOUCH valsartan ...... 33 SYR(HALF UNIT) 154, 204 LANCET ...... 137 valsartan-hydrochlorothiazide ULTRA FLO INSULIN UNILET EXCELITE II ...... 33 SYRINGE ...... 154, 204 LANCET ...... 137 vancomycin ...... 18

249 VANDAZOLE ...... 226 VIRTUSSIN AC ...... 226 WAL-SOM VANICREAM HC ...... 79 VIRT-VITE ...... 95, 96 (DIPHENHYDRAMINE) . 55 VANISHPOINT INSULIN VIRT-VITE PLUS ...... 82 WAL-ZYR (KETOTIFEN) . 214 SYRINGE ...... 156, 206 VITAFOL FE+ (WITH warfarin ...... 116 VANISHPOINT SYRINGE DOCUSATE) ...... 94 WARM STEAM VAPORIZER ...... 156 VITAFOL GUMMIES ...... 94 ...... 172, 207 VAPORIZER CLEANING 167, VITAFOL NANO ...... 94 WAVESENSE CONTROL 206 VITAFOL ULTRA ...... 94 SOLUTION ...... 138, 207 VAPORIZER INHALANT 167, VITAFOL-OB ...... 94 WEBCOL ...... 30 206 VITAFOL-OB+DHA ...... 94 Wera (28) ...... 66 vaporizers...... 172 VITAFOL-ONE ...... 94 WESTAB PLUS ...... 94 VARUBI ...... 108 VITAMED MD ONE RX ..... 94 WESTHROID ...... 106 VASCEPA ...... 36 Vitamin D2 ...... 95 WIDE-SEAL DIAPHRAGM VCF CONTRACEPTIVE VITAMIN D3 ...... 95 60 ...... 122, 207 FILM ...... 70 VIVA DHA ...... 94 WIDE-SEAL DIAPHRAGM VCF CONTRACEPTIVE GEL VIVAGUARD INO CTRL 65 ...... 122, 207 ...... 70 SOLN-L1,2,3 ...... 138, 206 WIDE-SEAL DIAPHRAGM Velivet Triphasic Regimen VIVAGUARD INO CTRL 70 ...... 122, 207 (28) ...... 68 SOLN-L1,L3 ...... 138, 206 WIDE-SEAL DIAPHRAGM VENA-BAL DHA ...... 93 VIVAGUARD INO CTRL 75 ...... 122, 207 VENCLEXTA ...... 24 SOLN-L2 ...... 138, 207 WIDE-SEAL DIAPHRAGM VENCLEXTA STARTING VIVAGUARD LANCET ... 138, 80 ...... 122, 207 PACK ...... 24 207 WIDE-SEAL DIAPHRAGM venlafaxine ...... 47, 48 VIXONE NEBULIZER..... 158, 85 ...... 122, 207 verapamil ...... 35, 38, 39 207 WIDE-SEAL DIAPHRAGM VERASENS CONTROL VIXONE NEBULIZER- 90 ...... 122, 207 SOLN-LEVEL 1 ... 138, 206 ADULT MASK ...... 158, 207 WIDE-SEAL DIAPHRAGM VERIFINE PEN NEEDLE 156, VIXONE NEBULIZER- 95 ...... 122, 207 206 PEDIATRIC MSK . 158, 207 WILLIS THE WHALE VERTICALM ...... 107 Volnea (28) ...... 60 COMPRESSR NEB .... 167, Vestura (28) ...... 66 voriconazole ...... 11 207 V-GO 20 ...... 167, 206 VORTEX ADULT MASK . 167, WILZIN ...... 9 V-GO 30 ...... 167, 206 207 WINDMILL TRAINER ..... 167, V-GO 40 ...... 167, 206 VORTEX HOLDING 207 VICKS WARM STEAM CHAMBER ...... 167, 207 WING TIP TUBING . 167, 208 VAPORIZER ...... 172, 206 VORTEX VHC FROG MASK- WOMEN'S PRENATAL VICTOZA 2-PAK ...... 99 CHILD ...... 167, 207 PLUS DHA ...... 95 VICTOZA 3-PAK ...... 99 VORTEX VHC LADYBUG Wymzya Fe ...... 66 Vienva ...... 66 MASK-TODDLR .. 167, 207 X vigabatrin ...... 43 VOSEVI ...... 18 XALKORI ...... 23 VINATE GT ...... 93 VOTRIENT ...... 28 XARELTO ...... 117 VINATE II ...... 93 VP-CH PLUS ...... 94 XARELTO DVT-PE TREAT VINATE ULTRA ...... 93 VP-CH-PNV ...... 94 30D START ...... 117 VINYL CATHETER . 171, 206 VP-PNV-DHA ...... 94 XIGDUO XR ...... 98 Viorele (28)...... 60 Vyfemla (28) ...... 66 XTANDI ...... 23 VIOS AEROSOL DELIVERY Vylibra ...... 66 XULANE ...... 68 SYSTEM ...... 167 VYVANSE ...... 52 Xylon 10 ...... 2 VIRACEPT ...... 21 W Z VIREAD ...... 15, 18 WAL-DRAM 2 ...... 107 Zafemy ...... 69 VIRT-NATE DHA ...... 93 WAL-PROXEN ...... 7 zafirlukast ...... 220

250 zaleplon ...... 56 Zenatane ...... 70 zonisamide ...... 46 ZANTAC-360 (FAMOTIDINE) Zenzedi ...... 54 ZONTIVITY ...... 119 ...... 109 zidovudine ...... 14, 15 Zovia 1/35E (28) ...... 66 Zarah ...... 66 ziprasidone hcl ...... 53 Zovia 1-35 (28) ...... 66 Zarontin ...... 46 ZIRGAN ...... 217 Zumandimine (28) ...... 66 ZARONTIN ...... 46 ZOLINZA ...... 25 ZYDELIG ...... 27 ZARXIO ...... 117 zolmitriptan ...... 55 ZYLET ...... 213 ZELBORAF ...... 24 zolpidem ...... 56

251