Quantity Limit Program Summary

Home , Autoinjector, Injector pen, Respimat

Program Target Agent Dosage/Strength Quantity Unit Days

Note: Quantity limits apply to all available MultiSource Code (MSC) products

Acute Migraine *(QL applies to Comm, HIM, NR A and NR F) The following acute migraine products are subject to QL: Amerge (naratriptan) Tablets, Axert (almotriptan) Tablets, Frova (frovatriptan) Tablets, Imitrex (sumatriptan) Injection, Sumatriptan Injection, Imitrex, Sumatriptan (sumatriptan) Nasal Spray, Imitrex (sumatriptan) Tablets, Maxalt (rizatriptan) MLT Tablets, Maxalt (rizatriptan) Tablets, Onzetra Xsail (sumatriptan) nasal powder, Relpax (eletriptan) Tablets, Sumavel DosePro (sumatriptan) Injection, Tosymra (sumatriptan) nasal spray, Treximet (sumatriptan/naproxen) Tablets, Zembrace Symtouch (sumatriptan injection), Zomig (zolmitriptan) Nasal Spray, Zomig (zolmitriptan) Tablets, Zomig (zolmitriptan) ZMT Tablets. **Specific Acute Migraine QL information is included in the individual program document ND_PS_Acute_Migraine_5HT_ST_QL ADHD Agents *(QL applies to Comm, HIM, NR A and NR F) ADHD Agents Adderall (amphetamine/dextroamphetamine) 5 mg tablet 2 tablet(s) 1 ADHD Agents Adderall (amphetamine/dextroamphetamine) 7.5 mg tablet 2 tablet(s) 1 ADHD Agents Adderall (amphetamine/dextroamphetamine) 10 mg tablet 2 tablet(s) 1 ADHD Agents Adderall (amphetamine/dextroamphetamine) 12.5 mg tablet 2 tablet(s) 1 ADHD Agents Adderall (amphetamine/dextroamphetamine) 15 mg tablet 2 tablet(s) 1 ADHD Agents Adderall (amphetamine/dextroamphetamine) 20 mg tablet 3 tablet(s) 1 ADHD Agents Adderall (amphetamine/dextroamphetamine) 30 mg tablet 2 tablet(s) 1 ADHD Agents Adderall XR (amphetamine/dextroamphetamine ER) 5 mg capsule 1 capsule(s) 1 ADHD Agents Adderall XR (amphetamine/dextroamphetamine ER) 10 mg capsule 1 capsule(s) 1 ADHD Agents Adderall XR (amphetamine/dextroamphetamine ER) 15 mg capsule 1 capsule(s) 1 ADHD Agents Adderall XR (amphetamine/dextroamphetamine ER) 20 mg capsule 1 capsule(s) 1 ADHD Agents Adderall XR (amphetamine/dextroamphetamine ER) 25 mg capsule 1 capsule(s) 1 ADHD Agents Adderall XR (amphetamine/dextroamphetamine ER) 30 mg capsule 1 capsule(s) 1 ADHD Agents Adhansia XR (methylphenidate ER) 25 mg capsule 1 capsule(s) 1 ADHD Agents Adhansia XR (methylphenidate ER) 35 mg capsule 1 capsule(s) 1 ADHD Agents Adhansia XR (methylphenidate ER) 45 mg capsule 1 capsule(s) 1 ADHD Agents Adhansia XR (methylphenidate ER) 55 mg capsule 1 capsule(s) 1 ADHD Agents Adhansia XR (methylphenidate ER) 70 mg capsule 1 capsule(s) 1 ADHD Agents Adhansia XR (methylphenidate ER) 85 mg capsule 1 capsule(s) 1 ADHD Agents Adzenys ER, Amphetamine ER suspension 1.25 mg/1 mL suspension 15 mL(s) 1 ADHD Agents Adzenys XR-ODT (amphetamine ER) 3.1 mg oral disintegrating tablet 2 tablet(s) 1 ADHD Agents Adzenys XR-ODT (amphetamine ER) 6.3 mg oral disintegrating tablet 2 tablet(s) 1 ADHD Agents Adzenys XR-ODT (amphetamine ER) 9.4 mg oral disintegrating tablet 1 tablet(s) 1 ADHD Agents Adzenys XR-ODT (amphetamine ER) 12.5 mg oral disintegrating tablet 1 tablet(s) 1 ADHD Agents Adzenys XR-ODT (amphetamine ER) 15.7 mg oral disintegrating tablet 1 tablet(s) 1 ADHD Agents Adzenys XR-ODT (amphetamine ER) 18.8 mg oral disintegrating tablet 1 tablet(s) 1 ADHD Agents Aptensio XR, Methylphenidate ER capsule 10 mg capsule 1 capsule(s) 1 ADHD Agents Aptensio XR, Methylphenidate ER capsule 15 mg capsule 1 capsule(s) 1 ADHD Agents Aptensio XR, Methylphenidate ER capsule 20 mg capsule 1 capsule(s) 1 ADHD Agents Aptensio XR, Methylphenidate ER capsule 30 mg capsule 1 capsule(s) 1 ADHD Agents Aptensio XR, Methylphenidate ER capsule 40 mg capsule 1 capsule(s) 1 ADHD Agents Aptensio XR, Methylphenidate ER capsule 50 mg capsule 1 capsule(s) 1

Program Target Agent Dosage/Strength Quantity Unit Days

Note: Quantity limits apply to all available MultiSource Code (MSC) products

ADHD Agents Aptensio XR, Methylphenidate ER capsule 60 mg capsule 1 capsule(s) 1 ADHD Agents Concerta (methylphenidate ER) 18 mg tablet 1 tablet(s) 1 ADHD Agents Concerta (methylphenidate ER) 27 mg tablet 1 tablet(s) 1 ADHD Agents Concerta (methylphenidate ER) 36 mg tablet 2 tablet(s) 1 ADHD Agents Concerta (methylphenidate ER) 54 mg tablet 1 tablet(s) 1 ADHD Agents Cotempla XR ODT (methylphenidate ER orally dissolving tablet) 8.6 mg orally disintegrating tablet 1 tablet(s) 1 ADHD Agents Cotempla XR ODT (methylphenidate ER orally dissolving tablet) 17.3 mg orally disintegrating tablet 2 tablet(s) 1 ADHD Agents Cotempla XR ODT (methylphenidate ER orally dissolving tablet) 25.9 mg orally disintegrating tablet 2 tablet(s) 1 ADHD Agents Daytrana (methylphenidate transdermal patch) 10 mg/9 hr patch 1 patch(s) 1 ADHD Agents Daytrana (methylphenidate transdermal patch) 15 mg/9 hr patch 1 patch(s) 1 ADHD Agents Daytrana (methylphenidate transdermal patch) 20 mg/9 hr patch 1 patch(s) 1 ADHD Agents Daytrana (methylphenidate transdermal patch) 30 mg/9 hr patch 1 patch(s) 1 ADHD Agents Desoxyn (methamphetamine) 5 mg tablet 5 tablet(s) 1 ADHD Agents Dexedrine (dextroamphetamine extended-release) 5 mg extended-release capsule 3 capsule(s) 1 ADHD Agents Dexedrine (dextroamphetamine extended-release) 10 mg extended-release capsule 4 capsule(s) 1 ADHD Agents Dexedrine (dextroamphetamine extended-release) 15 mg extended-release capsule 4 capsule(s) 1 ADHD Agents dextroamphetamine 5 mg tablet 3 tablet(s) 1 ADHD Agents dextroamphetamine 10 mg tablet 6 tablet(s) 1 ADHD Agents Dyanavel XR (amphetamine XR) 2.5 mg/mL suspension 8 mL(s) 1 ADHD Agents Evekeo (amphetamine) 5 mg tablet 3 tablet(s) 1 ADHD Agents Evekeo (amphetamine) 10 mg tablet 6 tablet(s) 1 ADHD Agents Evekeo ODT (amphetamine) 5 mg orally disintegrating tablet 2 tablet(s) 1 ADHD Agents Evekeo ODT (amphetamine) 10 mg orally disintegrating tablet 2 tablet(s) 1 ADHD Agents Evekeo ODT (amphetamine) 15 mg orally disintegrating tablet 2 tablet(s) 1 ADHD Agents Evekeo ODT (amphetamine) 20 mg orally disintegrating tablet 2 tablet(s) 1 ADHD Agents Focalin (dexmethylphenidate) 2.5 mg tablet 2 tablet(s) 1 ADHD Agents Focalin (dexmethylphenidate) 5 mg tablet 2 tablet(s) 1 ADHD Agents Focalin (dexmethylphenidate) 10 mg tablet 2 tablet(s) 1 ADHD Agents Focalin XR (dexmethylphenidate extended-release) 5 mg capsule 1 capsule(s) 1 ADHD Agents Focalin XR (dexmethylphenidate extended-release) 10 mg capsule 1 capsule(s) 1 ADHD Agents Focalin XR (dexmethylphenidate extended-release) 15 mg capsule 1 capsule(s) 1 ADHD Agents Focalin XR (dexmethylphenidate extended-release) 20 mg capsule 1 capsule(s) 1 ADHD Agents Focalin XR (dexmethylphenidate extended-release) 25 mg capsule 1 capsule(s) 1 ADHD Agents Focalin XR (dexmethylphenidate extended-release) 30 mg capsule 1 capsule(s) 1 ADHD Agents Focalin XR (dexmethylphenidate extended-release) 35 mg capsule 1 capsule(s) 1 ADHD Agents Focalin XR (dexmethylphenidate extended-release) 40 mg capsule 1 capsule(s) 1 ADHD Agents Intuniv (guanfacine extended-release) 1 mg ER tablet 1 tablet(s) 1 ADHD Agents Intuniv (guanfacine extended-release) 2 mg ER tablet 1 tablet(s) 1 ADHD Agents Intuniv (guanfacine extended-release) 3 mg ER tablet 1 tablet(s) 1 ADHD Agents Intuniv (guanfacine extended-release) 4 mg ER tablet 1 tablet(s) 1 ADHD Agents Jornay PM (methylphenidate extended-release) 20 mg ER capsule 1 capsule(s) 1 ADHD Agents Jornay PM (methylphenidate extended-release) 40 mg ER capsule 1 capsule(s) 1 ADHD Agents Jornay PM (methylphenidate extended-release) 60 mg ER capsule 1 capsule(s) 1 ADHD Agents Jornay PM (methylphenidate extended-release) 80 mg ER capsule 1 capsule(s) 1 ADHD Agents Jornay PM (methylphenidate extended-release) 100 mg ER capsule 1 capsule(s) 1 ADHD Agents Kapvay (clonidine extended-release) 0.1 mg ER tablet 4 tablet(s) 1 ADHD Agents Metadate CD (methylphenidate ER) 10 mg capsule 1 capsule(s) 1

Program Target Agent Dosage/Strength Quantity Unit Days

Note: Quantity limits apply to all available MultiSource Code (MSC) products

ADHD Agents Metadate CD (methylphenidate ER) 20 mg capsule 1 capsule(s) 1 ADHD Agents Metadate CD (methylphenidate ER) 30 mg capsule 1 capsule(s) 1 ADHD Agents Metadate CD (methylphenidate ER) 40 mg capsule 1 capsule(s) 1 ADHD Agents Metadate CD (methylphenidate ER) 50 mg capsule 1 capsule(s) 1 ADHD Agents Metadate CD (methylphenidate ER) 60 mg capsule 1 capsule(s) 1 ADHD Agents Metadate ER (methylphenidate ER) 20 mg tablet 3 tablet(s) 1 ADHD Agents Methylin, Methylphenidate Chewable Tablet 2.5 mg chewable tablet 3 tablet(s) 1 ADHD Agents Methylin, Methylphenidate Chewable Tablet 5 mg chewable tablet 3 tablet(s) 1 ADHD Agents Methylin, Methylphenidate Chewable Tablet 10 mg chewable tablet 6 tablet(s) 1 ADHD Agents Methylin (methylphenidate) 5 mg/5 mL solution 15 mL(s) 1 ADHD Agents Methylin (methylphenidate) 10 mg/5 mL solution 30 mL(s) 1 ADHD Agents methylphenidate ER 10 mg tablet 3 tablet(s) 1 ADHD Agents methylphenidate ER 20 mg tablet 3 tablet(s) 1 ADHD Agents methylphenidate ER 18 mg tablet 1 tablet(s) 1 ADHD Agents methylphenidate ER 27 mg tablet 1 tablet(s) 1 ADHD Agents methylphenidate ER 36 mg tablet 2 tablet(s) 1 ADHD Agents methylphenidate ER 54 mg tablet 1 tablet(s) 1 ADHD Agents methylphenidate ER 72 mg tablet 1 tablet(s) 1 ADHD Agents Mydayis 12.5 mg capsule 1 capsule(s) 1 ADHD Agents Mydayis 25 mg capsule 1 capsule(s) 1 ADHD Agents Mydayis 37.5 mg capsule 1 capsule(s) 1 ADHD Agents Mydayis 50 mg capsule 1 capsule(s) 1 ADHD Agents Procentra (dextroamphetamine) 5 mg/5 mL oral solution 60 mL(s) 1 ADHD Agents Quillichew (methylphenidate ER chewable) 20 mg 1 tablet(s) 1 ADHD Agents Quillichew (methylphenidate ER chewable) 30 mg 2 tablet(s) 1 ADHD Agents Quillichew (methylphenidate ER chewable) 40 mg 1 tablet(s) 1 ADHD Agents Quillivant XR (methylphenidate ER) 25 mg/5 mL oral suspension 12 mL(s) 1 ADHD Agents Relexxii (methylphenidate ER) 72 mg tablet 1 tablet(s) 1 ADHD Agents Ritalin (methylphenidate) 5 mg tablet 3 tablet(s) 1 ADHD Agents Ritalin (methylphenidate) 10 mg tablet 3 tablet(s) 1 ADHD Agents Ritalin (methylphenidate) 20 mg tablet 3 tablet(s) 1 ADHD Agents Ritalin LA (methylphenidate ER) 10 mg capsule 1 capsule(s) 1 ADHD Agents Ritalin LA (methylphenidate ER) 20 mg capsule 1 capsule(s) 1 ADHD Agents Ritalin LA (methylphenidate ER) 30 mg capsule 1 capsule(s) 1 ADHD Agents Ritalin LA (methylphenidate ER) 40 mg capsule 1 capsule(s) 1 ADHD Agents Ritalin LA (methylphenidate ER) 60 mg capsule 1 capsule(s) 1 ADHD Agents Strattera (atomoxetine) 10 mg capsule 2 capsule(s) 1 ADHD Agents Strattera (atomoxetine) 18 mg capsule 2 capsule(s) 1 ADHD Agents Strattera (atomoxetine) 25 mg capsule 2 capsule(s) 1 ADHD Agents Strattera (atomoxetine) 40 mg capsule 2 capsule(s) 1 ADHD Agents Strattera (atomoxetine) 60 mg capsule 1 capsule(s) 1 ADHD Agents Strattera (atomoxetine) 80 mg capsule 1 capsule(s) 1 ADHD Agents Strattera (atomoxetine) 100 mg capsule 1 capsule(s) 1 ADHD Agents Vyvanse (lisdexamfetamine) 10 mg capsule 1 capsule(s) 1 ADHD Agents Vyvanse (lisdexamfetamine) 20 mg capsule 1 capsule(s) 1 ADHD Agents Vyvanse (lisdexamfetamine) 30 mg capsule 1 capsule(s) 1 ADHD Agents Vyvanse (lisdexamfetamine) 40 mg capsule 1 capsule(s) 1

Program Target Agent Dosage/Strength Quantity Unit Days

Note: Quantity limits apply to all available MultiSource Code (MSC) products

ADHD Agents Vyvanse (lisdexamfetamine) 50 mg capsule 1 capsule(s) 1 ADHD Agents Vyvanse (lisdexamfetamine) 60 mg capsule 1 capsule(s) 1 ADHD Agents Vyvanse (lisdexamfetamine) 70 mg capsule 1 capsule(s) 1 ADHD Agents Vyvanse chewable (lisdexamfetamine) 10 mg chewable tablet 1 tablet(s) 1 ADHD Agents Vyvanse chewable (lisdexamfetamine) 20 mg chewable tablet 1 tablet(s) 1 ADHD Agents Vyvanse chewable (lisdexamfetamine) 30 mg chewable tablet 1 tablet(s) 1 ADHD Agents Vyvanse chewable (lisdexamfetamine) 40 mg chewable tablet 1 tablet(s) 1 ADHD Agents Vyvanse chewable (lisdexamfetamine) 50 mg chewable tablet 1 tablet(s) 1 ADHD Agents Vyvanse chewable (lisdexamfetamine) 60 mg chewable tablet 1 tablet(s) 1 ADHD Agents Zenzedi (dextroamphetamine) 2.5 mg tablet 3 tablet(s) 1 ADHD Agents Zenzedi (dextroamphetamine) 7.5 mg tablet 3 tablet(s) 1 ADHD Agents Zenzedi (dextroamphetamine) 15 mg tablet 3 tablet(s) 1 ADHD Agents Zenzedi (dextroamphetamine) 20 mg tablet 3 tablet(s) 1 ADHD Agents Zenzedi (dextroamphetamine) 30 mg tablet 2 tablet(s) 1 Ampyra *(QL applies to Comm and HIM) Ampyra Ampyra (dalfampridine) 10 mg tablet 2 tablet(s) 30 Androgens and Anabolic Steroids *(QL applies to Comm and HIM) Androgens and Anabolic Steroids Androderm (testosterone transdermal system) 2 mg/day transdermal system 1 patch(es) 1 Androgens and Anabolic Steroids Androderm (testosterone transdermal system) 4 mg/day transdermal system 1 patch(es) 1 Androgens and Anabolic Steroids AndroGel, Testosterone Gel (testosterone gel) 1% gel, 25 mg/2.5 gm packet 2 packet(s) 1 Androgens and Anabolic Steroids AndroGel, Testosterone Gel (testosterone gel) 1% gel, 50 mg/5 gm packet 2 packet(s) 1 Androgens and Anabolic Steroids Testosterone Gel 1% gel, 75 gm pump bottle 4 pump bottle(s) 30 Androgens and Anabolic Steroids AndroGel (testosterone gel) 1.62% gel, 20.25 mg/1.25 gm packet 1 packet(s) 1 Androgens and Anabolic Steroids AndroGel (testosterone gel) 1.62% gel, 40.5 mg/2.5 gm packet 2 packet(s) 1 Androgens and Anabolic Steroids AndroGel (testosterone gel) 1.62% gel, 75 gm pump bottle 2 pump bottle(s) 30 Androgens and Anabolic Steroids Axiron (testosterone solution) 30 mg/1.5 mL, 90 mL pump bottle 2 pump bottle(s) 30 Androgens and Anabolic Steroids Fortesta (testosterone gel) 2% gel, 60 gm pump bottle 2 pump bottle(s) 30 Androgens and Anabolic Steroids Natesto, Testosterone nasal gel 5.5 mg/actuation, 11 gm pump bottle (60 actuations/pump bottle) 3 pump bottle(s) 30 Androgens and Anabolic Steroids Striant (testosterone buccal system) 30 mg buccal system 2 system(s) 1 Androgens and Anabolic Steroids Testim (testosterone gel) 1% gel, 5 gm tube 2 tube(S) 1 Androgens and Anabolic Steroids Vogelxo (testosterone gel) 1% gel, 50 mg/5 gm tube 2 tube(S) 1 Androgens and Anabolic Steroids Vogelxo (testosterone gel) 1% gel, 50 mg/5 gm packet 2 tube(S) 1 Androgens and Anabolic Steroids Vogelxo (testosterone gel) 1% gel, 12.5 mg/actuation, 75 gm pump bottle (carton of 2 pump 4 pump bottle(s) 30 Androgens and Anabolic Steroids Aveed (testosterone undeconoate) 250bottles) mg/mL; 3 mL vial 1 vial(s) 28 Androgens and Anabolic Steroids testosterone enanthate 200 mg/mL, 5 mL multiple dose vial 1 vial(s) 28 Androgens and Anabolic Steroids Xyosted (testosterone enanthate) 50 mg/0.5 mL 4 autoinjector(s) 28 Androgens and Anabolic Steroids Xyosted (testosterone enanthate) 75 mg/0.5 mL 4 autoinjector(s) 28 Androgens and Anabolic Steroids Xyosted (testosterone enanthate) 100 mg/0.5 mL 4 autoinjector(s) 28 Androgens and Anabolic Steroids Depo-Testosterone (testosterone cypionate) 100 mg/mL, 10 mL multiple dose vial 1 vial(s) 28 Androgens and Anabolic Steroids Depo-Testosterone (testosterone cypionate) 200 mg/mL, 1 mL vial 10 vial(s) 28 Androgens and Anabolic Steroids Depo-Testosterone (testosterone cypionate) 200 mg/mL, 10 mL multiple dose vial 1 vial(s) 28 Androgens and Anabolic Steroids Depo-Testosterone (testosterone cypionate) 200 mg/mL, 30 mL vial 1 vial(s) 84 Androgens and Anabolic Steroids Testopel (testosterone pellets) 75 mg 6 pellet(s) 90 Androgens and Anabolic Steroids Android (methyltestosterone) 10 mg capsule 20 capsule(s) 1 Androgens and Anabolic Steroids Androxy (fluoxymesterone) 10 mg tablet 4 tablet(s) 1

Program Target Agent Dosage/Strength Quantity Unit Days

Note: Quantity limits apply to all available MultiSource Code (MSC) products

Androgens and Anabolic Steroids Jatenzo (testosterone) 158 mg capsule 2 capsule(s) 1 Androgens and Anabolic Steroids Jatenzo (testosterone) 198 mg capsule 4 capsule(s) 1 Androgens and Anabolic Steroids Jatenzo (testosterone) 237 mg capsule 2 capsule(s) 1 Androgens and Anabolic Steroids Methitest (methyltestosterone) 10 mg tablet 20 capsule(s) 1 Androgens and Anabolic Steroids Testred (methyltestosterone)b 10 mg capsule 20 capsule(s) 1 Antidepressants *(QL applies to Comm, HIM, NR A and NR F) Antidepressants Celexa (citalopram) 10 mg tablet 1 tablet(s) 1 Antidepressants Celexa (citalopram) 20 mg tablet 1 tablet(s) 1 Antidepressants Celexa (citalopram) 40 mg tablet 1 tablet(s) 1 Antidepressants Celexa (citalopram) 10 mg/5 mL oral solution 20 mL(s) 1 Antidepressants Lexapro (escitalopram) 5 mg tablet 1 tablet(s) 1 Antidepressants Lexapro (escitalopram) 10 mg tablet 1 tablet(s) 1 Antidepressants Lexapro (escitalopram) 20 mg tablet 1 tablet(s) 1 Antidepressants Lexapro (escitalopram) 5 mg/5 mL oral solution 20 mL(s) 1 Antidepressants fluvoxamine ER 100 mg extended-release capsule 2 capsule(s) 1 Antidepressants fluvoxamine ER 150 mg extended-release capsule 2 capsule(s) 1 Antidepressants fluvoxamine 25 mg tablet 1 tablet(s) 1 Antidepressants fluvoxamine 50 mg tablet 1 tablet(s) 1 Antidepressants fluvoxamine 100 mg tablet 3 tablet(s) 1 Antidepressants Paxil (paroxetine) 10 mg tablet 1 tablet(s) 1 Antidepressants Paxil (paroxetine) 20 mg tablet 1 tablet(s) 1 Antidepressants Paxil (paroxetine) 30 mg tablet 2 tablet(s) 1 Antidepressants Paxil (paroxetine) 40 mg tablet 1 tablet(s) 1 Antidepressants Paxil (paroxetine) 10 mg/5 mL suspension 30 mL(s) 1 Antidepressants Paxil CR (paroxetine ER) 12.5 mg controlled-release tablet 1 tablet(s) 1 Antidepressants Paxil CR (paroxetine ER) 25 mg controlled-release tablet 2 tablet(s) 1 Antidepressants Paxil CR (paroxetine ER) 37.5 mg controlled-release tablet 2 tablet(s) 1 Antidepressants Pexeva (paroxetine) 10 mg tablet 1 tablet(s) 1 Antidepressants Pexeva (paroxetine) 20 mg tablet 1 tablet(s) 1 Antidepressants Pexeva (paroxetine) 30 mg tablet 2 tablet(s) 1 Antidepressants Pexeva (paroxetine) 40 mg tablet 1 tablet(s) 1 Antidepressants Prozac, (fluoxetine) 10 mg capsule 1 capsule(s) 1 Antidepressants Prozac, (fluoxetine) 20 mg capsule 4 capsule(s) 1 Antidepressants Prozac, (fluoxetine) 40 mg capsule 2 capsule(s) 1 Antidepressants Prozac, (fluoxetine) 10 mg tablet 1 tablet(s) 1 Antidepressants Prozac, (fluoxetine) 20 mg tablet 4 tablet(s) 1 Antidepressants Prozac, (fluoxetine) 60 mg tablet 1 tablet(s) 1 Antidepressants Prozac, (fluoxetine) 20 mg/5 mL oral solution 20 mL(s) 1 Antidepressants Prozac Weekly (fluoxetine) 90 mg delayed-release capsule 4 capsule(s) 28 Antidepressants Zoloft (sertraline) 25 mg tablet 1 tablet(s) 1 Antidepressants Zoloft (sertraline) 50 mg tablet 1 tablet(s) 1 Antidepressants Zoloft (sertraline) 100 mg tablet 2 tablet(s) 1 Antidepressants Zoloft (sertraline) 20 mg/mL oral concentrate 10 mL(s) 1 Antidepressants Cymbalta (duloxetine) 20 mg delayed-release capsule 2 capsule(s) 1 Antidepressants Cymbalta (duloxetine) 30 mg delayed-release capsule 2 capsule(s) 1

Program Target Agent Dosage/Strength Quantity Unit Days

Note: Quantity limits apply to all available MultiSource Code (MSC) products

Antidepressants Cymbalta (duloxetine) 60 mg delayed-release capsule 2 capsule(s) 1 Antidepressants Desvenlafaxine 50 mg extended-release tablet 1 tablet(s) 1 Antidepressants Desvenlafaxine 100 mg extended-release tablet 1 tablet(s) 1 Antidepressants Desvenlafaxine fumarate 50 mg extended-release tablet 1 tablet(s) 1 Antidepressants Desvenlafaxine fumarate 100 mg extended-release tablet 1 tablet(s) 1 Antidepressants Drizalma Sprinkle 20 mg delayed release sprinkle capsule 2 capsule(s) 1 Antidepressants Drizalma Sprinkle 30 mg delayed release sprinkle capsule 2 capsule(s) 1 Antidepressants Drizalma Sprinkle 40 mg delayed release sprinkle capsule 2 capsule(s) 1 Antidepressants Drizalma Sprinkle 60 mg delayed release sprinkle capsule 2 capsule(s) 1 Antidepressants Duloxetine delayed release 40 mg delayed release capsule 3 capsule(s) 1 Antidepressants Effexor (venlafaxine) 37.5 mg tablet 3 tablet(s) 1 Antidepressants Effexor (venlafaxine) 50 mg tablet 3 tablet(s) 1 Antidepressants Effexor (venlafaxine) 75 mg tablet 3 tablet(s) 1 Antidepressants Effexor (venlafaxine) 100 mg tablet 3 tablet(s) 1 Antidepressants Effexor XR (venlafaxine ER) 37.5 mg extended-release capsule 1 capsule(s) 1 Antidepressants Effexor XR (venlafaxine ER) 75 mg extended-release capsule 3 capsule(s) 1 Antidepressants Effexor XR (venlafaxine ER) 150 mg extended-release capsule 1 capsule(s) 1 Antidepressants Fetzima (levomilnacipran) 20 mg extended-release capsule 1 capsule(s) 1 Antidepressants Fetzima (levomilnacipran) 40 mg extended-release capsule 1 capsule(s) 1 Antidepressants Fetzima (levomilnacipran) 80 mg extended-release capsule 1 capsule(s) 1 Antidepressants Fetzima (levomilnacipran) 120 mg extended-release capsule 1 capsule(s) 1 Antidepressants Fetzima (levomilnacipran) Titration pack (2 x 20 mg, 26 x 40 mg) 1 kit(s) 180 Antidepressants Khedezla (desvenlafaxine) 50 mg extended-release tablet 1 tablet(s) 1 Antidepressants Khedezla (desvenlafaxine) 100 mg extended-release tablet 1 tablet(s) 1 Antidepressants duloxetine 40 mg delayed release capsule 3 capsule(s) 1 Antidepressants Venlafaxine ER 37.5 mg extended-release tablet 1 tablet(s) 1 Antidepressants Venlafaxine ER 75 mg extended-release tablet 3 tablet(s) 1 Antidepressants Venlafaxine ER 150 mg extended-release tablet 1 tablet(s) 1 Antidepressants Venlafaxine ER 225 mg extended-release tablet 1 tablet(s) 1 Antidepressants Pristiq (desvenlafaxine) 25 mg extended-release tablet 1 tablet(s) 1 Antidepressants Pristiq (desvenlafaxine) 50 mg extended-release tablet 1 tablet(s) 1 Antidepressants Pristiq (desvenlafaxine) 100 mg extended-release tablet 1 tablet(s) 1 Antidepressants Aplenzin (bupropion) 174 mg extended-release tablet 1 tablet(s) 1 Antidepressants Aplenzin (bupropion) 348 mg extended-release tablet 1 tablet(s) 1 Antidepressants Aplenzin (bupropion) 522 mg extended-release tablet 1 tablet(s) 1 Antidepressants Trintellix (vortioxetine) 5 mg tablet 1 tablet(s) 1 Antidepressants Trintellix (vortioxetine) 10 mg tablet 1 tablet(s) 1 Antidepressants Trintellix (vortioxetine) 20 mg tablet 1 tablet(s) 1 Antidepressants Forfivo XL (bupropion) 450 mg extended-release tablet 1 tablet(s) 1 Antidepressants Maprotiline 25 mg tablet 3 tablet(s) 1 Antidepressants Maprotiline 50 mg tablet 3 tablet(s) 1 Antidepressants Maprotiline 75 mg tablet 3 tablet(s) 1 Antidepressants Remeron (mirtazapine) 7.5 mg tablet 1 tablet(s) 1 Antidepressants Remeron (mirtazapine) 15 mg tablet 1 tablet(s) 1 Antidepressants Remeron (mirtazapine) 30 mg tablet 1 tablet(s) 1 Antidepressants Remeron (mirtazapine) 45 mg tablet 1 tablet(s) 1 Antidepressants Remeron SolTab (mirtazapine) 15 mg orally-disintegrating tablet 1 tablet(s) 1

Program Target Agent Dosage/Strength Quantity Unit Days

Note: Quantity limits apply to all available MultiSource Code (MSC) products

Antidepressants Remeron SolTab (mirtazapine) 30 mg orally-disintegrating tablet 1 tablet(s) 1 Antidepressants Remeron SolTab (mirtazapine) 45 mg orally-disintegrating tablet 1 tablet(s) 1 Antidepressants Viibryd (vilazodone) 10 mg tablet 1 tablet(s) 1 Antidepressants Viibryd (vilazodone) 20 mg tablet 1 tablet(s) 1 Antidepressants Viibryd (vilazodone) 40 mg tablet 1 tablet(s) 1 Antidepressants Viibryd (vilazodone) Starter Kit (7 x 10mg, 23 x 20mg) 1 kit(s) 180 Antidepressants Wellbutrin (bupropion) 75 mg tablet 2 tablet(s) 1 Antidepressants Wellbutrin (bupropion) 100 mg tablet 4 tablet(s) 1 Antidepressants Wellbutrin SR, Budeprion SR (bupropion SR) 100 mg sustained-release tablet 2 tablet(s) 1 Antidepressants Wellbutrin SR, Budeprion SR (bupropion SR) 150 mg sustained-release tablet 2 tablet(s) 1 Antidepressants Wellbutrin SR, Budeprion SR (bupropion SR) 200 mg sustained-release tablet 2 tablet(s) 1 Antidepressants Wellbutrin XL, Budeprion XL (bupropion ER) 150 mg extended-release tablet 1 tablet(s) 1 Antidepressants Wellbutrin XL, Budeprion XL (bupropion ER) 300 mg extended-release tablet 1 tablet(s) 1 Antipsychotics, Atypical *(QL applies to Comm, HIM, NR A and NR F) Antipsychotics, Atypical Abilify (aripiprazole) 2 mg tablet 1 tablet(s) 1 Antipsychotics, Atypical Abilify (aripiprazole) 5 mg tablet 1 tablet(s) 1 Antipsychotics, Atypical Abilify (aripiprazole) 10 mg tablet 1 tablet(s) 1 Antipsychotics, Atypical Abilify (aripiprazole) 15 mg tablet 1 tablet(s) 1 Antipsychotics, Atypical Abilify (aripiprazole) 20 mg tablet 1 tablet(s) 1 Antipsychotics, Atypical Abilify (aripiprazole) 30 mg tablet 1 tablet(s) 1 Antipsychotics, Atypical aripiprazole 1 mg/mL oral solution 30 mL(s) 1 Antipsychotics, Atypical aripiprazole 10 mg orally disintegrating tablet 2 tablet(s) 1 Antipsychotics, Atypical aripiprazole 15 mg orally disintegrating tablet 2 tablet(s) 1 Antipsychotics, Atypical Abilify Maintena (aripiprazole extended release) 300 mg reconstituted suspension vial 1 vial(s) 28 Antipsychotics, Atypical Abilify Maintena (aripiprazole extended release) 300 mg suspension syringe 1 syringe(s) 28 Antipsychotics, Atypical Abilify Maintena (aripiprazole extended release) 400 mg reconstituted suspension vial 1 vial(s) 28 Antipsychotics, Atypical Abilify Maintena (aripiprazole extended release) 400 mg suspension syringe 1 syringe(s) 28 Antipsychotics, Atypical Abilify Mycite (aripiprazole with sensor) 2 mg tablet 1 tablet(s) 1 Antipsychotics, Atypical Abilify Mycite (aripiprazole with sensor) 5 mg tablet 1 tablet(s) 1 Antipsychotics, Atypical Abilify Mycite (aripiprazole with sensor) 10 mg tablet 1 tablet(s) 1 Antipsychotics, Atypical Abilify Mycite (aripiprazole with sensor) 15 mg tablet 1 tablet(s) 1 Antipsychotics, Atypical Abilify Mycite (aripiprazole with sensor) 20 mg tablet 1 tablet(s) 1 Antipsychotics, Atypical Abilify Mycite (aripiprazole with sensor) 30 mg tablet 1 tablet(s) 1 Antipsychotics, Atypical Aristada (aripiprazole lauroxil injection) 441 mg injection 1 syringe(s) 28 Antipsychotics, Atypical Aristada (aripiprazole lauroxil injection) 662 mg injection 1 syringe(s) 28 Antipsychotics, Atypical Aristada (aripiprazole lauroxil injection) 882 mg injection 1 syringe(s) 28 Antipsychotics, Atypical Aristada (aripiprazole lauroxil injection) 1064 mg injection 1 syringe(s) 56 Antipsychotics, Atypical Aristada Initio (aripiprazole lauroxil extended-release injection) 675 mg injection 1 kit(s) 180 Antipsychotics, Atypical Caplyta (lumataperone) 42 mg capsule 1 capsule(s) 1 Antipsychotics, Atypical Clozaril (clozapine) 25 mg tablet 3 tablet(s) 30 Antipsychotics, Atypical Clozaril (clozapine) 50 mg tablet 3 tablet(s) 1 Antipsychotics, Atypical Clozaril (clozapine) 100 mg tablet 9 tablet(s) 1 Antipsychotics, Atypical Clozaril (clozapine) 200 mg tablet 4 tablet(s) 1 Antipsychotics, Atypical Fanapt (iloperidone) 1 mg tablet 2 tablet(s) 1 Antipsychotics, Atypical Fanapt (iloperidone) 2 mg tablet 2 tablet(s) 1 Antipsychotics, Atypical Fanapt (iloperidone) 4 mg tablet 2 tablet(s) 1

Program Target Agent Dosage/Strength Quantity Unit Days

Note: Quantity limits apply to all available MultiSource Code (MSC) products

Antipsychotics, Atypical Fanapt (iloperidone) 6 mg tablet 2 tablet(s) 1 Antipsychotics, Atypical Fanapt (iloperidone) 8 mg tablet 2 tablet(s) 1 Antipsychotics, Atypical Fanapt (iloperidone) 10 mg tablet 2 tablet(s) 1 Antipsychotics, Atypical Fanapt (iloperidone) 12 mg tablet 2 tablet(s) 1 Antipsychotics, Atypical Fanapt (iloperidone) Titration pak 1 pack(s) 180 Antipsychotics, Atypical FazaClo (clozapine) 12.5 mg orally disintegrating tablet 3 tablet(s) 1 Antipsychotics, Atypical FazaClo (clozapine) 25 mg orally disintegrating tablet 9 tablet(s) 1 Antipsychotics, Atypical FazaClo (clozapine) 100 mg orally disintegrating tablet 3 tablet(s) 1 Antipsychotics, Atypical FazaClo (clozapine) 150 mg orally disintegrating tablet 6 tablet(s) 1 Antipsychotics, Atypical FazaClo (clozapine) 200 mg orally disintegrating tablet 4 tablet(s) 1 Antipsychotics, Atypical Geodon (ziprasidone) 20 mg capsule 2 capsule(s) 1 Antipsychotics, Atypical Geodon (ziprasidone) 40 mg capsule 2 capsule(s) 1 Antipsychotics, Atypical Geodon (ziprasidone) 60 mg capsule 2 capsule(s) 1 Antipsychotics, Atypical Geodon (ziprasidone) 80 mg capsule 2 capsule(s) 1 Antipsychotics, Atypical Geodon (ziprasidone) 20 mg/mL injection 2 vial(s) 1 Antipsychotics, Atypical Invega (paliperidone) 1.5 mg tablet 1 tablet(s) 1 Antipsychotics, Atypical Invega (paliperidone) 3 mg tablet 1 tablet(s) 1 Antipsychotics, Atypical Invega (paliperidone) 6 mg tablet 2 tablet(s) 1 Antipsychotics, Atypical Invega (paliperidone) 9 mg tablet 1 tablet(s) 1 Antipsychotics, Atypical Invega Trinza (paliperidone) 273 mg / 0.875 mL 1 syringe(s) 90 Antipsychotics, Atypical Invega Trinza (paliperidone) 410 mg / 1.315 mL 1 syringe(s) 90 Antipsychotics, Atypical Invega Trinza (paliperidone) 546 mg / 1.75 mL 1 syringe(s) 90 Antipsychotics, Atypical Invega Trinza (paliperidone) 819 mg / 2.625 mL 1 syringe(s) 90 Antipsychotics, Atypical Invega Sustenna (paliperidone) 39 mg/kit extended-release injection 1 kit(s) 28 Antipsychotics, Atypical Invega Sustenna (paliperidone) 78 mg/kit extended-release injection 1 kit(s) 28 Antipsychotics, Atypical Invega Sustenna (paliperidone) 117 mg/kit extended-release injection 1 kit(s) 28 Antipsychotics, Atypical Invega Sustenna (paliperidone) 156 mg/kit extended-release injection 1 kit(s) 28 Antipsychotics, Atypical Invega Sustenna (paliperidone) 234 mg/kit extended-release injection 1 kit(s) 28 Antipsychotics, Atypical Latuda (lurasidone) 20 mg tablet 1 tablet(s) 1 Antipsychotics, Atypical Latuda (lurasidone) 40 mg tablet 1 tablet(s) 1 Antipsychotics, Atypical Latuda (lurasidone) 60 mg tablet 1 tablet(s) 1 Antipsychotics, Atypical Latuda (lurasidone) 80 mg tablet 2 tablet(s) 1 Antipsychotics, Atypical Latuda (lurasidone) 120 mg tablet 1 tablet(s) 1 Antipsychotics, Atypical Perseris (risperidone) 90 mg kit extended-release injection 1 kit(s) 30 Antipsychotics, Atypical Perseris (risperidone) 120 mg kit extended-release injection 1 kit(s) 30 Antipsychotics, Atypical Rexulti (brexpiprazole) 0.25 mg tablet 1 tablet(s) 1 Antipsychotics, Atypical Rexulti (brexpiprazole) 0.5 mg tablet 1 tablet(s) 1 Antipsychotics, Atypical Rexulti (brexpiprazole) 1 mg tablet 1 tablet(s) 1 Antipsychotics, Atypical Rexulti (brexpiprazole) 2 mg tablet 1 tablet(s) 1 Antipsychotics, Atypical Rexulti (brexpiprazole) 3 mg tablet 1 tablet(s) 1 Antipsychotics, Atypical Rexulti (brexpiprazole) 4 mg tablet 1 tablet(s) 1 Antipsychotics, Atypical Risperdal (risperidone) 0.25 mg tablet 2 tablet(s) 1 Antipsychotics, Atypical Risperdal (risperidone) 0.5 mg tablet 2 tablet(s) 1 Antipsychotics, Atypical Risperdal (risperidone) 1 mg tablet 2 tablet(s) 1 Antipsychotics, Atypical Risperdal (risperidone) 2 mg tablet 2 tablet(s) 1 Antipsychotics, Atypical Risperdal (risperidone) 3 mg tablet 2 tablet(s) 1 Antipsychotics, Atypical Risperdal (risperidone) 4 mg tablet 4 tablet(s) 1

Program Target Agent Dosage/Strength Quantity Unit Days

Note: Quantity limits apply to all available MultiSource Code (MSC) products

Antipsychotics, Atypical Risperdal (risperidone) 1 mg/mL oral solution 16 mL(s) 1 Antipsychotics, Atypical risperidone 0.25 mg orally disintegrating tablet 2 tablet(s) 1 Antipsychotics, Atypical Risperdal M-Tab (risperidone) 0.5 mg orally disintegrating tablet 2 tablet(s) 1 Antipsychotics, Atypical Risperdal M-Tab (risperidone) 1 mg orally disintegrating tablet 2 tablet(s) 1 Antipsychotics, Atypical risperidone 2 mg orally disintegrating tablet 2 tablet(s) 1 Antipsychotics, Atypical Risperdal M-Tab (risperidone) 3 mg orally disintegrating tablet 2 tablet(s) 1 Antipsychotics, Atypical Risperdal M-Tab (risperidone) 4 mg orally disintegrating tablet 4 tablet(s) 1 Antipsychotics, Atypical Risperdal Consta (risperidone) 12.5 mg/vial long-acting injection 2 vial(s) 28 Antipsychotics, Atypical Risperdal Consta (risperidone) 25 mg/vial long-acting injection 2 vial(s) 28 Antipsychotics, Atypical Risperdal Consta (risperidone) 37.5 mg/vial long-acting injection 2 vial(s) 28 Antipsychotics, Atypical Risperdal Consta (risperidone) 50 mg/vial long-acting injection 2 vial(s) 28 Antipsychotics, Atypical Saphris (asenapine) 2.5 mg sublingual tablet 2 tablet(s) 1 Antipsychotics, Atypical Saphris (asenapine) 5 mg sublingual tablet 2 tablet(s) 1 Antipsychotics, Atypical Saphris (asenapine) 10 mg sublingual tablet 2 tablet(s) 1 Antipsychotics, Atypical Secuado (asenapine) 3.8 mg/ 24hr transdermal patch 1 patch(es) 1 Antipsychotics, Atypical Secuado (asenapine) 5.7 mg/ 24hr transdermal patch 1 patch(es) 1 Antipsychotics, Atypical Secuado (asenapine) 7.6 mg/ 24hr transdermal patch 1 patch(es) 1 Antipsychotics, Atypical Seroquel (quetiapine) 25 mg tablet 3 tablet(s) 1 Antipsychotics, Atypical Seroquel (quetiapine) 50 mg tablet 3 tablet(s) 1 Antipsychotics, Atypical Seroquel (quetiapine) 100 mg tablet 3 tablet(s) 1 Antipsychotics, Atypical Seroquel (quetiapine) 200 mg tablet 3 tablet(s) 1 Antipsychotics, Atypical Seroquel (quetiapine) 300 mg tablet 2 tablet(s) 1 Antipsychotics, Atypical Seroquel (quetiapine) 400 mg tablet 2 tablet(s) 1 Antipsychotics, Atypical Seroquel XR (quetiapine) 50 mg extended-release tablet 2 tablet(s) 1 Antipsychotics, Atypical Seroquel XR (quetiapine) 150 mg extended-release tablet 1 tablet(s) 1 Antipsychotics, Atypical Seroquel XR (quetiapine) 200 mg extended-release tablet 1 tablet(s) 1 Antipsychotics, Atypical Seroquel XR (quetiapine) 300 mg extended-release tablet 2 tablet(s) 1 Antipsychotics, Atypical Seroquel XR (quetiapine) 400 mg extended-release tablet 2 tablet(s) 1 Antipsychotics, Atypical Versacloz (clozapine) 50 mg/mL oral suspension 18 mL(s) 1 Antipsychotics, Atypical Vraylar (cariprazine) 1.5 mg capsule 1 capsule(s) 1 Antipsychotics, Atypical Vraylar (cariprazine) 3 mg capsule 1 capsule(s) 1 Antipsychotics, Atypical Vraylar (cariprazine) 4.5 mg capsule 1 capsule(s) 1 Antipsychotics, Atypical Vraylar (cariprazine) 6 mg capsule 1 capsule(s) 1 Antipsychotics, Atypical Vraylar (cariprazine) Titration Therapy Pack 1 pack(s) 180 Antipsychotics, Atypical Zyprexa (olanzapine) 2.5 mg tablet 1 tablet(s) 1 Antipsychotics, Atypical Zyprexa (olanzapine) 5 mg tablet 1 tablet(s) 1 Antipsychotics, Atypical Zyprexa (olanzapine) 7.5 mg tablet 1 tablet(s) 1 Antipsychotics, Atypical Zyprexa (olanzapine) 10 mg tablet 1 tablet(s) 1 Antipsychotics, Atypical Zyprexa (olanzapine) 15 mg tablet 1 tablet(s) 1 Antipsychotics, Atypical Zyprexa (olanzapine) 20 mg tablet 1 tablet(s) 1 Antipsychotics, Atypical Zyprexa (olanzapine) 10 mg/vial injection 3 vial(s) 1 Antipsychotics, Atypical Zyprexa Zydis (olanzapine) 5 mg orally disintegrating tablet 1 tablet(s) 1 Antipsychotics, Atypical Zyprexa Zydis (olanzapine) 10 mg orally disintegrating tablet 1 tablet(s) 1 Antipsychotics, Atypical Zyprexa Zydis (olanzapine) 15 mg orally disintegrating tablet 1 tablet(s) 1 Antipsychotics, Atypical Zyprexa Zydis (olanzapine) 20 mg orally disintegrating tablet 1 tablet(s) 1 Antipsychotics, Atypical Zyprexa Relprevv (olanzapine) 210 mg vial extended-release injection 2 vial(s) 28 Antipsychotics, Atypical Zyprexa Relprevv (olanzapine) 300 mg vial extended-release injection 2 vial(s) 28

Program Target Agent Dosage/Strength Quantity Unit Days

Note: Quantity limits apply to all available MultiSource Code (MSC) products

Antipsychotics, Atypical Zyprexa Relprevv (olanzapine) 405 mg vial extended-release injection 1 vial(s) 28 Antiretroviral *(QL applies to NR A and NR F) Antiretroviral Aptivus (tipranavir) 100 mg/mL oral solution 380 mL(s) 30 Antiretroviral Aptivus (tipranavir) 250 mg capsule 4 capsule(s) 1 Antiretroviral Atripla (efavirenz/emtricitabine/tenofovir) 600 mg/200 mg/300 mg tablet 1 tablet(s) 1 Antiretroviral Biktarvy (bictegravir/emtricitabine/tenofovir) 50 mg/200 mg/25 mg tablet 1 tablet(s) 1 Antiretroviral Cimduo, Temixys (lamivudine/tenofovir) 300 mg/300 mg tablet 1 tablet(s) 1 Antiretroviral Combivir (lamivudine/zidovudine) 150 mg/300 mg tablet 2 tablet(s) 1 Antiretroviral Complera (emtricitabine/rilpivirine/tenofovir) 200 mg/25 mg/300 mg tablet 1 tablet(s) 1 Antiretroviral Crixivan (indinavir) 200 mg capsule 9 capsule(s) 1 Antiretroviral Crixivan (indinavir) 400 mg capsule 6 capsule(s) 1 Antiretroviral Delstrigo (doravirine/lamivudine/tenofovir) 100 mg/300 mg/300 mg 1 tablet(s) 1 Antiretroviral Descovy (emtricitabine/tenofovir) 200 mg / 25 mg tablet 1 tablet(s) 1 Antiretroviral Dovato (dolutegravir/lamivudine) 50 mg / 300 mg tablet 1 tablet(s) 1 Antiretroviral Edurant (rilpivirine) 25 mg tablet 1 tablet(s) 1 Antiretroviral Emtriva (emtricitabine) 10 mg/mL oral solution 680 mL(s) 28 Antiretroviral Emtriva (emtricitabine) 200 mg capsule 1 capsule(s) 1 Antiretroviral Epivir (lamivudine) 10 mg/mL oral solution 960 mL(s) 30 Antiretroviral Epivir (lamivudine) 150 mg tablet 2 tablet(s) 1 Antiretroviral Epivir (lamivudine) 300 mg tablet 1 tablet(s) 1 Antiretroviral Epzicom (lamivudine/abacavir) 600 mg/300 mg tablet 1 tablet(s) 1 Antiretroviral Evotaz (atazanavir/cobicistat) 300 mg/150 mg tablet 1 tablet(s) 1 Antiretroviral Fuzeon (enfuvirtide) 108 mg/vial (to deliver 90 mg/mL dose) 2 vial(s) 1 Antiretroviral Genvoya (elvitegravir/cobicistat/emtricitabine/tenofovir) 150 mg/150 mg/200 mg/ 10 mg tablet 1 tablet(s) 1 Antiretroviral Intelence (etravirine) 25 mg tablet 4 tablet(s) 1 Antiretroviral Intelence (etravirine) 100 mg tablet 2 tablet(s) 1 Antiretroviral Intelence (etravirine) 200 mg tablet 2 tablet(s) 1 Antiretroviral Invirase (saquinavir mesylate) 200 mg capsule 10 capsule(s) 1 Antiretroviral Invirase (saquinavir mesylate) 500 mg tablet 4 tablet(s) 1 Antiretroviral Isentress (raltegravir) 25 mg chewable tablets 6 tablet(s) 1 Antiretroviral Isentress (raltegravir) 100 mg chewable tablets 6 tablet(s) 1 Antiretroviral Isentress (raltegravir) 400 mg tablets 2 tablet(s) 1 Antiretroviral Isentress (raltegravir) 100 mg packet for suspension 2 packet(s) 1 Antiretroviral Isentress HD (raltegravir) 600 mg tablets 2 tablet(s) 1 Antiretroviral Juluca (dolutegravir/rilpivirine) 50 mg/25 mg tablets 1 tablet 1 Antiretroviral Kaletra (lopinavir/ritonavir) 80 mg/20 mg per mL oral solution 480 mL(s) 30 Antiretroviral Kaletra (lopinavir/ritonavir) 100 mg/25 mg tablet 6 tablet(s) 1 Antiretroviral Kaletra (lopinavir/ritonavir) 200 mg/50 mg tablet 4 tablet(s) 1 Antiretroviral Lexiva (fosamprenavir) 50 mg/mL oral suspension 1800 mL(s) 30 Antiretroviral Lexiva (fosamprenavir) 700 mg tablet 4 tablet(s) 1 Antiretroviral Norvir (ritonavir) 80 mg/mL oral solution 480 mL(s) 30 Antiretroviral Norvir (ritonavir) 100 mg capsule 12 capsule(s) 1 Antiretroviral Norvir (ritonavir) 100 mg tablet 12 tablet(s) 1 Antiretroviral Norvir (ritonavir) 100 mg powder packet 12 packet(s) 1 Antiretroviral Odefsey (emtricitabine/rilpivirine/tenofovir) 200 mg/25 mg/25 mg 1 tablet(s) 1 Antiretroviral Pifeltro (doravirine) 100 mg 1 tablet(s) 1

Program Target Agent Dosage/Strength Quantity Unit Days

Note: Quantity limits apply to all available MultiSource Code (MSC) products

Antiretroviral Prezcobix (darunavir/cobicistat) 800 mg/150 mg tablet 1 tablet(s) 1 Antiretroviral Prezista (darunavir) 100 mg/mL suspension 400 mL(s) 30 Antiretroviral Prezista (darunavir) 75 mg tablet 10 tablet(s) 1 Antiretroviral Prezista (darunavir) 150 mg tablet 6 tablet(s) 1 Antiretroviral Prezista (darunavir) 600 mg tablet 2 tablet(s) 1 Antiretroviral Prezista (darunavir) 800 mg tablet 1 tablet(s) 1 Antiretroviral Rescriptor (delavirdine) 100 mg tablet 12 tablet(s) 1 Antiretroviral Rescriptor (delavirdine) 200 mg tablet 6 tablet(s) 1 Antiretroviral Retrovir (zidovudine) 50 mg/5 mL syrup 1920 mL(s) 30 Antiretroviral Retrovir (zidovudine) 100 mg capsule 6 capsule(s) 1 Antiretroviral Reyataz (atazanavir) 150 mg capsule 1 capsule(s) 1 Antiretroviral Reyataz (atazanavir) 200 mg capsule 2 capsule(s) 1 Antiretroviral Reyataz (atazanavir) 300 mg capsule 1 capsule(s) 1 Antiretroviral Reyataz (atazanavir) 50 mg powder packet 8 packet(s) 1 Antiretroviral Selzentry (maraviroc) 20 mg/mL oral solution 61.334 mL(s) 1 Antiretroviral Selzentry (maraviroc) 25 mg tablet 8 tablet(s) 1 Antiretroviral Selzentry (maraviroc) 75 mg tablet 2 tablet(s) 1 Antiretroviral Selzentry (maraviroc) 150 mg tablet 2 tablet(s) 1 Antiretroviral Selzentry (maraviroc) 300 mg tablet 4 tablet(s) 1 Antiretroviral Stribild (elvitegravir/cobicistat/emtricitabine/tenofovir) 150 mg/150 mg/200 mg/300mg 1 tablet(s) 1 Antiretroviral Sustiva (efavirenz) 50 mg capsule 3 tablet(s) 1 Antiretroviral Sustiva (efavirenz) 200 mg capsule 2 tablet(s) 1 Antiretroviral Sustiva (efavirenz) 600 mg tablet 1 tablet(s) 1 Antiretroviral Symfi (efavirenz/lamivudine/tenofovir) 600 mg/300 mg/300mg 1 tablet(s) 1 Antiretroviral Symfi Lo (efavirenz/lamivudine/tenofovir) 400 mg/300 mg/300mg 1 tablet(s) 1 Antiretroviral Symtuza (darunavir/cobicistat/emtricitabine/tenofovir) 800 mg/150 mg/200 mg/10 mg 1 tablet(s) 1 Antiretroviral Temixys (lamivudine/tenofovir) 300 mg/300 mg tablet 1 tablet(s) 1 Antiretroviral Tivicay PD (dolutegravir) 5 mg tablet tablet(s) 1 Antiretroviral Tivicay (dolutegravir) 10 mg tablet 2 tablet(s) 1 Antiretroviral Tivicay (dolutegravir) 25 mg tablet 2 tablet(s) 1 Antiretroviral Tivicay (dolutegravir) 50 mg tablet 2 tablet(s) 1 Antiretroviral Triumeq (abacavir/dolutegravir/lamivudine) 600 mg/50 mg/300 mg tablet 1 tablet(s) 1 Antiretroviral Trizivir (abacavir/lamivudine/zidovudine) 300 mg/150 mg/300 mg tablet 2 tablet(s) 1 Antiretroviral Truvada (emtricitabine/tenofovir) 100/150 mg tablet 1 tablet(s) 1 Antiretroviral Truvada (emtricitabine/tenofovir) 133/200 mg tablet 1 tablet(s) 1 Antiretroviral Truvada (emtricitabine/tenofovir) 167/250 mg tablet 1 tablet(s) 1 Antiretroviral Truvada (emtricitabine/tenofovir) 200 mg/300 mg tablet 1 tablet(s) 1 Antiretroviral Tybost (cobicistat) 150 mg tablet 1 tablet(s) 1 Antiretroviral Videx (didanosine) 2 g powder (10 mg/mL) 1200 mL(s) 30 Antiretroviral Videx (didanosine) 4 g powder (10 mg/mL) 1200 mL(s) 30 Antiretroviral Videx EC (didanosine) 125 mg capsule 1 capsule(s) 1 Antiretroviral Videx EC (didanosine) 200 mg capsule 1 capsule(s) 1 Antiretroviral Videx EC (didanosine) 250 mg capsule 1 capsule(s) 1 Antiretroviral Videx EC (didanosine) 400 mg capsule 1 capsule(s) 1 Antiretroviral Viracept (nelfinavir) 250 mg tablet 9 tablet(s) 1 Antiretroviral Viracept (nelfinavir) 625 mg tablet 4 tablet(s) 1 Antiretroviral Viramune (nevirapine) 50 mg/5 mL suspension 1200 mL(s) 30

Program Target Agent Dosage/Strength Quantity Unit Days

Note: Quantity limits apply to all available MultiSource Code (MSC) products

Antiretroviral Viramune (nevirapine) 200 mg tablet 2 tablet(s) 1 Antiretroviral Viramune XR (nevirapine) 100 mg extended-release tablet 3 tablet(s) 1 Antiretroviral Viramune XR (nevirapine) 400 mg extended-release tablet 1 tablet(s) 1 Antiretroviral Viread (tenofovir) 150 mg tablet 1 tablet(s) 1 Antiretroviral Viread (tenofovir) 200 mg tablet 1 tablet(s) 1 Antiretroviral Viread (tenofovir) 250 mg tablet 1 tablet(s) 1 Antiretroviral Viread (tenofovir) 300 mg tablet 1 tablet(s) 1 Antiretroviral Viread (tenofovir) 40 mg/1g oral powder for reconstitution 8 gram(s) 1 Antiretroviral Zerit (stavudine) 1 mg/mL oral solution 2400 mL(s) 30 Antiretroviral Zerit (stavudine) 15 mg capsule 2 capsule(s) 1 Antiretroviral Zerit (stavudine) 20 mg capsule 2 capsule(s) 1 Antiretroviral Zerit (stavudine) 30 mg capsule 2 capsule(s) 1 Antiretroviral Zerit (stavudine) 40 mg capsule 2 capsule(s) 1 Antiretroviral Ziagen (abacavir) 20 mg/mL oral solution 960 mL(s) 30 Antiretroviral Ziagen (abacavir) 300 mg tablet 2 tablet(s) 1 Antiretroviral zidovudine 300 mg tablet 2 tablet(s) 1 ARB/Renin Inhibitors *(QL applies to Comm and HIM) ARB/Renin Inhibitors Atacand (candesartan) 4 mg tablets 2 tablet(s) 1 ARB/Renin Inhibitors Atacand (candesartan) 8 mg tablets 2 tablet(s) 1 ARB/Renin Inhibitors Atacand (candesartan) 16 mg tablets 2 tablet(s) 1 ARB/Renin Inhibitors Atacand (candesartan) 32 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Atacand HCT (candesartan/hydrochlorothiazide) 16 mg/12.5 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Atacand HCT (candesartan/hydrochlorothiazide) 32 mg/12.5 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Atacand HCT (candesartan/hydrochlorothiazide) 32 mg/25 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Avapro (irbesartan) 75 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Avapro (irbesartan) 150 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Avapro (irbesartan) 300 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Avalide (irbesartan/hydrochlorothiazide) 150 mg/12.5 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Avalide (irbesartan/hydrochlorothiazide) 300 mg/12.5 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Avalide (irbesartan/hydrochlorothiazide) 300 mg/25 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Azor (amlodipine/olmesartan medoxomil) 5 mg/20 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Azor (amlodipine/olmesartan medoxomil) 5 mg/40 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Azor (amlodipine/olmesartan medoxomil) 10 mg/20 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Azor (amlodipine/olmesartan medoxomil) 10 mg/40 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Benicar (olmesartan) 5 mg tablets 2 tablet(s) 1 ARB/Renin Inhibitors Benicar (olmesartan) 20 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Benicar (olmesartan) 40 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Benicar HCT (olmesartan/hydrochlorothiazide) 20 mg/12.5 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Benicar HCT (olmesartan/hydrochlorothiazide) 40 mg/12.5 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Benicar HCT (olmesartan/hydrochlorothiazide) 40 mg/25 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Byvalson (nebivolol/valsartan) 5 mg/80 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Cozaar (losartan) 25 mg tablets 2 tablet(s) 1 ARB/Renin Inhibitors Cozaar (losartan) 50 mg tablets 2 tablet(s) 1 ARB/Renin Inhibitors Cozaar (losartan) 100 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Diovan (valsartan) 40 mg tablets 2 tablet(s) 1 ARB/Renin Inhibitors Diovan (valsartan) 80 mg tablets 2 tablet(s) 1

Program Target Agent Dosage/Strength Quantity Unit Days

Note: Quantity limits apply to all available MultiSource Code (MSC) products

ARB/Renin Inhibitors Diovan (valsartan) 160 mg tablets 2 tablet(s) 1 ARB/Renin Inhibitors Diovan (valsartan) 320 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Diovan HCT (valsartan/hydrochlorothiazide) 80 mg/12.5 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Diovan HCT (valsartan/hydrochlorothiazide) 160 mg/12.5 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Diovan HCT (valsartan/hydrochlorothiazide) 160 mg/25 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Diovan HCT (valsartan/hydrochlorothiazide) 320 mg/12.5 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Diovan HCT (valsartan/hydrochlorothiazide) 320 mg/25 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Edarbi (azilsartan) 40 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Edarbi (azilsartan) 80 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Edarbyclor (azilsartan/chlorthalidone) 40 mg/12.5 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Edarbyclor (azilsartan/chlorthalidone) 40 mg/25 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Exforge (amlodipine/valsartan) 5 mg/160 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Exforge (amlodipine/valsartan) 5 mg/320 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Exforge (amlodipine/valsartan) 10 mg/160 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Exforge (amlodipine/valsartan) 10 mg/320 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Exforge HCT (amlodipine/valsartan/hydrochlorothiazide) 5 mg/160 mg/12.5 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Exforge HCT (amlodipine/valsartan/hydrochlorothiazide) 5 mg/160 mg/25 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Exforge HCT (amlodipine/valsartan/hydrochlorothiazide) 10 mg/160 mg/12.5 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Exforge HCT (amlodipine/valsartan/hydrochlorothiazide) 10 mg/160 mg/25 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Exforge HCT (amlodipine/valsartan/hydrochlorothiazide) 10 mg/320 mg/25 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Hyzaar (losartan/hydrochlorothiazide) 50 mg/12.5 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Hyzaar (losartan/hydrochlorothiazide) 100 mg/12.5 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Hyzaar (losartan/hydrochlorothiazide) 100 mg/25 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Micardis (telmisartan) 20 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Micardis (telmisartan) 40 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Micardis (telmisartan) 80 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Micardis HCT (telmisartan/hydrochlorothiazide) 40 mg/12.5 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Micardis HCT (telmisartan/hydrochlorothiazide) 80 mg/12.5 mg tablets 2 tablet(s) 1 ARB/Renin Inhibitors Micardis HCT (telmisartan/hydrochlorothiazide) 80 mg/25 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Teveten (eprosartan) 400 mg tablets 2 tablet(s) 1 ARB/Renin Inhibitors Teveten, eprosartan 600 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Tribenzor (olmesartan/amlodipine/hydrochlorothiazide) 20 mg/5 mg/12.5 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Tribenzor (olmesartan/amlodipine/hydrochlorothiazide) 40 mg/5 mg/12.5 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Tribenzor (olmesartan/amlodipine/hydrochlorothiazide) 40 mg/5 mg/25 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Tribenzor (olmesartan/amlodipine/hydrochlorothiazide) 40 mg/10 mg/12.5 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Tribenzor (olmesartan/amlodipine/hydrochlorothiazide) 40 mg/10 mg/25 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Twynsta (telmisartan/amlodipine) 40 mg/5 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Twynsta (telmisartan/amlodipine) 40 mg/10 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Twynsta (telmisartan/amlodipine) 80 mg/5 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Twynsta (telmisartan/amlodipine) 80 mg/10 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Tekturna (aliskiren) 150 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Tekturna (aliskiren) 300 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Tekturna HCT (aliskiren/hydrochlorothiazide) 150 mg/12.5 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Tekturna HCT (aliskiren/hydrochlorothiazide) 150 mg/25 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Tekturna HCT (aliskiren/hydrochlorothiazide) 300 mg/12.5 mg tablets 1 tablet(s) 1 ARB/Renin Inhibitors Tekturna HCT (aliskiren/hydrochlorothiazide) 300 mg/25 mg tablets 1 tablet(s) 1

Program Target Agent Dosage/Strength Quantity Unit Days

Note: Quantity limits apply to all available MultiSource Code (MSC) products

Biologic Immunomodulators *(QL applies to Comm and HIM) Biologic Immunomodulators Actemra (tocilizumab) 162 mg/0.9 mL auto-injector 4 auto-injector(s) 28 Biologic Immunomodulators Actemra (tocilizumab) 162 mg/0.9 mL syringe 4 syringe(s) 28 Biologic Immunomodulators Cimzia (certolizumab) 2 x 200 mg/mL syringe, kit 2 kit(s) 28 Biologic Immunomodulators Cimzia (certolizumab) 6 x 200 mg/mL syringe, starter kit 1 kit(s) 180 Biologic Immunomodulators Cosentyx (secukinumab) 150 mg/mL auto-injector pens (2 pens) 2 pen(s) 28 Biologic Immunomodulators Cosentyx (secukinumab) 150 mg/mL auto-injector pens 1 pen(s) 28 Biologic Immunomodulators Cosentyx (secukinumab) 150 mg/mL syringe 1 syringe(s) 28 Biologic Immunomodulators Cosentyx (secukinumab) 300 mg/2 mL (2 x 150 mg/mL syringes) syringe 2 syringe(s) 28 Biologic Immunomodulators Enbrel (etanercept) 25 mg/vial, kit 8 vial(s) 28 Biologic Immunomodulators Enbrel (etanercept) 50 mg/mL SureClick autoinjector 4 autoinjector(s) 28 Biologic Immunomodulators Enbrel (etanercept) mini 50 mg/mL mini injector cartridge 4 cartridge(s) 28 Biologic Immunomodulators Enbrel (etanercept) 25 mg/0.5mL 4 syringe(s) 28 Biologic Immunomodulators Enbrel (etanercept) 50 mg/mL syringe 4 syringe(s) 28 Biologic Immunomodulators Humira (adalimumab) 10 mg/0.1 mL syringe 2 syringe(s) 28 Biologic Immunomodulators Humira (adalimumab) 10 mg/0.2 mL syringe 2 syringe(s) 28 Biologic Immunomodulators Humira (adalimumab) 20 mg/0.2 mL syringe, kit 2 syringe(s) 28 Biologic Immunomodulators Humira (adalimumab) 20 mg/0.4 mL syringe, kit 2 syringe(s) 28 Biologic Immunomodulators Humira (adalimumab) 40 mg/0.8 mL syringe, kit 2 syringe(s) 28 Biologic Immunomodulators Humira (adalimumab) 40mg/0.8 mL syringe, Pediatric Crohn's Disease Starter kit (3 syringes) 3 syringe(s) 180 Biologic Immunomodulators Humira (adalimumab) 40mg/0.8 mL syringe, Pediatric Crohn's Disease Starter kit (6 syringes) 6 syringe(s) 180 Biologic Immunomodulators Humira (adalimumab) 40 mg/0.8 mL syringe, kit 2 syringe(s) 28 Biologic Immunomodulators Humira (adalimumab) 80 mg/0.8 mL syringe, Pediatric Crohn’s Disease Starter kit 3 syringe(s) 180 Biologic Immunomodulators Humira (adalimumab) 40 mg/0.4 mL and 80 mg/0.8 mL syringe, Pediatric Crohn’s Disease 2 syringe(s) 180 Starter kit Biologic Immunomodulators Humira (adalimumab) 40 mg/0.8 mL pen, kit 2 pen(s) 28 Biologic Immunomodulators Humira (adalimumab) 40 mg/0.8 mL pen, Crohn’s disease, ulcerative colitis, or hidradenitis 6 pen(s) 180 suppurativa Starter kit Biologic Immunomodulators Humira (adalimumab) 40 mg/0.8 mL pen, Psoriasis, uveitis Starter kit 4 pen(s) 180 Biologic Immunomodulators Humira (adalimumab) 40 mg/0.4 mL pen 2 pen(s) 28 Biologic Immunomodulators Humira (adalimumab) 80 mg/0.8 mL pen, Crohn’s disease, ulcerative colitis, or hidradenitis 3 pen(s) 180 suppurativa Starter kit Biologic Immunomodulators Humira (adalimumab) 80 mg/0.8 mL and 40 mg/0.4 mL pen, Psoriasis, uveitis Starter kit 3 pen(s) 180 Biologic Immunomodulators Kevzara (sarilumab) 150 mg/1.14 mL pen 2 pen(s) 28 Biologic Immunomodulators Kevzara (sarilumab) 200 mg/1.14 mL pen 2 pens(s) 28 Biologic Immunomodulators Kevzara (sarilumab) 150 mg/1.14 mL syringe 2 syringe(s) 28 Biologic Immunomodulators Kevzara (sarilumab) 200 mg/1.14 mL syringe 2 syringe(s) 28 Biologic Immunomodulators Kineret (anakinra) 100 mg syringe 28 syringe(s) 28 Biologic Immunomodulators Olumiant (baricitinib) 1 mg tablet 1 tablet(s) 1 Biologic Immunomodulators Olumiant (baricitinib) 2 mg tablet 1 tablet(s) 1 Biologic Immunomodulators Orencia (abatacept) 50 mg/0.4 mL syringe 4 syringe(s) 28 Biologic Immunomodulators Orencia (abatacept) 87.5 mg/ 0.7 mL syringe 4 syringe(s) 28 Biologic Immunomodulators Orencia (abatacept) 125 mg/mL syringe 4 syringe(s) 28 Biologic Immunomodulators Orencia (abatacept) 125 mg/mL ClickJect autoinjector 4 autoinjector(s) 28 Biologic Immunomodulators Rinvoq (upadacitinib) 15 mg tablet 1 tablet(s) 1 Biologic Immunomodulators Siliq (brodalumab) syringe 210 mg/1.5 mL syringe 2 syringe(s) 28

Program Target Agent Dosage/Strength Quantity Unit Days

Note: Quantity limits apply to all available MultiSource Code (MSC) products

Biologic Immunomodulators Simponi (golimumab) auto-injector 50 mg/0.5 mL auto-injector 1 autoinjector(s) 28 Biologic Immunomodulators Simponi (golimumab) auto-injector 100 mg/1 mL auto-injector 1 autoinjector(s) 28 Biologic Immunomodulators Simponi (golimumab) syringe 50 mg/0.5 mL syringe 1 syringe(s) 28 Biologic Immunomodulators Simponi (golimumab) syringe 100 mg/1 mL syringe 1 syringe(s) 28 Biologic Immunomodulators Skyrizi (risankizumab) 2 x 75 mg/0.83 mL syringe, kit 1 kit(s) 84 Biologic Immunomodulators Stelara (ustekinumab) 45 mg/0.5 mL vial 1 vial(s) 84 Biologic Immunomodulators Stelara (ustekinumab) 45 mg/0.5 mL syringe 1 syringe(s) 84 Biologic Immunomodulators Stelara (ustekinumab) 90 mg/1 mL syringe 1 syringe(s) 56 Biologic Immunomodulators Taltz (ixekizumab) 80 mg/mL autoinjector 1 syringe(s) 28 Biologic Immunomodulators Taltz (ixekizumab) 80 mg/mL syringe 1 syringe(s) 28 Biologic Immunomodulators Tremfya (guselkumab) 100 mg/mL pen 1 pen(s) 56 Biologic Immunomodulators Tremfya (guselkumab) 100 mg/mL syringe 1 syringe(s) 56 Biologic Immunomodulators Xeljanz (tofacitinib) 5 mg tablet 2 tablet(s) 1 Biologic Immunomodulators Xeljanz (tofacitinib) 10 mg tablet 224 tablet(s) 365 Biologic Immunomodulators Xeljanz XR (tofacitinib extended release) 11 mg tablet 1 tablet(s) 1 Biologic Immunomodulators Xeljanz XR (tofacitinib extended release) 22 mg tablet 112 tablet(s) 365 Buprenorphine, Buprenorphine Naloxone for Opioid Dependence *(QL applies to Comm, HIM, NR A , and NR F) Buprenorphine, Buprenorphine / Naloxone for buprenorphine 2 mg sublingual tablet 15 tablet(s) 90 Opioid Dependence Buprenorphine, Buprenorphine / Naloxone for buprenorphine 8 mg sublingual tablet 15 tablet(s) 90 Opioid Dependence Buprenorphine, Buprenorphine / Naloxone for Bunavail (buprenorphine/naloxone) 2.1 mg / 0.3 mg buccal film 3 film(s) 1 Opioid Dependence Buprenorphine, Buprenorphine / Naloxone for Bunavail (buprenorphine/naloxone) 4.2 mg / 0.7 mg buccal film 2 film(s) 1 Opioid Dependence Buprenorphine, Buprenorphine / Naloxone for Bunavail (buprenorphine/naloxone) 6.3 mg / 1 mg buccal film 2 film(s) 1 Opioid Dependence Buprenorphine, Buprenorphine / Naloxone for Suboxone (buprenorphine/naloxone) 2 mg/0.5 mg sublingual tablet 4 tablet(s) 1 Opioid Dependence Buprenorphine, Buprenorphine / Naloxone for Suboxone (buprenorphine/naloxone) 8 mg/2 mg sublingual tablet 3 tablet(s) 1 Opioid Dependence Buprenorphine, Buprenorphine / Naloxone for Suboxone (buprenorphine/naloxone) 2 mg/0.5 mg sublingual film 4 film(s) 1 Opioid Dependence Buprenorphine, Buprenorphine / Naloxone for Suboxone (buprenorphine/naloxone) 4 mg/1 mg sublingual film 1 film(s) 1 Opioid Dependence Buprenorphine, Buprenorphine / Naloxone for Suboxone (buprenorphine/naloxone) 8 mg/2 mg sublingual film 2 film(s) 1 Opioid Dependence Buprenorphine, Buprenorphine / Naloxone for Suboxone (buprenorphine/naloxone) 12 mg/3 mg sublingual film 2 film(s) 1 Opioid Dependence Buprenorphine, Buprenorphine / Naloxone for Zubsolv (buprenorphine/naloxone) 0.7 mg/0.18 mg sublingual tablet 1 tablet(s) 1 Opioid Dependence Buprenorphine, Buprenorphine / Naloxone for Zubsolv (buprenorphine/naloxone) 1.4 mg/0.36 mg sublingual tablet 3 tablet(s) 1 Opioid Dependence Buprenorphine, Buprenorphine / Naloxone for Zubsolv (buprenorphine/naloxone) 2.9 g/0.71 mg sublingual tablet 1 tablet(s) 1 Opioid Dependence

Program Target Agent Dosage/Strength Quantity Unit Days

Note: Quantity limits apply to all available MultiSource Code (MSC) products

Buprenorphine, Buprenorphine / Naloxone for Zubsolv (buprenorphine/naloxone) 5.7mg/1.4 mg sublingual tablet 1 tablet(s) 1 Opioid Dependence Buprenorphine, Buprenorphine / Naloxone for Zubsolv (buprenorphine/naloxone) 8.6 mg/2.1 mg sublingual tablet 2 tablet(s) 1 Opioid Dependence Buprenorphine, Buprenorphine / Naloxone for Zubsolv (buprenorphine/naloxone) 11.4 mg/2.9 mg sublingual tablet 2 tablet(s) 1 Opioid Dependence CFTR *(QL applies to Comm and HIM) CFTR Kalydeco (ivacaftor) 25 mg oral granules 2 packet(s) 1 CFTR Kalydeco (ivacaftor) 50 mg oral granules 2 packet(s) 1 CFTR Kalydeco (ivacaftor) 75 mg oral granules 2 packet(s) 1 CFTR Kalydeco (ivacaftor) 150 mg tablet 2 tablet(s) 1 CFTR Orkambi (lumacaftor/ivacaftor) 100 mg/125 mg oral granules 2 packet(s) 1 CFTR Orkambi (lumacaftor/ivacaftor) 150 mg/188 mg oral granules 2 packet(s) 1 CFTR Orkambi (lumacaftor/ivacaftor) 100 mg/125 mg tablet 4 tablet(s) 1 CFTR Orkambi (lumacaftor/ivacaftor) 200 mg/125 mg tablet 4 tablet(s) 1 CFTR Symdeko (tezacaftor/ivacaftor and ivacaftor co-packaged) 50 mg/75 mg tablet and 75 mg ivacaftor tablet 2 tablet(s) 1 CFTR Symdeko (tezacaftor/ivacaftor and ivacaftor co-packaged) 100 mg/150 mg tablet and 150 mg ivacaftor tablet 2 tablet(s) 1 CFTR Trikafta (elexacaftor/tezacaftor/ivacaftor and ivacaftor co-packaged)100 mg/50 mg/75 mg tablet and 150 mg ivacaftor tablet 3 tablet(s) 1 CGRP *(QL applies to Comm and HIM) CGRP Aimovig (erenumab) 70 mg/mL auto-injector pen 1 autoinjector(s) 30 CGRP Aimovig (erenumab) 140 mg/mL auto-injector pen 1 autoinjector(s) 30 CGRP Ajovy (fremanezumab) 225 mg/1.5 mL auto-injector 3 syringe(s) 84 CGRP Ajovy (fremanezumab) 225 mg/1.5 mL prefilled syringe 3 syringe(s) 84 CGRP Emgality (galcanezumab) 100 mg/mL syringe 9 syringe(s) 180 CGRP Emgality (galcanezumab) 120 mg/mL auto-injector pen 1 autoinjector(s)s 30 CGRP Emgality (galcanezumab) 120 mg/mL syringe 1 autoinjector(s)s 30 CGRP Nurtec ODT (rimegepant) 75 mg oral disintegrating tablet 40 tablet(s) 90 CGRP Ubrelvy (ubrogepant) 50 mg tablet 16 tablet(s) 30 CGRP Ubrelvy (ubrogepant) 100 mg tablet 16 tablet(s) 30 Combination NSAID *(QL applies to Comm and HIM) Combination NSAID Consensi (amlodipine/celecoxib) 2.5 mg / 200 mg tablet 1 tablet(s) 1 Combination NSAID Consensi (amlodipine/celecoxib) 5 mg / 200 mg tablet 1 tablet(s) 1 Combination NSAID Consensi (amlodipine/celecoxib) 10 mg / 200 mg tablet 1 tablet(s) 1 Combination NSAID Duexis (ibuprofen/famotidine) 800 mg / 26.6 mg tablet 3 tablet(s) 1 Combination NSAID Vimovo (naproxen/esomeprazole) 375 m / 20 mg tablet 2 tablet(s) 1 Combination NSAID Vimovo (naproxen/esomeprazole) 500 m / 20 mg tablet 2 tablet(s) 1 Combination NSAID Yosprala, Aspirin/Omeprazole 81 mg / 40 mg tablet 1 tablet(s) 1 Combination NSAID Yosprala, Aspirin/Omeprazole 325 mg / 40 mg tablet 1 tablet(s) 1 COX-2 *(QL applies to Comm and HIM) COX-2 Celebrex (celecoxib) 50 mg capsule 2 capsule(s) 1 COX-2 Celebrex (celecoxib) 100 mg capsule 2 capsule(s) 1 COX-2 Celebrex (celecoxib) 200 mg capsule 2 capsule(s) 1 COX-2 Celebrex (celecoxib) 400 mg capsule 1 capsule(s) 1

Program Target Agent Dosage/Strength Quantity Unit Days

Note: Quantity limits apply to all available MultiSource Code (MSC) products

DPP-4 Inhibitors *(QL applies to NR A and NR F) DPP-4 Inhibitors Glyxambi (empagliflozin/linagliptin) 10 mg/5 mg tablet 1 tablet(s) 1 DPP-4 Inhibitors Glyxambi (empagliflozin/linagliptin) 25 mg/5 mg tablet 1 tablet(s) 1 DPP-4 Inhibitors Januvia (sitagliptin) 25 mg tablet 1 tablet(s) 1 DPP-4 Inhibitors Januvia (sitagliptin) 50 mg tablet 1 tablet(s) 1 DPP-4 Inhibitors Januvia (sitagliptin) 100 mg tablet 1 tablet(s) 1 DPP-4 Inhibitors Nesina (alogliptin) 6.25mg tablet 1 tablet(s) 1 DPP-4 Inhibitors Nesina (alogliptin) 12.5mg tablet 1 tablet(s) 1 DPP-4 Inhibitors Nesina (alogliptin) 25mg tablet 1 tablet(s) 1 DPP-4 Inhibitors Onglyza (saxagliptin) 2.5 mg tablet 1 tablet(s) 1 DPP-4 Inhibitors Onglyza (saxagliptin) 5 mg tablet 1 tablet(s) 1 DPP-4 Inhibitors Tradjenta (linagliptin) 5 mg tablet 1 tablet(s) 1 DPP-4 Inhibitors Janumet (sitagliptin/metformin) 50 mg/500 mg tablet 2 tablet(s) 1 DPP-4 Inhibitors Janumet (sitagliptin/metformin) 50 mg/1000 mg tablet 2 tablet(s) 1 DPP-4 Inhibitors Janumet XR (sitagliptin/metformin extended-release) 50 mg/500 mg tablet 1 tablet(s) 1 DPP-4 Inhibitors Janumet XR (sitagliptin/metformin extended-release) 50 mg/1000 mg tablet 2 tablet(s) 1 DPP-4 Inhibitors Janumet XR (sitagliptin/metformin extended-release) 100 mg/1000 mg tablet 1 tablet(s) 1 DPP-4 Inhibitors Jentadueto (linagliptin/metformin) 2.5 mg/500 mg tablet 2 tablet(s) 1 DPP-4 Inhibitors Jentadueto (linagliptin/metformin) 2.5 mg/850 mg tablet 2 tablet(s) 1 DPP-4 Inhibitors Jentadueto (linagliptin/metformin) 2.5 mg/1000 mg tablet 2 tablet(s) 1 DPP-4 Inhibitors Jentadueto XR (linagliptin/metformin ER) 2.5 mg/1000 mg tablet 2 tablet(s) 1 DPP-4 Inhibitors Jentadueto XR (linagliptin/metformin ER) 5 mg/1000 mg tablet 1 tablet(s) 1 DPP-4 Inhibitors Kazano (alogliptin/metformin) 12.5mg/500mg tablet 2 tablet(s) 1 DPP-4 Inhibitors Kazano (alogliptin/metformin) 12.5mg/100mg tablet 2 tablet(s) 1 DPP-4 Inhibitors Kombiglyze XR (saxagliptin/metformin) 2.5 mg/1000 mg tablet 2 tablet(s) 1 DPP-4 Inhibitors Kombiglyze XR (saxagliptin/metformin) 5 mg/500 mg tablet 1 tablet(s) 1 DPP-4 Inhibitors Kombiglyze XR (saxagliptin/metformin) 5 mg/1000 mg tablet 1 tablet(s) 1 DPP-4 Inhibitors Oseni (alogliptin/pioglitazone) 12.5mg/15mg tablet 1 tablet(s) 1 DPP-4 Inhibitors Oseni (alogliptin/pioglitazone) 12.5mg/30mg tablet 1 tablet(s) 1 DPP-4 Inhibitors Oseni (alogliptin/pioglitazone) 12.5mg/45mg tablet 1 tablet(s) 1 DPP-4 Inhibitors Oseni (alogliptin/pioglitazone) 25mg/15mg tablet 1 tablet(s) 1 DPP-4 Inhibitors Oseni (alogliptin/pioglitazone) 25mg/30mg tablet 1 tablet(s) 1 DPP-4 Inhibitors Oseni (alogliptin/pioglitazone) 25mg/45mg tablet 1 tablet(s) 1 DPP-4 Inhibitors Qtern (dapagliflozin/saxagliptin) 5 mg/5 mg tablet 1 tablet(s) 1 DPP-4 Inhibitors Qtern (dapagliflozin/saxagliptin) 10 mg/5 mg tablet 1 tablet(s) 1 DPP-4 Inhibitors Steglujan (ertugliflozin/sitagliptin) 5 mg/100 mg tablet 1 tablet(s) 1 DPP-4 Inhibitors Steglujan (ertugliflozin/sitagliptin) 15 mg/100 mg tablet 1 tablet(s) 1 Fibromyalgia (Lyrica, Savella) *(QL applies to Comm, HIM, NR A and NR F) Fibromyalgia (Lyrica, Savella) Lyrica (pregabalin) 25 mg capsule 3 capsule(s) 1 Fibromyalgia (Lyrica, Savella) Lyrica (pregabalin) 50 mg capsule 3 capsule(s) 1 Fibromyalgia (Lyrica, Savella) Lyrica (pregabalin) 75 mg capsule 3 capsule(s) 1 Fibromyalgia (Lyrica, Savella) Lyrica (pregabalin) 100 mg capsule 3 capsule(s) 1

Program Target Agent Dosage/Strength Quantity Unit Days

Note: Quantity limits apply to all available MultiSource Code (MSC) products

Fibromyalgia (Lyrica, Savella) Lyrica (pregabalin) 150 mg capsule 3 capsule(s) 1 Fibromyalgia (Lyrica, Savella) Lyrica (pregabalin) 200 mg capsule 3 capsule(s) 1 Fibromyalgia (Lyrica, Savella) Lyrica (pregabalin) 225 mg capsule 2 capsule(s) 1 Fibromyalgia (Lyrica, Savella) Lyrica (pregabalin) 300 mg capsule 2 capsule(s) 1 Fibromyalgia (Lyrica, Savella) Lyrica (pregabalin) 20 mg/mL oral solution 30 mL(s) 1 Fibromyalgia (Lyrica, Savella) Savella (milnacipran) 12.5 mg tablet 2 tablet(s) 1 Fibromyalgia (Lyrica, Savella) Savella (milnacipran) 25 mg tablet 2 tablet(s) 1 Fibromyalgia (Lyrica, Savella) Savella (milnacipran) 50 mg tablet 2 tablet(s) 1 Fibromyalgia (Lyrica, Savella) Savella (milnacipran) 100 mg tablet 2 tablet(s) 1 Fibromyalgia (Lyrica, Savella) Savella (milnacipran) Titration pack: 5 x 12.5 mg, 8 x 25 mg, 1 pack(s) 180 42 x 50 mg tablets Gabapentin ER *(QL applies to Comm , HIM, NR A and NR F) Gabapentin ER Gralise (gabapentin) 300 mg extended-release tablets 1 tablet(s) 1 Gabapentin ER Gralise (gabapentin) 600 mg extended-release tablets 3 tablet(s) 1 Gabapentin ER Gralise (gabapentin) Starter Pack: 300 mg (9) & 600 mg (69) 1 pack(s) 180 Gabapentin ER Horizant (gabapentin enacarbil) 300 mg extended-release tablets 2 tablet(s) 1 Gabapentin ER Horizant (gabapentin enacarbil) 600 mg extended-release tablets 2 tablet(s) 1 GLP-1 Agonists *(QL applies to Comm, HIM, NR A and NR F) GLP-1 Agonists Adlyxin (lixisenatide) 20 mcg/injection 3 mL pens 2 pen(s) 28 GLP-1 Agonists Adlyxin (lixisenatide) Starter Pack (2 pens) 2 pen(s) 180 GLP-1 Agonists Byetta (exenatide) 5 mcg/dose prefilled pen 1 pen(s) 30 GLP-1 Agonists Byetta (exenatide) 10 mcg/dose prefilled pen 1 pen(s) 30 GLP-1 Agonists Bydureon (exenatide ER) 2 mg/vial in single dose tray; 4 trays/carton 4 tray(s) 28 GLP-1 Agonists Bydureon (exenatide ER) 2 mg/pen; 4 trays/carton 4 pen(s) 28 GLP-1 Agonists Bydureon BCise (exenatide ER) 2 mg/autoinjector; 4 autoinjector/carton 4 autoinjector(s) 28 GLP-1 Agonists Ozempic (semaglutide) 2 mg single-patient pen (0.25-0.5 mg per injection) 1 pen(s) 28 GLP-1 Agonists Ozempic (semaglutide) 2 mg single-patient pen (1 mg per injection) 2 pen(s) 28 GLP-1 Agonists Rybelsus (semaglutide) 3 mg tablet 30 tablet(s) 180 GLP-1 Agonists Rybelsus (semaglutide) 7 mg tablet 1 tablet(s) 1 GLP-1 Agonists Rybelsus (semaglutide) 14 mg tablet 1 tablet(s) 1 GLP-1 Agonists Tanzeum (albiglutide) 30 mg single-dose pen 4 pen(s) 28 GLP-1 Agonists Tanzeum (albiglutide) 50 mg single-dose pen 4 pen(s) 28 GLP-1 Agonists Trulicity (dulaglutide) 0.75 mg/0.5 mL syringe and pens 4 pen(s) 28 GLP-1 Agonists Trulicity (dulaglutide) 1.5 mg/0.5 mL syringe and pens 4 pen(s) 28 GLP-1 Agonists Victoza (liraglutide) 18 mg/3 mL pen 3 pen(s) 30 Hereditary Angioedema *(QL applies to Comm and HIM) Hereditary Angioedema Berinert (C1-esterase inhibitor) 500 units/10 mL 10 vial(s) 30 Hereditary Angioedema Cinryze (C1-esterase inhibitor) 500 units/10 mL 20 vial(s) 30 Hereditary Angioedema Firazyr (icatibant) 30 mg/3 mL syringe 6 syringe(s) 30 Hereditary Angioedema Haegarda (C1 Esterase Inhibitor [Human]) 2000 Unit 24 vial(s) 28 Hereditary Angioedema Haegarda (C1 Esterase Inhibitor [Human]) 3000 Unit 16 vial(s) 28 Hereditary Angioedema Kalbitor (Ecallantide) 3 - 10 mg/mL single use vials 12 vial(s) 30 Hereditary Angioedema Ruconest (C1-esterase inhibitor, recombinant) 2100 unit single use vials 8 vial(s) 30 Hereditary Angioedema Takhzyro (lanadelumab-flyo) 300 mg/2 mL vial 2 vial(s) 28

Program Target Agent Dosage/Strength Quantity Unit Days

Note: Quantity limits apply to all available MultiSource Code (MSC) products

HoFH *(QL applies to Comm and HIM) HoFH Juxtapid (lomitapide) 5 mg capsule 1 capsule(s) 1 HoFH Juxtapid (lomitapide) 10 mg capsule 1 capsule(s) 1 HoFH Juxtapid (lomitapide) 20 mg capsule 1 capsule(s) 1 HoFH Juxtapid (lomitapide) 30 mg capsule 1 capsule(s) 1 HoFH Juxtapid (lomitapide) 40 mg capsule 1 capsule(s) 1 HoFH Juxtapid (lomitapide) 60 mg capsule 1 capsule(s) 1 HoFH Kynamro (mipomersen) 200 mg/mL solution 1 injection(s) 7 Insomnia *(QL applies to Comm, HIM, NR A and NR F) Insomnia Ambien (zolpidem) 5 mg tablet 1 tablet(s) 1 Insomnia Ambien (zolpidem) 10 mg tablet 1 tablet(s) 1 Insomnia Ambien CR (zolpidem) 6.25 mg extended-release tablet 1 tablet(s) 1 Insomnia Ambien CR (zolpidem) 12.5 mg extended-release tablet 1 tablet(s) 1 Insomnia Belsomra (suvorexant) 5 mg tablet 1 tablet(s) 1 Insomnia Belsomra (suvorexant) 10 mg tablet 1 tablet(s) 1 Insomnia Belsomra (suvorexant) 15 mg tablet 1 tablet(s) 1 Insomnia Belsomra (suvorexant) 20 mg tablet 1 tablet(s) 1 Insomnia Dayvigo (lemborexant) 5 mg tablet 1 tablet(s) 1 Insomnia Dayvigo (lemborexant) 10 mg tablet 1 tablet(s) 1 Insomnia Edluar (zolpidem) 5 mg sublingual tablet 1 tablet(s) 1 Insomnia Edluar (zolpidem) 10 mg sublingual tablet 1 tablet(s) 1 Insomnia Intermezzo (zolpidem) 1.75 mg sublingual tablet 1 tablet(s) 1 Insomnia Intermezzo (zolpidem) 3.5 mg sublingual tablet 1 tablet(s) 1 Insomnia Lunesta (eszopiclone) 1 mg tablet 1 tablet(s) 1 Insomnia Lunesta (eszopiclone) 2 mg tablet 1 tablet(s) 1 Insomnia Lunesta (eszopiclone) 3 mg tablet 1 tablet(s) 1 Insomnia Rozerem (ramelteon) 8 mg tablet 1 tablet(s) 1 Insomnia Silenor (doxepin) 3 mg tablet 1 tablet(s) 1 Insomnia Silenor (doxepin) 6 mg tablet 1 tablet(s) 1 Insomnia Sonata (zaleplon) 5 mg capsule 1 capsule(s) 1 Insomnia Sonata (zaleplon) 10 mg capsule 1 capsule(s) 1 Insomnia Zolpimist (zolpidem) Oral Spray 5 mg/actuation 1 bottle(s) 30 Insulins *(QL applies to NR A and NR F) Insulins Fiasp (insulin aspart) 100 U/mL: 10 mL vial, 3 mL pen/cartridge 100 mL(s) 30 Insulins NovoLog, Insulin Aspart 100 U/mL: 10 mL vial, 3 mL pen/cartridge 100 mL(s) 30 Insulins Basaglar (insulin glargine) 3 mL pen 100 mL(s) 30 Insulins Lantus (insulin glargine) 100 U/mL: 10 mL vial, 3 mL device/cartridge 100 mL(s) 30 Insulins Toujeo (insulin glargine) 300 U/mL: 1.5 mL pen 100 mL(s) 30 Insulins Toujeo Max (insulin glargine) 300 U/mL: 3 mL pen 100 mL(s) 30 Insulins Apidra (insulin glulisine) 100 U/mL: 10 mL vial, 3 mL pen/cartridge 100 mL(s) 30 Insulins Admelog (insulin lispro) 100 U/mL: 10 mL vial, 3 mL pen 100 mL(s) 30 Insulins Humalog, Insulin Lispro 100 U/mL: 10 mL vial, 3 mL pen/cartridge 100 mL(s) 30 Insulins Humalog Junior Kwikpen (insulin lispro) 100 U/mL: 3 mL pen 100 mL(s) 30 Insulins Humalog Kwikpen U200 (insulin lispro) 200 U/mL: 3 mL pen 100 mL(s) 30

Program Target Agent Dosage/Strength Quantity Unit Days

Note: Quantity limits apply to all available MultiSource Code (MSC) products

Insulins Lyumjev (insulin lispro-aabc) 100 U/mL 100 U/mL: 10 mL vial, 3 mL pen 100 mL(s) 30 Insulins Lyumjev (insulin lispro-aabc) 200 U/mL 200 U/mL: 10 mL vial, 3 mL pen 100 mL(s) 30 Insulins Levemir (insulin detemir) 100 U/mL: 10 mL vial, 3 mL pen 100 mL(s) 30 Insulins Tresiba (insulin degludec) 100 U/mL: 3 mL pen 100 mL(s) 30 Insulins Tresiba (insulin degludec) 100 U/mL: 10 mL vial 100 mL(s) 30 Insulins Tresiba (insulin degludec) 200 U/mL: 3 mL pen 100 mL(s) 30 Insulins Humulin R, Novolin R, Relion R (insulin regular) 100 U/mL: 10 mL vial, 3 mL pen 100 mL(s) 30 Insulins Humulin R 500 U/mL: 3 mL pen 100 mL(s) 30 Insulins Novolin R 100 U/mL: 3 mL pen 100 mL(s) 30 Insulins Humulin R 500 U/mL: 20 mL vial 100 mL(s) 30 Insulins Humulin N, Novolin N 100 U/mL: 10 mL vial, 3 mL pen 100 mL(s) 30 Insulins NovoLog 70/30, insulin aspart protamine/insulin aspart (insulin mixed)100 U/mL: 10 mL vial, 3 mL pen 100 mL(s) 30 Insulins Humalog 75/25; Humalog 50/50 (insulin mixed) 100 U/mL: 10 mL vial, 3 mL pen 100 mL(s) 30 Insulins Humulin 70/30 (insulin mixed) 100 U/mL: 10 mL vial, 3 mL pen 100 mL(s) 30 Insulins Afrezza 4 unit cartridge packs 2520 cartridge(s) 30 Insulins Afrezza 8 unit cartridge packs 1260 cartridge(s) 30 Insulins Afrezza 12 unit cartridge packs 900 cartridge(s) 30 Insulins Afrezza 30 X 4 unit cartridge + 60 X 8 unit cartridge mix packs 1530 cartridge(s) 30 Insulins Afrezza 60 X 4 unit cartridge + 30 X 8 unit cartridge mix packs 1890 cartridge(s) 30 Insulins Afrezza 60 x 8 unit cartridge + 30 x 12 unit cartridge mix packs 1080 cartridge(s) 30 Insulins Afrezza 90 x 4 unit cartridge + 90 x 8 unit cartridge mix packs 1800 cartridge(s) 30 Insulins Afrezza 60 x 4 unit cartridge + 60 x 8 unit cartridge + 60 x 12 unit cartridge mix packs1260 cartridge(s) 30 Insulins Afrezza 90 x 8 unit cartridge + 90 x 12 unit cartridge 1260 cartridge(s) 30 Insulin Combination *(QL applies to Comm, HIM, NR A and NR F) Insulin Combination Soliqua (insulin glargine/lixisenatide) 100 units/mL insulin glargine / 33 mcg/mL lixisenatide 5 pen(s) 30 Insulin Combination Xultophy (insulin degludec/liraglutide) 100 units/mL insulin degludec / 3.6 mg liraglutide 5 pen(s) 30 Ketorolac *(QL applies to Comm, HIM, NR A and NR F) Ketorolac Ketorolac 10 mg tablet 20 tablet(s) 5 Ketorolac Sprix, Ketorolac Nasal Spray 1.7 g bottle 5 bottle(s) 5 Low Molelcular Weight Heparins (LMWH) and Arixtra*(QL applies to Comm, HIM, NR A and NR F) Low Molelcular Weight Heparins (LMWH) and Arixtra (fondaparinux) Single-dose syringe 2.5 mg/ 0.5 ml 30 syringe(s) 90 LowArixtra Molelcular Weight Heparins (LMWH) and Arixtra (fondaparinux) Single-dose syringe 5 mg/ 0.4 ml 30 syringe(s) 90 LowArixtra Molelcular Weight Heparins (LMWH) and Arixtra (fondaparinux) Single-dose syringe 7.5 mg/ 0.6 ml 30 syringe(s) 90 LowArixtra Molelcular Weight Heparins (LMWH) and Arixtra (fondaparinux) Single-dose syringe 10 mg/ 0.8 ml 30 syringe(s) 90 LowArixtra Molelcular Weight Heparins (LMWH) and Fragmin (dalteparin) Single-dose syringe 2,500 IU/ 0.2 ml 30 syringe(s) 90 LowArixtra Molelcular Weight Heparins (LMWH) and Fragmin (dalteparin) Single-dose syringe 5,000 IU/ 0.2 ml 30 syringe(s) 90 LowArixtra Molelcular Weight Heparins (LMWH) and Fragmin (dalteparin) Single-dose syringe 7,500 IU/ 0.3 ml 30 syringe(s) 90 LowArixtra Molelcular Weight Heparins (LMWH) and Fragmin (dalteparin) Single-dose graduated syringe 10,000 IU/ 1 ml 30 syringe(s) 90 LowArixtra Molelcular Weight Heparins (LMWH) and Fragmin (dalteparin) Single-dose syringe 12,500 IU/ 0.5 ml 30 syringe(s) 90 LowArixtra Molelcular Weight Heparins (LMWH) and Fragmin (dalteparin) Single-dose syringe 15,000 IU/ 0.6 ml 30 syringe(s) 90 LowArixtra Molelcular Weight Heparins (LMWH) and Fragmin (dalteparin) Single-dose syringe 18,000 IU/ 0.72 ml 30 syringe(s) 90 LowArixtra Molelcular Weight Heparins (LMWH) and Fragmin (dalteparin) Multi-dose vial 95,000 IU/ 3.8 mL (25,000 IU/ 1 mL) 10 vial(s) 90 LowArixtra Molelcular Weight Heparins (LMWH) and Lovenox (enoxaparin) Single-dose syringe 30 mg/ 0.3 ml 30 syringe(s) 90 LowArixtra Molelcular Weight Heparins (LMWH) and Lovenox (enoxaparin) Single-dose syringe 40 mg/ 0.4 ml 30 syringe(s) 90 Arixtra

Program Target Agent Dosage/Strength Quantity Unit Days

Note: Quantity limits apply to all available MultiSource Code (MSC) products

Low Molelcular Weight Heparins (LMWH) and Lovenox (enoxaparin) Single-dose graduated syringe 60 mg/ 0.6 ml 30 syringe(s) 90 LowArixtra Molelcular Weight Heparins (LMWH) and Lovenox (enoxaparin) Single-dose graduated syringe 80 mg/ 0.8 ml 30 syringe(s) 90 LowArixtra Molelcular Weight Heparins (LMWH) and Lovenox (enoxaparin) Single-dose graduated syringe 100 mg/ 1 ml 30 syringe(s) 90 LowArixtra Molelcular Weight Heparins (LMWH) and Lovenox (enoxaparin) Single-dose graduated syringe 120 mg/ 0.8 ml 30 syringe(s) 90 LowArixtra Molelcular Weight Heparins (LMWH) and Lovenox (enoxaparin) Single-dose graduated syringe 150 mg/ 1 ml 30 syringe(s) 90 LowArixtra Molelcular Weight Heparins (LMWH) and Lovenox (enoxaparin) Multiple dose vial 300 mg/ 3 ml 10 vial(s) 90 MetforminArixtra ER *(QL applies to NR A and NR F) Metformin ER Fortamet (metformin osmotic ER) 500 mg 3 tablet(s) 1 Metformin ER Fortamet (metformin osmotic ER) 1000 mg 2 tablet(s) 1 Metformin ER Glucophage XR (metformin ER) 500 mg 4 tablet(s) 1 Metformin ER Glucophage XR (metformin ER) 750 mg 2 tablet(s) 1 Metformin ER Glumetza (metformin modified release ER) 500 mg 3 tablet(s) 1 Metformin ER Glumetza (metformin modified release ER) 1000 mg 2 tablet(s) 1 Multiple Sclerosis *(QL applies to Comm and HIM) Multiple Sclerosis Aubagio (teriflunomide) 7 mg tablet 1 tablet(s) 1 Multiple Sclerosis Aubagio (teriflunomide) 14 mg tablet 1 tablet(s) 1 Multiple Sclerosis Avonex (interferon β-1a) 30 mcg/0.5mL vial 4 vial(s) 28 Multiple Sclerosis Avonex (interferon β-1a) 30 mcg/0.5 mL Autoinjector pen 4 pen(s) 28 Multiple Sclerosis Avonex (interferon β-1a) 30 mcg/0.5 mL prefilled syringe 1 kit 28 Multiple Sclerosis Betaseron (interferon β-1b) 0.3 mg vial 14 vial(s) 28 Multiple Sclerosis Copaxone (glatiramer) 20 mg/mL syringe 30 syringe(s) 30 Multiple Sclerosis Copaxone (glatiramer) 40 mg/mL syringe 12 syringe(s) 28 Multiple Sclerosis Extavia (interferon β-1b) 0.3 mg vial 15 vial(s) 30 Multiple Sclerosis Gilenya (fingolimod) 0.25 mg tablet 1 tablet(s) 1 Multiple Sclerosis Gilenya (fingolimod) 0.5 mg tablet 1 tablet(s) 1 Multiple Sclerosis Glatopa (glatiramer) 20 mg/mL prefilled syringe 30 syringe(s) 30 Multiple Sclerosis Glatopa (glatiramer) 40 mg/mL prefilled syringe 12 syringe(s) 28 Multiple Sclerosis Mavenclad (cladribine) 10 mg (4 tablet pack) 8 tablet(s) 301 Multiple Sclerosis Mavenclad (cladribine) 10 mg (5 tablet pack) 10 tablet(s) 301 Multiple Sclerosis Mavenclad (cladribine) 10 mg (6 tablet pack) 12 tablet(s) 301 Multiple Sclerosis Mavenclad (cladribine) 10 mg (7 tablet pack) 14 tablet(s) 301 Multiple Sclerosis Mavenclad (cladribine) 10 mg (8 tablet pack) 8 tablet(s) 301 Multiple Sclerosis Mavenclad (cladribine) 10 mg (9 tablet pack) 9 tablet(s) 301 Multiple Sclerosis Mavenclad (cladribine) 10 mg (10 tablet pack) 20 tablet(s) 301 Multiple Sclerosis Mayzent (siponimod) starter pack 12 tablets 180 Multiple Sclerosis Mayzent (siponimod) 0.25 mg tablets 4 tablet 1 Multiple Sclerosis Mayzent (siponimod) 2 mg tablets 1 tablet 1 Multiple Sclerosis Plegridy (peginterferon β-1a) 125 mcg/0.5mL pen 2 pen(s) 28 Multiple Sclerosis Plegridy (peginterferon β-1a) Starter kit- pen- 1 kit 180 Multiple Sclerosis Plegridy (peginterferon β-1a) 125 mcg/0.5 mL syringe 2 syringe(s) 28 Multiple Sclerosis Plegridy (peginterferon β-1a) Starter kit- syringe 1 kit 180 Multiple Sclerosis Rebif (interferon β-1a) 22 mcg/0.5 mL 12 syringe(s) 28 Multiple Sclerosis Rebif (interferon β-1a) 44 mcg/0.5 mL 12 syringe(s) 28 Multiple Sclerosis Rebif (interferon β-1a) Titration pack: 6 x 8.8 mcg/0.2 mL + 1 kit 180 6 x 22 mcg/0.5 mL

Program Target Agent Dosage/Strength Quantity Unit Days

Note: Quantity limits apply to all available MultiSource Code (MSC) products

Multiple Sclerosis Rebif Rebidose (interferon β-1a) 22 mcg/0.5 mL 12 syringe(s) 28 Multiple Sclerosis Rebif Rebidose (interferon β-1a) 44 mcg/0.5 mL 12 syringe(s) 28 Multiple Sclerosis Rebif Rebidose (interferon β-1a) Titration pack: 6 x 8.8 mcg/0.2 mL + 1 kit 180 6 x 22 mcg/0.5 mL Multiple Sclerosis Tecfidera (dimethyl fumarate) Starter kit (14 x 120 mg and 46 x 240 mg) 60 capsule(s) 180 Multiple Sclerosis Tecfidera (dimethyl fumarate) 120 mg capsules 56 capsule(s) 180 Multiple Sclerosis Tecfidera (dimethyl fumarate) 240 mg capsules 2 capsule(s) 1 Multiple Sclerosis Vumerity (diroximel fumarate) Starter Bottle 231 mg 106 capsule(s) 180 Multiple Sclerosis Vumerity (diroximel fumarate) 231 mg 4 capsule(s) 1 Multiple Sclerosis Zeposia (ozanimod) 7-day starter kit (4 X 0.23 mg capsules and 3 X 0.46 mg capsules) 7 capsule(s) 180 Multiple Sclerosis Zeposia (ozanimod) Starter Kit (7-day starter pack and 0.92 mg capsules 30 count bottle) 37 capsule(s) 180 Multiple Sclerosis Zeposia (ozanimod) 0.92 mg capsules 1 capsule 1 Nasal Antiepileptics *(QL applies to Comm, HIM, NR A and NR F) Nasal Antiepileptics Nayzilam (midazolam) 5 mg/ 0.1 mL nasal inhaler 10 spray bottle(s) 30 Nasal Antiepileptics Valtoco (diazepam) 5 mg/ 0.1 mL nasal inhaler 10 pack(s) 30 Nasal Antiepileptics Valtoco (diazepam) 10 mg/ 0.1 mL nasal inhaler 10 pack(s) 30 Nasal Antiepileptics Valtoco (diazepam) 15 mg (2 x 7.5 mg/ 0.1 mL) nasal inhaler 10 pack(s) 30 Nasal Antiepileptics Valtoco (diazepam) 20 mg (2 x 10 mg/ 0.1 mL) nasal inhaler 10 pack(s) 30 Nasal Inhalers *(QL applies to Comm, HIM, NR A and NR F) Nasal Inhalers azelastine 0.1% 137 mcg/spray (30 mL, 200 sprays) 2 bottle(s) 30 Nasal Inhalers Astepro (azelastine 0.15%) 205.5 mcg/spray (30 mL, 200 sprays) 2 bottle(s) 30 Nasal Inhalers Patanase (olopatadine) 665 mcg/spray (30.5 gm, 240 sprays) 1 bottle(s) 30 Nasal Inhalers Atrovent (ipratropium 0.03%) 21 mcg/spray (30 mL, 345 sprays) 2 bottle(s) 30 Nasal Inhalers Atrovent (ipratropium 0.06%) 42 mcg/spray (15 mL, 165 sprays) 3 bottle(s) 30 Nasal Inhalers Beconase AQ (beclomethasone) 42 mcg/spray (25 gm, 180 sprays) 2 bottle(s) 30 Nasal Inhalers Flonase (fluticasone propionate) 50 mcg/spray (16 gm, 120 sprays) 1 bottle(s) 30 Nasal Inhalers Flunisolide 25 mcg/spray (25 mL, 200 sprays) 3 bottle(s) 30 Nasal Inhalers Nasacort (triamcinolone) 55 mcg/spray (16.5 gm, 120 sprays) 1 bottle(s) 30 Nasal Inhalers Nasonex (mometasone) 50 mcg/spray (17 gm, 120 sprays) 2 bottle(s) 30 Nasal Inhalers Omnaris (ciclesonide) 50 mcg/spray (12.5 gm, 120 sprays) 1 bottle(s) 30 Nasal Inhalers Qnasl (beclomethasone dipropionate) 40 mcg/spray (6.8 gm, 60 sprays) 1 canister(s) 30 Nasal Inhalers Qnasl (beclomethasone dipropionate) 80 mcg/spray (10.6 gm, 120 sprays) 1 canister(s) 30 Nasal Inhalers Rhinocort Aqua (budesonide) 32 mcg/spray (8.6 gm, 120 sprays) 2 bottle(s) 30 Nasal Inhalers Xhance (fluticasone) 93 mcg/actuation (16 mLs, 120 sprays) 2 bottle(s) 30 Nasal Inhalers Zetonna (ciclesonide) 37 mcg/actuation (6.1 gm, 60 actuations) 1 canister(s) 30 Nasal Inhalers Dymista (azelastine/fluticasone) 137 mcg/50 mcg/spray (23 gm, 120 sprays) 1 bottle(s) 30 Oncology Self-Administered *(QL applies to Comm, HIM) Oncology Self-Administered Afinitor (everolimus) 2.5 mg tablets 1 tablet(s) 1 Oncology Self-Administered Afinitor (everolimus) 5 mg tablets 1 tablet(s) 1 Oncology Self-Administered Afinitor (everolimus) 7.5 mg tablets 1 tablet(s) 1 Oncology Self-Administered Afinitor (everolimus) 10 mg tablets 1 tablet(s) 1 Oncology Self-Administered Afinitor Disperz (everolimus) 2 mg tablets 2 tablet(s) 1 Oncology Self-Administered Afinitor Disperz (everolimus) 3 mg tablets 3 tablet(s) 1

Program Target Agent Dosage/Strength Quantity Unit Days

Note: Quantity limits apply to all available MultiSource Code (MSC) products

Oncology Self-Administered Afinitor Disperz (everolimus) 5 mg tablets 2 tablet(s) 1 Oncology Self-Administered Alecensa (alectinib) 150 mg capsule 8 capsule(s) 1 Oncology Self-Administered Alunbrig (brigatinib) 30 tablet 6 tablet(s) 1 Oncology Self-Administered Alunbrig (brigatinib) 90 mg tablet 1 tablet(s) 1 Oncology Self-Administered Alunbrig (brigatinib) 180 mg tablet 1 tablet(s) 1 Oncology Self-Administered Alunbrig (brigatinib) Initiation pack 1 pack(s) 180 Oncology Self-Administered Ayvakit (avapritinib) 100 mg tablets 1 tablet(s) 1 Oncology Self-Administered Ayvakit (avapritinib) 200 mg tablets 1 tablet(s) 1 Oncology Self-Administered Ayvakit (avapritinib) 300 mg tablets 1 tablet(s) 1 Oncology Self-Administered Balversa (erdafitinib) 3 mg tablet 3 tablet(s) 1 Oncology Self-Administered Balversa (erdafitinib) 4 mg tablet 2 tablet(s) 1 Oncology Self-Administered Balversa (erdafitinib) 5 mg tablet 1 tablet(s) 1 Oncology Self-Administered Bosulif (bosutinib) 100 mg tablets 4 tablet(s) 1 Oncology Self-Administered Bosulif (bosutinib) 400 mg tablets 1 tablet(s) 1 Oncology Self-Administered Bosulif (bosutinib) 500 mg tablets 1 tablet(s) 1 Oncology Self-Administered Braftovi (encorafenib) 50 mg capsules 6 capsules 1 Oncology Self-Administered Braftovi (encorafenib) 75 mg capsules 6 capsules 1 Oncology Self-Administered Brukinsa (zanubrutinib) 80 mg capsules 4 capsule(s) 1 Oncology Self-Administered Cabometyx (cabozantinib) 20 mg tablets 1 tablet(s) 1 Oncology Self-Administered Cabometyx (cabozantinib) 40 mg tablets 1 tablet(s) 1 Oncology Self-Administered Cabometyx (cabozantinib) 60 mg tablets 1 tablet(s) 1 Oncology Self-Administered Calquence (acalabrutinib) 100 mg capsules 2 capsule(s) 1 Oncology Self-Administered Caprelsa (vandetanib) 100 mg tablets 2 tablet(s) 1 Oncology Self-Administered Caprelsa (vandetanib) 300 mg tablets 1 tablet(s) 1 Oncology Self-Administered Cometriq (cabozantinib) 140 mg (oral capsule) daily dose carton 112 tablet(s) 28 Oncology Self-Administered Cometriq (cabozantinib) 100 mg (oral capsule) daily dose carton 56 capsule(s) 28 Oncology Self-Administered Cometriq (cabozantinib) 60 mg (oral capsule) daily dose carton 84 capsule(s) 28 Oncology Self-Administered Copiktra (duvelisib) 15 mg capsule 56 capsule(s) 28 Oncology Self-Administered Copiktra (duvelisib) 25 mg capsule 56 capsule(s) 28 Oncology Self-Administered Cotellic (cobimetinib) 20 mg tablet 63 capsule(s) 28 Oncology Self-Administered Daurismo (glasdegib) 25 mg tablet 2 tablet(s) 1 Oncology Self-Administered Daurismo (glasdegib) 100 mg tablet 1 tablet(s) 1 Oncology Self-Administered Erivedge (vismodegib) 150 mg capsule 1 capsule(s) 1 Oncology Self-Administered Erleada (apalutamide) 60 mg tablet 4 tablet(s) 1 Oncology Self-Administered Farydak (panobinostat) 10 mg capsule 6 capsule(s) 21 Oncology Self-Administered Farydak (panobinostat) 15 mg capsule 6 capsule(s) 21 Oncology Self-Administered Farydak (panobinostat) 20 mg capsule 6 capsule(s) 21 Oncology Self-Administered Gilotrif (afatinib) 20 mg tablet 1 tablet(s) 1 Oncology Self-Administered Gilotrif (afatinib) 30 mg tablet 1 tablet(s) 1 Oncology Self-Administered Gilotrif (afatinib) 40 mg tablet 1 tablet(s) 1 Oncology Self-Administered Gleevec (imatinib) 100 mg tablets 3 tablet(s) 1 Oncology Self-Administered Gleevec (imatinib) 400 mg tablets 2 tablet(s) 1 Oncology Self-Administered Ibrance (palbociclib) 75 mg capsule 21 capsule(s) 28 Oncology Self-Administered Ibrance (palbociclib) 100 mg capsule 21 capsule(s) 28 Oncology Self-Administered Ibrance (palbociclib) 125 mg capsule 21 capsule(s) 28 Oncology Self-Administered Iclusig (ponatinib) 15 mg tablet 2 tablet(s) 1 Oncology Self-Administered Iclusig (ponatinib) 45 mg tablet 1 tablet(s) 1

Program Target Agent Dosage/Strength Quantity Unit Days

Note: Quantity limits apply to all available MultiSource Code (MSC) products

Oncology Self-Administered Idhifa (enasidenib) 50 mg tablet 1 tablet(s) 1 Oncology Self-Administered Idhifa (enasidenib) 100 mg tablet 1 tablet(s) 1 Oncology Self-Administered Imbruvica (ibrutinib) 70 mg capsule 1 capsule(s) 1 Oncology Self-Administered Imbruvica (ibrutinib) 140 mg capsule 2 capsule(s) 1 Oncology Self-Administered Imbruvica (ibrutinib) 140 mg tablet 1 tablet(s) 1 Oncology Self-Administered Imbruvica (ibrutinib) 280 mg tablet 1 tablet(s) 1 Oncology Self-Administered Imbruvica (ibrutinib) 420 mg tablet 1 tablet(s) 1 Oncology Self-Administered Imbruvica (ibrutinib) 560 mg tablet 1 tablet(s) 1 Oncology Self-Administered Inlyta (axitinib) 1 mg tablets 6 tablet(s) 1 Oncology Self-Administered Inlyta (axitinib) 5 mg tablets 4 tablet(s) 1 Oncology Self-Administered Inrebic (fedratinib) 100 mg capsules 4 capsule(s) 1 Oncology Self-Administered Iressa (gefitinib) 250 mg tablet 1 tablet(s) 1 Oncology Self-Administered Jakafi (ruxolitinib) 5 mg tablets 2 tablet(s) 1 Oncology Self-Administered Jakafi (ruxolitinib) 10 mg tablets 2 tablet(s) 1 Oncology Self-Administered Jakafi (ruxolitinib) 15 mg tablets 2 tablet(s) 1 Oncology Self-Administered Jakafi (ruxolitinib) 20 mg tablets 2 tablet(s) 1 Oncology Self-Administered Jakafi (ruxolitinib) 25 mg tablets 2 tablet(s) 1 Oncology Self-Administered Kisqali (ribociclib) 200 mg tablets 63 tablet(s) 28 Oncology Self-Administered Kisqali (ribociclib) 200 mg tablets 21 tablet(s) 28 Oncology Self-Administered Kisqali (ribociclib) 200 mg tablets 42 tablet(s) 28 Oncology Self-Administered Kisqali (ribociclib) 200 mg tablets 63 tablet(s) 28 Oncology Self-Administered Kisqali Femara Pack (ribociclib and letrozole co-packaged) 200 mg ribociclib tablets and 2.5 mg letrozole tablets 91 tablet(s) 28 Oncology Self-Administered Kisqali Femara Pack (ribociclib and letrozole co-packaged) 200 mg ribociclib tablets and 2.5 mg letrozole tablets 49 tablet(s) 28 Oncology Self-Administered Kisqali Femara Pack (ribociclib and letrozole co-packaged) 200 mg ribociclib tablets and 2.5 mg letrozole tablets 70 tablet(s) 28 Oncology Self-Administered Kisqali Femara Pack (ribociclib and letrozole co-packaged) 200 mg ribociclib tablets and 2.5 mg letrozole tablets 91 tablet(s) 28 Oncology Self-Administered Koselugo (selumetinib) 10 mg capsules 8 capsule(s) 1 Oncology Self-Administered Koselugo (selumetinib) 25 mg capsules 4 capsule(s) 1 Oncology Self-Administered Lenvima (lenvatinib) 4 mg capsule therapy pack 1 capsule(s) 1 Oncology Self-Administered Lenvima (lenvatinib) 8 mg capsule therapy pack 2 capsule(s) 1 Oncology Self-Administered Lenvima (lenvatinib) 10 mg capsule therapy pack 1 capsule(s) 1 Oncology Self-Administered Lenvima (lenvatinib) 12 mg (3 x 4 mg capsules daily) therapy pack 3 capsule(s) 1 Oncology Self-Administered Lenvima (lenvatinib) 14 mg (10 mg and 4 mg capsule daily) therapy pack 2 capsule(s) 1 Oncology Self-Administered Lenvima (lenvatinib) 18 mg (10 mg and 2 x 4 mg capsules daily) therapy pack 3 capsule(s) 1 Oncology Self-Administered Lenvima (lenvatinib) 20 mg (2 x 10mg capsules daily) therapy pack 2 capsule(s) 1 Oncology Self-Administered Lenvima (lenvatinib) 24 mg (2 x 10mg and 1 x 4 mg capsules daily) therapy pack 3 capsule(s) 1 Oncology Self-Administered Lonsurf (trifluridine/tipiracil) 15 mg/6.14 mg tablets 100 tablet(s) 28 Oncology Self-Administered Lonsurf (trifluridine/tipiracil) 20 mg/8.19 mg tablets 80 tablet(s) 28 Oncology Self-Administered Lorbrena (lorlatinib) 25 mg tablet 3 tablet(s) 1 Oncology Self-Administered Lorbrena (lorlatinib) 100 mg tablet 1 tablet(s) 1 Oncology Self-Administered Lynparza (olaparib) capsules 50 mg capsule 16 capsule(s) 1 Oncology Self-Administered Lynparza (olaparib) tablets 100 mg tablet 4 tablet(s) 1 Oncology Self-Administered Lynparza (olaparib) tablets 150 mg tablet 4 tablet(s) 1 Oncology Self-Administered Mekinist (trametinib) 0.5 mg tablet 1 tablet(s) 1 Oncology Self-Administered Mekinist (trametinib) 2 mg tablet 1 tablet(s) 1 Oncology Self-Administered Mektovi (binimetinib) 15 mg tablet 6 tablest(s) 1 Oncology Self-Administered Nerlynx (neratinib) 40 mg tablet 6 tablet(s) 1 Oncology Self-Administered Nexavar (sorafenib) 200 mg tablets 4 tablet(s) 1

Program Target Agent Dosage/Strength Quantity Unit Days

Note: Quantity limits apply to all available MultiSource Code (MSC) products

Oncology Self-Administered Ninlaro (ixazomib) 2.3 mg capsule 3 capsule(s) 28 Oncology Self-Administered Ninlaro (ixazomib) 3 mg capsule 3 capsule(s) 28 Oncology Self-Administered Ninlaro (ixazomib) 4 mg capsule 3 capsule(s) 28 Oncology Self-Administered Nubeqa 300 mg tablet 4 tablet(s) 1 Oncology Self-Administered Odomzo (sonidegib) 200 mg capsule 1 capsule(s) 1 Oncology Self-Administered Pemazyre (pemigatinib) 4.5 mg tablet 14 tablet(s) 21 Oncology Self-Administered Pemazyre (pemigatinib) 9 mg tablet 14 tablet(s) 21 Oncology Self-Administered Pemazyre (pemigatinib) 13.5 mg tablet 14 tablet(s) 21 Oncology Self-Administered Piqray (alpelisib) 200 mg daily dose pack (200 mg tablets) 1 pack(es) 28 Oncology Self-Administered Piqray (alpelisib) 250 mg daily dose pack (200 mg tablets and 50 mg tablets) 1 box(es) 28 Oncology Self-Administered Piqray (alpelisib) 300 mg daily dose pack (150 mg tablets) 1 box(es) 28 Oncology Self-Administered Pomalyst (pomalidomide) 1 mg capsule 21 capsule(s) 28 Oncology Self-Administered Pomalyst (pomalidomide) 2 mg capsule 21 capsule(s) 28 Oncology Self-Administered Pomalyst (pomalidomide) 3 mg capsule 21 capsule(s) 28 Oncology Self-Administered Pomalyst (pomalidomide) 4 mg capsule 21 capsule(s) 28 Oncology Self-Administered Revlimid (lenalidomide) 2.5 mg capsules 1 capsule(s) 1 Oncology Self-Administered Revlimid (lenalidomide) 5 mg capsules 1 capsule(s) 1 Oncology Self-Administered Revlimid (lenalidomide) 10 mg capsules 1 capsule(s) 1 Oncology Self-Administered Revlimid (lenalidomide) 15 mg capsules 21 capsule(s) 28 Oncology Self-Administered Revlimid (lenalidomide) 20 mg capsules 21 capsule(s) 28 Oncology Self-Administered Revlimid (lenalidomide) 25 mg capsules 21 capsule(s) 28 Oncology Self-Administered Rozlytrek (entrectinib) 100 mg capsules 1 capsule(s) 1 Oncology Self-Administered Rozlytrek (entrectinib) 200 mg capsules 3 capsule(s) 1 Oncology Self-Administered Rubraca (rucaparib) 200 mg tablets 4 tablet(s) 1 Oncology Self-Administered Rubraca (rucaparib) 250 mg tablets 4 tablet(s) 1 Oncology Self-Administered Rubraca (rucaparib) 300 mg tablets 4 tablet(s) 1 Oncology Self-Administered Rydapt (midostaurin) 25 mg capsules 8 capsule(s) 1 Oncology Self-Administered Sprycel (dasatinib) 20 mg tablets 3 tablet(s) 1 Oncology Self-Administered Sprycel (dasatinib) 50 mg tablets 1 tablet(s) 1 Oncology Self-Administered Sprycel (dasatinib) 70 mg tablets 1 tablet(s) 1 Oncology Self-Administered Sprycel (dasatinib) 80 mg tablets 1 tablet(s) 1 Oncology Self-Administered Sprycel (dasatinib) 100 mg tablets 1 tablet(s) 1 Oncology Self-Administered Sprycel (dasatinib) 140 mg tablets 1 tablet(s) 1 Oncology Self-Administered Stivarga (regorafenib) 40 mg tablets 3 tablet(s) 28 Oncology Self-Administered Sutent (sunitinib) 12.5 mg capsules 3 capsule(s) 1 Oncology Self-Administered Sutent (sunitinib) 25 mg capsules 1 capsule(s) 1 Oncology Self-Administered Sutent (sunitinib) 37.5 mg capsules 1 capsule(s) 1 Oncology Self-Administered Sutent (sunitinib) 50 mg capsules 1 capsule(s) 1 Oncology Self-Administered Tabrecta (capmatinib) 150 mg tablet 4 tablet(s) 1 Oncology Self-Administered Tabrecta (capmatinib) 200 mg tablet 4 tablet(s) 1 Oncology Self-Administered Tafinlar (dabrafenib 50 mg capsule 4 capsule(s) 1 Oncology Self-Administered Tafinlar (dabrafenib 75 mg capsule 4 capsule(s) 1 Oncology Self-Administered Tagrisso (osimertinib) 40 mg tablets 1 tablet(s) 1 Oncology Self-Administered Tagrisso (osimertinib) 80 mg tablets 1 tablet(s) 1 Oncology Self-Administered Talzenna (talazoparib) 0.25 mg capsule 3 capsule(s) 1 Oncology Self-Administered Talzenna (talazoparib) 1 mg capsule 1 capsule(s) 1 Oncology Self-Administered Tarceva (erlotinib) 25 mg tablets 2 tablet(s) 1

Program Target Agent Dosage/Strength Quantity Unit Days

Note: Quantity limits apply to all available MultiSource Code (MSC) products

Oncology Self-Administered Tarceva (erlotinib) 100 mg tablets 1 tablet(s) 1 Oncology Self-Administered Tarceva (erlotinib) 150 mg tablets 1 tablet(s) 1 Oncology Self-Administered Tasigna (nilotinib) 50 mg capsules 4 capsule(s) 1 Oncology Self-Administered Tasigna (nilotinib) 150 mg capsules 4 capsule(s) 1 Oncology Self-Administered Tasigna (nilotinib) 200 mg capsules 4 capsule(s) 1 Oncology Self-Administered Tazverik (tazemetostat) 200 mg tablets 8 tablet(s) 1 Oncology Self-Administered Thalomid (thalidomide) 50 mg capsules 1 capsule(s) 1 Oncology Self-Administered Thalomid (thalidomide) 100 mg capsules 1 capsule(s) 1 Oncology Self-Administered Thalomid (thalidomide) 150 mg capsules 2 capsule(s) 1 Oncology Self-Administered Thalomid (thalidomide) 200 mg capsules 2 capsule(s) 1 Oncology Self-Administered Tibsovo (ivosidenib) 250 mg tablets 2 tablet(s) 1 Oncology Self-Administered Tukysa (tucatinib) 50 mg tablet 10 tablet(s) 1 Oncology Self-Administered Tukysa (tucatinib) 150 mg tablet 4 tablet(s) 1 Oncology Self-Administered Turalio (pexidartinib) 200 mg capsules 4 capsule(s) 1 Oncology Self-Administered Tykerb (lapatinib) 250 mg tablets 6 tablet(s) 1 Oncology Self-Administered Venclexta (venetoclax) 10 mg tablets 2 tablet(s) 1 Oncology Self-Administered Venclexta (venetoclax) 50 mg tablets 1 tablet(s) 1 Oncology Self-Administered Venclexta (venetoclax) 100 mg tablets 6 tablet(s) 1 Oncology Self-Administered Venclexta (venetoclax) Starter pack 42 tablet(s) 180 Oncology Self-Administered Verzenio (abemaciclib) 50 mg tablets 2 tablet(s) 1 Oncology Self-Administered Verzenio (abemaciclib) 100 mg tablets 2 tablet(s) 1 Oncology Self-Administered Verzenio (abemaciclib) 150 mg tablets 2 tablet(s) 1 Oncology Self-Administered Verzenio (abemaciclib) 200 mg tablets 2 tablet(s) 1 Oncology Self-Administered Vitrakvi (larotrectinib) 25 mg capsule 6 capsule(s) 1 Oncology Self-Administered Vitrakvi (larotrectinib) 100 mg capsule 2 capsule(s) 1 Oncology Self-Administered Vitrakvi (larotrectinib) 20 mg/mL solution 10 milliliter(s) 1 Oncology Self-Administered Vizimpro (dacomitinib) 15 mg tablets 1 tablet(s) 1 Oncology Self-Administered Vizimpro (dacomitinib) 30 mg tablets 1 tablet(s) 1 Oncology Self-Administered Vizimpro (dacomitinib) 45 mg tablets 1 tablet(s) 1 Oncology Self-Administered Votrient (pazopanib) 200 mg tablets 4 tablet(s) 1 Oncology Self-Administered Xalkori (crizotinib) 200 mg capsules 2 capsule(s) 1 Oncology Self-Administered Xalkori (crizotinib) 250 mg capsules 2 capsule(s) 1 Oncology Self-Administered Xospata (gilteritinib) 40 mg tablet 3 tablet(s) 1 Oncology Self-Administered Xpovio (selinexor) 40 mg once weekly therapy pack (20 mg tablets) 1 box(es) 28 Oncology Self-Administered Xpovio (selinexor) 40 mg twice weekly therapy pack (20 mg tablets) 1 box(es) 28 Oncology Self-Administered Xpovio (selinexor) 60 mg once weekly therapy pack (20 mg tablets) 1 box(es) 28 Oncology Self-Administered Xpovio (selinexor) 60 mg twice weekly therapy pack (20 mg tablets) 1 box(es) 28 Oncology Self-Administered Xpovio (selinexor) 80 mg once weekly therapy pack (20 mg tablets) 1 box(es) 28 Oncology Self-Administered Xpovio (selinexor) 80 mg twice weekly therapy pack (20 mg tablets) 1 box(es) 28 Oncology Self-Administered Xpovio (selinexor) 100 mg once weekly therapy pack (20 mg tablets) 1 box(es) 28 Oncology Self-Administered Xtandi (enzalutamide) 40 mg capsules 4 capsule(s) 1 Oncology Self-Administered Yonsa (abiraterone acetate) 125 mg tablets 4 tablet(s) 1 Oncology Self-Administered Zejula (niraparib) 100 mg capsules 3 capsule(s) 1 Oncology Self-Administered Zelboraf (vemurafenib) 240 mg tablets 8 tablet(s) 1 Oncology Self-Administered Zolinza (vorinostat) 100 mg capsules 4 capsule(s) 1 Oncology Self-Administered Zydelig (idelalisib) 100 mg tablets 2 tablet(s) 1 Oncology Self-Administered Zydelig (idelalisib) 150 mg tablets 2 tablet(s) 1

Program Target Agent Dosage/Strength Quantity Unit Days

Note: Quantity limits apply to all available MultiSource Code (MSC) products

Oncology Self-Administered Zykadia (ceritinib) 150 mg capsules 3 capsule(s) 1 Oncology Self-Administered Zykadia (ceritinib) 150 mg tablets 3 capsule(s) 1 Oncology Self-Administered Zytiga (abiraterone) 250 mg tablets 4 tablet(s) 1 Oncology Self-Administered Zytiga (abiraterone) 500 mg tablets 2 tablet(s) 1 Ophthalmic Prostaglandins *(QL applies to Comm, HIM, NR A and NR F) Ophthalmic Prostaglandins Lumigan (bimatoprost–0.01%) 2.5 mL bottle 3 mL(s) 30

Ophthalmic Prostaglandins Lumigan (bimatoprost–0.01%) 5 mL bottle 3 mL(s) 30

Ophthalmic Prostaglandins Lumigan (bimatoprost–0.01%) 7.5 mL bottle 3 mL(s) 30

Ophthalmic Prostaglandins bimatoprost-0.03% 2.5 mL bottle 3 mL(s) 30

Ophthalmic Prostaglandins bimatoprost-0.03% 3 mL(s) 30 5 mL bottle

Ophthalmic Prostaglandins bimatoprost-0.03% 3 mL(s) 30 7.5 mL bottle

Ophthalmic Prostaglandins Rescula (unoprostone-0.15%) 5 mL(s) 30 5 mL bottle

Ophthalmic Prostaglandins Travatan Z (travoprost) 3 mL(s) 30 2.5 mL bottle

Ophthalmic Prostaglandins Travatan Z (travoprost) 5 mL bottle 3 mL(s) 30

Ophthalmic Prostaglandins Travoprost 2.5 mL bottle 3 mL(s) 30

Program Target Agent Dosage/Strength Quantity Unit Days

Note: Quantity limits apply to all available MultiSource Code (MSC) products

Ophthalmic Prostaglandins Travoprost 5 mL bottle 3 mL(s) 30

Ophthalmic Prostaglandins Vyzulta (latanoprostene bunod) 2.5 mL bottle 3 mL(s) 30

Ophthalmic Prostaglandins Vyzulta (latanoprostene bunod) 5 mL bottle 3 mL(s) 30

Ophthalmic Prostaglandins Xalatan (latanoprost) 2.5 mL bottle 3 mL(s) 30

Ophthalmic Prostaglandins Xelpros (latanoprost emulsion) 2.5 mL bottle 3 mL(s) 30

Ophthalmic Prostaglandins Zioptan (tafluprost) 0.3 mL/single-use container 30 container(s) 30

Ophthalmic Prostaglandins Zioptan (tafluprost) 30 container(s) 30 0.3 mL/single-use container

Oral Inhalers *(QL applies to Comm, HIM, NR A and NR F) Oral Inhalers Atrovent HFA (ipratropium) 17 mcg/actuation (12.9 gm, 200 actuations) 2 canister(s) 30 Oral Inhalers Combivent Respimat (ipratropium/albuterol) 20 mcg/100 mcg/actuation (4.0 gm, 120 actuations) 2 canister(s) 30 Oral Inhalers Incruse Ellipta (umeclidinium) 62.5 mcg/blister 30 blister(s) 30 Oral Inhalers Seebri Neohaler (glycopyrrolate) 15.6 mcg/ inhalation (box of 60 capsules) 60 capsule(s) 30 Oral Inhalers Spiriva Handihaler (tiotropium) 18 mcg/inhalation (carton of 5, 30, or 90 capsules) 30 capsule(s) 30 Oral Inhalers Spiriva Respimat (tiotropium) 1.25 mcg/actuation (4 g cartridge) 1 cartridge(s) 30 Oral Inhalers Spiriva Respimat (tiotropium) 2.5 mcg/actuation (4 g cartridge) 1 cartridge(s) 30 Oral Inhalers Tudorza Pressair (aclidinium bromide) 400 mcg/actuation (1 canister, 60 actuations) 1 canister(s) 30 Oral Inhalers ProAir HFA, Albuterol sulfate HFA 90 mcg/actuation (8.5 gm, 200 actuations) 2 canister(s) 30 Oral Inhalers ProAir Respiclick (albuterol sulfate) 90 mcg/actuation (200 actuations) 2 inhaler(s) 30 Oral Inhalers ProAir Digihaler (albuterol sulfate) 90 mcg/actuation (200 actuations) 2 inhaler(s) 30 Oral Inhalers Proventil HFA (albuterol sulfate) 90 mcg/actuation (6.7 gm, 200 actuations) 2 canister(s) 30 Oral Inhalers Ventolin HFA, Albuterol sulfate HFA 90 mcg/actuation (18 gm, 200 actuations) 2 canister(s) 30 Oral Inhalers Ventolin HFA (albuterol sulfate) 90 mcg/actuation (8 gm, 60 actuations) 2 canister(s) 30 Oral Inhalers Xopenex HFA, Levalbuterol HFA 45 mcg/actuation (15 gm, 200 actuations) 2 canister(s) 30 Oral Inhalers Arcapta Neohaler (indacaterol) 75 mcg/inhalation (Neohaler inhaler and box of 5 blister cards of 6 30 capsule(s) 30 capsules each, total 30)

Program Target Agent Dosage/Strength Quantity Unit Days

Note: Quantity limits apply to all available MultiSource Code (MSC) products

Oral Inhalers Foradil (formoterol) 12 mcg/inhalation (Aerolizer inhaler and blister pack of 12 or 60) 60 blister(s) 30 Oral Inhalers Serevent (salmeterol 50 mcg/inhalation (disposable inhalation device and 60 blisters) 60 blister(s) 30 Oral Inhalers Striverdi Respimat (olodaterol) 2.5 mcg/actuation (inhaler device and 60 actuation cartridge) 1 cartridge(s) 30 Oral Inhalers Advair Diskus (fluticasone/salmeterol) 100 mcg/50 mcg (inhalation device, 60 blisters) 60 blister(s) 30 Oral Inhalers Advair Diskus (fluticasone/salmeterol) 250 mcg/50 mcg per inhalation (disposable inhalation device and 60 60 blister(s) 30 Oral Inhalers Advair Diskus (fluticasone/salmeterol) 500blisters) mcg/50 mcg per inhalation (disposable inhalation device and 60 60 blister(s) 30 Oral Inhalers Advair HFA (fluticasone/ salmeterol) 45blisters) mcg/21 mcg (12 gm, 120 actuations) 1 canister(s) 30 Oral Inhalers Advair HFA (fluticasone/ salmeterol) 115 mcg/21 mcg (12 gm, 120 actuations) 1 canister(s) 30 Oral Inhalers Advair HFA (fluticasone/ salmeterol) 230 mcg/21 mcg (12 gm, 120 actuations) 1 canister(s) 30 Oral Inhalers Aerospan (flunisolide) 80 mcg per inhalation (8.9 gm, 120 actuations 2 canister(s) 30 Oral Inhalers AirDuo Respiclick, 1 inhaler(s) 30 55 mcg/14 mcg (0.45 gm, 60 actuations) Fluticasone/Salmeterol Oral Inhalers AirDuo Respiclick, 1 inhaler(s) 30 113 mcg/14 mcg (0.45 gm, 60 actuations) Fluticasone/Salmeterol Oral Inhalers AirDuo Respiclick, 1 inhaler(s) 30 232 mcg/14 mcg (0.45 gm, 60 actuations) Fluticasone/Salmeterol Oral Inhalers Alvesco (ciclesonide) 80 mcg/actuation (6.1 gm, 60 actuations) 1 canister(s) 30 Oral Inhalers Alvesco (ciclesonide) 160 mcg/actuation (6.1 gm, 60 actuations) 2 canister(s) 30 Oral Inhalers Armonair Respiclick (fluticasone) 55 mcg/actuation (0.9 g, 60 actuations) 1 inhaler(s) 30 Oral Inhalers Armonair Respiclick (fluticasone) 113 mcg/actuation (0.9 g, 60 actuations) 1 inhaler(s) 30 Oral Inhalers Armonair Respiclick (fluticasone) 232 mcg/actuation (0.9g, 60 actuations) 1 inhaler(s) 30 Oral Inhalers Arnuity Ellipta (fluticasone) 50 mcg/blister 30 blister(s) 30 Oral Inhalers Arnuity Ellipta (fluticasone) 100 mcg/blister 30 blister(s) 30 Oral Inhalers Arnuity Ellipta (fluticasone) 200 mcg/blister 30 blister(s) 30 Oral Inhalers Asmanex HFA (mometasone) 50 mcg/actuation (13 gm, 120 actuations) 1 canister(s) 30 Oral Inhalers Asmanex HFA (mometasone) 100 mcg/actuation (13 gm, 120 actuations) 1 canister(s) 30 Oral Inhalers Asmanex HFA (mometasone) 200 mcg/actuation (13 gm, 120 actuations) 1 canister(s) 30 Oral Inhalers Asmanex (mometasone) 110 mcg/actuation (30 actuations) 1 canister(s) 30 Oral Inhalers Asmanex (mometasone) 220 mcg/actuation (30, 60, 120 actuations) 1 canister(s) 30 Oral Inhalers Breo Ellipta (fluticasone/vilanterol) 100 mcg/25 mcg (60 blisters, 30 actuations) 60 blister(s) 30 Oral Inhalers Breo Ellipta (fluticasone/vilanterol) 200 mcg/25 mcg (60 blisters, 30 actuations) 60 blister(s) 30 Oral Inhalers Dulera (mometasone/formoterol) 50 mcg/5 mcg (13 gm, 120 actuations) 1 canister(s) 30 Oral Inhalers Dulera (mometasone/formoterol) 100 mcg/5 mcg (13 gm, 120 actuations) 1 canister(s) 30 Oral Inhalers Dulera (mometasone/formoterol) 200 mcg/5 mcg (13 gm, 120 actuations) 1 canister(s) 30 Oral Inhalers Flovent Diskus (fluticasone) 50 mcg/inhalation (60 blisters/carton) 60 blister(s) 30 Oral Inhalers Flovent Diskus (fluticasone) 100 mcg/inhalation (60 blisters/carton) 60 blister(s) 30 Oral Inhalers Flovent Diskus (fluticasone) 250 mcg/inhalation (60 blisters/carton) 240 blister(s) 30 Oral Inhalers Flovent HFA (fluticasone) 44 mcg/actuation (10.6 gm, 120 actuations) 1 canister(s) 30 Oral Inhalers Flovent HFA (fluticasone) 110 mcg/actuation (12 gm, 120 actuations) 1 canister(s) 30 Oral Inhalers Flovent HFA (fluticasone) 220 mcg/actuation (12 gm, 120 actuations) 2 canister(s) 30 Oral Inhalers Pulmicort Flexhaler (budesonide) 90 mcg/actuation (60 actuations) 1 canister(s) 30 Oral Inhalers Pulmicort Flexhaler (budesonide) 180 mcg/actuation (120 actuations) 2 canister(s) 30 Oral Inhalers Qvar (beclomethasone) 40 mcg/actuation (8.7 gm, 120 actuations) 1 canister(s) 30 Oral Inhalers Qvar (beclomethasone) 80 mcg/actuation (8.7 gm, 120 actuations) 2 canister(s) 30 Oral Inhalers Qvar Redihaler 40 mcg/actuation (10.6 gm, 120 actuations) 1 canister(s) 30 Oral Inhalers Qvar Redihaler 80 mcg/actuation (10.6 gm, 120 actuations) 2 canister(s) 30 Oral Inhalers Symbicort, Budesonide/formoterol 80 mcg/4.5 mcg (10.2 gm, 120 actuations) 1 canister(s) 30

Program Target Agent Dosage/Strength Quantity Unit Days

Note: Quantity limits apply to all available MultiSource Code (MSC) products

Oral Inhalers Symbicort, Budesonide/formoterol 160 mcg/4.5 mcg (10.2 gm, 120 actuations) 1 canister(s) 30 Oral Inhalers Trelegy Ellipta (fluticasone/umeclidinium/vilanterol) 100 mcg/62.5 mcg/25 mcg (30 inhalations) 1 inhaler(s) 30 Oral Inhalers Anoro Ellipta (umeclidinium/vilanterol) 62.5 mcg/25 mcg (60 blisters, 30 actuations) 1 inhaler (s) 30 Oral Inhalers Bevespi Aerosphere (glycopyrrolate/formoterol) 9 mcg/4.8 mcg (120 inhalation canister) 1 canister(s) 30 Oral Inhalers Duaklir Pressair (aclidinium bromide/formoterol fumarate) 400 mcg/12 mcg (60 actuations) 1 inhaler(s) 30 Oral Inhalers Stiolto Respimat (tiotropium/olodaterol) 2.5 mcg/2.5 mcg (4 grams, 60 actuations) 1 cartridge(s) 30 Oral Inhalers Utibron Neohaler (indacaterol/glycopyrrolate) 27.5 mcg/15.6 mg/inhalation (Box of 60 inhalation capsules) 60 capsule(s) 30 Oral PAH *(QL applies to Comm and HIM) Oral PAH Adcirca (tadalafil) 20 mg tablet 60 tablet(s) 30 Oral PAH Adempas (riociguat) 0.5 mg tablet 90 tablet(s) 30 Oral PAH Adempas (riociguat) 1 mg tablet 90 tablet(s) 30 Oral PAH Adempas (riociguat) 1.5 mg tablet 90 tablet(s) 30 Oral PAH Adempas (riociguat) 2 mg tablet 90 tablet(s) 30 Oral PAH Adempas (riociguat) 2.5 mg tablet 90 tablet(s) 30 Oral PAH Letairis (ambrisentan) 5 mg tablet a 30 tablet(s) 30 Oral PAH Letairis (ambrisentan) 10 mg tablet a 30 tablet(s) 30 Oral PAH Opsumit (macitentan) 10 mg tablet 30 tablet(s) 30 Oral PAH Revatio (sildenafil)a 20 mg tablet 90 tablet(s) 30 Oral PAH Revatio (sildenafil)a 10 mg/mL suspension 224 mL(s) 30 Oral PAH Tracleer (bosentan) 32 mg 120 tablet(s) 30 Oral PAH Tracleer (bosentan)a 62.5 mg tablet 60 tablet(s) 30 Oral PAH Tracleer (bosentan)a 125 mg tablet 60 tablet(s) 30 Oral PAH Tyvaso (inhaled treprostinil) 0.6 mg/mL system starter kit 1 kit(s) 180 Oral PAH Tyvaso (inhaled treprostinil) 0.6 mg/mL system refill kit 1 package(s) 28 Oral PAH Tyvaso (inhaled treprostinil) 0.6 mg/mL 4 pack carton 7 carton(s) 28 Oral PAH Tyvaso (inhaled treprostinil) Institutional starter kit 1 kit(s) 180 Oral PAH Ventavis (iloprost) 10 mcg/mL inhalation solution 9 package(s) 30 Oral PAH Ventavis (iloprost) 20 mcg/mL inhalation solution 9 package(s) 30 Oral PAH Uptravi (selexipag) Titration pack 1 pack(s) 180 Oral PAH Uptravi (selexipag) 200 mcg tablet 60 tablet(s) 30 Oral PAH Uptravi (selexipag) Titration Bottle 140 tablet(s) 180 200 mcg tablet Oral PAH Uptravi (selexipag) 400 mcg tablet 60 tablet(s) 30 Oral PAH Uptravi (selexipag) 600 mcg tablet 60 tablet(s) 30 Oral PAH Uptravi (selexipag) 800 mcg tablet 60 tablet(s) 30 Oral PAH Uptravi (selexipag) 1000 mcg tablet 60 tablet(s) 30 Oral PAH Uptravi (selexipag) 1200 mcg tablet 60 tablet(s) 30 Oral PAH Uptravi (selexipag) 1400 mcg tablet 60 tablet(s) 30 Oral PAH Uptravi (selexipag) 1600 mcg tablet 60 tablet(s) 30 Otezla *(QL applies to Comm and HIM) Otezla Otezla (apremilast) 10 mg, 20 mg & 30 mg tablet starter pack (four week) 55 tablet(s) 180 Otezla Otezla (apremilast) 30mg tablets 2 tablet(s) 1 Pain Medications (Combination Products) *(QL applies to Comm, HIM, NR A and NR F)

Program Target Agent Dosage/Strength Quantity Unit Days

Note: Quantity limits apply to all available MultiSource Code (MSC) products

Pain Medications (Combination Products) Allzital (butalbital/acetaminophen) 25 mg/325 mg tablet 12 tablet(s) 1 Pain Medications (Combination Products) Butalbital/Aspirin/Caffeine 50 mg/325 mg/40 mg tablet 6 tablet(s) 1 Pain Medications (Combination Products) Fiornal (butalbital/aspirin/caffeine) 50 mg/325 mg/40 mg capsule 6 capsule(s) 1 Pain Medications (Combination Products) Tencon 50 mg/325 mg tablet 6 tablet(s) 1 (butalbital/acetaminophen) Pain Medications (Combination Products) Vanatol LQ, Vanatol S (butalbital/acetaminophen/caffeine) 50 mg/325 mg/40 mg/15 mL solution 90 ml(s) 1 Pain Medications (Combination Products) butalbital/acetaminophen/caffeine 50 mg/325 mg/40 mg capsule 6 capsule(s) 1 Pain Medications (Combination Products) Esgic (butalbital/acetaminophen/caffeine) 50 mg/325 mg/40 mg tablet 6 tablet(s) 1 Pain Medications (Combination Products) Fioricet (butalbital/acetaminophen/caffeine) 50 mg/300 mg/40 mg capsule 6 capsule(s) 1 Pain Medications (Combination Products) butalbital/acetaminophen 50 mg/300 mg tablet 6 tablet(s) 1 Pain Medications (Combination Products) Butal/APAP (bultalbital/acetaminophen) 50 mg/300 mg capsule 6 capsule(s) 1 Parathyroid Hormone Analog *(QL applies to Comm and HIM) Parathyroid Hormone Analog Forteo (teriparatide) 250 mcg/mL injection 1 pen(s) 28 Parathyroid Hormone Analog Tymlos (abaloparatide) 2000 mcg/mL injection 1 pen(s) 30 PPIs *(QL applies to Comm, HIM, NR A and NR F) PPIs Aciphex (rabeprazole) 20 mg delayed-release tablets 1 tablet(s) 1 PPIs Aciphex (rabeprazole) 5 mg delayed-release capsules 1 capsule(s) 1 PPIs Aciphex (rabeprazole) 10 mg delayed-release capsules 1 capsule(s) 1 PPIs Dexilant (dexlansoprazole) 30 mg delayed-release capsules 1 capsule(s) 1 PPIs Dexilant (dexlansoprazole) 60 mg delayed-release capsules 1 capsule(s) 1 PPIs Esomeprazole strontium 24.65 mg delayed-release capsules 1 capsule(s) 1 PPIs Esomeprazole strontium 49.3 mg delayed-release capsules 1 capsule(s) 1 PPIs Nexium (esomeprazole) 20 mg delayed-release capsules 1 capsule(s) 1 PPIs Nexium (esomeprazole) 40 mg delayed-release capsules 1 capsule(s) 1 PPIs Nexium (esomeprazole) 2.5 mg delayed-release oral suspension 1 packet(s) 1 PPIs Nexium (esomeprazole) 5 mg delayed-release oral suspension 1 packet(s) 1 PPIs Nexium (esomeprazole) 10 mg delayed-release oral suspension 1 packet(s) 1 PPIs Nexium (esomeprazole) 20 mg delayed-release oral suspension 1 packet(s) 1 PPIs Nexium (esomeprazole) 40 mg delayed-release oral suspension 1 packet(s) 1 PPIs Prevacid (lansoprazole) 15 mg delayed-release capsules 1 capsule(s) 1 PPIs Prevacid (lansoprazole) 30 mg delayed-release capsules 1 capsule(s) 1 PPIs Prevacid (lansoprazole) 15 mg delayed-release orally disintegrating tablet 1 tablet(s) 1 PPIs Prevacid (lansoprazole) 30 mg delayed-release orally disintegrating tablet 1 tablet(s) 1 PPIs Prilosec (omeprazole) 10 mg delayed-release capsules 1 capsule(s) 1 PPIs Prilosec (omeprazole) 20 mg delayed-release capsules 1 capsule(s) 1 PPIs Prilosec (omeprazole) 40 mg delayed-release capsules 1 capsule(s) 1 PPIs Prilosec (omeprazole) 2.5 mg oral suspension (packets) 2 packet(s) 1 PPIs Prilosec (omeprazole) 10 mg oral suspension (packets) 1 packet(s) 1 PPIs Protonix (pantoprazole) 40 mg delayed-release oral suspension (packets) 1 packet(s) 1 PPIs Protonix (pantoprazole) 20 mg delayed-release tablets 1 tablet(s) 1 PPIs Protonix (pantoprazole) 40 mg delayed-release tablets 1 tablet(s) 1 PPIs Zegerid (omeprazole/sodium bicarbonate) 20 mg immediate-release capsules 1 capsule(s) 1 PPIs Zegerid (omeprazole/sodium bicarbonate) 40 mg immediate-release capsules 1 capsule(s) 1 PPIs Zegerid (omeprazole/sodium bicarbonate) 20 mg powder for oral suspension (packets) 1 packet(s) 1 PPIs Zegerid (omeprazole/sodium bicarbonate) 40 mg powder for oral suspension (packets) 1 packet(s) 1

Program Target Agent Dosage/Strength Quantity Unit Days

Note: Quantity limits apply to all available MultiSource Code (MSC) products

Progesterones *(QL applies to NR A and NR F) Progesterones Crinone (progesterone) 4% vaginal gel 6 applicator(s) 30 Progesterones Crinone (progesterone) 8% vaginal gel 60 applicator(s) 30 Progesterones Endometrin (progesterone) 100 mg vaginal insert 84 insert(s) 28 SGLT2 Inhibitors *(QL applies to NR A and NR F) SGLT2 Inhibitors Farxiga (dapagliflozin) 5 mg tablet 1 tablet(s) 1 SGLT2 Inhibitors Farxiga (dapagliflozin) 10 mg tablet 1 tablet(s) 1 SGLT2 Inhibitors Invokana (canagliflozin) 100 mg tablet 1 tablet(s) 1 SGLT2 Inhibitors Invokana (canagliflozin) 300 mg tablet 1 tablet(s) 1 SGLT2 Inhibitors Invokamet (canagliflozin/metformin) 50 mg/500 mg tablet 2 tablet(s) 1 SGLT2 Inhibitors Invokamet (canagliflozin/metformin) 50 mg/1000 mg tablet 2 tablet(s) 1 SGLT2 Inhibitors Invokamet (canagliflozin/metformin) 150 mg/500 mg tablet 2 tablet(s) 1 SGLT2 Inhibitors Invokamet (canagliflozin/metformin) 150 mg/1000 mg tablet 2 tablet(s) 1 SGLT2 Inhibitors Invokamet XR (canagliflozin/metformin ER) 50 mg/500 mg tablet 2 tablet(s) 1 SGLT2 Inhibitors Invokamet XR (canagliflozin/metformin ER) 50 mg/1000 mg tablet 2 tablet(s) 1 SGLT2 Inhibitors Invokamet XR (canagliflozin/metformin ER) 150 mg/500 mg tablet 2 tablet(s) 1 SGLT2 Inhibitors Invokamet XR (canagliflozin/metformin ER) 150 mg/1000 mg tablet 2 tablet(s) 1 SGLT2 Inhibitors Jardiance (empagliflozin) 10 mg tablet 1 tablet(s) 1 SGLT2 Inhibitors Jardiance (empagliflozin) 25 mg tablet 1 tablet(s) 1 SGLT2 Inhibitors Segluromet (ertugliflozin/metformin) 2.5 mg/500 mg tablet 4 tablet(s) 1 SGLT2 Inhibitors Segluromet (ertugliflozin/metformin) 2.5 mg/1000 mg tablet 2 tablet(s) 1 SGLT2 Inhibitors Segluromet (ertugliflozin/metformin) 7.5 mg/500 mg tablet 2 tablet(s) 1 SGLT2 Inhibitors Segluromet (ertugliflozin/metformin) 7.5 mg/1000 mg tablet 2 tablet(s) 1 SGLT2 Inhibitors Steglatro (ertugliflozin) 5 mg tablet 2 tablet(s) 1 SGLT2 Inhibitors Steglatro (ertugliflozin) 15 mg tablet 1 tablet(s) 1 SGLT2 Inhibitors Synjardy (empagliflozin/metformin) 5 mg/500 mg tablet 2 tablet(s) 1 SGLT2 Inhibitors Synjardy (empagliflozin/metformin) 5 mg/1000 mg tablet 2 tablet(s) 1 SGLT2 Inhibitors Synjardy (empagliflozin/metformin) 12.5 mg/500 mg tablet 2 tablet(s) 1 SGLT2 Inhibitors Synjardy (empagliflozin/metformin) 12.5 mg/1000 mg tablet 2 tablet(s) 1 SGLT2 Inhibitors Synjardy XR (empagliflozin/metformin ER) 5 mg/1000 mg tablet 2 tablet(s) 1 SGLT2 Inhibitors Synjardy XR (empagliflozin/metformin ER) 10 mg/1000 mg tablet 2 tablet(s) 1 SGLT2 Inhibitors Synjardy XR (empagliflozin/metformin ER) 12.5 mg/1000 mg tablet 2 tablet(s) 1 SGLT2 Inhibitors Synjardy XR (empagliflozin/metformin ER) 25 mg/1000 mg tablet 1 tablet(s) 1 SGLT2 Inhibitors Xigduo XR (dapagliflozin/metformin ER) 2.5 mg/1000 mg tablet 1 tablet(s) 1 SGLT2 Inhibitors Xigduo XR (dapagliflozin/metformin ER) 5 mg/500 mg tablet 1 tablet(s) 1 SGLT2 Inhibitors Xigduo XR (dapagliflozin/metformin ER) 5 mg/1000 mg tablet 2 tablet(s) 1 SGLT2 Inhibitors Xigduo XR (dapagliflozin/metformin ER) 10 mg/500 mg tablet 1 tablet(s) 1 SGLT2 Inhibitors Xigduo XR (dapagliflozin/metformin ER) 10 mg/1000 mg tablet 1 tablet(s) 1