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Ambetter 2020 Prescription Drug List

Ambetter 2020 Prescription Drug List

2020 List

Effective December 1, 2020

Ambetter.SunshineHealth.com Formulary Introduction

FORMULARY

The Ambetter from Sunshine Health Formulary, or Preferred Drug List, is a guide to available brand and generic drugs that are approved by the Food and Drug Administration (FDA) and covered through your prescription drug beneft. Generic drugs have the same active ingredients as their brand name counterparts and should be considered the frst line of treatment. The FDA requires generics to be safe and work the same as brand name drugs. If there is no generic available, there may be more than one brand name drug to treat a condition. Preferred brand name drugs are listed on Tier 2 to help identify brand drugs that are clinically appropriate, safe, and cost-efective treatment options, if a generic on the formulary is not suitable for your condition.

Please note, the Formulary is not meant to be a complete list of the drugs covered under your prescription beneft. Not all dosage forms or strengths of a drug may be covered. This list is periodically reviewed and updated and may be subject to change. Drugs may be added or removed, or additional requirements may be added in order to approve continued usage of a specifc drug.

Specifc prescription beneft plan designs may not cover certain products or categories, regardless of their appearance in this document. Please check your benefts for coverage limitations and your share of cost for your drugs.

Drug List Key: Brand name drugs are listed in CAPS and generic drugs are lower case. Drugs are covered under diferent copay tiers depending on your beneft:

Tier 0 - No copayment for those drugs that are used for prevention and are mandated by the Afordable Care Act. Select oral contraceptives, vitamin D, folic acid for women of child bearing age, over-the-counter (OTC) aspirin, and smoking cessation products may be covered under this tier. Certain age or gender limits apply.

Tier 1 - Lowest copayment for those drugs that ofer the greatest value compared to other drugs used to treat similar conditions. Select over-the-counter (OTC), generic or brand name drugs may be covered under this tier.

Tier 2 - Medium copayment covers brand name drugs that are generally more afordable, or may be preferred compared to other drugs to treat the same conditions.

Tier 3 - Highest copayment covers higher cost brand name drugs. This tier may also cover non-specialty drugs that are not on the Preferred Drug List but approval has been granted for coverage.

Tier 4 - Coverage for this tier is for “specialty” drugs used to treat complex, chronic conditions that may require special handling, storage or clinical management. For members who do not have a Tier 4 plan, these drugs may be covered under Tier 3.

Prior Authorization for Non-Formulary Drugs To obtain prior authorization for a non-formulary drug, your provider must fill out the Prior Authorization form. Envolve Pharmacy Solutions will respond via fax or phone within 24 hours of receipt of all necessary information for urgent requests, and within 72 hours for non-urgent requests, unless state law requires faster response. If the request is disapproved, the notice of disapproval will contain a clear explanation of the specific reasons for disapproving the prior authorization request, or if the request was incomplete, the explanation will identify the missing material information that is necessary to complete the request. Formulary Abbreviations:

Abbreviation Term What it means

AL Age Limit Some drugs are only covered for certain ages.

QL Quantity Limit Some drugs are only covered for a certain amount.

Your doctor must ask for approval from Ambetter before PA Prior Authorization some drugs will be covered.

In some cases, you must first try certain drugs before Ambetter covers another drug for your medical condition. ST Step Therapy For example, if Drug A and Drug B both treat your medical condition, Ambetter may not cover Drug B unless you try Drug A first. This product is not covered unless you or your provider NF Non-formulary request an exception. Alternative are listed next to non-covered product

These drugs are made in both prescription form and RX/OTC Prescription and OTC Over-the-counter (OTC) form. Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- amphetamine- QL(2 ea daily) OBESITY/ANOREXIANTS - Drugs to Treat dextroamphetamine cp24 5 ADHD, Sleep and Eating Disorders mg-5 mg-5 mg-5 mg, 6.25 1 mg-6.25 mg-6.25 mg-6.25 Amphetamines mg, 7.5 mg-7.5 mg-7.5 mg- ADDERALL TABS 1.875 QL(3 ea daily) 7.5 mg MG-1.875 MG-1.875 MG- amphetamine- QL(3 ea daily) 1.875 MG, 3.125 MG-3.125 dextroamphetamine tabs MG-3.125 MG-3.125 MG, 1.875 mg-1.875 mg-1.875 3.75 MG-3.75 MG-3.75 mg-1.875 mg, 3.125 mg- MG-3.75 MG, 1.25 MG- NF 3.125 mg-3.125 mg-3.125 1 1.25 MG-1.25 MG-1.25 mg, 3.75 mg-3.75 mg-3.75 MG, 2.5 MG-2.5 MG-2.5 mg-3.75 mg, 1.25 mg-1.25 MG-2.5 MG, 5 MG-5 MG-5 mg-1.25 mg-1.25 mg, 2.5 MG-5 MG (Use mg-2.5 mg-2.5 mg-2.5 mg, amphetamine- 5 mg-5 mg-5 mg-5 mg dextroamphetamine) amphetamine- QL(2 ea daily) ADDERALL TABS 7.5 MG- QL(2 ea daily) dextroamphetamine tabs 1 7.5 MG-7.5 MG-7.5 MG NF 7.5 mg-7.5 mg-7.5 mg-7.5 (Use amphetamine- mg dextroamphetamine) QL(5 ea daily); ADDERALL XR CP24 1.25 QL(1 ea daily) DESOXYN TABS (Use NF methamphetamine hcl) AL(At least 6 MG-1.25 MG-1.25 MG-1.25 yrs old) MG, 2.5 MG-2.5 MG-2.5 NF MG-2.5 MG (Use DEXEDRINE CP24 10 MG, QL(4 ea daily) amphetamine- 15 MG (Use NF dextroamphetamine) dextroamphetamine sulfate) ADDERALL XR CP24 3.75 DEXEDRINE CP24 5 MG MG-3.75 MG-3.75 MG-3.75 NF MG (Use amphetamine- (Use dextroamphetamine NF dextroamphetamine) sulfate) ADDERALL XR CP24 5 QL(2 ea daily) dextroamphetamine sulfate 1 QL(4 ea daily) MG-5 MG-5 MG-5 MG, cp24 10 mg, 15 mg 6.25 MG-6.25 MG-6.25 dextroamphetamine sulfate 1 MG-6.25 MG, 7.5 MG-7.5 NF cp24 5 mg MG-7.5 MG-7.5 MG (Use dextroamphetamine sulfate 1 QL(4 ea daily) amphetamine- tabs 10 mg, 5 mg dextroamphetamine) QL(5 ea daily); ADZENYS ER SUER (Use NF methamphetamine hcl tabs 3 AL(At least 6 amphetamine) yrs old) amphetamine- QL(1 ea daily) VYVANSE CAPS 10 MG, ST; QL(1 ea dextroamphetamine cp24 20 MG, 30 MG, 40 MG, 50 3 daily) 1.25 mg-1.25 mg-1.25 mg- 1 MG, 60 MG, 70 MG 1.25 mg, 2.5 mg-2.5 mg- 2.5 mg-2.5 mg Anorexiants Non-Amphetamine amphetamine- ADIPEX-P CAPS (Use NF PA phentermine hcl) dextroamphetamine cp24 1 3.75 mg-3.75 mg-3.75 mg- phendimetrazine tartrate 1 PA 3.75 mg tabs 35 mg

Ambetter Sunshine Formulary Updated December 1, 2020

1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits phentermine hcl caps 15 PA 1 DAYTRANA PTCH 3 PA; QL(1 ea mg, 30 mg, 37.5 mg daily) REGIMEX TABS (Use NF dexmethylphenidate hcl QL(1 ea daily) benzphetamine hcl) cp24 25 mg, 35 mg, 40 mg, 1 10 mg, 15 mg, 20 mg, 30 Anti-Obesity Agents mg, 5 mg BELVIQ TABS 3 PA QL(2 ea daily); dexmethylphenidate hcl 1 AL(At least 6 tabs 10 mg, 2.5 mg, 5 mg CONTRAVE TB12 3 PA yrs old) QL(2 ea daily); Attention-Deficit/Hyperactivity Disorder (ADHD) FOCALIN TABS (Use NF dexmethylphenidate hcl) AL(At least 6 QL(2 ea daily); yrs old) atomoxetine hcl caps 10 1 AL(At least 6 mg, 18 mg, 25 mg, 40 mg FOCALIN XR CP24 (Use NF QL(1 ea daily) yrs old) dexmethylphenidate hcl) QL(1 ea daily); atomoxetine hcl caps 100 QL(30 ml 1 AL(At least 6 METHYLIN SOLN (Use NF mg, 60 mg, 80 mg methylphenidate hcl) daily); AL(At yrs old) least 6 yrs old) clonidine hcl (adhd) tb12 1 methylphenidate hcl cp24 1 AL(At least 6 20 mg, 40 mg yrs old) QL(1 ea daily); guanfacine hcl (adhd) tb24 1 AL(At least 6 QL(3 ea daily); methylphenidate hcl cp24 1 AL(At least 6 yrs old) 30 mg yrs old) QL(1 ea daily); INTUNIV TB24 (Use NF methylphenidate hcl cpcr QL(1 ea daily); guanfacine hcl (adhd)) AL(At least 6 yrs old) 40 mg, 10 mg, 20 mg, 30 1 AL(At least 6 mg, 50 mg, 60 mg yrs old) KAPVAY TB12 (Use NF clonidine hcl (adhd)) QL(30 ml methylphenidate hcl soln 1 daily); AL(At 10 mg/5ml, 5 mg/5ml STRATTERA CAPS 10 QL(2 ea daily); least 6 yrs old) MG, 18 MG, 25 MG, 40 MG NF AL(At least 6 (Use atomoxetine hcl) yrs old) QL(5 ea daily); methylphenidate hcl tabs 1 AL(At least 6 20 mg, 10 mg STRATTERA CAPS 100 QL(1 ea daily); yrs old) MG, 60 MG, 80 MG (Use NF AL(At least 6 atomoxetine hcl) yrs old) QL(6 ea daily); methylphenidate hcl tabs 5 1 AL(At least 6 mg Dopamine and Norepinephrine Reuptake yrs old) SUNOSI TABS 3 PA QL(3 ea daily); methylphenidate hcl tbcr 10 1 AL(At least 6 mg, 20 mg Stimulants - Misc. yrs old) PA; QL(1 ea QL(1 ea daily); methylphenidate hcl tbcr 18 1 AL(At least 6 1 daily); AL(At mg, 27 mg armodafinil tabs least 17 yrs yrs old) old) QL(2 ea daily); methylphenidate hcl tbcr 36 1 AL(At least 6 CONCERTA TBCR 18 MG, QL(1 ea daily); mg, 54 mg 27 MG (Use NF AL(At least 6 yrs old) methylphenidate hcl) yrs old) PA; QL(1 ea daily); AL(At CONCERTA TBCR 36 MG, QL(2 ea daily); modafinil tabs 100 mg 1 54 MG (Use NF AL(At least 6 least 16 yrs methylphenidate hcl) yrs old) old)

Ambetter Sunshine Formulary Updated December 1, 2020

2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; QL(2 ea ARIKAYCE SUSP 4 PA daily); AL(At modafinil tabs 200 mg 1 least 16 yrs in saline soln old) 0.8 mg/ml-0.9 %, 0.9 %-1 1 PA; QL(1 ea mg/ml, 0.9 %-1.2 mg/ml, 0.9 %-1.6 mg/ml NUVIGIL TABS (Use NF daily); AL(At armodafinil) least 17 yrs gentamicin sulfate soln 40 1 old) mg/ml PA; QL(1 ea KITABIS PAK NEBU (Use NF PA PROVIGIL TABS 100 MG NF daily); AL(At ) (Use modafinil) least 16 yrs old) sulfate tabs 1 PA; QL(2 ea sulfate caps 1 PROVIGIL TABS 200 MG NF daily); AL(At (Use modafinil) least 16 yrs old) sulfate solr 3 RITALIN LA CP24 20 MG, AL(At least 6 TOBI NEBU (Use NF PA 40 MG (Use NF yrs old) tobramycin) methylphenidate hcl) tobramycin nebu 300 4 PA QL(3 ea daily); mg/5ml RITALIN LA CP24 30 MG NF AL(At least 6 (Use methylphenidate hcl) tobramycin sulfate soln 10 yrs old) mg/ml, 40 mg/ml, 80 1 RITALIN TABS 20 MG, 10 QL(5 ea daily); mg/2ml MG (Use methylphenidate NF AL(At least 6 hcl) yrs old) ANALGESICS - ANTI-INFLAMMATORY - Drugs to Treat Pain, Swelling, Muscle and Joint QL(6 ea daily); Conditions RITALIN TABS 5 MG (Use NF methylphenidate hcl) AL(At least 6 yrs old) Anti-TNF-alpha - Monoclonal Antibodies HUMIRA PEDIATRIC PA; QL(0.143 ALLERGENIC EXTRACTS/BIOLOGICALS MISC CROHNS DISEASE 4 ea daily) STARTER PACK PSKT 40 Allergenic Extracts MG/0.8ML PA GRASTEK SUBL 3 PA; 1 rtl pack lmt amt,180 rtl Biologicals Misc HUMIRA PEDIATRIC pack lmt ADAGEN SOLN 4 PA; SP CROHNS DISEASE 4 day(s),1 mail STARTER PACK PSKT 80 pack lmt MG/0.8ML, amt,180 mail AMEBICIDES pack lmt day(s), Amebicides PA; QL(0.143 SOLOSEC PACK 3 PA 4 ea daily,30 ea HUMIRA PEN PNKT per fill retail,30 - Drugs to Treat Bacterial ea per fill mail) PA; QL(0.143 HUMIRA PEN-CD/UC/HS ea daily,30 ea Aminoglycosides STARTER PNKT 40 4 MG/0.8ML per fill retail,30 sulfate soln 1 ea per fill mail)

Ambetter Sunshine Formulary Updated December 1, 2020

3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; 1 rtl pack RIDAURA CAPS 3 QL(3 ea daily) lmt amt,180 rtl pack lmt Interleukin-1 Blockers HUMIRA PEN-CD/UC/HS day(s),1 mail STARTER PNKT 80 4 PA; QL(0.286 MG/0.8ML pack lmt ARCALYST SOLR 4 amt,180 mail ea daily); SP pack lmt Interleukin-1 (IL-1Ra) day(s), KINERET SOSY 4 PA; SP PA; 1 rtl pack lmt amt,180 rtl Interleukin-1beta Blockers pack lmt PA HUMIRA PEN-PS/UV 4 day(s),1 mail ILARIS SOLN 4 STARTER PNKT pack lmt amt,180 mail Interleukin-6 Receptor Inhibitors pack lmt ACTEMRA SOLN IV 200 PA; SP day(s), MG/10ML, 400 MG/20ML, 4 PA; QL(0.143 80 MG/4ML HUMIRA PEN-PS/UV ea daily,30 ea 4 ACTEMRA SOSY SC 162 4 PA; QL(0.129 STARTER PNKT per fill retail,30 MG/0.9ML ml daily); SP ea per fill mail) KEVZARA SOAJ 4 PA HUMIRA PSKT 4 PA; QL(0.143 ea daily) KEVZARA SOSY 4 PA SIMPONI ARIA SOLN 4 PA Anti-inflammatory Agents (NSAIDs) SIMPONI SOAJ 100 4 PA; QL(0.357 MG/ML ml daily); SP ANAPROX DS TABS (Use NF naproxen ) SIMPONI SOAJ 50 4 PA; QL(0.0179 MG/0.5ML ml daily); SP ARTHROTEC 50 TBEC (Use diclofenac w/ NF SIMPONI SOSY 100 4 PA; QL(0.357 misoprostol) MG/ML ml daily); SP ARTHROTEC 75 TBEC SIMPONI SOSY 50 4 PA; QL(0.0179 (Use diclofenac w/ NF MG/0.5ML ml daily); SP misoprostol) Antirheumatic - Inhibitors CELEBREX CAPS 100 PA; QL(2 ea PA MG, 200 MG, 50 MG (Use NF daily) OLUMIANT TABS 4 celecoxib) RINVOQ TB24 4 PA CELEBREX CAPS 400 MG NF PA; QL(1 ea (Use celecoxib) daily) PA; QL(2 ea XELJANZ TABS 10 MG 4 celecoxib caps 100 mg, 1 PA; QL(2 ea daily) 200 mg, 50 mg daily) PA; QL(2 ea PA; QL(1 ea XELJANZ TABS 5 MG 4 celecoxib caps 400 mg 1 daily); SP daily) PA; QL(1 ea XELJANZ XR TB24 4 CHILDRENS ADVIL SUSP NF RX/OTC daily) (Use ibuprofen) Antirheumatic Antimetabolites CHILDRENS MOTRIN NF RX/OTC PA; QL(1.714 SUSP (Use ibuprofen) METHOTREXATE TABS 4 ea daily); SP DAYPRO TABS (Use NF oxaprozin) Gold Compounds

Ambetter Sunshine Formulary Updated December 1, 2020

4 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits diclofenac potassium tabs 1 NAPROSYN SUSP 125 NF PA MG/5ML (Use naproxen) diclofenac sodium tb24 1 NAPROSYN TABS 500 NF MG (Use naproxen) diclofenac sodium tbec 1 naproxen sodium tabs 550 1 mg diclofenac w/ misoprostol 1 tbec naproxen susp 125 mg/5ml 1 PA EC-NAPROSYN TBEC 500 NF naproxen tabs 250 mg, 375 1 MG (Use naproxen) mg, 500 mg etodolac caps 200 mg, 300 1 mg naproxen tbec 500 mg 1 etodolac tabs 400 mg, 500 1 mg oxaprozin tabs 1 FELDENE CAPS (Use NF piroxicam caps 1 piroxicam) fenoprofen tabs 1 ST; QL(4 ea sulindac tabs 1 600 mg daily) flurbiprofen tabs 50 mg, 1 tolmetin sodium caps 1 100 mg tolmetin sodium tabs 1 ibuprofen susp 100 mg/5ml 1 RX/OTC ibuprofen tabs 400 mg, 600 Phosphodiesterase 4 (PDE4) Inhibitors 1 PA; QL(2 ea mg, 800 mg OTEZLA TABS 4 daily) indomethacin caps 25 mg, 1 50 mg OTEZLA TBPK 4 PA indomethacin cpcr 75 mg 1 Synthesis Inhibitors ketoprofen caps 50 mg, 75 1 ARAVA TABS (Use NF QL(1 ea daily) mg leflunomide) ketorolac tromethamine 1 QL(0.667 ea QL(1 ea daily) tabs or 10 mg daily) leflunomide tabs 1 LODINE TABS (Use NF Selective Costimulation Modulators etodolac) ORENCIA CLICKJECT 4 PA meclofenamate sodium 1 SOAJ caps ORENCIA SOLR IV 250 4 PA; SP ST; Must try MG mefenamic acid caps 1 ibuprofen. ORENCIA SOSY SC 125 4 PA; QL(0.143 ;QL(5 ea daily) MG/ML ml daily); SP meloxicam tabs 1 QL(1 ea daily) ORENCIA SOSY SC 50 4 PA; QL(0.143 MG/0.4ML, 87.5 MG/0.7ML ml daily) MOBIC TABS (Use NF QL(1 ea daily) meloxicam) Soluble Receptor Agents PA; nabumetone tabs 1 ENBREL MINI SOCT 4 PA; QL(0.286 NALFON TABS 600 MG NF ST; QL(4 ea ENBREL SOLR 25 MG 4 (Use fenoprofen calcium) daily) ea daily); SP

Ambetter Sunshine Formulary Updated December 1, 2020

5 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ENBREL SOSY 25 4 PA; QL(0.146 ANALGESICS - OPIOID - Drugs to Treat Pain, MG/0.5ML ml daily); SP Muscle and Joint Conditions PA; QL(0.28 ml ENBREL SOSY 50 MG/ML 4 Opioid daily); SP ACTIQ LPOP (Use fentanyl NF PA; QL(4 ea ENBREL SURECLICK 4 PA; QL(0.143 citrate) daily) SOAJ ml daily); SP QL(3 ea daily) ANALGESICS - NonNarcotic - Drugs to Treat ARYMO ER TBEA 3 Pain, Muscle and Joint Conditions New starts CODEINE SULFATE TABS 1 Analgesic Combinations 15 MG, 60 MG limited to 7 day supply butalbital-acetaminophen 1 tabs 325 mg-50 mg CODEINE SULFATE TABS New starts butalbital-acetaminophen- 30 MG (Use codeine 1 limited to 7 day sulfate) supply caffeine caps 300 mg-40 1 mg-50 mg, 325 mg-40 mg- New starts codeine sulfate tabs 30 mg, 1 limited to 7 day 50 mg 60 mg butalbital-acetaminophen- supply caffeine tabs 325 mg-40 1 CONZIP CP24 (Use NF mg-50 mg tramadol hcl) DEMEROL SOLN 100 butalbital-aspirin-caffeine 1 caps MG/ML, 25 MG/ML, 50 NF BUTALBITAL/ACETAMINO MG/ML (Use meperidine PHEN CAPS (Use NF hcl) butalbital-acetaminophen) DILAUDID LIQD OR 1 New starts ESGIC TABS (Use MG/ML (Use NF limited to 7 day butalbital-acetaminophen- NF hydromorphone hcl) supply caffeine) DILAUDID SOLN IJ 1 FIORICET CAPS (Use MG/ML, 2 MG/ML (Use NF butalbital-acetaminophen- NF hydromorphone hcl) caffeine) New starts DILAUDID TABS OR 2 limited to 7 day FIORINAL CAPS (Use NF MG, 4 MG, 8 MG (Use NF butalbital-aspirin-caffeine) hydromorphone hcl) supply;QL(8 ea daily) Salicylates DOLOPHINE TABS 10 MG NF QL(10 ea daily) AL(At least 45 (Use methadone hcl) aspirin chew or 81 mg 0 yrs old - Up to DOLOPHINE TABS 5 MG NF QL(4 ea daily) 79 yrs old) (Use methadone hcl) AL(At least 45 DURAGESIC PT72 (Use NF QL(0.34 ea aspirin tabs or 325 mg 0 yrs old - Up to fentanyl) daily) 79 yrs old) QL(2 ea daily) AL(At least 45 EMBEDA CPCR 3 aspirin tbec or 81 mg 0 yrs old - Up to EXALGO TB24 12 MG, 16 PA; QL(2 ea 79 yrs old) MG, 8 MG (Use NF daily) diflunisal tabs 1 hydromorphone hcl) EXALGO TB24 32 MG NF PA; QL(1 ea salsalate tabs 1 (Use hydromorphone hcl) daily)

Ambetter Sunshine Formulary Updated December 1, 2020

6 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits fentanyl citrate lpop bu PA; QL(4 ea methadone hcl conc or 10 1 QL(10 ml daily) 1200 mcg, 1600 mcg, 200 1 daily) mg/ml mcg, 400 mcg, 600 mcg, methadone hcl soln ij 10 1 800 mcg mg/ml fentanyl pt72 100 mcg/hr, QL(0.34 ea METHADONE HCL SOLN 12 mcg/hr, 25 mcg/hr, 50 1 daily) IJ 10 MG/ML (Use 1 mcg/hr, 75 mcg/hr methadone hcl) FENTORA TABS (Use NF methadone hcl soln or 10 1 QL(50 ml daily) fentanyl citrate) mg/5ml hydrocodone bitartrate PA; QL(2 ea 1 methadone hcl soln or 5 1 QL(100 ml cp12 daily) mg/5ml daily) New starts methadone hcl tabs or 10 QL(10 ea daily) hydromorphone hcl liqd or 1 limited to 7 day 1 1 mg/ml mg supply methadone hcl tabs or 5 1 QL(4 ea daily) hydromorphone hcl soln ij mg 10 mg/ml, 50 mg/5ml, 500 1 mg/50ml methadone hcl tbso or 40 1 QL(2 ea daily) mg New starts METHADOSE CONC (Use QL(10 ml daily) hydromorphone hcl tabs or 1 limited to 7 day NF 2 mg, 4 mg, 8 mg supply;QL(8 ea methadone hcl) daily) METHADOSE SUGAR- QL(10 ml daily) FREE CONC (Use NF hydromorphone hcl tb24 or 1 PA; QL(2 ea 12 mg, 16 mg, 8 mg daily) methadone hcl) PA; QL(2 ea hydromorphone hcl tb24 or 1 PA; QL(1 ea MORPHABOND ER T12A 3 32 mg daily) daily) HYDROMORPHONE morphine sulfate cp24 or PA; QL(2 ea 100 mg, 20 mg, 30 mg, 50 1 daily) HYDROCHLORIDE SOLN NF IJ 10 MG/ML (Use mg, 60 mg, 80 mg hydromorphone hcl) morphine sulfate soln ij 0.5 1 QL(2 ea daily) mg/ml, 1 mg/ml HYSINGLA ER T24A 3 MORPHINE SULFATE KADIAN CP24 100 MG, 20 PA; QL(2 ea SOLN IV 10 MG/ML (Use NF morphine sulfate) MG, 30 MG, 50 MG, 60 NF daily) MG, 80 MG (Use morphine New starts sulfate) morphine sulfate soln or 10 1 limited to 7 day New starts mg/5ml supply;QL(100 levorphanol tartrate tabs 2 1 limited to 7 day ml daily) mg supply New starts morphine sulfate soln or 20 limited to 7 day meperidine hcl soln ij 100 1 1 mg/ml, 25 mg/ml, 50 mg/ml mg/5ml supply;QL(50 ml daily) New starts morphine sulfate tabs or 15 meperidine hcl soln or 50 1 limited to 7 day 1 mg/5ml supply;QL(500 mg ml per fill retail) New starts New starts morphine sulfate tabs or 15 1 limited to 7 day mg, 30 mg supply;QL(6 ea meperidine hcl tabs or 100 1 limited to 7 day mg, 50 mg supply;QL(6 ea daily) daily) Ambetter Sunshine Formulary Updated December 1, 2020

7 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits morphine sulfate tbcr or QL(2 ea daily) New starts 1 100 mg, 15 mg, 200 mg, 30 ULTRAM TABS (Use NF limited to 7 day mg, 60 mg tramadol hcl) supply;QL(8 ea daily) MS CONTIN TBCR (Use NF QL(2 ea daily) morphine sulfate) PA; QL(2 ea XTAMPZA ER C12A 2 PA; QL(2 ea daily) NUCYNTA ER TB12 2 daily) ZOHYDRO ER CP12 (Use 3 PA; QL(2 ea PA; QL(6 ea hydrocodone bitartrate) daily) NUCYNTA TABS 2 daily) Opioid Combinations OPANA TABS (Use NF PA; QL(12 ea New starts oxymorphone hcl) daily) acetaminophen w/ codeine 1 limited to 7 day soln 12 mg/5ml-120 supply;QL(75 New starts mg/5ml limited to 7 day ml daily) OXAYDO TABS 5 MG 2 supply;QL(12 New starts ea daily) acetaminophen w/ codeine 1 limited to 7 day oxycodone hcl t12a 15 mg, QL(2 ea daily) tabs 15 mg-300 mg supply;QL(13 30 mg, 60 mg, 10 mg, 20 3 ea daily) mg, 80 mg, 40 mg New starts New starts acetaminophen w/ codeine 1 limited to 7 day tabs 30 mg-300 mg supply;QL(12 oxycodone hcl tabs 10 mg, 1 limited to 7 day 20 mg, 15 mg, 30 mg, 5 mg supply;QL(12 ea daily) ea daily) New starts OXYCONTIN T12A 3 QL(2 ea daily) acetaminophen w/ codeine 1 limited to 7 day tabs 300 mg-60 mg supply;QL(6 ea daily) oxymorphone hcl tabs 10 1 PA; QL(12 ea mg, 5 mg daily) acetaminophen-caff- New starts oxymorphone hcl tb12 10 PA; QL(2 ea dihydrocod caps 16 mg-30 1 limited to 7 day mg, 15 mg, 20 mg, 30 mg, 3 daily) mg-320.5 mg supply 5 mg, 7.5 mg acetaminophen-caff- PA; New starts dihydrocod caps 16 mg-30 3 limited to 7 day oxymorphone hcl tb12 40 3 PA; QL(4 ea mg daily) mg-320.5 mg supply New starts butalbital-acetaminophen- New starts caffeine w/ codeine caps limited to 7 day ROXICODONE TABS (Use NF limited to 7 day 1 oxycodone hcl) supply;QL(12 30 mg-300 mg-40 mg-50 supply ea daily) mg butalbital-acetaminophen- New starts ROXYBOND TABA 3 QL(12 ea daily) caffeine w/ codeine caps 1 limited to 7 day PA 30 mg-325 mg-40 mg-50 supply;QL(6 ea SUBSYS LIQD 3 mg daily) New starts New starts butalbital-aspirin-caffeine limited to 7 day 1 limited to 7 day 1 tramadol hcl tabs 50 mg supply;QL(8 ea w/cod caps supply;QL(6 ea daily) daily) FIORICET/CODEINE New starts tramadol hcl tb24 100 mg, 1 QL(1 ea daily) 200 mg, 300 mg CAPS (Use butalbital- NF limited to 7 day acetaminophen-caffeine w/ supply codeine)

Ambetter Sunshine Formulary Updated December 1, 2020

8 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits New starts New starts FIORINAL/CODEINE #3 limited to 7 day 2 CAPS (Use butalbital- NF ROXICET SOLN limited to 7 day aspirin-caffeine w/cod) supply;QL(6 ea supply daily) New starts HYDROCODONE New starts tramadol-acetaminophen 1 limited to 7 day BITARTRATE/ACETAMIN 1 limited to 7 day tabs supply;QL(8 ea OPHEN SOLN supply daily) New starts hydrocodone- TYLENOL/CODEINE #3 New starts acetaminophen soln 108 limited to 7 day NF limited to 7 day 1 supply;QL(180 TABS (Use acetaminophen mg/5ml-2.5 mg/5ml, 217 w/ codeine) supply;QL(12 mg/10ml-5 mg/10ml, 325 ml daily) ea daily) mg/15ml-7.5 mg/15ml New starts TYLENOL/CODEINE #4 hydrocodone- New starts NF limited to 7 day limited to 7 day TABS (Use acetaminophen acetaminophen tabs 10 1 w/ codeine) supply;QL(6 ea mg-300 mg, 300 mg-5 mg, supply;QL(13 daily) 300 mg-7.5 mg ea daily) New starts hydrocodone- New starts ULTRACET TABS (Use NF limited to 7 day acetaminophen tabs 10 1 limited to 7 day tramadol-acetaminophen) supply;QL(8 ea mg-325 mg, 325 mg-5 mg, supply;QL(12 daily) 325 mg-7.5 mg ea daily) Opioid Partial Agonists hydrocodone-ibuprofen PA PA tabs 10 mg-200 mg, 200 1 BUNAVAIL FILM 3 mg-5 mg BUPRENEX SOLN (Use NF New starts buprenorphine hcl) hydrocodone-ibuprofen 1 limited to 7 day tabs 200 mg-7.5 mg supply;QL(5 ea buprenorphine hcl soln ij 1 daily) 0.3 mg/ml New starts buprenorphine hcl subl sl 2 1 QL(3 ea daily) LORTAB ELIX 2 limited to 7 day mg, 8 mg supply buprenorphine hcl- PA; QL(3 ea New starts naloxone hcl dihydrate film 1 daily) NORCO TABS (Use limited to 7 day 0.5 mg-2 mg, 1 mg-4 mg hydrocodone- NF buprenorphine hcl- PA; QL(2 ea acetaminophen) supply;QL(12 ea daily) naloxone hcl dihydrate film 1 daily) oxycodone w/ New starts 12 mg-3 mg, 2 mg-8 mg buprenorphine hcl- QL(3 ea daily) acetaminophen tabs 10 1 limited to 7 day mg-325 mg, 325 mg-5 mg, supply;QL(12 naloxone hcl dihydrate subl 1 325 mg-7.5 mg ea daily) 0.5 mg-2 mg, 2 mg-8 mg New starts buprenorphine ptwk td 10 PA; QL(0.143 mcg/hr, 15 mcg/hr, 20 ea daily) 1 limited to 7 day 1 oxycodone-ibuprofen tabs supply;QL(1 ea mcg/hr, 5 mcg/hr, 7.5 daily) mcg/hr PERCOCET TABS 10 MG- New starts butorphanol tartrate soln ij 1 325 MG, 325 MG-5 MG, limited to 7 day 1 mg/ml, 2 mg/ml 325 MG-7.5 MG (Use NF supply;QL(12 butorphanol tartrate soln na 1 PA oxycodone w/ ea daily) 10 mg/ml acetaminophen)

Ambetter Sunshine Formulary Updated December 1, 2020

9 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BUTRANS PTWK 10 PA; QL(0.143 cypionate soln 1 MCG/HR, 15 MCG/HR, 20 NF ea daily) im 100 mg/ml, 200 mg/ml MCG/HR, 5 MCG/HR (Use 1 buprenorphine) soln im BUTRANS PTWK 7.5 PA; QL(0.143 VOGELXO GEL (Use NF MCG/HR (Use 3 ea daily) testosterone) buprenorphine) VOGELXO PUMP GEL NF nalbuphine hcl soln 1 QL(8 ml daily) (Use testosterone) New starts ANORECTAL AND RELATED PRODUCTS - pentazocine w/ naloxone 1 limited to 7 day Rectal Drugs to Treat Pain, Swelling and Itching tabs supply Intrarectal SUBOXONE FILM 0.5 MG- PA; QL(3 ea CORTENEMA ENEM (Use NF 2 MG, 1 MG-4 MG (Use NF daily) (intrarectal)) buprenorphine hcl- hydrocortisone (intrarectal) 1 naloxone hcl dihydrate) enem SUBOXONE FILM 12 MG- PA; QL(2 ea UCERIS FOAM RE 2 4 PA 3 MG, 2 MG-8 MG (Use NF daily) MG/ACT buprenorphine hcl- naloxone hcl dihydrate) Rectal Steroids -ANABOLIC - Drugs to Regulate ANUSOL-HC CREA (Use NF hydrocortisone (rectal)) Anabolic Steroids hydrocortisone (rectal) crea 1

ANADROL-50 TABS 3 1 (rectal) supp tabs 1 PROCTOCORT CREA (Use hydrocortisone NF Androgens (rectal)) PA; QL(1 ea ANDRODERM PT24 2 PROCTOCORT SUPP daily) (Use hydrocortisone NF ANDROGEL GEL 25 acetate (rectal)) MG/2.5GM, 50 MG/5GM NF Vasodilating Agents (Use testosterone) RECTIV OINT 3 caps 1 DEPO-TESTOSTERONE - Drugs to Treat Worm SOLN (Use testosterone NF Infections cypionate) Anthelmintics METHITEST TABS 3 albendazole tabs 1 PA TESTIM GEL (Use NF ALBENZA TABS (Use NF PA testosterone) albendazole) TESTOSTERONE BILTRICIDE TABS (Use NF PA CYPIONATE SOLN IJ 200 1 ) MG/ML soln 1 ij 200 mg/ml

Ambetter Sunshine Formulary Updated December 1, 2020

10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 ea daily,6 sulfamethoxazole- 1 ea per fill trimethoprim susp retail,6 ea per sulfamethoxazole- 1 fill mail)1 rtl trimethoprim tabs EMVERM CHEW 2 MAX fill,60 rtl day(s) supply,1 Agents mail MAX fill,60 ALINIA SUSR 2 mail day(s) supply, ALINIA TABS 2 tabs 1 atovaquone susp 1 praziquantel tabs 1 PA MEPRON SUSP (Use NF atovaquone) STROMECTOL TABS (Use NF ivermectin) Carbapenems ANTI-INFECTIVE AGENTS - MISC. - Drugs to 1 Treat Bacterial Infections ertapenem sodium solr Anti-infective Agents - Misc. imipenem-cilastatin solr 1 solr 3 INVANZ SOLR (Use NF ertapenem sodium) FLAGYL TABS 500 MG NF (Use ) meropenem solr 1 3 PA; QL(3 ea IMPAVIDO CAPS daily) MERREM SOLR (Use NF meropenem) metronidazole tabs or 250 1 PRIMAXIN IV SOLR (Use NF mg, 500 mg imipenem-cilastatin) NEBUPENT SOLR (Use 3 isethionate) Chloramphenicols sodium PA; SP PENTAM 300 SOLR (Use 3 4 pentamidine isethionate) succinate solr Cyclic Lipopeptides pentamidine isethionate 1 solr CUBICIN RF SOLR (Use NF trimethoprim tabs 1 daptomycin) CUBICIN SOLR (Use NF vancomycin hcl solr iv 1000 1 daptomycin) mg DAPTOMYCIN SOLR 350 NF XIFAXAN TABS 3 PA; AL(At least MG (Use daptomycin) 12 yrs old) daptomycin solr 500 mg 1 Anti-infective Misc. - Combinations BACTRIM DS TABS (Use Glycopeptides sulfamethoxazole- NF FIRVANQ SOLR 2 QL(300 ml per trimethoprim) fill retail) BACTRIM TABS (Use QL(4 ea sulfamethoxazole- NF VANCOCIN CAPS (Use NF vancomycin hcl) daily,40 ea per trimethoprim) fill retail) sulfamethoxazole- 1 trimethoprim soln Ambetter Sunshine Formulary Updated December 1, 2020

11 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(4 ea susr or 100 1 VANCOCIN HCL CAPS NF daily,40 ea per mg/5ml (Use vancomycin hcl) fill retail) PA; QL(2 ea linezolid tabs or 600 mg 1 QL(4 ea daily) vancomycin hcl caps or 1 daily,40 ea per 125 mg, 250 mg PA fill retail) SIVEXTRO TABS OR 3 vancomycin hcl solr iv 10 ZYVOX SUSR OR 100 NF gm, 500 mg, 1 gm, 1000 1 MG/5ML (Use linezolid) mg ZYVOX TABS OR 600 MG NF PA; QL(2 ea VANCOMYCIN QL(300 ml per (Use linezolid) daily) HYDROCHLORIDE SOLR 2 fill retail) OR 250 MG/5ML Polymyxins Leprostatics polymyxin b sulfate solr 1 dapsone tabs or 100 mg, 3 Urinary Anti-infectives 25 mg fosfomycin tromethamine 1 pack CLEOCIN CAPS OR 75 FURADANTIN SUSP (Use NF MG, 150 MG, 300 MG (Use NF nitrofurantoin) hcl) HIPREX TABS (Use NF CLEOCIN PEDIATRIC methenamine hippurate) GRANULES SOLR (Use NF MACROBID CAPS (Use clindamycin palmitate nitrofurantoin monohyd NF hydrochloride) macro) CLEOCIN PHOSPHATE MACRODANTIN CAPS SOLN IJ 300 MG/2ML, 600 100 MG, 50 MG (Use NF MG/4ML, 900 MG/6ML, 9 NF nitrofurantoin macrocrystal) GM/60ML (Use clindamycin phosphate) methenamine hippurate 1 tabs clindamycin hcl caps 1 MONUROL PACK (Use 3 fosfomycin tromethamine) clindamycin palmitate 1 hydrochloride solr nitrofurantoin macrocrystal 1 caps 100 mg, 50 mg clindamycin phosphate 1 soln nitrofurantoin monohyd 1 macro caps LINCOCIN SOLN (Use NF hcl) nitrofurantoin susp 1 lincomycin hcl soln 1 ANTIANGINAL AGENTS - Drugs to Treat Chest Monobactams Pain Antianginals-Other AZACTAM SOLR (Use NF aztreonam) RANEXA TB12 1000 MG NF QL(2 ea daily) (Use ranolazine) aztreonam solr 1 RANEXA TB12 500 MG 2 QL(3 ea daily) CAYSTON SOLR 4 PA; QL(3 ml (Use ranolazine) daily) ranolazine tb12 1000 mg 1 QL(2 ea daily) Oxazolidinones

Ambetter Sunshine Formulary Updated December 1, 2020

12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ranolazine tb12 500 mg 1 QL(3 ea daily) meprobamate tabs 1

Nitrates VISTARIL CAPS (Use NF hydroxyzine pamoate) ISORDIL TITRADOSE TABS 5 MG (Use NF Benzodiazepines isosorbide dinitrate) alprazolam tabs 0.25 mg, 1 QL(4 ea daily) isosorbide dinitrate tabs 30 1 0.5 mg, 1 mg, 2 mg mg, 10 mg, 20 mg, 5 mg alprazolam tb24 0.5 mg, 1 1 isosorbide dinitrate tbcr 40 1 mg, 2 mg, 3 mg mg alprazolam tbdp 0.25 mg, 1 isosorbide mononitrate 1 0.5 mg, 1 mg, 2 mg tabs ATIVAN TABS OR 0.5 MG, NF QL(3 ea daily) isosorbide mononitrate 1 2 MG (Use lorazepam) tb24 ATIVAN TABS OR 1 MG NF QL(4 ea daily) NITRO-BID OINT 3 (Use lorazepam) NITRO-DUR PT24 0.1 chlordiazepoxide hcl caps 1 MG/HR, 0.2 MG/HR, 0.4 NF clorazepate dipotassium 1 MG/HR, 0.6 MG/HR (Use tabs nitroglycerin) diazepam conc or 5 mg/ml 1 nitroglycerin cpcr or 2.5 1 QL(4 ea daily) mg, 6.5 mg, 9 mg diazepam soln or 5 mg/5ml 1 nitroglycerin pt24 td 0.1 mg/hr, 0.2 mg/hr, 0.4 1 diazepam tabs or 10 mg, 2 1 QL(4 ea daily) mg/hr, 0.6 mg/hr mg, 5 mg NITROGLYCERIN SOLN 1 IV 5 MG/ML lorazepam conc or 2 mg/ml 1 lorazepam tabs or 0.5 mg, QL(3 ea daily) nitroglycerin subl sl 0.3 mg, 1 1 0.4 mg, 0.6 mg 2 mg QL(4 ea daily) NITROSTAT SUBL (Use NF lorazepam tabs or 1 mg 1 nitroglycerin) oxazepam caps 30 mg, 10 1 ANTIANXIETY AGENTS - Drugs to Treat Anxiety mg, 15 mg Antianxiety Agents - Misc. TRANXENE T TABS (Use NF clorazepate dipotassium) buspirone hcl tabs 10 mg, 1 30 mg, 15 mg, 7.5 mg VALIUM TABS (Use NF QL(4 ea daily) diazepam) buspirone hcl tabs 5 mg 1 QL(6 ea daily) XANAX TABS (Use NF QL(4 ea daily) alprazolam) hydroxyzine hcl soln im 50 1 mg/ml XANAX XR TB24 (Use NF alprazolam) hydroxyzine hcl syrp or 10 1 mg/5ml ANTIARRHYTHMICS - Drugs to treat abnormal heart rhythms hydroxyzine hcl tabs or 10 1 mg, 25 mg, 50 mg Antiarrhythmics Type I-A hydroxyzine pamoate caps 1 disopyramide phosphate 1 caps Ambetter Sunshine Formulary Updated December 1, 2020

13 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NORPACE CAPS (Use NF XOLAIR SOLR 150 MG 4 PA; QL(0.214 disopyramide phosphate) ea daily); SP procainamide hcl soln 500 1 XOLAIR SOSY 150 4 PA mg/ml MG/ML, 75 MG/0.5ML quinidine sulfate tabs 1 Bronchodilators - Anticholinergics Limit 2 inhalers Antiarrhythmics Type I-B 3 per ATROVENT HFA AERS month;QL(0.44 mexiletine hcl caps 150 1 mg, 200 mg, 250 mg gm daily) Antiarrhythmics Type I-C INCRUSE ELLIPTA AEPB 2 flecainide acetate tabs 1 ipratropium bromide soln 1 QL(15 ml daily) propafenone hcl cp12 1 SPIRIVA HANDIHALER 2 QL(1 ea daily) CAPS propafenone hcl tabs 1 SPIRIVA RESPIMAT 2 AERS RYTHMOL SR CP12 (Use NF propafenone hcl) Leukotriene Modulators Antiarrhythmics Type III ACCOLATE TABS (Use NF QL(2 ea daily) zafirlukast) amiodarone hcl soln iv 150 1 mg/3ml, 50 mg/ml montelukast sodium chew 1 QL(1 ea daily) 4 mg, 5 mg amiodarone hcl tabs or 100 1 mg, 200 mg, 400 mg montelukast sodium pack 4 1 PA; QL(1 ea mg daily) CORDARONE TABS (Use NF amiodarone hcl) montelukast sodium tabs 1 QL(1 ea daily) 10 mg dofetilide caps 1 SINGULAIR CHEW 4 MG, QL(1 ea daily) 5 MG (Use montelukast NF MULTAQ TABS 3 sodium) SINGULAIR PACK 4 MG PA; QL(1 ea TIKOSYN CAPS (Use NF NF dofetilide) (Use montelukast sodium) daily) ANTIASTHMATIC AND BRONCHODILATOR SINGULAIR TABS 10 MG NF QL(1 ea daily) AGENTS - Drugs to Treat Lung Conditions (Use montelukast sodium) QL(2 ea daily) Anti-Inflammatory Agents zafirlukast tabs 1 CROMOLYN SODIUM 1 QL(8 ml daily) QL(4 ea daily) NEBU zileuton tb12 1 QL(8 ml daily) cromolyn sodium nebu 1 ZYFLO CR TB12 (Use NF QL(4 ea daily) zileuton) Antiasthmatic - Monoclonal Antibodies Selective Phosphodiesterase 4 (PDE4) Inhibitors FASENRA PEN SOAJ 4 PA

FASENRA SOSY 4 PA

NUCALA SOLR 100 MG 4 PA

Ambetter Sunshine Formulary Updated December 1, 2020

14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea ADVAIR DISKUS AEPB daily)30 rtl (Use - NF MAX day(s) salmeterol) supply,180 rtl DALIRESP TABS 250 3 lmt day(s),30 ADVAIR HFA AERO 2 MCG mail MAX AIRDUO RESPICLICK day(s) 113/14 AEPB (Use NF supply,180 mail fluticasone-salmeterol) lmt day(s), AIRDUO RESPICLICK DALIRESP TABS 500 3 232/14 AEPB (Use NF MCG fluticasone-salmeterol) Inhalants AIRDUO RESPICLICK PA 55/14 AEPB (Use NF ALVESCO AERS 3 fluticasone-salmeterol) ARNUITY ELLIPTA AEPB 2 Limit 2 Inhalers per month;1 rtl albuterol sulfate aers in 108 pack lmt per ASMANEX HFA AERO 100 2 1 MCG/ACT, 200 MCG/ACT mcg/act fill,2 rtl MAX ASMANEX TWISTHALER fill,30 rtl day(s) 120 METERED DOSES 2 supply, AEPB Limit 2 inhalers ASMANEX TWISTHALER per month;1 rtl 14 METERED DOSES 2 albuterol sulfate aers in 108 1 pack lmt per AEPB mcg/act fill,2 rtl MAX fill,30 rtl day(s) ASMANEX TWISTHALER supply, 30 METERED DOSES 2 AEPB albuterol sulfate nebu in QL(15 ml daily) 0.083 %, 0.63 mg/3ml, 1.25 1 ASMANEX TWISTHALER mg/3ml 60 METERED DOSES 2 AEPB albuterol sulfate nebu in 0.5 1 %, 2.5 mg/0.5ml ASMANEX TWISTHALER 7 METERED DOSES 2 albuterol sulfate syrp or 2 1 AEPB mg/5ml albuterol sulfate tabs or 2 (inhalation) 1 PA; QL(4 ml 1 susp daily) mg, 4 mg albuterol sulfate tb12 or 4 1 FLOVENT DISKUS AEPB 2 mg, 8 mg QL(2 ea daily) FLOVENT HFA AERO 2 ANORO ELLIPTA AEPB 2 ARCAPTA NEOHALER PULMICORT FLEXHALER 2 2 AEPB CAPS BEVESPI AEROSPHERE QL(0.36 gm PULMICORT SUSP (Use NF PA; QL(4 ml 2 budesonide (inhalation)) daily) AERO daily) QVAR REDIHALER AERB 2 BREO ELLIPTA AEPB 2

Sympathomimetics BROVANA NEBU 3 PA; QL(4 ml daily)

Ambetter Sunshine Formulary Updated December 1, 2020

15 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits budesonide-formoterol 1 TRELEGY ELLIPTA AEPB fumarate dihydrate aero 100 MCG/INH-25 2 MCG/INH-62.5 MCG/INH epinephrine hcl soln 1 UTIBRON NEOHALER 3 PA fluticasone-salmeterol aepb CAPS 100 mcg/dose-50 Limit 2 inhalers mcg/dose, 250 mcg/dose- 1 per month;1 rtl 50 mcg/dose, 50 VENTOLIN HFA AERS 2 pack lmt per mcg/dose-500 mcg/dose (Use albuterol sulfate) fill,2 rtl MAX ipratropium-albuterol soln 1 QL(18 ml daily) fill,30 rtl day(s) supply, levalbuterol hcl nebu 0.31 PA; QL(12 ml XOPENEX PA mg/3ml, 0.63 mg/3ml, 1.25 1 daily) CONCENTRATE NEBU NF mg/3ml (Use levalbuterol hcl) levalbuterol hcl nebu 1.25 1 PA PA; Limit 2 mg/0.5ml XOPENEX HFA AERO 3 inhalers per PA; Limit 2 (Use levalbuterol tartrate) month;QL(1 gm daily) 3 inhalers per levalbuterol tartrate aero month;QL(1 gm XOPENEX NEBU (Use NF PA; QL(12 ml daily) levalbuterol hcl) daily) metaproterenol sulfate syrp 1 Xanthines metaproterenol sulfate tabs 1 aminophylline soln 1 Limit 2 inhalers ELIXOPHYLLIN ELIX 1 per month;1 rtl theophylline soln 80 QL(56 ml daily) PROAIR HFA AERS (Use 2 pack lmt per 1 albuterol sulfate) fill,2 rtl MAX mg/15ml fill,30 rtl day(s) theophylline tb12 100 mg, 1 supply, 200 mg, 300 mg, 450 mg Limit 2 inhalers theophylline tb24 400 mg, 1 per month;1 rtl 600 mg PROVENTIL HFA AERS 2 pack lmt per (Use albuterol sulfate) fill,2 rtl MAX ANTICOAGULANTS - Blood Thinners fill,30 rtl day(s) Coumarin Anticoagulants supply, COUMADIN TABS (Use 2 SEREVENT DISKUS 2 warfarin sodium) AEPB warfarin sodium tabs 1 STRIVERDI RESPIMAT 2 AERS SYMBICORT AERO (Use Direct Factor Xa Inhibitors budesonide-formoterol 2 QL(42 ea per fumarate dihydrate) 3 42 days BEVYXXA CAPS retail,42 ea per terbutaline sulfate soln 1 42 days mail) ELIQUIS STARTER PACK 2 QL(2.47 ea terbutaline sulfate tabs 1 TBPK daily) ELIQUIS TABS 2 QL(2.47 ea daily) Ambetter Sunshine Formulary Updated December 1, 2020

16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1 rtl MAX QL(4.5 ml per XARELTO STARTER 2 180 days PACK TBPK fill,365 rtl fondaparinux sodium soln day(s) supply, 4 retail,4.5 ml per 2.5 mg/0.5ml 180 days mail); XARELTO TABS 10 MG, 2 QL(1 ea daily) 20 MG SP QL(3.6 ml per XARELTO TABS 15 MG, 2 QL(2 ea daily) 2.5 MG 180 days fondaparinux sodium soln 5 4 retail,3.6 ml per Heparins And Heparinoid-Like Agents mg/0.4ml 180 days mail); QL(7.2 ml per SP ARIXTRA SOLN 10 180 days QL(5.4 ml per MG/0.8ML (Use NF retail,7.2 ml per 180 days fondaparinux sodium) 180 days mail); fondaparinux sodium soln 4 retail,5.4 ml per SP 7.5 mg/0.6ml 180 days mail); QL(4.5 ml per SP ARIXTRA SOLN 2.5 180 days FRAGMIN SOLN 10000 PA; SP MG/0.5ML (Use NF retail,4.5 ml per UNIT/ML, 12500 fondaparinux sodium) 180 days mail); UNIT/0.5ML, 15000 SP UNIT/0.6ML, 18000 4 QL(3.6 ml per UNT/0.72ML, 2500 ARIXTRA SOLN 5 180 days UNIT/0.2ML, 5000 MG/0.4ML (Use NF retail,3.6 ml per UNIT/0.2ML, 7500 fondaparinux sodium) 180 days mail); UNIT/0.3ML SP HEPARIN LOCK FLUSH QL(5.4 ml per SOLN (Use heparin sodium NF ARIXTRA SOLN 7.5 180 days (porcine) lock flush) MG/0.6ML (Use NF retail,5.4 ml per heparin sod (porcine) in 1 fondaparinux sodium) 180 days mail); d5w soln 40 unit/ml-5 % SP heparin sodium (porcine) enoxaparin sodium soln ij 4 QL(6 ml daily) soln 20000 unit/ml, 10000 1 300 mg/3ml unit/ml, 5000 unit/ml enoxaparin sodium soln sc 4 QL(2 ml daily) HEPARIN SODIUM/NACL 100 mg/ml, 150 mg/ml 0.45% SOLN 0.45 %- 1 12500 UNIT/250ML enoxaparin sodium soln sc 4 QL(1.6 ml 120 mg/0.8ml, 80 mg/0.8ml daily) HEPARIN SODIUM/SODIUM enoxaparin sodium soln sc 4 QL(0.6 ml 30 mg/0.3ml daily); SP CHLORIDE 0.9% SOLN IV NF QL(0.8 ml 0.9 %-1000 UNIT/500ML enoxaparin sodium soln sc 4 daily,30 day(s) (Use heparin (porcine) in 40 mg/0.4ml limit); SP sodium chloride) QL(1.2 ml LOVENOX SOLN IJ 300 QL(6 ml daily) enoxaparin sodium soln sc 4 daily,30 day(s) MG/3ML (Use enoxaparin NF 60 mg/0.6ml limit); SP sodium) QL(7.2 ml per LOVENOX SOLN SC 100 QL(2 ml daily) 180 days MG/ML, 150 MG/ML (Use NF fondaparinux sodium soln 4 retail,7.2 ml per enoxaparin sodium) 10 mg/0.8ml 180 days mail); LOVENOX SOLN SC 120 QL(1.6 ml SP MG/0.8ML, 80 MG/0.8ML NF daily) (Use enoxaparin sodium) Ambetter Sunshine Formulary Updated December 1, 2020

17 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LOVENOX SOLN SC 30 QL(0.6 ml PA; QL(10 ea MG/0.3ML (Use NF daily); SP VALTOCO LQPK 4 per 30 days enoxaparin sodium) retail) LOVENOX SOLN SC 40 QL(0.8 ml Anticonvulsants - Misc. MG/0.4ML (Use NF daily,30 day(s) ST; QL(2 ea enoxaparin sodium) limit); SP APTIOM TABS 3 daily) LOVENOX SOLN SC 60 QL(1.2 ml PA; QL(80 ml MG/0.6ML (Use NF daily,30 day(s) BANZEL SUSP 40 MG/ML 2 (Use rufinamide) daily) enoxaparin sodium) limit); SP BANZEL TABS 200 MG 2 PA; QL(2 ea Thrombin Inhibitors daily) QL(2 ea daily) PA; QL(8 ea PRADAXA CAPS 3 BANZEL TABS 400 MG 2 daily) ANTICONVULSANTS - Drugs to Treat BRIVIACT SOLN OR 10 3 PA MG/ML AMPA Glutamate Receptor Antagonists BRIVIACT TABS OR 10 PA FYCOMPA TABS 10 MG, PA MG, 100 MG, 25 MG, 50 3 12 MG, 2 MG, 4 MG, 6 MG, 3 MG, 75 MG 8 MG chew 100 1 Anticonvulsants - Benzodiazepines mg PA; QL(16 ml carbamazepine cp12 100 clobazam susp 2.5 mg/ml 1 1 daily) mg carbamazepine cp12 200 QL(6 ea daily) clobazam tabs 10 mg, 20 1 PA; QL(2 ea 1 mg daily) mg carbamazepine cp12 300 QL(4 ea daily) clonazepam tabs 0.5 mg, 1 1 1 mg, 2 mg mg DIASTAT ACUDIAL GEL carbamazepine susp 100 1 (Use diazepam 3 mg/5ml (anticonvulsant)) carbamazepine tabs 200 1 DIASTAT PEDIATRIC GEL mg (Use diazepam 3 carbamazepine tb12 100 1 QL(4 ea daily) (anticonvulsant)) mg, 400 mg diazepam (anticonvulsant) 3 carbamazepine tb12 200 1 QL(6 ea daily) gel mg KLONOPIN TABS (Use NF CARBATROL CP12 100 NF clonazepam) MG (Use carbamazepine) PA; QL(10 ea CARBATROL CP12 200 NF QL(6 ea daily) NAYZILAM SOLN 3 per 30 days MG (Use carbamazepine) retail) CARBATROL CP12 300 NF QL(4 ea daily) ONFI SUSP 2.5 MG/ML NF PA; QL(16 ml MG (Use carbamazepine) (Use clobazam) daily) PA; QL(12 ea DIACOMIT CAPS 250 MG 4 ONFI TABS 10 MG, 20 MG NF PA; QL(2 ea daily) (Use clobazam) daily) DIACOMIT CAPS 500 MG 4 PA; QL(6 ea PA; QL(10 ea daily) VALTOCO LIQD 4 per 30 days DIACOMIT PACK 250 MG 4 PA; QL(12 ea retail) daily)

Ambetter Sunshine Formulary Updated December 1, 2020

18 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits levetiracetam tabs or 500 QL(6 ea daily) DIACOMIT PACK 500 MG 4 PA; QL(6 ea 1 daily) mg EPIDIOLEX SOLN 3 PA levetiracetam tb24 or 500 1 QL(4 ea daily) mg, 750 mg gabapentin caps 100 mg, 1 LYRICA CAPS 100 MG, PA; QL(3 ea 300 mg, 400 mg 150 MG, 200 MG, 25 MG, 2 daily) 50 MG, 75 MG (Use gabapentin soln 250 1 QL(60 ml daily) mg/5ml, 300 mg/6ml pregabalin) LYRICA CAPS 225 MG, PA; QL(2 ea gabapentin tabs 600 mg, 1 2 800 mg 300 MG (Use pregabalin) daily) KEPPRA SOLN IV 500 QL(30 ml daily) LYRICA SOLN 20 MG/ML 2 PA; QL(30 ml MG/5ML (Use NF (Use pregabalin) daily) levetiracetam) MYSOLINE TABS (Use NF ) KEPPRA SOLN OR 100 NF QL(30 ml daily) MG/ML (Use levetiracetam) NEURONTIN CAPS 100 MG, 300 MG, 400 MG (Use NF KEPPRA TABS OR 1000 NF QL(3 ea daily) MG (Use levetiracetam) gabapentin) KEPPRA TABS OR 250 QL(4 ea daily) NEURONTIN SOLN 250 NF QL(60 ml daily) MG, 750 MG (Use NF MG/5ML (Use gabapentin) levetiracetam) NEURONTIN TABS 600 MG, 800 MG (Use NF KEPPRA TABS OR 500 NF QL(6 ea daily) MG (Use levetiracetam) gabapentin) susp 300 QL(40 ml daily) KEPPRA XR TB24 (Use NF QL(4 ea daily) 1 levetiracetam) mg/5ml, 60 mg/ml LAMICTAL CHEWABLE oxcarbazepine tabs 150 1 QL(3 ea daily) DISPERSIBLE CHEW (Use NF mg, 300 mg ) oxcarbazepine tabs 600 mg 1 QL(4 ea daily) LAMICTAL ODT TBDP 100 QL(1 ea daily) MG, 200 MG, 25 MG, 50 NF pregabalin caps 100 mg, PA; QL(3 ea MG (Use lamotrigine) 150 mg, 200 mg, 25 mg, 50 1 daily) mg, 75 mg LAMICTAL TABS (Use NF lamotrigine) pregabalin caps 225 mg, 1 PA; QL(2 ea 300 mg daily) lamotrigine chew 25 mg, 5 1 PA; QL(30 ml mg pregabalin soln 20 mg/ml 1 daily) lamotrigine tabs 100 mg, 1 150 mg, 200 mg, 25 mg primidone tabs 1 lamotrigine tbdp 100 mg, 1 QL(1 ea daily) 200 mg, 25 mg, 50 mg QUDEXY XR CS24 (Use NF levetiracetam soln iv 500 QL(30 ml daily) ) 1 PA; QL(80 ml mg/5ml rufinamide susp 1 daily) levetiracetam soln or 100 1 QL(30 ml daily) mg/ml, 500 mg/5ml TEGRETOL SUSP (Use 2 carbamazepine) levetiracetam tabs or 1000 1 QL(3 ea daily) mg TEGRETOL TABS (Use 2 carbamazepine) levetiracetam tabs or 250 1 QL(4 ea daily) mg, 750 mg

Ambetter Sunshine Formulary Updated December 1, 2020

19 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TEGRETOL-XR TB12 100 QL(4 ea daily) susp 600 mg/5ml 1 QL(30 ml daily) MG, 400 MG (Use NF carbamazepine) felbamate tabs 400 mg 1 QL(9 ea daily) TEGRETOL-XR TB12 200 NF QL(6 ea daily) MG (Use carbamazepine) felbamate tabs 600 mg 1 QL(6 ea daily) TOPAMAX SPRINKLE QL(6 ea daily) CPSP 15 MG (Use NF FELBATOL SUSP 600 NF QL(30 ml daily) topiramate) MG/5ML (Use felbamate) TOPAMAX SPRINKLE QL(8 ea daily) FELBATOL TABS 400 MG NF QL(9 ea daily) CPSP 25 MG (Use NF (Use felbamate) topiramate) FELBATOL TABS 600 MG NF QL(6 ea daily) (Use felbamate) TOPAMAX TABS 100 MG NF QL(4 ea daily) (Use topiramate) GABA Modulators TOPAMAX TABS 200 MG QL(2 ea daily) NF GABITRIL TABS 2 MG, 4 NF (Use topiramate) MG (Use tiagabine hcl) TOPAMAX TABS 25 MG, QL(6 ea daily) NF SABRIL PACK (Use NF PA; QL(6 ea 50 MG (Use topiramate) vigabatrin) daily); SP QL(6 ea daily) topiramate cpsp 15 mg 1 SABRIL TABS (Use 4 PA; QL(6 ea vigabatrin) daily); SP QL(8 ea daily) topiramate cpsp 25 mg 1 tiagabine hcl tabs 2 mg, 4 1 mg topiramate tabs 100 mg 1 QL(4 ea daily) 4 PA; QL(6 ea vigabatrin pack daily); SP QL(2 ea daily) topiramate tabs 200 mg 1 PA; QL(6 ea vigabatrin tabs 4 daily); SP topiramate tabs 25 mg, 50 1 QL(6 ea daily) mg Hydantoins TRILEPTAL SUSP 300 QL(40 ml daily) CEREBYX SOLN (Use NF MG/5ML (Use NF fosphenytoin sodium) oxcarbazepine) DILANTIN CAPS 100 MG TRILEPTAL TABS 150 QL(3 ea daily) (Use sodium 2 MG, 300 MG (Use NF extended) oxcarbazepine) DILANTIN CAPS 30 MG 2 TRILEPTAL TABS 600 MG NF QL(4 ea daily) (Use oxcarbazepine) DILANTIN INFATABS 2 VIMPAT SOLN IV 200 3 QL(40 ml daily) CHEW (Use phenytoin) MG/20ML DILANTIN-125 SUSP (Use 2 VIMPAT SOLN OR 10 3 PA; QL(40 ml phenytoin) MG/ML daily) fosphenytoin sodium soln 1 VIMPAT TABS OR 100 PA; QL(2 ea 3 MG, 150 MG, 200 MG, 50 daily) PEGANONE TABS 3 MG PHENYTEK CAPS (Use ZONEGRAN CAPS (Use NF QL(6 ea daily) zonisamide) phenytoin sodium 2 extended) zonisamide caps 1 QL(6 ea daily) phenytoin chew 1 Carbamates

Ambetter Sunshine Formulary Updated December 1, 2020

20 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits phenytoin sodium extended 1 mirtazapine tbdp 15 mg 1 QL(3 ea daily) caps QL(1.5 ea mirtazapine tbdp 30 mg 1 phenytoin sodium soln 1 daily) phenytoin susp 1 mirtazapine tbdp 45 mg 1

Succinimides REMERON SOLTAB TBDP NF QL(3 ea daily) 15 MG (Use mirtazapine) CELONTIN CAPS 3 QL(4 ea daily) REMERON SOLTAB TBDP NF QL(1.5 ea 30 MG (Use mirtazapine) daily) ethosuximide caps 250 mg 1 QL(6 ea daily) REMERON SOLTAB TBDP NF 45 MG (Use mirtazapine) ethosuximide soln 250 1 QL(30 ml daily) mg/5ml REMERON TABS 15 MG NF QL(3 ea daily) (Use mirtazapine) ZARONTIN CAPS 250 MG 2 QL(6 ea daily) (Use ethosuximide) REMERON TABS 30 MG NF QL(1.5 ea ZARONTIN SOLN 250 QL(30 ml daily) (Use mirtazapine) daily) MG/5ML (Use NF Antidepressants - Misc. ethosuximide) hcl tabs 100 mg, 1 QL(3 ea daily) Valproic Acid 75 mg DEPACON SOLN (Use NF QL(4 ea daily) sodium) bupropion hcl tb12 100 mg 1 QL(3 ea daily) DEPAKENE CAPS (Use NF bupropion hcl tb12 150 mg 1 valproic acid) QL(2 ea daily) DEPAKENE SOLN (Use NF bupropion hcl tb12 200 mg 1 valproate sodium) bupropion hcl tb24 150 mg 1 QL(3 ea daily) DEPAKOTE ER TB24 (Use NF divalproex sodium) bupropion hcl tb24 300 mg 1 QL(1 ea daily) DEPAKOTE TBEC (Use NF divalproex sodium) FORFIVO XL TB24 (Use NF divalproex sodium tb24 250 1 bupropion hcl) mg, 500 mg maprotiline hcl tabs 3 divalproex sodium tbec 125 1 mg, 250 mg, 500 mg WELLBUTRIN SR TB12 QL(4 ea daily) valproate sodium soln 1 100 MG (Use bupropion NF hcl) valproic acid caps or 1 WELLBUTRIN SR TB12 QL(3 ea daily) 150 MG (Use bupropion NF ANTIDEPRESSANTS - Drugs to Treat hcl) WELLBUTRIN SR TB12 QL(2 ea daily) Alpha-2 Receptor Antagonists (Tetracyclics) 200 MG (Use bupropion NF hcl) QL(3 ea daily) mirtazapine tabs 15 mg 1 WELLBUTRIN XL TB24 QL(3 ea daily) QL(1.5 ea 150 MG (Use bupropion NF mirtazapine tabs 30 mg 1 daily) hcl) mirtazapine tabs 7.5 mg, 1 QL(1 ea daily) 45 mg Ambetter Sunshine Formulary Updated December 1, 2020

21 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits WELLBUTRIN XL TB24 QL(1 ea daily) escitalopram oxalate tabs 5 1 QL(4 ea daily) 300 MG (Use bupropion NF mg hcl) fluoxetine hcl caps 10 mg 1 QL(1 ea daily) Monoamine Oxidase Inhibitors (MAOIs) QL(3 ea daily) EMSAM PT24 3 QL(1 ea daily) fluoxetine hcl caps 20 mg 1 QL(2 ea daily) MARPLAN TABS 2 QL(6 ea daily) fluoxetine hcl caps 40 mg 1 fluoxetine hcl cpdr 90 mg 1 NARDIL TABS (Use NF phenelzine sulfate) fluoxetine hcl soln 20 1 QL(20 ml daily) PARNATE TABS (Use NF mg/5ml tranylcypromine sulfate) fluoxetine hcl tabs 10 mg, 1 QL(1 ea daily) phenelzine sulfate tabs 1 60 mg fluoxetine hcl tabs 20 mg 1 QL(3 ea daily) tranylcypromine sulfate 1 tabs FLUOXETINE QL(1 ea daily) N-Methyl-D-aspartic acid (NMDA) Receptor HYDROCHLORIDE TABS NF (Use fluoxetine hcl) SPRAVATO 56MG DOSE 4 PA SOPK fluvoxamine maleate tabs 1 QL(3 ea daily) 100 mg SPRAVATO 84MG DOSE 4 PA SOPK fluvoxamine maleate tabs 1 QL(2 ea daily) Selective Serotonin Reuptake Inhibitors (SSRIs) 25 mg, 50 mg CELEXA TABS 10 MG QL(4 ea daily) LEXAPRO TABS 10 MG NF QL(2 ea daily) (Use citalopram NF (Use escitalopram oxalate) hydrobromide) LEXAPRO TABS 20 MG NF QL(1 ea daily) CELEXA TABS 20 MG QL(2 ea daily) (Use escitalopram oxalate) (Use citalopram NF LEXAPRO TABS 5 MG NF QL(4 ea daily) hydrobromide) (Use escitalopram oxalate) CELEXA TABS 40 MG QL(1 ea daily) hcl tabs 10 mg 1 QL(6 ea daily) (Use citalopram NF hydrobromide) paroxetine hcl tabs 20 mg 1 QL(3 ea daily) citalopram hydrobromide 1 QL(20 ml daily) soln 10 mg/5ml paroxetine hcl tabs 30 mg 1 QL(2 ea daily) citalopram hydrobromide 1 QL(4 ea daily) tabs 10 mg paroxetine hcl tabs 40 mg 1 QL(1 ea daily) citalopram hydrobromide QL(2 ea daily) 1 paroxetine hcl tb24 12.5 1 QL(1 ea daily) tabs 20 mg mg citalopram hydrobromide QL(1 ea daily) 1 paroxetine hcl tb24 37.5 1 QL(2 ea daily) tabs 40 mg mg, 25 mg escitalopram oxalate soln 5 QL(20 ml daily) 1 PAXIL CR TB24 12.5 MG NF QL(1 ea daily) mg/5ml (Use paroxetine hcl) escitalopram oxalate tabs QL(2 ea daily) 1 PAXIL CR TB24 37.5 MG, NF QL(2 ea daily) 10 mg 25 MG (Use paroxetine hcl) escitalopram oxalate tabs 1 QL(1 ea daily) QL(30 ml daily) 20 mg PAXIL SUSP 10 MG/5ML 3

Ambetter Sunshine Formulary Updated December 1, 2020

22 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PAXIL TABS 10 MG (Use NF QL(6 ea daily) duloxetine hcl cpep or 40 1 paroxetine hcl) mg PAXIL TABS 20 MG (Use NF QL(3 ea daily) EFFEXOR XR CP24 150 NF QL(2 ea daily) paroxetine hcl) MG (Use venlafaxine hcl) PAXIL TABS 30 MG (Use NF QL(2 ea daily) EFFEXOR XR CP24 37.5 NF QL(4 ea daily) paroxetine hcl) MG (Use venlafaxine hcl) PAXIL TABS 40 MG (Use NF QL(1 ea daily) EFFEXOR XR CP24 75 NF QL(5 ea daily) paroxetine hcl) MG (Use venlafaxine hcl) PROZAC CAPS 10 MG NF QL(1 ea daily) FETZIMA CP24 3 PA (Use fluoxetine hcl) FETZIMA TITRATION PA PROZAC CAPS 20 MG NF QL(3 ea daily) 3 (Use fluoxetine hcl) PACK C4PK KHEDEZLA TB24 (Use PROZAC CAPS 40 MG NF QL(2 ea daily) NF (Use fluoxetine hcl) desvenlafaxine) PRISTIQ TB24 100 MG QL(4 ea daily) sertraline hcl conc 20 1 QL(10 ml daily) mg/ml (Use desvenlafaxine NF QL(2 ea daily) succinate) sertraline hcl tabs 100 mg 1 PRISTIQ TB24 25 MG, 50 QL(1 ea daily) MG (Use desvenlafaxine NF sertraline hcl tabs 25 mg, 1 QL(4 ea daily) 50 mg succinate) venlafaxine hcl cp24 150 QL(2 ea daily) ZOLOFT CONC 20 MG/ML NF QL(10 ml daily) 1 (Use sertraline hcl) mg venlafaxine hcl cp24 37.5 QL(4 ea daily) ZOLOFT TABS 100 MG NF QL(2 ea daily) 1 (Use sertraline hcl) mg QL(5 ea daily) ZOLOFT TABS 25 MG, 50 NF QL(4 ea daily) venlafaxine hcl cp24 75 mg 1 MG (Use sertraline hcl) venlafaxine hcl tabs 100 QL(3 ea daily) Serotonin Modulators mg, 25 mg, 37.5 mg, 50 1 nefazodone hcl tabs 3 mg, 75 mg venlafaxine hcl tb24 150 1 QL(2 ea daily) trazodone hcl tabs 1 mg venlafaxine hcl tb24 225 1 ST; QL(1 ea TRINTELLIX TABS 3 PA; QL(1 ea mg daily) daily) venlafaxine hcl tb24 75 mg, 1 QL(1 ea daily) VIIBRYD STARTER PACK 3 PA 37.5 mg KIT PA; QL(1 ea Tricyclic Agents VIIBRYD TABS 3 daily) amitriptyline hcl tabs 1 Serotonin-Norepinephrine Reuptake Inhibitors amoxapine tabs 3 CYMBALTA CPEP (Use NF QL(2 ea daily) duloxetine hcl) ANAFRANIL CAPS (Use NF PA desvenlafaxine succinate 1 QL(4 ea daily) clomipramine hcl) tb24 100 mg clomipramine hcl caps 1 PA desvenlafaxine succinate 1 QL(1 ea daily) tb24 25 mg, 50 mg desipramine hcl tabs 1 duloxetine hcl cpep or 20 1 QL(2 ea daily) mg, 30 mg, 60 mg Ambetter Sunshine Formulary Updated December 1, 2020

23 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits doxepin hcl caps 1 DUETACT TABS (Use QL(1 ea daily) pioglitazone hcl- NF doxepin hcl conc 1 glimepiride) glipizide-metformin hcl tabs QL(2 ea daily) imipramine hcl tabs 1 2.5 mg-250 mg, 2.5 mg- 1 500 mg imipramine pamoate caps 1 glipizide-metformin hcl tabs 1 QL(4 ea daily) 5 mg-500 mg NORPRAMIN TABS (Use NF glyburide-metformin tabs 1 QL(2 ea daily) desipramine hcl) 1.25 mg-250 mg nortriptyline hcl caps 1 glyburide-metformin tabs QL(4 ea daily) 2.5 mg-500 mg, 5 mg-500 1 nortriptyline hcl soln 1 mg GLYXAMBI TABS 3 PA PAMELOR CAPS (Use NF nortriptyline hcl) INVOKAMET TABS 3 PA protriptyline hcl tabs 1 JANUMET TABS 2 SURMONTIL CAPS (Use NF trimipramine maleate) JANUMET XR TB24 2 TOFRANIL TABS (Use NF imipramine hcl) JENTADUETO TABS 2 trimipramine maleate caps 1 JENTADUETO XR TB24 2 ANTIDIABETICS - Drugs to Regulate Blood Sugar KAZANO TABS (Use NF alogliptin-metformin hcl) Alpha-Glucosidase Inhibitors OSENI TABS (Use NF acarbose tabs 1 QL(3 ea daily) alogliptin-pioglitazone) pioglitazone hcl-glimepiride QL(1 ea daily) GLYSET TABS (Use NF 1 miglitol) tabs pioglitazone hcl-metformin 1 QL(2 ea daily) miglitol tabs 1 hcl tabs repaglinide-metformin hcl QL(2 ea daily) PRECOSE TABS (Use NF QL(3 ea daily) 1 acarbose) tabs QL(2 ea daily) Antidiabetic - Amylin Analogs SEGLUROMET TABS 2 SYMLINPEN 120 SOPN 2 PA; QL(0.36 ml daily) SYNJARDY TABS 2 SYMLINPEN 60 SOPN 2 PA; QL(0.2 ml daily) SYNJARDY XR TB24 2 Antidiabetic Combinations XIGDUO XR TB24 10 MG- PA 1000 MG, 10 MG-500 MG, 3 ACTOPLUS MET TABS QL(2 ea daily) 1000 MG-5 MG, 5 MG-500 (Use pioglitazone hcl- NF MG metformin hcl) XULTOPHY 100/3.6 SOPN 3 PA Biguanides Ambetter Sunshine Formulary Updated December 1, 2020

24 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLUCOPHAGE TABS QL(2.5 ea Incretin Mimetic Agents (GLP-1 Receptor NF 1000 MG (Use metformin daily) PA; QL(0.143 hcl) BYDUREON BCISE AUIJ 2 ml daily) QL(5 ea daily) GLUCOPHAGE TABS 500 NF PA; QL(0.143 MG (Use metformin hcl) BYDUREON PEN PEN 2 ea daily) GLUCOPHAGE TABS 850 NF QL(3 ea daily) MG (Use metformin hcl) BYDUREON SRER 2 PA; QL(0.143 ea daily) GLUCOPHAGE XR TB24 NF (Use metformin hcl) PA; Limit 2.4ml BYETTA SOPN 10 2 per metformin hcl tabs 1000 1 QL(2.5 ea MCG/0.04ML month;QL(0.08 mg daily) ml daily) metformin hcl tabs 500 mg 1 QL(5 ea daily) PA; Limit 1.2ml BYETTA SOPN 5 2 per metformin hcl tabs 850 mg 1 QL(3 ea daily) MCG/0.02ML month;QL(0.04 ml daily) metformin hcl tb24 500 mg, 1 PA 750 mg TANZEUM PEN 3 Diabetic Other TRULICITY SOPN 2 PA; QL(0.143 ml daily) BAQSIMI ONE PACK 3 QL(0.069 ea POWD daily) VICTOZA SOPN 2 PA; QL(0.3 ml daily) BAQSIMI TWO PACK 3 QL(0.069 ea POWD daily) Insulin Sensitizing Agents diazoxide susp 1 ACTOS TABS (Use NF QL(1 ea daily) pioglitazone hcl) GLUCAGEN HYPOKIT 3 QL(0.035 ea QL(1 ea daily) SOLR daily) AVANDIA TABS 3 GLUCAGON 3 QL(0.035 ea QL(1 ea daily) EMERGENCY KIT KIT daily) pioglitazone hcl tabs 1 GVOKE PFS SOSY 3 QL(0.02 ml Insulin daily) BASAGLAR KWIKPEN 2 PROGLYCEM SUSP (Use 3 SOPN diazoxide) FIASP FLEXTOUCH 2 Dipeptidyl Peptidase-4 (DPP-4) Inhibitors SOPN PA; QL(1 ea alogliptin benzoate tabs 3 FIASP PENFILL SOCT 2 daily) JANUVIA TABS 2 QL(1 ea daily) FIASP SOLN 2 HUMULIN R U-500 NESINA TABS (Use 3 PA; QL(1 ea 3 alogliptin benzoate) daily) (CONCENTRATED) SOLN HUMULIN R U-500 ONGLYZA TABS 3 PA; QL(1 ea 3 daily) KWIKPEN SOPN QL(1 ea daily) LEVEMIR FLEXTOUCH 2 TRADJENTA TABS 2 SOPN Dopamine Receptor Agonists - Antidiabetic LEVEMIR SOLN 2 CYCLOSET TABS 3 QL(6 ea daily)

Ambetter Sunshine Formulary Updated December 1, 2020

25 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NOVOLIN 70/30 FLEXPEN 2 INVOKANA TABS 3 PA; QL(1 ea RELION SUPN daily) NOVOLIN 70/30 FLEXPEN 2 JARDIANCE TABS 2 SUPN

NOVOLIN 70/30 RELION 2 STEGLATRO TABS 2 SUSP Sulfonylureas NOVOLIN 70/30 SUSP 2 AMARYL TABS 1 MG, 2 NF QL(4 ea daily) NOVOLIN N RELION 2 MG (Use glimepiride) SUSP AMARYL TABS 4 MG (Use NF QL(2 ea daily) NOVOLIN N SUSP 2 glimepiride) chlorpropamide tabs 100 1 QL(3 ea daily) NOVOLIN R RELION 2 mg SOLN glimepiride tabs 1 mg, 2 mg 1 QL(4 ea daily) NOVOLIN R SOLN 2 glimepiride tabs 4 mg 1 QL(2 ea daily) NOVOLOG FLEXPEN 2 SOPN glipizide tabs 10 mg, 5 mg 1 QL(4 ea daily) NOVOLOG MIX 70/30 PREFILLED FLEXPEN 2 glipizide tb24 10 mg, 2.5 1 QL(2 ea daily) SUPN mg, 5 mg NOVOLOG MIX 70/30 2 GLUCOTROL TABS (Use NF QL(4 ea daily) SUSP glipizide) NOVOLOG PENFILL 2 GLUCOTROL XL TB24 NF QL(2 ea daily) SOCT (Use glipizide) NOVOLOG SOLN 2 glyburide micronized tabs 1 QL(4 ea daily)

TRESIBA FLEXTOUCH 3 PA QL(4 ea daily) SOPN glyburide tabs 1 TRESIBA SOLN 3 PA GLYNASE TABS (Use NF QL(4 ea daily) glyburide micronized) Meglitinide Analogues tolazamide tabs 1 QL(4 ea daily) nateglinide tabs 1 QL(3 ea daily) tolbutamide tabs 1 QL(6 ea daily) PRANDIN TABS 1 MG NF QL(4 ea daily) (Use repaglinide) ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs to Treat Diarrhea PRANDIN TABS 2 MG NF QL(8 ea daily) (Use repaglinide) Antiperistaltic Agents repaglinide tabs 0.5 mg, 1 QL(4 ea daily) 1 diphenoxylate w/ atropine 1 mg liqd QL(8 ea daily) repaglinide tabs 2 mg 1 diphenoxylate w/ atropine 1 tabs STARLIX TABS (Use QL(3 ea daily) NF IMODIUM A-D CAPS 2 MG NF RX/OTC nateglinide) (Use loperamide hcl) Sodium-Glucose Co-Transporter 2 (SGLT2) LOMOTIL TABS (Use NF diphenoxylate w/ atropine) FARXIGA TABS 3 PA

Ambetter Sunshine Formulary Updated December 1, 2020

26 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RX/OTC loperamide hcl caps 2 mg 1 ANZEMET TABS 3 PA; QL(0.167 ea daily) MOTOFEN TABS 3 granisetron hcl soln iv 0.1 1 mg/ml, 1 mg/ml AND SPECIFIC ANTAGONISTS granisetron hcl tabs or 1 1 QL(0.34 ea mg daily) Antidotes - Chelating Agents ondansetron hcl soln ij 4 1 CHEMET CAPS 3 mg/2ml ondansetron hcl soln or 4 1 QL(3.34 ml deferasirox pack 180 mg, 4 PA mg/5ml daily) 360 mg, 90 mg ondansetron hcl tabs or 24 1 QL(0.143 ea deferasirox tabs 360 mg, 4 PA; SP mg daily) 90 mg, 180 mg QL(4 ea deferasirox tbso 125 mg, PA; SP 4 ondansetron hcl tabs or 4 1 daily,60 ea per 250 mg, 500 mg mg fill retail,60 ea deferiprone tabs 1 per fill mail) QL(3 ea EXJADE TBSO (Use PA; SP 4 ondansetron hcl tabs or 8 1 daily,45 ea per deferasirox) mg fill retail,45 ea per fill mail) FERRIPROX TABS 500 3 MG (Use deferiprone) ondansetron tbdp 4 mg 1 QL(1 ea daily) JADENU SPRINKLE PACK 4 PA (Use deferasirox) ondansetron tbdp 8 mg 1 JADENU TABS (Use 4 PA; SP deferasirox) palonosetron hcl soln 1 Antidotes and Specific Antagonists ZOFRAN SOLN 4 MG/5ML NF QL(3.34 ml deferoxamine mesylate solr 4 PA (Use ondansetron hcl) daily) QL(4 ea DESFERAL SOLR (Use PA 4 ZOFRAN TABS 4 MG (Use NF daily,60 ea per deferoxamine mesylate) ondansetron hcl) fill retail,60 ea VISTOGARD PACK 4 PA per fill mail) QL(3 ea Opioid Antagonists ZOFRAN TABS 8 MG (Use NF daily,45 ea per ondansetron hcl) fill retail,45 ea naloxone hcl soln 0.4 1 mg/ml, 4 mg/10ml per fill mail) naltrexone hcl tabs 1 Antiemetics - Anticholinergic meclizine hcl tabs 12.5 mg, 1 RX/OTC QL(2 ea per fill 25 mg retail)2 rtl MAX QL(0.34 ea NARCAN LIQD 3 scopolamine pt72 1 fill,30 rtl day(s) daily) supply, TIGAN CAPS OR 300 MG ANTIEMETICS - Drugs to Treat and (Use trimethobenzamide NF hcl) 5-HT3 Receptor Antagonists TRANSDERM SCOP PT72 2 QL(0.34 ea (Use scopolamine) daily) ALOXI SOLN (Use NF palonosetron hcl) Ambetter Sunshine Formulary Updated December 1, 2020

27 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRANSDERM-SCOP PT72 2 QL(0.34 ea (Use scopolamine) daily) ANTIFUNGALS - Drugs to Treat Fungal Infections trimethobenzamide hcl 1 Antifungal - Glucan Synthesis Inhibitors caps CANCIDAS SOLR (Use NF Antiemetics - Miscellaneous caspofungin acetate) caspofungin acetate solr 50 AKYNZEO CAPS OR 0.5 3 PA 1 MG-300 MG mg, 70 mg AKYNZEO SOLR IV 0.25 4 PA ERAXIS SOLR 3 MG-235 MG micafungin sodium solr 100 1 CESAMET CAPS 3 mg, 50 mg PA; QL(4 ea MYCAMINE SOLR 3 daily)3 rtl MAX fill,365 rtl Antifungals DICLEGIS TBEC (Use 3 doxylamine-pyridoxine) day(s) supply,3 mail MAX ABELCET SUSP 3 fill,365 mail day(s) supply, AMBISOME SUSR 3 PA; QL(4 ea daily)3 rtl MAX solr 3 fill,365 rtl ANCOBON CAPS (Use NF doxylamine-pyridoxine tbec 1 day(s) supply,3 flucytosine) mail MAX fill,365 mail flucytosine caps 1 day(s) supply, microsize susp 1 AL(At least 2 dronabinol caps 1 125 mg/5ml yrs old) griseofulvin microsize tabs MARINOL CAPS (Use NF 1 dronabinol) 500 mg griseofulvin ultramicrosize 1 Substance P/Neurokinin 1 (NK1) Receptor tabs aprepitant caps 125 mg, 40 1 PA; QL(0.067 mg ea daily) nystatin tabs 1 PA; QL(0.134 aprepitant caps 80 mg 1 QL(1 ea daily) ea daily) terbinafine hcl tabs 1 EMEND CAPS OR 125 PA; QL(0.067 Imidazole-Related Antifungals MG, 40 MG (Use NF ea daily) aprepitant) CRESEMBA CAPS OR 3 PA 186 MG EMEND CAPS OR 80 MG NF PA; QL(0.134 (Use aprepitant) ea daily) DIFLUCAN SUSR (Use NF ) EMEND SOLR IV 150 MG PA (Use fosaprepitant 4 DIFLUCAN TABS (Use NF dimeglumine) fluconazole) fluconazole susr 1 fosaprepitant dimeglumine 4 PA solr fluconazole tabs 1 VARUBI TBPK 3 PA PA; QL(4 ea caps 100 mg 1 daily) Ambetter Sunshine Formulary Updated December 1, 2020

28 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; QL(20 ml itraconazole soln 10 mg/ml 1 ALLEGRA QL(2 ea daily) daily) TABS 60 MG (Use 1 fexofenadine hcl) tabs 1 cetirizine hcl caps 10 mg 1 QL(1 ea daily) NOXAFIL SUSP OR 40 3 QL(20 ml daily) MG/ML cetirizine hcl chew 5 mg, 10 1 QL(1 ea daily) mg SPORANOX CAPS 100 NF PA; QL(4 ea MG (Use itraconazole) daily) cetirizine hcl soln 1 mg/ml, 1 QL(10 ml 5 mg/5ml daily); RX/OTC SPORANOX PULSEPAK NF PA; QL(4 ea CAPS (Use itraconazole) daily) cetirizine hcl syrp 1 mg/ml, 1 QL(10 ml 5 mg/5ml daily); RX/OTC SPORANOX SOLN 10 NF PA; QL(20 ml MG/ML (Use itraconazole) daily) cetirizine hcl tabs 5 mg, 10 1 QL(1 ea daily) mg TOLSURA CAPS 4 PA CLARINEX TABS 5 MG NF QL(1 ea daily) (Use desloratadine) VFEND TABS 200 MG, 50 NF QL(4 ea daily) MG (Use voriconazole) CLARITIN ALLERGY CHILDRENS SYRP (Use 1 voriconazole tabs or 200 1 QL(4 ea daily) mg, 50 mg loratadine) CLARITIN CAPS (Use 1 - Drugs to Treat loratadine) Antihistamines - Alkylamines CLARITIN CHEW (Use 1 loratadine) dexchlorpheniramine 1 maleate soln CLARITIN CHILDRENS 1 CHEW (Use loratadine) Antihistamines - Ethanolamines CLARITIN REDITABS carbinoxamine maleate 1 TBDP 10 MG (Use 1 soln 4 mg/5ml loratadine) carbinoxamine maleate 1 CLARITIN REDITABS 1 tabs 4 mg TBDP 5 MG clemastine fumarate tabs 1 CLARITIN SYRP (Use 1 2.68 mg loratadine) diphenhydramine hcl caps 1 CLARITIN TABS (Use 1 or 50 mg loratadine) diphenhydramine hcl elix or 1 RX/OTC QL(1 ea daily) 12.5 mg/5ml desloratadine tabs 5 mg 1 diphenhydramine hcl soln ij 1 QL(1 ea daily) 50 mg/ml desloratadine tbdp 2.5 mg 1 Antihistamines - Non-Sedating fexofenadine hcl susp 30 1 QL(30 ml daily) mg/5ml ALLEGRA ALLERGY QL(30 ml daily) fexofenadine hcl tabs 180 QL(1 ea daily) CHILDRENS SUSP 30 1 1 MG/5ML (Use fexofenadine mg hcl) fexofenadine hcl tabs 60 1 QL(2 ea daily) mg ALLEGRA ALLERGY 1 QL(2 ea daily) CHILDRENS TBDP 30 MG levocetirizine QL(10 ml ALLEGRA ALLERGY QL(1 ea daily) dihydrochloride soln 2.5 1 daily); RX/OTC TABS 180 MG (Use 1 mg/5ml fexofenadine hcl) Ambetter Sunshine Formulary Updated December 1, 2020

29 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits levocetirizine 1 QL(1 ea daily); ezetimibe-simvastatin tabs 1 QL(1 ea daily) dihydrochloride tabs 5 mg RX/OTC VYTORIN TABS (Use NF QL(1 ea daily) loratadine caps 1 ezetimibe-simvastatin) loratadine chew 1 Antihyperlipidemics - Misc. icosapent ethyl caps 1 PA loratadine soln 1 LOVAZA CAPS (Use NF QL(4 ea daily) loratadine syrp 1 omega-3-acid ethyl esters) omega-3-acid ethyl esters 1 QL(4 ea daily) loratadine tabs 1 caps PA loratadine tbdp 1 VASCEPA CAPS 3 XYZAL ALLERGY 24HR QL(10 ml Bile Acid Sequestrants CHILDRENS SOLN (Use daily); RX/OTC NF cholestyramine light pack 4 1 QL(6 ea daily) levocetirizine gm dihydrochloride) cholestyramine light powd 1 QL(24 gm XYZAL ALLERGY 24HR QL(1 ea daily); 4 gm/dose daily) TABS (Use levocetirizine NF RX/OTC dihydrochloride) cholestyramine pack 4 gm 1 QL(6 ea daily) ZYRTEC ALLERGY CAPS QL(1 ea daily) 1 cholestyramine powd 4 1 QL(25.2 gm (Use cetirizine hcl) gm/dose daily) ZYRTEC ALLERGY TABS QL(1 ea daily) 1 colesevelam hcl pack 3.75 1 PA; QL(1 ea (Use cetirizine hcl) gm daily) ZYRTEC CHILDRENS QL(10 ml colesevelam hcl tabs 625 1 QL(7 ea daily) ALLERGY SOLN (Use 1 daily); RX/OTC mg cetirizine hcl) COLESTID FLAVORED QL(6 gm daily) Antihistamines - Phenothiazines GRAN 5 GM (Use NF colestipol hcl) PHENERGAN SOLN (Use NF promethazine hcl) COLESTID FLAVORED QL(6 ea daily) PACK 5 GM/7.5GM (Use NF promethazine hcl soln 1 colestipol hcl) promethazine hcl supp 1 COLESTID GRAN 5 GM NF QL(6 gm daily) (Use colestipol hcl) promethazine hcl syrp 1 COLESTID PACK 5 GM NF QL(6 ea daily) (Use colestipol hcl) promethazine hcl tabs 1 COLESTID TABS 1 GM NF QL(16 ea daily) (Use colestipol hcl) Antihistamines - Piperidines colestipol hcl gran 5 gm 1 QL(6 gm daily) hcl syrp 1 colestipol hcl pack 5 gm 1 QL(6 ea daily) cyproheptadine hcl tabs 1 colestipol hcl tabs 1 gm 1 QL(16 ea daily) ANTIHYPERLIPIDEMICS - Drugs to Treat High QUESTRAN LIGHT POWD NF QL(24 gm (Use cholestyramine light) daily) Antihyperlipidemics - Combinations

Ambetter Sunshine Formulary Updated December 1, 2020

30 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QUESTRAN PACK 4 GM NF QL(6 ea daily) $0 copay for (Use cholestyramine) generic only, lovastatin tabs 10 mg, 20 1 age 40 to QUESTRAN POWD 4 QL(25.2 gm mg GM/DOSE (Use NF daily) 76;QL(1 ea cholestyramine) daily); PV $0 copay for WELCHOL PACK 3.75 GM NF PA; QL(1 ea (Use colesevelam hcl) daily) generic only, lovastatin tabs 40 mg 1 age 40 to WELCHOL TABS 625 MG NF QL(7 ea daily) 76;QL(2 ea (Use colesevelam hcl) daily); PV Fibric Acid Derivatives PRAVACHOL TABS (Use NF QL(1 ea daily) pravastatin sodium) fenofibrate micronized caps 1 QL(1 ea daily) 134 mg, 200 mg, 67 mg pravastatin sodium tabs 1 QL(1 ea daily) fenofibrate tabs 145 mg, 48 1 QL(1 ea daily) mg, 54 mg, 160 mg rosuvastatin calcium tabs 1 QL(1 ea daily) FIBRICOR TABS 105 MG, NF 35 MG (Use fenofibric acid) SIMCOR TB24 2 PA; QL(1 ea daily) gemfibrozil tabs 1 QL(2 ea daily) simvastatin tabs 80 mg, 10 1 QL(1 ea daily) mg, 20 mg, 40 mg, 5 mg LIPOFEN CAPS (Use NF fenofibrate) ZOCOR TABS (Use NF QL(1 ea daily) simvastatin) LOPID TABS (Use NF QL(2 ea daily) gemfibrozil) Intestinal Cholesterol Absorption Inhibitors TRICOR TABS (Use NF QL(1 ea daily) QL(1 ea daily) fenofibrate) ezetimibe tabs 1 HMG CoA Reductase Inhibitors ZETIA TABS (Use NF QL(1 ea daily) ezetimibe) ADVICOR TB24 1000 MG- 3 PA; QL(2 ea 20 MG daily) Nicotinic Acid Derivatives ADVICOR TB24 1000 MG- 3 PA; QL(1 ea niacin (antihyperlipidemic) QL(2 ea daily) 40 MG daily) tbcr 1000 mg, 500 mg, 750 1 mg ALTOPREV TB24 3 ST; QL(1 ea daily) NIASPAN TBCR (Use NF QL(2 ea daily) niacin (antihyperlipidemic)) atorvastatin calcium tabs 1 QL(1 ea daily) Proprotein Convertase Subtilisin/Kexin Type 9 CRESTOR TABS (Use NF QL(1 ea daily) PA; QL(0.0714 rosuvastatin calcium) REPATHA SOSY 4 ml daily) fluvastatin sodium caps 20 3 QL(1 ea daily) REPATHA SURECLICK PA; QL(0.0714 mg 4 SOAJ ml daily) fluvastatin sodium caps 40 3 QL(2 ea daily) mg ANTIHYPERTENSIVES - Drugs to Treat High Blood Pressure LIPITOR TABS (Use NF QL(1 ea daily) atorvastatin calcium) ACE Inhibitors ACCUPRIL TABS (Use LIVALO TABS 3 ST; QL(1 ea NF daily) quinapril hcl) ALTACE CAPS (Use NF ramipril)

Ambetter Sunshine Formulary Updated December 1, 2020

31 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits benazepril hcl tabs 1 EDARBI TABS 3 ST; QL(1 ea daily) captopril tabs 1 eprosartan mesylate tabs 1 QL(1 ea daily) enalapril maleate tabs 1 irbesartan tabs 1 QL(1 ea daily) fosinopril sodium tabs 1 losartan potassium tabs or 1 QL(1 ea daily) 100 mg, 25 mg, 50 mg lisinopril tabs 1 MICARDIS TABS (Use NF QL(1 ea daily) telmisartan) LOTENSIN TABS (Use NF benazepril hcl) olmesartan medoxomil tabs 1 QL(1 ea daily) moexipril hcl tabs 1 telmisartan tabs 1 QL(1 ea daily) perindopril erbumine tabs 1 valsartan tabs 1 QL(1 ea daily) PRINIVIL TABS (Use NF lisinopril) Antiadrenergic Antihypertensives CARDURA TABS (Use NF quinapril hcl tabs 1 doxazosin mesylate) CATAPRES TABS (Use NF QL(8 ea daily) ramipril caps 1 clonidine hcl) trandolapril tabs 1 CATAPRES-TTS-1 PTWK NF QL(0.15 ea (Use clonidine) daily) VASOTEC TABS (Use NF CATAPRES-TTS-2 PTWK NF QL(0.15 ea enalapril maleate) (Use clonidine) daily) ZESTRIL TABS (Use NF CATAPRES-TTS-3 PTWK NF QL(0.15 ea lisinopril) (Use clonidine) daily) Agents for Pheochromocytoma clonidine hcl tabs 1 QL(8 ea daily) DIBENZYLINE CAPS (Use PA NF QL(0.15 ea phenoxybenzamine hcl) clonidine ptwk 3 daily) phenoxybenzamine hcl 3 PA caps doxazosin mesylate tabs 1 Angiotensin II Receptor Antagonists guanfacine hcl tabs 1 ATACAND TABS (Use NF QL(1 ea daily) candesartan cilexetil) methyldopa tabs 1 QL(6 ea daily) AVAPRO TABS (Use NF QL(1 ea daily) irbesartan) MINIPRESS CAPS (Use NF QL(4 ea daily) prazosin hcl) BENICAR TABS (Use NF QL(1 ea daily) olmesartan medoxomil) prazosin hcl caps 1 QL(4 ea daily) candesartan cilexetil tabs 1 QL(1 ea daily) terazosin hcl caps 1 COZAAR TABS (Use NF QL(1 ea daily) losartan potassium) Antihypertensive Combinations DIOVAN TABS (Use NF QL(1 ea daily) valsartan)

Ambetter Sunshine Formulary Updated December 1, 2020

32 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ACCURETIC TABS 10 QL(3 ea daily) EXFORGE HCT TABS MG-12.5 MG (Use NF (Use amlodipine-valsartan- NF quinapril- ) hydrochlorothiazide) EXFORGE TABS (Use ACCURETIC TABS 12.5 QL(4 ea daily) amlodipine besylate- NF MG-20 MG (Use quinapril- NF valsartan) hydrochlorothiazide) fosinopril sodium & 1 ACCURETIC TABS 20 QL(2 ea daily) hydrochlorothiazide tabs MG-25 MG (Use quinapril- NF HYZAAR TABS 100 MG- QL(1 ea daily) hydrochlorothiazide) 12.5 MG, 100 MG-25 MG NF amlodipine besylate- 1 (Use losartan potassium & benazepril hcl caps hydrochlorothiazide) amlodipine besylate- 1 ST HYZAAR TABS 12.5 MG- QL(2 ea daily) olmesartan medoxomil tabs 50 MG (Use losartan NF potassium & amlodipine besylate- 1 valsartan tabs hydrochlorothiazide) irbesartan- amlodipine-valsartan- 1 1 hydrochlorothiazide tabs hydrochlorothiazide tabs ATACAND HCT TABS lisinopril & 1 (Use candesartan cilexetil- NF hydrochlorothiazide tabs hydrochlorothiazide) LOPRESSOR HCT TABS (Use metoprolol & NF atenolol & chlorthalidone 1 tabs hydrochlorothiazide) AVALIDE TABS (Use losartan potassium & QL(1 ea daily) irbesartan- NF hydrochlorothiazide tabs 1 hydrochlorothiazide) 100 mg-12.5 mg, 100 mg- 25 mg AZOR TABS (Use ST amlodipine besylate- NF losartan potassium & QL(2 ea daily) olmesartan medoxomil) hydrochlorothiazide tabs 1 12.5 mg-50 mg benazepril & 1 hydrochlorothiazide tabs LOTENSIN HCT TABS (Use benazepril & NF BENICAR HCT TABS (Use hydrochlorothiazide) olmesartan medoxomil- NF hydrochlorothiazide) LOTREL CAPS (Use amlodipine besylate- NF bisoprolol & 1 QL(2 ea daily) benazepril hcl) hydrochlorothiazide tabs metoprolol & 1 candesartan cilexetil- 1 hydrochlorothiazide tabs hydrochlorothiazide tabs MICARDIS HCT TABS CORZIDE TABS 40 MG-5 (Use telmisartan- NF MG (Use nadolol & NF hydrochlorothiazide) ) olmesartan medoxomil- ST DIOVAN HCT TABS (Use amlodipine- 1 valsartan- NF hydrochlorothiazide tabs hydrochlorothiazide) olmesartan medoxomil- 1 enalapril maleate & 1 hydrochlorothiazide tabs hydrochlorothiazide tabs

Ambetter Sunshine Formulary Updated December 1, 2020

33 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits quinapril- QL(3 ea daily) Selective Receptor Antagonists hydrochlorothiazide tabs 10 1 mg-12.5 mg tabs 1 quinapril- QL(4 ea daily) INSPRA TABS (Use NF hydrochlorothiazide tabs 1 eplerenone) 12.5 mg-20 mg quinapril- QL(2 ea daily) Vasodilators hydrochlorothiazide tabs 20 1 hydralazine hcl soln 1 mg-25 mg TARKA TBCR (Use NF hydralazine hcl tabs 1 trandolapril-verapamil hcl) minoxidil tabs 1 telmisartan-amlodipine tabs 1 ANTIMALARIALS - Drugs to Treat Malaria telmisartan- 1 hydrochlorothiazide tabs (Parasitic Infections) TENORETIC 100 TABS Antimalarial Combinations (Use atenolol & NF Covered for chlorthalidone) malaria TENORETIC 50 TABS treatment only. (Use atenolol & NF Limit 1 fill every chlorthalidone) 180 days;QL(12 ea trandolapril-verapamil hcl 1 tbcr atovaquone-proguanil hcl 1 per fill retail,12 tabs ea per fill TRIBENZOR TABS (Use ST mail)1 rtl MAX olmesartan medoxomil- NF fill,180 rtl amlodipine- day(s) supply,1 hydrochlorothiazide) mail MAX TWYNSTA TABS (Use NF fill,180 mail telmisartan-amlodipine) day(s) supply, valsartan- 1 Covered for hydrochlorothiazide tabs malaria VASERETIC TABS (Use treatment only. enalapril maleate & NF Limit 1 fill every hydrochlorothiazide) 180 ZESTORETIC TABS (Use days;QL(24 ea per fill retail,24 lisinopril & NF COARTEM TABS 2 hydrochlorothiazide) ea per fill mail)1 rtl MAX ZIAC TABS (Use bisoprolol NF QL(2 ea daily) fill,180 rtl & hydrochlorothiazide) day(s) supply,1 Antihypertensives - Misc. mail MAX PA fill,180 mail VECAMYL TABS 3 day(s) supply, Direct Renin Inhibitors aliskiren fumarate tabs 1 QL(1 ea daily)

TEKTURNA TABS (Use 2 QL(1 ea daily) aliskiren fumarate) Ambetter Sunshine Formulary Updated December 1, 2020

34 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Covered for Antimyasthenic/Cholinergic Agents malaria treatment only. FIRDAPSE TABS 4 PA Limit 1 fill every 180 GUANIDINE HCL TABS 2 days;QL(12 ea MESTINON SOLN 60 MALARONE TABS (Use NF per fill retail,12 atovaquone-proguanil hcl) ea per fill MG/5ML (Use 2 mail)1 rtl MAX pyridostigmine bromide) fill,180 rtl MESTINON TABS 60 MG day(s) supply,1 (Use pyridostigmine NF mail MAX bromide) fill,180 mail MESTINON TIMESPAN day(s) supply, TBCR (Use pyridostigmine NF Antimalarials bromide) NEOSTIGMINE PA chloroquine phosphate 1 tabs METHYLSULFATE SOSY 3 3 MG/3ML PA; QL(3 ea DARAPRIM TABS 3 daily) pyridostigmine bromide 1 soln 60 mg/5ml hydroxychloroquine sulfate 1 tabs pyridostigmine bromide 1 tabs 60 mg QL(2 ea per 30 KRINTAFEL TABS 3 days retail) pyridostigmine bromide tbcr 1 180 mg Covered for PA; QL(10 ea malaria RUZURGI TABS 4 treatment only. daily) Limit 1 fill every ANTIMYCOBACTERIAL AGENTS - Drugs to 180 days;QL(5 Treat Tuberculosis (Bacterial Infections) mefloquine hcl tabs 1 ea daily)1 rtl MAX fill,180 rtl Anti TB Combinations day(s) supply,1 RIFAMATE CAPS 3 mail MAX fill,180 mail RIFATER TABS 3 QL(6 ea daily) day(s) supply, PLAQUENIL TABS (Use NF Antimycobacterial Agents hydroxychloroquine sulfate) CAPASTAT SULFATE 3 primaquine phosphate tabs 3 SOLR QL(4 ea daily) PRIMAQUINE cycloserine caps 1 PHOSPHATE TABS (Use 3 primaquine phosphate) ethambutol hcl tabs 1 PA; QL(3 ea pyrimethamine tabs 1 daily) isoniazid soln ij 100 mg/ml 1 QUALAQUIN CAPS (Use NF PA; isoniazid syrp or 50 mg/5ml 1 quinine sulfate) PA; ISONIAZID TABS OR 100 1 quinine sulfate caps 1 MG ANTIMYASTHENIC/CHOLINERGIC AGENTS Ambetter Sunshine Formulary Updated December 1, 2020

35 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits isoniazid tabs or 100 mg, 1 carboplatin soln 450 PA 300 mg mg/45ml, 150 mg/15ml, 50 4 mg/5ml MYAMBUTOL TABS (Use NF ethambutol hcl) carboplatin soln 50 mg/5ml 4 PA; SP MYCOBUTIN CAPS (Use NF PA ) carmustine solr 4 PA; SP PASER PACK 3 QL(3 ea daily) cisplatin soln 100 4 PA; SP mg/100ml PRIFTIN TABS 3 cisplatin soln 200 4 PA mg/200ml, 50 mg/50ml pyrazinamide tabs 1 cyclophosphamide caps or 4 PA; SP rifabutin caps 1 PA 25 mg, 50 mg cyclophosphamide solr ij 1 4 PA; SP RIFADIN CAPS (Use NF gm, 2 gm, 500 mg rifampin) EVOMELA SOLR 4 PA RIFADIN SOLR (Use NF rifampin) GLEOSTINE CAPS 10 MG 4 PA; SP rifampin caps 1 GLEOSTINE CAPS 100 4 PA rifampin solr 1 MG, 40 MG IFEX SOLR 1 GM (Use NF PA; SP SIRTURO TABS 100 MG 3 PA ifosfamide) IFEX SOLR 3 GM 4 PA TRECATOR TABS 3 QL(4 ea daily) ifosfamide soln 1 gm/20ml 4 PA; SP ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer ifosfamide solr 1 gm 4 PA; SP Alkylating Agents IFOSFAMIDE SOLR 3 GM 4 PA ALKERAN SOLR (Use NF melphalan hcl) LEUKERAN TABS 4 PA; SP ALKERAN TABS (Use NF melphalan) melphalan hcl solr 1 BELRAPZO SOLN 4 PA melphalan tabs 1 BENDAMUSTINE 4 PA HYDROCHLORIDE SOLN MUSTARGEN SOLR 4 PA; SP BENDEKA SOLN 4 PA MYLERAN TABS 4 PA; SP BICNU SOLR (Use NF PA; SP carmustine) oxaliplatin soln 100 4 PA; SP mg/20ml, 50 mg/10ml busulfan soln 4 PA; SP TEMODAR CAPS OR 100 PA; SP MG, 140 MG, 180 MG, 20 BUSULFEX SOLN (Use NF PA; SP NF busulfan) MG, 250 MG, 5 MG (Use temozolomide)

Ambetter Sunshine Formulary Updated December 1, 2020

36 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TEMODAR SOLR IV 100 4 PA; SP fluorouracil soln 1 gm/20ml, 4 PA MG 2.5 gm/50ml, 5 gm/100ml temozolomide caps 4 PA; SP fluorouracil soln 500 4 PA; SP mg/10ml TEPADINA SOLR 100 MG 4 PA PA; (Use thiotepa) FOLOTYN SOLN 4 TEPADINA SOLR 15 MG NF PA; SP gemcitabine hcl solr 1 gm 4 PA (Use thiotepa) PA; thiotepa solr 100 mg 4 PA gemcitabine hcl solr 2 gm 4 PA; SP gemcitabine hcl solr 200 4 PA; SP thiotepa solr 15 mg 4 mg TREANDA SOLR 4 PA; SP GEMCITABINE HYDROCHLORIDE SOLN NF YONDELIS SOLR 4 PA 1 GM/10ML, 2 GM/20ML, 200 MG/2ML (Use gemcitabine hcl) ZANOSAR SOLR 4 PA; SP GEMZAR SOLR 1 GM 4 PA Antimetabolites (Use gemcitabine hcl) PA GEMZAR SOLR 200 MG NF PA; SP ALIMTA SOLR 100 MG 4 (Use gemcitabine hcl) ALIMTA SOLR 500 MG 4 PA; SP mercaptopurine tabs 1

ARRANON SOLN 4 PA; SP methotrexate sodium soln ij 1 SP 25 mg/ml azacitidine susr 4 PA; SP methotrexate sodium soln ij 250 mg/10ml, 50 mg/2ml, 1 capecitabine tabs 4 PA; SP 50 mg/2ml methotrexate sodium solr ij 1 SP cladribine soln 4 PA 1 gm methotrexate sodium tabs 1 SP clofarabine soln 4 PA; SP or 2.5 mg PA; SP CLOLAR SOLN (Use NF PA; SP TABLOID TABS 4 clofarabine) TREXALL TABS 4 PA; SP soln 100 mg/ml, 4 PA; SP 20 mg/ml VIDAZA SUSR (Use NF PA; SP DACOGEN SOLR (Use NF PA; SP azacitidine) decitabine) XELODA TABS (Use NF PA; SP decitabine solr 4 PA; SP capecitabine) Antineoplastic - Angiogenesis Inhibitors floxuridine solr 4 PA; SP AVASTIN SOLN 100 4 PA; SP MG/4ML fludarabine phosphate soln 4 PA; SP AVASTIN SOLN 400 4 PA fludarabine phosphate solr 4 PA; SP MG/16ML CYRAMZA SOLN 4 PA

Ambetter Sunshine Formulary Updated December 1, 2020

37 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MVASI SOLN 4 PA POTELIGEO SOLN 4 PA PA; SP ZALTRAP SOLN 100 4 PA; SP RITUXAN SOLN 4 MG/4ML PA ZIRABEV SOLN 4 PA RUXIENCE SOLN 4 Antineoplastic - Antibodies TECENTRIQ SOLN 1200 4 PA MG/20ML ADCETRIS SOLR 4 PA; SP VECTIBIX SOLN 100 4 PA; SP MG/5ML ARZERRA CONC 4 PA; SP VECTIBIX SOLN 400 4 PA MG/20ML BAVENCIO SOLN 4 PA YERVOY SOLN 4 PA; SP BESPONSA SOLR 4 PA Antineoplastic - Cellular PA BLINCYTO SOLR 4 PROVENGE SUSP 4 PA PA CAMPATH SOLN 4 Antineoplastic - Hedgehog Pathway Inhibitors PA DARZALEX SOLN 4 PA DAURISMO TABS 4 PA ERIVEDGE CAPS 4 PA; QL(1 ea EMPLICITI SOLR 4 daily); SP PA; QL(1 ea ERBITUX SOLN 4 PA; SP ODOMZO CAPS 4 daily) GAZYVA SOLN 4 PA Antineoplastic - Hormonal and Related Agents PA; QL(4 ea PA; SP tabs 4 HERCEPTIN SOLR 4 daily); SP QL(1 ea daily) IMFINZI SOLN 4 PA anastrozole tabs 1 PA ARIMIDEX TABS (Use NF QL(1 ea daily) KADCYLA SOLR 4 anastrozole) KEYTRUDA SOLN 4 PA AROMASIN TABS (Use NF QL(1 ea daily); ) SP PA PA; QL(1 ea LARTRUVO SOLN 4 tabs 4 daily); SP PA LIBTAYO SOLN 4 CASODEX TABS (Use NF PA; QL(1 ea bicalutamide) daily); SP LUMOXITI SOLR 4 PA ELIGARD KIT 22.5 MG 4 PA; SP MYLOTARG SOLR 4 PA ELIGARD KIT 30 MG 4 PA; SP OPDIVO SOLN 4 PA ELIGARD KIT 45 MG 4 PA; SP PERJETA SOLN 4 PA; SP ELIGARD KIT 7.5 MG 4 PA; QL(0.0089 ea daily); SP PORTRAZZA SOLN 4 PA EMCYT CAPS 4 PA; SP

Ambetter Sunshine Formulary Updated December 1, 2020

38 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily); PA; QL(4 ea exemestane tabs 4 XTANDI CAPS 4 SP daily); SP FARESTON TABS (Use 2 YONSA TABS 4 PA toremifene citrate) PA; QL(0.0119 FASLODEX SOLN (Use 4 PA; QL(0.357 ZOLADEX IMPL 10.8 MG 4 fulvestrant) ml daily); SP ea daily); SP PA; QL(0.0357 FEMARA TABS (Use NF ZOLADEX IMPL 3.6 MG 4 letrozole) ea daily); SP PA; QL(0.143 ZYTIGA TABS 250 MG PA; QL(4 ea FIRMAGON SOLR 4 NF ea daily); SP (Use abiraterone acetate) daily); SP PA; QL(6 ea PA; QL(2 ea caps 4 ZYTIGA TABS 500 MG 4 daily); SP daily) PA; QL(0.357 fulvestrant soln 4 Antineoplastic - Immunomodulators ml daily); SP PA; QL(1 ea POMALYST CAPS 4 letrozole tabs 1 daily) Antineoplastic - XPO1 Inhibitors leuprolide acetate kit 4 PA; SP XPOVIO 100 MG ONCE 4 PA WEEKLY TBPK LUPRON DEPOT (1- 4 PA; QL(0.0357 MONTH) KIT ea daily); SP XPOVIO 60 MG ONCE 4 PA WEEKLY TBPK LUPRON DEPOT (3- 4 PA; SP MONTH) KIT XPOVIO 80 MG ONCE 4 PA WEEKLY TBPK LUPRON DEPOT (4- 4 PA; QL(0.1339 MONTH) KIT ea daily); SP XPOVIO 80 MG TWICE 4 PA WEEKLY TBPK LUPRON DEPOT (6- 4 PA; QL(0.0089 MONTH) KIT ea daily); SP Antineoplastic PA; SP LYSODREN TABS 4 bleomycin sulfate solr 15 4 PA; SP unit acetate susp 1 COSMEGEN SOLR (Use NF PA; SP dactinomycin) tabs 1 dactinomycin solr 4 PA; SP NILANDRON TABS (Use NF QL(2 ea daily) ) daunorubicin hcl soln 4 PA; nilutamide tabs 1 QL(2 ea daily) DAUNORUBICIN PA; HYDROCHLORIDE SOLN 4 NUBEQA TABS 4 PA 20 MG/4ML (Use daunorubicin hcl) tamoxifen citrate tabs 0 DAUNORUBICIN PA; HYDROCHLORIDE SOLN 4 toremifene citrate tabs 1 50 MG/10ML DOXIL INJ (Use PA; SP TRELSTAR MIXJECT 4 PA; SP NF SUSR doxorubicin hcl liposomal) PA doxorubicin hcl liposomal 4 PA; SP VANTAS KIT 4 inj doxorubicin hcl soln 4 PA; SP

Ambetter Sunshine Formulary Updated December 1, 2020

39 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits doxorubicin hcl solr 4 PA; SP BRAFTOVI CAPS 4 PA; SP

ELLENCE SOLN 50 PA; SP BRUKINSA CAPS 4 PA MG/25ML (Use epirubicin NF hcl) CAPRELSA TABS 4 PA; QL(1 ea daily); SP epirubicin hcl soln 50 4 PA; SP mg/25ml PA; QL(2 ea COMETRIQ KIT 4 IDAMYCIN PFS SOLN 10 PA; SP daily); SP MG/10ML, 5 MG/5ML (Use NF COMETRIQ KIT 4 PA; QL(4 ea idarubicin hcl) daily); SP IDAMYCIN PFS SOLN 20 PA COMETRIQ KIT 4 PA; QL(3 ea MG/20ML (Use idarubicin NF daily); SP hcl) COPIKTRA CAPS 4 PA idarubicin hcl soln 10 4 PA; SP mg/10ml, 5 mg/5ml PA; QL(1 ea erlotinib hcl tabs 4 daily); SP idarubicin hcl soln 20 4 PA mg/20ml PA; QL(1 ea everolimus tabs 4 daily); SP mitomycin solr iv 20 mg 4 PA; SP PA; QL(1 ea GILOTRIF TABS 4 mitoxantrone hcl conc 4 PA; SP daily) GLEEVEC TABS (Use NF PA; QL(2 ea valrubicin soln 4 PA; SP imatinib mesylate) daily); SP ICLUSIG TABS 15 MG, 45 4 PA VALSTAR SOLN (Use 4 PA; SP MG valrubicin) PA; QL(2 ea imatinib mesylate tabs 4 Antineoplastic Combinations daily); SP PA VYXEOS SUSR 4 IMBRUVICA CAPS 140 4 PA; QL(3 ea MG daily) Antineoplastic Enzyme Inhibitors PA; QL(1 ea IMBRUVICA CAPS 70 MG 4 PA; QL(1 ea daily) AFINITOR TABS 10 MG 4 daily); SP IMBRUVICA TABS 140 PA; QL(1 ea AFINITOR TABS 2.5 MG, 5 PA; QL(1 ea MG, 280 MG, 420 MG, 560 4 daily) MG, 7.5 MG (Use 4 daily); SP MG everolimus) INLYTA TABS 4 PA; QL(2 ea daily); SP AYVAKIT TABS 4 PA; SL(1 ea daily) INREBIC CAPS 4 PA BALVERSA TABS 4 PA IRESSA TABS 4 PA BELEODAQ SOLR 4 PA ISTODAX (OVERFILL) 4 PA; SP BORTEZOMIB SOLR 4 PA; SOLR JAKAFI TABS 10 MG, 20 4 PA; SP BOSULIF TABS 100 MG, 4 PA; QL(1 ea MG 500 MG daily); SP JAKAFI TABS 15 MG, 25 4 PA; QL(2 ea BOSULIF TABS 400 MG 4 PA; MG, 5 MG daily); SP KYPROLIS SOLR 4 PA

Ambetter Sunshine Formulary Updated December 1, 2020

40 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; QL(6 ea PA; QL(4 ea lapatinib ditosylate tabs 4 STIVARGA TABS 4 daily); SP daily); SP LENVIMA 10 MG DAILY 4 PA; QL(1 ea SUTENT CAPS 12.5 MG, 4 PA; QL(1 ea DOSE CPPK daily) 25 MG, 50 MG daily); SP LENVIMA 12MG DAILY 4 PA; QL(3 ea TABRECTA TABS 4 PA DOSE CPPK daily) PA; QL(4 ea LENVIMA 14 MG DAILY 4 PA; QL(2 ea TAFINLAR CAPS 4 DOSE CPPK daily) daily) PA LENVIMA 18 MG DAILY 4 PA; QL(3 ea TALZENNA CAPS 4 DOSE CPPK daily) TARCEVA TABS (Use PA; QL(1 ea LENVIMA 20 MG DAILY 4 PA; QL(2 ea 4 DOSE CPPK daily) erlotinib hcl) daily); SP TASIGNA CAPS 150 MG, PA; QL(4 ea LENVIMA 24 MG DAILY 4 PA; QL(3 ea 4 DOSE CPPK daily) 200 MG daily); SP PA; QL(4 ea LENVIMA 4 MG DAILY 4 PA; QL(1 ea TASIGNA CAPS 50 MG 4 DOSE CPPK daily) daily) PA LENVIMA 8 MG DAILY 4 PA; QL(2 ea TAZVERIK TABS 4 DOSE CPPK daily) PA; QL(0.143 temsirolimus soln 4 LORBRENA TABS 4 PA ml daily); SP PA LYNPARZA TABS 4 PA; QL(16 ea TIBSOVO TABS 4 daily) TORISEL SOLN (Use NF PA; QL(0.143 MEKINIST TABS 0.5 MG 4 PA; QL(3 ea temsirolimus) ml daily); SP daily) TURALIO CAPS 4 PA; AC MEKINIST TABS 2 MG 4 PA; QL(1 ea daily) TYKERB TABS (Use 4 PA; QL(6 ea MEKTOVI TABS 4 PA; SP lapatinib ditosylate) daily); SP VELCADE SOLR 4 PA; SP NEXAVAR TABS 4 PA; QL(4 ea daily); SP VITRAKVI CAPS 4 PA NINLARO CAPS 4 PA; QL(0.143 ea daily) VITRAKVI SOLN 4 PA PIQRAY 200MG DAILY 4 PA DOSE TBPK VIZIMPRO TABS 4 PA PIQRAY 250MG DAILY PA 4 PA; QL(4 ea DOSE TBPK VOTRIENT TABS 4 PIQRAY 300MG DAILY PA daily); SP 4 PA; QL(2 ea DOSE TBPK XALKORI CAPS 4 daily); SP RETEVMO CAPS 4 PA XOSPATA TABS 4 PA ROMIDEPSIN SOLR 10 4 PA; SP MG ZELBORAF TABS 4 PA; SP PA ROZLYTREK CAPS 4 PA; QL(4 ea ZOLINZA CAPS 4 PA; QL(1 ea daily); SP SPRYCEL TABS 4 daily); SP ZYDELIG TABS 4 PA; QL(2 ea daily) Ambetter Sunshine Formulary Updated December 1, 2020

41 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; SP ZYKADIA CAPS 4 PA; QL(5 ea KEPIVANCE SOLR 4 daily) Antineoplastic Rescue/ Agents PA ERWINAZE SOLR 4 PA; SP KHAPZORY SOLR 4 PA; SP leucovorin calcium solr ij ONCASPAR SOLN 4 100 mg, 200 mg, 350 mg, 1 50 mg, 500 mg Antineoplastics Misc. leucovorin calcium tabs or PA; SP 1 ACTIMMUNE SOLN 4 25 mg, 5 mg, 10 mg, 15 mg PA arsenic trioxide soln 10 4 PA; SP mesna soln 4 mg/10ml MESNEX SOLN IV 100 PA; SP 4 PA bexarotene caps 4 MG/ML (Use mesna) PA; SP dacarbazine solr 100 mg 4 PA VORAXAZE SOLR 4 dacarbazine solr 200 mg 4 PA; SP Mitotic Inhibitors ABRAXANE SUSR 4 PA; SP HYDREA CAPS (Use NF hydroxyurea) docetaxel conc 20 mg/ml 4 PA; SP hydroxyurea caps 1 DOCETAXEL SOLN 20 4 PA; SP MG/2ML INTRON A SOLN 10 4 PA MU/ML, 6000000 UNIT/ML docetaxel soln 20 mg/2ml 4 PA; SP INTRON A SOLR 18 MU 4 PA; SP DOCETAXEL SOLN 20 4 PA; SP MATULANE CAPS 4 PA; SP MG/2ML (Use docetaxel) ETOPOPHOS SOLR 4 PA; SP NIPENT SOLR 4 PA; SP etoposide caps 4 PA; SP PHOTOFRIN SOLR 4 PA; SP etoposide soln 4 PA; SP PROLEUKIN SOLR 4 PA; SP HALAVEN SOLN 4 PA; SP SYLATRON KIT 4 PA; SP IXEMPRA KIT SOLR 15 4 PA; SP SYNRIBO SOLR 4 PA; SP MG IXEMPRA KIT SOLR 45 4 PA TARGRETIN CAPS OR 75 NF PA; SP MG MG (Use bexarotene) JEVTANA SOLN 4 PA; SP TICE BCG SUSR 4 PA MARQIBO SUSP 4 PA tretinoin (chemotherapy) 1 caps NAVELBINE SOLN 10 PA; SP Chemotherapy Adjuncts MG/ML (Use vinorelbine NF tartrate) ELITEK SOLR 4 PA

Ambetter Sunshine Formulary Updated December 1, 2020

42 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NAVELBINE SOLN 50 PA hcl soln 4 4 PA MG/5ML (Use vinorelbine NF mg/4ml tartrate) TOPOTECAN HCL SOLN PA paclitaxel conc 150 PA; SP 4 MG/4ML (Use topotecan 4 mg/25ml, 100 mg/16.7ml, 6 4 hcl) mg/ml topotecan hcl solr 4 mg 4 PA; SP paclitaxel conc 30 mg/5ml, 4 PA 300 mg/50ml, 6 mg/ml ANTIPARKINSON AND RELATED THERAPY TAXOL CONC (Use 4 PA AGENTS - Drugs to Treat Parkinson's Disease paclitaxel) Antiparkinson Adjunctive Therapy TAXOTERE CONC 20 NF PA; SP MG/ML (Use docetaxel) carbidopa tabs 1 TAXOTERE CONC 80 NF LODOSYN TABS (Use NF MG/4ML (Use docetaxel) carbidopa) PA; SP TENIPOSIDE SOLN 4 Antiparkinson Anticholinergics vinblastine sulfate soln 4 PA benztropine mesylate soln 1 vincristine sulfate soln 4 PA; SP benztropine mesylate tabs 1 COGENTIN SOLN (Use vinorelbine tartrate soln 10 4 PA; SP NF mg/ml benztropine mesylate) vinorelbine tartrate soln 50 4 PA trihexyphenidyl hcl soln 1 mg/5ml Oncolytic Viral Agents trihexyphenidyl hcl tabs 1 IMLYGIC SUSP 4 PA Antiparkinson COMT Inhibitors COMTAN TABS (Use NF QL(8 ea daily) Topoisomerase I Inhibitors entacapone) CAMPTOSAR SOLN 300 PA QL(8 ea daily) MG/15ML (Use irinotecan 4 entacapone tabs 1 hcl) TASMAR TABS (Use 3 CAMPTOSAR SOLN 40 PA; SP tolcapone) MG/2ML, 100 MG/5ML NF (Use irinotecan hcl) tolcapone tabs 3 HYCAMTIN CAPS OR 0.25 4 PA; SP MG, 1 MG Antiparkinson Dopaminergics amantadine hcl caps 1 HYCAMTIN SOLR IV 4 MG NF PA; SP (Use topotecan hcl) amantadine hcl syrp 1 irinotecan hcl soln 300 4 PA mg/15ml amantadine hcl tabs 1 irinotecan hcl soln 40 4 PA; SP mg/2ml, 100 mg/5ml APOKYN SOCT 4 PA; ONIVYDE INJ 4 PA bromocriptine mesylate 1 caps TOPOTECAN HCL SOLN 4 PA 4 MG/4ML

Ambetter Sunshine Formulary Updated December 1, 2020

43 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits bromocriptine mesylate 1 SINEMET TABS (Use NF tabs carbidopa-levodopa) carbidopa-levodopa tabs 1 STALEVO 100 TABS (Use carbidopa-levodopa- 1 carbidopa-levodopa tbcr 1 entacapone) STALEVO 100 TABS (Use carbidopa-levodopa tbdp 1 carbidopa-levodopa- NF entacapone) carbidopa-levodopa- 1 STALEVO 125 TABS (Use entacapone tabs carbidopa-levodopa- 1 MIRAPEX TABS 0.125 MG QL(4 ea daily) entacapone) (Use pramipexole NF STALEVO 150 TABS (Use dihydrochloride) carbidopa-levodopa- 1 MIRAPEX TABS 0.25 MG, entacapone) 0.5 MG, 0.75 MG, 1 MG, NF STALEVO 200 TABS (Use 1.5 MG (Use pramipexole carbidopa-levodopa- 1 dihydrochloride) entacapone) NEUPRO PT24 2 STALEVO 50 TABS (Use carbidopa-levodopa- 1 PARLODEL CAPS (Use NF entacapone) bromocriptine mesylate) STALEVO 75 TABS (Use PARLODEL TABS (Use NF carbidopa-levodopa- 1 bromocriptine mesylate) entacapone) pramipexole QL(4 ea daily) Antiparkinson Monoamine Oxidase Inhibitors dihydrochloride tabs 0.125 1 mg AZILECT TABS (Use NF PA; QL(1 ea rasagiline mesylate) daily) pramipexole PA; QL(1 ea dihydrochloride tabs 0.25 1 rasagiline mesylate tabs 1 mg, 0.5 mg, 0.75 mg, 1 mg, daily) 1.5 mg selegiline hcl caps 1 REQUIP TABS (Use NF ropinirole hydrochloride) selegiline hcl tabs 1 REQUIP XL TB24 12 MG, ST; QL(2 ea 8 MG (Use ropinirole NF daily) ANTIPSYCHOTICS/ANTIMANIC AGENTS - hydrochloride) Drugs to Treat Mood Disorders REQUIP XL TB24 2 MG, 4 ST; QL(1 ea Antimanic Agents MG, 6 MG (Use ropinirole NF daily) hydrochloride) carbonate caps 1 ropinirole hydrochloride tabs 1 tabs 0.25 mg, 3 mg, 0.5 1 mg, 1 mg, 2 mg, 4 mg, 5 mg lithium carbonate tbcr 1 ropinirole hydrochloride 1 ST; QL(2 ea LITHIUM SOLN 1 tb24 12 mg, 8 mg daily) LITHOBID TBCR (Use ropinirole hydrochloride 1 ST; QL(1 ea NF tb24 2 mg, 4 mg, 6 mg daily) lithium carbonate) SINEMET CR TBCR (Use NF Antipsychotics - Misc. carbidopa-levodopa) Ambetter Sunshine Formulary Updated December 1, 2020

44 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 3 ST; QL(2 ea EQUETRO CP12 100 MG daily) HALDOL DECANOATE QL(0.036 ml ST; QL(8 ea EQUETRO CP12 200 MG 3 100 SOLN (Use haloperidol NF daily) daily) decanoate) ST; QL(4 ea EQUETRO CP12 300 MG 3 HALDOL DECANOATE 50 QL(0.036 ml daily) SOLN (Use haloperidol NF daily) GEODON CAPS OR 20 QL(2 ea daily); decanoate) MG, 40 MG, 60 MG, 80 MG NF AL(At least 18 HALDOL SOLN (Use NF (Use ziprasidone hcl) yrs old) haloperidol lactate) PA; QL(1 ea QL(0.036 ml LATUDA TABS 3 haloperidol decanoate soln 1 daily) daily) QL(2 ea daily); ziprasidone hcl caps 1 AL(At least 18 haloperidol lactate conc 1 yrs old) haloperidol lactate soln 1 Benzisoxazoles FANAPT TABS 2 PA; QL(2 ea haloperidol tabs 1 daily) Dibenzapines FANAPT TITRATION 2 PA PACK TABS clozapine tabs 1 INVEGA TB24 1.5 MG, 3 QL(1 ea daily) MG, 9 MG (Use NF clozapine tbdp 1 paliperidone) CLOZARIL TABS (Use INVEGA TB24 6 MG (Use NF QL(2 ea daily) NF paliperidone) clozapine) FAZACLO TBDP 100 MG, paliperidone tb24 1.5 mg, 3 1 QL(1 ea daily) mg, 9 mg 12.5 MG, 25 MG (Use NF clozapine) paliperidone tb24 6 mg 1 QL(2 ea daily) FAZACLO TBDP 200 MG, 1 150 MG (Use clozapine) PA; QL(0.072 PERSERIS PRSY 2 ea daily) loxapine succinate caps 1 RISPERDAL CONSTA PA; QL(0.072 2 QL(0.215 ea SRER ea daily) olanzapine solr im 10 mg 1 daily) RISPERDAL SOLN 1 NF QL(8 ml daily) MG/ML (Use risperidone) olanzapine tabs or 10 mg, 1 QL(2 ea daily) 15 mg, 20 mg, 7.5 mg RISPERDAL TABS 0.25 QL(4 ea daily) olanzapine tabs or 2.5 mg, QL(4 ea daily) MG, 0.5 MG, 1 MG, 2 MG, NF 1 3 MG, 4 MG (Use 5 mg risperidone) olanzapine tbdp or 10 mg, 1 QL(8 ml daily) 15 mg, 20 mg, 5 mg risperidone soln 1 mg/ml 1 quetiapine fumarate tabs QL(4 ea daily); risperidone tabs 0.25 mg, QL(4 ea daily) 100 mg, 200 mg, 25 mg, 50 1 AL(At least 10 0.5 mg, 1 mg, 2 mg, 3 mg, 1 mg yrs old) 4 mg QL(2 ea daily); quetiapine fumarate tabs 1 AL(At least 10 risperidone tbdp 0.25 mg, 3 QL(2 ea daily) 300 mg, 400 mg mg, 4 mg, 0.5 mg, 1 mg, 2 1 yrs old) mg quetiapine fumarate tb24 1 PA; QL(1 ea 150 mg, 200 mg, 50 mg daily) Ambetter Sunshine Formulary Updated December 1, 2020

45 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits quetiapine fumarate tb24 1 PA; QL(2 ea prochlorperazine supp 1 300 mg, 400 mg daily) SAPHRIS SUBL 10 MG, 5 2 PA; QL(2 ea thioridazine hcl tabs 1 MG daily) SAPHRIS SUBL 2.5 MG 2 PA trifluoperazine hcl tabs 1 SEROQUEL TABS 100 QL(4 ea daily); Quinolinone Derivatives MG, 200 MG, 25 MG, 50 NF AL(At least 10 QL(1 ea daily); MG (Use quetiapine yrs old) ABILIFY TABS (Use NF aripiprazole) AL(At least 6 fumarate) yrs old) SEROQUEL TABS 300 QL(2 ea daily); QL(30 ml MG, 400 MG (Use NF AL(At least 10 aripiprazole soln 1 mg/ml 3 daily); AL(At quetiapine fumarate) yrs old) least 6 yrs old) SEROQUEL XR TB24 150 PA; QL(1 ea aripiprazole tabs 10 mg, 15 QL(1 ea daily); MG, 200 MG, 50 MG (Use NF daily) mg, 2 mg, 20 mg, 30 mg, 5 1 AL(At least 6 quetiapine fumarate) mg yrs old) SEROQUEL XR TB24 300 PA; QL(2 ea PA MG, 400 MG (Use NF daily) REXULTI TABS 3 quetiapine fumarate) Thioxanthenes ZYPREXA SOLR IM 10 NF QL(0.215 ea MG (Use olanzapine) daily) thiothixene caps 1 ZYPREXA TABS OR 10 QL(2 ea daily) MG, 15 MG, 20 MG, 7.5 NF ANTIVIRALS - Drugs to Treat Viral Infections MG (Use olanzapine) Antiretrovirals ZYPREXA TABS OR 2.5 QL(4 ea daily) MG, 5 MG (Use NF abacavir sulfate soln 1 olanzapine) abacavir sulfate tabs 1 ZYPREXA ZYDIS TBDP NF (Use olanzapine) abacavir sulfate- 1 QL(1 ea daily) Phenothiazines tabs abacavir sulfate- QL(2 ea daily) chlorpromazine hcl soln ij 3 1 25 mg/ml, 50 mg/2ml lamivudine-zidovudine tabs chlorpromazine hcl tabs or APTIVUS CAPS 250 MG 2 QL(4 ea daily) 10 mg, 200 mg, 25 mg, 100 1 mg, 50 mg APTIVUS SOLN 100 2 QL(10 ml daily) MG/ML fluphenazine hcl conc or 5 1 mg/ml atazanavir sulfate caps 150 1 QL(2 ea daily) mg, 200 mg fluphenazine hcl elix or 2.5 1 mg/5ml atazanavir sulfate caps 300 1 QL(1 ea daily) mg fluphenazine hcl soln ij 2.5 1 mg/ml ATRIPLA TABS (Use QL(1 ea daily) -emtricitabine- fluphenazine hcl tabs or 1 1 NF mg, 10 mg, 2.5 mg, 5 mg fumarate) perphenazine tabs 1 BIKTARVY TABS 2 QL(1 ea daily) prochlorperazine maleate 1 tabs Ambetter Sunshine Formulary Updated December 1, 2020

46 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CIMDUO TABS 2 QL(1 ea daily) EPIVIR TABS 150 MG 2 QL(2 ea daily) (Use lamivudine) COMBIVIR TABS (Use 3 EPIVIR TABS 300 MG 3 QL(1 ea daily) lamivudine-zidovudine) (Use lamivudine) COMPLERA TABS 3 QL(1 ea daily) EPZICOM TABS (Use QL(1 ea daily) abacavir sulfate- 2 CRIXIVAN CAPS 200 MG 2 QL(9 ea daily) lamivudine) QL(1 ea QL(6 ea daily) CRIXIVAN CAPS 400 MG 2 2 daily)30 rtl lmt EVOTAZ TABS day(s),30 mail DELSTRIGO TABS 2 ST; QL(1 ea lmt day(s), daily) fosamprenavir calcium tabs 1 QL(4 ea daily) DESCOVY TABS 2 QL(1 ea daily) FUZEON SOLR 4 PA; SP didanosine cpdr 200 mg 1 QL(2 ea daily) GENVOYA TABS 2 QL(1 ea daily) didanosine cpdr 250 mg 1 INTELENCE TABS 100 2 QL(4 ea daily) didanosine cpdr 400 mg 1 QL(1 ea daily) MG INTELENCE TABS 200 2 QL(2 ea daily) DOVATO TABS 2 MG QL(8 ea daily) EDURANT TABS 2 QL(1 ea daily) INTELENCE TABS 25 MG 2 QL(10 ea daily) efavirenz caps 200 mg 1 QL(2 ea daily) INVIRASE CAPS 200 MG 2 QL(4 ea daily) efavirenz caps 50 mg 1 QL(3 ea daily) INVIRASE TABS 500 MG 2 QL(1 ea daily) ISENTRESS CHEW 100 2 efavirenz tabs 600 mg 1 MG, 25 MG efavirenz-emtricitabine- QL(1 ea daily) ISENTRESS HD TABS 2 QL(2 ea daily) tenofovir disoproxil 1 fumarate tabs ISENTRESS TABS 400 2 QL(2 ea daily) efavirenz-lamivudine- QL(1 ea daily) MG tenofovir disoproxil 1 JULUCA TABS 2 QL(1 ea daily) fumarate tabs QL(1 ea daily) KALETRA SOLN 100 QL(12.5 ml emtricitabine caps 1 MG/5ML-400 MG/5ML 2 daily) QL(1 ea (Use lopinavir-) emtricitabine-tenofovir 1 daily,30 day(s) KALETRA TABS 100 MG- QL(4 ea daily) disoproxil fumarate tabs 2 limit) 25 MG, 200 MG-50 MG QL(30 ml daily) EMTRIVA CAPS 200 MG 2 QL(1 ea daily) lamivudine soln 10 mg/ml 1 (Use emtricitabine) QL(2 ea daily) EMTRIVA SOLN 10 2 lamivudine tabs 150 mg 1 MG/ML lamivudine tabs 300 mg 1 QL(1 ea daily) EPIVIR SOLN 10 MG/ML 2 QL(30 ml daily) (Use lamivudine) lamivudine-zidovudine tabs 1

Ambetter Sunshine Formulary Updated December 1, 2020

47 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LEXIVA SUSP 50 MG/ML 2 QL(56 ml daily) ritonavir tabs 1 QL(12 ea daily)

LEXIVA TABS 700 MG QL(4 ea daily) SELZENTRY SOLN 20 2 QL(30 ml daily) (Use fosamprenavir 2 MG/ML calcium) SELZENTRY TABS 150 2 QL(2 ea daily) QL(12.5 ml MG, 25 MG, 75 MG lopinavir-ritonavir soln 1 daily) SELZENTRY TABS 300 2 QL(4 ea daily) susp 50 mg/5ml 1 QL(40 ml daily) MG stavudine caps 1 QL(2 ea daily) nevirapine tabs 200 mg 1 STRIBILD TABS 2 QL(1 ea daily) nevirapine tb24 100 mg 1 QL(3 ea daily) SUSTIVA CAPS 200 MG 2 QL(2 ea daily) nevirapine tb24 400 mg 1 QL(1 ea daily) (Use efavirenz) SUSTIVA CAPS 50 MG 2 QL(3 ea daily) QL(12 ea (Use efavirenz) daily)30 rtl lmt NORVIR PACK 100 MG 2 day(s),30 mail SUSTIVA TABS 600 MG 2 QL(1 ea daily) lmt day(s), (Use efavirenz) SYMFI LO TABS (Use QL(1 ea daily) NORVIR SOLN 80 MG/ML 2 QL(15 ml daily) efavirenz-lamivudine- 2 tenofovir disoproxil NORVIR TABS 100 MG 2 QL(12 ea daily) (Use ritonavir) fumarate) SYMFI TABS (Use QL(1 ea daily) ODEFSEY TABS 2 QL(1 ea daily) efavirenz-lamivudine- 2 tenofovir disoproxil PIFELTRO TABS 2 fumarate) QL(1 ea daily) SYMTUZA TABS 2 ST; QL(1 ea PREZCOBIX TABS 2 daily) QL(1 ea daily) PREZISTA SUSP 100 2 QL(12 ml daily) TEMIXYS TABS 2 MG/ML tenofovir disoproxil PREZISTA TABS 150 MG, 2 QL(2 ea daily) 1 600 MG, 75 MG fumarate tabs PREZISTA TABS 800 MG 2 QL(1 ea daily) TIVICAY TABS 2 QL(1 ea daily) RESCRIPTOR TABS 2 QL(6 ea daily) TRIUMEQ TABS 2 TRIZIVIR TABS (Use QL(2 ea daily) RETROVIR CAPS (Use 3 zidovudine) abacavir sulfate- 2 lamivudine-zidovudine) RETROVIR IV INFUSION 1 SOLN TRUVADA TABS 100 MG- QL(1 ea 150 MG, 133 MG-200 MG, 2 daily,30 day(s) RETROVIR SYRP (Use 3 167 MG-250 MG limit) zidovudine) TRUVADA TABS 200 MG- QL(1 ea REYATAZ CAPS 150 MG, QL(2 ea daily) 300 MG (Use emtricitabine- 2 daily,30 day(s) 200 MG (Use atazanavir 2 tenofovir disoproxil limit) sulfate) fumarate) REYATAZ CAPS 300 MG 2 QL(1 ea daily) QL(1 ea daily) (Use atazanavir sulfate) TYBOST TABS 2

Ambetter Sunshine Formulary Updated December 1, 2020

48 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIDEX EC CPDR 125 MG 3 sodium solr 1

VIDEX EC CPDR 200 MG NF QL(2 ea daily) VALCYTE TABS 450 MG NF PA; QL(4 ea (Use didanosine) (Use hcl) daily) VIDEX EC CPDR 250 MG 3 valganciclovir hcl tabs 450 1 PA; QL(4 ea (Use didanosine) mg daily) VIDEX EC CPDR 400 MG NF QL(1 ea daily) Agents ) (Use didanosine PA; QL(1 ea dipivoxil tabs 4 VIDEXPEDIATRIC SOLR 2 daily); SP BARACLUDE SOLN 0.05 4 PA; QL(20 ml VIRACEPT TABS 250 MG 2 QL(10 ea daily) MG/ML daily); SP QL(4 ea daily) BARACLUDE TABS 0.5 4 PA; QL(1 ea VIRACEPT TABS 625 MG 2 MG, 1 MG (Use ) daily); SP DAKLINZA TABS 30 MG, PA; QL(1 ea VIRAMUNE SUSP 50 1 QL(40 ml daily) 4 MG/5ML (Use nevirapine) 60 MG daily) PA; QL(1 ea VIRAMUNE TABS 200 MG 3 entecavir tabs 4 (Use nevirapine) daily); SP EPCLUSA TABS 100 MG- PA; QL(1 ea VIRAMUNE XR TB24 100 2 QL(3 ea daily) 4 MG (Use nevirapine) 400 MG daily) EPIVIR HBV SOLN 5 PA; QL(60 ml VIRAMUNE XR TB24 400 2 QL(1 ea daily) 2 MG (Use nevirapine) MG/ML daily); SP EPIVIR HBV TABS 100 3 QL(3 ea daily); VIREAD POWD 40 MG/GM 2 MG (Use lamivudine (hbv)) SP HARVONI TABS 400 MG- PA; QL(1 ea VIREAD TABS 150 MG, 2 QL(1 ea daily) 4 200 MG, 250 MG 90 MG daily); SP VIREAD TABS 300 MG HEPSERA TABS (Use 4 PA; QL(1 ea (Use tenofovir disoproxil 2 adefovir dipivoxil) daily); SP fumarate) QL(3 ea daily); lamivudine (hbv) tabs 1 SP ZERIT CAPS (Use NF QL(2 ea daily) stavudine) LEDIPASVIR/SOFOSBUVI 4 PA; QL(1 ea R TABS daily); SP ZIAGEN SOLN 20 MG/ML 2 (Use abacavir sulfate) MAVYRET TABS 4 PA; QL(3 ea daily) ZIAGEN TABS 300 MG 3 (Use abacavir sulfate) MODERIBA 1200 DOSE 4 PA zidovudine caps 1 PACK TBPK PEGASYS PROCLICK 4 PA; QL(0.0714 zidovudine syrp 1 SOLN ml daily); SP PA; QL(0.0714 PEGASYS SOLN 4 zidovudine tabs 1 ml daily); SP PEGINTRON KIT 4 PA; QL(0.143 CMV Agents ea daily); SP soln 3 REBETOL CAPS 200 MG NF PA; QL(7 ea (Use (hepatitis c)) daily) CYTOVENE SOLR (Use NF ganciclovir sodium) REBETOL SOLN 40 4 PA; QL(35 ml MG/ML daily); SP

Ambetter Sunshine Formulary Updated December 1, 2020

49 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RIBASPHERE RIBAPAK 4 PA ZOVIRAX TABS OR 400 QL(5 ea daily) TBPK MG, 800 MG (Use NF acyclovir) RIBASPHERE TABS 4 PA Influenza Agents ribavirin (hepatitis c) caps PA; QL(7 ea 1 FLUMADINE TABS (Use NF QL(2 ea daily) 200 mg daily) rimantadine hydrochloride) ribavirin (hepatitis c) tabs 1 PA; QL(7 ea QL(10 ea per 200 mg daily) fill retail,10 ea ribavirin (hepatitis c) tabs 4 PA per fill mail)1 rtl 600 mg oseltamivir phosphate caps 1 MAX fill,90 rtl or 30 mg, 45 mg, 75 mg day(s) supply,1 SOFOSBUVIR/VELPATAS 4 PA; QL(1 ea VIR TABS daily) mail MAX fill,90 mail day(s) SOVALDI TABS 400 MG 4 PA; QL(1 ea daily); SP supply, Limit 1 fill every VEMLIDY TABS 4 PA; QL(1 ea daily); SP 90 days.;QL(125 oseltamivir phosphate susr VOSEVI TABS 4 PA 1 ml per fill or 6 mg/ml retail)1 rtl MAX ZEPATIER TABS 4 PA fill,90 rtl day(s) supply, Herpes Agents RELENZA DISKHALER 2 QL(5 ea AEPB daily,50 ea per acyclovir caps 200 mg 1 rimantadine hydrochloride 1 QL(2 ea daily) fill retail,50 ea tabs per fill mail) QL(10 ea per QL(13.34 ml acyclovir susp 200 mg/5ml 1 fill retail,10 ea daily) TAMIFLU CAPS 30 MG, 45 per fill mail)1 rtl MAX fill,90 rtl acyclovir tabs 400 mg, 800 1 QL(5 ea daily) MG, 75 MG (Use NF mg oseltamivir phosphate) day(s) supply,1 mail MAX fill,90 tabs 125 mg, 1 QL(3 ea daily) 250 mg mail day(s) supply, QL(4 ea daily) famciclovir tabs 500 mg 1 Limit 1 fill every 90 valacyclovir hcl tabs 1 gm, 1 QL(4 ea daily) 1000 mg TAMIFLU SUSR 6 MG/ML days.;QL(125 (Use oseltamivir NF ml per fill valacyclovir hcl tabs 500 1 QL(2 ea daily) phosphate) retail)1 rtl MAX mg fill,90 rtl day(s) VALTREX TABS 1 GM NF QL(4 ea daily) supply, (Use valacyclovir hcl) BETA BLOCKERS - Drugs to Treat High Blood VALTREX TABS 500 MG NF QL(2 ea daily) Pressure (Use valacyclovir hcl) QL(5 ea Alpha-Beta Blockers ZOVIRAX CAPS OR 200 NF daily,50 ea per carvedilol tabs 1 MG (Use acyclovir) fill retail,50 ea per fill mail) COREG TABS (Use NF carvedilol) ZOVIRAX SUSP OR 200 NF QL(13.34 ml MG/5ML (Use acyclovir) daily) Ambetter Sunshine Formulary Updated December 1, 2020

50 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits labetalol hcl soln 1 propranolol hcl soln 1 labetalol hcl tabs 1 propranolol hcl tabs 1

Beta Blockers Cardio-Selective sotalol hcl (afib/afl) tabs 1 acebutolol hcl caps 1 sotalol hcl tabs 120 mg, 1 QL(2 ea daily) 160 mg, 80 mg atenolol tabs 1 sotalol hcl tabs 240 mg 1 betaxolol hcl tabs 1 timolol maleate tabs 1 bisoprolol fumarate tabs 1 CALCIUM CHANNEL BLOCKERS - Drugs to Treat High Blood Pressure BYSTOLIC TABS 10 MG, 2 PA; QL(1 ea 2.5 MG, 5 MG daily) Calcium Channel Blockers PA; QL(2 ea BYSTOLIC TABS 20 MG 2 ADALAT CC TB24 (Use NF daily) nifedipine) LOPRESSOR TABS (Use NF metoprolol tartrate) amlodipine besylate tabs 1 metoprolol succinate tb24 1 CALAN SR TBCR (Use NF verapamil hcl) metoprolol tartrate soln iv 5 1 CALAN TABS (Use NF mg/5ml verapamil hcl) metoprolol tartrate tabs or 1 CARDIZEM CD CP24 (Use NF 100 mg, 25 mg, 50 mg hcl coated beads) TENORMIN TABS (Use NF CARDIZEM LA TB24 420 atenolol) MG, 180 MG, 240 MG, 300 NF TOPROL XL TB24 (Use NF MG, 360 MG (Use metoprolol succinate) diltiazem hcl coated beads) Beta Blockers Non-Selective CARDIZEM TABS (Use NF diltiazem hcl) BETAPACE AF TABS (Use NF sotalol hcl (afib/afl)) diltiazem hcl coated beads 1 cp24 BETAPACE TABS (Use NF QL(2 ea daily) sotalol hcl) diltiazem hcl coated beads 1 tb24 CORGARD TABS (Use NF nadolol) diltiazem hcl cp12 or 120 1 PA; QL(75 ml mg, 60 mg, 90 mg HEMANGEOL SOLN 4 daily) diltiazem hcl cp24 or 120 1 mg, 180 mg, 240 mg INDERAL LA CP24 (Use NF propranolol hcl) diltiazem hcl extended release beads cp24 120 1 nadolol tabs 1 mg, 180 mg, 240 mg, 300 mg, 360 mg pindolol tabs 1 diltiazem hcl soln iv 50 1 mg/10ml propranolol hcl cp24 1 DILTIAZEM HCL SOLR IV 1 100 MG Ambetter Sunshine Formulary Updated December 1, 2020

51 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits diltiazem hcl tabs or 120 1 VERELAN PM CP24 300 1 mg, 60 mg, 30 mg, 90 mg MG (Use verapamil hcl) felodipine tb24 1 CARDIOTONICS - Drugs to Treat and Abnormal Heart Rhythm isradipine caps 1 Cardiac Glycosides nicardipine hcl caps 1 digoxin soln 1 nicardipine hcl soln 1 digoxin tabs 1

LANOXIN SOLN IJ 0.25 2 nifedipine caps 1 MG/ML (Use digoxin) nifedipine tb24 1 LANOXIN TABS OR 250 MCG, 125 MCG (Use 2 nimodipine caps 1 digoxin) LANOXIN TABS OR 62.5 2 nisoldipine tb24 17 mg, 20 MCG mg, 30 mg, 34 mg, 40 mg, 1 8.5 mg CARDIOVASCULAR AGENTS - MISC. - Drugs to Treat Heart and Circulation Conditions NORVASC TABS (Use NF amlodipine besylate) Cardioplegic Solutions PLEGISOL SOLN (Use PROCARDIA CAPS (Use NF NF nifedipine) cardioplegic soln) PROCARDIA XL TB24 NF Cardiovascular Agents Misc. - Combinations (Use nifedipine) amlodipine besylate- 1 QL(1 ea daily) SULAR TB24 (Use NF atorvastatin calcium tabs nisoldipine) TIAZAC CP24 120 MG, BIDIL TABS 2 180 MG, 240 MG, 300 MG, NF CADUET TABS (Use QL(1 ea daily) 360 MG (Use diltiazem hcl amlodipine besylate- NF extended release beads) atorvastatin calcium) verapamil hcl cp24 1 ENTRESTO TABS 3 PA verapamil hcl soln 1 Impotence Agents PA; BPH verapamil hcl tabs 1 CIALIS TABS 5 MG (Use NF tadalafil) Only;QL(1 ea daily) verapamil hcl tbcr 1 PA; QL(0.1334 sildenafil citrate tabs 1 VERELAN CP24 120 MG, ea daily) 180 MG, 240 MG (Use NF STENDRA TABS 3 QL(0.134 ea verapamil hcl) daily) VERELAN CP24 360 MG 1 PA; BPH (Use verapamil hcl) tadalafil tabs 5 mg 1 Only;QL(1 ea VERELAN PM CP24 100 daily) NF MG, 200 MG (Use VIAGRA TABS (Use NF PA; QL(0.1334 verapamil hcl) sildenafil citrate) ea daily) Prostaglandin Vasodilators Ambetter Sunshine Formulary Updated December 1, 2020

52 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits epoprostenol sodium solr 4 PA sildenafil citrate (pulmonary PA; QL(37.5 ml hypertension) soln iv 10 4 daily); SP mg/12.5ml FLOLAN SOLR (Use NF PA epoprostenol sodium) sildenafil citrate (pulmonary PA; QL(6 ml ORENITRAM TBCR 0.125 PA hypertension) susr or 10 4 daily) MG, 0.25 MG, 1 MG, 2.5 3 mg/ml MG sildenafil citrate (pulmonary PA; QL(3 ea 4 REMODULIN SOLN 4 PA; SP hypertension) tabs or 20 daily); SP mg PA; SP treprostinil soln 4 tadalafil (pulmonary 4 PA; QL(2 ea hypertension) tabs daily); SP PA; SP VENTAVIS SOLN 4 Pulmonary Hypertension - Sol Guanylate Cyclase ADEMPAS TABS 0.5 MG, 4 PA; QL(3 ea Pulmonary Hypertension - Endothelin Receptor 1.5 MG, 2 MG, 2.5 MG daily) PA; QL(1 ea ambrisentan tabs 4 daily); SP Sinus Node Inhibitors PA; QL(2 ea CORLANOR SOLN 5 PA; QL(15 ml tabs 125 mg 4 3 daily); SP MG/5ML daily) PA; QL(2 ea CORLANOR TABS 5 MG, PA; QL(2 ea bosentan tabs 62.5 mg 4 3 daily) 7.5 MG daily) Transthyretin Stabilizers LETAIRIS TABS (Use 4 PA; QL(1 ea ambrisentan) daily); SP VYNDAMAX CAPS 4 PA; QL(1 ea daily) OPSUMIT TABS 4 PA; QL(1 ea daily) VYNDAQEL CAPS 4 PA; QL(4 ea daily) TRACLEER TABS 125 MG 4 PA; QL(2 ea (Use bosentan) daily); SP CEPHALOSPORINS - Drugs to Treat Bacterial TRACLEER TABS 62.5 4 PA; QL(2 ea Infections MG (Use bosentan) daily) Cephalosporins - 1st Generation PA; QL(2 ea TRACLEER TBSO 32 MG 4 daily) cefadroxil caps 1 Pulmonary Hypertension - Phosphodiesterase cefadroxil susr 1 ADCIRCA TABS (Use PA; QL(2 ea NF tadalafil (pulmonary daily); SP cefadroxil tabs 1 hypertension)) REVATIO SOLN IV 10 PA; QL(37.5 ml cefazolin sodium solr ij 20 1 gm, 500 mg, 1 gm, 10 gm MG/12.5ML (Use sildenafil NF daily); SP citrate (pulmonary hypertension)) cephalexin caps 1 REVATIO SUSR OR 10 PA; QL(6 ml cephalexin susr 1 MG/ML (Use sildenafil NF daily) citrate (pulmonary cephalexin tabs 1 hypertension)) REVATIO TABS OR 20 PA; QL(3 ea KEFLEX CAPS (Use NF MG (Use sildenafil citrate NF daily); SP cephalexin) (pulmonary hypertension)) Cephalosporins - 2nd Generation

Ambetter Sunshine Formulary Updated December 1, 2020

53 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cefaclor caps 1 SUPRAX SUSR 100 ST MG/5ML, 200 MG/5ML NF cefaclor susr 1 (Use cefixime) Cephalosporins - 4th Generation CEFOTAN SOLR (Use NF cefotetan disodium) cefepime hcl solr 1 cefotetan disodium solr 1 1 MAXIPIME SOLR IJ 1 GM, NF gm, 2 gm 2 GM (Use cefepime hcl) cefotetan disodium solr 10 3 gm Cephalosporins - 5th Generation cefoxitin sodium solr ij 10 1 TEFLARO SOLR 3 gm CONTRACEPTIVES - Drugs to Prevent cefoxitin sodium solr iv 1 1 gm, 2 gm cefprozil susr 1 Combination Contraceptives - Oral BALCOLTRA TABS 0 cefprozil tabs 1 BEYAZ TABS (Use cefuroxime axetil tabs 1 -ethinyl 0 -levomefolate cefuroxime sodium solr ij 1 calcium) 7.5 gm, 750 mg desogestrel & ethinyl 0 Cephalosporins - 3rd Generation estradiol tabs desogestrel-ethinyl 0 cefdinir caps 1 estradiol (biphasic) tabs cefdinir susr 1 desogestrel-ethinyl 0 estradiol (triphasic) tabs cefditoren pivoxil tabs 200 3 drospirenone-ethinyl 0 mg estradiol tabs cefditoren pivoxil tabs 400 1 drospirenone-ethinyl mg estradiol-levomefolate 0 calcium tabs cefixime susr 100 mg/5ml, 1 ST 200 mg/5ml ESTROSTEP FE TABS (Use norethindrone 0 cefotaxime sodium solr 1 1 gm, 2 gm acetate-ethinyl estradiol-fe) cefpodoxime proxetil susr 1 ethynodiol diacet & eth 0 estrad tabs cefpodoxime proxetil tabs 1 GENERESS FE CHEW (Use norethindrone & 0 ceftazidime solr ij 2 gm, 1 1 ethinyl estradiol-fe) gm, 6 gm & eth 0 ceftriaxone sodium solr ij 1 1 estradiol tabs gm, 2 gm, 250 mg, 500 mg levonorgestrel-eth estradiol 0 CLAFORAN SOLR (Use NF (triphasic) tabs cefotaxime sodium) levonorgestrel-ethinyl 0 FORTAZ SOLR IJ 1 GM NF estradiol (91-day) tabs (Use ceftazidime)

Ambetter Sunshine Formulary Updated December 1, 2020

54 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits levonorgestrel-ethinyl 0 ORTHO-CYCLEN TABS estradiol (continuous) tabs (Use -ethinyl 0 estradiol) LO LOESTRIN FE TABS 0 ORTHO-NOVUM 1/35 LOSEASONIQUE TABS TABS (Use norethindrone 0 (Use levonorgestrel-ethinyl 0 & eth estradiol) estradiol (91-day)) ORTHO-NOVUM 7/7/7 0 MINASTRIN 24 FE CHEW 0 TABS (Use norethindrone- eth estradiol (triphasic)) MINASTRIN 24 FE CHEW QUARTETTE TABS (Use (Use norethin acet & 0 levonorgestrel-ethinyl 0 estrad-fe) estradiol (91-day)) MIRCETTE TABS (Use SAFYRAL TABS (Use desogestrel-ethinyl 0 drospirenone-ethinyl 0 estradiol (biphasic)) estradiol-levomefolate calcium) NATAZIA TABS 0 SEASONIQUE TABS (Use norethin acet & estrad-fe 0 levonorgestrel-ethinyl 0 chew 1 mg-20 mcg-75 mg estradiol (91-day)) norethin acet & estrad-fe TRI-NORINYL 28 TABS tabs 1.5 mg-30 mcg-75 mg, 0 (Use norethindrone-eth 0 1 mg-20 mcg-75 mg, 1 mg- estradiol (triphasic)) 20 mcg-75 mg TYBLUME TABS 0 norethindrone & eth 0 estradiol tabs YASMIN 28 TABS (Use drospirenone-ethinyl 0 norethindrone & ethinyl 0 estradiol-fe chew estradiol) YAZ TABS (Use norethindrone acet & eth 0 estra tabs drospirenone-ethinyl 0 estradiol) norethindrone acetate- 0 ethinyl estradiol-fe tabs Combination Contraceptives - Transdermal norethindrone-eth estradiol 0 -ethinyl 0 (triphasic) tabs estradiol ptwk norgestimate-ethinyl 0 Combination Contraceptives - Vaginal estradiol (triphasic) tabs ANNOVERA RING 0 PA norgestimate-ethinyl 0 estradiol tabs -ethinyl 0 & ethinyl 0 estradiol ring estradiol tabs NUVARING RING (Use ORTHO TRI-CYCLEN LO etonogestrel-ethinyl 0 TABS (Use norgestimate- 0 estradiol) ethinyl estradiol (triphasic)) Copper Contraceptives - IUD ORTHO TRI-CYCLEN TABS (Use norgestimate- 0 PARAGARD ethinyl estradiol (triphasic)) INTRAUTERINE COPPER 0 CONTRACEPTIVE T380A IUD

Ambetter Sunshine Formulary Updated December 1, 2020

55 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Emergency Contraceptives - Steroid Drugs to Treat Systemic Swelling Conditions ELLA TABS 0 Glucocorticosteroids levonorgestrel (emergency 0 PA oc) tabs budesonide cpep 3 mg 1 PLAN B ONE-STEP TABS CELESTONE-SOLUSPAN (Use levonorgestrel 0 SUSP (Use NF (emergency oc)) sod phosphate & acetate) Progestin Contraceptives - IUD CORTEF TABS (Use NF hydrocortisone) KYLEENA IUD 0 acetate tabs 1 LILETTA IUD 0 DEPO-MEDROL SUSP 20 3 MIRENA IUD 0 MG/ML DEPO-MEDROL SUSP 80 SKYLA IUD 0 MG/ML, 40 MG/ML (Use NF Progestin Contraceptives - Implants acetate) elix 0.5 1 NEXPLANON IMPL 0 mg/5ml Progestin Contraceptives - Injectable DEXAMETHASONE 1 INTENSOL CONC DEPO-PROVERA QL(1 ml per 90 dexamethasone sodium CONTRACEPTIVE SUSP 0 days retail) (Use phosphate soln ij 120 1 acetate (contraceptive)) mg/30ml, 20 mg/5ml, 4 mg/ml DEPO-PROVERA QL(1 ml per 90 dexamethasone soln 0.5 CONTRACEPTIVE SUSY NF days retail) 1 (Use medroxyprogesterone mg/5ml acetate (contraceptive)) dexamethasone tabs 1 mg, 1.5 mg, 2 mg, 0.5 mg, 0.75 1 DEPO-SUBQ PROVERA 0 104 SUSY mg, 4 mg, 6 mg medroxyprogesterone QL(1 ml per 90 EMFLAZA SUSP 4 PA acetate (contraceptive) 0 days retail) susp EMFLAZA TABS 4 PA medroxyprogesterone QL(1 ml per 90 acetate (contraceptive) 0 days retail) ENTOCORT EC CPEP NF PA susy (Use budesonide) Progestin Contraceptives - Oral hydrocortisone tabs 1 norethindrone 0 KENALOG-40 SUSP (Use NF (contraceptive) tabs acetonide) ORTHO MICRONOR MEDROL DOSEPAK TBPK NF TABS (Use norethindrone 0 (Use methylprednisolone) (contraceptive)) MEDROL TABS 16 MG, 32 PA; QL(1 ea SLYND TABS 0 MG, 8 MG, 4 MG (Use NF daily) methylprednisolone)

Ambetter Sunshine Formulary Updated December 1, 2020

56 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MEDROL TABS 2 MG 3 SOLU-MEDROL SOLR 2 3 GM methylprednisolone acetate 1 SOLU-MEDROL SOLR 500 susp 80 mg/ml, 40 mg/ml MG (Use 1 methylprednisolone sod methylprednisolone sod 1 succ solr succ) methylprednisolone tabs 1 1 susp 40 mg/ml methylprednisolone tbpk 1 VERIPRED 20 SOLN (Use sodium NF MILLIPRED DP TBPK 3 phosphate) MILLIPRED SOLN 10 MG/5ML (Use prednisolone NF acetate tabs 1 sodium phosphate) COUGH/COLD/ALLERGY - Drugs to Treat MILLIPRED TABS 5 MG 3 Cough, Cold and Allergy Symptoms ORAPRED ODT TBDP Antitussives (Use prednisolone sodium NF QL(6 ea daily) phosphate) benzonatate caps 100 mg 1 PEDIAPRED SOLN (Use QL(4 ea daily) prednisolone sodium NF benzonatate caps 150 mg 1 phosphate) benzonatate caps 200 mg 1 QL(3 ea daily) prednisolone sodium phosphate soln or 10 TESSALON PERLES NF QL(6 ea daily) mg/5ml, 15 mg/5ml, 20 1 CAPS (Use benzonatate) mg/5ml, 25 mg/5ml, 5 mg/5ml Cough/Cold/Allergy Combinations prednisolone sodium ALLEGRA-D 12 HOUR QL(2 ea daily) phosphate tbdp or 10 mg, 3 ALLERGY & 15 mg, 30 mg CONGESTION TB12 (Use NF fexofenadine- prednisolone soln 1 pseudoephedrine) ALLEGRA-D 24 HOUR QL(1 ea daily) soln 1 ALLERGY & CONGESTION TB24 (Use NF prednisone tabs 1 fexofenadine- pseudoephedrine) prednisone tbpk 1 cetirizine-pseudoephedrine 1 QL(2 ea daily) 2 rtl MAX fill,30 tb12 SOLU-CORTEF SOLR 100 3 CLARITIN-D 12 HOUR QL(2 ea daily) MG, 1000 MG, 500 MG rtl day(s) supply, TB12 (Use loratadine & 1 pseudoephedrine) SOLU-CORTEF SOLR 250 3 MG CLARITIN-D 24 HOUR QL(1 ea daily) SOLU-MEDROL SOLR TB24 (Use loratadine & 1 pseudoephedrine) 125 MG, 40 MG, 1000 MG NF (Use methylprednisolone fexofenadine- QL(2 ea daily) sod succ) pseudoephedrine tb12 120 1 mg-60 mg Ambetter Sunshine Formulary Updated December 1, 2020

57 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily) fexofenadine- AZELEX CREA 3 ST; AL(At least pseudoephedrine tb24 180 1 12 yrs old) mg-240 mg BENZACLIN GEL (Use PA; AL(At least HYDROCODONE clindamycin phosphate- NF 12 yrs old) BITARTRATE/GUAIFENES 2 benzoyl peroxide) IN SOLN BENZACLIN WITH PUMP PA; AL(At least loratadine & QL(2 ea daily) GEL (Use clindamycin NF 12 yrs old) pseudoephedrine tb12 120 1 phosphate-benzoyl mg-5 mg peroxide) loratadine & QL(1 ea daily) BENZAMYCIN GEL (Use PA; AL(At least pseudoephedrine tb24 10 1 benzoyl peroxide- NF 12 yrs old) mg-10 mg-240 mg-240 mg, ) 10 mg-240 mg AL(At least 12 BENZEFOAM FOAM (Use NF ZYRTEC-D QL(2 ea daily) benzoyl peroxide) yrs old); ALLERGY/CONGESTION 1 RX/OTC TB12 (Use cetirizine- BENZEFOAM ULTRA AL(At least 12 pseudoephedrine) FOAM (Use benzoyl NF yrs old) Misc. Respiratory Inhalants peroxide) BENZOYL PEROXIDE AL(At least 12 HYPER-SAL NEBU (Use NF 2 sodium chloride (inhalant)) CLEANSER LIQD yrs old) AL(At least 12 HYPERSAL NEBU 3.5 % 1 benzoyl peroxide foam 5.3 1 yrs old); % HYPERSAL NEBU 7 % RX/OTC (Use sodium chloride NF benzoyl peroxide foam 9.8 1 AL(At least 12 (inhalant)) % yrs old) NEBUSAL NEBU 1 benzoyl peroxide gel 5 %, 1 AL(At least 12 10 % yrs old) sodium chloride (inhalant) 1 benzoyl peroxide liqd 4 %, 1 AL(At least 12 nebu 7 % 7 %, 10 % yrs old) Mucolytics benzoyl peroxide- 1 PA; AL(At least erythromycin gel 12 yrs old) acetylcysteine soln 1 CLEOCIN-T GEL (Use AL(At least 12 DERMATOLOGICALS - Drugs to Treat Skin clindamycin phosphate NF yrs old) Conditions (topical)) CLEOCIN-T LOTN (Use AL(At least 12 Products clindamycin phosphate NF yrs old) PA; AL(At least adapalene crea 0.1 % 1 (topical)) 12 yrs old) CLEOCIN-T SOLN (Use AL(At least 12 PA; AL(At least clindamycin phosphate NF yrs old) adapalene gel 0.1 % 1 12 yrs old); (topical)) RX/OTC CLEOCIN-T SWAB (Use AL(At least 12 ST; AL(At least adapalene gel 0.3 % 1 clindamycin phosphate NF yrs old) 12 yrs old) (topical)) ST; AL(At least adapalene lotn 0.1 % 1 CLINDAGEL GEL (Use AL(At least 12 12 yrs old) clindamycin phosphate NF yrs old) (topical)) adapalene-benzoyl 1 ST; AL(At least peroxide gel 12 yrs old)

Ambetter Sunshine Formulary Updated December 1, 2020

58 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits clindamycin phosphate 1 PA; AL(At least PANOXYL-4 CREAMY AL(At least 12 (topical) foam 12 yrs old) WASH LIQD (Use benzoyl NF yrs old) peroxide) clindamycin phosphate 1 AL(At least 12 (topical) gel yrs old) AL(At least 12 RETIN-A CREA (Use NF yrs old - Up to clindamycin phosphate 1 AL(At least 12 tretinoin) (topical) lotn yrs old) 30 yrs old) clindamycin phosphate AL(At least 12 AL(At least 12 1 RETIN-A GEL (Use NF (topical) soln yrs old) tretinoin) yrs old - Up to 30 yrs old) clindamycin phosphate 1 AL(At least 12 (topical) swab yrs old) RETIN-A MICRO GEL 0.1 PA; AL(At least % (Use tretinoin NF 12 yrs old - Up clindamycin phosphate- PA; AL(At least microsphere) to 30 yrs old) benzoyl peroxide 1 12 yrs old) (refrigerate) gel RETIN-A MICRO PUMP PA; AL(At least GEL 0.1 % (Use tretinoin NF 12 yrs old - Up clindamycin phosphate- PA; AL(At least microsphere) to 30 yrs old) benzoyl peroxide gel 1 %-5 1 12 yrs old) % sulfacetamide sodium 1 AL(At least 12 (acne) lotn yrs old) clindamycin phosphate- 1 ST; AL(At least tretinoin gel 12 yrs old) sulfacetamide sodium w/ 1 AL(At least 12 sulfur crea 10 %-5 % yrs old) DIFFERIN CREA 0.1 % NF PA; AL(At least (Use adapalene) 12 yrs old) sulfacetamide sodium w/ 1 AL(At least 12 sulfur emul 10 %-5 % yrs old) PA; AL(At least DIFFERIN GEL 0.1 % (Use NF sulfacetamide sodium w/ ST; AL(At least adapalene) 12 yrs old); 1 RX/OTC sulfur liqd 4.5 %-9 % 12 yrs old) sulfacetamide sodium- AL(At least 12 DIFFERIN GEL 0.3 % (Use NF ST; AL(At least 1 adapalene) 12 yrs old) sulfur in vehicle emul yrs old) SUMADAN WASH LIQD ST; AL(At least DIFFERIN LOTN 0.1 % 1 ST; AL(At least 12 yrs old) (Use sulfacetamide sodium NF 12 yrs old) w/ sulfur) DUAC GEL (Use PA; AL(At least clindamycin phosphate- 12 yrs old) AL(At least 12 NF tretinoin crea 0.05 %, 0.1 1 yrs old - Up to benzoyl peroxide %, 0.025 % (refrigerate)) 30 yrs old) EPIDUO GEL (Use ST; AL(At least AL(At least 12 tretinoin gel 0.01 %, 0.025 1 yrs old - Up to adapalene-benzoyl NF 12 yrs old) % peroxide) 30 yrs old) erythromycin (acne aid) AL(At least 12 PA; AL(At least 1 tretinoin microsphere gel 1 12 yrs old - Up pads yrs old) 0.1 % to 30 yrs old) erythromycin (acne aid) 1 AL(At least 12 soln yrs old) ZIANA GEL (Use ST; AL(At least clindamycin phosphate- NF 12 yrs old) EVOCLIN FOAM (Use PA; AL(At least tretinoin) clindamycin phosphate NF 12 yrs old) (topical)) Agents for External Genital and Perianal PA; AL(At least isotretinoin caps 3 VEREGEN OINT 3 12 yrs old) KLARON LOTN (Use AL(At least 12 Anti-inflammatory Agents - Topical sulfacetamide sodium NF yrs old) PA; QL(2 ea diclofenac epolamine ptch 1 (acne)) daily)

Ambetter Sunshine Formulary Updated December 1, 2020

59 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; QL(2 ea diclofenac epolamine ptch 3 clotrimazole w/ 1 daily) betamethasone crea diclofenac sodium (topical) 1 QL(3.34 gm clotrimazole w/ 1 gel 1 % daily); RX/OTC betamethasone lotn FLECTOR PTCH 3 PA; QL(2 ea econazole nitrate crea 1 daily) FLECTOR PTCH (Use 3 PA; QL(2 ea ERTACZO CREA 3 diclofenac epolamine) daily) EXELDERM CREA (Use VOLTAREN GEL (Use NF QL(3.34 gm 3 diclofenac sodium (topical)) daily); RX/OTC sulconazole nitrate) Antibiotics - Topical EXELDERM SOLN 3 ALTABAX OINT 2 JUBLIA SOLN 3 PA

CORTISPORIN CREA 2 KERYDIN SOLN (Use 3 PA tavaborole) CORTISPORIN OINT 2 ketoconazole (topical) crea 1 2 % gentamicin sulfate (topical) 1 QL(1 gm daily) crea ketoconazole (topical) 1 sham 2 % gentamicin sulfate (topical) 1 oint QL(90 gm per LOPROX CREA (Use NF fill retail)1 rtl oint 1 ciclopirox olamine) MAX fill,30 rtl day(s) supply, NEO-SYNALAR CREA 3 PA LOPROX SHAMPOO NF SHAM (Use ciclopirox) Antifungals - Topical LOPROX SUSP (Use NF butenafine hcl crea 1 RX/OTC ciclopirox olamine) LOTRIMIN AF CREA (Use NF RX/OTC CICLODAN SOLUTION NF clotrimazole (topical)) KIT KIT (Use ciclopirox) LOTRIMIN AF JOCK ITCH RX/OTC ciclopirox gel ex 0.77 % 1 CREA (Use clotrimazole NF (topical)) QL(90 gm per fill retail)1 rtl LOTRIMIN ULTRA CREA RX/OTC ciclopirox olamine crea 1 1 MAX fill,30 rtl (Use butenafine hcl) day(s) supply, LOTRISONE CREA (Use clotrimazole w/ NF ciclopirox olamine susp 1 betamethasone) PA ciclopirox sham ex 1 % 1 luliconazole crea 1 LUZU CREA (Use 3 PA ciclopirox soln ex 8 % 1 luliconazole) clotrimazole (topical) crea 1 RX/OTC clotrimazole (topical) soln 1 RX/OTC

Ambetter Sunshine Formulary Updated December 1, 2020

60 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(3 gm Limit 1 Fill per daily)1 rtl MAX 180 days;QL(3 fill,180 rtl gm daily)1 rtl 1 day(s) supply,1 MAX fill,180 rtl naftifine hcl crea 1 % oxiconazole nitrate crea 1 mail MAX day(s) supply,1 fill,180 mail mail MAX day(s) supply, fill,180 mail QL(2 gm day(s) supply, daily)1 rtl MAX Limit 1 Fill per fill,180 rtl 180 days;QL(3 naftifine hcl crea 2 % 1 day(s) supply,1 gm daily)1 rtl mail MAX OXISTAT CREA (Use NF MAX fill,180 rtl fill,180 mail oxiconazole nitrate) day(s) supply,1 day(s) supply, mail MAX QL(3 gm fill,180 mail daily)1 rtl MAX day(s) supply, fill,180 rtl Limit 1 Fill per naftifine hcl gel 1 % 1 day(s) supply,1 180 days;QL(2 mail MAX ml daily)1 rtl fill,180 mail OXISTAT LOTN 2 MAX fill,180 rtl day(s) supply, day(s) supply,1 QL(2 gm mail MAX daily)1 rtl MAX fill,180 mail fill,180 rtl day(s) supply, NAFTIN CREA 2 % (Use NF naftifine hcl) day(s) supply,1 PENLAC NAIL LACQUER NF mail MAX SOLN (Use ciclopirox) fill,180 mail day(s) supply, sulconazole nitrate crea 1 QL(3 gm sulconazole nitrate soln 1 daily)1 rtl MAX fill,180 rtl PA NAFTIN GEL 1 % (Use 3 tavaborole soln 1 naftifine hcl) day(s) supply,1 mail MAX VUSION OINT (Use fill,180 mail - oxide- NF day(s) supply, white petrolatum) NIZORAL SHAM (Use NF ketoconazole (topical)) Antineoplastic or Premalignant Lesion Agents - CARAC CREA (Use NF nystatin (topical) crea 1 fluorouracil (topical)) diclofenac sodium (actinic 1 PA; QL(3.34 nystatin (topical) oint 1 keratoses) gel gm daily) EFUDEX CREA (Use NF nystatin (topical) powd 1 fluorouracil (topical)) nystatin-triamcinolone crea 1 fluorouracil (topical) crea 5 1 % nystatin-triamcinolone oint 1 fluorouracil (topical) soln 2 1 %, 5 % PANRETIN GEL 3

Ambetter Sunshine Formulary Updated December 1, 2020

61 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(3 ea per fill PA; Limit 1 fill retail,3 ea per every 180 fill mail)1 rtl days;QL(45 gm 2 MAX fill,60 rtl per fill retail,45 PICATO GEL 0.015 % day(s) supply,1 gm per fill ZONALON CREA (Use 3 mail MAX fill,60 doxepin hcl (antipruritic)) mail)1 rtl MAX mail day(s) fill,180 rtl supply, day(s) supply,1 QL(2 ea per fill mail MAX retail,2 ea per fill,180 mail fill mail)1 rtl day(s) supply, PICATO GEL 0.05 % 2 MAX fill,60 rtl Antipsoriatics day(s) supply,1 acitretin caps 10 mg, 17.5 1 QL(1 ea daily) mail MAX fill,60 mg mail day(s) supply, acitretin caps 25 mg 1 QL(2 ea daily) PA; SP TARGRETIN GEL EX 1 % 4 PA; QL(4 gm calcipotriene crea 1 daily) Antipruritics - Topical PA; QL(4 gm calcipotriene oint 1 PA; Limit 1 fill daily) every 180 PA; QL(4 ml days;QL(45 gm calcipotriene soln 1 per fill retail,45 daily) gm per fill calcitriol (topical) oint 1 doxepin hcl (antipruritic) 3 mail)1 rtl MAX crea fill,180 rtl COSENTYX 4 PA day(s) supply,1 SENSOREADY PEN SOAJ mail MAX PA fill,180 mail COSENTYX SOSY 4 day(s) supply, DOVONEX CREA (Use NF PA; QL(4 gm PA; Limit 1 fill calcipotriene) daily) every 180 PA days;QL(45 gm ILUMYA SOSY 4 per fill retail,45 QL(4 ea daily) gm per fill methoxsalen rapid caps 1 PRUDOXIN CREA (Use 3 doxepin hcl (antipruritic)) mail)1 rtl MAX OXSORALEN ULTRA QL(4 ea daily) fill,180 rtl CAPS (Use methoxsalen NF day(s) supply,1 rapid) mail MAX fill,180 mail SILIQ SOSY 4 PA day(s) supply, SKYRIZI PSKT 4 PA

SORIATANE CAPS 10 MG NF QL(1 ea daily) (Use acitretin) SORIATANE CAPS 25 MG NF QL(2 ea daily) (Use acitretin) STELARA SOLN SC 45 4 PA MG/0.5ML

Ambetter Sunshine Formulary Updated December 1, 2020

62 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits STELARA SOSY SC 45 4 PA; SP dipropionate 1 MG/0.5ML, 90 MG/ML crea TALTZ SOAJ 4 PA alclometasone dipropionate 1 oint TALTZ SOSY 4 PA QL(60 gm per fill retail,60 gm tazarotene crea 1 per fill mail)1 rtl MAX fill,30 rtl crea 1 TAZORAC CREA 0.05 % 2 day(s) supply,1 mail MAX fill,30 mail day(s) TAZORAC CREA 0.1 % NF (Use tazarotene) supply, TAZORAC GEL 0.05 %, 2 amcinonide lotn 3 0.1 % TREMFYA SOPN 4 PA AMCINONIDE OINT 3 PA betamethasone 1 TREMFYA SOSY 4 dipropionate (topical) crea betamethasone VECTICAL OINT (Use 1 1 calcitriol (topical)) dipropionate (topical) lotn Antiseborrheic Products betamethasone 1 dipropionate (topical) oint selenium sulfide lotn 2.5 % 1 betamethasone dipropionate augmented 1 Antivirals - Topical crea acyclovir topical crea 1 betamethasone dipropionate augmented 1 acyclovir topical oint 1 lotn betamethasone DENAVIR CREA 3 dipropionate augmented 1 oint ZOVIRAX CREA EX 5 % 3 (Use acyclovir topical) 1 crea ZOVIRAX OINT EX 5 % NF (Use acyclovir topical) betamethasone valerate 1 foam Burn Products betamethasone valerate 1 acetate pack 3 lotn betamethasone valerate 1 SILVADENE CREA (Use NF oint ) calcipotriene- ST silver sulfadiazine crea 1 betamethasone 1 dipropionate oint SULFAMYLON CREA 85 3 MG/GM calcipotriene- ST betamethasone 1 SULFAMYLON PACK 5 % NF dipropionate susp (Use mafenide acetate) PA; QL(3 gm propionate crea 1 Corticosteroids - Topical daily)

Ambetter Sunshine Formulary Updated December 1, 2020

63 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1 PA; QL(1 gm oint 0.25 1 emollient base crea daily) % ST; QL(3 gm PA clobetasol propionate foam 1 diacetate crea 1 daily) ST; QL(2 gm PA clobetasol propionate gel 1 oint 1 daily) PA; QL(1 gm DIPROLENE AF CREA clobetasol propionate oint 1 daily) (Use betamethasone NF dipropionate augmented) PA; QL(3.34 ml clobetasol propionate soln 1 daily) DIPROLENE OINT (Use betamethasone NF pivalate crea 3 dipropionate augmented) ELOCON CREA (Use NF CLODERM CREA 3 furoate) ELOCON OINT (Use CLODERM CREA (Use 3 NF ) mometasone furoate) acetonide crea 1 CLODERM PUMP CREA 3 0.01 %, 0.025 % QL(118.28 ml CORDRAN CREA 0.05 % NF (Use flurandrenolide) oil 1 per fill retail)1 0.01 % rtl MAX fill,30 rtl CORDRAN LOTN 0.05 % NF (Use flurandrenolide) day(s) supply, fluocinolone acetonide oil CORDRAN TAPE 4 3 1 MCG/SQCM 0.01 % fluocinolone acetonide oint CUTIVATE LOTN (Use NF 1 ) 0.025 % QL(118.28 ml fluocinolone acetonide soln 1 DERMA-SMOOTHE/FS per fill retail)1 0.01 % BODY OIL (Use NF QL(4 gm daily) fluocinolone acetonide) rtl MAX fill,30 rtl crea 0.05 % 1 day(s) supply, DERMA-SMOOTHE/FS fluocinonide emulsified 1 SCALP OIL (Use NF base crea fluocinolone acetonide) fluocinonide gel 0.05 % 1 crea 1 QL(4 gm daily) fluocinonide oint 0.05 % 1 desonide lotn 1 QL(4 ml daily) fluocinonide soln 0.05 % 1 desonide oint 1 QL(3 gm daily) flurandrenolide crea 2 QL(2 gm daily) DESOWEN CREA (Use NF QL(4 gm daily) desonide) flurandrenolide lotn 2 QL(2 ml daily) DESOWEN LOTN (Use NF QL(4 ml daily) desonide) fluticasone propionate crea 1 desoximetasone crea 0.25 1 % fluticasone propionate lotn 1 desoximetasone gel 0.05 1 % fluticasone propionate oint 1

Ambetter Sunshine Formulary Updated December 1, 2020

64 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits crea 1 PA MONISTAT SOOTHING RX/OTC CARE ITCH RELIEF CREA NF (Use hydrocortisone halobetasol propionate 1 crea (topical)) halobetasol propionate oint 1 OLUX FOAM (Use NF ST; QL(3 gm clobetasol propionate) daily) HALOG CREA (Use 3 PA halcinonide) crea 1 HALOG OINT 3 PA prednicarbate oint 1 PA hydrocortisone (topical) 1 RX/OTC PSORCON CREA 2 crea 1 % SYNALAR CREA (Use hydrocortisone (topical) 1 NF crea 2.5 % fluocinolone acetonide) SYNALAR OINT (Use hydrocortisone (topical) 1 NF lotn 2.5 % fluocinolone acetonide) SYNALAR SOLN (Use hydrocortisone (topical) 1 RX/OTC NF oint 1 % fluocinolone acetonide) TACLONEX OINT (Use ST hydrocortisone (topical) 1 oint 2.5 % calcipotriene- NF betamethasone HYDROCORTISONE dipropionate) ACETATE/LIDOCAINE HYDROCHLORIDE CREA NF TACLONEX SUSP (Use ST (Use lidocaine- calcipotriene- 3 hydrocortisone acetate) betamethasone dipropionate) 1 crea TEMOVATE CREA (Use NF PA; QL(3 gm clobetasol propionate) daily) hydrocortisone butyrate 1 oint TEMOVATE OINT (Use NF PA; QL(1 gm clobetasol propionate) daily) hydrocortisone butyrate 1 soln TOPICORT CREA 0.25 % NF (Use desoximetasone) 1 crea TOPICORT GEL 0.05 % NF (Use desoximetasone) hydrocortisone valerate 1 oint TOPICORT OINT 0.25 % NF (Use desoximetasone) LOCOID CREA (Use NF hydrocortisone butyrate) triamcinolone acetonide (topical) crea 0.025 %, 0.5 1 LOCOID SOLN (Use NF %, 0.1 % hydrocortisone butyrate) triamcinolone acetonide LUXIQ FOAM (Use NF (topical) lotn 0.025 %, 0.1 1 betamethasone valerate) % mometasone furoate crea 1 triamcinolone acetonide (topical) oint 0.025 %, 0.1 1 mometasone furoate oint 1 %, 0.5 % triamcinolone acetonide- 1 PA mometasone furoate soln 1 dimethicone-silicone kit

Ambetter Sunshine Formulary Updated December 1, 2020

65 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AL(At least 2 TRIDESILON CREA (Use NF QL(4 gm daily) tacrolimus (topical) oint 1 desonide) yrs old) ULTRAVATE CREA (Use NF Keratolytic/Antimitotic Agents halobetasol propionate) podofilox soln 1 ULTRAVATE OINT (Use NF halobetasol propionate) Local Anesthetics - Topical Eczema Agents lidocaine hcl gel ex 2 % 1 QL(4 ml daily) DUPIXENT SOSY 200 4 PA MG/1.14ML, 300 MG/2ML QL(4 ml daily); lidocaine hcl gel ex 2 % 1 Emollient/Keratolytic Agents RX/OTC QL(4 ml daily) HYDRO 35 FOAM (Use NF lidocaine hcl prsy ex 2 % 1 urea in lactic acid vehicle) Emollients lidocaine hcl soln ex 4 % 1 LAC-HYDRIN CREA (Use RX/OTC lidocaine ptch 5 % 1 PA lactic acid (ammonium NF lactate)) lidocaine-prilocaine crea 1 QL(1 gm daily) LAC-HYDRIN TWELVE RX/OTC LOTN (Use lactic acid NF LIDODERM PTCH (Use NF PA (ammonium lactate)) lidocaine) QL(10 ea per lactic acid (ammonium 1 RX/OTC lactate) crea 12 % fill retail,10 ea per fill mail)1 rtl lactic acid (ammonium 1 RX/OTC lactate) lotn 12 % 3 MAX fill,30 rtl SYNERA PTCH day(s) supply,1 Enzymes - Topical mail MAX fill,30 PA mail day(s) SANTYL OINT 3 supply, Immunomodulating Agents - Topical Phosphodiesterase 4 (PDE4) Inhibitors - Topical QL(12 ea per PA; QL(2 gm ALDARA CREA (Use NF EUCRISA OINT 3 ) fill retail,12 ea daily) per fill mail) Rosacea Agents QL(12 ea per imiquimod crea 5 % 1 fill retail,12 ea gel 1 PA per fill mail) FINACEA GEL (Use NF PA ZYCLARA CREA (Use NF azelaic acid) imiquimod) METROCREAM CREA ZYCLARA PUMP CREA NF (Use metronidazole NF 3.75 % (Use imiquimod) (topical)) Immunosuppressive Agents - Topical METROGEL GEL (Use NF metronidazole (topical)) ELIDEL CREA (Use NF PA; AL(At least pimecrolimus) 2 yrs old) METROLOTION LOTN PA; AL(At least (Use metronidazole NF pimecrolimus crea 1 2 yrs old) (topical)) metronidazole (topical) PROTOPIC OINT (Use NF AL(At least 2 1 tacrolimus (topical)) yrs old) crea

Ambetter Sunshine Formulary Updated December 1, 2020

66 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits metronidazole (topical) gel 1 Diagnostic Tests CHEMSTRIP-K STRP 1 metronidazole (topical) lotn 1 FORA GTEL BLOOD PA; QL(1 gm MIRVASO GEL 3 TEST STRIPS 1 daily) STRP ORACEA CPDR (Use NF GOJJI BLOOD KETONE 1 (rosacea)) TEST STRIPS STRP SOOLANTRA CREA (Use NF ivermectin (rosacea)) KETONE STRP 1 Scabicides & Pediculicides KETONE TEST STRIPS 1 STRP lotn 1 PA KETOSTIX STRP 1 ELIMITE CREA (Use NF permethrin) NOVA MAX PLUS KETONE TESTSTRIPS 1 EURAX CREA 3 STRP EURAX LOTN (Use NF PA PRECISION XTRA STRP 1 crotamiton) PTS PANELS KETONE 1 lindane sham 3 TEST STRP malathion lotn 1 RELION KETONE STRP 1 RELION KETONE TEST NATROBA SUSP (Use 1 PA 1 spinosad) STRIPS STRP Limit 100 per NIX CREME RINSE LIQD NF TRUE METRIX BLOOD (Use permethrin) 1 month;QL(3.34 GLUCOSETEST STRIPS ea daily); OVIDE LOTN (Use NF STRP malathion) RX/OTC Limit 100 per permethrin crea ex 5 % 1 1 month;QL(3.34 TRUETRACK TEST STRP ea daily); permethrin liqd ex 1 % 1 RX/OTC SKLICE LOTN 3 PA DIGESTIVE AIDS - Drugs to Treat Low Digestive Enzymes spinosad susp 1 PA Digestive Enzymes

ULESFIA LOTN 3 CREON CPEP 2 Wound Care Products SUCRAID SOLN 3 REGRANEX GEL 3 ZENPEP CPEP 2

DIAGNOSTIC PRODUCTS - Drugs to Treat Heart, Circulation Conditions and Blood Pressure Diagnostic Drugs Carbonic Anhydrase Inhibitors GLUCAGEN DIAGNOSTIC 3 QL(0.035 ea SOLR daily)

Ambetter Sunshine Formulary Updated December 1, 2020

67 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cp12 500 1 QL(2 ea daily) ethacrynic acid tabs 1 QL(16 ea daily) mg acetazolamide sodium solr 1 soln 1 acetazolamide tabs 125 mg 1 QL(8 ea daily) furosemide tabs 1 QL(4 ea daily) LASIX TABS (Use NF acetazolamide tabs 250 mg 1 furosemide) KEVEYIS TABS 4 PA; QL(4 ea torsemide tabs 1 daily) methazolamide tabs 1 QL(6 ea daily) Potassium Sparing Diuretics ALDACTONE TABS (Use NF Combinations ) ALDACTAZIDE TABS 25 hcl tabs 1 MG-25 MG (Use NF spironolactone & DYRENIUM CAPS (Use 3 QL(3 ea daily) hydrochlorothiazide) ) amiloride & 1 spironolactone tabs 1 hydrochlorothiazide tabs DYAZIDE CAPS (Use triamterene caps 1 QL(3 ea daily) triamterene & NF hydrochlorothiazide) and -Like Diuretics MAXZIDE TABS (Use triamterene & NF tabs 1 hydrochlorothiazide) chlorthalidone tabs 1 MAXZIDE-25 TABS (Use triamterene & NF QL(2 ea daily) hydrochlorothiazide) hydrochlorothiazide caps 1 QL(2 ea daily) spironolactone & 1 hydrochlorothiazide tabs 1 hydrochlorothiazide tabs QL(1 ea daily) triamterene & 1 tabs 1.25 mg 1 hydrochlorothiazide caps indapamide tabs 2.5 mg 1 QL(2 ea daily) triamterene & 1 hydrochlorothiazide tabs tabs 1 Loop Diuretics QL(2 ea daily) soln ij 0.25 1 tabs 1 mg/ml MICROZIDE CAPS (Use QL(2 ea daily) bumetanide tabs or 0.5 mg, 1 QL(5 ea daily) NF 1 mg, 2 mg hydrochlorothiazide) ENDOCRINE AND METABOLIC AGENTS - BUMEX TABS (Use NF QL(5 ea daily) bumetanide) MISC. - Drugs to Treat Disease and Regulate Hormones DEMADEX TABS (Use NF torsemide) Bone Density Regulators EDECRIN TABS (Use QL(16 ea daily) NF ACTONEL TABS 150 MG NF PA; QL(0.036 ethacrynic acid) (Use risedronate sodium) ea daily)

Ambetter Sunshine Formulary Updated December 1, 2020

68 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ACTONEL TABS 35 MG NF PA; QL(0.143 risedronate sodium tabs 35 1 PA; QL(0.143 (Use risedronate sodium) ea daily) mg ea daily) ACTONEL TABS 5 MG NF PA; QL(1 ea risedronate sodium tbec 35 1 PA (Use risedronate sodium) daily) mg alendronate sodium tabs 1 QL(0.143 ea TYMLOS SOPN 4 PA; 35 mg, 70 mg daily) PA; SP alendronate sodium tabs 1 QL(1 ea daily) XGEVA SOLN 4 40 mg, 10 mg, 5 mg zoledronic acid conc 4 PA; SP ATELVIA TBEC (Use NF PA 4 risedronate sodium) mg/5ml BONIVA SOLN IV 3 PA; SP ZOLEDRONIC ACID SOLN 4 PA; SP MG/3ML (Use ibandronate NF 4 MG/100ML sodium) zoledronic acid soln 4 4 PA; SP mg/100ml, 5 mg/100ml BONIVA TABS OR 150 MG NF QL(0.036 ea (Use ibandronate sodium) daily) ZOLEDRONIC ACID SOLR 4 PA; SP 4 MG 1 calcitonin (salmon) soln ZOMETA CONC 4 PA; SP MG/5ML (Use zoledronic NF etidronate disodium tabs 1 acid) PA; QL(0.09 ml ZOMETA SOLN 4 PA; SP FORTEO SOPN 4 4 daily); SP MG/100ML FOSAMAX PLUS D TABS 3 PA; QL(0.143 Corticotropin ea daily) ACTHAR GEL 4 PA FOSAMAX TABS (Use NF QL(0.143 ea alendronate sodium) daily) Fertility Regulators ibandronate sodium soln iv 4 PA; SP 3 mg/3ml CHORIONIC 4 PA; SP GONADOTROPIN SOLR ibandronate sodium tabs or 1 QL(0.036 ea 150 mg daily) NOVAREL SOLR 10000 4 PA; SP UNIT pamidronate disodium soln 4 PA; SP 30 mg/10ml, 90 mg/10ml PREGNYL W/DILUENT PA; SP BENZYLALCOHOL/NACL 4 PAMIDRONATE PA; SP SOLR DISODIUM SOLN 6 4 MG/ML GnRH/LHRH Antagonists PA pamidronate disodium solr 4 PA; SP CETROTIDE KIT 4 30 mg, 90 mg PA; 1 rtl MAX ganirelix acetate sosy 4 PA 4 fill,180 rtl PROLIA SOSY day(s) supply,; GANIRELIX ACETATE PA SP SOSY (Use ganirelix 4 acetate) RECLAST SOLN (Use NF PA; SP zoledronic acid) Growth Hormone Receptor Antagonists SOMAVERT SOLR 10 MG, PA; SP risedronate sodium tabs 1 PA; QL(0.036 4 150 mg ea daily) 15 MG, 20 MG risedronate sodium tabs 30 1 PA; QL(1 ea Growth Hormone Releasing Hormones (GHRH) mg, 5 mg daily)

Ambetter Sunshine Formulary Updated December 1, 2020

69 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EGRIFTA SOLR 4 PA LUPANETA PACK KIT 4 PA

EGRIFTA SV SOLR 4 PA LUPRON DEPOT-PED (1- 4 PA; SP MONTH) KIT Growth Hormones LUPRON DEPOT-PED (3- 4 PA; SP MONTH) KIT 30 MG GENOTROPIN MINIQUICK 4 PA; SP SOLR 0.2 MG SYNAREL SOLN 4 PA; SP GENOTROPIN SOLR 5 4 PA; SP MG Metabolic Modifiers HUMATROPE COMBO 4 PA; SP ALDURAZYME SOLN 4 PA; SP PACK SOLR PA; SP BUPHENYL POWD (Use NF PA HUMATROPE SOLR 4 sodium phenylbutyrate) NORDITROPIN FLEXPRO PA; SP BUPHENYL TABS (Use NF PA SOPN 10 MG/1.5ML, 15 4 sodium phenylbutyrate) MG/1.5ML, 5 MG/1.5ML calcitriol caps 1 NORDITROPIN FLEXPRO 4 PA SOPN 30 MG/3ML calcitriol soln 1 NUTROPIN AQ NUSPIN 4 PA; SP 10 SOPN CARBAGLU TABS 4 PA; SP OMNITROPE SOCT 10 PA; SP 4 PA; QL(4 ea MG/1.5ML, 5 MG/1.5ML cinacalcet hcl tabs 4 daily); SP SAIZEN SOLR 4 PA; SP CYSTADANE POWD 4 PA; SP SAIZENPREP PA; SP RECONSTITUTIONKIT 4 doxercalciferol caps 1 SOLR SEROSTIM SOLR 4 PA; SP doxercalciferol soln 1 PA; SP ZOMACTON SOLR 4 PA; SP ELAPRASE SOLN 4 PA; SP FABRAZYME SOLR 35 4 PA; SP ZORBTIVE SOLR 4 MG GALAFOLD CAPS 4 PA; QL(0.5 ea Hormone Receptor Modulators daily) EVISTA TABS (Use NF QL(1 ea daily) HECTOROL SOLN 4 raloxifene hcl) MCG/2ML (Use NF OSPHENA TABS 3 PA doxercalciferol) KUVAN PACK 100 MG, PA raloxifene hcl tabs 0 QL(1 ea daily) 500 MG (Use sapropterin 4 dihydrochloride) Insulin-Like Growth Factors (Somatomedins) KUVAN TBSO 100 MG PA; SP INCRELEX SOLN 4 PA; SP (Use sapropterin 4 dihydrochloride) LHRH/GnRH Analog Pituitary LUMIZYME SOLR 4 PA; SP FENSOLVI KIT 4 PA; SP MYALEPT SOLR 4 PA

Ambetter Sunshine Formulary Updated December 1, 2020

70 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NAGLAZYME SOLN 4 PA; SP acetate 1 spray soln PA; SP nitisinone caps 4 desmopressin acetate tabs 1 QL(6 ea daily) or 0.1 mg ORFADIN CAPS 10 MG, 2 PA; SP 4 desmopressin acetate tabs 1 QL(8 ea daily) MG, 5 MG (Use nitisinone) or 0.2 mg PA PALYNZIQ SOSY 4 STIMATE SOLN 4 PA; SP paricalcitol caps 1 Prolactin Inhibitors paricalcitol soln 1 cabergoline tabs 1

ROCALTROL CAPS (Use NF Somatostatic Agents calcitriol) octreotide acetate soln 4 PA; SP ROCALTROL SOLN (Use NF calcitriol) SANDOSTATIN LAR 4 PA DEPOT KIT sapropterin dihydrochloride 4 PA pack 100 mg, 500 mg SANDOSTATIN SOLN NF PA; SP (Use octreotide acetate) sapropterin dihydrochloride 4 PA; SP tbso 100 mg SIGNIFOR SOLN 4 PA SENSIPAR TABS (Use NF PA; QL(4 ea cinacalcet hcl) daily); SP SOMATULINE DEPOT 4 PA; QL(0.0179 SOLN 120 MG/0.5ML ml daily); SP sodium phenylbutyrate 1 PA powd SOMATULINE DEPOT 4 PA; QL(0.0075 SOLN 60 MG/0.2ML ml daily); SP sodium phenylbutyrate tabs 1 PA SOMATULINE DEPOT 4 PA; QL(0.011 SOLN 90 MG/0.3ML ml daily); SP ZEMPLAR CAPS (Use NF paricalcitol) Receptor Antagonists ZEMPLAR SOLN (Use NF JYNARQUE TABS 15 MG, 4 PA; QL(2 ea paricalcitol) 30 MG daily); SP Posterior Pituitary Hormones JYNARQUE TBPK 4 PA; SP DDAVP SOLN IJ 4 PA MCG/ML (Use NF SAMSCA TABS (Use 4 PA; QL(2 ea desmopressin acetate) ) daily); SP PA; QL(2 ea DDAVP SOLN NA 0.01 % tolvaptan tabs 4 (Use desmopressin acetate NF daily); SP spray) ESTROGENS - Hormone Replacement/Modifying DDAVP TABS OR 0.1 MG QL(6 ea daily) Drugs (Use desmopressin NF acetate) Combinations DDAVP TABS OR 0.2 MG QL(8 ea daily) CLIMARA PRO PTWK 3 (Use desmopressin NF acetate) DUAVEE TABS 3 PA desmopressin acetate soln 1 PA ij 4 mcg/ml FEMHRT LOW DOSE TABS (Use norethindrone NF desmopressin acetate 1 acetate-ethinyl estradiol) spray refrigerated soln

Ambetter Sunshine Formulary Updated December 1, 2020

71 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits norethindrone acetate- 1 PREMARIN TABS 2 ethinyl estradiol tabs VIVELLE-DOT PTTW (Use NF QL(0.286 ea PREMPHASE TABS 2 estradiol) daily) PREMPRO TABS 2 FLUOROQUINOLONES - Drugs to Treat Bacterial Infections Estrogens Fluoroquinolones CLIMARA PTWK (Use NF AVELOX SOLN IV 0.8 %- 1 estradiol) 400 MG/250ML DELESTROGEN OIL 10 1 AVELOX TABS OR 400 NF MG/ML MG (Use moxifloxacin hcl) DELESTROGEN OIL 20 PA MG/ML, 40 MG/ML (Use NF BAXDELA SOLR 3 estradiol valerate) BAXDELA TABS 3 PA DEPO-ESTRADIOL OIL 3 2 rtl MAX fill,30 DIVIGEL GEL 0.25 CIPRO SUSR 5 2 GM/100ML, 500 MG/5ML rtl day(s) MG/0.25GM, 0.5 3 supply, MG/0.5GM, 1 MG/GM CIPRO TABS 250 MG, 500 NF ELESTRIN GEL 3 MG (Use ciprofloxacin hcl) ciprofloxacin hcl tabs 1 ESTRACE TABS (Use NF estradiol) ciprofloxacin in d5w soln 3 estradiol pttw td 0.025 QL(0.286 ea 200 mg/100ml-5 % mg/24hr, 0.0375 mg/24hr, 1 daily) 0.05 mg/24hr, 0.075 2 rtl MAX fill,30 mg/24hr, 0.1 mg/24hr ciprofloxacin susr 1 rtl day(s) supply, estradiol ptwk td 0.05 mg/24hr, 0.06 mg/24hr, ciprofloxacin-ciprofloxacin 1 0.075 mg/24hr, 0.1 1 hcl tb24 mg/24hr, 37.5 mcg/24hr, LEVAQUIN TABS (Use NF 0.025 mg/24hr levofloxacin) levofloxacin in d5w soln 5 estradiol tabs or 0.5 mg, 1 1 1 mg, 2 mg %-500 mg/100ml estradiol valerate oil 1 levofloxacin soln 1

ESTROGEL GEL 3 levofloxacin tabs 1 MOXIFLOXACIN EVAMIST SOLN 3 HYDROCHLORIDE/SODIU 1 M HYDROCHLORIDE MENEST TABS 3 SOLN MENOSTAR PTWK 3 moxifloxacin hcl tabs 1

MINIVELLE PTTW (Use NF QL(0.286 ea ofloxacin tabs 1 estradiol) daily) PREMARIN SOLR 2 GASTROINTESTINAL AGENTS - MISC. - Miscellaneous Gastrointestinal Drugs Ambetter Sunshine Formulary Updated December 1, 2020

72 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Bile Acid Synthesis Disorder Agents DELZICOL CPDR (Use NF mesalamine) CHOLBAM CAPS 4 PA; SP DIPENTUM CAPS 2 Gallstone Solubilizing Agents ENTYVIO SOLR 4 PA ACTIGALL CAPS (Use NF ursodiol) PA; 30 rtl lmt URSO 250 TABS (Use NF INFLECTRA SOLR 4 day(s),30 mail ursodiol) lmt day(s), URSO FORTE TABS (Use NF LIALDA TBEC (Use NF ursodiol) mesalamine) ursodiol caps 1 mesalamine cp24 or 0.375 1 gm ursodiol tabs 1 mesalamine cpdr or 400 1 mg Gastrointestinal Chloride Channel Activators mesalamine enem re 4 gm 1 AMITIZA CAPS 2 PA; QL(2 ea daily) mesalamine supp re 1000 1 Gastrointestinal Stimulants mg mesalamine tbec or 1.2 gm 1 metoclopramide hcl soln ij 1 5 mg/ml mesalamine tbec or 800 1 QL(6 ea daily) metoclopramide hcl soln or 1 QL(60 ml daily) mg 10 mg/10ml, 5 mg/5ml REMICADE SOLR 4 PA; SP metoclopramide hcl tabs or 1 QL(6 ea daily) 5 mg, 10 mg PA; 30 rtl lmt REGLAN TABS (Use NF QL(6 ea daily) RENFLEXIS SOLR 4 day(s),30 mail metoclopramide hcl) lmt day(s), Inflammatory Bowel Agents STELARA SOLN IV 130 4 PA MG/26ML APRISO CP24 (Use 2 mesalamine) sulfasalazine tabs 1 ASACOL HD TBEC (Use NF QL(6 ea daily) mesalamine) sulfasalazine tbec 1 AZULFIDINE EN-TABS NF TBEC (Use sulfasalazine) Intestinal Acidifiers lactulose (encephalopathy) AZULFIDINE TABS (Use NF 1 sulfasalazine) soln balsalazide disodium caps 1 Irritable Bowel Syndrome (IBS) Agents alosetron hcl tabs 1 QL(2 ea daily) CANASA SUPP (Use NF mesalamine) LINZESS CAPS 145 MCG, PA PA; QL(0.0714 3 CIMZIA KIT 4 290 MCG ea daily); SP PA; QL(1 ea LINZESS CAPS 72 MCG 3 CIMZIA STARTER KIT KIT 4 PA; QL(0.214 daily) ea daily); SP LOTRONEX TABS (Use NF QL(2 ea daily) COLAZAL CAPS (Use NF alosetron hcl) balsalazide disodium) Ambetter Sunshine Formulary Updated December 1, 2020

73 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Peripheral Opioid Receptor Antagonists RESECTISOL SOLN 1 ENTEREG CAPS 3 sodium chloride (gu 1 irrigant) soln RELISTOR SOLN SC 12 3 PA MG/0.6ML, 8 MG/0.4ML SORBITOL SOLN IR 3 %, 1 3.3 % Phosphate Binder Agents SORBITOL- 1 calcium acetate (phosphate 1 SOLN binder) caps SORBITOL/MANNITOL 1 calcium acetate (phosphate 1 RX/OTC IRRIGATION SOLN binder) tabs FOSRENOL CHEW 1000 Interstitial Cystitis Agents MG, 500 MG, 750 MG (Use NF ELMIRON CAPS 2 lanthanum carbonate) Prostatic Hypertrophy Agents lanthanum carbonate chew 1 alfuzosin hcl tb24 1 QL(1 ea daily) PHOSLYRA SOLN 2 AVODART CAPS (Use NF QL(1 ea daily) RENVELA PACK (Use NF dutasteride) sevelamer carbonate) dutasteride caps 1 QL(1 ea daily) RENVELA TABS (Use NF sevelamer carbonate) finasteride tabs 1 5 mg only sevelamer carbonate pack 1 FLOMAX CAPS (Use NF tamsulosin hcl) sevelamer carbonate tabs 1 PROSCAR TABS (Use NF 5 mg only VELPHORO CHEW 3 PA finasteride) RAPAFLO CAPS (Use NF GENITOURINARY AGENTS - MISCELLANEOUS silodosin) - Miscellaneous Drugs to Treat Reproductive Organs and Urinary System silodosin caps 8 mg, 4 mg 1 Alkalinizers tamsulosin hcl caps 1 potassium citrate 1 (alkalinizer) tbcr 1080 mg UROXATRAL TB24 (Use NF QL(1 ea daily) alfuzosin hcl) sodium citrate & citric acid 1 RX/OTC soln Urinary Analgesics UROCIT-K 10 TBCR (Use phenazopyridine hcl tabs 1 potassium citrate NF 100 mg, 200 mg (alkalinizer)) PYRIDIUM TABS (Use NF Cystinosis Agents phenazopyridine hcl) CYSTAGON CAPS 3 PA GOUT AGENTS - Drugs to Treat Gout Genitourinary Irrigants Gout Agent Combinations w/ probenecid 1 acetic acid soln 1 tabs PA glycine (gu irrigant) soln 1 DUZALLO TABS 3

Ambetter Sunshine Formulary Updated December 1, 2020

74 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Gout Agents Platelet Aggregation Inhibitors allopurinol tabs 1 AGGRENOX CP12 (Use NF PA; QL(2 ea aspirin-dipyridamole) daily) QL(1 ea daily) colchicine tabs 1 AGRYLIN CAPS (Use NF anagrelide hcl) QL(6 ea per fill COLCRYS TABS (Use 2 anagrelide hcl caps 1 colchicine) retail,6 ea per fill mail) PA; QL(2 ea PA; QL(1 ea aspirin-dipyridamole cp12 1 febuxostat tabs 1 daily) daily) BRILINTA TABS 2 KRYSTEXXA SOLN 4 PA CABLIVI KIT 4 PA MITIGARE CAPS (Use NF colchicine) cilostazol tabs 1 ULORIC TABS (Use 3 PA; QL(1 ea febuxostat) daily) clopidogrel bisulfate tabs 1 300 mg ZURAMPIC TABS 3 PA clopidogrel bisulfate tabs 1 QL(1 ea daily) ZYLOPRIM TABS (Use NF 75 mg allopurinol) dipyridamole tabs 1 Uricosurics EFFIENT TABS (Use NF QL(1 ea daily) probenecid tabs 1 prasugrel hcl) HEMATOLOGICAL AGENTS - MISC. - Drugs to PLAVIX TABS 300 MG NF Treat Blood Disorders (Use clopidogrel bisulfate) PLAVIX TABS 75 MG (Use NF QL(1 ea daily) Bradykinin B2 Receptor Antagonists clopidogrel bisulfate) FIRAZYR SOLN (Use 4 PA; QL(9 ml QL(1 ea daily) icatibant acetate) daily) prasugrel hcl tabs 1 PA; QL(9 ml icatibant acetate soln 4 3 daily) REOPRO SOLN Complement Inhibitors ZONTIVITY TABS 3 PA PA CINRYZE SOLR 4 HEMATOPOIETIC AGENTS - Drugs to Treat Blood Disorders HAEGARDA SOLR 4 PA Agents for Gaucher Disease PA; QL(0.143 RUCONEST SOLR 4 CERDELGA CAPS 4 PA; QL(2 ea ea daily) daily) PA SOLIRIS SOLN 4 CEREZYME SOLR 4 PA; SP Hematorheologic Agents ELELYSO SOLR 4 PA; SP pentoxifylline tbcr 1 QL(3 ea daily) PA; QL(3 ea miglustat caps 4 Plasma Kallikrein Inhibitors daily); SP PA; SP TAKHZYRO SOLN 4 PA; VPRIV SOLR 4

Ambetter Sunshine Formulary Updated December 1, 2020

75 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZAVESCA CAPS (Use NF PA; QL(3 ea NEUPOGEN SOLN 4 PA; SP miglustat) daily); SP Agents for Sickle Disease NEUPOGEN SOSY 4 PA; SP DROXIA CAPS 3 NIVESTYM SOSY 300 PA MCG/0.5ML, 480 4 OXBRYTA TABS 4 PA MCG/0.8ML NPLATE SOLR 250 MCG, 4 PA; SP Cobalamins 500 MCG cyanocobalamin soln ij 1 QL(1 ml daily) PROCRIT SOLN 10000 PA; SP 1000 mcg/ml UNIT/ML, 2000 UNIT/ML, 3 Folic Acid/Folates 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML folic acid tabs or 1 mg 0 RX/OTC PROCRIT SOLN 40000 4 PA; SP UNIT/ML folic acid tabs or 400 mcg 0 PROMACTA PACK 12.5 4 PA; QL(1 ea Hematopoietic Growth Factors MG daily) ARANESP ALBUMIN PA; SP PROMACTA TABS 12.5 4 PA; SP FREE SOLN 100 MCG/ML, 4 MG, 25 MG, 50 MG, 75 MG 40 MCG/ML, 60 MCG/ML RETACRIT SOLN 10000 PA UNIT/ML, 2000 UNIT/ML, ARANESP ALBUMIN 4 SP FREE SOLN 25 MCG/ML 20000 UNIT/2ML, 3000 4 UNIT/ML, 4000 UNIT/ML, ARANESP ALBUMIN PA; SP 40000 UNIT/ML FREE SOSY 150 MCG/0.3ML, 200 4 UDENYCA SOSY 4 PA MCG/0.4ML, 300 MCG/0.6ML, 500 MCG/ML PA; 30 rtl lmt ZARXIO SOSY 4 day(s),30 mail DOPTELET TABS 4 PA lmt day(s), Hematopoietic Mixtures EPOGEN SOLN 3 PA; SP ferrous fumarate-folic acid 1 QL(1 ea daily) FULPHILA SOSY 4 PA; tabs Iron GRANIX SOLN 4 PA FER-IN-SOL SOLN (Use 0 AL(Up to 1 yrs ferrous sulfate) old ) GRANIX SOSY 4 PA ferrous sulfate soln or 15 0 AL(Up to 1 yrs mg/ml old ) LEUKINE SOLR 4 PA; SP ferrous sulfate tabs or 325 0 MIRCERA SOSY 4 PA mg, 65 mg ferrous sulfate tbec or 325 0 MULPLETA TABS 4 PA mg INFED SOLN 4 PA NEULASTA ONPRO KIT 4 PA; SP PSKT VENOFER SOLN 4 PA NEULASTA SOSY 4 PA; SP Stem Cell Mobilizers

Ambetter Sunshine Formulary Updated December 1, 2020

76 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MOZOBIL SOLN 4 PA; SP estazolam tabs 1 HEMOSTATICS - Drugs to Stop Bleeding/Treat ST; QL(1 ea Blood Disorders 1 daily); AL(At eszopiclone tabs least 18 yrs Hemostatics - Systemic old) AMICAR TABS 1000 MG, PA HALCION TABS (Use NF 500 MG (Use aminocaproic NF triazolam) acid) ST; QL(1 ea aminocaproic acid tabs or PA 1 LUNESTA TABS (Use NF daily); AL(At 1000 mg, 500 mg eszopiclone) least 18 yrs old) CYKLOKAPRON SOLN NF (Use tranexamic acid) RESTORIL CAPS (Use NF QL(1 ea daily) temazepam) LYSTEDA TABS (Use NF tranexamic acid) temazepam caps 1 QL(1 ea daily) tranexamic acid soln 1 triazolam tabs 1 tranexamic acid tabs 1 QL(2 ea daily); HYPNOTICS/SEDATIVES/SLEEP DISORDER zaleplon caps 10 mg 1 AL(At least 18 AGENTS yrs old) QL(1 ea daily); Hypnotics zaleplon caps 5 mg 1 AL(At least 18 elix 20 1 yrs old) mg/5ml QL(1 ea daily); phenobarbital soln 20 zolpidem tartrate tabs or 10 1 AL(At least 18 1 mg, 5 mg mg/5ml yrs old) phenobarbital tabs 100 mg, ST; Must try 15 mg, 30 mg, 64.8 mg, 1 immediate zolpidem tartrate tbcr or 97.2 mg, 16.2 mg, 32.4 mg 1 release 12.5 mg, 6.25 mg Hypnotics - Tricyclic Agents zolpidem.;QL(1 ea daily) PA; QL(1 ea doxepin hcl (sleep) tabs 1 daily) Orexin Receptor Antagonists PA SILENOR TABS (Use 3 PA; QL(1 ea BELSOMRA TABS 3 doxepin hcl (sleep)) daily) Non-Barbiturate Hypnotics Selective Melatonin Receptor Agonists PA; QL(1 ea ST; Must try HETLIOZ CAPS 3 immediate daily) AMBIEN CR TBCR (Use NF ) release ST; QL(1 ea zolpidem tartrate zolpidem.;QL(1 1 daily); AL(At ea daily) ramelteon tabs least 18 yrs QL(1 ea daily); old) AMBIEN TABS (Use NF zolpidem tartrate) AL(At least 18 ST; QL(1 ea yrs old) ROZEREM TABS (Use 3 daily); AL(At ramelteon) least 18 yrs DORAL TABS (Use NF quazepam) old) LAXATIVES - Bowel Treatment Drugs Ambetter Sunshine Formulary Updated December 1, 2020

77 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Bulk Laxatives docusate calcium caps 1 calcium polycarbophil tabs 1 docusate sodium caps or 1 250 mg, 100 mg FIBERCON TABS (Use NF calcium polycarbophil) LOCAL ANESTHETICS-Parenteral - Drugs for Numbing Laxative Combinations Local Anesthetics - Amides CLENPIQ SOLN 3 PA lidocaine hcl (local anesth.) 1 COLYTE-FLAVOR PACKS soln ij 0.5 %, 1 %, 2 % SOLR (Use peg 3350-kcl- NF MARCAINE SOLN 0.5 % NF sod bicarb-sod chloride- (Use bupivacaine hcl) sod sulfate) NAROPIN SOLN 5 MG/ML, GOLYTELY SOLR 2.97 2 MG/ML (Use ropivacaine NF GM-22.74 GM-236 GM- hcl) 5.86 GM-6.74 GM (Use 0 XYLOCAINE SOLN 0.5 %, peg 3350-kcl-sod bicarb- 1 % (Use lidocaine hcl NF sod chloride-sod sulfate) (local anesth.)) MOVIPREP SOLR (Use PA XYLOCAINE-MPF SOLN peg 3350-kcl-nacl-na 2 (Use lidocaine hcl (local NF sulfate-na ascorbate- anesth.)) ascorbic acid) ZINGO JTAJ (Use peg 3350-kcl-nacl-na PA lidocaine hcl (local NF sulfate-na ascorbate- 1 anesth.)) ascorbic acid solr peg 3350-kcl-sod bicarb- - Drugs to Treat Bacterial Infections sod chloride-sod sulfate 0 solr 2.97 gm-22.74 gm-236 gm-5.86 gm-6.74 gm azithromycin pack or 1 gm 1 PREPOPIK PACK 3 PA azithromycin solr iv 500 mg 1 SUPREP BOWEL PREP 0 KIT SOLN azithromycin susr or 100 1 Laxatives - Miscellaneous mg/5ml, 200 mg/5ml lactulose soln 10 gm/15ml, QL(6 ea per fill 1 azithromycin tabs or 250 1 retail,6 ea per 20 gm/30ml mg fill mail) Saline Laxatives QL(4 ea per fill PA azithromycin tabs or 500 1 retail,4 ea per OSMOPREP TABS 3 mg fill mail) Stimulant Laxatives azithromycin tabs or 600 1 QL(0.286 ea bisacodyl tbec or 5 mg 1 mg daily) ZITHROMAX PACK OR 1 NF DULCOLAX TBEC OR 5 NF GM (Use azithromycin) MG (Use bisacodyl) ZITHROMAX SOLR IV 500 NF Surfactant Laxatives MG (Use azithromycin) COLACE CAPS (Use NF docusate sodium) Ambetter Sunshine Formulary Updated December 1, 2020

78 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZITHROMAX SUSR OR DIFICID TABS 2 100 MG/5ML, 200 MG/5ML NF (Use azithromycin) MEDICAL DEVICES AND SUPPLIES QL(6 ea per fill ZITHROMAX TABS OR NF 250 MG (Use azithromycin) retail,6 ea per Contraceptives fill mail) AIMSCO LUBRICATED 0 QL(2 ea daily) QL(4 ea per fill MISC ZITHROMAX TABS OR NF retail,4 ea per 500 MG (Use azithromycin) fill mail) CAYA DPRH 0 ZITHROMAX TABS OR QL(0.286 ea NF DUREX EXTRA 0 QL(2 ea daily) 600 MG (Use azithromycin) daily) SENSITIVE DEVI QL(4 ea per fill FANTASY LUBRICATED QL(2 ea daily) ZITHROMAX TRI-PAK NF retail,4 ea per 0 TABS (Use azithromycin) MISC fill mail) FANTASY QL(2 ea daily) QL(6 ea per fill LUBRICATED/SPERMICID 0 ZITHROMAX Z-PAK TABS NF (Use azithromycin) retail,6 ea per E MISC fill mail) FC FEMALE CONDOM 0 QL(1 ea daily) MISC clarithromycin susr 1 FEMCAP DEVI 0 clarithromycin tabs 1 K-Y ME & YOU EXTRA 0 QL(2 ea daily) LUBRICATED DEVI clarithromycin tb24 1 K-Y ME & YOU INTENSE 0 QL(2 ea daily) DEVI KAMELEON LUBRICATED 0 QL(2 ea daily) E.E.S. GRANULES SUSR MISC (Use erythromycin NF QL(2 ea daily) ethylsuccinate) KIMONO COLORS DEVI 0 ERYPED 200 SUSR (Use KIMONO LUBRICATED 0 QL(2 ea daily) erythromycin NF MISC ethylsuccinate) KIMONO MICRO THIN QL(2 ea daily) ERYPED 400 SUSR (Use PLUS SPERMICIDE 0 erythromycin 3 LUBRICATED MISC ethylsuccinate) KIMONO PLUS QL(2 ea daily) SPERMICIDE 0 erythromycin base cpep 3 250 mg LUBRICATED MISC KIMONO PLUS QL(2 ea daily) erythromycin base tabs 3 250 mg, 500 mg SPERMICIDE/LUBRICATE 0 D MISC erythromycin base tbec 1 250 mg, 333 mg, 500 mg KIMONO PS LUBRICATED 0 QL(2 ea daily) erythromycin MISC ethylsuccinate susr 200 1 KIMONO PS PLUS QL(2 ea daily) mg/5ml, 400 mg/5ml SPERMICIDE/LUBRICATE 0 D MISC erythromycin 3 ethylsuccinate tabs 400 mg KIMONO SENSATION 0 QL(2 ea daily) LUBRICATED MISC Fidaxomicin

Ambetter Sunshine Formulary Updated December 1, 2020

79 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KIMONO SENSATION QL(2 ea daily) TRUSTEX WITH QL(2 ea daily) 0 PLUS SPERMICIDE NONOXYNOL- 0 LUBRICATED MISC 9/RIBBED/STUDDED MISC KIMONO SPECIAL DEVI 0 QL(2 ea daily) TRUSTEX/RIA 0 QL(2 ea daily) MAXX LUBRICATED MISC 0 QL(2 ea daily) LUBRICATED MISC TRUSTEX/RIA QL(2 ea daily) MAXX PLUS SPERMICIDE 0 QL(2 ea daily) LUBRICATED 0 LUBRICATED MISC SPERMICIDE MISC OMNIFLEX DIAPHRAGM 0 TRUSTEX/RIA QL(2 ea daily) DPRH LUBRICATED/SPERMICID 0 E MISC PREMIUM CONDOMS 0 QL(2 ea daily) LUBRICATED MISC WIDE-SEAL SILICONE REALITY LATEX QL(2 ea daily) DIAPHRAGM KIT 60 0 CONDOMS/LUBRICATED 0 DPRH MISC WIDE-SEAL SILICONE DIAPHRAGM KIT 65 0 REALITY LATEX/ULTRA 0 QL(2 ea daily) TEXTURED DEVI DPRH WIDE-SEAL SILICONE REALITY LATEX/ULTRA 0 QL(2 ea daily) THIN DEVI DIAPHRAGM KIT 70 0 DPRH TRUSTEX COLOR 0 QL(2 ea daily) CONDOMS + LUBE MISC WIDE-SEAL SILICONE DIAPHRAGM KIT 75 0 TRUSTEX LUBRICATED 0 QL(2 ea daily) EXTRALARGE MISC DPRH WIDE-SEAL SILICONE TRUSTEX LUBRICATED 0 QL(2 ea daily) EXTRASTRENGTH MISC DIAPHRAGM KIT 80 0 DPRH TRUSTEX LUBRICATED 0 QL(2 ea daily) MISC WIDE-SEAL SILICONE DIAPHRAGM KIT 85 0 TRUSTEX QL(2 ea daily) DPRH LUBRICATED/RIBBED/ST 0 UDDED MISC WIDE-SEAL SILICONE DIAPHRAGM KIT 90 0 TRUSTEX QL(2 ea daily) DPRH LUBRICATED/SPERMICID 0 E EXTRA LARGE MISC WIDE-SEAL SILICONE DIAPHRAGM KIT 95 0 TRUSTEX QL(2 ea daily) DPRH LUBRICATED/SPERMICID 0 E EXTRA STRENGTH Diabetic Supplies MISC 1ST TIER UNILET QL(6.6667 ea TRUSTEX QL(2 ea daily) COMFORTOUCH 1 daily) LUBRICATED/SPERMICID 0 LANCETS 28G MISC E MISC 1ST TIER UNILET QL(6.6667 ea TRUSTEX NATURAL QL(2 ea daily) COMFORTOUCH 1 daily) LANCETS 30G MISC CONDOMS 0 +LUBE/LUBRICATED ACCU-CHEK FASTCLIX 1 QL(6.6667 ea MISC LANCETS MISC daily) ACCU-CHEK MULTICLIX 1 QL(6.6667 ea LANCETS MISC daily)

Ambetter Sunshine Formulary Updated December 1, 2020

80 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ACCU-CHEK SAFE-T-PRO 1 QL(6.6667 ea AIMSCO TWIST LANCETS 1 QL(6.6667 ea LANCETS MISC daily) 32G MISC daily) ACCU-CHEK SAFE-T-PRO 1 QL(6.6667 ea AIMSCO TWIST LANCETS 1 QL(6.6667 ea PLUSLANCETS MISC daily) 33G MISC daily) ACCU-CHEK SOFTCLIX 1 QL(6.6667 ea ALTERNATE SITE 1 LANCETS MISC daily) LANCING DEVICE MISC ACTI-LANCE LANCETS 1 QL(6.6667 ea AQUA LANCE 28G MISC daily) ADJUSTABLE LANCING 1 ACTI-LANCE LITE QL(6.6667 ea DEVICE DEVI SAFETY LANCETS 28G 1 daily) AQUALANCE LANCETS 1 QL(6.6667 ea MISC ULTRA THIN 30G MISC daily) ACTI-LANCE SPECIAL QL(6.6667 ea ASSURE COMFORT QL(6.6667 ea SAFETY LANCETS 17G 1 daily) LANCETS ULTRA THIN 1 daily) MISC 28G MISC ACTI-LANCE SPECIAL QL(6.6667 ea ASSURE HAEMOLANCE QL(6.6667 ea SAFETYLANCETS 17G 1 daily) PLUS HIGH FLOW 18G 1 daily) MISC MISC ACTI-LANCE UNIVERSAL QL(6.6667 ea ASSURE HAEMOLANCE QL(6.6667 ea SAFETY LANCETS 23G 1 daily) PLUS LOW FLOW 25G 1 daily) MISC MISC ADJUSTABLE LANCING 1 ASSURE HAEMOLANCE QL(6.6667 ea DEVICE MISC PLUS MICRO FLOW 28G 1 daily) MISC ADVANCED MOBILE 1 QL(6.6667 ea LANCET 30G MISC daily) ASSURE HAEMOLANCE QL(6.6667 ea PLUS NORMAL FLOW 1 daily) ADVOCATE CONTROL 1 SOLUTIONHIGH LIQD 21G MISC ASSURE HAEMOLANCE QL(6.6667 ea ADVOCATE LANCETS 1 QL(6.6667 ea 30G MISC daily) PLUS PEDIATRIC BLADE 1 daily) MISC ADVOCATE LANCETS 1 QL(6.6667 ea MISC daily) ASSURE LANCE 1 QL(6.6667 ea LANCETS 21G MISC daily) ADVOCATE LANCING 1 DEVICE MISC ASSURE LANCE 1 QL(6.6667 ea LANCETS MISC daily) ADVOCATE RAPID-SAFE 1 LANCING DEVICE MISC ASSURE LANCE PLUS QL(6.6667 ea SAFETYLANCETS 25G 1 daily) ADVOCATE REDI-CODE+ MISC CONTROL SOLUTION 1 HIGH SOLN ASSURE LANCE PLUS QL(6.6667 ea SAFETYLANCETS 30G 1 daily) ADVOCATE SAFETY 1 QL(6.6667 ea MISC LANCETS 26G MISC daily) ASSURE LANCE SAFETY 1 QL(6.6667 ea ADVOCATE SAFETY 1 QL(6.6667 ea LANCET 28G MISC daily) LANCETS MISC daily) QL(6.6667 ea ASSURE LANCETS MISC 1 AGAMATRIX CONTROL 1 daily) HIGH SOLN AURORA LANCET SUPER 1 QL(6.6667 ea AGAMATRIX ULTRA-THIN 1 QL(6.6667 ea THIN30G MISC daily) LANCETS 33G MISC daily) AURORA LANCET THIN 1 QL(6.6667 ea 23G MISC daily) Ambetter Sunshine Formulary Updated December 1, 2020

81 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AUTO-LANCET MINI MISC 1 CARETOUCH TWIST 1 QL(6.6667 ea LANCETS 33G MISC daily) AUTO-LANCET MISC 1 CLEANLET LANCETS 28G 1 QL(6.6667 ea MISC daily) AUTOLET IMPRESSION 1 CLEVER CHEK LANCETS 1 QL(6.6667 ea LANCING DEVICE MISC ULTRATHIN 30G MISC daily) AUTOLET LANCING 1 CLEVER CHEK LANCETS 1 QL(6.6667 ea DEVICE MISC ULTRATHIN MISC daily) AUTOLET MINI MISC 1 CLEVER CHOICE QL(6.6667 ea COMFORT EZLANCETS 1 daily) AUTOLET PLUS MISC 1 21G MISC CLEVER CHOICE QL(6.6667 ea BD LANCET ULTRAFINE 1 QL(6.6667 ea COMFORT EZLANCETS 1 daily) 30G MISC daily) 23G MISC BD LANCET ULTRAFINE 1 QL(6.6667 ea CLEVER CHOICE QL(6.6667 ea 33G MISC daily) COMFORT EZLANCETS 1 daily) BD MICROTAINER 1 QL(6.6667 ea 28G MISC LANCETS MISC daily) CLEVER CHOICE BULLSEYE MINI SAFETY 1 QL(6.6667 ea GLUCOSE CONTROL 1 LANCETS MISC daily) HIGH LIQD BULLSEYE SAFETY QL(6.6667 ea 1 COAGUCHEK LANCETS 1 QL(6.6667 ea LANCETS MISC daily) MISC daily) CARDIOCOM LANCING 1 COMFORT ASSURED QL(6.6667 ea DEVICE MISC LANCETS MICRO THIN 1 daily) 33G MISC CAREONE ADVANCED 1 LANCINGDEVICE MISC COMFORT ASSURED QL(6.6667 ea LANCETS SUPER THIN 1 daily) CAREONE LANCET THIN 1 QL(6.6667 ea MISC daily) 28G MISC COMFORT LANCETS QL(6.6667 ea CAREONE LANCET 1 QL(6.6667 ea 1 ULTRA THIN MISC daily) MISC daily) CONTOUR HIGH CARESENS LANCETS 1 QL(6.6667 ea 1 MISC daily) CONTROL LIQD QL(6.6667 ea CARETOUCH LANCING CVS LANCETS 21G MISC 1 DEVICEWITH EJECTOR 1 daily) MISC CVS LANCETS MICRO 1 QL(6.6667 ea THIN 33G MISC daily) CARETOUCH SAFETY 1 QL(6.6667 ea LANCETS/26G MISC daily) CVS LANCETS MICRO- 1 QL(6.6667 ea THIN 33G MISC daily) CARETOUCH SAFETY 1 QL(6.6667 ea LANCETS/28G MISC daily) CVS LANCETS ORIGINAL 1 QL(6.6667 ea MISC daily) CARETOUCH SAFETY 1 QL(6.6667 ea LANCETS/30G MISC daily) CVS LANCETS THIN 26G 1 QL(6.6667 ea MISC daily) CARETOUCH TWIST 1 QL(6.6667 ea LANCETS 28G MISC daily) CVS LANCETS ULTRA 1 QL(6.6667 ea THIN 30G MISC daily) CARETOUCH TWIST 1 QL(6.6667 ea LANCETS 30G MISC daily) CVS LANCETS ULTRA- 1 QL(6.6667 ea THIN 30G MISC daily)

Ambetter Sunshine Formulary Updated December 1, 2020

82 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CVS LANCING DEVICE 1 E-ZJECT LANCETS 1 QL(6.6667 ea MISC MICRO-THIN 33G MISC daily) CVS ULTRA THIN 1 QL(6.6667 ea EASY COMFORT QL(6.6667 ea LANCETS MISC daily) LANCETS 30G/PULL TOP 1 daily) MISC DIATHRIVE LANCETS 1 QL(6.6667 ea MISC daily) EASY COMFORT QL(6.6667 ea LANCETS 30G/THIN TOP 1 daily) DIATHRIVE LANCETS 1 QL(6.6667 ea ULTRA THIN 30G MISC daily) MISC EASY COMFORT QL(6.6667 ea DIATHRIVE LANCING 1 1 DEVICE MISC LANCETS MISC daily) DIATRUE GLUCOSE EASY COMFORT QL(6.6667 ea CONTROL SOLUTION 1 LANCETS TWIST TOP 1 daily) LEVEL 3 SOLN MISC EASY MINI EJECT DROPLET LANCETS 1 QL(6.6667 ea 1 ULTRA THIN 30G MISC daily) LANCING DEVICE MISC EASY MINI LANCING DROPLET LANCING 1 1 DEVICE MISC DEVICE MISC EASY PLUS II CONTROL DROPLET PERSONAL 1 QL(6.6667 ea 1 LANCETS30G MISC daily) SOLUTION HIGH SOLN DRUG MART EASY STEP CONTROL 1 ADJUSTABLE LANCING 1 SOLUTION HIGH SOLN DEVICE MISC EASY TALK CONTROL 1 SOLUTION HIGH SOLN DRUG MART LANCETS 1 QL(6.6667 ea THIN MISC daily) EASY TOUCH LANCETS QL(6.6667 ea DRUG MART ON-THE-GO QL(6.6667 ea 21G/PRESSURE 1 daily) LANCETS GENTLE 30G 1 daily) ACTIVATED MISC MISC EASY TOUCH LANCETS QL(6.6667 ea DRUG MART UNILET QL(6.6667 ea 23G/PRESSURE 1 daily) LANCETSSUPER THIN 1 daily) ACTIVATED MISC 30G MISC EASY TOUCH LANCETS QL(6.6667 ea DRUG MART UNILET QL(6.6667 ea 26G/PRESSURE 1 daily) LANCETSULTRA THIN 1 daily) ACTIVATED MISC 28G MISC EASY TOUCH LANCETS 1 QL(6.6667 ea DRUG MART UNILET QL(6.6667 ea 26G/PULL-TOP MISC daily) MICRO THIN LANCETS 1 daily) EASY TOUCH LANCETS QL(6.6667 ea 33G MISC 28G/PRESSURE 1 daily) ACTIVATED MISC E-Z JECT LANCETS 21G 1 QL(6.6667 ea MISC daily) EASY TOUCH LANCETS 1 QL(6.6667 ea 28G/PULL-TOP MISC daily) E-Z JECT LANCETS 1 QL(6.6667 ea COLOR MISC daily) EASY TOUCH LANCETS 1 QL(6.6667 ea 28G/TWIST MISC daily) E-Z JECT LANCETS MISC 1 QL(6.6667 ea daily) EASY TOUCH LANCETS QL(6.6667 ea 30G/BUTTON-ACTIVATED 1 daily) E-Z JECT LANCETS 1 QL(6.6667 ea SUPER THIN 30G MISC daily) MISC EASY TOUCH LANCETS QL(6.6667 ea E-Z JECT LANCETS THIN 1 QL(6.6667 ea 26G MISC daily) 30G/PRESSURE 1 daily) ACTIVATED MISC Ambetter Sunshine Formulary Updated December 1, 2020

83 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH LANCETS 1 QL(6.6667 ea EMBRACE LANCETS 1 QL(6.6667 ea 30G/PULL-TOP MISC daily) ULTRA THIN 30G MISC daily) EASY TOUCH LANCETS 1 QL(6.6667 ea EMBRACE LANCING 30G/TWIST MISC daily) DEVICE WITH EJECTOR 1 EASY TOUCH LANCETS QL(6.6667 ea MISC 32G/PRESSURE 1 daily) EMBRACE TALK ACTIVATED MISC GLUCOSE CONTROL 1 SOLUTION HIGH SOLN EASY TOUCH LANCETS 1 QL(6.6667 ea 32G/PULL-TOP MISC daily) EQL COLOR LANCETS 1 QL(6.6667 ea 21G MISC daily) EASY TOUCH LANCETS 1 QL(6.6667 ea 32G/TWIST MISC daily) EQL COLOR LANCETS 1 QL(6.6667 ea MICRO THIN 33G MISC daily) EASY TOUCH LANCETS 1 QL(6.6667 ea 33G/TWIST MISC daily) EQL SUPER THIN 1 QL(6.6667 ea LANCETS 30G MISC daily) EASY TOUCH LANCING 1 DEVICE/EJECTOR MISC EQL THIN LANCETS 26G 1 QL(6.6667 ea EASY TOUCH SAFETY QL(6.6667 ea MISC daily) LANCETS21G/PRESSURE 1 daily) EZ SMART BLOOD QL(6.6667 ea ACTIVATED MISC GLUCOSE LANCETS 1 daily) EASY TOUCH SAFETY QL(6.6667 ea MISC 1 LANCETS23G/PRESSURE daily) EZ-LETS LANCETS 21G 1 QL(6.6667 ea ACTIVATED MISC MISC daily) EASY TOUCH SAFETY QL(6.6667 ea EZ-LETS LANCETS 26G 1 QL(6.6667 ea LANCETS26G/BUTTON 1 daily) SUPER-SOFT MISC daily) ACTIVATED MISC EZ-LETS LANCETS 28G 1 QL(6.6667 ea EASY TOUCH SAFETY QL(6.6667 ea ULTRA-SOFT MISC daily) LANCETS26G/PRESSURE 1 daily) EZ-LETS LANCETS 30G 1 QL(6.6667 ea ACTIVATED MISC MISC daily) EASY TOUCH SAFETY QL(6.6667 ea FIFTY50 SAFETY SEAL 1 QL(6.6667 ea LANCETS28G/BUTTON 1 daily) LANCETS 30G MISC daily) ACTIVATED MISC FIFTY50 SAFETY SEAL 1 QL(6.6667 ea EASY TOUCH SAFETY QL(6.6667 ea LANCETS 32G MISC daily) LANCETS28G/PRESSURE 1 daily) ACTIVATED MISC FIFTY50 UNILET 1 QL(6.6667 ea LANCETS 33G MISC daily) EASY TRAK GLUCOSE QL(6.6667 ea CONTROLSOLUTION 1 FINE 30 MISC 1 HIGH SOLN daily) FINGERSTIX LANCETS QL(6.6667 ea EASY TWIST & CAP 1 QL(6.6667 ea 1 LANCETS MISC daily) MISC daily) FORA CONTROL EASYGLUCO CONTROL 1 1 SOLUTION HIGH SOLN SOLUTION HIGH SOLN QL(6.6667 ea EASYMAX CONTROL 1 FORA LANCETS MISC 1 SOLUTIONHIGH SOLN daily) FORA LANCING DEVICE ELEMENT HIGH 1 1 CONTROL LIQD MISC EMBRACE GLUCOSE FORA LANCING 1 CONTROL SOLUTION 1 DEVICE/CLEARCAP MISC HIGH LIQD Ambetter Sunshine Formulary Updated December 1, 2020

84 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FORACARE GDH GENTLE-LET LANCETS QL(6.6667 ea CONTROL SOLUTION 1 GENERAL PURPOSE 1 daily) HIGH SOLN STYLE/FINE POINT MISC FORTISCARE CONTROL 1 GENTLE-LET LANCETS QL(6.6667 ea SOLUTIONS HIGH SOLN GENERAL PURPOSE 1 daily) FREDS PHARMACY STYLE/MEDIUM POINT AUTOLET LANCING 1 MISC DEVICE MISC GENTLE-LET LANCETS QL(6.6667 ea FREDS PHARMACY QL(6.6667 ea SAFETY STYLE/FINE 1 daily) UNILET LANCETS SUPER 1 daily) POINT MISC THIN 30G MISC GENTLE-LET LANCETS QL(6.6667 ea FREDS PHARMACY QL(6.6667 ea SAFETY STYLE/MEDIUM 1 daily) UNILET LANCETS ULTRA 1 daily) POINT MISC THIN 28G MISC GLOBAL INJECT EASE 1 QL(6.6667 ea LANCETS 28G MISC daily) FREESTYLE LANCETS 1 QL(6.6667 ea MISC daily) GLOBAL INJECT EASE 1 QL(6.6667 ea LANCETS 30G MISC daily) FREESTYLE UNISTICK II 1 QL(6.6667 ea LANCETS MISC daily) GLOBAL LANCING 1 DEVICE MISC GENTEEL BUTTERFLY 1 QL(6.6667 ea TOUCH LANCETS MISC daily) GLUCOCOM HIGH 1 GENTEEL LANCING CONTROL LIQD DEVICE/BUFF BLACK 1 GLUCOCOM LANCETS 1 QL(6.6667 ea MISC 28G MISC daily) GENTEEL LANCING GLUCOCOM LANCETS 1 QL(6.6667 ea DEVICE/BUTTERFLY 1 30G MISC daily) BLUE MISC GLUCOCOM LANCETS 1 QL(6.6667 ea GENTEEL LANCING 33G MISC daily) DEVICE/GLORIOUS 1 GNP LANCETS 21G MISC 1 QL(6.6667 ea GOLD MISC daily) GENTEEL LANCING GNP LANCETS MICRO 1 QL(6.6667 ea DEVICE/PLAYFUL 1 THIN 33G MISC daily) PURPLE MISC GNP LANCETS MISC 1 QL(6.6667 ea GENTEEL LANCING daily) DEVICE/PRECIOUS 1 PLATINUM MISC GNP LANCETS SUPER 1 QL(6.6667 ea THIN 30G MISC daily) GENTEEL LANCING DEVICE/PRINCESS PINK 1 GNP LANCETS THIN 26G 1 QL(6.6667 ea MISC MISC daily) GENTEEL LANCING GNP LANCETS THIN 1 QL(6.6667 ea DEVICE/STATELY SILVER 1 MISC daily) MISC GNP MICRO THIN 1 QL(6.6667 ea GENTEEL LANCING LANCETS 33G MISC daily) DEVICE/WILLOWY WHITE 1 GNP SUPER THIN 1 QL(6.6667 ea MISC LANCETS/30G MISC daily) GOJJI LANCING GENTLE-LET GP 1 QL(6.6667 ea LANCETS MISC daily) DEVICE/CLEAR CAP 1 MISC

Ambetter Sunshine Formulary Updated December 1, 2020

85 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GOJJI STERILE LANCETS 1 QL(6.6667 ea HEALTH CARE LANCING 1 30G MISC daily) DEVICE MISC GOODSENSE COLOR QL(6.6667 ea HEALTHY ACCENTS LANCETS MICRO-THIN 1 daily) AUTOLET IMPRESSION 1 33G UNIVERSAL MISC LANCING DEVICE MISC GOODSENSE LANCETS 1 QL(6.6667 ea HEALTHY ACCENTS QL(6.6667 ea MICRO-THIN 33G MISC daily) UNILET LANCETS SUPER 1 daily) GOODSENSE LANCETS QL(6.6667 ea THIN 30G MISC MICRO-THIN 33G 1 daily) QL(6.6667 ea HY-VEE LANCETS MISC 1 UNIVERSAL MISC daily) GOODSENSE LANCETS QL(6.6667 ea HY-VEE THIN LANCETS 1 QL(6.6667 ea ULTRA-THIN 26G 1 daily) MISC daily) UNIVERSAL MISC IN TOUCH LANCING 1 GOODSENSE LANCETS 1 QL(6.6667 ea DEVICE MISC ULTRA-THIN 30G MISC daily) IN TOUCH STERILE 1 QL(6.6667 ea GOODSENSE LANCETS QL(6.6667 ea LANCETS30G MISC daily) ULTRA-THIN 30G 1 daily) INFINITY CONTROL 1 UNIVERSAL MISC SOLUTION HIGH SOLN GOODSENSE LANCING 1 KINNEY LANCETS MISC 1 QL(6.6667 ea DEVICE MISC daily) H-E-B INCONTROL KINNEY THIN LANCETS 1 QL(6.6667 ea ADVANCEDLANCING 1 MISC daily) DEVICE MISC KROGER AUTOLET 1 H-E-B INCONTROL QL(6.6667 ea LANCING DEVICE MISC LANCETS MICRO THIN 1 daily) 33G MISC KROGER HEALTHPRO QL(6.6667 ea TWIST LANCETS/26G 1 daily) H-E-B INCONTROL QL(6.6667 ea MISC LANCETS SUPER THIN 1 daily) 30G MISC KROGER LANCETS 21G 1 QL(6.6667 ea MISC daily) H-E-B INCONTROL QL(6.6667 ea LANCETS ULTRA THIN 1 daily) KROGER LANCETS 1 QL(6.6667 ea 28G MISC MICRO THIN33G MISC daily) QL(6.6667 ea HAEMOLANCE LOW 1 QL(6.6667 ea KROGER LANCETS MISC 1 FLOW LANCETS MISC daily) daily) KROGER LANCETS QL(6.6667 ea HAEMOLANCE MISC 1 QL(6.6667 ea 1 daily) SUPER THIN MISC daily) KROGER LANCETS THIN QL(6.6667 ea HAEMOLANCE PLUS 1 QL(6.6667 ea 1 HIGH FLOW MISC daily) 26G MISC daily) KROGER LANCETS THIN QL(6.6667 ea HAEMOLANCE PLUS 1 QL(6.6667 ea 1 LOW FLOW MISC daily) MISC daily) KROGER LANCETS QL(6.6667 ea HAEMOLANCE PLUS 1 QL(6.6667 ea 1 MAX FLOW MISC daily) ULTRATHIN30G MISC daily) KROGER LANCING HAEMOLANCE PLUS 1 QL(6.6667 ea 1 MISC daily) DEVICE MISC LANCET DEVICE HAEMOLANCE PLUS 1 QL(6.6667 ea 1 PEDIATRIC FLOW MISC daily) ADJUSTABLE MISC

Ambetter Sunshine Formulary Updated December 1, 2020

86 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LANCET DEVICE WITH 1 LANCING DEVICE MISC 1 EJECTOR MISC LANCETS 26G TWIST 1 QL(6.6667 ea LANZO MISC 1 TOP MISC daily) LEADER ADVANCED LANCETS 28G MISC 1 QL(6.6667 ea 1 daily) LANCING DEVICE MISC LIBERTY CONTROL LANCETS 30G MISC 1 QL(6.6667 ea 1 daily) SOLUTION HIGH SOLN LIBERTY MEDICAL QL(6.6667 ea LANCETS 30G TWIST 1 QL(6.6667 ea 1 TOP MISC daily) LANCETS 30G MISC daily) LIBERTY MINI LANCING LANCETS 30G/TWIST 1 QL(6.6667 ea 1 TOP MISC daily) DEVICE MISC LIFESCAN UNISTIK 2 QL(6.6667 ea LANCETS 31G TWIST 1 QL(6.6667 ea TOP MISC daily) DEEP PENETRATION 1 daily) MISC LANCETS 33G QL(6.6667 ea UNIVERSAL DESIGN 1 daily) LIFESCAN UNISTIK II 1 QL(6.6667 ea MISC LANCETS MISC daily) LITE TOUCH LANCETS QL(6.6667 ea LANCETS MICRO THIN 1 QL(6.6667 ea 1 33G MISC daily) MISC daily) LITE TOUCH LANCING LANCETS MISC 1 QL(6.6667 ea 1 daily) PEN MISC LITETOUCH LANCETS QL(6.6667 ea LANCETS SAFETY SEAL 1 QL(6.6667 ea 1 21G MISC daily) MICRO THIN 33G MISC daily) LIVE BETTER ADVANCED LANCETS SAFETY SEAL 1 QL(6.6667 ea 1 26G MISC daily) LANCING DEVICE MISC LIVE BETTER LANCET QL(6.6667 ea LANCETS SAFETY SEAL 1 QL(6.6667 ea 1 28G MISC daily) SUPERTHIN 30G MISC daily) LIVE BETTER LANCET QL(6.6667 ea LANCETS SAFETY SEAL 1 QL(6.6667 ea 1 30G MISC daily) ULTRATHIN 28G MISC daily) LONGS LANCETS QL(6.6667 ea LANCETS SUPER THIN 1 QL(6.6667 ea 1 28G MISC daily) STANDARD MISC daily) LONGS LANCETS THIN QL(6.6667 ea LANCETS THIN MISC 1 QL(6.6667 ea 1 daily) MISC daily) LONGS LANCETS ULTRA QL(6.6667 ea LANCETS TWIST TOP 1 QL(6.6667 ea 1 MISC daily) THIN MISC daily) MEDICHOICE PRE-SET QL(6.6667 ea LANCETS ULTRA FINE 1 QL(6.6667 ea MISC daily) SAFETY LANCET DUAL 1 daily) USE MISC LANCETS ULTRA THIN 1 QL(6.6667 ea 30G MISC daily) MEDICHOICE PRE-SET QL(6.6667 ea SAFETY LANCET LOW 1 daily) LANCETS ULTRA THIN 1 QL(6.6667 ea FLOW MISC MISC daily) MEDICHOICE PRE-SET QL(6.6667 ea LANCETSBULLSEYE 1 QL(6.6667 ea SAFETY LANCET 1 daily) SAFETY MISC daily) MEDIUM FLOW MISC LANCING DEVICE 1 MEDICHOICE PRE-SET QL(6.6667 ea ADJUSTABLE MISC SAFETY LANCET 1 daily) MODERATE FLOW MISC Ambetter Sunshine Formulary Updated December 1, 2020

87 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MEDICHOICE SAFETY QL(6.6667 ea 1 MEIJER LANCETS 1 QL(6.6667 ea LANCETEXTRA MISC daily) UNIVERSAL33G MISC daily) MEDICHOICE SAFETY QL(6.6667 ea 1 MEIJER SUPER THIN 1 QL(6.6667 ea LANCETNORMAL MISC daily) LANCETS MISC daily) MEDISENSE THIN QL(6.6667 ea 1 MICROLET LANCETS 1 QL(6.6667 ea LANCETS MISC daily) MISC daily) MEDLANCE PLUS EXTRA 1 QL(6.6667 ea MICROLET NEXT MISC 1 LANCETS 21G MISC daily) MICROTAINER SAFETY QL(6.6667 ea MEDLANCE PLUS 1 QL(6.6667 ea LANCETS LITE 25G MISC daily) FLOW 1 daily) LANCET/STERILE/SINGL MEDLANCE PLUS 1 QL(6.6667 ea LANCETS MISC daily) E-USE MISC MINI LANCING DEVICE MEDLANCE PLUS LITE 1 QL(6.6667 ea 1 LANCETS 25G MISC daily) MISC MEDLANCE PLUS QL(6.6667 ea MM LANCING DEVICE 1 SPECIAL LANCETS 1 daily) MISC 0.8MM MISC MM TWIST LANCETS 1 QL(6.6667 ea MISC daily) MEDLANCE PLUS 1 QL(6.6667 ea SUPERLITE 30G MISC daily) MONOLET LANCETS 1 QL(6.6667 ea MEDLANCE PLUS QL(6.6667 ea MISC daily) MONOLET OPD LANCETS QL(6.6667 ea SUPERLITE 1 daily) 1 30G/COMFORT MAX MISC daily) MISC MONOLETTOR SAFETY 1 QL(6.6667 ea MEDLANCE PLUS QL(6.6667 ea LANCETS MISC daily) UNIVERSAL LANCETS 1 daily) MPD SAFETY LANCET 1 QL(6.6667 ea 21G MISC 21G/1.8MM MISC daily) MEDLANCE PLUS/LITE QL(6.6667 ea 1 MPD SAFETY LANCET 1 QL(6.6667 ea 25G MISC daily) 28G/1.8MM MISC daily) QL(6.6667 ea MEDLANCE/EXTRA MISC 1 MPD SAFETY LANCET 1 QL(6.6667 ea daily) 30G/1.8MM MISC daily) QL(6.6667 ea MEDLANCE/LITE MISC 1 MPD SAFETY LANCETS 1 QL(6.6667 ea daily) 23G/1.8MM MISC daily) MEDLANCE/UNIVERSAL QL(6.6667 ea 1 MULTI-LANCET DEVICE 1 MISC daily) MISC MEIJER COLOR QL(6.6667 ea MYGLUCOHEALTH MGH QL(6.6667 ea LANCETS UNIVERSAL 1 daily) SOFTLANCE LANCETS 1 daily) 33G MISC 30G MISC QL(6.6667 ea MEIJER LANCETS MISC 1 NOVA SAFETY LANCETS 1 QL(6.6667 ea daily) 23G MISC daily) MEIJER LANCETS THIN QL(6.6667 ea 1 NOVA SAFETY LANCETS 1 QL(6.6667 ea MISC daily) 28G MISC daily) MEIJER LANCETS QL(6.6667 ea 1 NOVA SUREFLEX 1 QL(6.6667 ea UNIVERSAL21G MISC daily) LANCETS MISC daily) MEIJER LANCETS QL(6.6667 ea 1 NOVA SUREFLEX 1 UNIVERSAL30G MISC daily) LANCING DEVICE MISC

Ambetter Sunshine Formulary Updated December 1, 2020

88 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.6667 ea PHARMACIST CHOICE QL(6.6667 ea ON CALL LANCETS MISC 1 daily) ULTRA THIN LANCETS 1 daily) 31G MISC ON CALL LANCING 1 DEVICE MISC PHARMACIST CHOICE QL(6.6667 ea ULTRA THIN LANCETS 1 daily) ON CALL PLUS LANCETS 1 QL(6.6667 ea MISC daily) 33G MISC PHARMACIST CHOICE QL(6.6667 ea ON CALL PLUS LANCING 1 DEVICE MISC ULTRA THIN LANCETS 1 daily) MISC ONETOUCH CLUB QL(6.6667 ea LANCETS FINE POINT 1 daily) PHARMACY COUNTER 1 QL(6.6667 ea MISC LANCETS MISC daily) QL(6.6667 ea ONETOUCH DELICA QL(6.6667 ea PIP LANCETS/28G MISC 1 LANCETS EXTRA FINE 1 daily) daily) 33G MISC PIP LANCETS/30G MISC 1 QL(6.6667 ea daily) ONETOUCH DELICA 1 QL(6.6667 ea LANCETS FINE 30G MISC daily) PRECISION THINS GP 1 QL(6.6667 ea LANCET MISC daily) ONETOUCH DELICA 1 LANCING DEVICE MISC PREFERRED PLUS QL(6.6667 ea ONETOUCH DELICA QL(6.6667 ea LANCETS COLORED 21G 1 daily) PLUS LANCETS EXTRA 1 daily) MISC FINE 33G MISC PREFERRED PLUS QL(6.6667 ea ONETOUCH DELICA QL(6.6667 ea LANCETS SUPER THIN 1 daily) PLUS LANCETS FINE 30G 1 daily) 30G MISC MISC PREFERRED PLUS 1 QL(6.6667 ea ONETOUCH DELICA LANCETS THIN 26G MISC daily) PLUS LANCING DEVICE 1 PRESSURE ACTIVATED QL(6.6667 ea MISC SAFETYLANCET 21G 1 daily) MISC ONETOUCH FINEPOINT 1 QL(6.6667 ea LANCETS MISC daily) PRO COMFORT 1 QL(6.6667 ea LANCETS 30G MISC daily) ONETOUCH ULTRASOFT 1 QL(6.6667 ea LANCETS MISC daily) PRO COMFORT 1 QL(6.6667 ea ONETOUCH VERIO LANCETS 31G MISC daily) 1 CONTROL SOLUTION PRODIGY CONTROL 1 HIGH SOLN SOLUTIONHIGH SOLN PC LANCETS SUPER 1 QL(6.6667 ea PRODIGY LANCING 1 THIN 30G MISC daily) DEVICE MISC PERFECT LANCETS 30G 1 QL(6.6667 ea PRODIGY PRESSURE QL(6.6667 ea MISC daily) ACTIVATED SAFETY 1 daily) PERFECT PRESSURE QL(6.6667 ea LANCETS MISC 1 ACTIVATED SAFETY daily) PRODIGY SAFETY 1 QL(6.6667 ea LANCETS 28G MISC LANCETS MISC daily) PHARMACIST CHOICE QL(6.6667 ea PRODIGY TWIST TOP 1 QL(6.6667 ea ULTRA THIN LANCETS 1 daily) LANCETS MISC daily) 28G MISC PSS SELECT GP 1 QL(6.6667 ea PHARMACIST CHOICE QL(6.6667 ea LANCETS MISC daily) ULTRA THIN LANCETS 1 daily) PSS SELECT SAFETY 1 QL(6.6667 ea 30G MISC LANCETS MISC daily) Ambetter Sunshine Formulary Updated December 1, 2020

89 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PUSH BUTTON SAFETY 1 QL(6.6667 ea READYLANCE SAFETY QL(6.6667 ea LANCETS 21G MISC daily) LANCETS/28G/1.8MM 1 daily) MISC PUSH BUTTON SAFETY 1 QL(6.6667 ea LANCETS 28G MISC daily) READYLANCE SAFETY QL(6.6667 ea LANCETS/30G/1.6MM 1 daily) PX ADVANCED LANCING 1 DEVICE MISC MISC QL(6.6667 ea PX LANCET AUTO 1 REALITY LANCETS MISC 1 INJECTOR MISC daily) REALITY TRIGGER QL(6.6667 ea PX LANCETS ULTRA 1 QL(6.6667 ea 1 THIN 28G MISC daily) LANCETS MISC daily) RELION 2-IN-1 LANCET PX LANCETS ULTRA 1 QL(6.6667 ea 1 THIN MISC daily) DEVICES 30G MISC RELION 2-IN-1 LANCING QC ADVANCED LANCING 1 1 DEVICE MISC DEVICE 25G MISC RELION 2-IN-1 LANCING QC LANCETS SUPER 1 QL(6.6667 ea 1 THIN MISC daily) DEVICE 30G MISC RELION LANCETS QL(6.6667 ea QC LANCETS ULTRA 1 QL(6.6667 ea 1 THIN MISC daily) MICRO-THIN33G MISC daily) RELION LANCETS QL(6.6667 ea QC UNILET LANCETS 1 QL(6.6667 ea 1 28G/ULTRA THIN MISC daily) STANDARD 21G MISC daily) RELION LANCETS THIN QL(6.6667 ea QC UNILET LANCETS 1 QL(6.6667 ea 1 33G/MICRO THIN MISC daily) 26G MISC daily) RA E-ZJECT COLOR QL(6.6667 ea RELION LANCETS 1 QL(6.6667 ea LANCETSMICRO-THIN 1 daily) ULTRA-THIN30G MISC daily) 33G MISC RELION LANCING 1 DEVICE MISC RA E-ZJECT LANCETS 1 QL(6.6667 ea 28G MISC daily) RELION ULTRA THIN 1 QL(6.6667 ea LANCETS/30G MISC daily) RA E-ZJECT LANCETS 1 QL(6.6667 ea THIN 26G MISC daily) RELION ULTRA THIN 1 QL(6.6667 ea LANCETS30G MISC daily) RA E-ZJECT LANCETS 1 QL(6.6667 ea THIN 28G MISC daily) RELION ULTRA THIN QL(6.6667 ea PLUS LANCETS 32G 1 daily) RA E-ZJECT LANCETS 1 QL(6.6667 ea ULTRATHIN 30G MISC daily) MISC RELION ULTRA THIN QL(6.6667 ea RA LANCING DEVICE 1 MISC PLUS LANCETS 33G 1 daily) MISC READYLANCE SAFETY QL(6.6667 ea LANCETS/21G/2.2MM 1 daily) REXALL LANCETS ULTRA 1 QL(6.6667 ea MISC THIN MISC daily) READYLANCE SAFETY QL(6.6667 ea RIGHTEST GC300 HIGH 1 LANCETS/23G/1.8MM 1 daily) CONTROL LIQD MISC RIGHTEST GD500 1 READYLANCE SAFETY QL(6.6667 ea LANCING DEVICE MISC LANCETS/26G/1.8MM 1 daily) RIGHTEST GL300 1 QL(6.6667 ea MISC LANCETS MISC daily) SAFE-T-LANCE LOW 1 QL(6.6667 ea FLOW 25G MISC daily)

Ambetter Sunshine Formulary Updated December 1, 2020

90 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SAFE-T-LANCE NORMAL 1 QL(6.6667 ea SELECT-LITE LANCING 1 FLOW21G MISC daily) DEVICE MISC SAFE-T-LANCE PLUS QL(6.6667 ea SHOPKO AUTOLET 1 SAFETYLANCET HIGH 1 daily) LANCING DEVICE MISC FLOW MISC SHOPKO ON-THE-GO QL(6.6667 ea SAFE-T-LANCE PLUS QL(6.6667 ea COMFORTLANCETS 30G 1 daily) SAFETYLANCET LOW 1 daily) MISC FLOW MISC SHOPKO UNILET QL(6.6667 ea SAFE-T-LANCE PLUS QL(6.6667 ea LANCETS SUPER THIN 1 daily) SAFETYLANCET 1 daily) 30G MISC NORMAL FLOW MISC SHOPKO UNILET QL(6.6667 ea SAFETY LANCET QL(6.6667 ea LANCETS ULTRA THIN 1 daily) 21G/PRESSURE 1 daily) 28G MISC ACTIVATED MISC SIDE BUTTON SAFETY 1 QL(6.6667 ea SAFETY LANCET QL(6.6667 ea LANCET21G MISC daily) 23G/PRESSURE 1 daily) SIMPLE DIAGNOSTICS 1 ACTIVATED MISC LANCING DEVICE MISC SAFETY LANCET QL(6.6667 ea SINGLE-LET MISC 1 QL(6.6667 ea 28G/PRESSURE 1 daily) daily) ACTIVATED MISC SM MICRO THIN 1 QL(6.6667 ea SAFETY LANCET QL(6.6667 ea LANCETS 33G MISC daily) 30G/PRESSURE 1 daily) ACTIVATED MISC SM TRUEDRAW LANCING 1 DEVICE MISC SAFETY LANCETS 21G 1 QL(6.6667 ea MISC daily) SMART DIABETES VANTAGE LANCING 1 SAFETY LANCETS 28G 1 QL(6.6667 ea DEVICE MISC MISC daily) SMART SENSE COLOR QL(6.6667 ea QL(6.6667 ea SAFETY LANCETS MISC 1 LANCETS UNIVERSAL 1 daily) daily) 33G MISC SAFETY LET LANCETS 1 QL(6.6667 ea SMART SENSE QL(6.6667 ea MISC daily) STANDARD LANCETS 1 daily) SAFETY SEAL LANCETS 1 QL(6.6667 ea UNIVERSAL 21G MISC 28G MISC daily) SMART SENSE SUPER QL(6.6667 ea 1 SAFETY SEAL LANCETS 1 QL(6.6667 ea THIN LANCETS daily) 30G MISC daily) UNIVERSAL 30G MISC SAPS HEALTH CARE QL(6.6667 ea SMART SENSE THIN QL(6.6667 ea TWIST TOP LANCETS 1 daily) LANCETSUNIVERSAL 1 daily) MISC 26G MISC SAPS HEALTH TWIST 1 QL(6.6667 ea SMARTEST LANCETS 1 QL(6.6667 ea TOP LANCETS 30G MISC daily) 28G MISC daily) SAPSCARE TWIST TOP 1 QL(6.6667 ea SOLUS V2 CONTROL 1 LANCETS 30G MISC daily) HIGH SOLN SOLUS V2 LANCING SB LANCETS THIN MISC 1 QL(6.6667 ea 1 daily) DEVICE MISC SB LANCETS ULTRA 1 QL(6.6667 ea SOLUS V2 PRESSURE QL(6.6667 ea THIN MISC daily) ACTIVATED SAFETY 1 daily) LANCETS 28G MISC Ambetter Sunshine Formulary Updated December 1, 2020

91 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SOLUS V2 TWIST 1 QL(6.6667 ea TGT LANCET ULTRA 1 QL(6.6667 ea LANCETS 30G MISC daily) THIN 30G MISC daily) QL(6.6667 ea TGT LANCING DEVICE STERILANCE TL MISC 1 1 daily) MISC SUPER THIN LANCETS 1 QL(6.6667 ea THINLETS GP LANCETS 1 QL(6.6667 ea MISC daily) MISC daily) SURE COMFORT 1 QL(6.6667 ea TODAYS HEALTH LANCETS 18G MISC daily) ADVANCED LANCING 1 DEVICE MISC SURE COMFORT 1 QL(6.6667 ea LANCETS 21G MISC daily) TODAYS HEALTH SUPER 1 QL(6.6667 ea THINLANCETS 30G MISC daily) SURE COMFORT 1 QL(6.6667 ea LANCETS 23G MISC daily) TODAYS HEALTH ULTRA 1 QL(6.6667 ea THINLANCETS 28G MISC daily) SURE COMFORT 1 QL(6.6667 ea LANCETS 28G MISC daily) TOPCARE LANCETS 1 QL(6.6667 ea MICRO-THIN 33G MISC daily) SURE COMFORT 1 QL(6.6667 ea LANCETS 30G MISC daily) TRAVEL LANCETS 30G 1 QL(6.6667 ea MISC daily) SURE COMFORT 1 LANCING PEN MISC TRAVEL LANCETS 1 QL(6.6667 ea ADVANCED 28G MISC daily) SURE-LANCE FLAT 1 QL(6.6667 ea LANCETS MISC daily) TRUE COMFORT TWIST 1 QL(6.6667 ea TOP LANCETS 30G MISC daily) SURE-LANCE LANCETS 1 QL(6.6667 ea 26G MISC daily) TRUE METRIX CONTROL SOLUTION LEVEL 3 1 SURE-LANCE THIN 1 QL(6.6667 ea LANCETS 28G MISC daily) SOLN TRUEDRAW LANCING SURE-LANCE ULTRA 1 QL(6.6667 ea 1 THIN LANCETS MISC daily) DEVICE MISC TRUEPLUS LANCETS 1 QL(6.6667 ea SURE-PEN MISC 1 26G MISC daily) TRUEPLUS LANCETS QL(6.6667 ea SURE-TOUCH LANCETS 1 QL(6.6667 ea 1 UNIVERSAL MISC daily) 28G MISC daily) TRUEPLUS LANCETS QL(6.6667 ea SURELITE LANCETS 1 QL(6.6667 ea 1 MISC daily) 28G SUPER THIN MISC daily) SURESTEP PRO HIGH TRUEPLUS LANCETS 1 QL(6.6667 ea GLUCOSECONTROL 1 30G MISC daily) LIQD TRUEPLUS LANCETS 1 QL(6.6667 ea 30G ULTRA THIN MISC daily) TECHLITE AST LANCETS 1 QL(6.6667 ea MISC daily) TRUEPLUS LANCETS 1 QL(6.6667 ea 33G MICRO THIN MISC daily) TECHLITE LANCETS 30G 1 QL(6.6667 ea MISC daily) TRUEPLUS LANCETS 1 QL(6.6667 ea 33G MISC daily) TECHLITE LANCETS 1 QL(6.6667 ea MISC daily) TRUEPLUS SAFETY 1 QL(6.6667 ea LANCETS 28G MISC daily) TGT LANCET MICRO 1 QL(6.6667 ea THIN 33G MISC daily) ULTI-LANCE AUTOMATIC/ 1 CLEAR TIP MISC TGT LANCET THIN 26G 1 QL(6.6667 ea MISC daily) ULTILET CLASSIC 1 QL(6.6667 ea LANCETS MISC daily)

Ambetter Sunshine Formulary Updated December 1, 2020

92 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTILET LANCETS 33G 1 QL(6.6667 ea UNISTIK PRO SAFETY 1 QL(6.6667 ea MISC daily) LANCET 25G MISC daily) QL(6.6667 ea UNISTIK PRO SAFETY QL(6.6667 ea ULTILET LANCETS MISC 1 1 daily) LANCET 28G MISC daily) ULTILET SAFETY QL(6.6667 ea UNISTIK SAFETY 1 QL(6.6667 ea LANCETS 21G X 2.2MM 1 daily) LANCETS 28G MISC daily) MISC UNISTIK SAFETY 1 QL(6.6667 ea ULTILET SAFETY 1 QL(6.6667 ea LANCETS 30G MISC daily) LANCETS 23G MISC daily) UNISTIK TOUCH SAFETY 1 QL(6.6667 ea ULTRA THIN LANCETS 1 QL(6.6667 ea LANCETS 21G MISC daily) 31G MISC daily) UNISTIK TOUCH SAFETY 1 QL(6.6667 ea ULTRA-CARE LANCETS 1 QL(6.6667 ea LANCETS 23G MISC daily) 30G MISC daily) UNISTIK TOUCH SAFETY 1 QL(6.6667 ea ULTRA-THIN II AUTO 1 QL(6.6667 ea LANCETS 28G MISC daily) LANCET MISC daily) UNISTIK TOUCH SAFETY 1 QL(6.6667 ea ULTRA-THIN II LANCETS 1 QL(6.6667 ea LANCETS 30G MISC daily) 28G MISC daily) UNISTRIP CONTROL 1 ULTRA-THIN II LANCETS 1 QL(6.6667 ea SOLUTIONHIGH SOLN 30G MISC daily) UNIVERSAL 1 LANCETS 1 QL(6.6667 ea UNILET COMFORTOUCH 1 QL(6.6667 ea THIN26G MISC daily) LANCET MISC daily) UNIVERSAL 1 LANCETS 1 QL(6.6667 ea QL(6.6667 ea ULTRA THIN 30G MISC daily) UNILET EXCELITE II MISC 1 daily) UNIVERSAL 1 QL(6.6667 ea LANCETS/33G/MICRO- 1 daily) UNILET EXCELITE MISC 1 QL(6.6667 ea daily) THIN MISC UNILET G.P. LANCET 1 QL(6.6667 ea VALUE PLUS LANCETS 1 QL(6.6667 ea MISC daily) STANDARD 21G MISC daily) UNILET G.P. SUPERLITE 1 QL(6.6667 ea VALUE PLUS LANCETS 1 QL(6.6667 ea LANCET MISC daily) SUPERTHIN 30G MISC daily) UNILET GP 28 ULTRA 1 QL(6.6667 ea VALUE PLUS LANCETS 1 QL(6.6667 ea THIN MISC daily) THIN 26G MISC daily) VALUE PLUS LANCING UNILET LANCET MISC 1 QL(6.6667 ea 1 daily) DEVICE MISC UNILET LANCETS 1 QL(6.6667 ea VALUMARK LANCET 1 QL(6.6667 ea MICRO-THIN33G MISC daily) SUPER THIN 30G MISC daily) UNILET LANCETS 1 QL(6.6667 ea VALUMARK LANCET 1 QL(6.6667 ea SUPER-THIN30G MISC daily) ULTRA THIN 28G MISC daily) UNILET LANCETS 1 QL(6.6667 ea VIDA MIA AUTOLET 1 ULTRA-THIN 28G MISC daily) LANCINGDEVICE MISC UNILET SUPERLITE 1 QL(6.6667 ea VIDA MIA UNILET QL(6.6667 ea LANCET MISC daily) LANCETS SUPER THIN 1 daily) 30G MISC UNISTIK 3 GENTLE MISC 1 QL(6.6667 ea daily) VIDA MIA UNILET QL(6.6667 ea LANCETS ULTRA THIN 1 daily) UNISTIK PRO SAFETY 1 QL(6.6667 ea LANCET 21G MISC daily) 28G MISC

Ambetter Sunshine Formulary Updated December 1, 2020

93 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VITALET PRO LANCETS 1 QL(6.6667 ea 1ST TIER UNIFINE QL(5 ea daily); MISC daily) PENTIPSPLUS/MINI/31GX 1 RX/OTC 5MM MISC VITALET PRO PLUS 1 QL(6.6667 ea LANCETS MISC daily) 1ST TIER UNIFINE QL(5 ea daily); PENTIPSPLUS/ORIGINAL/ 1 RX/OTC VIVAGUARD LANCETS 1 QL(6.6667 ea MISC daily) 29GX12MM MISC 1ST TIER UNIFINE QL(5 ea daily) VIVAGUARD LANCING 1 DEVICE MISC PENTIPSPLUS/ULTRA 1 SHORT/31GX6MM MISC WALGREENS ADVANCED QL(6.6667 ea TRAVELLANCETS 28G 1 daily) ABOUTTIME PEN 1 QL(5 ea daily); MISC NEEDLE 32GX 5/32" MISC RX/OTC WALGREENS COMFORT QL(6.6667 ea ABOUTTIME PEN QL(5 ea daily); ASSUREDLANCETS 1 daily) NEEDLES 30GX 5/16" 1 RX/OTC MICRO THIN/33G MISC MISC WALGREENS COMFORT QL(6.6667 ea ABOUTTIME PEN QL(5 ea daily); ASSUREDLANCETS 1 daily) NEEDLES 31G X 3/16" 1 RX/OTC SUPER THIN/28G MISC MISC ABOUTTIME PEN QL(5 ea daily); WALGREENS LANCETS 1 QL(6.6667 ea MISC daily) NEEDLES 31G X 5/16" 1 RX/OTC MISC WALGREENS THIN 1 QL(6.6667 ea LANCETS MISC daily) ADVOCATE INSULIN PEN QL(5 ea daily) NEEDLES 29GX12.7MM 1 WALGREENS ULTRA 1 QL(6.6667 ea MISC THIN LANCETS MISC daily) ADVOCATE INSULIN PEN QL(5 ea daily); Parenteral Therapy Supplies NEEDLES 31GX5MM 1 RX/OTC 1ST TIER UNIFINE QL(5 ea daily); MISC PENTIPS/MINI/31GX5MM 1 RX/OTC ADVOCATE INSULIN PEN QL(5 ea daily); MISC NEEDLES 31GX8MM 1 RX/OTC 1ST TIER UNIFINE QL(5 ea daily); MISC PENTIPS29GX12MM 1 RX/OTC ADVOCATE INSULIN QL(5 ea daily); MISC SYRINGE/U- 1 RX/OTC 100/0.3ML/29GX1/2" MISC 1ST TIER UNIFINE 1 QL(5 ea daily) PENTIPS31GX6MM MISC ADVOCATE INSULIN QL(5 ea daily); SYRINGE/U- RX/OTC 1ST TIER UNIFINE 1 QL(5 ea daily); 1 PENTIPS31GX8MM MISC RX/OTC 100/0.3ML/30GX5/16" MISC 1ST TIER UNIFINE 1 QL(5 ea daily); PENTIPS32GX4MM MISC RX/OTC ADVOCATE INSULIN QL(5 ea daily) SYRINGE/U- 1ST TIER UNIFINE 1 QL(5 ea daily) 1 PENTIPS32GX6MM MISC 100/0.3ML/31GX5/16" MISC 1ST TIER UNIFINE QL(5 ea daily); PENTIPSPLUS 31GX8MM 1 RX/OTC ADVOCATE INSULIN QL(5 ea daily); MISC SYRINGE/U- 1 RX/OTC 100/0.5ML/29GX1/2" MISC 1ST TIER UNIFINE QL(5 ea daily); PENTIPSPLUS 32GX4MM 1 RX/OTC ADVOCATE INSULIN QL(5 ea daily); MISC SYRINGE/U- 1 RX/OTC 100/0.5ML/30GX5/16" MISC

Ambetter Sunshine Formulary Updated December 1, 2020

94 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADVOCATE INSULIN QL(5 ea daily) B-D INSULIN SYRINGE QL(5 ea daily) SYRINGE/U- 1 ULTRAFINE/0.3ML/30G X 1 100/0.5ML/31GX5/16" 1/2" MISC MISC B-D INSULIN SYRINGE QL(5 ea daily) ADVOCATE INSULIN QL(5 ea daily); ULTRAFINE/0.5ML/30G X 1 SYRINGE/U- 1 RX/OTC 1/2" MISC 100/1ML/29GX1/2" MISC BD LO-DOSE INSULIN QL(5 ea daily); ADVOCATE INSULIN QL(5 ea daily); SYRINGE MICROFINE 1 RX/OTC SYRINGE/U- 1 RX/OTC IV/0.5ML/28G X 1/2" MISC 100/1ML/30GX5/16" MISC BD AUTOSHIELD 29G X 1 QL(5 ea daily) ADVOCATE INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/U- 1 BD INSULIN SYRINGE QL(5 ea daily); 100/1ML/31GX5/16" MISC LUER-LOK/U-100/1ML 1 RX/OTC ASSURE ID INSULIN QL(5 ea daily); MISC SAFETYSYRINGE/U- 1 RX/OTC BD INSULIN SYRINGE QL(5 ea daily); 100/0.5ML/29G X 1/2" MICROFINE IV/U- 1 RX/OTC MISC 100/0.5ML/28G X 1/2" ASSURE ID INSULIN QL(5 ea daily); MISC SAFETYSYRINGE/U- 1 RX/OTC BD INSULIN SYRINGE QL(5 ea daily) 100/1ML/29G X 1/2" MISC MICROFINE IV/U- 1 ASSURE ID SAFETY PEN QL(5 ea daily); 100/1ML/27G X 5/8" MISC NEEDLES 30G X 5/16" 1 RX/OTC BD INSULIN SYRINGE QL(5 ea daily); MISC MICROFINE IV/U- 1 RX/OTC ASSURE ID SAFETY PEN QL(5 ea daily); 100/1ML/28G X 1/2" MISC NEEDLES 31G X 3/16" 1 RX/OTC BD INSULIN SYRINGE QL(5 ea daily); MISC MICROFINE/U- 1 RX/OTC AURORA PEN NEEDLES 1 QL(5 ea daily); 100/0.5ML/28G X 1/2" 29GX12MM MISC RX/OTC MISC AURORA PEN NEEDLES 1 QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) 31G X6MM MISC MICROFINE/U- 1 100/1ML/27G X 5/8" MISC AURORA PEN NEEDLES 1 QL(5 ea daily); 31G X8MM MISC RX/OTC BD INSULIN SYRINGE QL(5 ea daily); MICROFINE/U- 1 RX/OTC AURORA UNIFINE 1 QL(5 ea daily); PENTIPS/32GX5/32" MISC RX/OTC 100/1ML/28G X 1/2" MISC AURORA UNIFINE QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily); PENTIPS/MINI/31GX3/16" 1 RX/OTC SAFETYGLIDE/1ML/29G X 1 RX/OTC MISC 1/2" MISC B-D INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE 1 QL(5 ea daily); ULTRAFINE II/0.3ML/31G 1 SLIP TIP/U-100/1ML MISC RX/OTC X 5/16" MISC BD INSULIN SYRINGE QL(5 ea daily) B-D INSULIN SYRINGE QL(5 ea daily) ULTRA-FINE/0.3ML/30G X 1 ULTRAFINE II/0.5ML/31G 1 12.7MM MISC X 5/16" MISC BD INSULIN SYRINGE QL(5 ea daily) B-D INSULIN SYRINGE QL(5 ea daily) ULTRA-FINE/0.3ML/31G X 1 ULTRAFINE II/1ML/31G X 1 8MM MISC 5/16" MISC BD INSULIN SYRINGE QL(5 ea daily) ULTRA-FINE/0.5ML/30G X 1 12.7MM MISC Ambetter Sunshine Formulary Updated December 1, 2020

95 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN QL(5 ea daily); ULTRA-FINE/0.5ML/31G X 1 SYRINGE/0.3ML/29G X 1 RX/OTC 8MM MISC 12.7MM MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN QL(5 ea daily); ULTRA-FINE/1/2 1 SYRINGE/0.5ML/29G X 1 RX/OTC UNIT/0.3ML/31G X 8MM 12.7MM MISC MISC BD INSULIN QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) SYRINGE/1ML/27G X 1 RX/OTC ULTRA-FINE/1ML/30G X 1 12.7MM MISC 12.7MM MISC BD INSULIN QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) SYRINGE/1ML/29G X 1 RX/OTC ULTRA-FINE/1ML/31G X 1 12.7MM MISC 8MM MISC BD INSULIN QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) SYRINGE/DETACHABLE 1 ULTRAFINE HALF- 1 NEEDLE/U-100/1ML/25G UNIT/0.3ML/31G X 5/16" X 1" MISC MISC BD INSULIN QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) SYRINGE/DETACHABLE 1 ULTRAFINE/0.3ML/30G X 1 NEEDLE/U-100/1ML/25G 1/2" MISC X 5/8" MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN QL(5 ea daily) 1 ULTRAFINE/0.3ML/31G X SYRINGE/DETACHABLE 1 5/16" MISC NEEDLE/U-100/1ML/26G BD INSULIN SYRINGE QL(5 ea daily) X 1/2" MISC 1 ULTRAFINE/0.5ML/30G X BD INSULIN SYRINGE/U- 1 QL(5 ea daily); 1/2" MISC 100/1ML/27G X 1/2" MISC RX/OTC BD INSULIN SYRINGE QL(5 ea daily) BD PEN QL(5 ea daily) ULTRAFINE/0.5ML/31G X 1 NEEDLE/MICRO/ULTRA- 1 5/16" MISC FINE/32G X 6MM MISC BD INSULIN SYRINGE QL(5 ea daily) BD PEN QL(5 ea daily); ULTRAFINE/1ML/30G X 1 NEEDLE/MINI/ULTRA- 1 RX/OTC 1/2" MISC FINE/31G X 5MM MISC BD INSULIN SYRINGE QL(5 ea daily); BD PEN NEEDLE/NANO QL(5 ea daily); ULTRAFINE/U- 1 RX/OTC 2ND GEN/32G X 5/32" 1 RX/OTC 100/0.3ML/29G X 1/2" MISC MISC BD PEN QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily); NEEDLE/NANO/ULTRA- 1 RX/OTC ULTRAFINE/U- 1 RX/OTC FINE/32G X 4MM MISC 100/0.5ML/29G X 1/2" BD PEN QL(5 ea daily) MISC NEEDLE/ORIGINAL/ULTR 1 BD INSULIN SYRINGE QL(5 ea daily); A-FINE/29G X 12.7MM ULTRAFINE/U- 1 RX/OTC MISC 100/1ML/29G X 1/2" MISC BD PEN QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) NEEDLE/SHORT/ULTRA- 1 RX/OTC ULTRAFINE/U- 1 FINE/31G X 8MM MISC 100/1ML/30G X 1/2" MISC

Ambetter Sunshine Formulary Updated December 1, 2020

96 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD SAFETY-GLIDE QL(5 ea daily); CAREFINE PEN QL(5 ea daily) INSULIN 1 RX/OTC NEEDLES 32GX6MM 1 SYRINGE/0.5ML/29G X MISC 1/2" MISC CAREONE INSULIN QL(5 ea daily) BD SAFETY-LOK INSULIN QL(5 ea daily); SYRINGES/0.3ML/30G X 1 SYRINGE/PERM 1 RX/OTC 1/2" MISC NEEDLE/UF/1ML/29G X CAREONE INSULIN QL(5 ea daily) 1/2" MISC SYRINGES/0.3ML/31G X 1 BD SAFETYGLIDE QL(5 ea daily); 5/16" MISC INSULIN 1 RX/OTC CAREONE INSULIN QL(5 ea daily) SYRINGE/0.3ML/29G X SYRINGES/0.5ML/30G X 1 1/2" MISC 1/2" MISC BD SAFETYGLIDE QL(5 ea daily) CAREONE INSULIN QL(5 ea daily) INSULIN 1 SYRINGES/0.5ML/31G X 1 SYRINGE/0.3ML/31G X 5/16" MISC 5/16" MISC CAREONE INSULIN QL(5 ea daily) BD SAFETYGLIDE QL(5 ea daily) SYRINGES/1ML/30G X 1 INSULIN 1 1/2" MISC SYRINGE/1ML/31G X 15/64" MISC CAREONE INSULIN QL(5 ea daily) SYRINGES/1ML/31GX5/16 1 BD SAFETYGLIDE QL(5 ea daily); " MISC INSULIN 1 RX/OTC SYSYRINGE/0.5ML/30G X CAREONE UNIFINE QL(5 ea daily); 5/16" MISC PENTIPS 29GX12MM 1 RX/OTC MISC BD VEO INSULIN QL(5 ea daily) CAREONE UNIFINE QL(5 ea daily); SYRINGE ULTRA- 1 1 FINE/1ML/31G X 6MM PENTIPS 31GX5MM MISC RX/OTC MISC CAREONE UNIFINE 1 QL(5 ea daily) BD VEO INSULIN QL(5 ea daily) PENTIPS 31GX6MM MISC CAREONE UNIFINE QL(5 ea daily); SYRINGE ULTRA-FINE/U- 1 1 100/1ML/31G X 15/64" PENTIPS 31GX8MM MISC RX/OTC MISC CAREONE UNIFINE QL(5 ea daily); PENTIPS PEN NEEDLES 1 RX/OTC CAREFINE PEN NEEDLE 1 QL(5 ea daily); 32GX4MM MISC RX/OTC 32GX4MM MISC CAREONE UNIFINE QL(5 ea daily); CAREFINE PEN 1 QL(5 ea daily); NEEDLES 29GX1/2" MISC RX/OTC PENTIPS PLUS PEN 1 RX/OTC CAREFINE PEN QL(5 ea daily); NEEDLES 29GX12MM NEEDLES 30GX5/16" 1 RX/OTC MISC MISC CAREONE UNIFINE QL(5 ea daily); CAREFINE PEN QL(5 ea daily) PENTIPS PLUS PEN 1 RX/OTC NEEDLES 31GX6MM 1 NEEDLES 31GX5MM MISC MISC CAREFINE PEN QL(5 ea daily); CAREONE UNIFINE QL(5 ea daily) NEEDLES 31GX8MM 1 RX/OTC PENTIPS PLUS PEN 1 MISC NEEDLES 31GX6MM MISC CAREFINE PEN QL(5 ea daily); NEEDLES 32GX5MM 1 RX/OTC MISC

Ambetter Sunshine Formulary Updated December 1, 2020

97 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CAREONE UNIFINE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); PENTIPS PLUS PEN 1 RX/OTC COMFORT EZINSULIN 1 RX/OTC NEEDLES 31GX8MM SYRINGE/0.5ML/29G X MISC 1/2" MISC CAREONE UNIFINE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily) PENTIPS PLUS PEN 1 RX/OTC COMFORT EZINSULIN 1 NEEDLES 32GX4MM SYRINGE/0.5ML/30G X MISC 1/2" MISC CARETOUCH PEN QL(5 ea daily) CLEVER CHOICE QL(5 ea daily); 1 NEEDLES 31G X 6 MM COMFORT EZINSULIN 1 RX/OTC MISC SYRINGE/0.5ML/30G X CARETOUCH PEN QL(5 ea daily); 5/16" MISC NEEDLES 31GX 5MM 1 RX/OTC CLEVER CHOICE QL(5 ea daily) MISC COMFORT EZINSULIN 1 CARETOUCH PEN QL(5 ea daily); SYRINGE/0.5ML/31G X NEEDLES 31GX 8MM 1 RX/OTC 5/16" MISC MISC CLEVER CHOICE QL(5 ea daily) CARETOUCH PEN QL(5 ea daily); COMFORT EZINSULIN 1 NEEDLES 32GX 4MM 1 RX/OTC SYRINGE/1.0ML/30G X MISC 1/2" MISC CARETOUCH PEN QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); NEEDLES 32GX 5MM 1 RX/OTC COMFORT EZINSULIN 1 RX/OTC MISC SYRINGE/1ML/28G X 1/2" MISC CLEVER CHOICE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); COMFORT EZINSULIN 1 RX/OTC PEN NEEDLES 31GX8MM COMFORT EZINSULIN 1 RX/OTC MISC SYRINGE/1ML/29G X 1/2" MISC CLEVER CHOICE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); COMFORT EZINSULIN 1 RX/OTC SYRINGE/0.3ML/29G X COMFORT EZINSULIN 1 RX/OTC 1/2" MISC SYRINGE/1ML/30G X 5/16" MISC CLEVER CHOICE QL(5 ea daily) CLEVER CHOICE QL(5 ea daily) COMFORT EZINSULIN 1 SYRINGE/0.3ML/30G X COMFORT EZINSULIN 1 1/2" MISC SYRINGE/U- 100/1ML/31GX5/16" MISC CLEVER CHOICE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); COMFORT EZINSULIN 1 RX/OTC SYRINGE/0.3ML/30G X COMFORT EZPEN 1 RX/OTC 5/16" MISC NEEDLES 29GX12MM MISC CLEVER CHOICE QL(5 ea daily) CLEVER CHOICE QL(5 ea daily); COMFORT EZINSULIN 1 SYRINGE/0.3ML/31G X COMFORT EZPEN 1 RX/OTC 5/16" MISC NEEDLES 31GX5MM MISC CLEVER CHOICE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily) COMFORT EZINSULIN 1 RX/OTC SYRINGE/0.5ML/28G X COMFORT EZPEN 1 1/2" MISC NEEDLES 31GX6MM MISC

Ambetter Sunshine Formulary Updated December 1, 2020

98 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLEVER CHOICE QL(5 ea daily); COMFORT ASSIST QL(5 ea daily); COMFORT EZPEN 1 RX/OTC INSULIN 1 RX/OTC NEEDLES 31GX8MM SYRINGE/0.3ML/30G X MISC 5/16" MISC CLEVER CHOICE QL(5 ea daily); COMFORT ASSIST QL(5 ea daily) COMFORT EZPEN 1 RX/OTC INSULIN 1 NEEDLES 32GX4MM SYRINGE/0.3ML/31G X MISC 5/16" MISC CLEVER CHOICE QL(5 ea daily); COMFORT ASSIST QL(5 ea daily); COMFORT EZPEN 1 RX/OTC INSULIN 1 RX/OTC NEEDLES 32GX5MM SYRINGE/0.5ML/29G X MISC 1/2" MISC CLEVER CHOICE QL(5 ea daily) COMFORT ASSIST QL(5 ea daily); COMFORT EZPEN 1 INSULIN 1 RX/OTC NEEDLES 32GX6MM SYRINGE/0.5ML/30G X MISC 5/16" MISC CLICKFINE PEN NEEDLE 1 QL(5 ea daily); COMFORT ASSIST QL(5 ea daily) 32GX5/32" MISC RX/OTC INSULIN 1 CLICKFINE PEN NEEDLE QL(5 ea daily) SYRINGE/0.5ML/31G X UNIVERSAL/31GX1/4" 1 5/16" MISC MISC COMFORT ASSIST QL(5 ea daily); CLICKFINE PEN NEEDLE QL(5 ea daily); INSULIN 1 RX/OTC UNIVERSAL/31GX5/16" 1 RX/OTC SYRINGE/1ML/29G X 1/2" MISC MISC CLICKFINE PEN QL(5 ea daily) COMFORT ASSIST QL(5 ea daily); NEEDLES 31G X 1/4" 1 INSULIN 1 RX/OTC MISC SYRINGE/1ML/30G X 5/16" MISC CLICKFINE PEN QL(5 ea daily); NEEDLES 31G X 3/16" 1 RX/OTC COMFORT ASSIST QL(5 ea daily) MISC INSULIN 1 SYRINGE/1ML/31G X CLICKFINE PEN QL(5 ea daily); 5/16" MISC NEEDLES 31G X 5/16" 1 RX/OTC MISC COMFORT EZ INSULIN QL(5 ea daily) SYRINGE/U- 1 CLICKFINE PEN QL(5 ea daily); 100/0.5ML/31G X 5/16" NEEDLES 31G X 8MM 1 RX/OTC MISC MISC COMFORT EZ INSULIN QL(5 ea daily) CLICKFINE PEN QL(5 ea daily); SYRINGE/U-100/1ML/31G 1 NEEDLES 32G X 5/32" 1 RX/OTC X 5/16" MISC MISC COMFORT EZ 1 QL(5 ea daily); CLICKFINE PEN 1 QL(5 ea daily) MICRO/32G X 4MM MISC RX/OTC NEEDLES/31GX1/4" MISC COMFORT EZ 1 QL(5 ea daily); CLICKFINE UNIVERSAL QL(5 ea daily); SHORT/31G X 8MM MISC RX/OTC PEN NEEDLES 31GX5/16" 1 RX/OTC MISC COMFORT EZ/31G X 5MM 1 QL(5 ea daily); MISC RX/OTC COMFORT ASSIST QL(5 ea daily); INSULIN SYRINGE 1 RX/OTC COMFORT EZ/31G X 6MM 1 QL(5 ea daily) 0.3ML/29G X 1/2" MISC MISC

Ambetter Sunshine Formulary Updated December 1, 2020

99 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DIATHRIVE PEN QL(5 ea daily) DROPLET INSULIN QL(5 ea daily) NEEDLE/31 G X 6MM 1 SYRINGE U-100/1ML/31G 1 MISC X 15/64" MISC DIATHRIVE PEN QL(5 ea daily); DROPLET INSULIN QL(5 ea daily) NEEDLE/31 GX 8MM 1 RX/OTC SYRINGE U-100/1ML/31G 1 MISC X 5/16" MISC DIATHRIVE PEN 1 QL(5 ea daily); DROPLET INSULIN QL(5 ea daily) NEEDLE/31GX 5MM MISC RX/OTC SYRINGE/U- 1 100/0.3ML/31G X 5/16" DIATHRIVE PEN 1 QL(5 ea daily); NEEDLE/32GX 4MM MISC RX/OTC MISC DROPLET INSULIN QL(5 ea daily); DROPLET INSULIN QL(5 ea daily) SYRINGE 0.3ML/29G X 1 RX/OTC SYRINGE/U- 1 1/2" MISC 100/0.5ML/30G X 1/2" MISC DROPLET INSULIN QL(5 ea daily); SYRINGE 0.5ML/29G X 1 RX/OTC DROPLET INSULIN QL(5 ea daily) 1/2" MISC SYRINGE/U- 1 100/0.5ML/31G X 5/16" DROPLET INSULIN QL(5 ea daily); MISC SYRINGE 1ML/29G X 1/2" 1 RX/OTC MISC DROPLET INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/30G 1 DROPLET INSULIN QL(5 ea daily) X 1/2" MISC SYRINGE U-100/0.3/31G 1 X 5/16" MISC DROPLET INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/31G 1 DROPLET INSULIN QL(5 ea daily) X 15/64" MISC SYRINGE U- 1 100/0.3ML/30G X 1/2" DROPLET INSULIN QL(5 ea daily) MISC SYRINGE/U-100/1ML/31G 1 X 5/16" MISC DROPLET INSULIN QL(5 ea daily); DROPLET PEN NEEDLES QL(5 ea daily); SYRINGE U- 1 RX/OTC 1 100/0.3ML/30G X 5/16" 29GX12MM MISC RX/OTC MISC DROPLET PEN NEEDLES 1 QL(5 ea daily); DROPLET INSULIN QL(5 ea daily) 30G X 5/16" MISC RX/OTC SYRINGE U- 1 DROPLET PEN NEEDLES 1 QL(5 ea daily); 100/0.5ML/30G X 1/2" 31GX5MM MISC RX/OTC MISC DROPLET PEN NEEDLES 1 QL(5 ea daily) DROPLET INSULIN QL(5 ea daily); 31GX6MM MISC SYRINGE U- RX/OTC 1 DROPLET PEN NEEDLES 1 QL(5 ea daily); 100/0.5ML/30G X 5/16" 31GX8MM MISC RX/OTC MISC DROPLET PEN NEEDLES 1 QL(5 ea daily) DROPLET INSULIN QL(5 ea daily) 32G X 1/4" MISC SYRINGE U- 1 100/0.5ML/31G X 5/16" DROPLET PEN NEEDLES 1 QL(5 ea daily); MISC 32G X 3/16" MISC RX/OTC DROPLET INSULIN QL(5 ea daily) DROPLET PEN NEEDLES 1 QL(5 ea daily); SYRINGE U-100/1ML/30G 1 32G X 5/32" MISC RX/OTC X 1/2" MISC DROPLET PEN NEEDLES 1 QL(5 ea daily); DROPLET INSULIN QL(5 ea daily); 32GX4MM MISC RX/OTC SYRINGE U-100/1ML/30G 1 RX/OTC DROPLET PEN NEEDLES 1 QL(5 ea daily); X 5/16" MISC 32GX5MM MISC RX/OTC

Ambetter Sunshine Formulary Updated December 1, 2020

100 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DROPLET PEN NEEDLES QL(5 ea daily) 1 EASY COMFORT PEN 1 QL(5 ea daily); 32GX6MM MISC NEEDLES31GX5/16" MISC RX/OTC DROPSAFE SAFETY PEN QL(5 ea daily); EASY COMFORT PEN 1 QL(5 ea daily); NEEDLES/31G X 5/16" 1 RX/OTC NEEDLES32GX5/32" MISC RX/OTC MISC EASY TOUCH 32GX5MM 1 QL(5 ea daily); DROPSAFE SAFTEY PEN QL(5 ea daily) MISC RX/OTC NEEDLES/31G X 1/4" 1 EASY TOUCH 32GX6MM 1 QL(5 ea daily) MISC MISC DRUG MART UNIFINE 1 QL(5 ea daily); EASY TOUCH FLIPLOCK QL(5 ea daily); PENTIPS 31GX5MM MISC RX/OTC SAFETY INSULIN 1 RX/OTC DRUG MART UNIFINE QL(5 ea daily); SYRINGE 1ML/29GX1/2" PENTIPS29G X 12MM 1 RX/OTC MISC MISC EASY TOUCH FLIPLOCK QL(5 ea daily) DRUG MART UNIFINE QL(5 ea daily) 1 SAFETY INSULIN 1 PENTIPS31GX6MM MISC SYRINGE 1ML/30GX1/2" MISC DRUG MART UNIFINE 1 QL(5 ea daily); PENTIPS31GX8MM MISC RX/OTC EASY TOUCH FLIPLOCK QL(5 ea daily); SAFETY INSULIN RX/OTC DRUG MART UNIFINE 1 QL(5 ea daily); 1 PENTIPS32GX4MM MISC RX/OTC SYRINGE 1ML/30GX5/16" MISC DRUG MART UNIFINE QL(5 ea daily); PENTIPSPLUS 32GX4MM 1 RX/OTC EASY TOUCH FLIPLOCK QL(5 ea daily) MISC SAFETY INSULIN 1 SYRINGE 1ML/31GX5/16" EASY COMFORT INSULIN QL(5 ea daily); MISC SYRINGE/0.5ML/30G X 1 RX/OTC 5/16" MISC EASY TOUCH INSULIN QL(5 ea daily); SYRINGE/0.3ML/30G X 1 RX/OTC EASY COMFORT INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/0.5ML/31G X 1 5/16" MISC EASY TOUCH INSULIN QL(5 ea daily) SYRINGE/0.3ML/31G X 1 EASY COMFORT INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/1ML/30G X 1 RX/OTC 5/16" MISC EASY TOUCH INSULIN QL(5 ea daily); SYRINGE/0.5ML/29G X 1 RX/OTC EASY COMFORT INSULIN QL(5 ea daily) 1/2" MISC SYRINGE/1ML/31G X 1 5/16" MISC EASY TOUCH INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X 1 RX/OTC EASY COMFORT INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/U- 1 100/0.5ML/30G X 1/2" EASY TOUCH INSULIN QL(5 ea daily); MISC SYRINGE/1ML/30G X 1 RX/OTC 5/16" MISC EASY COMFORT INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/30G 1 EASY TOUCH INSULIN QL(5 ea daily); X 1/2" MISC SYRINGE/SAFETY/U- 1 RX/OTC 100/0.5ML/29G X 1/2" EASY COMFORT PEN 1 QL(5 ea daily) MISC NEEDLES31GX1/4" MISC EASY TOUCH INSULIN QL(5 ea daily); EASY COMFORT PEN QL(5 ea daily); SYRINGE/SAFETY/U- 1 RX/OTC NEEDLES31GX3/16" 1 RX/OTC 100/0.5ML/30G X 5/16" MISC MISC

Ambetter Sunshine Formulary Updated December 1, 2020

101 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH INSULIN QL(5 ea daily); EASY TOUCH PEN QL(5 ea daily); SYRINGE/SAFETY/U- 1 RX/OTC NEEDLES 31GX5/16" 1 RX/OTC 100/1ML/29G X 1/2" MISC MISC EASY TOUCH INSULIN QL(5 ea daily) EASY TOUCH PEN 1 QL(5 ea daily) SYRINGE/SAFETY/U- 1 NEEDLES 32GX1/4" MISC 100/1ML/30G X 1/2" MISC EASY TOUCH PEN QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily) NEEDLES 32GX3/16" 1 RX/OTC SYRINGE/U- 1 MISC 100/0.3ML/30G X 1/2" EASY TOUCH PEN QL(5 ea daily); MISC NEEDLES 32GX5/32" 1 RX/OTC EASY TOUCH INSULIN QL(5 ea daily) MISC SYRINGE/U- 1 EASY TOUCH PEN QL(5 ea daily); 100/0.5ML/27G X 1/2" NEEDLES/31G X 3/16" 1 RX/OTC MISC MISC EASY TOUCH INSULIN QL(5 ea daily); EASY TOUCH SAFETY QL(5 ea daily) SYRINGE/U- 1 RX/OTC PEN NEEDLES/29G X 1 100/0.5ML/28G X 1/2" 8MM MISC MISC EASY TOUCH SAFETY QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily) PEN NEEDLES/30G X 1 RX/OTC SYRINGE/U- 1 5/16" MISC 100/0.5ML/30G X 1/2" MISC EASY TOUCH QL(5 ea daily); SHEATHLOCK SAFETY 1 RX/OTC EASY TOUCH INSULIN QL(5 ea daily) INSULIN SYRINGE SYRINGE/U- 1 1ML/29GX1/2" MISC 100/0.5ML/31G X 5/16" MISC EASY TOUCH QL(5 ea daily); SHEATHLOCK SAFETY 1 RX/OTC EASY TOUCH INSULIN QL(5 ea daily); INSULIN SYRINGE SYRINGE/U-100/1ML/27G 1 RX/OTC 1ML/30GX5/16" MISC X 1/2" MISC EASY TOUCH QL(5 ea daily) EASY TOUCH INSULIN QL(5 ea daily); SHEATHLOCK SAFETY 1 SYRINGE/U-100/1ML/28G 1 RX/OTC INSULIN SYRINGE X 1/2" MISC 1ML/31GX5/16" MISC EASY TOUCH INSULIN QL(5 ea daily); EASY TOUCH QL(5 ea daily) SYRINGE/U-100/1ML/29G 1 RX/OTC SHEATHLOCK SAFETY 1 X 1/2" MISC SYRINGE 1ML/30GX1/2" EASY TOUCH INSULIN QL(5 ea daily) MISC SYRINGE/U-100/1ML/30G 1 ELITE-THIN INSULIN QL(5 ea daily) X 1/2" MISC SYRINGE/0.3ML/31G X 1 EASY TOUCH INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/U-100/1ML/31G 1 ELITE-THIN INSULIN QL(5 ea daily); X 5/16" MISC SYRINGE/0.5ML/29G X 1 RX/OTC EASY TOUCH PEN QL(5 ea daily); 1/2" MISC NEEDLE 30G X 5/16" 1 RX/OTC ELITE-THIN INSULIN QL(5 ea daily); MISC SYRINGE/0.5ML/30G X 1 RX/OTC EASY TOUCH PEN 1 QL(5 ea daily); 5/16" MISC NEEDLES 29GX1/2" MISC RX/OTC ELITE-THIN INSULIN QL(5 ea daily); EASY TOUCH PEN 1 QL(5 ea daily) SYRINGE/1ML/30G X 1 RX/OTC NEEDLES 31GX1/4" MISC 5/16" MISC

Ambetter Sunshine Formulary Updated December 1, 2020

102 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ELITE-THIN INSULIN QL(5 ea daily); EXEL COMFORT POINT QL(5 ea daily) SYRINGE/U- 1 RX/OTC INSULIN PEN NEEDLES 1 100/0.5ML/28G X 1/2" 31G X 6MM MISC MISC EXEL COMFORT POINT QL(5 ea daily); ELITE-THIN INSULIN QL(5 ea daily) INSULIN PEN NEEDLES 1 RX/OTC SYRINGE/U- 1 31G X 8MM MISC 100/0.5ML/31G X 5/16" EXEL COMFORT POINT QL(5 ea daily); MISC INSULIN 1 RX/OTC ELITE-THIN INSULIN QL(5 ea daily); SYRINGE/0.3ML/29G X SYRINGE/U-100/1ML/28G 1 RX/OTC 1/2" MISC X 1/2" MISC EXEL COMFORT POINT QL(5 ea daily); ELITE-THIN INSULIN QL(5 ea daily); INSULIN 1 RX/OTC SYRINGE/U-100/1ML/29G 1 RX/OTC SYRINGE/0.3ML/30G X X 1/2" MISC 5/16" MISC ELITE-THIN INSULIN QL(5 ea daily) EXEL COMFORT POINT QL(5 ea daily); SYRINGE/U-100/1ML/31G 1 INSULIN 1 RX/OTC X 5/16" MISC SYRINGE/0.5ML/28G X EQL INSULIN QL(5 ea daily); 1/2" MISC SYRINGE/0.3ML/29G X 1 RX/OTC EXEL COMFORT POINT QL(5 ea daily); 1/2" MISC INSULIN 1 RX/OTC EQL INSULIN QL(5 ea daily); SYRINGE/0.5ML/29G X SYRINGE/0.3ML/30G X 1 RX/OTC 1/2" MISC 5/16" MISC EXEL COMFORT POINT QL(5 ea daily); EQL INSULIN QL(5 ea daily) INSULIN 1 RX/OTC SYRINGE/0.3ML/31G X 1 SYRINGE/0.5ML/30G X 5/16" MISC 5/16" MISC EQL INSULIN QL(5 ea daily); EXEL COMFORT POINT QL(5 ea daily); SYRINGE/0.5ML/29G X 1 RX/OTC INSULIN 1 RX/OTC 1/2" MISC SYRINGE/1ML/28G X 1/2" MISC EQL INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X 1 RX/OTC EXEL COMFORT POINT QL(5 ea daily); 5/16" MISC INSULIN 1 RX/OTC SYRINGE/1ML/29G X 1/2" EQL INSULIN QL(5 ea daily) MISC SYRINGE/0.5ML/31G X 1 5/16" MISC EXEL COMFORT POINT QL(5 ea daily); INSULIN 1 RX/OTC EQL INSULIN QL(5 ea daily); SYRINGE/1ML/30G X SYRINGE/1ML/29G X 1/2" 1 RX/OTC 5/16" MISC MISC FIFTY50 PEN NEEDLES 1 QL(5 ea daily); EQL INSULIN QL(5 ea daily); 31G X3/16" (5MM) MISC RX/OTC SYRINGE/1ML/30G X 1 RX/OTC 5/16" MISC FIFTY50 PEN NEEDLES 1 QL(5 ea daily); 31G X5/16" (8MM) MISC RX/OTC EQL INSULIN QL(5 ea daily) SYRINGE/1ML/31G X 1 FIFTY50 PEN NEEDLES 1 QL(5 ea daily); 5/16" MISC 31GX5MM MISC RX/OTC EXEL COMFORT POINT QL(5 ea daily); FIFTY50 PEN QL(5 ea daily); INSULIN PEN NEEDLES 1 RX/OTC NEEDLES/31GX8MM 1 RX/OTC 29G X 12MM MISC MISC

Ambetter Sunshine Formulary Updated December 1, 2020

103 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FIFTY50 PEN QL(5 ea daily); GLOBAL EASE INJECT QL(5 ea daily); NEEDLES/32GX4MM 1 RX/OTC PEN NEEDLES 31GX8MM 1 RX/OTC MISC MISC FIFTY50 PEN QL(5 ea daily) GLOBAL EASE INJECT QL(5 ea daily); NEEDLES/32GX6MM 1 PEN NEEDLES 32GX4MM 1 RX/OTC MISC MISC FIFTY50 SUPERIOR QL(5 ea daily) GLOBAL EASE INJECT QL(5 ea daily); COMFORTINSULIN 1 PEN NEEEDLES 1 RX/OTC SYRINGE/0.3ML/31G X 31GX5MM MISC 5/16" MISC GLOBAL EASY GLIDE QL(5 ea daily) FIFTY50 SUPERIOR QL(5 ea daily) INSULIN 1 COMFORTINSULIN 1 SYRINGE/1ML/31G X SYRINGE/0.5ML/31G X 15/64" MISC 5/16" MISC GLOBAL EASY GLIDE QL(5 ea daily) FIFTY50 SUPERIOR QL(5 ea daily) INSULINSYRINGE/U- 1 COMFORTINSULIN 1 100/0.3ML/31G X 5/16" SYRINGE/1ML/31G X MISC 5/16" MISC GLOBAL EASY GLIDE QL(5 ea daily); FREDS PHARMACY QL(5 ea daily); PEN NEEDLES 32GX4MM 1 RX/OTC UNIFINE PENTIPS PEN 1 RX/OTC MISC NEEDLES 32GX4MM GLOBAL INJECT EASE QL(5 ea daily); MISC INSULIN SYRINGE/U- 1 RX/OTC FREDS PHARMACY QL(5 ea daily); 100/0.3ML/29G X 1/2" UNIFINE PENTIPS PLUS 1 RX/OTC MISC 31GX5MM MISC GLOBAL INJECT EASE QL(5 ea daily) FREDS PHARMACY QL(5 ea daily); INSULIN SYRINGE/U- 1 UNIFINE PENTIPS PLUS 1 RX/OTC 100/0.3ML/30G X 1/2" 31GX8MM MISC MISC FREESTYLE PRECISION QL(5 ea daily); GLOBAL INJECT EASE QL(5 ea daily); INSULIN SYRINGE/U- 1 RX/OTC INSULIN SYRINGE/U- 1 RX/OTC 100/0.5ML/30G X 5/16" 100/0.3ML/30G X 5/16" MISC MISC FREESTYLE PRECISION QL(5 ea daily) GLOBAL INJECT EASE QL(5 ea daily) INSULIN SYRINGE/U- 1 INSULIN SYRINGE/U- 1 100/0.5ML/31G X 5/16" 100/0.3ML/31G X 5/16" MISC MISC FREESTYLE PRECISION QL(5 ea daily) GLOBAL INJECT EASE QL(5 ea daily); INSULIN SYRINGE/U- 1 INSULIN SYRINGE/U- 1 RX/OTC 100/1ML/31G X 5/16" 100/0.5ML/28G X 1/2" MISC MISC FREESTYLE PRECISION QL(5 ea daily); GLOBAL INJECT EASE QL(5 ea daily); INSULIN SYRINGES/U- 1 RX/OTC INSULIN SYRINGE/U- 1 RX/OTC 100/1ML/30G X 5/16" 100/0.5ML/29G X 1/2" MISC MISC GLOBAL EASE INJECT QL(5 ea daily); GLOBAL INJECT EASE QL(5 ea daily) 1 PEN NEEDLES RX/OTC INSULIN SYRINGE/U- 1 29GX12MM MISC 100/0.5ML/30G X 1/2" MISC

Ambetter Sunshine Formulary Updated December 1, 2020

104 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLOBAL INJECT EASE QL(5 ea daily); GLUCOPRO INSULIN QL(5 ea daily) INSULIN SYRINGE/U- 1 RX/OTC SYRINGE/U- 1 100/0.5ML/30G X 5/16" 100/0.5ML/30G X 1/2" MISC MISC GLOBAL INJECT EASE QL(5 ea daily) GLUCOPRO INSULIN QL(5 ea daily); INSULIN SYRINGE/U- 1 SYRINGE/U- 1 RX/OTC 100/0.5ML/31G X 5/16" 100/0.5ML/30G X 5/16" MISC MISC GLOBAL INJECT EASE QL(5 ea daily); GLUCOPRO INSULIN QL(5 ea daily) 1 INSULIN SYRINGE/U- RX/OTC SYRINGE/U- 1 100/1ML/28G X 1/2" MISC 100/0.5ML/31G X 5/16" GLOBAL INJECT EASE QL(5 ea daily); MISC INSULIN SYRINGE/U- 1 RX/OTC GLUCOPRO INSULIN QL(5 ea daily) 100/1ML/29G X 1/2" MISC SYRINGE/U-100/1ML/30G 1 GLOBAL INJECT EASE QL(5 ea daily) X 1/2" MISC INSULIN SYRINGE/U- 1 GLUCOPRO INSULIN QL(5 ea daily); 100/1ML/30G X 1/2" MISC SYRINGE/U-100/1ML/30G 1 RX/OTC GLOBAL INJECT EASE QL(5 ea daily); X 5/16" MISC INSULIN SYRINGE/U- 1 RX/OTC GLUCOPRO INSULIN QL(5 ea daily) 100/1ML/30G X 5/16" SYRINGE/U-100/1ML/31G 1 MISC X 5/16" MISC GLOBAL INJECT EASE QL(5 ea daily) GNP CLICKFINE PEN QL(5 ea daily); INSULIN SYRINGE/U- 1 NEEDLEUNIVERSAL/31G 1 RX/OTC 100/1ML/31G X 5/16" X5/16" MISC MISC GNP CLICKFINE QL(5 ea daily) GLOBAL INSULIN QL(5 ea daily) UNIVERSAL PEN 1 SYRINGE/U- 1 NEEDLES 31GX1/4" MISC 100/0.3ML/30G X 1/2" GNP CLICKFINE QL(5 ea daily); MISC UNIVERSAL PEN 1 RX/OTC GLOBAL INSULIN QL(5 ea daily); NEEDLES 31GX5/16" SYRINGES/U- 1 RX/OTC MISC 100/0.3ML/30GX5/16" GNP INSULIN QL(5 ea daily); MISC SYRINGE/0.3ML/29G X 1 RX/OTC GLUCOPRO INSULIN QL(5 ea daily) 1/2" MISC SYRINGE/U- 1 GNP INSULIN QL(5 ea daily); 100/0.3ML/30G X 1/2" SYRINGE/0.3ML/30G X 1 RX/OTC MISC 5/16" MISC GLUCOPRO INSULIN QL(5 ea daily); GNP INSULIN QL(5 ea daily) SYRINGE/U- 1 RX/OTC SYRINGE/0.3ML/31G X 1 100/0.3ML/30G X 5/16" 5/16" MISC MISC GNP INSULIN QL(5 ea daily); GLUCOPRO INSULIN QL(5 ea daily) SYRINGE/0.5ML/28G X 1 RX/OTC SYRINGE/U- 1 1/2" MISC 100/0.3ML/31G X 5/16" MISC GNP INSULIN QL(5 ea daily); SYRINGE/0.5ML/29G X 1 RX/OTC 1/2" MISC

Ambetter Sunshine Formulary Updated December 1, 2020

105 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GNP INSULIN QL(5 ea daily); GNP ULTRA COMFORT QL(5 ea daily); 1 SYRINGE/0.5ML/30G X RX/OTC INSULIN 1 RX/OTC 5/16" MISC SYRINGE/0.5ML/30G X GNP INSULIN QL(5 ea daily) 5/16" SHORT MISC SYRINGE/0.5ML/31G X 1 GNP ULTRA COMFORT QL(5 ea daily) 5/16" MISC INSULIN 1 GNP INSULIN QL(5 ea daily); SYRINGE/0.5ML/31G X SYRINGE/1ML/28G X 1/2" 1 RX/OTC 5/16" SHORT MISC MISC GNP ULTRA COMFORT QL(5 ea daily); GNP INSULIN QL(5 ea daily); INSULIN 1 RX/OTC SYRINGE/1ML/29G X 1/2" 1 RX/OTC SYRINGE/1ML/28G X 1/2" MISC MISC GNP INSULIN QL(5 ea daily); GNP ULTRA COMFORT QL(5 ea daily); SYRINGE/1ML/30G X 1 RX/OTC INSULIN 1 RX/OTC 5/16" MISC SYRINGE/1ML/29G X 1/2" MISC GNP INSULIN QL(5 ea daily) SYRINGE/1ML/31G X 1 GNP ULTRA COMFORT QL(5 ea daily); 5/16" MISC INSULIN 1 RX/OTC SYRINGE/1ML/30G X GNP ULTICARE PEN QL(5 ea daily); 5/16" SHORT MISC NEEDLES/31GX5/16" 1 RX/OTC MISC GNP ULTRA COMFORT QL(5 ea daily) INSULIN 1 GNP ULTICARE PEN QL(5 ea daily); SYRINGE/1ML/31G X NEEDLES/32GX 5/32" 1 RX/OTC 5/16" SHORT MISC MISC GOODSENSE CLICKFINE QL(5 ea daily); GNP ULTICARE PEN QL(5 ea daily) 1 SAFETY PEN 1 RX/OTC NEEDLES/32GX1/4" MISC NEEDLE/31G X 3/16" GNP ULTRA COMFORT QL(5 ea daily); MISC INSULIN 1 RX/OTC GOODSENSE PEN QL(5 ea daily); SYRINGE/0.3ML/29G X NEEDLE/PENFINE 1 RX/OTC 1/2" MISC CLASSIC/31G X 3/16" GNP ULTRA COMFORT QL(5 ea daily); MISC INSULIN 1 RX/OTC GOODSENSE PEN QL(5 ea daily); SYRINGE/0.3ML/30G X NEEDLE/PENFINE 1 RX/OTC 5/16" SHORT MISC CLASSIC/31G X 5/16" GNP ULTRA COMFORT QL(5 ea daily) MISC INSULIN 1 GOODSENSE PEN QL(5 ea daily) SYRINGE/0.3ML/31G X NEEDLE/PENFINE 1 5/16" SHORT MISC CLASSIC/32G X 1/4" MISC GNP ULTRA COMFORT QL(5 ea daily); GOODSENSE PEN QL(5 ea daily); INSULIN RX/OTC 1 NEEDLE/PENFINE 1 RX/OTC SYRINGE/0.5ML/28G X CLASSIC/32G X 5/32" 1/2" MISC MISC GNP ULTRA COMFORT QL(5 ea daily); H-E-B IN CONTROL PEN QL(5 ea daily); INSULIN 1 RX/OTC NEEDLES 31GX5MM 1 RX/OTC SYRINGE/0.5ML/29G X MISC 1/2" MISC

Ambetter Sunshine Formulary Updated December 1, 2020

106 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits H-E-B IN CONTROL PEN QL(5 ea daily) HEALTHWISE PEN QL(5 ea daily); NEEDLES 31GX6MM 1 NEEDLES 29GX12MM 1 RX/OTC MISC MISC H-E-B IN CONTROL PEN QL(5 ea daily); HEALTHWISE SHORT QL(5 ea daily); NEEDLES 31GX8MM 1 RX/OTC PEN NEEDLES 31GX8MM 1 RX/OTC MISC MISC H-E-B IN CONTROL PEN QL(5 ea daily); HEALTHWISE SHORT QL(5 ea daily); NEEDLES/NANO/32GX4M 1 RX/OTC PEN NEEDLES/31G X 1 RX/OTC M MISC 3/16" MISC H-E-B IN CONTROL QL(5 ea daily); HEALTHWISE SHORT QL(5 ea daily); UNIFINEPENTIPS PLUS 1 RX/OTC PEN NEEDLES/31G X 1 RX/OTC 31GX5MM MISC 5/16" MISC H-E-B IN CONTROL QL(5 ea daily); HEALTHWISE UNIFINE QL(5 ea daily); UNIFINEPENTIPS PLUS 1 RX/OTC PENTIPS PEN NEEDLES 1 RX/OTC 32GX4MM MISC 32GX4MM MISC H-E-B INCONTROL PEN QL(5 ea daily); HEALTHY ACCENTS QL(5 ea daily); 1 NEEDLES 29GX12MM RX/OTC UNIFINE PENTIPS PEN 1 RX/OTC MISC NEEDLES 29GX12MM HEALTHWISE INSULIN QL(5 ea daily); MISC SYRINGE/U- 1 RX/OTC HEALTHY ACCENTS QL(5 ea daily); 100/0.3ML/30G X 5/16" UNIFINE PENTIPS PEN 1 RX/OTC MISC NEEDLES 31GX5MM HEALTHWISE INSULIN QL(5 ea daily) MISC SYRINGE/U- 1 HEALTHY ACCENTS QL(5 ea daily) 100/0.3ML/31G X 5/16" UNIFINE PENTIPS PEN 1 MISC NEEDLES 31GX6MM HEALTHWISE INSULIN QL(5 ea daily); MISC SYRINGE/U- 1 RX/OTC HEALTHY ACCENTS QL(5 ea daily); 100/0.5ML/30G X 5/16" UNIFINE PENTIPS PEN 1 RX/OTC MISC NEEDLES 31GX8MM HEALTHWISE INSULIN QL(5 ea daily) MISC SYRINGE/U- 1 HEALTHY ACCENTS QL(5 ea daily); 100/0.5ML/31G X 5/16" UNIFINE PENTIPS PEN 1 RX/OTC MISC NEEDLES 32GX4MM HEALTHWISE INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/30G 1 RX/OTC HM ULTICARE INSULIN QL(5 ea daily) X 5/16" MISC SYRINGE/1ML/30G X 1/2" 1 HEALTHWISE INSULIN QL(5 ea daily) MISC SYRINGE/U-100/1ML/31G 1 HM ULTICARE INSULIN QL(5 ea daily) X 5/16" MISC SYRINGE/U- 1 HEALTHWISE MICRON QL(5 ea daily); 100/0.3ML/31G X 5/16" PEN NEEDLES/32G X 1 RX/OTC MISC 5/32" MISC HM ULTICARE SHORT QL(5 ea daily); HEALTHWISE MINI PEN QL(5 ea daily) PEN NEEDLES 31GX8MM 1 RX/OTC NEEDLES 31GX6MM 1 MISC MISC INSULIN QL(5 ea daily) SYRINGE/0.3ML/29G X 1" 1 MISC

Ambetter Sunshine Formulary Updated December 1, 2020

107 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INSULIN QL(5 ea daily); INSULIN QL(5 ea daily); SYRINGE/0.3ML/29G X 1 RX/OTC SYRINGE/NEEDLE 1 RX/OTC 1/2" MISC 1ML/29G X 1/2" MISC INSULIN QL(5 ea daily); INSULIN QL(5 ea daily); SYRINGE/0.3ML/30G X 1 RX/OTC SYRINGE/NEEDLE 1 RX/OTC 5/16" MISC 1ML/30G X 5/16" MISC INSULIN QL(5 ea daily) INSULIN QL(5 ea daily) SYRINGE/0.3ML/31G X 1 SYRINGE/NEEDLE 1 5/16" MISC 1ML/31G X 5/16" MISC INSULIN QL(5 ea daily) INSULIN SYRINGE/U- QL(5 ea daily); SYRINGE/0.5ML/27G X 1 100/0.3ML/29G X 1/2" 1 RX/OTC 1/2" MISC MISC INSULIN QL(5 ea daily); INSULIN SYRINGE/U- QL(5 ea daily); SYRINGE/0.5ML/28G X 1 RX/OTC 100/0.5ML/29G X 1/2" 1 RX/OTC 1/2" MISC MISC INSULIN QL(5 ea daily) INSULIN SYRINGE/U- 1 QL(5 ea daily); SYRINGE/0.5ML/30G X 1 100/1ML/29G X 1/2" MISC RX/OTC 1/2" MISC INSULIN SYRINGE/U- QL(5 ea daily) INSULIN QL(5 ea daily); 100/1ML/30G X 5/16" 1 SYRINGE/0.5ML/30G X 1 RX/OTC MISC 5/16" MISC INSULIN SYRINGE/U- QL(5 ea daily); INSULIN QL(5 ea daily) 100/1ML/30G X 5/16" 1 RX/OTC SYRINGE/0.5ML/31G X 1 MISC 5/16" MISC INSULIN SYRINGE/U- QL(5 ea daily) INSULIN QL(5 ea daily); 100/1ML/31G X 5/16" 1 SYRINGE/1ML/28G X 1/2" 1 RX/OTC MISC MISC INSULIN QL(5 ea daily) INSULIN QL(5 ea daily); SYRINGES/0.5ML/27GX1/ 1 SYRINGE/1ML/29G X 1/2" 1 RX/OTC 2" MISC MISC INSULIN QL(5 ea daily); INSULIN QL(5 ea daily); SYRINGES/0.5ML/28GX1/ 1 RX/OTC SYRINGE/1ML/30G X 1 RX/OTC 2" MISC 5/16" MISC INSULIN QL(5 ea daily); INSULIN QL(5 ea daily); SYRINGES/0.5ML/29GX1/ 1 RX/OTC SYRINGE/NEEDLE 1 RX/OTC 2" MISC 0.3ML/30G X 5/16" MISC INSULIN QL(5 ea daily); INSULIN QL(5 ea daily) SYRINGES/0.5ML/30GX5/ 1 RX/OTC SYRINGE/NEEDLE 1 16" MISC 0.3ML/31G X 5/16" MISC INSULIN QL(5 ea daily) INSULIN QL(5 ea daily); SYRINGES/0.5ML/31GX 1 SYRINGE/NEEDLE 1 RX/OTC 5/16" MISC 0.5ML/29G X 1/2" MISC INSULIN QL(5 ea daily) INSULIN QL(5 ea daily); SYRINGES/0.5ML/31GX5/ 1 SYRINGE/NEEDLE 1 RX/OTC 16" MISC 0.5ML/30G X 5/16" MISC INSULIN QL(5 ea daily); INSULIN QL(5 ea daily) SYRINGES/1ML/27GX/1/2" 1 RX/OTC SYRINGE/NEEDLE 1 MISC 0.5ML/31G X 5/16" MISC Ambetter Sunshine Formulary Updated December 1, 2020

108 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INSULIN QL(5 ea daily); KINRAY INSULIN QL(5 ea daily); SYRINGES/1ML/27GX1/2" 1 RX/OTC SYRINGE/0.5ML/29G X 1 RX/OTC MISC 1/2" MISC INSULIN QL(5 ea daily); KMART VALU PLUS QL(5 ea daily); SYRINGES/1ML/28GX1/2" 1 RX/OTC INSULIN 1 RX/OTC MISC SYRINGE/1ML/29G MISC INSULIN QL(5 ea daily); KMART VALU PLUS QL(5 ea daily); SYRINGES/1ML/29GX1/2" 1 RX/OTC INSULIN 1 RX/OTC MISC SYRINGE/1ML/30G MISC INSULIN QL(5 ea daily) KROGER INSULIN QL(5 ea daily); SYRINGES/1ML/30GX1/2" 1 SYRINGE/0.3ML/29G X 1 RX/OTC MISC 1/2" MISC INSULIN QL(5 ea daily) KROGER INSULIN QL(5 ea daily); SYRINGES/1ML/31GX5/16 1 SYRINGE/0.3ML/30G X 1 RX/OTC " MISC 5/16" MISC INSUPEN 29G X 12MM 1 QL(5 ea daily); KROGER INSULIN QL(5 ea daily) MISC RX/OTC SYRINGE/0.3ML/31G X 1 5/16" MISC INSUPEN 31G X 5MM 1 QL(5 ea daily); MISC RX/OTC KROGER INSULIN QL(5 ea daily); SYRINGE/0.5ML/29G X 1 RX/OTC INSUPEN 31G X 8MM 1 QL(5 ea daily); MISC RX/OTC 1/2" MISC KROGER INSULIN QL(5 ea daily); INSUPEN 32G X 4MM 1 QL(5 ea daily); MISC RX/OTC SYRINGE/0.5ML/30G X 1 RX/OTC 5/16" MISC INSUPEN PEN NEEDLES 1 QL(5 ea daily); 32G X4MM MISC RX/OTC KROGER INSULIN QL(5 ea daily) SYRINGE/0.5ML/31G X 1 INSUPEN SENSITIVE 1 QL(5 ea daily) 5/16" MISC 32GX6MM MISC KROGER INSULIN QL(5 ea daily); INSUPEN ULTRAFIN 1 QL(5 ea daily); SYRINGE/1ML/29G X 1/2" 1 RX/OTC 29GX12MM MISC RX/OTC MISC INSUPEN ULTRAFIN 1 QL(5 ea daily); KROGER INSULIN QL(5 ea daily); 30GX8MM MISC RX/OTC SYRINGE/1ML/30G X 1 RX/OTC INSUPEN ULTRAFIN 1 QL(5 ea daily) 5/16" MISC 31GX6MM MISC KROGER INSULIN QL(5 ea daily) INSUPEN ULTRAFIN 1 QL(5 ea daily); SYRINGE/1ML/31G X 1 31GX8MM MISC RX/OTC 5/16" MISC KINRAY INSULIN QL(5 ea daily) KROGER PEN NEEDLES 1 QL(5 ea daily); SYRINGE PREFERRED 1 29G X12MM MISC RX/OTC PLUS/0.3ML/31G X 5/16" KROGER PEN NEEDLES 1 QL(5 ea daily); MISC 31G X8MM MISC RX/OTC KINRAY INSULIN QL(5 ea daily) KROGER PEN NEEDLES 1 QL(5 ea daily) SYRINGE PREFERRED 1 31GX1/4" MISC PLUS/0.5ML/31G X 5/16" MISC KROGER PEN 1 QL(5 ea daily) NEEDLES/31G X1/4" MISC KINRAY INSULIN QL(5 ea daily) KROGER PEN QL(5 ea daily); SYRINGE PREFERRED 1 PLUS/1ML/31G X 5/16" NEEDLES/31G X3/16" 1 RX/OTC MISC MISC

Ambetter Sunshine Formulary Updated December 1, 2020

109 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KROGER PEN QL(5 ea daily); LEADER UNIFINE QL(5 ea daily); NEEDLES/31G X5/16" 1 RX/OTC PENTIPS/MINI/31GX3/16" 1 RX/OTC MISC MISC KROGER PEN QL(5 ea daily); LEADER UNIFINE QL(5 ea daily); NEEDLES/32G X5/32" 1 RX/OTC PENTIPS/NANO/32GX5/32 1 RX/OTC MISC " MISC LEADER INSULIN QL(5 ea daily); LEADER UNIFINE QL(5 ea daily); SYRINGE/0.3ML/29G X 1 RX/OTC PENTIPS/PLUS/32GX5/32" 1 RX/OTC 1/2" MISC MISC LEADER INSULIN QL(5 ea daily); LITETOUCH INSULIN PEN QL(5 ea daily); SYRINGE/0.3ML/30G X 1 RX/OTC NEEDLES/32G X 1 RX/OTC 5/16" MISC 4MM/MINI MISC LEADER INSULIN QL(5 ea daily) LITETOUCH INSULIN QL(5 ea daily); SYRINGE/0.3ML/31G X 1 SYRINGE/0.3ML/29G X 1 RX/OTC 5/16" MISC 1/2" MISC LEADER INSULIN QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily); SYRINGE/0.5ML/28G X 1 RX/OTC SYRINGE/0.3ML/30G X 1 RX/OTC 1/2" MISC 5/16" MISC LEADER INSULIN QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily) SYRINGE/0.5ML/29G X 1 RX/OTC SYRINGE/0.3ML/31G X 1 1/2" MISC 5/16" MISC LEADER INSULIN QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X 1 RX/OTC SYRINGE/0.5ML/30G X 1 RX/OTC 5/16" MISC 5/16" MISC LEADER INSULIN QL(5 ea daily) LITETOUCH INSULIN QL(5 ea daily) SYRINGE/0.5ML/31G X 1 SYRINGE/0.5ML/31G X 1 5/16" MISC 5/16" MISC LEADER INSULIN QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily); SYRINGE/1ML/28G X 1/2" 1 RX/OTC SYRINGE/1ML/30G X 1 RX/OTC MISC 5/16" MISC LEADER INSULIN QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily); SYRINGE/1ML/29G X 1/2" 1 RX/OTC SYRINGE/U- 1 RX/OTC MISC 100/0.3ML/30G X 5/16" LEADER INSULIN QL(5 ea daily); MISC SYRINGE/1ML/30G X 1 RX/OTC LITETOUCH INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/U- 1 LEADER INSULIN QL(5 ea daily) 100/0.3ML/31G X 5/16" SYRINGE/1ML/31G X 1 MISC 5/16" MISC LITETOUCH INSULIN QL(5 ea daily); LEADER UNIFINE QL(5 ea daily); SYRINGE/U- 1 RX/OTC 100/0.5ML/28G X 1/2" PENTIPS 1 RX/OTC PLUS/MINI/31GX3/16" MISC MISC LITETOUCH INSULIN QL(5 ea daily); LEADER UNIFINE QL(5 ea daily); SYRINGE/U- 1 RX/OTC 100/0.5ML/29G X 1/2" PENTIPS 1 RX/OTC PLUS/SHORT/31GX5/16" MISC MISC

Ambetter Sunshine Formulary Updated December 1, 2020

110 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LITETOUCH INSULIN QL(5 ea daily); MAGELLAN INSULIN QL(5 ea daily); SYRINGE/U- 1 RX/OTC SAFETY SYRINGE/U- 1 RX/OTC 100/0.5ML/30G X 5/16" 100/0.3ML/29G X 1/2" MISC MISC LITETOUCH INSULIN QL(5 ea daily) MAGELLAN INSULIN QL(5 ea daily); SYRINGE/U- 1 SAFETY SYRINGE/U- 1 RX/OTC 100/0.5ML/31G X 5/16" 100/0.3ML/30G X 5/16" MISC MISC LITETOUCH INSULIN QL(5 ea daily); MAGELLAN INSULIN QL(5 ea daily); 1 SYRINGE/U-100/1ML/28G RX/OTC SAFETY SYRINGE/U- 1 RX/OTC X 1/2" MISC 100/0.5ML/29G X 1/2" LITETOUCH INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/29G 1 RX/OTC MAGELLAN INSULIN QL(5 ea daily); X 1/2" MISC SAFETY SYRINGE/U- 1 RX/OTC LITETOUCH INSULIN QL(5 ea daily); 100/0.5ML/30G X 5/16" SYRINGE/U-100/1ML/30G 1 RX/OTC MISC X 5/16" MISC MAGELLAN INSULIN QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily) SAFETY SYRINGE/U- 1 RX/OTC SYRINGE/U-100/1ML/31G 1 100/1ML/29G X 1/2" MISC X 5/16" MISC MAGELLAN INSULIN QL(5 ea daily); LITETOUCH PEN QL(5 ea daily) SAFETY SYRINGE/U- 1 RX/OTC NEEDLES 29GX12.7MM 1 100/1ML/30G X 5/16" MISC MISC LITETOUCH PEN QL(5 ea daily) MARATHON MEDICAL QL(5 ea daily); NEEDLES 31G X 6MM 1 PENTIPS29GX12MM 1 RX/OTC MISC MISC LITETOUCH PEN QL(5 ea daily) MARATHON MEDICAL 1 QL(5 ea daily); PENTIPS31GX5MM MISC RX/OTC NEEDLES 31G X 1 6MM/ULTRA SHORT MARATHON MEDICAL 1 QL(5 ea daily); MISC PENTIPS31GX8MM MISC RX/OTC LITETOUCH PEN QL(5 ea daily); MARATHON MEDICAL 1 QL(5 ea daily); NEEDLES 31GX8MM 1 RX/OTC PENTIPS32GX4MM MISC RX/OTC SHORT MISC MAXI-COMFORT INSULIN QL(5 ea daily); LITETOUCH PEN QL(5 ea daily); SYRINGE/U- 1 RX/OTC NEEDLES/31G X 3/16" 1 RX/OTC 100/0.5ML/28GX1/2" MISC MISC MAXI-COMFORT INSULIN QL(5 ea daily); LITETOUCH PEN QL(5 ea daily); SYRINGE/U- 1 RX/OTC NEEDLES/31G X 1 RX/OTC 100/1ML/28GX1/2" MISC 5MM/MINI MISC MAXI-COMFORT SAFETY QL(5 ea daily) LITETOUCH PEN QL(5 ea daily); PEN NEEDLE/29G X 5/16" 1 NEEDLES/31G X 1 RX/OTC MISC 8MM/SHORT MISC MAXICOMFORT II PEN QL(5 ea daily) LONGS INSULIN QL(5 ea daily) NEEDLES/31G X 1/4" 1 SYRINGE/0.5ML/31G X 1 MISC 5/16" MISC MAXICOMFORT INSULIN QL(5 ea daily) SYRINGES 27G X 1/2" 1 MISC

Ambetter Sunshine Formulary Updated December 1, 2020

111 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MAXICOMFORT INSULIN QL(5 ea daily); MM INSULIN SYRINGE/U- QL(5 ea daily) SYRINGES 27G X 1/2" 1 RX/OTC 100/1ML/31G X 5/16" 1 MISC MISC MEDIC INSULIN QL(5 ea daily); MM PEN NEEDLES 31G X 1 QL(5 ea daily) SYRINGE/0.3ML/30G X 1 RX/OTC 1/4" MISC 5/16" MISC MM PEN NEEDLES 31G X 1 QL(5 ea daily); MEDIC INSULIN QL(5 ea daily); 3/16" MISC RX/OTC SYRINGE/0.5ML/30G X 1 RX/OTC MM PEN NEEDLES 31G X 1 QL(5 ea daily); 5/16" MISC 5/16" MISC RX/OTC MEDICINE SHOPPE PEN QL(5 ea daily); MM PEN NEEDLES 32G X 1 QL(5 ea daily); NEEDLES 29G X 12MM 1 RX/OTC 5/32" MISC RX/OTC MISC MONOJECT INSULIN 1 QL(5 ea daily); MEDICINE SHOPPE PEN QL(5 ea daily) SYRINGE/1ML MISC RX/OTC NEEDLES 31G X 6MM 1 MISC MONOJECT INSULIN QL(5 ea daily) SYRINGE/1ML/31G X 1 MEDICINE SHOPPE PEN QL(5 ea daily); 5/16" MISC NEEDLES 31G X 8MM 1 RX/OTC MISC MONOJECT INSULIN QL(5 ea daily) SYRINGE/DETACH 1 MEIJER PEN NEEDLES 1 QL(5 ea daily); NEEDLE/1ML/25G X 5/8" 29G X12MM MISC RX/OTC MISC MEIJER PEN NEEDLES 1 QL(5 ea daily) MONOJECT INSULIN QL(5 ea daily); 31G X6MM MISC SYRINGE/DETACH 1 RX/OTC MEIJER PEN NEEDLES 1 QL(5 ea daily); NEEDLE/1ML/27G X 1/2" 31G X8MM MISC RX/OTC MISC MICRODOT PEN QL(5 ea daily) MONOJECT INSULIN QL(5 ea daily); 1 NEEDLE/31G X 6 MM SYRINGE/PERM 1 RX/OTC MISC NEEDLE/1ML/28G X 1/2" MICRODOT PEN QL(5 ea daily); MISC NEEDLE/32G X 4 MM 1 RX/OTC MONOJECT INSULIN QL(5 ea daily); MISC SYRINGE/PERM 1 RX/OTC MM INSULIN SYRINGE/U- QL(5 ea daily); NEEDLE/U-100/0.5ML/28G 100/0.3ML/30G X 5/16" 1 RX/OTC X 1/2" MISC MISC MONOJECT INSULIN QL(5 ea daily); MM INSULIN SYRINGE/U- QL(5 ea daily) SYRINGE/SAFETY/PERM 1 RX/OTC 100/0.3ML/31G X 5/16" 1 NEEDLE/0.3ML/29G X 1/2" MISC MISC MM INSULIN SYRINGE/U- QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily); 100/1/2ML/30G X 5/16" 1 RX/OTC SYRINGE/SAFETY/PERM 1 RX/OTC MISC NEEDLE/0.3ML/29GX1/2" MISC MM INSULIN SYRINGE/U- QL(5 ea daily) 100/1/2ML/31G X 5/16" 1 MONOJECT INSULIN QL(5 ea daily); MISC SYRINGE/SAFETY/PERM 1 RX/OTC NEEDLE/0.5ML/29G X 1/2" MM INSULIN SYRINGE/U- QL(5 ea daily); MISC 100/1ML/30G X 5/16" 1 RX/OTC MISC MONOJECT INSULIN QL(5 ea daily); SYRINGE/SAFETY/PERM 1 RX/OTC NEEDLE/1ML/29G X 1/2" MISC

Ambetter Sunshine Formulary Updated December 1, 2020

112 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MONOJECT INSULIN QL(5 ea daily); MONOJECT ULTRA QL(5 ea daily) 1 SYRINGE/SOFTPACK/1M RX/OTC COMFORT INSULIN 1 L/27G X 1/2" MISC SYRINGE/0.5ML/31G X MONOJECT INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/SOFTPACK/U- 1 RX/OTC MONOJECT ULTRA QL(5 ea daily); 100/0.5ML/28G X 1/2" COMFORT INSULIN 1 RX/OTC MISC SYRINGE/1ML/28G X 1/2" MONOJECT INSULIN QL(5 ea daily); MISC SYRINGE/U- 1 RX/OTC MONOJECT ULTRA QL(5 ea daily); 100/0.3ML/30G X 5/16" COMFORT INSULIN 1 RX/OTC MISC SYRINGE/1ML/29G X 1/2" MONOJECT INSULIN QL(5 ea daily); MISC SYRINGE/U- 1 RX/OTC MS INSULIN QL(5 ea daily) 100/0.5ML/30G X 5/16" SYRINGE/0.3ML/31G X 1 MISC 5/16" MISC MONOJECT INSULIN QL(5 ea daily); MS INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/28G 1 RX/OTC SYRINGE/0.5ML/31G X 1 X 1/2" MISC 5/16" MISC MONOJECT INSULIN QL(5 ea daily); MS INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/30G 1 RX/OTC SYRINGE/1ML/31G X 1 X 5/16" MISC 5/16" MISC MONOJECT INSULIN QL(5 ea daily); NOVOFINE 32GX6MM 1 QL(5 ea daily) SYRINGEREGULAR LUER 1 RX/OTC MISC TIP/SOFTPACK/1ML MISC NOVOFINE AUTOCOVER 1 QL(5 ea daily); MONOJECT ULTRA QL(5 ea daily); 30GX8MM MISC RX/OTC COMFORT INSULIN RX/OTC 1 NOVOFINE PLUS 1 QL(5 ea daily); SYRINGE/0.3ML/29G X 32GX4MM MISC RX/OTC 1/2" MISC NOVOTWIST 32GX5MM 1 QL(5 ea daily); MONOJECT ULTRA QL(5 ea daily); MISC RX/OTC COMFORT INSULIN 1 RX/OTC SYRINGE/0.3ML/30G X PC UNIFINE PENTIPS 1 QL(5 ea daily); 5/16" MISC 29G X1/2" MISC RX/OTC MONOJECT ULTRA QL(5 ea daily) PC UNIFINE PENTIPS 1 QL(5 ea daily); 31G X5MM MINI MISC RX/OTC COMFORT INSULIN 1 SYRINGE/0.3ML/31G X PC UNIFINE PENTIPS QL(5 ea daily) 5/16" MISC 31G X6MM ULTRA 1 MONOJECT ULTRA QL(5 ea daily); SHORT MISC PC UNIFINE PENTIPS QL(5 ea daily); COMFORT INSULIN 1 RX/OTC 1 SYRINGE/0.5ML/28G X 31G X8MM SHORT MISC RX/OTC 1/2" MISC PEN NEEDLES 29G X 1 QL(5 ea daily); MONOJECT ULTRA QL(5 ea daily); 12MM MISC RX/OTC COMFORT INSULIN RX/OTC 1 PEN NEEDLES 29GX1/2" 1 QL(5 ea daily); SYRINGE/0.5ML/29G X MISC RX/OTC 1/2" MISC PEN NEEDLES 1 QL(5 ea daily); MONOJECT ULTRA QL(5 ea daily); 29GX12MM MISC RX/OTC COMFORT INSULIN RX/OTC 1 PEN NEEDLES 30GX5/16" 1 QL(5 ea daily); SYRINGE/0.5ML/30G X MISC RX/OTC 5/16" MISC

Ambetter Sunshine Formulary Updated December 1, 2020

113 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PEN NEEDLES 30GX8MM 1 QL(5 ea daily); PENTIPS 31G X 8MM 1 QL(5 ea daily); MISC RX/OTC MISC RX/OTC PEN NEEDLES 31G X 1/4" QL(5 ea daily) 1 PENTIPS 31GX5MM MISC 1 QL(5 ea daily); SHORT MISC RX/OTC PEN NEEDLES 31G X 1 QL(5 ea daily); PENTIPS 31GX6MM MISC 1 QL(5 ea daily) 3/16" MISC RX/OTC QL(5 ea daily); PEN NEEDLES 31G X 1 QL(5 ea daily); PENTIPS 31GX8MM MISC 1 5MM MISC RX/OTC RX/OTC PENTIPS 32G X 4MM QL(5 ea daily); PEN NEEDLES 31G X 1 QL(5 ea daily) 1 6MM MISC MISC RX/OTC QL(5 ea daily); PEN NEEDLES 31G X 1 QL(5 ea daily); PENTIPS 32GX4MM MISC 1 8MM MISC RX/OTC RX/OTC PRECISION SURE-DOSE QL(5 ea daily); PEN NEEDLES 31GX5/16" 1 QL(5 ea daily); MISC RX/OTC INSULIN 1 RX/OTC SYRINGE/0.3ML/30G X PEN NEEDLES 31GX6MM 1 QL(5 ea daily) (1/4") MISC 5/16" MISC PRECISION SURE-DOSE QL(5 ea daily); PEN NEEDLES 31GX8MM 1 QL(5 ea daily); (5/16") MISC RX/OTC INSULIN 1 RX/OTC SYRINGE/0.5ML/28G X PEN NEEDLES 31GX8MM 1 QL(5 ea daily); 1/2" MISC MISC RX/OTC PRECISION SURE-DOSE QL(5 ea daily); PEN NEEDLES 32G X QL(5 ea daily); 1 INSULIN 1 RX/OTC 4MM MISC RX/OTC SYRINGE/0.5ML/29G X PEN NEEDLES 32G X 1 QL(5 ea daily); 1/2" MISC 5MM MISC RX/OTC PRECISION SURE-DOSE QL(5 ea daily) PEN NEEDLES 32G X 1 QL(5 ea daily) INSULIN 1 6MM MISC SYRINGE/0.5ML/30G X 3/8" MISC PEN NEEDLES 32GX4MM 1 QL(5 ea daily); MISC RX/OTC PRECISION SURE-DOSE QL(5 ea daily); INSULIN RX/OTC PEN NEEDLES/29G X 1/2" 1 QL(5 ea daily); 1 MISC RX/OTC SYRINGE/1ML/28G X 1/2" MISC PEN NEEDLES/31G X 1/4" 1 QL(5 ea daily) MISC PRECISION SURE-DOSE QL(5 ea daily); PLUSINSULIN 1 RX/OTC PEN NEEDLES/31G X 1 QL(5 ea daily); SYRINGE/0.3ML/29G X 3/16" MISC RX/OTC 1/2" MISC PEN NEEDLES/31G X 1 QL(5 ea daily); PRECISION SURE-DOSE QL(5 ea daily); 5/16" MISC RX/OTC PLUSINSULIN 1 RX/OTC PEN NEEDLES/31G X 1 QL(5 ea daily) SYRINGE/1ML/29G X 1/2" 6MM MISC MISC PEN NEEDLES/32G X 1 QL(5 ea daily); PREFERRED PLUS QL(5 ea daily); 5/32" MISC RX/OTC INSULIN SYRINGE/U- 1 RX/OTC 100/0.3ML/29G X 1/2" PENTIPS 29G X 12MM 1 QL(5 ea daily); MISC RX/OTC MISC PREFERRED PLUS QL(5 ea daily); PENTIPS 29GX12MM 1 QL(5 ea daily); MISC RX/OTC INSULIN SYRINGE/U- 1 RX/OTC 100/0.3ML/30G X 5/16" PENTIPS 31G X 5MM 1 QL(5 ea daily); MISC RX/OTC MISC Ambetter Sunshine Formulary Updated December 1, 2020

114 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREFERRED PLUS QL(5 ea daily); PRO COMFORT INSULIN QL(5 ea daily); INSULIN SYRINGE/U- 1 RX/OTC SYRINGES/0.5ML/30G X 1 RX/OTC 100/0.5ML/28G X 1/2" 5/16" MISC MISC PRO COMFORT INSULIN QL(5 ea daily) PREFERRED PLUS QL(5 ea daily); SYRINGES/0.5ML/31G X 1 INSULIN SYRINGE/U- 1 RX/OTC 5/16" MISC 100/0.5ML/29G X 1/2" PRO COMFORT INSULIN QL(5 ea daily) MISC SYRINGES/1ML/30G X 1 PREFERRED PLUS QL(5 ea daily); 1/2" MISC INSULIN SYRINGE/U- 1 RX/OTC PRO COMFORT INSULIN QL(5 ea daily); 100/0.5ML/30G X 5/16" SYRINGES/1ML/30G X 1 RX/OTC MISC 5/16" MISC PREFERRED PLUS QL(5 ea daily); PRO COMFORT INSULIN QL(5 ea daily) INSULIN SYRINGE/U- 1 RX/OTC SYRINGES/1ML/31G X 1 100/1ML/28G X 1/2" MISC 5/16" MISC PREFERRED PLUS QL(5 ea daily); PRO COMFORT PEN QL(5 ea daily); INSULIN SYRINGE/U- 1 RX/OTC NEEDLES/31G X 8MM 1 RX/OTC 100/1ML/29G X 1/2" MISC MISC PREFERRED PLUS QL(5 ea daily); PRO COMFORT PEN QL(5 ea daily); INSULIN SYRINGE/U- 1 RX/OTC NEEDLES/32G X 4MM 1 RX/OTC 100/1ML/30G X 5/16" MISC MISC PRO COMFORT PEN QL(5 ea daily); PREFERRED PLUS QL(5 ea daily); NEEDLES/32G X 5MM 1 RX/OTC UNIFINE PENTIPS 29G X 1 RX/OTC MISC 12MM MISC PRO COMFORT PEN QL(5 ea daily) PREFERRED PLUS QL(5 ea daily) NEEDLES/32G X 6MM 1 UNIFINE PENTIPS 31G X 1 MISC 6MM ULTRA SHORT MISC PRODIGY INSULIN QL(5 ea daily) SYRING/U-100/0.3ML/31G 1 PREFERRED PLUS QL(5 ea daily); X 5/16" MISC UNIFINE PENTIPS 31G X 1 RX/OTC 8MM SHORT MISC PRODIGY INSULIN QL(5 ea daily) SYRINGE/1/2ML/31G X 1 PREFERRED PLUS QL(5 ea daily); 5/16" MISC UNIFINE PENTIPS 1 RX/OTC 32GX4MM MISC PRODIGY INSULIN QL(5 ea daily); SYRINGE/1ML/28G X 1/2" 1 RX/OTC PREFERRED PLUS QL(5 ea daily); MISC UNIFINE 1 RX/OTC PENTIPS/MINI/31GX5MM PURE COMFORT PEN 1 QL(5 ea daily) MISC NEEDLE 32G X6MM MISC PURE COMFORT PEN QL(5 ea daily); PREVENT SAFETY PEN 1 QL(5 ea daily) NEEDLES 31GX1/4" MISC NEEDLE/32G X 5MM 1 RX/OTC MISC PREVENT SAFETY PEN QL(5 ea daily); NEEDLES 31GX5/16" 1 RX/OTC PURE COMFORT PEN 1 QL(5 ea daily); MISC NEEDLE/32G X4MM MISC RX/OTC PRO COMFORT INSULIN QL(5 ea daily) PX EXTRA SHORT PEN QL(5 ea daily) SYRINGES/0.5ML/30G X 1 NEEDLES 31GX6MM 1 1/2" MISC MISC

Ambetter Sunshine Formulary Updated December 1, 2020

115 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PX INSULIN SYRINGE/U- QL(5 ea daily) REALITY INSULIN QL(5 ea daily); 100/0.5ML/30G X 1/2" 1 SYRINGE/U-100/1ML/29G 1 RX/OTC MISC X 1/2" MISC PX MINI PEN NEEDLES 1 QL(5 ea daily); RELION INSULIN QL(5 ea daily) 31GX5MM MISC RX/OTC SYRINGE 1 1ML/31GX15/64" MISC PX PEN NEEDLE 1 QL(5 ea daily); 29GX12MM MISC RX/OTC RELION INSULIN QL(5 ea daily); SYRINGE/U-00/1ML/29G X 1 RX/OTC PX PEN NEEDLE 1 QL(5 ea daily); 31GX8MM MISC RX/OTC 1/2" MISC PX SHORTLENGTH PEN QL(5 ea daily); RELION INSULIN QL(5 ea daily); NEEDLES/31GX8MM 1 RX/OTC SYRINGE/U- 1 RX/OTC MISC 100/0.3ML/29G X 1/2" MISC QC PEN NEEDLES 29G X 1 QL(5 ea daily); 12MM MISC RX/OTC RELION INSULIN QL(5 ea daily); SYRINGE/U- 1 RX/OTC QC PEN NEEDLES 31G X 1 QL(5 ea daily) 100/0.3ML/30G X 5/16" 6MM MISC MISC QC PEN NEEDLES 31G X 1 QL(5 ea daily); RELION INSULIN QL(5 ea daily) 8MM MISC RX/OTC SYRINGE/U- 1 QC UNIFINE PENTIPS 1 QL(5 ea daily); 100/0.3ML/31G X 5/16" 32GX4MM MISC RX/OTC MISC RA INSULIN QL(5 ea daily); RELION INSULIN QL(5 ea daily); SYRINGE/0.5ML/29G X 1 RX/OTC SYRINGE/U- 1 RX/OTC 1/2" MISC 100/0.5ML/29G X 1/2" RA INSULIN QL(5 ea daily); MISC SYRINGE/1ML/29G X 1/2" 1 RX/OTC RELION INSULIN QL(5 ea daily); MISC SYRINGE/U- 1 RX/OTC RA INSULIN SYRINGE/U- QL(5 ea daily); 100/0.5ML/30G X 5/16" 100/0.5ML/30G X 5/16" 1 RX/OTC MISC MISC RELION INSULIN QL(5 ea daily) RA INSULIN SYRINGE/U- QL(5 ea daily); SYRINGE/U- 1 100/1 ML/30G X 5/16" 1 RX/OTC 100/0.5ML/31G X 5/16" MISC MISC RELION INSULIN QL(5 ea daily); RA PEN NEEDLES 31G X 1 QL(5 ea daily); 5MM3/16" MISC RX/OTC SYRINGE/U-100/1ML/30G 1 RX/OTC X 5/16" MISC RA PEN NEEDLES 31G X 1 QL(5 ea daily); 8MM5/16" MISC RX/OTC RELION INSULIN QL(5 ea daily) REALITY INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/31G 1 X 15/64" MISC SYRINGE/U- 1 RX/OTC 100/0.5ML/28G X 1/2" RELION INSULIN QL(5 ea daily) MISC SYRINGE/U-100/1ML/31G 1 REALITY INSULIN QL(5 ea daily); X 5/16" MISC RELION MINI PEN QL(5 ea daily) SYRINGE/U- 1 RX/OTC 100/0.5ML/29G X 1/2" NEEDLES 31GX6MM 1 MISC MISC REALITY INSULIN QL(5 ea daily); RELION PEN NEEDLES 1 QL(5 ea daily); SYRINGE/U-100/1ML/28G 1 RX/OTC 29GX12MM MISC RX/OTC X 1/2" MISC

Ambetter Sunshine Formulary Updated December 1, 2020

116 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RELION PEN NEEDLES 1 QL(5 ea daily); SB INSULIN SYRINGE/U- QL(5 ea daily); 31GX5/16" MISC RX/OTC 100/0.5ML/29G X 1/2" 1 RX/OTC MISC RELION PEN NEEDLES 1 QL(5 ea daily) 31GX6MM MISC SB INSULIN SYRINGE/U- QL(5 ea daily); 100/0.5ML/30G X 5/16" 1 RX/OTC RELION PEN NEEDLES 1 QL(5 ea daily); 31GX8MM MISC RX/OTC MISC SB INSULIN SYRINGE/U- QL(5 ea daily); RELION PEN NEEDLES 1 QL(5 ea daily); 1 32G X5/32" MISC RX/OTC 100/1ML/29G X 1/2" MISC RX/OTC SB INSULIN SYRINGE/U- QL(5 ea daily); RELION PEN NEEDLES 1 QL(5 ea daily); 32GX4MM MISC RX/OTC 100/1ML/30G X 5/16" 1 RX/OTC MISC RELION PEN QL(5 ea daily) NEEDLES/31G X1/4" 1 SB INSULIN SYRINGE/U- QL(5 ea daily) MISC 100/1ML/31G X 5/16" 1 MISC RELION SHORT PEN 1 QL(5 ea daily); NEEDLES31GX8MM MISC RX/OTC SECURESAFE SAFETY QL(5 ea daily); INSULIN SYRINGES/U- 1 RX/OTC SAFESNAP INSULIN QL(5 ea daily); 100/0.5ML/29GX1/2" MISC SYRINGE/0.3ML/30G X 1 RX/OTC 5/16" MISC SECURESAFE SAFETY QL(5 ea daily); INSULIN SYRINGES/U- 1 RX/OTC SAFESNAP INSULIN QL(5 ea daily); 100/1ML/29GX1/2" MISC SYRINGE/0.5ML/29G X 1 RX/OTC 1/2" MISC SHOPKO UNIFINE QL(5 ea daily); PENTIPS PEN 1 RX/OTC SAFESNAP INSULIN QL(5 ea daily); NEEDLES/MICRO/32GX4 SYRINGE/0.5ML/30G X 1 RX/OTC MM MISC 5/16" MISC SHOPKO UNIFINE QL(5 ea daily); SAFESNAP INSULIN QL(5 ea daily); PENTIPS PEN 1 RX/OTC SYRINGE/1ML/28G X 1/2" 1 RX/OTC NEEDLES/MINI/31GX5MM MISC MISC SAFESNAP INSULIN QL(5 ea daily); SHOPKO UNIFINE QL(5 ea daily); SYRINGE/1ML/29G X 1/2" 1 RX/OTC PENTIPS PEN 1 RX/OTC MISC NEEDLES/ORIGINAL/29G SAFETY INSULIN QL(5 ea daily); X12MM MISC SYRINGES 1 RX/OTC SHOPKO UNIFINE QL(5 ea daily); 0.5ML/29GX1/2" MISC PENTIPS PEN 1 RX/OTC SAFETY INSULIN QL(5 ea daily); NEEDLES/SHORT/31GX8 SYRINGES 1 RX/OTC MM MISC 0.5ML/30GX5/16" MISC SHOPKO UNIFINE QL(5 ea daily); SAFETY INSULIN QL(5 ea daily); PENTIPS PLUS PEN 1 RX/OTC SYRINGES 1ML/27GX1/2" 1 RX/OTC NEEDLES/MICRO/REMOV MISC R/32GX4MM MISC SAFETY INSULIN QL(5 ea daily); SHOPKO UNIFINE QL(5 ea daily); SYRINGES 1ML/29GX1/2" 1 RX/OTC PENTIPS PLUS PEN 1 RX/OTC MISC NEEDLES/MINI/REMOVE SAFETY INSULIN QL(5 ea daily) R/31GX5MM MISC SYRINGES 1ML/30GX1/2" 1 SHOPKO UNIFINE QL(5 ea daily); MISC PENTIPS PLUS PEN 1 RX/OTC NEEDLES/REMOVER/29G X12MM MISC

Ambetter Sunshine Formulary Updated December 1, 2020

117 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SHOPKO UNIFINE QL(5 ea daily); SURE COMFORT QL(5 ea daily); PENTIPS PLUS PEN 1 RX/OTC INSULIN SYRINGE/U- 1 RX/OTC NEEDLES/SHORT/REMO 100/1ML/29G X 1/2" MISC VR/31GX8MM MISC SURE COMFORT QL(5 ea daily) SURE COMFORT QL(5 ea daily); INSULIN SYRINGE/U- 1 INSULIN SYRINGE/U- 1 RX/OTC 100/1ML/30G X 1/2" MISC 100/0.3ML/29G X 1/2" SURE COMFORT QL(5 ea daily); MISC INSULIN SYRINGE/U- 1 RX/OTC SURE COMFORT QL(5 ea daily) 100/1ML/30G X 5/16" INSULIN SYRINGE/U- 1 MISC 100/0.3ML/30G X 1/2" SURE COMFORT QL(5 ea daily) MISC INSULIN SYRINGE/U- 1 SURE COMFORT QL(5 ea daily); 100/1ML/31G X 5/16" INSULIN SYRINGE/U- 1 RX/OTC MISC 100/0.3ML/30G X 5/16" SURE COMFORT PEN QL(5 ea daily) MISC NEEDLES29GX1/2" 1 SURE COMFORT QL(5 ea daily) 12.7MM MISC INSULIN SYRINGE/U- 1 SURE COMFORT PEN QL(5 ea daily); 100/0.3ML/31G X 5/16 NEEDLES30GX5/16" 1 RX/OTC MISC SHORT MISC SURE COMFORT QL(5 ea daily) SURE COMFORT PEN QL(5 ea daily); INSULIN SYRINGE/U- 1 NEEDLES31GX3/16" 1 RX/OTC 100/0.3ML/31G X 5/16" (5MM) MISC MISC SURE COMFORT PEN QL(5 ea daily); SURE COMFORT QL(5 ea daily); NEEDLES31GX5/16" 1 RX/OTC INSULIN SYRINGE/U- 1 RX/OTC (8MM) MISC 100/0.5ML/28G X 1/2" MISC SURE COMFORT PEN 1 QL(5 ea daily); NEEDLES32GX5/32" MISC RX/OTC SURE COMFORT QL(5 ea daily); SURE COMFORT PEN QL(5 ea daily) INSULIN SYRINGE/U- 1 RX/OTC 1 100/0.5ML/29G X 1/2" NEEDLES32GX6MM MISC MISC SURE-FINE PEN QL(5 ea daily) SURE COMFORT QL(5 ea daily) NEEDLES 29GX1/2" 1 12.7MM MISC INSULIN SYRINGE/U- 1 100/0.5ML/30G X 1/2" SURE-FINE PEN QL(5 ea daily); MISC NEEDLES 31GX3/16" 5MM 1 RX/OTC SURE COMFORT QL(5 ea daily); MISC SURE-FINE PEN QL(5 ea daily); INSULIN SYRINGE/U- 1 RX/OTC 100/0.5ML/30G X 5/16" NEEDLES 31GX5/16" 8MM 1 RX/OTC MISC MISC SURE COMFORT QL(5 ea daily) SURE-JECT INSULIN QL(5 ea daily); SYRINGE/U- RX/OTC INSULIN SYRINGE/U- 1 1 100/0.5ML/31G X 5/16 100/0.3ML/29G X 1/2" MISC MISC SURE COMFORT QL(5 ea daily); SURE-JECT INSULIN QL(5 ea daily); INSULIN SYRINGE/U- 1 RX/OTC SYRINGE/U- 1 RX/OTC 100/1ML/28G X 1/2" MISC 100/0.3ML/30G X 5/16" MISC

Ambetter Sunshine Formulary Updated December 1, 2020

118 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SURE-JECT INSULIN QL(5 ea daily) TECHLITE INSULIN QL(5 ea daily); SYRINGE/U- 1 SYRINGEU- 1 RX/OTC 100/0.3ML/31G X 5/16" 100/0.5ML/29G X 1/2" MISC MISC SURE-JECT INSULIN QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily) SYRINGE/U- 1 RX/OTC SYRINGEU- 1 100/0.5ML/28G X 1/2" 100/0.5ML/30G X 1/2" MISC MISC SURE-JECT INSULIN QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily); SYRINGE/U- 1 RX/OTC SYRINGEU- 1 RX/OTC 100/0.5ML/29G X 1/2" 100/0.5ML/30G X 5/16" MISC MISC SURE-JECT INSULIN QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily) SYRINGE/U- 1 RX/OTC SYRINGEU- 1 100/0.5ML/30G X 5/16" 100/0.5ML/31G X 5/16" MISC MISC SURE-JECT INSULIN QL(5 ea daily) TECHLITE INSULIN QL(5 ea daily); SYRINGE/U- 1 SYRINGEU-100/1ML/29G 1 RX/OTC 100/0.5ML/31G X 5/16" X 1/2" MISC MISC TECHLITE INSULIN QL(5 ea daily) SURE-JECT INSULIN QL(5 ea daily); SYRINGEU-100/1ML/30G 1 SYRINGE/U-100/1ML/28G 1 RX/OTC X 1/2" MISC X 1/2" MISC TECHLITE INSULIN QL(5 ea daily); SURE-JECT INSULIN QL(5 ea daily); SYRINGEU-100/1ML/30G 1 RX/OTC SYRINGE/U-100/1ML/29G 1 RX/OTC X 5/16" MISC X 1/2" MISC TECHLITE INSULIN QL(5 ea daily) SURE-JECT INSULIN QL(5 ea daily); SYRINGEU-100/1ML/31G 1 SYRINGE/U-100/1ML/30G 1 RX/OTC X 15/64" MISC X 5/16" MISC TECHLITE INSULIN QL(5 ea daily) SURE-JECT INSULIN QL(5 ea daily) SYRINGEU-100/1ML/31G 1 SYRINGE/U-100/1ML/31G 1 X 5/16" MISC X 5/16" MISC TECHLITE PEN NEEDLES 1 QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily); 29GX 12 MM MISC RX/OTC SYRINGEU- RX/OTC 1 TECHLITE PEN NEEDLES 1 QL(5 ea daily); 100/0.3ML/29G X 1/2" 31GX 5MM MISC RX/OTC MISC TECHLITE PEN QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily) NEEDLES/31GX 5MM 1 RX/OTC SYRINGEU- 1 MISC 100/0.3ML/30G X 1/2" MISC TECHLITE PEN QL(5 ea daily) NEEDLES/31GX 6 MM 1 TECHLITE INSULIN QL(5 ea daily); MISC SYRINGEU- 1 RX/OTC 100/0.3ML/30G X 5/16" TECHLITE PEN QL(5 ea daily); MISC NEEDLES/31GX 8MM 1 RX/OTC MISC TECHLITE INSULIN QL(5 ea daily) TECHLITE PEN QL(5 ea daily); SYRINGEU- 1 100/0.3ML/31G X 5/16" NEEDLES/32GX 4MM 1 RX/OTC MISC MISC

Ambetter Sunshine Formulary Updated December 1, 2020

119 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TECHLITE PEN QL(5 ea daily) TOPCARE ULTRA QL(5 ea daily); NEEDLES/32GX 6MM 1 COMFORT INSULIN RX/OTC MISC SYRINGE/U- 1 TODAYS HEALTH MINI QL(5 ea daily) 100/0.5ML/29G X 1/2" PEN NEEDLES 31G X 1/4" 1 MISC MISC TOPCARE ULTRA QL(5 ea daily); TODAYS HEALTH QL(5 ea daily); COMFORT INSULIN 1 RX/OTC ORIGINAL PEN NEEDLES 1 RX/OTC SYRINGE/U-100/1ML/29G 29G X 1/2" MISC X 1/2" MISC TODAYS HEALTH SHORT QL(5 ea daily); TRUE COMFORT INSULIN QL(5 ea daily) PEN NEEDLES 31G X 1 RX/OTC SYRINGE/0.5ML/31G X 1 5/16" MISC 5/16" MISC TOPCARE CLICKFINE QL(5 ea daily) TRUE COMFORT INSULIN QL(5 ea daily) UNIVERSAL PEN EEDLES 1 SYRINGE/1ML/31G X 1 31GX1/4" MISC 5/16" MISC TOPCARE CLICKFINE QL(5 ea daily); TRUE COMFORT PEN QL(5 ea daily); UNIVERSAL PEN EEDLES 1 RX/OTC NEEDLES31G X 5MM 1 RX/OTC 31GX5/16" MISC MISC TOPCARE ULTRA QL(5 ea daily); TRUE COMFORT PEN QL(5 ea daily) NEEDLES31G X 6MM 1 COMFORT INSULIN 1 RX/OTC SYRINGE/0.3ML/30G X MISC 5/16" MISC TRUE COMFORT PEN QL(5 ea daily); TOPCARE ULTRA QL(5 ea daily) NEEDLES32G X 4MM 1 RX/OTC MISC COMFORT INSULIN 1 SYRINGE/0.3ML/31G X TRUEPLUS 5-BEVEL PEN QL(5 ea daily) 5/16" MISC NEEDLES 29GX12.7MM 1 TOPCARE ULTRA QL(5 ea daily); MISC COMFORT INSULIN 1 RX/OTC TRUEPLUS 5-BEVEL PEN QL(5 ea daily); SYRINGE/0.5ML/30G X NEEDLES 31GX5MM 1 RX/OTC 5/16" MISC MISC TOPCARE ULTRA QL(5 ea daily) TRUEPLUS 5-BEVEL PEN QL(5 ea daily) COMFORT INSULIN 1 NEEDLES 31GX6MM 1 SYRINGE/0.5ML/31G X MISC 5/16" MISC TRUEPLUS 5-BEVEL PEN QL(5 ea daily); TOPCARE ULTRA QL(5 ea daily); NEEDLES 31GX8MM 1 RX/OTC COMFORT INSULIN 1 RX/OTC MISC SYRINGE/1ML/30G X TRUEPLUS 5-BEVEL PEN QL(5 ea daily); 5/16" MISC NEEDLES 32GX4MM 1 RX/OTC TOPCARE ULTRA QL(5 ea daily) MISC COMFORT INSULIN 1 TRUEPLUS INSULIN QL(5 ea daily); SYRINGE/1ML/31G X SYRINGE/U- 1 RX/OTC 5/16" MISC 100/0.3ML/29G X 1/2" TOPCARE ULTRA QL(5 ea daily); MISC COMFORT INSULIN RX/OTC TRUEPLUS INSULIN QL(5 ea daily); SYRINGE/U- 1 SYRINGE/U- 1 RX/OTC 100/0.3ML/29G X 1/2" 100/0.3ML/30G X 5/16" MISC MISC

Ambetter Sunshine Formulary Updated December 1, 2020

120 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUEPLUS INSULIN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily); SYRINGE/U- 1 SAFETY 1 RX/OTC 100/0.3ML/31G X 5/16" SYRINGE/0.5ML/29G X MISC 1/2" MISC TRUEPLUS INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); SYRINGE/U- 1 RX/OTC SAFETY 1 RX/OTC 100/0.5ML/28G X 1/2" SYRINGE/1ML/29G X 1/2" MISC MISC TRUEPLUS INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); SYRINGE/U- 1 RX/OTC SYRINGE/0.3ML/29G X 1 RX/OTC 100/0.5ML/29G X 1/2" 1/2" MISC MISC ULTICARE INSULIN QL(5 ea daily) TRUEPLUS INSULIN QL(5 ea daily); SYRINGE/0.3ML/30G X 1 SYRINGE/U- 1 RX/OTC 1/2" MISC 100/0.5ML/30G X 5/16" ULTICARE INSULIN QL(5 ea daily); MISC SYRINGE/0.3ML/30G X 1 RX/OTC TRUEPLUS INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/U- 1 ULTICARE INSULIN QL(5 ea daily); 100/0.5ML/31G X 5/16" SYRINGE/0.5ML/28G X 1 RX/OTC MISC 1/2" MISC TRUEPLUS INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/28G 1 RX/OTC SYRINGE/0.5ML/29G X 1 RX/OTC X 1/2" MISC 1/2" MISC TRUEPLUS INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/29G 1 RX/OTC SYRINGE/0.5ML/30G X 1 X 1/2" MISC 1/2" MISC TRUEPLUS INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/30G 1 RX/OTC SYRINGE/0.5ML/30G X 1 RX/OTC X 5/16" MISC 5/16" MISC TRUEPLUS INSULIN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/31G 1 SYRINGE/1ML/28G X 1/2" 1 RX/OTC X 5/16" MISC MISC TRUEPLUS PEN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); NEEDLES 29GX12MM 1 RX/OTC SYRINGE/1ML/29G X 1/2" 1 RX/OTC MISC MISC TRUEPLUS PEN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) NEEDLES 31GX5MM 1 RX/OTC SYRINGE/1ML/30G X 1/2" 1 MISC MISC TRUEPLUS PEN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily); NEEDLES 31GX6MM 1 SYRINGE/1ML/30G X 1 RX/OTC MISC 5/16" MISC TRUEPLUS PEN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); NEEDLES 31GX8MM 1 RX/OTC SYRINGE/SHORT/0.3ML/3 1 RX/OTC MISC 0G X 5/16" MISC TRUEPLUS PEN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) NEEDLES 32GX4MM 1 RX/OTC SYRINGE/SHORT/0.3ML/3 1 MISC 1G X 5/16" MISC

Ambetter Sunshine Formulary Updated December 1, 2020

121 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTICARE INSULIN QL(5 ea daily); ULTICARE MICRO PEN QL(5 ea daily); SYRINGE/SHORT/0.5ML/3 1 RX/OTC NEEDLES 31G X 8MM 1 RX/OTC 0G X 5/16" MISC MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE MICRO PEN QL(5 ea daily); SYRINGE/SHORT/0.5ML/3 1 NEEDLES 32G X 4MM 1 RX/OTC 1G X 5/16" MISC MISC ULTICARE INSULIN QL(5 ea daily); ULTICARE MICRO PEN QL(5 ea daily) SYRINGE/SHORT/1ML/30 1 RX/OTC NEEDLES/31G X 1/4" 1 G X 5/16" MISC MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE MICRO PEN QL(5 ea daily); SYRINGE/SHORT/1ML/31 1 NEEDLES/31G X 5/16" 1 RX/OTC G X 5/16" MISC MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE MICRO PEN QL(5 ea daily); SYRINGE/U- 1 NEEDLES/32G X 4MM 1 RX/OTC 100/0.3ML/30G X 1/2" MISC MISC ULTICARE MICRO PEN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) NEEDLES/32G X 5/32" 1 RX/OTC SYRINGE/U- 1 MISC 100/0.3ML/31G X 5/16" ULTICARE MINI PEN QL(5 ea daily) MISC NEEDLES 31GX6MM 1 ULTICARE INSULIN QL(5 ea daily) MISC SYRINGE/U- 1 ULTICARE MINI PEN QL(5 ea daily) 100/0.5ML/30G X 1/2" NEEDLES ULTI-FINE IV 1 MISC MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE MINI PEN QL(5 ea daily) SYRINGE/U- 1 NEEDLES/31G X 6MM 1 100/0.5ML/31G X 5/16" MISC MISC ULTICARE MINI PEN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily) NEEDLES/32G X 1/4" 1 SYRINGE/U-100/1ML/30G 1 MISC X 1/2" MISC ULTICARE MINI PEN 1 QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily) NEEDLES31GX6MM MISC SYRINGE/U-100/1ML/31G 1 X 5/16" MISC ULTICARE ORIGINAL QL(5 ea daily) PEN NEEDLES ULTI-FINE 1 ULTICARE INSULIN QL(5 ea daily) MISC SYRINGEULTRAFINE U- 1 100/0.3ML/31G X 5/16" ULTICARE PEN NEEDLES 1 QL(5 ea daily); MISC 31GX 5MM MISC RX/OTC ULTICARE INSULIN QL(5 ea daily) ULTICARE PEN NEEDLES 1 QL(5 ea daily); 31GX 5MM/MINI MISC RX/OTC SYRINGEULTRAFINE U- 1 100/0.5ML/31G X 5/16" ULTICARE PEN QL(5 ea daily) MISC NEEDLES/29GX 12.7MM 1 ULTICARE INSULIN QL(5 ea daily) MISC ULTICARE SHORT PEN QL(5 ea daily); SYRINGEULTRAFINE U- 1 100/1ML/31G X 5/16" NEEDLES 31GX8MM 1 RX/OTC MISC MISC

Ambetter Sunshine Formulary Updated December 1, 2020

122 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTICARE SHORT PEN QL(5 ea daily); ULTILET INSULIN QL(5 ea daily) NEEDLES ULTI-FINE IV 1 RX/OTC SYRINGE/SHORT/0.3ML/3 1 MISC 0G X 12.7MM MISC ULTICARE SHORT PEN QL(5 ea daily); ULTILET INSULIN QL(5 ea daily); NEEDLES/31G X 8MM 1 RX/OTC SYRINGE/SHORT/0.3ML/3 1 RX/OTC MISC 0G X 5/16" MISC ULTIGUARD QL(5 ea daily); ULTILET INSULIN QL(5 ea daily) SAFEPACK/MICROPEN RX/OTC SYRINGE/SHORT/0.3ML/3 1 NEEDLE/32G X 1 1G X 5/16" MISC 5/32"/SHARPS CONTA ULTILET INSULIN QL(5 ea daily); MISC SYRINGE/SHORT/0.5ML/3 1 RX/OTC ULTIGUARD QL(5 ea daily) 0G X 5/16" MISC SAFEPACK/MINI PEN ULTILET INSULIN QL(5 ea daily) NEEDLE/31G X 1 SYRINGE/SHORT/0.5ML/3 1 1/4"/SHARPS CONTAIN 1G X 5/16" MISC MISC ULTILET INSULIN QL(5 ea daily); ULTIGUARD QL(5 ea daily); SYRINGE/SHORT/1ML/30 1 RX/OTC SAFEPACK/MINI PEN RX/OTC G X 5/16" MISC NEEDLE/31G X 1 3/16"/SHARPS CONTAI ULTILET INSULIN QL(5 ea daily) MISC SYRINGE/SHORT/1ML/31 1 G X 5/16" MISC ULTIGUARD QL(5 ea daily) SAFEPACK/MINI PEN ULTILET INSULIN QL(5 ea daily) NEEDLE/32G X 1 SYRINGE/U- 1 1/4"/SHARPS CONTAIN 100/0.5ML/30G X 1/2" MISC MISC ULTIGUARD QL(5 ea daily); ULTILET INSULIN QL(5 ea daily) SAFEPACK/SHORTPEN RX/OTC SYRINGE/U-100/1ML/30G 1 NEEDLE/31G X 1 X 1/2" MISC 5/16"/SHARPS CONTA ULTILET PEN NEEDLE 1 QL(5 ea daily) MISC 29GX12.7MM MISC ULTILET INSULIN QL(5 ea daily); ULTILET PEN NEEDLE 1 QL(5 ea daily); SYRINGE/0.3ML/30G X 1 RX/OTC 31GX5MM MISC RX/OTC 8MM MISC ULTILET PEN NEEDLE 1 QL(5 ea daily); ULTILET INSULIN QL(5 ea daily) 31GX8MM MISC RX/OTC SYRINGE/0.3ML/31G X 1 ULTILET PEN NEEDLE 1 QL(5 ea daily); 8MM MISC 32GX4MM MISC RX/OTC ULTILET INSULIN QL(5 ea daily); ULTILET PEN NEEDLE 1 QL(5 ea daily); SYRINGE/0.5ML/30G X 1 RX/OTC 32GX4MM/SHORT MISC RX/OTC 8MM MISC ULTILET SHORT PEN QL(5 ea daily); ULTILET INSULIN QL(5 ea daily); NEEDLES 31GX5/16" 1 RX/OTC SYRINGE/1ML/30G X 1 RX/OTC MISC 8MM MISC ULTILET SHORT PEN 1 QL(5 ea daily); ULTILET INSULIN QL(5 ea daily) NEEDLES31GX3/16" MISC RX/OTC SYRINGE/1ML/31G X 1 ULTRA COMFORT QL(5 ea daily); 8MM MISC INSULIN SYRINGE/U- 1 RX/OTC 100/0.3ML/30G X 5/16" MISC

Ambetter Sunshine Formulary Updated December 1, 2020

123 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTRA FLO INSULIN PEN 1 QL(5 ea daily); ULTRA-COMFORT QL(5 ea daily) NEEDLES MISC RX/OTC INSULIN SYRINGE/U- 1 ULTRA FLO INSULIN QL(5 ea daily); 100/1ML/31G X 5/16" SYRINGE 0.3ML/29G X 1 RX/OTC MISC 1/2" MISC ULTRA-THIN II INSULIN QL(5 ea daily); ULTRA THIN PEN QL(5 ea daily); SYRINGE SHORT/U- 1 RX/OTC NEEDLES 32G X 4MM 1 RX/OTC 100/0.3ML/30GX5/16" MISC MISC ULTRA-COMFORT QL(5 ea daily); ULTRA-THIN II INSULIN QL(5 ea daily) SYRINGE SHORT/U- INSULIN SYRINGE/U- 1 RX/OTC 1 100/0.3ML/29G X 1/2" 100/0.3ML/31GX5/16" MISC MISC ULTRA-COMFORT QL(5 ea daily); ULTRA-THIN II INSULIN QL(5 ea daily); SYRINGE SHORT/U- RX/OTC INSULIN SYRINGE/U- 1 RX/OTC 1 100/0.3ML/30G X 5/16" 100/0.5ML/30GX5/16" MISC MISC ULTRA-COMFORT QL(5 ea daily) ULTRA-THIN II INSULIN QL(5 ea daily) SYRINGE SHORT/U- INSULIN SYRINGE/U- 1 1 100/0.3ML/31G X 5/16" 100/0.5ML/31GX5/16" MISC MISC ULTRA-COMFORT QL(5 ea daily); ULTRA-THIN II INSULIN QL(5 ea daily); SYRINGE SHORT/U- 1 RX/OTC INSULIN SYRINGE/U- 1 RX/OTC 100/0.5ML/28G X 1/2" 100/1ML/30GX5/16" MISC MISC ULTRA-THIN II INSULIN QL(5 ea daily) ULTRA-COMFORT QL(5 ea daily); SYRINGE SHORT/U- 1 100/1ML/31GX5/16" MISC INSULIN SYRINGE/U- 1 RX/OTC 100/0.5ML/29G X 1/2" ULTRA-THIN II INSULIN QL(5 ea daily); MISC SYRINGE/U- 1 RX/OTC ULTRA-COMFORT QL(5 ea daily); 100/0.5ML/29GX1/2" MISC INSULIN SYRINGE/U- 1 RX/OTC ULTRA-THIN II INSULIN QL(5 ea daily); 100/0.5ML/30G X 5/16" SYRINGE/U- 1 RX/OTC MISC 100/1ML/29GX1/2" MISC ULTRA-COMFORT QL(5 ea daily) ULTRA-THIN II MINI PEN QL(5 ea daily); INSULIN SYRINGE/U- 1 NEEEDLES/31GX3/16" 1 RX/OTC 100/0.5ML/31G X 5/16" MISC MISC ULTRA-THIN II PEN 1 QL(5 ea daily) ULTRA-COMFORT QL(5 ea daily); NEEDLES 29GX1/2" MISC INSULIN SYRINGE/U- 1 RX/OTC ULTRA-THIN II PEN QL(5 ea daily); 100/1ML/28G X 1/2" MISC NEEDLES/SHORT/31GX5/ 1 RX/OTC ULTRA-COMFORT QL(5 ea daily); 16" MISC INSULIN SYRINGE/U- 1 RX/OTC ULTRACARE INSULIN QL(5 ea daily); 100/1ML/29G X 1/2" MISC SYRINGE/U- 1 RX/OTC ULTRA-COMFORT QL(5 ea daily); 100/0.3ML/30G X 5/16" INSULIN SYRINGE/U- 1 RX/OTC MISC 100/1ML/30G X 5/16" ULTRACARE INSULIN QL(5 ea daily) MISC SYRINGE/U- 1 100/0.3ML/31G X 5/16" MISC

Ambetter Sunshine Formulary Updated December 1, 2020

124 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTRACARE INSULIN QL(5 ea daily) UNIFINE PENTIPS 1 QL(5 ea daily); SYRINGE/U- 1 31GX8MM MISC RX/OTC 100/0.5ML/30G X 1/2" UNIFINE PENTIPS 1 QL(5 ea daily); MISC 32GX4MM MISC RX/OTC ULTRACARE INSULIN QL(5 ea daily); UNIFINE PENTIPS 1 QL(5 ea daily) SYRINGE/U- 1 RX/OTC 32GX6MM MISC 100/0.5ML/30G X 5/16" MISC UNIFINE PENTIPS PLUS 1 QL(5 ea daily); 29GX12MM MISC RX/OTC ULTRACARE INSULIN QL(5 ea daily) UNIFINE PENTIPS PLUS QL(5 ea daily); SYRINGE/U- 1 1 100/0.5ML/31G X 5/16" 31GX5MM MISC RX/OTC MISC UNIFINE PENTIPS PLUS 1 QL(5 ea daily) ULTRACARE INSULIN QL(5 ea daily) 31GX6MM MISC SYRINGE/U-100/1ML/30G 1 UNIFINE PENTIPS PLUS 1 QL(5 ea daily); X 1/2" MISC 31GX8MM MISC RX/OTC ULTRACARE INSULIN QL(5 ea daily); UNIFINE PENTIPS PLUS 1 QL(5 ea daily); SYRINGE/U-100/1ML/30G 1 RX/OTC 32GX4MM MISC RX/OTC X 5/16" MISC UNIFINE SAFECONTROL QL(5 ea daily); ULTRACARE INSULIN QL(5 ea daily) PEN NEEDLE/30G X 5/16" 1 RX/OTC SYRINGE/U-100/1ML/31G 1 MISC X 5/16" MISC VALUE HEALTH INSULIN QL(5 ea daily); ULTRACARE PEN QL(5 ea daily) SYRINGE/U- 1 RX/OTC NEEDLES/31G X 1/4" 1 100/0.5ML/29G X 1/2" MISC MISC ULTRACARE PEN QL(5 ea daily); VALUE HEALTH INSULIN QL(5 ea daily); NEEDLES/31G X 3/16" 1 RX/OTC SYRINGE/U-100/1ML/29G 1 RX/OTC MISC X 1/2" MISC ULTRACARE PEN QL(5 ea daily); VALUMARK PEN QL(5 ea daily); NEEDLES/31G X 5/16" 1 RX/OTC NEEDLES 29GX12MM 1 RX/OTC MISC MISC ULTRACARE PEN QL(5 ea daily) VALUMARK PEN QL(5 ea daily) NEEDLES/32G X 1/14" 1 NEEDLES 31GX 6MM 1 MISC MISC ULTRACARE PEN QL(5 ea daily); VALUMARK PEN QL(5 ea daily); NEEDLES/32G X 3/16" 1 RX/OTC NEEDLES 31GX 8MM 1 RX/OTC MISC MISC ULTRACARE PEN QL(5 ea daily); VANISHPOINT INSULIN QL(5 ea daily) NEEDLES/32G X 5/32" 1 RX/OTC SYRINGE/0.5ML/30G X 1 MISC 1/2" MISC VANISHPOINT INSULIN QL(5 ea daily); UNIFINE PENTIPS 1 QL(5 ea daily); 29GX12MM MISC RX/OTC SYRINGE/0.5ML/30G X 1 RX/OTC 5/16" MISC UNIFINE PENTIPS 31G X 1 QL(5 ea daily); 3/16" MISC RX/OTC VANISHPOINT INSULIN QL(5 ea daily); SYRINGE/1ML/29G X 1/2" 1 RX/OTC UNIFINE PENTIPS 1 QL(5 ea daily); 31GX5MM MISC RX/OTC MISC VANISHPOINT INSULIN QL(5 ea daily); UNIFINE PENTIPS 1 QL(5 ea daily) 31GX6MM MISC SYRINGE/1ML/30G X 1 RX/OTC 5/16" MISC

Ambetter Sunshine Formulary Updated December 1, 2020

125 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIDA MIA UNIFINE 1 QL(5 ea daily); D.H.E. 45 SOLN (Use PENTIPS32GX4MM MISC RX/OTC dihydroergotamine NF VIDA MIA UNIFINE QL(5 ea daily) mesylate) PENTIPSMINI 31GX6MM 1 dihydroergotamine 1 MISC mesylate soln ij 1 mg/ml VIDA MIA UNIFINE QL(5 ea daily); dihydroergotamine 1 PA; QL(0.267 PENTIPSORIGINAL 1 RX/OTC mesylate soln na 4 mg/ml ml daily) 29GX12MM MISC dihydroergotamine 1 QL(0.267 ml VIDA MIA UNIPFINE QL(5 ea daily); mesylate soln na 4 mg/ml daily) PENTIPSSHORT 1 RX/OTC QL(0.667 ea ERGOMAR SUBL 3 31GX8MM MISC daily) VP INSULIN SYRINGE/U- QL(5 ea daily); MIGRANAL SOLN (Use QL(0.267 ml 100/0.3ML/29G X 1/2" 1 RX/OTC dihydroergotamine NF daily) MISC mesylate) WEGMANS UNIFINE QL(5 ea daily); PENTIPS PLUS 32GX4MM 1 RX/OTC Serotonin Agonists MISC ST; QL(0.4 ea almotriptan malate tabs daily); AL(At WEGMANS UNIFINE QL(5 ea daily); 1 12.5 mg least 12 yrs PENTIPS 1 RX/OTC old) PLUS/MINI/31GX5MM MISC ST; QL(0.3 ea almotriptan malate tabs daily); AL(At WEGMANS UNIFINE QL(5 ea daily); 1 6.25 mg least 12 yrs PENTIPS 1 RX/OTC old) PLUS/SHORT/31GX8MM MISC QL(0.3 ea AMERGE TABS (Use NF daily); AL(At WEGMANS UNIFINE QL(5 ea daily) naratriptan hcl) least 18 yrs PENTIPS PLUS/ULTRA 1 old) SHORT/31GX6MM MISC ST; QL(0.2 ea MIGRAINE PRODUCTS - Drugs to Treat Migraine eletriptan hydrobromide 1 daily); AL(At tabs least 18 yrs Calcitonin Gene-Related Peptide (CGRP) old) PA; QL(0.04 ml ST; QL(0.4 ea AIMOVIG SOAJ 3 daily) FROVA TABS (Use NF daily); AL(At frovatriptan succinate) least 18 yrs AJOVY SOSY 3 PA; QL(0.06 ml old) daily) ST; QL(0.4 ea EMGALITY SOAJ 120 PA 3 1 daily); AL(At MG/ML frovatriptan succinate tabs least 18 yrs EMGALITY SOSY 120 3 PA old) MG/ML QL(0.2 ea IMITREX SOLN NA 20 Migraine Combinations NF daily); AL(At MG/ACT, 5 MG/ACT (Use least 18 yrs CAFERGOT TABS (Use NF sumatriptan) ergotamine w/ caffeine) old) ergotamine w/ caffeine tabs QL(0.134 ml 1 IMITREX SOLN SC 6 daily); AL(At or 1 mg-100 mg MG/0.5ML (Use NF sumatriptan succinate) least 18 yrs Migraine Products old)

Ambetter Sunshine Formulary Updated December 1, 2020

126 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(0.134 ml QL(0.134 ml IMITREX STATDOSE NF daily); AL(At sumatriptan succinate soaj 1 daily); AL(At REFILL SOCT (Use least 18 yrs sumatriptan succinate) least 18 yrs sc 4 mg/0.5ml, 6 mg/0.5ml old) old) QL(0.134 ml QL(0.134 ml IMITREX STATDOSE NF daily); AL(At sumatriptan succinate soct 1 daily); AL(At SYSTEM SOAJ (Use least 18 yrs sumatriptan succinate) least 18 yrs sc 4 mg/0.5ml, 6 mg/0.5ml old) old) QL(0.3 ea QL(0.134 ml IMITREX TABS OR 100 NF daily); AL(At sumatriptan succinate soln 1 daily); AL(At MG, 25 MG, 50 MG (Use least 18 yrs sumatriptan succinate) least 18 yrs sc 6 mg/0.5ml old) old) QL(0.6 ea QL(0.134 ml MAXALT TABS (Use NF daily); AL(At rizatriptan benzoate) daily); AL(At sumatriptan succinate sosy 1 least 6 yrs old) sc 6 mg/0.5ml least 18 yrs MAXALT-MLT TBDP 10 QL(0.6 ea old) MG (Use rizatriptan NF daily); AL(At QL(0.3 ea benzoate) least 6 yrs old) sumatriptan succinate tabs 1 daily); AL(At QL(0.4 ea or 100 mg, 25 mg, 50 mg least 18 yrs MAXALT-MLT TBDP 5 MG NF old) (Use rizatriptan benzoate) daily); AL(At least 6 yrs old) ST; QL(0.3 ea QL(0.3 ea 1 daily); AL(At zolmitriptan tabs least 12 yrs 1 daily); AL(At naratriptan hcl tabs least 18 yrs old) old) ST; QL(0.3 ea ST; QL(0.2 ea 1 daily); AL(At zolmitriptan tbdp least 12 yrs RELPAX TABS (Use NF daily); AL(At eletriptan hydrobromide) least 18 yrs old) old) ST; QL(0.2 ea QL(0.6 ea ZOMIG SOLN NA 2.5 MG, 3 daily); AL(At rizatriptan benzoate tabs 1 daily); AL(At 5 MG least 12 yrs 10 mg least 6 yrs old) old) QL(0.4 ea ST; QL(0.3 ea rizatriptan benzoate tabs 5 1 daily); AL(At ZOMIG TABS OR 2.5 MG, daily); AL(At mg NF least 6 yrs old) 5 MG (Use zolmitriptan) least 12 yrs old) QL(0.6 ea rizatriptan benzoate tbdp 1 daily); AL(At ST; QL(0.3 ea 10 mg least 6 yrs old) ZOMIG ZMT TBDP (Use NF daily); AL(At zolmitriptan) least 12 yrs QL(0.4 ea old) rizatriptan benzoate tbdp 5 1 daily); AL(At mg least 6 yrs old) MINERALS & ELECTROLYTES QL(0.2 ea Bicarbonates 1 daily); AL(At sumatriptan soln least 18 yrs SODIUM ACETATE SOLN 1 old) 2 MEQ/ML sodium acetate soln 4 1 meq/ml Calcium Ambetter Sunshine Formulary Updated December 1, 2020

127 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits calcium chloride (dihydrate) 1 POTASSIUM soln CHLORIDE/DEXTROSE/L ACTATED RINGERS CALCIUM GLUCONATE 1 SOLN IV 10 % SOLN 129 MEQ/L-130 MEQ/L-2.7 MEQ/L-24 1 calcium gluconate soln iv 1 MEQ/L-28 MEQ/L-5 %, 130 10 % MEQ/L-149 MEQ/L-24 Electrolyte Mixtures MEQ/L-28 MEQ/L-3 MEQ/L-5 % dextrose in lactated ringers 1 soln ringer's soln 1 ELLIOTTS B SOLN 4 PA IONOSOL-MB/DEXTROSE magnesium sulfate soln ij 1 5% SOLN 20 MEQ/L-22 50 % MEQ/L-23 MEQ/L-25 MEQ/L-3 MEQ/L-3 MEQ/L- 1 Phosphate 5 %, 20 MEQ/L-22 MEQ/L- potassium phosphates soln 1 23 MEQ/L-25 MEQ/L-3 224 mg/ml-236 mg/ml MEQ/L-3 MMOLE/L-5 % Potassium ISOLYTE-P/DEXTROSE 1 K-TAB TBCR 10 MEQ (Use NF 5% SOLN potassium chloride) ISOLYTE-S SOLN 1 K-TAB TBCR 8 MEQ (Use 1 potassium chloride) KCL 0.3%/D5W/NACL 1 0.9% SOLN potassium acetate soln 1 lactated ringer's soln 109 potassium bicarb & chloride 1 meq/l-130 meq/l-28 meq/l-3 tbef meq/l-4 meq/l, 20 1 mg/100ml-30 mg/100ml- potassium bicarbonate tbef 1 310 mg/100ml-600 mg/100ml potassium chloride cpcr or 1 10 meq, 8 meq NORMOSOL-M IN D5W 1 SOLN potassium chloride microencapsulated crystals 1 NORMOSOL-R SOLN 1 er tbcr potassium chloride pack or 1 PA parenteral electrolytes conc 1 20 meq PLASMA-LYTE A SOLN 1 POTASSIUM CHLORIDE SOLN IV 10 MEQ/100ML, 1 10 MEQ/50ML PLASMA-LYTE-148 SOLN 1 potassium chloride soln iv 2 1 potassium chloride in meq/ml dextrose & sodium chloride 1 potassium chloride soln or 1 soln 10 % potassium chloride in 1 potassium chloride tbcr or 1 dextrose soln 10 meq, 8 meq potassium chloride in nacl 1 soln Sodium

Ambetter Sunshine Formulary Updated December 1, 2020

128 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits sodium chloride soln ij 2.5 1 cyclosporine modified (for 1 meq/ml microemulsion) soln sodium chloride soln iv 3 cyclosporine soln 1 %, 5 %, 23.4 %, 4 meq/ml, 1 0.45 %, 0.9 % everolimus 4 PA; QL(20 ea (immunosuppressant) tabs daily); SP MISCELLANEOUS THERAPEUTIC CLASSES IMURAN TABS (Use NF Chelating Agents azathioprine) mycophenolate mofetil CUPRIMINE CAPS (Use 3 PA 1 penicillamine) caps 250 mg mycophenolate mofetil tabs DEPEN TITRATABS TABS 3 QL(8 ea daily) 1 (Use penicillamine) 500 mg PA mycophenolate sodium 1 penicillamine caps 1 tbec penicillamine tabs 1 QL(8 ea daily) MYFORTIC TBEC (Use NF mycophenolate sodium) SYPRINE CAPS (Use NF PA; QL(8 ea NEORAL CAPS (Use trientine hcl) daily); SP cyclosporine modified (for NF PA; QL(8 ea microemulsion)) trientine hcl caps 4 daily); SP NEORAL SOLN (Use Immunomodulators cyclosporine modified (for NF microemulsion)) REVLIMID CAPS 10 MG, PA; QL(1 ea 15 MG, 2.5 MG, 25 MG, 5 4 daily); SP NULOJIX SOLR 4 PA; SP MG PROGRAF CAPS OR 0.5 REVLIMID CAPS 20 MG 4 MG, 1 MG, 5 MG (Use NF tacrolimus) PA; QL(3 ea THALOMID CAPS 4 daily); SP PROGRAF PACK OR 0.2 2 PA MG, 1 MG Immunosuppressive Agents PROGRAF SOLN IV 5 2 ATGAM INJ 4 PA; SP MG/ML RAPAMUNE TABS 0.5 AZASAN TABS 3 MG, 1 MG, 2 MG (Use NF sirolimus) AZATHIOPRINE SOLR IJ 1 100 MG SANDIMMUNE CAPS OR 100 MG, 25 MG (Use NF azathioprine tabs or 50 mg 1 cyclosporine) SANDIMMUNE SOLN IV CELLCEPT CAPS 250 MG 50 MG/ML (Use NF (Use mycophenolate NF cyclosporine) mofetil) CELLCEPT TABS 500 MG SIMULECT SOLR 3 (Use mycophenolate NF mofetil) sirolimus tabs 0.5 mg, 1 1 mg, 2 mg cyclosporine caps 1 tacrolimus caps 1 cyclosporine modified (for 1 microemulsion) caps Ambetter Sunshine Formulary Updated December 1, 2020

129 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits THYMOGLOBULIN SOLR 4 PA; SP triamcinolone acetonide 1 (mouth) pste ZORTRESS TABS 0.25 PA; QL(20 ea Throat Products - Misc. MG, 0.5 MG, 0.75 MG (Use 4 daily); SP everolimus cevimeline hcl caps 1 (immunosuppressant)) EVOXAC CAPS (Use NF Irrigation Solutions cevimeline hcl) irrigation solutions, 1 physiological soln pilocarpine hcl (oral) tabs 1 lactated ringer's (irrigation) 1 SALAGEN TABS (Use NF soln pilocarpine hcl (oral)) ringer's irrigation soln 1 MULTIVITAMINS water for irrigation, sterile 1 Multiple Vitamins w/ Minerals soln CORVITE TABS (Use Potassium Removing Agents multiple vitamins w/ NF minerals & folic acid) sodium polystyrene 1 sulfonate powd or Prenatal Vitamins sodium polystyrene CLASSIC PRENATAL 2 QL(1 ea daily) sulfonate susp or 15 1 TABS gm/60ml CVS PRENATAL TABS 2 QL(1 ea daily) MOUTH/THROAT/DENTAL AGENTS EQL PRENATAL 2 QL(1 ea daily) Anesthetics Topical Oral FORMULA TABS lidocaine hcl (mouth-throat) 1 QL(4 ml daily) GNP PRENATAL TABS 2 QL(1 ea daily) soln 2 % GOODSENSE PRENATAL QL(1 ea daily) lidocaine hcl (mouth-throat) 1 2 soln 4 % VITAMINS TABS Anti-infectives - Throat HM PRENATAL TABS 2 QL(1 ea daily) clotrimazole troc 1 KP PRENATAL 2 QL(1 ea daily) MULTIVITAMINS TABS nystatin (mouth-throat) 1 susp M-NATAL PLUS TABS 2 QL(1 ea daily); RX/OTC Antiseptics - Mouth/Throat MULTI PRENATAL TABS 2 QL(1 ea daily) chlorhexidine gluconate 1 (mouth-throat) soln NEONATAL COMPLETE QL(1 ea daily); DEBACTEROL SOLN 2 TABS 0.2 MG-1.84 MG-10 RX/OTC MCG-10 MG-1000 MCG-12 PERIDEX SOLN (Use MCG-120 MG-1200 MCG-2 2 chlorhexidine gluconate NF MG-2 MG-20 MG-200 MG- (mouth-throat)) 25 MG-27 MG-3 MG-5 MG- 9.2 MG Dental Products QL(1 ea daily); NEONATAL PLUS TABS 2 stannous fluoride conc mt 0 RX/OTC RX/OTC 0.63 % NEONATAL VITAMIN 2 QL(1 ea daily) Steroids - Mouth/Throat/Dental TABS Ambetter Sunshine Formulary Updated December 1, 2020

130 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily); PRENATAL VITAMINS QL(1 ea daily); NIVA-PLUS TABS 2 2 RX/OTC PLUS LOW IRON TABS RX/OTC QL(1 ea daily); PRENATAL VITAMINS QL(1 ea daily) O-CAL FA TABS 2 2 RX/OTC TABS ONE VITE WOMENS QL(1 ea daily); PRENATRIX TABS 2 QL(1 ea daily); PRENATALVITAMIN PLUS 2 RX/OTC RX/OTC TABS QL(1 ea daily); PREPLUS TABS 2 ONE VITE WOMENS 2 QL(1 ea daily) RX/OTC PRENATALVITAMIN TABS PX PRENATAL 2 QL(1 ea daily) PRENATAL LOW IRON 2 QL(1 ea daily) MULTIVITAMINS TABS TABS QC PRENATAL TABS 2 QL(1 ea daily) PRENATAL 2 QL(1 ea daily) MULTIVITAMIN TABS RA PRENATAL QL(1 ea daily) FORMULA/FOLICACID 2 PRENATAL ONE DAILY 2 QL(1 ea daily) TABS TABS QL(1 ea daily) PRENATAL PLUS TABS 2 QL(1 ea daily); RA PRENATAL TABS 2 RX/OTC PRENATAL TABS 0.8 MG- QL(1 ea daily) RIGHT STEP PRENATAL 2 QL(1 ea daily) 1.5 MG-1.7 MG-100 MG-11 TABS UNIT-18 MG-2.6 MG-25 SM PRENATAL VITAMINS 2 QL(1 ea daily) MG-263 MG-27 MG-4 TABS MCG-400 UNIT-4000 THERANATAL CORE 2 QL(1 ea daily); UNIT, 0.8 MG-1.7 MG-1.8 NUTRITION TABS RX/OTC MG-120 MG-2.6 MG-20 TRICARE TABS 2 QL(1 ea daily); MG-200 MG-25 MG-28 RX/OTC MG-30 UNIT-400 UNIT- VITATHELY/GINGER QL(1 ea daily); 4000 UNIT-8 MCG, 1.7 2 2 MG-1.8 MG-120 MG-2.6 TABS RX/OTC QL(1 ea daily); MG-20 MG-200 MG-25 VOL-PLUS TABS 2 MG-28 MG-30 UNIT-400 RX/OTC UNIT-4000 UNIT-8 MCG- WESTAB PLUS TABS 2 QL(1 ea daily); 800 MCG, 1.7 MG-1.84 RX/OTC MG-100 MG-11 UNIT-160 MG-18 MG-2.6 MG-200 MUSCULOSKELETAL THERAPY AGENTS - MG-25 MG-27 MG-4 MCG- Drugs to Treat Spasms 400 UNIT-4000 UNIT-800 Central Muscle Relaxants MCG baclofen tabs or 10 mg, 20 1 PRENATAL TABS 1 MG- QL(1 ea daily); mg 1.84 MG-10 MG-12 MCG- RX/OTC 120 MG-2 MG-20 MG-200 2 carisoprodol tabs 1 MG-22 MG-25 MG-27 MG- 3 MG-400 UNIT-4000 UNIT chlorzoxazone tabs 500 mg 1 QL(6 ea daily) PRENATAL VITAMIN & QL(1 ea daily) 2 cyclobenzaprine hcl tabs 1 QL(3 ea daily) MINERAL TABS 10 mg, 5 mg PRENATAL VITAMIN 2 QL(1 ea daily) QL(4 ea daily) TABS metaxalone tabs 800 mg 1 PRENATAL QL(1 ea daily) 2 methocarbamol tabs or 500 1 VITAMIN/IRON TABS mg, 750 mg

Ambetter Sunshine Formulary Updated December 1, 2020

131 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits orphenadrine citrate tb12 QL(2 ea daily) Limit 2 inhalers 1 FLONASE ALLERGY or 100 mg per RELIEF SUSP (Use NF month;QL(32 ROBAXIN TABS OR 500 NF fluticasone propionate MG (Use methocarbamol) (nasal)) ml per 30 days retail); RX/OTC ROBAXIN-750 TABS (Use NF 1 rtl pack lmt methocarbamol) (nasal) soln 1 per fill, SKELAXIN TABS (Use NF QL(4 ea daily) metaxalone) Limit 2 inhalers per fluticasone propionate SOMA TABS (Use NF 1 month;QL(32 carisoprodol) (nasal) susp ml per 30 days tizanidine hcl caps 1 retail); RX/OTC mometasone furoate 1 PA; QL(1.14 tizanidine hcl tabs 1 (nasal) susp gm daily) NASACORT ALLERGY ZANAFLEX CAPS (Use NF tizanidine hcl) 24HR AERO (Use NF triamcinolone acetonide ZANAFLEX TABS (Use NF (nasal)) tizanidine hcl) NASACORT ALLERGY Direct Muscle Relaxants 24HR CHILDRENS AERO NF (Use triamcinolone DANTRIUM CAPS (Use NF QL(4 ea daily) dantrolene sodium) acetonide (nasal)) NASONEX SUSP (Use PA; QL(1.14 dantrolene sodium caps or 1 QL(4 ea daily) 100 mg, 50 mg, 25 mg mometasone furoate NF gm daily) (nasal)) NASAL AGENTS - SYSTEMIC AND TOPICAL - Drugs to treat the Nose or Sinus triamcinolone acetonide 1 (nasal) aero Nasal Antiallergy NEUROMUSCULAR AGENTS - Drugs to azelastine hcl soln 1 Relax/Paralyze Muscles ALS Agents olopatadine hcl (nasal) soln 1 RILUTEK TABS (Use NF riluzole) PATANASE SOLN (Use NF olopatadine hcl (nasal)) riluzole tabs 3 Nasal Anticholinergics Neuromuscular Blocking Agent - Neurotoxins ipratropium bromide (nasal) 1 QL(1 ml daily) soln 0.03 % BOTOX SOLR 3 PA ipratropium bromide (nasal) 1 soln 0.06 % DYSPORT SOLR 3 PA Nasal Steroids XEOMIN SOLR 3 PA budesonide (nasal) susp 1 Limit 2 inhalers NUTRIENTS FLONASE ALLERGY per Proteins RELIEF CHILDRENS NF month;QL(32 SUSP (Use fluticasone CLINIMIX propionate (nasal)) ml per 30 days retail); RX/OTC 4.25%/DEXTROSE 10% 3 SOLN Ambetter Sunshine Formulary Updated December 1, 2020

132 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLINIMIX tropicamide soln 1 4.25%/DEXTROSE 25% 3 SOLN Miotics CLINIMIX ISOPTO CARPINE SOLN NF 4.25%/DEXTROSE 5% 3 (Use pilocarpine hcl) SOLN PHOSPHOLINE IODIDE 3 CLINIMIX 5%/DEXTROSE 3 SOLR 25% SOLN CLINIMIX E pilocarpine hcl soln 1 5%/DEXTROSE 20% 3 SOLN Ophthalmic Adrenergic Agents ALPHAGAN P SOLN 0.15 OPHTHALMIC AGENTS - Drugs to Treat the Eye % (Use brimonidine NF tartrate) Artificial Tears and Lubricants apraclonidine hcl soln 1 LACRISERT INST 3 brimonidine tartrate soln 1 Beta-blockers - Ophthalmic IOPIDINE SOLN 0.5 % BETAGAN SOLN (Use NF NF levobunolol hcl) (Use apraclonidine hcl) betaxolol hcl (ophth) soln 1 IOPIDINE SOLN 1 % 3 PA carteolol hcl (ophth) soln 1 SIMBRINZA SUSP 3

COMBIGAN SOLN 2 Ophthalmic Anti-infectives COSOPT SOLN (Use AZASITE SOLN 3 dorzolamide hcl-timolol NF maleate) bacitracin (ophthalmic) oint 3 dorzolamide hcl-timolol BLEPH-10 SOLN (Use maleate soln 0.5 %-2 %, 20 1 sulfacetamide sodium NF mg/ml-5 mg/ml, 22.3 (ophth)) mg/ml-6.8 mg/ml CILOXAN SOLN (Use NF levobunolol hcl soln 1 ciprofloxacin hcl (ophth)) ciprofloxacin hcl (ophth) 1 metipranolol soln 1 soln erythromycin (ophth) oint 1 timolol maleate (ophth) 1 solg 0.25 %, 0.5 % gatifloxacin (ophth) soln 1 timolol maleate (ophth) 1 soln 0.25 %, 0.5 % gentamicin sulfate (ophth) 1 TIMOPTIC SOLN (Use NF oint timolol maleate (ophth)) gentamicin sulfate (ophth) 1 TIMOPTIC-XE SOLG (Use NF soln timolol maleate (ophth)) KLARITY-A SOLN 3 Cycloplegic Mydriatics MYDRIACYL SOLN (Use NF levofloxacin (ophth) soln 1 tropicamide) Ambetter Sunshine Formulary Updated December 1, 2020

133 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits moxifloxacin hcl (ophth) 1 Ophthalmic Steroids soln ALREX SUSP 3 PA NATACYN SUSP 2 dexamethasone sodium 1 neomycin-bacitracin zn- 1 phosphate (ophth) soln polymyxin oint PA NEOSPORIN SOLN (Use DUREZOL EMUL 3 neomycin-polymyxin- NF (ophth) 1 gramicidin) susp OCUFLOX SOLN (Use NF PA ofloxacin (ophth)) FML FORTE SUSP 3 ofloxacin (ophth) soln 1 FML LIQUIFILM SUSP (Use fluorometholone NF polymyxin b-trimethoprim 1 (ophth)) soln FML OINT 3 PA POLYTRIM SOLN (Use NF polymyxin b-trimethoprim) LOTEMAX GEL 3 PA sulfacetamide sodium 1 (ophth) soln LOTEMAX OINT 3 PA tobramycin (ophth) soln 1 LOTEMAX SUSP (Use 3 PA etabonate) TOBREX SOLN (Use NF tobramycin (ophth)) loteprednol etabonate susp 1 PA soln 1 MAXIDEX SUSP 3 PA VIGAMOX SOLN (Use NF moxifloxacin hcl (ophth)) MAXITROL OINT (Use neomycin-polymy- NF VIROPTIC SOLN (Use NF dexameth) trifluridine) MAXITROL SUSP (Use ZIRGAN GEL 2 neomycin-polymy- NF dexameth) ZYMAXID SOLN (Use NF gatifloxacin (ophth)) neomycin-polymy- 1 dexameth oint Ophthalmic Immunomodulators neomycin-polymy- 1 RESTASIS EMUL 2 PA dexameth susp neomycin-polymyxin-hc 1 RESTASIS MULTIDOSE 2 PA (ophth) susp EMUL OMNIPRED SUSP (Use Ophthalmic Local Anesthetics NF (ophth)) ALCAINE SOLN (Use NF proparacaine hcl) PRED FORTE SUSP (Use prednisolone acetate NF proparacaine hcl soln 1 (ophth)) Ophthalmic Nerve Growth Factors PRED MILD SUSP 3 PA OXERVATE SOLN 4 PA

Ambetter Sunshine Formulary Updated December 1, 2020

134 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits prednisolone acetate 1 ketorolac tromethamine 1 (ophth) susp (ophth) soln PREDNISOLONE 1 ketotifen fumarate (ophth) 1 ACETATE P-F SUSP soln PREDNISOLONE SODIUM LASTACAFT SOLN 3 PA PHOSPHATE SOLN OP 1 3 % ST; QL(0.2 ml NEVANAC SUSP 3 TOBRADEX SUSP (Use daily) NF tobramycin- olopatadine hcl soln 1 RX/OTC dexamethasone) PATADAY SOLN (Use RX/OTC tobramycin- 1 NF dexamethasone susp olopatadine hcl) Ophthalmics - Misc. PATANOL SOLN (Use NF RX/OTC olopatadine hcl) ACULAR LS SOLN (Use ketorolac tromethamine NF TRUSOPT SOLN (Use NF (ophth)) dorzolamide hcl) ACULAR SOLN (Use ZADITOR SOLN (Use 1 ketorolac tromethamine NF ketotifen fumarate (ophth)) (ophth)) ZERVIATE SOLN 3 PA ALOCRIL SOLN 3 PA Prostaglandins - Ophthalmic PA ALOMIDE SOLN 3 bimatoprost soln 3 azelastine hcl (ophth) soln 1 latanoprost soln 1 PA BEPREVE SOLN 3 LUMIGAN SOLN 3 ST bromfenac sodium (ophth) 1 TRAVATAN Z SOLN (Use 2 soln travoprost) cromolyn sodium (ophth) 1 soln travoprost soln 1 XALATAN SOLN (Use CYSTARAN SOLN 2 PA; QL(2.143 NF ml daily) latanoprost) diclofenac sodium (ophth) 1 ZIOPTAN SOLN 2 soln dorzolamide hcl soln 1 OTIC AGENTS - Drugs to Treat the Ear

ELESTAT SOLN (Use NF Otic Agents - Miscellaneous epinastine hcl (ophth)) acetic acid (otic) soln 1 EMADINE SOLN 3 Otic Anti-infectives epinastine hcl (ophth) soln 1 CETRAXAL SOLN (Use 1 ciprofloxacin hcl (otic)) flurbiprofen sodium soln 1 ciprofloxacin hcl (otic) soln 1 ST; QL(0.2 ml ILEVRO SUSP 3 daily) FLOXIN OTIC SOLN (Use NF ofloxacin (otic)) Ambetter Sunshine Formulary Updated December 1, 2020

135 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ofloxacin (otic) soln 1 GAMMAGARD S/D IGA PA; SP LESS THAN 1MCG/ML 4 Otic Combinations SOLR PA; SP CIPRO HC SUSP 3 GAMMAKED SOLN 4 CIPRODEX SUSP (Use PA GAMUNEX-C SOLN 4 PA; SP ciprofloxacin- 2 dexamethasone) HIZENTRA SOLN 1 PA; SP 4 ciprofloxacin- PA GM/5ML, 10 GM/50ML, 2 1 GM/10ML, 4 GM/20ML dexamethasone susp Passive Immunizing Agents - Combinations ciprofloxacin-fluocinolone 1 PA; QL(0.5 ea acetonide soln daily) HYQVIA KIT 4 PA COLY-MYCIN S SUSP 3 PENICILLINS - Drugs to Treat Bacterial Infections CORTISPORIN-TC SUSP 3 Aminopenicillins neomycin-polymyxin-hc 1 (otic) soln amoxicillin caps 1 neomycin-polymyxin-hc 1 amoxicillin chew 1 (otic) susp OTOVEL SOLN (Use PA; QL(0.5 ea amoxicillin susr 1 ciprofloxacin-fluocinolone 3 daily) acetonide) amoxicillin tabs 1 Otic Steroids DERMOTIC OIL (Use ampicillin caps 1 fluocinolone acetonide NF ampicillin sodium solr ij 1 1 (otic)) gm fluocinolone acetonide 1 ampicillin sodium solr iv 10 1 (otic) oil gm hydrocortisone w/acetic 1 acid soln Natural Penicillins PENICILLIN G PASSIVE IMMUNIZING AND TREATMENT POTASSIUM IN ISO- AGENTS - Antibody Drugs to Treat Low Immune OSMOTIC DEXTROSE 1 System SOLN 40000 UNIT/ML, Immune Serums 60000 UNIT/ML CUVITRU SOLN 1 PA; SP penicillin g potassium solr 1 GM/5ML, 10 GM/50ML, 2 4 5000000 unit GM/10ML, 4 GM/20ML PENICILLIN G PROCAINE 3 GAMMAGARD LIQUID PA; SP SUSP SOLN 1 GM/10ML, 10 4 penicillin g sodium solr 3 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 5 GM/50ML penicillin v potassium solr 1 GAMMAGARD LIQUID 4 PA SOLN 30 GM/300ML penicillin v potassium tabs 1 Penicillin Combinations

Ambetter Sunshine Formulary Updated December 1, 2020

136 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits amoxicillin & pot 1 oxacillin sodium solr iv 10 1 clavulanate chew gm amoxicillin & pot 1 PROGESTINS - Hormone Replacement/Modifying clavulanate susr Drugs amoxicillin & pot 1 Progestins clavulanate tabs AYGESTIN TABS (Use 0 amoxicillin & pot 1 norethindrone acetate) clavulanate tb12 medroxyprogesterone 1 ampicillin & sulbactam acetate tabs sodium solr ij 0.5 gm-1 gm, 1 1 gm-2 gm MEGACE ES SUSP (Use PA megestrol acetate NF ampicillin & sulbactam 1 (appetite)) sodium solr iv 10 gm-5 gm megestrol acetate 1 PA AUGMENTIN ES-600 (appetite) susp SUSR (Use amoxicillin & NF pot clavulanate) norethindrone acetate tabs 0 AUGMENTIN SUSR 250 micronized MG/5ML-62.5 MG/5ML NF 1 (Use amoxicillin & pot caps clavulanate) PROMETRIUM CAPS (Use NF AUGMENTIN TABS 125 progesterone micronized) PROVERA TABS (Use MG-875 MG, 125 MG-500 NF MG (Use amoxicillin & pot medroxyprogesterone NF clavulanate) acetate) AUGMENTIN XR TB12 PSYCHOTHERAPEUTIC AND NEUROLOGICAL (Use amoxicillin & pot NF AGENTS - MISC. - Drugs to Treat Mental and clavulanate) Emotional Conditions piperacillin sodium- 1 Agents for Chemical Dependency tazobactam sodium solr UNASYN BULK PACK acamprosate calcium tbec 1 SOLR (Use ampicillin & NF ANTABUSE TABS (Use NF sulbactam sodium) disulfiram) UNASYN SOLR (Use ampicillin & sulbactam NF disulfiram tabs 1 sodium) PA; QL(224 ea ZOSYN SOLR 0.25 GM-2 LUCEMYRA TABS 3 per 14 days GM, 0.375 GM-3 GM, 0.5 retail) GM-4 GM, 36 GM-4.5 GM NF (Use piperacillin sodium- Anti-Cataplectic Agents tazobactam sodium) XYREM SOLN 4 PA; QL(18 ml daily); SP Penicillinase-Resistant Penicillins Antidementia Agents dicloxacillin sodium caps 1 ARICEPT TABS 10 MG QL(2 ea daily) (Use donepezil NF nafcillin sodium solr ij 1 gm 1 hydrochloride) oxacillin sodium solr ij 1 gm 1

Ambetter Sunshine Formulary Updated December 1, 2020

137 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ARICEPT TABS 5 MG QL(1 ea daily) AUSTEDO TABS 4 PA; QL(4 ea (Use donepezil NF daily) hydrochloride) PA; QL(3 ea tetrabenazine tabs 4 donepezil hydrochloride 1 QL(2 ea daily) daily); SP tabs 10 mg XENAZINE TABS (Use NF PA; QL(3 ea donepezil hydrochloride 1 QL(1 ea daily) tetrabenazine) daily); SP tabs 5 mg Multiple Sclerosis Agents donepezil hydrochloride 1 QL(2 ea daily) tbdp 10 mg AMPYRA TB12 (Use NF PA; QL(2 ea dalfampridine) daily); SP donepezil hydrochloride QL(1 ea daily) 1 PA tbdp 5 mg AUBAGIO TABS 4 galantamine hydrobromide QL(1 ea daily) PA; QL(0.0714 1 AVONEX PEN AJKT 4 cp24 16 mg, 24 mg, 8 mg ea daily); SP galantamine hydrobromide QL(6 ml daily) 1 AVONEX PSKT 4 PA; QL(0.0714 soln 4 mg/ml ml daily); SP galantamine hydrobromide QL(2 ea daily) 1 BETASERON KIT 4 PA; QL(0.0357 tabs 12 mg, 4 mg, 8 mg ea daily); SP memantine hcl tabs 1 COPAXONE SOSY 20 PA; QL(1 ml MG/ML (Use glatiramer NF daily); SP memantine hcl tabs 10 mg 1 QL(2 ea daily) acetate) COPAXONE SOSY 40 PA; QL(0.429 memantine hcl tabs 5 mg 1 QL(1 ea daily) MG/ML (Use glatiramer NF ml daily); SP acetate) NAMENDA TABS 10 MG QL(2 ea daily) NF PA; QL(2 ea (Use memantine hcl) dalfampridine tb12 4 daily); SP NAMENDA TABS 5 MG NF QL(1 ea daily) (Use memantine hcl) dimethyl fumarate cpdr 4 PA NAMENDA TITRATION PA PAK TABS (Use NF dimethyl fumarate misc 4 ) memantine hcl PA; QL(0.0357 EXTAVIA KIT 4 RAZADYNE ER CP24 (Use NF QL(1 ea daily) ea daily); SP galantamine hydrobromide) PA; 30 rtl lmt RAZADYNE TABS (Use NF QL(2 ea daily) GILENYA CAPS 0.25 MG 4 day(s),30 mail galantamine hydrobromide) lmt day(s), rivastigmine tartrate caps 1 GILENYA CAPS 0.5 MG 4 PA; SP

Combination Psychotherapeutics glatiramer acetate sosy 20 3 PA; QL(1 ml mg/ml daily); SP perphenazine-amitriptyline 1 QL(4 ea daily) tabs glatiramer acetate sosy 40 3 PA; QL(0.429 mg/ml ml daily); SP Fibromyalgia Agents MAVENCLAD TBPK 4 PA SAVELLA TABS 2 PA; QL(2 ea daily) MAYZENT STARTER 4 PA SAVELLA TITRATION 2 PA PACK TBPK PACK MISC MAYZENT TABS 4 PA Movement Disorder Drug Therapy

Ambetter Sunshine Formulary Updated December 1, 2020

138 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OCREVUS SOLN 4 PA Restless Leg Syndrome (RLS) Agents PA; QL(2 ea HORIZANT TBCR 3 PLEGRIDY SOPN 4 PA; QL(0.0357 daily) ml daily) Smoking Deterrents PLEGRIDY SOSY 4 PA bupropion hcl (smoking 0 QL(2 ea daily) deterrent) tb12 PLEGRIDY STARTER 4 PA PACK SOPN CHANTIX CONTINUING 0 QL(2 ea daily) MONTHPAK TABS PLEGRIDY STARTER 4 PA; QL(0.0357 PACK SOSY ml daily) CHANTIX STARTING 0 MONTH PAK TABS REBIF REBIDOSE SOAJ 4 PA; QL(0.214 ml daily); SP CHANTIX TABS 0 QL(2 ea daily) REBIF REBIDOSE 4 PA; SP TITRATIONPACK SOAJ NICODERM CQ PT24 (Use 0 QL(1 ea daily) PA; QL(0.214 nicotine) REBIF SOSY 4 ml daily); SP GUM (Use 0 nicotine polacrilex) REBIF TITRATION PACK 4 PA; SP SOSY NICORETTE LOZG (Use 0 nicotine polacrilex) TECFIDERA CPDR (Use 4 PA dimethyl fumarate) NICORETTE MINI LOZG 0 TECFIDERA STARTER PA (Use nicotine polacrilex) PACK MISC (Use dimethyl 4 NICORETTE STARTER fumarate) KIT GUM (Use nicotine 0 PA; QL(0.536 polacrilex) TYSABRI CONC 4 ml daily); SP nicotine polacrilex gum 0 Postherpetic Neuralgia (PHN)/Neuropathic Pain nicotine polacrilex lozg 0 LYRICA CR TB24 165 MG, 3 PA; QL(1 ea 82.5 MG daily) nicotine pt24 0 QL(1 ea daily) PA; QL(2 ea LYRICA CR TB24 330 MG 3 daily) NICOTINE Premenstrual Dysphoric Disorder (PMDD) Agents TRANSDERMAL SYSTEM 0 KIT fluoxetine hcl (pmdd) caps 1 QL(1 ea daily) 10 mg NICOTROL INHALER 0 INHA fluoxetine hcl (pmdd) caps 1 QL(3 ea daily) 20 mg NICOTROL NS SOLN 0 Pseudobulbar Affect (PBA) Agents ZYBAN TB12 (Use QL(2 ea daily) NUEDEXTA CAPS 3 PA bupropion hcl (smoking 0 deterrent)) Psychotherapeutic and Neurological Agents - Transthyretin Amyloidosis Agents ergoloid mesylates tabs 3 TEGSEDI SOSY 4 PA

ORAP TABS (Use NF RESPIRATORY AGENTS - MISC. - Drugs to pimozide) Treat Lung Conditions pimozide tabs 1 Alpha-Proteinase Inhibitor (Human)

Ambetter Sunshine Formulary Updated December 1, 2020

139 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ARALAST NP SOLR 1000 4 PA; SP doxycycline (monohydrate) 1 MG, 400 MG caps 75 mg ARALAST NP SOLR 500 4 PA doxycycline (monohydrate) 1 QL(2 ea daily) MG tabs 100 mg PROLASTIN-C SOLN 1000 4 PA; doxycycline (monohydrate) 1 MG/20ML tabs 50 mg PROLASTIN-C SOLR 1000 4 PA; SP doxycycline hyclate caps or 1 QL(2 ea daily) MG 50 mg, 100 mg ZEMAIRA SOLR 4 PA; SP doxycycline hyclate solr iv 1 100 mg Cystic Fibrosis Agents doxycycline hyclate tabs or 1 QL(2 ea daily) PA; QL(2 ea 100 mg, 20 mg KALYDECO TABS 150 MG 4 daily); SP MINOCIN CAPS OR 50 NF QL(3 ea daily) MG (Use hcl) ORKAMBI PACK 100 MG- 4 PA; QL(2 ea 125 MG, 150 MG-188 MG daily) minocycline hcl caps 50 1 QL(3 ea daily) mg, 75 mg, 100 mg ORKAMBI TABS 100 MG- 4 PA; QL(4 ea 125 MG, 125 MG-200 MG daily) minocycline hcl tabs 100 1 QL(3 ea daily) PA; QL(2.5 ml mg, 50 mg, 75 mg PULMOZYME SOLN 4 daily); SP TARGADOX TABS (Use NF PA; QL(3 ea doxycycline hyclate) TRIKAFTA TBPK 4 daily) hcl caps 1 QL(8 ea daily) Pulmonary Fibrosis Agents VIBRAMYCIN CAPS 100 QL(2 ea daily) PA; QL(2 ea OFEV CAPS 4 MG (Use doxycycline NF daily) hyclate) SULFONAMIDES - Drugs to Treat Bacterial XIMINO CP24 135 MG, 45 Infections MG, 90 MG (Use NF minocycline hcl) Sulfonamides THYROID AGENTS - Drugs to Regulate Thyroid SULFADIAZINE TABS 1 Hormones - Drugs to Treat Bacterial Antithyroid Agents Infections methimazole tabs 1 solr 1 propylthiouracil tabs 1 TAPAZOLE TABS (Use NF TIGECYCLINE SOLR 3 methimazole) Thyroid Hormones TYGACIL SOLR (Use 3 tigecycline) ARMOUR THYROID TABS QL(1 ea daily) Tetracyclines 120 MG, 15 MG, 30 MG, 2 60 MG, 90 MG (Use hcl tabs 1 thyroid) ARMOUR THYROID TABS QL(1 ea daily) doxycycline (monohydrate) 1 QL(2 ea daily) 2 caps 100 mg, 50 mg 180 MG, 240 MG, 300 MG CYTOMEL TABS (Use NF liothyronine sodium) Ambetter Sunshine Formulary Updated December 1, 2020

140 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits levothyroxine sodium tabs glycopyrrolate soln ij 4 1 or 300 mcg, 100 mcg, 112 mg/20ml mcg, 125 mcg, 137 mcg, 1 glycopyrrolate tabs or 1 1 150 mcg, 175 mcg, 200 mg, 2 mg mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg LIBRAX CAPS (Use chlordiazepoxide hcl- NF liothyronine sodium soln 1 clidinium bromide) methscopolamine bromide 1 liothyronine sodium tabs 1 tabs H-2 Antagonists NATURE-THROID NT-2.5 2 TABS hcl soln 1 QL(20 ml daily) NATURE-THROID TABS 2 cimetidine tabs 200 mg 1 RX/OTC SYNTHROID TABS (Use 2 levothyroxine sodium) cimetidine tabs 300 mg, 1 400 mg, 800 mg thyroid tabs 1 QL(1 ea daily) famotidine in nacl soln 1 TRIOSTAT SOLN (Use NF liothyronine sodium) famotidine soln iv 20 mg/2ml, 200 mg/20ml, 40 1 WESTHROID TABS 2 mg/4ml famotidine susr or 40 1 QL(10 ml daily) WP THYROID TABS 2 mg/5ml TOXOIDS famotidine tabs or 20 mg 1 RX/OTC

Toxoid Combinations famotidine tabs or 40 mg 1 ADACEL SUSP 0 NIZATIDINE CAPS 150 1 MG BOOSTRIX SUSP 0 nizatidine caps 150 mg, 1 ULCER DRUGS - Drugs to Treat Bowel, Intestine 300 mg and Stomach Conditions nizatidine soln 15 mg/ml 1 QL(20 ml daily) Antispasmodics PEPCID AC MAXIMUM RX/OTC atropine sulfate soln ij 0.1 1 STRENGTH TABS (Use NF mg/ml, 0.4 mg/ml, 1 mg/ml famotidine) atropine sulfate sosy ij 0.25 1 PEPCID SUSR 40 MG/5ML NF QL(10 ml daily) mg/5ml (Use famotidine) chlordiazepoxide hcl- 1 PEPCID TABS 20 MG (Use NF RX/OTC clidinium bromide caps famotidine) dicyclomine hcl caps or 10 1 PEPCID TABS 40 MG (Use NF mg famotidine) dicyclomine hcl soln or 10 1 hcl caps or 150 1 mg/5ml mg, 300 mg dicyclomine hcl tabs or 20 1 ranitidine hcl soln ij 150 1 mg mg/6ml

Ambetter Sunshine Formulary Updated December 1, 2020

141 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ranitidine hcl syrp or 15 QL(40 ml daily) omeprazole cpdr 10 mg, 40 1 QL(2 ea daily) mg/ml, 150 mg/10ml, 75 1 mg mg/5ml QL(2 ea daily); omeprazole cpdr 20 mg 1 ranitidine hcl tabs or 150 1 RX/OTC RX/OTC mg omeprazole magnesium 1 QL(4 ea daily) ranitidine hcl tabs or 300 1 cpdr mg omeprazole magnesium 1 QL(4 ea daily) TAGAMET HB TABS (Use NF RX/OTC tbec cimetidine) omeprazole tbec 20 mg 1 QL(2 ea daily) ZANTAC 150 MAXIMUM RX/OTC STRENGTH TABS (Use NF pantoprazole sodium tbec 1 QL(1 ea daily) ranitidine hcl) or 20 mg ZANTAC SOLN 25 MG/ML, pantoprazole sodium tbec 1 25 MG/ML (Use ranitidine NF or 40 mg hcl) PREVACID 24HR CPDR NF QL(2 ea daily); Misc. Anti-Ulcer (Use lansoprazole) RX/OTC PREVACID CPDR 15 MG QL(2 ea daily); CARAFATE SUSP 1 2 QL(40 ml daily) NF GM/10ML (Use sucralfate) (Use lansoprazole) RX/OTC PREVACID CPDR 30 MG CARAFATE TABS 1 GM NF QL(4 ea daily) NF (Use sucralfate) (Use lansoprazole) QL(40 ml daily) PRILOSEC OTC TBEC QL(4 ea daily) sucralfate susp 1 gm/10ml 1 (Use omeprazole 1 magnesium) sucralfate tabs 1 gm 1 QL(4 ea daily) PROTONIX TBEC OR 20 QL(1 ea daily) Proton Pump Inhibitors MG (Use pantoprazole NF sodium) ACIPHEX TBEC (Use NF QL(1 ea daily) rabeprazole sodium) PROTONIX TBEC OR 40 MG (Use pantoprazole NF DEXILANT CPDR 3 PA; QL(1 ea sodium) daily) rabeprazole sodium tbec 1 QL(1 ea daily) esomeprazole magnesium 1 QL(2 ea daily); cpdr 20 mg RX/OTC Ulcer Drugs - Prostaglandins esomeprazole magnesium 3 QL(1 ea daily) cpdr 40 mg CYTOTEC TABS (Use NF QL(4 ea daily) ) QL(2 ea daily); misoprostol lansoprazole cpdr 15 mg 1 RX/OTC misoprostol tabs 1 QL(4 ea daily) lansoprazole cpdr 30 mg 1 Ulcer Therapy Combinations NEXIUM 24HR TBEC 1 QL(2 ea daily) omeprazole-sodium QL(1 ea daily); bicarbonate caps 1100 mg- 1 RX/OTC NEXIUM CPDR 20 MG QL(2 ea daily); 20 mg (Use esomeprazole NF RX/OTC ZEGERID CAPS 1100 MG- RX/OTC magnesium) 20 MG (Use omeprazole- NF NEXIUM CPDR 40 MG QL(1 ea daily) sodium bicarbonate) (Use esomeprazole NF URINARY ANTI-INFECTIVES - Drugs to Treat magnesium) Bladder/ Infections Urinary Anti-infectives Ambetter Sunshine Formulary Updated December 1, 2020

142 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits nitrofurantoin monohyd 1 URECHOLINE TABS 10 QL(4 ea daily) macro caps MG, 5 MG, 50 MG (Use NF bethanechol chloride) URINARY ANTISPASMODICS - Drugs to Treat Miscellaneous Bladder Spasms URECHOLINE TABS 25 MG (Use bethanechol NF Urinary Antispasmodic - Antimuscarinics chloride) QL(1 ea daily) darifenacin hydrobromide 1 Urinary Antispasmodics - Direct Muscle Relaxants tb24 flavoxate hcl tabs 1 DETROL LA CP24 (Use NF QL(1 ea daily) tolterodine tartrate) VACCINES DETROL TABS (Use NF tolterodine tartrate) Bacterial Vaccines DITROPAN XL TB24 (Use NF oxybutynin chloride) MENACTRA INJ 0 ENABLEX TB24 (Use NF QL(1 ea daily) darifenacin hydrobromide) MENQUADFI INJ 0 oxybutynin chloride syrp 1 MENVEO SOLR 0 oxybutynin chloride tabs 1 PNEUMOVAX 23 INJ 0 oxybutynin chloride tb24 1 PNEUMOVAX 23/1 DOSE 0 INJ PA; QL(1 ea solifenacin succinate tabs 1 daily) PREVNAR 13 SUSP 0 tolterodine tartrate cp24 2 1 QL(1 ea daily) Viral Vaccines mg, 4 mg Limit 1 dose tolterodine tartrate tabs 1 1 AFLURIA 2018-2019 SUSP 0 per season;1 rtl mg, 2 mg MAX fill,180 rtl PA; QL(1 ea TOVIAZ TB24 3 day(s) supply, daily) Limit 1 dose trospium chloride cp24 60 QL(1 ea daily) 1 AFLURIA PF 2018-2019 0 per season;1 rtl mg SUSY MAX fill,180 rtl day(s) supply, trospium chloride tabs 20 1 mg Limit 1 dose AFLURIA QUADRIVALENT per season;1 rtl VESICARE TABS (Use 3 PA; QL(1 ea 0 solifenacin succinate) daily) 2018-2019 SUSP MAX fill,180 rtl day(s) supply, Urinary Antispasmodics - Beta-3 Adrenergic Limit 1 dose 3 PA MYRBETRIQ TB24 AFLURIA QUADRIVALENT 0 per season;1 rtl 2018-2019 SUSY MAX fill,180 rtl Urinary Antispasmodics - Cholinergic Agonists day(s) supply, bethanechol chloride tabs 1 QL(4 ea daily) Limit 1 dose 10 mg, 5 mg, 50 mg AFLURIA QUADRIVALENT 0 per season;1 rtl 2019-2020 SUSP MAX fill,180 rtl bethanechol chloride tabs 1 25 mg day(s) supply,

Ambetter Sunshine Formulary Updated December 1, 2020

143 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 1 dose Limit 1 dose FLUBLOK AFLURIA QUADRIVALENT 0 per season;1 rtl 0 per season;1 rtl 2019-2020 SUSY MAX fill,180 rtl QUADRIVALENT 2018- 2019 SOSY MAX fill,180 rtl day(s) supply, day(s) supply, Limit 1 dose Limit 1 dose FLUBLOK AFLURIA QUADRIVALENT 0 per season;1 rtl 0 per season;1 rtl 2020-2021 SUSP MAX fill,180 rtl QUADRIVALENT 2019- 2020 SOSY MAX fill,180 rtl day(s) supply, day(s) supply, Limit 1 dose Limit 1 dose FLUBLOK AFLURIA QUADRIVALENT 0 per season;1 rtl 0 per season;1 rtl 2020-2021 SUSY MAX fill,180 rtl QUADRIVALENT 2020- 2021 SOSY MAX fill,180 rtl day(s) supply, day(s) supply, 1 rtl MAX Limit 1 dose ENGERIX-B INJ 0 fill,365 rtl FLUCELVAX QUADRIVALENT 2018- 0 per season;1 rtl day(s) supply, MAX fill,180 rtl 2019 SUSP 1 rtl MAX day(s) supply, ENGERIX-B SUSP 0 fill,365 rtl Limit 1 dose day(s) supply, FLUCELVAX QUADRIVALENT 2018- 0 per season;1 rtl Limit 1 dose 2019 SUSY MAX fill,180 rtl day(s) supply, FLUAD 2018-2019 SUSY 0 per season;1 rtl MAX fill,180 rtl Limit 1 dose FLUCELVAX day(s) supply, 0 per season;1 rtl QUADRIVALENT 2019- MAX fill,180 rtl Limit 1 dose 2020 SUSP per season;1 rtl day(s) supply, FLUAD 2019-2020 SUSY 0 MAX fill,180 rtl Limit 1 dose day(s) supply, FLUCELVAX QUADRIVALENT 2019- 0 per season;1 rtl Limit 1 dose 2020 SUSY MAX fill,180 rtl day(s) supply, FLUAD 2020-2021 SUSY 0 per season;1 rtl MAX fill,180 rtl Limit 1 dose FLUCELVAX day(s) supply, 0 per season;1 rtl QUADRIVALENT 2020- MAX fill,180 rtl FLUAD QUADRIVALENT 1 rtl MAX 2021 SUSP INFLUENZA VACCINE 0 fill,180 rtl day(s) supply, FOR ADULTS PRSY day(s) supply, Limit 1 dose FLUCELVAX Limit 1 dose QUADRIVALENT 2020- 0 per season;1 rtl MAX fill,180 rtl FLUARIX QUADRIVALENT 0 per season;1 rtl 2021 SUSY 2018-2019 SUSY MAX fill,180 rtl day(s) supply, day(s) supply, Limit 1 dose FLULAVAL Limit 1 dose QUADRIVALENT 2018- 0 per season;1 rtl MAX fill,180 rtl FLUARIX QUADRIVALENT 0 per season;1 rtl 2019 SUSP 2019-2020 SUSY MAX fill,180 rtl day(s) supply, day(s) supply, Limit 1 dose FLULAVAL Limit 1 dose QUADRIVALENT 2018- 0 per season;1 rtl MAX fill,180 rtl FLUARIX QUADRIVALENT 0 per season;1 rtl 2019 SUSY 2020-2021 SUSY MAX fill,180 rtl day(s) supply, day(s) supply, Limit 1 dose FLULAVAL QUADRIVALENT 2019- 0 per season;1 rtl 2020 SUSP MAX fill,180 rtl day(s) supply,

Ambetter Sunshine Formulary Updated December 1, 2020

144 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 1 dose 1 rtl MAX FLULAVAL 0 QUADRIVALENT 2019- 0 per season;1 rtl GARDASIL 9 SUSP fill,365 rtl MAX fill,180 rtl day(s) supply, 2020 SUSY day(s) supply, 1 rtl MAX Limit 1 dose GARDASIL 9 SUSY 0 fill,365 rtl FLULAVAL 0 per season;1 rtl day(s) supply, QUADRIVALENT 2020- MAX fill,180 rtl 2021 SUSY 1 rtl MAX day(s) supply, HAVRIX SUSP 0 fill,365 rtl Limit 1 dose day(s) supply, FLUMIST 0 per season;1 rtl 1 rtl MAX QUADRIVALENT SUSP MAX fill,180 rtl HEPLISAV-B SOLN 0 fill,365 rtl day(s) supply, day(s) supply, Limit 1 dose 1 rtl MAX FLUZONE HIGH-DOSE PF 0 per season;1 rtl HEPLISAV-B SOSY 0 fill,365 rtl 2018-2019 SUSY MAX fill,180 rtl day(s) supply, day(s) supply, 1 rtl MAX Limit 1 dose IPOL INACTIVATED IPV 0 fill,365 rtl INJ FLUZONE HIGH-DOSE PF 0 per season;1 rtl day(s) supply, 2019-2020 SUSY MAX fill,180 rtl day(s) supply, 1 rtl MAX M-M-R II SOLR 0 fill,365 rtl 1 rtl MAX day(s) supply, FLUZONE HIGH-DOSE PF 0 2020-2021 SUSY fill,180 rtl day(s) supply, 1 rtl MAX RECOMBIVAX HB SUSP 0 fill,365 rtl Limit 1 dose day(s) supply, FLUZONE per season;1 rtl QUADRIVALENT 2018- 0 1 rtl MAX 2019 SUSP MAX fill,180 rtl day(s) supply, ROTARIX SUSR 0 fill,365 rtl day(s) supply, Limit 1 dose FLUZONE per season;1 rtl 1 rtl MAX QUADRIVALENT 2018- 0 ROTATEQ SOLN 0 fill,365 rtl 2019 SUSY MAX fill,180 rtl day(s) supply, day(s) supply, AL(At least 50 Limit 1 dose SHINGRIX SUSR 0 FLUZONE per season;1 rtl yrs old) QUADRIVALENT 2019- 0 1 rtl MAX 2020 SUSP MAX fill,180 rtl day(s) supply, TWINRIX SUSP 0 fill,365 rtl Limit 1 dose day(s) supply, FLUZONE per season;1 rtl 1 rtl MAX QUADRIVALENT 2019- 0 TWINRIX SUSY 0 fill,365 rtl 2020 SUSY MAX fill,180 rtl day(s) supply, day(s) supply, Limit 1 dose 1 rtl MAX FLUZONE VAQTA SUSP 0 fill,365 rtl 0 per season;1 rtl QUADRIVALENT 2020- MAX fill,180 rtl day(s) supply, 2021 SUSP day(s) supply, 1 rtl MAX Limit 1 dose VARIVAX INJ 0 fill,365 rtl FLUZONE day(s) supply, QUADRIVALENT 2020- 0 per season;1 rtl MAX fill,180 rtl 2021 SUSY ZOSTAVAX SUSR 0 AL(At least 50 day(s) supply, yrs old) VAGINAL AND RELATED PRODUCTS Ambetter Sunshine Formulary Updated December 1, 2020

145 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Miscellaneous Vaginal Products Anaphylaxis Therapy Agents INTRAROSA INST 3 PA QL(2 ea per fill retail,2 ea per Spermicides fill mail)2 rtl epinephrine (anaphylaxis) 1 MAX fill,365 rtl SHUR-SEAL GEL 0 soaj 0.15 mg/0.3ml day(s) supply,2 mail MAX TODAY SPONGE MISC 0 fill,365 mail day(s) supply, Vaginal Anti-infectives QL(2 ea per fill CLEOCIN CREA VA 2 % epinephrine (anaphylaxis) 2 retail)2 rtl MAX (Use clindamycin NF soaj 0.3 mg/0.3ml fill,365 rtl phosphate vaginal) day(s) supply, clindamycin phosphate 1 QL(2 ea per fill vaginal crea retail,2 ea per fill mail)2 rtl clotrimazole vaginal crea 1 1 % epinephrine (anaphylaxis) 2 MAX fill,365 rtl soaj 0.3 mg/0.3ml day(s) supply,2 GYNAZOLE-1 CREA 3 mail MAX fill,365 mail GYNE-LOTRIMIN CREA NF day(s) supply, (Use clotrimazole vaginal) EPIPEN 2-PAK SOAJ (Use NF METROGEL-VAGINAL epinephrine (anaphylaxis)) GEL (Use metronidazole NF vaginal) QL(2 ea per fill retail,2 ea per metronidazole vaginal gel 1 EPIPEN-JR 2-PAK SOAJ fill mail)2 rtl MAX fill,365 rtl miconazole nitrate vaginal (Use epinephrine 2 1 (anaphylaxis)) day(s) supply,2 supp 200 mg mail MAX terconazole vaginal crea 1 fill,365 mail day(s) supply, terconazole vaginal supp 1 Vasopressors Vaginal Estrogens midodrine hcl tabs 1 ESTRACE CREA (Use NF estradiol vaginal) VITAMINS estradiol vaginal crea 1 Oil Soluble Vitamins cholecalciferol caps 1.25 1 estradiol vaginal tabs 1 mg, 50000 unit cholecalciferol tabs 400 0 FEMRING RING 3 unit DRISDOL CAPS (Use 0 PREMARIN CREA 2 ergocalciferol) VAGIFEM TABS (Use NF ergocalciferol caps or 1.25 0 estradiol vaginal) mg, 50000 unit VASOPRESSORS - Drugs to Treat Heart and ergocalciferol soln or 8000 1 Circulation Conditions unit/ml

Ambetter Sunshine Formulary Updated December 1, 2020

146 Drug Requirements/ Drug Name Tier Limits VITAMIN D2 TABS 400 0 AL(At least 65 UNIT yrs old) Water Soluble Vitamins niacin cpcr or 500 mg, 250 1 mg niacin tabs or 50 mg, 250 1 mg, 100 mg, 500 mg niacin tbcr or 750 mg, 250 1 mg, 500 mg NIACIN TR TBCR 1 niacinamide tabs or 100 1 mg, 500 mg SLO-NIACIN TBCR (Use 1 niacin)

Ambetter Sunshine Formulary Updated December 1, 2020

147 Index 1ST TIER UNIFINE ACCU-CHEK SAFE-T-PRO ADEMPAS 53 PENTIPS/MINI/31GX5MM 94 PLUSLANCETS 81 ADIPEX-P 1 1ST TIER UNIFINE ACCU-CHEK SOFTCLIX PENTIPS29GX12MM 94 LANCETS 81 ADJUSTABLE LANCING DEVICE 81 1ST TIER UNIFINE ACCUPRIL 31 ADVAIR DISKUS 15 PENTIPS31GX6MM 94 ACCURETIC 33 1ST TIER UNIFINE ADVAIR HFA 15 PENTIPS31GX8MM 94 acebutolol hcl 51 ADVANCED MOBILE LANCET 1ST TIER UNIFINE acetaminophen w/ codeine 8 30G 81 PENTIPS32GX4MM 94 acetaminophen-caff- ADVICOR 31 1ST TIER UNIFINE dihydrocod 8 ADVOCATE CONTROL PENTIPS32GX6MM 94 acetazolamide 68 SOLUTIONHIGH 81 1ST TIER UNIFINE ADVOCATE INSULIN PEN PENTIPSPLUS 31GX8MM 94 acetazolamide sodium 68 acetic acid 74 NEEDLES 29GX12.7MM 94 1ST TIER UNIFINE ADVOCATE INSULIN PEN PENTIPSPLUS 32GX4MM 94 acetic acid (otic) 135 NEEDLES 31GX5MM 94 1ST TIER UNIFINE acetylcysteine 58 ADVOCATE INSULIN PEN PENTIPSPLUS/MINI/31GX5MM ACIPHEX 142 NEEDLES 31GX8MM 94 94 ADVOCATE INSULIN 1ST TIER UNIFINE acitretin 62 SYRINGE/U- PENTIPSPLUS/ORIGINAL/29GX ACTEMRA 4 100/0.3ML/29GX1/2" 94 12MM 94 ADVOCATE INSULIN 1ST TIER UNIFINE ACTHAR 69 ACTI-LANCE LANCETS SYRINGE/U- PENTIPSPLUS/ULTRA 100/0.3ML/30GX5/16" 94 SHORT/31GX6MM 94 28G 81 ACTI-LANCE LITE SAFETY ADVOCATE INSULIN 1ST TIER UNILET SYRINGE/U- COMFORTOUCH LANCETS LANCETS 28G 81 ACTI-LANCE SPECIAL 100/0.3ML/31GX5/16" 94 28G 80 ADVOCATE INSULIN 1ST TIER UNILET SAFETY LANCETS 17G 81 ACTI-LANCE SPECIAL SYRINGE/U- COMFORTOUCH LANCETS 100/0.5ML/29GX1/2" 94 30G 80 SAFETYLANCETS 17G 81 ACTI-LANCE UNIVERSAL ADVOCATE INSULIN abacavir sulfate 46 SAFETY LANCETS 23G 81 SYRINGE/U- abacavir sulfate-lamivudine 46 ACTIGALL 73 100/0.5ML/30GX5/16" 94 ADVOCATE INSULIN abacavir sulfate-lamivudine- ACTIMMUNE 42 zidovudine 46 SYRINGE/U- ABELCET 28 ACTIQ 6 100/0.5ML/31GX5/16" 95 ADVOCATE INSULIN ABILIFY 46 ACTONEL 68,69 ACTOPLUS MET 24 SYRINGE/U-100/1ML/29GX1/2" abiraterone acetate 38 95 ABOUTTIME PEN NEEDLE ACTOS 25 ADVOCATE INSULIN 32GX 5/32" 94 ACULAR 135 SYRINGE/U-100/1ML/30GX5/16" ABOUTTIME PEN NEEDLES ACULAR LS 135 95 30GX 5/16" 94 ADVOCATE INSULIN ABOUTTIME PEN NEEDLES acyclovir 50 SYRINGE/U-100/1ML/31GX5/16" 31G X 3/16" 94 acyclovir topical 63 95 ABOUTTIME PEN NEEDLES ADACEL 141 ADVOCATE LANCETS 81 31G X 5/16" 94 ADAGEN 3 ADVOCATE LANCETS 30G 81 ABRAXANE 42 ADALAT CC 51 ADVOCATE LANCING acamprosate calcium 137 adapalene 58 DEVICE 81 acarbose 24 adapalene-benzoyl ADVOCATE RAPID-SAFE ACCOLATE 14 LANCING DEVICE 81 peroxide 58 ADVOCATE REDI-CODE+ ACCU-CHEK FASTCLIX ADCETRIS 38 LANCETS 80 CONTROL SOLUTION ACCU-CHEK MULTICLIX ADCIRCA 53 HIGH 81 LANCETS 80 ADDERALL 1 ADVOCATE SAFETY ACCU-CHEK SAFE-T-PRO ADDERALL XR 1 LANCETS 81 LANCETS 81 ADVOCATE SAFETY LANCETS adefovir dipivoxil 49 26G 81

Index 1 ADZENYS ER 1 allopurinol 75 amphetamine- AFINITOR 40 almotriptan malate 126 dextroamphetamine 1 amphotericin b 28 AFLURIA 2018-2019 143 ALOCRIL 135 ampicillin 136 AFLURIA PF 2018-2019 143 alogliptin benzoate 25 ampicillin & sulbactam AFLURIA QUADRIVALENT ALOMIDE 135 sodium 137 2018-2019 143 alosetron hcl 73 AFLURIA QUADRIVALENT ampicillin sodium 136 2019-2020 143 ALOXI 27 AMPYRA 138 AFLURIA QUADRIVALENT ALPHAGAN P 133 ANADROL-50 10 2020-2021 144 alprazolam 13 ANAFRANIL 23 AGAMATRIX CONTROL HIGH 81 ALREX 134 anagrelide hcl 75 AGAMATRIX ULTRA-THIN ALTABAX 60 ANAPROX DS 4 LANCETS 33G 81 ALTACE 31 anastrozole 38 AGGRENOX 75 ALTERNATE SITE LANCING ANCOBON 28 DEVICE 81 AGRYLIN 75 ANDRODERM 10 ALTOPREV 31 AIMOVIG 126 ANDROGEL 10 ALVESCO 15 AIMSCO LUBRICATED 79 ANNOVERA 55 AIMSCO TWIST LANCETS amantadine hcl 43 ANORO ELLIPTA 15 32G 81 AMARYL 26 ANTABUSE 137 AIMSCO TWIST LANCETS AMBIEN 77 33G 81 ANUSOL-HC 10 AMBIEN CR 77 AIRDUO RESPICLICK ANZEMET 27 113/14 15 AMBISOME 28 APOKYN 43 AIRDUO RESPICLICK ambrisentan 53 232/14 15 apraclonidine hcl 133 amcinonide 63 AIRDUO RESPICLICK 55/1415 aprepitant 28 AMCINONIDE 63 AJOVY 126 APRISO 73 AMERGE 126 AKYNZEO 28 APTIOM 18 AMICAR 77 albendazole 10 APTIVUS 46 amikacin sulfate 3 ALBENZA 10 AQUA LANCE ADJUSTABLE amiloride & albuterol sulfate 15 LANCING DEVICE 81 hydrochlorothiazide 68 AQUALANCE LANCETS ULTRA ALCAINE 134 amiloride hcl 68 THIN 30G 81 alclometasone dipropionate 63 aminocaproic acid 77 ARALAST NP 140 ALDACTAZIDE 68 aminophylline 16 ARANESP ALBUMIN FREE 76 ALDACTONE 68 amiodarone hcl 14 ARAVA 5 ALDARA 66 AMITIZA 73 ARCALYST 4 ALDURAZYME 70 amitriptyline hcl 23 ARCAPTA NEOHALER 15 alendronate sodium 69 amlodipine besylate 51 ARICEPT 137,138 alfuzosin hcl 74 amlodipine besylate- ARIKAYCE 3 ALIMTA 37 atorvastatin calcium 52 amlodipine besylate-benazepril ARIMIDEX 38 ALINIA 11 hcl 33 aripiprazole 46 aliskiren fumarate 34 amlodipine besylate-olmesartan ARIXTRA 17 ALKERAN 36 medoxomil 33 armodafinil 2 ALLEGRA ALLERGY 29 amlodipine besylate- valsartan 33 ARMOUR THYROID 140 ALLEGRA ALLERGY amlodipine-valsartan- ARNUITY ELLIPTA 15 CHILDRENS 29 hydrochlorothiazide 33 ALLEGRA-D 12 HOUR AROMASIN 38 ALLERGY & CONGESTION 57 amoxapine 23 ARRANON 37 ALLEGRA-D 24 HOUR amoxicillin 136 arsenic trioxide 42 ALLERGY & CONGESTION 57 amoxicillin & pot clavulanate 137 ARTHROTEC 50 4

Index 2 ARTHROTEC 75 4 ATGAM 129 AZASITE 133 ARYMO ER 6 ATIVAN 13 AZATHIOPRINE 129 ARZERRA 38 atomoxetine hcl 2 azathioprine 129 ASACOL HD 73 atorvastatin calcium 31 azelaic acid 66 ASMANEX HFA 15 atovaquone 11 azelastine hcl 132 ASMANEX TWISTHALER 120 atovaquone-proguanil hcl 34 azelastine hcl (ophth) 135 METERED DOSES 15 ATRIPLA 46 AZELEX 58 ASMANEX TWISTHALER 14 METERED DOSES 15 atropine sulfate 141 AZILECT 44 ASMANEX TWISTHALER 30 ATROVENT HFA 14 azithromycin 78 METERED DOSES 15 AUBAGIO 138 AZOR 33 ASMANEX TWISTHALER 60 METERED DOSES 15 AUGMENTIN 137 aztreonam 12 ASMANEX TWISTHALER 7 AUGMENTIN ES-600 137 AZULFIDINE 73 METERED DOSES 15 AUGMENTIN XR 137 AZULFIDINE EN-TABS 73 aspirin 6 AURORA LANCET SUPER B-D INSULIN SYRINGE aspirin-dipyridamole 75 THIN30G 81 ULTRAFINE II/0.3ML/31G X ASSURE COMFORT LANCETS AURORA LANCET THIN 5/16" 95 ULTRA THIN 28G 81 23G 81 B-D INSULIN SYRINGE ASSURE HAEMOLANCE PLUS AURORA PEN NEEDLES ULTRAFINE II/0.5ML/31G X HIGH FLOW 18G 81 29GX12MM 95 5/16" 95 ASSURE HAEMOLANCE PLUS AURORA PEN NEEDLES 31G B-D INSULIN SYRINGE LOW FLOW 25G 81 X6MM 95 ULTRAFINE II/1ML/31G X ASSURE HAEMOLANCE PLUS AURORA PEN NEEDLES 31G 5/16" 95 MICRO FLOW 28G 81 X8MM 95 B-D INSULIN SYRINGE ASSURE HAEMOLANCE PLUS AURORA UNIFINE ULTRAFINE/0.3ML/30G X NORMAL FLOW 21G 81 PENTIPS/32GX5/32" 95 1/2" 95 ASSURE HAEMOLANCE PLUS AURORA UNIFINE B-D INSULIN SYRINGE PEDIATRIC BLADE 81 PENTIPS/MINI/31GX3/16" ULTRAFINE/0.5ML/30G X ASSURE ID INSULIN 95 1/2" 95 SAFETYSYRINGE/U- AUSTEDO 138 bacitracin 11 100/0.5ML/29G X 1/2" 95 AUTO-LANCET 82 bacitracin (ophthalmic) 133 ASSURE ID INSULIN AUTO-LANCET MINI 82 SAFETYSYRINGE/U- baclofen 131 100/1ML/29G X 1/2" 95 AUTOLET IMPRESSION BACTRIM 11 ASSURE ID SAFETY PEN LANCING DEVICE 82 AUTOLET LANCING BACTRIM DS 11 NEEDLES 30G X 5/16" 95 BALCOLTRA 54 ASSURE ID SAFETY PEN DEVICE 82 NEEDLES 31G X 3/16" 95 AUTOLET MINI 82 balsalazide disodium 73 ASSURE LANCE LANCETS 81 AUTOLET PLUS 82 BALVERSA 40 ASSURE LANCE LANCETS AVALIDE 33 BANZEL 18 21G 81 AVANDIA 25 BAQSIMI ONE PACK 25 ASSURE LANCE PLUS SAFETYLANCETS 25G 81 AVAPRO 32 BAQSIMI TWO PACK 25 ASSURE LANCE PLUS AVASTIN 37 BARACLUDE 49 SAFETYLANCETS 30G 81 AVELOX 72 BASAGLAR KWIKPEN 25 ASSURE LANCE SAFETY AVODART 74 BAVENCIO 38 LANCET 28G 81 ASSURE LANCETS 81 AVONEX 138 BAXDELA 72 BD LO-DOSE INSULIN ATACAND 32 AVONEX PEN 138 AYGESTIN 137 SYRINGE MICROFINE ATACAND HCT 33 IV/0.5ML/28G X 1/2" 95 atazanavir sulfate 46 AYVAKIT 40 BD AUTOSHIELD 29G X ATELVIA 69 azacitidine 37 5/16" 95 AZACTAM 12 BD INSULIN SYRINGE LUER- atenolol 51 LOK/U-100/1ML 95 atenolol & chlorthalidone 33 AZASAN 129

Index 3 BD INSULIN SYRINGE BD INSULIN SYRINGE BD SAFETY-GLIDE INSULIN MICROFINE IV/U- ULTRAFINE/U-100/0.5ML/29G SYRINGE/0.5ML/29G X 1/2" 97 100/0.5ML/28G X 1/2" 95 X 1/2" 96 BD SAFETY-LOK INSULIN BD INSULIN SYRINGE BD INSULIN SYRINGE SYRINGE/PERM MICROFINE IV/U-100/1ML/27G ULTRAFINE/U-100/1ML/29G X NEEDLE/UF/1ML/29G X X 5/8" 95 1/2" 96 1/2" 97 BD INSULIN SYRINGE BD INSULIN SYRINGE BD SAFETYGLIDE INSULIN MICROFINE IV/U-100/1ML/28G ULTRAFINE/U-100/1ML/30G X SYRINGE/0.3ML/29G X 1/2" 97 X 1/2" 95 1/2" 96 BD SAFETYGLIDE INSULIN BD INSULIN SYRINGE BD INSULIN SYRINGE/0.3ML/31G X MICROFINE/U-100/0.5ML/28G X SYRINGE/0.3ML/29G X 5/16" 97 1/2" 95 12.7MM 96 BD SAFETYGLIDE INSULIN BD INSULIN SYRINGE BD INSULIN SYRINGE/1ML/31G X MICROFINE/U-100/1ML/27G X SYRINGE/0.5ML/29G X 15/64" 97 5/8" 95 12.7MM 96 BD SAFETYGLIDE INSULIN BD INSULIN SYRINGE BD INSULIN SYSYRINGE/0.5ML/30G X MICROFINE/U-100/1ML/28G X SYRINGE/1ML/27G X 5/16" 97 1/2" 95 12.7MM 96 BD VEO INSULIN SYRINGE BD INSULIN SYRINGE BD INSULIN ULTRA-FINE/1ML/31G X SAFETYGLIDE/1ML/29G X SYRINGE/1ML/29G X 6MM 97 1/2" 95 12.7MM 96 BD VEO INSULIN SYRINGE BD INSULIN SYRINGE SLIP BD INSULIN ULTRA-FINE/U-100/1ML/31G X TIP/U-100/1ML 95 SYRINGE/DETACHABLE 15/64" 97 BD INSULIN SYRINGE ULTRA- NEEDLE/U-100/1ML/25G X BELEODAQ 40 FINE/0.3ML/30G X 12.7MM 95 1" 96 BELRAPZO 36 BD INSULIN SYRINGE ULTRA- BD INSULIN FINE/0.3ML/31G X 8MM 95 SYRINGE/DETACHABLE BELSOMRA 77 BD INSULIN SYRINGE ULTRA- NEEDLE/U-100/1ML/25G X BELVIQ 2 FINE/0.5ML/30G X 12.7MM 95 5/8" 96 benazepril & BD INSULIN SYRINGE ULTRA- BD INSULIN hydrochlorothiazide 33 FINE/0.5ML/31G X 8MM 96 SYRINGE/DETACHABLE benazepril hcl 32 BD INSULIN SYRINGE ULTRA- NEEDLE/U-100/1ML/26G X BENDAMUSTINE FINE/1/2 UNIT/0.3ML/31G X 1/2" 96 HYDROCHLORIDE 36 8MM 96 BD INSULIN SYRINGE/U- BENDEKA 36 BD INSULIN SYRINGE ULTRA- 100/1ML/27G X 1/2" 96 FINE/1ML/30G X 12.7MM 96 BD LANCET ULTRAFINE BENICAR 32 BD INSULIN SYRINGE ULTRA- 30G 82 BENICAR HCT 33 FINE/1ML/31G X 8MM 96 BD LANCET ULTRAFINE BENZACLIN 58 BD INSULIN SYRINGE 33G 82 ULTRAFINE HALF- BD MICROTAINER BENZACLIN WITH PUMP 58 UNIT/0.3ML/31G X 5/16" 96 LANCETS 82 BENZAMYCIN 58 BD INSULIN SYRINGE BD PEN BENZEFOAM 58 ULTRAFINE/0.3ML/30G X NEEDLE/MICRO/ULTRA- BENZEFOAM ULTRA 58 1/2" 96 FINE/32G X 6MM 96 BD INSULIN SYRINGE BD PEN benzonatate 57 ULTRAFINE/0.3ML/31G X NEEDLE/MINI/ULTRA- benzoyl peroxide 58 5/16" 96 FINE/31G X 5MM 96 BENZOYL PEROXIDE BD INSULIN SYRINGE BD PEN NEEDLE/NANO 2ND CLEANSER 58 ULTRAFINE/0.5ML/30G X GEN/32G X 5/32" 96 benzoyl peroxide- 1/2" 96 BD PEN erythromycin 58 BD INSULIN SYRINGE NEEDLE/NANO/ULTRA- benztropine mesylate 43 ULTRAFINE/0.5ML/31G X FINE/32G X 4MM 96 5/16" 96 BD PEN BEPREVE 135 BD INSULIN SYRINGE NEEDLE/ORIGINAL/ULTRA- BESPONSA 38 ULTRAFINE/1ML/30G X FINE/29G X 12.7MM 96 BETAGAN 133 1/2" 96 BD PEN betamethasone dipropionate BD INSULIN SYRINGE NEEDLE/SHORT/ULTRA- (topical) 63 ULTRAFINE/U-100/0.3ML/29G X FINE/31G X 8MM 96 betamethasone dipropionate 1/2" 96 augmented 63

Index 4 betamethasone valerate 63 bumetanide 68 calcium gluconate 128 BETAPACE 51 BUMEX 68 calcium polycarbophil 78 BETAPACE AF 51 BUNAVAIL 9 CAMPATH 38 BETASERON 138 BUPHENYL 70 CAMPTOSAR 43 betaxolol hcl 51 BUPRENEX 9 CANASA 73 betaxolol hcl (ophth) 133 buprenorphine 9 CANCIDAS 28 bethanechol chloride 143 buprenorphine hcl 9 candesartan cilexetil 32 BEVESPI AEROSPHERE 15 buprenorphine hcl-naloxone hcl candesartan cilexetil- BEVYXXA 16 dihydrate 9 hydrochlorothiazide 33 bupropion hcl 21 CAPASTAT SULFATE 35 bexarotene 42 bupropion hcl (smoking capecitabine 37 BEYAZ 54 deterrent) 139 CAPRELSA 40 bicalutamide 38 buspirone hcl 13 captopril 32 BICNU 36 busulfan 36 CARAC 61 BIDIL 52 BUSULFEX 36 CARAFATE 142 BIKTARVY 46 butalbital-acetaminophen 6 CARBAGLU 70 BILTRICIDE 10 butalbital-acetaminophen- carbamazepine 18 bimatoprost 135 caffeine 6 butalbital-acetaminophen- CARBATROL 18 bisacodyl 78 caffeine w/ codeine 8 carbidopa 43 bisoprolol & butalbital-aspirin-caffeine 6 hydrochlorothiazide 33 carbidopa-levodopa 44 butalbital-aspirin-caffeine bisoprolol fumarate 51 carbidopa-levodopa-entacapone w/cod 8 44 bleomycin sulfate 39 BUTALBITAL/ACETAMINOPH carbinoxamine maleate 29 BLEPH-10 133 EN 6 carboplatin 36 BLINCYTO 38 butenafine hcl 60 butorphanol tartrate 9 CARDIOCOM LANCING BONIVA 69 DEVICE 82 BOOSTRIX 141 BUTRANS 10 CARDIZEM 51 BORTEZOMIB 40 BYDUREON 25 CARDIZEM CD 51 bosentan 53 BYDUREON BCISE 25 CARDIZEM LA 51 BOSULIF 40 BYDUREON PEN 25 CARDURA 32 BOTOX 132 BYETTA 25 CAREFINE PEN NEEDLE BRAFTOVI 40 BYSTOLIC 51 32GX4MM 97 cabergoline 71 CAREFINE PEN NEEDLES BREO ELLIPTA 15 29GX1/2" 97 BRILINTA 75 CABLIVI 75 CAREFINE PEN NEEDLES brimonidine tartrate 133 CADUET 52 30GX5/16" 97 BRIVIACT 18 CAFERGOT 126 CAREFINE PEN NEEDLES CALAN 51 31GX6MM 97 bromfenac sodium (ophth) 135 CAREFINE PEN NEEDLES bromocriptine mesylate 43 CALAN SR 51 31GX8MM 97 BROVANA 15 calcipotriene 62 CAREFINE PEN NEEDLES 32GX5MM 97 BRUKINSA 40 calcipotriene-betamethasone dipropionate 63 CAREFINE PEN NEEDLES budesonide 56 calcitonin (salmon) 69 32GX6MM 97 budesonide (inhalation) 15 CAREONE ADVANCED calcitriol 70 LANCINGDEVICE 82 budesonide (nasal) 132 calcitriol (topical) 62 CAREONE INSULIN budesonide-formoterol fumarate calcium acetate (phosphate SYRINGES/0.3ML/30G X dihydrate 16 binder) 74 1/2" 97 BULLSEYE MINI SAFETY calcium chloride CAREONE INSULIN LANCETS 82 (dihydrate) 128 SYRINGES/0.3ML/31G X BULLSEYE SAFETY 5/16" 97 LANCETS 82 CALCIUM GLUCONATE 128

Index 5 CAREONE INSULIN CARETOUCH TWIST CETRAXAL 135 SYRINGES/0.5ML/30G X LANCETS 30G 82 CETROTIDE 69 1/2" 97 CARETOUCH TWIST CAREONE INSULIN LANCETS 33G 82 cevimeline hcl 130 SYRINGES/0.5ML/31G X carisoprodol 131 CHANTIX 139 5/16" 97 carmustine 36 CHANTIX CONTINUING CAREONE INSULIN MONTHPAK 139 SYRINGES/1ML/30G X 1/2" 97 carteolol hcl (ophth) 133 CHANTIX STARTING MONTH CAREONE INSULIN carvedilol 50 PAK 139 SYRINGES/1ML/31GX5/16" 97 CASODEX 38 CHEMET 27 CAREONE LANCET THIN 82 caspofungin acetate 28 CHEMSTRIP-K 67 CAREONE LANCET ULTRA THIN 82 CATAPRES 32 CHILDRENS ADVIL 4 CAREONE UNIFINE PENTIPS CATAPRES-TTS-1 32 CHILDRENS MOTRIN 4 29GX12MM 97 CATAPRES-TTS-2 32 chloramphenicol sodium CAREONE UNIFINE PENTIPS CATAPRES-TTS-3 32 succinate 11 31GX5MM 97 chlordiazepoxide hcl 13 CAYA 79 CAREONE UNIFINE PENTIPS chlordiazepoxide hcl-clidinium 31GX6MM 97 CAYSTON 12 bromide 141 CAREONE UNIFINE PENTIPS cefaclor 54 chlorhexidine gluconate (mouth- 31GX8MM 97 cefadroxil 53 throat) 130 CAREONE UNIFINE PENTIPS chloroquine phosphate 35 PEN NEEDLES 32GX4MM 97 cefazolin sodium 53 CAREONE UNIFINE PENTIPS cefdinir 54 chlorothiazide 68 PLUS PEN NEEDLES cefditoren pivoxil 54 chlorpromazine hcl 46 29GX12MM 97 chlorpropamide 26 CAREONE UNIFINE PENTIPS cefepime hcl 54 PLUS PEN NEEDLES cefixime 54 chlorthalidone 68 31GX5MM 97 CEFOTAN 54 chlorzoxazone 131 CAREONE UNIFINE PENTIPS cefotaxime sodium 54 CHOLBAM 73 PLUS PEN NEEDLES cholecalciferol 146 31GX6MM 97 cefotetan disodium 54 CAREONE UNIFINE PENTIPS cefoxitin sodium 54 cholestyramine 30 PLUS PEN NEEDLES cefpodoxime proxetil 54 cholestyramine light 30 31GX8MM 98 CHORIONIC CAREONE UNIFINE PENTIPS cefprozil 54 GONADOTROPIN 69 PLUS PEN NEEDLES ceftazidime 54 CIALIS 52 32GX4MM 98 ceftriaxone sodium 54 CICLODAN SOLUTION KIT 60 CARESENS LANCETS 82 cefuroxime axetil 54 ciclopirox 60 CARETOUCH LANCING cefuroxime sodium 54 DEVICEWITH EJECTOR 82 ciclopirox olamine 60 CARETOUCH PEN NEEDLES CELEBREX 4 cidofovir 49 31G X 6 MM 98 celecoxib 4 cilostazol 75 CARETOUCH PEN NEEDLES CELESTONE-SOLUSPAN 56 31GX 5MM 98 CILOXAN 133 CARETOUCH PEN NEEDLES CELEXA 22 CIMDUO 47 31GX 8MM 98 CELLCEPT 129 cimetidine 141 CARETOUCH PEN NEEDLES CELONTIN 21 cimetidine hcl 141 32GX 4MM 98 CARETOUCH PEN NEEDLES cephalexin 53 CIMZIA 73 32GX 5MM 98 CERDELGA 75 CIMZIA STARTER KIT 73 CARETOUCH SAFETY CEREBYX 20 cinacalcet hcl 70 LANCETS/26G 82 CEREZYME 75 CARETOUCH SAFETY CINRYZE 75 LANCETS/28G 82 CESAMET 28 CIPRO 72 CARETOUCH SAFETY cetirizine hcl 29 CIPRO HC 136 LANCETS/30G 82 cetirizine-pseudoephedrine CIPRODEX 136 CARETOUCH TWIST LANCETS 57 28G 82 ciprofloxacin 72

Index 6 ciprofloxacin hcl 72 CLEVER CHOICE COMFORT CLEVER CHOICE COMFORT ciprofloxacin hcl (ophth) 133 EZINSULIN EZPEN NEEDLES SYRINGE/0.5ML/28G X 32GX5MM 99 ciprofloxacin hcl (otic) 135 1/2" 98 CLEVER CHOICE COMFORT ciprofloxacin in d5w 72 CLEVER CHOICE COMFORT EZPEN NEEDLES ciprofloxacin-ciprofloxacin EZINSULIN 32GX6MM 99 hcl 72 SYRINGE/0.5ML/29G X CLEVER CHOICE GLUCOSE ciprofloxacin-dexamethasone 1/2" 98 CONTROL HIGH 82 136 CLEVER CHOICE COMFORT CLICKFINE PEN NEEDLE ciprofloxacin-fluocinolone EZINSULIN 32GX5/32" 99 acetonide 136 SYRINGE/0.5ML/30G X CLICKFINE PEN NEEDLE cisplatin 36 1/2" 98 UNIVERSAL/31GX1/4" 99 CLICKFINE PEN NEEDLE citalopram hydrobromide 22 CLEVER CHOICE COMFORT EZINSULIN UNIVERSAL/31GX5/16" 99 cladribine 37 SYRINGE/0.5ML/30G X CLICKFINE PEN NEEDLES 31G CLAFORAN 54 5/16" 98 X 1/4" 99 CLARINEX 29 CLEVER CHOICE COMFORT CLICKFINE PEN NEEDLES 31G X 3/16" 99 clarithromycin 79 EZINSULIN SYRINGE/0.5ML/31G X CLICKFINE PEN NEEDLES 31G CLARITIN 29 5/16" 98 X 5/16" 99 CLARITIN ALLERGY CLEVER CHOICE COMFORT CLICKFINE PEN NEEDLES 31G CHILDRENS 29 EZINSULIN X 8MM 99 CLARITIN CHILDRENS 29 SYRINGE/1.0ML/30G X CLICKFINE PEN NEEDLES 32G X 5/32" 99 CLARITIN REDITABS 29 1/2" 98 CLEVER CHOICE COMFORT CLICKFINE PEN CLARITIN-D 12 HOUR 57 EZINSULIN NEEDLES/31GX1/4" 99 CLARITIN-D 24 HOUR 57 SYRINGE/1ML/28G X 1/2" 98 CLICKFINE UNIVERSAL PEN CLASSIC PRENATAL 130 CLEVER CHOICE COMFORT NEEDLES 31GX5/16" 99 CLIMARA 72 CLEANLET LANCETS 28G 82 EZINSULIN SYRINGE/1ML/29G X 1/2" 98 CLIMARA PRO 71 clemastine fumarate 29 CLEVER CHOICE COMFORT CLINDAGEL 58 CLENPIQ 78 EZINSULIN clindamycin hcl 12 CLEOCIN 12,146 SYRINGE/1ML/30G X 5/16" 98 clindamycin palmitate CLEOCIN PEDIATRIC hydrochloride 12 GRANULES 12 CLEVER CHOICE COMFORT clindamycin phosphate 12 CLEOCIN PHOSPHATE 12 EZINSULIN SYRINGE/U- 100/1ML/31GX5/16" 98 clindamycin phosphate CLEOCIN-T 58 CLEVER CHOICE COMFORT (topical) 59 CLEVER CHEK LANCETS EZLANCETS 21G 82 clindamycin phosphate ULTRATHIN 82 CLEVER CHOICE COMFORT vaginal 146 CLEVER CHEK LANCETS EZLANCETS 23G 82 clindamycin phosphate-benzoyl ULTRATHIN 30G 82 CLEVER CHOICE COMFORT peroxide 59 CLEVER CHOICE COMFORT EZLANCETS 28G 82 clindamycin phosphate-benzoyl EZINSULIN PEN NEEDLES CLEVER CHOICE COMFORT peroxide (refrigerate) 59 31GX8MM 98 EZPEN NEEDLES clindamycin phosphate- CLEVER CHOICE COMFORT 29GX12MM 98 tretinoin 59 EZINSULIN CLEVER CHOICE COMFORT CLINIMIX 4.25%/DEXTROSE SYRINGE/0.3ML/29G X 1/2" 98 EZPEN NEEDLES 10% 132 CLEVER CHOICE COMFORT 31GX5MM 98 CLINIMIX 4.25%/DEXTROSE EZINSULIN CLEVER CHOICE COMFORT 25% 133 SYRINGE/0.3ML/30G X 1/2" 98 EZPEN NEEDLES CLINIMIX 4.25%/DEXTROSE CLEVER CHOICE COMFORT 31GX6MM 98 5% 133 EZINSULIN CLEVER CHOICE COMFORT CLINIMIX 5%/DEXTROSE SYRINGE/0.3ML/30G X EZPEN NEEDLES 25% 133 5/16" 98 31GX8MM 99 CLINIMIX E 5%/DEXTROSE CLEVER CHOICE COMFORT CLEVER CHOICE COMFORT 20% 133 EZINSULIN EZPEN NEEDLES clobazam 18 SYRINGE/0.3ML/31G X 32GX4MM 99 clobetasol propionate 63 5/16" 98

Index 7 clobetasol propionate emollient COMFORT ASSIST INSULIN CORTISPORIN 60 base 64 SYRINGE/0.5ML/29G X CORTISPORIN-TC 136 clocortolone pivalate 64 1/2" 99 CORVITE 130 CLODERM 64 COMFORT ASSIST INSULIN SYRINGE/0.5ML/30G X CORZIDE 33 CLODERM PUMP 64 5/16" 99 COSENTYX 62 clofarabine 37 COMFORT ASSIST INSULIN COSENTYX SENSOREADY CLOLAR 37 SYRINGE/0.5ML/31G X PEN 62 5/16" 99 clomipramine hcl 23 COMFORT ASSIST INSULIN COSMEGEN 39 clonazepam 18 SYRINGE/1ML/29G X 1/2" 99 COSOPT 133 clonidine 32 COMFORT ASSIST INSULIN COUMADIN 16 clonidine hcl 32 SYRINGE/1ML/30G X COZAAR 32 5/16" 99 clonidine hcl (adhd) 2 COMFORT ASSIST INSULIN CREON 67 clopidogrel bisulfate 75 SYRINGE/1ML/31G X CRESEMBA 28 clorazepate dipotassium 13 5/16" 99 CRESTOR 31 clotrimazole 130 COMFORT ASSURED CRIXIVAN 47 LANCETS MICRO THIN clotrimazole (topical) 60 33G 82 CROMOLYN SODIUM 14 clotrimazole vaginal 146 COMFORT ASSURED cromolyn sodium 14 clotrimazole w/ LANCETS SUPER THIN cromolyn sodium (ophth) 135 28G 82 betamethasone 60 crotamiton 67 clozapine 45 COMFORT EZ INSULIN SYRINGE/U-100/0.5ML/31G X CUBICIN 11 CLOZARIL 45 5/16" 99 CUBICIN RF 11 COAGUCHEK LANCETS 82 COMFORT EZ INSULIN CUPRIMINE 129 COARTEM 34 SYRINGE/U-100/1ML/31G X CUTIVATE 64 CODEINE SULFATE 6 5/16" 99 COMFORT EZ MICRO/32G X CUVITRU 136 codeine sulfate 6 4MM 99 CVS LANCETS 21G 82 COGENTIN 43 COMFORT EZ SHORT/31G X CVS LANCETS MICRO THIN COLACE 78 8MM 99 33G 82 COMFORT EZ/31G X COLAZAL 73 CVS LANCETS MICRO-THIN 5MM 99 33G 82 colchicine 75 COMFORT EZ/31G X CVS LANCETS ORIGINAL 82 colchicine w/ probenecid 74 6MM 99 CVS LANCETS THIN 26G 82 COLCRYS 75 COMFORT LANCETS 82 COMPLERA 47 CVS LANCETS ULTRA THIN colesevelam hcl 30 30G 82 COLESTID 30 COMTAN 43 CVS LANCETS ULTRA-THIN COLESTID FLAVORED 30 CONCERTA 2 30G 82 colestipol hcl 30 CONTOUR HIGH CVS LANCING DEVICE 83 CONTROL 82 COLY-MYCIN S 136 CVS PRENATAL 130 CONTRAVE 2 CVS ULTRA THIN COLYTE-FLAVOR PACKS 78 CONZIP 6 LANCETS 83 COMBIGAN 133 COPAXONE 138 cyanocobalamin 76 COMBIVIR 47 COPIKTRA 40 cyclobenzaprine hcl 131 COMETRIQ 40 CORDARONE 14 cyclophosphamide 36 COMFORT ASSIST INSULIN cycloserine 35 SYRINGE 0.3ML/29G X 1/2" 99 CORDRAN 64 COMFORT ASSIST INSULIN COREG 50 CYCLOSET 25 SYRINGE/0.3ML/30G X CORGARD 51 cyclosporine 129 5/16" 99 CORLANOR 53 cyclosporine modified (for COMFORT ASSIST INSULIN microemulsion) 129 56 SYRINGE/0.3ML/31G X CORTEF CYKLOKAPRON 77 10 5/16" 99 CORTENEMA CYMBALTA 23 56

Index 8 cyproheptadine hcl 30 DEPAKOTE 21 DIACOMIT 18 CYRAMZA 37 DEPAKOTE ER 21 DIASTAT ACUDIAL 18 CYSTADANE 70 DEPEN TITRATABS 129 DIASTAT PEDIATRIC 18 CYSTAGON 74 DEPO-ESTRADIOL 72 DIATHRIVE LANCETS 83 CYSTARAN 135 DEPO-MEDROL 56 DIATHRIVE LANCETS ULTRA cytarabine 37 DEPO-PROVERA THIN 30G 83 DIATHRIVE LANCING CYTOMEL 140 CONTRACEPTIVE 56 DEPO-SUBQ PROVERA DEVICE 83 CYTOTEC 142 104 56 DIATHRIVE PEN NEEDLE/31 G CYTOVENE 49 DEPO-TESTOSTERONE 10 X 6MM 100 DIATHRIVE PEN NEEDLE/31 D.H.E. 45 126 DERMA-SMOOTHE/FS GX 8MM 100 dacarbazine 42 BODY 64 DIATHRIVE PEN NEEDLE/31GX DERMA-SMOOTHE/FS 5MM 100 DACOGEN 37 SCALP 64 dactinomycin 39 DIATHRIVE PEN NEEDLE/32GX DERMOTIC 136 4MM 100 DAKLINZA 49 DESCOVY 47 DIATRUE GLUCOSE CONTROL dalfampridine 138 DESFERAL 27 SOLUTION LEVEL 3 83 DALIRESP 15 desipramine hcl 23 diazepam 13 danazol 10 desloratadine 29 diazepam (anticonvulsant) 18 DANTRIUM 132 desmopressin acetate 71 diazoxide 25 dantrolene sodium 132 desmopressin acetate DIBENZYLINE 32 dapsone 12 spray 71 DICLEGIS 28 DAPTOMYCIN 11 desmopressin acetate spray diclofenac epolamine 59 refrigerated 71 daptomycin 11 desogestrel & ethinyl diclofenac potassium 5 DARAPRIM 35 estradiol 54 diclofenac sodium 5 darifenacin hydrobromide 143 desogestrel-ethinyl estradiol diclofenac sodium (actinic (biphasic) 54 keratoses) 61 DARZALEX 38 desogestrel-ethinyl estradiol diclofenac sodium (ophth) 135 daunorubicin hcl 39 (triphasic) 54 diclofenac sodium (topical) 60 DAUNORUBICIN desonide 64 diclofenac w/ misoprostol 5 HYDROCHLORIDE 39 DESOWEN 64 DAURISMO 38 dicloxacillin sodium 137 desoximetasone 64 DAYPRO 4 dicyclomine hcl 141 DESOXYN 1 DAYTRANA 2 didanosine 47 desvenlafaxine succinate 23 DDAVP 71 DIFFERIN 59 DETROL 143 DEBACTEROL 130 DIFICID 79 DETROL LA 143 decitabine 37 diflorasone diacetate 64 dexamethasone 56 DIFLUCAN 28 deferasirox 27 DEXAMETHASONE deferiprone 27 INTENSOL 56 diflunisal 6 deferoxamine mesylate 27 dexamethasone sodium digoxin 52 DELESTROGEN 72 phosphate 56 dihydroergotamine dexamethasone sodium mesylate 126 DELSTRIGO 47 phosphate (ophth) 134 DILANTIN 20 DELZICOL 73 dexchlorpheniramine DILANTIN INFATABS 20 DEMADEX 68 maleate 29 DILANTIN-125 20 demeclocycline hcl 140 DEXEDRINE 1 DILAUDID 6 DEMEROL 6 DEXILANT 142 diltiazem hcl 51 DENAVIR 63 dexmethylphenidate hcl 2 DILTIAZEM HCL 51 DEPACON 21 dextroamphetamine sulfate 1 dextrose in lactated diltiazem hcl 52 DEPAKENE 21 ringers 128 diltiazem hcl coated beads 51

Index 9 diltiazem hcl extended release DROPLET INSULIN SYRINGE DROPLET PEN NEEDLES 32G beads 51 1ML/29G X 1/2" 100 X 5/32" 100 dimethyl fumarate 138 DROPLET INSULIN SYRINGE DROPLET PEN NEEDLES DIOVAN 32 U-100/0.3/31G X 5/16" 100 32GX4MM 100 DROPLET INSULIN SYRINGE DROPLET PEN NEEDLES DIOVAN HCT 33 U-100/0.3ML/30G X 1/2" 100 32GX5MM 100 DIPENTUM 73 DROPLET INSULIN SYRINGE DROPLET PEN NEEDLES diphenhydramine hcl 29 U-100/0.3ML/30G X 5/16"100 32GX6MM 101 DROPLET INSULIN SYRINGE DROPLET PERSONAL diphenoxylate w/ atropine 26 U-100/0.5ML/30G X 1/2" 100 LANCETS30G 83 DIPROLENE 64 DROPLET INSULIN SYRINGE DROPSAFE SAFETY PEN DIPROLENE AF 64 U-100/0.5ML/30G X 5/16"100 NEEDLES/31G X 5/16" 101 dipyridamole 75 DROPLET INSULIN SYRINGE DROPSAFE SAFTEY PEN U-100/0.5ML/31G X 5/16"100 NEEDLES/31G X 1/4" 101 disopyramide phosphate 13 DROPLET INSULIN SYRINGE drospirenone-ethinyl disulfiram 137 U-100/1ML/30G X 1/2" 100 estradiol 54 DITROPAN XL 143 DROPLET INSULIN SYRINGE drospirenone-ethinyl estradiol- U-100/1ML/30G X 5/16" 100 levomefolate calcium 54 divalproex sodium 21 DROPLET INSULIN SYRINGE DROXIA 76 DIVIGEL 72 U-100/1ML/31G X 15/64" 100 DRUG MART ADJUSTABLE docetaxel 42 DROPLET INSULIN SYRINGE LANCING DEVICE 83 DOCETAXEL 42 U-100/1ML/31G X 5/16" 100 DRUG MART LANCETS DROPLET INSULIN THIN 83 docetaxel 42 SYRINGE/U-100/0.3ML/31G X DRUG MART ON-THE-GO docusate calcium 78 5/16" 100 LANCETS GENTLE 30G 83 docusate sodium 78 DROPLET INSULIN DRUG MART UNIFINE PENTIPS SYRINGE/U-100/0.5ML/30G X dofetilide 14 31GX5MM 101 1/2" 100 DRUG MART UNIFINE DOLOPHINE 6 DROPLET INSULIN PENTIPS29G X 12MM 101 donepezil hydrochloride 138 SYRINGE/U-100/0.5ML/31G X DRUG MART UNIFINE DOPTELET 76 5/16" 100 PENTIPS31GX6MM 101 DROPLET INSULIN DRUG MART UNIFINE DORAL 77 SYRINGE/U-100/1ML/30G X PENTIPS31GX8MM 101 dorzolamide hcl 135 1/2" 100 DRUG MART UNIFINE dorzolamide hcl-timolol DROPLET INSULIN PENTIPS32GX4MM 101 maleate 133 SYRINGE/U-100/1ML/31G X DRUG MART UNIFINE DOVATO 47 15/64" 100 PENTIPSPLUS 32GX4MM 101 DROPLET INSULIN DOVONEX 62 DRUG MART UNILET SYRINGE/U-100/1ML/31G X LANCETSSUPER THIN 30G83 doxazosin mesylate 32 5/16" 100 DRUG MART UNILET doxepin hcl 24 DROPLET LANCETS ULTRA LANCETSULTRA THIN 28G 83 doxepin hcl (antipruritic) 62 THIN 30G 83 DRUG MART UNILET MICRO DROPLET LANCING THIN LANCETS 33G 83 doxepin hcl (sleep) 77 DEVICE 83 DUAC 59 doxercalciferol 70 DROPLET PEN NEEDLES DUAVEE 71 DOXIL 39 29GX12MM 100 DROPLET PEN NEEDLES 30G DUETACT 24 doxorubicin hcl 39 X 5/16" 100 DULCOLAX 78 doxorubicin hcl liposomal 39 DROPLET PEN NEEDLES duloxetine hcl 23 doxycycline (monohydrate) 140 31GX5MM 100 DUPIXENT 66 doxycycline hyclate 140 DROPLET PEN NEEDLES 31GX6MM 100 DURAGESIC 6 doxylamine-pyridoxine 28 DROPLET PEN NEEDLES DUREX EXTRA SENSITIVE 79 DRISDOL 146 31GX8MM 100 DUREZOL 134 dronabinol 28 DROPLET PEN NEEDLES 32G dutasteride 74 DROPLET INSULIN SYRINGE X 1/4" 100 0.3ML/29G X 1/2" 100 DROPLET PEN NEEDLES 32G DUZALLO 74 DROPLET INSULIN SYRINGE X 3/16" 100 DYAZIDE 68 0.5ML/29G X 1/2" 100

Index 10 DYRENIUM 68 EASY TOUCH EASY TOUCH INSULIN DYSPORT 132 32GX6MM 101 SYRINGE/U-100/1ML/28G X EASY TOUCH FLIPLOCK 1/2" 102 E-Z JECT LANCETS 83 SAFETY INSULIN SYRINGE EASY TOUCH INSULIN E-Z JECT LANCETS 21G 83 1ML/29GX1/2" 101 SYRINGE/U-100/1ML/29G X E-Z JECT LANCETS EASY TOUCH FLIPLOCK 1/2" 102 COLOR 83 SAFETY INSULIN SYRINGE EASY TOUCH INSULIN E-Z JECT LANCETS SUPER 1ML/30GX1/2" 101 SYRINGE/U-100/1ML/30G X THIN 30G 83 EASY TOUCH FLIPLOCK 1/2" 102 E-Z JECT LANCETS THIN SAFETY INSULIN SYRINGE EASY TOUCH INSULIN 26G 83 1ML/30GX5/16" 101 SYRINGE/U-100/1ML/31G X E-ZJECT LANCETS MICRO- EASY TOUCH FLIPLOCK 5/16" 102 THIN 33G 83 SAFETY INSULIN SYRINGE EASY TOUCH LANCETS E.E.S. GRANULES 79 1ML/31GX5/16" 101 21G/PRESSURE EASY COMFORT INSULIN EASY TOUCH INSULIN ACTIVATED 83 SYRINGE/0.5ML/30G X SYRINGE/0.3ML/30G X EASY TOUCH LANCETS 5/16" 101 5/16" 101 23G/PRESSURE EASY COMFORT INSULIN EASY TOUCH INSULIN ACTIVATED 83 SYRINGE/0.5ML/31G X SYRINGE/0.3ML/31G X EASY TOUCH LANCETS 5/16" 101 5/16" 101 26G/PRESSURE EASY COMFORT INSULIN EASY TOUCH INSULIN ACTIVATED 83 SYRINGE/1ML/30G X SYRINGE/0.5ML/29G X EASY TOUCH LANCETS 5/16" 101 1/2" 101 26G/PULL-TOP 83 EASY COMFORT INSULIN EASY TOUCH INSULIN EASY TOUCH LANCETS SYRINGE/1ML/31G X SYRINGE/0.5ML/30G X 28G/PRESSURE 5/16" 101 5/16" 101 ACTIVATED 83 EASY COMFORT INSULIN EASY TOUCH INSULIN EASY TOUCH LANCETS SYRINGE/U-100/0.5ML/30G X SYRINGE/1ML/30G X 28G/PULL-TOP 83 1/2" 101 5/16" 101 EASY TOUCH LANCETS EASY COMFORT INSULIN EASY TOUCH INSULIN 28G/TWIST 83 SYRINGE/U-100/1ML/30G X SYRINGE/SAFETY/U- EASY TOUCH LANCETS 1/2" 101 100/0.5ML/29G X 1/2" 101 30G/BUTTON-ACTIVATED 83 EASY TOUCH LANCETS EASY COMFORT LANCETS83 EASY TOUCH INSULIN SYRINGE/SAFETY/U- 30G/PRESSURE EASY COMFORT LANCETS 100/0.5ML/30G X 5/16" 101 ACTIVATED 83 30G/PULL TOP 83 EASY TOUCH INSULIN EASY TOUCH LANCETS EASY COMFORT LANCETS SYRINGE/SAFETY/U- 30G/PULL-TOP 84 30G/THIN TOP 83 100/1ML/29G X 1/2" 102 EASY TOUCH LANCETS EASY COMFORT LANCETS EASY TOUCH INSULIN 30G/TWIST 84 TWIST TOP 83 SYRINGE/SAFETY/U- EASY TOUCH LANCETS EASY COMFORT PEN 100/1ML/30G X 1/2" 102 32G/PRESSURE NEEDLES31GX1/4" 101 EASY TOUCH INSULIN ACTIVATED 84 EASY COMFORT PEN SYRINGE/U-100/0.3ML/30G X EASY TOUCH LANCETS 101 NEEDLES31GX3/16" 1/2" 102 32G/PULL-TOP 84 EASY COMFORT PEN EASY TOUCH INSULIN EASY TOUCH LANCETS NEEDLES31GX5/16" 101 32G/TWIST 84 EASY COMFORT PEN SYRINGE/U-100/0.5ML/27G X 1/2" 102 EASY TOUCH LANCETS NEEDLES32GX5/32" 101 33G/TWIST 84 EASY MINI EJECT LANCING EASY TOUCH INSULIN SYRINGE/U-100/0.5ML/28G X EASY TOUCH LANCING DEVICE 83 DEVICE/EJECTOR 84 EASY MINI LANCING 1/2" 102 EASY TOUCH INSULIN EASY TOUCH PEN NEEDLE DEVICE 83 30G X 5/16" 102 EASY PLUS II CONTROL SYRINGE/U-100/0.5ML/30G X 1/2" 102 EASY TOUCH PEN NEEDLES SOLUTION HIGH 83 29GX1/2" 102 EASY STEP CONTROL EASY TOUCH INSULIN SYRINGE/U-100/0.5ML/31G X EASY TOUCH PEN NEEDLES SOLUTION HIGH 83 31GX1/4" 102 EASY TALK CONTROL 5/16" 102 EASY TOUCH INSULIN EASY TOUCH PEN NEEDLES SOLUTION HIGH 83 31GX5/16" 102 EASY TOUCH 32GX5MM 101 SYRINGE/U-100/1ML/27G X 1/2" 102

Index 11 EASY TOUCH PEN NEEDLES efavirenz-emtricitabine- ELLIOTTS B 128 32GX1/4" 102 tenofovir disoproxil ELMIRON 74 EASY TOUCH PEN NEEDLES fumarate 47 32GX3/16" 102 efavirenz-lamivudine-tenofovir ELOCON 64 EASY TOUCH PEN NEEDLES disoproxil fumarate 47 EMADINE 135 32GX5/32" 102 EFFEXOR XR 23 EMBEDA 6 EASY TOUCH PEN EFFIENT 75 EMBRACE GLUCOSE NEEDLES/31G X 3/16" 102 EFUDEX 61 CONTROL SOLUTION EASY TOUCH SAFETY HIGH 84 LANCETS21G/PRESSURE EGRIFTA 70 EMBRACE LANCETS ULTRA ACTIVATED 84 EGRIFTA SV 70 THIN 30G 84 EASY TOUCH SAFETY EMBRACE LANCING DEVICE LANCETS23G/PRESSURE ELAPRASE 70 ELELYSO 75 WITH EJECTOR 84 ACTIVATED 84 EMBRACE TALK GLUCOSE EASY TOUCH SAFETY ELEMENT HIGH CONTROL SOLUTION LANCETS26G/BUTTON CONTROL 84 HIGH 84 ACTIVATED 84 ELESTAT 135 EMCYT 38 EASY TOUCH SAFETY ELESTRIN 72 LANCETS26G/PRESSURE EMEND 28 ACTIVATED 84 eletriptan hydrobromide 126 EMFLAZA 56 EASY TOUCH SAFETY ELIDEL 66 EMGALITY 126 LANCETS28G/BUTTON ELIGARD 38 ACTIVATED 84 EMPLICITI 38 EASY TOUCH SAFETY ELIMITE 67 EMSAM 22 LANCETS28G/PRESSURE ELIQUIS 16 emtricitabine 47 ACTIVATED 84 ELIQUIS STARTER PACK 16 emtricitabine-tenofovir disoproxil EASY TOUCH SAFETY PEN ELITE-THIN INSULIN fumarate 47 NEEDLES/29G X 8MM 102 SYRINGE/0.3ML/31G X EMTRIVA 47 EASY TOUCH SAFETY PEN 5/16" 102 NEEDLES/30G X 5/16" 102 ELITE-THIN INSULIN EMVERM 11 EASY TOUCH SHEATHLOCK SYRINGE/0.5ML/29G X ENABLEX 143 SAFETY INSULIN SYRINGE 1/2" 102 enalapril maleate 32 1ML/29GX1/2" 102 ELITE-THIN INSULIN enalapril maleate & EASY TOUCH SHEATHLOCK SYRINGE/0.5ML/30G X hydrochlorothiazide 33 SAFETY INSULIN SYRINGE 5/16" 102 ENBREL 5,6 1ML/30GX5/16" 102 ELITE-THIN INSULIN EASY TOUCH SHEATHLOCK SYRINGE/1ML/30G X ENBREL MINI 5 SAFETY INSULIN SYRINGE 5/16" 102 ENBREL SURECLICK 6 1ML/31GX5/16" 102 ELITE-THIN INSULIN ENGERIX-B 144 EASY TOUCH SHEATHLOCK SYRINGE/U-100/0.5ML/28G X enoxaparin sodium 17 SAFETY SYRINGE 1/2" 103 1ML/30GX1/2" 102 ELITE-THIN INSULIN entacapone 43 EASY TRAK GLUCOSE SYRINGE/U-100/0.5ML/31G X entecavir 49 CONTROLSOLUTION HIGH 84 5/16" 103 ENTEREG 74 EASY TWIST & CAP ELITE-THIN INSULIN LANCETS 84 SYRINGE/U-100/1ML/28G X ENTOCORT EC 56 EASYGLUCO CONTROL 1/2" 103 ENTRESTO 52 SOLUTION HIGH 84 ELITE-THIN INSULIN ENTYVIO 73 EASYMAX CONTROL SYRINGE/U-100/1ML/29G X EPCLUSA 49 SOLUTIONHIGH 84 1/2" 103 EC-NAPROSYN 5 ELITE-THIN INSULIN EPIDIOLEX 19 econazole nitrate 60 SYRINGE/U-100/1ML/31G X EPIDUO 59 EDARBI 32 5/16" 103 epinastine hcl (ophth) 135 ELITEK 42 EDECRIN 68 epinephrine (anaphylaxis) 146 ELIXOPHYLLIN 16 EDURANT 47 epinephrine hcl 16 ELLA 56 efavirenz 47 EPIPEN 2-PAK 146 ELLENCE 40 EPIPEN-JR 2-PAK 146

Index 12 epirubicin hcl 40 ERWINAZE 42 EXEL COMFORT POINT EPIVIR 47 ERYPED 200 79 INSULIN PEN NEEDLES 31G X 8MM 103 EPIVIR HBV 49 ERYPED 400 79 EXEL COMFORT POINT eplerenone 34 erythromycin (acne aid) 59 INSULIN SYRINGE/0.3ML/29G X EPOGEN 76 erythromycin (ophth) 133 1/2" 103 EXEL COMFORT POINT epoprostenol sodium 53 erythromycin base 79 INSULIN SYRINGE/0.3ML/30G X eprosartan mesylate 32 erythromycin 5/16" 103 EPZICOM 47 ethylsuccinate 79 EXEL COMFORT POINT escitalopram oxalate 22 EQL COLOR LANCETS 21G84 INSULIN SYRINGE/0.5ML/28G X EQL COLOR LANCETS MICRO ESGIC 6 1/2" 103 EXEL COMFORT POINT THIN 33G 84 esomeprazole EQL INSULIN magnesium 142 INSULIN SYRINGE/0.5ML/29G X SYRINGE/0.3ML/29G X estazolam 77 1/2" 103 103 EXEL COMFORT POINT 1/2" ESTRACE 72 INSULIN SYRINGE/0.5ML/30G X EQL INSULIN estradiol 72 SYRINGE/0.3ML/30G X 5/16" 103 EXEL COMFORT POINT 5/16" 103 estradiol vaginal 146 EQL INSULIN estradiol valerate 72 INSULIN SYRINGE/1ML/28G X SYRINGE/0.3ML/31G X 1/2" 103 ESTROGEL 72 EXEL COMFORT POINT 5/16" 103 EQL INSULIN ESTROSTEP FE 54 INSULIN SYRINGE/1ML/29G X SYRINGE/0.5ML/29G X eszopiclone 77 1/2" 103 103 EXEL COMFORT POINT 1/2" ethacrynic acid 68 INSULIN SYRINGE/1ML/30G X EQL INSULIN ethambutol hcl 35 SYRINGE/0.5ML/30G X 5/16" 103 5/16" 103 ethosuximide 21 EXELDERM 60 EQL INSULIN ethynodiol diacet & eth exemestane 39 SYRINGE/0.5ML/31G X estrad 54 EXFORGE 33 etidronate disodium 69 5/16" 103 EXFORGE HCT 33 EQL INSULIN etodolac 5 SYRINGE/1ML/29G X 1/2" 103 etonogestrel-ethinyl EXJADE 27 EQL INSULIN estradiol 55 EXTAVIA 138 SYRINGE/1ML/30G X ETOPOPHOS 42 EZ SMART BLOOD GLUCOSE 5/16" 103 etoposide 42 LANCETS 84 EQL INSULIN EZ-LETS LANCETS 21G 84 SYRINGE/1ML/31G X EUCRISA 66 EZ-LETS LANCETS 26G 5/16" 103 EURAX 67 SUPER-SOFT 84 EQL PRENATAL EVAMIST 72 EZ-LETS LANCETS 28G FORMULA 130 ULTRA-SOFT 84 EQL SUPER THIN LANCETS everolimus 40 30G 84 everolimus EZ-LETS LANCETS 30G 84 EQL THIN LANCETS 26G 84 (immunosuppressant) 129 ezetimibe 31 EQUETRO 45 EVISTA 70 ezetimibe-simvastatin 30 ERAXIS 28 EVOCLIN 59 FABRAZYME 70 ERBITUX 38 EVOMELA 36 famciclovir 50 ergocalciferol 146 EVOTAZ 47 famotidine 141 ergoloid mesylates 139 EVOXAC 130 famotidine in nacl 141 ERGOMAR 126 EXALGO 6 FANAPT 45 ergotamine w/ caffeine 126 EXEL COMFORT POINT FANAPT TITRATION PACK 45 INSULIN PEN NEEDLES 29G FANTASY LUBRICATED 79 ERIVEDGE 38 X 12MM 103 erlotinib hcl 40 EXEL COMFORT POINT FANTASY LUBRICATED/SPERMICIDE ERTACZO 60 INSULIN PEN NEEDLES 31G X 6MM 103 79 ertapenem sodium 11 FARESTON 39

Index 13 FARXIGA 26 FIFTY50 SAFETY SEAL FLUARIX QUADRIVALENT FASENRA 14 LANCETS 32G 84 2020-2021 144 FIFTY50 SUPERIOR FLUBLOK QUADRIVALENT FASENRA PEN 14 COMFORTINSULIN 2018-2019 144 FASLODEX 39 SYRINGE/0.3ML/31G X FLUBLOK QUADRIVALENT FAZACLO 45 5/16" 104 2019-2020 144 FIFTY50 SUPERIOR FLUBLOK QUADRIVALENT FC FEMALE CONDOM 79 COMFORTINSULIN 2020-2021 144 febuxostat 75 SYRINGE/0.5ML/31G X FLUCELVAX QUADRIVALENT felbamate 20 5/16" 104 2018-2019 144 FELBATOL 20 FIFTY50 SUPERIOR FLUCELVAX QUADRIVALENT COMFORTINSULIN 2019-2020 144 FELDENE 5 SYRINGE/1ML/31G X FLUCELVAX QUADRIVALENT felodipine 52 5/16" 104 2020-2021 144 FEMARA 39 FIFTY50 UNILET LANCETS fluconazole 28 FEMCAP 79 33G 84 flucytosine 28 FINACEA 66 FEMHRT LOW DOSE 71 fludarabine phosphate 37 finasteride 74 FEMRING 146 fludrocortisone acetate 57 FINE 30 84 fenofibrate 31 FLULAVAL QUADRIVALENT FINGERSTIX LANCETS 84 2018-2019 144 fenofibrate micronized 31 FIORICET 6 FLULAVAL QUADRIVALENT fenoprofen calcium 5 2019-2020 144 FIORICET/CODEINE 8 FENSOLVI 70 FLULAVAL QUADRIVALENT FIORINAL 6 fentanyl 7 2020-2021 145 FIORINAL/CODEINE #3 9 FLUMADINE 50 fentanyl citrate 7 FIRAZYR 75 FLUMIST QUADRIVALENT145 FENTORA 7 FIRDAPSE 35 flunisolide (nasal) 132 FER-IN-SOL 76 FIRMAGON 39 fluocinolone acetonide 64 FERRIPROX 27 FIRVANQ 11 fluocinolone acetonide ferrous fumarate-folic acid 76 FLAGYL 11 (otic) 136 ferrous sulfate 76 fluocinonide 64 flavoxate hcl 143 FETZIMA 23 fluocinonide emulsified base 64 flecainide acetate 14 FETZIMA TITRATION PACK23 fluorometholone (ophth) 134 FLECTOR 60 fexofenadine hcl 29 fluorouracil 37 FLOLAN 53 fexofenadine-pseudoephedrine fluorouracil (topical) 61 FLOMAX 74 57,58 fluoxetine hcl 22 FIASP 25 FLONASE ALLERGY fluoxetine hcl (pmdd) 139 FIASP FLEXTOUCH 25 RELIEF 132 FLONASE ALLERGY RELIEF FLUOXETINE FIASP PENFILL 25 CHILDRENS 132 HYDROCHLORIDE 22 FIBERCON 78 FLOVENT DISKUS 15 fluphenazine hcl 46 FIBRICOR 31 FLOVENT HFA 15 flurandrenolide 64 FIFTY50 PEN NEEDLES 31G FLOXIN OTIC 135 flurbiprofen 5 X3/16" (5MM) 103 FIFTY50 PEN NEEDLES 31G floxuridine 37 flurbiprofen sodium 135 X5/16" (8MM) 103 FLUAD 2018-2019 144 flutamide 39 FIFTY50 PEN NEEDLES FLUAD 2019-2020 144 fluticasone propionate 64 31GX5MM 103 FLUAD 2020-2021 144 fluticasone propionate FIFTY50 PEN FLUAD QUADRIVALENT (nasal) 132 NEEDLES/31GX8MM 103 fluticasone-salmeterol 16 FIFTY50 PEN INFLUENZA VACCINE FOR NEEDLES/32GX4MM 104 ADULTS 144 fluvastatin sodium 31 FIFTY50 PEN FLUARIX QUADRIVALENT fluvoxamine maleate 22 NEEDLES/32GX6MM 104 2018-2019 144 FLUZONE HIGH-DOSE PF 2018- FLUARIX QUADRIVALENT FIFTY50 SAFETY SEAL 2019 145 LANCETS 30G 84 2019-2020 144

Index 14 FLUZONE HIGH-DOSE PF 2019- FREDS PHARMACY UNILET GENOTROPIN MINIQUICK 70 2020 145 LANCETS SUPER THIN gentamicin in saline 3 FLUZONE HIGH-DOSE PF 2020- 30G 85 2021 145 FREDS PHARMACY UNILET gentamicin sulfate 3 FLUZONE QUADRIVALENT LANCETS ULTRA THIN gentamicin sulfate (ophth) 133 2018-2019 145 28G 85 gentamicin sulfate (topical) 60 FLUZONE QUADRIVALENT FREESTYLE LANCETS 85 GENTEEL BUTTERFLY TOUCH 2019-2020 145 FREESTYLE PRECISION LANCETS 85 FLUZONE QUADRIVALENT INSULIN SYRINGE/U- GENTEEL LANCING 2020-2021 145 100/0.5ML/30G X 5/16" 104 DEVICE/BUFF BLACK 85 FML 134 FREESTYLE PRECISION GENTEEL LANCING FML FORTE 134 INSULIN SYRINGE/U- DEVICE/BUTTERFLY BLUE 85 FML LIQUIFILM 134 100/0.5ML/31G X 5/16" 104 GENTEEL LANCING FREESTYLE PRECISION DEVICE/GLORIOUS GOLD 85 FOCALIN 2 INSULIN SYRINGE/U- GENTEEL LANCING FOCALIN XR 2 100/1ML/31G X 5/16" 104 DEVICE/PLAYFUL PURPLE 85 folic acid 76 FREESTYLE PRECISION GENTEEL LANCING FOLOTYN 37 INSULIN SYRINGES/U- DEVICE/PRECIOUS 100/1ML/30G X 5/16" 104 PLATINUM 85 fondaparinux sodium 17 FREESTYLE UNISTICK II GENTEEL LANCING FORA CONTROL SOLUTION LANCETS 85 DEVICE/PRINCESS PINK 85 HIGH 84 FROVA 126 GENTEEL LANCING FORA GTEL BLOOD KETONE frovatriptan succinate 126 DEVICE/STATELY SILVER 85 TEST STRIPS 67 GENTEEL LANCING FORA LANCETS 84 FULPHILA 76 DEVICE/WILLOWY WHITE 85 FORA LANCING DEVICE 84 fulvestrant 39 GENTLE-LET GP LANCETS 85 FORA LANCING FURADANTIN 12 GENTLE-LET LANCETS DEVICE/CLEARCAP 84 furosemide 68 GENERAL PURPOSE STYLE/FINE POINT 85 FORACARE GDH CONTROL FUZEON 47 SOLUTION HIGH 85 GENTLE-LET LANCETS FORFIVO XL 21 FYCOMPA 18 GENERAL PURPOSE FORTAZ 54 gabapentin 19 STYLE/MEDIUM POINT 85 GABITRIL 20 GENTLE-LET LANCETS FORTEO 69 SAFETY STYLE/FINE FORTISCARE CONTROL GALAFOLD 70 POINT 85 SOLUTIONS HIGH 85 galantamine GENTLE-LET LANCETS FOSAMAX 69 hydrobromide 138 SAFETY STYLE/MEDIUM FOSAMAX PLUS D 69 GAMMAGARD LIQUID 136 POINT 85 GAMMAGARD S/D IGA LESS fosamprenavir calcium 47 GENVOYA 47 THAN 1MCG/ML 136 GEODON 45 fosaprepitant dimeglumine 28 GAMMAKED 136 GILENYA 138 fosfomycin tromethamine 12 GAMUNEX-C 136 GILOTRIF 40 fosinopril sodium 32 ganciclovir sodium 49 glatiramer acetate 138 fosinopril sodium & ganirelix acetate 69 hydrochlorothiazide 33 GLEEVEC 40 GANIRELIX ACETATE 69 fosphenytoin sodium 20 GLEOSTINE 36 GARDASIL 9 145 FOSRENOL 74 glimepiride 26 gatifloxacin (ophth) 133 FRAGMIN 17 glipizide 26 GAZYVA 38 FREDS PHARMACY AUTOLET glipizide-metformin hcl 24 LANCING DEVICE 85 gemcitabine hcl 37 GLOBAL EASE INJECT PEN FREDS PHARMACY UNIFINE GEMCITABINE NEEDLES 29GX12MM 104 PENTIPS PEN NEEDLES HYDROCHLORIDE 37 GLOBAL EASE INJECT PEN 32GX4MM 104 gemfibrozil 31 NEEDLES 31GX8MM 104 FREDS PHARMACY UNIFINE GEMZAR 37 GLOBAL EASE INJECT PEN PENTIPS PLUS 31GX5MM 104 NEEDLES 32GX4MM 104 FREDS PHARMACY UNIFINE GENERESS FE 54 GLOBAL EASE INJECT PEN PENTIPS PLUS 31GX8MM 104 GENOTROPIN 70 NEEEDLES 31GX5MM 104

Index 15 GLOBAL EASY GLIDE INSULIN GLUCAGEN GNP CLICKFINE UNIVERSAL SYRINGE/1ML/31G X DIAGNOSTIC 67 PEN NEEDLES 31GX1/4" 105 15/64" 104 GLUCAGEN HYPOKIT 25 GNP CLICKFINE UNIVERSAL GLOBAL EASY GLIDE GLUCAGON EMERGENCY PEN NEEDLES 31GX5/16" 105 INSULINSYRINGE/U- KIT 25 GNP INSULIN 100/0.3ML/31G X 5/16" 104 GLUCOCOM HIGH SYRINGE/0.3ML/29G X GLOBAL EASY GLIDE PEN CONTROL 85 1/2" 105 NEEDLES 32GX4MM 104 GLUCOCOM LANCETS GNP INSULIN GLOBAL INJECT EASE INSULIN 28G 85 SYRINGE/0.3ML/30G X SYRINGE/U-100/0.3ML/29G X GLUCOCOM LANCETS 5/16" 105 1/2" 104 30G 85 GNP INSULIN GLOBAL INJECT EASE INSULIN GLUCOCOM LANCETS SYRINGE/0.3ML/31G X SYRINGE/U-100/0.3ML/30G X 33G 85 5/16" 105 1/2" 104 GLUCOPHAGE 25 GNP INSULIN GLOBAL INJECT EASE INSULIN SYRINGE/0.5ML/28G X SYRINGE/U-100/0.3ML/30G X GLUCOPHAGE XR 25 1/2" 105 5/16" 104 GLUCOPRO INSULIN GNP INSULIN GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.3ML/30G X SYRINGE/0.5ML/29G X SYRINGE/U-100/0.3ML/31G X 1/2" 105 1/2" 105 5/16" 104 GLUCOPRO INSULIN GNP INSULIN GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.3ML/30G X SYRINGE/0.5ML/30G X SYRINGE/U-100/0.5ML/28G X 5/16" 105 5/16" 106 1/2" 104 GLUCOPRO INSULIN GNP INSULIN GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.3ML/31G X SYRINGE/0.5ML/31G X SYRINGE/U-100/0.5ML/29G X 5/16" 105 5/16" 106 1/2" 104 GLUCOPRO INSULIN GNP INSULIN GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.5ML/30G X SYRINGE/1ML/28G X 1/2" 106 SYRINGE/U-100/0.5ML/30G X 1/2" 105 GNP INSULIN 1/2" 104 GLUCOPRO INSULIN SYRINGE/1ML/29G X 1/2" 106 GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.5ML/30G X GNP INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" 105 SYRINGE/1ML/30G X 5/16" 105 GLUCOPRO INSULIN 5/16" 106 GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.5ML/31G X GNP INSULIN SYRINGE/U-100/0.5ML/31G X 5/16" 105 SYRINGE/1ML/31G X 5/16" 105 GLUCOPRO INSULIN 5/16" 106 GLOBAL INJECT EASE INSULIN SYRINGE/U-100/1ML/30G X GNP LANCETS 85 1/2" 105 SYRINGE/U-100/1ML/28G X GNP LANCETS 21G 85 1/2" 105 GLUCOPRO INSULIN SYRINGE/U-100/1ML/30G X GNP LANCETS MICRO THIN GLOBAL INJECT EASE INSULIN 33G 85 SYRINGE/U-100/1ML/29G X 5/16" 105 GLUCOPRO INSULIN GNP LANCETS SUPER THIN 1/2" 105 30G 85 GLOBAL INJECT EASE INSULIN SYRINGE/U-100/1ML/31G X SYRINGE/U-100/1ML/30G X 5/16" 105 GNP LANCETS THIN 85 1/2" 105 GLUCOTROL 26 GNP LANCETS THIN 26G 85 GLOBAL INJECT EASE INSULIN GLUCOTROL XL 26 GNP MICRO THIN LANCETS SYRINGE/U-100/1ML/30G X glyburide 26 33G 85 5/16" 105 GNP PRENATAL 130 glyburide micronized 26 GLOBAL INJECT EASE INSULIN GNP SUPER THIN SYRINGE/U-100/1ML/31G X glyburide-metformin 24 LANCETS/30G 85 5/16" 105 glycine (gu irrigant) 74 GNP ULTICARE PEN GLOBAL INJECT EASE glycopyrrolate 141 NEEDLES/31GX5/16" 106 LANCETS 28G 85 GNP ULTICARE PEN GLOBAL INJECT EASE GLYNASE 26 NEEDLES/32GX 5/32" 106 LANCETS 30G 85 GLYSET 24 GNP ULTICARE PEN GLOBAL INSULIN SYRINGE/U- GLYXAMBI 24 NEEDLES/32GX1/4" 106 100/0.3ML/30G X 1/2" 105 GNP CLICKFINE PEN GNP ULTRA COMFORT GLOBAL INSULIN SYRINGES/U- INSULIN SYRINGE/0.3ML/29G X 100/0.3ML/30GX5/16" 105 NEEDLEUNIVERSAL/31GX5/1 6" 105 1/2" 106 GLOBAL LANCING DEVICE 85

Index 16 GNP ULTRA COMFORT GOODSENSE PEN HAEMOLANCE PLUS 86 INSULIN SYRINGE/0.3ML/30G X NEEDLE/PENFINE HAEMOLANCE PLUS HIGH 5/16" SHORT 106 CLASSIC/31G X 3/16" 106 FLOW 86 GNP ULTRA COMFORT GOODSENSE PEN HAEMOLANCE PLUS LOW INSULIN SYRINGE/0.3ML/31G X NEEDLE/PENFINE FLOW 86 5/16" SHORT 106 CLASSIC/31G X 5/16" 106 HAEMOLANCE PLUS MAX GNP ULTRA COMFORT GOODSENSE PEN FLOW 86 INSULIN SYRINGE/0.5ML/28G X NEEDLE/PENFINE HAEMOLANCE PLUS 1/2" 106 CLASSIC/32G X 1/4" 106 PEDIATRIC FLOW 86 GNP ULTRA COMFORT GOODSENSE PEN HALAVEN 42 INSULIN SYRINGE/0.5ML/29G X NEEDLE/PENFINE 1/2" 106 CLASSIC/32G X 5/32" 106 halcinonide 65 GNP ULTRA COMFORT GOODSENSE PRENATAL HALCION 77 INSULIN SYRINGE/0.5ML/30G X VITAMINS 130 HALDOL 45 5/16" SHORT 106 granisetron hcl 27 HALDOL DECANOATE 100 45 GNP ULTRA COMFORT GRANIX 76 INSULIN SYRINGE/0.5ML/31G X HALDOL DECANOATE 50 45 5/16" SHORT 106 GRASTEK 3 halobetasol propionate 65 GNP ULTRA COMFORT griseofulvin microsize 28 HALOG 65 INSULIN SYRINGE/1ML/28G X griseofulvin ultramicrosize 28 1/2" 106 haloperidol 45 GNP ULTRA COMFORT guanfacine hcl 32 haloperidol decanoate 45 INSULIN SYRINGE/1ML/29G X guanfacine hcl (adhd) 2 haloperidol lactate 45 1/2" 106 GUANIDINE HCL 35 HARVONI 49 GNP ULTRA COMFORT GVOKE PFS 25 INSULIN SYRINGE/1ML/30G X HAVRIX 145 5/16" SHORT 106 GYNAZOLE-1 146 HEALTH CARE LANCING GNP ULTRA COMFORT GYNE-LOTRIMIN 146 DEVICE 86 INSULIN SYRINGE/1ML/31G X H-E-B IN CONTROL PEN HEALTHWISE INSULIN 5/16" SHORT 106 NEEDLES 31GX5MM 106 SYRINGE/U-100/0.3ML/30G X GOJJI BLOOD KETONE TEST H-E-B IN CONTROL PEN 5/16" 107 STRIPS 67 NEEDLES 31GX6MM 107 HEALTHWISE INSULIN GOJJI LANCING H-E-B IN CONTROL PEN SYRINGE/U-100/0.3ML/31G X DEVICE/CLEAR CAP 85 NEEDLES 31GX8MM 107 5/16" 107 GOJJI STERILE LANCETS H-E-B IN CONTROL PEN HEALTHWISE INSULIN 30G 86 NEEDLES/NANO/32GX4MM SYRINGE/U-100/0.5ML/30G X GOLYTELY 78 107 5/16" 107 GOODSENSE CLICKFINE H-E-B IN CONTROL HEALTHWISE INSULIN SAFETY PEN NEEDLE/31G X UNIFINEPENTIPS PLUS SYRINGE/U-100/0.5ML/31G X 3/16" 106 31GX5MM 107 5/16" 107 GOODSENSE COLOR H-E-B IN CONTROL HEALTHWISE INSULIN LANCETS MICRO-THIN 33G UNIFINEPENTIPS PLUS SYRINGE/U-100/1ML/30G X UNIVERSAL 86 32GX4MM 107 5/16" 107 GOODSENSE LANCETS H-E-B INCONTROL HEALTHWISE INSULIN MICRO-THIN 33G 86 ADVANCEDLANCING SYRINGE/U-100/1ML/31G X GOODSENSE LANCETS DEVICE 86 5/16" 107 MICRO-THIN 33G H-E-B INCONTROL LANCETS HEALTHWISE MICRON PEN UNIVERSAL 86 MICRO THIN 33G 86 NEEDLES/32G X 5/32" 107 GOODSENSE LANCETS H-E-B INCONTROL LANCETS HEALTHWISE MINI PEN SUPER THIN 30G 86 NEEDLES 31GX6MM 107 ULTRA-THIN 26G HEALTHWISE PEN NEEDLES UNIVERSAL 86 H-E-B INCONTROL LANCETS ULTRA THIN 28G 86 29GX12MM 107 GOODSENSE LANCETS HEALTHWISE SHORT PEN ULTRA-THIN 30G 86 H-E-B INCONTROL PEN GOODSENSE LANCETS NEEDLES 29GX12MM 107 NEEDLES 31GX8MM 107 HAEGARDA 75 HEALTHWISE SHORT PEN ULTRA-THIN 30G NEEDLES/31G X 3/16" 107 UNIVERSAL 86 HAEMOLANCE 86 HEALTHWISE SHORT PEN GOODSENSE LANCING HAEMOLANCE LOW FLOW NEEDLES/31G X 5/16" 107 DEVICE 86 LANCETS 86

Index 17 HEALTHWISE UNIFINE HUMIRA PEN-CD/UC/HS icatibant acetate 75 PENTIPS PEN NEEDLES STARTER 3,4 ICLUSIG 40 32GX4MM 107 HUMIRA PEN-PS/UV HEALTHY ACCENTS AUTOLET STARTER 4 icosapent ethyl 30 IMPRESSION LANCING HUMULIN R U-500 IDAMYCIN PFS 40 DEVICE 86 (CONCENTRATED) 25 idarubicin hcl 40 HEALTHY ACCENTS UNIFINE HUMULIN R U-500 PENTIPS PEN NEEDLES KWIKPEN 25 IFEX 36 29GX12MM 107 HY-VEE LANCETS 86 ifosfamide 36 HEALTHY ACCENTS UNIFINE HY-VEE THIN LANCETS 86 IFOSFAMIDE 36 PENTIPS PEN NEEDLES ILARIS 4 31GX5MM 107 HYCAMTIN 43 HEALTHY ACCENTS UNIFINE hydralazine hcl 34 ILEVRO 135 PENTIPS PEN NEEDLES HYDREA 42 ILUMYA 62 31GX6MM 107 HYDRO 35 66 imatinib mesylate 40 HEALTHY ACCENTS UNIFINE IMBRUVICA 40 PENTIPS PEN NEEDLES hydrochlorothiazide 68 31GX8MM 107 hydrocodone bitartrate 7 IMFINZI 38 HEALTHY ACCENTS UNIFINE HYDROCODONE imipenem-cilastatin 11 PENTIPS PEN NEEDLES BITARTRATE/ACETAMINOPH imipramine hcl 24 32GX4MM 107 EN 9 imipramine pamoate 24 HEALTHY ACCENTS UNILET HYDROCODONE LANCETS SUPER THIN BITARTRATE/GUAIFENESIN imiquimod 66 30G 86 58 IMITREX 126,127 HECTOROL 70 hydrocodone- IMITREX STATDOSE HEMANGEOL 51 acetaminophen 9 REFILL 127 HEPARIN LOCK FLUSH 17 hydrocodone-ibuprofen 9 IMITREX STATDOSE SYSTEM 127 heparin sod (porcine) in d5w 17 hydrocortisone 56 hydrocortisone (intrarectal) 10 IMLYGIC 43 heparin sodium (porcine) 17 IMODIUM A-D 26 HEPARIN SODIUM/NACL hydrocortisone (rectal) 10 0.45% 17 hydrocortisone (topical) 65 IMPAVIDO 11 HEPARIN SODIUM/SODIUM hydrocortisone acetate IMURAN 129 CHLORIDE 0.9% 17 (rectal) 10 IN TOUCH LANCING HEPLISAV-B 145 HYDROCORTISONE DEVICE 86 HEPSERA 49 ACETATE/LIDOCAINE IN TOUCH STERILE HYDROCHLORIDE 65 LANCETS30G 86 HERCEPTIN 38 hydrocortisone butyrate 65 INCRELEX 70 HETLIOZ 77 hydrocortisone valerate 65 INCRUSE ELLIPTA 14 HIPREX 12 hydrocortisone w/acetic indapamide 68 HIZENTRA 136 acid 136 INDERAL LA 51 HM PRENATAL 130 hydromorphone hcl 7 indomethacin 5 HM ULTICARE INSULIN HYDROMORPHONE SYRINGE/1ML/30G X 1/2" 107 HYDROCHLORIDE 7 INFED 76 HM ULTICARE INSULIN hydroxychloroquine sulfate 35 INFINITY CONTROL SOLUTION HIGH 86 SYRINGE/U-100/0.3ML/31G X hydroxyurea 42 5/16" 107 INFLECTRA 73 HM ULTICARE SHORT PEN hydroxyzine hcl 13 INLYTA 40 NEEDLES 31GX8MM 107 hydroxyzine pamoate 13 INREBIC 40 139 HORIZANT HYPER-SAL 58 INSPRA 34 HUMATROPE 70 HYPERSAL 58 INSULIN SYRINGE/0.3ML/29G X HUMATROPE COMBO HYQVIA 136 1" 107 PACK 70 HYSINGLA ER 7 INSULIN SYRINGE/0.3ML/29G X HUMIRA 4 1/2" 108 HUMIRA PEDIATRIC CROHNS HYZAAR 33 INSULIN SYRINGE/0.3ML/30G X DISEASE STARTER PACK 3 ibandronate sodium 69 5/16" 108 HUMIRA PEN 3 ibuprofen 5

Index 18 INSULIN SYRINGE/0.3ML/31G X INSULIN irbesartan 32 5/16" 108 SYRINGES/0.5ML/31GX5/16" irbesartan-hydrochlorothiazide INSULIN SYRINGE/0.5ML/27G X 108 33 1/2" 108 INSULIN IRESSA 40 INSULIN SYRINGE/0.5ML/28G X SYRINGES/1ML/27GX/1/2" 1/2" 108 108 irinotecan hcl 43 INSULIN SYRINGE/0.5ML/30G X INSULIN irrigation solutions, 1/2" 108 SYRINGES/1ML/27GX1/2" physiological 130 INSULIN SYRINGE/0.5ML/30G X 109 ISENTRESS 47 5/16" 108 INSULIN ISENTRESS HD 47 INSULIN SYRINGE/0.5ML/31G X SYRINGES/1ML/28GX1/2" ISOLYTE-P/DEXTROSE 5/16" 108 109 5% 128 INSULIN SYRINGE/1ML/28G X INSULIN ISOLYTE-S 128 1/2" 108 SYRINGES/1ML/29GX1/2" INSULIN SYRINGE/1ML/29G X 109 isoniazid 35 1/2" 108 INSULIN ISONIAZID 35 INSULIN SYRINGE/1ML/30G X SYRINGES/1ML/30GX1/2" isoniazid 36 5/16" 108 109 INSULIN SYRINGE/NEEDLE INSULIN ISOPTO CARPINE 133 0.3ML/30G X 5/16" 108 SYRINGES/1ML/31GX5/16" ISORDIL TITRADOSE 13 INSULIN SYRINGE/NEEDLE 109 isosorbide dinitrate 13 0.3ML/31G X 5/16" 108 INSUPEN 29G X 12MM 109 INSULIN SYRINGE/NEEDLE isosorbide mononitrate 13 0.5ML/29G X 1/2" 108 INSUPEN 31G X 5MM 109 isotretinoin 59 INSULIN SYRINGE/NEEDLE INSUPEN 31G X 8MM 109 isradipine 52 0.5ML/30G X 5/16" 108 INSUPEN 32G X 4MM 109 INSULIN SYRINGE/NEEDLE ISTODAX (OVERFILL) 40 INSUPEN PEN NEEDLES 32G itraconazole 28,29 0.5ML/31G X 5/16" 108 X4MM 109 INSULIN SYRINGE/NEEDLE INSUPEN SENSITIVE ivermectin 11 1ML/29G X 1/2" 108 32GX6MM 109 IXEMPRA KIT 42 INSULIN SYRINGE/NEEDLE INSUPEN ULTRAFIN JADENU 27 1ML/30G X 5/16" 108 29GX12MM 109 INSULIN SYRINGE/NEEDLE INSUPEN ULTRAFIN JADENU SPRINKLE 27 1ML/31G X 5/16" 108 30GX8MM 109 JAKAFI 40 INSULIN SYRINGE/U- INSUPEN ULTRAFIN 24 100/0.3ML/29G X 1/2" 108 JANUMET 31GX6MM 109 JANUMET XR 24 INSULIN SYRINGE/U- INSUPEN ULTRAFIN 100/0.5ML/29G X 1/2" 108 31GX8MM 109 JANUVIA 25 INSULIN SYRINGE/U- JARDIANCE 26 100/1ML/29G X 1/2" 108 INTELENCE 47 INSULIN SYRINGE/U- INTRAROSA 146 JENTADUETO 24 100/1ML/30G X 5/16" 108 INTRON A 42 JENTADUETO XR 24 INSULIN SYRINGE/U- INTUNIV 2 JEVTANA 42 100/1ML/31G X 5/16" 108 INSULIN INVANZ 11 JUBLIA 60 SYRINGES/0.5ML/27GX1/2" INVEGA 45 JULUCA 47 108 INVIRASE 47 JYNARQUE 71 INSULIN INVOKAMET 24 K-TAB 128 SYRINGES/0.5ML/28GX1/2" K-Y ME & YOU EXTRA 108 INVOKANA 26 INSULIN IONOSOL-MB/DEXTROSE LUBRICATED 79 SYRINGES/0.5ML/29GX1/2" 5% 128 K-Y ME & YOU INTENSE 79 108 IOPIDINE 133 KADCYLA 38 INSULIN IPOL INACTIVATED IPV 145 KADIAN 7 SYRINGES/0.5ML/30GX5/16" KALETRA 47 108 ipratropium bromide 14 INSULIN ipratropium bromide KALYDECO 140 SYRINGES/0.5ML/31GX (nasal) 132 KAMELEON LUBRICATED 79 5/16" 108 ipratropium-albuterol 16 KAPVAY 2

Index 19 KAZANO 24 KINRAY INSULIN SYRINGE KROGER LANCETS KCL 0.3%/D5W/NACL PREFERRED PLUS/1ML/31G ULTRATHIN30G 86 0.9% 128 X 5/16" 109 KROGER LANCING KEFLEX 53 KINRAY INSULIN DEVICE 86 SYRINGE/0.5ML/29G X KROGER PEN NEEDLES 29G KENALOG-40 56 1/2" 109 X12MM 109 KEPIVANCE 42 KITABIS PAK 3 KROGER PEN NEEDLES 31G KEPPRA 19 X8MM 109 KLARITY-A 133 KROGER PEN NEEDLES KEPPRA XR 19 KLARON 59 31GX1/4" 109 KERYDIN 60 KLONOPIN 18 KROGER PEN NEEDLES/31G ketoconazole 29 KMART VALU PLUS INSULIN X1/4" 109 ketoconazole (topical) 60 SYRINGE/1ML/29G 109 KROGER PEN NEEDLES/31G KMART VALU PLUS INSULIN X3/16" 109 KETONE 67 SYRINGE/1ML/30G 109 KROGER PEN NEEDLES/31G KETONE TEST STRIPS 67 KP PRENATAL X5/16" 110 ketoprofen 5 MULTIVITAMINS 130 KROGER PEN NEEDLES/32G X5/32" 110 ketorolac tromethamine 5 KRINTAFEL 35 KRYSTEXXA 75 ketorolac tromethamine KROGER AUTOLET LANCING (ophth) 135 DEVICE 86 KUVAN 70 KETOSTIX 67 KROGER HEALTHPRO TWIST KYLEENA 56 LANCETS/26G 86 ketotifen fumarate (ophth) 135 KROGER INSULIN KYPROLIS 40 KEVEYIS 68 SYRINGE/0.3ML/29G X labetalol hcl 51 KEVZARA 4 1/2" 109 LAC-HYDRIN 66 KROGER INSULIN LAC-HYDRIN TWELVE 66 KEYTRUDA 38 SYRINGE/0.3ML/30G X KHAPZORY 42 5/16" 109 LACRISERT 133 KHEDEZLA 23 KROGER INSULIN lactated ringer's 128 KIMONO COLORS 79 SYRINGE/0.3ML/31G X lactated ringer's (irrigation) 130 5/16" 109 lactic acid (ammonium KIMONO LUBRICATED 79 KROGER INSULIN KIMONO MICRO THIN PLUS lactate) 66 SYRINGE/0.5ML/29G X lactulose 78 SPERMICIDE LUBRICATED79 1/2" 109 KIMONO PLUS SPERMICIDE KROGER INSULIN lactulose (encephalopathy) 73 LUBRICATED 79 SYRINGE/0.5ML/30G X LAMICTAL 19 KIMONO PLUS 5/16" 109 LAMICTAL CHEWABLE SPERMICIDE/LUBRICATED KROGER INSULIN DISPERSIBLE 19 79 SYRINGE/0.5ML/31G X LAMICTAL ODT 19 KIMONO PS LUBRICATED 79 5/16" 109 KIMONO PS PLUS KROGER INSULIN lamivudine 47 SPERMICIDE/LUBRICATED SYRINGE/1ML/29G X lamivudine (hbv) 49 79 1/2" 109 lamivudine-zidovudine 47 KIMONO SENSATION KROGER INSULIN lamotrigine 19 LUBRICATED 79 SYRINGE/1ML/30G X LANCET DEVICE KIMONO SENSATION PLUS 5/16" 109 ADJUSTABLE 86 SPERMICIDE LUBRICATED80 KROGER INSULIN LANCET DEVICE WITH KIMONO SPECIAL 80 SYRINGE/1ML/31G X EJECTOR 87 5/16" 109 KINERET 4 LANCETS 87 KROGER LANCETS 86 KINNEY LANCETS 86 LANCETS 26G TWIST TOP 87 KROGER LANCETS 21G 86 KINNEY THIN LANCETS 86 KROGER LANCETS MICRO LANCETS 28G 87 KINRAY INSULIN SYRINGE 86 LANCETS 30G 87 PREFERRED PLUS/0.3ML/31G THIN33G KROGER LANCETS SUPER LANCETS 30G TWIST TOP 87 X 5/16" 109 THIN 86 KINRAY INSULIN SYRINGE LANCETS 30G/TWIST TOP 87 KROGER LANCETS THIN 86 PREFERRED PLUS/0.5ML/31G LANCETS 31G TWIST TOP 87 X 5/16" 109 KROGER LANCETS THIN 26G 86

Index 20 LANCETS 33G UNIVERSAL LEADER INSULIN LEVAQUIN 72 DESIGN 87 SYRINGE/0.5ML/31G X LEVEMIR 25 LANCETS MICRO THIN 5/16" 110 33G 87 LEADER INSULIN LEVEMIR FLEXTOUCH 25 LANCETS SAFETY SEAL SYRINGE/1ML/28G X levetiracetam 19 21G 87 1/2" 110 levobunolol hcl 133 LANCETS SAFETY SEAL LEADER INSULIN levocetirizine 26G 87 SYRINGE/1ML/29G X dihydrochloride 29,30 LANCETS SAFETY SEAL 1/2" 110 28G 87 LEADER INSULIN levofloxacin 72 LANCETS SAFETY SEAL SYRINGE/1ML/30G X levofloxacin (ophth) 133 30G 87 5/16" 110 levofloxacin in d5w 72 LANCETS SUPER THIN LEADER INSULIN levonorgestrel & eth 28G 87 SYRINGE/1ML/31G X estradiol 54 LANCETS THIN 87 5/16" 110 levonorgestrel (emergency LANCETS TWIST TOP 87 LEADER UNIFINE PENTIPS oc) 56 PLUS/MINI/31GX3/16" 110 LANCETS ULTRA FINE 87 levonorgestrel-eth estradiol LEADER UNIFINE PENTIPS (triphasic) 54 LANCETS ULTRA THIN 87 PLUS/SHORT/31GX5/16" levonorgestrel-ethinyl estradiol LANCETS ULTRA THIN 110 (91-day) 54 30G 87 LEADER UNIFINE levonorgestrel-ethinyl estradiol LANCETSBULLSEYE PENTIPS/MINI/31GX3/16" (continuous) 55 SAFETY 87 110 levorphanol tartrate 7 LEADER UNIFINE LANCING DEVICE 87 levothyroxine sodium 141 LANCING DEVICE PENTIPS/NANO/32GX5/32" ADJUSTABLE 87 110 LEXAPRO 22 LANOXIN 52 LEADER UNIFINE LEXIVA 48 PENTIPS/PLUS/32GX5/32" LIALDA 73 lansoprazole 142 110 lanthanum carbonate 74 LIBERTY CONTROL SOLUTION LEDIPASVIR/SOFOSBUVIR HIGH 87 LANZO 87 49 LIBERTY MEDICAL LANCETS lapatinib ditosylate 41 leflunomide 5 30G 87 LARTRUVO 38 LENVIMA 10 MG DAILY LIBERTY MINI LANCING DOSE 41 DEVICE 87 LASIX 68 LENVIMA 12MG DAILY LIBRAX 141 LASTACAFT 135 DOSE 41 LIBTAYO 38 latanoprost 135 LENVIMA 14 MG DAILY DOSE 41 lidocaine 66 LATUDA 45 LENVIMA 18 MG DAILY lidocaine hcl 66 LEADER ADVANCED LANCING DOSE 41 DEVICE 87 LENVIMA 20 MG DAILY lidocaine hcl (local anesth.) 78 LEADER INSULIN DOSE 41 lidocaine hcl (mouth-throat) 130 SYRINGE/0.3ML/29G X LENVIMA 24 MG DAILY lidocaine-prilocaine 66 1/2" 110 DOSE 41 LEADER INSULIN LIDODERM 66 LENVIMA 4 MG DAILY LIFESCAN UNISTIK 2 DEEP SYRINGE/0.3ML/30G X DOSE 41 5/16" 110 LENVIMA 8 MG DAILY PENETRATION 87 LEADER INSULIN LIFESCAN UNISTIK II DOSE 41 LANCETS 87 SYRINGE/0.3ML/31G X LETAIRIS 53 5/16" 110 LILETTA 56 LEADER INSULIN letrozole 39 LINCOCIN 12 SYRINGE/0.5ML/28G X leucovorin calcium 42 lincomycin hcl 12 1/2" 110 LEUKERAN 36 lindane 67 LEADER INSULIN LEUKINE 76 SYRINGE/0.5ML/29G X linezolid 12 1/2" 110 leuprolide acetate 39 LINZESS 73 LEADER INSULIN levalbuterol hcl 16 liothyronine sodium 141 SYRINGE/0.5ML/30G X levalbuterol tartrate 16 5/16" 110 LIPITOR 31

Index 21 LIPOFEN 31 LITETOUCH LANCETS MICRO LORTAB 9 lisinopril 32 THIN 33G 87 losartan potassium 32 LITETOUCH PEN NEEDLES lisinopril & 29GX12.7MM 111 losartan potassium & hydrochlorothiazide 33 LITETOUCH PEN NEEDLES hydrochlorothiazide 33 LITE TOUCH LANCETS 87 31G X 6MM 111 LOSEASONIQUE 55 LITE TOUCH LANCING LITETOUCH PEN NEEDLES LOTEMAX 134 PEN 87 31G X 6MM/ULTRA LOTENSIN 32 LITETOUCH INSULIN PEN SHORT 111 NEEDLES/32G X LITETOUCH PEN NEEDLES LOTENSIN HCT 33 4MM/MINI 110 31GX8MM SHORT 111 loteprednol etabonate 134 LITETOUCH INSULIN LITETOUCH PEN LOTREL 33 SYRINGE/0.3ML/29G X NEEDLES/31G X 3/16" 111 LOTRIMIN AF 60 1/2" 110 LITETOUCH PEN LITETOUCH INSULIN NEEDLES/31G X LOTRIMIN AF JOCK ITCH 60 SYRINGE/0.3ML/30G X 5MM/MINI 111 LOTRIMIN ULTRA 60 5/16" 110 LITETOUCH PEN LOTRISONE 60 LITETOUCH INSULIN NEEDLES/31G X SYRINGE/0.3ML/31G X 8MM/SHORT 111 LOTRONEX 73 5/16" 110 LITHIUM 44 lovastatin 31 LITETOUCH INSULIN lithium carbonate 44 LOVAZA 30 SYRINGE/0.5ML/30G X LOVENOX 17,18 5/16" 110 LITHOBID 44 LITETOUCH INSULIN LIVALO 31 loxapine succinate 45 SYRINGE/0.5ML/31G X LIVE BETTER ADVANCED LUCEMYRA 137 5/16" 110 LANCING DEVICE 87 luliconazole 60 LITETOUCH INSULIN LIVE BETTER LANCET LUMIGAN 135 SYRINGE/1ML/30G X SUPERTHIN 30G 87 5/16" 110 LIVE BETTER LANCET LUMIZYME 70 LITETOUCH INSULIN ULTRATHIN 28G 87 LUMOXITI 38 SYRINGE/U-100/0.3ML/30G X LO LOESTRIN FE 55 LUNESTA 77 5/16" 110 LITETOUCH INSULIN LOCOID 65 LUPANETA PACK 70 SYRINGE/U-100/0.3ML/31G X LODINE 5 LUPRON DEPOT (1- 5/16" 110 LODOSYN 43 MONTH) 39 LITETOUCH INSULIN LUPRON DEPOT (3- LOMOTIL 26 MONTH) 39 SYRINGE/U-100/0.5ML/28G X LONGS INSULIN 1/2" 110 LUPRON DEPOT (4- LITETOUCH INSULIN SYRINGE/0.5ML/31G X MONTH) 39 5/16" 111 LUPRON DEPOT (6- SYRINGE/U-100/0.5ML/29G X LONGS LANCETS 1/2" 110 MONTH) 39 LITETOUCH INSULIN STANDARD 87 LUPRON DEPOT-PED (1- SYRINGE/U-100/0.5ML/30G X LONGS LANCETS THIN 87 MONTH) 70 5/16" 111 LONGS LANCETS ULTRA LUPRON DEPOT-PED (3- LITETOUCH INSULIN THIN 87 MONTH) 70 SYRINGE/U-100/0.5ML/31G X loperamide hcl 27 LUXIQ 65 5/16" 111 LOPID 31 LUZU 60 LITETOUCH INSULIN lopinavir-ritonavir 48 LYNPARZA 41 SYRINGE/U-100/1ML/28G X 1/2" 111 LOPRESSOR 51 LYRICA 19 LITETOUCH INSULIN LOPRESSOR HCT 33 LYRICA CR 139 SYRINGE/U-100/1ML/29G X LOPROX 60 LYSODREN 39 1/2" 111 LITETOUCH INSULIN LOPROX SHAMPOO 60 LYSTEDA 77 SYRINGE/U-100/1ML/30G X loratadine 30 M-M-R II 145 5/16" 111 loratadine & M-NATAL PLUS 130 LITETOUCH INSULIN pseudoephedrine 58 MACROBID 12 SYRINGE/U-100/1ML/31G X 13 lorazepam MACRODANTIN 12 5/16" 111 LORBRENA 41

Index 22 mafenide acetate 63 MAXITROL 134 MEDLANCE PLUS UNIVERSAL MAGELLAN INSULIN SAFETY MAXX LUBRICATED 80 LANCETS 21G 88 SYRINGE/U-100/0.3ML/29G X MEDLANCE PLUS/LITE MAXX PLUS SPERMICIDE 25G 88 1/2" 111 LUBRICATED 80 MEDLANCE/EXTRA 88 MAGELLAN INSULIN SAFETY MAXZIDE 68 SYRINGE/U-100/0.3ML/30G X MEDLANCE/LITE 88 MAXZIDE-25 68 5/16" 111 MEDLANCE/UNIVERSAL 88 MAGELLAN INSULIN SAFETY MAYZENT 138 SYRINGE/U-100/0.5ML/29G X MAYZENT STARTER MEDROL 56,57 1/2" 111 PACK 138 MEDROL DOSEPAK 56 MAGELLAN INSULIN SAFETY meclizine hcl 27 medroxyprogesterone SYRINGE/U-100/0.5ML/30G X meclofenamate sodium 5 acetate 137 5/16" 111 medroxyprogesterone acetate MAGELLAN INSULIN SAFETY MEDIC INSULIN (contraceptive) 56 SYRINGE/U-100/1ML/29G X SYRINGE/0.3ML/30G X 5/16" 112 mefenamic acid 5 1/2" 111 mefloquine hcl 35 MAGELLAN INSULIN SAFETY MEDIC INSULIN SYRINGE/U-100/1ML/30G X SYRINGE/0.5ML/30G X MEGACE ES 137 5/16" 111 5/16" 112 megestrol acetate 39 MEDICHOICE PRE-SET magnesium sulfate 128 megestrol acetate SAFETY LANCET DUAL (appetite) 137 MALARONE 35 USE 87 MEDICHOICE PRE-SET MEIJER COLOR LANCETS malathion 67 UNIVERSAL 33G 88 maprotiline hcl 21 SAFETY LANCET LOW FLOW 87 MEIJER LANCETS 88 MARATHON MEDICAL MEDICHOICE PRE-SET MEIJER LANCETS THIN 88 PENTIPS29GX12MM 111 MARATHON MEDICAL SAFETY LANCET MEDIUM MEIJER LANCETS PENTIPS31GX5MM 111 FLOW 87 UNIVERSAL21G 88 MARATHON MEDICAL MEDICHOICE PRE-SET MEIJER LANCETS PENTIPS31GX8MM 111 SAFETY LANCET MODERATE UNIVERSAL30G 88 MARATHON MEDICAL FLOW 87 MEIJER LANCETS PENTIPS32GX4MM 111 MEDICHOICE SAFETY UNIVERSAL33G 88 LANCETEXTRA 88 MEIJER PEN NEEDLES 29G MARCAINE 78 MEDICHOICE SAFETY X12MM 112 MARINOL 28 LANCETNORMAL 88 MEIJER PEN NEEDLES 31G MARPLAN 22 MEDICINE SHOPPE PEN X6MM 112 MARQIBO 42 NEEDLES 29G X 12MM 112 MEIJER PEN NEEDLES 31G MEDICINE SHOPPE PEN X8MM 112 MATULANE 42 NEEDLES 31G X 6MM 112 MEIJER SUPER THIN MAVENCLAD 138 MEDICINE SHOPPE PEN LANCETS 88 MAVYRET 49 NEEDLES 31G X 8MM 112 MEKINIST 41 MEDISENSE THIN MEKTOVI 41 MAXALT 127 LANCETS 88 MAXALT-MLT 127 MEDLANCE PLUS EXTRA meloxicam 5 MAXI-COMFORT INSULIN LANCETS 21G 88 melphalan 36 SYRINGE/U- MEDLANCE PLUS melphalan hcl 36 100/0.5ML/28GX1/2" 111 LANCETS 88 MAXI-COMFORT INSULIN MEDLANCE PLUS LANCETS memantine hcl 138 SYRINGE/U-100/1ML/28GX1/2" LITE 25G 88 MENACTRA 143 111 MEDLANCE PLUS LITE MENEST 72 MAXI-COMFORT SAFETY PEN LANCETS 25G 88 MENOSTAR 72 NEEDLE/29G X 5/16" 111 MEDLANCE PLUS SPECIAL MAXICOMFORT II PEN LANCETS 0.8MM 88 MENQUADFI 143 NEEDLES/31G X 1/4" 111 MEDLANCE PLUS MENVEO 143 MAXICOMFORT INSULIN SUPERLITE 30G 88 meperidine hcl 7 MEDLANCE PLUS SYRINGES 27G X 1/2" 111 meprobamate 13 MAXIDEX 134 SUPERLITE 30G/COMFORT MEPRON 11 MAXIPIME 54 MAX 88 mercaptopurine 37

Index 23 meropenem 11 mexiletine hcl 14 MM INSULIN SYRINGE/U- MERREM 11 micafungin sodium 28 100/1ML/31G X 5/16" 112 MM LANCING DEVICE 88 mesalamine 73 MICARDIS 32 MM PEN NEEDLES 31G X mesna 42 MICARDIS HCT 33 1/4" 112 MESNEX 42 miconazole nitrate MM PEN NEEDLES 31G X MESTINON 35 vaginal 146 3/16" 112 MICRODOT PEN MM PEN NEEDLES 31G X MESTINON TIMESPAN 35 NEEDLE/31G X 6 MM 112 5/16" 112 metaproterenol sulfate 16 MICRODOT PEN MM PEN NEEDLES 32G X metaxalone 131 NEEDLE/32G X 4 MM 112 5/32" 112 metformin hcl 25 MICROLET LANCETS 88 MM TWIST LANCETS 88 methadone hcl 7 MICROLET NEXT 88 MOBIC 5 MICROTAINER SAFETY modafinil 2,3 METHADONE HCL 7 FLOW methadone hcl 7 MODERIBA 1200 DOSE LANCET/STERILE/SINGLE- PACK 49 METHADOSE 7 USE 88 moexipril hcl 32 MICROZIDE 68 METHADOSE SUGAR-FREE 7 mometasone furoate 65 methamphetamine hcl 1 midodrine hcl 146 mometasone furoate methazolamide 68 miglitol 24 (nasal) 132 methenamine hippurate 12 miglustat 75 MONISTAT SOOTHING CARE MIGRANAL 126 ITCH RELIEF 65 methimazole 140 MONOJECT INSULIN METHITEST 10 MILLIPRED 57 SYRINGE/1ML 112 methocarbamol 131 MILLIPRED DP 57 MONOJECT INSULIN METHOTREXATE 4 MINASTRIN 24 FE 55 SYRINGE/1ML/31G X 5/16" 112 methotrexate sodium 37 MINI LANCING DEVICE 88 MONOJECT INSULIN methoxsalen rapid 62 MINIPRESS 32 SYRINGE/DETACH methscopolamine bromide 141 MINIVELLE 72 NEEDLE/1ML/25G X 5/8" 112 MINOCIN 140 MONOJECT INSULIN methyclothiazide 68 SYRINGE/DETACH methyldopa 32 minocycline hcl 140 NEEDLE/1ML/27G X 1/2" 112 METHYLIN 2 minoxidil 34 MONOJECT INSULIN methylphenidate hcl 2 MIRAPEX 44 SYRINGE/PERM MIRCERA 76 NEEDLE/1ML/28G X 1/2" 112 methylprednisolone 57 MONOJECT INSULIN methylprednisolone acetate 57 MIRCETTE 55 SYRINGE/PERM NEEDLE/U- methylprednisolone sod MIRENA 56 100/0.5ML/28G X 1/2" 112 succ 57 mirtazapine 21 MONOJECT INSULIN metipranolol 133 SYRINGE/SAFETY/PERM MIRVASO 67 NEEDLE/0.3ML/29G X 1/2" 112 metoclopramide hcl 73 misoprostol 142 MONOJECT INSULIN metolazone 68 MITIGARE 75 SYRINGE/SAFETY/PERM metoprolol & mitomycin 40 NEEDLE/0.3ML/29GX1/2" 112 hydrochlorothiazide 33 MONOJECT INSULIN metoprolol succinate 51 mitoxantrone hcl 40 SYRINGE/SAFETY/PERM MM INSULIN SYRINGE/U- metoprolol tartrate 51 NEEDLE/0.5ML/29G X 1/2" 112 100/0.3ML/30G X 5/16" 112 MONOJECT INSULIN METROCREAM 66 MM INSULIN SYRINGE/U- SYRINGE/SAFETY/PERM METROGEL 66 100/0.3ML/31G X 5/16" 112 NEEDLE/1ML/29G X 1/2" 112 METROGEL-VAGINAL 146 MM INSULIN SYRINGE/U- MONOJECT INSULIN 100/1/2ML/30G X 5/16" 112 METROLOTION 66 SYRINGE/SOFTPACK/1ML/27G MM INSULIN SYRINGE/U- X 1/2" 113 metronidazole 11 100/1/2ML/31G X 5/16" 112 MONOJECT INSULIN metronidazole (topical) 66 MM INSULIN SYRINGE/U- SYRINGE/SOFTPACK/U- 100/1ML/30G X 5/16" 112 metronidazole vaginal 146 100/0.5ML/28G X 1/2" 113

Index 24 MONOJECT INSULIN MOXIFLOXACIN NAGLAZYME 71 SYRINGE/U-100/0.3ML/30G X HYDROCHLORIDE/SODIUM nalbuphine hcl 10 5/16" 113 HYDROCHLORIDE 72 MONOJECT INSULIN moxifloxacin hcl 72 NALFON 5 SYRINGE/U-100/0.5ML/30G X moxifloxacin hcl (ophth) 134 naloxone hcl 27 5/16" 113 naltrexone hcl 27 MONOJECT INSULIN MOZOBIL 77 SYRINGE/U-100/1ML/28G X MPD SAFETY LANCET NAMENDA 138 1/2" 113 21G/1.8MM 88 NAMENDA TITRATION MONOJECT INSULIN MPD SAFETY LANCET PAK 138 SYRINGE/U-100/1ML/30G X 28G/1.8MM 88 NAPROSYN 5 5/16" 113 MPD SAFETY LANCET naproxen 5 30G/1.8MM 88 MONOJECT INSULIN naproxen sodium 5 SYRINGEREGULAR LUER MPD SAFETY LANCETS TIP/SOFTPACK/1ML 113 23G/1.8MM 88 naratriptan hcl 127 MONOJECT ULTRA COMFORT MS CONTIN 8 NARCAN 27 INSULIN SYRINGE/0.3ML/29G X MS INSULIN NARDIL 22 1/2" 113 SYRINGE/0.3ML/31G X NAROPIN 78 MONOJECT ULTRA COMFORT 5/16" 113 INSULIN SYRINGE/0.3ML/30G X MS INSULIN NASACORT ALLERGY SYRINGE/0.5ML/31G X 24HR 132 5/16" 113 NASACORT ALLERGY 24HR MONOJECT ULTRA COMFORT 5/16" 113 INSULIN SYRINGE/0.3ML/31G X MS INSULIN CHILDRENS 132 5/16" 113 SYRINGE/1ML/31G X NASONEX 132 MONOJECT ULTRA COMFORT 5/16" 113 NATACYN 134 INSULIN SYRINGE/0.5ML/28G X MULPLETA 76 NATAZIA 55 1/2" 113 MULTAQ 14 MONOJECT ULTRA COMFORT nateglinide 26 INSULIN SYRINGE/0.5ML/29G X MULTI PRENATAL 130 NATROBA 67 1/2" 113 MULTI-LANCET DEVICE 88 NATURE-THROID 141 MONOJECT ULTRA COMFORT mupirocin 60 NATURE-THROID NT-2.5 141 INSULIN SYRINGE/0.5ML/30G X 5/16" 113 MUSTARGEN 36 NAVELBINE 42,43 MONOJECT ULTRA COMFORT MVASI 38 NAYZILAM 18 INSULIN SYRINGE/0.5ML/31G X MYALEPT 70 NEBUPENT 11 5/16" 113 MYAMBUTOL 36 NEBUSAL 58 MONOJECT ULTRA COMFORT INSULIN SYRINGE/1ML/28G X MYCAMINE 28 nefazodone hcl 23 1/2" 113 MYCOBUTIN 36 NEO-SYNALAR 60 MONOJECT ULTRA COMFORT mycophenolate mofetil 129 neomycin sulfate 3 INSULIN SYRINGE/1ML/29G X mycophenolate sodium 129 neomycin-bacitracin zn- 1/2" 113 MYDRIACYL 133 polymyxin 134 MONOLET LANCETS 88 neomycin-polymy- MONOLET OPD LANCETS 88 MYFORTIC 129 dexameth 134 MONOLETTOR SAFETY MYGLUCOHEALTH MGH neomycin-polymyxin-hc LANCETS 88 SOFTLANCE LANCETS (ophth) 134 montelukast sodium 14 30G 88 neomycin-polymyxin-hc MYLERAN 36 (otic) 136 MONUROL 12 MYLOTARG 38 NEONATAL COMPLETE 130 MORPHABOND ER 7 MYRBETRIQ 143 NEONATAL PLUS 130 morphine sulfate 7 MYSOLINE 19 NEONATAL VITAMIN 130 MORPHINE SULFATE 7 nabumetone 5 NEORAL 129 morphine sulfate 7,8 nadolol 51 NEOSPORIN 134 MOTOFEN 27 nafcillin sodium 137 NEOSTIGMINE MOVIPREP 78 METHYLSULFATE 35 naftifine hcl 61 NESINA 25 NAFTIN 61 NEULASTA 76

Index 25 NEULASTA ONPRO KIT 76 NIX CREME RINSE 67 NOVOLIN 70/30 FLEXPEN 26 NEUPOGEN 76 NIZATIDINE 141 NOVOLIN 70/30 FLEXPEN NEUPRO 44 nizatidine 141 RELION 26 NOVOLIN 70/30 RELION 26 NEURONTIN 19 NIZORAL 61 NOVOLIN N 26 NEVANAC 135 NORCO 9 NOVOLIN N RELION 26 nevirapine 48 NORDITROPIN FLEXPRO 70 NOVOLIN R 26 NEXAVAR 41 norelgestromin-ethinyl NOVOLIN R RELION 26 NEXIUM 142 estradiol 55 norethin acet & estrad-fe 55 NOVOLOG 26 NEXIUM 24HR 142 norethindrone & eth NOVOLOG FLEXPEN 26 NEXPLANON 56 estradiol 55 NOVOLOG MIX 70/30 26 niacin 147 norethindrone & ethinyl NOVOLOG MIX 70/30 niacin (antihyperlipidemic) 31 estradiol-fe 55 norethindrone PREFILLED FLEXPEN 26 NIACIN TR 147 (contraceptive) 56 NOVOLOG PENFILL 26 niacinamide 147 norethindrone acet & eth NOVOTWIST 32GX5MM 113 NIASPAN 31 estra 55 NOXAFIL 29 nicardipine hcl 52 norethindrone acetate 137 NPLATE 76 NICODERM CQ 139 norethindrone acetate-ethinyl estradiol 72 NUBEQA 39 NICORETTE 139 norethindrone acetate-ethinyl NUCALA 14 NICORETTE MINI 139 estradiol-fe 55 NUCYNTA 8 NICORETTE STARTER norethindrone-eth estradiol NUCYNTA ER 8 KIT 139 (triphasic) 55 NUEDEXTA 139 nicotine 139 norgestimate-ethinyl estradiol 55 NULOJIX 129 nicotine polacrilex 139 norgestimate-ethinyl estradiol NUTROPIN AQ NUSPIN 10 70 NICOTINE TRANSDERMAL (triphasic) 55 SYSTEM 139 norgestrel & ethinyl NUVARING 55 NICOTROL INHALER 139 estradiol 55 NUVIGIL 3 NICOTROL NS 139 NORMOSOL-M IN D5W 128 nystatin 28 nifedipine 52 NORMOSOL-R 128 nystatin (mouth-throat) 130 NILANDRON 39 NORPACE 14 nystatin (topical) 61 nilutamide 39 NORPRAMIN 24 nystatin-triamcinolone 61 nimodipine 52 nortriptyline hcl 24 O-CAL FA 131 NINLARO 41 NORVASC 52 OCREVUS 139 NIPENT 42 NORVIR 48 octreotide acetate 71 nisoldipine 52 NOVA MAX PLUS KETONE OCUFLOX 134 TESTSTRIPS 67 nitisinone 71 NOVA SAFETY LANCETS ODEFSEY 48 NITRO-BID 13 23G 88 ODOMZO 38 NITRO-DUR 13 NOVA SAFETY LANCETS OFEV 140 nitrofurantoin 12 28G 88 ofloxacin 72 NOVA SUREFLEX nitrofurantoin macrocrystal 12 LANCETS 88 ofloxacin (ophth) 134 nitrofurantoin monohyd NOVA SUREFLEX LANCING ofloxacin (otic) 136 macro 12 DEVICE 88 olanzapine 45 nitroglycerin 13 NOVAREL 69 olmesartan medoxomil 32 NITROGLYCERIN 13 NOVOFINE 32GX6MM 113 olmesartan medoxomil- nitroglycerin 13 NOVOFINE AUTOCOVER amlodipine-hydrochlorothiazide NITROSTAT 13 30GX8MM 113 33 NOVOFINE PLUS NIVA-PLUS 131 olmesartan medoxomil- 32GX4MM 113 hydrochlorothiazide 33 NIVESTYM 76 NOVOLIN 70/30 26 olopatadine hcl 135

Index 26 olopatadine hcl (nasal) 132 ORAPRED ODT 57 pamidronate disodium 69 OLUMIANT 4 ORENCIA 5 PANOXYL-4 CREAMY OLUX 65 ORENCIA CLICKJECT 5 WASH 59 PANRETIN 61 omega-3-acid ethyl esters 30 ORENITRAM 53 pantoprazole sodium 142 omeprazole 142 ORFADIN 71 PARAGARD INTRAUTERINE omeprazole magnesium 142 ORKAMBI 140 COPPER CONTRACEPTIVE omeprazole-sodium orphenadrine citrate 132 T380A 55 bicarbonate 142 ORTHO MICRONOR 56 parenteral electrolytes 128 OMNIFLEX DIAPHRAGM 80 ORTHO TRI-CYCLEN 55 paricalcitol 71 OMNIPRED 134 ORTHO TRI-CYCLEN LO 55 PARLODEL 44 OMNITROPE 70 ORTHO-CYCLEN 55 PARNATE 22 ON CALL LANCETS 89 ORTHO-NOVUM 1/35 55 paromomycin sulfate 3 ON CALL LANCING DEVICE 89 ORTHO-NOVUM 7/7/7 55 paroxetine hcl 22 ON CALL PLUS LANCETS 89 oseltamivir phosphate 50 PASER 36 ON CALL PLUS LANCING OSENI 24 PATADAY 135 DEVICE 89 OSMOPREP 78 PATANASE 132 ONCASPAR 42 OSPHENA 70 PATANOL 135 ondansetron 27 OTEZLA 5 PAXIL 22,23 ondansetron hcl 27 OTOVEL 136 PAXIL CR 22 ONE VITE WOMENS OVIDE 67 PC LANCETS SUPER THIN PRENATALVITAMIN 131 30G 89 ONE VITE WOMENS oxacillin sodium 137 PC UNIFINE PENTIPS 29G PRENATALVITAMIN PLUS 131 oxaliplatin 36 X1/2" 113 ONETOUCH CLUB LANCETS oxandrolone 10 PC UNIFINE PENTIPS 31G FINE POINT 89 oxaprozin 5 X5MM MINI 113 ONETOUCH DELICA LANCETS PC UNIFINE PENTIPS 31G EXTRA FINE 33G 89 OXAYDO 8 X6MM ULTRA SHORT 113 ONETOUCH DELICA LANCETS oxazepam 13 PC UNIFINE PENTIPS 31G FINE 30G 89 OXBRYTA 76 X8MM SHORT 113 ONETOUCH DELICA LANCING PEDIAPRED 57 DEVICE 89 oxcarbazepine 19 ONETOUCH DELICA PLUS peg 3350-kcl-nacl-na sulfate-na OXERVATE 134 ascorbate-ascorbic acid 78 LANCETS EXTRA FINE oxiconazole nitrate 61 33G 89 peg 3350-kcl-sod bicarb-sod ONETOUCH DELICA PLUS OXISTAT 61 chloride-sod sulfate 78 LANCETS FINE 30G 89 OXSORALEN ULTRA 62 PEGANONE 20 ONETOUCH DELICA PLUS oxybutynin chloride 143 PEGASYS 49 LANCING DEVICE 89 PEGASYS PROCLICK 49 ONETOUCH FINEPOINT oxycodone hcl 8 LANCETS 89 oxycodone w/ PEGINTRON 49 ONETOUCH ULTRASOFT acetaminophen 9 PEN NEEDLES 29G X LANCETS 89 oxycodone-ibuprofen 9 12MM 113 ONETOUCH VERIO CONTROL OXYCONTIN 8 PEN NEEDLES 29GX1/2" 113 SOLUTION HIGH 89 oxymorphone hcl 8 PEN NEEDLES ONFI 18 29GX12MM 113 paclitaxel 43 ONGLYZA 25 PEN NEEDLES 30GX5/16" 113 paliperidone 45 ONIVYDE 43 PEN NEEDLES 30GX8MM 114 palonosetron hcl 27 OPANA 8 PEN NEEDLES 31G X 1/4" PALYNZIQ 71 SHORT 114 OPDIVO 38 PAMELOR 24 PEN NEEDLES 31G X OPSUMIT 53 3/16" 114 pamidronate disodium 69 ORACEA 67 PEN NEEDLES 31G X PAMIDRONATE 5MM 114 ORAP 139 DISODIUM 69

Index 27 PEN NEEDLES 31G X PERCOCET 9 pioglitazone hcl 25 6MM 114 PERFECT LANCETS 30G 89 pioglitazone hcl-glimepiride 24 PEN NEEDLES 31G X 8MM 114 PERFECT PRESSURE pioglitazone hcl-metformin ACTIVATED SAFETY hcl 24 PEN NEEDLES 31GX5/16" 114 LANCETS 28G 89 PIP LANCETS/28G 89 PEN NEEDLES 31GX6MM PERIDEX 130 (1/4") 114 PIP LANCETS/30G 89 PEN NEEDLES 31GX8MM 114 perindopril erbumine 32 piperacillin sodium-tazobactam PEN NEEDLES 31GX8MM PERJETA 38 sodium 137 (5/16") 114 permethrin 67 PIQRAY 200MG DAILY DOSE 41 PEN NEEDLES 32G X perphenazine 46 4MM 114 PIQRAY 250MG DAILY perphenazine-amitriptyline DOSE 41 PEN NEEDLES 32G X 138 5MM 114 PIQRAY 300MG DAILY PEN NEEDLES 32G X PERSERIS 45 DOSE 41 6MM 114 PHARMACIST CHOICE piroxicam 5 PEN NEEDLES 32GX4MM 114 ULTRA THIN LANCETS 89 PLAN B ONE-STEP 56 PHARMACIST CHOICE PEN NEEDLES/29G X 1/2" 114 ULTRA THIN LANCETS PLAQUENIL 35 PEN NEEDLES/31G X 1/4" 114 28G 89 PLASMA-LYTE A 128 PEN NEEDLES/31G X PHARMACIST CHOICE PLASMA-LYTE-148 128 3/16" 114 ULTRA THIN LANCETS PLAVIX 75 PEN NEEDLES/31G X 30G 89 5/16" 114 PHARMACIST CHOICE PLEGISOL 52 PEN NEEDLES/31G X ULTRA THIN LANCETS PLEGRIDY 139 6MM 114 31G 89 PLEGRIDY STARTER PEN NEEDLES/32G X PHARMACIST CHOICE PACK 139 5/32" 114 ULTRA THIN LANCETS PNEUMOVAX 23 143 penicillamine 129 33G 89 PNEUMOVAX 23/1 DOSE 143 penicillin g potassium 136 PHARMACY COUNTER LANCETS 89 podofilox 66 PENICILLIN G POTASSIUM IN polymyxin b sulfate 12 ISO-OSMOTIC phenazopyridine hcl 74 DEXTROSE 136 phendimetrazine tartrate 1 polymyxin b-trimethoprim 134 PENICILLIN G PROCAINE 136 phenelzine sulfate 22 POLYTRIM 134 penicillin g sodium 136 PHENERGAN 30 POMALYST 39 penicillin v potassium 136 phenobarbital 77 PORTRAZZA 38 PENLAC NAIL LACQUER 61 phenoxybenzamine hcl 32 potassium acetate 128 PENTAM 300 11 phentermine hcl 2 potassium bicarb & chloride128 pentamidine isethionate 11 PHENYTEK 20 potassium bicarbonate 128 pentazocine w/ naloxone 10 phenytoin 20 potassium chloride 128 PENTIPS 29G X 12MM 114 phenytoin sodium 21 POTASSIUM CHLORIDE 128 PENTIPS 29GX12MM 114 phenytoin sodium potassium chloride 128 PENTIPS 31G X 5MM 114 extended 21 potassium chloride in PHOSLYRA 74 dextrose 128 PENTIPS 31G X 8MM 114 PHOSPHOLINE IODIDE 133 potassium chloride in dextrose & PENTIPS 31GX5MM 114 sodium chloride 128 PHOTOFRIN 42 PENTIPS 31GX6MM 114 potassium chloride in nacl 128 PICATO 62 PENTIPS 31GX8MM 114 potassium chloride PIFELTRO 48 PENTIPS 32G X 4MM 114 microencapsulated crystals pilocarpine hcl 133 er 128 PENTIPS 32GX4MM 114 pilocarpine hcl (oral) 130 POTASSIUM pentoxifylline 75 CHLORIDE/DEXTROSE/LACTA pimecrolimus 66 PEPCID 141 TED RINGERS 128 PEPCID AC MAXIMUM pimozide 139 potassium citrate STRENGTH 141 pindolol 51 (alkalinizer) 74

Index 28 potassium phosphates 128 PREFERRED PLUS INSULIN PRENATAL POTELIGEO 38 SYRINGE/U-100/0.3ML/30G X VITAMIN/IRON 131 5/16" 114 PRENATAL VITAMINS 131 PRADAXA 18 PREFERRED PLUS INSULIN PRENATAL VITAMINS PLUS pramipexole dihydrochloride 44 SYRINGE/U-100/0.5ML/28G X LOW IRON 131 PRANDIN 26 1/2" 115 PRENATRIX 131 PREFERRED PLUS INSULIN prasugrel hcl 75 SYRINGE/U-100/0.5ML/29G X PREPLUS 131 PRAVACHOL 31 1/2" 115 PREPOPIK 78 pravastatin sodium 31 PREFERRED PLUS INSULIN PRESSURE ACTIVATED praziquantel 11 SYRINGE/U-100/0.5ML/30G X SAFETYLANCET 21G 89 5/16" 115 prazosin hcl 32 PREVACID 142 PREFERRED PLUS INSULIN PREVACID 24HR 142 PRECISION SURE-DOSE SYRINGE/U-100/1ML/28G X INSULIN SYRINGE/0.3ML/30G X 1/2" 115 PREVENT SAFETY PEN 5/16" 114 PREFERRED PLUS INSULIN NEEDLES 31GX1/4" 115 PRECISION SURE-DOSE SYRINGE/U-100/1ML/29G X PREVENT SAFETY PEN INSULIN SYRINGE/0.5ML/28G X 1/2" 115 NEEDLES 31GX5/16" 115 1/2" 114 PREFERRED PLUS INSULIN PREVNAR 13 143 PRECISION SURE-DOSE SYRINGE/U-100/1ML/30G X PREZCOBIX 48 INSULIN SYRINGE/0.5ML/29G X 5/16" 115 PREZISTA 48 1/2" 114 PREFERRED PLUS LANCETS PRECISION SURE-DOSE COLORED 21G 89 PRIFTIN 36 INSULIN SYRINGE/0.5ML/30G X PREFERRED PLUS LANCETS PRILOSEC OTC 142 3/8" 114 SUPER THIN 30G 89 primaquine phosphate 35 PRECISION SURE-DOSE PREFERRED PLUS LANCETS PRIMAQUINE PHOSPHATE 35 INSULIN SYRINGE/1ML/28G X THIN 26G 89 1/2" 114 PREFERRED PLUS UNIFINE PRIMAXIN IV 11 PRECISION SURE-DOSE PENTIPS 29G X 12MM 115 primidone 19 PLUSINSULIN PREFERRED PLUS UNIFINE PRINIVIL 32 SYRINGE/0.3ML/29G X PENTIPS 31G X 6MM ULTRA 1/2" 114 SHORT 115 PRISTIQ 23 PRECISION SURE-DOSE PREFERRED PLUS UNIFINE PRO COMFORT INSULIN PLUSINSULIN PENTIPS 31G X 8MM SYRINGES/0.5ML/30G X SYRINGE/1ML/29G X 1/2" 114 SHORT 115 1/2" 115 PRECISION THINS GP PREFERRED PLUS UNIFINE PRO COMFORT INSULIN LANCET 89 PENTIPS 32GX4MM 115 SYRINGES/0.5ML/30G X PRECISION XTRA 67 PREFERRED PLUS UNIFINE 5/16" 115 PRO COMFORT INSULIN PRECOSE 24 PENTIPS/MINI/31GX5MM 115 SYRINGES/0.5ML/31G X PRED FORTE 134 pregabalin 19 5/16" 115 PRO COMFORT INSULIN PRED MILD 134 PREGNYL W/DILUENT prednicarbate 65 SYRINGES/1ML/30G X BENZYLALCOHOL/NACL 69 1/2" 115 prednisolone 57 PREMARIN 72 PRO COMFORT INSULIN prednisolone acetate PREMIUM CONDOMS SYRINGES/1ML/30G X (ophth) 135 LUBRICATED 80 5/16" 115 PREDNISOLONE ACETATE P- PREMPHASE 72 PRO COMFORT INSULIN F 135 PREMPRO 72 SYRINGES/1ML/31G X prednisolone sodium 5/16" 115 phosphate 57 PRENATAL 131 PRO COMFORT LANCETS PREDNISOLONE SODIUM PRENATAL LOW IRON 131 30G 89 PHOSPHATE 135 PRENATAL PRO COMFORT LANCETS prednisone 57 MULTIVITAMIN 131 31G 89 PREFERRED PLUS INSULIN PRENATAL ONE DAILY 131 PRO COMFORT PEN SYRINGE/U-100/0.3ML/29G X PRENATAL PLUS 131 NEEDLES/31G X 8MM 115 1/2" 114 PRO COMFORT PEN PRENATAL VITAMIN 131 NEEDLES/32G X 4MM 115 PRENATAL VITAMIN & MINERAL 131

Index 29 PRO COMFORT PEN PROVIGIL 3 QC PEN NEEDLES 29G X NEEDLES/32G X 5MM 115 PROZAC 23 12MM 116 PRO COMFORT PEN QC PEN NEEDLES 31G X NEEDLES/32G X 6MM 115 PRUDOXIN 62 6MM 116 PROAIR HFA 16 PSORCON 65 QC PEN NEEDLES 31G X probenecid 75 PSS SELECT GP 8MM 116 LANCETS 89 QC PRENATAL 131 procainamide hcl 14 PSS SELECT SAFETY QC UNIFINE PENTIPS PROCARDIA 52 LANCETS 89 32GX4MM 116 PROCARDIA XL 52 PTS PANELS KETONE QC UNILET LANCETS prochlorperazine 46 TEST 67 28G/ULTRA THIN 90 PULMICORT 15 QC UNILET LANCETS prochlorperazine maleate 46 PULMICORT FLEXHALER15 33G/MICRO THIN 90 PROCRIT 76 PULMOZYME 140 QUALAQUIN 35 PROCTOCORT 10 PURE COMFORT PEN QUARTETTE 55 PRODIGY CONTROL NEEDLE 32G X6MM 115 QUDEXY XR 19 SOLUTIONHIGH 89 PURE COMFORT PEN QUESTRAN 31 PRODIGY INSULIN SYRING/U- NEEDLE/32G X 5MM 115 100/0.3ML/31G X 5/16" 115 PURE COMFORT PEN QUESTRAN LIGHT 30 PRODIGY INSULIN NEEDLE/32G X4MM 115 quetiapine fumarate 45 SYRINGE/1/2ML/31G X PUSH BUTTON SAFETY 5/16" 115 quinapril hcl 32 LANCETS 21G 90 quinapril-hydrochlorothiazide PRODIGY INSULIN PUSH BUTTON SAFETY SYRINGE/1ML/28G X 1/2" 115 34 LANCETS 28G 90 quinidine sulfate 14 PRODIGY LANCING PX ADVANCED LANCING DEVICE 89 DEVICE 90 quinine sulfate 35 PRODIGY PRESSURE PX EXTRA SHORT PEN QVAR REDIHALER 15 ACTIVATED SAFETY NEEDLES 31GX6MM 115 RA E-ZJECT COLOR LANCETS 89 PX INSULIN SYRINGE/U- PRODIGY SAFETY LANCETSMICRO-THIN 33G 90 100/0.5ML/30G X 1/2" 116 RA E-ZJECT LANCETS 28G90 LANCETS 89 PX LANCET AUTO PRODIGY TWIST TOP RA E-ZJECT LANCETS THIN INJECTOR 90 26G 90 LANCETS 89 PX LANCETS ULTRA progesterone micronized 137 RA E-ZJECT LANCETS THIN THIN 90 28G 90 PROGLYCEM 25 PX LANCETS ULTRA THIN RA E-ZJECT LANCETS PROGRAF 129 28G 90 ULTRATHIN 30G 90 PX MINI PEN NEEDLES PROLASTIN-C 140 RA INSULIN 31GX5MM 116 SYRINGE/0.5ML/29G X PROLEUKIN 42 PX PEN NEEDLE 1/2" 116 PROLIA 69 29GX12MM 116 RA INSULIN SYRINGE/1ML/29G PX PEN NEEDLE PROMACTA 76 X 1/2" 116 31GX8MM 116 RA INSULIN SYRINGE/U- promethazine hcl 30 PX PRENATAL 100/0.5ML/30G X 5/16" 116 PROMETRIUM 137 MULTIVITAMINS 131 RA INSULIN SYRINGE/U-100/1 PX SHORTLENGTH PEN propafenone hcl 14 ML/30G X 5/16" 116 NEEDLES/31GX8MM 116 RA LANCING DEVICE 90 proparacaine hcl 134 pyrazinamide 36 propranolol hcl 51 RA PEN NEEDLES 31G X PYRIDIUM 74 5MM3/16" 116 propylthiouracil 140 pyridostigmine bromide 35 RA PEN NEEDLES 31G X PROSCAR 74 pyrimethamine 35 8MM5/16" 116 PROTONIX 142 QC ADVANCED LANCING RA PRENATAL 131 PROTOPIC 66 DEVICE 90 RA PRENATAL protriptyline hcl 24 QC LANCETS SUPER FORMULA/FOLICACID 131 THIN 90 142 PROVENGE 38 rabeprazole sodium QC LANCETS ULTRA raloxifene hcl 70 PROVENTIL HFA 16 THIN 90 77 PROVERA 137 ramelteon

Index 30 ramipril 32 RELION 2-IN-1 LANCING RELION ULTRA THIN PLUS RANEXA 12 DEVICE 30G 90 LANCETS 32G 90 RELION INSULIN SYRINGE RELION ULTRA THIN PLUS ranitidine hcl 141,142 1ML/31GX15/64" 116 LANCETS 33G 90 ranolazine 12,13 RELION INSULIN SYRINGE/U- RELISTOR 74 RAPAFLO 74 00/1ML/29G X 1/2" 116 RELPAX 127 RELION INSULIN SYRINGE/U- RAPAMUNE 129 100/0.3ML/29G X 1/2" 116 REMERON 21 rasagiline mesylate 44 RELION INSULIN SYRINGE/U- REMERON SOLTAB 21 RAZADYNE 138 100/0.3ML/30G X 5/16" 116 REMICADE 73 RAZADYNE ER 138 RELION INSULIN SYRINGE/U- 100/0.3ML/31G X 5/16" 116 REMODULIN 53 READYLANCE SAFETY RELION INSULIN SYRINGE/U- RENFLEXIS 73 LANCETS/21G/2.2MM 90 100/0.5ML/29G X 1/2" 116 READYLANCE SAFETY RENVELA 74 RELION INSULIN SYRINGE/U- REOPRO 75 LANCETS/23G/1.8MM 90 100/0.5ML/30G X 5/16" 116 READYLANCE SAFETY RELION INSULIN SYRINGE/U- repaglinide 26 LANCETS/26G/1.8MM 90 100/0.5ML/31G X 5/16" 116 repaglinide-metformin hcl 24 READYLANCE SAFETY RELION INSULIN SYRINGE/U- REPATHA 31 LANCETS/28G/1.8MM 90 100/1ML/30G X 5/16" 116 READYLANCE SAFETY RELION INSULIN SYRINGE/U- REPATHA SURECLICK 31 LANCETS/30G/1.6MM 90 100/1ML/31G X 15/64" 116 REQUIP 44 REALITY INSULIN SYRINGE/U- RELION INSULIN SYRINGE/U- REQUIP XL 44 100/0.5ML/28G X 1/2" 116 100/1ML/31G X 5/16" 116 REALITY INSULIN SYRINGE/U- RESCRIPTOR 48 100/0.5ML/29G X 1/2" 116 RELION KETONE 67 RELION KETONE TEST RESECTISOL 74 REALITY INSULIN SYRINGE/U- RESTASIS 134 100/1ML/28G X 1/2" 116 STRIPS 67 REALITY INSULIN SYRINGE/U- RELION LANCETS MICRO- RESTASIS MULTIDOSE 134 100/1ML/29G X 1/2" 116 THIN33G 90 RESTORIL 77 REALITY LANCETS 90 RELION LANCETS STANDARD 21G 90 RETACRIT 76 REALITY LATEX RELION LANCETS THIN RETEVMO 41 CONDOMS/LUBRICATED 80 26G 90 RETIN-A 59 REALITY LATEX/ULTRA RELION LANCETS ULTRA- TEXTURED 80 THIN30G 90 RETIN-A MICRO 59 REALITY LATEX/ULTRA RELION LANCING RETIN-A MICRO PUMP 59 THIN 80 DEVICE 90 REALITY TRIGGER RETROVIR 48 RELION MINI PEN NEEDLES RETROVIR IV INFUSION 48 LANCETS 90 31GX6MM 116 REBETOL 49 RELION PEN NEEDLES REVATIO 53 REBIF 139 29GX12MM 116 REVLIMID 129 REBIF REBIDOSE 139 RELION PEN NEEDLES REXALL LANCETS ULTRA REBIF REBIDOSE 31GX5/16" 117 THIN 90 TITRATIONPACK 139 RELION PEN NEEDLES REXULTI 46 31GX6MM 117 REBIF TITRATION PACK 139 RELION PEN NEEDLES REYATAZ 48 RECLAST 69 31GX8MM 117 RIBASPHERE 50 RECOMBIVAX HB 145 RELION PEN NEEDLES 32G RIBASPHERE RIBAPAK 50 X5/32" 117 ribavirin (hepatitis c) 50 RECTIV 10 RELION PEN NEEDLES REGIMEX 2 32GX4MM 117 RIDAURA 4 REGLAN 73 RELION PEN NEEDLES/31G rifabutin 36 REGRANEX 67 X1/4" 117 RIFADIN 36 RELION SHORT PEN RELENZA DISKHALER 50 NEEDLES31GX8MM 117 RIFAMATE 35 RELION 2-IN-1 LANCET RELION ULTRA THIN rifampin 36 DEVICES 30G 90 LANCETS/30G 90 RIFATER 35 RELION 2-IN-1 LANCING RELION ULTRA THIN RIGHT STEP PRENATAL 131 DEVICE 25G 90 LANCETS30G 90

Index 31 RIGHTEST GC300 HIGH SAFE-T-LANCE PLUS SAMSCA 71 CONTROL 90 SAFETYLANCET LOW SANDIMMUNE 129 RIGHTEST GD500 LANCING FLOW 91 DEVICE 90 SAFE-T-LANCE PLUS SANDOSTATIN 71 RIGHTEST GL300 SAFETYLANCET NORMAL SANDOSTATIN LAR LANCETS 90 FLOW 91 DEPOT 71 RILUTEK 132 SAFESNAP INSULIN SANTYL 66 riluzole 132 SYRINGE/0.3ML/30G X SAPHRIS 46 5/16" 117 rimantadine hydrochloride 50 SAFESNAP INSULIN sapropterin dihydrochloride 71 ringer's 128 SYRINGE/0.5ML/29G X SAPS HEALTH CARE TWIST 1/2" 117 TOP LANCETS 91 ringer's irrigation 130 SAPS HEALTH TWIST TOP RINVOQ 4 SAFESNAP INSULIN SYRINGE/0.5ML/30G X LANCETS 30G 91 risedronate sodium 69 5/16" 117 SAPSCARE TWIST TOP RISPERDAL 45 SAFESNAP INSULIN LANCETS 30G 91 SAVELLA 138 RISPERDAL CONSTA 45 SYRINGE/1ML/28G X 1/2" 117 SAVELLA TITRATION risperidone 45 SAFESNAP INSULIN PACK 138 RITALIN 3 SYRINGE/1ML/29G X SB INSULIN SYRINGE/U- RITALIN LA 3 1/2" 117 100/0.5ML/29G X 1/2" 117 SB INSULIN SYRINGE/U- ritonavir 48 SAFETY INSULIN SYRINGES 0.5ML/29GX1/2" 117 100/0.5ML/30G X 5/16" 117 RITUXAN 38 SAFETY INSULIN SYRINGES SB INSULIN SYRINGE/U- rivastigmine tartrate 138 0.5ML/30GX5/16" 117 100/1ML/29G X 1/2" 117 rizatriptan benzoate 127 SAFETY INSULIN SYRINGES SB INSULIN SYRINGE/U- 1ML/27GX1/2" 117 100/1ML/30G X 5/16" 117 ROBAXIN 132 SAFETY INSULIN SYRINGES SB INSULIN SYRINGE/U- ROBAXIN-750 132 1ML/29GX1/2" 117 100/1ML/31G X 5/16" 117 ROCALTROL 71 SAFETY INSULIN SYRINGES SB LANCETS THIN 91 ROMIDEPSIN 41 1ML/30GX1/2" 117 SB LANCETS ULTRA THIN 91 SAFETY LANCET ropinirole hydrochloride 44 21G/PRESSURE scopolamine 27 rosuvastatin calcium 31 ACTIVATED 91 SEASONIQUE 55 ROTARIX 145 SAFETY LANCET SECURESAFE SAFETY 23G/PRESSURE INSULIN SYRINGES/U- ROTATEQ 145 ACTIVATED 91 100/0.5ML/29GX1/2" 117 ROXICET 9 SAFETY LANCET SECURESAFE SAFETY ROXICODONE 8 28G/PRESSURE INSULIN SYRINGES/U- ROXYBOND 8 ACTIVATED 91 100/1ML/29GX1/2" 117 SAFETY LANCET SEGLUROMET 24 ROZEREM 77 30G/PRESSURE SELECT-LITE LANCING ROZLYTREK 41 ACTIVATED 91 DEVICE 91 RUCONEST 75 SAFETY LANCETS 91 selegiline hcl 44 rufinamide 19 SAFETY LANCETS 21G 91 selenium sulfide 63 RUXIENCE 38 SAFETY LANCETS 28G 91 SELZENTRY 48 RUZURGI 35 SAFETY LET LANCETS 91 SENSIPAR 71 RYTHMOL SR 14 SAFETY SEAL LANCETS SEREVENT DISKUS 16 28G 91 SABRIL 20 SAFETY SEAL LANCETS SEROQUEL 46 SAFE-T-LANCE LOW FLOW 30G 91 SEROQUEL XR 46 25G 90 SAFE-T-LANCE NORMAL SAFYRAL 55 SEROSTIM 70 FLOW21G 91 SAIZEN 70 sertraline hcl 23 SAFE-T-LANCE PLUS SAIZENPREP sevelamer carbonate 74 SAFETYLANCET HIGH RECONSTITUTIONKIT 70 SHINGRIX 145 FLOW 91 SALAGEN 130 SHOPKO AUTOLET LANCING salsalate 6 DEVICE 91

Index 32 SHOPKO ON-THE-GO SIMULECT 129 SOLU-CORTEF 57 COMFORTLANCETS 30G 91 simvastatin 31 SOLU-MEDROL 57 SHOPKO UNIFINE PENTIPS PEN SINEMET 44 SOLUS V2 CONTROL HIGH91 NEEDLES/MICRO/32GX4MM SINEMET CR 44 SOLUS V2 LANCING 117 SINGLE-LET 91 DEVICE 91 SHOPKO UNIFINE PENTIPS SOLUS V2 PRESSURE PEN NEEDLES/MINI/31GX5MM SINGULAIR 14 ACTIVATED SAFETY LANCETS 117 sirolimus 129 28G 91 SHOPKO UNIFINE PENTIPS SIRTURO 36 SOLUS V2 TWIST LANCETS 30G 92 PEN SIVEXTRO 12 NEEDLES/ORIGINAL/29GX12M SOMA 132 SKELAXIN 132 M 117 SOMATULINE DEPOT 71 SKLICE 67 SHOPKO UNIFINE PENTIPS SOMAVERT 69 PEN SKYLA 56 SOOLANTRA 67 NEEDLES/SHORT/31GX8MM SKYRIZI 62 117 SORBITOL 74 SLO-NIACIN 147 SHOPKO UNIFINE PENTIPS SORBITOL-MANNITOL 74 PLUS PEN SLYND 56 SORBITOL/MANNITOL NEEDLES/MICRO/REMOVR/32 SM MICRO THIN LANCETS IRRIGATION 74 GX4MM 117 33G 91 SORIATANE 62 SHOPKO UNIFINE PENTIPS SM PRENATAL PLUS PEN VITAMINS 131 sotalol hcl 51 NEEDLES/MINI/REMOVER/31G SM TRUEDRAW LANCING sotalol hcl (afib/afl) 51 X5MM 117 DEVICE 91 SOVALDI 50 SHOPKO UNIFINE PENTIPS SMART DIABETES VANTAGE PLUS PEN LANCING DEVICE 91 spinosad 67 NEEDLES/REMOVER/29GX12M SMART SENSE COLOR SPIRIVA HANDIHALER 14 M 117 LANCETS UNIVERSAL SPIRIVA RESPIMAT 14 SHOPKO UNIFINE PENTIPS 33G 91 spironolactone 68 PLUS PEN SMART SENSE STANDARD LANCETS UNIVERSAL spironolactone & NEEDLES/SHORT/REMOVR/31 hydrochlorothiazide 68 GX8MM 118 21G 91 SHOPKO UNILET LANCETS SMART SENSE SUPER THIN SPORANOX 29 SUPER THIN 30G 91 LANCETS UNIVERSAL SPORANOX PULSEPAK 29 SHOPKO UNILET LANCETS 30G 91 SPRAVATO 56MG DOSE 22 SMART SENSE THIN ULTRA THIN 28G 91 SPRAVATO 84MG DOSE 22 SHUR-SEAL 146 LANCETSUNIVERSAL SIDE BUTTON SAFETY 26G 91 SPRYCEL 41 LANCET21G 91 SMARTEST LANCETS STALEVO 100 44 SIGNIFOR 71 28G 91 STALEVO 125 44 SODIUM ACETATE 127 sildenafil citrate 52 STALEVO 150 44 127 sildenafil citrate (pulmonary sodium acetate STALEVO 200 44 129 hypertension) 53 sodium chloride STALEVO 50 44 sodium chloride (gu SILENOR 77 STALEVO 75 44 SILIQ 62 irrigant) 74 sodium chloride (inhalant) 58 stannous fluoride 130 silodosin 74 sodium citrate & citric acid 74 STARLIX 26 SILVADENE 63 sodium phenylbutyrate 71 stavudine 48 silver sulfadiazine 63 sodium polystyrene STEGLATRO 26 SIMBRINZA 133 sulfonate 130 STELARA 63,73 SOFOSBUVIR/VELPATASVIR SIMCOR 31 STENDRA 52 SIMPLE DIAGNOSTICS 50 LANCING DEVICE 91 solifenacin succinate 143 STERILANCE TL 92 SIMPONI 4 SOLIRIS 75 STIMATE 71 SIMPONI ARIA 4 SOLOSEC 3 STIVARGA 41

Index 33 STRATTERA 2 SURE COMFORT INSULIN SURE-JECT INSULIN streptomycin sulfate 3 SYRINGE/U-100/0.5ML/30G X SYRINGE/U-100/0.3ML/29G X 1/2" 118 1/2" 118 STRIBILD 48 SURE COMFORT INSULIN SURE-JECT INSULIN STRIVERDI RESPIMAT 16 SYRINGE/U-100/0.5ML/30G X SYRINGE/U-100/0.3ML/30G X STROMECTOL 11 5/16" 118 5/16" 118 SURE COMFORT INSULIN SURE-JECT INSULIN SUBOXONE 10 SYRINGE/U-100/0.5ML/31G X SYRINGE/U-100/0.3ML/31G X SUBSYS 8 5/16 118 5/16" 119 SUCRAID 67 SURE COMFORT INSULIN SURE-JECT INSULIN sucralfate 142 SYRINGE/U-100/1ML/28G X SYRINGE/U-100/0.5ML/28G X 1/2" 118 1/2" 119 SULAR 52 SURE COMFORT INSULIN SURE-JECT INSULIN sulconazole nitrate 61 SYRINGE/U-100/1ML/29G X SYRINGE/U-100/0.5ML/29G X sulfacetamide sodium (acne)59 1/2" 118 1/2" 119 sulfacetamide sodium SURE COMFORT INSULIN SURE-JECT INSULIN (ophth) 134 SYRINGE/U-100/1ML/30G X SYRINGE/U-100/0.5ML/30G X sulfacetamide sodium w/ 1/2" 118 5/16" 119 sulfur 59 SURE COMFORT INSULIN SURE-JECT INSULIN sulfacetamide sodium-sulfur in SYRINGE/U-100/1ML/30G X SYRINGE/U-100/0.5ML/31G X urea vehicle 59 5/16" 118 5/16" 119 SULFADIAZINE 140 SURE COMFORT INSULIN SURE-JECT INSULIN sulfamethoxazole-trimethoprim SYRINGE/U-100/1ML/31G X SYRINGE/U-100/1ML/28G X 5/16" 118 1/2" 119 11 SURE COMFORT LANCETS SURE-JECT INSULIN SULFAMYLON 63 18G 92 SYRINGE/U-100/1ML/29G X sulfasalazine 73 SURE COMFORT LANCETS 1/2" 119 sulindac 5 21G 92 SURE-JECT INSULIN SURE COMFORT LANCETS SUMADAN WASH 59 SYRINGE/U-100/1ML/30G X 23G 92 5/16" 119 sumatriptan 127 SURE COMFORT LANCETS SURE-JECT INSULIN sumatriptan succinate 127 28G 92 SYRINGE/U-100/1ML/31G X SUNOSI 2 SURE COMFORT LANCETS 5/16" 119 30G 92 SURE-LANCE FLAT SUPER THIN LANCETS 92 SURE COMFORT LANCING LANCETS 92 SUPRAX 54 PEN 92 SURE-LANCE LANCETS SUPREP BOWEL PREP KIT78 SURE COMFORT PEN 26G 92 SURE COMFORT INSULIN NEEDLES29GX1/2" SURE-LANCE THIN LANCETS SYRINGE/U-100/0.3ML/29G X 12.7MM 118 28G 92 1/2" 118 SURE COMFORT PEN SURE-LANCE ULTRA THIN SURE COMFORT INSULIN NEEDLES30GX5/16" LANCETS 92 SYRINGE/U-100/0.3ML/30G X SHORT 118 SURE-PEN 92 1/2" 118 SURE COMFORT PEN SURE-TOUCH LANCETS SURE COMFORT INSULIN NEEDLES31GX3/16" UNIVERSAL 92 SYRINGE/U-100/0.3ML/30G X (5MM) 118 SURELITE LANCETS 92 SURE COMFORT PEN 5/16" 118 SURESTEP PRO HIGH SURE COMFORT INSULIN NEEDLES31GX5/16" (8MM) 118 GLUCOSECONTROL 92 SYRINGE/U-100/0.3ML/31G X SURMONTIL 24 5/16 118 SURE COMFORT PEN SURE COMFORT INSULIN NEEDLES32GX5/32" 118 SUSTIVA 48 SYRINGE/U-100/0.3ML/31G X SURE COMFORT PEN SUTENT 41 5/16" 118 NEEDLES32GX6MM 118 SURE-FINE PEN NEEDLES SYLATRON 42 SURE COMFORT INSULIN SYMBICORT 16 SYRINGE/U-100/0.5ML/28G X 29GX1/2" 12.7MM 118 1/2" 118 SURE-FINE PEN NEEDLES SYMFI 48 SURE COMFORT INSULIN 31GX3/16" 5MM 118 SYMFI LO 48 SYRINGE/U-100/0.5ML/29G X SURE-FINE PEN NEEDLES 31GX5/16" 8MM 118 SYMLINPEN 120 24 1/2" 118 SYMLINPEN 60 24

Index 34 SYMTUZA 48 TECHLITE INSULIN telmisartan-hydrochlorothiazide SYNALAR 65 SYRINGEU-100/0.3ML/30G X 34 5/16" 119 temazepam 77 SYNAREL 70 TECHLITE INSULIN TEMIXYS 48 SYNERA 66 SYRINGEU-100/0.3ML/31G X TEMODAR 36,37 SYNJARDY 24 5/16" 119 TECHLITE INSULIN TEMOVATE 65 SYNJARDY XR 24 SYRINGEU-100/0.5ML/29G X temozolomide 37 SYNRIBO 42 1/2" 119 temsirolimus 41 SYNTHROID 141 TECHLITE INSULIN TENIPOSIDE 43 SYPRINE 129 SYRINGEU-100/0.5ML/30G X 1/2" 119 tenofovir disoproxil fumarate 48 TABLOID 37 TECHLITE INSULIN TENORETIC 100 34 TABRECTA 41 SYRINGEU-100/0.5ML/30G X TENORETIC 50 34 TACLONEX 65 5/16" 119 TENORMIN 51 tacrolimus 129 TECHLITE INSULIN SYRINGEU-100/0.5ML/31G X TEPADINA 37 tacrolimus (topical) 66 5/16" 119 terazosin hcl 32 tadalafil 52 TECHLITE INSULIN tadalafil (pulmonary SYRINGEU-100/1ML/29G X terbinafine hcl 28 hypertension) 53 1/2" 119 terbutaline sulfate 16 TAFINLAR 41 TECHLITE INSULIN terconazole vaginal 146 SYRINGEU-100/1ML/30G X TAGAMET HB 142 1/2" 119 TESSALON PERLES 57 TAKHZYRO 75 TECHLITE INSULIN TESTIM 10 TALTZ 63 SYRINGEU-100/1ML/30G X TESTOSTERONE TALZENNA 41 5/16" 119 CYPIONATE 10 TECHLITE INSULIN testosterone cypionate 10 TAMIFLU 50 SYRINGEU-100/1ML/31G X testosterone enanthate 10 tamoxifen citrate 39 15/64" 119 tetrabenazine 138 tamsulosin hcl 74 TECHLITE INSULIN tetracycline hcl 140 TANZEUM 25 SYRINGEU-100/1ML/31G X 5/16" 119 TGT LANCET MICRO THIN TAPAZOLE 140 TECHLITE LANCETS 92 33G 92 TARCEVA 41 TECHLITE LANCETS 30G 92 TGT LANCET THIN 26G 92 TARGADOX 140 TECHLITE PEN NEEDLES TGT LANCET ULTRA THIN TARGRETIN 42,62 29GX 12 MM 119 30G 92 TARKA 34 TECHLITE PEN NEEDLES TGT LANCING DEVICE 92 31GX 5MM 119 TASIGNA 41 THALOMID 129 TECHLITE PEN theophylline 16 TASMAR 43 NEEDLES/31GX 5MM 119 THERANATAL CORE tavaborole 61 TECHLITE PEN NEEDLES/31GX 6 MM 119 NUTRITION 131 TAXOL 43 TECHLITE PEN THINLETS GP LANCETS 92 TAXOTERE 43 NEEDLES/31GX 8MM 119 thioridazine hcl 46 tazarotene 63 TECHLITE PEN thiotepa 37 TAZORAC 63 NEEDLES/32GX 4MM 119 TECHLITE PEN thiothixene 46 TAZVERIK 41 NEEDLES/32GX 6MM 120 THYMOGLOBULIN 130 TECENTRIQ 38 TEFLARO 54 thyroid 141 TECFIDERA 139 TEGRETOL 19 tiagabine hcl 20 TECFIDERA STARTER TEGRETOL-XR 20 TIAZAC 52 PACK 139 TECHLITE AST LANCETS 92 TEGSEDI 139 TIBSOVO 41 TECHLITE INSULIN SYRINGEU- TEKTURNA 34 TICE BCG 42 100/0.3ML/29G X 1/2" 119 telmisartan 32 TIGAN 27 TECHLITE INSULIN SYRINGEU- telmisartan-amlodipine 34 tigecycline 140 100/0.3ML/30G X 1/2" 119

Index 35 TIGECYCLINE 140 TOPCARE ULTRA COMFORT TRELEGY ELLIPTA 16 TIKOSYN 14 INSULIN SYRINGE/0.3ML/31G TRELSTAR MIXJECT 39 X 5/16" 120 timolol maleate 51 TOPCARE ULTRA COMFORT TREMFYA 63 timolol maleate (ophth) 133 INSULIN SYRINGE/0.5ML/30G treprostinil 53 TIMOPTIC 133 X 5/16" 120 TRESIBA 26 TOPCARE ULTRA COMFORT TIMOPTIC-XE 133 INSULIN SYRINGE/0.5ML/31G TRESIBA FLEXTOUCH 26 TIVICAY 48 X 5/16" 120 tretinoin 59 tizanidine hcl 132 TOPCARE ULTRA COMFORT tretinoin (chemotherapy) 42 TOBI 3 INSULIN SYRINGE/1ML/30G X tretinoin microsphere 59 5/16" 120 TOBRADEX 135 TOPCARE ULTRA COMFORT TREXALL 37 tobramycin 3 INSULIN SYRINGE/1ML/31G X TRI-NORINYL 28 55 tobramycin (ophth) 134 5/16" 120 triamcinolone acetonide 57 tobramycin sulfate 3 TOPCARE ULTRA COMFORT triamcinolone acetonide INSULIN SYRINGE/U- tobramycin- (mouth) 130 100/0.3ML/29G X 1/2" 120 triamcinolone acetonide dexamethasone 135 TOPCARE ULTRA COMFORT TOBREX 134 (nasal) 132 INSULIN SYRINGE/U- triamcinolone acetonide TODAY SPONGE 146 100/0.5ML/29G X 1/2" 120 (topical) 65 TODAYS HEALTH ADVANCED TOPCARE ULTRA COMFORT triamcinolone acetonide- LANCING DEVICE 92 INSULIN SYRINGE/U- dimethicone-silicone 65 TODAYS HEALTH MINI PEN 100/1ML/29G X 1/2" 120 triamterene 68 NEEDLES 31G X 1/4" 120 TOPICORT 65 triamterene & TODAYS HEALTH ORIGINAL topiramate 20 hydrochlorothiazide 68 PEN NEEDLES 29G X 1/2" 120 TODAYS HEALTH SHORT PEN TOPOTECAN HCL 43 triazolam 77 NEEDLES 31G X 5/16" 120 topotecan hcl 43 TRIBENZOR 34 TODAYS HEALTH SUPER TOPROL XL 51 TRICARE 131 THINLANCETS 30G 92 TRICOR 31 TODAYS HEALTH ULTRA toremifene citrate 39 THINLANCETS 28G 92 TORISEL 41 TRIDESILON 66 TOFRANIL 24 torsemide 68 trientine hcl 129 tolazamide 26 TOVIAZ 143 trifluoperazine hcl 46 tolbutamide 26 TRACLEER 53 trifluridine 134 tolcapone 43 TRADJENTA 25 trihexyphenidyl hcl 43 tolmetin sodium 5 tramadol hcl 8 TRIKAFTA 140 TOLSURA 29 tramadol-acetaminophen 9 TRILEPTAL 20 tolterodine tartrate 143 trandolapril 32 trimethobenzamide hcl 28 tolvaptan 71 trandolapril-verapamil hcl 34 trimethoprim 11 TOPAMAX 20 tranexamic acid 77 trimipramine maleate 24 TOPAMAX SPRINKLE 20 TRANSDERM SCOP 27 TRINTELLIX 23 TOPCARE CLICKFINE TRANSDERM-SCOP 28 TRIOSTAT 141 UNIVERSAL PEN EEDLES TRANXENE T 13 TRIUMEQ 48 31GX1/4" 120 TOPCARE CLICKFINE tranylcypromine sulfate 22 TRIZIVIR 48 UNIVERSAL PEN EEDLES TRAVATAN Z 135 tropicamide 133 31GX5/16" 120 TRAVEL LANCETS 30G 92 trospium chloride 143 TOPCARE LANCETS MICRO- TRAVEL LANCETS TRUE COMFORT INSULIN THIN 33G 92 ADVANCED 28G 92 SYRINGE/0.5ML/31G X TOPCARE ULTRA COMFORT travoprost 135 5/16" 120 INSULIN SYRINGE/0.3ML/30G X trazodone hcl 23 TRUE COMFORT INSULIN 5/16" 120 SYRINGE/1ML/31G X TREANDA 37 5/16" 120 TRECATOR 36

Index 36 TRUE COMFORT PEN TRUEPLUS LANCETS TRUSTEX/RIA NEEDLES31G X 5MM 120 28G 92 LUBRICATED/SPERMICIDE TRUE COMFORT PEN TRUEPLUS LANCETS 28G 80 NEEDLES31G X 6MM 120 SUPER THIN 92 TRUVADA 48 TRUE COMFORT PEN TRUEPLUS LANCETS TURALIO 41 NEEDLES32G X 4MM 120 30G 92 TRUE COMFORT TWIST TOP TRUEPLUS LANCETS 30G TWINRIX 145 LANCETS 30G 92 ULTRA THIN 92 TWYNSTA 34 TRUE METRIX BLOOD TRUEPLUS LANCETS TYBLUME 55 GLUCOSETEST STRIPS 67 33G 92 TRUE METRIX CONTROL TRUEPLUS LANCETS 33G TYBOST 48 SOLUTION LEVEL 3 92 MICRO THIN 92 TYGACIL 140 TRUEDRAW LANCING TRUEPLUS PEN NEEDLES TYKERB 41 DEVICE 92 29GX12MM 121 TRUEPLUS 5-BEVEL PEN TRUEPLUS PEN NEEDLES TYLENOL/CODEINE #3 9 NEEDLES 29GX12.7MM 120 31GX5MM 121 TYLENOL/CODEINE #4 9 TRUEPLUS 5-BEVEL PEN TRUEPLUS PEN NEEDLES TYMLOS 69 NEEDLES 31GX5MM 120 31GX6MM 121 TYSABRI 139 TRUEPLUS 5-BEVEL PEN TRUEPLUS PEN NEEDLES NEEDLES 31GX6MM 120 31GX8MM 121 UCERIS 10 TRUEPLUS 5-BEVEL PEN TRUEPLUS PEN NEEDLES UDENYCA 76 NEEDLES 31GX8MM 120 32GX4MM 121 ULESFIA 67 TRUEPLUS 5-BEVEL PEN TRUEPLUS SAFETY NEEDLES 32GX4MM 120 LANCETS 28G 92 ULORIC 75 TRUEPLUS INSULIN TRUETRACK TEST 67 ULTI-LANCE AUTOMATIC/ CLEAR TIP 92 SYRINGE/U-100/0.3ML/29G X TRULICITY 25 1/2" 120 ULTICARE INSULIN SAFETY TRUEPLUS INSULIN TRUSOPT 135 SYRINGE/0.5ML/29G X SYRINGE/U-100/0.3ML/30G X TRUSTEX COLOR CONDOMS 1/2" 121 5/16" 120 + LUBE 80 ULTICARE INSULIN SAFETY TRUEPLUS INSULIN TRUSTEX LUBRICATED 80 SYRINGE/1ML/29G X 1/2" 121 SYRINGE/U-100/0.3ML/31G X TRUSTEX LUBRICATED ULTICARE INSULIN 5/16" 121 EXTRALARGE 80 SYRINGE/0.3ML/29G X TRUEPLUS INSULIN TRUSTEX LUBRICATED 1/2" 121 SYRINGE/U-100/0.5ML/28G X EXTRASTRENGTH 80 ULTICARE INSULIN 1/2" 121 TRUSTEX SYRINGE/0.3ML/30G X TRUEPLUS INSULIN LUBRICATED/RIBBED/STUDD 1/2" 121 SYRINGE/U-100/0.5ML/29G X ED 80 ULTICARE INSULIN 1/2" 121 TRUSTEX SYRINGE/0.3ML/30G X TRUEPLUS INSULIN LUBRICATED/SPERMICIDE 5/16" 121 SYRINGE/U-100/0.5ML/30G X 80 ULTICARE INSULIN 5/16" 121 TRUSTEX SYRINGE/0.5ML/28G X TRUEPLUS INSULIN LUBRICATED/SPERMICIDE 1/2" 121 SYRINGE/U-100/0.5ML/31G X EXTRA LARGE 80 ULTICARE INSULIN 5/16" 121 TRUSTEX SYRINGE/0.5ML/29G X TRUEPLUS INSULIN LUBRICATED/SPERMICIDE 1/2" 121 SYRINGE/U-100/1ML/28G X EXTRA STRENGTH 80 ULTICARE INSULIN 1/2" 121 TRUSTEX NATURAL SYRINGE/0.5ML/30G X TRUEPLUS INSULIN CONDOMS 1/2" 121 SYRINGE/U-100/1ML/29G X +LUBE/LUBRICATED 80 ULTICARE INSULIN 1/2" 121 TRUSTEX WITH SYRINGE/0.5ML/30G X TRUEPLUS INSULIN NONOXYNOL- 5/16" 121 SYRINGE/U-100/1ML/30G X 9/RIBBED/STUDDED 80 ULTICARE INSULIN 5/16" 121 TRUSTEX/RIA SYRINGE/1ML/28G X 1/2" 121 TRUEPLUS INSULIN LUBRICATED 80 ULTICARE INSULIN SYRINGE/U-100/1ML/31G X TRUSTEX/RIA LUBRICATED SYRINGE/1ML/29G X 1/2" 121 5/16" 121 SPERMICIDE 80 ULTICARE INSULIN SYRINGE/1ML/30G X 1/2" 121 TRUEPLUS LANCETS 26G 92

Index 37 ULTICARE INSULIN ULTICARE MICRO PEN ULTILET INSULIN SYRINGE/1ML/30G X NEEDLES/32G X 5/32" 122 SYRINGE/1ML/31G X 8MM123 5/16" 121 ULTICARE MINI PEN ULTILET INSULIN ULTICARE INSULIN NEEDLES 31GX6MM 122 SYRINGE/SHORT/0.3ML/30G X SYRINGE/SHORT/0.3ML/30G X ULTICARE MINI PEN 12.7MM 123 5/16" 121 NEEDLES ULTI-FINE IV 122 ULTILET INSULIN ULTICARE INSULIN ULTICARE MINI PEN SYRINGE/SHORT/0.3ML/30G X SYRINGE/SHORT/0.3ML/31G X NEEDLES/31G X 6MM 122 5/16" 123 5/16" 121 ULTICARE MINI PEN ULTILET INSULIN ULTICARE INSULIN NEEDLES/32G X 1/4" 122 SYRINGE/SHORT/0.3ML/31G X SYRINGE/SHORT/0.5ML/30G X ULTICARE MINI PEN 5/16" 123 5/16" 122 NEEDLES31GX6MM 122 ULTILET INSULIN ULTICARE INSULIN ULTICARE ORIGINAL PEN SYRINGE/SHORT/0.5ML/30G X SYRINGE/SHORT/0.5ML/31G X NEEDLES ULTI-FINE 122 5/16" 123 5/16" 122 ULTICARE PEN NEEDLES ULTILET INSULIN ULTICARE INSULIN 31GX 5MM 122 SYRINGE/SHORT/0.5ML/31G X SYRINGE/SHORT/1ML/30G X ULTICARE PEN NEEDLES 5/16" 123 5/16" 122 31GX 5MM/MINI 122 ULTILET INSULIN ULTICARE INSULIN ULTICARE PEN SYRINGE/SHORT/1ML/30G X SYRINGE/SHORT/1ML/31G X NEEDLES/29GX 12.7MM 122 5/16" 123 5/16" 122 ULTICARE SHORT PEN ULTILET INSULIN ULTICARE INSULIN NEEDLES 31GX8MM 122 SYRINGE/SHORT/1ML/31G X SYRINGE/U-100/0.3ML/30G X ULTICARE SHORT PEN 5/16" 123 1/2" 122 NEEDLES ULTI-FINE IV 123 ULTILET INSULIN SYRINGE/U- ULTICARE INSULIN ULTICARE SHORT PEN 100/0.5ML/30G X 1/2" 123 SYRINGE/U-100/0.3ML/31G X NEEDLES/31G X 8MM 123 ULTILET INSULIN SYRINGE/U- 5/16" 122 ULTIGUARD 100/1ML/30G X 1/2" 123 ULTICARE INSULIN SAFEPACK/MICROPEN ULTILET LANCETS 93 SYRINGE/U-100/0.5ML/30G X NEEDLE/32G X 5/32"/SHARPS CONTA 123 ULTILET LANCETS 33G 93 1/2" 122 ULTILET PEN NEEDLE ULTICARE INSULIN ULTIGUARD SAFEPACK/MINI PEN NEEDLE/31G X 29GX12.7MM 123 SYRINGE/U-100/0.5ML/31G X ULTILET PEN NEEDLE 5/16" 122 1/4"/SHARPS CONTAIN 123 ULTIGUARD SAFEPACK/MINI 31GX5MM 123 ULTICARE INSULIN ULTILET PEN NEEDLE SYRINGE/U-100/1ML/30G X PEN NEEDLE/31G X 3/16"/SHARPS CONTAI 123 31GX8MM 123 1/2" 122 ULTILET PEN NEEDLE ULTICARE INSULIN ULTIGUARD SAFEPACK/MINI PEN NEEDLE/32G X 32GX4MM 123 SYRINGE/U-100/1ML/31G X ULTILET PEN NEEDLE 5/16" 122 1/4"/SHARPS CONTAIN 123 ULTIGUARD 32GX4MM/SHORT 123 ULTICARE INSULIN ULTILET SAFETY LANCETS SYRINGEULTRAFINE U- SAFEPACK/SHORTPEN NEEDLE/31G X 5/16"/SHARPS 21G X 2.2MM 93 100/0.3ML/31G X 5/16" 122 ULTILET SAFETY LANCETS ULTICARE INSULIN CONTA 123 ULTILET CLASSIC 23G 93 SYRINGEULTRAFINE U- ULTILET SHORT PEN 100/0.5ML/31G X 5/16" 122 LANCETS 92 ULTILET INSULIN NEEDLES 31GX5/16" 123 ULTICARE INSULIN ULTILET SHORT PEN SYRINGEULTRAFINE U- SYRINGE/0.3ML/30G X 8MM 123 NEEDLES31GX3/16" 123 100/1ML/31G X 5/16" 122 ULTRA COMFORT INSULIN ULTICARE MICRO PEN ULTILET INSULIN SYRINGE/0.3ML/31G X SYRINGE/U-100/0.3ML/30G X NEEDLES 31G X 8MM 122 5/16" 123 ULTICARE MICRO PEN 8MM 123 ULTILET INSULIN ULTRA FLO INSULIN PEN NEEDLES 32G X 4MM 122 NEEDLES 124 ULTICARE MICRO PEN SYRINGE/0.5ML/30G X 8MM 123 ULTRA FLO INSULIN SYRINGE NEEDLES/31G X 1/4" 122 0.3ML/29G X 1/2" 124 ULTICARE MICRO PEN ULTILET INSULIN SYRINGE/1ML/30G X ULTRA THIN LANCETS NEEDLES/31G X 5/16" 122 31G 93 ULTICARE MICRO PEN 8MM 123 ULTRA THIN PEN NEEDLES NEEDLES/32G X 4MM 122 32G X 4MM 124

Index 38 ULTRA-CARE LANCETS ULTRA-THIN II INSULIN UNIFINE PENTIPS 31G X 30G 93 SYRINGE/U- 3/16" 125 ULTRA-COMFORT INSULIN 100/1ML/29GX1/2" 124 UNIFINE PENTIPS SYRINGE/U-100/0.3ML/29G X ULTRA-THIN II LANCETS 31GX5MM 125 1/2" 124 28G 93 UNIFINE PENTIPS ULTRA-COMFORT INSULIN ULTRA-THIN II LANCETS 31GX6MM 125 SYRINGE/U-100/0.3ML/30G X 30G 93 UNIFINE PENTIPS 5/16" 124 ULTRA-THIN II MINI PEN 31GX8MM 125 ULTRA-COMFORT INSULIN NEEEDLES/31GX3/16" 124 UNIFINE PENTIPS SYRINGE/U-100/0.3ML/31G X ULTRA-THIN II PEN NEEDLES 32GX4MM 125 5/16" 124 29GX1/2" 124 UNIFINE PENTIPS ULTRA-COMFORT INSULIN ULTRA-THIN II PEN 32GX6MM 125 SYRINGE/U-100/0.5ML/28G X NEEDLES/SHORT/31GX5/16" UNIFINE PENTIPS PLUS 1/2" 124 124 29GX12MM 125 ULTRA-COMFORT INSULIN ULTRACARE INSULIN UNIFINE PENTIPS PLUS SYRINGE/U-100/0.5ML/29G X SYRINGE/U-100/0.3ML/30G X 31GX5MM 125 1/2" 124 5/16" 124 UNIFINE PENTIPS PLUS ULTRA-COMFORT INSULIN ULTRACARE INSULIN 31GX6MM 125 SYRINGE/U-100/0.5ML/30G X SYRINGE/U-100/0.3ML/31G X UNIFINE PENTIPS PLUS 5/16" 124 5/16" 124 31GX8MM 125 ULTRA-COMFORT INSULIN ULTRACARE INSULIN UNIFINE PENTIPS PLUS SYRINGE/U-100/0.5ML/31G X SYRINGE/U-100/0.5ML/30G X 32GX4MM 125 5/16" 124 1/2" 125 UNIFINE SAFECONTROL PEN ULTRA-COMFORT INSULIN ULTRACARE INSULIN NEEDLE/30G X 5/16" 125 SYRINGE/U-100/1ML/28G X SYRINGE/U-100/0.5ML/30G X UNILET COMFORTOUCH 1/2" 124 5/16" 125 LANCET 93 ULTRA-COMFORT INSULIN ULTRACARE INSULIN UNILET EXCELITE 93 SYRINGE/U-100/1ML/29G X SYRINGE/U-100/0.5ML/31G X UNILET EXCELITE II 93 1/2" 124 5/16" 125 UNILET G.P. LANCET 93 ULTRA-COMFORT INSULIN ULTRACARE INSULIN SYRINGE/U-100/1ML/30G X SYRINGE/U-100/1ML/30G X UNILET G.P. SUPERLITE 5/16" 124 1/2" 125 LANCET 93 ULTRA-COMFORT INSULIN ULTRACARE INSULIN UNILET GP 28 ULTRA THIN93 SYRINGE/U-100/1ML/31G X SYRINGE/U-100/1ML/30G X UNILET LANCET 93 5/16" 124 5/16" 125 UNILET LANCETS MICRO- ULTRA-THIN II AUTO ULTRACARE INSULIN THIN33G 93 LANCET 93 SYRINGE/U-100/1ML/31G X UNILET LANCETS SUPER- ULTRA-THIN II INSULIN 5/16" 125 THIN30G 93 SYRINGE SHORT/U- ULTRACARE PEN UNILET LANCETS ULTRA-THIN 100/0.3ML/30GX5/16" 124 NEEDLES/31G X 1/4" 125 28G 93 ULTRA-THIN II INSULIN ULTRACARE PEN UNILET SUPERLITE SYRINGE SHORT/U- NEEDLES/31G X 3/16" 125 LANCET 93 100/0.3ML/31GX5/16" 124 ULTRACARE PEN UNISTIK 3 GENTLE 93 ULTRA-THIN II INSULIN NEEDLES/31G X 5/16" 125 UNISTIK PRO SAFETY LANCET SYRINGE SHORT/U- ULTRACARE PEN 21G 93 100/0.5ML/30GX5/16" 124 NEEDLES/32G X 1/14" 125 UNISTIK PRO SAFETY LANCET ULTRA-THIN II INSULIN ULTRACARE PEN 25G 93 SYRINGE SHORT/U- NEEDLES/32G X 3/16" 125 UNISTIK PRO SAFETY LANCET 100/0.5ML/31GX5/16" 124 ULTRACARE PEN 28G 93 ULTRA-THIN II INSULIN NEEDLES/32G X 5/32" 125 UNISTIK SAFETY LANCETS SYRINGE SHORT/U- ULTRACET 9 28G 93 100/1ML/30GX5/16" 124 ULTRAM 8 UNISTIK SAFETY LANCETS ULTRA-THIN II INSULIN ULTRAVATE 66 30G 93 SYRINGE SHORT/U- UNISTIK TOUCH SAFETY 100/1ML/31GX5/16" 124 UNASYN 137 LANCETS 21G 93 ULTRA-THIN II INSULIN UNASYN BULK PACK 137 UNISTIK TOUCH SAFETY SYRINGE/U- UNIFINE PENTIPS LANCETS 23G 93 100/0.5ML/29GX1/2" 124 29GX12MM 125 UNISTIK TOUCH SAFETY LANCETS 28G 93

Index 39 UNISTIK TOUCH SAFETY VALUMARK PEN NEEDLES VIDA MIA UNIFINE LANCETS 30G 93 31GX 8MM 125 PENTIPSMINI 31GX6MM 126 UNISTRIP CONTROL VANCOCIN 11 VIDA MIA UNIFINE SOLUTIONHIGH 93 VANCOCIN HCL 12 PENTIPSORIGINAL UNIVERSAL 1 LANCETS 29GX12MM 126 THIN26G 93 vancomycin hcl 11,12 VIDA MIA UNILET LANCETS UNIVERSAL 1 LANCETS ULTRA VANCOMYCIN SUPER THIN 30G 93 THIN 30G 93 HYDROCHLORIDE 12 VIDA MIA UNILET LANCETS UNIVERSAL 1 VANISHPOINT INSULIN ULTRA THIN 28G 93 LANCETS/33G/MICRO-THIN SYRINGE/0.5ML/30G X VIDA MIA UNIPFINE 93 1/2" 125 PENTIPSSHORT URECHOLINE 143 VANISHPOINT INSULIN 31GX8MM 126 SYRINGE/0.5ML/30G X VIDAZA 37 UROCIT-K 10 74 5/16" 125 UROXATRAL 74 VANISHPOINT INSULIN VIDEX EC 49 URSO 250 73 SYRINGE/1ML/29G X VIDEXPEDIATRIC 49 URSO FORTE 73 1/2" 125 vigabatrin 20 VANISHPOINT INSULIN VIGAMOX 134 ursodiol 73 SYRINGE/1ML/30G X UTIBRON NEOHALER 16 5/16" 125 VIIBRYD 23 VAGIFEM 146 VANTAS 39 VIIBRYD STARTER PACK 23 valacyclovir hcl 50 VAQTA 145 VIMPAT 20 VALCYTE 49 VARIVAX 145 vinblastine sulfate 43 valganciclovir hcl 49 VARUBI 28 vincristine sulfate 43 VALIUM 13 VASCEPA 30 vinorelbine tartrate 43 valproate sodium 21 VASERETIC 34 VIRACEPT 49 valproic acid 21 VASOTEC 32 VIRAMUNE 49 valrubicin 40 VECAMYL 34 VIRAMUNE XR 49 valsartan 32 VECTIBIX 38 VIREAD 49 valsartan-hydrochlorothiazide VECTICAL 63 VIROPTIC 134 34 VELCADE 41 VISTARIL 13 VALSTAR 40 VELPHORO 74 VISTOGARD 27 VALTOCO 18 VEMLIDY 50 VITALET PRO LANCETS 94 VALTREX 50 venlafaxine hcl 23 VITALET PRO PLUS VALUE HEALTH INSULIN LANCETS 94 VENOFER 76 SYRINGE/U-100/0.5ML/29G X VITAMIN D2 147 VENTAVIS 53 1/2" 125 VITATHELY/GINGER 131 VALUE HEALTH INSULIN VENTOLIN HFA 16 VITRAKVI 41 SYRINGE/U-100/1ML/29G X verapamil hcl 52 1/2" 125 VIVAGUARD LANCETS 94 VALUE PLUS LANCETS VEREGEN 59 VIVAGUARD LANCING STANDARD 21G 93 VERELAN 52 DEVICE 94 VALUE PLUS LANCETS VERELAN PM 52 VIVELLE-DOT 72 SUPERTHIN 30G 93 VALUE PLUS LANCETS THIN VERIPRED 20 57 VIZIMPRO 41 26G 93 VESICARE 143 VOGELXO 10 VALUE PLUS LANCING VFEND 29 VOGELXO PUMP 10 DEVICE 93 VOL-PLUS 131 VALUMARK LANCET SUPER VIAGRA 52 THIN 30G 93 VIBRAMYCIN 140 VOLTAREN 60 VALUMARK LANCET ULTRA VICTOZA 25 VORAXAZE 42 THIN 28G 93 VIDA MIA AUTOLET voriconazole 29 VALUMARK PEN NEEDLES LANCINGDEVICE 93 VOSEVI 50 29GX12MM 125 VIDA MIA UNIFINE VALUMARK PEN NEEDLES PENTIPS32GX4MM 126 VOTRIENT 41 31GX 6MM 125

Index 40 VP INSULIN SYRINGE/U- XALATAN 135 ZANOSAR 37 100/0.3ML/29G X 1/2" 126 XALKORI 41 ZANTAC 142 VPRIV 75 XANAX 13 ZANTAC 150 MAXIMUM VUSION 61 XANAX XR 13 STRENGTH 142 VYNDAMAX 53 ZARONTIN 21 XARELTO 17 VYNDAQEL 53 XARELTO STARTER ZARXIO 76 VYTORIN 30 PACK 17 ZAVESCA 76 VYVANSE 1 XELJANZ 4 ZEGERID 142 VYXEOS 40 XELJANZ XR 4 ZELBORAF 41 WALGREENS ADVANCED XELODA 37 ZEMAIRA 140 TRAVELLANCETS 28G 94 XENAZINE 138 ZEMPLAR 71 WALGREENS COMFORT ASSUREDLANCETS MICRO XEOMIN 132 ZENPEP 67 THIN/33G 94 XGEVA 69 ZEPATIER 50 WALGREENS COMFORT XIFAXAN 11 ZERIT 49 ASSUREDLANCETS SUPER THIN/28G 94 XIGDUO XR 24 ZERVIATE 135 WALGREENS LANCETS 94 XIMINO 140 ZESTORETIC 34 WALGREENS THIN XOLAIR 14 ZESTRIL 32 LANCETS 94 XOPENEX 16 ZETIA 31 WALGREENS ULTRA THIN XOPENEX ZIAC 34 LANCETS 94 CONCENTRATE 16 ZIAGEN 49 warfarin sodium 16 XOPENEX HFA 16 ZIANA 59 water for irrigation, sterile 130 XOSPATA 41 zidovudine 49 WEGMANS UNIFINE PENTIPS XPOVIO 100 MG ONCE PLUS 32GX4MM 126 WEEKLY 39 zileuton 14 WEGMANS UNIFINE PENTIPS XPOVIO 60 MG ONCE ZINGO 78 PLUS/MINI/31GX5MM 126 WEEKLY 39 ZIOPTAN 135 WEGMANS UNIFINE PENTIPS XPOVIO 80 MG ONCE PLUS/SHORT/31GX8MM 126 WEEKLY 39 ziprasidone hcl 45 WEGMANS UNIFINE PENTIPS XPOVIO 80 MG TWICE ZIRABEV 38 PLUS/ULTRA WEEKLY 39 ZIRGAN 134 SHORT/31GX6MM 126 XTAMPZA ER 8 WELCHOL 31 ZITHROMAX 78,79 XTANDI 39 WELLBUTRIN SR 21 ZITHROMAX TRI-PAK 79 XULTOPHY 100/3.6 24 WELLBUTRIN XL 21,22 ZITHROMAX Z-PAK 79 XYLOCAINE 78 WESTAB PLUS 131 ZOCOR 31 XYLOCAINE-MPF 78 WESTHROID 141 ZOFRAN 27 XYREM 137 WIDE-SEAL SILICONE ZOHYDRO ER 8 DIAPHRAGM KIT 60 80 XYZAL ALLERGY 24HR 30 ZOLADEX 39 WIDE-SEAL SILICONE XYZAL ALLERGY 24HR zoledronic acid 69 DIAPHRAGM KIT 65 80 CHILDRENS 30 WIDE-SEAL SILICONE YASMIN 28 55 ZOLEDRONIC ACID 69 DIAPHRAGM KIT 70 80 YAZ 55 zoledronic acid 69 WIDE-SEAL SILICONE YERVOY 38 ZOLEDRONIC ACID 69 DIAPHRAGM KIT 75 80 ZOLINZA 41 WIDE-SEAL SILICONE YONDELIS 37 DIAPHRAGM KIT 80 80 YONSA 39 zolmitriptan 127 WIDE-SEAL SILICONE ZADITOR 135 ZOLOFT 23 DIAPHRAGM KIT 85 80 zolpidem tartrate 77 WIDE-SEAL SILICONE zafirlukast 14 DIAPHRAGM KIT 90 80 zaleplon 77 ZOMACTON 70 WIDE-SEAL SILICONE ZALTRAP 38 ZOMETA 69 DIAPHRAGM KIT 95 80 ZANAFLEX 132 ZOMIG 127 WP THYROID 141

Index 41 ZOMIG ZMT 127 ZONALON 62 ZONEGRAN 20 zonisamide 20 ZONTIVITY 75 ZORBTIVE 70 ZORTRESS 130 ZOSTAVAX 145 ZOSYN 137 ZOVIRAX 50,63 ZURAMPIC 75 ZYBAN 139 ZYCLARA 66 ZYCLARA PUMP 66 ZYDELIG 41 ZYFLO CR 14 ZYKADIA 42 ZYLOPRIM 75 ZYMAXID 134 ZYPREXA 46 ZYPREXA ZYDIS 46 ZYRTEC ALLERGY 30 ZYRTEC CHILDRENS ALLERGY 30 ZYRTEC-D ALLERGY/CONGESTION 58 ZYTIGA 39 ZYVOX 12

Index 42 0 . FROM I sunshine health. Insured by Celtic Insurance Company

© 2019 Celtic Insurance Company. All rights reserved. AMB19-FL-C-00236 Statement of Non-Discrimination

Ambetter from Sunshine Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Ambetter from Sunshine Health does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Ambetter from Sunshine Health:

 Provides free aids and services to people with disabilities to communicate effectively with us, such as:

 Qualified sign language interpreters  Written information in other formats (large print, audio, accessible electronic formats, other formats)

 Provides free language services to people whose primary language is not English, such as:

 Qualified interpreters  Information written in other languages

If you need these services, contact Ambetter from Sunshine Health at 1-877-687-1169 (Relay FL 1-800- 955-8770).

If you believe that Ambetter from Sunshine Health has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Grievance/Appeals Unit Sunshine Health, 1301 International Parkway, Suite 400, Sunrise, Florida 33323, 1-877-687-1169 (Relay Florida 1-800-955-8770), Fax, 1-866-534-5972. You can file a grievance by mail, fax, or email. If you need help filing a grievance, Ambetter from Sunshine Health is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD).

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

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Si oumenm, oubyen yon moun w ap ede, gen kesyon nou ta renmen poze sou Ambetter from Sunshine Health, ou gen tout dwa pou w jwenn èd French ak enfmasyon nan lang manman w san sa pa koute w anyen. Pou w pale avèk yon entèprèt, sonnen nimewo Creole: 1-877-687-1169 (Relay Florida 1-800-955-8770).

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В случае возникновения у вас или у лица, которому вы помогаете, каких-либо вопросов о программе страхования Ambetter from Sunshine Russian: Health вы имеете право получить бесплатную помощь и информацию на своем родном языке. Чтобы поговорить с переводчиком, позвоните по телефону 1-877-687-1169 (Relay Florida 1-800-955-8770).

ذاإ كان ل يكد أ لو خصشىد أهداعست ولحةئلس Ambetter from Sunshine Health ل، اكيد قحل في ال ولصح على ةداعسالم اتوممعلالو تكلغبةيرورضال من وند أ ةي ةفلتك . لل حدثت م مع مجرت Arabic: تصلا بـ Relay Florida 1-800-955-8770) 1-877-687-1169) .

Se lei, o una persona che lei sta aiutando, avesse domande su Ambetter from Sunshine Health, ha diritto a usufruire gratuitamente di assistenza Italian: e informazioni nella sua lingua. Per parlare con un interprete, chiami l’1-877-687-1169 (Relay Florida 1-800-955-8770).

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