Medimpact Drug Formulary

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Standard Formulary MedPerform Medium

January, 2021

Copyright © 2020 MedImpact Healthcare Systems, Inc. All rights reserved. This document is confidential and proprietary to MedImpact and contains material MedImpact may consider Trade Secrets. This document is intended for specified use by Business Partners of MedImpact under permission by MedImpact and may not otherwise be used, reproduced, transmitted, published, or disclosed to others without prior written authorization. MedImpact maintains the sole and exclusive ownership, right, title, and interest in and to this document. MedPerform Medium Formulary

What is the standard formulary?

The MedImpact formulary is a list of covered drugs selected by physician and pharmacist subject matter experts who collaboratively support MedImpact’s Pharmacy and Therapeutics (P&T) Committee. The plan will cover drugs listed in the formulary as long as the drug is indicated for the clinical condition, is prescribed in the appropriate manner, the prescription is filled at a participating network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Formulary (drug list) change?

Drugs may be added or deleted from the formulary during the year. If a drug is removed from the formulary, [or] adds prior authorization, quantity limits and/or step therapy restrictions on a drug or moves a drug to a higher cost-sharing tier], the plan will notify affected members of the change before the change becomes effective. If the Food and Drug Administration (FDA) deems a drug on the formulary to be unsafe or the drug’s manufacturer removes the drug from the market, the plan will immediately remove the drug from the formulary.

Is member’s medication included in the formulary? There are 3 ways for a member to confirm their current medication is on their plan-specific formulary:

➢ Drug Categories The drugs in this formulary are grouped into categories according to the types of medical conditions that they are used to treat.

➢ Alphabetical Index Listing If the member is not sure what category to look under, the member should look for the drug in the Index. The Index provides an alphabetical list of all the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. First, look in the Index and find the drug. Next to the drug, there is a page number where the member can find coverage information. Then turn to the page listed in the Index and find the name of the drug in the first column of the list on that page.

➢ Website or Mobile App Drug search capability is on the MedImpact Consumer Portal (MedImpact.com), mobile app (available in Apple and Google apps store), or member plan’s website.

What are generic drugs? The plan covers both brand name and generic drugs provided they are prescribed per FDA approved indications and in accordance with the plans benefit design. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Generic drugs appear in the formulary listing with all lower-case letters and italicized (i.e. terbutaline oral tablet 2.5 mg). Brand drugs appear in formulary listing with all upper-case letters (i.e. DIPHEN ORAL ELIXIR 12.5 MG/5ML).

The contents of this page are confidential and proprietary to MedImpact and may include information MedImpact considers trade secrets. This page may not be reproduced, transmitted, published, or disclosed to others without prior written authorization.

MedPerform Medium Formulary

Are there any restrictions on coverage of drugs on the formulary? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: For certain drugs within the Formulary, a recommended prescribing guideline may apply. These guidelines are noted throughout the Formulary listing using the following symbols:

Symbol Guideline Description AGE Age Edit Coverage depends on member age PA Prior Authorization Requires specific physician request and clinical criteria process for prescription to dispense to member QL Quantity Limit Prescription coverage quantity limits for specific drugs per prescription and/or time period ST Step Therapy Coverage requires a trial of certain clinically appropriate alternative drug(s) before obtaining the prescribed drug.

SP Specialty Drug Coverage may require dispensing from a specialty pharmacy. Specialty copay/coinsurance applies according to benefit plan.

The member can find out if the drug has any additional requirements or limits by looking within the formulary.

The member can ask the plan to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat the health condition. See the section: “How does a member request an exception to the formulary?”

Tier Benefit Design A tier benefit design is where a member is responsible for a portion of the cost of a prescription drug based on the drug’s tier and copayment or coinsurance. Specialty drugs may be covered at a higher copay or coinsurance. Essential Health Benefit/Preventative Care medications, if available on the plan - will be covered without cost sharing ($0 copay for members). An example of a formulary tier design:

➢ Tier 1: Generic medications ➢ Tier 2: Preferred brand medications (formulary agents) ➢ Tier 3: Non-preferred brand medications (non-formulary agents)

Are there general exclusions on the formulary? Many members have specific benefit inclusions, exclusions, copayments, or a lack of coverage, which are reflected in other Plan Benefit Documents.

The Formulary applies only to outpatient drugs provided to members and does not apply to medications used in inpatient settings. If a member has any specific questions regarding their coverage, they should contact their plan. Examples of possible formulary and/or benefit exclusions include:

MedPerform Medium Formulary

➢ Over the Counter (OTC) medications or their equivalents, unless the plan offers coverage of OTC medications ➢ Drugs specifically listed as not covered ➢ Anti-Obesity drugs ➢ Medical food/nutritional supplements ➢ Non-Diabetic supplies/Diagnostic supplies/Ostomy supplies/Devices ➢ Disposable Needles & Syringes (Non-Insulin related) ➢ Any drug products used for cosmetic purposes. ➢ Experimental drug products or any drug product used in an experimental manner ➢ Repackaged drugs and institutional use drugs (e.g. hospital use) ➢ Lifestyle drugs (e.g. sexual dysfunction, infertility) ➢ Non self-administered injectable drug products unless otherwise specified in the Formulary listing

What if a drug is not on the Formulary? If a drug is not included on the formulary, the member should contact the plan. If the member is informed that the plan does not cover the drug, the member has two options:

1. The member can ask the plan for a list of similar drugs that are covered by the plan. When the member receives the list, she/he should show it to the doctor and ask the doctor to prescribe a similar drug that is covered by the plan and is determined by the doctor to be an appropriate alternative drug.

2. The member can ask the plan to make an exception and cover the drug.

How does a member request an exception to the Formulary? The member will need to contact the plan for details on how to file an exception request.

For more information MedImpact encourages members to review the Summary Benefit Design, Evidence of Coverage, MedImpact Consumer Portal, or plan’s website for more detailed PBM plan information.

MedImpact Healthcare Systems, Inc. 10181 Scripps Gateway Ct. San Diego, CA 92131 Phone: 800.788.2949 MedImpact.com

Table of Contents

Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants...... 3 Allergenic Extracts/Biologicals Misc...... 7 Alternative Medicines...... 8 Amebicides...... 9 Aminoglycosides...... 9 Analgesics - Anti-Inflammatory...... 9 Analgesics - Nonnarcotic...... 14 Analgesics - Opioid...... 18 Androgens-Anabolic...... 28 Anorectal Agents...... 29 Anthelmintics...... 30 Antianginal Agents...... 30 Antianxiety Agents...... 32 Antiarrhythmics...... 33 Antiasthmatic And Bronchodilator Agents...... 34 Anticoagulants...... 41 Anticonvulsants...... 43 Antidepressants...... 53 Antidiabetics...... 57 Antidiarrheal/Probiotic Agents...... 66 Antidotes And Specific Antagonists...... 67 Antiemetics...... 68 Antifungals...... 69 Antihistamines...... 70 Antihyperlipidemics...... 72 Antihypertensives...... 77 Anti-Infective Agents - Misc...... 82 Antimalarials...... 85 Antimyasthenic/Cholinergic Agents...... 85 Antimycobacterial Agents...... 86 Antineoplastics And Adjunctive Therapies...... 86 Antiparkinson And Related Therapy Agents...... 95 Antipsychotics/Antimanic Agents...... 98 Antiseptics & Disinfectants...... 101 Antivirals...... 101 Beta Blockers...... 107 Calcium Channel Blockers...... 109 Cardiotonics...... 111 Cardiovascular Agents - Misc...... 112 Cephalosporins...... 115 Chemicals...... 116 Contraceptives...... 116 Corticosteroids...... 129

1 Cough/Cold/Allergy...... 131 Dermatologicals...... 134 Diabetes...... 165 Diagnostic Products...... 166 Dietary Products/Dietary Management Products...... 166 Digestive Aids...... 168 Diuretics...... 168 Endocrine And Metabolic Agents - Misc...... 170 Estrogens...... 175 Fluoroquinolones...... 178 Gastrointestinal Agents - Misc...... 179 General Anesthetics...... 182 Genitourinary Agents - Miscellaneous...... 182 Gout Agents...... 184 Hematological Agents - Misc...... 185 Hematopoietic Agents...... 189 Hemostatics...... 195 Hypnotics/Sedatives/Sleep Disorder Agents...... 196 Laxatives...... 198 Local Anesthetics-Parenteral...... 199 Macrolides...... 199 Medical Devices And Supplies...... 200 Migraine Products...... 255 Minerals & Electrolytes...... 258 Miscellaneous Therapeutic Classes...... 261 Mouth/Throat/Dental Agents...... 265 Multivitamins...... 267 Musculoskeletal Therapy Agents...... 273 Nasal Agents - Systemic And Topical...... 275 Neurological Disease - Miscellaneous...... 276 Neuromuscular Agents...... 276 Nutrients...... 276 Ophthalmic Agents...... 277 Otic Agents...... 287 Oxytocics...... 288 Passive Immunizing And Treatment Agents...... 288 Penicillins...... 289 Pharmaceutical Adjuvants...... 290 Progestins...... 296 Psychotherapeutic And Neurological Agents - Misc...... 297 Respiratory Agents - Misc...... 307 Sulfonamides...... 307 Tetracyclines...... 308 Thyroid Agents...... 309 Toxoids...... 311 Ulcer Drugs/Antispasmodics/Anticholinergics...... 311 Urinary Antispasmodics...... 316 Vaccines...... 317 Vaginal Products...... 320 Vasopressors...... 322 Vitamins...... 322

2 Drug Status Notes Adhd/Anti-Narcolepsy/Anti- Obesity/Anorexiants Amphetamines ADDERALL XR ORAL CAPSULE (Amphetamine- Tier 1 QL (1 EA per 1 day) EXTENDED RELEASE 24 HOUR 10 Dextroamphet ER) MG, 15 MG, 5 MG ADDERALL XR ORAL CAPSULE (Amphetamine- Tier 1 QL (2 EA per 1 day) EXTENDED RELEASE 24 HOUR 20 Dextroamphet ER) MG, 25 MG, 30 MG amphetamine sulfate oral tablet 10 mg, 5 (Evekeo) Tier 1 PA mg amphetamine-dextroamphetamine oral (Adderall) Tier 1 QL (2 EA per 1 day) tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg dextroamphetamine sulfate er oral (Dexedrine) Tier 1 QL (2 EA per 1 day) capsule extended release 24 hour 10 mg, 5 mg dextroamphetamine sulfate er oral (Dexedrine) Tier 1 QL (4 EA per 1 day) capsule extended release 24 hour 15 mg dextroamphetamine sulfate oral solution (ProCentra) Tier 1 QL (1800 ML per 30 days) 5 mg/5ml dextroamphetamine sulfate oral tablet 10 (Zenzedi) Tier 1 QL (6 EA per 1 day) mg dextroamphetamine sulfate oral tablet 5 (Zenzedi) Tier 1 QL (3 EA per 1 day) mg DYANAVEL XR ORAL SUSPENSION Tier 3 ST: Requires prior EXTENDED RELEASE 2.5 MG/ML prescription for Dextroamphetamine/amph etamine within the past 120 days; QL (240 ML per 30 days) EVEKEO ODT ORAL TABLET Tier 3 ST: Requires prior DISPERSIBLE 10 MG prescription for Dextroamphetamine/amph etamine within the past 120 days; QL (4 EA per 1 day)

MedPerform Medium Formulary 01/01/2021

Copyright © 2004-2021 MedImpact Healthcare Systems, Inc. All rights reserved. This document is proprietary to MedImpact. MedImpact maintains the sole and exclusive ownership, right, title, and interest in and to this document. This document is intended for informational use only and is not intended to replace professional medical advice or treatment, or diagnose, treat, cure, or prevent any disease or medical condition. This document is subject to change. Your estimated coverage and copayment/coinsurance may vary based on your benefit plan.

3 Drug Status Notes EVEKEO ODT ORAL TABLET Tier 3 ST: Requires prior DISPERSIBLE 15 MG, 20 MG prescription for Dextroamphetamine/amph etamine within the past 120 days; QL (2 EA per 1 day) EVEKEO ODT ORAL TABLET Tier 3 ST: Requires prior DISPERSIBLE 5 MG prescription for Dextroamphetamine/amph etamine within the past 120 days; QL (8 EA per 1 day) methamphetamine hcl oral tablet 5 mg (Desoxyn) Tier 1 QL (5 EA per 1 day) MYDAYIS ORAL CAPSULE EXTENDED Tier 2 QL (1 EA per 1 day) RELEASE 24 HOUR 12.5 MG, 25 MG, 37.5 MG, 50 MG PROCENTRA ORAL SOLUTION 5 (Dextroamphetamine Tier 1 QL (1800 ML per 30 days) MG/5ML Sulfate) VYVANSE ORAL CAPSULE 10 MG, 20 Tier 2 QL (1 EA per 1 day) MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG VYVANSE ORAL TABLET CHEWABLE Tier 2 QL (1 EA per 1 day) 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG ZENZEDI ORAL TABLET 10 MG (Dextroamphetamine Tier 1 QL (6 EA per 1 day) Sulfate) ZENZEDI ORAL TABLET 15 MG, 2.5 Tier 3 ST: Requires prior MG, 7.5 MG prescription for Dextroamphetamine Sulfate within the past 120 days; QL (3 EA per 1 day) ZENZEDI ORAL TABLET 20 MG, 30 MG Tier 3 ST: Requires prior prescription for Dextroamphetamine Sulfate within the past 120 days; QL (2 EA per 1 day) ZENZEDI ORAL TABLET 5 MG (Dextroamphetamine Tier 1 QL (3 EA per 1 day) Sulfate)

MedPerform Medium Formulary 01/01/2021

4 Drug Status Notes Analeptics caffeine citrate oral solution 20 mg/ml, Tier 1 60 mg/3ml Anorexiants Non-Amphetamine benzphetamine hcl oral tablet 25 mg, 50 Tier 1 mg diethylpropion hcl er oral tablet extended Tier 1 release 24 hour 75 mg diethylpropion hcl oral tablet 25 mg Tier 1 LOMAIRA ORAL TABLET 8 MG Tier 3 phendimetrazine tartrate oral tablet 35 Tier 1 mg phentermine hcl oral capsule 15 mg, 30 Tier 1 mg phentermine hcl oral capsule 37.5 mg (Adipex-P) Tier 1 phentermine hcl oral tablet 37.5 mg (Adipex-P) Tier 1 Anti-Obesity Agents CONTRAVE ORAL TABLET Tier 2 PA EXTENDED RELEASE 12 HOUR 8-90 MG SAXENDA SUBCUTANEOUS Tier 2 PA SOLUTION PEN-INJECTOR 18 MG/3ML XENICAL ORAL CAPSULE 120 MG Tier 3 PA Attention-Deficit/Hyperactivity Disorder (Adhd) Agents atomoxetine hcl oral capsule 10 mg, 18 (Strattera) Tier 1 QL (2 EA per 1 day) mg, 25 mg, 40 mg atomoxetine hcl oral capsule 100 mg, 60 (Strattera) Tier 1 QL (1 EA per 1 day) mg, 80 mg clonidine hcl er oral tablet extended (Kapvay) Tier 1 QL (4 EA per 1 day) release 12 hour 0.1 mg guanfacine hcl er oral tablet extended (Intuniv) Tier 1 QL (1 EA per 1 day) release 24 hour 1 mg, 2 mg, 3 mg, 4 mg

MedPerform Medium Formulary 01/01/2021

5 Drug Status Notes Dopamine And Norepinephrine Reuptake Inhibitors (Dnris) SUNOSI ORAL TABLET 150 MG, 75 Tier 3 PA MG Histamine H3-Receptor Antagonist/Inverse Agonists WAKIX ORAL TABLET 17.8 MG, 4.45 Tier 3 PA; SP MG Stimulants - Misc. armodafinil oral tablet 150 mg, 200 mg, (Nuvigil) Tier 1 QL (1 EA per 1 day) 250 mg armodafinil oral tablet 50 mg (Nuvigil) Tier 1 QL (3 EA per 1 day) CONCERTA ORAL TABLET (Methylphenidate HCl ER) Tier 1 QL (1 EA per 1 day) EXTENDED RELEASE 18 MG, 27 MG, 54 MG CONCERTA ORAL TABLET (Methylphenidate HCl ER) Tier 1 QL (2 EA per 1 day) EXTENDED RELEASE 36 MG DAYTRANA TRANSDERMAL PATCH Tier 3 ST: Requires prior 10 MG/9HR, 15 MG/9HR, 20 MG/9HR, prescription for 30 MG/9HR Methylphenidate HCL within the past 120 days; QL (1 EA per 1 day) dexmethylphenidate hcl er oral capsule (Focalin XR) Tier 1 QL (1 EA per 1 day) extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg dexmethylphenidate hcl oral tablet 10 (Focalin) Tier 1 QL (2 EA per 1 day) mg, 2.5 mg, 5 mg METADATE ER ORAL TABLET (Methylphenidate HCl ER) Tier 1 QL (3 EA per 1 day) EXTENDED RELEASE 20 MG methylphenidate hcl er (cd) oral capsule Tier 1 QL (1 EA per 1 day) extended release 10 mg, 20 mg, 40 mg, 50 mg, 60 mg methylphenidate hcl er (cd) oral capsule Tier 1 QL (2 EA per 1 day) extended release 30 mg

MedPerform Medium Formulary 01/01/2021

6 Drug Status Notes methylphenidate hcl er (la) oral capsule (Ritalin LA) Tier 1 QL (1 EA per 1 day) extended release 24 hour 10 mg, 20 mg, 40 mg methylphenidate hcl er (la) oral capsule (Ritalin LA) Tier 1 QL (2 EA per 1 day) extended release 24 hour 30 mg methylphenidate hcl er (la) oral capsule Tier 1 QL (1 EA per 1 day) extended release 24 hour 60 mg methylphenidate hcl er oral tablet Tier 1 QL (3 EA per 1 day) extended release 10 mg methylphenidate hcl er oral tablet (Metadate ER) Tier 1 QL (3 EA per 1 day) extended release 20 mg methylphenidate hcl oral solution 10 (Methylin) Tier 1 mg/5ml, 5 mg/5ml methylphenidate hcl oral tablet 10 mg, (Ritalin) Tier 1 QL (3 EA per 1 day) 20 mg, 5 mg methylphenidate hcl oral tablet chewable Tier 1 QL (3 EA per 1 day) 10 mg, 2.5 mg, 5 mg modafinil oral tablet 100 mg, 200 mg (Provigil) Tier 1 QL (2 EA per 1 day) QUILLICHEW ER ORAL TABLET Tier 3 QL (1 EA per 1 day) CHEWABLE EXTENDED RELEASE 20 MG, 40 MG QUILLICHEW ER ORAL TABLET Tier 3 QL (2 EA per 1 day) CHEWABLE EXTENDED RELEASE 30 MG QUILLIVANT XR ORAL SUSPENSION Tier 3 60mL BOTTLE; QL (60 ML RECONSTITUTED ER 25 MG/5ML per 30 days) Allergenic Extracts/Biologicals Misc Allergenic Extracts dandelion subcutaneous solution 1:20 Tier 3 GRASTEK SUBLINGUAL TABLET Tier 2 PA SUBLINGUAL 2800 BAU ODACTRA SUBLINGUAL TABLET Tier 2 PA SUBLINGUAL 12 SQ-HDM ORALAIR SUBLINGUAL TABLET Tier 2 PA SUBLINGUAL 300 IR

MedPerform Medium Formulary 01/01/2021

7 Drug Status Notes PALFORZIA (12 MG DAILY DOSE) Tier 2 PA; SP ORAL 2 X 1 MG & 10 MG PALFORZIA (120 MG DAILY DOSE) Tier 2 PA; SP ORAL 20 MG & 100 MG PALFORZIA (160 MG DAILY DOSE) Tier 2 PA; SP ORAL 3 X 20 MG & 100 MG PALFORZIA (20 MG DAILY DOSE) Tier 2 PA; SP ORAL 20 MG PALFORZIA (200 MG DAILY DOSE) Tier 2 PA; SP ORAL 2 X 100 MG PALFORZIA (240 MG DAILY DOSE) Tier 2 PA; SP ORAL 2 X 20 MG & 2 X 100 MG PALFORZIA (3 MG DAILY DOSE) Tier 2 PA; SP ORAL 3 X 1 MG PALFORZIA (300 MG MAINTENANCE) Tier 2 PA; SP ORAL PACKET 300 MG PALFORZIA (300 MG TITRATION) Tier 2 PA; SP ORAL PACKET 300 MG PALFORZIA (40 MG DAILY DOSE) Tier 2 PA; SP ORAL 2 X 20 MG PALFORZIA (6 MG DAILY DOSE) Tier 2 PA; SP ORAL 6 X 1 MG PALFORZIA (80 MG DAILY DOSE) Tier 2 PA; SP ORAL 4 X 20 MG PALFORZIA INITIAL ESCALATION Tier 2 PA; SP ORAL 0.5 & 1 & 1.5 & 3 & 6 MG RAGWITEK SUBLINGUAL TABLET Tier 2 PA SUBLINGUAL 12 AMB A 1-U Alternative Medicines Alternative Medicine - A's NEOKE RA LIPOIC ORAL POWDER Tier 3 800 MG/GM Alternative Medicine - P's EC-RX DHEA EXTERNAL CREAM 10 Tier 3 %, 4 %

MedPerform Medium Formulary 01/01/2021

8 Drug Status Notes Amebicides Amebicides SOLOSEC ORAL PACKET 2 GM Tier 3 ST: At least 2 prior prescriptions for Clindamycin HCL, Clindamycin Palmitate HCL, Clindamycin Phosphate vaginal, Metronidazole, or Tinidazole within the past 365 days; QL (1 EA per 30 days) Aminoglycosides Aminoglycosides ARIKAYCE INHALATION SUSPENSION Tier 3 PA; SP 590 MG/8.4ML KITABIS PAK INHALATION (Tobramycin) Tier 3 PA; SP NEBULIZATION SOLUTION 300 MG/5ML neomycin sulfate oral tablet 500 mg Tier 1 paromomycin sulfate oral capsule 250 Tier 1 mg TOBI PODHALER INHALATION Tier 2 PA; SP CAPSULE 28 MG tobramycin inhalation nebulization (Bethkis) Tier 1 PA; SP solution 300 mg/4ml tobramycin inhalation nebulization (Kitabis Pak) Tier 1 PA; SP solution 300 mg/5ml tobramycin pak inhalation nebulization (Kitabis Pak) Tier 1 PA; SP solution 300 mg/5ml Analgesics - Anti-Inflammatory Analgesics - Anti-Inflammatory Combinations equapax/ibuprofen/minrex oral therapy Tier 3 pack 800 mg PRASTERA ORAL KIT 200 & 400 MG Tier 3

MedPerform Medium Formulary 01/01/2021

9 Drug Status Notes Antirheumatic - Enzyme Inhibitors RINVOQ ORAL TABLET EXTENDED Tier 2 PA; SP RELEASE 24 HOUR 15 MG XELJANZ ORAL TABLET 10 MG, 5 MG Tier 2 PA; SP XELJANZ XR ORAL TABLET Tier 2 PA; SP EXTENDED RELEASE 24 HOUR 11 MG, 22 MG Antirheumatic Antimetabolites methotrexate (anti-rheumatic) oral tablet Tier 1 2.5 mg OTREXUP SUBCUTANEOUS Tier 2 QL (1.6 ML per 28 days) SOLUTION AUTO-INJECTOR 10 MG/0.4ML, 12.5 MG/0.4ML, 15 MG/0.4ML, 17.5 MG/0.4ML, 20 MG/0.4ML, 22.5 MG/0.4ML, 25 MG/0.4ML Anti-Tnf-Alpha - Monoclonal Antibodies HUMIRA PEDIATRIC CROHNS START Tier 2 PA; SP SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML HUMIRA PEN SUBCUTANEOUS PEN- Tier 2 PA; SP INJECTOR KIT 40 MG/0.4ML, 40 MG/0.8ML HUMIRA PEN-CD/UC/HS STARTER Tier 2 PA; SP SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML, 80 MG/0.8ML HUMIRA PEN-PS/UV/ADOL HS START Tier 2 PA; SP SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-PSOR/UVEIT STARTER Tier 2 PA; SP SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML & 40MG/0.4ML

MedPerform Medium Formulary 01/01/2021

10 Drug Status Notes HUMIRA SUBCUTANEOUS Tier 2 PA; SP PREFILLED SYRINGE KIT 10 MG/0.1ML, 10 MG/0.2ML, 20 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.4ML, 40 MG/0.8ML SIMPONI SUBCUTANEOUS Tier 3 PA; SP SOLUTION AUTO-INJECTOR 100 MG/ML SIMPONI SUBCUTANEOUS Tier 3 PA; SP SOLUTION PREFILLED SYRINGE 100 MG/ML Gold Compounds RIDAURA ORAL CAPSULE 3 MG Tier 3 Interleukin-1 Blockers ARCALYST SUBCUTANEOUS Tier 3 SP SOLUTION RECONSTITUTED 220 MG Interleukin-1 Receptor Antagonist (Il- 1Ra) KINERET SUBCUTANEOUS Tier 3 PA; SP SOLUTION PREFILLED SYRINGE 100 MG/0.67ML Interleukin-6 Receptor Inhibitors ACTEMRA ACTPEN SUBCUTANEOUS Tier 3 PA; SP SOLUTION AUTO-INJECTOR 162 MG/0.9ML ACTEMRA SUBCUTANEOUS Tier 3 PA; SP SOLUTION PREFILLED SYRINGE 162 MG/0.9ML Nonsteroidal Anti-Inflammatory Agents (Nsaids) celecoxib oral capsule 100 mg, 200 mg, (CeleBREX) Tier 1 400 mg, 50 mg dermacinrx analgesic combopak Tier 3 combination kit 75 mg diclofenac potassium oral tablet 50 mg Tier 1

MedPerform Medium Formulary 01/01/2021

11 Drug Status Notes diclofenac sodium er oral tablet Tier 1 extended release 24 hour 100 mg diclofenac sodium oral tablet delayed Tier 1 release 25 mg, 50 mg, 75 mg diclofenac-misoprostol oral tablet (Arthrotec) Tier 1 delayed release 50-0.2 mg, 75-0.2 mg ec-naproxen oral tablet delayed release (EC-Naprosyn) Tier 1 375 mg ec-naproxen oral tablet delayed release Tier 1 500 mg etodolac er oral tablet extended release Tier 1 24 hour 400 mg, 500 mg, 600 mg etodolac oral capsule 200 mg, 300 mg Tier 1 etodolac oral tablet 400 mg (Lodine) Tier 1 etodolac oral tablet 500 mg Tier 1 flurbiprofen oral tablet 100 mg Tier 1 IBU ORAL TABLET 400 MG, 600 MG, (Ibuprofen) Tier 1 800 MG IBUPAK ORAL KIT 600 MG Tier 3 ibuprofen oral suspension 100 mg/5ml (Childrens Advil) Tier 1 ibuprofen oral tablet 400 mg, 600 mg, (IBU) Tier 1 800 mg INDOCIN ORAL SUSPENSION 25 Tier 2 MG/5ML indomethacin er oral capsule extended Tier 1 release 75 mg indomethacin oral capsule 25 mg, 50 mg Tier 1 ketoprofen er oral capsule extended Tier 1 release 24 hour 200 mg ketoprofen oral capsule 25 mg, 50 mg, Tier 1 75 mg ketorolac tromethamine injection solution Tier 1 15 mg/ml, 30 mg/ml ketorolac tromethamine intramuscular Tier 1 solution 60 mg/2ml

MedPerform Medium Formulary 01/01/2021

12 Drug Status Notes ketorolac tromethamine oral tablet 10 mg Tier 1 QL (4 EA per 1 day) meclofenamate sodium oral capsule 100 Tier 1 mg, 50 mg mefenamic acid oral capsule 250 mg Tier 1 meloxicam oral tablet 15 mg, 7.5 mg (Mobic) Tier 1 nabumetone oral tablet 500 mg, 750 mg (Relafen) Tier 1 naproxen dr oral tablet delayed release (EC-Naprosyn) Tier 1 375 mg naproxen dr oral tablet delayed release Tier 1 500 mg naproxen oral tablet 250 mg, 375 mg, Tier 1 500 mg naproxen sodium oral tablet 275 mg Tier 1 naproxen sodium oral tablet 550 mg (Anaprox DS) Tier 1 NUDROXIPAK M-15 COMBINATION Tier 3 KIT 15 MG oxaprozin oral tablet 600 mg (Daypro) Tier 1 piroxicam oral capsule 10 mg, 20 mg (Feldene) Tier 1 PREVIDOLRX ANALGESIC Tier 3 COMBINATION THERAPY PACK 75- 20-0.025 MG-MG-% QMIIZ ODT ORAL TABLET Tier 3 ST: Requires prior DISPERSIBLE 15 MG, 7.5 MG prescription for generic Meloxicam tablets within the past 120 DAYS; QL (1 EA per 1 day) RELAFEN ORAL TABLET 500 MG, 750 (Nabumetone) Tier 1 MG sulindac oral tablet 150 mg, 200 mg Tier 1 tolmetin sodium oral capsule 400 mg Tier 1 tolmetin sodium oral tablet 600 mg Tier 1 TORONOVA II SUIK COMBINATION Tier 3 KIT 30 MG/ML TORONOVA SUIK COMBINATION KIT Tier 3 30 MG/ML

MedPerform Medium Formulary 01/01/2021

13 Drug Status Notes Phosphodiesterase 4 (Pde4) Inhibitors OTEZLA ORAL TABLET 30 MG Tier 2 PA; SP OTEZLA ORAL TABLET THERAPY Tier 2 PA; SP PACK 10 & 20 & 30 MG Pyrimidine Synthesis Inhibitors leflunomide oral tablet 10 mg, 20 mg (Arava) Tier 1 Selective Costimulation Modulators ORENCIA CLICKJECT Tier 3 PA; SP SUBCUTANEOUS SOLUTION AUTO- INJECTOR 125 MG/ML ORENCIA SUBCUTANEOUS Tier 3 PA; SP SOLUTION PREFILLED SYRINGE 125 MG/ML, 50 MG/0.4ML, 87.5 MG/0.7ML Soluble Tumor Necrosis Factor Receptor Agents ENBREL MINI SUBCUTANEOUS Tier 2 PA; SP SOLUTION CARTRIDGE 50 MG/ML ENBREL SUBCUTANEOUS SOLUTION Tier 2 PA; SP 25 MG/0.5ML ENBREL SUBCUTANEOUS SOLUTION Tier 2 PA; SP PREFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML ENBREL SUBCUTANEOUS SOLUTION Tier 2 PA; SP RECONSTITUTED 25 MG ENBREL SURECLICK Tier 2 PA; SP SUBCUTANEOUS SOLUTION AUTO- INJECTOR 50 MG/ML Analgesics - Nonnarcotic Analgesic Combinations BUPAP ORAL TABLET 50-300 MG (Butalbital-Acetaminophen) Tier 1 ST: Requires prior prescription for generic Butalbital/acetaminophen 50mg-325mg combination product within the past 120 days; QL (6 EA per 1 day)

MedPerform Medium Formulary 01/01/2021

14 Drug Status Notes butalbital-acetaminophen oral tablet 50- (Bupap) Tier 1 ST: Requires prior 300 mg prescription for generic Butalbital/acetaminophen 50mg-325mg combination product within the past 120 days; QL (6 EA per 1 day) butalbital-acetaminophen oral tablet 50- (Tencon) Tier 1 325 mg butalbital-apap-caffeine oral capsule 50- (Fioricet) Tier 1 300-40 mg butalbital-apap-caffeine oral capsule 50- (Esgic) Tier 1 325-40 mg butalbital-apap-caffeine oral tablet 50- (Esgic) Tier 1 325-40 mg butalbital-aspirin-caffeine oral capsule (Fiorinal) Tier 1 50-325-40 mg butalbital-aspirin-caffeine oral tablet 50- Tier 1 325-40 mg ESGIC ORAL CAPSULE 50-325-40 MG (Butalbital-APAP-Caffeine) Tier 1 TENCON ORAL TABLET 50-325 MG (Butalbital-Acetaminophen) Tier 3 ZEBUTAL ORAL CAPSULE 50-325-40 (Butalbital-APAP-Caffeine) Tier 1 MG Salicylates aspirin 81 oral tablet chewable 81 mg (Bayer Low Dose) $0 aspirin adult low strength oral tablet (Bayer Low Dose) $0 chewable 81 mg aspirin adult oral tablet 325 mg (Bayer Advanced Aspirin $0 Reg St) aspirin childrens oral tablet chewable 81 (Bayer Low Dose) $0 mg aspirin low dose oral tablet chewable 81 (Bayer Low Dose) $0 mg aspirin low strength oral tablet chewable (Bayer Low Dose) $0 81 mg aspirin oral tablet 325 mg (Bayer Advanced Aspirin $0 Reg St)

MedPerform Medium Formulary 01/01/2021

15 Drug Status Notes aspirin oral tablet chewable 81 mg (Bayer Low Dose) $0 BAYER ADVANCED ASPIRIN REG ST (Aspirin Adult) $0 ORAL TABLET 325 MG BAYER ASPIRIN ORAL TABLET 325 (Aspirin Adult) $0 MG BAYER LOW DOSE ORAL TABLET (GNP Adult Aspirin Low $0 CHEWABLE 81 MG Strength) childrens aspirin low strength oral tablet (Bayer Low Dose) $0 chewable 81 mg childrens aspirin oral tablet chewable 81 (Bayer Low Dose) $0 mg cvs aspirin adult low dose oral tablet (Bayer Low Dose) $0 chewable 81 mg cvs aspirin oral tablet 325 mg (Bayer Advanced Aspirin $0 Reg St) diflunisal oral tablet 500 mg Tier 1 eq aspirin low dose oral tablet chewable (Bayer Low Dose) $0 81 mg eq aspirin oral tablet 325 mg (Bayer Advanced Aspirin $0 Reg St) eq childrens aspirin oral tablet chewable (Bayer Low Dose) $0 81 mg eql aspirin low dose oral tablet chewable (Bayer Low Dose) $0 81 mg gnp adult aspirin low strength oral tablet (Bayer Low Dose) $0 chewable 81 mg gnp aspirin oral tablet 325 mg (Bayer Advanced Aspirin $0 Reg St) goodsense aspirin adult low st oral tablet (Bayer Low Dose) $0 chewable 81 mg goodsense aspirin oral tablet 325 mg (Bayer Advanced Aspirin $0 Reg St) goodsense aspirin oral tablet chewable (Bayer Low Dose) $0 81 mg hm aspirin oral tablet 325 mg (Bayer Advanced Aspirin $0 Reg St)

MedPerform Medium Formulary 01/01/2021

16 Drug Status Notes hm aspirin oral tablet chewable 81 mg (Bayer Low Dose) $0 mm aspirin oral tablet 325 mg (Bayer Advanced Aspirin $0 Reg St) NORWICH ASPIRIN ORAL TABLET 325 (Aspirin Adult) $0 MG px aspirin oral tablet 325 mg (Bayer Advanced Aspirin $0 Reg St) px aspirin oral tablet chewable 81 mg (Bayer Low Dose) $0 qc aspirin low dose oral tablet chewable (Bayer Low Dose) $0 81 mg qc aspirin oral tablet 325 mg (Bayer Advanced Aspirin $0 Reg St) qc childrens aspirin oral tablet chewable (Bayer Low Dose) $0 81 mg ra aspirin adult low dose oral tablet (Bayer Low Dose) $0 chewable 81 mg ra aspirin adult low strength oral tablet (Bayer Low Dose) $0 chewable 81 mg ra aspirin childrens oral tablet chewable (Bayer Low Dose) $0 81 mg ra aspirin oral tablet 325 mg (Bayer Advanced Aspirin $0 Reg St) ra childrens aspirin oral tablet chewable (Bayer Low Dose) $0 81 mg ra pain relief aspirin oral tablet 325 mg (Bayer Advanced Aspirin $0 Reg St) salsalate oral tablet 500 mg, 750 mg Tier 1 sb aspirin oral tablet 325 mg (Bayer Advanced Aspirin $0 Reg St) sb childrens aspirin oral tablet chewable (Bayer Low Dose) $0 81 mg sm aspirin adult low strength oral tablet (Bayer Low Dose) $0 chewable 81 mg sm aspirin low dose oral tablet chewable (Bayer Low Dose) $0 81 mg

MedPerform Medium Formulary 01/01/2021

17 Drug Status Notes sm aspirin oral tablet 325 mg (Bayer Advanced Aspirin $0 Reg St) sm childrens aspirin oral tablet chewable (Bayer Low Dose) $0 81 mg ST JOSEPH LOW DOSE ORAL (GNP Adult Aspirin Low $0 TABLET CHEWABLE 81 MG Strength) Analgesics - Opioid Opioid Agonists ARYMO ER ORAL TABLET EXTENDED Tier 3 ST: Requires 7 consecutive RELEASE ABUSE-DETERRENT 15 days therapy of current MG, 30 MG, 60 MG short-acting opioid prescription; QL (3 EA per 1 day) codeine sulfate oral tablet 30 mg Tier 1 QL (12 EA per 1 day); AGE (Min 12 Years) DEMEROL INJECTION SOLUTION 75 Tier 3 MG/ML DSUVIA SUBLINGUAL TABLET Tier 3 PA SUBLINGUAL 30 MCG fentanyl citrate buccal lozenge on a (Actiq) Tier 1 PA handle 1200 mcg, 1600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl citrate-nacl intravenous solution Tier 3 prefilled syringe 500-0.9 mcg/50ml-% fentanyl transdermal patch 72 hour 100 (Duragesic-100) Tier 1 PA; ST: Requires 7 mcg/hr consecutive days therapy of current short-acting opioid prescription; QL (1 EA per 3 days) fentanyl transdermal patch 72 hour 12 (Duragesic-12) Tier 1 PA; ST: Requires 7 mcg/hr consecutive days therapy of current short-acting opioid prescription; QL (1 EA per 3 days)

MedPerform Medium Formulary 01/01/2021

18 Drug Status Notes fentanyl transdermal patch 72 hour 25 (Duragesic-25) Tier 1 PA; ST: Requires 7 mcg/hr consecutive days therapy of current short-acting opioid prescription; QL (1 EA per 3 days) fentanyl transdermal patch 72 hour 37.5 Tier 1 PA; ST: Requires 7 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr consecutive days therapy of current short-acting opioid prescription; QL (1 EA per 3 days) fentanyl transdermal patch 72 hour 50 (Duragesic-50) Tier 1 PA; ST: Requires 7 mcg/hr consecutive days therapy of current short-acting opioid prescription; QL (1 EA per 3 days) fentanyl transdermal patch 72 hour 75 (Duragesic-75) Tier 1 PA; ST: Requires 7 mcg/hr consecutive days therapy of current short-acting opioid prescription; QL (1 EA per 3 days) hydrocodone bitartrate er oral capsule (Zohydro ER) Tier 1 QL (2 EA per 1 day) extended release 12 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg hydromorphone hcl er oral tablet Tier 1 PA; QL (1 EA per 1 day) extended release 24 hour 12 mg, 16 mg, 8 mg hydromorphone hcl er oral tablet Tier 1 PA; QL (2 EA per 1 day) extended release 24 hour 32 mg hydromorphone hcl oral liquid 1 mg/ml (Dilaudid) Tier 1 hydromorphone hcl oral tablet 2 mg, 4 (Dilaudid) Tier 1 mg, 8 mg hydromorphone hcl rectal suppository 3 Tier 1 mg hydromorphone hcl-nacl injection Tier 1 solution prefilled syringe 30-0.9 mg/30ml-%

MedPerform Medium Formulary 01/01/2021

19 Drug Status Notes hydromorphone hcl-nacl intravenous Tier 3 solution prefilled syringe 30-0.9 mg/30ml-% HYSINGLA ER ORAL TABLET ER 24 Tier 2 ST: Requires 7 consecutive HOUR ABUSE-DETERRENT 100 MG, days therapy of current 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, short-acting opioid 80 MG prescription; QL (1 EA per 1 day) levorphanol tartrate oral tablet 2 mg Tier 1 ST: Requires 7 consecutive days therapy of current short-acting opioid prescription meperidine hcl injection solution 100 (Demerol) Tier 1 mg/ml, 25 mg/ml, 50 mg/ml meperidine hcl oral solution 50 mg/5ml Tier 1 QL (30 ML per 1 day) meperidine hcl oral tablet 50 mg Tier 1 QL (6 EA per 1 day) methadone hcl injection solution 10 Tier 1 ST: Requires 7 consecutive mg/ml days therapy of current short-acting opioid prescription; QL (4 ML per 1 day) METHADONE HCL INTENSOL ORAL (Methadone HCl) Tier 1 ST: Requires 7 consecutive CONCENTRATE 10 MG/ML days therapy of current short-acting opioid prescription; QL (4 ML per 1 day) methadone hcl oral concentrate 10 (Methadone HCl Intensol) Tier 1 ST: Requires 7 consecutive mg/ml days therapy of current short-acting opioid prescription; QL (4 ML per 1 day) methadone hcl oral solution 10 mg/5ml Tier 1 ST: Requires 7 consecutive days therapy of current short-acting opioid prescription; QL (20 ML per 1 day)

MedPerform Medium Formulary 01/01/2021

20 Drug Status Notes methadone hcl oral solution 5 mg/5ml Tier 1 ST: Requires 7 consecutive days therapy of current short-acting opioid prescription; QL (40 ML per 1 day) methadone hcl oral tablet 10 mg (Dolophine) Tier 1 ST: Requires 7 consecutive days therapy of current short-acting opioid prescription; QL (4 EA per 1 day) methadone hcl oral tablet 5 mg (Dolophine) Tier 1 ST: Requires 7 consecutive days therapy of current short-acting opioid prescription; QL (8 EA per 1 day) methadone hcl oral tablet soluble 40 mg (Methadose) Tier 1 ST: Requires 7 consecutive days therapy of current short-acting opioid prescription; QL (1 EA per 1 day) METHADOSE ORAL TABLET (Methadone HCl) Tier 1 ST: Requires 7 consecutive SOLUBLE 40 MG days therapy of current short-acting opioid prescription; QL (1 EA per 1 day) morphine sulfate (concentrate) oral Tier 1 solution 100 mg/5ml, 20 mg/ml morphine sulfate er beads oral capsule Tier 1 ST: Requires 7 consecutive extended release 24 hour 120 mg days therapy of current short-acting opioid prescription; QL (2 EA per 1 day) morphine sulfate er beads oral capsule Tier 1 ST: Requires 7 consecutive extended release 24 hour 30 mg, 45 mg, days therapy of current 60 mg, 75 mg, 90 mg short-acting opioid prescription; QL (1 EA per 1 day)

MedPerform Medium Formulary 01/01/2021

21 Drug Status Notes morphine sulfate er oral tablet extended (MS Contin) Tier 1 ST: Requires 7 consecutive release 100 mg, 15 mg, 200 mg, 30 mg, days therapy of current 60 mg short-acting opioid prescription; QL (3 EA per 1 day) morphine sulfate intravenous solution Tier 3 0.5 mg/ml morphine sulfate intravenous solution 1 Tier 1 mg/ml morphine sulfate oral solution 10 Tier 1 mg/5ml, 20 mg/5ml morphine sulfate oral tablet 15 mg, 30 Tier 1 mg morphine sulfate rectal suppository 10 Tier 1 mg, 20 mg, 30 mg, 5 mg morphine sulfate-nacl intravenous Tier 3 solution 100-0.9 mg/100ml-%, 50-0.9 mg/50ml-%, 500-0.9 mg/100ml-% NUCYNTA ER ORAL TABLET Tier 2 ST: Requires 7 consecutive EXTENDED RELEASE 12 HOUR 100 days therapy of current MG, 150 MG, 200 MG, 250 MG, 50 MG short-acting opioid prescription; QL (2 EA per 1 day) NUCYNTA ORAL TABLET 100 MG, 50 Tier 2 QL (6 EA per 1 day) MG, 75 MG OXAYDO ORAL TABLET 5 MG (oxyCODONE HCl) Tier 3 OXAYDO ORAL TABLET 7.5 MG Tier 3 oxycodone hcl er oral tablet er 12 hour (OxyCONTIN) Tier 1 ST: Requires 7 consecutive abuse-deterrent 10 mg, 15 mg, 20 mg, days therapy of current 30 mg, 40 mg, 60 mg short-acting opioid prescription; QL (2 EA per 1 day) oxycodone hcl er oral tablet er 12 hour (OxyCONTIN) Tier 1 ST: Requires 7 consecutive abuse-deterrent 80 mg days therapy of current short-acting opioid prescription; QL (4 EA per 1 day)

MedPerform Medium Formulary 01/01/2021

22 Drug Status Notes oxycodone hcl oral capsule 5 mg Tier 1 oxycodone hcl oral concentrate 100 Tier 1 mg/5ml oxycodone hcl oral solution 5 mg/5ml Tier 1 oxycodone hcl oral tablet 10 mg, 20 mg Tier 1 oxycodone hcl oral tablet 15 mg, 30 mg (Roxicodone) Tier 1 oxycodone hcl oral tablet 5 mg (Oxaydo) Tier 1 OXYCONTIN ORAL TABLET ER 12 (oxyCODONE HCl ER) Tier 2 ST: Requires 7 consecutive HOUR ABUSE-DETERRENT 10 MG, 20 days therapy of current MG, 40 MG short-acting opioid prescription; QL (2 EA per 1 day) OXYCONTIN ORAL TABLET ER 12 (OxyCODONE HCl ER) Tier 2 ST: Requires 7 consecutive HOUR ABUSE-DETERRENT 15 MG, 30 days therapy of current MG, 60 MG short-acting opioid prescription; QL (2 EA per 1 day) OXYCONTIN ORAL TABLET ER 12 (OxyCODONE HCl ER) Tier 2 ST: Requires 7 consecutive HOUR ABUSE-DETERRENT 80 MG days therapy of current short-acting opioid prescription; QL (4 EA per 1 day) oxymorphone hcl er oral tablet extended Tier 1 ST: Requires 7 consecutive release 12 hour 10 mg, 15 mg, 20 mg, 5 days therapy of current mg, 7.5 mg short-acting opioid prescription; QL (2 EA per 1 day) oxymorphone hcl er oral tablet extended Tier 1 ST: Requires 7 consecutive release 12 hour 30 mg, 40 mg days therapy of current short-acting opioid prescription; QL (4 EA per 1 day) oxymorphone hcl oral tablet 10 mg (Opana) Tier 1 oxymorphone hcl oral tablet 5 mg Tier 1 QDOLO ORAL SOLUTION 5 MG/ML Tier 3 PA

MedPerform Medium Formulary 01/01/2021

23 Drug Status Notes ROXYBOND ORAL TABLET ABUSE- Tier 3 DETERRENT 15 MG, 30 MG, 5 MG SYNAPRYN FUSEPAQ ORAL Tier 3 SUSPENSION RECONSTITUTED 10 MG/ML tramadol hcl er (biphasic) oral tablet Tier 1 ST: Requires 7 consecutive extended release 24 hour 100 mg days therapy of current short-acting opioid prescription; QL (3 EA per 1 day); AGE (Min 12 Years) tramadol hcl er (biphasic) oral tablet Tier 1 ST: Requires 7 consecutive extended release 24 hour 200 mg, 300 days therapy of current mg short-acting opioid prescription; QL (1 EA per 1 day); AGE (Min 12 Years) tramadol hcl er oral capsule extended Tier 1 QL (1 EA per 1 day); AGE release 24 hour 150 mg (Min 12 Years) tramadol hcl er oral tablet extended Tier 1 ST: Requires 7 consecutive release 24 hour 100 mg days therapy of current short-acting opioid prescription; QL (3 EA per 1 day); AGE (Min 12 Years) tramadol hcl er oral tablet extended Tier 1 ST: Requires 7 consecutive release 24 hour 200 mg, 300 mg days therapy of current short-acting opioid prescription; QL (1 EA per 1 day); AGE (Min 12 Years) tramadol hcl oral tablet 50 mg (Ultram) Tier 1 QL (8 EA per 1 day); AGE (Min 12 Years) XTAMPZA ER ORAL CAPSULE ER 12 Tier 3 ST: Requires 7 consecutive HOUR ABUSE-DETERRENT 13.5 MG, days therapy of current 18 MG, 9 MG short-acting opioid prescription; QL (2 EA per 1 day)

MedPerform Medium Formulary 01/01/2021

24 Drug Status Notes XTAMPZA ER ORAL CAPSULE ER 12 Tier 3 ST: Requires 7 consecutive HOUR ABUSE-DETERRENT 27 MG days therapy of current short-acting opioid prescription; QL (4 EA per 1 day) XTAMPZA ER ORAL CAPSULE ER 12 Tier 3 ST: Requires 7 consecutive HOUR ABUSE-DETERRENT 36 MG days therapy of current short-acting opioid prescription; QL (8 EA per 1 day) Opioid Combinations acetaminophen-codeine #2 oral tablet Tier 1 QL (12 EA per 1 day); AGE 300-15 mg (Min 12 Years) acetaminophen-codeine #3 oral tablet Tier 1 QL (12 EA per 1 day); AGE 300-30 mg (Min 12 Years) acetaminophen-codeine #4 oral tablet Tier 1 QL (6 EA per 1 day); AGE 300-60 mg (Min 12 Years) acetaminophen-codeine oral solution Tier 1 QL (150 ML per 1 day); 120-12 mg/5ml AGE (Min 12 Years) acetaminophen-codeine oral tablet 300- Tier 1 QL (12 EA per 1 day); AGE 15 mg, 300-30 mg (Min 12 Years) acetaminophen-codeine oral tablet 300- Tier 1 QL (6 EA per 1 day); AGE 60 mg (Min 12 Years) APADAZ ORAL TABLET 4.08-325 MG, (Benzhydrocodone- Tier 3 ST: Requires prior 6.12-325 MG, 8.16-325 MG Acetaminophen) prescription for Hydrocodone/acetaminoph en tablets within the past 120 days; QL (12 EA per 1 day) ASCOMP-CODEINE ORAL CAPSULE (Butalbital-ASA-Caff- Tier 1 QL (6 EA per 1 day); AGE 50-325-40-30 MG Codeine) (Min 12 Years) benzhydrocodone-acetaminophen oral (Apadaz) Tier 1 ST: Requires prior tablet 4.08-325 mg, 6.12-325 mg, 8.16- prescription for 325 mg Hydrocodone/acetaminoph en tablets within the past 120 days; QL (12 EA per 1 day)

MedPerform Medium Formulary 01/01/2021

25 Drug Status Notes butalbital-apap-caff-cod oral capsule 50- (Fioricet/Codeine) Tier 1 QL (6 EA per 1 day); AGE 300-40-30 mg (Min 12 Years) butalbital-apap-caff-cod oral capsule 50- Tier 1 QL (6 EA per 1 day); AGE 325-40-30 mg (Min 12 Years) butalbital-asa-caff-codeine oral capsule (Ascomp-Codeine) Tier 1 QL (6 EA per 1 day); AGE 50-325-40-30 mg (Min 12 Years) ENDOCET ORAL TABLET 10-325 MG, (oxyCODONE- Tier 1 QL (12 EA per 1 day) 5-325 MG, 7.5-325 MG Acetaminophen) ENDOCET ORAL TABLET 2.5-325 MG (Oxycodone- Tier 1 QL (12 EA per 1 day) Acetaminophen) hydrocodone-acetaminophen oral Tier 1 QL (184 ML per 1 day) solution 2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325 mg/15ml hydrocodone-acetaminophen oral tablet Tier 1 QL (13 EA per 1 day) 10-300 mg, 7.5-300 mg hydrocodone-acetaminophen oral tablet (Norco) Tier 1 QL (12 EA per 1 day) 10-325 mg, 5-325 mg, 7.5-325 mg hydrocodone-acetaminophen oral tablet (Xodol) Tier 1 QL (13 EA per 1 day) 5-300 mg hydrocodone-ibuprofen oral tablet 10- Tier 1 200 mg, 5-200 mg, 7.5-200 mg LORTAB ORAL ELIXIR 10-300 Tier 3 QL (200 ML per 1 day) MG/15ML oxycodone-acetaminophen oral tablet (Endocet) Tier 1 QL (12 EA per 1 day) 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5- 325 mg oxycodone-aspirin oral tablet 4.8355-325 Tier 1 mg PRIMLEV ORAL TABLET 10-300 MG, 5- (oxyCODONE- Tier 3 QL (13 EA per 1 day) 300 MG Acetaminophen) PRIMLEV ORAL TABLET 7.5-300 MG Tier 3 QL (13 EA per 1 day) PROLATE ORAL TABLET 10-300 MG, (oxyCODONE- Tier 3 QL (13 EA per 1 day) 5-300 MG Acetaminophen) PROLATE ORAL TABLET 7.5-300 MG Tier 3 QL (13 EA per 1 day) tramadol-acetaminophen oral tablet (Ultracet) Tier 1 QL (10 EA per 1 day); AGE 37.5-325 mg (Min 12 Years)

MedPerform Medium Formulary 01/01/2021

26 Drug Status Notes Opioid Partial Agonists BUNAVAIL BUCCAL FILM 2.1-0.3 MG Tier 3 QL (1 EA per 1 day) BUNAVAIL BUCCAL FILM 4.2-0.7 MG, Tier 3 QL (2 EA per 1 day) 6.3-1 MG buprenorphine hcl injection solution 0.3 (Buprenex) Tier 1 mg/ml buprenorphine hcl sublingual tablet Tier 1 QL (3 EA per 1 day) sublingual 2 mg, 8 mg buprenorphine hcl-naloxone hcl (Suboxone) Tier 1 QL (2 EA per 1 day) sublingual film 12-3 mg, 8-2 mg buprenorphine hcl-naloxone hcl (Suboxone) Tier 1 QL (1 EA per 1 day) sublingual film 2-0.5 mg, 4-1 mg buprenorphine hcl-naloxone hcl Tier 1 QL (3 EA per 1 day) sublingual tablet sublingual 2-0.5 mg, 8- 2 mg buprenorphine transdermal patch weekly (Butrans) Tier 1 ST: Requires 7 consecutive 10 mcg/hr, 15 mcg/hr, 20 mcg/hr, 5 days therapy of current mcg/hr, 7.5 mcg/hr short-acting opioid prescription; QL (4 EA per 28 days) butorphanol tartrate injection solution 1 Tier 1 mg/ml, 2 mg/ml butorphanol tartrate nasal solution 10 Tier 1 mg/ml nalbuphine hcl injection solution 10 Tier 1 mg/ml, 20 mg/ml pentazocine-naloxone hcl oral tablet 50- Tier 1 0.5 mg ZUBSOLV SUBLINGUAL TABLET Tier 2 QL (1 EA per 1 day) SUBLINGUAL 0.7-0.18 MG, 1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 MG ZUBSOLV SUBLINGUAL TABLET Tier 2 QL (2 EA per 1 day) SUBLINGUAL 8.6-2.1 MG

MedPerform Medium Formulary 01/01/2021

27 Drug Status Notes Androgens-Anabolic Anabolic Steroids ANADROL-50 ORAL TABLET 50 MG Tier 3 PA oxandrolone oral tablet 10 mg, 2.5 mg Tier 1 PA Androgens ANDRODERM TRANSDERMAL PATCH Tier 3 PA 24 HOUR 2 MG/24HR, 4 MG/24HR danazol oral capsule 100 mg, 200 mg, Tier 1 50 mg ec-rx testosterone transdermal cream Tier 3 0.2 %, 0.4 %, 10 %, 20 % JATENZO ORAL CAPSULE 158 MG, Tier 3 PA 198 MG, 237 MG methitest oral tablet 10 mg Tier 3 PA methyltestosterone oral capsule 10 mg Tier 1 PA testosterone compounding kit Tier 3 transdermal cream 20 % testosterone cypionate injection solution Tier 3 PA 200 mg/ml testosterone cypionate intramuscular (Depo-Testosterone) Tier 1 PA solution 100 mg/ml, 200 mg/ml testosterone enanthate intramuscular Tier 1 PA solution 200 mg/ml testosterone transdermal gel 1.62 %, (AndroGel Pump) Tier 1 PA 20.25 mg/act (1.62%) testosterone transdermal gel 10 mg/act (Fortesta) Tier 1 PA (2%) testosterone transdermal gel 12.5 mg/act (Vogelxo Pump) Tier 1 PA (1%) testosterone transdermal gel 20.25 (AndroGel) Tier 1 PA mg/1.25gm (1.62%), 25 mg/2.5gm (1%), 40.5 mg/2.5gm (1.62%) testosterone transdermal gel 50 mg/5gm (Vogelxo) Tier 1 PA (1%) testosterone transdermal solution 30 Tier 1 PA mg/act

MedPerform Medium Formulary 01/01/2021

28 Drug Status Notes VOGELXO PUMP TRANSDERMAL GEL (Testosterone) Tier 3 PA 12.5 MG/ACT (1%) VOGELXO TRANSDERMAL GEL 50 (Testosterone) Tier 3 PA MG/5GM (1%) XYOSTED SUBCUTANEOUS Tier 3 PA SOLUTION AUTO-INJECTOR 100 MG/0.5ML, 50 MG/0.5ML, 75 MG/0.5ML Anorectal Agents Intrarectal Steroids CORTIFOAM EXTERNAL FOAM 10 % Tier 3 hydrocortisone rectal enema 100 (Cortenema) Tier 1 mg/60ml UCERIS RECTAL FOAM 2 MG/ACT Tier 3 ST: Requires prior prescription for Mesalamine enema within the past 120 days Rectal Combinations ANA-LEX RECTAL KIT 2-2 % (Lidocaine-Hydrocortisone Tier 1 Ace) ANALPRAM-HC EXTERNAL LOTION Tier 2 2.5-1 % hydrocortisone ace-pramoxine external (Analpram-HC) Tier 1 cream 1-1 % hydrocort-pramoxine (perianal) external (Analpram HC) Tier 1 cream 2.5-1 % lidocaine-hydrocort (perianal) external (Lidocort) Tier 1 cream 3-0.5 % lidocaine-hydrocortisone ace rectal gel Tier 1 2.8-0.55 % lidocaine-hydrocortisone ace rectal kit 2- (Ana-Lex) Tier 1 2 % lidocaine-hydrocortisone ace rectal kit 3- Tier 1 0.5 %, 3-1 %, 3-2.5 % LIDOCORT EXTERNAL CREAM 3-0.5 (Lidocaine-Hydrocort Tier 1 % (Perianal))

MedPerform Medium Formulary 01/01/2021

29 Drug Status Notes PROCORT EXTERNAL CREAM 1.85- Tier 3 1.15 % PROCTOFOAM HC EXTERNAL FOAM Tier 2 1-1 % Rectal Steroids anucort-hc rectal suppository 25 mg (Anusol-HC) Tier 1 ANUSOL-HC RECTAL SUPPOSITORY (Hydrocortisone Acetate) Tier 1 25 MG HEMMOREX-HC RECTAL (Hydrocortisone Acetate) Tier 1 SUPPOSITORY 25 MG hydrocortisone (perianal) external cream (Procto-Pak) Tier 1 1 % hydrocortisone (perianal) external cream (Procto-Med HC) Tier 1 2.5 % hydrocortisone acetate rectal (Anusol-HC) Tier 1 suppository 25 mg hydrocortisone acetate rectal (Proctocort) Tier 1 suppository 30 mg PROCTO-MED HC EXTERNAL CREAM (Hydrocortisone (Perianal)) Tier 1 2.5 % PROCTO-PAK EXTERNAL CREAM 1 % (Hydrocortisone (Perianal)) Tier 1 PROCTOZONE-HC EXTERNAL (Hydrocortisone (Perianal)) Tier 1 CREAM 2.5 % Vasodilating Agents RECTIV RECTAL OINTMENT 0.4 % Tier 3 Anthelmintics Anthelmintics albendazole oral tablet 200 mg (Albenza) Tier 1 EMVERM ORAL TABLET CHEWABLE Tier 2 PA 100 MG ivermectin oral tablet 3 mg (Stromectol) Tier 1 praziquantel oral tablet 600 mg (Biltricide) Tier 1 Antianginal Agents Antianginals-Other ranolazine er oral tablet extended (Ranexa) Tier 1 QL (2 EA per 1 day) release 12 hour 1000 mg

MedPerform Medium Formulary 01/01/2021

30 Drug Status Notes ranolazine er oral tablet extended (Ranexa) Tier 1 QL (4 EA per 1 day) release 12 hour 500 mg Nitrates DILATRATE-SR ORAL CAPSULE Tier 3 EXTENDED RELEASE 40 MG isosorbide dinitrate oral tablet 10 mg, 20 Tier 1 mg, 30 mg isosorbide dinitrate oral tablet 40 mg, 5 (Isordil Titradose) Tier 1 mg isosorbide mononitrate er oral tablet Tier 1 extended release 24 hour 120 mg, 30 mg, 60 mg isosorbide mononitrate oral tablet 10 mg, Tier 1 20 mg MINITRAN TRANSDERMAL PATCH 24 (Nitroglycerin) Tier 1 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR NITRO-BID TRANSDERMAL Tier 2 OINTMENT 2 % NITRO-DUR TRANSDERMAL PATCH Tier 2 24 HOUR 0.3 MG/HR, 0.8 MG/HR nitroglycerin sublingual tablet sublingual (Nitrostat) Tier 1 0.3 mg, 0.4 mg, 0.6 mg nitroglycerin transdermal patch 24 hour (Minitran) Tier 1 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr nitroglycerin translingual solution 0.4 (Nitrolingual) Tier 1 mg/spray NITROMIST TRANSLINGUAL Tier 3 AEROSOL SOLUTION 400 MCG/SPRAY NITRO-TIME ORAL CAPSULE (Nitroglycerin ER) Tier 3 EXTENDED RELEASE 2.5 MG NITRO-TIME ORAL CAPSULE (Nitroglycerin ER) Tier 2 EXTENDED RELEASE 6.5 MG, 9 MG

MedPerform Medium Formulary 01/01/2021

31 Drug Status Notes Antianxiety Agents Antianxiety Agents - Misc. buspirone hcl oral tablet 10 mg, 15 mg, Tier 1 30 mg, 5 mg, 7.5 mg hydroxyzine hcl oral syrup 10 mg/5ml Tier 1 hydroxyzine hcl oral tablet 10 mg, 25 Tier 1 mg, 50 mg hydroxyzine pamoate oral capsule 100 Tier 1 mg hydroxyzine pamoate oral capsule 25 (Vistaril) Tier 1 mg, 50 mg meprobamate oral tablet 200 mg, 400 Tier 1 mg Benzodiazepines alprazolam er oral tablet extended (Xanax XR) Tier 1 release 24 hour 0.5 mg, 1 mg, 2 mg, 3 mg ALPRAZOLAM INTENSOL ORAL Tier 2 CONCENTRATE 1 MG/ML alprazolam oral tablet 0.25 mg, 0.5 mg, 1 (Xanax) Tier 1 mg, 2 mg alprazolam oral tablet dispersible 0.25 Tier 1 mg, 0.5 mg, 1 mg, 2 mg alprazolam xr oral tablet extended (Xanax XR) Tier 1 release 24 hour 0.5 mg, 1 mg, 2 mg, 3 mg chlordiazepoxide hcl oral capsule 10 mg, Tier 1 25 mg, 5 mg clorazepate dipotassium oral tablet 15 Tier 1 mg, 3.75 mg clorazepate dipotassium oral tablet 7.5 (Tranxene-T) Tier 1 mg DIAZEPAM INTENSOL ORAL (Diazepam) Tier 1 CONCENTRATE 5 MG/ML diazepam oral concentrate 5 mg/ml (Diazepam Intensol) Tier 1 diazepam oral solution 5 mg/5ml Tier 1

MedPerform Medium Formulary 01/01/2021

32 Drug Status Notes diazepam oral tablet 10 mg, 2 mg, 5 mg (Valium) Tier 1 LORAZEPAM INTENSOL ORAL (LORazepam) Tier 1 CONCENTRATE 2 MG/ML lorazepam oral concentrate 2 mg/ml (LORazepam Intensol) Tier 1 lorazepam oral tablet 0.5 mg, 1 mg, 2 (Ativan) Tier 1 mg oxazepam oral capsule 10 mg, 15 mg, Tier 1 30 mg Antiarrhythmics Antiarrhythmics Type I-A disopyramide phosphate oral capsule (Norpace) Tier 1 100 mg, 150 mg NORPACE CR ORAL CAPSULE Tier 2 EXTENDED RELEASE 12 HOUR 100 MG, 150 MG quinidine gluconate er oral tablet Tier 1 extended release 324 mg quinidine sulfate oral tablet 200 mg, 300 Tier 1 mg Antiarrhythmics Type I-B mexiletine hcl oral capsule 150 mg, 200 Tier 1 mg, 250 mg Antiarrhythmics Type I-C flecainide acetate oral tablet 100 mg, Tier 1 150 mg, 50 mg propafenone hcl er oral capsule (Rythmol SR) Tier 1 extended release 12 hour 225 mg, 325 mg, 425 mg propafenone hcl oral tablet 150 mg, 225 Tier 1 mg, 300 mg Antiarrhythmics Type Iii amiodarone hcl oral tablet 100 mg, 200 (Pacerone) Tier 1 mg, 400 mg dofetilide oral capsule 125 mcg, 250 (Tikosyn) Tier 1 mcg, 500 mcg MULTAQ ORAL TABLET 400 MG Tier 2

MedPerform Medium Formulary 01/01/2021

33 Drug Status Notes PACERONE ORAL TABLET 100 MG, (Amiodarone HCl) Tier 1 200 MG, 400 MG Antiasthmatic And Bronchodilator Agents Antiasthmatic - Monoclonal Antibodies FASENRA PEN SUBCUTANEOUS Tier 2 PA; SP SOLUTION AUTO-INJECTOR 30 MG/ML NUCALA SUBCUTANEOUS SOLUTION Tier 2 PA; SP AUTO-INJECTOR 100 MG/ML NUCALA SUBCUTANEOUS SOLUTION Tier 2 PA; SP PREFILLED SYRINGE 100 MG/ML Anti-Inflammatory Agents cromolyn sodium inhalation nebulization Tier 1 solution 20 mg/2ml Asthma And Bronchodilator Agent Combinations DIFIL-G FORTE ORAL LIQUID 100-100 Tier 3 MG/5ML Bronchodilators - Anticholinergics ATROVENT HFA INHALATION Tier 2 QL (25.8 GM per 30 days) AEROSOL SOLUTION 17 MCG/ACT INCRUSE ELLIPTA INHALATION Tier 2 QL (1 EA per 1 day) AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH ipratropium bromide inhalation solution Tier 1 0.02 % LONHALA MAGNAIR REFILL KIT Tier 3 QL (2 ML per 1 day) INHALATION SOLUTION 25 MCG/ML LONHALA MAGNAIR STARTER KIT Tier 3 QL (2 ML per 1 day) INHALATION SOLUTION 25 MCG/ML SPIRIVA HANDIHALER INHALATION Tier 2 QL (1 EA per 1 day) CAPSULE 18 MCG SPIRIVA RESPIMAT INHALATION Tier 2 QL (4 GM per 30 days) AEROSOL SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT

MedPerform Medium Formulary 01/01/2021

34 Drug Status Notes Leukotriene Modulators montelukast sodium oral packet 4 mg (Singulair) Tier 1 montelukast sodium oral tablet 10 mg (Singulair) Tier 1 montelukast sodium oral tablet chewable (Singulair) Tier 1 4 mg, 5 mg zafirlukast oral tablet 10 mg, 20 mg (Accolate) Tier 1 Selective Phosphodiesterase 4 (Pde4) Inhibitors DALIRESP ORAL TABLET 250 MCG, Tier 2 ST: Requires prior 500 MCG prescription for Fluticasone Furoate-Vilanterol, Fluticasone-Salmeterol, Salmeterol Xinafoate, or Tiotropium Bromide Monohydrate within the past 120 days; QL (1 EA per 1 day) Steroid Inhalants ARNUITY ELLIPTA INHALATION Tier 2 QL (1 EA per 1 day) AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT, 50 MCG/ACT ASMANEX (120 METERED DOSES) Tier 3 ST: At least 2 prior INHALATION AEROSOL POWDER prescriptions for BREATH ACTIVATED 220 MCG/INH Beclomethasone Dipropionate HFA, Fluticasone Furoate (inhalation), Fluticasone Propionate (inhalation), or Fluticasone Propionate HFA within the past 365 days; QL (1 EA per 30 days)

MedPerform Medium Formulary 01/01/2021

35 Drug Status Notes ASMANEX (14 METERED DOSES) Tier 3 ST: At least 2 prior INHALATION AEROSOL POWDER prescriptions for BREATH ACTIVATED 220 MCG/INH Beclomethasone Dipropionate HFA, Fluticasone Furoate (inhalation), Fluticasone Propionate (inhalation), or Fluticasone Propionate HFA within the past 365 days; QL (1 EA per 30 days) ASMANEX (30 METERED DOSES) Tier 3 ST: At least 2 prior INHALATION AEROSOL POWDER prescriptions for BREATH ACTIVATED 110 MCG/INH, Beclomethasone 220 MCG/INH Dipropionate HFA, Fluticasone Furoate (inhalation), Fluticasone Propionate (inhalation), or Fluticasone Propionate HFA within the past 365 days; QL (1 EA per 30 days) ASMANEX (60 METERED DOSES) Tier 3 ST: At least 2 prior INHALATION AEROSOL POWDER prescriptions for BREATH ACTIVATED 220 MCG/INH Beclomethasone Dipropionate HFA, Fluticasone Furoate (inhalation), Fluticasone Propionate (inhalation), or Fluticasone Propionate HFA within the past 365 days; QL (1 EA per 30 days)

MedPerform Medium Formulary 01/01/2021

36 Drug Status Notes ASMANEX (7 METERED DOSES) Tier 3 ST: At least 2 prior INHALATION AEROSOL POWDER prescriptions for BREATH ACTIVATED 110 MCG/INH Beclomethasone Dipropionate HFA, Fluticasone Furoate (inhalation), Fluticasone Propionate (inhalation), or Fluticasone Propionate HFA within the past 365 days; QL (1 EA per 30 days) ASMANEX HFA INHALATION Tier 3 ST: At least 2 prior AEROSOL 100 MCG/ACT, 200 prescriptions for MCG/ACT, 50 MCG/ACT Beclomethasone Dipropionate HFA, Fluticasone Furoate (inhalation), Fluticasone Propionate (inhalation), or Fluticasone Propionate HFA within the past 365 days; QL (13 GM per 30 days) budesonide inhalation suspension 0.25 (Pulmicort) Tier 1 QL (4 ML per 1 day) mg/2ml, 0.5 mg/2ml budesonide inhalation suspension 1 (Pulmicort) Tier 1 QL (2 ML per 1 day) mg/2ml FLOVENT DISKUS INHALATION Tier 2 QL (2 EA per 1 day) AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 50 MCG/BLIST FLOVENT DISKUS INHALATION Tier 2 QL (4 EA per 1 day) AEROSOL POWDER BREATH ACTIVATED 250 MCG/BLIST FLOVENT HFA INHALATION Tier 2 QL (12 GM per 30 days) AEROSOL 110 MCG/ACT FLOVENT HFA INHALATION Tier 2 QL (24 GM per 30 days) AEROSOL 220 MCG/ACT

MedPerform Medium Formulary 01/01/2021

37 Drug Status Notes FLOVENT HFA INHALATION Tier 2 QL (21.2 GM per 30 days) AEROSOL 44 MCG/ACT PULMICORT FLEXHALER Tier 3 ST: At least 2 prior INHALATION AEROSOL POWDER prescriptions for BREATH ACTIVATED 180 MCG/ACT, Beclomethasone 90 MCG/ACT Dipropionate HFA, Fluticasone Furoate (inhalation), Fluticasone Propionate (inhalation), or Fluticasone Propionate HFA within the past 365 days; QL (1 EA per 30 days) QVAR REDIHALER INHALATION Tier 2 QL (21.2 GM per 30 days) AEROSOL BREATH ACTIVATED 40 MCG/ACT, 80 MCG/ACT Sympathomimetics ADVAIR DISKUS INHALATION (Fluticasone-Salmeterol) Tier 1 QL (2 EA per 1 day) AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE, 250- 50 MCG/DOSE, 500-50 MCG/DOSE ADVAIR HFA INHALATION AEROSOL Tier 2 QL (12 GM per 30 days) 115-21 MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT albuterol sulfate er oral tablet extended Tier 1 release 12 hour 4 mg, 8 mg albuterol sulfate hfa inhalation aerosol (Ventolin HFA) Tier 1 solution 108 (90 base) mcg/act albuterol sulfate inhalation nebulization Tier 1 solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml, 1.25 mg/3ml, 2.5 mg/0.5ml albuterol sulfate oral syrup 2 mg/5ml Tier 1 albuterol sulfate oral tablet 2 mg, 4 mg Tier 1 ANORO ELLIPTA INHALATION Tier 2 QL (2 EA per 1 day) AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/INH

MedPerform Medium Formulary 01/01/2021

38 Drug Status Notes ARCAPTA NEOHALER INHALATION Tier 3 ST: Requires prior CAPSULE 75 MCG prescription for Olodaterol HCL and Salmeterol Xinafoate within the past 365 days; QL (1 EA per 1 day) BREO ELLIPTA INHALATION Tier 2 QL (2 EA per 1 day) AEROSOL POWDER BREATH ACTIVATED 100-25 MCG/INH, 200-25 MCG/INH BREZTRI AEROSPHERE INHALATION Tier 2 QL (10.7 GM per 30 days) AEROSOL 160-9-4.8 MCG/ACT BROVANA INHALATION Tier 3 ST: Requires prior NEBULIZATION SOLUTION 15 prescription for Formoterol MCG/2ML Fumarate, Olodaterol HCL, or Salmeterol Xinafoate within the past 120 days; QL (4 ML per 1 day) COMBIVENT RESPIMAT INHALATION Tier 2 AEROSOL SOLUTION 20-100 MCG/ACT ipratropium-albuterol inhalation solution Tier 1 0.5-2.5 (3) mg/3ml levalbuterol hcl inhalation nebulization (Xopenex) Tier 1 solution 0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/3ml levalbuterol hcl inhalation nebulization (Xopenex Concentrate) Tier 1 solution 1.25 mg/0.5ml levalbuterol tartrate inhalation aerosol 45 (Xopenex HFA) Tier 1 mcg/act PERFOROMIST INHALATION Tier 2 QL (4 ML per 1 day) NEBULIZATION SOLUTION 20 MCG/2ML PROAIR RESPICLICK INHALATION Tier 2 AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) MCG/ACT

MedPerform Medium Formulary 01/01/2021

39 Drug Status Notes SEREVENT DISKUS INHALATION Tier 2 QL (2 EA per 1 day) AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE STIOLTO RESPIMAT INHALATION Tier 2 QL (4 GM per 30 days) AEROSOL SOLUTION 2.5-2.5 MCG/ACT STRIVERDI RESPIMAT INHALATION Tier 2 QL (4 GM per 30 days) AEROSOL SOLUTION 2.5 MCG/ACT SYMBICORT INHALATION AEROSOL (Budesonide-Formoterol Tier 2 QL (10.2 GM per 30 days) 160-4.5 MCG/ACT Fumarate) SYMBICORT INHALATION AEROSOL (Budesonide-Formoterol Tier 2 QL (40.8 GM per 30 days) 80-4.5 MCG/ACT Fumarate) terbutaline sulfate oral tablet 2.5 mg, 5 Tier 1 mg TRELEGY ELLIPTA INHALATION Tier 2 QL (2 EA per 1 day) AEROSOL POWDER BREATH ACTIVATED 100-62.5-25 MCG/INH, 200-62.5-25 MCG/INH VENTOLIN HFA INHALATION (Albuterol Sulfate HFA) Tier 3 AEROSOL SOLUTION 108 (90 BASE) MCG/ACT XOPENEX HFA INHALATION (Levalbuterol Tartrate) Tier 3 AEROSOL 45 MCG/ACT Xanthines ELIXOPHYLLIN ORAL ELIXIR 80 Tier 3 MG/15ML THEO-24 ORAL CAPSULE EXTENDED Tier 2 RELEASE 24 HOUR 100 MG, 200 MG, 300 MG, 400 MG theophylline er oral tablet extended Tier 1 release 12 hour 300 mg, 450 mg theophylline er oral tablet extended Tier 1 release 24 hour 400 mg, 600 mg theophylline oral solution 80 mg/15ml Tier 1

MedPerform Medium Formulary 01/01/2021

40 Drug Status Notes Anticoagulants Anticoagulants - Misc. sodium citrate in vitro solution prefilled Tier 3 syringe 4 % Coumarin Anticoagulants JANTOVEN ORAL TABLET 1 MG, 10 (Warfarin Sodium) Tier 1 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG warfarin sodium oral tablet 1 mg, 10 mg, (Jantoven) Tier 1 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg Direct Factor Xa Inhibitors ELIQUIS DVT/PE STARTER PACK Tier 2 QL (74 EA per 30 days) ORAL TABLET THERAPY PACK 5 MG ELIQUIS ORAL TABLET 2.5 MG Tier 2 QL (2 EA per 1 day) ELIQUIS ORAL TABLET 5 MG Tier 2 QL (74 EA per 30 days) XARELTO ORAL TABLET 10 MG, 20 Tier 2 QL (1 EA per 1 day) MG XARELTO ORAL TABLET 15 MG, 2.5 Tier 2 QL (2 EA per 1 day) MG XARELTO STARTER PACK ORAL Tier 2 QL (51 EA per 30 days) TABLET THERAPY PACK 15 & 20 MG Heparins And Heparinoid-Like Agents enoxaparin sodium injection solution 300 (Lovenox) Tier 1 SP; QL (1 ML per 1 day) mg/3ml enoxaparin sodium subcutaneous (Lovenox) Tier 1 SP solution 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml fondaparinux sodium subcutaneous (Arixtra) Tier 1 SP; QL (24 ML per 30 solution 10 mg/0.8ml days) fondaparinux sodium subcutaneous (Arixtra) Tier 1 SP; QL (15 ML per 30 solution 2.5 mg/0.5ml days) fondaparinux sodium subcutaneous (Arixtra) Tier 1 SP; QL (12 ML per 30 solution 5 mg/0.4ml days)

MedPerform Medium Formulary 01/01/2021

41 Drug Status Notes fondaparinux sodium subcutaneous (Arixtra) Tier 1 SP; QL (18 ML per 30 solution 7.5 mg/0.6ml days) FRAGMIN SUBCUTANEOUS Tier 2 SP; QL (2 ML per 1 day) SOLUTION 10000 UNIT/ML FRAGMIN SUBCUTANEOUS Tier 2 SP; QL (1 ML per 1 day) SOLUTION 12500 UNIT/0.5ML FRAGMIN SUBCUTANEOUS Tier 2 SP; QL (36 ML per 30 SOLUTION 15000 UNIT/0.6ML days) FRAGMIN SUBCUTANEOUS Tier 2 SP; QL (43.2 ML per 30 SOLUTION 18000 UNT/0.72ML days) FRAGMIN SUBCUTANEOUS Tier 2 SP; QL (12 ML per 30 SOLUTION 2500 UNIT/0.2ML, 5000 days) UNIT/0.2ML FRAGMIN SUBCUTANEOUS Tier 2 SP; QL (18 ML per 30 SOLUTION 7500 UNIT/0.3ML days) FRAGMIN SUBCUTANEOUS Tier 2 SP; QL (7.6 ML per 30 SOLUTION 95000 UNIT/3.8ML days) heparin (porcine) in nacl intravenous Tier 1 solution 1000-0.9 ut/500ml-% heparin (porcine) in nacl intravenous Tier 3 solution 2500-0.9 ut/500ml-%, 5000-0.9 ut/500ml-% heparin lock flush intravenous solution Tier 1 10 unit/ml heparin sodium (porcine) injection Tier 1 solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection Tier 1 solution 5000 unit/0.5ml heparin sodium lock flush intravenous Tier 1 solution 100 unit/ml hepmed combination kit 100&0.9&2.5- Tier 3 2.5 ut/ml&% In Vitro/Lock Anticoagulants acd formula a in vitro solution 0.73-2.45- (ACD-A noClot-50) Tier 3 2.2 gm/100ml

MedPerform Medium Formulary 01/01/2021

42 Drug Status Notes ACD-A NOCLOT-50 IN VITRO (ACD Formula A) Tier 3 SOLUTION 0.73-2.45-2.2 GM/100ML anticoagulant cit dext soln a in vitro (ACD-A noClot-50) Tier 1 solution 0.8-2.45-2.2 gm/100ml REGIOCIT IN VITRO SOLUTION 0.529 Tier 3 % TRICITRASOL IN VITRO Tier 3 CONCENTRATE 46.7 % Anticonvulsants Ampa Glutamate Receptor Antagonists FYCOMPA ORAL SUSPENSION 0.5 Tier 3 QL (680 ML per 28 days) MG/ML FYCOMPA ORAL TABLET 10 MG, 12 Tier 3 QL (1 EA per 1 day) MG, 8 MG FYCOMPA ORAL TABLET 2 MG Tier 3 QL (4 EA per 1 day) FYCOMPA ORAL TABLET 4 MG, 6 MG Tier 3 QL (2 EA per 1 day) Anticonvulsants - Benzodiazepines clobazam oral suspension 2.5 mg/ml (Onfi) Tier 1 QL (480 ML per 30 days) clobazam oral tablet 10 mg, 20 mg (Onfi) Tier 1 QL (2 EA per 1 day) clonazepam oral tablet 0.5 mg, 1 mg, 2 (KlonoPIN) Tier 1 mg clonazepam oral tablet dispersible 0.125 Tier 1 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg DIASTAT ACUDIAL RECTAL GEL 10 (DiazePAM) Tier 3 QL (1 EA per 1 FILL) MG, 20 MG DIASTAT PEDIATRIC RECTAL GEL 2.5 (DiazePAM) Tier 3 QL (1 EA per 1 FILL) MG diazepam rectal gel 10 mg, 20 mg (Diastat AcuDial) Tier 1 QL (1 EA per 1 FILL) diazepam rectal gel 2.5 mg (Diastat Pediatric) Tier 1 QL (1 EA per 1 FILL) KLONOPIN ORAL TABLET 0.5 MG, 1 (clonazePAM) Tier 3 MG, 2 MG NAYZILAM NASAL SOLUTION 5 Tier 3 QL (10 EA per 30 days) MG/0.1ML SYMPAZAN ORAL FILM 10 MG, 20 MG, Tier 3 PA 5 MG

MedPerform Medium Formulary 01/01/2021

43 Drug Status Notes VALTOCO 10 MG DOSE NASAL Tier 3 QL (10 EA per 30 days) LIQUID 10 MG/0.1ML VALTOCO 15 MG DOSE NASAL Tier 3 QL (10 EA per 30 days) LIQUID THERAPY PACK 7.5 MG/0.1ML VALTOCO 20 MG DOSE NASAL Tier 3 QL (10 EA per 30 days) LIQUID THERAPY PACK 10 MG/0.1ML VALTOCO 5 MG DOSE NASAL LIQUID Tier 3 QL (10 EA per 30 days) 5 MG/0.1ML Anticonvulsants - Misc. APTIOM ORAL TABLET 200 MG, 400 Tier 3 QL (1 EA per 1 day) MG APTIOM ORAL TABLET 600 MG, 800 Tier 3 QL (2 EA per 1 day) MG BANZEL ORAL TABLET 200 MG Tier 3 QL (16 EA per 1 day) BANZEL ORAL TABLET 400 MG Tier 3 QL (8 EA per 1 day) BRIVIACT ORAL SOLUTION 10 MG/ML Tier 3 QL (600 ML per 30 days) BRIVIACT ORAL TABLET 10 MG, 100 Tier 3 QL (2 EA per 1 day) MG, 25 MG, 50 MG, 75 MG carbamazepine er oral capsule extended (Carbatrol) Tier 1 release 12 hour 100 mg, 200 mg, 300 mg carbamazepine er oral tablet extended (TEGretol-XR) Tier 1 release 12 hour 100 mg, 200 mg, 400 mg carbamazepine oral suspension 100 (TEGretol) Tier 1 mg/5ml carbamazepine oral tablet 200 mg (Epitol) Tier 1 carbamazepine oral tablet chewable 100 Tier 1 mg CARBATROL ORAL CAPSULE (CarBAMazepine ER) Tier 3 EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG DIACOMIT ORAL CAPSULE 250 MG, Tier 3 PA; SP 500 MG DIACOMIT ORAL PACKET 250 MG, Tier 3 PA; SP 500 MG

MedPerform Medium Formulary 01/01/2021

44 Drug Status Notes EPIDIOLEX ORAL SOLUTION 100 Tier 3 PA; SP MG/ML EPITOL ORAL TABLET 200 MG (carBAMazepine) Tier 1 FANATREX FUSEPAQ ORAL Tier 3 SUSPENSION 25 MG/ML FINTEPLA ORAL SOLUTION 2.2 Tier 3 PA; SP MG/ML gabapentin oral capsule 100 mg, 300 (Neurontin) Tier 1 mg, 400 mg gabapentin oral solution 250 mg/5ml, (Neurontin) Tier 1 300 mg/6ml gabapentin oral tablet 600 mg, 800 mg (Neurontin) Tier 1 KEPPRA ORAL SOLUTION 100 MG/ML (levETIRAcetam) Tier 3 KEPPRA ORAL TABLET 1000 MG, 500 (levETIRAcetam) Tier 3 MG KEPPRA ORAL TABLET 250 MG, 750 (LevETIRAcetam) Tier 3 MG KEPPRA XR ORAL TABLET (LevETIRAcetam ER) Tier 3 EXTENDED RELEASE 24 HOUR 500 MG, 750 MG LAMICTAL ODT ORAL KIT 21 X 25 MG Tier 3 & 7 X 50 MG, 42 X 50 MG & 14X100 MG LAMICTAL ODT ORAL KIT 25 & 50 & (lamoTRIgine) Tier 3 100 MG LAMICTAL ODT ORAL TABLET (LamoTRIgine) Tier 3 QL (3 EA per 1 day) DISPERSIBLE 100 MG LAMICTAL ODT ORAL TABLET (LamoTRIgine) Tier 3 QL (2 EA per 1 day) DISPERSIBLE 200 MG LAMICTAL ODT ORAL TABLET (LamoTRIgine) Tier 3 QL (6 EA per 1 day) DISPERSIBLE 25 MG, 50 MG LAMICTAL ORAL TABLET 100 MG, 150 (LamoTRIgine) Tier 3 MG, 200 MG LAMICTAL ORAL TABLET 25 MG (lamoTRIgine) Tier 3 LAMICTAL ORAL TABLET CHEWABLE (LamoTRIgine) Tier 3 25 MG, 5 MG

MedPerform Medium Formulary 01/01/2021

45 Drug Status Notes LAMICTAL STARTER ORAL KIT 35 X (lamoTRIgine Starter Kit- Tier 3 25 MG Blue) LAMICTAL STARTER ORAL KIT 42 X (lamoTRIgine Starter Kit- Tier 3 25 MG & 7 X 100 MG Orange) LAMICTAL STARTER ORAL KIT 84 X (lamoTRIgine Starter Kit- Tier 3 25 MG & 14X100 MG Green) LAMICTAL XR ORAL KIT 21 X 25 MG & Tier 3 7 X 50 MG, 25 & 50 & 100 MG, 50 & 100 & 200 MG LAMICTAL XR ORAL TABLET (LamoTRIgine ER) Tier 3 QL (3 EA per 1 day) EXTENDED RELEASE 24 HOUR 100 MG LAMICTAL XR ORAL TABLET (LamoTRIgine ER) Tier 3 QL (2 EA per 1 day) EXTENDED RELEASE 24 HOUR 200 MG, 250 MG, 300 MG LAMICTAL XR ORAL TABLET (LamoTRIgine ER) Tier 3 QL (6 EA per 1 day) EXTENDED RELEASE 24 HOUR 25 MG, 50 MG lamotrigine er oral tablet extended (LaMICtal XR) Tier 1 QL (3 EA per 1 day) release 24 hour 100 mg lamotrigine er oral tablet extended (LaMICtal XR) Tier 1 QL (2 EA per 1 day) release 24 hour 200 mg, 250 mg, 300 mg lamotrigine er oral tablet extended (LaMICtal XR) Tier 1 QL (6 EA per 1 day) release 24 hour 25 mg, 50 mg lamotrigine oral kit 25 & 50 & 100 mg (LaMICtal ODT) Tier 1 lamotrigine oral tablet 100 mg, 150 mg, (Subvenite) Tier 1 200 mg, 25 mg lamotrigine oral tablet chewable 25 mg, (LaMICtal) Tier 1 5 mg lamotrigine oral tablet dispersible 100 (LaMICtal ODT) Tier 1 QL (3 EA per 1 day) mg lamotrigine oral tablet dispersible 200 (LaMICtal ODT) Tier 1 QL (2 EA per 1 day) mg lamotrigine oral tablet dispersible 25 mg, (LaMICtal ODT) Tier 1 QL (6 EA per 1 day) 50 mg

MedPerform Medium Formulary 01/01/2021

46 Drug Status Notes lamotrigine starter kit-blue oral kit 35 x (Subvenite Starter Kit- Tier 1 25 mg Blue) lamotrigine starter kit-green oral kit 84 x (Subvenite Starter Kit- Tier 1 25 mg & 14x100 mg Green) lamotrigine starter kit-orange oral kit 42 x (Subvenite Starter Kit- Tier 1 25 mg & 7 x 100 mg Orange) levetiracetam er oral tablet extended (Keppra XR) Tier 1 release 24 hour 500 mg, 750 mg levetiracetam oral solution 100 mg/ml (Keppra) Tier 1 levetiracetam oral tablet 1000 mg, 250 (Keppra) Tier 1 mg, 500 mg, 750 mg LYRICA ORAL CAPSULE 100 MG, 150 (Pregabalin) Tier 2 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 20 MG/ML (Pregabalin) Tier 2 MYSOLINE ORAL TABLET 250 MG, 50 (Primidone) Tier 3 MG NEURONTIN ORAL CAPSULE 100 MG, (Gabapentin) Tier 3 300 MG, 400 MG NEURONTIN ORAL SOLUTION 250 (Gabapentin) Tier 3 MG/5ML NEURONTIN ORAL TABLET 600 MG, (Gabapentin) Tier 3 800 MG oxcarbazepine oral suspension 300 (Trileptal) Tier 1 mg/5ml oxcarbazepine oral tablet 150 mg, 300 (Trileptal) Tier 1 mg, 600 mg OXTELLAR XR ORAL TABLET Tier 3 QL (1 EA per 1 day) EXTENDED RELEASE 24 HOUR 150 MG, 300 MG OXTELLAR XR ORAL TABLET Tier 3 QL (4 EA per 1 day) EXTENDED RELEASE 24 HOUR 600 MG pregabalin oral capsule 100 mg, 150 mg, (Lyrica) Tier 1 200 mg, 225 mg, 25 mg, 300 mg, 50 mg, 75 mg

MedPerform Medium Formulary 01/01/2021

47 Drug Status Notes pregabalin oral solution 20 mg/ml (Lyrica) Tier 1 primidone oral tablet 250 mg, 50 mg (Mysoline) Tier 1 QUDEXY XR ORAL CAPSULE ER 24 (Topiramate ER) Tier 3 QL (1 EA per 1 day) HOUR SPRINKLE 100 MG, 25 MG, 50 MG QUDEXY XR ORAL CAPSULE ER 24 (Topiramate ER) Tier 3 QL (2 EA per 1 day) HOUR SPRINKLE 150 MG, 200 MG rufinamide oral suspension 40 mg/ml (Banzel) Tier 1 QL (80 ML per 1 day) SPRITAM ORAL TABLET Tier 3 QL (2 EA per 1 day) DISINTEGRATING SOLUBLE 1000 MG SPRITAM ORAL TABLET Tier 3 QL (4 EA per 1 day) DISINTEGRATING SOLUBLE 250 MG, 500 MG, 750 MG SUBVENITE ORAL TABLET 100 MG, (LamoTRIgine) Tier 1 150 MG, 200 MG SUBVENITE ORAL TABLET 25 MG (lamoTRIgine) Tier 1 SUBVENITE STARTER KIT-BLUE (lamoTRIgine Starter Kit- Tier 1 ORAL KIT 35 X 25 MG Blue) SUBVENITE STARTER KIT-GREEN (lamoTRIgine Starter Kit- Tier 1 ORAL KIT 84 X 25 MG & 14X100 MG Green) SUBVENITE STARTER KIT-ORANGE (lamoTRIgine Starter Kit- Tier 1 ORAL KIT 42 X 25 MG & 7 X 100 MG Orange) TEGRETOL ORAL SUSPENSION 100 (CarBAMazepine) Tier 3 MG/5ML TEGRETOL ORAL TABLET 200 MG (carBAMazepine) Tier 3 TEGRETOL-XR ORAL TABLET (CarBAMazepine ER) Tier 3 EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 400 MG TOPAMAX ORAL TABLET 100 MG, 200 (Topiramate) Tier 3 MG, 25 MG, 50 MG TOPAMAX SPRINKLE ORAL CAPSULE (Topiramate) Tier 3 SPRINKLE 15 MG, 25 MG topiramate er oral capsule er 24 hour (Qudexy XR) Tier 1 QL (1 EA per 1 day) sprinkle 100 mg, 25 mg, 50 mg topiramate er oral capsule er 24 hour (Qudexy XR) Tier 1 QL (2 EA per 1 day) sprinkle 150 mg, 200 mg

MedPerform Medium Formulary 01/01/2021

48 Drug Status Notes topiramate oral capsule sprinkle 15 mg, (Topamax Sprinkle) Tier 1 25 mg topiramate oral tablet 100 mg, 200 mg, (Topamax) Tier 1 25 mg, 50 mg TRILEPTAL ORAL SUSPENSION 300 (OXcarbazepine) Tier 3 MG/5ML TRILEPTAL ORAL TABLET 150 MG, (OXcarbazepine) Tier 3 300 MG, 600 MG TROKENDI XR ORAL CAPSULE Tier 2 QL (2 EA per 1 day) EXTENDED RELEASE 24 HOUR 100 MG, 200 MG TROKENDI XR ORAL CAPSULE Tier 2 QL (8 EA per 1 day) EXTENDED RELEASE 24 HOUR 25 MG TROKENDI XR ORAL CAPSULE Tier 2 QL (4 EA per 1 day) EXTENDED RELEASE 24 HOUR 50 MG VIMPAT ORAL SOLUTION 10 MG/ML Tier 2 QL (1200 ML per 30 days) VIMPAT ORAL TABLET 100 MG, 150 Tier 2 QL (2 EA per 1 day) MG, 200 MG, 50 MG ZONEGRAN ORAL CAPSULE 100 MG, (Zonisamide) Tier 3 25 MG zonisamide oral capsule 100 mg, 25 mg (Zonegran) Tier 1 zonisamide oral capsule 50 mg Tier 1 Carbamates felbamate oral suspension 600 mg/5ml (Felbatol) Tier 1 QL (30 ML per 1 day) felbamate oral tablet 400 mg (Felbatol) Tier 1 QL (9 EA per 1 day) felbamate oral tablet 600 mg (Felbatol) Tier 1 QL (6 EA per 1 day) FELBATOL ORAL SUSPENSION 600 (Felbamate) Tier 3 QL (30 ML per 1 day) MG/5ML FELBATOL ORAL TABLET 400 MG (Felbamate) Tier 3 QL (9 EA per 1 day) FELBATOL ORAL TABLET 600 MG (Felbamate) Tier 3 QL (6 EA per 1 day)

MedPerform Medium Formulary 01/01/2021

49 Drug Status Notes XCOPRI (250 MG DAILY DOSE) ORAL Tier 2 ST: Requires prior TABLET THERAPY PACK 50 & 200 MG prescription for Carbamazepine, Divalproex Sodium, Gabapentin, Lamotrigine, Levetiracetam, Oxcarbazepine, Topiramate, Valproic Acid, or Zonisamide within the past 120 days; QL (1 EA per 1 day) XCOPRI (350 MG DAILY DOSE) ORAL Tier 2 ST: Requires prior TABLET THERAPY PACK 150 & 200 prescription for MG Carbamazepine, Divalproex Sodium, Gabapentin, Lamotrigine, Levetiracetam, Oxcarbazepine, Topiramate, Valproic Acid, or Zonisamide within the past 120 days; QL (1 EA per 1 day) XCOPRI ORAL TABLET 100 MG, 150 Tier 2 ST: Requires prior MG, 50 MG prescription for Carbamazepine, Divalproex Sodium, Gabapentin, Lamotrigine, Levetiracetam, Oxcarbazepine, Topiramate, Valproic Acid, or Zonisamide within the past 120 days; QL (1 EA per 1 day)

MedPerform Medium Formulary 01/01/2021

50 Drug Status Notes XCOPRI ORAL TABLET 200 MG Tier 2 ST: Requires prior prescription for Carbamazepine, Divalproex Sodium, Gabapentin, Lamotrigine, Levetiracetam, Oxcarbazepine, Topiramate, Valproic Acid, or Zonisamide within the past 120 days; QL (2 EA per 1 day) XCOPRI ORAL TABLET THERAPY Tier 2 ST: Requires prior PACK 14 X 12.5 MG & 14 X 25 MG, 14 prescription for X 150 MG & 14 X200 MG, 14 X 50 MG & Carbamazepine, 14 X100 MG Divalproex Sodium, Gabapentin, Lamotrigine, Levetiracetam, Oxcarbazepine, Topiramate, Valproic Acid, or Zonisamide within the past 120 days; QL (1 EA per 1 day) Gaba Modulators GABITRIL ORAL TABLET 12 MG, 2 MG, (TiaGABine HCl) Tier 3 QL (4 EA per 1 day) 4 MG GABITRIL ORAL TABLET 16 MG (TiaGABine HCl) Tier 3 QL (3 EA per 1 day) tiagabine hcl oral tablet 12 mg, 2 mg, 4 (Gabitril) Tier 1 QL (4 EA per 1 day) mg tiagabine hcl oral tablet 16 mg (Gabitril) Tier 1 QL (3 EA per 1 day) vigabatrin oral packet 500 mg (Vigadrone) Tier 1 SP; QL (6 EA per 1 day) vigabatrin oral tablet 500 mg (Sabril) Tier 1 SP; QL (6 EA per 1 day) VIGADRONE ORAL PACKET 500 MG (Vigabatrin) Tier 1 SP; QL (6 EA per 1 day) Hydantoins DILANTIN INFATABS ORAL TABLET (Phenytoin) Tier 3 CHEWABLE 50 MG DILANTIN ORAL CAPSULE 100 MG (Phenytoin Sodium Tier 3 Extended)

MedPerform Medium Formulary 01/01/2021

51 Drug Status Notes DILANTIN ORAL CAPSULE 30 MG Tier 2 DILANTIN ORAL SUSPENSION 125 (Phenytoin) Tier 3 MG/5ML PEGANONE ORAL TABLET 250 MG Tier 3 PHENYTEK ORAL CAPSULE 200 MG, (Phenytoin Sodium Tier 3 300 MG Extended) PHENYTOIN INFATABS ORAL TABLET (Phenytoin) Tier 1 CHEWABLE 50 MG phenytoin oral suspension 100 mg/4ml, (Dilantin) Tier 1 125 mg/5ml phenytoin oral tablet chewable 50 mg (Phenytoin Infatabs) Tier 1 phenytoin sodium extended oral capsule (Dilantin) Tier 1 100 mg phenytoin sodium extended oral capsule (Phenytek) Tier 1 200 mg, 300 mg Succinimides CELONTIN ORAL CAPSULE 300 MG Tier 3 ethosuximide oral capsule 250 mg (Zarontin) Tier 1 ethosuximide oral solution 250 mg/5ml (Zarontin) Tier 1 ZARONTIN ORAL CAPSULE 250 MG (Ethosuximide) Tier 3 ZARONTIN ORAL SOLUTION 250 (Ethosuximide) Tier 3 MG/5ML Valproic Acid DEPAKOTE ER ORAL TABLET (Divalproex Sodium ER) Tier 3 EXTENDED RELEASE 24 HOUR 250 MG, 500 MG DEPAKOTE ORAL TABLET DELAYED (Divalproex Sodium) Tier 3 RELEASE 125 MG, 250 MG, 500 MG DEPAKOTE SPRINKLES ORAL (Divalproex Sodium) Tier 3 CAPSULE DELAYED RELEASE SPRINKLE 125 MG divalproex sodium er oral tablet (Depakote ER) Tier 1 extended release 24 hour 250 mg, 500 mg divalproex sodium oral capsule delayed (Depakote Sprinkles) Tier 1 release sprinkle 125 mg

MedPerform Medium Formulary 01/01/2021

52 Drug Status Notes divalproex sodium oral tablet delayed (Depakote) Tier 1 release 125 mg, 250 mg, 500 mg valproic acid oral capsule 250 mg Tier 1 valproic acid oral solution 250 mg/5ml Tier 1 Antidepressants Alpha-2 Receptor Antagonists (Tetracyclics) mirtazapine oral tablet 15 mg, 30 mg (Remeron) Tier 1 mirtazapine oral tablet 45 mg, 7.5 mg Tier 1 mirtazapine oral tablet dispersible 15 (Remeron SolTab) Tier 1 mg, 30 mg, 45 mg Antidepressants - Misc. bupropion hcl er (sr) oral tablet extended (Wellbutrin SR) Tier 1 release 12 hour 100 mg, 200 mg bupropion hcl er (sr) oral tablet extended (Wellbutrin SR) Tier 1 QL (2 EA per 1 day); AGE release 12 hour 150 mg (Min 18 Years) bupropion hcl er (xl) oral tablet extended (Wellbutrin XL) Tier 1 release 24 hour 150 mg, 300 mg bupropion hcl oral tablet 100 mg, 75 mg Tier 1 maprotiline hcl oral tablet 25 mg, 50 mg, Tier 1 75 mg Monoamine Oxidase Inhibitors (Maois) EMSAM TRANSDERMAL PATCH 24 Tier 3 QL (1 EA per 1 day) HOUR 12 MG/24HR, 6 MG/24HR, 9 MG/24HR MARPLAN ORAL TABLET 10 MG Tier 3 phenelzine sulfate oral tablet 15 mg (Nardil) Tier 1 tranylcypromine sulfate oral tablet 10 mg (Parnate) Tier 1 N-Methyl-D-Aspartic Acid (Nmda) Receptor Antagonists SPRAVATO (56 MG DOSE) NASAL Tier 3 PA; SP SOLUTION THERAPY PACK 28 MG/DEVICE SPRAVATO (84 MG DOSE) NASAL Tier 3 PA; SP SOLUTION THERAPY PACK 28 MG/DEVICE

MedPerform Medium Formulary 01/01/2021

53 Drug Status Notes Selective Serotonin Reuptake Inhibitors (Ssris) citalopram hydrobromide oral solution 10 Tier 1 mg/5ml citalopram hydrobromide oral tablet 10 (CeleXA) Tier 1 mg, 20 mg, 40 mg escitalopram oxalate oral solution 5 Tier 1 mg/5ml escitalopram oxalate oral tablet 10 mg, (Lexapro) Tier 1 20 mg, 5 mg fluoxetine hcl oral capsule 10 mg, 20 mg, (PROzac) Tier 1 40 mg fluoxetine hcl oral capsule delayed Tier 1 release 90 mg fluoxetine hcl oral solution 20 mg/5ml Tier 1 fluoxetine hcl oral tablet 10 mg, 20 mg, Tier 1 60 mg fluvoxamine maleate er oral capsule Tier 1 QL (2 EA per 1 day) extended release 24 hour 100 mg, 150 mg fluvoxamine maleate oral tablet 100 mg, Tier 1 25 mg, 50 mg paroxetine hcl er oral tablet extended (Paxil CR) Tier 1 release 24 hour 12.5 mg, 25 mg, 37.5 mg paroxetine hcl oral tablet 10 mg, 20 mg, (Paxil) Tier 1 30 mg, 40 mg PAXIL ORAL SUSPENSION 10 MG/5ML Tier 2 sertraline hcl oral concentrate 20 mg/ml (Zoloft) Tier 1 sertraline hcl oral tablet 100 mg, 25 mg, (Zoloft) Tier 1 50 mg Serotonin Modulators nefazodone hcl oral tablet 100 mg, 150 Tier 1 mg, 200 mg, 250 mg, 50 mg trazodone hcl oral tablet 100 mg, 150 Tier 1 mg, 300 mg, 50 mg

MedPerform Medium Formulary 01/01/2021

54 Drug Status Notes TRINTELLIX ORAL TABLET 10 MG, 20 Tier 2 QL (1 EA per 1 day) MG, 5 MG VIIBRYD ORAL TABLET 10 MG, 20 MG, Tier 2 QL (1 EA per 1 day) 40 MG VIIBRYD STARTER PACK ORAL KIT 10 Tier 2 QL (1 EA per 1 day) & 20 MG Serotonin-Norepinephrine Reuptake Inhibitors (Snris) desvenlafaxine succinate er oral tablet (Pristiq) Tier 1 extended release 24 hour 100 mg, 25 mg, 50 mg DRIZALMA SPRINKLE ORAL Tier 3 QL (6 EA per 1 day) CAPSULE DELAYED RELEASE SPRINKLE 20 MG DRIZALMA SPRINKLE ORAL Tier 3 QL (4 EA per 1 day) CAPSULE DELAYED RELEASE SPRINKLE 30 MG DRIZALMA SPRINKLE ORAL Tier 3 QL (3 EA per 1 day) CAPSULE DELAYED RELEASE SPRINKLE 40 MG DRIZALMA SPRINKLE ORAL Tier 3 QL (2 EA per 1 day) CAPSULE DELAYED RELEASE SPRINKLE 60 MG duloxetine hcl oral capsule delayed (Cymbalta) Tier 1 release particles 20 mg, 30 mg, 60 mg

MedPerform Medium Formulary 01/01/2021

55 Drug Status Notes FETZIMA ORAL CAPSULE EXTENDED Tier 2 ST: At least 2 prior RELEASE 24 HOUR 120 MG, 20 MG, prescriptions for Bupropion 40 MG, 80 MG HCL (smoking Deterrent), Bupropion HCL, Citalopram Hydrobromide, Escitalopram Oxalate, Fluoxetine HCL, Fluoxetine HCL, Mirtazapine, Paroxetine HCL, Paroxetine Mesylate (vasomotor), or Venlafaxine HCL within the past 365 days; QL (1 EA per 1 day) FETZIMA TITRATION ORAL CAPSULE Tier 2 ST: At least 2 prior ER 24 HOUR THERAPY PACK 20 & 40 prescriptions for Bupropion MG HCL (smoking Deterrent), Bupropion HCL, Citalopram Hydrobromide, Escitalopram Oxalate, Fluoxetine HCL, Fluoxetine HCL, Mirtazapine, Paroxetine HCL, Paroxetine Mesylate (vasomotor), or Venlafaxine HCL within the past 365 days; QL (1 EA per 1 day) venlafaxine hcl er oral capsule extended (Effexor XR) Tier 1 release 24 hour 150 mg, 37.5 mg, 75 mg venlafaxine hcl er oral tablet extended Tier 1 release 24 hour 150 mg, 225 mg, 37.5 mg, 75 mg venlafaxine hcl oral tablet 100 mg, 25 Tier 1 mg, 37.5 mg, 50 mg, 75 mg Tricyclic Agents amitriptyline hcl oral tablet 10 mg, 100 Tier 1 mg, 150 mg, 25 mg, 50 mg, 75 mg

MedPerform Medium Formulary 01/01/2021

56 Drug Status Notes amoxapine oral tablet 100 mg, 150 mg, Tier 1 25 mg, 50 mg clomipramine hcl oral capsule 25 mg, 50 (Anafranil) Tier 1 mg, 75 mg desipramine hcl oral tablet 10 mg, 25 mg (Norpramin) Tier 1 desipramine hcl oral tablet 100 mg, 150 Tier 1 mg, 50 mg, 75 mg doxepin hcl oral capsule 10 mg, 100 mg, Tier 1 150 mg, 25 mg, 50 mg, 75 mg doxepin hcl oral concentrate 10 mg/ml Tier 1 imipramine hcl oral tablet 10 mg, 25 mg, Tier 1 50 mg imipramine pamoate oral capsule 100 Tier 1 mg, 125 mg, 150 mg, 75 mg nortriptyline hcl oral capsule 10 mg, 25 (Pamelor) Tier 1 mg, 50 mg, 75 mg nortriptyline hcl oral solution 10 mg/5ml Tier 1 protriptyline hcl oral tablet 10 mg, 5 mg Tier 1 trimipramine maleate oral capsule 100 Tier 1 mg, 25 mg, 50 mg Antidiabetics Alpha-Glucosidase Inhibitors acarbose oral tablet 100 mg, 25 mg, 50 (Precose) Tier 1 mg miglitol oral tablet 100 mg, 25 mg, 50 mg (Glyset) Tier 1 Antidiabetic - Amylin Analogs SYMLINPEN 120 SUBCUTANEOUS Tier 2 SOLUTION PEN-INJECTOR 2700 MCG/2.7ML SYMLINPEN 60 SUBCUTANEOUS Tier 2 SOLUTION PEN-INJECTOR 1500 MCG/1.5ML Antidiabetic Combinations glipizide-metformin hcl oral tablet 2.5- Tier 1 250 mg, 2.5-500 mg, 5-500 mg

MedPerform Medium Formulary 01/01/2021

57 Drug Status Notes glyburide-metformin oral tablet 1.25-250 Tier 1 mg, 2.5-500 mg, 5-500 mg GLYXAMBI ORAL TABLET 10-5 MG, Tier 3 ST: Requires prior 25-5 MG prescription for Dapagliflozin Propanediol, Dapagliflozin-Metformin HCL, Empagliflozin, Empagliflozin-Metformin HCL, Sitagliptin Phosphate, or Sitagliptin-Metformin HCL within the past 120 days; QL (1 EA per 1 day) JANUMET ORAL TABLET 50-1000 MG, Tier 2 QL (2 EA per 1 day) 50-500 MG JANUMET XR ORAL TABLET Tier 2 QL (1 EA per 1 day) EXTENDED RELEASE 24 HOUR 100- 1000 MG JANUMET XR ORAL TABLET Tier 2 QL (2 EA per 1 day) EXTENDED RELEASE 24 HOUR 50- 1000 MG, 50-500 MG JENTADUETO ORAL TABLET 2.5-1000 Tier 3 ST: Requires prior MG, 2.5-500 MG, 2.5-850 MG prescription for Sitagliptin Phosphate or Sitagliptin- Metformin HCL within the past 120 days; QL (2 EA per 1 day) JENTADUETO XR ORAL TABLET Tier 3 ST: Requires prior EXTENDED RELEASE 24 HOUR 2.5- prescription for Sitagliptin 1000 MG Phosphate or Sitagliptin- Metformin HCL within the past 120 days; QL (2 EA per 1 day)

MedPerform Medium Formulary 01/01/2021

58 Drug Status Notes JENTADUETO XR ORAL TABLET Tier 3 ST: Requires prior EXTENDED RELEASE 24 HOUR 5- prescription for Sitagliptin 1000 MG Phosphate or Sitagliptin- Metformin HCL within the past 120 days; QL (1 EA per 1 day) pioglitazone hcl-glimepiride oral tablet (Duetact) Tier 1 ST: Requires prior 30-2 mg, 30-4 mg prescription for Metformin, preferred Sulfonylurea, or preferred Metformin/Sulfonylurea combination within the past 120 days pioglitazone hcl-metformin hcl oral tablet (Actoplus Met) Tier 1 ST: Requires prior 15-500 mg, 15-850 mg prescription for Metformin, preferred Sulfonylurea, or preferred Metformin/Sulfonylurea combination within the past 120 days SOLIQUA SUBCUTANEOUS Tier 2 ST: Requires prior SOLUTION PEN-INJECTOR 100-33 prescription for Dulaglutide, UNT-MCG/ML Exenatide, Insulin Degludec, Insulin Detemir, Insulin Glargine, Liraglutide, or Semaglutide within the past 120 days; QL (30 ML per 28 days) SYNJARDY ORAL TABLET 12.5-1000 Tier 2 QL (2 EA per 1 day) MG, 12.5-500 MG, 5-1000 MG, 5-500 MG SYNJARDY XR ORAL TABLET Tier 2 QL (1 EA per 1 day) EXTENDED RELEASE 24 HOUR 10- 1000 MG, 25-1000 MG SYNJARDY XR ORAL TABLET Tier 2 QL (2 EA per 1 day) EXTENDED RELEASE 24 HOUR 12.5- 1000 MG, 5-1000 MG

MedPerform Medium Formulary 01/01/2021

59 Drug Status Notes XIGDUO XR ORAL TABLET Tier 2 QL (1 EA per 1 day) EXTENDED RELEASE 24 HOUR 10- 1000 MG, 10-500 MG, 5-500 MG XIGDUO XR ORAL TABLET Tier 2 QL (2 EA per 1 day) EXTENDED RELEASE 24 HOUR 2.5- 1000 MG, 5-1000 MG XULTOPHY SUBCUTANEOUS Tier 2 ST: Requires prior SOLUTION PEN-INJECTOR 100-3.6 prescription for Dulaglutide, UNIT-MG/ML Exenatide, Insulin Degludec, Insulin Detemir, Insulin Glargine, Liraglutide, or Semaglutide within the past 120 days; QL (15 ML per 28 days) Biguanides metformin hcl er (osm) oral tablet (Fortamet) Tier 1 ST: Requires prior extended release 24 hour 1000 mg, 500 prescription for Metformin mg HCL within the past 120 days metformin hcl er oral tablet extended Tier 1 release 24 hour 500 mg, 750 mg metformin hcl oral solution 500 mg/5ml (Riomet) Tier 1 metformin hcl oral tablet 1000 mg, 500 Tier 1 mg, 850 mg RIOMET ER ORAL SUSPENSION Tier 3 ST: Requires prior RECONSTITUTED ER 500 MG/5ML prescription for immediate release Metformin (tablets/solution) or Metformin ER tablets within the past 120 days; QL (20 ML per 1 day) Diabetic Other BAQSIMI ONE PACK NASAL POWDER Tier 2 QL (4 EA per 1 FILL) 3 MG/DOSE BAQSIMI TWO PACK NASAL POWDER Tier 2 QL (4 EA per 1 FILL) 3 MG/DOSE diazoxide oral suspension 50 mg/ml (Proglycem) Tier 1

MedPerform Medium Formulary 01/01/2021

60 Drug Status Notes GLUCAGEN HYPOKIT INJECTION Tier 3 SOLUTION RECONSTITUTED 1 MG GVOKE HYPOPEN 1-PACK Tier 2 QL (0.4 ML per 1 FILL) SUBCUTANEOUS SOLUTION AUTO- INJECTOR 0.5 MG/0.1ML GVOKE HYPOPEN 1-PACK Tier 2 QL (0.8 ML per 1 FILL) SUBCUTANEOUS SOLUTION AUTO- INJECTOR 1 MG/0.2ML GVOKE HYPOPEN 2-PACK Tier 2 QL (0.4 ML per 1 FILL) SUBCUTANEOUS SOLUTION AUTO- INJECTOR 0.5 MG/0.1ML GVOKE HYPOPEN 2-PACK Tier 2 QL (0.8 ML per 1 FILL) SUBCUTANEOUS SOLUTION AUTO- INJECTOR 1 MG/0.2ML GVOKE PFS SUBCUTANEOUS Tier 2 QL (0.4 ML per 1 FILL) SOLUTION PREFILLED SYRINGE 0.5 MG/0.1ML GVOKE PFS SUBCUTANEOUS Tier 2 QL (0.8 ML per 1 FILL) SOLUTION PREFILLED SYRINGE 1 MG/0.2ML KORLYM ORAL TABLET 300 MG Tier 2 PA; SP Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors JANUVIA ORAL TABLET 100 MG, 25 Tier 2 QL (1 EA per 1 day) MG, 50 MG TRADJENTA ORAL TABLET 5 MG Tier 3 ST: Requires prior prescription for Sitagliptin Phosphate or Sitagliptin- Metformin HCL within the past 120 days; QL (1 EA per 1 day)

MedPerform Medium Formulary 01/01/2021

61 Drug Status Notes Dopamine Receptor Agonists - Antidiabetic CYCLOSET ORAL TABLET 0.8 MG Tier 3 ST: Requires prior prescription for Glipizide/metformin HCL, Glyburide/metformin HCL, or Metformin HCL within the past 120 days Incretin Mimetic Agents (Glp-1 Receptor Agonists) BYDUREON BCISE SUBCUTANEOUS Tier 2 QL (0.85 ML per 7 days) AUTO-INJECTOR 2 MG/0.85ML BYDUREON SUBCUTANEOUS PEN- Tier 2 QL (1 EA per 7 days) INJECTOR 2 MG BYETTA 10 MCG PEN Tier 2 QL (2.4 ML per 30 days) SUBCUTANEOUS SOLUTION PEN- INJECTOR 10 MCG/0.04ML BYETTA 5 MCG PEN Tier 2 QL (1.2 ML per 30 days) SUBCUTANEOUS SOLUTION PEN- INJECTOR 5 MCG/0.02ML OZEMPIC (0.25 OR 0.5 MG/DOSE) Tier 2 QL (3 ML per 28 days) SUBCUTANEOUS SOLUTION PEN- INJECTOR 2 MG/1.5ML OZEMPIC (1 MG/DOSE) Tier 2 QL (3 ML per 28 days) SUBCUTANEOUS SOLUTION PEN- INJECTOR 2 MG/1.5ML RYBELSUS ORAL TABLET 14 MG, 3 Tier 2 QL (1 EA per 1 day) MG, 7 MG TRULICITY SUBCUTANEOUS Tier 2 QL (2 ML per 28 days) SOLUTION PEN-INJECTOR 0.75 MG/0.5ML, 1.5 MG/0.5ML, 3 MG/0.5ML, 4.5 MG/0.5ML VICTOZA SUBCUTANEOUS Tier 2 QL (9 ML per 30 days) SOLUTION PEN-INJECTOR 18 MG/3ML

MedPerform Medium Formulary 01/01/2021

62 Drug Status Notes Insulin AFREZZA INHALATION POWDER 12 Tier 3 PA UNIT, 4 & 8 & 12 UNIT, 4 UNIT, 8 UNIT, 90 X 4 UNIT & 90X8 UNIT, 90 X 8 UNIT & 90X12 UNIT FIASP FLEXTOUCH SUBCUTANEOUS Tier 3 ST: Requires prior SOLUTION PEN-INJECTOR 100 prescription for Insulin UNIT/ML Lispro within the past 120 days; QL (30 ML per 28 days) FIASP PENFILL SUBCUTANEOUS Tier 3 ST: Requires prior SOLUTION CARTRIDGE 100 UNIT/ML prescription for Insulin Lispro within the past 120 days; QL (30 ML per 28 days) FIASP SUBCUTANEOUS SOLUTION Tier 3 ST: Requires prior 100 UNIT/ML prescription for Insulin Lispro within the past 120 days; QL (40 ML per 28 days) HUMALOG JUNIOR KWIKPEN (Insulin Lispro Junior Tier 2 QL (30 ML per 28 days) SUBCUTANEOUS SOLUTION PEN- KwikPen) INJECTOR 100 UNIT/ML HUMALOG KWIKPEN (Insulin Lispro (1 Unit Tier 1 QL (30 ML per 28 days) SUBCUTANEOUS SOLUTION PEN- Dial)) INJECTOR 100 UNIT/ML HUMALOG KWIKPEN Tier 2 QL (12 ML per 28 days) SUBCUTANEOUS SOLUTION PEN- INJECTOR 200 UNIT/ML HUMALOG MIX 50/50 KWIKPEN Tier 2 QL (30 ML per 28 days) SUBCUTANEOUS SUSPENSION PEN- INJECTOR (50-50) 100 UNIT/ML HUMALOG MIX 50/50 Tier 2 QL (40 ML per 28 days) SUBCUTANEOUS SUSPENSION (50- 50) 100 UNIT/ML

MedPerform Medium Formulary 01/01/2021

63 Drug Status Notes HUMALOG MIX 75/25 KWIKPEN (Insulin Lispro Prot & Tier 2 QL (30 ML per 28 days) SUBCUTANEOUS SUSPENSION PEN- Lispro) INJECTOR (75-25) 100 UNIT/ML HUMALOG MIX 75/25 Tier 2 QL (40 ML per 28 days) SUBCUTANEOUS SUSPENSION (75- 25) 100 UNIT/ML HUMALOG SUBCUTANEOUS (Insulin Lispro) Tier 1 QL (40 ML per 28 days) SOLUTION 100 UNIT/ML HUMALOG SUBCUTANEOUS Tier 2 QL (30 ML per 28 days) SOLUTION CARTRIDGE 100 UNIT/ML HUMULIN 70/30 KWIKPEN Tier 2 QL (30 ML per 28 days) SUBCUTANEOUS SUSPENSION PEN- INJECTOR (70-30) 100 UNIT/ML HUMULIN 70/30 SUBCUTANEOUS Tier 2 QL (40 ML per 28 days) SUSPENSION (70-30) 100 UNIT/ML HUMULIN N KWIKPEN Tier 2 QL (30 ML per 28 days) SUBCUTANEOUS SUSPENSION PEN- INJECTOR 100 UNIT/ML HUMULIN N SUBCUTANEOUS Tier 2 QL (40 ML per 28 days) SUSPENSION 100 UNIT/ML HUMULIN R INJECTION SOLUTION Tier 2 QL (40 ML per 28 days) 100 UNIT/ML HUMULIN R U-500 (CONCENTRATED) Tier 2 QL (40 ML per 28 days) SUBCUTANEOUS SOLUTION 500 UNIT/ML HUMULIN R U-500 KWIKPEN Tier 2 QL (24 ML per 28 days) SUBCUTANEOUS SOLUTION PEN- INJECTOR 500 UNIT/ML LANTUS SOLOSTAR Tier 2 QL (30 ML per 28 days) SUBCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML LANTUS SUBCUTANEOUS SOLUTION Tier 2 QL (40 ML per 28 days) 100 UNIT/ML LEVEMIR FLEXTOUCH Tier 2 QL (30 ML per 28 days) SUBCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML

MedPerform Medium Formulary 01/01/2021

64 Drug Status Notes LEVEMIR SUBCUTANEOUS Tier 2 QL (40 ML per 28 days) SOLUTION 100 UNIT/ML TOUJEO MAX SOLOSTAR Tier 2 QL (18 ML per 28 days) SUBCUTANEOUS SOLUTION PEN- INJECTOR 300 UNIT/ML TOUJEO SOLOSTAR Tier 2 QL (13.5 ML per 28 days) SUBCUTANEOUS SOLUTION PEN- INJECTOR 300 UNIT/ML TRESIBA FLEXTOUCH Tier 2 QL (30 ML per 28 days) SUBCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML TRESIBA FLEXTOUCH Tier 2 QL (18 ML per 28 days) SUBCUTANEOUS SOLUTION PEN- INJECTOR 200 UNIT/ML TRESIBA SUBCUTANEOUS Tier 2 QL (40 ML per 28 days) SOLUTION 100 UNIT/ML Insulin Sensitizing Agents AVANDIA ORAL TABLET 2 MG, 4 MG Tier 3 ST: Requires prior prescription for metformin (IR/ER), a sulfonylurea, pioglitazone or a combination product containing any two of the three previous agents within the previous 120 days pioglitazone hcl oral tablet 15 mg, 30 (Actos) Tier 1 mg, 45 mg Meglitinide Analogues nateglinide oral tablet 120 mg, 60 mg (Starlix) Tier 1 repaglinide oral tablet 0.5 mg, 1 mg, 2 Tier 1 mg Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors FARXIGA ORAL TABLET 10 MG, 5 MG Tier 2 QL (1 EA per 1 day) JARDIANCE ORAL TABLET 10 MG, 25 Tier 2 QL (1 EA per 1 day) MG

MedPerform Medium Formulary 01/01/2021

65 Drug Status Notes Sulfonylureas glimepiride oral tablet 1 mg, 2 mg, 4 mg (Amaryl) Tier 1 glipizide er oral tablet extended release (Glucotrol XL) Tier 1 24 hour 10 mg, 2.5 mg, 5 mg glipizide oral tablet 10 mg, 5 mg (Glucotrol) Tier 1 glipizide xl oral tablet extended release (Glucotrol XL) Tier 1 24 hour 10 mg, 2.5 mg, 5 mg glyburide micronized oral tablet 1.5 mg, (Glynase) Tier 1 3 mg, 6 mg glyburide oral tablet 1.25 mg, 2.5 mg, 5 Tier 1 mg tolbutamide oral tablet 500 mg Tier 1 Antidiarrheal/Probiotic Agents Antidiarrheal - Chloride Channel Antagonists MYTESI ORAL TABLET DELAYED Tier 3 ST: Requires prior RELEASE 125 MG prescription for Antiretrovirals within the past 120 days; QL (2 EA per 1 day) Antidiarrheal/Probiotic Agents - Misc. lactojen oral capsule (Abatinex) Tier 1 prodigen oral capsule (Acidophilus High-Potency) Tier 3 promella in prebiotic oral capsule (Acidophilus High-Potency) Tier 3 provad oral capsule (Acidophilus High-Potency) Tier 3 VISBIOME ORAL PACKET (Probiotic) Tier 3 VSL#3 DS ORAL PACKET (Probiotic) Tier 3 zelac oral capsule (Acidophilus High-Potency) Tier 3 Antidiarrheal/Probiotic Combinations probichew oral tablet chewable (Align Prebiotic-Probiotic) Tier 3 RESTORA RX ORAL CAPSULE 60-1.25 Tier 3 MG Antiperistaltic Agents diphenoxylate-atropine oral liquid 2.5- Tier 1 0.025 mg/5ml

MedPerform Medium Formulary 01/01/2021

66 Drug Status Notes diphenoxylate-atropine oral tablet 2.5- (Lomotil) Tier 1 0.025 mg loperamide hcl oral capsule 2 mg (Imodium A-D) Tier 1 opium oral tincture 10 mg/ml (1%) Tier 1 Antidotes And Specific Antagonists Antidote Combinations DUODOTE INTRAMUSCULAR Tier 3 SOLUTION AUTO-INJECTOR 2.1-600 MG Antidotes - Chelating Agents CHEMET ORAL CAPSULE 100 MG Tier 3 deferasirox granules oral packet 180 mg, (Jadenu Sprinkle) Tier 1 PA; SP 360 mg, 90 mg deferasirox oral tablet 180 mg, 360 mg, (Jadenu) Tier 1 PA; SP 90 mg deferasirox oral tablet soluble 125 mg, (Exjade) Tier 1 PA; SP 250 mg, 500 mg deferiprone oral tablet 500 mg (Ferriprox) Tier 1 PA; SP FERRIPROX ORAL SOLUTION 100 Tier 3 PA; SP MG/ML FERRIPROX ORAL TABLET 1000 MG Tier 3 PA; SP FERRIPROX TWICE-A-DAY ORAL Tier 3 PA; SP TABLET 1000 MG Antidotes And Specific Antagonists deferoxamine mesylate injection solution Tier 1 PA reconstituted 2 gm deferoxamine mesylate injection solution (Desferal) Tier 1 PA reconstituted 500 mg RADIOGARDASE ORAL CAPSULE 0.5 Tier 3 GM VISTOGARD ORAL PACKET 10 GM Tier 2 SP; QL (24 EA per 14 days) Opioid Antagonists naloxone hcl injection solution cartridge Tier 1 0.4 mg/ml

MedPerform Medium Formulary 01/01/2021

67 Drug Status Notes naloxone hcl injection solution prefilled Tier 1 syringe 2 mg/2ml naltrexone hcl oral tablet 50 mg Tier 1 NARCAN NASAL LIQUID 4 MG/0.1ML Tier 2 QL (4 EA per 30 days) Antiemetics 5-Ht3 Receptor Antagonists ANZEMET ORAL TABLET 100 MG Tier 3 ST: Requires prior prescription for Ondansetron (tablets, ODT) within the past 120 days; QL (4 EA per 1 FILL) ANZEMET ORAL TABLET 50 MG Tier 3 ST: Requires prior prescription for Ondansetron (tablets, ODT) within the past 120 days; QL (8 EA per 1 FILL) granisetron hcl oral tablet 1 mg Tier 1 ST: Requires prior prescription for Ondansetron (tablets, ODT) within the past 120 days; QL (8 EA per 30 days) ondansetron hcl oral solution 4 mg/5ml Tier 1 QL (50 ML per 15 days) ondansetron hcl oral tablet 24 mg, 8 mg Tier 1 ondansetron hcl oral tablet 4 mg (Zofran) Tier 1 ondansetron oral tablet dispersible 4 mg, Tier 1 8 mg SANCUSO TRANSDERMAL PATCH 3.1 Tier 3 ST: Requires prior MG/24HR prescription for Ondansetron (tablets, ODT) within the past 120 days; QL (1 EA per 7 days) Antiemetics - Anticholinergic meclizine hcl oral tablet 12.5 mg Tier 1 meclizine hcl oral tablet 25 mg (Dramamine Less Drowsy) Tier 1 meclizine hcl oral tablet chewable 25 mg (Bonine) Tier 1

MedPerform Medium Formulary 01/01/2021

68 Drug Status Notes scopolamine transdermal patch 72 hour (Transderm Scop (1.5 Tier 1 1 mg/3days MG)) trimethobenzamide hcl oral capsule 300 (Tigan) Tier 1 mg Antiemetics - Miscellaneous AKYNZEO ORAL CAPSULE 300-0.5 Tier 2 QL (1 EA per 28 days) MG doxylamine-pyridoxine oral tablet (Diclegis) Tier 1 QL (4 EA per 1 day) delayed release 10-10 mg dronabinol oral capsule 10 mg, 2.5 mg, 5 (Marinol) Tier 1 ST: Requires prior mg prescription for a 5HT3 antagoist, corticosteroid, Emend, or Megestrol suspension within the past 120 days; QL (2 EA per 1 day) SYNDROS ORAL SOLUTION 5 MG/ML Tier 3 ST: Requires prior prescription for Dronabinol capsules or Megestrol Acetate suspension within the past 120 days; QL (2 ML per 1 day) Substance P/Neurokinin 1 (Nk1) Receptor Antagonists aprepitant oral capsule 125 mg Tier 1 QL (1 EA per 21 days) aprepitant oral capsule 40 mg (Emend) Tier 1 QL (1 EA per 28 days) aprepitant oral capsule 80 & 125 mg (Emend Tri-Pack) Tier 1 QL (3 EA per 21 days) aprepitant oral capsule 80 mg (Emend) Tier 1 QL (2 EA per 21 days) EMEND ORAL SUSPENSION Tier 2 QL (3 EA per 21 days) RECONSTITUTED 125 MG/5ML VARUBI (180 MG DOSE) ORAL Tier 3 QL (2 EA per 14 days) TABLET THERAPY PACK 2 X 90 MG Antifungals Antifungals bio-statin oral capsule 1000000 unit, Tier 3 500000 unit

MedPerform Medium Formulary 01/01/2021

69 Drug Status Notes bio-statin oral powder Tier 1 flucytosine oral capsule 250 mg, 500 mg (Ancobon) Tier 1 griseofulvin microsize oral suspension Tier 1 125 mg/5ml griseofulvin microsize oral tablet 500 mg Tier 1 griseofulvin ultramicrosize oral tablet 125 Tier 1 mg, 250 mg nystatin oral tablet 500000 unit Tier 1 terbinafine hcl oral tablet 250 mg (LamISIL) Tier 1 Imidazole-Related Antifungals CRESEMBA ORAL CAPSULE 186 MG Tier 3 fluconazole oral suspension (Diflucan) Tier 1 reconstituted 10 mg/ml, 40 mg/ml fluconazole oral tablet 100 mg, 150 mg, (Diflucan) Tier 1 200 mg, 50 mg itraconazole oral capsule 100 mg (Sporanox) Tier 1 itraconazole oral solution 10 mg/ml (Sporanox) Tier 1 ketoconazole oral tablet 200 mg Tier 1 NOXAFIL ORAL SUSPENSION 40 Tier 3 MG/ML posaconazole oral tablet delayed release (Noxafil) Tier 1 100 mg tolsura oral capsule 65 mg Tier 3 PA voriconazole oral suspension (Vfend) Tier 1 reconstituted 40 mg/ml voriconazole oral tablet 200 mg, 50 mg (Vfend) Tier 1 Antihistamines Antihistamines - Ethanolamines carbinoxamine maleate oral solution 4 Tier 1 AGE (Min 1 Years) mg/5ml carbinoxamine maleate oral tablet 4 mg Tier 1 AGE (Min 1 Years) clemastine fumarate oral tablet 2.68 mg Tier 1 DICOPANOL FUSEPAQ ORAL Tier 3 SUSPENSION RECONSTITUTED 5 MG/ML

MedPerform Medium Formulary 01/01/2021

70 Drug Status Notes DICOPANOL RAPIDPAQ ORAL Tier 3 SUSPENSION RECONSTITUTED 5 MG/ML diphen oral elixir 12.5 mg/5ml Tier 1 di-phen oral liquid 12.5 mg/5ml (Banophen) Tier 1 diphenhydramine hcl oral elixir 12.5 Tier 1 mg/5ml KARBINAL ER ORAL SUSPENSION Tier 3 ST: Requires prior EXTENDED RELEASE 4 MG/5ML prescription for Carbinoxamine Maleate within the past 120 days; QL (960 ML per 30 days); AGE (Min 1 Years) Antihistamines - Non-Sedating cetirizine hcl oral solution 1 mg/ml, 5 (KLS Aller-Tec Childrens) Tier 1 mg/5ml desloratadine oral tablet 5 mg (Clarinex) Tier 1 QL (1 EA per 1 day) desloratadine oral tablet dispersible 2.5 Tier 1 ST: Requires prior mg, 5 mg prescription for Desloratadine or Levocetirizine tablets within the past 120 days; QL (1 EA per 1 day) levocetirizine dihydrochloride oral (Xyzal Allergy 24HR Tier 1 ST: Requires prior solution 2.5 mg/5ml Childrens) prescription for Desloratadine or Levocetirizine tablets within the past 120 days; QL (10 ML per 1 day) levocetirizine dihydrochloride oral tablet (Xyzal Allergy 24HR) Tier 1 5 mg Antihistamines - Phenothiazines promethazine hcl injection solution 25 (Phenergan) Tier 1 mg/ml, 50 mg/ml promethazine hcl oral solution 6.25 Tier 1 mg/5ml

MedPerform Medium Formulary 01/01/2021

71 Drug Status Notes promethazine hcl oral syrup 6.25 mg/5ml Tier 1 promethazine hcl oral tablet 12.5 mg, 25 Tier 1 mg, 50 mg promethazine hcl rectal suppository 12.5 (Promethegan) Tier 1 mg, 25 mg PROMETHEGAN RECTAL (Promethazine HCl) Tier 1 SUPPOSITORY 12.5 MG, 25 MG PROMETHEGAN RECTAL Tier 3 SUPPOSITORY 50 MG Antihistamines - Piperidines cyproheptadine hcl oral syrup 2 mg/5ml Tier 1 cyproheptadine hcl oral tablet 4 mg Tier 1 Antihyperlipidemics Antihyperlipidemics - Combinations ezetimibe-simvastatin oral tablet 10-10 (Vytorin) Tier 1 QL (1 EA per 1 day) mg, 10-20 mg, 10-40 mg, 10-80 mg NEXLIZET ORAL TABLET 180-10 MG Tier 2 ST: Requires prior prescription for a generic statin within the past 120 days omega-3 rx complete oral therapy pack 1 Tier 3 gm OMEGA-3/D-3 WELLNESS PACK (Sure Result O3D3 Tier 3 ORAL KIT 1 & 1000 GM & UNIT System) sure result o3d3 system oral kit 1 & 1000 (Omega-3/D-3 Wellness Tier 3 gm & unit Pack) Antihyperlipidemics - Misc. omega-3-acid ethyl esters oral capsule 1 (Lovaza) Tier 1 QL (4 EA per 1 day) gm VASCEPA ORAL CAPSULE 0.5 GM Tier 2 QL (8 EA per 1 day) VASCEPA ORAL CAPSULE 1 GM (Icosapent Ethyl) Tier 2 QL (4 EA per 1 day) Bile Acid Sequestrants cholestyramine light oral packet 4 gm (Prevalite) Tier 1 cholestyramine light oral powder 4 (Prevalite) Tier 1 gm/dose cholestyramine oral packet 4 gm (Questran) Tier 1

MedPerform Medium Formulary 01/01/2021

72 Drug Status Notes cholestyramine oral powder 4 gm/dose (Questran) Tier 1 colesevelam hcl oral packet 3.75 gm (Welchol) Tier 1 colesevelam hcl oral tablet 625 mg (Welchol) Tier 1 colestipol hcl oral granules 5 gm (Colestid) Tier 1 colestipol hcl oral packet 5 gm (Colestid) Tier 1 colestipol hcl oral tablet 1 gm (Colestid) Tier 1 PREVALITE ORAL PACKET 4 GM (Cholestyramine Light) Tier 1 PREVALITE ORAL POWDER 4 (Cholestyramine Light) Tier 1 GM/DOSE Fibric Acid Derivatives fenofibrate micronized oral capsule 134 Tier 1 mg, 200 mg, 67 mg fenofibrate oral capsule 134 mg, 200 mg, Tier 1 67 mg fenofibrate oral capsule 150 mg, 50 mg (Lipofen) Tier 1 fenofibrate oral tablet 120 mg, 40 mg (Fenoglide) Tier 1 fenofibrate oral tablet 145 mg, 48 mg (Tricor) Tier 1 fenofibrate oral tablet 160 mg, 54 mg Tier 1 fenofibric acid oral capsule delayed (Trilipix) Tier 1 release 135 mg, 45 mg fenofibric acid oral tablet 105 mg (Fibricor) Tier 1 FIBRICOR ORAL TABLET 105 MG, 35 (Fenofibric Acid) Tier 3 MG gemfibrozil oral tablet 600 mg (Lopid) Tier 1 LIPOFEN ORAL CAPSULE 150 MG, 50 (Fenofibrate) Tier 3 ST: Requires prior MG prescription for Fenofibrate Micronized, Fenofibrate, or Gemfibrozil within the past 120 days

MedPerform Medium Formulary 01/01/2021

73 Drug Status Notes Hmg Coa Reductase Inhibitors ALTOPREV ORAL TABLET EXTENDED Tier 3 ST: At least 2 prior RELEASE 24 HOUR 20 MG, 40 MG, 60 prescriptions for MG Atorvastatin Calcium, Lovastatin, Pravastatin Sodium, or Simvastatin within the past 365 days; QL (1 EA per 1 day) atorvastatin calcium oral tablet 10 mg, (Lipitor) Tier 1 $0 COPAY IF AGE 40-75 20 mg YEARS AND NO HISTORY OF CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS; QL (1 EA per 1 day) atorvastatin calcium oral tablet 40 mg, (Lipitor) Tier 1 QL (1 EA per 1 day) 80 mg equapax/atorvastatin/coq10 oral therapy Tier 3 pack 20 & 100 mg EZALLOR SPRINKLE ORAL CAPSULE Tier 3 QL (1 EA per 1 day) SPRINKLE 10 MG, 20 MG, 40 MG, 5 MG flolipid oral suspension 20 mg/5ml, 40 Tier 3 PA mg/5ml fluvastatin sodium er oral tablet (Lescol XL) Tier 1 $0 COPAY IF AGE 40-75 extended release 24 hour 80 mg YEARS AND NO HISTORY OF CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS; ST: At least 2 prior prescriptions for Atorvastatin Calcium, Lovastatin, Pravastatin Sodium, or Simvastatin within the past 365 days; QL (1 EA per 1 day)

MedPerform Medium Formulary 01/01/2021

74 Drug Status Notes fluvastatin sodium oral capsule 20 mg, Tier 1 $0 COPAY IF AGE 40-75 40 mg YEARS AND NO HISTORY OF CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS; ST: At least 2 prior prescriptions for Atorvastatin Calcium, Lovastatin, Pravastatin Sodium, or Simvastatin within the past 365 days; QL (2 EA per 1 day) LIVALO ORAL TABLET 1 MG, 2 MG, 4 Tier 2 QL (1 EA per 1 day) MG lovastatin oral tablet 10 mg, 20 mg, 40 Tier 1 $0 COPAY IF AGE 40-75 mg YEARS AND NO HISTORY OF CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS; QL (2 EA per 1 day) pravastatin sodium oral tablet 10 mg, 80 Tier 1 $0 COPAY IF AGE 40-75 mg YEARS AND NO HISTORY OF CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS; QL (1 EA per 1 day) pravastatin sodium oral tablet 20 mg, 40 (Pravachol) Tier 1 $0 COPAY IF AGE 40-75 mg YEARS AND NO HISTORY OF CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS; QL (1 EA per 1 day)

MedPerform Medium Formulary 01/01/2021

75 Drug Status Notes rosuvastatin calcium oral tablet 10 mg, 5 (Crestor) Tier 1 $0 COPAY IF AGE 40-75 mg YEARS AND NO HISTORY OF CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS; QL (1 EA per 1 day) rosuvastatin calcium oral tablet 20 mg, (Crestor) Tier 1 QL (1 EA per 1 day) 40 mg simvastatin oral tablet 10 mg, 20 mg, 40 (Zocor) Tier 1 $0 COPAY IF AGE 40-75 mg YEARS AND NO HISTORY OF CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS; QL (1 EA per 1 day) simvastatin oral tablet 5 mg Tier 1 $0 COPAY IF AGE 40-75 YEARS AND NO HISTORY OF CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS; QL (1 EA per 1 day) simvastatin oral tablet 80 mg (Zocor) Tier 1 QL (1 EA per 1 day) ZYPITAMAG ORAL TABLET 2 MG, 4 Tier 3 ST: Requires prior MG prescription for Pitavastatin Calcium within the past 120 days; QL (1 EA per 1 day) Intestinal Cholesterol Absorption Inhibitors ezetimibe oral tablet 10 mg (Zetia) Tier 1 QL (1 EA per 1 day) Microsomal Triglyceride Transfer Protein (Mtp) Inhibitors JUXTAPID ORAL CAPSULE 10 MG, 20 Tier 2 PA; SP MG, 30 MG, 5 MG Nicotinic Acid Derivatives niacin er (antihyperlipidemic) oral tablet (Niaspan) Tier 1 extended release 1000 mg, 500 mg, 750 mg

MedPerform Medium Formulary 01/01/2021

76 Drug Status Notes NIACOR ORAL TABLET 500 MG (Niacin Tier 3 (Antihyperlipidemic)) Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitors PRALUENT SUBCUTANEOUS Tier 2 ST: Requires prior SOLUTION AUTO-INJECTOR 150 prescription for a generic MG/ML, 75 MG/ML statin within the past 120 days REPATHA PUSHTRONEX SYSTEM Tier 2 ST: Requires prior SUBCUTANEOUS SOLUTION prescription for a generic CARTRIDGE 420 MG/3.5ML statin within the past 120 days REPATHA SUBCUTANEOUS Tier 2 ST: Requires prior SOLUTION PREFILLED SYRINGE 140 prescription for a generic MG/ML statin within the past 120 days REPATHA SURECLICK Tier 2 ST: Requires prior SUBCUTANEOUS SOLUTION AUTO- prescription for a generic INJECTOR 140 MG/ML statin within the past 120 days Unknown NEXLETOL ORAL TABLET 180 MG Tier 2 ST: Requires prior prescription for a generic statin within the past 120 days Antihypertensives Ace Inhibitors benazepril hcl oral tablet 10 mg, 20 mg, (Lotensin) Tier 1 40 mg benazepril hcl oral tablet 5 mg Tier 1 captopril oral tablet 100 mg, 12.5 mg, 25 Tier 1 mg, 50 mg enalapril maleate oral tablet 10 mg, 2.5 (Vasotec) Tier 1 mg, 20 mg, 5 mg

MedPerform Medium Formulary 01/01/2021

77 Drug Status Notes EPANED ORAL SOLUTION 1 MG/ML Tier 3 ST: Requires prior prescription for Enalapril tablets within the past 120 days if 12 years of age and older; QL (1200 ML per 30 days) fosinopril sodium oral tablet 10 mg, 20 Tier 1 mg, 40 mg lisinopril oral tablet 10 mg, 20 mg (Prinivil) Tier 1 lisinopril oral tablet 2.5 mg, 30 mg, 40 (Zestril) Tier 1 mg, 5 mg moexipril hcl oral tablet 15 mg, 7.5 mg Tier 1 perindopril erbumine oral tablet 2 mg, 4 Tier 1 mg, 8 mg QBRELIS ORAL SOLUTION 1 MG/ML Tier 3 ST: Requires prior prescription for Lisinopril tablets within the past 120 days if 12 years of age and older; QL (1200 ML per 30 days) quinapril hcl oral tablet 10 mg, 20 mg, 40 (Accupril) Tier 1 mg, 5 mg ramipril oral capsule 1.25 mg, 10 mg, 2.5 (Altace) Tier 1 mg, 5 mg trandolapril oral tablet 1 mg, 2 mg Tier 1 trandolapril oral tablet 4 mg (Mavik) Tier 1 Agents For Pheochromocytoma metyrosine oral capsule 250 mg (Demser) Tier 1 phenoxybenzamine hcl oral capsule 10 (Dibenzyline) Tier 1 PA; SP mg Angiotensin Ii Receptor Antagonists candesartan cilexetil oral tablet 16 mg, (Atacand) Tier 1 32 mg, 4 mg, 8 mg EDARBI ORAL TABLET 40 MG, 80 MG Tier 2 irbesartan oral tablet 150 mg, 300 mg, (Avapro) Tier 1 75 mg

MedPerform Medium Formulary 01/01/2021

78 Drug Status Notes losartan potassium oral tablet 100 mg, (Cozaar) Tier 1 25 mg, 50 mg olmesartan medoxomil oral tablet 20 mg, (Benicar) Tier 1 40 mg, 5 mg telmisartan oral tablet 20 mg, 40 mg, 80 (Micardis) Tier 1 mg valsartan oral tablet 160 mg, 320 mg, 40 (Diovan) Tier 1 mg, 80 mg Antiadrenergic Antihypertensives clonidine hcl oral tablet 0.1 mg, 0.2 mg, (Catapres) Tier 1 0.3 mg clonidine transdermal patch weekly 0.1 (Catapres-TTS-1) Tier 1 mg/24hr clonidine transdermal patch weekly 0.2 (Catapres-TTS-2) Tier 1 mg/24hr clonidine transdermal patch weekly 0.3 (Catapres-TTS-3) Tier 1 mg/24hr doxazosin mesylate oral tablet 1 mg, 2 (Cardura) Tier 1 mg, 4 mg, 8 mg guanfacine hcl oral tablet 1 mg, 2 mg Tier 1 methyldopa oral tablet 250 mg, 500 mg Tier 1 prazosin hcl oral capsule 1 mg, 2 mg, 5 (Minipress) Tier 1 mg terazosin hcl oral capsule 1 mg, 10 mg, Tier 1 2 mg, 5 mg Antihypertensive Combinations amlodipine besy-benazepril hcl oral (Lotrel) Tier 1 capsule 10-20 mg, 10-40 mg, 5-10 mg, 5-20 mg amlodipine besy-benazepril hcl oral Tier 1 capsule 2.5-10 mg, 5-40 mg amlodipine besylate-valsartan oral tablet (Exforge) Tier 1 10-160 mg, 10-320 mg, 5-160 mg, 5-320 mg amlodipine-olmesartan oral tablet 10-20 (Azor) Tier 1 mg, 10-40 mg, 5-20 mg, 5-40 mg

MedPerform Medium Formulary 01/01/2021

79 Drug Status Notes amlodipine-valsartan-hctz oral tablet 10- (Exforge HCT) Tier 1 160-12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg atenolol-chlorthalidone oral tablet 100-25 (Tenoretic 100) Tier 1 mg atenolol-chlorthalidone oral tablet 50-25 (Tenoretic 50) Tier 1 mg benazepril-hydrochlorothiazide oral (Lotensin HCT) Tier 1 tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg benazepril-hydrochlorothiazide oral Tier 1 tablet 5-6.25 mg bisoprolol-hydrochlorothiazide oral tablet (Ziac) Tier 1 10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg candesartan cilexetil-hctz oral tablet 16- (Atacand HCT) Tier 1 12.5 mg, 32-12.5 mg, 32-25 mg captopril-hydrochlorothiazide oral tablet Tier 1 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg EDARBYCLOR ORAL TABLET 40-12.5 Tier 2 MG, 40-25 MG enalapril-hydrochlorothiazide oral tablet (Vaseretic) Tier 1 10-25 mg enalapril-hydrochlorothiazide oral tablet Tier 1 5-12.5 mg fosinopril sodium-hctz oral tablet 10-12.5 Tier 1 mg, 20-12.5 mg irbesartan-hydrochlorothiazide oral tablet (Avalide) Tier 1 150-12.5 mg, 300-12.5 mg lisinopril-hydrochlorothiazide oral tablet (Zestoretic) Tier 1 10-12.5 mg, 20-12.5 mg, 20-25 mg losartan potassium-hctz oral tablet 100- (Hyzaar) Tier 1 12.5 mg, 100-25 mg, 50-12.5 mg methyldopa-hydrochlorothiazide oral Tier 1 tablet 250-15 mg, 250-25 mg metoprolol-hydrochlorothiazide oral Tier 1 tablet 100-25 mg, 100-50 mg

MedPerform Medium Formulary 01/01/2021

80 Drug Status Notes metoprolol-hydrochlorothiazide oral (Lopressor HCT) Tier 1 tablet 50-25 mg olmesartan medoxomil-hctz oral tablet (Benicar HCT) Tier 1 20-12.5 mg, 40-12.5 mg, 40-25 mg olmesartan-amlodipine-hctz oral tablet (Tribenzor) Tier 1 20-5-12.5 mg, 40-10-12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg propranolol-hctz oral tablet 40-25 mg, Tier 1 80-25 mg quinapril-hydrochlorothiazide oral tablet (Accuretic) Tier 1 10-12.5 mg, 20-12.5 mg, 20-25 mg TEKTURNA HCT ORAL TABLET 150- Tier 3 12.5 MG, 150-25 MG, 300-12.5 MG, 300-25 MG telmisartan-amlodipine oral tablet 40-10 (Twynsta) Tier 1 mg, 40-5 mg, 80-10 mg, 80-5 mg telmisartan-hctz oral tablet 40-12.5 mg, (Micardis HCT) Tier 1 80-12.5 mg, 80-25 mg trandolapril-verapamil hcl er oral tablet Tier 1 extended release 1-240 mg trandolapril-verapamil hcl er oral tablet (Tarka) Tier 1 extended release 2-180 mg, 2-240 mg, 4-240 mg valsartan-hydrochlorothiazide oral tablet (Diovan HCT) Tier 1 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg Antihypertensives - Misc. VECAMYL ORAL TABLET 2.5 MG Tier 3 PA Direct Renin Inhibitors aliskiren fumarate oral tablet 150 mg, (Tekturna) Tier 1 300 mg Selective Aldosterone Receptor Antagonists (Saras) eplerenone oral tablet 25 mg, 50 mg (Inspra) Tier 1

MedPerform Medium Formulary 01/01/2021

81 Drug Status Notes Vasodilators hydralazine hcl oral tablet 10 mg, 100 Tier 1 mg, 25 mg, 50 mg minoxidil oral tablet 10 mg, 2.5 mg Tier 1 Anti-Infective Agents - Misc. Anti-Infective Agents - Misc. AEMCOLO ORAL TABLET DELAYED Tier 3 ST: Requires prior RELEASE 194 MG prescription for Azithromycin, Levofloxacin, or Ofloxacin within the past 120 days; QL (12 EA per 1 FILL) FIRST-METRONIDAZOLE ORAL Tier 3 SUSPENSION RECONSTITUTED 50 MG/ML IMPAVIDO ORAL CAPSULE 50 MG Tier 2 PA METRONIDAZOLE Tier 3 BENZO+SYRSPEND ORAL SUSPENSION RECONSTITUTED 50 MG/ML metronidazole oral capsule 375 mg (Flagyl) Tier 1 metronidazole oral tablet 250 mg Tier 1 metronidazole oral tablet 500 mg (Flagyl) Tier 1 pentamidine isethionate inhalation (Nebupent) Tier 1 solution reconstituted 300 mg PRIMSOL ORAL SOLUTION 50 Tier 2 MG/5ML tinidazole oral tablet 250 mg, 500 mg Tier 1 trimethoprim oral tablet 100 mg Tier 1 XIFAXAN ORAL TABLET 200 MG Tier 3 PA XIFAXAN ORAL TABLET 550 MG Tier 2 PA Anti-Infective Misc. - Combinations HYOPHEN ORAL TABLET 81.6 MG Tier 3 me/naphos/mb/hyo1 oral tablet 81.6 mg (Urogesic-Blue) Tier 1 PHOSPHASAL ORAL TABLET 81.6 MG (Urin DS) Tier 1

MedPerform Medium Formulary 01/01/2021

82 Drug Status Notes sulfamethoxazole-trimethoprim oral (Sulfatrim Pediatric) Tier 1 suspension 200-40 mg/5ml sulfamethoxazole-trimethoprim oral (Bactrim) Tier 1 tablet 400-80 mg sulfamethoxazole-trimethoprim oral (Bactrim DS) Tier 1 tablet 800-160 mg SULFATRIM PEDIATRIC ORAL (Sulfamethoxazole- Tier 1 SUSPENSION 200-40 MG/5ML Trimethoprim) URELLE ORAL TABLET 81 MG (Uro-458) Tier 1 URETRON D/S ORAL TABLET 81.6 MG (Urin DS) Tier 1 URIBEL ORAL CAPSULE 118 MG (UroAv-B) Tier 1 URIMAR-T ORAL TABLET 120 MG Tier 3 urin ds oral tablet 81.6 mg (Phosphasal) Tier 1 uro-458 oral tablet 81 mg (Urelle) Tier 1 uro-mp oral capsule 118 mg (Uribel) Tier 1 USTELL ORAL CAPSULE 120 MG (Uticap) Tier 1 uticap oral capsule 120 mg (Ustell) Tier 1 UTIRA-C ORAL TABLET 81.6 MG (Urin DS) Tier 1 UTRONA-C ORAL TABLET 81.6 MG (Urin DS) Tier 1 VILAMIT MB ORAL CAPSULE 118 MG (UroAv-B) Tier 1 VILEVEV MB ORAL TABLET 81 MG (Uro-458) Tier 1 Antiprotozoal Agents ALINIA ORAL SUSPENSION Tier 3 RECONSTITUTED 100 MG/5ML ALINIA ORAL TABLET 500 MG Tier 3 atovaquone oral suspension 750 mg/5ml (Mepron) Tier 1 LAMPIT ORAL TABLET 120 MG, 30 MG Tier 3 Glycopeptides FIRVANQ ORAL SOLUTION Tier 2 QL (300 ML per 1 FILL) RECONSTITUTED 25 MG/ML FIRVANQ ORAL SOLUTION (Vancomycin HCl) Tier 3 QL (600 ML per 1 FILL) RECONSTITUTED 50 MG/ML vancomycin hcl oral capsule 125 mg (Vancocin HCl) Tier 1 QL (56 EA per 1 FILL) vancomycin hcl oral capsule 250 mg (Vancocin) Tier 1 QL (112 EA per 1 FILL)

MedPerform Medium Formulary 01/01/2021

83 Drug Status Notes vancomycin hcl oral solution (Firvanq) Tier 1 QL (600 ML per 1 FILL) reconstituted 250 mg/5ml VANCOMYCIN+SYRSPEND SF ORAL Tier 3 SUSPENSION 50 MG/ML Leprostatics dapsone oral tablet 100 mg, 25 mg Tier 1 Lincosamides clindamycin hcl oral capsule 150 mg, (Cleocin) Tier 1 300 mg, 75 mg clindamycin palmitate hcl oral solution (Cleocin) Tier 1 reconstituted 75 mg/5ml Monobactams CAYSTON INHALATION SOLUTION Tier 2 PA; SP RECONSTITUTED 75 MG Oxazolidinones linezolid oral suspension reconstituted (Zyvox) Tier 1 100 mg/5ml linezolid oral tablet 600 mg (Zyvox) Tier 1 SIVEXTRO ORAL TABLET 200 MG Tier 2 ST: Requires prior prescription for Linezolid (600mg tablets) within the past 120 days; QL (1 EA per 1 day) Unknown fosfomycin tromethamine oral packet 3 (Monurol) Tier 1 gm methenamine hippurate oral tablet 1 gm (Hiprex) Tier 1 methenamine mandelate oral tablet 0.5 Tier 1 gm, 1 gm nitrofurantoin macrocrystal oral capsule (Macrodantin) Tier 1 100 mg, 50 mg nitrofurantoin macrocrystal oral capsule (Macrodantin) Tier 1 QL (4 EA per 1 day) 25 mg nitrofurantoin monohyd macro oral (Macrobid) Tier 1 capsule 100 mg nitrofurantoin oral suspension 25 mg/5ml Tier 1

MedPerform Medium Formulary 01/01/2021

84 Drug Status Notes XENLETA ORAL TABLET 600 MG Tier 3 PA Antimalarials Antimalarial Combinations atovaquone-proguanil hcl oral tablet 250- (Malarone) Tier 1 100 mg, 62.5-25 mg COARTEM ORAL TABLET 20-120 MG Tier 3 pyrimethamine-leucovorin oral capsule Tier 3 12.5-2.5 mg, 25-10 mg, 25-5 mg, 50-10 mg, 50-20 mg, 50-25 mg, 75-25 mg Antimalarials ARAKODA ORAL TABLET 100 MG Tier 3 chloroquine phosphate oral tablet 250 Tier 1 QL (36 EA per 16 days) mg chloroquine phosphate oral tablet 500 Tier 1 QL (18 EA per 16 days) mg hydroxychloroquine sulfate oral tablet (Plaquenil) Tier 1 QL (100 EA per 30 days) 200 mg KRINTAFEL ORAL TABLET 150 MG Tier 2 QL (2 EA per 1 FILL) mefloquine hcl oral tablet 250 mg Tier 1 primaquine phosphate oral tablet 26.3 Tier 1 mg pyrimethamine oral tablet 25 mg (Daraprim) Tier 1 PA; SP quinine sulfate oral capsule 324 mg (Qualaquin) Tier 1 Antimyasthenic/Cholinergic Agents Antimyasthenic/Cholinergic Agents FIRDAPSE ORAL TABLET 10 MG Tier 3 PA; SP pyridostigmine bromide er oral tablet (Mestinon) Tier 1 extended release 180 mg pyridostigmine bromide oral solution 60 (Mestinon) Tier 1 mg/5ml pyridostigmine bromide oral tablet 30 mg Tier 1 pyridostigmine bromide oral tablet 60 mg (Mestinon) Tier 1 RUZURGI ORAL TABLET 10 MG Tier 3 PA; SP

MedPerform Medium Formulary 01/01/2021

85 Drug Status Notes Antimycobacterial Agents Antimycobacterial Agents cycloserine oral capsule 250 mg Tier 1 ethambutol hcl oral tablet 100 mg Tier 1 ethambutol hcl oral tablet 400 mg (Myambutol) Tier 1 isoniazid oral syrup 50 mg/5ml Tier 1 isoniazid oral tablet 100 mg, 300 mg Tier 1 PASER ORAL PACKET 4 GM Tier 3 PRIFTIN ORAL TABLET 150 MG Tier 3 pyrazinamide oral tablet 500 mg Tier 1 rifabutin oral capsule 150 mg (Mycobutin) Tier 1 rifampin oral capsule 150 mg, 300 mg Tier 1 RIFAMPIN+SYRSPEND SF ORAL Tier 3 SUSPENSION 25 MG/ML SIRTURO ORAL TABLET 100 MG, 20 Tier 3 PA; SP MG TRECATOR ORAL TABLET 250 MG Tier 3 Antineoplastics And Adjunctive Therapies Alkylating Agents cyclophosphamide oral capsule 25 mg, Tier 1 SP 50 mg GLEOSTINE ORAL CAPSULE 10 MG, Tier 3 PA; SP 100 MG, 40 MG LEUKERAN ORAL TABLET 2 MG Tier 2 SP melphalan oral tablet 2 mg (Alkeran) Tier 1 MYLERAN ORAL TABLET 2 MG Tier 2 SP temozolomide oral capsule 100 mg, 140 (Temodar) Tier 1 PA; SP mg, 180 mg, 20 mg, 250 mg, 5 mg Antimetabolites capecitabine oral tablet 150 mg, 500 mg (Xeloda) Tier 1 PA; SP mercaptopurine oral tablet 50 mg Tier 1 methotrexate oral tablet 2.5 mg Tier 1

MedPerform Medium Formulary 01/01/2021

86 Drug Status Notes methotrexate sodium (pf) injection Tier 1 solution 1 gm/40ml, 250 mg/10ml, 50 mg/2ml methotrexate sodium injection solution Tier 1 250 mg/10ml, 50 mg/2ml methotrexate sodium injection solution Tier 1 reconstituted 1 gm methotrexate sodium oral tablet 2.5 mg Tier 1 ONUREG ORAL TABLET 200 MG, 300 Tier 2 PA; SP MG PURIXAN ORAL SUSPENSION 2000 Tier 2 SP; ST: Requires prior MG/100ML prescription for Mercaptopurine within the past 120 days TABLOID ORAL TABLET 40 MG Tier 2 SP TREXALL ORAL TABLET 10 MG, 15 Tier 2 MG, 5 MG, 7.5 MG XATMEP ORAL SOLUTION 2.5 MG/ML Tier 3 SP; ST: Requires prior prescription for Methotrexate tablets or vial within the past 120 days if 12 years of age and older; QL (120 ML per 60 days) Antineoplastic - Bcl-2 Inhibitors VENCLEXTA ORAL TABLET 10 MG, Tier 2 PA; SP 100 MG, 50 MG VENCLEXTA STARTING PACK ORAL Tier 2 PA; SP TABLET THERAPY PACK 10 & 50 & 100 MG Antineoplastic - Hedgehog Pathway Inhibitors DAURISMO ORAL TABLET 100 MG, 25 Tier 2 PA; SP MG ERIVEDGE ORAL CAPSULE 150 MG Tier 2 PA; SP; QL (1 EA per 1 day) ODOMZO ORAL CAPSULE 200 MG Tier 2 PA; SP

MedPerform Medium Formulary 01/01/2021

87 Drug Status Notes Antineoplastic - Hormonal And Related Agents abiraterone acetate oral tablet 250 mg (Zytiga) Tier 1 PA; SP anastrozole oral tablet 1 mg (Arimidex) Tier 1 $0 COPAY IF 40 YEARS OF AGE OR OLDER; QL (1 EA per 1 day) bicalutamide oral tablet 50 mg (Casodex) Tier 1 ELIGARD SUBCUTANEOUS KIT 22.5 Tier 2 PA; SP MG, 30 MG, 45 MG, 7.5 MG EMCYT ORAL CAPSULE 140 MG Tier 2 SP ERLEADA ORAL TABLET 60 MG Tier 2 PA; SP exemestane oral tablet 25 mg (Aromasin) Tier 1 $0 COPAY IF 35 YEARS OF AGE OR OLDER; QL (1 EA per 1 day) FIRMAGON (240 MG DOSE) Tier 3 SP; QL (2 EA per 365 SUBCUTANEOUS SOLUTION days) RECONSTITUTED 120 MG/VIAL FIRMAGON SUBCUTANEOUS Tier 3 SP; QL (1 EA per 30 days) SOLUTION RECONSTITUTED 80 MG flutamide oral capsule 125 mg Tier 1 letrozole oral tablet 2.5 mg (Femara) Tier 1 leuprolide acetate injection kit 1 Tier 1 PA; SP mg/0.2ml leuprolide acetate-bupivacaine Tier 3 intramuscular solution 25-5 mg/ml LYSODREN ORAL TABLET 500 MG Tier 2 SP megestrol acetate oral suspension 40 Tier 1 mg/ml, 400 mg/10ml megestrol acetate oral tablet 20 mg, 40 Tier 1 mg nilutamide oral tablet 150 mg (Nilandron) Tier 1 SP; QL (2 EA per 1 day) NUBEQA ORAL TABLET 300 MG Tier 2 PA; SP SOLTAMOX ORAL SOLUTION 10 Tier 2 MG/5ML tamoxifen citrate oral tablet 10 mg, 20 $0 mg

MedPerform Medium Formulary 01/01/2021

88 Drug Status Notes toremifene citrate oral tablet 60 mg (Fareston) Tier 1 PA; SP XTANDI ORAL CAPSULE 40 MG Tier 2 PA; SP YONSA ORAL TABLET 125 MG Tier 3 PA; SP ZYTIGA ORAL TABLET 500 MG Tier 2 PA; SP Antineoplastic - Immunomodulators POMALYST ORAL CAPSULE 1 MG, 2 Tier 2 PA; SP MG, 3 MG, 4 MG Antineoplastic Antibiotics JELMYTO SOLUTION Tier 3 PA; SP RECONSTITUTED 80 (2 X 40) MG Antineoplastic Combinations INQOVI ORAL TABLET 35-100 MG Tier 2 PA; SP KISQALI FEMARA (400 MG DOSE) Tier 3 PA; SP ORAL TABLET THERAPY PACK 200 & 2.5 MG KISQALI FEMARA (600 MG DOSE) Tier 3 PA; SP ORAL TABLET THERAPY PACK 200 & 2.5 MG KISQALI FEMARA(200 MG DOSE) Tier 3 PA; SP ORAL TABLET THERAPY PACK 200 & 2.5 MG LONSURF ORAL TABLET 15-6.14 MG, Tier 2 PA; SP 20-8.19 MG Antineoplastic Enzyme Inhibitors AFINITOR DISPERZ ORAL TABLET Tier 2 PA; SP SOLUBLE 2 MG, 3 MG, 5 MG AFINITOR ORAL TABLET 10 MG Tier 2 PA; SP ALECENSA ORAL CAPSULE 150 MG Tier 2 PA; SP ALUNBRIG ORAL TABLET 180 MG, 30 Tier 3 PA; SP MG, 90 MG ALUNBRIG ORAL TABLET THERAPY Tier 3 PA; SP PACK 90 & 180 MG AYVAKIT ORAL TABLET 100 MG, 200 Tier 2 PA; SP MG, 300 MG BALVERSA ORAL TABLET 3 MG, 4 Tier 2 PA; SP MG, 5 MG

MedPerform Medium Formulary 01/01/2021

89 Drug Status Notes BOSULIF ORAL TABLET 100 MG Tier 2 PA; SP; QL (3 EA per 1 day) BOSULIF ORAL TABLET 400 MG, 500 Tier 2 PA; SP; QL (1 EA per 1 MG day) BRAFTOVI ORAL CAPSULE 75 MG Tier 2 PA; SP BRUKINSA ORAL CAPSULE 80 MG Tier 2 PA; SP CABOMETYX ORAL TABLET 20 MG, Tier 2 PA; SP 40 MG, 60 MG CALQUENCE ORAL CAPSULE 100 MG Tier 2 PA; SP CAPRELSA ORAL TABLET 100 MG Tier 3 PA; SP; QL (2 EA per 1 day) CAPRELSA ORAL TABLET 300 MG Tier 3 PA; SP; QL (1 EA per 1 day) COMETRIQ (100 MG DAILY DOSE) Tier 2 PA; SP; QL (4 EA per 1 ORAL KIT 80 & 20 MG day) COMETRIQ (140 MG DAILY DOSE) Tier 2 PA; SP; QL (4 EA per 1 ORAL KIT 3 X 20 MG & 80 MG day) COMETRIQ (60 MG DAILY DOSE) Tier 2 PA; SP; QL (4 EA per 1 ORAL KIT 20 MG day) COPIKTRA ORAL CAPSULE 15 MG, 25 Tier 3 PA; SP MG COTELLIC ORAL TABLET 20 MG Tier 2 PA; SP; QL (63 EA per 28 days) erlotinib hcl oral tablet 100 mg, 150 mg, (Tarceva) Tier 1 PA; SP 25 mg everolimus oral tablet 2.5 mg, 5 mg, 7.5 (Afinitor) Tier 1 PA; SP mg FARYDAK ORAL CAPSULE 10 MG, 15 Tier 2 PA; SP MG, 20 MG GAVRETO ORAL CAPSULE 100 MG Tier 2 PA; SP GILOTRIF ORAL TABLET 20 MG, 30 Tier 2 PA; SP MG, 40 MG IBRANCE ORAL CAPSULE 100 MG, Tier 2 PA; SP 125 MG, 75 MG IBRANCE ORAL TABLET 100 MG, 125 Tier 2 PA; SP MG, 75 MG

MedPerform Medium Formulary 01/01/2021

90 Drug Status Notes ICLUSIG ORAL TABLET 15 MG Tier 2 PA; SP; QL (2 EA per 1 day) ICLUSIG ORAL TABLET 45 MG Tier 2 PA; SP; QL (1 EA per 1 day) IDHIFA ORAL TABLET 100 MG, 50 MG Tier 3 PA; SP imatinib mesylate oral tablet 100 mg, (Gleevec) Tier 1 PA; SP 400 mg IMBRUVICA ORAL CAPSULE 140 MG, Tier 2 PA; SP 70 MG IMBRUVICA ORAL TABLET 140 MG, Tier 2 PA; SP 280 MG, 420 MG, 560 MG INLYTA ORAL TABLET 1 MG, 5 MG Tier 2 PA; SP INREBIC ORAL CAPSULE 100 MG Tier 2 PA; SP IRESSA ORAL TABLET 250 MG Tier 2 PA; SP JAKAFI ORAL TABLET 10 MG, 15 MG, Tier 2 PA; SP 20 MG, 25 MG, 5 MG KISQALI (200 MG DOSE) ORAL Tier 3 PA; SP TABLET THERAPY PACK 200 MG KISQALI (400 MG DOSE) ORAL Tier 3 PA; SP TABLET THERAPY PACK 200 MG KISQALI (600 MG DOSE) ORAL Tier 3 PA; SP TABLET THERAPY PACK 200 MG KOSELUGO ORAL CAPSULE 10 MG, Tier 2 PA; SP 25 MG lapatinib ditosylate oral tablet 250 mg (Tykerb) Tier 1 PA; SP LENVIMA (10 MG DAILY DOSE) ORAL Tier 2 PA; SP CAPSULE THERAPY PACK 10 MG LENVIMA (12 MG DAILY DOSE) ORAL Tier 2 PA; SP CAPSULE THERAPY PACK 3 X 4 MG LENVIMA (14 MG DAILY DOSE) ORAL Tier 2 PA; SP CAPSULE THERAPY PACK 10 & 4 MG LENVIMA (18 MG DAILY DOSE) ORAL Tier 2 PA; SP CAPSULE THERAPY PACK 10 MG & 2 X 4 MG LENVIMA (20 MG DAILY DOSE) ORAL Tier 2 PA; SP CAPSULE THERAPY PACK 2 X 10 MG

MedPerform Medium Formulary 01/01/2021

91 Drug Status Notes LENVIMA (24 MG DAILY DOSE) ORAL Tier 2 PA; SP CAPSULE THERAPY PACK 2 X 10 MG & 4 MG LENVIMA (4 MG DAILY DOSE) ORAL Tier 2 PA; SP CAPSULE THERAPY PACK 4 MG LENVIMA (8 MG DAILY DOSE) ORAL Tier 2 PA; SP CAPSULE THERAPY PACK 2 X 4 MG LORBRENA ORAL TABLET 100 MG, 25 Tier 2 PA; SP MG LYNPARZA ORAL TABLET 100 MG, Tier 2 PA; SP 150 MG MEKINIST ORAL TABLET 0.5 MG, 2 Tier 2 PA; SP MG MEKTOVI ORAL TABLET 15 MG Tier 2 PA; SP; QL (6 EA per 1 day) NERLYNX ORAL TABLET 40 MG Tier 3 PA; SP NEXAVAR ORAL TABLET 200 MG Tier 2 PA; SP; QL (4 EA per 1 day) NINLARO ORAL CAPSULE 2.3 MG, 3 Tier 2 PA; SP MG, 4 MG PEMAZYRE ORAL TABLET 13.5 MG, Tier 2 PA; SP 4.5 MG, 9 MG PIQRAY (200 MG DAILY DOSE) ORAL Tier 2 PA; SP TABLET THERAPY PACK 200 MG PIQRAY (250 MG DAILY DOSE) ORAL Tier 2 PA; SP TABLET THERAPY PACK 200 & 50 MG PIQRAY (300 MG DAILY DOSE) ORAL Tier 2 PA; SP TABLET THERAPY PACK 2 X 150 MG QINLOCK ORAL TABLET 50 MG Tier 2 PA; SP RETEVMO ORAL CAPSULE 40 MG, 80 Tier 2 PA; SP MG ROZLYTREK ORAL CAPSULE 100 MG, Tier 2 PA; SP 200 MG RUBRACA ORAL TABLET 200 MG, 250 Tier 3 PA; SP MG, 300 MG RYDAPT ORAL CAPSULE 25 MG Tier 2 PA; SP

MedPerform Medium Formulary 01/01/2021

92 Drug Status Notes SPRYCEL ORAL TABLET 100 MG, 140 Tier 2 PA; SP MG, 20 MG, 50 MG, 70 MG, 80 MG STIVARGA ORAL TABLET 40 MG Tier 2 PA; SP; QL (3 EA per 1 day) SUTENT ORAL CAPSULE 12.5 MG, 25 Tier 2 PA; SP; QL (1 EA per 1 MG, 37.5 MG, 50 MG day) TABRECTA ORAL TABLET 150 MG, Tier 2 PA; SP 200 MG TAFINLAR ORAL CAPSULE 50 MG, 75 Tier 2 PA; SP MG TAGRISSO ORAL TABLET 40 MG, 80 Tier 2 PA; SP MG TALZENNA ORAL CAPSULE 0.25 MG, Tier 2 PA; SP 1 MG TASIGNA ORAL CAPSULE 150 MG, Tier 2 PA; SP; QL (4 EA per 1 200 MG, 50 MG day) TAZVERIK ORAL TABLET 200 MG Tier 2 PA; SP TIBSOVO ORAL TABLET 250 MG Tier 2 PA; SP TUKYSA ORAL TABLET 150 MG, 50 Tier 2 PA; SP MG TURALIO ORAL CAPSULE 200 MG Tier 2 PA; SP VERZENIO ORAL TABLET 100 MG, Tier 2 PA; SP 150 MG, 200 MG, 50 MG VITRAKVI ORAL CAPSULE 100 MG, 25 Tier 2 PA; SP MG VITRAKVI ORAL SOLUTION 20 MG/ML Tier 2 PA; SP VIZIMPRO ORAL TABLET 15 MG, 30 Tier 2 PA; SP MG, 45 MG VOTRIENT ORAL TABLET 200 MG Tier 2 PA; SP; QL (4 EA per 1 day) XALKORI ORAL CAPSULE 200 MG, Tier 2 PA; SP 250 MG XOSPATA ORAL TABLET 40 MG Tier 2 PA; SP ZEJULA ORAL CAPSULE 100 MG Tier 2 PA; SP ZELBORAF ORAL TABLET 240 MG Tier 2 PA; SP; QL (8 EA per 1 day)

MedPerform Medium Formulary 01/01/2021

93 Drug Status Notes ZOLINZA ORAL CAPSULE 100 MG Tier 2 SP ZYDELIG ORAL TABLET 100 MG, 150 Tier 2 PA; SP MG ZYKADIA ORAL TABLET 150 MG Tier 2 PA; SP Antineoplastics Misc. ACTIMMUNE SUBCUTANEOUS Tier 3 PA; SP SOLUTION 2000000 UNIT/0.5ML ALFERON N INJECTION SOLUTION Tier 3 SP 5000000 UNIT/ML bexarotene oral capsule 75 mg (Targretin) Tier 1 PA; SP hydroxyurea oral capsule 500 mg (Hydrea) Tier 1 INTRON A INJECTION SOLUTION Tier 2 PA; SP 10000000 UNIT/ML, 6000000 UNIT/ML INTRON A INJECTION SOLUTION Tier 2 PA; SP RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT MATULANE ORAL CAPSULE 50 MG Tier 2 SP SYNRIBO SUBCUTANEOUS Tier 3 PA; SP SOLUTION RECONSTITUTED 3.5 MG tretinoin oral capsule 10 mg Tier 1 SP Chemotherapy Rescue/Antidote Agents leucovorin calcium oral tablet 10 mg, 15 Tier 1 mg, 25 mg, 5 mg MESNEX ORAL TABLET 400 MG Tier 3 Mitotic Inhibitors etoposide oral capsule 50 mg Tier 1 Topoisomerase I Inhibitors HYCAMTIN ORAL CAPSULE 0.25 MG, Tier 2 SP 1 MG Unknown XPOVIO (100 MG ONCE WEEKLY) Tier 2 PA; SP ORAL TABLET THERAPY PACK 20 MG XPOVIO (40 MG ONCE WEEKLY) Tier 2 PA; SP ORAL TABLET THERAPY PACK 20 MG XPOVIO (40 MG TWICE WEEKLY) Tier 2 PA; SP ORAL TABLET THERAPY PACK 20 MG

MedPerform Medium Formulary 01/01/2021

94 Drug Status Notes XPOVIO (60 MG ONCE WEEKLY) Tier 2 PA; SP ORAL TABLET THERAPY PACK 20 MG XPOVIO (60 MG TWICE WEEKLY) Tier 2 PA; SP ORAL TABLET THERAPY PACK 20 MG XPOVIO (80 MG ONCE WEEKLY) Tier 2 PA; SP ORAL TABLET THERAPY PACK 20 MG XPOVIO (80 MG TWICE WEEKLY) Tier 2 PA; SP ORAL TABLET THERAPY PACK 20 MG Antiparkinson And Related Therapy Agents Antiparkinson Adjuvants carbidopa oral tablet 25 mg (Lodosyn) Tier 1 NOURIANZ ORAL TABLET 20 MG, 40 Tier 3 PA MG Antiparkinson Anticholinergics benztropine mesylate oral tablet 0.5 mg, Tier 1 1 mg, 2 mg trihexyphenidyl hcl oral solution 0.4 Tier 1 mg/ml trihexyphenidyl hcl oral tablet 2 mg, 5 mg Tier 1 Antiparkinson Comt Inhibitors entacapone oral tablet 200 mg (Comtan) Tier 1 ONGENTYS ORAL CAPSULE 50 MG Tier 3 PA tolcapone oral tablet 100 mg (Tasmar) Tier 1 ST: Requires prior prescription for Entacapone within the past 120 days; QL (3 EA per 1 day) Antiparkinson Dopaminergics amantadine hcl oral capsule 100 mg Tier 1 amantadine hcl oral syrup 50 mg/5ml Tier 1 amantadine hcl oral tablet 100 mg Tier 1 APOKYN SUBCUTANEOUS SOLUTION Tier 3 PA; SP CARTRIDGE 30 MG/3ML bromocriptine mesylate oral capsule 5 (Parlodel) Tier 1 mg

MedPerform Medium Formulary 01/01/2021

95 Drug Status Notes bromocriptine mesylate oral tablet 2.5 (Parlodel) Tier 1 mg carbidopa-levodopa er oral tablet Tier 1 extended release 25-100 mg, 50-200 mg carbidopa-levodopa oral tablet 10-100 (Sinemet) Tier 1 mg, 25-100 mg, 25-250 mg carbidopa-levodopa oral tablet Tier 1 dispersible 10-100 mg, 25-100 mg, 25- 250 mg carbidopa-levodopa-entacapone oral (Stalevo 50) Tier 1 tablet 12.5-50-200 mg carbidopa-levodopa-entacapone oral (Stalevo 75) Tier 1 tablet 18.75-75-200 mg carbidopa-levodopa-entacapone oral (Stalevo 100) Tier 1 tablet 25-100-200 mg carbidopa-levodopa-entacapone oral (Stalevo 125) Tier 1 tablet 31.25-125-200 mg carbidopa-levodopa-entacapone oral (Stalevo 150) Tier 1 tablet 37.5-150-200 mg carbidopa-levodopa-entacapone oral (Stalevo 200) Tier 1 tablet 50-200-200 mg DUOPA ENTERAL SUSPENSION 4.63- Tier 3 PA; SP 20 MG/ML INBRIJA INHALATION CAPSULE 42 Tier 3 PA; SP MG KYNMOBI SUBLINGUAL FILM 10 MG, Tier 3 PA; SP 15 MG, 20 MG, 25 MG, 30 MG NEUPRO TRANSDERMAL PATCH 24 Tier 2 ST: Requires prior HOUR 1 MG/24HR, 2 MG/24HR, 3 prescription for immediate- MG/24HR, 4 MG/24HR, 6 MG/24HR, 8 release Pramipexole or MG/24HR immediate-release Ropinirole within the past 120 days; QL (1 EA per 1 day)

MedPerform Medium Formulary 01/01/2021

96 Drug Status Notes pramipexole dihydrochloride er oral (Mirapex ER) Tier 1 ST: Requires prior tablet extended release 24 hour 0.375 prescription for immediate- mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, release Pramipexole or 3.75 mg, 4.5 mg immediate-release Ropinirole within the past 120 days; QL (1 EA per 1 day) pramipexole dihydrochloride oral tablet (Mirapex) Tier 1 0.125 mg, 0.5 mg, 0.75 mg, 1 mg pramipexole dihydrochloride oral tablet Tier 1 0.25 mg, 1.5 mg ropinirole hcl er oral tablet extended Tier 1 ST: Requires prior release 24 hour 12 mg, 2 mg, 4 mg, 6 prescription for immediate- mg, 8 mg release Pramipexole or immediate-release Ropinirole within the past 120 days; QL (1 EA per 1 day) ropinirole hcl oral tablet 0.25 mg, 0.5 mg, Tier 1 1 mg, 2 mg, 3 mg, 4 mg, 5 mg RYTARY ORAL CAPSULE EXTENDED Tier 3 ST: Requires prior RELEASE 23.75-95 MG, 36.25-145 MG, prescription for 48.75-195 MG, 61.25-245 MG Carbidopa/levodopa within the past 120 days; QL (10 EA per 1 day) STALEVO 100 ORAL TABLET 25-100- (Carbidopa-Levodopa- Tier 3 200 MG Entacapone) STALEVO 125 ORAL TABLET 31.25- (Carbidopa-Levodopa- Tier 3 125-200 MG Entacapone) STALEVO 150 ORAL TABLET 37.5-150- (Carbidopa-Levodopa- Tier 3 200 MG Entacapone) STALEVO 200 ORAL TABLET 50-200- (Carbidopa-Levodopa- Tier 3 200 MG Entacapone) STALEVO 50 ORAL TABLET 12.5-50- (Carbidopa-Levodopa- Tier 3 200 MG Entacapone) STALEVO 75 ORAL TABLET 18.75-75- (Carbidopa-Levodopa- Tier 3 200 MG Entacapone)

MedPerform Medium Formulary 01/01/2021

97 Drug Status Notes Antiparkinson Monoamine Oxidase Inhibitors rasagiline mesylate oral tablet 0.5 mg, 1 (Azilect) Tier 1 QL (1 EA per 1 day) mg selegiline hcl oral capsule 5 mg Tier 1 selegiline hcl oral tablet 5 mg Tier 1 XADAGO ORAL TABLET 100 MG, 50 Tier 3 ST: Requires prior MG prescription for Carbidopa/levodopa within the past 120 days; QL (1 EA per 1 day) ZELAPAR ORAL TABLET Tier 3 ST: Requires prior DISPERSIBLE 1.25 MG prescription for generic Selegiline capsules or tablets within the past 120 days; QL (2 EA per 1 day) Antipsychotics/Antimanic Agents Antimanic Agents lithium carbonate er oral tablet extended (Lithobid) Tier 1 release 300 mg lithium carbonate er oral tablet extended Tier 1 release 450 mg lithium carbonate oral capsule 150 mg, Tier 1 300 mg, 600 mg lithium carbonate oral tablet 300 mg Tier 1 LITHOBID ORAL TABLET EXTENDED (Lithium Carbonate ER) Tier 3 RELEASE 300 MG Antipsychotics - Misc. CAPLYTA ORAL CAPSULE 42 MG Tier 3 QL (1 EA per 1 day) EQUETRO ORAL CAPSULE Tier 3 EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG LATUDA ORAL TABLET 120 MG, 20 Tier 2 QL (1 EA per 1 day) MG, 40 MG, 60 MG LATUDA ORAL TABLET 80 MG Tier 2 QL (2 EA per 1 day) NUPLAZID ORAL CAPSULE 34 MG Tier 3 PA; SP

MedPerform Medium Formulary 01/01/2021

98 Drug Status Notes NUPLAZID ORAL TABLET 10 MG Tier 3 PA; SP VRAYLAR ORAL CAPSULE 1.5 MG, 3 Tier 2 QL (1 EA per 1 day) MG, 4.5 MG, 6 MG VRAYLAR ORAL CAPSULE THERAPY Tier 2 QL (1 EA per 4 days) PACK 1.5 & 3 MG ziprasidone hcl oral capsule 20 mg, 40 (Geodon) Tier 1 QL (2 EA per 1 day) mg, 60 mg, 80 mg Benzisoxazoles FANAPT ORAL TABLET 1 MG, 10 MG, Tier 3 QL (2 EA per 1 day) 12 MG, 2 MG, 4 MG, 6 MG, 8 MG FANAPT TITRATION PACK ORAL Tier 3 QL (8 EA per 28 days) TABLET 1 & 2 & 4 & 6 MG paliperidone er oral tablet extended (Invega) Tier 1 QL (1 EA per 1 day) release 24 hour 1.5 mg, 3 mg, 9 mg paliperidone er oral tablet extended (Invega) Tier 1 QL (2 EA per 1 day) release 24 hour 6 mg risperidone oral solution 1 mg/ml (RisperDAL) Tier 1 QL (8 ML per 1 day) risperidone oral tablet 0.25 mg Tier 1 QL (2 EA per 1 day) risperidone oral tablet 0.5 mg, 1 mg, 2 (RisperDAL) Tier 1 QL (2 EA per 1 day) mg, 3 mg, 4 mg risperidone oral tablet dispersible 0.25 Tier 1 QL (2 EA per 1 day) mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg Butyrophenones haloperidol lactate oral concentrate 2 Tier 1 mg/ml haloperidol oral tablet 0.5 mg, 1 mg, 10 Tier 1 mg, 2 mg, 20 mg, 5 mg Dibenzapines ADASUVE INHALATION AEROSOL Tier 2 SP POWDER BREATH ACTIVATED 10 MG clozapine oral tablet 100 mg, 200 mg, 25 (Clozaril) Tier 1 QL (3 EA per 1 day) mg, 50 mg clozapine oral tablet dispersible 100 mg, Tier 1 QL (3 EA per 1 day) 12.5 mg, 150 mg, 200 mg, 25 mg loxapine succinate oral capsule 10 mg, Tier 1 25 mg, 5 mg, 50 mg

MedPerform Medium Formulary 01/01/2021

99 Drug Status Notes olanzapine oral tablet 10 mg, 15 mg, 2.5 (ZyPREXA) Tier 1 QL (1 EA per 1 day) mg, 20 mg, 5 mg, 7.5 mg olanzapine oral tablet dispersible 10 mg, (ZyPREXA Zydis) Tier 1 QL (1 EA per 1 day) 15 mg, 20 mg, 5 mg quetiapine fumarate er oral tablet (SEROquel XR) Tier 1 QL (1 EA per 1 day) extended release 24 hour 150 mg, 200 mg, 300 mg, 400 mg, 50 mg quetiapine fumarate oral tablet 100 mg, (SEROquel) Tier 1 QL (3 EA per 1 day) 200 mg, 25 mg, 300 mg, 400 mg, 50 mg SAPHRIS SUBLINGUAL TABLET Tier 2 QL (2 EA per 1 day) SUBLINGUAL 10 MG, 2.5 MG, 5 MG SECUADO TRANSDERMAL PATCH 24 Tier 3 QL (1 EA per 1 day) HOUR 3.8 MG/24HR, 5.7 MG/24HR, 7.6 MG/24HR VERSACLOZ ORAL SUSPENSION 50 Tier 3 QL (18 ML per 1 day) MG/ML Dihydroindolones molindone hcl oral tablet 10 mg Tier 1 QL (8 EA per 1 day) molindone hcl oral tablet 25 mg Tier 1 QL (9 EA per 1 day) molindone hcl oral tablet 5 mg Tier 1 Phenothiazines chlorpromazine hcl oral tablet 10 mg, Tier 1 100 mg, 200 mg, 25 mg, 50 mg COMPRO RECTAL SUPPOSITORY 25 (Prochlorperazine) Tier 1 MG fluphenazine hcl oral concentrate 5 Tier 1 mg/ml fluphenazine hcl oral elixir 2.5 mg/5ml Tier 1 fluphenazine hcl oral tablet 1 mg, 10 mg, Tier 1 2.5 mg, 5 mg perphenazine oral tablet 16 mg, 2 mg, 4 Tier 1 mg, 8 mg prochlorperazine maleate oral tablet 10 Tier 1 mg, 5 mg prochlorperazine rectal suppository 25 (Compro) Tier 1 mg

MedPerform Medium Formulary 01/01/2021

100 Drug Status Notes thioridazine hcl oral tablet 10 mg, 100 Tier 1 mg, 25 mg, 50 mg trifluoperazine hcl oral tablet 1 mg, 10 Tier 1 mg, 2 mg, 5 mg Quinolinone Derivatives ABILIFY MYCITE ORAL TABLET 10 Tier 3 PA; SP MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG aripiprazole oral solution 1 mg/ml Tier 1 QL (30 ML per 1 day) aripiprazole oral tablet 10 mg, 15 mg, 2 (Abilify) Tier 1 QL (1 EA per 1 day) mg, 20 mg, 30 mg, 5 mg aripiprazole oral tablet dispersible 10 mg Tier 1 QL (3 EA per 1 day) aripiprazole oral tablet dispersible 15 mg Tier 1 QL (2 EA per 1 day) REXULTI ORAL TABLET 0.25 MG, 0.5 Tier 2 QL (1 EA per 1 day) MG, 1 MG, 2 MG, 3 MG, 4 MG Thioxanthenes thiothixene oral capsule 1 mg, 10 mg, 2 Tier 1 mg, 5 mg Antiseptics & Disinfectants Chlorine Antiseptics chlorhexidine gluconate solution 20 % Tier 3 Antivirals Antiretrovirals abacavir sulfate oral solution 20 mg/ml (Ziagen) Tier 1 SP; QL (960 ML per 30 days) abacavir sulfate oral tablet 300 mg (Ziagen) Tier 1 SP; QL (2 EA per 1 day) abacavir sulfate-lamivudine oral tablet (Epzicom) Tier 1 SP; QL (1 EA per 1 day) 600-300 mg abacavir-lamivudine-zidovudine oral (Trizivir) Tier 1 SP; QL (2 EA per 1 day) tablet 300-150-300 mg APTIVUS ORAL CAPSULE 250 MG Tier 2 SP; QL (4 EA per 1 day) APTIVUS ORAL SOLUTION 100 MG/ML Tier 2 SP; QL (380 ML per 30 days) atazanavir sulfate oral capsule 150 mg, (Reyataz) Tier 1 SP; QL (2 EA per 1 day) 200 mg atazanavir sulfate oral capsule 300 mg (Reyataz) Tier 1 SP; QL (1 EA per 1 day)

MedPerform Medium Formulary 01/01/2021

101 Drug Status Notes BIKTARVY ORAL TABLET 50-200-25 Tier 2 SP; QL (1 EA per 1 day) MG CIMDUO ORAL TABLET 300-300 MG Tier 2 SP; QL (1 EA per 1 day) COMPLERA ORAL TABLET 200-25-300 Tier 2 SP; QL (1 EA per 1 day) MG CRIXIVAN ORAL CAPSULE 200 MG, Tier 2 SP 400 MG DELSTRIGO ORAL TABLET 100-300- Tier 2 SP; QL (1 EA per 1 day) 300 MG DESCOVY ORAL TABLET 200-25 MG Tier 2 SP; QL (1 EA per 1 day) didanosine oral capsule delayed release Tier 1 SP; QL (2 EA per 1 day) 200 mg didanosine oral capsule delayed release Tier 1 SP; QL (1 EA per 1 day) 250 mg, 400 mg DOVATO ORAL TABLET 50-300 MG Tier 2 SP; QL (1 EA per 1 day) EDURANT ORAL TABLET 25 MG Tier 2 SP; QL (1 EA per 1 day) efavirenz oral capsule 200 mg, 50 mg (Sustiva) Tier 1 SP efavirenz oral tablet 600 mg (Sustiva) Tier 1 SP efavirenz-emtricitab-tenofovir oral tablet (Atripla) Tier 1 SP; QL (1 EA per 1 day) 600-200-300 mg efavirenz-lamivudine-tenofovir oral tablet (Symfi Lo) Tier 1 SP; QL (1 EA per 1 day) 400-300-300 mg efavirenz-lamivudine-tenofovir oral tablet (Symfi) Tier 1 SP; QL (1 EA per 1 day) 600-300-300 mg emtricitabine oral capsule 200 mg (Emtriva) Tier 1 SP; QL (1 EA per 1 day) emtricitabine-tenofovir df oral tablet 200- (Truvada) Tier 1 SP; $0 COPAY IF NO 300 mg HISTORY OF ANTIRETROVIRAL MEDICATION IN 120 DAYS; QL (1 EA per 1 day) EMTRIVA ORAL SOLUTION 10 MG/ML Tier 2 SP; QL (850 ML per 30 days) EVOTAZ ORAL TABLET 300-150 MG Tier 2 SP; QL (1 EA per 1 day) fosamprenavir calcium oral tablet 700 (Lexiva) Tier 1 SP; QL (4 EA per 1 day) mg

MedPerform Medium Formulary 01/01/2021

102 Drug Status Notes FUZEON SUBCUTANEOUS SOLUTION Tier 2 SP; QL (2 EA per 1 day) RECONSTITUTED 90 MG GENVOYA ORAL TABLET 150-150- Tier 2 SP; QL (1 EA per 1 day) 200-10 MG INTELENCE ORAL TABLET 100 MG, 25 Tier 2 SP; QL (4 EA per 1 day) MG INTELENCE ORAL TABLET 200 MG Tier 2 SP; QL (2 EA per 1 day) INVIRASE ORAL TABLET 500 MG Tier 2 SP; QL (4 EA per 1 day) ISENTRESS HD ORAL TABLET 600 Tier 2 SP; QL (2 EA per 1 day) MG ISENTRESS ORAL PACKET 100 MG Tier 2 SP; QL (2 EA per 1 day) ISENTRESS ORAL TABLET 400 MG Tier 2 SP; QL (2 EA per 1 day) ISENTRESS ORAL TABLET Tier 2 SP; QL (6 EA per 1 day) CHEWABLE 100 MG, 25 MG JULUCA ORAL TABLET 50-25 MG Tier 2 SP; QL (1 EA per 1 day) KALETRA ORAL TABLET 100-25 MG Tier 2 SP; QL (2 EA per 1 day) KALETRA ORAL TABLET 200-50 MG Tier 2 SP; QL (4 EA per 1 day) lamivudine oral solution 10 mg/ml (Epivir) Tier 1 SP; QL (960 ML per 30 days) lamivudine oral tablet 150 mg (Epivir) Tier 1 SP; QL (2 EA per 1 day) lamivudine oral tablet 300 mg (Epivir) Tier 1 SP; QL (1 EA per 1 day) lamivudine-zidovudine oral tablet 150- (Combivir) Tier 1 SP; QL (2 EA per 1 day) 300 mg LEXIVA ORAL SUSPENSION 50 Tier 2 SP; QL (1800 ML per 30 MG/ML days) lopinavir-ritonavir oral solution 400-100 (Kaletra) Tier 1 SP; QL (480 ML per 30 mg/5ml days) nevirapine er oral tablet extended Tier 1 SP; QL (3 EA per 1 day) release 24 hour 100 mg nevirapine er oral tablet extended (Viramune XR) Tier 1 SP; QL (1 EA per 1 day) release 24 hour 400 mg nevirapine oral suspension 50 mg/5ml (Viramune) Tier 1 SP; QL (1200 ML per 30 days) nevirapine oral tablet 200 mg Tier 1 SP; QL (2 EA per 1 day) NORVIR ORAL PACKET 100 MG Tier 2 SP; QL (12 EA per 1 day)

MedPerform Medium Formulary 01/01/2021

103 Drug Status Notes NORVIR ORAL SOLUTION 80 MG/ML Tier 2 SP; QL (480 ML per 30 days) ODEFSEY ORAL TABLET 200-25-25 Tier 2 SP; QL (1 EA per 1 day) MG PIFELTRO ORAL TABLET 100 MG Tier 2 SP; QL (2 EA per 1 day) PREZCOBIX ORAL TABLET 800-150 Tier 2 SP; QL (1 EA per 1 day) MG PREZISTA ORAL SUSPENSION 100 Tier 2 SP; QL (400 ML per 30 MG/ML days) PREZISTA ORAL TABLET 150 MG Tier 2 SP; QL (8 EA per 1 day) PREZISTA ORAL TABLET 600 MG Tier 2 SP; QL (2 EA per 1 day) PREZISTA ORAL TABLET 75 MG Tier 2 SP; QL (16 EA per 1 day) PREZISTA ORAL TABLET 800 MG Tier 2 SP; QL (1 EA per 1 day) REYATAZ ORAL PACKET 50 MG Tier 2 SP; QL (5 EA per 1 day) ritonavir oral tablet 100 mg (Norvir) Tier 1 SP; QL (12 EA per 1 day) rukobia oral tablet extended release 12 Tier 2 PA; SP hour 600 mg SELZENTRY ORAL SOLUTION 20 Tier 2 SP; QL (31 ML per 1 day) MG/ML SELZENTRY ORAL TABLET 150 MG, Tier 2 SP; QL (2 EA per 1 day) 75 MG SELZENTRY ORAL TABLET 25 MG, Tier 2 SP; QL (4 EA per 1 day) 300 MG stavudine oral capsule 15 mg, 20 mg Tier 1 SP; QL (2 EA per 1 day) stavudine oral capsule 30 mg, 40 mg (Zerit) Tier 1 SP; QL (2 EA per 1 day) STRIBILD ORAL TABLET 150-150-200- Tier 2 SP; QL (1 EA per 1 day) 300 MG SYMTUZA ORAL TABLET 800-150-200- Tier 2 SP; QL (1 EA per 1 day) 10 MG TEMIXYS ORAL TABLET 300-300 MG Tier 2 SP; QL (1 EA per 1 day) tenofovir disoproxil fumarate oral tablet (Viread) Tier 1 SP; $0 COPAY IF NO 300 mg HISTORY OF ANTIRETROVIRAL MEDICATION IN 120 DAYS; QL (1 EA per 1 day)

MedPerform Medium Formulary 01/01/2021

104 Drug Status Notes TIVICAY ORAL TABLET 10 MG, 25 MG, Tier 2 SP; QL (2 EA per 1 day) 50 MG TIVICAY PD ORAL TABLET SOLUBLE Tier 2 SP; QL (6 EA per 1 day) 5 MG TRIUMEQ ORAL TABLET 600-50-300 Tier 2 SP; QL (1 EA per 1 day) MG TRUVADA ORAL TABLET 100-150 MG, Tier 2 SP; QL (1 EA per 1 day) 133-200 MG, 167-250 MG TYBOST ORAL TABLET 150 MG Tier 2 QL (1 EA per 1 day) VIRACEPT ORAL TABLET 250 MG, 625 Tier 2 SP MG VIREAD ORAL POWDER 40 MG/GM Tier 2 SP; QL (240 GM per 30 days) VIREAD ORAL TABLET 150 MG, 200 Tier 2 SP; QL (1 EA per 1 day) MG, 250 MG zidovudine oral capsule 100 mg (Retrovir) Tier 1 SP; QL (6 EA per 1 day) zidovudine oral syrup 50 mg/5ml (Retrovir) Tier 1 SP; QL (1920 ML per 30 days) zidovudine oral tablet 300 mg Tier 1 SP; QL (2 EA per 1 day) Cmv Agents PREVYMIS ORAL TABLET 240 MG, Tier 3 PA 480 MG valganciclovir hcl oral solution (Valcyte) Tier 1 reconstituted 50 mg/ml valganciclovir hcl oral tablet 450 mg (Valcyte) Tier 1 Hepatitis Agents adefovir dipivoxil oral tablet 10 mg (Hepsera) Tier 1 SP; QL (1 EA per 1 day) BARACLUDE ORAL SOLUTION 0.05 Tier 2 SP; QL (630 ML per 30 MG/ML days) entecavir oral tablet 0.5 mg, 1 mg (Baraclude) Tier 1 SP; QL (1 EA per 1 day) EPCLUSA ORAL TABLET 200-50 MG Tier 2 PA; SP EPCLUSA ORAL TABLET 400-100 MG (Sofosbuvir-Velpatasvir) Tier 2 PA; SP EPIVIR HBV ORAL SOLUTION 5 Tier 2 QL (720 ML per 30 days) MG/ML

MedPerform Medium Formulary 01/01/2021

105 Drug Status Notes HARVONI ORAL PACKET 33.75-150 Tier 2 PA; SP MG, 45-200 MG HARVONI ORAL TABLET 45-200 MG Tier 2 PA; SP HARVONI ORAL TABLET 90-400 MG (Ledipasvir-Sofosbuvir) Tier 2 PA; SP lamivudine oral tablet 100 mg (Epivir HBV) Tier 1 QL (1 EA per 1 day) MAVYRET ORAL TABLET 100-40 MG Tier 2 PA; SP PEGASYS SUBCUTANEOUS Tier 2 PA; SP SOLUTION 180 MCG/0.5ML, 180 MCG/ML PEGINTRON SUBCUTANEOUS KIT 50 Tier 3 PA; SP MCG/0.5ML ribavirin oral capsule 200 mg Tier 1 ribavirin oral tablet 200 mg Tier 1 SOVALDI ORAL PACKET 150 MG, 200 Tier 3 PA; SP MG SOVALDI ORAL TABLET 200 MG, 400 Tier 3 PA; SP MG VEMLIDY ORAL TABLET 25 MG Tier 3 SP; ST: Requires prior prescription for Tenofovir Disoproxil Fumarate within the past 120 days; QL (1 EA per 1 day) VOSEVI ORAL TABLET 400-100-100 Tier 2 PA; SP MG Herpes Agents acyclovir oral capsule 200 mg Tier 1 acyclovir oral suspension 200 mg/5ml (Zovirax) Tier 1 acyclovir oral tablet 400 mg, 800 mg Tier 1 famciclovir oral tablet 125 mg, 250 mg, Tier 1 500 mg SITAVIG BUCCAL TABLET 50 MG Tier 3 QL (4 EA per 365 days) valacyclovir hcl oral tablet 1 gm, 500 mg (Valtrex) Tier 1 Influenza Agents oseltamivir phosphate oral capsule 30 (Tamiflu) Tier 1 QL (40 EA per 180 days) mg

MedPerform Medium Formulary 01/01/2021

106 Drug Status Notes oseltamivir phosphate oral capsule 45 (Tamiflu) Tier 1 QL (20 EA per 180 days) mg, 75 mg oseltamivir phosphate oral suspension (Tamiflu) Tier 1 QL (360 ML per 180 days) reconstituted 6 mg/ml RELENZA DISKHALER INHALATION Tier 3 QL (40 EA per 180 days) AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER rimantadine hcl oral tablet 100 mg Tier 1 XOFLUZA (40 MG DOSE) ORAL Tier 2 QL (4 EA per 180 days) TABLET THERAPY PACK 2 X 20 MG XOFLUZA (80 MG DOSE) ORAL Tier 2 QL (4 EA per 180 days) TABLET THERAPY PACK 2 X 40 MG Misc. Antivirals favipiravir oral tablet 200 mg Tier 3 Respiratory Syncytial Virus (Rsv) Agents ribavirin inhalation solution reconstituted (Virazole) Tier 1 6 gm Beta Blockers Alpha-Beta Blockers carvedilol oral tablet 12.5 mg, 25 mg, (Coreg) Tier 1 3.125 mg, 6.25 mg carvedilol phosphate er oral capsule (Coreg CR) Tier 1 extended release 24 hour 10 mg, 20 mg, 40 mg, 80 mg labetalol hcl oral tablet 100 mg, 200 mg, Tier 1 300 mg Beta Blockers Cardio-Selective acebutolol hcl oral capsule 200 mg, 400 Tier 1 mg atenolol oral tablet 100 mg, 25 mg, 50 (Tenormin) Tier 1 mg ATENOLOL+SYRSPEND SF ORAL Tier 3 SUSPENSION 1 MG/ML betaxolol hcl oral tablet 10 mg, 20 mg Tier 1

MedPerform Medium Formulary 01/01/2021

107 Drug Status Notes bisoprolol fumarate oral tablet 10 mg, 5 Tier 1 mg BYSTOLIC ORAL TABLET 10 MG, 2.5 Tier 2 MG, 20 MG, 5 MG FIRST - METOPROLOL ORAL Tier 3 SOLUTION 10 MG/ML FIRST-ATENOLOL ORAL SOLUTION Tier 3 10 MG/ML, 2 MG/ML KAPSPARGO SPRINKLE ORAL Tier 3 CAPSULE ER 24 HOUR SPRINKLE 100 MG, 200 MG, 25 MG, 50 MG metoprolol succinate er oral tablet (Toprol XL) Tier 1 extended release 24 hour 100 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 100 mg, 50 (Lopressor) Tier 1 mg metoprolol tartrate oral tablet 25 mg, Tier 1 37.5 mg, 75 mg Beta Blockers Non-Selective HEMANGEOL ORAL SOLUTION 4.28 Tier 3 ST: Requires prior MG/ML prescription for generic Propranolol oral solution within the past 120 days if 1 year of age and older; QL (360 ML per 30 days) nadolol oral tablet 20 mg, 40 mg, 80 mg (Corgard) Tier 1 pindolol oral tablet 10 mg, 5 mg Tier 1 propranolol hcl er oral capsule extended (Inderal LA) Tier 1 release 24 hour 120 mg, 160 mg, 60 mg, 80 mg propranolol hcl oral solution 20 mg/5ml, Tier 1 40 mg/5ml propranolol hcl oral tablet 10 mg, 20 mg, Tier 1 40 mg, 60 mg, 80 mg SORINE ORAL TABLET 120 MG, 160 (Sotalol HCl) Tier 1 MG, 240 MG, 80 MG

MedPerform Medium Formulary 01/01/2021

108 Drug Status Notes sotalol hcl (af) oral tablet 120 mg, 160 (Betapace AF) Tier 1 mg, 80 mg sotalol hcl oral tablet 120 mg, 160 mg, (Sorine) Tier 1 240 mg, 80 mg SOTYLIZE ORAL SOLUTION 5 MG/ML Tier 3 QL: 8 BOTTLES IN 30 DAYS; ST: Requires prior prescription for Sotalol tablets within the past 120 days timolol maleate oral tablet 10 mg, 20 mg, Tier 1 5 mg Calcium Channel Blockers Calcium Channel Blockers AMLODIPINE BES+SYRSPEND SF Tier 3 ORAL SUSPENSION 1 MG/ML amlodipine besylate oral tablet 10 mg, (Norvasc) Tier 1 2.5 mg, 5 mg CARDIZEM LA ORAL TABLET Tier 3 EXTENDED RELEASE 24 HOUR 120 MG CARTIA XT ORAL CAPSULE (Diltiazem HCl ER Coated Tier 1 EXTENDED RELEASE 24 HOUR 120 Beads) MG CARTIA XT ORAL CAPSULE (DilTIAZem HCl ER Tier 1 EXTENDED RELEASE 24 HOUR 180 Coated Beads) MG, 240 MG, 300 MG CONJUPRI ORAL TABLET 2.5 MG, 5 Tier 3 PA MG diltiazem hcl er beads oral capsule (Taztia XT) Tier 1 extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl er beads oral capsule (Tiadylt ER) Tier 1 extended release 24 hour 420 mg diltiazem hcl er coated beads oral (Cartia XT) Tier 1 capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg

MedPerform Medium Formulary 01/01/2021

109 Drug Status Notes diltiazem hcl er coated beads oral (Cardizem CD) Tier 1 capsule extended release 24 hour 360 mg diltiazem hcl er coated beads oral tablet (Matzim LA) Tier 1 extended release 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er oral capsule extended Tier 1 release 12 hour 120 mg, 60 mg, 90 mg diltiazem hcl er oral capsule extended Tier 1 release 24 hour 120 mg, 180 mg, 240 mg diltiazem hcl oral tablet 120 mg, 30 mg, (Cardizem) Tier 1 60 mg diltiazem hcl oral tablet 90 mg Tier 1 dilt-xr oral capsule extended release 24 Tier 1 hour 120 mg, 180 mg, 240 mg felodipine er oral tablet extended release Tier 1 24 hour 10 mg, 2.5 mg, 5 mg isradipine oral capsule 2.5 mg, 5 mg Tier 1 KATERZIA ORAL SUSPENSION 1 Tier 3 PA MG/ML MATZIM LA ORAL TABLET EXTENDED (dilTIAZem HCl ER Coated Tier 1 RELEASE 24 HOUR 180 MG, 240 MG, Beads) 300 MG, 360 MG, 420 MG nicardipine hcl oral capsule 20 mg, 30 Tier 1 mg nifedipine er oral tablet extended release (Afeditab CR) Tier 1 24 hour 30 mg, 60 mg nifedipine er oral tablet extended release Tier 1 24 hour 90 mg nifedipine er osmotic release oral tablet (Procardia XL) Tier 1 extended release 24 hour 30 mg, 60 mg, 90 mg nifedipine oral capsule 10 mg (Procardia) Tier 1 nifedipine oral capsule 20 mg Tier 1 nimodipine oral capsule 30 mg Tier 1

MedPerform Medium Formulary 01/01/2021

110 Drug Status Notes nisoldipine er oral tablet extended (Sular) Tier 1 release 24 hour 17 mg, 34 mg, 8.5 mg nisoldipine er oral tablet extended Tier 1 release 24 hour 20 mg, 25.5 mg, 30 mg, 40 mg NYMALIZE ORAL SOLUTION 6 MG/ML Tier 3 PA; SP TAZTIA XT ORAL CAPSULE (Diltiazem HCl ER Beads) Tier 1 EXTENDED RELEASE 24 HOUR 120 MG, 240 MG, 300 MG, 360 MG TAZTIA XT ORAL CAPSULE (DilTIAZem HCl ER Tier 1 EXTENDED RELEASE 24 HOUR 180 Beads) MG TIADYLT ER ORAL CAPSULE (Diltiazem HCl ER Beads) Tier 1 EXTENDED RELEASE 24 HOUR 120 MG, 240 MG, 300 MG, 360 MG, 420 MG TIADYLT ER ORAL CAPSULE (DilTIAZem HCl ER Tier 1 EXTENDED RELEASE 24 HOUR 180 Beads) MG verapamil hcl er oral capsule extended (Verelan) Tier 1 release 24 hour 120 mg, 180 mg, 240 mg verapamil hcl er oral tablet extended (Calan SR) Tier 1 release 120 mg, 180 mg, 240 mg verapamil hcl oral tablet 120 mg, 40 mg, Tier 1 80 mg VERELAN ORAL CAPSULE (Verapamil HCl ER) Tier 3 EXTENDED RELEASE 24 HOUR 360 MG VERELAN PM ORAL CAPSULE (Verapamil HCl ER) Tier 3 EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 300 MG Cardiotonics Cardiac Glycosides DIGITEK ORAL TABLET 125 MCG, 250 (Digoxin) Tier 1 MCG

MedPerform Medium Formulary 01/01/2021

111 Drug Status Notes DIGOX ORAL TABLET 125 MCG, 250 (Digoxin) Tier 1 MCG digoxin oral solution 0.05 mg/ml Tier 1 digoxin oral tablet 125 mcg, 250 mcg (Digitek) Tier 1 LANOXIN ORAL TABLET 125 MCG, (Digoxin) Tier 3 250 MCG LANOXIN ORAL TABLET 62.5 MCG Tier 3 Cardiovascular Agents - Misc. Cardiovascular Agents Misc. - Combinations amlodipine-atorvastatin oral tablet 10-10 (Caduet) Tier 1 QL (1 EA per 1 day) mg, 10-20 mg, 10-40 mg, 10-80 mg, 5- 10 mg, 5-20 mg, 5-40 mg, 5-80 mg amlodipine-atorvastatin oral tablet 2.5-10 Tier 1 QL (1 EA per 1 day) mg, 2.5-20 mg, 2.5-40 mg BIDIL ORAL TABLET 20-37.5 MG Tier 2 ENTRESTO ORAL TABLET 24-26 MG, Tier 2 QL (2 EA per 1 day) 49-51 MG, 97-103 MG Impotence Agents bi-mix intracavernosal solution Tier 3 reconstituted 150-5 mg CAVERJECT IMPULSE Tier 3 QL (1 EA per 5 days) INTRACAVERNOSAL KIT 10 MCG, 20 MCG CAVERJECT INTRACAVERNOSAL Tier 3 QL (1 EA per 5 days) SOLUTION RECONSTITUTED 40 MCG EDEX INTRACAVERNOSAL KIT 10 Tier 3 QL: 6 INJECTIONS IN 30 MCG, 20 MCG, 40 MCG DAYS IFE-BIMIX 30/1 INTRACAVERNOSAL Tier 3 SOLUTION 30-1 MG/ML MUSE URETHRAL PELLET 1000 MCG, Tier 3 QL (1 EA per 5 days) 125 MCG, 250 MCG, 500 MCG phenylephrine hcl intracavernosal Tier 3 solution 2 mg/2ml quad-mix intracavernosal solution Tier 3 reconstituted 150-10-0.1-1 mg

MedPerform Medium Formulary 01/01/2021

112 Drug Status Notes sildenafil citrate oral tablet 100 mg, 25 (Viagra) Tier 1 QL (1 EA per 5 days) mg, 50 mg super bi-mix intracavernosal solution Tier 3 reconstituted 150-10 mg super quad-mix intracavernosal solution Tier 3 reconstituted 150-20-0.2-2 mg super tri-mix intracavernosal solution Tier 3 reconstituted 150-10-100 mg-mg-mcg tadalafil oral tablet 10 mg, 20 mg (Cialis) Tier 1 QL (1 EA per 5 days) tadalafil oral tablet 2.5 mg, 5 mg (Cialis) Tier 1 PA; QL (1 EA per 1 day) tri-mix intracavernosal solution Tier 3 reconstituted 150-5-50 mg-mg-mcg vardenafil hcl oral tablet 10 mg, 20 mg (Levitra) Tier 1 ST: Requires prior prescription for Sildenafil Citrate within the past 120 days; QL (1 EA per 5 days) vardenafil hcl oral tablet 2.5 mg, 5 mg Tier 1 ST: Requires prior prescription for Sildenafil Citrate within the past 120 days; QL (1 EA per 5 days) vardenafil hcl oral tablet dispersible 10 (Staxyn) Tier 1 ST: Requires prior mg prescription for Sildenafil Citrate within the past 120 days; QL (1 EA per 5 days) Peripheral Vasodilators isoxsuprine hcl oral tablet 10 mg, 20 mg Tier 1 papaverine hcl injection solution 30 Tier 1 mg/ml Prostaglandin Vasodilators ORENITRAM ORAL TABLET Tier 2 PA; SP EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG, 5 MG treprostinil injection solution 100 (Remodulin) Tier 1 PA; SP mg/20ml, 20 mg/20ml, 200 mg/20ml, 50 mg/20ml

MedPerform Medium Formulary 01/01/2021

113 Drug Status Notes TYVASO INHALATION SOLUTION 0.6 Tier 3 PA; SP MG/ML TYVASO REFILL INHALATION Tier 3 PA; SP SOLUTION 0.6 MG/ML TYVASO STARTER INHALATION Tier 3 PA; SP SOLUTION 0.6 MG/ML VENTAVIS INHALATION SOLUTION 10 Tier 3 PA; SP MCG/ML, 20 MCG/ML Pulmonary Hypertension - Endothelin Receptor Antagonists ambrisentan oral tablet 10 mg, 5 mg (Letairis) Tier 1 PA; SP bosentan oral tablet 125 mg, 62.5 mg (Tracleer) Tier 1 PA; SP OPSUMIT ORAL TABLET 10 MG Tier 2 PA; SP TRACLEER ORAL TABLET SOLUBLE Tier 2 PA; SP 32 MG Pulmonary Hypertension - Phosphodiesterase Inhibitors ALYQ ORAL TABLET 20 MG (Tadalafil (PAH)) Tier 1 PA; SP sildenafil citrate oral suspension (Revatio) Tier 1 PA; SP reconstituted 10 mg/ml sildenafil citrate oral tablet 20 mg (Revatio) Tier 1 PA tadalafil (pah) oral tablet 20 mg (Alyq) Tier 1 PA; SP; QL (1 EA per 5 days) Pulmonary Hypertension - Prostacyclin Receptor Agonist UPTRAVI ORAL TABLET 1000 MCG, Tier 2 PA; SP 1200 MCG, 1400 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG UPTRAVI ORAL TABLET THERAPY Tier 2 PA; SP PACK 200 & 800 MCG Pulmonary Hypertension - Sol Guanylate Cyclase Stimulator ADEMPAS ORAL TABLET 0.5 MG, 1 Tier 2 PA; SP MG, 1.5 MG, 2 MG, 2.5 MG

MedPerform Medium Formulary 01/01/2021

114 Drug Status Notes Sinus Node Inhibitors CORLANOR ORAL SOLUTION 5 Tier 2 QL (20 ML per 1 day) MG/5ML CORLANOR ORAL TABLET 5 MG, 7.5 Tier 2 QL (2 EA per 1 day) MG Unknown VYNDAMAX ORAL CAPSULE 61 MG Tier 3 PA; SP VYNDAQEL ORAL CAPSULE 20 MG Tier 3 PA; SP Cephalosporins Cephalosporins - 1St Generation cefadroxil oral capsule 500 mg Tier 1 cefadroxil oral suspension reconstituted Tier 1 250 mg/5ml, 500 mg/5ml cefadroxil oral tablet 1 gm Tier 1 cephalexin oral capsule 250 mg, 500 (Keflex) Tier 1 mg, 750 mg cephalexin oral suspension reconstituted Tier 1 125 mg/5ml, 250 mg/5ml cephalexin oral tablet 250 mg, 500 mg Tier 1 Cephalosporins - 2Nd Generation cefaclor er oral tablet extended release Tier 1 12 hour 500 mg cefaclor oral capsule 250 mg, 500 mg Tier 1 cefaclor oral suspension reconstituted Tier 1 125 mg/5ml, 250 mg/5ml, 375 mg/5ml cefprozil oral suspension reconstituted Tier 1 125 mg/5ml, 250 mg/5ml cefprozil oral tablet 250 mg, 500 mg Tier 1 cefuroxime axetil oral tablet 250 mg, 500 Tier 1 mg Cephalosporins - 3Rd Generation cefdinir oral capsule 300 mg Tier 1 cefdinir oral suspension reconstituted Tier 1 125 mg/5ml, 250 mg/5ml cefixime oral capsule 400 mg (Suprax) Tier 1

MedPerform Medium Formulary 01/01/2021

115 Drug Status Notes cefixime oral suspension reconstituted (Suprax) Tier 1 100 mg/5ml, 200 mg/5ml cefpodoxime proxetil oral suspension Tier 1 reconstituted 100 mg/5ml, 50 mg/5ml cefpodoxime proxetil oral tablet 100 mg, Tier 1 200 mg SUPRAX ORAL SUSPENSION Tier 2 RECONSTITUTED 500 MG/5ML SUPRAX ORAL TABLET CHEWABLE Tier 2 100 MG, 200 MG Chemicals Acids, Bases, & Buffers potassium hydroxide external solution 5 Tier 1 % sodium hydroxide external solution 10 % Tier 1 Bulk Chemicals - A's enovarx-amitriptyline external kit 2 % Tier 3 Contraceptives Combination Contraceptives - Oral AFIRMELLE ORAL TABLET 0.1-20 MG- (Levonorgestrel-Ethinyl $0 MCG Estrad) ALTAVERA ORAL TABLET 0.15-30 MG- (Marlissa) $0 MCG alyacen 1/35 oral tablet 1-35 mg-mcg (Cyclafem 1/35) $0 alyacen 7/7/7 oral tablet 0.5/0.75/1-35 (Cyclafem 7/7/7) $0 mg-mcg AMETHIA LO ORAL TABLET 0.1-0.02 & (Levonorgest-Eth Estrad $0 QL (91 EA per 84 days) 0.01 MG 91-Day) AMETHIA ORAL TABLET 0.15-0.03 (Levonorgest-Eth Estrad $0 QL (91 EA per 84 days) &0.01 MG 91-Day) AMETHYST ORAL TABLET 90-20 MCG (Levonorgestrel-Ethinyl $0 Estrad) APRI ORAL TABLET 0.15-30 MG-MCG $0 ARANELLE ORAL TABLET 0.5/1/0.5-35 $0 MG-MCG

MedPerform Medium Formulary 01/01/2021

116 Drug Status Notes ASHLYNA ORAL TABLET 0.15-0.03 (Levonorgest-Eth Estrad $0 QL (91 EA per 84 days) &0.01 MG 91-Day) AUBRA EQ ORAL TABLET 0.1-20 MG- (Levonorgestrel-Ethinyl $0 MCG Estrad) AUBRA ORAL TABLET 0.1-20 MG-MCG (Levonorgestrel-Ethinyl $0 Estrad) AUROVELA 1.5/30 ORAL TABLET 1.5- (Norethindrone Acet- $0 30 MG-MCG Ethinyl Est) AUROVELA 1/20 ORAL TABLET 1-20 (Norethindrone Acet- $0 MG-MCG Ethinyl Est) AUROVELA 24 FE ORAL TABLET 1-20 $0 MG-MCG(24) AUROVELA FE 1.5/30 ORAL TABLET (Norethin Ace-Eth Estrad- $0 1.5-30 MG-MCG FE) AUROVELA FE 1/20 ORAL TABLET 1- (Norethin Ace-Eth Estrad- $0 20 MG-MCG FE) AVIANE ORAL TABLET 0.1-20 MG- (Levonorgestrel-Ethinyl $0 MCG Estrad) AYUNA ORAL TABLET 0.15-30 MG- (Marlissa) $0 MCG AZURETTE ORAL TABLET 0.15- (Desogestrel-Ethinyl $0 0.02/0.01 MG (21/5) Estradiol) BALCOLTRA ORAL TABLET 0.1-20 $0 ST: At least 2 prior MG-MCG(21) prescriptions for generic oral contraceptives within the past 365 days; QL (1 EA per 1 day) BALZIVA ORAL TABLET 0.4-35 MG- (Briellyn) $0 MCG BEKYREE ORAL TABLET 0.15- (Desogestrel-Ethinyl $0 0.02/0.01 MG (21/5) Estradiol) BLISOVI 24 FE ORAL TABLET 1-20 $0 MG-MCG(24) BLISOVI FE 1.5/30 ORAL TABLET 1.5- (Norethin Ace-Eth Estrad- $0 30 MG-MCG FE)

MedPerform Medium Formulary 01/01/2021

117 Drug Status Notes BLISOVI FE 1/20 ORAL TABLET 1-20 (Norethin Ace-Eth Estrad- $0 MG-MCG FE) briellyn oral tablet 0.4-35 mg-mcg (Balziva) $0 CAMRESE LO ORAL TABLET 0.1-0.02 (Levonorgest-Eth Estrad $0 QL (91 EA per 84 days) & 0.01 MG 91-Day) CAMRESE ORAL TABLET 0.15-0.03 (Levonorgest-Eth Estrad $0 QL (91 EA per 84 days) &0.01 MG 91-Day) CAZIANT ORAL TABLET 0.1/0.125/0.15 $0 -0.025 MG CHARLOTTE 24 FE ORAL TABLET (Norethin Ace-Eth Estrad- $0 CHEWABLE 1-20 MG-MCG(24) FE) CHATEAL EQ ORAL TABLET 0.15-30 (Marlissa) $0 MG-MCG CHATEAL ORAL TABLET 0.15-30 MG- (Marlissa) $0 MCG CRYSELLE-28 ORAL TABLET 0.3-30 $0 MG-MCG CYCLAFEM 1/35 ORAL TABLET 1-35 (Alyacen 1/35) $0 MG-MCG CYCLAFEM 7/7/7 ORAL TABLET (Alyacen 7/7/7) $0 0.5/0.75/1-35 MG-MCG CYRED EQ ORAL TABLET 0.15-30 MG- $0 MCG CYRED ORAL TABLET 0.15-30 MG- $0 MCG DASETTA 1/35 ORAL TABLET 1-35 (Alyacen 1/35) $0 MG-MCG DASETTA 7/7/7 ORAL TABLET (Alyacen 7/7/7) $0 0.5/0.75/1-35 MG-MCG DAYSEE ORAL TABLET 0.15-0.03 (Levonorgest-Eth Estrad $0 QL (91 EA per 84 days) &0.01 MG 91-Day) DELYLA ORAL TABLET 0.1-20 MG- (Levonorgestrel-Ethinyl $0 MCG Estrad) desogestrel-ethinyl estradiol oral tablet (Azurette) $0 0.15-0.02/0.01 mg (21/5)

MedPerform Medium Formulary 01/01/2021

118 Drug Status Notes drospiren-eth estrad-levomefol oral (Beyaz) $0 tablet 3-0.02-0.451 mg drospiren-eth estrad-levomefol oral (Tydemy) $0 tablet 3-0.03-0.451 mg drospirenone-ethinyl estradiol oral tablet (Gianvi) $0 3-0.02 mg drospirenone-ethinyl estradiol oral tablet (Ocella) $0 3-0.03 mg ELINEST ORAL TABLET 0.3-30 MG- $0 MCG EMOQUETTE ORAL TABLET 0.15-30 $0 MG-MCG ENPRESSE-28 ORAL TABLET 50- (Levonorg-Eth Estrad $0 30/75-40/ 125-30 MCG Triphasic) ENSKYCE ORAL TABLET 0.15-30 MG- $0 MCG ESTARYLLA ORAL TABLET 0.25-35 (Norgestimate-Eth $0 MG-MCG Estradiol) ethynodiol diac-eth estradiol oral tablet (Kelnor 1/35) $0 1-35 mg-mcg ethynodiol diac-eth estradiol oral tablet (Kelnor 1/50) $0 1-50 mg-mcg FALESSA ORAL KIT 20-1-0.1 MCG-MG Tier 3 FALMINA ORAL TABLET 0.1-20 MG- (Levonorgestrel-Ethinyl $0 MCG Estrad) FAYOSIM ORAL TABLET 42-21-21-7 (Levonorgest-Eth Est & $0 DAYS Eth Est) FEMYNOR ORAL TABLET 0.25-35 MG- (Norgestimate-Eth $0 MCG Estradiol) GEMMILY ORAL CAPSULE 1-20 MG- (Norethin Ace-Eth Estrad- $0 ST: At least 2 prior MCG(24) FE) prescriptions for generic oral contraceptives within the past 365 days GIANVI ORAL TABLET 3-0.02 MG (Drospirenone-Ethinyl $0 Estradiol)

MedPerform Medium Formulary 01/01/2021

119 Drug Status Notes HAILEY 1.5/30 ORAL TABLET 1.5-30 (Norethindrone Acet- $0 MG-MCG Ethinyl Est) HAILEY 24 FE ORAL TABLET 1-20 MG- $0 MCG(24) HAILEY FE 1.5/30 ORAL TABLET 1.5- (Norethin Ace-Eth Estrad- $0 30 MG-MCG FE) HAILEY FE 1/20 ORAL TABLET 1-20 (Norethin Ace-Eth Estrad- $0 MG-MCG FE) INTROVALE ORAL TABLET 0.15-0.03 (Levonorgest-Eth Estrad $0 QL (91 EA per 84 days) MG 91-Day) ISIBLOOM ORAL TABLET 0.15-30 MG- $0 MCG JAIMIESS ORAL TABLET 0.15-0.03 (Levonorgest-Eth Estrad $0 QL (91 EA per 84 days) &0.01 MG 91-Day) JASMIEL ORAL TABLET 3-0.02 MG (Drospirenone-Ethinyl $0 Estradiol) JOLESSA ORAL TABLET 0.15-0.03 MG (Levonorgest-Eth Estrad $0 QL (91 EA per 84 days) 91-Day) JULEBER ORAL TABLET 0.15-30 MG- $0 MCG JUNEL 1.5/30 ORAL TABLET 1.5-30 (Norethindrone Acet- $0 MG-MCG Ethinyl Est) JUNEL 1/20 ORAL TABLET 1-20 MG- (Norethindrone Acet- $0 MCG Ethinyl Est) JUNEL FE 1.5/30 ORAL TABLET 1.5-30 (Norethin Ace-Eth Estrad- $0 MG-MCG FE) JUNEL FE 1/20 ORAL TABLET 1-20 (Norethin Ace-Eth Estrad- $0 MG-MCG FE) JUNEL FE 24 ORAL TABLET 1-20 MG- $0 MCG(24) KAITLIB FE ORAL TABLET (Norethin-Eth Estradiol-Fe) $0 CHEWABLE 0.8-25 MG-MCG KALLIGA ORAL TABLET 0.15-30 MG- $0 MCG KARIVA ORAL TABLET 0.15-0.02/0.01 (Desogestrel-Ethinyl $0 MG (21/5) Estradiol)

MedPerform Medium Formulary 01/01/2021

120 Drug Status Notes KELNOR 1/35 ORAL TABLET 1-35 MG- (Ethynodiol Diac-Eth $0 MCG Estradiol) KELNOR 1/50 ORAL TABLET 1-50 MG- (Ethynodiol Diac-Eth $0 MCG Estradiol) KURVELO ORAL TABLET 0.15-30 MG- (Marlissa) $0 MCG LARIN 1.5/30 ORAL TABLET 1.5-30 (Norethindrone Acet- $0 MG-MCG Ethinyl Est) LARIN 1/20 ORAL TABLET 1-20 MG- (Norethindrone Acet- $0 MCG Ethinyl Est) LARIN 24 FE ORAL TABLET 1-20 MG- $0 MCG(24) LARIN FE 1.5/30 ORAL TABLET 1.5-30 (Norethin Ace-Eth Estrad- $0 MG-MCG FE) LARIN FE 1/20 ORAL TABLET 1-20 (Norethin Ace-Eth Estrad- $0 MG-MCG FE) LARISSIA ORAL TABLET 0.1-20 MG- (Levonorgestrel-Ethinyl $0 MCG Estrad) LAYOLIS FE ORAL TABLET (Norethin-Eth Estradiol-Fe) $0 CHEWABLE 0.8-25 MG-MCG LEENA ORAL TABLET 0.5/1/0.5-35 MG- $0 MCG LESSINA ORAL TABLET 0.1-20 MG- (Levonorgestrel-Ethinyl $0 MCG Estrad) LEVONEST ORAL TABLET 50-30/75- (Levonorg-Eth Estrad $0 40/ 125-30 MCG Triphasic) levonorgest-eth est & eth est oral tablet (Fayosim) $0 QL (91 EA per 84 days) 42-21-21-7 days levonorgest-eth estrad 91-day oral tablet (Amethia Lo) $0 QL (91 EA per 84 days) 0.1-0.02 & 0.01 mg levonorgest-eth estrad 91-day oral tablet (Amethia) $0 QL (91 EA per 84 days) 0.15-0.03 &0.01 mg levonorgest-eth estrad 91-day oral tablet (Introvale) $0 QL (91 EA per 84 days) 0.15-0.03 mg levonorgestrel-ethinyl estrad oral tablet (Tyblume) $0 0.1-20 mg-mcg

MedPerform Medium Formulary 01/01/2021

121 Drug Status Notes levonorgestrel-ethinyl estrad oral tablet (Altavera) $0 QL (91 EA per 84 days) 0.15-30 mg-mcg levonorgestrel-ethinyl estrad oral tablet (Amethyst) $0 90-20 mcg levonorg-eth estrad triphasic oral tablet (Enpresse-28) $0 50-30/75-40/ 125-30 mcg LEVORA 0.15/30 (28) ORAL TABLET (Marlissa) $0 0.15-30 MG-MCG LILLOW ORAL TABLET 0.15-30 MG- (Marlissa) $0 MCG LO LOESTRIN FE ORAL TABLET 1 $0 ST: At least 2 prior MG-10 MCG / 10 MCG prescriptions for generic oral contraceptives within the past 365 days LOESTRIN 1.5/30 (21) ORAL TABLET (Norethindrone Acet- $0 1.5-30 MG-MCG Ethinyl Est) LOESTRIN 1/20 (21) ORAL TABLET 1- (Norethindrone Acet- $0 20 MG-MCG Ethinyl Est) LOESTRIN FE 1.5/30 ORAL TABLET (Norethin Ace-Eth Estrad- $0 1.5-30 MG-MCG FE) LOESTRIN FE 1/20 ORAL TABLET 1-20 (Norethin Ace-Eth Estrad- $0 MG-MCG FE) LOJAIMIESS ORAL TABLET 0.1-0.02 & (Levonorgest-Eth Estrad $0 QL (91 EA per 84 days) 0.01 MG 91-Day) LORYNA ORAL TABLET 3-0.02 MG (Drospirenone-Ethinyl $0 Estradiol) LOW-OGESTREL ORAL TABLET 0.3- $0 30 MG-MCG LO-ZUMANDIMINE ORAL TABLET 3- (Drospirenone-Ethinyl $0 0.02 MG Estradiol) LUTERA ORAL TABLET 0.1-20 MG- (Levonorgestrel-Ethinyl $0 MCG Estrad) marlissa oral tablet 0.15-30 mg-mcg (Altavera) $0 MELODETTA 24 FE ORAL TABLET (Norethin Ace-Eth Estrad- $0 CHEWABLE 1-20 MG-MCG(24) FE)

MedPerform Medium Formulary 01/01/2021

122 Drug Status Notes MIBELAS 24 FE ORAL TABLET (Norethin Ace-Eth Estrad- $0 CHEWABLE 1-20 MG-MCG(24) FE) MICROGESTIN 1.5/30 ORAL TABLET (Norethindrone Acet- $0 1.5-30 MG-MCG Ethinyl Est) MICROGESTIN 1/20 ORAL TABLET 1- (Norethindrone Acet- $0 20 MG-MCG Ethinyl Est) MICROGESTIN 24 FE ORAL TABLET $0 1-20 MG-MCG MICROGESTIN FE 1.5/30 ORAL (Norethin Ace-Eth Estrad- $0 TABLET 1.5-30 MG-MCG FE) MICROGESTIN FE 1/20 ORAL TABLET (Norethin Ace-Eth Estrad- $0 1-20 MG-MCG FE) MILI ORAL TABLET 0.25-35 MG-MCG (Norgestimate-Eth $0 Estradiol) MONO-LINYAH ORAL TABLET 0.25-35 (Norgestimate-Eth $0 MG-MCG Estradiol) NATAZIA ORAL TABLET 3/2-2/2-3/1 $0 ST: At least 2 prior MG prescriptions for generic oral contraceptives within the past 365 days NECON 0.5/35 (28) ORAL TABLET 0.5- $0 35 MG-MCG NIKKI ORAL TABLET 3-0.02 MG (Drospirenone-Ethinyl $0 Estradiol) norethin ace-eth estrad-fe oral capsule (Gemmily) $0 ST: At least 2 prior 1-20 mg-mcg(24) prescriptions for generic oral contraceptives within the past 365 days norethin ace-eth estrad-fe oral tablet 1.5- (Aurovela Fe 1.5/30) $0 30 mg-mcg norethin ace-eth estrad-fe oral tablet 1- (Aurovela FE 1/20) $0 20 mg-mcg norethin ace-eth estrad-fe oral tablet (Charlotte 24 Fe) $0 chewable 1-20 mg-mcg(24) norethindrone acet-ethinyl est oral tablet (Aurovela 1.5/30) $0 1.5-30 mg-mcg

MedPerform Medium Formulary 01/01/2021

123 Drug Status Notes norethindrone acet-ethinyl est oral tablet (Aurovela 1/20) $0 1-20 mg-mcg norethin-eth estradiol-fe oral tablet (Wymzya Fe) $0 chewable 0.4-35 mg-mcg norethin-eth estradiol-fe oral tablet (Kaitlib Fe) $0 chewable 0.8-25 mg-mcg norgestimate-eth estradiol oral tablet (Estarylla) $0 0.25-35 mg-mcg norgestim-eth estrad triphasic oral tablet (Tri-Lo-Estarylla) $0 0.18/0.215/0.25 mg-25 mcg norgestim-eth estrad triphasic oral tablet (Tri Femynor) $0 0.18/0.215/0.25 mg-35 mcg NORTREL 0.5/35 (28) ORAL TABLET $0 0.5-35 MG-MCG NORTREL 1/35 (21) ORAL TABLET 1- (Alyacen 1/35) $0 35 MG-MCG NORTREL 1/35 (28) ORAL TABLET 1- (Alyacen 1/35) $0 35 MG-MCG NORTREL 7/7/7 ORAL TABLET (Alyacen 7/7/7) $0 0.5/0.75/1-35 MG-MCG OCELLA ORAL TABLET 3-0.03 MG (Drospirenone-Ethinyl $0 Estradiol) ORSYTHIA ORAL TABLET 0.1-20 MG- (Levonorgestrel-Ethinyl $0 MCG Estrad) PHILITH ORAL TABLET 0.4-35 MG- (Briellyn) $0 MCG PIMTREA ORAL TABLET 0.15- (Desogestrel-Ethinyl $0 0.02/0.01 MG (21/5) Estradiol) PIRMELLA 1/35 ORAL TABLET 1-35 (Alyacen 1/35) $0 MG-MCG PIRMELLA 7/7/7 ORAL TABLET (Alyacen 7/7/7) $0 0.5/0.75/1-35 MG-MCG PORTIA-28 ORAL TABLET 0.15-30 MG- (Marlissa) $0 MCG PREVIFEM ORAL TABLET 0.25-35 MG- (Norgestimate-Eth $0 MCG Estradiol)

MedPerform Medium Formulary 01/01/2021

124 Drug Status Notes RECLIPSEN ORAL TABLET 0.15-30 $0 MG-MCG RIVELSA ORAL TABLET 42-21-21-7 (Levonorgest-Eth Est & $0 DAYS Eth Est) SETLAKIN ORAL TABLET 0.15-0.03 (Levonorgest-Eth Estrad $0 QL (91 EA per 84 days) MG 91-Day) SIMLIYA ORAL TABLET 0.15-0.02/0.01 (Desogestrel-Ethinyl $0 MG (21/5) Estradiol) SIMPESSE ORAL TABLET 0.15-0.03 (Levonorgest-Eth Estrad $0 QL (91 EA per 84 days) &0.01 MG 91-Day) SPRINTEC 28 ORAL TABLET 0.25-35 (Norgestimate-Eth $0 MG-MCG Estradiol) SRONYX ORAL TABLET 0.1-20 MG- (Levonorgestrel-Ethinyl $0 MCG Estrad) SYEDA ORAL TABLET 3-0.03 MG (Drospirenone-Ethinyl $0 Estradiol) TARINA 24 FE ORAL TABLET 1-20 MG- $0 MCG(24) TARINA FE 1/20 EQ ORAL TABLET 1- (Norethin Ace-Eth Estrad- $0 20 MG-MCG FE) TARINA FE 1/20 ORAL TABLET 1-20 (Norethin Ace-Eth Estrad- $0 MG-MCG FE) TILIA FE ORAL TABLET 1-20/1-30/1-35 $0 MG-MCG TRI FEMYNOR ORAL TABLET (Norgestim-Eth Estrad $0 0.18/0.215/0.25 MG-35 MCG Triphasic) TRI-ESTARYLLA ORAL TABLET (Norgestim-Eth Estrad $0 0.18/0.215/0.25 MG-35 MCG Triphasic) TRI-LEGEST FE ORAL TABLET 1-20/1- $0 30/1-35 MG-MCG TRI-LINYAH ORAL TABLET (Norgestim-Eth Estrad $0 0.18/0.215/0.25 MG-35 MCG Triphasic) TRI-LO-ESTARYLLA ORAL TABLET (Norgestim-Eth Estrad $0 0.18/0.215/0.25 MG-25 MCG Triphasic) TRI-LO-MARZIA ORAL TABLET (Norgestim-Eth Estrad $0 0.18/0.215/0.25 MG-25 MCG Triphasic)

MedPerform Medium Formulary 01/01/2021

125 Drug Status Notes TRI-LO-MILI ORAL TABLET (Norgestim-Eth Estrad $0 0.18/0.215/0.25 MG-25 MCG Triphasic) TRI-LO-SPRINTEC ORAL TABLET (Norgestim-Eth Estrad $0 0.18/0.215/0.25 MG-25 MCG Triphasic) TRI-MILI ORAL TABLET 0.18/0.215/0.25 (Norgestim-Eth Estrad $0 MG-35 MCG Triphasic) TRI-PREVIFEM ORAL TABLET (Norgestim-Eth Estrad $0 0.18/0.215/0.25 MG-35 MCG Triphasic) TRI-SPRINTEC ORAL TABLET (Norgestim-Eth Estrad $0 0.18/0.215/0.25 MG-35 MCG Triphasic) TRIVORA (28) ORAL TABLET 50-30/75- (Levonorg-Eth Estrad $0 40/ 125-30 MCG Triphasic) TRI-VYLIBRA LO ORAL TABLET (Norgestim-Eth Estrad $0 0.18/0.215/0.25 MG-25 MCG Triphasic) TRI-VYLIBRA ORAL TABLET (Norgestim-Eth Estrad $0 0.18/0.215/0.25 MG-35 MCG Triphasic) TYBLUME ORAL TABLET 0.1-20 MG- (Levonorgestrel-Ethinyl Tier 3 ST: Requires prior MCG Estrad) prescription for a generic contraceptive within the past 120 days TYDEMY ORAL TABLET 3-0.03-0.451 (Drospiren-Eth Estrad- $0 MG Levomefol) VELIVET ORAL TABLET 0.1/0.125/0.15 $0 -0.025 MG VIENVA ORAL TABLET 0.1-20 MG- (Levonorgestrel-Ethinyl $0 MCG Estrad) viorele oral tablet 0.15-0.02/0.01 mg (Azurette) $0 (21/5) VOLNEA ORAL TABLET 0.15-0.02/0.01 (Desogestrel-Ethinyl $0 MG (21/5) Estradiol) VYFEMLA ORAL TABLET 0.4-35 MG- (Briellyn) $0 MCG VYLIBRA ORAL TABLET 0.25-35 MG- (Norgestimate-Eth $0 MCG Estradiol) WERA ORAL TABLET 0.5-35 MG-MCG $0

MedPerform Medium Formulary 01/01/2021

126 Drug Status Notes WYMZYA FE ORAL TABLET (Norethin-Eth Estradiol-Fe) $0 CHEWABLE 0.4-35 MG-MCG ZARAH ORAL TABLET 3-0.03 MG (Drospirenone-Ethinyl $0 Estradiol) ZOVIA 1/35 (28) ORAL TABLET 1-35 (Ethynodiol Diac-Eth $0 MG-MCG Estradiol) ZOVIA 1/35E (28) ORAL TABLET 1-35 (Ethynodiol Diac-Eth $0 MG-MCG Estradiol) ZUMANDIMINE ORAL TABLET 3-0.03 (Drospirenone-Ethinyl $0 MG Estradiol) Combination Contraceptives - Transdermal TWIRLA TRANSDERMAL PATCH Tier 3 QL (3 EA per 28 days) WEEKLY 120-30 MCG/24HR XULANE TRANSDERMAL PATCH Tier 3 QL (3 EA per 28 days) WEEKLY 150-35 MCG/24HR Combination Contraceptives - Vaginal ANNOVERA VAGINAL RING 0.013-0.15 $0 ST: Requires prior MG/24HR prescription for Etonogestrel-Ethinyl Estradiol within the past 120 days; QL (1 EA per 365 days) ELURYNG VAGINAL RING 0.12-0.015 (Etonogestrel-Ethinyl $0 QL (1 EA per 28 days) MG/24HR Estradiol) etonogestrel-ethinyl estradiol vaginal ring (EluRyng) $0 QL (1 EA per 28 days) 0.12-0.015 mg/24hr Emergency Contraceptives AFTERA ORAL TABLET 1.5 MG (Levonorgestrel) $0 ECONTRA EZ ORAL TABLET 1.5 MG (Levonorgestrel) $0 ECONTRA ONE-STEP ORAL TABLET (Levonorgestrel) $0 1.5 MG ELLA ORAL TABLET 30 MG $0 levonorgestrel oral tablet 1.5 mg (Aftera) $0 MY CHOICE ORAL TABLET 1.5 MG (Levonorgestrel) $0 MY WAY ORAL TABLET 1.5 MG (Levonorgestrel) $0

MedPerform Medium Formulary 01/01/2021

127 Drug Status Notes NEW DAY ORAL TABLET 1.5 MG (Levonorgestrel) $0 OPCICON ONE-STEP ORAL TABLET (Levonorgestrel) $0 1.5 MG OPTION 2 ORAL TABLET 1.5 MG (Levonorgestrel) $0 PREVENTEZA ORAL TABLET 1.5 MG (Levonorgestrel) $0 REACT ORAL TABLET 1.5 MG (Levonorgestrel) $0 TAKE ACTION ORAL TABLET 1.5 MG (Levonorgestrel) $0 Progestin Contraceptives - Implants NEXPLANON SUBCUTANEOUS $0 QL (1 EA per 365 days) IMPLANT 68 MG Progestin Contraceptives - Injectable DEPO-SUBQ PROVERA 104 $0 QL (0.65 ML per 84 days) SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE 104 MG/0.65ML medroxyprogesterone acetate (Depo-Provera) $0 QL (1 ML per 84 days) intramuscular suspension 150 mg/ml medroxyprogesterone acetate (Depo-Provera) $0 QL (1 ML per 84 days) intramuscular suspension prefilled syringe 150 mg/ml Progestin Contraceptives - Iud KYLEENA INTRAUTERINE $0 INTRAUTERINE DEVICE 19.5 MG Progestin Contraceptives - Oral CAMILA ORAL TABLET 0.35 MG (Norethindrone) $0 DEBLITANE ORAL TABLET 0.35 MG (Norethindrone) $0 ERRIN ORAL TABLET 0.35 MG (Norethindrone) $0 HEATHER ORAL TABLET 0.35 MG (Norethindrone) $0 INCASSIA ORAL TABLET 0.35 MG (Norethindrone) $0 JENCYCLA ORAL TABLET 0.35 MG (Norethindrone) $0 LYZA ORAL TABLET 0.35 MG (Norethindrone) $0 NORA-BE ORAL TABLET 0.35 MG (Norethindrone) $0 norethindrone oral tablet 0.35 mg (Camila) $0 NORLYDA ORAL TABLET 0.35 MG (Norethindrone) $0 NORLYROC ORAL TABLET 0.35 MG (Norethindrone) $0 SHAROBEL ORAL TABLET 0.35 MG (Norethindrone) $0

MedPerform Medium Formulary 01/01/2021

128 Drug Status Notes SLYND ORAL TABLET 4 MG $0 ST: Requires prior prescription for a generic contraceptive within the past 120 days; QL (1 EA per 1 day) TULANA ORAL TABLET 0.35 MG (Norethindrone) $0 Corticosteroids Glucocorticosteroids active injection kl-3 combination kit 40-1 (Interarticular Joint) Tier 3 mg/ml-% ALKINDI SPRINKLE ORAL CAPSULE Tier 3 PA SPRINKLE 0.5 MG, 1 MG, 2 MG, 5 MG BETALOAN SUIK COMBINATION KIT (Pod-Care 100CG) Tier 3 30 MG/5ML budesonide er oral tablet extended (Uceris) Tier 1 ST: Requires prior release 24 hour 9 mg prescription for Balsalazide Disodium within the past 120 days budesonide oral capsule delayed release (Entocort EC) Tier 1 particles 3 mg CONTRAST ALLERGY PREMED PACK Tier 3 ORAL KIT 3 X 50 MG & 1 X 50 MG cortisone acetate oral tablet 25 mg Tier 1 DECADRON ORAL TABLET 0.5 MG, (Dexamethasone) Tier 1 0.75 MG, 4 MG, 6 MG DEXAMETHASONE INTENSOL ORAL Tier 3 CONCENTRATE 1 MG/ML dexamethasone oral elixir 0.5 mg/5ml Tier 1 dexamethasone oral solution 0.5 mg/5ml Tier 1 dexamethasone oral tablet 0.5 mg, 0.75 (Decadron) Tier 1 mg, 4 mg, 6 mg dexamethasone oral tablet 1 mg, 1.5 mg, Tier 1 2 mg DEXONTO 0.4% IONTOPHORESIS Tier 3 SOLUTION 20 MG/5ML

MedPerform Medium Formulary 01/01/2021

129 Drug Status Notes EMFLAZA ORAL SUSPENSION 22.75 Tier 3 PA; SP MG/ML EMFLAZA ORAL TABLET 18 MG, 30 Tier 3 PA; SP MG, 36 MG, 6 MG HEMADY ORAL TABLET 20 MG Tier 3 hydrocortisone oral tablet 10 mg, 20 mg, (Cortef) Tier 1 5 mg MEDPREDKIT COMBINATION KIT 4 Tier 1 MG MEDROL ORAL TABLET 2 MG Tier 2 MEDROLOAN II SUIK COMBINATION Tier 3 KIT 40 MG/ML MEDROLOAN SUIK COMBINATION Tier 3 KIT 40 MG/ML methylprednisolone oral tablet 16 mg, 32 (Medrol) Tier 1 mg, 4 mg, 8 mg methylprednisolone oral tablet therapy (Medrol) Tier 1 pack 4 mg MILLIPRED DP 12-DAY ORAL TABLET Tier 2 THERAPY PACK 5 MG (48) MILLIPRED ORAL TABLET 5 MG Tier 2 p-care k40g combination kit 40 mg/ml (Triloan II SUIK) Tier 3 p-care k80g combination kit 40 mg/ml (Triloan II SUIK) Tier 3 physicians ez use joint/tunnel (Interarticular Joint) Tier 3 combination kit 40-1 mg/ml-% pod-care 100cg combination kit 30 (Betaloan SUIK) Tier 3 mg/5ml pod-care 100kg combination kit 40 (Triloan II SUIK) Tier 3 mg/ml prednisolone oral solution 15 mg/5ml Tier 1 prednisolone sodium phosphate oral Tier 1 solution 10 mg/5ml, 15 mg/5ml, 20 mg/5ml prednisolone sodium phosphate oral (Pediapred) Tier 1 solution 6.7 (5 base) mg/5ml

MedPerform Medium Formulary 01/01/2021

130 Drug Status Notes prednisolone sodium phosphate oral (Orapred ODT) Tier 1 tablet dispersible 10 mg, 15 mg, 30 mg PREDNISONE INTENSOL ORAL Tier 2 CONCENTRATE 5 MG/ML prednisone oral solution 5 mg/5ml Tier 1 prednisone oral tablet 1 mg, 10 mg, 2.5 Tier 1 mg, 20 mg, 5 mg, 50 mg prednisone oral tablet therapy pack 10 Tier 1 mg (21), 10 mg (48), 5 mg (21), 5 mg (48) SOLU-CORTEF INJECTION SOLUTION Tier 3 RECONSTITUTED 100 MG TRILOAN II SUIK COMBINATION KIT (P-Care K80G) Tier 3 40 MG/ML TRILOAN SUIK COMBINATION KIT 40 (P-Care K80G) Tier 3 MG/ML Mineralocorticoids fludrocortisone acetate oral tablet 0.1 mg Tier 1 Cough/Cold/Allergy Antitussives benzonatate oral capsule 100 mg (Tessalon Perles) Tier 1 benzonatate oral capsule 150 mg, 200 Tier 1 mg hydrocodone-homatropine oral syrup 5- (Hycodan) Tier 1 QL (30 ML per 1 day); AGE 1.5 mg/5ml (Min 18 Years) hydrocodone-homatropine oral tablet 5- Tier 1 QL (6 EA per 1 day); AGE 1.5 mg (Min 18 Years) hydromet oral syrup 5-1.5 mg/5ml (Hycodan) Tier 1 QL (30 ML per 1 day); AGE (Min 18 Years) Cough/Cold/Allergy Combinations BROMFED DM ORAL SYRUP 30-2-10 (Pseudoeph-Bromphen- Tier 1 MG/5ML DM) capcof oral syrup 5-2-10 mg/5ml Tier 3 AGE (Min 12 Years)

MedPerform Medium Formulary 01/01/2021

131 Drug Status Notes CLARINEX-D 12 HOUR ORAL TABLET Tier 3 ST: Requires prior EXTENDED RELEASE 12 HOUR 2.5- prescription for 120 MG Desloratadine or Levocetirizine tablets within the past 120 days; QL (2 EA per 1 day) coditussin ac oral liquid 200-10 mg/5ml Tier 3 AGE (Min 12 Years) coditussin dac oral liquid 30-10-200 Tier 3 AGE (Min 12 Years) mg/5ml g tussin ac oral solution 100-10 mg/5ml Tier 1 AGE (Min 12 Years) GILPHEX TR ORAL TABLET 10-388 Tier 3 MG GILTUSS TR ORAL TABLET 10-28-388 Tier 3 MG guaiatussin ac oral syrup 100-10 mg/5ml Tier 1 AGE (Min 12 Years) guaifenesin ac oral syrup 100-10 mg/5ml Tier 1 AGE (Min 12 Years) guaifenesin dac oral solution 30-10-100 Tier 1 AGE (Min 12 Years) mg/5ml guaifenesin-codeine oral solution 100-10 Tier 1 AGE (Min 12 Years) mg/5ml HISTEX-AC ORAL SYRUP 10-2.5-10 Tier 3 AGE (Min 12 Years) MG/5ML hydrocod polst-cpm polst er oral Tier 1 QL (10 ML per 1 day); AGE suspension extended release 10-8 (Min 18 Years) mg/5ml MAR-COF BP ORAL LIQUID 30-2-7.5 Tier 3 AGE (Min 12 Years) MG/5ML maxi-tuss ac oral solution 100-10 Tier 1 mg/5ml maxi-tuss cd oral liquid 10-4-10 mg/5ml Tier 3 AGE (Min 12 Years) m-clear wc oral solution 100-6.3 mg/5ml Tier 3 AGE (Min 12 Years) M-END PE ORAL LIQUID 3.33-1.33- Tier 3 AGE (Min 12 Years) 6.33 MG/5ML NEOTUSS PLUS ORAL LIQUID 7.5-4- Tier 3 30 MG/5ML

MedPerform Medium Formulary 01/01/2021

132 Drug Status Notes NINJACOF-XG ORAL LIQUID 200-8 Tier 3 AGE (Min 12 Years) MG/5ML poly-tussin ac oral liquid 10-4-10 mg/5ml Tier 3 AGE (Min 12 Years) promethazine-codeine oral solution 6.25- Tier 1 QL (30 ML per 1 day); AGE 10 mg/5ml (Min 18 Years) promethazine-codeine oral syrup 6.25- Tier 1 QL (30 ML per 1 day); AGE 10 mg/5ml (Min 18 Years) promethazine-dm oral syrup 6.25-15 Tier 1 mg/5ml promethazine-phenyleph-codeine oral Tier 1 QL (30 ML per 1 day); AGE syrup 6.25-5-10 mg/5ml (Min 18 Years) promethazine-phenylephrine oral syrup Tier 1 6.25-5 mg/5ml PRO-RED AC ORAL SYRUP 5-1-9 Tier 3 AGE (Min 12 Years) MG/5ML pseudoeph-bromphen-dm oral syrup 30- (Bromfed DM) Tier 1 2-10 mg/5ml RYDEX ORAL LIQUID 10-1.33-6.33 Tier 3 AGE (Min 12 Years) MG/5ML SEMPREX-D ORAL CAPSULE 8-60 MG Tier 3 trymine cg oral liquid 225-7.5 mg/5ml (Mar-Cof CG Expectorant) Tier 1 AGE (Min 12 Years) TUSNEL C ORAL SYRUP 30-10-100 Tier 3 AGE (Min 12 Years) MG/5ML TUSSICAPS ORAL CAPSULE Tier 3 QL (2 EA per 1 day); AGE EXTENDED RELEASE 12 HOUR 10-8 (Min 18 Years) MG TUXARIN ER ORAL TABLET Tier 3 ST: Requires prior EXTENDED RELEASE 12 HOUR 54.3-8 prescription for MG Promethazine/codeine within the past 120 days; QL (2 EA per 1 day); AGE (Min 18 Years)

MedPerform Medium Formulary 01/01/2021

133 Drug Status Notes TUZISTRA XR ORAL SUSPENSION Tier 3 ST: Requires prior EXTENDED RELEASE 14.7-2.8 prescriptions for MG/5ML Chlorpheniramine/codeine and Promethazine HCL/codeine within the past 365 days; QL (200 ML per 10 days); AGE (Min 18 Years) virtussin a/c oral solution 100-10 mg/5ml Tier 1 AGE (Min 12 Years) virtussin ac w/alc oral liquid 100-10 Tier 1 AGE (Min 12 Years) mg/5ml virtussin dac oral solution 30-10-100 Tier 1 AGE (Min 12 Years) mg/5ml Z-TUSS AC ORAL LIQUID 2-9 MG/5ML Tier 3 AGE (Min 12 Years) Expectorants SSKI ORAL SOLUTION 1 GM/ML Tier 3 Misc. Respiratory Inhalants HYPERSAL INHALATION Tier 3 NEBULIZATION SOLUTION 3.5 % sodium chloride inhalation nebulization Tier 1 solution 0.9 %, 10 %, 3 % sodium chloride inhalation nebulization (HyperSal) Tier 1 solution 7 % Mucolytics acetylcysteine inhalation solution 10 %, Tier 1 20 % Dermatologicals Acne Products ACZONE EXTERNAL GEL 7.5 % (Dapsone) Tier 3 adapalene external cream 0.1 % (Differin) Tier 1 AGE (Max 25 Years) adapalene external gel 0.1 %, 0.3 % (Differin) Tier 1 AGE (Max 25 Years) adapalene-benzoyl per-clindamy Tier 1 external gel 0.3-2.5-1 % adapalene-benzoyl per-niacinam Tier 1 external gel 0.3-2.5-4 %

MedPerform Medium Formulary 01/01/2021

134 Drug Status Notes adapalene-benzoyl peroxide external gel (Epiduo) Tier 1 AGE (Max 25 Years) 0.1-2.5 % AKLIEF EXTERNAL CREAM 0.005 % Tier 3 AGE (Max 25 Years) ALTRENO EXTERNAL LOTION 0.05 % Tier 3 AGE (Max 25 Years) AMNESTEEM ORAL CAPSULE 10 MG, (ISOtretinoin) Tier 1 20 MG, 40 MG AVAR CLEANSER EXTERNAL (Sulfacetamide Sodium- Tier 1 QL (1419 GM per 1 FILL) EMULSION 10-5 % Sulfur) AVAR-E EMOLLIENT EXTERNAL (Sulfacetamide Sodium- Tier 1 CREAM 10-5 % Sulfur) AVAR-E GREEN EXTERNAL CREAM (Sulfacetamide Sodium- Tier 1 10-5 % Sulfur) AVITA EXTERNAL CREAM 0.025 % (Tretinoin) Tier 1 AGE (Max 25 Years) AVITA EXTERNAL GEL 0.025 % (Tretinoin) Tier 1 AGE (Max 25 Years) azelaic acid-niacinamide external cream Tier 1 15-4 % AZELEX EXTERNAL CREAM 20 % Tier 3 benz per-clind-niacin-tretin external gel Tier 1 2.5-1-2-0.025 %, 5-1-2-0.025 %, 5-1-2- 0.05 % BENZEPRO EXTERNAL 5.8 % Tier 3 BENZEPRO EXTERNAL FOAM 5.2 %, Tier 3 9.7 % BENZEPRO EXTERNAL LIQUID 6.8 % Tier 3 BENZEPRO SHORT CONTACT (Benzoyl Peroxide) Tier 1 EXTERNAL FOAM 9.8 % benzoyl perox-hydrocortisone external (Vanoxide-HC) Tier 1 lotion 5-0.5 % benzoyl peroxide external foam 9.8 % (BenzePrO Short Contact) Tier 1 benzoyl peroxide-erythromycin external (Benzamycin) Tier 1 gel 5-3 % bp 10-1 external emulsion 10-1 % Tier 1 bp cleansing wash external emulsion 10- Tier 3 4 % bp wash external liquid 2.5 % (PanOxyl) Tier 1

MedPerform Medium Formulary 01/01/2021

135 Drug Status Notes CLARAVIS ORAL CAPSULE 10 MG, 20 (ISOtretinoin) Tier 1 MG, 30 MG, 40 MG CLINDACIN ETZ EXTERNAL SWAB 1 (Clindamycin Phosphate) Tier 1 % CLINDACIN-P EXTERNAL SWAB 1 % (Clindamycin Phosphate) Tier 1 CLINDAGEL EXTERNAL GEL 1 % (Clindamycin Phosphate) Tier 3 ST: Requires prior prescription for Clindamycin Phosphate 1% gel within the past 120 days clindamy-benzoyl per-niacinam external Tier 1 gel 1-5-4 %, 2.5-1-4 % clindamycin phos-benzoyl perox external (Acanya) Tier 1 gel 1.2-2.5 % clindamycin phos-benzoyl perox external (Neuac) Tier 1 gel 1.2-5 % clindamycin phos-benzoyl perox external (BenzaClin) Tier 1 gel 1-5 % clindamycin phos-niacinamide external Tier 1 gel 1-4 % clindamycin phos-niacinamide external Tier 1 lotion 1-4 % clindamycin phosphate external foam 1 (Evoclin) Tier 1 % clindamycin phosphate external gel 1 % (Clindagel) Tier 1 ST: Requires prior prescription for Clindamycin Phosphate 1% gel within the past 120 days clindamycin phosphate external lotion 1 (Cleocin-T) Tier 1 % clindamycin phosphate external solution Tier 1 QL (180 ML per 1 FILL) 1 % clindamycin phosphate external swab 1 (Clindacin ETZ) Tier 1 %

MedPerform Medium Formulary 01/01/2021

136 Drug Status Notes clindamycin-niacin-tretinoin external Tier 1 cream 1-4-0.025 % clind-niacin-spironolac-tretin external gel Tier 1 1-4-2-0.025 % CLINOIN EXTERNAL CREAM 1.25- Tier 3 0.025-1 % dapsone external gel 5 %, 7.5 % (Aczone) Tier 1 dapsone-niacinamide external gel 6-4 %, Tier 1 8.5-4 % dapsone-niacinamide-spironolac Tier 1 external gel 6-2-5 %, 8.5-2-5 % deoxia external gel 1-4 % Tier 3 deoxia external lotion 1-4 % Tier 3 diadimaxia external gel 6-2-5 % Tier 3 diaoxia external gel 6-4 % Tier 3 diasdimaxia external gel 8.5-2-5 % Tier 3 diasoxia external gel 8.5-4 % Tier 3 DIFFERIN EXTERNAL LOTION 0.1 % Tier 3 AGE (Max 25 Years) dimoxia external gel 4-5 % Tier 3 draxace external suspension 2-8 % Tier 3 draxace lotion cleanser external Tier 3 suspension 2-8 % drixece external suspension 5-10 % Tier 3 eceoxia external cream 4-10 % Tier 3 ENZOCLEAR EXTERNAL FOAM 9.8 % (Benzoyl Peroxide) Tier 1 EPIDUO FORTE EXTERNAL GEL 0.3- Tier 2 AGE (Max 25 Years) 2.5 % ery external pad 2 % Tier 3 erythromycin external gel 2 % (Erygel) Tier 1 erythromycin external solution 2 % Tier 1 QL (180 ML per 1 FILL) ethoxia external cream 4-0.05 % Tier 3 hyaluronate-niacinam-tretinoin external Tier 1 cream 0.5-4-0.025 %, 0.5-4-0.05 %, 0.5- 4-0.1 %

MedPerform Medium Formulary 01/01/2021

137 Drug Status Notes INOVA 4/1 ACNE CONTROL THERAPY Tier 3 EXTERNAL KIT 4 & 1 & 5 % INOVA 8/2 ACNE CONTROL THERAPY Tier 3 EXTERNAL KIT 8 & 2 & 5 % INOVA EXTERNAL KIT 4 & 5 %, 8 & 5 Tier 3 % isotretinoin oral capsule 10 mg, 20 mg, (Amnesteem) Tier 1 40 mg isotretinoin oral capsule 30 mg (Claravis) Tier 1 ithoxia external cream 4-0.1 % Tier 3 MYORISAN ORAL CAPSULE 10 MG, (ISOtretinoin) Tier 1 20 MG, 30 MG, 40 MG NEUAC EXTERNAL GEL 1.2-5 % (Clindamycin Phos- Tier 1 Benzoyl Perox) niacinamide-spironolactone external gel Tier 1 4-5 % niacinamide-sulfacetamide external Tier 1 cream 4-10 % niacinamide-tazarotene external cream Tier 1 4-0.05 %, 4-0.1 % niacinamide-tretinoin external cream 4- Tier 1 0.025 %, 4-0.05 % niacinamide-tretinoin external gel 4- Tier 1 0.025 %, 4-0.05 % niacin-spironolacton-tretinoin external Tier 1 gel 2-5-0.025 %, 2-5-0.05 % ONEXTON EXTERNAL GEL 1.2-3.75 % Tier 2 PLEXION CLEANSING CLOTH Tier 3 EXTERNAL PAD 9.8-4.8 % PR BENZOYL PEROXIDE EXTERNAL Tier 3 LIQUID 6.9 % resorcinol-sulfur external lotion 2-5 % (Rezamid) Tier 1 RETIN-A MICRO PUMP EXTERNAL Tier 3 AGE (Max 25 Years) GEL 0.06 %, 0.08 % RIAX EXTERNAL FOAM 5.5 %, 9.5 % Tier 3

MedPerform Medium Formulary 01/01/2021

138 Drug Status Notes salicylic acid-sulfacetamide external Tier 1 suspension 2-8 %, 5-10 % sss 10-5 external cream 10-5 % (Avar-e Emollient) Tier 1 sss 10-5 external foam 10-5 % Tier 3 sulfacetamide sodium (acne) external (Klaron) Tier 1 lotion 10 % sulfacetamide sodium-sulfur external (Avar-e LS) Tier 1 cream 10-2 % sulfacetamide sodium-sulfur external (Avar-e Emollient) Tier 1 cream 10-5 % sulfacetamide sodium-sulfur external (Plexion) Tier 1 cream 9.8-4.8 % sulfacetamide sodium-sulfur external (Avar Cleanser) Tier 1 QL (1419 GM per 1 FILL) emulsion 10-5 % sulfacetamide sodium-sulfur external (Avar LS Cleanser) Tier 1 liquid 10-2 % sulfacetamide sodium-sulfur external (Plexion Cleanser) Tier 1 liquid 9.8-4.8 % sulfacetamide sodium-sulfur external (Sumaxin Wash) Tier 1 liquid 9-4 % sulfacetamide sodium-sulfur external (Sumadan Wash) Tier 1 liquid 9-4.5 % sulfacetamide sodium-sulfur external Tier 1 lotion 10-5 % sulfacetamide sodium-sulfur external (Plexion) Tier 1 lotion 9.8-4.8 % sulfacetamide sodium-sulfur external (Sumaxin) Tier 1 pad 10-4 % sulfacetamide sodium-sulfur external Tier 1 suspension 10-5 % sulfacetamide sod-sulfur wash external (Sumadan) Tier 1 kit 9-4.5 % sulfacetamide-sulfur in urea external Tier 1 QL (1419 ML per 1 FILL) emulsion 10-5 % sulfamez wash external emulsion 10-1 % Tier 1

MedPerform Medium Formulary 01/01/2021

139 Drug Status Notes SUMADAN XLT EXTERNAL KIT 9-4.5 Tier 3 % tardeoxia external cream 1-4-0.025 % Tier 3 tardimaxia external gel 2-5-0.025 % Tier 3 taroxia external cream 4-0.025 % Tier 3 tretinoin external cream 0.025 % (Avita) Tier 1 AGE (Max 25 Years) tretinoin external cream 0.05 %, 0.1 % (Retin-A) Tier 1 AGE (Max 25 Years) tretinoin external gel 0.01 % (Retin-A) Tier 1 AGE (Max 25 Years) tretinoin external gel 0.025 % (Avita) Tier 1 AGE (Max 25 Years) tretinoin external gel 0.05 % (Atralin) Tier 1 AGE (Max 25 Years) tretinoin microsphere external gel 0.04 (Retin-A Micro) Tier 1 AGE (Max 25 Years) %, 0.1 % tretinoin microsphere pump external gel (Retin-A Micro) Tier 1 AGE (Max 25 Years) 0.04 % VANOXIDE-HC EXTERNAL LOTION 5- (Benzoyl Perox- Tier 1 0.5 % Hydrocortisone) vardimaxia external gel 2-5-0.05 % Tier 3 varoxia external cream 4-0.05 % Tier 3 varoxia external gel 4-0.05 % Tier 3 ZACARE EXTERNAL KIT 4 & 0.2 %, 8 & Tier 3 0.2 % zaclir cleansing external lotion 8 % Tier 3 ZENATANE ORAL CAPSULE 10 MG, (ISOtretinoin) Tier 1 20 MG, 30 MG, 40 MG Analgesics - Topical A.A.G.C. KIT IN TERODERM Tier 3 EXTERNAL CREAM 8-4-10-4 % active-prep kit iv external cream Tier 3 active-tramadol external cream 8 % Tier 3 baclofen external cream 2 % Tier 3 enovarx-baclofen external cream 1 % Tier 3 enovarx-tramadol external cream 5 % Tier 3

MedPerform Medium Formulary 01/01/2021

140 Drug Status Notes Antibiotics - Topical ALTABAX EXTERNAL OINTMENT 1 % Tier 3 ST: Requires prior prescription for Mupirocin within the past 120 days CENTANY AT EXTERNAL KIT 2 % Tier 3 CENTANY EXTERNAL OINTMENT 2 % (Mupirocin) Tier 3 CORTISPORIN EXTERNAL CREAM Tier 2 3.5-10000-0.5 CORTISPORIN EXTERNAL OINTMENT Tier 2 1 % gentamicin sulfate external cream 0.1 % Tier 1 QL (90 GM per 1 FILL) gentamicin sulfate external ointment 0.1 Tier 1 % mupirocin calcium external cream 2 % Tier 1 QL (90 GM per 1 FILL) mupirocin external ointment 2 % (Centany) Tier 1 NEO-SYNALAR EXTERNAL CREAM Tier 3 ST: Requires prior 0.5-0.025 % prescriptions for Bacitracin Zinc and Fluocinolone Acetonide within the past 365 days NEO-SYNALAR EXTERNAL KIT 0.5- Tier 3 ST: Requires prior 0.025 % prescriptions for Bacitracin Zinc and Fluocinolone Acetonide within the past 365 days XEPI EXTERNAL CREAM 1 % Tier 3 ST: Requires prior prescription for Mupirocin within the past 120 days Antifungals - Topical active-prep kit v external cream Tier 3 ALA-QUIN EXTERNAL CREAM 3-0.5 % Tier 3 CICLODAN EXTERNAL SOLUTION 8 % (Ciclopirox) Tier 1 QL (19.8 ML per 1 FILL) ciclopirox external gel 0.77 % Tier 1 ciclopirox external shampoo 1 % (Loprox) Tier 1 ciclopirox external solution 8 % (Ciclodan) Tier 1 QL (19.8 ML per 1 FILL)

MedPerform Medium Formulary 01/01/2021

141 Drug Status Notes ciclopirox olamine external cream 0.77 (Loprox) Tier 1 QL (180 GM per 1 FILL) % ciclopirox olamine external suspension (Loprox) Tier 1 QL (180 ML per 1 FILL) 0.77 % ciclopirox treatment external kit 8 % Tier 3 clotrimazole external cream 1 % (Desenex) Tier 1 clotrimazole external solution 1 % (FungiCure Tier 1 Intensive/NailGuard) clotrimazole-betamethasone external Tier 1 cream 1-0.05 % clotrimazole-betamethasone external Tier 1 lotion 1-0.05 % DERMAZENE EXTERNAL CREAM 1-1 (Hydrocortisone- Tier 1 % Iodoquinol) difmetioxrime external solution 4-2-1-4 % Tier 3 econazole nitrate external cream 1 % Tier 1 QL (170 GM per 1 FILL) econazole nitrate-niacinamide external Tier 1 cream 1-4 % ECOZA EXTERNAL FOAM 1 % Tier 3 EXELDERM EXTERNAL CREAM 1 % (Sulconazole Nitrate) Tier 2 EXELDERM EXTERNAL SOLUTION 1 (Sulconazole Nitrate) Tier 2 % EXODERM EXTERNAL LOTION 25-1 % Tier 3 flucon-ibuprof-itracon-terbina external Tier 1 solution 4-2-1-4 % fungimez external solution (Myco Nail) Tier 3 hydrocortisone-iodoquinol external (Dermazene) Tier 1 cream 1-1 % imioxia external cream 1-4 % Tier 3 iodoquimez-hc external cream 1-1.9 % (Vytone) Tier 1 iodoquinol-hc-ketoconazole external Tier 1 cream 1-2.5-2 % iodoquinol-hydrocortisone-aloe external (Vytone) Tier 1 cream 1-1.9 % ketoconazole external cream 2 % Tier 1 QL (180 GM per 1 FILL)

MedPerform Medium Formulary 01/01/2021

142 Drug Status Notes ketoconazole external shampoo 2 % Tier 1 QL (360 ML per 1 FILL) ketoconazole-hydrocortisone external Tier 1 cream 2-2.5 % KETODAN EXTERNAL KIT 2 % Tier 3 LUZU EXTERNAL CREAM 1 % (Luliconazole) Tier 3 ST: Requires prior prescriptions for Clotrimazole and Ketoconazole within the past 365 days; QL (60 GM per 28 days) MENTAX EXTERNAL CREAM 1 % (Butenafine HCl) Tier 3 miconazole-zinc oxide-petrolat external (Vusion) Tier 1 ointment 0.25-15-81.35 % naftifine hcl external cream 1 % Tier 1 naftifine hcl external cream 2 % (Naftin) Tier 1 QL (180 GM per 1 FILL) naftifine hcl external gel 1 % (Naftin) Tier 1 NAFTIN EXTERNAL GEL 2 % Tier 2 NYAMYC EXTERNAL POWDER (Nystatin) Tier 1 100000 UNIT/GM nystatin external cream 100000 unit/gm Tier 1 nystatin external ointment 100000 Tier 1 unit/gm nystatin external powder 100000 unit/gm (Nyamyc) Tier 1 nystatin-triamcinolone external cream Tier 1 100000-0.1 unit/gm-% nystatin-triamcinolone external ointment Tier 1 100000-0.1 unit/gm-% NYSTOP EXTERNAL POWDER 100000 (Nystatin) Tier 1 UNIT/GM oxiconazole nitrate external cream 1 % (Oxistat) Tier 1 QL (180 GM per 1 FILL) OXISTAT EXTERNAL LOTION 1 % Tier 3 pheodoyo external cream 1-2.5-2 % Tier 3 pheyo external cream 2.5-2 % Tier 3 RECURA EXTERNAL CREAM Tier 3 tavaborole external solution 5 % (Kerydin) Tier 1 PA

MedPerform Medium Formulary 01/01/2021

143 Drug Status Notes VUSION EXTERNAL OINTMENT 0.25- (Miconazole-Zinc Oxide- Tier 3 15-81.35 % Petrolat) Anti-Inflammatory Agents - Topical active-ketoprofen external cream 5 % Tier 3 active-prep kit i external cream Tier 3 active-prep kit ii external cream Tier 3 active-prep kit iii external cream Tier 3 aif #2 drug preparation kit external Tier 3 cream aif #3 drug preparation kit external Tier 3 cream dfs/ms/menth/cap pak combination kit Tier 3 1.5 % diclofenac epolamine external patch 1.3 (Flector) Tier 1 % diclofenac sodium external gel 1 % (Voltaren) Tier 1 diclofenac sodium external solution 1.5 Tier 1 % dual complex formula 1 kit external Tier 3 cream enovarx-diclofenac sodium external Tier 3 cream 2.5 % enovarx-ibuprofen external cream 10 % Tier 3 enovarx-naproxen external cream 10 % Tier 3 fbl kit external cream 15-4-5 % Tier 3 K.B.G.L IN TERODERM EXTERNAL Tier 3 CREAM 15-4-10-2 % KETOPHENE RAPIDPAQ EXTERNAL Tier 3 CREAM 20 % ketorolac tromethamine external gel 2 % Tier 3 LICART EXTERNAL PATCH 24 HOUR Tier 3 ST: Requires prior 1.3 % prescription for Diclofenac Epolamine within the past 120 days; QL (1 EA per 1 day) napro external cream 15 % Tier 3

MedPerform Medium Formulary 01/01/2021

144 Drug Status Notes np #2 drug preparation kit external Tier 3 cream triple complex formula 3 kit external Tier 3 cream 20-2-10 % vp fc kit external cream Tier 3 vp gkl kit external cream 20-2-10 % Tier 3 Antineoplastic Or Premalignant Lesion Agents - Topical AMELUZ EXTERNAL GEL 10 % Tier 3 diclofenac sodium external gel 3 % Tier 1 QL (100 GM per 1 FILL) diclofenac-na hyaluron-niacin external Tier 1 gel 3-2-4 % FLUOROPLEX EXTERNAL CREAM 1 % Tier 3 fluorouracil external cream 0.5 % (Carac) Tier 1 PA fluorouracil external cream 5 % (Efudex) Tier 1 fluorouracil external solution 2 %, 5 % Tier 1 hyalucil-4 transdermal cream 2-4 % Tier 3 imiquimod-levocetirizin-niacin external Tier 1 gel 5-1-2 % imiquimod-levocet-tretinoin external gel Tier 1 5-1-0.05 % LEVULAN KERASTICK EXTERNAL Tier 3 SOLUTION RECONSTITUTED 20 % ORMECA COMBINATION KIT 3 & 46- Tier 3 0.4-1.1 %-MG PANRETIN EXTERNAL GEL 0.1 % Tier 3 SP PICATO EXTERNAL GEL 0.015 % Tier 2 QL (3 EA per 28 days) PICATO EXTERNAL GEL 0.05 % Tier 2 QL (2 EA per 28 days) TARGRETIN EXTERNAL GEL 1 % Tier 2 PA; SP TOLAK EXTERNAL CREAM 4 % Tier 2 VALCHLOR EXTERNAL GEL 0.016 % Tier 2 PA; SP Antipsoriatics acitretin oral capsule 10 mg, 25 mg (Soriatane) Tier 1 SP acitretin oral capsule 17.5 mg Tier 1 SP calcipotriene external cream 0.005 % (Dovonex) Tier 1

MedPerform Medium Formulary 01/01/2021

145 Drug Status Notes calcipotriene external ointment 0.005 % (Calcitrene) Tier 1 calcipotriene external solution 0.005 % Tier 1 CALCITRENE EXTERNAL OINTMENT (Calcipotriene) Tier 1 0.005 % COSENTYX (300 MG DOSE) Tier 2 PA; SP SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML COSENTYX SENSOREADY (300 MG) Tier 2 PA; SP SUBCUTANEOUS SOLUTION AUTO- INJECTOR 150 MG/ML COSENTYX SENSOREADY PEN Tier 2 PA; SP SUBCUTANEOUS SOLUTION AUTO- INJECTOR 150 MG/ML COSENTYX SUBCUTANEOUS Tier 2 PA; SP SOLUTION PREFILLED SYRINGE 150 MG/ML DRITHO-CREME HP EXTERNAL Tier 2 CREAM 1 % methoxsalen rapid oral capsule 10 mg (Oxsoralen Ultra) Tier 1 SILIQ SUBCUTANEOUS SOLUTION Tier 3 PA; SP PREFILLED SYRINGE 210 MG/1.5ML SKYRIZI (150 MG DOSE) Tier 2 PA; SP SUBCUTANEOUS PREFILLED SYRINGE KIT 75 MG/0.83ML SORILUX EXTERNAL FOAM 0.005 % (Calcipotriene) Tier 3 STELARA SUBCUTANEOUS Tier 2 PA; SP SOLUTION 45 MG/0.5ML STELARA SUBCUTANEOUS Tier 2 PA; SP SOLUTION PREFILLED SYRINGE 45 MG/0.5ML, 90 MG/ML tazarotene external cream 0.1 % (Tazorac) Tier 1 TAZORAC EXTERNAL CREAM 0.05 % Tier 2 TAZORAC EXTERNAL GEL 0.05 %, 0.1 Tier 3 %

MedPerform Medium Formulary 01/01/2021

146 Drug Status Notes TREMFYA SUBCUTANEOUS Tier 2 PA; SP SOLUTION PEN-INJECTOR 100 MG/ML TREMFYA SUBCUTANEOUS Tier 2 PA; SP SOLUTION PREFILLED SYRINGE 100 MG/ML VECTICAL EXTERNAL OINTMENT 3 (Calcitriol) Tier 3 MCG/GM ZITHRANOL EXTERNAL SHAMPOO 1 Tier 3 % Antiseborrheic Products ciclopirox-clobetasol external shampoo Tier 1 0.77-0.05 % ciclopirox-clobetasol-sal acid external Tier 1 shampoo 0.77-0.05-3 % ciclopirox-salicylic acid external Tier 3 shampoo 0.77-2 % ESKATA EXTERNAL SOLUTION 40 % Tier 3 OVACE PLUS EXTERNAL CREAM 10 Tier 3 % OVACE PLUS EXTERNAL FOAM 9.8 % Tier 3 OVACE PLUS EXTERNAL LOTION 9.8 Tier 3 ST: Requires prior % prescription for Ciclopirox (shampoo/gel) or Ketoconazole (shampoo/cream) within the past 120 days selenium sulfide external lotion 2.5 % Tier 1 selenium sulfide external shampoo 2.25 Tier 1 % selenium sulfide external shampoo 2.3 (SelRx) Tier 1 % sodium sulfacetamide external shampoo (Ovace Plus) Tier 1 10 % sodium sulfacetamide wash external Tier 3 liquid 10 %

MedPerform Medium Formulary 01/01/2021

147 Drug Status Notes sulfacetamide sodium external gel 10 % (Ovace Plus Wash) Tier 1 (cleans) sulfacetamide sodium external liquid 10 (Ovace Plus Wash) Tier 1 % Antivirals - Topical acyclovir external ointment 5 % (Zovirax) Tier 1 Burn Products mafenide acetate external packet 5 % (Sulfamylon) Tier 1 silver sulfadiazine external cream 1 % (SSD) Tier 1 SSD EXTERNAL CREAM 1 % (Silver Sulfadiazine) Tier 1 SULFAMYLON EXTERNAL CREAM 85 Tier 3 MG/GM Cauterizing Agents ARZOL SILVER NIT APPLICATORS (Grafco Silver Nit Tier 1 EXTERNAL 75-25 % Applicator) grafco silver nit applicator external 75-25 (Arzol Silver Nit Tier 1 % Applicators) silver nitrate external solution 0.5 %, 10 Tier 1 %, 25 %, 50 % TRI-CHLOR EXTERNAL LIQUID 80 % Tier 3 Corticosteroids - Topical ADVANCED ALLERGY COLLECTION Tier 3 EXTERNAL KIT 2.5 % ALA SCALP EXTERNAL LOTION 2 % Tier 3 ala-cort external cream 1 % (Aveeno Anti-Itch Max St) Tier 1 ala-cort external cream 2.5 % Tier 1 alclometasone dipropionate external Tier 1 cream 0.05 % alclometasone dipropionate external Tier 1 ointment 0.05 % amcinonide external cream 0.1 % Tier 1 amcinonide external lotion 0.1 % Tier 1

MedPerform Medium Formulary 01/01/2021

148 Drug Status Notes amcinonide external ointment 0.1 % Tier 1 ST: Requires prior prescription for Betamethasone 0.05% (ointment, augmented cream), Desoximetasone (cream, gel, ointment), Fluocinonide 0.05% (gel, ointment, solution, cream) within the past 120 days BESER EXTERNAL LOTION 0.05 % (Fluticasone Propionate) Tier 1 betamethasone dipropionate aug (Diprolene AF) Tier 1 external cream 0.05 % betamethasone dipropionate aug Tier 1 external gel 0.05 % betamethasone dipropionate aug Tier 1 external lotion 0.05 % betamethasone dipropionate aug (Diprolene) Tier 1 external ointment 0.05 % betamethasone dipropionate external Tier 1 cream 0.05 % betamethasone dipropionate external Tier 1 lotion 0.05 % betamethasone dipropionate external Tier 1 ointment 0.05 % betamethasone valerate external cream Tier 1 0.1 % betamethasone valerate external foam (Luxiq) Tier 1 0.12 % betamethasone valerate external lotion Tier 1 0.1 % betamethasone valerate external Tier 1 ointment 0.1 % calcipotriene-betameth diprop external (Taclonex) Tier 1 ointment 0.005-0.064 % calcipotriene-betameth diprop external (Taclonex) Tier 1 suspension 0.005-0.064 %

MedPerform Medium Formulary 01/01/2021

149 Drug Status Notes calcipotriene-clobetasol prop external Tier 1 solution 0.005-0.05 % CAPEX EXTERNAL SHAMPOO 0.01 % Tier 3 chlooxia external cream 0.05-4 % Tier 3 chlooxia external ointment 0.05-4 % Tier 3 chlooxia external solution 0.05-4 % Tier 3 clobetasol prop emollient base external Tier 1 cream 0.05 % clobetasol propionate e external cream Tier 1 0.05 % clobetasol propionate emulsion external (Tovet) Tier 1 foam 0.05 % clobetasol propionate external cream (Temovate) Tier 1 0.05 % clobetasol propionate external foam 0.05 (Olux) Tier 1 % clobetasol propionate external gel 0.05 Tier 1 % clobetasol propionate external liquid 0.05 (Clobex Spray) Tier 1 % clobetasol propionate external lotion (Clobex) Tier 1 0.05 % clobetasol propionate external ointment (Temovate) Tier 1 0.05 % clobetasol propionate external shampoo (Clodan) Tier 1 0.05 % clobetasol propionate external solution Tier 1 0.05 % clobetasol prop-levocetirizine external Tier 1 shampoo 0.05-2 % clobetasol prop-niacinamide external Tier 1 cream 0.05-4 % clobetasol prop-niacinamide external Tier 1 ointment 0.05-4 % clobetasol prop-niacinamide external Tier 1 solution 0.05-4 %

MedPerform Medium Formulary 01/01/2021

150 Drug Status Notes clobetavix external kit 0.05 % Tier 3 clocortolone pivalate external cream 0.1 (Cloderm) Tier 1 % CLODAN EXTERNAL KIT 0.05 % Tier 3 CLODAN EXTERNAL SHAMPOO 0.05 (Clobetasol Propionate) Tier 1 % CLODERM EXTERNAL CREAM 0.1 % (Clocortolone Pivalate) Tier 3 CORDRAN EXTERNAL CREAM 0.025 Tier 3 % CORDRAN EXTERNAL TAPE 4 Tier 3 ST: Requires prior MCG/SQCM prescription for Betamethasone Augmented (ointment, gel, lotion), Clobetasol (spray, lotion, gel, ointment, cream, solution), Fluocinonide 0.1% cream, or Halobetasol 0.05% (cream, ointment) withn the past 120 days; QL (2 EA per 30 days) CORTANE-B EXTERNAL LOTION 10- Tier 3 10-1 MG/ML desonide external cream 0.05 % (DesOwen) Tier 1 desonide external gel 0.05 % (Desonate) Tier 1 ST: Requires prior prescription for Betamethasone (0.05% lotion, 0.1% cream), Desonide 0.05% ointment, Fluticasone 0.05% creanm Hydrocortisone 0.2% cream, or Triamcinolone (0.1% lotion, 0.025% ointment) within the past 120 days desonide external lotion 0.05 % Tier 1 desonide external ointment 0.05 % Tier 1

MedPerform Medium Formulary 01/01/2021

151 Drug Status Notes desoximetasone external cream 0.05 %, (Topicort) Tier 1 0.25 % desoximetasone external gel 0.05 % (Topicort) Tier 1 desoximetasone external liquid 0.25 % (Topicort Spray) Tier 1 ST: Requires prior prescription for Betamethasone augmented 0.05% (cream, gel, lotion, ointment), Clobetasol, Desoximetasone (cream, gel, ointment), Fluocinonide (cream, gel), or Halobetasol (cream, ointment) within the past 120 days desoximetasone external ointment 0.05 (Topicort) Tier 1 %, 0.25 % DUOBRII EXTERNAL LOTION 0.01- Tier 3 ST: Requires prior 0.045 % prescription for Betamethasone augmented 0.05% (cream, gel, lotion, ointment), Clobetasol, Desoximetasone (cream, gel, ointment), Fluocinonide (cream, gel), or Halobetasol (cream, ointment) within the past 120 days; QL (200 GM per 28 days) ENSTILAR EXTERNAL FOAM 0.005- Tier 3 0.064 % EPIFOAM EXTERNAL FOAM 1-1 % Tier 3 fluocinolone acet-niacinamide external Tier 1 cream 0.01-4 %, 0.025-4 % fluocinolone acetonide body external oil (Derma-Smoothe/FS Tier 1 0.01 % Body) fluocinolone acetonide external cream Tier 1 0.01 %

MedPerform Medium Formulary 01/01/2021

152 Drug Status Notes fluocinolone acetonide external cream (Synalar) Tier 1 0.025 % fluocinolone acetonide external ointment (Synalar) Tier 1 0.025 % fluocinolone acetonide external solution (Synalar) Tier 1 0.01 % fluocinolone acetonide scalp external oil (Derma-Smoothe/FS Tier 1 0.01 % Scalp) fluocinonide emulsified base external Tier 1 cream 0.05 % fluocinonide external cream 0.05 % Tier 1 fluocinonide external cream 0.1 % (Vanos) Tier 1 fluocinonide external gel 0.05 % Tier 1 fluocinonide external ointment 0.05 % Tier 1 fluocinonide external solution 0.05 % Tier 1 flurandrenolide external cream 0.05 % (Nolix) Tier 1 ST: Requires prior prescription for Betamethasone (0.05% lotion, 0.1% cream), Desonide 0.05% ointment, Fluticasone 0.05% creanm Hydrocortisone 0.2% cream, or Triamcinolone (0.1% lotion, 0.025% ointment) within the past 120 days flurandrenolide external lotion 0.05 % (Nolix) Tier 1 flurandrenolide external ointment 0.05 % (Cordran) Tier 1 fluticasone propionate external cream Tier 1 0.05 % fluticasone propionate external lotion (Beser) Tier 1 0.05 % fluticasone propionate external ointment Tier 1 0.005 %

MedPerform Medium Formulary 01/01/2021

153 Drug Status Notes halcinonide external cream 0.1 % (Halog) Tier 1 ST: Requires prior prescription for Betamethasone 0.05% (ointment, augmented cream), Desoximetasone (cream, gel, ointment), Fluocinonide 0.05% (gel, ointment, solution, cream) within the past 120 days halobetasol propionate external cream Tier 1 0.05 % halobetasol propionate external ointment Tier 1 0.05 % HALOG EXTERNAL OINTMENT 0.1 % Tier 3 ST: Requires prior prescription for Betamethasone 0.05% (ointment, augmented cream), Desoximetasone (cream, gel, ointment), Fluocinonide 0.05% (gel, ointment, solution, cream) within the past 120 days HALOG EXTERNAL SOLUTION 0.1 % Tier 3 ST: Requires prior prescription for Betamethasone 0.05% (ointment, augmented cream), Desoximetasone (cream, gel, ointment), Fluocinonide 0.05% (gel, ointment, solution, cream) within the past 120 days hydrocortisone ace-pramoxine external (Pramosone) Tier 1 cream 2.5-1 % hydrocortisone butyr lipo base external (Locoid Lipocream) Tier 1 cream 0.1 % hydrocortisone butyrate external cream Tier 1 0.1 %

MedPerform Medium Formulary 01/01/2021

154 Drug Status Notes hydrocortisone butyrate external lotion (Locoid) Tier 1 ST: Requires prior 0.1 % prescription for Betamethasone (0.05% lotion, 0.1% cream), Desonide 0.05% ointment, Fluticasone 0.05% creanm Hydrocortisone 0.2% cream, or Triamcinolone (0.1% lotion, 0.025% ointment) within the past 120 days hydrocortisone butyrate external Tier 1 ST: Requires prior ointment 0.1 % prescription for Betamethasone (0.05% lotion, 0.1% cream), Desonide 0.05% ointment, Fluticasone 0.05% creanm Hydrocortisone 0.2% cream, or Triamcinolone (0.1% lotion, 0.025% ointment) within the past 120 days hydrocortisone butyrate external solution Tier 1 0.1 % hydrocortisone external cream 1 % (Aveeno Anti-Itch Max St) Tier 1 hydrocortisone external cream 2.5 % Tier 1 hydrocortisone external lotion 2.5 % Tier 1 hydrocortisone external ointment 1 % (Cortizone-10) Tier 1 hydrocortisone external ointment 2.5 % Tier 1 hydrocortisone valerate external cream Tier 1 0.2 % hydrocortisone valerate external Tier 1 ointment 0.2 % mezparox-hc external cream 1-2.5 % (Pramosone) Tier 1 mezparox-hc forte external cream 2.5- Tier 3 2.5 %

MedPerform Medium Formulary 01/01/2021

155 Drug Status Notes mometasone furoate external cream 0.1 Tier 1 % mometasone furoate external ointment Tier 1 0.1 % mometasone furoate external solution Tier 1 0.1 % niacinamide-triamcinolone acet external Tier 1 cream 4-0.1 % NOLIX EXTERNAL CREAM 0.05 % (Flurandrenolide) Tier 1 ST: Requires prior prescription for Betamethasone (0.05% lotion, 0.1% cream), Desonide 0.05% ointment, Fluticasone 0.05% creanm Hydrocortisone 0.2% cream, or Triamcinolone (0.1% lotion, 0.025% ointment) within the past 120 days NOLIX EXTERNAL LOTION 0.05 % (Flurandrenolide) Tier 1 NUCORT EXTERNAL LOTION 2 % Tier 3 PANDEL EXTERNAL CREAM 0.1 % Tier 2 ST: Requires prior prescription for Betamethasone (0.05% lotion, 0.1% cream), Desonide 0.05% ointment, Fluticasone 0.05% creanm Hydrocortisone 0.2% cream, or Triamcinolone (0.1% lotion, 0.025% ointment) within the past 120 days paramox-hc external gel 1-2 % (Novacort) Tier 1 PRAMOSONE EXTERNAL CREAM 1-1 Tier 2 % PRAMOSONE EXTERNAL LOTION 1-1 Tier 2 %, 1-2.5 %

MedPerform Medium Formulary 01/01/2021

156 Drug Status Notes PRAMOSONE EXTERNAL OINTMENT Tier 2 1-1 %, 1-2.5 % prednicarbate external cream 0.1 % Tier 1 prednicarbate external ointment 0.1 % Tier 1 SCALACORT DK EXTERNAL KIT 2 & 2- Tier 2 2 % SCARZEN SKIN REPAIR EXTERNAL Tier 3 ST: Requires prior KIT 0.1 & 5 % (LOTION) prescriptions for Triamcinolone 0.1% cream, Dimethicone 5%, and Silicone Tape within the past 365 days SERNIVO EXTERNAL EMULSION 0.05 Tier 3 ST: Requires prior % prescription for Triamcinolone Acetonide 0.147mg/g spray within the past 120 days SYNALAR (CREAM) EXTERNAL KIT Tier 3 0.025 % SYNALAR (OINTMENT) EXTERNAL Tier 3 KIT 0.025 % SYNALAR TS EXTERNAL KIT 0.01 % Tier 3 TEXACORT EXTERNAL SOLUTION 2.5 Tier 2 % TOVET EXTERNAL FOAM 0.05 % (Clobetasol Propionate Tier 1 Emulsion) triamcinolone acetonide external aerosol (Kenalog) Tier 1 solution 0.147 mg/gm triamcinolone acetonide external cream Tier 1 0.025 % triamcinolone acetonide external cream (Triderm) Tier 1 0.1 %, 0.5 % triamcinolone acetonide external lotion Tier 1 0.025 %, 0.1 % triamcinolone acetonide external Tier 1 ointment 0.025 %, 0.1 %, 0.5 %

MedPerform Medium Formulary 01/01/2021

157 Drug Status Notes TRIAMSIL COMBIPAK EXTERNAL Tier 3 THERAPY PACK 0.1 & 5 % triamsil multipak external therapy pack Tier 3 0.1 & 5 % TRIDERM EXTERNAL CREAM 0.1 %, (Triamcinolone Acetonide) Tier 1 0.5 % Eczema Agents DUPIXENT SUBCUTANEOUS Tier 2 PA; SP SOLUTION PREFILLED SYRINGE 200 MG/1.14ML, 300 MG/2ML Emollient/Keratolytic Agents CEM-UREA EXTERNAL SOLUTION 45 Tier 3 % CEROVEL EXTERNAL LOTION 40 % (Urea) Tier 1 protexa external cream 42 % Tier 3 UMECTA MOUSSE EXTERNAL FOAM Tier 1 40 % urea external cream 39 % (Uredeb) Tier 1 urea external cream 40 %, 45 % Tier 1 urea external cream 47 % (Keralac) Tier 1 urea external lotion 40 % (Cerovel) Tier 1 urea hydrating external foam 35 % Tier 3 urea nail external gel 45 % (Uramaxin) Tier 1 urea-c40 external lotion 40 % (Cerovel) Tier 1 UREDEB EXTERNAL CREAM 39 % (Xurea) Tier 1 uremez-40 external cream 40 % Tier 1 URESOL EXTERNAL CREAM 42.5 % Tier 3 xurea external cream 39 % (Uredeb) Tier 1 Emollients ammonium lactate external cream 12 % Tier 1 ammonium lactate external lotion 12 % (AL12) Tier 1 lactic acid e external cream 10-3500 %- Tier 1 unt/30gm lactic acid external lotion 10 % Tier 1

MedPerform Medium Formulary 01/01/2021

158 Drug Status Notes Enzymes - Topical SANTYL EXTERNAL OINTMENT 250 Tier 3 UNIT/GM Hair Growth Agents betamethasone diprop-minoxidil external Tier 1 solution 0.05-5 % finasteride-minoxidil external solution Tier 1 0.1-7 % minoxidil-progest-tretinoin external Tier 1 solution 7-0.1-0.025 % progesterone-minoxidil external solution Tier 1 0.1-7 % Immunomodulating Agents - Topical imiquimod external cream 5 % (Aldara) Tier 1 QL (24 EA per 30 days) Immunosuppressive Agents - Topical hyaluronate-niacin-tacrolimus external Tier 1 cream 1-4-0.1 % niacinamide-tacrolimus external ointment Tier 1 4-0.1 % pimecrolimus external cream 1 % (Elidel) Tier 1 tacrolimus external cream 0.1 % Tier 1 tacrolimus external ointment 0.03 %, 0.1 (Protopic) Tier 1 % Keratolytic/Antimitotic Agents cantharidin external solution 0.7 % Tier 3 cimetidine-lido-salicylic acid external Tier 1 cream 10-5-40 % CONDYLOX EXTERNAL GEL 0.5 % Tier 3 ST: Requires prior prescription for Podofilox within the past 120 days GORDOFILM EXTERNAL SOLUTION Tier 3 16.7-16.7 % KERALYT SCALP EXTERNAL KIT 6 % Tier 3 podocon external solution 25 % Tier 3 podofilox external solution 0.5 % Tier 1 salicylic acid er external solution 28.5 % (UltraSal-ER) Tier 1

MedPerform Medium Formulary 01/01/2021

159 Drug Status Notes salicylic acid external cream 6 % Tier 1 salicylic acid external foam 6 % (Salvax) Tier 1 salicylic acid external liquid 27.5 % (Virasal) Tier 1 salicylic acid external lotion 6 % Tier 1 salicylic acid external shampoo 6 % (Salex) Tier 1 salicylic acid external solution 26 % Tier 1 salicylic acid wart remover external liquid (Virasal) Tier 1 27.5 % salimez external cream 6 % Tier 1 salimez forte external cream 10 % Tier 3 SALVAX DUO PLUS EXTERNAL KIT 6 Tier 3 & 35 % XALIX EXTERNAL SOLUTION 28 % Tier 3 Liniments MEDI-DERM-RX EXTERNAL CREAM Tier 3 0.035-5-20 % MEDROX-RX EXTERNAL OINTMENT Tier 3 0.05-7-20 % Local Anesthetics - Topical 1ST MEDX-PATCH/ LIDOCAINE Tier 3 EXTERNAL PATCH 4-0.0375-5-20 % 7T LIDO EXTERNAL GEL 2 % Tier 1 alegenix external disk 0.0375-5 % Tier 1 ANACAINE EXTERNAL OINTMENT 10 Tier 3 % anodynerx external patch 0.05-2.5-5 % Tier 3 benzo-lidocaine-tetracaine external Tier 1 ointment 20-10-10 % CADIRAMD EXTERNAL KIT 2.5-2.5 % Tier 3 cbd4 freeze pump maximum str external (Icy Hot Lidocaine Plus Tier 3 cream 4-1 % Menthol) CETACAINE EXTERNAL AEROSOL 2- Tier 3 2-14 % CETACAINE EXTERNAL LIQUID 2-2-14 Tier 3 %

MedPerform Medium Formulary 01/01/2021

160 Drug Status Notes CLEVER CHOICE COMFORT EZ Tier 3 TRANSDERMAL PATCH 2-4-1 %, 20-4- 1 % DERMACINRX DUOPATCH Tier 3 PHARMAPAK EXTERNAL THERAPY PACK 5 & 3-10 % DERMACINRX NEUROTRAL Tier 3 PHARMAPAK EXTERNAL THERAPY PACK 5 & 0.025 % eha external lotion 4 % Tier 3 enovarx-lidocaine hcl external cream 10 Tier 3 %, 5 % GEBAUERS SPRAY AND STRETCH Tier 3 EXTERNAL AEROSOL gen7t external lotion 3.5 % Tier 3 gen7t external patch 3.5 % Tier 3 gen7t plus external lotion 3.5-7 % Tier 3 gen7t plus external patch 3.5-7 % Tier 3 GLYDO EXTERNAL PREFILLED (Lidocaine HCl Tier 1 SYRINGE 2 % Urethral/Mucosal) L.E.T. EXTERNAL GEL 4-0.05-0.5 % Tier 3 levatio external patch 0.03-5 % (Alivio) Tier 3 lidocaine external ointment 5 % Tier 1 QL (240 GM per 30 days) lidocaine external patch 5 % (Lidoderm) Tier 1 QL (3 EA per 1 day) lidocaine hcl external cream 3 % Tier 1 lidocaine hcl external cream 4.12 % (Lydexa) Tier 1 lidocaine hcl external solution 4 % Tier 1 lidocaine hcl urethral/mucosal external Tier 1 gel 2 % lidocaine hcl urethral/mucosal external (Glydo) Tier 1 prefilled syringe 2 % lidocaine-prilocaine external cream 2.5- Tier 1 2.5 % lidocaine-tetracaine external cream 23-7 Tier 1 %

MedPerform Medium Formulary 01/01/2021

161 Drug Status Notes lidocanna external patch 4 % (Aspercreme Lidocaine) Tier 1 lido-epinephrine-tetracaine external Tier 3 solution 4-0.05-0.5 % lidopin external cream 3 % Tier 1 lidopin external cream 3.25 % Tier 3 lidostream external kit 5 & 10 % Tier 3 LIDOTHOL EXTERNAL GEL 4.5-5 % Tier 3 LIDOTHOL EXTERNAL PATCH 4.5-5 % Tier 3 LIDTOPIC MAX EXTERNAL CREAM 10 Tier 3 % LYDEXA EXTERNAL CREAM 4.12 % (Lidocaine HCl) Tier 3 MEDI-DERM/L-RX EXTERNAL CREAM Tier 3 2-0.035-5-20 % medi-patch rx external patch 0.5-0.035- Tier 3 5-20 % PHARMACIST CHOICE TSX Tier 3 TRANSDERMAL PATCH 2-4-1 % PRAMOX EXTERNAL GEL 1 % Tier 3 premium lidocaine external ointment 5 % Tier 1 QL (240 GM per 30 days) premium scar external patch 2-4-30 % Tier 3 prepiv supply combination kit 2.5-2.5 & Tier 3 0.9 % PROLIDA EXTERNAL PATCH 4-1 % (CVS Cold & Hot Max Tier 1 Strength) QUTENZA (2 PATCH) EXTERNAL KIT 8 Tier 3 PA % QUTENZA EXTERNAL KIT 8 % Tier 3 PA SOOTHEE EXTERNAL PATCH 0.5- Tier 3 0.0375-5-2 % SX1 MEDICATED POST-OPERATIVE Tier 3 EXTERNAL KIT 2 % SYNERA EXTERNAL PATCH 70-70 MG Tier 3 synvexia tc external cream 4-1 % (Icy Hot Lidocaine Plus Tier 3 Menthol)

MedPerform Medium Formulary 01/01/2021

162 Drug Status Notes VENIPUNCTURE PX1 PHLEBOTOMY Tier 3 EXTERNAL KIT 2 % Misc. Dermatological Products GENADUR COMBINATION KIT Tier 3 PR CREAM EXTERNAL KIT Tier 3 PRESERA EXTERNAL FOAM Tier 3 STRATA CTX EXTERNAL GEL Tier 3 STRATA MARK EXTERNAL GEL Tier 3 STRATA XRT EXTERNAL GEL Tier 3 Misc. Topical benzoin compound external tincture (Steri-Strip Compound Tier 1 Benzoin) dermacinrx surgical combopak Tier 3 combination kit DRYSOL EXTERNAL SOLUTION 20 % Tier 2 essentra wipes 9x9" external 70 % Tier 3 PRE & POST SX POUCH EXTERNAL Tier 3 THERAPY PACK 4 & 2 & 5 % QBREXZA EXTERNAL PAD 2.4 % Tier 2 PA XERAC AC EXTERNAL SOLUTION Tier 3 6.25 % Phosphodiesterase 4 (Pde4) Inhibitors - Topical EUCRISA EXTERNAL OINTMENT 2 % Tier 2 Rosacea Agents aveidaoxia external gel 1-1-4 % Tier 3 azelaic acid external gel 15 % (Finacea) Tier 1 FINACEA EXTERNAL FOAM 15 % Tier 2 ivermectin-metronidazol-niacin external Tier 1 gel 1-1-4 % metronidazole external cream 0.75 % (Rosadan) Tier 1 metronidazole external gel 0.75 % (Rosadan) Tier 1 metronidazole external gel 1 % (Metrogel) Tier 1 metronidazole external lotion 0.75 % (MetroLotion) Tier 1 MIRVASO EXTERNAL GEL 0.33 % Tier 3

MedPerform Medium Formulary 01/01/2021

163 Drug Status Notes RHOFADE EXTERNAL CREAM 1 % Tier 3 ROSADAN EXTERNAL CREAM 0.75 % (MetroNIDAZOLE) Tier 1 ROSADAN EXTERNAL GEL 0.75 % (MetroNIDAZOLE) Tier 1 SOOLANTRA EXTERNAL CREAM 1 % Tier 3 ST: Requires prior prescription for Azelaic Acid within the past 120 days Scabicides & Pediculicides lindane external shampoo 1 % Tier 1 malathion external lotion 0.5 % (Ovide) Tier 1 NATROBA EXTERNAL SUSPENSION (Spinosad) Tier 3 0.9 % permethrin external cream 5 % (Elimite) Tier 1 SKLICE EXTERNAL LOTION 0.5 % Tier 3 Wound Care Products ALLEVYN GENTLE EXTERNAL PAD (Foam Dressing Circular Tier 3 Border) AQUACEL AG BURN EXTERNAL PAD Tier 3 4"X5" ATRAPRO CP EXTERNAL KIT Tier 3 CURITY HYPERTONIC NACL STRIP (Triple Helix Collagen 12" Tier 3 EXTERNAL Rope) CURITY NACL DRESSING 6"X6-3/4" (Foam Dressing Circular Tier 3 EXTERNAL PAD Border) HYDROFERA BLUE FOAM DRESSING (Foam Dressing Circular Tier 3 EXTERNAL PAD Border) HYDROFERA BLUE READY FOAM (Foam Dressing Circular Tier 3 EXTERNAL PAD Border) KENDALL ALGINATE 12" ROPE (Triple Helix Collagen 12" Tier 3 EXTERNAL Rope) KENDALL ALGINATE DRESS 2"X2" (Foam Dressing Circular Tier 3 EXTERNAL PAD Border) KENDALL ALGINATE DRESS 4"X4" (CVS Hydrocolloid Pads) Tier 3 EXTERNAL PAD KENDALL ALGINATE DRESS 4"X8" (Foam Dressing Circular Tier 3 EXTERNAL PAD Border)

MedPerform Medium Formulary 01/01/2021

164 Drug Status Notes KENDALL HYDROGEL GAUZE 2"X2" (CVS Hydrocolloid Pads) Tier 3 EXTERNAL PAD KENDALL HYDROGEL GAUZE 4"X4" (CVS Hydrocolloid Pads) Tier 3 EXTERNAL PAD KENDALL HYDROGEL GAUZE 4"X8" (CVS Hydrocolloid Pads) Tier 3 EXTERNAL PAD KENDALL HYDROGEL WOUND (CVS Hydrocolloid Pads) Tier 3 DRESS EXTERNAL lavare wound wash external gel (Microcyn Skin and Tier 3 Wound) MEDIHONEY WOUND/BURN (Foam Dressing Circular Tier 3 DRESSING EXTERNAL PAD Border) MICROCYN SKIN AND WOUND (Lavare Wound Wash) Tier 3 EXTERNAL GEL PICO WOUND THERAPY SYSTEM Tier 3 EXTERNAL KIT REGRANEX EXTERNAL GEL 0.01 % Tier 2 RTD WOUND CARE DRESSING (Foam Dressing Circular Tier 3 EXTERNAL PAD Border) THERAHONEY EXTERNAL SHEET Tier 3 VASHE CLEANSING EXTERNAL Tier 3 SOLUTION Diabetes Diabetic Supplies OMNIPOD 5 PACK Tier 2 OMNIPOD DASH 5 PACK PODS Tier 2 OMNIPOD DASH SYSTEM KIT Tier 2 QL (1 EA per 365 days) OMNIPOD STARTER KIT Tier 2 QL (1 EA per 365 days) Insulins LYUMJEV INJECTION SOLUTION 100 Tier 2 QL (40 ML per 28 days) UNIT/ML LYUMJEV KWIKPEN SUBCUTANEOUS Tier 2 QL (30 ML per 28 days) SOLUTION PEN-INJECTOR 100 UNIT/ML

MedPerform Medium Formulary 01/01/2021

165 Drug Status Notes LYUMJEV KWIKPEN SUBCUTANEOUS Tier 2 QL (12 ML per 28 days) SOLUTION PEN-INJECTOR 200 UNIT/ML Diagnostic Products Diagnostic Tests FREESTYLE INSULINX TEST IN VITRO (TGT Blood Glucose Test) Tier 2 QL (200 EA per 30 days) STRIP FREESTYLE LITE TEST IN VITRO (TGT Blood Glucose Test) Tier 2 QL (200 EA per 30 days) STRIP FREESTYLE PRECISION NEO TEST IN (TGT Blood Glucose Test) Tier 2 QL (200 EA per 30 days) VITRO STRIP FREESTYLE TEST IN VITRO STRIP (TGT Blood Glucose Test) Tier 2 QL (200 EA per 30 days) PRECISION XTRA BLOOD GLUCOSE (TGT Blood Glucose Test) Tier 2 QL (200 EA per 30 days) IN VITRO STRIP Dietary Products/Dietary Management Products Dietary Management Products APPTRIM ORAL CAPSULE Tier 3 APPTRIM-D ORAL CAPSULE Tier 3 ASTAMED MYO ORAL CAPSULE Tier 3 AVAILNEX ORAL TABLET CHEWABLE Tier 3 750 MG AXONA ORAL PACKET (Pro-Critic) Tier 3 DEPLIN 15 ORAL CAPSULE 15-90.314 (L-Methylfolate-Algae) Tier 3 MG DEPLIN 7.5 ORAL CAPSULE 7.5- (L-Methylfolate Forte) Tier 3 90.314 MG ELFOLATE ORAL TABLET 15 MG, 7.5 (L-methylfolate Calcium) Tier 3 MG ENLYTE ORAL CAPSULE (TL-ICare) Tier 3 ENTERAGAM ORAL PACKET 5 GM Tier 3 FOSTEUM ORAL CAPSULE 27-20-200 Tier 3 MG-MG-UNIT FOSTEUM PLUS ORAL CAPSULE (TL-ICare) Tier 3 FOVEX ORAL CAPSULE (TL-ICare) Tier 3

MedPerform Medium Formulary 01/01/2021

166 Drug Status Notes GABADONE ORAL CAPSULE (TL-ICare) Tier 3 GALAXTRA ORAL POWDER Tier 3 HYPERTENSA ORAL CAPSULE (TL-ICare) Tier 3 LDL CARE ORAL POWDER (VB6 P5P) Tier 3 LIMBREL ORAL CAPSULE 250 MG, Tier 3 500 MG LIMBREL250 ORAL CAPSULE 250-50 Tier 3 MG LIMBREL500 ORAL CAPSULE 500-50 Tier 3 MG LISTER-V ORAL CAPSULE (TL-ICare) Tier 3 l-methylfolate forte oral capsule 15- (Deplin 15) Tier 3 90.314 mg l-methylfolate forte oral capsule 7.5- (Deplin 7.5) Tier 3 90.314 mg l-methyl-mc nac oral tablet 6-2-600 mg (Metafolbic Plus) Tier 3 lormate oral capsule (EnLyte) Tier 3 MACUTEK ORAL TABLET Tier 3 DISPERSIBLE medactiv oral tablet Tier 3 METAFOLBIC PLUS ORAL TABLET 6- (L-Methyl-MC NAC) Tier 3 2-600 MG methaver oral capsule (EnLyte) Tier 3 neoke bhb oral powder (LDL Care) Tier 3 NEUREPA ORAL CAPSULE (TL-ICare) Tier 3 PERCURA ORAL CAPSULE (TL-ICare) Tier 3 pro-critic oral packet (Axona) Tier 3 PROLEEVA ORAL CAPSULE (TL-ICare) Tier 3 PULMONA ORAL CAPSULE (TL-ICare) Tier 3 RHEUMATE ORAL CAPSULE (TL-ICare) Tier 3 ribozel oral capsule (EnLyte) Tier 3 SENTRA AM ORAL CAPSULE (TL-ICare) Tier 3 SENTRA PM ORAL CAPSULE (TL-ICare) Tier 3 SULFZIX ORAL CAPSULE (TL-ICare) Tier 3 THERAMINE ORAL CAPSULE (TL-ICare) Tier 3

MedPerform Medium Formulary 01/01/2021

167 Drug Status Notes THERAMINE PLUS ORAL PACKET (Pro-Critic) Tier 3 tl-icare oral capsule (EnLyte) Tier 3 TOBAKIENT ORAL CAPSULE (TL-ICare) Tier 3 TREPADONE ORAL CAPSULE (TL-ICare) Tier 3 t-support max oral capsule (EnLyte) Tier 3 VASCAZEN ORAL CAPSULE 1 GM Tier 3 vb6 p5p oral powder (LDL Care) Tier 3 XAQUIL XR ORAL TABLET EXTENDED Tier 3 RELEASE 30 MG Digestive Aids Digestive Enzymes CREON ORAL CAPSULE DELAYED Tier 2 RELEASE PARTICLES 12000 UNIT, 24000-76000 UNIT, 3000-9500 UNIT, 36000 UNIT, 6000 UNIT enzadyne oral capsule (Abatrace) Tier 3 SUCRAID ORAL SOLUTION 8500 Tier 3 PA; SP UNIT/ML VIOKACE ORAL TABLET 10440 UNIT, Tier 3 20880 UNIT ZENPEP ORAL CAPSULE DELAYED Tier 2 RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000-63000 UNIT, 25000-79000 UNIT, 3000-14000 UNIT, 40000-126000 UNIT, 5000-24000 UNIT Diuretics Carbonic Anhydrase Inhibitors acetazolamide er oral capsule extended Tier 1 release 12 hour 500 mg acetazolamide oral tablet 125 mg, 250 Tier 1 mg KEVEYIS ORAL TABLET 50 MG Tier 2 PA; SP methazolamide oral tablet 25 mg, 50 mg Tier 1

MedPerform Medium Formulary 01/01/2021

168 Drug Status Notes Diuretic Combinations ALDACTAZIDE ORAL TABLET 50-50 Tier 3 MG amiloride-hydrochlorothiazide oral tablet Tier 1 5-50 mg spironolactone-hctz oral tablet 25-25 mg (Aldactazide) Tier 1 triamterene-hctz oral capsule 37.5-25 (Dyazide) Tier 1 mg triamterene-hctz oral tablet 37.5-25 mg (Maxzide-25) Tier 1 triamterene-hctz oral tablet 75-50 mg (Maxzide) Tier 1 Loop Diuretics bumetanide oral tablet 0.5 mg, 1 mg, 2 (Bumex) Tier 1 mg ethacrynic acid oral tablet 25 mg (Edecrin) Tier 1 furosemide oral solution 10 mg/ml, 8 Tier 1 mg/ml furosemide oral tablet 20 mg, 40 mg, 80 (Lasix) Tier 1 mg torsemide oral tablet 10 mg, 100 mg, 20 Tier 1 mg, 5 mg Potassium Sparing Diuretics amiloride hcl oral tablet 5 mg Tier 1 spironolactone oral tablet 100 mg, 25 (Aldactone) Tier 1 mg, 50 mg triamterene oral capsule 100 mg, 50 mg (Dyrenium) Tier 1 Thiazides And Thiazide-Like Diuretics chlorthalidone oral tablet 25 mg, 50 mg Tier 1 DIURIL ORAL SUSPENSION 250 Tier 3 MG/5ML hydrochlorothiazide oral capsule 12.5 Tier 1 mg hydrochlorothiazide oral tablet 12.5 mg, Tier 1 25 mg, 50 mg indapamide oral tablet 1.25 mg, 2.5 mg Tier 1 metolazone oral tablet 10 mg, 2.5 mg, 5 Tier 1 mg

MedPerform Medium Formulary 01/01/2021

169 Drug Status Notes Endocrine And Metabolic Agents - Misc. Adrenal Steroid Inhibitors ISTURISA ORAL TABLET 1 MG, 10 Tier 3 PA; SP MG, 5 MG Bone Density Regulators alendronate sodium oral solution 70 Tier 1 QL (75 ML per 7 days) mg/75ml alendronate sodium oral tablet 10 mg, 35 Tier 1 mg alendronate sodium oral tablet 70 mg (Fosamax) Tier 1 calcitonin (salmon) nasal solution 200 (Miacalcin) Tier 1 unit/act FORTEO SUBCUTANEOUS SOLUTION Tier 2 PA; SP; QL (2.4 ML per 28 PEN-INJECTOR 600 MCG/2.4ML days) FOSAMAX PLUS D ORAL TABLET 70- Tier 2 2800 MG-UNIT, 70-5600 MG-UNIT ibandronate sodium oral tablet 150 mg (Boniva) Tier 1 MIACALCIN INJECTION SOLUTION Tier 3 200 UNIT/ML NATPARA SUBCUTANEOUS Tier 3 PA; SP CARTRIDGE 100 MCG, 25 MCG, 50 MCG, 75 MCG risedronate sodium oral tablet 150 mg (Actonel) Tier 1 ST: Requires prior prescriptions for Alendronate Sodium and Ibandronate Sodium within the past 365 days; QL (1 EA per 30 days) risedronate sodium oral tablet 30 mg, 5 Tier 1 ST: Requires prior mg prescriptions for Alendronate Sodium and Ibandronate Sodium within the past 365 days; QL (1 EA per 1 day)

MedPerform Medium Formulary 01/01/2021

170 Drug Status Notes risedronate sodium oral tablet 35 mg (Actonel) Tier 1 ST: Requires prior prescriptions for Alendronate Sodium and Ibandronate Sodium within the past 365 days; QL (1 EA per 7 days) risedronate sodium oral tablet delayed (Atelvia) Tier 1 ST: Requires prior release 35 mg prescriptions for Alendronate Sodium and Ibandronate Sodium within the past 365 days; QL (1 EA per 7 days) TYMLOS SUBCUTANEOUS SOLUTION Tier 2 PA; SP PEN-INJECTOR 3120 MCG/1.56ML Fertility Regulators chorionic gonadotropin intramuscular (Novarel) Tier 3 ST: Requires prior solution reconstituted 10000 unit prescription for Choriogonadotropin Alfa or Chorionic Gonadotropin within the past 120 days clomiphene citrate oral tablet 50 mg Tier 1 FOLLISTIM AQ SUBCUTANEOUS Tier 3 SP; ST: Requires prior SOLUTION 300 UNT/0.36ML, 600 prescription for Follitropin UNT/0.72ML, 900 UNT/1.08ML Alfa within the past 120 days GONAL-F INJECTION SOLUTION Tier 2 SP RECONSTITUTED 1050 UNIT, 450 UNIT GONAL-F RFF REDIJECT Tier 2 SP SUBCUTANEOUS SOLUTION 300 UNIT/0.5ML, 450 UNT/0.75ML, 900 UNIT/1.5ML GONAL-F RFF SUBCUTANEOUS Tier 2 SP SOLUTION RECONSTITUTED 75 UNIT MENOPUR SUBCUTANEOUS Tier 2 SP SOLUTION RECONSTITUTED 75 UNIT

MedPerform Medium Formulary 01/01/2021

171 Drug Status Notes NOVAREL INTRAMUSCULAR (Chorionic Gonadotropin) Tier 2 SOLUTION RECONSTITUTED 10000 UNIT NOVAREL INTRAMUSCULAR Tier 2 SOLUTION RECONSTITUTED 5000 UNIT OVIDREL SUBCUTANEOUS Tier 2 INJECTABLE 250 MCG/0.5ML PREGNYL INTRAMUSCULAR (Chorionic Gonadotropin) Tier 3 ST: Requires prior SOLUTION RECONSTITUTED 10000 prescription for UNIT Choriogonadotropin Alfa or Chorionic Gonadotropin within the past 120 days Gnrh/Lhrh Antagonists CETROTIDE SUBCUTANEOUS KIT Tier 2 SP 0.25 MG ganirelix acetate subcutaneous solution Tier 1 SP; ST: Requires prior prefilled syringe 250 mcg/0.5ml prescription for Cetrorelix Acetate within the past 120 days ORILISSA ORAL TABLET 150 MG, 200 Tier 2 PA MG Growth Hormone Receptor Antagonists SOMAVERT SUBCUTANEOUS Tier 2 SP SOLUTION RECONSTITUTED 10 MG, 15 MG, 20 MG, 25 MG, 30 MG Growth Hormone Releasing Hormones (Ghrh) EGRIFTA SUBCUTANEOUS Tier 3 PA; SP SOLUTION RECONSTITUTED 2 MG EGRIFTA SV SUBCUTANEOUS Tier 3 PA; SP SOLUTION RECONSTITUTED 2 MG Growth Hormones NORDITROPIN FLEXPRO Tier 2 PA; SP SUBCUTANEOUS SOLUTION PEN- INJECTOR 10 MG/1.5ML, 15 MG/1.5ML, 30 MG/3ML, 5 MG/1.5ML

MedPerform Medium Formulary 01/01/2021

172 Drug Status Notes SEROSTIM SUBCUTANEOUS Tier 3 PA; SP SOLUTION RECONSTITUTED 4 MG, 5 MG, 6 MG ZORBTIVE SUBCUTANEOUS Tier 3 PA; SP SOLUTION RECONSTITUTED 8.8 MG Hormone Receptor Modulators OSPHENA ORAL TABLET 60 MG Tier 2 QL (1 EA per 1 day) raloxifene hcl oral tablet 60 mg (Evista) $0 QL (1 EA per 1 day) Insulin-Like Growth Factors (Somatomedins) INCRELEX SUBCUTANEOUS Tier 3 PA; SP SOLUTION 40 MG/4ML Lhrh/Gnrh Agonist Analog Pituitary Suppressants LUPANETA PACK COMBINATION KIT Tier 3 PA; SP 11.25 & 5 MG, 3.75 & 5 MG SYNAREL NASAL SOLUTION 2 MG/ML Tier 3 PA; SP Metabolic Modifiers calcitriol oral capsule 0.25 mcg, 0.5 mcg (Rocaltrol) Tier 1 calcitriol oral solution 1 mcg/ml (Rocaltrol) Tier 1 CARBAGLU ORAL TABLET 200 MG Tier 3 SP cinacalcet hcl oral tablet 30 mg, 60 mg (Sensipar) Tier 1 SP; QL (2 EA per 1 day) cinacalcet hcl oral tablet 90 mg (Sensipar) Tier 1 SP; QL (4 EA per 1 day) CYSTADANE ORAL POWDER Tier 3 SP doxercalciferol oral capsule 0.5 mcg, 1 Tier 1 mcg, 2.5 mcg GALAFOLD ORAL CAPSULE 123 MG Tier 3 PA; SP levocarnitine oral solution 1 gm/10ml (Carnitor) Tier 1 levocarnitine oral tablet 330 mg (Carnitor) Tier 1 levocarnitine sf oral solution 1 gm/10ml (Carnitor) Tier 1 MYALEPT SUBCUTANEOUS Tier 3 SP; QL (1 EA per 1 day) SOLUTION RECONSTITUTED 11.3 MG nitisinone oral capsule 10 mg, 2 mg, 5 (Orfadin) Tier 1 PA; SP mg

MedPerform Medium Formulary 01/01/2021

173 Drug Status Notes NITYR ORAL TABLET 10 MG, 2 MG, 5 Tier 2 PA; SP MG ORFADIN ORAL CAPSULE 20 MG Tier 2 PA; SP ORFADIN ORAL SUSPENSION 4 Tier 2 PA; SP MG/ML PALYNZIQ SUBCUTANEOUS Tier 2 PA; SP SOLUTION PREFILLED SYRINGE 10 MG/0.5ML, 2.5 MG/0.5ML, 20 MG/ML paricalcitol oral capsule 1 mcg, 2 mcg (Zemplar) Tier 1 paricalcitol oral capsule 4 mcg Tier 1 RAVICTI ORAL LIQUID 1.1 GM/ML Tier 3 PA; SP RAYALDEE ORAL CAPSULE Tier 2 QL (2 EA per 1 day) EXTENDED RELEASE 30 MCG REVCOVI INTRAMUSCULAR Tier 3 PA; SP SOLUTION 2.4 MG/1.5ML sapropterin dihydrochloride oral packet (Kuvan) Tier 1 PA; SP 100 mg, 500 mg sapropterin dihydrochloride oral tablet (Kuvan) Tier 1 PA; SP soluble 100 mg sodium phenylbutyrate oral powder 3 (Buphenyl) Tier 1 PA; SP gm/tsp sodium phenylbutyrate oral tablet 500 (Buphenyl) Tier 1 PA; SP mg STRENSIQ SUBCUTANEOUS Tier 2 PA; SP SOLUTION 18 MG/0.45ML, 28 MG/0.7ML, 40 MG/ML, 80 MG/0.8ML XURIDEN ORAL PACKET 2 GM Tier 2 PA; SP Posterior Pituitary Hormones DDAVP RHINAL TUBE NASAL Tier 2 SOLUTION 0.01 % desmopressin ace spray refrig nasal Tier 1 solution 0.01 % desmopressin acetate injection solution (DDAVP) Tier 1 4 mcg/ml desmopressin acetate oral tablet 0.1 mg, (DDAVP) Tier 1 0.2 mg

MedPerform Medium Formulary 01/01/2021

174 Drug Status Notes desmopressin acetate spray nasal (DDAVP) Tier 1 solution 0.01 % NOCDURNA SUBLINGUAL TABLET Tier 3 QL (1 EA per 1 day) SUBLINGUAL 27.7 MCG, 55.3 MCG STIMATE NASAL SOLUTION 1.5 Tier 3 MG/ML Progesterone Receptor Antagonists mifepristone oral tablet 200 mg (Mifeprex) Tier 1 Prolactin Inhibitors cabergoline oral tablet 0.5 mg Tier 1 Somatostatic Agents MYCAPSSA ORAL CAPSULE Tier 3 PA; SP DELAYED RELEASE 20 MG octreotide acetate injection solution 100 (SandoSTATIN) Tier 1 SP mcg/ml, 50 mcg/ml, 500 mcg/ml octreotide acetate injection solution 1000 Tier 1 SP mcg/ml, 200 mcg/ml SIGNIFOR SUBCUTANEOUS Tier 3 PA; SP SOLUTION 0.3 MG/ML, 0.6 MG/ML, 0.9 MG/ML Vasopressin Receptor Antagonists JYNARQUE ORAL TABLET 15 MG, 30 (Tolvaptan) Tier 2 PA; SP MG JYNARQUE ORAL TABLET THERAPY Tier 2 PA; SP PACK 15 MG, 30 & 15 MG, 45 & 15 MG, 60 & 30 MG, 90 & 30 MG tolvaptan oral tablet 15 mg (Jynarque) Tier 1 SP; QL (30 EA per 365 days) tolvaptan oral tablet 30 mg (Jynarque) Tier 1 SP; QL (60 EA per 365 days) Estrogens Estrogen Combinations AMABELZ ORAL TABLET 0.5-0.1 MG, (Estradiol-Norethindrone Tier 1 1-0.5 MG Acet) ANGELIQ ORAL TABLET 0.25-0.5 MG, Tier 3 0.5-1 MG

MedPerform Medium Formulary 01/01/2021

175 Drug Status Notes bi-est 50:50 transdermal cream Tier 3 bi-est 80:20 progesterone transdermal (Biest/Progesterone) Tier 3 cream bi-est progest-testosterone transdermal Tier 3 cream BIEST/PROGESTERONE (Bi-Est 80:20 Tier 3 TRANSDERMAL CREAM Progesterone) BIJUVA ORAL CAPSULE 1-100 MG Tier 3 CLIMARA PRO TRANSDERMAL Tier 3 QL (1 EA per 7 days) PATCH WEEKLY 0.045-0.015 MG/DAY COMBIPATCH TRANSDERMAL PATCH Tier 2 QL (2 EA per 7 days) TWICE WEEKLY 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY COVARYX HS ORAL TABLET 0.625- (Est Estrogens-Methyltest Tier 1 1.25 MG HS) COVARYX ORAL TABLET 1.25-2.5 MG (Est Estrogens-Methyltest) Tier 1 DUAVEE ORAL TABLET 0.45-20 MG Tier 2 EEMT HS ORAL TABLET 0.625-1.25 (Est Estrogens-Methyltest Tier 1 MG HS) EEMT ORAL TABLET 1.25-2.5 MG (Est Estrogens-Methyltest) Tier 1 est estrogens-methyltest ds oral tablet (Covaryx) Tier 1 1.25-2.5 mg est estrogens-methyltest hs oral tablet (Covaryx HS) Tier 1 0.625-1.25 mg est estrogens-methyltest oral tablet 1.25- (Covaryx) Tier 1 2.5 mg estradiol-norethindrone acet oral tablet (Amabelz) Tier 1 0.5-0.1 mg, 1-0.5 mg estriol-progesterone micro transdermal Tier 3 cream 4-20 mg/gm FYAVOLV ORAL TABLET 0.5-2.5 MG- (Norethindrone-Eth Tier 1 MCG, 1-5 MG-MCG Estradiol) JINTELI ORAL TABLET 1-5 MG-MCG (Norethindrone-Eth Tier 1 Estradiol) MIMVEY ORAL TABLET 1-0.5 MG (Estradiol-Norethindrone Tier 1 Acet)

MedPerform Medium Formulary 01/01/2021

176 Drug Status Notes norethindrone-eth estradiol oral tablet (Fyavolv) Tier 1 0.5-2.5 mg-mcg, 1-5 mg-mcg ORIAHNN ORAL CAPSULE THERAPY Tier 2 PA PACK 300-1-0.5 & 300 MG PREFEST ORAL TABLET 1/1-0.09 MG Tier 3 (15/15) PREMPHASE ORAL TABLET 0.625-5 Tier 2 MG PREMPRO ORAL TABLET 0.3-1.5 MG, Tier 2 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG Estrogens ALORA TRANSDERMAL PATCH (Estradiol) Tier 2 QL (2 EA per 7 days) TWICE WEEKLY 0.025 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR DELESTROGEN INTRAMUSCULAR Tier 3 OIL 10 MG/ML DEPO-ESTRADIOL INTRAMUSCULAR Tier 3 OIL 5 MG/ML DIVIGEL TRANSDERMAL GEL 0.25 Tier 2 MG/0.25GM, 0.5 MG/0.5GM, 0.75 MG/0.75GM, 1 MG/GM, 1.25 MG/1.25GM DOTTI TRANSDERMAL PATCH TWICE (Estradiol) Tier 1 QL (2 EA per 7 days) WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR ec-rx estradiol transdermal cream 0.4 %, Tier 3 0.6 % ELESTRIN TRANSDERMAL GEL 0.52 Tier 3 MG/0.87 GM (0.06%) estradiol oral tablet 0.5 mg, 1 mg, 2 mg (Estrace) Tier 1 estradiol transdermal patch twice weekly (Dotti) Tier 1 QL (2 EA per 7 days) 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr

MedPerform Medium Formulary 01/01/2021

177 Drug Status Notes estradiol transdermal patch weekly 0.025 (Climara) Tier 1 QL (1 EA per 7 days) mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr estradiol valerate intramuscular oil 20 (Delestrogen) Tier 1 mg/ml, 40 mg/ml EVAMIST TRANSDERMAL SOLUTION Tier 3 ST: Requires prior 1.53 MG/SPRAY prescription for Estradiol within the past 120 days LYLLANA TRANSDERMAL PATCH (Estradiol) Tier 1 QL (2 EA per 7 days) TWICE WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR MENEST ORAL TABLET 0.3 MG, 0.625 Tier 2 MG, 1.25 MG MENOSTAR TRANSDERMAL PATCH Tier 3 QL (1 EA per 7 days) WEEKLY 14 MCG/24HR PREMARIN ORAL TABLET 0.3 MG, Tier 2 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG Fluoroquinolones Fluoroquinolones BAXDELA ORAL TABLET 450 MG Tier 3 PA CIPRO ORAL SUSPENSION Tier 2 RECONSTITUTED 250 MG/5ML (5%), 500 MG/5ML (10%) ciprofloxacin hcl oral tablet 100 mg, 750 Tier 1 mg ciprofloxacin hcl oral tablet 250 mg, 500 (Cipro) Tier 1 mg levofloxacin oral solution 25 mg/ml Tier 1 levofloxacin oral tablet 250 mg, 500 mg, (Levaquin) Tier 1 750 mg moxifloxacin hcl oral tablet 400 mg Tier 1 ofloxacin oral tablet 300 mg, 400 mg Tier 1

MedPerform Medium Formulary 01/01/2021

178 Drug Status Notes Gastrointestinal Agents - Misc. Bile Acid Synthesis Disorder Agents CHOLBAM ORAL CAPSULE 250 MG, Tier 3 PA; SP 50 MG Farnesoid X Receptor (Fxr) Agonists OCALIVA ORAL TABLET 10 MG, 5 MG Tier 2 PA; SP Gallstone Solubilizing Agents CHENODAL ORAL TABLET 250 MG Tier 3 PA; SP ursodiol oral capsule 300 mg (Actigall) Tier 1 ursodiol oral tablet 250 mg (Urso 250) Tier 1 ursodiol oral tablet 500 mg (Urso Forte) Tier 1 URSODIOL+SYRSPEND SF ORAL Tier 3 SUSPENSION 30 MG/ML Gastrointestinal Antiallergy Agents cromolyn sodium oral concentrate 100 (Gastrocrom) Tier 1 mg/5ml Gastrointestinal Chloride Channel Activators AMITIZA ORAL CAPSULE 24 MCG, 8 Tier 3 ST: Requires prior MCG prescription for Linaclotide or Naloxegol Oxalate within the past 120 days; QL (2 EA per 1 day) Gastrointestinal Stimulants dexpanthenol injection solution 250 Tier 3 mg/ml GIMOTI NASAL SOLUTION 15 MG/ACT Tier 3 PA; SP metoclopramide hcl oral solution 10 Tier 1 mg/10ml, 5 mg/5ml metoclopramide hcl oral tablet 10 mg, 5 (Reglan) Tier 1 mg metoclopramide hcl oral tablet Tier 1 dispersible 10 mg, 5 mg Inflammatory Bowel Agents balsalazide disodium oral capsule 750 (Colazal) Tier 1 mg

MedPerform Medium Formulary 01/01/2021

179 Drug Status Notes CIMZIA PREFILLED SUBCUTANEOUS Tier 3 PA; SP KIT 2 X 200 MG/ML CIMZIA STARTER KIT Tier 3 PA; SP SUBCUTANEOUS KIT 6 X 200 MG/ML CIMZIA SUBCUTANEOUS KIT 2 X 200 Tier 3 PA; SP MG COLAZAL ORAL CAPSULE 750 MG (Balsalazide Disodium) Tier 1 LIALDA ORAL TABLET DELAYED (Mesalamine) Tier 1 RELEASE 1.2 GM mesalamine er oral capsule extended (Apriso) Tier 1 release 24 hour 0.375 gm mesalamine oral tablet delayed release (Asacol HD) Tier 1 800 mg mesalamine rectal enema 4 gm Tier 1 mesalamine rectal suppository 1000 mg (Canasa) Tier 1 mesalamine-cleanser rectal kit 4 gm (Rowasa) Tier 1 PENTASA ORAL CAPSULE Tier 2 EXTENDED RELEASE 250 MG, 500 MG SFROWASA RECTAL ENEMA 4 Tier 3 GM/60ML sulfasalazine oral tablet 500 mg (Azulfidine) Tier 1 sulfasalazine oral tablet delayed release (Azulfidine EN-tabs) Tier 1 500 mg Intestinal Acidifiers enulose oral solution 10 gm/15ml Tier 1 generlac oral solution 10 gm/15ml Tier 1 lactulose encephalopathy oral solution Tier 1 10 gm/15ml Irritable Bowel Syndrome (Ibs) Agents alosetron hcl oral tablet 0.5 mg, 1 mg (Lotronex) Tier 1 LINZESS ORAL CAPSULE 145 MCG, Tier 2 QL (1 EA per 1 day) 290 MCG, 72 MCG VIBERZI ORAL TABLET 100 MG, 75 Tier 3 PA MG

MedPerform Medium Formulary 01/01/2021

180 Drug Status Notes Peripheral Opioid Receptor Antagonists ENTEREG ORAL CAPSULE 12 MG Tier 3 MOVANTIK ORAL TABLET 12.5 MG, 25 Tier 2 QL (1 EA per 1 day) MG RELISTOR ORAL TABLET 150 MG Tier 3 PA; QL (3 EA per 1 day) RELISTOR SUBCUTANEOUS Tier 3 PA; QL (0.6 ML per 1 day) SOLUTION 12 MG/0.6ML RELISTOR SUBCUTANEOUS Tier 3 PA; QL (0.4 ML per 1 day) SOLUTION 8 MG/0.4ML Phosphate Binder Agents AURYXIA ORAL TABLET 1 GM 210 Tier 3 QL (12 EA per 1 day) MG(FE) calcium acetate (phos binder) oral (PhosLo) Tier 1 capsule 667 mg calcium acetate (phos binder) oral tablet (Calphron) Tier 1 667 mg calcium acetate oral tablet 667 mg (Calphron) Tier 1 FOSRENOL ORAL PACKET 1000 MG, Tier 3 750 MG lanthanum carbonate oral tablet (Fosrenol) Tier 1 chewable 1000 mg, 500 mg, 750 mg PHOSLYRA ORAL SOLUTION 667 Tier 3 MG/5ML sevelamer carbonate oral packet 0.8 gm, (Renvela) Tier 1 2.4 gm sevelamer carbonate oral tablet 800 mg (Renvela) Tier 1 sevelamer hcl oral tablet 400 mg Tier 1 sevelamer hcl oral tablet 800 mg (Renagel) Tier 1 VELPHORO ORAL TABLET Tier 2 CHEWABLE 500 MG Short Bowel Syndrome (Sbs) Agents GATTEX SUBCUTANEOUS KIT 5 MG Tier 2 PA; SP Tryptophan Hydroxylase Inhibitors XERMELO ORAL TABLET 250 MG Tier 2 PA; SP

MedPerform Medium Formulary 01/01/2021

181 Drug Status Notes General Anesthetics Anesthetics - Misc. ketamine hcl sublingual troche 100 mg Tier 3 Volatile Anesthetics desflurane inhalation solution (Suprane) Tier 1 isoflurane inhalation solution (Terrell) Tier 1 sevoflurane inhalation solution (Ultane) Tier 1 TERRELL INHALATION SOLUTION (Isoflurane) Tier 1 Genitourinary Agents - Miscellaneous Acidifiers K-PHOS NO 2 ORAL TABLET 305-700 Tier 3 MG Alkalinizers cytra k crystals oral packet 3300-1002 (Taron-Crystals) Tier 1 mg ORACIT ORAL SOLUTION 490-640 Tier 3 MG/5ML pot & sod cit-cit ac oral solution 550-500- Tier 1 334 mg/5ml potassium citrate er oral tablet extended (Urocit-K 10) Tier 1 release 10 meq (1080 mg) potassium citrate er oral tablet extended (Urocit-K 15) Tier 1 release 15 meq (1620 mg) potassium citrate er oral tablet extended (Urocit-K 5) Tier 1 release 5 meq (540 mg) potassium citrate-citric acid oral solution Tier 3 1100-334 mg/5ml sod citrate-citric acid oral solution 500- Tier 1 334 mg/5ml TARON-CRYSTALS ORAL PACKET (Cytra K Crystals) Tier 1 3300-1002 MG tricitrates oral solution 550-500-334 Tier 1 mg/5ml Cystinosis Agents CYSTAGON ORAL CAPSULE 150 MG, Tier 3 SP 50 MG

MedPerform Medium Formulary 01/01/2021

182 Drug Status Notes PROCYSBI ORAL CAPSULE DELAYED Tier 2 PA; SP RELEASE 25 MG, 75 MG PROCYSBI ORAL PACKET 300 MG, 75 Tier 2 PA; SP MG Genitourinary Irrigants acetic acid irrigation solution 0.25 % Tier 1 aminoacetic acid irrigation solution 1.5 % Tier 1 ARGYLE STERILE SALINE (Sodium Chloride) Tier 1 IRRIGATION SOLUTION 0.9 % CURITY STERILE SALINE IRRIGATION (Sodium Chloride) Tier 1 SOLUTION 0.9 % glycine irrigation solution 1.5 % Tier 1 glycine urologic irrigation solution 1.5 % Tier 1 neomycin-polymyxin b gu irrigation Tier 1 solution 40-200000 RENACIDIN IRRIGATION SOLUTION Tier 3 sodium chloride irrigation solution 0.9 % (Argyle Sterile Saline) Tier 1 Interstitial Cystitis Agents ELMIRON ORAL CAPSULE 100 MG Tier 2 PA pentosan polysulfate sodium oral Tier 3 capsule delayed release 150 mg, 200 mg Prostatic Hypertrophy Agents alfuzosin hcl er oral tablet extended (Uroxatral) Tier 1 release 24 hour 10 mg CARDURA XL ORAL TABLET Tier 3 EXTENDED RELEASE 24 HOUR 4 MG, 8 MG dutasteride oral capsule 0.5 mg (Avodart) Tier 1 dutasteride-tamsulosin hcl oral capsule (Jalyn) Tier 1 ST: Requires prior 0.5-0.4 mg prescription for Alfuzosin HCL, Doxazosin Mesylate, Finasteride 5mg, Prazosin HCL, Tamsulosin HCL, or Terazosin HCL within the past 120 days

MedPerform Medium Formulary 01/01/2021

183 Drug Status Notes finasteride oral tablet 5 mg (Proscar) Tier 1 silodosin oral capsule 4 mg, 8 mg (Rapaflo) Tier 1 ST: Requires prior prescription for Alfuzosin HCL, Doxazosin Mesylate, Finasteride 5mg, Prazosin HCL, Tamsulosin HCL, or Terazosin HCL within the past 120 days tamsulosin hcl oral capsule 0.4 mg (Flomax) Tier 1 Urinary Analgesics PHENAZO ORAL TABLET 200 MG (Phenazopyridine HCl) Tier 1 phenazopyridine hcl oral tablet 100 mg (Pyridium) Tier 1 phenazopyridine hcl oral tablet 200 mg (Phenazo) Tier 1 Urinary Stone Agents LITHOSTAT ORAL TABLET 250 MG Tier 3 THIOLA EC ORAL TABLET DELAYED Tier 2 SP RELEASE 100 MG, 300 MG THIOLA ORAL TABLET 100 MG Tier 2 SP Gout Agents Gout Agent Combinations colchicine-probenecid oral tablet 0.5-500 Tier 1 mg Gout Agents allopurinol oral tablet 100 mg, 300 mg (Zyloprim) Tier 1 colchicine oral tablet 0.6 mg (Colcrys) Tier 1 QL (4 EA per 1 day) febuxostat oral tablet 40 mg, 80 mg (Uloric) Tier 1 ST: Requires prior prescription for Allopurinol within the past 120 days; QL (1 EA per 1 day) GLOPERBA ORAL SOLUTION 0.6 Tier 3 ST: Requires prior MG/5ML prescription for Colchicine capsules or tablets within the past 120 days; QL (10 ML per 1 day) MITIGARE ORAL CAPSULE 0.6 MG (Colchicine) Tier 3 QL (2 EA per 1 day)

MedPerform Medium Formulary 01/01/2021

184 Drug Status Notes Uricosurics probenecid oral tablet 500 mg Tier 1 Hematological Agents - Misc. Antihemophilic Products ADVATE INTRAVENOUS SOLUTION Tier 3 SP RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT adynovate intravenous solution Tier 3 SP reconstituted 1000 unit, 1500 unit, 2000 unit, 250 unit, 3000 unit, 500 unit, 750 unit AFSTYLA INTRAVENOUS KIT 1000 Tier 3 SP UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 500 UNIT ALPHANATE/VWF COMPLEX/HUMAN Tier 3 SP INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT ALPHANINE SD INTRAVENOUS Tier 3 SP SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 500 UNIT ALPROLIX INTRAVENOUS SOLUTION Tier 3 SP RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT BENEFIX INTRAVENOUS KIT 1000 Tier 3 SP UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT COAGADEX INTRAVENOUS Tier 3 SP SOLUTION RECONSTITUTED 250 UNIT, 500 UNIT CORIFACT INTRAVENOUS KIT 1000- Tier 3 SP 1600 UNIT

MedPerform Medium Formulary 01/01/2021

185 Drug Status Notes ELOCTATE INTRAVENOUS SOLUTION Tier 3 SP RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT, 5000 UNIT, 6000 UNIT, 750 UNIT ESPEROCT INTRAVENOUS Tier 3 SP SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 3000 UNIT, 500 UNIT FEIBA INTRAVENOUS SOLUTION Tier 3 SP RECONSTITUTED 1000 UNIT, 2500 UNIT, 500 UNIT HEMLIBRA SUBCUTANEOUS Tier 3 PA; SP SOLUTION 105 MG/0.7ML, 150 MG/ML, 30 MG/ML, 60 MG/0.4ML HEMOFIL M INTRAVENOUS Tier 3 SP SOLUTION RECONSTITUTED 1000 UNIT, 1700 UNIT, 250 UNIT, 500 UNIT HUMATE-P INTRAVENOUS SOLUTION Tier 3 SP RECONSTITUTED 1000-2400 UNIT, 250-600 UNIT, 500-1200 UNIT IDELVION INTRAVENOUS SOLUTION Tier 3 SP RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3500 UNIT, 500 UNIT IXINITY INTRAVENOUS SOLUTION (Rixubis) Tier 3 SP RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT IXINITY INTRAVENOUS SOLUTION Tier 3 SP RECONSTITUTED 1500 UNIT JIVI INTRAVENOUS SOLUTION Tier 3 SP RECONSTITUTED 1000 UNIT, 2000 UNIT, 3000 UNIT, 500 UNIT KOATE INTRAVENOUS SOLUTION Tier 3 SP RECONSTITUTED 1000 UNIT, 250 UNIT, 500 UNIT

MedPerform Medium Formulary 01/01/2021

186 Drug Status Notes KOATE-DVI INTRAVENOUS Tier 3 SP SOLUTION RECONSTITUTED 1000 UNIT, 250 UNIT, 500 UNIT KOGENATE FS INTRAVENOUS KIT Tier 3 SP 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT KOVALTRY INTRAVENOUS Tier 3 SP SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT MONONINE INTRAVENOUS Tier 3 SP SOLUTION RECONSTITUTED 1000 UNIT NOVOEIGHT INTRAVENOUS Tier 3 SP SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT NOVOSEVEN RT INTRAVENOUS Tier 3 SP SOLUTION RECONSTITUTED 1 MG, 2 MG, 5 MG, 8 MG NUWIQ INTRAVENOUS KIT 1000 UNIT, Tier 3 SP 2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT NUWIQ INTRAVENOUS SOLUTION Tier 3 SP RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT obizur intravenous solution reconstituted Tier 3 SP 500 unit PROFILNINE INTRAVENOUS Tier 3 SP SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 500 UNIT REBINYN INTRAVENOUS SOLUTION Tier 3 SP RECONSTITUTED 1000 UNIT, 2000 UNIT, 500 UNIT

MedPerform Medium Formulary 01/01/2021

187 Drug Status Notes RECOMBINATE INTRAVENOUS Tier 3 SP SOLUTION RECONSTITUTED 1241- 1800 UNIT, 1801-2400 UNIT, 220-400 UNIT, 401-800 UNIT, 801-1240 UNIT rixubis intravenous solution reconstituted (Ixinity) Tier 3 SP 1000 unit, 2000 unit, 250 unit, 3000 unit, 500 unit SEVENFACT INTRAVENOUS Tier 3 SP SOLUTION RECONSTITUTED 1 MG, 5 MG TRETTEN INTRAVENOUS SOLUTION Tier 3 SP RECONSTITUTED 2000-3125 UNIT VONVENDI INTRAVENOUS SOLUTION Tier 3 SP RECONSTITUTED 1300 UNIT, 650 UNIT WILATE INTRAVENOUS KIT 1000-1000 Tier 3 SP UNIT, 500-500 UNIT XYNTHA INTRAVENOUS KIT 1000 Tier 3 SP UNIT, 2000 UNIT, 250 UNIT, 500 UNIT XYNTHA SOLOFUSE INTRAVENOUS Tier 3 SP KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT Bradykinin B2 Receptor Antagonists icatibant acetate subcutaneous solution (Firazyr) Tier 1 PA; SP 30 mg/3ml Complement Inhibitors BERINERT INTRAVENOUS KIT 500 Tier 3 PA; SP UNIT CINRYZE INTRAVENOUS SOLUTION Tier 3 PA; SP RECONSTITUTED 500 UNIT HAEGARDA SUBCUTANEOUS Tier 3 PA; SP SOLUTION RECONSTITUTED 2000 UNIT, 3000 UNIT RUCONEST INTRAVENOUS Tier 3 PA; SP SOLUTION RECONSTITUTED 2100 UNIT

MedPerform Medium Formulary 01/01/2021

188 Drug Status Notes Hemataologic - Tyrosine Kinase Inhibitors TAVALISSE ORAL TABLET 100 MG, Tier 3 PA; SP 150 MG Hematorheologic Agents pentoxifylline er oral tablet extended Tier 1 release 400 mg Plasma Kallikrein Inhibitors TAKHZYRO SUBCUTANEOUS Tier 3 PA; SP SOLUTION 300 MG/2ML Platelet Aggregation Inhibitors anagrelide hcl oral capsule 0.5 mg (Agrylin) Tier 1 anagrelide hcl oral capsule 1 mg Tier 1 aspirin-dipyridamole er oral capsule Tier 1 extended release 12 hour 25-200 mg BRILINTA ORAL TABLET 60 MG, 90 Tier 2 QL (2 EA per 1 day) MG CABLIVI INJECTION KIT 11 MG Tier 3 PA; SP cilostazol oral tablet 100 mg, 50 mg Tier 1 clopidogrel bisulfate oral tablet 300 mg Tier 1 QL (4 EA per 30 days) clopidogrel bisulfate oral tablet 75 mg (Plavix) Tier 1 dipyridamole oral tablet 25 mg, 50 mg, Tier 1 75 mg prasugrel hcl oral tablet 10 mg, 5 mg (Effient) Tier 1 QL (1 EA per 1 day) ZONTIVITY ORAL TABLET 2.08 MG Tier 3 QL (1 EA per 1 day) Hematopoietic Agents Agents For Gaucher Disease CERDELGA ORAL CAPSULE 84 MG Tier 3 PA; SP miglustat oral capsule 100 mg (Zavesca) Tier 1 PA; SP Agents For Sickle Cell Anemia DROXIA ORAL CAPSULE 200 MG, 300 Tier 3 MG, 400 MG ENDARI ORAL PACKET 5 GM Tier 3 PA; SP OXBRYTA ORAL TABLET 500 MG Tier 3 PA; SP SIKLOS ORAL TABLET 100 MG Tier 3 QL (2 EA per 1 day)

MedPerform Medium Formulary 01/01/2021

189 Drug Status Notes SIKLOS ORAL TABLET 1000 MG Tier 3 ST: Requires prior prescription for Droxia or Hydroxyurea within the past 365 days Cobalamins cyanocobalamin injection solution 1000 Tier 1 mcg/ml hydroxocobalamin acetate intramuscular Tier 1 solution 1000 mcg/ml NASCOBAL NASAL SOLUTION 500 Tier 3 MCG/0.1ML Folic Acid/Folates cvs folic acid oral tablet 800 mcg (FA-8) $0 FA-8 ORAL TABLET 800 MCG (Folic Acid) $0 folate oral tablet 400 mcg $0 folic acid injection solution 5 mg/ml Tier 1 folic acid oral tablet 1 mg Tier 1 folic acid oral tablet 400 mcg $0 folic acid oral tablet 800 mcg (FA-8) $0 gnp folic acid oral tablet 400 mcg $0 hm folic acid oral tablet 400 mcg $0 kp folic acid oral tablet 800 mcg (FA-8) $0 px folic acid oral tablet 400 mcg $0 qc folic acid oral tablet 800 mcg (FA-8) $0 ra folic acid oral tablet 400 mcg $0 ra folic acid oral tablet 800 mcg (FA-8) $0 sm folic acid oral tablet 400 mcg $0 yl folic acid oral tablet 400 mcg $0 Hematopoietic Growth Factors ARANESP (ALBUMIN FREE) Tier 3 PA; SP INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML

MedPerform Medium Formulary 01/01/2021

190 Drug Status Notes ARANESP (ALBUMIN FREE) Tier 3 PA; SP INJECTION SOLUTION PREFILLED SYRINGE 10 MCG/0.4ML, 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML DOPTELET ORAL TABLET 20 MG Tier 3 PA; SP EPOGEN INJECTION SOLUTION Tier 3 PA; SP 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML FULPHILA SUBCUTANEOUS Tier 2 PA; SP SOLUTION PREFILLED SYRINGE 6 MG/0.6ML GRANIX SUBCUTANEOUS SOLUTION Tier 2 PA; SP 300 MCG/ML, 480 MCG/1.6ML GRANIX SUBCUTANEOUS SOLUTION Tier 2 PA; SP PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML LEUKINE INJECTION SOLUTION Tier 2 PA; SP RECONSTITUTED 250 MCG MIRCERA INJECTION SOLUTION Tier 3 PA; SP PREFILLED SYRINGE 100 MCG/0.3ML, 150 MCG/0.3ML, 200 MCG/0.3ML, 30 MCG/0.3ML, 50 MCG/0.3ML, 75 MCG/0.3ML MULPLETA ORAL TABLET 3 MG Tier 3 PA; SP NEULASTA ONPRO SUBCUTANEOUS Tier 3 PA; SP PREFILLED SYRINGE KIT 6 MG/0.6ML NEULASTA SUBCUTANEOUS Tier 2 PA; SP SOLUTION PREFILLED SYRINGE 6 MG/0.6ML NEUPOGEN INJECTION SOLUTION Tier 3 PA; SP 300 MCG/ML, 480 MCG/1.6ML NEUPOGEN INJECTION SOLUTION Tier 3 PA; SP PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

MedPerform Medium Formulary 01/01/2021

191 Drug Status Notes NIVESTYM INJECTION SOLUTION 300 Tier 3 PA; SP MCG/ML, 480 MCG/1.6ML NIVESTYM INJECTION SOLUTION Tier 3 PA; SP PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML PROCRIT INJECTION SOLUTION Tier 2 PA; SP 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML PROMACTA ORAL PACKET 12.5 MG, Tier 2 PA; SP 25 MG PROMACTA ORAL TABLET 12.5 MG, Tier 2 PA; SP 25 MG, 50 MG, 75 MG RETACRIT INJECTION SOLUTION Tier 3 PA; SP 10000 UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML UDENYCA SUBCUTANEOUS Tier 3 PA; SP SOLUTION PREFILLED SYRINGE 6 MG/0.6ML ZARXIO INJECTION SOLUTION Tier 3 PA; SP PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML ZIEXTENZO SUBCUTANEOUS Tier 3 PA; SP SOLUTION PREFILLED SYRINGE 6 MG/0.6ML Hematopoietic Mixtures active fe oral tablet 75-1.25 mg Tier 3 CENTRATEX ORAL CAPSULE 106-1 Tier 3 MG cholecal df oral tablet 1-3800 mg-unit Tier 3 CHROMAGEN ORAL CAPSULE (Iron Complex) Tier 1 CIFEREX ORAL CAPSULE 1-3775 MG- (Cifrazol) Tier 3 UNIT cifrazol oral capsule 1-3775 mg-unit (Ciferex) Tier 3

MedPerform Medium Formulary 01/01/2021

192 Drug Status Notes CORVITA 150 ORAL TABLET 150-1.25 Tier 1 MG CORVITE 150 ORAL TABLET (Corvite Fe) Tier 3 corvite fe oral tablet (Corvite 150) Tier 3 DERMACINRX PUREFOLIX ORAL Tier 3 TABLET 1-5000 MG-UNIT durachol oral capsule 1-3775 mg-unit (Ciferex) Tier 3 FERIVA 21/7 ORAL TABLET 75-1 MG Tier 3 FERIVAFA ORAL CAPSULE 110-1 MG Tier 3 ferocon oral capsule (Tricon) Tier 1 ferotrinsic oral capsule (Tricon) Tier 1 FERRALET 90 ORAL TABLET 90-1 MG Tier 3 ferraplus 90 oral tablet 90-1 mg Tier 3 FERROCITE PLUS ORAL TABLET 106- (Hematinic Plus Tier 1 1 MG Vit/Minerals) FERRO-PLEX HEMATINIC ORAL Tier 3 TABLET 115-1 MG FERROTRIN ORAL CAPSULE Tier 3 folic d3 oral capsule 1-3775 mg-unit (Ciferex) Tier 3 FOLI-D ORAL TABLET 1-2000 MG- Tier 3 UNIT folite oral tablet Tier 3 FOLIVANE-F ORAL CAPSULE 125-1 Tier 3 MG FOLIVANE-PLUS ORAL CAPSULE (Virt-FeFA Plus) Tier 3 FOLIXAPURE ORAL TABLET 1-5000 Tier 3 MG-UNIT FOLTREXYL ORAL TABLET 1-5000 Tier 3 MG-UNIT foltrin oral capsule (Tricon) Tier 1 folvik-d oral tablet 1-3775 mg-unit (Folvite-D) Tier 1 FOLVITE-D ORAL TABLET 1-3775 MG- Tier 1 UNIT FOLVITE-FE ORAL TABLET 90-120- Tier 3 0.012-1 MG

MedPerform Medium Formulary 01/01/2021

193 Drug Status Notes FUSION PLUS ORAL CAPSULE Tier 3 hematinic plus vit/minerals oral tablet (Ferrocite Plus) Tier 1 106-1 mg hematinic/folic acid oral tablet 324-1 mg (Hemocyte-F) Tier 1 HEMATOGEN FA ORAL CAPSULE Tier 3 200-250-0.01-1 MG HEMOCYTE PLUS ORAL CAPSULE Tier 3 106-1 MG HEMOCYTE-F ORAL TABLET 324-1 (Hematinic/Folic Acid) Tier 1 MG hemocyte-plus oral tablet 106-1 mg (Ferrocite Plus) Tier 1 IFEREX 150 FORTE ORAL CAPSULE (Polysaccharide Iron Forte) Tier 1 150-25-1 MG-MCG-MG INTEGRA F ORAL CAPSULE 125-1 MG Tier 3 INTEGRA PLUS ORAL CAPSULE (Virt-FeFA Plus) Tier 3 IROSPAN 24/6 ORAL Tier 3 K-TAN PLUS ORAL CAPSULE 162- (PureVit DualFe Plus) Tier 1 115.2-1 MG MULTIGEN FOLIC ORAL TABLET 70- Tier 3 150-2-1 MG MULTIGEN ORAL TABLET 70 MG Tier 3 MULTIGEN PLUS ORAL TABLET 50- Tier 3 101-1 MG myferon 150 forte oral capsule 150-25-1 (iFerex 150 Forte) Tier 1 mg-mcg-mg NEPHRON FA ORAL TABLET Tier 3 NIFEREX ORAL TABLET (Corvite Fe) Tier 3 NUFERA ORAL TABLET (Corvite Fe) Tier 3 ortho df oral capsule 1-3775 mg-unit (Ciferex) Tier 3 ortho-folic oral capsule 1-3760 mg-unit Tier 3 poly-iron 150 forte oral capsule 150-25-1 (iFerex 150 Forte) Tier 1 mg-mcg-mg polysaccharide iron forte oral capsule (iFerex 150 Forte) Tier 1 150-25-1 mg-mcg-mg

MedPerform Medium Formulary 01/01/2021

194 Drug Status Notes purevit dualfe plus oral capsule 162- (K-Tan Plus) Tier 1 115.2-1 mg revesta oral capsule 1-5750 mg-unit Tier 3 se-tan plus oral capsule 162-115.2-1 mg (K-Tan Plus) Tier 1 taron forte oral capsule Tier 3 tl-hem 150 oral tablet 150-1 mg (Abatron AF) Tier 1 TRICON ORAL CAPSULE (Ferocon) Tier 1 trigels-f forte oral capsule 460-60-0.01-1 (Hematogen Forte) Tier 1 mg virt-fefa plus oral capsule (Folivane-Plus) Tier 3 Iron BPROTECTED PEDIA IRON ORAL (Iron Supplement $0 AGE (Max 1 Years) SOLUTION 75 (15 FE) MG/ML Childrens) ferrous sulfate oral solution 75 (15 fe) (BProtected Pedia Iron) $0 AGE (Max 1 Years) mg/ml iron supplement childrens oral solution (BProtected Pedia Iron) $0 AGE (Max 1 Years) 75 (15 fe) mg/ml pc pediatric iron drops oral solution 15 (BProtected Pedia Iron) $0 AGE (Max 1 Years) mg/ml Hemostatics Hemostatics - Systemic aminocaproic acid oral solution 0.25 (Amicar) Tier 1 gm/ml aminocaproic acid oral tablet 1000 mg, (Amicar) Tier 1 500 mg tranexamic acid oral tablet 650 mg (Lysteda) Tier 1 Hemostatics - Topical ARTISS EXTERNAL SOLUTION Tier 3 ASTRINGYN EXTERNAL SOLUTION Tier 3 259 MG/GM GEL-FLOW EXTERNAL KIT Tier 3 GELFOAM-JMI POWDER EXTERNAL Tier 3 KIT GELFOAM-JMI SPONGE EXTERNAL Tier 3 KIT

MedPerform Medium Formulary 01/01/2021

195 Drug Status Notes monsels ferric subsulfate external Tier 3 solution RECOTHROM EXTERNAL SOLUTION Tier 3 RECONSTITUTED 20000 UNIT, 5000 UNIT RECOTHROM SPRAY KIT EXTERNAL Tier 3 SOLUTION RECONSTITUTED 20000 UNIT TACHOSIL EXTERNAL PATCH 4.8 X Tier 3 4.8 CM, 9.5 X 4.8 CM THROMBIN-JMI EPISTAXIS Tier 3 EXTERNAL KIT 5000 UNIT THROMBIN-JMI EXTERNAL KIT 20000 Tier 3 UNIT, 5000 UNIT THROMBIN-JMI EXTERNAL Tier 3 SOLUTION RECONSTITUTED 20000 UNIT, 5000 UNIT THROMBOGEN EXTERNAL KIT 10000 Tier 3 UNIT THROMBOGEN EXTERNAL Tier 3 SOLUTION RECONSTITUTED 1000 UNIT, 10000 UNIT TISSEEL EXTERNAL KIT 10 ML, 2 ML, Tier 3 4 ML TISSEEL EXTERNAL SOLUTION Tier 3 Hypnotics/Sedatives/Sleep Disorder Agents Barbiturate Hypnotics phenobarbital oral elixir 20 mg/5ml Tier 1 phenobarbital oral tablet 100 mg, 15 mg, Tier 1 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg Hypnotic Combinations mko melt dose pack mouth/throat troche Tier 3 3-25-2 mg

MedPerform Medium Formulary 01/01/2021

196 Drug Status Notes Hypnotics - Tricyclic Agents doxepin hcl oral tablet 3 mg, 6 mg (Silenor) Tier 1 QL (1 EA per 1 day) Non-Barbiturate Hypnotics DORAL ORAL TABLET 15 MG (Quazepam) Tier 3 estazolam oral tablet 1 mg, 2 mg Tier 1 eszopiclone oral tablet 1 mg, 2 mg, 3 mg (Lunesta) Tier 1 QL (1 EA per 1 day) flurazepam hcl oral capsule 15 mg, 30 Tier 1 mg midazolam hcl (pf) injection solution 10 Tier 1 mg/2ml, 5 mg/ml midazolam hcl injection solution 10 Tier 1 mg/2ml, 5 mg/ml midazolam hcl oral syrup 2 mg/ml Tier 1 MIDAZOLAM+SYRSPEND SF ORAL Tier 3 SUSPENSION 1 MG/ML temazepam oral capsule 15 mg, 22.5 (Restoril) Tier 1 mg, 30 mg, 7.5 mg triazolam oral tablet 0.125 mg Tier 1 triazolam oral tablet 0.25 mg (Halcion) Tier 1 zaleplon oral capsule 10 mg, 5 mg Tier 1 QL (1 EA per 1 day) zolpidem tartrate er oral tablet extended (Ambien CR) Tier 1 QL (1 EA per 1 day) release 12.5 mg, 6.25 mg zolpidem tartrate oral tablet 10 mg, 5 mg (Ambien) Tier 1 QL (1 EA per 1 day) zolpidem tartrate sublingual tablet (Intermezzo) Tier 1 QL (1 EA per 1 day) sublingual 1.75 mg zolpidem tartrate sublingual tablet Tier 1 QL (1 EA per 1 day) sublingual 3.5 mg Orexin Receptor Antagonists BELSOMRA ORAL TABLET 10 MG, 15 Tier 2 QL (1 EA per 1 day) MG, 20 MG, 5 MG Selective Melatonin Receptor Agonists HETLIOZ ORAL CAPSULE 20 MG Tier 3 PA; SP

MedPerform Medium Formulary 01/01/2021

197 Drug Status Notes Laxatives Laxative Combinations CLENPIQ ORAL SOLUTION 10-3.5-12 Tier 2 $0 COPAY IF AGE 50-75 MG-GM -GM/160ML YEARS GAVILYTE-C ORAL SOLUTION Tier 3 RECONSTITUTED 240 GM GAVILYTE-G ORAL SOLUTION (PEG-3350/Electrolytes) Tier 1 $0 COPAY IF AGE 50-75 RECONSTITUTED 236 GM YEARS GAVILYTE-H ORAL KIT 5-210 MG-GM Tier 1 $0 COPAY IF AGE 50-75 YEARS GAVILYTE-N WITH FLAVOR PACK (PEG 3350-KCl-Na Bicarb- Tier 1 $0 COPAY IF AGE 50-75 ORAL SOLUTION RECONSTITUTED NaCl) YEARS 420 GM PCP 100 COMBINATION KIT Tier 3 peg 3350-kcl-na bicarb-nacl oral solution (GaviLyte-N with Flavor Tier 1 $0 COPAY IF AGE 50-75 reconstituted 420 gm Pack) YEARS peg-3350/electrolytes oral solution (GaviLyte-G) Tier 1 $0 COPAY IF AGE 50-75 reconstituted 236 gm YEARS peg-3350/electrolytes/ascorbat oral (MoviPrep) Tier 1 $0 COPAY IF AGE 50-75 solution reconstituted 100 gm YEARS peg-kcl-nacl-nasulf-na asc-c oral solution (MoviPrep) Tier 1 $0 COPAY IF AGE 50-75 reconstituted 100 gm YEARS PEG-PREP ORAL KIT 5-210 MG-GM Tier 1 $0 COPAY IF AGE 50-75 YEARS PLENVU ORAL SOLUTION Tier 3 $0 COPAY IF AGE 50-75 RECONSTITUTED 140 GM YEARS SUPREP BOWEL PREP KIT ORAL Tier 2 $0 COPAY IF AGE 50-75 SOLUTION 17.5-3.13-1.6 GM/177ML YEARS SUTAB ORAL TABLET 1479-225-188 Tier 3 MG TRILYTE ORAL SOLUTION (PEG 3350-KCl-Na Bicarb- Tier 1 $0 COPAY IF AGE 50-75 RECONSTITUTED 420 GM NaCl) YEARS Laxatives - Miscellaneous constulose oral solution 10 gm/15ml Tier 1 GIALAX ORAL KIT Tier 3

MedPerform Medium Formulary 01/01/2021

198 Drug Status Notes lactulose oral solution 10 gm/15ml, 20 Tier 1 gm/30ml Lubricant Laxatives mineral oil heavy oral oil Tier 1 Saline Laxatives OSMOPREP ORAL TABLET 1.102- Tier 3 $0 COPAY IF AGE 50-75 0.398 GM YEARS Local Anesthetics-Parenteral Local Anesthetic Combinations lets kit Tier 3 MARVONA SUIK COMBINATION KIT Tier 3 0.5 % Local Anesthetics - Amides bupivacaine hcl injection solution Tier 3 prefilled syringe 0.125 % (50 ml) Macrolides Azithromycin azithromycin oral suspension (Zithromax) Tier 1 reconstituted 100 mg/5ml, 200 mg/5ml azithromycin oral tablet 250 mg, 500 mg (Zithromax) Tier 1 azithromycin oral tablet 600 mg Tier 1 ZITHROMAX ORAL PACKET 1 GM (Azithromycin) Tier 3 Clarithromycin clarithromycin er oral tablet extended Tier 1 release 24 hour 500 mg clarithromycin oral suspension Tier 1 reconstituted 125 mg/5ml, 250 mg/5ml clarithromycin oral tablet 250 mg, 500 Tier 1 mg Erythromycins ERY-TAB ORAL TABLET DELAYED (Erythromycin Base) Tier 1 RELEASE 250 MG, 500 MG ERY-TAB ORAL TABLET DELAYED (Erythromycin) Tier 1 RELEASE 333 MG ERYTHROCIN STEARATE ORAL (Erythromycin Stearate) Tier 3 TABLET 250 MG

MedPerform Medium Formulary 01/01/2021

199 Drug Status Notes erythromycin base oral capsule delayed Tier 1 release particles 250 mg erythromycin base oral tablet 250 mg, Tier 1 500 mg erythromycin base oral tablet delayed (Ery-Tab) Tier 1 release 250 mg, 333 mg, 500 mg erythromycin ethylsuccinate oral (E.E.S. Granules) Tier 1 suspension reconstituted 200 mg/5ml erythromycin ethylsuccinate oral (EryPed 400) Tier 1 suspension reconstituted 400 mg/5ml erythromycin ethylsuccinate oral tablet (E.E.S. 400) Tier 1 400 mg erythromycin oral tablet delayed release (Ery-Tab) Tier 1 250 mg, 333 mg, 500 mg Fidaxomicin DIFICID ORAL TABLET 200 MG Tier 2 ST: Requires prior prescription for Vancomycin HCL within the past 120 days; QL (20 EA per 30 days) Medical Devices And Supplies Bandages-Dressings-Tape AMD FOAM DRESSING PAD 3-1/2"X3" Tier 3 AMD FOAM DRESSING PAD 4"X4" (RA Dressing Sponges) Tier 3 AMD FOAM DRESSING PAD 6"X6" (Bordered Gauze) Tier 3 AMD FOAM DRESSING TOPSHEET (RA Dressing Sponges) Tier 3 PAD 4"X4" BIOGUARD GAUZE SPONGES PAD (Sterile Gauze) Tier 3 2"X2" BIOGUARD GAUZE SPONGES PAD (RA Dressing Sponges) Tier 3 4"X4" BIOGUARD ISLAND DRESSINGS PAD Tier 3 4"X10" , 4"X14" , 4"X5" BIOGUARD NON-ADHERENT (QC Non-Adherent) Tier 3 DRESSING PAD 3"X4"

MedPerform Medium Formulary 01/01/2021

200 Drug Status Notes BIOGUARD NON-ADHERENT (CVS Non-Stick Pads) Tier 3 DRESSING PAD 3"X8" CURITY AMD ANTIMICROBIAL SPNGE (RA Dressing Sponges) Tier 3 PAD 4"X4" CURITY AMD ANTIMICROBIAL STRIP (Gauze Bandage) Tier 3 CURITY IODOFORM PACKING STRIP (Gauze Bandage) Tier 3 CURITY WOUND CLOSURE 1/2"X4" (SM Tier 3 Bandages/Clear/Assorted) CURITY WOUND CLOSURE 1/4"X1.5" (SM Tier 3 Bandages/Clear/Assorted) CURITY WOUND CLOSURE 1/4"X3" (SM Tier 3 Bandages/Clear/Assorted) CURITY WOUND CLOSURE 1/4"X4" (SM Tier 3 Bandages/Clear/Assorted) CURITY WOUND CLOSURE 1/8"X3" (SM Tier 3 Bandages/Clear/Assorted) EXCILON AMD DRAIN SPONGES PAD (RA Dressing Sponges) Tier 3 4"X4" KERLIX AMD ANTIMICROBIAL (Gauze Bandage) Tier 3 KERLIX AMD SUPER SPONGES PAD Tier 3 6"X6-3/4" TELFA AMD ISLAND DRESSING PAD Tier 3 4"X5" TELFA AMD ISLAND DRESSING PAD (CVS Gauze Pad Sterile) Tier 3 4"X8" TELFA AMD NON-ADHERENT PAD (CVS Non-Stick Pads) Tier 3 3"X8" Contraceptives CAYA VAGINAL DIAPHRAGM $0 FC FEMALE CONDOM $0 QL (30 EA per 30 days) FC2 FEMALE CONDOM $0 QL (30 EA per 30 days) FEMCAP VAGINAL DEVICE 22 MM, 26 $0 MM, 30 MM WIDE-SEAL DIAPHRAGM 60 VAGINAL $0 DIAPHRAGM 2 %

MedPerform Medium Formulary 01/01/2021

201 Drug Status Notes WIDE-SEAL DIAPHRAGM 65 VAGINAL $0 DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 70 VAGINAL $0 DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 75 VAGINAL $0 DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 80 VAGINAL $0 DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 85 VAGINAL $0 DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 90 VAGINAL $0 DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 95 VAGINAL $0 DIAPHRAGM 2 % Diabetic Supplies 1st tier unilet comfortouch (Accu-Chek FastClix Tier 2 Lancets) ACCU-CHEK FASTCLIX LANCETS (Walgreens Lancets Super Tier 2 Thin) ACCU-CHEK MULTICLIX LANCETS (Walgreens Lancets Super Tier 2 Thin) ACCU-CHEK SAFE-T PRO LANCETS (Walgreens Lancets Super Tier 2 Thin) ACCU-CHEK SOFTCLIX LANCETS (Walgreens Lancets Super Tier 2 Thin) acti-lance 28g (Accu-Chek FastClix Tier 2 Lancets) acti-lance lite lancets 28g (Accu-Chek FastClix Tier 2 Lancets) acti-lance special lancets 17g (Accu-Chek FastClix Tier 2 Lancets) acti-lance universal 23g (Accu-Chek FastClix Tier 2 Lancets) advanced mobile lancet (Accu-Chek FastClix Tier 2 Lancets)

MedPerform Medium Formulary 01/01/2021

202 Drug Status Notes ADVOCATE LANCETS (Walgreens Lancets Super Tier 2 Thin) ADVOCATE LANCETS 30G (Walgreens Lancets Super Tier 2 Thin) ADVOCATE SAFETY LANCETS (Walgreens Lancets Super Tier 2 Thin) ADVOCATE SAFETY LANCETS 26G (Walgreens Lancets Super Tier 2 Thin) AGAMATRIX ULTRA-THIN LANCETS (Walgreens Lancets Super Tier 2 Thin) aimsco twist lancets 32g (Accu-Chek FastClix Tier 2 Lancets) AIMSCO TWIST LANCETS 33G (Walgreens Lancets Super Tier 2 Thin) AQUALANCE LANCETS 30G (Walgreens Lancets Super Tier 2 Thin) assure comfort lancets 28g (Accu-Chek FastClix Tier 2 Lancets) ASSURE HAEMOLANCE PLUS HIGH (Walgreens Lancets Super Tier 2 Thin) ASSURE HAEMOLANCE PLUS LOW (Walgreens Lancets Super Tier 2 Thin) ASSURE HAEMOLANCE PLUS MICRO (Walgreens Lancets Super Tier 2 Thin) ASSURE HAEMOLANCE PLUS (Walgreens Lancets Super Tier 2 NORMAL Thin) ASSURE HAEMOLANCE PLUS PED (Walgreens Lancets Super Tier 2 Thin) ASSURE LANCE LANCETS (Walgreens Lancets Super Tier 2 Thin) ASSURE LANCE LANCETS 21G (Walgreens Lancets Super Tier 2 Thin) ASSURE LANCE PLUS SAFETY 25G (Walgreens Lancets Super Tier 2 Thin) ASSURE LANCE PLUS SAFETY 30G (Walgreens Lancets Super Tier 2 Thin)

MedPerform Medium Formulary 01/01/2021

203 Drug Status Notes ASSURE LANCE SAFETY LANCET (Walgreens Lancets Super Tier 2 28G Thin) ASSURE LANCETS (Walgreens Lancets Super Tier 2 Thin) aurora lancet super thin 30g (Accu-Chek FastClix Tier 2 Lancets) aurora lancet thin 23g (Accu-Chek FastClix Tier 2 Lancets) BD LANCET ULTRAFINE 30G (Walgreens Lancets Super Tier 2 Thin) BD LANCET ULTRAFINE 33G (Walgreens Lancets Super Tier 2 Thin) BD MICROTAINER LANCETS (Walgreens Lancets Super Tier 2 Thin) bullseye mini safety lancets (Accu-Chek FastClix Tier 2 Lancets) BULLSEYE SAFETY LANCETS (Walgreens Lancets Super Tier 2 Thin) careone lancet thin 23g (Accu-Chek FastClix Tier 2 Lancets) careone lancet ultra thin 28g (Accu-Chek FastClix Tier 2 Lancets) CARESENS LANCETS (Walgreens Lancets Super Tier 2 Thin) CARETOUCH SAFETY LANCETS (Walgreens Lancets Super Tier 2 Thin) CARETOUCH SAFETY LANCETS 26G (Walgreens Lancets Super Tier 2 Thin) CARETOUCH TWIST LANCETS 28G (Walgreens Lancets Super Tier 2 Thin) CARETOUCH TWIST LANCETS 30G (Walgreens Lancets Super Tier 2 Thin) CARETOUCH TWIST LANCETS 33G (Walgreens Lancets Super Tier 2 Thin) CLEANLET LANCETS 28G (Walgreens Lancets Super Tier 2 Thin)

MedPerform Medium Formulary 01/01/2021

204 Drug Status Notes CLEVER CHEK LANCETS (Walgreens Lancets Super Tier 2 Thin) CLEVER CHOICE LANCETS 21G (Walgreens Lancets Super Tier 2 Thin) CLEVER CHOICE LANCETS 23G (Walgreens Lancets Super Tier 2 Thin) CLEVER CHOICE LANCETS 28G (Walgreens Lancets Super Tier 2 Thin) COAGUCHEK LANCETS (Walgreens Lancets Super Tier 2 Thin) comfort assured lancets 28g (Accu-Chek FastClix Tier 2 Lancets) comfort assured lancets 33g (Accu-Chek FastClix Tier 2 Lancets) comfort lancets (Accu-Chek FastClix Tier 2 Lancets) cvs lancets 21g (Accu-Chek FastClix Tier 2 Lancets) cvs lancets micro thin 33g (Accu-Chek FastClix Tier 2 Lancets) cvs lancets original (Accu-Chek FastClix Tier 2 Lancets) cvs lancets thin 26g (Accu-Chek FastClix Tier 2 Lancets) cvs lancets ultra thin 30g (Accu-Chek FastClix Tier 2 Lancets) cvs lancets ultra-thin 30g (Accu-Chek FastClix Tier 2 Lancets) cvs ultra thin lancets (Accu-Chek FastClix Tier 2 Lancets) DEXCOM G6 RECEIVER DEVICE Tier 2 PA DIATHRIVE LANCET ULTRA THIN 30 (Walgreens Lancets Super Tier 2 Thin) DIATHRIVE LANCETS (Walgreens Lancets Super Tier 2 Thin)

MedPerform Medium Formulary 01/01/2021

205 Drug Status Notes DROPLET LANCETS ULTRA THIN 30G (Walgreens Lancets Super Tier 2 Thin) DROPLET PERSONAL LANCETS 30G (Walgreens Lancets Super Tier 2 Thin) drug mart lancets thin 26g (Accu-Chek FastClix Tier 2 Lancets) DRUG MART ON-THE-GO LANCET (Walgreens Lancets Super Tier 2 30G Thin) DRUG MART UNILET LANCETS 28G (Walgreens Lancets Super Tier 2 Thin) DRUG MART UNILET LANCETS 30G (Walgreens Lancets Super Tier 2 Thin) DRUG MART UNILET LANCETS 33G (Walgreens Lancets Super Tier 2 Thin) easy comfort lancets (Accu-Chek FastClix Tier 2 Lancets) easy comfort lancets twist top (Accu-Chek FastClix Tier 2 Lancets) EASY TOUCH LANCETS 21G (Walgreens Lancets Super Tier 2 Thin) EASY TOUCH LANCETS 23G (Walgreens Lancets Super Tier 2 Thin) EASY TOUCH LANCETS 26G (Walgreens Lancets Super Tier 2 Thin) EASY TOUCH LANCETS 28G (Walgreens Lancets Super Tier 2 Thin) EASY TOUCH LANCETS 28G/TWIST (Walgreens Lancets Super Tier 2 Thin) EASY TOUCH LANCETS 30G (Walgreens Lancets Super Tier 2 Thin) EASY TOUCH LANCETS 30G/TWIST (Walgreens Lancets Super Tier 2 Thin) EASY TOUCH LANCETS 32G (Walgreens Lancets Super Tier 2 Thin) EASY TOUCH LANCETS 32G/TWIST (Walgreens Lancets Super Tier 2 Thin)

MedPerform Medium Formulary 01/01/2021

206 Drug Status Notes EASY TOUCH LANCETS 33G/TWIST (Walgreens Lancets Super Tier 2 Thin) EASY TOUCH SAFETY LANCETS 21G (Walgreens Lancets Super Tier 2 Thin) EASY TOUCH SAFETY LANCETS 23G (Walgreens Lancets Super Tier 2 Thin) EASY TOUCH SAFETY LANCETS 26G (Walgreens Lancets Super Tier 2 Thin) EASY TOUCH SAFETY LANCETS 28G (Walgreens Lancets Super Tier 2 Thin) EASY TWIST & CAP LANCETS (Walgreens Lancets Super Tier 2 Thin) EMBRACE LANCETS ULTRA THIN 30G (Walgreens Lancets Super Tier 2 Thin) eql color lancets 21g (Accu-Chek FastClix Tier 2 Lancets) eql color lancets micro 33g (Accu-Chek FastClix Tier 2 Lancets) eql super thin lancets 30g (Accu-Chek FastClix Tier 2 Lancets) eql thin lancets 26g (Accu-Chek FastClix Tier 2 Lancets) E-Z JECT LANCET MICRO-THIN 33G (Walgreens Lancets Super Tier 2 Thin) E-Z JECT LANCET SUPER THIN 30G (Walgreens Lancets Super Tier 2 Thin) E-Z JECT LANCETS (Walgreens Lancets Super Tier 2 Thin) E-Z JECT LANCETS 21G (Walgreens Lancets Super Tier 2 Thin) E-Z JECT LANCETS THIN 26G (Walgreens Lancets Super Tier 2 Thin) EZ SMART BLOOD GLUCOSE (Walgreens Lancets Super Tier 2 LANCETS Thin) EZ-LETS LANCETS 21G (Walgreens Lancets Super Tier 2 Thin)

MedPerform Medium Formulary 01/01/2021

207 Drug Status Notes EZ-LETS LANCETS 26G (Walgreens Lancets Super Tier 2 Thin) EZ-LETS LANCETS 28G (Walgreens Lancets Super Tier 2 Thin) EZ-LETS LANCETS 30G (Walgreens Lancets Super Tier 2 Thin) FIFTY50 SAFETY SEAL LANCETS (Walgreens Lancets Super Tier 2 Thin) FIFTY50 UNILET LANCETS 33G (Walgreens Lancets Super Tier 2 Thin) FINE 30 (Walgreens Lancets Super Tier 2 Thin) FINGERSTIX LANCETS (Walgreens Lancets Super Tier 2 Thin) FORA LANCETS (Walgreens Lancets Super Tier 2 Thin) freds pharmacy unilet lanc 28g (Accu-Chek FastClix Tier 2 Lancets) freds pharmacy unilet lanc 30g (Accu-Chek FastClix Tier 2 Lancets) FREESTYLE LANCETS (Walgreens Lancets Super Tier 2 Thin) FREESTYLE UNISTICK II LANCETS (Walgreens Lancets Super Tier 2 Thin) GENTEEL BUTTERFLY TOUCH (Walgreens Lancets Super Tier 2 LANCET Thin) GENTLE-LET GP LANCETS (Walgreens Lancets Super Tier 2 Thin) GENTLE-LET LANCETS (Walgreens Lancets Super Tier 2 Thin) global inject ease lancets 28g (Accu-Chek FastClix Tier 2 Lancets) global inject ease lancets 30g (Accu-Chek FastClix Tier 2 Lancets) GLUCOCOM LANCETS 28G (Walgreens Lancets Super Tier 2 Thin)

MedPerform Medium Formulary 01/01/2021

208 Drug Status Notes GLUCOCOM LANCETS 30G (Walgreens Lancets Super Tier 2 Thin) GLUCOCOM LANCETS 33G (Walgreens Lancets Super Tier 2 Thin) gnp lancets (Accu-Chek FastClix Tier 2 Lancets) gnp lancets 21g (Accu-Chek FastClix Tier 2 Lancets) gnp lancets micro thin 33g (Accu-Chek FastClix Tier 2 Lancets) gnp lancets super thin 30g (Accu-Chek FastClix Tier 2 Lancets) gnp lancets thin (Accu-Chek FastClix Tier 2 Lancets) gnp lancets thin 26g (Accu-Chek FastClix Tier 2 Lancets) gnp micro thin lancets 33g (Accu-Chek FastClix Tier 2 Lancets) gnp super thin lancets 30g (Accu-Chek FastClix Tier 2 Lancets) GOJJI STERILE LANCETS (Walgreens Lancets Super Tier 2 Thin) goodsense color lancets 33g (Accu-Chek FastClix Tier 2 Lancets) goodsense lancets 26g univ (Accu-Chek FastClix Tier 2 Lancets) goodsense lancets 30g (Accu-Chek FastClix Tier 2 Lancets) goodsense lancets 30g univ (Accu-Chek FastClix Tier 2 Lancets) goodsense lancets 33g (Accu-Chek FastClix Tier 2 Lancets) goodsense lancets 33g univ (Accu-Chek FastClix Tier 2 Lancets) GUARDIAN REAL-TIME REPLACE PED Tier 3 DEVICE

MedPerform Medium Formulary 01/01/2021

209 Drug Status Notes HAEMOLANCE (Walgreens Lancets Super Tier 2 Thin) HAEMOLANCE LOW FLOW LANCETS (Walgreens Lancets Super Tier 2 Thin) HAEMOLANCE PLUS (Walgreens Lancets Super Tier 2 Thin) HAEMOLANCE PLUS HIGH FLOW (Walgreens Lancets Super Tier 2 Thin) HAEMOLANCE PLUS LOW FLOW (Walgreens Lancets Super Tier 2 Thin) HAEMOLANCE PLUS MAX FLOW (Walgreens Lancets Super Tier 2 Thin) HAEMOLANCE PLUS PEDIATRIC (Walgreens Lancets Super Tier 2 FLOW Thin) healthy accents unilet lancets (Accu-Chek FastClix Tier 2 Lancets) h-e-b incontrol lancets 28g (Accu-Chek FastClix Tier 2 Lancets) h-e-b incontrol lancets 30g (Accu-Chek FastClix Tier 2 Lancets) h-e-b incontrol lancets 33g (Accu-Chek FastClix Tier 2 Lancets) HY-VEE LANCETS (Walgreens Lancets Super Tier 2 Thin) hy-vee thin lancets (Accu-Chek FastClix Tier 2 Lancets) IN TOUCH STERILE LANCETS 30G (Walgreens Lancets Super Tier 2 Thin) kinney lancets (Accu-Chek FastClix Tier 2 Lancets) kinney thin lancets (Accu-Chek FastClix Tier 2 Lancets) KROGER HEALTHPRO LANCET 26G (Walgreens Lancets Super Tier 2 Thin) kroger lancets (Accu-Chek FastClix Tier 2 Lancets)

MedPerform Medium Formulary 01/01/2021

210 Drug Status Notes kroger lancets 21g (Accu-Chek FastClix Tier 2 Lancets) kroger lancets micro thin 33g (Accu-Chek FastClix Tier 2 Lancets) kroger lancets super thin (Accu-Chek FastClix Tier 2 Lancets) kroger lancets thin (Accu-Chek FastClix Tier 2 Lancets) kroger lancets thin 26g (Accu-Chek FastClix Tier 2 Lancets) kroger lancets ultrathin 30g (Accu-Chek FastClix Tier 2 Lancets) lancets (Accu-Chek FastClix Tier 2 Lancets) lancets 28g (Accu-Chek FastClix Tier 2 Lancets) lancets 30g (Accu-Chek FastClix Tier 2 Lancets) lancets micro thin 33g (Accu-Chek FastClix Tier 2 Lancets) lancets super thin 28g (Accu-Chek FastClix Tier 2 Lancets) lancets thin (Accu-Chek FastClix Tier 2 Lancets) LANCETS ULTRA FINE (Walgreens Lancets Super Tier 2 Thin) LANCETS ULTRA THIN (Walgreens Lancets Super Tier 2 Thin) lancets ultra thin 30g (Accu-Chek FastClix Tier 2 Lancets) LIBERTY MEDICAL LANCETS (Walgreens Lancets Super Tier 2 Thin) LIFESCAN UNISTIK 2 (Walgreens Lancets Super Tier 2 Thin) LIFESCAN UNISTIK II LANCETS (Walgreens Lancets Super Tier 2 Thin)

MedPerform Medium Formulary 01/01/2021

211 Drug Status Notes lite touch lancets (Accu-Chek FastClix Tier 2 Lancets) LITETOUCH LANCETS (Walgreens Lancets Super Tier 2 Thin) live better lancet super thin (Accu-Chek FastClix Tier 2 Lancets) live better lancet ultra thin (Accu-Chek FastClix Tier 2 Lancets) longs lancets standard (Accu-Chek FastClix Tier 2 Lancets) longs lancets thin (Accu-Chek FastClix Tier 2 Lancets) longs lancets ultra thin (Accu-Chek FastClix Tier 2 Lancets) medichoice safety lancet (Accu-Chek FastClix Tier 2 Lancets) medichoice safety lancet extra (Accu-Chek FastClix Tier 2 Lancets) medichoice safety lancet norm (Accu-Chek FastClix Tier 2 Lancets) MEDISENSE THIN LANCETS (Walgreens Lancets Super Tier 2 Thin) MEDLANCE EXTRA 21G (Walgreens Lancets Super Tier 2 Thin) MEDLANCE LITE 25G (Walgreens Lancets Super Tier 2 Thin) MEDLANCE PLUS EXTRA 21G (Walgreens Lancets Super Tier 2 Thin) MEDLANCE PLUS LANCETS (Walgreens Lancets Super Tier 2 Thin) MEDLANCE PLUS LITE 25G (Walgreens Lancets Super Tier 2 Thin) MEDLANCE PLUS SPECIAL 0.8MM (Walgreens Lancets Super Tier 2 Thin) MEDLANCE PLUS SUPERLITE 30G (Walgreens Lancets Super Tier 2 Thin)

MedPerform Medium Formulary 01/01/2021

212 Drug Status Notes MEDLANCE PLUS UNIVERSAL 21G (Walgreens Lancets Super Tier 2 Thin) MEDLANCE UNIVERSAL 21G (Walgreens Lancets Super Tier 2 Thin) MEIJER LANCETS (Walgreens Lancets Super Tier 2 Thin) MEIJER LANCETS THIN (Walgreens Lancets Super Tier 2 Thin) MEIJER LANCETS UNIVERSAL 21G (Walgreens Lancets Super Tier 2 Thin) MEIJER LANCETS UNIVERSAL 30G (Walgreens Lancets Super Tier 2 Thin) MEIJER LANCETS UNIVERSAL 33G (Walgreens Lancets Super Tier 2 Thin) MEIJER SUPER THIN LANCETS (Walgreens Lancets Super Tier 2 Thin) MICROLET LANCETS (Walgreens Lancets Super Tier 2 Thin) MM TWIST LANCETS (Walgreens Lancets Super Tier 2 Thin) MONOLET LANCETS (Walgreens Lancets Super Tier 2 Thin) MONOLET OPD LANCETS (Walgreens Lancets Super Tier 2 Thin) MONOLETTOR SAFETY LANCETS (Walgreens Lancets Super Tier 2 Thin) mpd safety lancet 21g (Accu-Chek FastClix Tier 2 Lancets) mpd safety lancet 23g (Accu-Chek FastClix Tier 2 Lancets) mpd safety lancet 28g (Accu-Chek FastClix Tier 2 Lancets) mpd safety lancet 30g (Accu-Chek FastClix Tier 2 Lancets) MYGLUCOHEALTH LANCETS 30G (Walgreens Lancets Super Tier 2 Thin)

MedPerform Medium Formulary 01/01/2021

213 Drug Status Notes NOVA SAFETY LANCETS 23G (Walgreens Lancets Super Tier 2 Thin) NOVA SAFETY LANCETS 28G (Walgreens Lancets Super Tier 2 Thin) NOVA SUREFLEX LANCETS (Walgreens Lancets Super Tier 2 Thin) ONETOUCH CLUB LANCETS FINE PT (Walgreens Lancets Super Tier 2 Thin) ONETOUCH DELICA LANCETS 30G (Walgreens Lancets Super Tier 2 Thin) ONETOUCH DELICA LANCETS 33G (Walgreens Lancets Super Tier 2 Thin) ONETOUCH DELICA PLUS (Walgreens Lancets Super Tier 2 LANCET30G Thin) ONETOUCH DELICA PLUS (Walgreens Lancets Super Tier 2 LANCET33G Thin) ONETOUCH FINEPOINT LANCETS (Walgreens Lancets Super Tier 2 Thin) ONETOUCH ULTRASOFT LANCETS (Walgreens Lancets Super Tier 2 Thin) pc lancets super thin 30g (Accu-Chek FastClix Tier 2 Lancets) PERFECT LANCETS 28G (Walgreens Lancets Super Tier 2 Thin) PERFECT LANCETS 30G (Walgreens Lancets Super Tier 2 Thin) PHARMACIST CHOICE LANCETS (Walgreens Lancets Super Tier 2 Thin) PHARMACY COUNTER LANCETS (Walgreens Lancets Super Tier 2 Thin) pip lancets 28g (Accu-Chek FastClix Tier 2 Lancets) pip lancets 30g (Accu-Chek FastClix Tier 2 Lancets) PRECISION THINS GP LANCETS (Walgreens Lancets Super Tier 2 Thin)

MedPerform Medium Formulary 01/01/2021

214 Drug Status Notes preferred plus lancets colored (Accu-Chek FastClix Tier 2 Lancets) preferred plus lancets thin (Accu-Chek FastClix Tier 2 Lancets) pressure activat safety lancet (Accu-Chek FastClix Tier 2 Lancets) pro comfort lancets 30g (Accu-Chek FastClix Tier 2 Lancets) pro comfort lancets 31g (Accu-Chek FastClix Tier 2 Lancets) PRODIGY LANCETS 28G (Walgreens Lancets Super Tier 2 Thin) PRODIGY SAFETY LANCETS 26G (Walgreens Lancets Super Tier 2 Thin) PRODIGY TWIST TOP LANCETS 28G (Walgreens Lancets Super Tier 2 Thin) PSS SELECT GP LANCETS (Walgreens Lancets Super Tier 2 Thin) PSS SELECT SAFETY LANCETS (Walgreens Lancets Super Tier 2 Thin) push button safety lancets (Accu-Chek FastClix Tier 2 Lancets) push button safety lancets 28g (Accu-Chek FastClix Tier 2 Lancets) px lancets ultra thin (Accu-Chek FastClix Tier 2 Lancets) px lancets ultra thin 28g (Accu-Chek FastClix Tier 2 Lancets) qc lancets super thin 30g (Accu-Chek FastClix Tier 2 Lancets) qc lancets ultra thin (Accu-Chek FastClix Tier 2 Lancets) qc unilet lancets 28g (Accu-Chek FastClix Tier 2 Lancets) qc unilet lancets micro thin (Accu-Chek FastClix Tier 2 Lancets)

MedPerform Medium Formulary 01/01/2021

215 Drug Status Notes RA E-ZJECT COLOR LANCETS 33G (Walgreens Lancets Super Tier 2 Thin) RA E-ZJECT LANCETS 28G (Walgreens Lancets Super Tier 2 Thin) RA E-ZJECT LANCETS THIN 26G (Walgreens Lancets Super Tier 2 Thin) RA E-ZJECT LANCETS THIN 28G (Walgreens Lancets Super Tier 2 Thin) RA E-ZJECT LANCETS ULTRA THIN (Walgreens Lancets Super Tier 2 Thin) READYLANCE SAFETY LANCETS (Walgreens Lancets Super Tier 2 Thin) reality lancets (Accu-Chek FastClix Tier 2 Lancets) reality trigger lancets (Accu-Chek FastClix Tier 2 Lancets) RELION LANCETS MICRO-THIN 33G (Walgreens Lancets Super Tier 2 Thin) RELION LANCETS STANDARD 21G (Walgreens Lancets Super Tier 2 Thin) RELION LANCETS THIN 26G (Walgreens Lancets Super Tier 2 Thin) RELION LANCETS ULTRA-THIN 30G (Walgreens Lancets Super Tier 2 Thin) RELION ULTRA THIN LANCETS 30G (Walgreens Lancets Super Tier 2 Thin) RELION ULTRA THIN PLUS LANCETS (Walgreens Lancets Super Tier 2 Thin) REXALL LANCETS ULTRA THIN 30G (Walgreens Lancets Super Tier 2 Thin) RIGHTEST GL300 LANCETS (Walgreens Lancets Super Tier 2 Thin) SAFE-T-LANCE (Walgreens Lancets Super Tier 2 Thin) SAFE-T-LANCE PLUS (Walgreens Lancets Super Tier 2 Thin)

MedPerform Medium Formulary 01/01/2021

216 Drug Status Notes safety lancet 21g/pressure act (Accu-Chek FastClix Tier 2 Lancets) safety lancet 23g/pressure act (Accu-Chek FastClix Tier 2 Lancets) safety lancet 28g/pressure act (Accu-Chek FastClix Tier 2 Lancets) safety lancet 30g/pressure act (Accu-Chek FastClix Tier 2 Lancets) SAFETY LANCETS (Walgreens Lancets Super Tier 2 Thin) SAFETY LANCETS 21G (Walgreens Lancets Super Tier 2 Thin) safety lancets 28g (Accu-Chek FastClix Tier 2 Lancets) SAFETY LET LANCETS (Walgreens Lancets Super Tier 2 Thin) SAFETY SEAL LANCETS (Walgreens Lancets Super Tier 2 Thin) saps health twist top lancets (Accu-Chek FastClix Tier 2 Lancets) saps twist top lancets (Accu-Chek FastClix Tier 2 Lancets) sapscare twist top lancets (Accu-Chek FastClix Tier 2 Lancets) sb lancets thin (Accu-Chek FastClix Tier 2 Lancets) sb lancets ultra thin (Accu-Chek FastClix Tier 2 Lancets) SHOPKO ON-THE-GO LANCETS 30G (Walgreens Lancets Super Tier 2 Thin) SHOPKO UNILET LANCETS 28G (Walgreens Lancets Super Tier 2 Thin) SHOPKO UNILET LANCETS 30G (Walgreens Lancets Super Tier 2 Thin) side button safety lancet (Accu-Chek FastClix Tier 2 Lancets)

MedPerform Medium Formulary 01/01/2021

217 Drug Status Notes SINGLE-LET (Walgreens Lancets Super Tier 2 Thin) sm lancets 33g (Accu-Chek FastClix Tier 2 Lancets) SMART SENSE COLOR LANCETS 33G (Walgreens Lancets Super Tier 2 Thin) SMART SENSE STANDARD LANCETS (Walgreens Lancets Super Tier 2 Thin) SMART SENSE SUPER THIN (Walgreens Lancets Super Tier 2 LANCETS Thin) SMART SENSE THIN LANCETS 26G (Walgreens Lancets Super Tier 2 Thin) SMARTEST LANCETS 28G (Walgreens Lancets Super Tier 2 Thin) SOLUS V2 LANCETS 28G (Walgreens Lancets Super Tier 2 Thin) SOLUS V2 TWIST LANCETS 30G (Walgreens Lancets Super Tier 2 Thin) STERILANCE TL (Walgreens Lancets Super Tier 2 Thin) super thin lancets (Accu-Chek FastClix Tier 2 Lancets) sure comfort lancets 18g (Accu-Chek FastClix Tier 2 Lancets) sure comfort lancets 21g (Accu-Chek FastClix Tier 2 Lancets) sure comfort lancets 23g (Accu-Chek FastClix Tier 2 Lancets) sure comfort lancets 28g (Accu-Chek FastClix Tier 2 Lancets) sure comfort lancets 30g (Accu-Chek FastClix Tier 2 Lancets) SURE-LANCE FLAT LANCETS (Walgreens Lancets Super Tier 2 Thin) SURE-LANCE LANCETS 26G (Walgreens Lancets Super Tier 2 Thin)

MedPerform Medium Formulary 01/01/2021

218 Drug Status Notes SURE-LANCE THIN LANCETS 28G (Walgreens Lancets Super Tier 2 Thin) SURE-LANCE ULTRA THIN LANCETS (Walgreens Lancets Super Tier 2 Thin) SURELITE LANCETS (Walgreens Lancets Super Tier 2 Thin) SURE-TOUCH LANCETS UNIVERSAL (Walgreens Lancets Super Tier 2 Thin) TECHLITE AST LANCETS (Walgreens Lancets Super Tier 2 Thin) TECHLITE LANCETS (Walgreens Lancets Super Tier 2 Thin) TECHLITE LANCETS 30G (Walgreens Lancets Super Tier 2 Thin) tgt lancet micro thin 33g (Accu-Chek FastClix Tier 2 Lancets) tgt lancet thin 26g (Accu-Chek FastClix Tier 2 Lancets) tgt lancet ultra thin 30g (Accu-Chek FastClix Tier 2 Lancets) THINLETS GP LANCETS (Walgreens Lancets Super Tier 2 Thin) todays health thin lancets 28g (Accu-Chek FastClix Tier 2 Lancets) todays health thin lancets 30g (Accu-Chek FastClix Tier 2 Lancets) topcare lancets micro-thin 33g (Accu-Chek FastClix Tier 2 Lancets) travel lancets (Accu-Chek FastClix Tier 2 Lancets) TRAVEL LANCETS ADVANCED 28G (Walgreens Lancets Super Tier 2 Thin) true comfort twist top lancets (Accu-Chek FastClix Tier 2 Lancets) TRUEPLUS LANCETS 26G (Walgreens Lancets Super Tier 2 Thin)

MedPerform Medium Formulary 01/01/2021

219 Drug Status Notes TRUEPLUS LANCETS 28G (Walgreens Lancets Super Tier 2 Thin) TRUEPLUS LANCETS 30G (Walgreens Lancets Super Tier 2 Thin) TRUEPLUS LANCETS 33G (Walgreens Lancets Super Tier 2 Thin) TRUEPLUS SAFETY LANCETS 28G (Walgreens Lancets Super Tier 2 Thin) ULTILET CLASSIC LANCETS (Walgreens Lancets Super Tier 2 Thin) ULTILET LANCETS (Walgreens Lancets Super Tier 2 Thin) ULTILET SAFETY LANCETS (Walgreens Lancets Super Tier 2 Thin) ULTILET SAFETY LANCETS 23G (Walgreens Lancets Super Tier 2 Thin) ultra thin lancets 31g (Accu-Chek FastClix Tier 2 Lancets) ultra-care lancets 30g (Accu-Chek FastClix Tier 2 Lancets) ULTRA-THIN II AUTO LANCET (Walgreens Lancets Super Tier 2 Thin) ULTRA-THIN II LANCETS (Walgreens Lancets Super Tier 2 Thin) UNILET COMFORTOUCH LANCET (Walgreens Lancets Super Tier 2 Thin) UNILET EXCELITE (Walgreens Lancets Super Tier 2 Thin) UNILET EXCELITE II (Walgreens Lancets Super Tier 2 Thin) UNILET G.P. LANCET (Walgreens Lancets Super Tier 2 Thin) UNILET G.P. SUPERLITE LANCET (Walgreens Lancets Super Tier 2 Thin) UNILET GP 28 ULTRA THIN (Walgreens Lancets Super Tier 2 Thin)

MedPerform Medium Formulary 01/01/2021

220 Drug Status Notes UNILET LANCET (Walgreens Lancets Super Tier 2 Thin) UNILET MICRO-THIN 33G (Walgreens Lancets Super Tier 2 Thin) UNILET SUPERLITE LANCET (Walgreens Lancets Super Tier 2 Thin) UNILET SUPER-THIN 30G (Walgreens Lancets Super Tier 2 Thin) UNILET ULTRA-THIN 28G (Walgreens Lancets Super Tier 2 Thin) UNISTIK 3 GENTLE (Walgreens Lancets Super Tier 2 Thin) UNISTIK PRO SAFETY LANCET (Walgreens Lancets Super Tier 2 Thin) UNISTIK SAFETY LANCETS 28G (Walgreens Lancets Super Tier 2 Thin) UNISTIK SAFETY LANCETS 30G (Walgreens Lancets Super Tier 2 Thin) UNISTIK TOUCH SAFETY LANC 21G (Walgreens Lancets Super Tier 2 Thin) UNISTIK TOUCH SAFETY LANC 23G (Walgreens Lancets Super Tier 2 Thin) UNISTIK TOUCH SAFETY LANC 28G (Walgreens Lancets Super Tier 2 Thin) UNISTIK TOUCH SAFETY LANC 30G (Walgreens Lancets Super Tier 2 Thin) UNIVERSAL 1 LANCETS THIN 26G (Walgreens Lancets Super Tier 2 Thin) UNIVERSAL 1 LANCETS THIN 33G (Walgreens Lancets Super Tier 2 Thin) UNIVERSAL 1 LANCETS ULTRA THIN (Walgreens Lancets Super Tier 2 Thin) value plus lancet standard 21g (Accu-Chek FastClix Tier 2 Lancets) value plus lancets super thin (Accu-Chek FastClix Tier 2 Lancets)

MedPerform Medium Formulary 01/01/2021

221 Drug Status Notes value plus lancets thin 26g (Accu-Chek FastClix Tier 2 Lancets) valumark lancet super thin 30g (Accu-Chek FastClix Tier 2 Lancets) valumark lancet ultra thin 28g (Accu-Chek FastClix Tier 2 Lancets) VIDA MIA UNILET LANCETS 28G (Walgreens Lancets Super Tier 2 Thin) VIDA MIA UNILET LANCETS 30G (Walgreens Lancets Super Tier 2 Thin) VIVAGUARD LANCETS (Walgreens Lancets Super Tier 2 Thin) walgreens adv travel lancets (Accu-Chek FastClix Tier 2 Lancets) WALGREENS LANCETS (Walgreens Lancets Super Tier 2 Thin) walgreens lancets micro thin (Accu-Chek FastClix Tier 2 Lancets) walgreens lancets super thin (Accu-Chek FastClix Tier 2 Lancets) WALGREENS THIN LANCETS (Walgreens Lancets Super Tier 2 Thin) WALGREENS ULTRA THIN LANCETS (Walgreens Lancets Super Tier 2 Thin) Foot Care Products BIOFREQUENCY INSOLES (Gel Insoles Womens) Tier 3 Impotence Aids RAPPORT RLS KIT Tier 3 RAPPORT VTD KIT Tier 3 Misc. Devices alcoh-wipe sheet Tier 3 Oral Hygiene Products MI PASTE DENTAL PASTE (RA Sensitive Tier 3 Toothpaste/Fl) MI PASTE PLUS DENTAL PASTE (RA Sensitive Tier 3 Toothpaste/Fl)

MedPerform Medium Formulary 01/01/2021

222 Drug Status Notes REMESENSE DENTAL 3 % Tier 3 Parenteral Therapy Supplies 1st tier unifine pentips 29g x 12mm , 31g (CareFine Pen Needles) Tier 2 x 6 mm 1st tier unifine pentips 31g x 5 mm , 31g (AboutTime Pen Needle) Tier 2 x 8 mm , 32g x 4 mm 1st tier unifine pentips 32g x 6 mm (BD Pen Needle Micro Tier 2 U/F) 1st tier unifine pentips 33g x 4 mm (Advocate Insulin Pen Tier 2 Needles) 1st tier unifine pentips plus 29g x 12mm , (CareFine Pen Needles) Tier 2 31g x 6 mm 1st tier unifine pentips plus 31g x 5 mm , (AboutTime Pen Needle) Tier 2 31g x 8 mm , 32g x 4 mm 1st tier unifine pentips plus 33g x 4 mm (Advocate Insulin Pen Tier 2 Needles) ABOUTTIME PEN NEEDLE 30G X 8 (Sure Comfort Pen Tier 2 MM , 31G X 8 MM Needles) ABOUTTIME PEN NEEDLE 31G X 5 (Easy Comfort Pen Tier 2 MM Needles) ABOUTTIME PEN NEEDLE 32G X 4 (QC Unifine Pentips) Tier 2 MM ADVOCATE INSULIN PEN NEEDLES (Sure Comfort Pen Tier 2 29G X 12.7MM , 31G X 8 MM Needles) ADVOCATE INSULIN PEN NEEDLES (Easy Comfort Pen Tier 2 31G X 5 MM Needles) ADVOCATE INSULIN PEN NEEDLES (1st Tier Unifine Pentips Tier 2 33G X 4 MM Plus) ADVOCATE INSULIN SYRINGE 29G X (TopCare Ultra Comfort Ins Tier 2 1/2" 0.3 ML Syr) ADVOCATE INSULIN SYRINGE 29G X (Insulin Syringe) Tier 2 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.5 ML ADVOCATE INSULIN SYRINGE 30G X (GNP Ultra Com Insulin Tier 2 5/16" 0.3 ML Syringe)

MedPerform Medium Formulary 01/01/2021

223 Drug Status Notes ADVOCATE INSULIN SYRINGE 30G X (Preferred Plus Insulin Tier 2 5/16" 1 ML Syringe) ADVOCATE INSULIN SYRINGE 31G X (MM Insulin Tier 2 5/16" 0.3 ML Syringe/Needle) ADVOCATE INSULIN SYRINGE 31G X (Insulin Syringe-Needle U- Tier 2 5/16" 0.5 ML 100) ADVOCATE INSULIN SYRINGE 31G X (Sure Comfort Insulin Tier 2 5/16" 1 ML Syringe) ASSURE ID INSULIN SAFETY SYR (Insulin Syringe) Tier 2 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML ASSURE ID SAFETY PEN NEEDLES (Pen Needles) Tier 2 30G X 5 MM ASSURE ID SAFETY PEN NEEDLES (Sure Comfort Pen Tier 2 30G X 8 MM Needles) ASSURE ID SAFETY PEN NEEDLES (Easy Comfort Pen Tier 2 31G X 5 MM Needles) aurora pen needles 29g x 12mm , 31g x (CareFine Pen Needles) Tier 2 6 mm aurora pen needles 31g x 8 mm (AboutTime Pen Needle) Tier 2 aurora unifine pentips 31g x 5 mm , 32g (AboutTime Pen Needle) Tier 2 x 4 mm AUTOJECT 2 (Inject-Ease) Tier 3 BD AUTOSHIELD 29G X 5MM , 29G X Tier 2 8MM BD AUTOSHIELD DUO 30G X 5 MM (Pen Needles) Tier 2 BD INSULIN SYR ULTRAFINE II 31G X (MM Insulin Tier 2 5/16" 0.3 ML Syringe/Needle) BD INSULIN SYR ULTRAFINE II 31G X (Insulin Syringe-Needle U- Tier 2 5/16" 0.5 ML 100) BD INSULIN SYRINGE 25G X 1" 1 ML, Tier 2 25G X 5/8" 1 ML, 26G X 1/2" 1 ML, 27.5G X 5/8" 2 ML BD INSULIN SYRINGE 27G X 1/2" 1 (Insulin Syringe) Tier 2 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML BD INSULIN SYRINGE 29G X 1/2" 0.3 (TopCare Ultra Comfort Ins Tier 2 ML Syr)

MedPerform Medium Formulary 01/01/2021

224 Drug Status Notes BD INSULIN SYRINGE HALF-UNIT 31G (MM Insulin Tier 2 X 5/16" 0.3 ML Syringe/Needle) BD INSULIN SYRINGE MICROFINE Tier 2 27G X 5/8" 1 ML BD INSULIN SYRINGE MICROFINE (Sure Comfort Insulin Tier 2 28G X 1/2" 0.5 ML Syringe) BD INSULIN SYRINGE MICROFINE (Insulin Syringe) Tier 2 28G X 1/2" 1 ML BD INSULIN SYRINGE U/F 1/2UNIT (MM Insulin Tier 2 31G X 5/16" 0.3 ML Syringe/Needle) BD INSULIN SYRINGE U/F 30G X 1/2" (Global Inject Ease Insulin Tier 2 0.3 ML Syr) BD INSULIN SYRINGE U/F 30G X 1/2" (Insulin Syringe) Tier 2 0.5 ML BD INSULIN SYRINGE U/F 30G X 1/2" (Ultracare Insulin Syringe) Tier 2 1 ML BD INSULIN SYRINGE U/F 31G X 5/16" (MM Insulin Tier 2 0.3 ML Syringe/Needle) BD INSULIN SYRINGE U/F 31G X 5/16" (Insulin Syringe-Needle U- Tier 2 0.5 ML 100) BD INSULIN SYRINGE U/F 31G X 5/16" (Sure Comfort Insulin Tier 2 1 ML Syringe) BD INSULIN SYRINGE U-100 1 ML (Kmart Valu Insulin Tier 2 Syringe 30G) BD INSULIN SYRINGE U-500 31G X Tier 2 6MM 0.5 ML BD INSULIN SYRINGE ULTRAFINE (TopCare Ultra Comfort Ins Tier 2 29G X 1/2" 0.3 ML Syr) BD INSULIN SYRINGE ULTRAFINE (Insulin Syringe) Tier 2 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.5 ML BD INSULIN SYRINGE ULTRAFINE (Global Inject Ease Insulin Tier 2 30G X 1/2" 0.3 ML Syr) BD INSULIN SYRINGE ULTRAFINE (Insulin Syringe-Needle U- Tier 2 31G X 5/16" 0.5 ML 100)

MedPerform Medium Formulary 01/01/2021

225 Drug Status Notes BD PEN NEEDLE MICRO U/F 32G X 6 (GNP UltiCare Pen Tier 2 MM Needles) BD PEN NEEDLE MINI U/F 31G X 5 MM (Easy Comfort Pen Tier 2 Needles) BD PEN NEEDLE NANO 2ND GEN 32G (QC Unifine Pentips) Tier 2 X 4 MM BD PEN NEEDLE NANO U/F 32G X 4 (QC Unifine Pentips) Tier 2 MM BD PEN NEEDLE ORIGINAL U/F 29G X (Sure Comfort Pen Tier 2 12.7MM Needles) BD PEN NEEDLE SHORT U/F 31G X 8 (Sure Comfort Pen Tier 2 MM Needles) BD SAFETYGLIDE INSULIN SYRINGE (TopCare Ultra Comfort Ins Tier 2 29G X 1/2" 0.3 ML Syr) BD SAFETYGLIDE INSULIN SYRINGE (Insulin Syringe) Tier 2 29G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML BD SAFETYGLIDE INSULIN SYRINGE (TechLITE Insulin Syringe) Tier 2 31G X 15/64" 0.3 ML, 31G X 15/64" 1 ML BD SAFETYGLIDE INSULIN SYRINGE (Global Easy Glide Insulin Tier 2 31G X 15/64" 0.5 ML Syr) BD SAFETYGLIDE INSULIN SYRINGE (MM Insulin Tier 2 31G X 5/16" 0.3 ML Syringe/Needle) BD SAFETY-LOK INSULIN SYRINGE (Insulin Syringe) Tier 2 29G X 1/2" 1 ML BD VEO INSULIN SYR U/F 1/2UNIT (TechLITE Insulin Syringe) Tier 2 31G X 15/64" 0.3 ML BD VEO INSULIN SYRINGE U/F 31G X (TechLITE Insulin Syringe) Tier 2 15/64" 0.3 ML, 31G X 15/64" 1 ML BD VEO INSULIN SYRINGE U/F 31G X (Global Easy Glide Insulin Tier 2 15/64" 0.5 ML Syr) CAREFINE PEN NEEDLES 29G X (1st Tier Unifine Pentips Tier 2 12MM Plus) CAREFINE PEN NEEDLES 30G X 8 (Sure Comfort Pen Tier 2 MM , 31G X 8 MM Needles)

MedPerform Medium Formulary 01/01/2021

226 Drug Status Notes CAREFINE PEN NEEDLES 31G X 6 (CareOne Unifine Pentips Tier 2 MM Plus) CAREFINE PEN NEEDLES 32G X 4 (QC Unifine Pentips) Tier 2 MM CAREFINE PEN NEEDLES 32G X 5 (Ultracare Pen Needles) Tier 2 MM CAREFINE PEN NEEDLES 32G X 6 (GNP UltiCare Pen Tier 2 MM Needles) careone insulin syringe 30g x 1/2" 0.3 (BD Insulin Syringe U/F) Tier 2 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml careone insulin syringe 31g x 5/16" 0.3 (Advocate Insulin Syringe) Tier 2 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml careone unifine pentips 29g x 12mm , (CareFine Pen Needles) Tier 2 31g x 6 mm careone unifine pentips 31g x 5 mm , (AboutTime Pen Needle) Tier 2 31g x 8 mm , 32g x 4 mm careone unifine pentips plus 29g x (CareFine Pen Needles) Tier 2 12mm , 31g x 6 mm careone unifine pentips plus 31g x 5 mm (AboutTime Pen Needle) Tier 2 , 31g x 8 mm , 32g x 4 mm CARETOUCH INSULIN SYRINGE 28G Tier 2 X 5/16" 1 ML, 29G X 5/16" 1 ML CARETOUCH PEN NEEDLES 31G X 5 (Easy Comfort Pen Tier 2 MM Needles) CARETOUCH PEN NEEDLES 31G X 6 (CareOne Unifine Pentips Tier 2 MM Plus) CARETOUCH PEN NEEDLES 31G X 8 (Sure Comfort Pen Tier 2 MM Needles) CARETOUCH PEN NEEDLES 32G X 4 (QC Unifine Pentips) Tier 2 MM CARETOUCH PEN NEEDLES 32G X 5 (Ultracare Pen Needles) Tier 2 MM CLEVER CHOICE COMFORT EZ 29G X (1st Tier Unifine Pentips Tier 2 12MM , 33G X 4 MM Plus) CLICKFINE PEN NEEDLES 31G X 5 (Easy Comfort Pen Tier 2 MM Needles)

MedPerform Medium Formulary 01/01/2021

227 Drug Status Notes clickfine pen needles 31g x 6 mm (CareFine Pen Needles) Tier 2 clickfine pen needles 31g x 8 mm , 32g x (AboutTime Pen Needle) Tier 2 4 mm COMFORT ASSIST INSULIN SYRINGE (TopCare Ultra Comfort Ins Tier 2 29G X 1/2" 0.3 ML Syr) COMFORT ASSIST INSULIN SYRINGE (Insulin Syringe) Tier 2 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.5 ML COMFORT ASSIST INSULIN SYRINGE (GNP Ultra Com Insulin Tier 2 30G X 5/16" 0.3 ML Syringe) COMFORT ASSIST INSULIN SYRINGE (Preferred Plus Insulin Tier 2 30G X 5/16" 1 ML Syringe) COMFORT ASSIST INSULIN SYRINGE (MM Insulin Tier 2 31G X 5/16" 0.3 ML Syringe/Needle) COMFORT ASSIST INSULIN SYRINGE (Insulin Syringe-Needle U- Tier 2 31G X 5/16" 0.5 ML 100) COMFORT ASSIST INSULIN SYRINGE (Sure Comfort Insulin Tier 2 31G X 5/16" 1 ML Syringe) COMFORT EZ INSULIN SYRINGE 28G (Sure Comfort Insulin Tier 2 X 1/2" 0.5 ML, 31G X 5/16" 1 ML Syringe) COMFORT EZ INSULIN SYRINGE 28G (Insulin Syringe) Tier 2 X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML COMFORT EZ INSULIN SYRINGE 29G (TopCare Ultra Comfort Ins Tier 2 X 1/2" 0.3 ML Syr) COMFORT EZ INSULIN SYRINGE 30G (Global Inject Ease Insulin Tier 2 X 1/2" 0.3 ML Syr) COMFORT EZ INSULIN SYRINGE 30G (Ultracare Insulin Syringe) Tier 2 X 1/2" 1 ML COMFORT EZ INSULIN SYRINGE 30G (GNP Ultra Com Insulin Tier 2 X 5/16" 0.3 ML Syringe) COMFORT EZ INSULIN SYRINGE 30G (Preferred Plus Insulin Tier 2 X 5/16" 1 ML Syringe) COMFORT EZ INSULIN SYRINGE 31G (MM Insulin Tier 2 X 5/16" 0.3 ML Syringe/Needle)

MedPerform Medium Formulary 01/01/2021

228 Drug Status Notes COMFORT EZ INSULIN SYRINGE 31G (Insulin Syringe-Needle U- Tier 2 X 5/16" 0.5 ML 100) COMFORT EZ MICRO PEN NEEDLES (QC Unifine Pentips) Tier 2 32G X 4 MM COMFORT EZ PEN NEEDLES 31G X 5 (Easy Comfort Pen Tier 2 MM , 33G X 5 MM , 33G X 6 MM Needles) COMFORT EZ PEN NEEDLES 31G X 6 (CareOne Unifine Pentips Tier 2 MM Plus) COMFORT EZ PEN NEEDLES 31G X 8 (Sure Comfort Pen Tier 2 MM Needles) COMFORT EZ PEN NEEDLES 32G X 4 (QC Unifine Pentips) Tier 2 MM COMFORT EZ PEN NEEDLES 32G X 5 (Ultracare Pen Needles) Tier 2 MM COMFORT EZ PEN NEEDLES 32G X 6 (GNP UltiCare Pen Tier 2 MM Needles) COMFORT EZ PEN NEEDLES 32G X 8 (Pure Comfort Pen Tier 2 MM Needle) COMFORT EZ PEN NEEDLES 33G X 4 (1st Tier Unifine Pentips Tier 2 MM Plus) COMFORT EZ PEN NEEDLES 33G X 8 Tier 2 MM COMFORT EZ SHORT PEN NEEDLES (Sure Comfort Pen Tier 2 31G X 8 MM Needles) DIATHRIVE PEN NEEDLE 31G X 5 MM (Easy Comfort Pen Tier 2 Needles) DIATHRIVE PEN NEEDLE 31G X 6 MM (CareOne Unifine Pentips Tier 2 Plus) DIATHRIVE PEN NEEDLE 31G X 8 MM (Sure Comfort Pen Tier 2 Needles) DIATHRIVE PEN NEEDLE 32G X 4 MM (QC Unifine Pentips) Tier 2 DROPLET INSULIN SYRINGE 29G X (TopCare Ultra Comfort Ins Tier 2 1/2" 0.3 ML Syr) DROPLET INSULIN SYRINGE 29G X (Insulin Syringe) Tier 2 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML

MedPerform Medium Formulary 01/01/2021

229 Drug Status Notes DROPLET INSULIN SYRINGE 30G X (Global Inject Ease Insulin Tier 2 1/2" 0.3 ML Syr) DROPLET INSULIN SYRINGE 30G X (Ultracare Insulin Syringe) Tier 2 1/2" 1 ML DROPLET INSULIN SYRINGE 30G X Tier 2 15/64" 0.3 ML, 30G X 15/64" 0.5 ML, 30G X 15/64" 1 ML DROPLET INSULIN SYRINGE 30G X (GNP Ultra Com Insulin Tier 2 5/16" 0.3 ML Syringe) DROPLET INSULIN SYRINGE 30G X (Preferred Plus Insulin Tier 2 5/16" 1 ML Syringe) DROPLET INSULIN SYRINGE 31G X (TechLITE Insulin Syringe) Tier 2 15/64" 0.3 ML, 31G X 15/64" 1 ML DROPLET INSULIN SYRINGE 31G X (Global Easy Glide Insulin Tier 2 15/64" 0.5 ML Syr) DROPLET INSULIN SYRINGE 31G X (MM Insulin Tier 2 5/16" 0.3 ML Syringe/Needle) DROPLET INSULIN SYRINGE 31G X (Insulin Syringe-Needle U- Tier 2 5/16" 0.5 ML 100) DROPLET INSULIN SYRINGE 31G X (Sure Comfort Insulin Tier 2 5/16" 1 ML Syringe) DROPLET MICRON 34G X 3.5 MM Tier 2 DROPLET PEN NEEDLES 29G X 10MM Tier 2 DROPLET PEN NEEDLES 29G X 12MM (1st Tier Unifine Pentips Tier 2 Plus) DROPLET PEN NEEDLES 30G X 8 MM (Sure Comfort Pen Tier 2 , 31G X 8 MM Needles) DROPLET PEN NEEDLES 31G X 5 MM (Easy Comfort Pen Tier 2 Needles) DROPLET PEN NEEDLES 31G X 6 MM (CareOne Unifine Pentips Tier 2 Plus) DROPLET PEN NEEDLES 32G X 4 MM (QC Unifine Pentips) Tier 2 DROPLET PEN NEEDLES 32G X 5 MM (Ultracare Pen Needles) Tier 2 DROPLET PEN NEEDLES 32G X 6 MM (GNP UltiCare Pen Tier 2 Needles)

MedPerform Medium Formulary 01/01/2021

230 Drug Status Notes DROPLET PEN NEEDLES 32G X 8 MM (Pure Comfort Pen Tier 2 Needle) dropsafe safety pen needles 31g x 6 mm (CareFine Pen Needles) Tier 2 dropsafe safety pen needles 31g x 8 mm (AboutTime Pen Needle) Tier 2 drug mart unifine pentips 29g x 12mm , (CareFine Pen Needles) Tier 2 31g x 6 mm drug mart unifine pentips 31g x 5 mm , (AboutTime Pen Needle) Tier 2 31g x 8 mm , 32g x 4 mm drug mart unifine pentips plus 32g x 4 (AboutTime Pen Needle) Tier 2 mm easy comfort insulin syringe 30g x 1/2" (BD Insulin Syringe U/F) Tier 2 0.5 ml, 30g x 1/2" 1 ml easy comfort insulin syringe 30g x 5/16" (Advocate Insulin Syringe) Tier 2 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml easy comfort insulin syringe 32g x 5/16" Tier 2 0.5 ml, 32g x 5/16" 1 ml easy comfort pen needles 31g x 5 mm , (AboutTime Pen Needle) Tier 2 31g x 8 mm , 32g x 4 mm easy comfort pen needles 31g x 6 mm (CareFine Pen Needles) Tier 2 easy comfort pen needles 33g x 4 mm (Advocate Insulin Pen Tier 2 Needles) easy comfort pen needles 33g x 5 mm , (Comfort EZ Pen Needles) Tier 2 33g x 6 mm easy glide pen needles 33g x 4 mm (Advocate Insulin Pen Tier 2 Needles) EASY TOUCH FLIPLOCK INSULIN SY (Insulin Syringe) Tier 2 29G X 1/2" 1 ML EASY TOUCH FLIPLOCK INSULIN SY (Ultracare Insulin Syringe) Tier 2 30G X 1/2" 1 ML EASY TOUCH FLIPLOCK INSULIN SY (Preferred Plus Insulin Tier 2 30G X 5/16" 1 ML Syringe) EASY TOUCH FLIPLOCK INSULIN SY (Sure Comfort Insulin Tier 2 31G X 5/16" 1 ML Syringe)

MedPerform Medium Formulary 01/01/2021

231 Drug Status Notes EASY TOUCH INSULIN SAFETY SYR (Insulin Syringe) Tier 2 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.5 ML EASY TOUCH INSULIN SAFETY SYR (Ultracare Insulin Syringe) Tier 2 30G X 1/2" 1 ML EASY TOUCH INSULIN SYRINGE 27G (Insulin Syringe/Needle) Tier 2 X 1/2" 0.5 ML EASY TOUCH INSULIN SYRINGE 27G (Insulin Syringe) Tier 2 X 1/2" 1 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML EASY TOUCH INSULIN SYRINGE 28G (Sure Comfort Insulin Tier 2 X 1/2" 0.5 ML, 31G X 5/16" 1 ML Syringe) EASY TOUCH INSULIN SYRINGE 30G (Global Inject Ease Insulin Tier 2 X 1/2" 0.3 ML Syr) EASY TOUCH INSULIN SYRINGE 30G (Ultracare Insulin Syringe) Tier 2 X 1/2" 1 ML EASY TOUCH INSULIN SYRINGE 30G (GNP Ultra Com Insulin Tier 2 X 5/16" 0.3 ML Syringe) EASY TOUCH INSULIN SYRINGE 30G (Preferred Plus Insulin Tier 2 X 5/16" 1 ML Syringe) EASY TOUCH INSULIN SYRINGE 31G (MM Insulin Tier 2 X 5/16" 0.3 ML Syringe/Needle) EASY TOUCH INSULIN SYRINGE 31G (Insulin Syringe-Needle U- Tier 2 X 5/16" 0.5 ML 100) EASY TOUCH PEN NEEDLES 29G X (1st Tier Unifine Pentips Tier 2 12MM Plus) EASY TOUCH PEN NEEDLES 30G X 5 (Pen Needles) Tier 2 MM EASY TOUCH PEN NEEDLES 30G X 8 (Sure Comfort Pen Tier 2 MM , 31G X 8 MM Needles) EASY TOUCH PEN NEEDLES 31G X 5 (Easy Comfort Pen Tier 2 MM Needles) EASY TOUCH PEN NEEDLES 31G X 6 (CareOne Unifine Pentips Tier 2 MM Plus)

MedPerform Medium Formulary 01/01/2021

232 Drug Status Notes EASY TOUCH PEN NEEDLES 32G X 4 (QC Unifine Pentips) Tier 2 MM EASY TOUCH PEN NEEDLES 32G X 5 (Ultracare Pen Needles) Tier 2 MM EASY TOUCH PEN NEEDLES 32G X 6 (GNP UltiCare Pen Tier 2 MM Needles) EASY TOUCH SAFETY PEN NEEDLES Tier 2 29G X 5MM , 29G X 8MM EASY TOUCH SAFETY PEN NEEDLES (Sure Comfort Pen Tier 2 30G X 8 MM Needles) EASY TOUCH SHEATHLOCK (Insulin Syringe) Tier 2 SYRINGE 29G X 1/2" 1 ML EASY TOUCH SHEATHLOCK (Ultracare Insulin Syringe) Tier 2 SYRINGE 30G X 1/2" 1 ML EASY TOUCH SHEATHLOCK (Preferred Plus Insulin Tier 2 SYRINGE 30G X 5/16" 1 ML Syringe) EASY TOUCH SHEATHLOCK (Sure Comfort Insulin Tier 2 SYRINGE 31G X 5/16" 1 ML Syringe) eql insulin syringe 29g x 1/2" 0.3 ml, 29g (Advocate Insulin Syringe) Tier 2 x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml EXEL COMFORT POINT INSULIN SYR (Sure Comfort Insulin Tier 2 28G X 1/2" 0.5 ML Syringe) EXEL COMFORT POINT INSULIN SYR (Insulin Syringe) Tier 2 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.5 ML EXEL COMFORT POINT INSULIN SYR (TopCare Ultra Comfort Ins Tier 2 29G X 1/2" 0.3 ML Syr) EXEL COMFORT POINT INSULIN SYR (GNP Ultra Com Insulin Tier 2 30G X 5/16" 0.3 ML Syringe) EXEL COMFORT POINT INSULIN SYR (Preferred Plus Insulin Tier 2 30G X 5/16" 1 ML Syringe) EXEL COMFORT POINT PEN NEEDLE (1st Tier Unifine Pentips Tier 2 29G X 12MM Plus)

MedPerform Medium Formulary 01/01/2021

233 Drug Status Notes EXEL COMFORT POINT PEN NEEDLE Tier 2 31G X 4 MM EXEL COMFORT POINT PEN NEEDLE (CareOne Unifine Pentips Tier 2 31G X 6 MM Plus) EXEL COMFORT POINT PEN NEEDLE (Sure Comfort Pen Tier 2 31G X 8 MM Needles) FIFTY50 PEN NEEDLES 31G X 5 MM (Easy Comfort Pen Tier 2 Needles) FIFTY50 PEN NEEDLES 31G X 8 MM (Sure Comfort Pen Tier 2 Needles) FIFTY50 PEN NEEDLES 32G X 4 MM (QC Unifine Pentips) Tier 2 FIFTY50 PEN NEEDLES 32G X 6 MM (GNP UltiCare Pen Tier 2 Needles) FIFTY50 SUPERIOR COMFORT SYR (MM Insulin Tier 2 31G X 5/16" 0.3 ML Syringe/Needle) FIFTY50 SUPERIOR COMFORT SYR (Insulin Syringe-Needle U- Tier 2 31G X 5/16" 0.5 ML 100) FIFTY50 SUPERIOR COMFORT SYR (Sure Comfort Insulin Tier 2 31G X 5/16" 1 ML Syringe) freds pharmacy unifine pentip+ 31g x 5 (AboutTime Pen Needle) Tier 2 mm , 31g x 8 mm freds pharmacy unifine pentips 32g x 4 (AboutTime Pen Needle) Tier 2 mm FREESTYLE PRECISION INS SYR 30G (Insulin Syringe) Tier 2 X 5/16" 0.5 ML FREESTYLE PRECISION INS SYR 30G (Preferred Plus Insulin Tier 2 X 5/16" 1 ML Syringe) FREESTYLE PRECISION INS SYR 31G (Insulin Syringe-Needle U- Tier 2 X 5/16" 0.5 ML 100) FREESTYLE PRECISION INS SYR 31G (Sure Comfort Insulin Tier 2 X 5/16" 1 ML Syringe) global ease inject pen needles 29g x (CareFine Pen Needles) Tier 2 12mm global ease inject pen needles 31g x 5 (AboutTime Pen Needle) Tier 2 mm , 31g x 8 mm , 32g x 4 mm

MedPerform Medium Formulary 01/01/2021

234 Drug Status Notes global easy glide insulin syr 31g x 15/64" (BD SafetyGlide Insulin Tier 2 0.3 ml, 31g x 15/64" 0.5 ml, 31g x 15/64" Syringe) 1 ml global easy glide insulin syr 31g x 5/16" (Advocate Insulin Syringe) Tier 2 0.3 ml global easy glide pen needles 32g x 4 (AboutTime Pen Needle) Tier 2 mm global inject ease insulin syr 28g x 1/2" (BD Insulin Syringe Tier 2 0.5 ml, 28g x 1/2" 1 ml MicroFine) global inject ease insulin syr 29g x 1/2" (Advocate Insulin Syringe) Tier 2 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml global inject ease insulin syr 30g x 1/2" (BD Insulin Syringe U/F) Tier 2 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml global insulin syringes 30g x 1/2" 0.3 ml (BD Insulin Syringe U/F) Tier 2 global insulin syringes 30g x 5/16" 0.3 ml (Advocate Insulin Syringe) Tier 2 GLUCOPRO INSULIN SYRINGE 30G X (Global Inject Ease Insulin Tier 2 1/2" 0.3 ML Syr) GLUCOPRO INSULIN SYRINGE 30G X (Insulin Syringe) Tier 2 1/2" 0.5 ML, 30G X 5/16" 0.5 ML GLUCOPRO INSULIN SYRINGE 30G X (Ultracare Insulin Syringe) Tier 2 1/2" 1 ML GLUCOPRO INSULIN SYRINGE 30G X (GNP Ultra Com Insulin Tier 2 5/16" 0.3 ML Syringe) GLUCOPRO INSULIN SYRINGE 30G X (Preferred Plus Insulin Tier 2 5/16" 1 ML Syringe) GLUCOPRO INSULIN SYRINGE 31G X (MM Insulin Tier 2 5/16" 0.3 ML Syringe/Needle) GLUCOPRO INSULIN SYRINGE 31G X (Insulin Syringe-Needle U- Tier 2 5/16" 0.5 ML 100) GLUCOPRO INSULIN SYRINGE 31G X (Sure Comfort Insulin Tier 2 5/16" 1 ML Syringe) gnp clickfine pen needles 31g x 6 mm (CareFine Pen Needles) Tier 2 gnp clickfine pen needles 31g x 8 mm (AboutTime Pen Needle) Tier 2

MedPerform Medium Formulary 01/01/2021

235 Drug Status Notes gnp insulin syringe 28g x 1/2" 0.5 ml, (BD Insulin Syringe Tier 2 28g x 1/2" 1 ml MicroFine) gnp insulin syringe 29g x 1/2" 0.3 ml, (Advocate Insulin Syringe) Tier 2 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml gnp ulticare pen needles 31g x 8 mm , (AboutTime Pen Needle) Tier 2 32g x 4 mm gnp ulticare pen needles 32g x 6 mm (BD Pen Needle Micro Tier 2 U/F) gnp ultra com insulin syringe 28g x 1/2" (BD Insulin Syringe Tier 2 0.5 ml, 28g x 1/2" 1 ml MicroFine) gnp ultra com insulin syringe 29g x 1/2" (Advocate Insulin Syringe) Tier 2 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml goodsense clickfine pen needle 31g x 5 (AboutTime Pen Needle) Tier 2 mm GOODSENSE PEN NEEDLE PENFINE (Easy Comfort Pen Tier 2 31G X 5 MM Needles) GOODSENSE PEN NEEDLE PENFINE (Sure Comfort Pen Tier 2 31G X 8 MM Needles) GOODSENSE PEN NEEDLE PENFINE (QC Unifine Pentips) Tier 2 32G X 4 MM GOODSENSE PEN NEEDLE PENFINE (GNP UltiCare Pen Tier 2 32G X 6 MM Needles) healthwise insulin syr/needle 30g x 5/16" (Advocate Insulin Syringe) Tier 2 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml healthwise micron pen needles 32g x 4 (AboutTime Pen Needle) Tier 2 mm healthwise mini pen needles 31g x 6 mm (CareFine Pen Needles) Tier 2 healthwise pen needles 29g x 12mm (CareFine Pen Needles) Tier 2

MedPerform Medium Formulary 01/01/2021

236 Drug Status Notes healthwise short pen needles 31g x 5 (AboutTime Pen Needle) Tier 2 mm , 31g x 8 mm healthwise unifine pentips 32g x 4 mm (AboutTime Pen Needle) Tier 2 healthy accents unifine pentip 29g x (CareFine Pen Needles) Tier 2 12mm , 31g x 6 mm healthy accents unifine pentip 31g x 5 (AboutTime Pen Needle) Tier 2 mm , 31g x 8 mm , 32g x 4 mm h-e-b incontrol pen needles 29g x 12mm (CareFine Pen Needles) Tier 2 , 31g x 6 mm h-e-b incontrol pen needles 31g x 5 mm , (AboutTime Pen Needle) Tier 2 31g x 8 mm , 32g x 4 mm H-E-B INCONTROL UNIFINE PENTIP (QC Unifine Pentips) Tier 2 32G X 4 MM HM ULTICARE INSULIN SYRINGE 30G (Ultracare Insulin Syringe) Tier 2 X 1/2" 1 ML HM ULTICARE INSULIN SYRINGE 31G (MM Insulin Tier 2 X 5/16" 0.3 ML Syringe/Needle) HM ULTICARE SHORT PEN NEEDLES (Sure Comfort Pen Tier 2 31G X 8 MM Needles) inject-ease (Autoject 2) Tier 3 insulin syringe 27g x 1/2" 0.5 ml (Easy Touch Insulin Tier 2 Syringe) insulin syringe 27g x 1/2" 1 ml (BD Insulin Syringe) Tier 2 insulin syringe 28g x 1/2" 0.5 ml, 28g x (BD Insulin Syringe Tier 2 1/2" 1 ml MicroFine) insulin syringe 29g x 1" 0.3 ml Tier 2 insulin syringe 29g x 1/2" 0.3 ml, 29g x (Advocate Insulin Syringe) Tier 2 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml insulin syringe 30g x 1/2" 0.5 ml, 30g x (BD Insulin Syringe U/F) Tier 2 1/2" 1 ml insulin syringe/needle 27g x 1/2" 0.5 ml (Easy Touch Insulin Tier 2 Syringe)

MedPerform Medium Formulary 01/01/2021

237 Drug Status Notes insulin syringe/needle 28g x 1/2" 0.5 ml, (BD Insulin Syringe Tier 2 28g x 1/2" 1 ml MicroFine) insulin syringe-needle u-100 29g x 1/2" (Advocate Insulin Syringe) Tier 2 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml insulin syringe-needle u-100 31g x 1/4" (UltiCare Insulin Syringe) Tier 2 0.3 ml, 31g x 1/4" 0.5 ml, 31g x 1/4" 1 ml insupen pen needles 29g x 12mm (CareFine Pen Needles) Tier 2 insupen pen needles 31g x 5 mm , 31g x (AboutTime Pen Needle) Tier 2 8 mm , 32g x 4 mm insupen pen needles 33g x 4 mm (Advocate Insulin Pen Tier 2 Needles) INSUPEN SENSITIVE 32G X 6 MM (GNP UltiCare Pen Tier 2 Needles) INSUPEN SENSITIVE 32G X 8 MM (Pure Comfort Pen Tier 2 Needle) INSUPEN ULTRAFIN 30G X 8 MM , (Sure Comfort Pen Tier 2 31G X 8 MM Needles) INSUPEN ULTRAFIN 31G X 6 MM (CareOne Unifine Pentips Tier 2 Plus) J-TIP KIT W/VIAL ADAPTERS KIT Tier 3 kinray insulin syringe 29g x 1/2" 0.5 ml, (Advocate Insulin Syringe) Tier 2 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml kmart valu insulin syringe 29g u-100 0.5 Tier 2 ml kmart valu insulin syringe 29g u-100 1 ml (BD Insulin Syringe) Tier 2 kmart valu insulin syringe 30g u-100 0.3 Tier 2 ml, u-100 0.5 ml kmart valu insulin syringe 30g u-100 1 ml (BD Insulin Syringe) Tier 2

MedPerform Medium Formulary 01/01/2021

238 Drug Status Notes kroger insulin syringe 29g x 1/2" 0.3 ml, (Advocate Insulin Syringe) Tier 2 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml kroger pen needles 29g x 12mm , 31g x (CareFine Pen Needles) Tier 2 6 mm kroger pen needles 31g x 5 mm , 31g x 8 (AboutTime Pen Needle) Tier 2 mm , 32g x 4 mm kroger pen needles 33g x 4 mm (Advocate Insulin Pen Tier 2 Needles) leader insulin syringe 28g x 1/2" 0.5 ml, (BD Insulin Syringe Tier 2 28g x 1/2" 1 ml MicroFine) leader insulin syringe 29g x 1/2" 0.3 ml, (Advocate Insulin Syringe) Tier 2 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml LEADER UNIFINE PENTIPS 31G X 5 (Easy Comfort Pen Tier 2 MM Needles) LEADER UNIFINE PENTIPS 32G X 4 (QC Unifine Pentips) Tier 2 MM LEADER UNIFINE PENTIPS PLUS 31G (Easy Comfort Pen Tier 2 X 5 MM Needles) LEADER UNIFINE PENTIPS PLUS 31G (Sure Comfort Pen Tier 2 X 8 MM Needles) LEADER UNIFINE PENTIPS PLUS 32G (QC Unifine Pentips) Tier 2 X 4 MM LITETOUCH INSULIN SYRINGE 28G X (Sure Comfort Insulin Tier 2 1/2" 0.5 ML, 31G X 5/16" 1 ML Syringe) LITETOUCH INSULIN SYRINGE 28G X (Insulin Syringe) Tier 2 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.5 ML LITETOUCH INSULIN SYRINGE 29G X (TopCare Ultra Comfort Ins Tier 2 1/2" 0.3 ML Syr)

MedPerform Medium Formulary 01/01/2021

239 Drug Status Notes LITETOUCH INSULIN SYRINGE 30G X (GNP Ultra Com Insulin Tier 2 5/16" 0.3 ML Syringe) LITETOUCH INSULIN SYRINGE 30G X (Preferred Plus Insulin Tier 2 5/16" 1 ML Syringe) LITETOUCH INSULIN SYRINGE 31G X (MM Insulin Tier 2 5/16" 0.3 ML Syringe/Needle) LITETOUCH INSULIN SYRINGE 31G X (Insulin Syringe-Needle U- Tier 2 5/16" 0.5 ML 100) LITETOUCH PEN NEEDLES 29G X (Sure Comfort Pen Tier 2 12.7MM , 31G X 8 MM Needles) LITETOUCH PEN NEEDLES 31G X 5 (Easy Comfort Pen Tier 2 MM Needles) LITETOUCH PEN NEEDLES 31G X 6 (CareOne Unifine Pentips Tier 2 MM Plus) LITETOUCH PEN NEEDLES 32G X 4 (QC Unifine Pentips) Tier 2 MM longs insulin syringe 31g x 5/16" 0.5 ml (Advocate Insulin Syringe) Tier 2 MAGELLAN INSULIN SAFETY SYR (TopCare Ultra Comfort Ins Tier 2 29G X 1/2" 0.3 ML Syr) MAGELLAN INSULIN SAFETY SYR (Insulin Syringe) Tier 2 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.5 ML MAGELLAN INSULIN SAFETY SYR (GNP Ultra Com Insulin Tier 2 30G X 5/16" 0.3 ML Syringe) MAGELLAN INSULIN SAFETY SYR (Preferred Plus Insulin Tier 2 30G X 5/16" 1 ML Syringe) MARATHON MEDICAL PENTIPS 29G X (1st Tier Unifine Pentips Tier 2 12MM Plus) MARATHON MEDICAL PENTIPS 31G X (Easy Comfort Pen Tier 2 5 MM Needles) MARATHON MEDICAL PENTIPS 31G X (Sure Comfort Pen Tier 2 8 MM Needles) MARATHON MEDICAL PENTIPS 32G X (QC Unifine Pentips) Tier 2 4 MM MAXICOMFORT II PEN NEEDLE 31G X (CareOne Unifine Pentips Tier 2 6 MM Plus)

MedPerform Medium Formulary 01/01/2021

240 Drug Status Notes MAXI-COMFORT INSULIN SYRINGE (Sure Comfort Insulin Tier 2 28G X 1/2" 0.5 ML Syringe) MAXI-COMFORT INSULIN SYRINGE (Insulin Syringe) Tier 2 28G X 1/2" 1 ML MAXI-COMFORT SAFETY PEN Tier 2 NEEDLE 29G X 5MM , 29G X 8MM MAXICOMFORT SYR 27G X 1/2" 27G X (Insulin Syringe/Needle) Tier 2 1/2" 0.5 ML MAXICOMFORT SYR 27G X 1/2" 27G X (Insulin Syringe) Tier 2 1/2" 1 ML medic insulin syringe 30g x 5/16" 0.3 ml, (Advocate Insulin Syringe) Tier 2 30g x 5/16" 0.5 ml medicine shoppe pen needles 29g x (CareFine Pen Needles) Tier 2 12mm , 31g x 6 mm medicine shoppe pen needles 31g x 8 (AboutTime Pen Needle) Tier 2 mm meijer pen needles 29g x 12mm , 31g x (CareFine Pen Needles) Tier 2 6 mm meijer pen needles 31g x 8 mm (AboutTime Pen Needle) Tier 2 MICRODOT PEN NEEDLE 31G X 6 MM (CareOne Unifine Pentips Tier 2 Plus) MICRODOT PEN NEEDLE 32G X 4 MM (QC Unifine Pentips) Tier 2 MICRODOT PEN NEEDLE 33G X 4 MM (1st Tier Unifine Pentips Tier 2 Plus) mm insulin syringe/needle 30g x 5/16" (Advocate Insulin Syringe) Tier 2 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml MM PEN NEEDLES 31G X 5 MM (Easy Comfort Pen Tier 2 Needles) MM PEN NEEDLES 31G X 6 MM (CareOne Unifine Pentips Tier 2 Plus) MM PEN NEEDLES 31G X 8 MM (Sure Comfort Pen Tier 2 Needles) MM PEN NEEDLES 32G X 4 MM (QC Unifine Pentips) Tier 2

MedPerform Medium Formulary 01/01/2021

241 Drug Status Notes MONOJECT INSULIN SYRINGE 25G X Tier 2 5/8" 1 ML MONOJECT INSULIN SYRINGE 27G X (Insulin Syringe) Tier 2 1/2" 1 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.5 ML MONOJECT INSULIN SYRINGE 28G X (Sure Comfort Insulin Tier 2 1/2" 0.5 ML, 31G X 5/16" 1 ML Syringe) MONOJECT INSULIN SYRINGE 29G X (TopCare Ultra Comfort Ins Tier 2 1/2" 0.3 ML Syr) MONOJECT INSULIN SYRINGE 30G X (GNP Ultra Com Insulin Tier 2 5/16" 0.3 ML Syringe) MONOJECT INSULIN SYRINGE 30G X (Preferred Plus Insulin Tier 2 5/16" 1 ML Syringe) MONOJECT INSULIN SYRINGE U-100 (Kmart Valu Insulin Tier 2 1 ML Syringe 30G) MONOJECT ULTRA COMFORT (Sure Comfort Insulin Tier 2 SYRINGE 28G X 1/2" 0.5 ML Syringe) MONOJECT ULTRA COMFORT (Insulin Syringe) Tier 2 SYRINGE 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.5 ML MONOJECT ULTRA COMFORT (TopCare Ultra Comfort Ins Tier 2 SYRINGE 29G X 1/2" 0.3 ML Syr) MONOJECT ULTRA COMFORT (GNP Ultra Com Insulin Tier 2 SYRINGE 30G X 5/16" 0.3 ML Syringe) MONOJECT ULTRA COMFORT (MM Insulin Tier 2 SYRINGE 31G X 5/16" 0.3 ML Syringe/Needle) MONOJECT ULTRA COMFORT (Insulin Syringe-Needle U- Tier 2 SYRINGE 31G X 5/16" 0.5 ML 100) ms insulin syringe 31g x 5/16" 0.3 ml, (Advocate Insulin Syringe) Tier 2 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml NORDIPEN 5 INJECTION DEVICE (Inject-Ease) Tier 3 NORDIPEN DELIVERY SYSTEM (Inject-Ease) Tier 3 NOVOFINE 32G X 6 MM (GNP UltiCare Pen Tier 2 Needles)

MedPerform Medium Formulary 01/01/2021

242 Drug Status Notes NOVOFINE AUTOCOVER 30G X 8 MM (Sure Comfort Pen Tier 2 Needles) NOVOFINE PLUS 32G X 4 MM (QC Unifine Pentips) Tier 2 NOVOTWIST 32G X 5 MM (Ultracare Pen Needles) Tier 2 OMNITROPE PEN 10 INJ DEVICE (Inject-Ease) Tier 3 OMNITROPE PEN 5 INJ DEVICE (Inject-Ease) Tier 3 pc unifine pentips 29g x 12mm , 31g x 6 (CareFine Pen Needles) Tier 2 mm pc unifine pentips 31g x 5 mm , 31g x 8 (AboutTime Pen Needle) Tier 2 mm pen needles 1/2" 29g x 12mm (CareFine Pen Needles) Tier 2 pen needles 29g x 12mm , 31g x 6 mm , (CareFine Pen Needles) Tier 2 32g x 5 mm pen needles 3/16" 31g x 5 mm (AboutTime Pen Needle) Tier 2 pen needles 30g x 5 mm (Assure ID Safety Pen Tier 2 Needles) pen needles 30g x 8 mm , 31g x 5 mm , (AboutTime Pen Needle) Tier 2 31g x 8 mm , 32g x 4 mm pen needles 32g x 6 mm (BD Pen Needle Micro Tier 2 U/F) pen needles 33g x 4 mm (Advocate Insulin Pen Tier 2 Needles) pen needles 5/16" 30g x 8 mm , 31g x 8 (AboutTime Pen Needle) Tier 2 mm PENTIPS 29G X 12MM (1st Tier Unifine Pentips Tier 2 Plus) PENTIPS 31G X 5 MM (Easy Comfort Pen Tier 2 Needles) PENTIPS 31G X 6 MM (CareOne Unifine Pentips Tier 2 Plus) PENTIPS 31G X 8 MM (Sure Comfort Pen Tier 2 Needles) PENTIPS 32G X 4 MM (QC Unifine Pentips) Tier 2 PRECISION SUREDOSE PLUS SYR (TopCare Ultra Comfort Ins Tier 2 29G X 1/2" 0.3 ML Syr)

MedPerform Medium Formulary 01/01/2021

243 Drug Status Notes PRECISION SUREDOSE PLUS SYR (Insulin Syringe) Tier 2 29G X 1/2" 1 ML PRECISION SURE-DOSE SYRINGE (Sure Comfort Insulin Tier 2 28G X 1/2" 0.5 ML Syringe) PRECISION SURE-DOSE SYRINGE (Insulin Syringe) Tier 2 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML PRECISION SURE-DOSE SYRINGE Tier 2 30G X 3/8" 0.5 ML PRECISION SURE-DOSE SYRINGE (GNP Ultra Com Insulin Tier 2 30G X 5/16" 0.3 ML Syringe) preferred plus insulin syringe 28g x 1/2" (BD Insulin Syringe Tier 2 0.5 ml, 28g x 1/2" 1 ml MicroFine) preferred plus insulin syringe 29g x 1/2" (Advocate Insulin Syringe) Tier 2 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml preferred plus unifine pentips 29g x (CareFine Pen Needles) Tier 2 12mm , 31g x 6 mm preferred plus unifine pentips 31g x 5 (AboutTime Pen Needle) Tier 2 mm , 31g x 8 mm , 32g x 4 mm PREVENT SAFETY PEN NEEDLES (CareOne Unifine Pentips Tier 2 31G X 6 MM Plus) PREVENT SAFETY PEN NEEDLES (Sure Comfort Pen Tier 2 31G X 8 MM Needles) PRO COMFORT INSULIN SYRINGE (Insulin Syringe) Tier 2 30G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML PRO COMFORT INSULIN SYRINGE (Ultracare Insulin Syringe) Tier 2 30G X 1/2" 1 ML PRO COMFORT INSULIN SYRINGE (Preferred Plus Insulin Tier 2 30G X 5/16" 1 ML Syringe) PRO COMFORT INSULIN SYRINGE (Insulin Syringe-Needle U- Tier 2 31G X 5/16" 0.5 ML 100) PRO COMFORT INSULIN SYRINGE (Sure Comfort Insulin Tier 2 31G X 5/16" 1 ML Syringe) pro comfort pen needles 31g x 8 mm , (AboutTime Pen Needle) Tier 2 32g x 4 mm

MedPerform Medium Formulary 01/01/2021

244 Drug Status Notes pro comfort pen needles 32g x 5 mm (CareFine Pen Needles) Tier 2 pro comfort pen needles 32g x 6 mm (BD Pen Needle Micro Tier 2 U/F) PRODIGY INSULIN SYRINGE 28G X (Insulin Syringe) Tier 2 1/2" 1 ML PRODIGY INSULIN SYRINGE 31G X (MM Insulin Tier 2 5/16" 0.3 ML Syringe/Needle) PRODIGY INSULIN SYRINGE 31G X (Insulin Syringe-Needle U- Tier 2 5/16" 0.5 ML 100) pure comfort pen needle 32g x 4 mm (AboutTime Pen Needle) Tier 2 pure comfort pen needle 32g x 5 mm (CareFine Pen Needles) Tier 2 pure comfort pen needle 32g x 6 mm (BD Pen Needle Micro Tier 2 U/F) pure comfort pen needle 32g x 8 mm (Comfort EZ Pen Needles) Tier 2 px extra short pen needles 31g x 6 mm (CareFine Pen Needles) Tier 2 px insulin syringe 30g x 1/2" 0.5 ml (BD Insulin Syringe U/F) Tier 2 px mini pen needles 31g x 5 mm (AboutTime Pen Needle) Tier 2 px pen needle 29g x 12mm (CareFine Pen Needles) Tier 2 px pen needle 31g x 8 mm (AboutTime Pen Needle) Tier 2 px shortlength pen needles 31g x 8 mm (AboutTime Pen Needle) Tier 2 qc pen needles 29g x 12mm , 31g x 6 (CareFine Pen Needles) Tier 2 mm qc pen needles 31g x 8 mm (AboutTime Pen Needle) Tier 2 qc unifine pentips 32g x 4 mm (AboutTime Pen Needle) Tier 2 ra insulin syringe 29g x 1/2" 0.5 ml, 29g (Advocate Insulin Syringe) Tier 2 x 1/2" 1 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml ra pen needles 31g x 5 mm , 31g x 8 mm (AboutTime Pen Needle) Tier 2 reality insulin syringe 28g x 1/2" 0.5 ml, (BD Insulin Syringe Tier 2 28g x 1/2" 1 ml MicroFine) reality insulin syringe 29g x 1/2" 0.5 ml, (Advocate Insulin Syringe) Tier 2 29g x 1/2" 1 ml RELI-ON INSULIN SYRINGE 29G 0.3 Tier 2 ML, 29G 0.5 ML, 30G 0.3 ML, 30G 0.5 ML, 30G 1 ML

MedPerform Medium Formulary 01/01/2021

245 Drug Status Notes RELION INSULIN SYRINGE 29G X 1/2" (TopCare Ultra Comfort Ins Tier 2 0.3 ML Syr) RELION INSULIN SYRINGE 29G X 1/2" (Insulin Syringe) Tier 2 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.5 ML RELI-ON INSULIN SYRINGE 29G X 1/2" (Insulin Syringe) Tier 2 1 ML RELION INSULIN SYRINGE 30G X (GNP Ultra Com Insulin Tier 2 5/16" 0.3 ML Syringe) RELION INSULIN SYRINGE 30G X (Preferred Plus Insulin Tier 2 5/16" 1 ML Syringe) RELION INSULIN SYRINGE 31G X (TechLITE Insulin Syringe) Tier 2 15/64" 0.3 ML, 31G X 15/64" 1 ML RELION INSULIN SYRINGE 31G X (Global Easy Glide Insulin Tier 2 15/64" 0.5 ML Syr) RELION INSULIN SYRINGE 31G X (MM Insulin Tier 2 5/16" 0.3 ML Syringe/Needle) RELION INSULIN SYRINGE 31G X (Insulin Syringe-Needle U- Tier 2 5/16" 0.5 ML 100) RELION INSULIN SYRINGE 31G X (Sure Comfort Insulin Tier 2 5/16" 1 ML Syringe) RELION MINI PEN NEEDLES 31G X 6 (CareOne Unifine Pentips Tier 2 MM Plus) RELION PEN NEEDLES 29G X 12MM (1st Tier Unifine Pentips Tier 2 Plus) RELION PEN NEEDLES 31G X 6 MM (CareOne Unifine Pentips Tier 2 Plus) RELION PEN NEEDLES 31G X 8 MM (Sure Comfort Pen Tier 2 Needles) RELION PEN NEEDLES 32G X 4 MM (QC Unifine Pentips) Tier 2 RELION SHORT PEN NEEDLES 31G X (Sure Comfort Pen Tier 2 8 MM Needles) safety insulin syringes 27g x 1/2" 1 ml (BD Insulin Syringe) Tier 2 safety insulin syringes 29g x 1/2" 0.5 ml, (Advocate Insulin Syringe) Tier 2 29g x 1/2" 1 ml, 30g x 5/16" 0.5 ml safety insulin syringes 30g x 1/2" 1 ml (BD Insulin Syringe U/F) Tier 2

MedPerform Medium Formulary 01/01/2021

246 Drug Status Notes sb insulin syringe 29g x 1/2" 0.5 ml, 29g (Advocate Insulin Syringe) Tier 2 x 1/2" 1 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 1 ml SECURESAFE INSULIN SYRINGE 29G (Insulin Syringe) Tier 2 X 1/2" 0.5 ML, 29G X 1/2" 1 ML SHOPKO UNIFINE PENTIPS 29G X (1st Tier Unifine Pentips Tier 2 12MM Plus) SHOPKO UNIFINE PENTIPS 31G X 5 (Easy Comfort Pen Tier 2 MM Needles) SHOPKO UNIFINE PENTIPS 31G X 8 (Sure Comfort Pen Tier 2 MM Needles) SHOPKO UNIFINE PENTIPS 32G X 4 (QC Unifine Pentips) Tier 2 MM SHOPKO UNIFINE PENTIPS PLUS 29G (1st Tier Unifine Pentips Tier 2 X 12MM Plus) SHOPKO UNIFINE PENTIPS PLUS 31G (Easy Comfort Pen Tier 2 X 5 MM Needles) SHOPKO UNIFINE PENTIPS PLUS 31G (Sure Comfort Pen Tier 2 X 8 MM Needles) SHOPKO UNIFINE PENTIPS PLUS 32G (QC Unifine Pentips) Tier 2 X 4 MM sure comfort insulin syringe 28g x 1/2" (BD Insulin Syringe Tier 2 0.5 ml, 28g x 1/2" 1 ml MicroFine) sure comfort insulin syringe 29g x 1/2" (Advocate Insulin Syringe) Tier 2 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml sure comfort insulin syringe 30g x 1/2" (BD Insulin Syringe U/F) Tier 2 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml sure comfort insulin syringe 31g x 1/4" (UltiCare Insulin Syringe) Tier 2 0.3 ml, 31g x 1/4" 0.5 ml, 31g x 1/4" 1 ml sure comfort pen needles 29g x 12.7mm (Advocate Insulin Pen Tier 2 Needles) sure comfort pen needles 30g x 8 mm , (AboutTime Pen Needle) Tier 2 31g x 5 mm , 31g x 8 mm

MedPerform Medium Formulary 01/01/2021

247 Drug Status Notes sure comfort pen needles 32g x 6 mm (BD Pen Needle Micro Tier 2 U/F) SURE-FINE PEN NEEDLES 29G X (Sure Comfort Pen Tier 2 12.7MM , 31G X 8 MM Needles) SURE-FINE PEN NEEDLES 31G X 5 (Easy Comfort Pen Tier 2 MM Needles) SURE-JECT INSULIN SYRINGE 28G X (Sure Comfort Insulin Tier 2 1/2" 0.5 ML, 31G X 5/16" 1 ML Syringe) SURE-JECT INSULIN SYRINGE 28G X (Insulin Syringe) Tier 2 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.5 ML SURE-JECT INSULIN SYRINGE 29G X (TopCare Ultra Comfort Ins Tier 2 1/2" 0.3 ML Syr) SURE-JECT INSULIN SYRINGE 30G X (GNP Ultra Com Insulin Tier 2 5/16" 0.3 ML Syringe) SURE-JECT INSULIN SYRINGE 30G X (Preferred Plus Insulin Tier 2 5/16" 1 ML Syringe) SURE-JECT INSULIN SYRINGE 31G X (MM Insulin Tier 2 5/16" 0.3 ML Syringe/Needle) SURE-JECT INSULIN SYRINGE 31G X (Insulin Syringe-Needle U- Tier 2 5/16" 0.5 ML 100) techlite insulin syringe 29g x 1/2" 0.3 ml, (Advocate Insulin Syringe) Tier 2 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml techlite insulin syringe 30g x 1/2" 0.3 ml, (BD Insulin Syringe U/F) Tier 2 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml techlite insulin syringe 31g x 15/64" 0.3 (BD SafetyGlide Insulin Tier 2 ml, 31g x 15/64" 0.5 ml, 31g x 15/64" 1 Syringe) ml TECHLITE PEN NEEDLES 29G X Tier 2 10MM TECHLITE PEN NEEDLES 29G X (1st Tier Unifine Pentips Tier 2 12MM Plus)

MedPerform Medium Formulary 01/01/2021

248 Drug Status Notes TECHLITE PEN NEEDLES 31G X 5 MM (Easy Comfort Pen Tier 2 Needles) TECHLITE PEN NEEDLES 31G X 6 MM (CareOne Unifine Pentips Tier 2 Plus) TECHLITE PEN NEEDLES 31G X 8 MM (Sure Comfort Pen Tier 2 Needles) TECHLITE PEN NEEDLES 32G X 4 MM (QC Unifine Pentips) Tier 2 TECHLITE PEN NEEDLES 32G X 6 MM (GNP UltiCare Pen Tier 2 Needles) TECHLITE PEN NEEDLES 32G X 8 MM (Pure Comfort Pen Tier 2 Needle) todays health mini pen needles 31g x 6 (CareFine Pen Needles) Tier 2 mm todays health pen needles 29g x 12mm (CareFine Pen Needles) Tier 2 todays health short pen needle 31g x 8 (AboutTime Pen Needle) Tier 2 mm topcare clickfine pen needles 31g x 6 (CareFine Pen Needles) Tier 2 mm topcare clickfine pen needles 31g x 8 (AboutTime Pen Needle) Tier 2 mm topcare ultra comfort ins syr 29g x 1/2" (Advocate Insulin Syringe) Tier 2 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml true comfort insulin syringe 31g x 5/16" (Advocate Insulin Syringe) Tier 2 0.5 ml, 31g x 5/16" 1 ml true comfort pen needles 31g x 5 mm , (AboutTime Pen Needle) Tier 2 32g x 4 mm true comfort pen needles 31g x 6 mm (CareFine Pen Needles) Tier 2 TRUEPLUS 5-BEVEL PEN NEEDLES (Sure Comfort Pen Tier 2 29G X 12.7MM , 31G X 8 MM Needles) TRUEPLUS 5-BEVEL PEN NEEDLES (Easy Comfort Pen Tier 2 31G X 5 MM Needles) TRUEPLUS 5-BEVEL PEN NEEDLES (CareOne Unifine Pentips Tier 2 31G X 6 MM Plus)

MedPerform Medium Formulary 01/01/2021

249 Drug Status Notes TRUEPLUS 5-BEVEL PEN NEEDLES (QC Unifine Pentips) Tier 2 32G X 4 MM TRUEPLUS INSULIN SYRINGE 28G X (Sure Comfort Insulin Tier 2 1/2" 0.5 ML, 31G X 5/16" 1 ML Syringe) TRUEPLUS INSULIN SYRINGE 28G X (Insulin Syringe) Tier 2 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.5 ML TRUEPLUS INSULIN SYRINGE 29G X (TopCare Ultra Comfort Ins Tier 2 1/2" 0.3 ML Syr) TRUEPLUS INSULIN SYRINGE 30G X (GNP Ultra Com Insulin Tier 2 5/16" 0.3 ML Syringe) TRUEPLUS INSULIN SYRINGE 30G X (Preferred Plus Insulin Tier 2 5/16" 1 ML Syringe) TRUEPLUS INSULIN SYRINGE 31G X (MM Insulin Tier 2 5/16" 0.3 ML Syringe/Needle) TRUEPLUS INSULIN SYRINGE 31G X (Insulin Syringe-Needle U- Tier 2 5/16" 0.5 ML 100) TRUEPLUS PEN NEEDLES 31G X 6 (CareOne Unifine Pentips Tier 2 MM Plus) ULTICARE INSULIN SAFETY SYR 29G (Insulin Syringe) Tier 2 X 1/2" 0.5 ML, 29G X 1/2" 1 ML ULTICARE INSULIN SYRINGE 28G X (Sure Comfort Insulin Tier 2 1/2" 0.5 ML, 31G X 1/4" 0.5 ML, 31G X Syringe) 1/4" 1 ML, 31G X 5/16" 1 ML ULTICARE INSULIN SYRINGE 28G X (Insulin Syringe) Tier 2 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML ULTICARE INSULIN SYRINGE 29G X (TopCare Ultra Comfort Ins Tier 2 1/2" 0.3 ML Syr) ULTICARE INSULIN SYRINGE 30G X (Global Inject Ease Insulin Tier 2 1/2" 0.3 ML Syr) ULTICARE INSULIN SYRINGE 30G X (Ultracare Insulin Syringe) Tier 2 1/2" 1 ML ULTICARE INSULIN SYRINGE 30G X (GNP Ultra Com Insulin Tier 2 5/16" 0.3 ML Syringe)

MedPerform Medium Formulary 01/01/2021

250 Drug Status Notes ULTICARE INSULIN SYRINGE 30G X (Preferred Plus Insulin Tier 2 5/16" 1 ML Syringe) ULTICARE INSULIN SYRINGE 31G X (Insulin Syringe-Needle U- Tier 2 1/4" 0.3 ML, 31G X 5/16" 0.5 ML 100) ULTICARE INSULIN SYRINGE 31G X (MM Insulin Tier 2 5/16" 0.3 ML Syringe/Needle) ULTICARE MICRO PEN NEEDLES 31G (CareOne Unifine Pentips Tier 2 X 6 MM Plus) ULTICARE MICRO PEN NEEDLES 31G (Sure Comfort Pen Tier 2 X 8 MM Needles) ULTICARE MICRO PEN NEEDLES 32G (QC Unifine Pentips) Tier 2 X 4 MM ULTICARE MINI PEN NEEDLES 31G X (CareOne Unifine Pentips Tier 2 6 MM Plus) ULTICARE MINI PEN NEEDLES 32G X (GNP UltiCare Pen Tier 2 6 MM Needles) ULTICARE PEN NEEDLES 29G X (Sure Comfort Pen Tier 2 12.7MM Needles) ULTICARE PEN NEEDLES 31G X 5 MM (Easy Comfort Pen Tier 2 Needles) ULTICARE SHORT PEN NEEDLES 31G (Sure Comfort Pen Tier 2 X 8 MM Needles) ultiguard safepack pen needle 31g x 5 (AboutTime Pen Needle) Tier 2 mm , 31g x 8 mm , 32g x 4 mm ultiguard safepack pen needle 31g x 6 (CareFine Pen Needles) Tier 2 mm ultiguard safepack pen needle 32g x 6 (BD Pen Needle Micro Tier 2 mm U/F) ULTILET INSULIN SYRINGE 30G X 1/2" (Insulin Syringe) Tier 2 0.5 ML, 30G X 5/16" 0.5 ML ULTILET INSULIN SYRINGE 30G X 1/2" (Ultracare Insulin Syringe) Tier 2 1 ML ULTILET INSULIN SYRINGE 30G X (GNP Ultra Com Insulin Tier 2 5/16" 0.3 ML Syringe) ULTILET INSULIN SYRINGE 30G X (Preferred Plus Insulin Tier 2 5/16" 1 ML Syringe)

MedPerform Medium Formulary 01/01/2021

251 Drug Status Notes ULTILET INSULIN SYRINGE 31G X 1/4" (Insulin Syringe-Needle U- Tier 2 0.3 ML 100) ULTILET INSULIN SYRINGE 31G X 1/4" (Sure Comfort Insulin Tier 2 1 ML, 31G X 5/16" 1 ML Syringe) ULTILET INSULIN SYRINGE 31G X (TechLITE Insulin Syringe) Tier 2 15/64" 0.3 ML ULTILET INSULIN SYRINGE 31G X (Global Easy Glide Insulin Tier 2 15/64" 0.5 ML Syr) ULTILET INSULIN SYRINGE 31G X (MM Insulin Tier 2 5/16" 0.3 ML Syringe/Needle) ULTILET INSULIN SYRINGE SHORT (Global Inject Ease Insulin Tier 2 30G X 1/2" 0.3 ML Syr) ULTILET INSULIN SYRINGE SHORT (GNP Ultra Com Insulin Tier 2 30G X 5/16" 0.3 ML Syringe) ULTILET INSULIN SYRINGE SHORT (Insulin Syringe) Tier 2 30G X 5/16" 0.5 ML ULTILET INSULIN SYRINGE SHORT (Preferred Plus Insulin Tier 2 30G X 5/16" 1 ML Syringe) ULTILET INSULIN SYRINGE SHORT (MM Insulin Tier 2 31G X 5/16" 0.3 ML Syringe/Needle) ULTILET INSULIN SYRINGE SHORT (Insulin Syringe-Needle U- Tier 2 31G X 5/16" 0.5 ML 100) ULTILET INSULIN SYRINGE SHORT (Sure Comfort Insulin Tier 2 31G X 5/16" 1 ML Syringe) ULTILET PEN NEEDLE 29G X 12.7MM , (Sure Comfort Pen Tier 2 31G X 8 MM Needles) ULTILET PEN NEEDLE 31G X 5 MM (Easy Comfort Pen Tier 2 Needles) ULTILET PEN NEEDLE 32G X 4 MM (QC Unifine Pentips) Tier 2 ultra comfort insulin syringe 30g x 5/16" (Advocate Insulin Syringe) Tier 2 0.3 ml ULTRA FLO INSULIN PEN NEEDLES (1st Tier Unifine Pentips Tier 2 29G X 12MM Plus) ULTRA FLO INSULIN SYRINGE 29G X (TopCare Ultra Comfort Ins Tier 2 1/2" 0.3 ML Syr)

MedPerform Medium Formulary 01/01/2021

252 Drug Status Notes ULTRA THIN PEN NEEDLES 32G X 4 (QC Unifine Pentips) Tier 2 MM ultracare insulin syringe 30g x 1/2" 0.5 (BD Insulin Syringe U/F) Tier 2 ml, 30g x 1/2" 1 ml ultracare insulin syringe 30g x 5/16" 0.3 (Advocate Insulin Syringe) Tier 2 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml ultracare pen needles 31g x 5 mm , 31g (AboutTime Pen Needle) Tier 2 x 8 mm , 32g x 4 mm ultracare pen needles 31g x 6 mm , 32g (CareFine Pen Needles) Tier 2 x 5 mm ultracare pen needles 32g x 6 mm (BD Pen Needle Micro Tier 2 U/F) ultracare pen needles 33g x 4 mm (Advocate Insulin Pen Tier 2 Needles) ultra-comfort insulin syringe 28g x 1/2" (BD Insulin Syringe Tier 2 0.5 ml, 28g x 1/2" 1 ml MicroFine) ultra-comfort insulin syringe 29g x 1/2" (Advocate Insulin Syringe) Tier 2 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml ULTRA-THIN II INS SYR SHORT 30G X (GNP Ultra Com Insulin Tier 2 5/16" 0.3 ML Syringe) ULTRA-THIN II INS SYR SHORT 30G X (Insulin Syringe) Tier 2 5/16" 0.5 ML ULTRA-THIN II INS SYR SHORT 30G X (Preferred Plus Insulin Tier 2 5/16" 1 ML Syringe) ULTRA-THIN II INS SYR SHORT 31G X (MM Insulin Tier 2 5/16" 0.3 ML Syringe/Needle) ULTRA-THIN II INS SYR SHORT 31G X (Insulin Syringe-Needle U- Tier 2 5/16" 0.5 ML 100) ULTRA-THIN II INS SYR SHORT 31G X (Sure Comfort Insulin Tier 2 5/16" 1 ML Syringe)

MedPerform Medium Formulary 01/01/2021

253 Drug Status Notes ULTRA-THIN II INSULIN SYRINGE 29G (Insulin Syringe) Tier 2 X 1/2" 0.5 ML, 29G X 1/2" 1 ML ULTRA-THIN II MINI PEN NEEDLE 31G (Easy Comfort Pen Tier 2 X 5 MM Needles) ULTRA-THIN II PEN NEEDLE SHORT (Sure Comfort Pen Tier 2 31G X 8 MM Needles) ULTRA-THIN II PEN NEEDLES 29G X (Sure Comfort Pen Tier 2 12.7MM Needles) UNIFINE PENTIPS 29G X 12MM , 33G (1st Tier Unifine Pentips Tier 2 X 4 MM Plus) UNIFINE PENTIPS 30G X 5 MM (Pen Needles) Tier 2 UNIFINE PENTIPS 31G X 5 MM (Easy Comfort Pen Tier 2 Needles) UNIFINE PENTIPS 31G X 6 MM (CareOne Unifine Pentips Tier 2 Plus) UNIFINE PENTIPS 31G X 8 MM (Sure Comfort Pen Tier 2 Needles) UNIFINE PENTIPS 32G X 4 MM (QC Unifine Pentips) Tier 2 UNIFINE PENTIPS 32G X 6 MM (GNP UltiCare Pen Tier 2 Needles) UNIFINE PENTIPS PLUS 29G X 12MM , (1st Tier Unifine Pentips Tier 2 33G X 4 MM Plus) UNIFINE PENTIPS PLUS 30G X 5 MM (Pen Needles) Tier 2 UNIFINE PENTIPS PLUS 31G X 5 MM (Easy Comfort Pen Tier 2 Needles) UNIFINE PENTIPS PLUS 31G X 6 MM (CareOne Unifine Pentips Tier 2 Plus) UNIFINE PENTIPS PLUS 31G X 8 MM (Sure Comfort Pen Tier 2 Needles) UNIFINE PENTIPS PLUS 32G X 4 MM (QC Unifine Pentips) Tier 2 UNIFINE SAFECONTROL PEN (Pen Needles) Tier 2 NEEDLE 30G X 5 MM UNIFINE SAFECONTROL PEN (Sure Comfort Pen Tier 2 NEEDLE 30G X 8 MM Needles) value health insulin syringe 29g x 1/2" (Advocate Insulin Syringe) Tier 2 0.5 ml, 29g x 1/2" 1 ml

MedPerform Medium Formulary 01/01/2021

254 Drug Status Notes valumark pen needles 29g x 12mm , 31g (CareFine Pen Needles) Tier 2 x 6 mm valumark pen needles 31g x 8 mm (AboutTime Pen Needle) Tier 2 VANISHPOINT INSULIN SYRINGE 29G (Insulin Syringe) Tier 2 X 1/2" 1 ML, 30G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML VANISHPOINT INSULIN SYRINGE 29G Tier 2 X 5/16" 1 ML, 30G X 3/16" 0.5 ML, 30G X 3/16" 1 ML VANISHPOINT INSULIN SYRINGE 30G (Preferred Plus Insulin Tier 2 X 5/16" 1 ML Syringe) VIDA MIA UNIFINE PENTIPS 29G X (1st Tier Unifine Pentips Tier 2 12MM Plus) VIDA MIA UNIFINE PENTIPS 31G X 6 (CareOne Unifine Pentips Tier 2 MM Plus) VIDA MIA UNIFINE PENTIPS 31G X 8 (Sure Comfort Pen Tier 2 MM Needles) VIDA MIA UNIFINE PENTIPS 32G X 4 (QC Unifine Pentips) Tier 2 MM vp insulin syringe 29g x 1/2" 0.3 ml (Advocate Insulin Syringe) Tier 2 wegmans unifine pentips plus 31g x 5 (AboutTime Pen Needle) Tier 2 mm , 31g x 8 mm , 32g x 4 mm wegmans unifine pentips plus 31g x 6 (CareFine Pen Needles) Tier 2 mm Migraine Products Migraine Combinations ergotamine-caffeine oral tablet 1-100 mg (Cafergot) Tier 1 QL (10 EA per 7 days) MIGERGOT RECTAL SUPPOSITORY Tier 2 QL (5 EA per 7 days) 2-100 MG MIGRAINE PACK COMBINATION Tier 3 THERAPY PACK 50 MG Migraine Products dihydroergotamine mesylate injection (D.H.E. 45) Tier 1 QL (15 ML per 14 days) solution 1 mg/ml

MedPerform Medium Formulary 01/01/2021

255 Drug Status Notes dihydroergotamine mesylate nasal (Migranal) Tier 1 ST: Requires prior solution 4 mg/ml prescription for Rizatriptan Benzoate or Sumatriptan Succinate within the past 180 days; QL (8 ML per 28 days) ERGOMAR SUBLINGUAL TABLET Tier 3 QL (10 EA per 7 days) SUBLINGUAL 2 MG Migraine Products - Monoclonal Antibodies AIMOVIG SUBCUTANEOUS Tier 2 PA SOLUTION AUTO-INJECTOR 140 MG/ML, 70 MG/ML EMGALITY (300 MG DOSE) Tier 2 PA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML EMGALITY SUBCUTANEOUS Tier 2 PA SOLUTION AUTO-INJECTOR 120 MG/ML EMGALITY SUBCUTANEOUS Tier 2 PA SOLUTION PREFILLED SYRINGE 120 MG/ML NURTEC ORAL TABLET DISPERSIBLE Tier 2 PA 75 MG UBRELVY ORAL TABLET 100 MG, 50 Tier 2 PA MG Serotonin Agonists almotriptan malate oral tablet 12.5 mg, Tier 1 ST: Requires prior 6.25 mg prescription for Rizatriptan Benzoate or Sumatriptan Succinate within the past 180 days; QL (12 EA per 30 days)

MedPerform Medium Formulary 01/01/2021

256 Drug Status Notes eletriptan hydrobromide oral tablet 20 (Relpax) Tier 1 ST: Requires prior mg, 40 mg prescription for Rizatriptan Benzoate or Sumatriptan Succinate within the past 180 days; QL (12 EA per 30 days) frovatriptan succinate oral tablet 2.5 mg (Frova) Tier 1 ST: Requires prior prescription for Rizatriptan Benzoate or Sumatriptan Succinate within the past 180 days; QL (18 EA per 30 days) naratriptan hcl oral tablet 1 mg, 2.5 mg (Amerge) Tier 1 QL (18 EA per 30 days) REYVOW ORAL TABLET 100 MG, 50 Tier 2 PA MG rizatriptan benzoate oral tablet 10 mg (Maxalt) Tier 1 QL (18 EA per 30 days) rizatriptan benzoate oral tablet 5 mg Tier 1 QL (18 EA per 30 days) rizatriptan benzoate oral tablet (Maxalt-MLT) Tier 1 QL (18 EA per 30 days) dispersible 10 mg rizatriptan benzoate oral tablet Tier 1 QL (18 EA per 30 days) dispersible 5 mg sumatriptan nasal solution 20 mg/act, 5 (Imitrex) Tier 1 QL (6 EA per 15 days) mg/act sumatriptan succinate oral tablet 100 mg (Imitrex) Tier 1 QL (9 EA per 30 days) sumatriptan succinate oral tablet 25 mg, (Imitrex) Tier 1 QL (3 EA per 5 days) 50 mg sumatriptan succinate refill (Imitrex STATdose Refill) Tier 1 QL (4 ML per 28 days) subcutaneous solution cartridge 4 mg/0.5ml, 6 mg/0.5ml sumatriptan succinate subcutaneous (Imitrex) Tier 1 QL (5 ML per 28 days) solution 6 mg/0.5ml sumatriptan succinate subcutaneous (Imitrex STATdose Tier 1 QL (4 ML per 28 days) solution auto-injector 4 mg/0.5ml, 6 System) mg/0.5ml sumatriptan succinate subcutaneous Tier 1 QL (4 ML per 28 days) solution prefilled syringe 6 mg/0.5ml

MedPerform Medium Formulary 01/01/2021

257 Drug Status Notes zolmitriptan oral tablet 2.5 mg, 5 mg (Zomig) Tier 1 ST: Requires prior prescription for Rizatriptan Benzoate or Sumatriptan Succinate within the past 180 days; QL (12 EA per 30 days) zolmitriptan oral tablet dispersible 2.5 (Zomig ZMT) Tier 1 ST: Requires prior mg, 5 mg prescription for Rizatriptan Benzoate or Sumatriptan Succinate within the past 180 days; QL (12 EA per 30 days) ZOMIG NASAL SOLUTION 2.5 MG Tier 2 ST: Requires prior prescription for Rizatriptan Benzoate or Sumatriptan Succinate within the past 180 days; QL (12 EA per 30 days) ZOMIG NASAL SOLUTION 5 MG Tier 2 ST: Requires prior prescription for Rizatriptan Benzoate or Sumatriptan Succinate within the past 180 days; QL (6 EA per 15 days) Minerals & Electrolytes Calcium CALCIFOL ORAL WAFER 1342-1.6 MG Tier 3 calcium-folic acid plus d oral wafer 1342- Tier 3 1 mg Fluoride FLORIVA ORAL LIQUID 0.25-400 MG- Tier 3 UNIT/ML FLUORABON ORAL SOLUTION 0.55 Tier 3 (0.25 F) MG/0.6ML fluoritab oral solution 0.275 (0.125 f) (NaFrinse Drops) Tier 1 mg/drop

MedPerform Medium Formulary 01/01/2021

258 Drug Status Notes fluoritab oral tablet chewable 0.55 (0.25 $0 AGE (Max 6 Years) f) mg, 1.1 (0.5 f) mg fluoritab oral tablet chewable 2.2 (1 f) mg (NaFrinse) $0 AGE (Max 6 Years) FLURA-DROPS ORAL SOLUTION 0.55 Tier 3 (0.25 F) MG/DROP NAFRINSE DROPS ORAL SOLUTION (Fluoritab) Tier 1 0.275 (0.125 F) MG/DROP NAFRINSE ORAL TABLET CHEWABLE (Fluoritab) $0 AGE (Max 6 Years) 2.2 (1 F) MG sodium fluoride oral solution 1.1 (0.5 f) $0 AGE (Max 6 Years) mg/ml sodium fluoride oral tablet chewable 0.55 $0 AGE (Max 6 Years) (0.25 f) mg, 1.1 (0.5 f) mg sodium fluoride oral tablet chewable 2.2 (NaFrinse) $0 AGE (Max 6 Years) (1 f) mg Iodine Products iodine strong oral solution 5 % Tier 1 Magnesium MAGNEBIND 400 ORAL TABLET 400- Tier 3 200-1 MG Phosphate K-PHOS ORAL TABLET 500 MG Tier 3 PHOSPHA 250 NEUTRAL ORAL (Virt-Phos 250 Neutral) Tier 1 TABLET 155-852-130 MG phosphorous oral tablet 155-852-130 mg (Phospha 250 Neutral) Tier 1 PHOSPHO-TRIN 250 NEUTRAL ORAL (Virt-Phos 250 Neutral) Tier 1 TABLET 155-852-130 MG virt-phos 250 neutral oral tablet 155-852- (Phospha 250 Neutral) Tier 1 130 mg Potassium EFFER-K ORAL TABLET Tier 3 EFFERVESCENT 10 MEQ, 20 MEQ EFFER-K ORAL TABLET Tier 1 EFFERVESCENT 25 MEQ KLOR-CON 10 ORAL TABLET (Potassium Chloride ER) Tier 1 EXTENDED RELEASE 10 MEQ

MedPerform Medium Formulary 01/01/2021

259 Drug Status Notes KLOR-CON M10 ORAL TABLET (Potassium Chloride Crys Tier 1 EXTENDED RELEASE 10 MEQ ER) KLOR-CON M15 ORAL TABLET Tier 2 EXTENDED RELEASE 15 MEQ KLOR-CON M20 ORAL TABLET (Potassium Chloride Crys Tier 1 EXTENDED RELEASE 20 MEQ ER) KLOR-CON ORAL PACKET 20 MEQ (Potassium Chloride) Tier 1 KLOR-CON ORAL TABLET EXTENDED (Potassium Chloride ER) Tier 1 RELEASE 8 MEQ KLOR-CON SPRINKLE ORAL (Potassium Chloride ER) Tier 1 CAPSULE EXTENDED RELEASE 10 MEQ, 8 MEQ KLOR-CON/EF ORAL TABLET Tier 1 EFFERVESCENT 25 MEQ K-PRIME ORAL TABLET Tier 1 EFFERVESCENT 25 MEQ K-TAB ORAL TABLET EXTENDED (Potassium Chloride ER) Tier 3 RELEASE 8 MEQ potassium chloride crys er oral tablet (Klor-Con M10) Tier 1 extended release 10 meq potassium chloride crys er oral tablet (Klor-Con M20) Tier 1 extended release 20 meq potassium chloride er oral capsule (Klor-Con Sprinkle) Tier 1 extended release 10 meq, 8 meq potassium chloride er oral tablet (Klor-Con 10) Tier 1 extended release 10 meq potassium chloride er oral tablet (K-Tab) Tier 1 extended release 20 meq potassium chloride er oral tablet (Klor-Con) Tier 1 extended release 8 meq potassium chloride oral packet 20 meq (Klor-Con) Tier 1 potassium chloride oral solution 20 Tier 1 meq/15ml (10%), 40 meq/15ml (20%) Sodium MONOJECT FLUSH SYRINGE (Sodium Chloride Flush) Tier 1 INTRAVENOUS SOLUTION 0.9 %

MedPerform Medium Formulary 01/01/2021

260 Drug Status Notes MONOJECT SODIUM CHLORIDE (Sodium Chloride Flush) Tier 1 FLUSH INTRAVENOUS SOLUTION 0.9 % normal saline flush intravenous solution (Monoject Flush Syringe) Tier 1 0.9 % saline flush intravenous solution 0.9 % (Monoject Flush Syringe) Tier 1 SALINE FLUSH ZR INTRAVENOUS (Sodium Chloride Flush) Tier 1 SOLUTION 0.9 % sodium chloride (pf) injection solution 0.9 Tier 1 % sodium chloride flush intravenous (Monoject Flush Syringe) Tier 1 solution 0.9 % sodium chloride intravenous solution Tier 1 0.45 %, 0.9 % SWABFLUSH SALINE FLUSH (Sodium Chloride Flush) Tier 1 INTRAVENOUS SOLUTION 0.9 % Zinc GALZIN ORAL CAPSULE 25 MG, 50 Tier 3 MG Miscellaneous Therapeutic Classes Chelating Agents CLOVIQUE ORAL CAPSULE 250 MG (Trientine HCl) Tier 1 PA; SP penicillamine oral capsule 250 mg (Cuprimine) Tier 1 PA; SP penicillamine oral tablet 250 mg (Depen Titratabs) Tier 1 PA; SP trientine hcl oral capsule 250 mg (Clovique) Tier 1 PA; SP Digital Therapy ENDEAVORRX (SilverCloud Self Guided) Tier 3 RESET FOR IOS OR ANDROID APP (SilverCloud Self Guided) Tier 3 RESET-O FOR IOS OR ANDROID APP (SilverCloud Self Guided) Tier 3 SOMRYST (SilverCloud Self Guided) Tier 3 Homeopathic Products ACUNOL ORAL TABLET (BHI Cold Symptom Relief) Tier 3 bhi uri-control oral tablet (Acunol) Tier 3 COLCIGEL EXTERNAL GEL (Calendula) Tier 3 ECZEMOL ORAL TABLET (BHI Cold Symptom Relief) Tier 3

MedPerform Medium Formulary 01/01/2021

261 Drug Status Notes HYLAFEM VAGINAL SUPPOSITORY Tier 3 morcin external cream (Arnicare Arnica) Tier 3 PSORIZIDE FORTE ORAL TABLET 30- (BHI Cold Symptom Relief) Tier 3 1-15 MG PSORIZIDE ULTRA ORAL TABLET (BHI Cold Symptom Relief) Tier 3 rapid gel rx external gel (ColciGel) Tier 3 SPEEDGEL RX EXTERNAL GEL (Calendula) Tier 3 TRANZGEL EXTERNAL GEL (Calendula) Tier 3 TRAUMEEL EXTERNAL OINTMENT (Calendula) Tier 3 TRAUMEEL ORAL TABLET (BHI Cold Symptom Relief) Tier 3 WELLMIND VERTIGO ORAL TABLET (BHI Cold Symptom Relief) Tier 3 Immunomodulators REVLIMID ORAL CAPSULE 10 MG, 15 Tier 2 PA; SP MG, 2.5 MG, 20 MG, 25 MG, 5 MG THALOMID ORAL CAPSULE 100 MG, Tier 2 PA; SP; QL (2 EA per 1 150 MG, 200 MG, 50 MG day) Immunosuppressive Agents ASTAGRAF XL ORAL CAPSULE Tier 2 SP EXTENDED RELEASE 24 HOUR 0.5 MG, 1 MG, 5 MG AZASAN ORAL TABLET 100 MG, 75 Tier 2 SP MG azathioprine oral tablet 50 mg (Imuran) Tier 1 SP cyclosporine modified oral capsule 100 (Gengraf) Tier 1 SP mg, 25 mg cyclosporine modified oral capsule 50 Tier 1 SP mg cyclosporine modified oral solution 100 (Gengraf) Tier 1 SP mg/ml cyclosporine oral capsule 100 mg, 25 mg (SandIMMUNE) Tier 1 SP ENSPRYNG SUBCUTANEOUS Tier 3 PA; SP SOLUTION PREFILLED SYRINGE 120 MG/ML

MedPerform Medium Formulary 01/01/2021

262 Drug Status Notes ENVARSUS XR ORAL TABLET Tier 2 SP EXTENDED RELEASE 24 HOUR 0.75 MG, 1 MG, 4 MG everolimus oral tablet 0.25 mg, 0.5 mg, (Zortress) Tier 1 SP 0.75 mg GENGRAF ORAL CAPSULE 100 MG, (CycloSPORINE Modified) Tier 1 SP 25 MG GENGRAF ORAL SOLUTION 100 (CycloSPORINE Modified) Tier 1 SP MG/ML mycophenolate mofetil oral capsule 250 (CellCept) Tier 1 SP mg mycophenolate mofetil oral suspension (CellCept) Tier 1 SP reconstituted 200 mg/ml mycophenolate mofetil oral tablet 500 (CellCept) Tier 1 SP mg mycophenolate sodium oral tablet (Myfortic) Tier 1 SP delayed release 180 mg, 360 mg NEORAL ORAL CAPSULE 100 MG, 25 (CycloSPORINE Modified) Tier 3 SP MG NEORAL ORAL SOLUTION 100 MG/ML (CycloSPORINE Modified) Tier 3 SP PROGRAF ORAL CAPSULE 0.5 MG, 1 (Tacrolimus) Tier 3 SP MG, 5 MG PROGRAF ORAL PACKET 0.2 MG, 1 Tier 2 SP MG RAPAMUNE ORAL SOLUTION 1 (Sirolimus) Tier 3 SP MG/ML RAPAMUNE ORAL TABLET 0.5 MG, 1 (Sirolimus) Tier 3 SP MG, 2 MG SANDIMMUNE ORAL CAPSULE 100 (CycloSPORINE) Tier 3 SP MG, 25 MG SANDIMMUNE ORAL SOLUTION 100 Tier 2 SP MG/ML sirolimus oral solution 1 mg/ml (Rapamune) Tier 1 SP sirolimus oral tablet 0.5 mg, 1 mg, 2 mg (Rapamune) Tier 1 SP tacrolimus oral capsule 0.5 mg, 1 mg, 5 (Prograf) Tier 1 SP mg

MedPerform Medium Formulary 01/01/2021

263 Drug Status Notes ZORTRESS ORAL TABLET 1 MG Tier 2 SP Irrigation Solutions ARGYLE STERILE WATER (Sterile Water for Irrigation) Tier 1 IRRIGATION SOLUTION lactated ringers irrigation solution Tier 1 PHYSIOLYTE IRRIGATION SOLUTION Tier 1 PHYSIOSOL IRRIGATION IRRIGATION Tier 1 SOLUTION ringers irrigation irrigation solution (Tis-U-Sol) Tier 1 sterile water for irrigation irrigation (Argyle Sterile Water) Tier 1 solution TIS-U-SOL IRRIGATION SOLUTION (Ringers Irrigation) Tier 1 water for irrigation, sterile irrigation (Argyle Sterile Water) Tier 1 solution Misc Natural Products azalgia oral capsule (7-Keto Lean) Tier 3 xyzmune oral capsule (7-Keto Lean) Tier 3 Miscellaneous Therapeutic Classes NEXAVIR INJECTION SOLUTION 25.5 Tier 3 MG/ML Potassium Removing Agents KIONEX ORAL SUSPENSION 15 (Sodium Polystyrene Tier 1 GM/60ML Sulfonate) LOKELMA ORAL PACKET 10 GM, 5 Tier 2 GM sodium polystyrene sulfonate oral Tier 1 powder sodium polystyrene sulfonate oral (Kionex) Tier 1 suspension 15 gm/60ml sodium polystyrene sulfonate rectal Tier 1 suspension 30 gm/120ml, 50 gm/200ml SPS ORAL SUSPENSION 15 GM/60ML (Sodium Polystyrene Tier 1 Sulfonate) VELTASSA ORAL PACKET 16.8 GM, Tier 3 PA 25.2 GM, 8.4 GM

MedPerform Medium Formulary 01/01/2021

264 Drug Status Notes Sclerosing Agents polidocanol intravenous solution 5 % Tier 3 Systemic Lupus Erythematosus Agents BENLYSTA SUBCUTANEOUS Tier 3 PA; SP SOLUTION AUTO-INJECTOR 200 MG/ML BENLYSTA SUBCUTANEOUS Tier 3 PA; SP SOLUTION PREFILLED SYRINGE 200 MG/ML Mouth/Throat/Dental Agents Anesthetics Topical Oral FIRST-MOUTHWASH BLM Tier 3 MOUTH/THROAT SUSPENSION lidocaine hcl mouth/throat solution 4 % Tier 1 lidocaine viscous hcl mouth/throat Tier 1 solution 2 % TOPEX TOPICAL ANESTHETIC Tier 1 MOUTH/THROAT AEROSOL 20 % Anti-Infectives - Throat clotrimazole mouth/throat troche 10 mg Tier 1 nystatin mouth/throat suspension Tier 1 100000 unit/ml ORAVIG BUCCAL TABLET 50 MG Tier 3 Antiseptics - Mouth/Throat chlorhexidine gluconate mouth/throat (Paroex) Tier 1 solution 0.12 % DEBACTEROL MOUTH/THROAT Tier 3 SOLUTION 30-50 % PAROEX MOUTH/THROAT SOLUTION (Chlorhexidine Gluconate) Tier 1 0.12 % PERIOGARD MOUTH/THROAT (Chlorhexidine Gluconate) Tier 1 SOLUTION 0.12 % Dental Products CAVAREST DENTAL GEL 1.1 % (SF) Tier 1 CLINPRO 5000 DENTAL PASTE 1.1 % (Sodium Fluoride 5000 Tier 1 PPM)

MedPerform Medium Formulary 01/01/2021

265 Drug Status Notes DENTA 5000 PLUS DENTAL CREAM (Sodium Fluoride 5000 Tier 1 1.1 % PPM) DENTAGEL DENTAL GEL 1.1 % (SF) Tier 1 EASYGEL DENTAL GEL 0.4 % Tier 1 FLUORIDEX DAILY RENEWAL Tier 1 MOUTH/THROAT CONCENTRATE 0.63 % FLUORIDEX DENTAL PASTE 1.1 % (Sodium Fluoride 5000 Tier 1 PPM) FLUORIDEX ENHANCED WHITENING (Sodium Fluoride 5000 Tier 1 DENTAL PASTE 1.1 % PPM) FLUORIDEX SENSITIVITY RELIEF (Sodium Fluoride 5000 Tier 1 DENTAL PASTE 1.1-5 % Sensitive) NAFRINSE DAILY ACIDULATED Tier 3 MOUTH/THROAT SOLUTION RECONSTITUTED 1 MG/5ML NAFRINSE DAILY/NEUTRAL Tier 3 MOUTH/THROAT SOLUTION RECONSTITUTED 0.05 % NAFRINSE WEEKLY MOUTH/THROAT Tier 3 SOLUTION RECONSTITUTED 0.2 % PREVIDENT MOUTH/THROAT Tier 3 SOLUTION 0.2 % sf 5000 plus dental cream 1.1 % (Denta 5000 Plus) Tier 1 sf dental gel 1.1 % (Cavarest) Tier 1 sodium fluoride 5000 plus dental cream (Denta 5000 Plus) Tier 1 1.1 % sodium fluoride 5000 ppm dental cream (Denta 5000 Plus) Tier 1 1.1 % sodium fluoride 5000 ppm dental paste (Clinpro 5000) Tier 1 1.1 % sodium fluoride 5000 sensitive dental (Fluoridex Sensitivity Tier 1 paste 1.1-5 % Relief) sodium fluoride dental cream 1.1 % (Denta 5000 Plus) Tier 1 sodium fluoride dental gel 1.1 % (Cavarest) Tier 1

MedPerform Medium Formulary 01/01/2021

266 Drug Status Notes Steroids - Mouth/Throat/Dental ORALONE MOUTH/THROAT PASTE (Triamcinolone Acetonide) Tier 1 0.1 % triamcinolone acetonide mouth/throat (Oralone) Tier 1 paste 0.1 % Throat Products - Misc. cevimeline hcl oral capsule 30 mg (Evoxac) Tier 1 NUMOISYN MOUTH/THROAT LIQUID (RA Dry Mouth) Tier 3 ORAFATE MOUTH/THROAT PASTE 10 Tier 3 % pilocarpine hcl oral tablet 5 mg, 7.5 mg (Salagen) Tier 1 Multivitamins B-Complex W/ Folic Acid NUTRIVIT ORAL LIQUID Tier 3 RENATABS WITH IRON ORAL 1 & 100 Tier 3 MG Multiple Vitamins & Fluoride-Folic Acid multivitamin/fluoride oral tablet chewable Tier 3 0.25-0.3 mg, 0.5-0.3 mg, 1-0.3 mg Multiple Vitamins W/ Minerals & Fluoride-Iron-Folic Acid QUFLORA FE ORAL TABLET Tier 3 CHEWABLE 0.25 MG Ped Multi Vitamins W/Fl & Fe multi-vit/iron/fluoride oral solution 0.25- Tier 1 10 mg/ml multi-vitamin/fluoride/iron oral solution Tier 1 0.25-10 mg/ml POLY-VI-FLOR/IRON ORAL Tier 3 SUSPENSION 0.25-7 MG/ML POLY-VI-FLOR/IRON ORAL TABLET Tier 3 CHEWABLE 0.5-10 MG QUFLORA FE PEDIATRIC ORAL Tier 3 LIQUID 0.25-9.5 MG/ML Ped Mv W/ Fluoride adc/f (0.5mg/ml) oral solution 0.5 mg/ml Tier 1

MedPerform Medium Formulary 01/01/2021

267 Drug Status Notes FLORIVA PLUS ORAL SOLUTION 0.25 (Multivitamin/Fluoride) Tier 3 MG/ML multivitamin/fluoride oral solution 0.25 (Floriva Plus) Tier 1 mg/ml multi-vitamin/fluoride oral solution 0.25 (Floriva Plus) Tier 1 mg/ml multivitamin/fluoride oral solution 0.5 (Quflora Pediatric) Tier 1 mg/ml multi-vitamin/fluoride oral solution 0.5 (Quflora Pediatric) Tier 1 mg/ml multivitamin/fluoride oral tablet chewable (Quflora Pediatric) Tier 3 0.25 mg, 0.5 mg, 1 mg multivitamins/fluoride oral tablet (Quflora Pediatric) Tier 1 chewable 0.5 mg POLY-VI-FLOR FS ORAL STRIP 0.25 Tier 3 MG, 0.5 MG, 1 MG POLY-VI-FLOR ORAL SUSPENSION Tier 3 0.25 MG/ML POLY-VI-FLOR ORAL TABLET Tier 3 CHEWABLE 0.25 MG, 0.5 MG, 1 MG QUFLORA GUMMIES ORAL TABLET Tier 3 CHEWABLE 0.125 MG QUFLORA PEDIATRIC ORAL (Multivitamin/Fluoride) Tier 3 SOLUTION 0.25 MG/ML QUFLORA PEDIATRIC ORAL (Poly-Vitamin/Fluoride) Tier 3 SOLUTION 0.5 MG/ML QUFLORA PEDIATRIC ORAL TABLET (Multivitamin/Fluoride) Tier 3 CHEWABLE 0.25 MG, 1 MG QUFLORA PEDIATRIC ORAL TABLET (Polyvitamin/Fluoride) Tier 3 CHEWABLE 0.5 MG TRI-VI-FLOR ORAL SUSPENSION 0.25 (Tri-Vi-Floro) Tier 3 MG/ML, 0.5 MG/ML tri-vi-floro oral suspension 0.25 mg/ml, (Tri-Vi-Flor) Tier 3 0.5 mg/ml tri-vite/fluoride oral solution 0.25 mg/ml, Tier 1 0.5 mg/ml

MedPerform Medium Formulary 01/01/2021

268 Drug Status Notes vitamins acd-fluoride oral solution 0.25 Tier 1 mg/ml Pediatric Multiple Vitamins & Minerals W/ Fluoride FLORIVA ORAL TABLET CHEWABLE Tier 3 0.25 MG, 0.5 MG, 1 MG Prenatal Vitamins ATABEX EC ORAL TABLET DELAYED Tier 3 RELEASE 29-1 MG ATABEX OB ORAL TABLET 29-1 MG Tier 3 azeschew prenatal/postnatal oral tablet Tier 3 chewable 13-1 mg CITRANATAL 90 DHA ORAL 90-1 & 300 Tier 3 MG CITRANATAL ASSURE ORAL 35-1 & Tier 3 300 MG CITRANATAL B-CALM ORAL 20-1 MG Tier 3 & 2 X 25 MG CITRANATAL BLOOM DHA ORAL 90-1 Tier 3 & 300 MG CITRANATAL BLOOM ORAL TABLET Tier 3 90-1 MG CITRANATAL DHA ORAL 27-1 & 250 Tier 3 MG CITRANATAL HARMONY ORAL Tier 3 CAPSULE 27-1-260 MG CITRANATAL MEDLEY ORAL Tier 3 CAPSULE 27-1-200 MG CITRANATAL RX ORAL TABLET 27-1 Tier 3 MG c-nate dha oral capsule 28-1-200 mg (Viva DHA) Tier 3 complete natal dha oral 29-1-200 & 250 Tier 3 mg completenate oral tablet chewable 29-1 Tier 3 mg CO-NATAL FA ORAL TABLET (PreTAB) Tier 3

MedPerform Medium Formulary 01/01/2021

269 Drug Status Notes CONCEPT DHA ORAL CAPSULE 53.5- (Virt-C DHA) Tier 3 38-1 MG CONCEPT OB ORAL CAPSULE 130- Tier 3 92.4-1 MG DUET DHA 400 ORAL 25-1 & 400 MG Tier 3 DUET DHA BALANCED ORAL 25-1 & Tier 3 267 MG ELITE-OB ORAL TABLET 50-1.25 MG Tier 3 FOLIVANE-OB ORAL CAPSULE 130- Tier 3 92.4-1 MG INATAL GT ORAL TABLET Tier 3 MARNATAL-F ORAL CAPSULE 60-1 Tier 3 MG m-natal plus oral tablet 27-1 mg (NeoNatal Plus) Tier 3 MYNATAL ORAL CAPSULE Tier 3 mynatal plus oral tablet (Vitafol-OB) Tier 3 mynatal-z oral tablet (Vitafol-OB) Tier 3 NATACHEW ORAL TABLET Tier 3 CHEWABLE 28-1 MG NATALVIT ORAL TABLET Tier 3 neonatal + dha oral 29-1 & 200 mg Tier 3 neonatal complete oral tablet 27-1 mg (NeoNatal Plus) Tier 3 neonatal complete oral tablet 29-1 mg (Co-Natal FA) Tier 3 neonatal fe oral tablet 90-1 mg Tier 3 NEONATAL PLUS ORAL TABLET 27-1 (Prenatal Plus) Tier 3 MG NESTABS DHA ORAL 32-1 MG (Tri-Tabs DHA) Tier 3 NESTABS ORAL TABLET 32-1 MG Tier 3 NIVA-PLUS ORAL TABLET 27-1 MG (Prenatal Plus) Tier 3 OB COMPLETE ORAL TABLET 50-1.25 Tier 3 MG OB COMPLETE PREMIER ORAL Tier 3 TABLET 30-20-1 MG OB COMPLETE/DHA ORAL CAPSULE Tier 3 30-10-1-200 MG

MedPerform Medium Formulary 01/01/2021

270 Drug Status Notes OBSTETRIX DHA ORAL 29-1 & 387 MG Tier 3 OBSTETRIX EC ORAL TABLET 29-1 Tier 3 MG OBSTETRIX ONE ORAL CAPSULE 38- Tier 3 1-225 MG O-CAL PRENATAL ORAL TABLET Tier 3 one vite womens plus oral tablet 27-1 (NeoNatal Plus) Tier 3 mg pnv tabs 29-1 oral tablet 29-1 mg (Prenatabs Rx) Tier 3 pnv-dha oral capsule 27-0.6-0.4-300 mg (Zatean-Pn DHA) Tier 3 pnv-dha+docusate oral capsule 27-1.25- Tier 3 300 mg pnv-omega oral capsule 28-0.6-0.4-340 (Zatean-Pn Plus) Tier 3 mg pnv-select oral tablet 27-0.6-0.4 mg Tier 3 prena 1 true oral 30-1.4 & 300 mg (VitaTrue) Tier 3 prena1 pearl oral capsule extended (VitaPearl) Tier 3 release 30-1.4-200 mg prenaissance oral capsule 29-1.25-325 Tier 3 mg prenaissance plus oral capsule 28-1-250 Tier 3 mg prenara oral capsule 15-1 mg Tier 3 PRENATABS RX ORAL TABLET 29-1 (Vol-Tab Rx) Tier 3 MG prenatal 19 oral tablet 29-1 mg Tier 3 prenatal 19 oral tablet chewable , 29-1 Tier 3 mg prenatal oral tablet 27-1 mg (NeoNatal Plus) Tier 3 prenatal plus iron oral tablet 29-1 mg (Prenatabs Rx) Tier 3 prenatal vitamin plus low iron oral tablet (NeoNatal Plus) Tier 3 27-1 mg PRENATAL-U ORAL CAPSULE 106.5-1 Tier 3 MG PRENATRIX ORAL TABLET 27-1 MG (Prenatal Plus) Tier 3

MedPerform Medium Formulary 01/01/2021

271 Drug Status Notes prenatvite complete oral tablet 1 mg Tier 3 prenatvite plus oral tablet 1 mg Tier 3 prenatvite rx oral tablet 0.8 mg Tier 3 preplus oral tablet 27-1 mg (NeoNatal Plus) Tier 3 pretab oral tablet 29-1 mg (Co-Natal FA) Tier 3 PROVIDA OB ORAL CAPSULE 20-20- Tier 3 1.25 MG relnate dha oral capsule 28-1-200 mg (Viva DHA) Tier 3 SELECT-OB ORAL TABLET Tier 3 CHEWABLE 29-0.6-0.4 MG, 29-1 MG SELECT-OB+DHA ORAL 29-1 & 250 Tier 3 MG se-natal 19 oral tablet 29-1 mg Tier 3 se-natal 19 oral tablet chewable 29-1 mg Tier 3 TARON-C DHA ORAL CAPSULE 53.5- (Virt-C DHA) Tier 3 38-1 MG TARON-PREX ORAL CAPSULE 30-1.2- Tier 3 265 MG thrivite rx oral tablet 29-1 mg (Prenatabs Rx) Tier 3 TRICARE ORAL TABLET (Prenatal Plus) Tier 3 TRICARE PRENATAL DHA ONE ORAL Tier 3 CAPSULE 27-1-500 MG trinatal rx 1 oral tablet 60-1 mg (Vinate One) Tier 3 TRINATE ORAL TABLET Tier 3 TRISTART ONE ORAL CAPSULE 35-1- Tier 3 215 MG tri-tabs dha oral 32-1 mg (Nestabs DHA) Tier 3 VINATE II ORAL TABLET 29-1 MG Tier 3 VINATE ONE ORAL TABLET 60-1 MG (Trinatal Rx 1) Tier 3 virt-c dha oral capsule 53.5-38-1 mg (Concept DHA) Tier 3 virt-nate dha oral capsule 28-1-200 mg (Viva DHA) Tier 3 virt-pn dha oral capsule 27-0.6-0.4-300 (Zatean-Pn DHA) Tier 3 mg virt-pn plus oral capsule 28-0.6-0.4-340 (Zatean-Pn Plus) Tier 3 mg

MedPerform Medium Formulary 01/01/2021

272 Drug Status Notes VITAFOL FE+ ORAL CAPSULE 90-0.6- Tier 3 0.4-200 MG VITAFOL GUMMIES ORAL TABLET Tier 3 CHEWABLE 3.33-0.333-34.8 MG VITAFOL ULTRA ORAL CAPSULE 29- Tier 3 0.6-0.4-200 MG VITAFOL-NANO ORAL TABLET 18-0.6- Tier 3 0.4 MG VITAFOL-OB ORAL TABLET (Mynatal Plus) Tier 3 VITAFOL-OB+DHA ORAL 65-1 & 250 Tier 3 MG VITAFOL-ONE ORAL CAPSULE 29-1- Tier 3 200 MG VITAMEDMD ONE RX/QUATREFOLIC Tier 3 ORAL CAPSULE 30-0.6-0.4-200 MG VITAPEARL ORAL CAPSULE (Prena1 Pearl) Tier 3 EXTENDED RELEASE 30-1.4-200 MG VITATHELY WITH GINGER ORAL (Prenatal Plus) Tier 3 TABLET 27-1 MG VITATRUE ORAL 30-1.4 & 300 MG (Prena 1 True) Tier 3 VIVA DHA ORAL CAPSULE 28-1-200 (Relnate DHA) Tier 3 MG vol-plus oral tablet 27-1 mg (NeoNatal Plus) Tier 3 vol-tab rx oral tablet 29-1 mg (Prenatabs Rx) Tier 3 vp-heme ob + dha oral 28-6-1 & 203 mg Tier 3 vp-pnv-dha oral capsule 28-1-215.8 mg Tier 3 westab plus oral tablet 27-1 mg (NeoNatal Plus) Tier 3 ZATEAN-PN DHA ORAL CAPSULE 27- (PNV-DHA) Tier 3 0.6-0.4-300 MG ZATEAN-PN PLUS ORAL CAPSULE (PNV-Omega) Tier 3 28-0.6-0.4-340 MG Musculoskeletal Therapy Agents Central Muscle Relaxants active-cyclobenzaprine transdermal (Cyclophene RapidPaq) Tier 3 cream 5 %

MedPerform Medium Formulary 01/01/2021

273 Drug Status Notes baclofen oral tablet 10 mg, 20 mg, 5 mg Tier 1 carisoprodol oral tablet 250 mg (Soma) Tier 1 QL (4 EA per 1 day) carisoprodol oral tablet 350 mg (Vanadom) Tier 1 QL (4 EA per 1 day) chlorzoxazone oral tablet 500 mg Tier 1 cyclobenzaprine hcl oral tablet 10 mg, 5 Tier 1 mg CYCLOPHENE RAPIDPAQ (Active-Cyclobenzaprine) Tier 3 TRANSDERMAL CREAM 5 % enovarx-cyclobenzaprine hcl Tier 3 transdermal cream 20 mg/gm FIRST-BACLOFEN ORAL Tier 3 SUSPENSION 1 MG/ML, 5 MG/ML metaxalone oral tablet 400 mg Tier 1 metaxalone oral tablet 800 mg (Skelaxin) Tier 1 methocarbamol oral tablet 500 mg Tier 1 methocarbamol oral tablet 750 mg (Robaxin-750) Tier 1 orphenadrine citrate er oral tablet Tier 1 extended release 12 hour 100 mg OZOBAX ORAL SOLUTION 5 MG/5ML Tier 3 PA TABRADOL FUSEPAQ ORAL Tier 3 SUSPENSION 1 MG/ML TABRADOL RAPIDPAQ ORAL Tier 3 SUSPENSION 1 MG/ML tizanidine hcl oral capsule 2 mg, 4 mg, 6 (Zanaflex) Tier 1 mg tizanidine hcl oral tablet 2 mg Tier 1 tizanidine hcl oral tablet 4 mg (Zanaflex) Tier 1 VANADOM ORAL TABLET 350 MG (Carisoprodol) Tier 1 QL (4 EA per 1 day) Direct Muscle Relaxants dantrolene sodium oral capsule 100 mg Tier 1 dantrolene sodium oral capsule 25 mg, (Dantrium) Tier 1 50 mg Muscle Relaxant Combinations carisoprodol-aspirin-codeine oral tablet Tier 1 QL (8 EA per 1 day); AGE 200-325-16 mg (Min 12 Years)

MedPerform Medium Formulary 01/01/2021

274 Drug Status Notes cyclo/gaba 10/300 oral therapy pack 10- Tier 3 300 mg METAXALL CP COMBINATION KIT 800 Tier 3 & 0.025 MG & % orphenadrine-asa-caffeine oral tablet 50- (Orphengesic Forte) Tier 1 QL (4 EA per 1 day) 770-60 mg ORPHENGESIC FORTE ORAL TABLET (Norgesic Forte) Tier 1 QL (4 EA per 1 day) 50-770-60 MG Nasal Agents - Systemic And Topical Nasal Agent Combinations azelastine-fluticasone nasal suspension (Dymista) Tier 1 QL (23 GM per 30 days) 137-50 mcg/act DERMACINRX AZENASE PAK NASAL Tier 3 THERAPY PACK 137 & 50 MCG/ACT Nasal Anesthetics cocaine hcl nasal solution 40 mg/ml (Numbrino) Tier 1 goprelto nasal solution 40 mg/ml (Numbrino) Tier 3 NUMBRINO NASAL SOLUTION 40 (Cocaine HCl) Tier 3 MG/ML Nasal Antiallergy azelastine hcl nasal solution 0.1 %, 0.15 Tier 1 QL (2 ML per 1 day) %, 137 mcg/spray olopatadine hcl nasal solution 0.6 % (Patanase) Tier 1 QL (30.5 GM per 30 days) Nasal Anticholinergics ipratropium bromide nasal solution 0.03 Tier 1 %, 0.06 % Nasal Steroids flunisolide nasal solution 25 mcg/act Tier 1 QL (25 ML per 30 days) (0.025%) fluticasone propionate nasal suspension (ClariSpray) Tier 1 QL (16 GM per 30 days) 50 mcg/act mometasone furoate nasal suspension (Nasonex) Tier 1 QL (17 GM per 30 days) 50 mcg/act QNASL CHILDRENS NASAL AEROSOL Tier 2 QL (6.8 GM per 30 days) SOLUTION 40 MCG/ACT

MedPerform Medium Formulary 01/01/2021

275 Drug Status Notes QNASL NASAL AEROSOL SOLUTION Tier 2 QL (10.6 GM per 30 days) 80 MCG/ACT SINUVA NASAL IMPLANT 1350 MCG Tier 3 PA XHANCE NASAL EXHALER Tier 2 ST: Requires prior SUSPENSION 93 MCG/ACT prescription for Flunisolide, Fluticasone Propionate, or Mometasone Furoate within the past 120 days; QL (32 ML per 30 days) Sympathomimetic Decongestants epinephrine hcl (nasal) nasal solution 0.1 (Adrenalin) Tier 1 % Neurological Disease - Miscellaneous Agents To Treat Multiple Sclerosis KESIMPTA SUBCUTANEOUS Tier 2 PA; SP SOLUTION AUTO-INJECTOR 20 MG/0.4ML Neuromuscular Agents Als Agents riluzole oral tablet 50 mg (Rilutek) Tier 1 TIGLUTIK ORAL SUSPENSION 50 Tier 3 PA; SP MG/10ML Spinal Muscular Atrophy Agents (Sma) EVRYSDI ORAL SOLUTION Tier 3 PA; SP RECONSTITUTED 0.75 MG/ML Nutrients Lipids DOJOLVI ORAL LIQUID 100 % Tier 3 PA; SP NEOKE MCT70 ORAL POWDER 70 Tier 3 GM/100GM Misc. Nutritional Substances CARDIOVID PLUS ORAL CAPSULE Tier 3 CYTOTINE ORAL POWDER (Creatine) Tier 3 Proteins AMINOAMRMS ORAL CAPSULE Tier 1 AMINORELIEFRMS ORAL CAPSULE Tier 1

MedPerform Medium Formulary 01/01/2021

276 Drug Status Notes n-acetyl-l-cysteine oral capsule 600 mg (NF Formulas NAC) Tier 1 NEOKE ALCAR ORAL POWDER Tier 3 Ophthalmic Agents Artificial Tears And Lubricants LACRISERT OPHTHALMIC INSERT 5 Tier 3 MG Beta-Blockers - Ophthalmic betaxolol hcl ophthalmic solution 0.5 % Tier 1 BETIMOL OPHTHALMIC SOLUTION Tier 3 0.25 %, 0.5 % BETOPTIC-S OPHTHALMIC Tier 3 SUSPENSION 0.25 % carteolol hcl ophthalmic solution 1 % Tier 1 COMBIGAN OPHTHALMIC SOLUTION Tier 2 0.2-0.5 % dorzolamide hcl-timolol mal ophthalmic (Cosopt) Tier 1 solution 22.3-6.8 mg/ml dorzolamide hcl-timolol mal pf (Cosopt PF) Tier 1 QL (2 EA per 1 day) ophthalmic solution 2-0.5 % latanoprost-timolol maleate ophthalmic Tier 3 solution 0.005-0.5 % levobunolol hcl ophthalmic solution 0.5 Tier 1 % timolol maleate ophthalmic solution 0.25 (Timoptic) Tier 1 %, 0.5 % timolol maleate ophthalmic solution 0.5 (Istalol) Tier 1 % (daily) timolol maleate pf ophthalmic solution (Timoptic Ocudose) Tier 1 ST: Requires prior 0.5 % prescription for Timolol Maleate within the past 120 days; QL (2 EA per 1 day) timolol-brimon-dorzol-latanopr Tier 3 ophthalmic solution 0.5-0.15-2 -0.005% timolol-brimonidine-dorzolamid Tier 3 ophthalmic solution 0.5-0.15-2 %

MedPerform Medium Formulary 01/01/2021

277 Drug Status Notes timolol-dorzolamid-latanoprost Tier 3 ophthalmic solution 0.5-0.15-0.005 % TIMOPTIC OCUDOSE OPHTHALMIC Tier 3 ST: Requires prior SOLUTION 0.25 % prescription for Timolol Maleate within the past 120 days; QL (2 EA per 1 day) TIMOPTIC-XE OPHTHALMIC GEL (Timolol Maleate) Tier 3 FORMING SOLUTION 0.25 %, 0.5 % Cycloplegic Mydriatics ALTAFRIN OPHTHALMIC SOLUTION (Phenylephrine HCl) Tier 1 10 %, 2.5 % atropine sulfate ophthalmic ointment 1 % Tier 1 atropine sulfate ophthalmic solution 0.01 Tier 3 % CYCLOMYDRIL OPHTHALMIC Tier 3 SOLUTION 0.2-1 % cyclopentolate hcl ophthalmic solution (Cyclogyl) Tier 1 0.5 %, 1 %, 2 % HOMATROPAIRE OPHTHALMIC Tier 3 SOLUTION 5 % ISOPTO ATROPINE OPHTHALMIC (Atropine Sulfate) Tier 3 SOLUTION 1 % phenylephrine hcl ophthalmic solution 10 (Altafrin) Tier 1 %, 2.5 % tropicamide-cyclopentolate-pe Tier 3 ophthalmic solution 1-1-2.5 % tropicamide-phenylephrine ophthalmic Tier 3 solution 1-2.5 % tropic-cyclopent-pe-ketorolac ophthalmic Tier 1 solution 1-1-10-0.5 % tropic-cyclopent-pe-ketorolac ophthalmic Tier 3 solution 1-1-2.5-0.5 % tropic-cyclopent-pe-ketorolac ophthalmic Tier 3 solution prefilled syringe 1-1-10-0.5 %, 1-1-2.5-0.5 %

MedPerform Medium Formulary 01/01/2021

278 Drug Status Notes tropic-cyclop-pe-keto-propar ophthalmic Tier 3 solution prefilled syringe tropic-proparaca-pe-ketorolac Tier 1 ophthalmic solution 1-0.5-2.5-0.5 % Miotics PHOSPHOLINE IODIDE OPHTHALMIC Tier 3 SOLUTION RECONSTITUTED 0.125 % pilocarpine hcl ophthalmic solution 1 %, (Isopto Carpine) Tier 1 2 %, 4 % Ophthalmic Adrenergic Agents ALPHAGAN P OPHTHALMIC Tier 2 SOLUTION 0.1 % apraclonidine hcl ophthalmic solution 0.5 Tier 1 % brimonidine tartrate ophthalmic solution (Alphagan P) Tier 1 0.15 % brimonidine tartrate ophthalmic solution Tier 1 0.2 % brimonidine-dorzolamide ophthalmic Tier 3 solution 0.15-2 % IOPIDINE OPHTHALMIC SOLUTION 1 Tier 3 % SIMBRINZA OPHTHALMIC Tier 2 SUSPENSION 1-0.2 % Ophthalmic Anti-Infectives ak-poly-bac ophthalmic ointment 500- (Polycin) Tier 1 10000 unit/gm AZASITE OPHTHALMIC SOLUTION 1 Tier 3 % BACIGUENT OPHTHALMIC OINTMENT (Bacitracin) Tier 3 500 UNIT/GM bacitracin ophthalmic ointment 500 Tier 1 unit/gm bacitracin-polymyxin b ophthalmic (Polycin) Tier 1 ointment 500-10000 unit/gm

MedPerform Medium Formulary 01/01/2021

279 Drug Status Notes BESIVANCE OPHTHALMIC Tier 2 SUSPENSION 0.6 % BETADINE OPHTHALMIC PREP (Povidone-Iodine) Tier 3 OPHTHALMIC SOLUTION 5 % CILOXAN OPHTHALMIC OINTMENT Tier 2 0.3 % ciprofloxacin hcl ophthalmic solution 0.3 (Ciloxan) Tier 1 % erythromycin ophthalmic ointment 5 Tier 1 mg/gm gatifloxacin ophthalmic solution 0.5 % (Zymaxid) Tier 1 GENTAK OPHTHALMIC OINTMENT 0.3 Tier 3 % gentamicin sulfate ophthalmic solution Tier 1 0.3 % KLARITY-A OPHTHALMIC SOLUTION Tier 3 1 % levofloxacin ophthalmic solution 0.5 % Tier 1 MITOSOL OPHTHALMIC KIT 0.2 MG Tier 3 moxifloxacin hcl (2x day) ophthalmic (Moxeza) Tier 1 solution 0.5 % moxifloxacin hcl ophthalmic solution 0.5 (Vigamox) Tier 1 % NATACYN OPHTHALMIC Tier 3 SUSPENSION 5 % neomycin-bacitracin zn-polymyx (Neo-Polycin) Tier 1 ophthalmic ointment 3.5-400-10000 , 5- 400-10000 neomycin-polymyxin-gramicidin Tier 1 ophthalmic solution 1.75-10000-.025 NEO-POLYCIN OPHTHALMIC (Neomycin-Bacitracin Zn- Tier 1 OINTMENT 3.5-400-10000 Polymyx) ofloxacin ophthalmic solution 0.3 % (Ocuflox) Tier 1 POLYCIN OPHTHALMIC OINTMENT (AK-Poly-Bac) Tier 1 500-10000 UNIT/GM

MedPerform Medium Formulary 01/01/2021

280 Drug Status Notes polymyxin b-trimethoprim ophthalmic (Polytrim) Tier 1 solution 10000-0.1 unit/ml-% povidone-iodine ophthalmic solution 5 % (Betadine Ophthalmic Tier 3 Prep) sulfacetamide sodium ophthalmic Tier 1 ointment 10 % sulfacetamide sodium ophthalmic (Bleph-10) Tier 1 solution 10 % tobramycin ophthalmic solution 0.3 % (Tobrex) Tier 1 TOBREX OPHTHALMIC OINTMENT 0.3 Tier 2 % trifluridine ophthalmic solution 1 % Tier 1 ZIRGAN OPHTHALMIC GEL 0.15 % Tier 2 Ophthalmic Immunomodulators CYCLOSPORINE IN KLARITY Tier 3 OPHTHALMIC EMULSION 0.1 % RESTASIS MULTIDOSE OPHTHALMIC Tier 2 QL (5.5 ML per 30 days) EMULSION 0.05 % RESTASIS OPHTHALMIC EMULSION Tier 2 QL (2 EA per 1 day) 0.05 % Ophthalmic Integrin Antagonists XIIDRA OPHTHALMIC SOLUTION 5 % Tier 2 QL (2 EA per 1 day) Ophthalmic Kinase Inhibitors RHOPRESSA OPHTHALMIC Tier 3 ST: At least 2 prior SOLUTION 0.02 % prescriptions for Bimatoprost, Brimonidine Tartrate, Brimonidine Tartrate-Timolol Maleate, Brinzolamide, Brinzolamide-Brimonidine Tartrate, Latanoprost, or Travoprost within the past 365 days; QL (2.5 ML per 30 days)

MedPerform Medium Formulary 01/01/2021

281 Drug Status Notes ROCKLATAN OPHTHALMIC Tier 3 ST: At least 2 prior SOLUTION 0.02-0.005 % prescriptions for Bimatoprost, Brimonidine Tartrate, Brimonidine Tartrate-Timolol Maleate, Brinzolamide, Brinzolamide-Brimonidine Tartrate, Latanoprost, or Travoprost within the past 365 days; QL (2.5 ML per 25 days) Ophthalmic Local Anesthetics AKTEN OPHTHALMIC GEL 3.5 % Tier 3 ALTACAINE OPHTHALMIC SOLUTION (Tetracaine HCl) Tier 1 0.5 % proparacaine hcl ophthalmic solution 0.5 (Alcaine) Tier 1 % tetracaine hcl ophthalmic solution 0.5 % (Altacaine) Tier 1 Ophthalmic Nerve Growth Factors OXERVATE OPHTHALMIC SOLUTION Tier 3 PA; SP 0.002 % Ophthalmic Photoenhancers PHOTREXA VISCOUS OPHTHALMIC Tier 3 SOLUTION PREFILLED SYRINGE 0.146-20 % PHOTREXA-PHOTREXA VISCOUS KIT Tier 3 OPHTHALMIC SOLUTION PREFILLED SYRINGE 0.146 &0.146-20 % Ophthalmic Steroids ALREX OPHTHALMIC SUSPENSION Tier 2 0.2 % bacitra-neomycin-polymyxin-hc (Neo-Polycin HC) Tier 1 ophthalmic ointment 1 % BLEPHAMIDE OPHTHALMIC (Sulfacetamide- Tier 2 SUSPENSION 10-0.2 % Prednisolone) BLEPHAMIDE S.O.P. OPHTHALMIC Tier 2 OINTMENT 10-0.2 %

MedPerform Medium Formulary 01/01/2021

282 Drug Status Notes dexamethasone sodium phosphate Tier 1 ophthalmic solution 0.1 % DEXTENZA OPHTHALMIC INSERT 0.4 Tier 3 MG double pm ophthalmic solution Tier 3 reconstituted 1-0.5 % DUREZOL OPHTHALMIC EMULSION Tier 2 0.05 % FLAREX OPHTHALMIC SUSPENSION Tier 2 0.1 % fluorometholone ophthalmic suspension (FML Liquifilm) Tier 1 0.1 % FML FORTE OPHTHALMIC Tier 2 SUSPENSION 0.25 % FML OPHTHALMIC OINTMENT 0.1 % Tier 2 INVELTYS OPHTHALMIC Tier 3 QL (5.6 ML per 14 days) SUSPENSION 1 % KLARITY-L OPHTHALMIC EMULSION Tier 3 0.2 %, 0.5 % LOTEMAX OPHTHALMIC GEL 0.5 % Tier 2 LOTEMAX OPHTHALMIC OINTMENT Tier 2 0.5 % LOTEMAX SM OPHTHALMIC GEL 0.38 Tier 2 % loteprednol etabonate ophthalmic (Lotemax) Tier 1 suspension 0.5 % MAXIDEX OPHTHALMIC SUSPENSION Tier 3 0.1 % neomycin-polymyxin-dexameth (Maxitrol) Tier 1 ophthalmic ointment 3.5-10000-0.1 neomycin-polymyxin-dexameth (Maxitrol) Tier 1 ophthalmic suspension 3.5-10000-0.1 neomycin-polymyxin-hc ophthalmic Tier 1 suspension 3.5-10000-1 NEO-POLYCIN HC OPHTHALMIC (Bacitra-Neomycin- Tier 1 OINTMENT 1 % Polymyxin-HC)

MedPerform Medium Formulary 01/01/2021

283 Drug Status Notes PRED FORTE OPHTHALMIC (prednisoLONE Acetate) Tier 3 SUSPENSION 1 % PRED MILD OPHTHALMIC Tier 2 SUSPENSION 0.12 % PRED-G OPHTHALMIC SUSPENSION Tier 3 0.3-1 % PRED-G S.O.P. OPHTHALMIC Tier 3 OINTMENT 0.3-0.6 % prednisol ace-moxiflox-bromfen Tier 3 ophthalmic suspension 1-0.5-0.075 % prednisolone acetate ophthalmic (Pred Forte) Tier 1 suspension 1 % prednisolone acetate p-f ophthalmic (Pred Forte) Tier 3 suspension 1 % prednisolone acetate-nepafenac Tier 3 ophthalmic suspension 1-0.1 % prednisolone acet-moxifloxacin Tier 3 ophthalmic suspension 1-0.5 % prednisolone sodium phosphate Tier 1 ophthalmic solution 1 % prednisolone-bromfenac ophthalmic Tier 1 solution 1-0.075 % prednisolone-bromfenac ophthalmic Tier 1 suspension 1-0.075 % prednisolone-gatifloxacin ophthalmic Tier 3 suspension 1-0.5 % prednisolone-moxifloxacin ophthalmic Tier 3 solution 1-0.5 % prednisolon-gatiflox-bromfenac Tier 3 ophthalmic solution 1-0.5-0.075 % prednisolon-gatiflox-bromfenac Tier 3 ophthalmic suspension 1-0.5-0.075 % prednisolon-moxiflox-bromfenac Tier 3 ophthalmic solution 1-0.5-0.075 % prednisolon-moxiflox-nepafenac Tier 3 ophthalmic suspension 1-0.5-0.1 %

MedPerform Medium Formulary 01/01/2021

284 Drug Status Notes sulfacetamide-prednisolone ophthalmic Tier 1 solution 10-0.23 % TOBRADEX OPHTHALMIC OINTMENT Tier 2 0.3-0.1 % TOBRADEX ST OPHTHALMIC Tier 3 SUSPENSION 0.3-0.05 % tobramycin-dexamethasone ophthalmic (TobraDex) Tier 1 suspension 0.3-0.1 % triple pmb ophthalmic solution Tier 3 reconstituted 1-0.5-0.09 % triple pmk ophthalmic solution Tier 3 reconstituted 1-0.5-0.5 % ZYLET OPHTHALMIC SUSPENSION Tier 2 0.5-0.3 % Ophthalmic Surgical Aids GELFILM OPHTHALMIC FILM Tier 3 MEMBRANEBLUE OPHTHALMIC Tier 3 SOLUTION 0.15 % VISIONBLUE OPHTHALMIC Tier 3 SOLUTION 0.06 % Ophthalmics - Misc. ALOCRIL OPHTHALMIC SOLUTION 2 Tier 2 % ALOMIDE OPHTHALMIC SOLUTION Tier 2 0.1 % azelastine hcl ophthalmic solution 0.05 Tier 1 % AZOPT OPHTHALMIC SUSPENSION 1 Tier 2 % bromfenac sodium (once-daily) Tier 1 ophthalmic solution 0.09 % BROMSITE OPHTHALMIC SOLUTION Tier 3 0.075 % chondroitin sulfate ophthalmic solution Tier 3 0.25 %

MedPerform Medium Formulary 01/01/2021

285 Drug Status Notes cromolyn sodium ophthalmic solution 4 Tier 1 % CYSTADROPS OPHTHALMIC Tier 2 PA; SP SOLUTION 0.37 % CYSTARAN OPHTHALMIC SOLUTION Tier 2 PA; SP 0.44 % diclofenac sodium ophthalmic solution Tier 1 0.1 % dorzolamide hcl ophthalmic solution 2 % (Trusopt) Tier 1 epinastine hcl ophthalmic solution 0.05 Tier 1 % flurbiprofen sodium ophthalmic solution Tier 1 0.03 % ILEVRO OPHTHALMIC SUSPENSION Tier 2 0.3 % ketorolac tromethamine ophthalmic (Acular LS) Tier 1 solution 0.4 % ketorolac tromethamine ophthalmic (Acular) Tier 1 solution 0.5 % NEVANAC OPHTHALMIC Tier 3 SUSPENSION 0.1 % olopatadine hcl ophthalmic solution 0.1 (Pataday) Tier 1 % olopatadine hcl ophthalmic solution 0.2 (Pataday) Tier 1 QL (3 ML per 30 days) % PROLENSA OPHTHALMIC SOLUTION Tier 2 0.07 % UPNEEQ OPHTHALMIC SOLUTION 0.1 Tier 3 % Prostaglandins - Ophthalmic bimatoprost ophthalmic solution 0.03 % Tier 1 QL (2.5 ML per 30 days) latanoprost ophthalmic solution 0.005 % (Xalatan) Tier 1 LUMIGAN OPHTHALMIC SOLUTION Tier 2 QL (2.5 ML per 25 days) 0.01 % travoprost (bak free) ophthalmic solution (Travatan Z) Tier 1 QL (2.5 ML per 25 days) 0.004 %

MedPerform Medium Formulary 01/01/2021

286 Drug Status Notes VYZULTA OPHTHALMIC SOLUTION Tier 3 ST: At least 3 prior 0.024 % prescriptions for Bimatoprost, Latanoprost, or Travoprost within the past 365 days; QL (2.5 ML per 25 days) XELPROS OPHTHALMIC EMULSION Tier 3 ST: At least 3 prior 0.005 % prescriptions for Bimatoprost, Latanoprost, or Travoprost within the past 365 days; QL (2.5 ML per 25 days) ZIOPTAN OPHTHALMIC SOLUTION Tier 3 ST: At least 3 prior 0.0015 % prescriptions for Bimatoprost, Latanoprost, or Travoprost within the past 365 days; QL (1 EA per 1 day) Otic Agents Otic Agents - Miscellaneous acetic acid otic solution 2 % Tier 1 Otic Anti-Infectives CETRAXAL OTIC SOLUTION 0.2 % (Ciprofloxacin HCl) Tier 3 ofloxacin otic solution 0.3 % Tier 1 Otic Combinations CIPRO HC OTIC SUSPENSION 0.2-1 % Tier 3 ciprofloxacin-dexamethasone otic (Ciprodex) Tier 1 suspension 0.3-0.1 % CORTIC-ND OTIC SOLUTION 10-10-1 (Exotic-HC) Tier 1 MG/ML CORTISPORIN-TC OTIC SUSPENSION Tier 3 3.3-3-10-0.5 MG/ML exotic-hc otic solution 10-10-1 mg/ml (Cortic-ND) Tier 1 neomycin-polymyxin-hc otic solution 1 Tier 1 %, 3.5-10000-1

MedPerform Medium Formulary 01/01/2021

287 Drug Status Notes neomycin-polymyxin-hc otic suspension Tier 1 3.5-10000-1 OTOVEL OTIC SOLUTION 0.3-0.025 % (Ciprofloxacin- Tier 3 Fluocinolone PF) PRAMOTIC OTIC LIQUID 1-0.1 % Tier 3 Otic Steroids FLAC OTIC OIL 0.01 % (Fluocinolone Acetonide) Tier 1 fluocinolone acetonide otic oil 0.01 % (Flac) Tier 1 hydrocortisone-acetic acid otic solution (Acetasol HC) Tier 1 1-2 % Oxytocics Abortifacients/Agents For Cervical Ripening CERVIDIL VAGINAL INSERT 10 MG Tier 3 PREPIDIL VAGINAL GEL 0.5 MG/3GM Tier 3 PROSTIN E2 VAGINAL SUPPOSITORY Tier 3 20 MG Oxytocics METHERGINE ORAL TABLET 0.2 MG (Methylergonovine Tier 1 QL (28 EA per 30 days) Maleate) methylergonovine maleate oral tablet 0.2 (Methergine) Tier 1 QL (28 EA per 30 days) mg Passive Immunizing And Treatment Agents Antitoxins-Antivenins ANASCORP INTRAVENOUS Tier 3 SOLUTION RECONSTITUTED Immune Serums CUTAQUIG SUBCUTANEOUS Tier 3 PA; SP SOLUTION 1 GM/6ML, 1.65 GM/10ML, 2 GM/12ML, 3.3 GM/20ML, 4 GM/24ML, 8 GM/48ML CUVITRU SUBCUTANEOUS Tier 3 PA; SP SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML, 8 GM/40ML

MedPerform Medium Formulary 01/01/2021

288 Drug Status Notes GAMMAGARD INJECTION SOLUTION Tier 3 PA; SP 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, 5 GM/50ML GAMMAKED INJECTION SOLUTION 1 Tier 3 PA; SP GM/10ML, 10 GM/100ML, 20 GM/200ML, 5 GM/50ML GAMUNEX-C INJECTION SOLUTION 1 Tier 3 PA; SP GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 40 GM/400ML, 5 GM/50ML HIZENTRA SUBCUTANEOUS Tier 3 PA; SP SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML XEMBIFY SUBCUTANEOUS Tier 3 PA; SP SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML Passive Immunizing Agents - Combinations HYQVIA SUBCUTANEOUS KIT 10 Tier 3 PA; SP GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, 5 GM/50ML Penicillins Aminopenicillins amoxicillin oral capsule 250 mg, 500 mg Tier 1 amoxicillin oral suspension reconstituted Tier 1 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml amoxicillin oral tablet 500 mg, 875 mg Tier 1 amoxicillin oral tablet chewable 125 mg, Tier 1 250 mg ampicillin oral capsule 500 mg Tier 1 Natural Penicillins penicillin v potassium oral solution Tier 1 reconstituted 125 mg/5ml, 250 mg/5ml

MedPerform Medium Formulary 01/01/2021

289 Drug Status Notes penicillin v potassium oral tablet 250 mg, Tier 1 500 mg Penicillin Combinations amoxicillin-pot clavulanate er oral tablet Tier 1 extended release 12 hour 1000-62.5 mg amoxicillin-pot clavulanate oral Tier 1 suspension reconstituted 200-28.5 mg/5ml, 400-57 mg/5ml amoxicillin-pot clavulanate oral (Augmentin) Tier 1 suspension reconstituted 250-62.5 mg/5ml amoxicillin-pot clavulanate oral (Augmentin ES-600) Tier 1 suspension reconstituted 600-42.9 mg/5ml amoxicillin-pot clavulanate oral tablet Tier 1 250-125 mg, 875-125 mg amoxicillin-pot clavulanate oral tablet (Augmentin) Tier 1 500-125 mg amoxicillin-pot clavulanate oral tablet Tier 1 chewable 200-28.5 mg, 400-57 mg Penicillinase-Resistant Penicillins dicloxacillin sodium oral capsule 250 mg, Tier 1 500 mg Pharmaceutical Adjuvants Gelatin Capsules (Empty) capsule ezeefit #0 clear capsule (DRcaps Size 0) Tier 3 capsule ezeefit #00 clear capsule (DRcaps Size 0) Tier 3 DRCAPS SIZE 0 CAPSULE (Empty Capsule Size 0 Tier 3 Orange) DRCAPS SIZE 00 CAPSULE (Empty Capsule Size 0 Tier 3 Orange) DRCAPS SIZE 1 CAPSULE (Empty Capsule Size 0 Tier 3 Orange) Liquid Vehicles ADA EXTERNAL SHAMPOO Tier 3

MedPerform Medium Formulary 01/01/2021

290 Drug Status Notes bacteriostatic water(benz alc) injection Tier 3 solution DERMACINRX TOPICAL BASE (TDM Solution) Tier 3 EXTERNAL SOLUTION FLAVOR BLEND ORAL SUSPENSION (Suspension Vehicle) Tier 3 flavor plus oral liquid (Ora-Plus) Tier 3 flavor sweet oral syrup (Ora-Sweet) Tier 3 flavor sweet-sf oral syrup (Ora-Sweet) Tier 3 FOAMIL EXTERNAL LIQUID Tier 3 LOZIBASE S (Lozibase) Tier 3 mouth wash-gp oral liquid Tier 3 mouthwash-af oral liquid Tier 3 mouthwash-om oral liquid Tier 3 ORA-BLEND ORAL SUSPENSION (Suspension Vehicle) Tier 3 ORA-BLEND SF ORAL SUSPENSION (Suspension Vehicle) Tier 3 ORA-PLUS ORAL LIQUID (Oral Suspend) Tier 3 ORA-SWEET ORAL SYRUP (Flavor Sweet) Tier 3 ORA-SWEET SF ORAL SYRUP (Flavor Sweet) Tier 3 PCCA ACACIA SYRUP BASE ORAL Tier 3 SYRUP PCCA SWEET-SF ORAL SYRUP (Flavor Sweet) Tier 3 PCCA SYRUP VEHICLE ORAL SYRUP (Flavor Sweet) Tier 3 PCCA-PLUS ORAL SUSPENSION (Suspension Vehicle) Tier 3 RHEOSPRAY EXTERNAL LIQUID Tier 3 saline bacteriostatic injection solution 0.9 Tier 1 % SERAQUA EXTERNAL LIQUID Tier 3 sodium chloride bacteriostatic injection Tier 1 solution 0.9 % SOLYDRA EXTERNAL LIQUID Tier 3 SUSPENDRX W/BITTERBLOC SWEET (Suspension Vehicle) Tier 3 ORAL SUSPENSION SUSPENDRX W/BITTERBLOC (Suspension Vehicle) Tier 3 UNSWEET ORAL SUSPENSION SYRPALTA (RED) ORAL SYRUP (Flavor Sweet) Tier 3

MedPerform Medium Formulary 01/01/2021

291 Drug Status Notes syrpalta oral syrup (Ora-Sweet) Tier 3 syrpalta oral syrup 85 % Tier 3 SYRSPEND SF ORAL LIQUID (Oral Suspend) Tier 3 SYRSPEND SF PH4 ORAL Tier 3 SUSPENSION RECONSTITUTED tdm solution external solution (DermacinRx Topical Tier 3 Base) U-MILD EXTERNAL SHAMPOO Tier 3 UNISPEND ANHYDROUS (Suspension Vehicle) Tier 3 SWEETENED ORAL SUSPENSION VERSAFREE ORAL SYRUP (Flavor Sweet) Tier 3 VERSAPLUS ORAL SYRUP (Flavor Sweet) Tier 3 VERSAPRO EXTERNAL SHAMPOO Tier 3 Semi Solid Vehicles 1st base external cream (Alba-Derm) Tier 3 advanced base plus external cream (Alba-Derm) Tier 3 ALBA-DERM EXTERNAL CREAM (Cream Base) Tier 3 ALPAWASH EXTERNAL OINTMENT (Fattibase) Tier 3 ALTADERM EXTERNAL CREAM (Cream Base) Tier 3 ANHYDROUS BASE CREAM (Anhydrous Cream Base) Tier 3 anhydrous cream base cream (Anhydrous Base) Tier 3 ATREVIS HYDROGEL EXTERNAL (Cream Base) Tier 3 CREAM AUXIPRO VANISHING EXTERNAL (Cream Base) Tier 3 CREAM bravura all-in-one external cream (Alba-Derm) Tier 3 CARBOGEL 940 GEL (Carbomer Aqueous) Tier 3 CARBOHOL 940 GEL (Carbomer Aqueous) Tier 3 cela base external cream (Alba-Derm) Tier 3 CHRYSADERM DAY EXTERNAL (Cream Base) Tier 3 CREAM CHRYSADERM NIGHT EXTERNAL (Cream Base) Tier 3 CREAM cutis plus external cream (Alba-Derm) Tier 3

MedPerform Medium Formulary 01/01/2021

292 Drug Status Notes DURABASE ADVANCED EXTERNAL (Cream Base) Tier 3 CREAM DURABASE EXTERNAL CREAM (Cream Base) Tier 3 EMOLIVAN EXTERNAL CREAM (Cream Base) Tier 3 ESPUMIL FOAM (Lipofoam RX) Tier 3 fagron ls plus external cream (Alba-Derm) Tier 3 fagron natural external cream (Alba-Derm) Tier 3 fagron supreme external cream (Alba-Derm) Tier 3 FITALITE EXTERNAL CREAM (Cream Base) Tier 3 freedom adaptaderm external cream (Alba-Derm) Tier 3 freedom derma serum external cream (Alba-Derm) Tier 3 FREEDOM DERMA-D EXTERNAL (Cream Base) Tier 3 CREAM FREEDOM DERMA-N EXTERNAL (Cream Base) Tier 3 CREAM HUMCO BASE PAIN MGMT (Cream Base) Tier 3 EXTERNAL CREAM HYDROGEL GEL (Carbomer Aqueous) Tier 3 LIOPEN ABSORPTION ENHANCING (Cream Base) Tier 3 EXTERNAL CREAM lipo cream base external cream (Alba-Derm) Tier 3 LIPOCREAM BASE EXTERNAL (Cream Base) Tier 3 CREAM lipofoam rx foam (Espumil) Tier 3 lipolayer external cream (Lipozyme) Tier 3 lipopen ultra base external cream (Alba-Derm) Tier 3 liposomal heavy external cream (Alba-Derm) Tier 3 liposomal regular external cream (Alba-Derm) Tier 3 LIPOZYME EXTERNAL CREAM (Lipolayer) Tier 3 MEDIDERM EXTERNAL CREAM (Cream Base) Tier 3 MEDIHOL BASE GEL (Universal Water) Tier 3 MULTIBASE EXTERNAL CREAM (Cream Base) Tier 3 NOURILITE EXTERNAL CREAM (Cream Base) Tier 3 NOURIVAN ANTIOX BASE EXTERNAL (Cream Base) Tier 3 CREAM

MedPerform Medium Formulary 01/01/2021

293 Drug Status Notes OCCLUVAN EXTERNAL OINTMENT (Hydrophilic) Tier 3 OMNIBASE EXTERNAL CREAM (Cream Base) Tier 3 PCCA ALADERM BASE EXTERNAL (Cream Base) Tier 3 CREAM PCCA ANHYDROUS BASE OINTMENT (Anhydrous Base) Tier 3 PCCA ANHYDROUS LIPODERM BASE (Cream Base) Tier 3 EXTERNAL CREAM PCCA BIOPEPTIDE BASE EXTERNAL (Cream Base) Tier 3 CREAM PCCA COBASE #1 EXTERNAL Tier 3 OINTMENT PCCA COSMETIC HRT BASE (Cream Base) Tier 3 EXTERNAL CREAM PCCA CUSTOM LIPO-MAX EXTERNAL (Lipolayer) Tier 3 CREAM PCCA ELLAGE VAGINAL CREAM (Anhydrous Cream Base) Tier 3 PCCA LIPODERM BASE EXTERNAL (Cream Base) Tier 3 CREAM PCCA LIPOSOMIC BASE DRY (Lipolayer) Tier 3 EXTERNAL CREAM PCCA LIPOSOMIC BASE NORMAL (Lipolayer) Tier 3 EXTERNAL CREAM PCCA LIPOSOMIC BASE OILY (Lipolayer) Tier 3 EXTERNAL CREAM PCCA LIPOSOMIC BASE SENSITIVE (Lipolayer) Tier 3 EXTERNAL CREAM PCCA MVC BASE EXTERNAL CREAM (Cream Base) Tier 3 PCCA NATACREAM EXTERNAL (Cream Base) Tier 3 CREAM PCCA POLYPEG BASE EXTERNAL (Fattibase) Tier 3 OINTMENT PCCA PRACASIL TM-PLUS BASE (Cream Base) Tier 3 EXTERNAL CREAM PCCA VANISHING CREAM BASE (Cream Base) Tier 3 EXTERNAL CREAM

MedPerform Medium Formulary 01/01/2021

294 Drug Status Notes PCCA VANISHING CREAM LIGHT (Cream Base) Tier 3 EXTERNAL CREAM PCCA VANPEN BASE EXTERNAL (Cream Base) Tier 3 CREAM PENCREAM EXTERNAL CREAM (Cream Base) Tier 3 penderm external cream (Alba-Derm) Tier 3 pensomal external cream (Alba-Derm) Tier 3 pentaphene base external cream (Alba-Derm) Tier 3 PERFORMAX SALT SUPPORTIVE (Cream Base) Tier 3 BASE EXTERNAL CREAM PHARMABASE COSMETIC EXTERNAL (Cream Base) Tier 3 CREAM PHARMABASE HEAVY EXTERNAL (Cream Base) Tier 3 CREAM PHYTOBASE EXTERNAL CREAM (Cream Base) Tier 3 PLO GEL - MEDIFLO EXTERNAL KIT Tier 3 PLO GEL - MEDIFLO PRE-MIXED (Lecithin Organogel) Tier 3 EXTERNAL GEL plo transdermal external cream (TDC Max) Tier 3 plo20 base external gel (PLO Gel - Mediflo Pre- Tier 3 Mixed) PLO20 FLOWABLE EXTERNAL GEL (Lecithin Organogel) Tier 3 p-siloxan ds external cream (Alba-Derm) Tier 3 sa3 derm external cream (Alba-Derm) Tier 3 salt durable cream external cream (Alba-Derm) Tier 3 SALT STABLE LS ADVANCED (Cream Base) Tier 3 EXTERNAL CREAM SALTSTABLE LO EXTERNAL CREAM (Cream Base) Tier 3 SANARE ADVANCED SCAR THERAPY (Cream Base) Tier 3 EXTERNAL CREAM sanare scar therapy external cream (Alba-Derm) Tier 3 SEDANARE EXTERNAL CREAM (Cream Base) Tier 3 silosome transdermal external cream (TDC Max) Tier 3 silprotex plus external cream (Alba-Derm) Tier 3 skyy derm external cream (Alba-Derm) Tier 3

MedPerform Medium Formulary 01/01/2021

295 Drug Status Notes TDC MAX EXTERNAL CREAM (Transdermal Pain Base) Tier 3 teroderm external cream (Alba-Derm) Tier 3 teroderm-plus external cream (Alba-Derm) Tier 3 tightening base external cream (Alba-Derm) Tier 3 transdermal pain base external cream (TDC Max) Tier 3 universal water gel (Medihol Base) Tier 3 vanishing cream botanical base external (Alba-Derm) Tier 3 cream vanishing external cream (Alba-Derm) Tier 3 vanish-pen external cream (Alba-Derm) Tier 3 VERSAPRO EXTERNAL CREAM (Cream Base) Tier 3 VERSAPRO FOAM (Lipofoam RX) Tier 3 versatile cream base external cream (Alba-Derm) Tier 3 VERSATILE RICH BASE EXTERNAL (Cream Base) Tier 3 CREAM vp dermabase external cream (Alba-Derm) Tier 3 XEMATOP BASE EXTERNAL CREAM (Cream Base) Tier 3 ZOE SCRIPTS IDEALBASE EXTERNAL (Cream Base) Tier 3 CREAM Progestins Progestins ec-rx progesterone transdermal cream Tier 3 10 %, 20 % medroxyprogesterone acetate oral tablet (Provera) Tier 1 10 mg, 2.5 mg, 5 mg megestrol acetate oral suspension 625 Tier 1 ST: Requires prior mg/5ml prescription for Megestrol Acetate 40mg/mL suspension within the past 120 days norethindrone acetate oral tablet 5 mg (Aygestin) Tier 1 progesterone compounding kit Tier 3 transdermal cream 20 % progesterone intramuscular oil 50 mg/ml Tier 1

MedPerform Medium Formulary 01/01/2021

296 Drug Status Notes progesterone micronized oral capsule (Prometrium) Tier 1 100 mg, 200 mg progesterone micronized transdermal Tier 3 cream 10 % Psychotherapeutic And Neurological Agents - Misc. Agents For Chemical Dependency acamprosate calcium oral tablet delayed Tier 1 release 333 mg disulfiram oral tablet 250 mg, 500 mg Tier 1 LUCEMYRA ORAL TABLET 0.18 MG Tier 3 PA Anti-Cataplectic Agents XYREM ORAL SOLUTION 500 MG/ML Tier 3 PA; SP XYWAV ORAL SOLUTION 500 MG/ML Tier 3 PA; SP Antidementia Agents donepezil hcl oral tablet 10 mg, 23 mg, 5 (Aricept) Tier 1 mg donepezil hcl oral tablet dispersible 10 Tier 1 mg, 5 mg galantamine hydrobromide er oral (Razadyne ER) Tier 1 QL (1 EA per 1 day) capsule extended release 24 hour 16 mg, 24 mg, 8 mg galantamine hydrobromide oral solution Tier 1 QL (200 ML per 30 days) 4 mg/ml galantamine hydrobromide oral tablet 12 Tier 1 QL (2 EA per 1 day) mg, 4 mg, 8 mg memantine hcl er oral capsule extended (Namenda XR) Tier 1 QL (1 EA per 1 day) release 24 hour 14 mg, 21 mg, 28 mg, 7 mg memantine hcl oral solution 10 mg/5ml, Tier 1 QL (300 ML per 30 days) 2 mg/ml memantine hcl oral tablet 10 mg, 5 mg (Namenda) Tier 1 QL (2 EA per 1 day) memantine hcl oral tablet 28 x 5 mg & 21 (Namenda Titration Pak) Tier 1 QL (49 EA per 28 days) x 10 mg

MedPerform Medium Formulary 01/01/2021

297 Drug Status Notes NAMENDA XR TITRATION PACK Tier 2 QL (1 EA per 1 day) ORAL CAPSULE EXTENDED RELEASE 24 HOUR 7 & 14 & 21 NAMZARIC ORAL CAPSULE ER 24 Tier 2 ST: Requires prior HOUR THERAPY PACK 7 & 14 & 21 prescriptions for Donepezil &28 -10 MG HCL and Memantine HCL within the past 365 days; QL (1 EA per 1 day) NAMZARIC ORAL CAPSULE Tier 2 ST: Requires prior EXTENDED RELEASE 24 HOUR 14-10 prescriptions for Donepezil MG, 21-10 MG, 28-10 MG, 7-10 MG HCL and Memantine HCL within the past 365 days; QL (1 EA per 1 day) rivastigmine tartrate oral capsule 1.5 mg, Tier 1 3 mg, 4.5 mg, 6 mg rivastigmine transdermal patch 24 hour (Exelon) Tier 1 QL (1 EA per 1 day) 13.3 mg/24hr, 4.6 mg/24hr, 9.5 mg/24hr Combination Psychotherapeutics chlordiazepoxide-amitriptyline oral tablet Tier 1 10-25 mg, 5-12.5 mg olanzapine-fluoxetine hcl oral capsule Tier 1 QL (1 EA per 1 day) 12-25 mg olanzapine-fluoxetine hcl oral capsule (Symbyax) Tier 1 QL (1 EA per 1 day) 12-50 mg, 3-25 mg, 6-25 mg, 6-50 mg perphenazine-amitriptyline oral tablet 2- Tier 1 10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg Fibromyalgia Agents SAVELLA ORAL TABLET 100 MG, 12.5 Tier 2 MG, 25 MG, 50 MG SAVELLA TITRATION PACK ORAL Tier 2 12.5 & 25 & 50 MG Hypoactive Sexual Desire Disorder (Hsdd) Agents ADDYI ORAL TABLET 100 MG Tier 3 PA

MedPerform Medium Formulary 01/01/2021

298 Drug Status Notes VYLEESI SUBCUTANEOUS SOLUTION Tier 3 PA AUTO-INJECTOR 1.75 MG/0.3ML Movement Disorder Drug Therapy AUSTEDO ORAL TABLET 12 MG, 6 Tier 3 PA; SP MG, 9 MG INGREZZA ORAL CAPSULE 40 MG, 80 Tier 3 PA; SP MG INGREZZA ORAL CAPSULE THERAPY Tier 3 PA; SP PACK 40 & 80 MG tetrabenazine oral tablet 12.5 mg, 25 mg (Xenazine) Tier 1 PA; SP Multiple Sclerosis Agents AUBAGIO ORAL TABLET 14 MG, 7 MG Tier 2 PA; SP AVONEX PEN INTRAMUSCULAR Tier 2 PA; SP AUTO-INJECTOR KIT 30 MCG/0.5ML AVONEX PREFILLED Tier 2 PA; SP INTRAMUSCULAR PREFILLED SYRINGE KIT 30 MCG/0.5ML BETASERON SUBCUTANEOUS KIT Tier 2 PA; SP 0.3 MG COPAXONE SUBCUTANEOUS (Glatiramer Acetate) Tier 2 PA; SP SOLUTION PREFILLED SYRINGE 20 MG/ML, 40 MG/ML dalfampridine er oral tablet extended (Ampyra) Tier 1 PA; SP release 12 hour 10 mg dimethyl fumarate oral capsule delayed (Tecfidera) Tier 1 PA; SP release 120 mg, 240 mg dimethyl fumarate starter pack oral 120 (Tecfidera) Tier 1 PA; SP & 240 mg GILENYA ORAL CAPSULE 0.5 MG Tier 2 PA; SP glatiramer acetate subcutaneous (Glatopa) Tier 1 PA; SP solution prefilled syringe 20 mg/ml, 40 mg/ml GLATOPA SUBCUTANEOUS (Glatiramer Acetate) Tier 1 PA; SP SOLUTION PREFILLED SYRINGE 20 MG/ML, 40 MG/ML

MedPerform Medium Formulary 01/01/2021

299 Drug Status Notes MAVENCLAD (10 TABS) ORAL Tier 2 PA; SP TABLET THERAPY PACK 10 MG MAVENCLAD (4 TABS) ORAL TABLET Tier 2 PA; SP THERAPY PACK 10 MG MAVENCLAD (5 TABS) ORAL TABLET Tier 2 PA; SP THERAPY PACK 10 MG MAVENCLAD (6 TABS) ORAL TABLET Tier 2 PA; SP THERAPY PACK 10 MG MAVENCLAD (7 TABS) ORAL TABLET Tier 2 PA; SP THERAPY PACK 10 MG MAVENCLAD (8 TABS) ORAL TABLET Tier 2 PA; SP THERAPY PACK 10 MG MAVENCLAD (9 TABS) ORAL TABLET Tier 2 PA; SP THERAPY PACK 10 MG MAYZENT ORAL TABLET 0.25 MG, 2 Tier 2 PA; SP MG PLEGRIDY STARTER PACK Tier 2 PA; SP SUBCUTANEOUS SOLUTION PEN- INJECTOR 63 & 94 MCG/0.5ML PLEGRIDY STARTER PACK Tier 2 PA; SP SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 63 & 94 MCG/0.5ML PLEGRIDY SUBCUTANEOUS Tier 2 PA; SP SOLUTION PEN-INJECTOR 125 MCG/0.5ML PLEGRIDY SUBCUTANEOUS Tier 2 PA; SP SOLUTION PREFILLED SYRINGE 125 MCG/0.5ML REBIF REBIDOSE SUBCUTANEOUS Tier 2 PA; SP SOLUTION AUTO-INJECTOR 22 MCG/0.5ML, 44 MCG/0.5ML REBIF REBIDOSE TITRATION PACK Tier 2 PA; SP SUBCUTANEOUS SOLUTION AUTO- INJECTOR 6X8.8 & 6X22 MCG

MedPerform Medium Formulary 01/01/2021

300 Drug Status Notes REBIF SUBCUTANEOUS SOLUTION Tier 2 PA; SP PREFILLED SYRINGE 22 MCG/0.5ML, 44 MCG/0.5ML REBIF TITRATION PACK Tier 2 PA; SP SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6X8.8 & 6X22 MCG VUMERITY ORAL CAPSULE DELAYED Tier 2 PA; SP RELEASE 231 MG ZEPOSIA 7-DAY STARTER PACK Tier 3 PA; SP ORAL CAPSULE THERAPY PACK 4 X 0.23MG & 3 X 0.46MG ZEPOSIA ORAL CAPSULE 0.92 MG Tier 3 PA; SP ZEPOSIA STARTER KIT ORAL Tier 3 PA; SP CAPSULE THERAPY PACK 0.23MG & 0.46MG & 0.92MG Postherpetic Neuralgia (Phn)/Neuropathic Pain Agents CONVENIENCE PAK COMBINATION Tier 3 THERAPY PACK 600 & 5 MG & % GPL PAK COMBINATION THERAPY Tier 3 PACK 300-4.12 MG-% LIDO GB-300 COMBINATION Tier 3 THERAPY PACK 300 & 4.12 MG & % Premenstrual Dysphoric Disorder (Pmdd) Agents fluoxetine hcl (pmdd) oral tablet 10 mg, (Sarafem) Tier 1 20 mg Pseudobulbar Affect (Pba) Agents NUEDEXTA ORAL CAPSULE 20-10 MG Tier 3 PA Psychotherapeutic And Neurological Agents - Misc. ergoloid mesylates oral tablet 1 mg Tier 1 pimozide oral tablet 1 mg, 2 mg Tier 1

MedPerform Medium Formulary 01/01/2021

301 Drug Status Notes Smoking Deterrents bupropion hcl er (smoking det) oral tablet Tier 2 SP; QL (2 EA per 1 day); extended release 12 hour 150 mg AGE (Min 18 Years) CHANTIX CONTINUING MONTH PAK Tier 2 SP; QL (2 EA per 1 day); ORAL TABLET 1 MG AGE (Min 18 Years) CHANTIX ORAL TABLET 0.5 MG, 1 MG Tier 2 SP; QL (2 EA per 1 day); AGE (Min 18 Years) CHANTIX STARTING MONTH PAK Tier 2 SP; QL (2 EA per 1 day); ORAL TABLET 0.5 MG X 11 & 1 MG X AGE (Min 18 Years) 42 cvs nicotine mouth/throat gum 2 mg (KLS Quit2) Tier 2 SP; QL (24 EA per 1 day); AGE (Min 18 Years) cvs nicotine mouth/throat gum 4 mg (KLS Quit4) Tier 2 SP; QL (24 EA per 1 day); AGE (Min 18 Years) cvs nicotine mouth/throat lozenge 2 mg (KLS Quit2) Tier 2 SP; QL (20 EA per 1 day); AGE (Min 18 Years) cvs nicotine polacrilex mouth/throat gum (KLS Quit2) Tier 2 SP; QL (24 EA per 1 day); 2 mg AGE (Min 18 Years) cvs nicotine polacrilex mouth/throat gum (KLS Quit4) Tier 2 SP; QL (24 EA per 1 day); 4 mg AGE (Min 18 Years) cvs nicotine polacrilex mouth/throat (KLS Quit2) Tier 2 SP; QL (20 EA per 1 day); lozenge 2 mg AGE (Min 18 Years) cvs nicotine polacrilex mouth/throat (KLS Quit4) Tier 2 SP; QL (20 EA per 1 day); lozenge 4 mg AGE (Min 18 Years) cvs nicotine transdermal patch 24 hour (Nicoderm CQ) Tier 2 SP; QL (1 EA per 1 day); 14 mg/24hr, 21 mg/24hr, 7 mg/24hr AGE (Min 18 Years) eq nicotine mouth/throat gum 4 mg (KLS Quit4) Tier 2 SP; QL (24 EA per 1 day); AGE (Min 18 Years) eq nicotine mouth/throat lozenge 4 mg (KLS Quit4) Tier 2 SP; QL (20 EA per 1 day); AGE (Min 18 Years) eq nicotine polacrilex mouth/throat gum (KLS Quit2) Tier 2 SP; QL (24 EA per 1 day); 2 mg AGE (Min 18 Years) eq nicotine polacrilex mouth/throat gum (KLS Quit4) Tier 2 SP; QL (24 EA per 1 day); 4 mg AGE (Min 18 Years) eq nicotine polacrilex mouth/throat (KLS Quit2) Tier 2 SP; QL (20 EA per 1 day); lozenge 2 mg AGE (Min 18 Years)

MedPerform Medium Formulary 01/01/2021

302 Drug Status Notes eq nicotine polacrilex mouth/throat (KLS Quit4) Tier 2 SP; QL (20 EA per 1 day); lozenge 4 mg AGE (Min 18 Years) eq nicotine step 3 transdermal patch 24 (Nicoderm CQ) Tier 2 SP; QL (1 EA per 1 day); hour 7 mg/24hr AGE (Min 18 Years) eq nicotine transdermal patch 24 hour 14 (Nicoderm CQ) Tier 2 SP; QL (1 EA per 1 day); mg/24hr, 21 mg/24hr, 7 mg/24hr AGE (Min 18 Years) eql nicotine polacrilex mouth/throat gum (KLS Quit2) Tier 2 SP; QL (24 EA per 1 day); 2 mg AGE (Min 18 Years) eql nicotine polacrilex mouth/throat (KLS Quit2) Tier 2 SP; QL (20 EA per 1 day); lozenge 2 mg AGE (Min 18 Years) eql nicotine polacrilex mouth/throat (KLS Quit4) Tier 2 SP; QL (20 EA per 1 day); lozenge 4 mg AGE (Min 18 Years) gnp nicotine mini mouth/throat lozenge 2 (KLS Quit2) Tier 2 SP; QL (20 EA per 1 day); mg AGE (Min 18 Years) gnp nicotine polacrilex mouth/throat gum (KLS Quit2) Tier 2 SP; QL (24 EA per 1 day); 2 mg AGE (Min 18 Years) gnp nicotine polacrilex mouth/throat gum (KLS Quit4) Tier 2 SP; QL (24 EA per 1 day); 4 mg AGE (Min 18 Years) gnp nicotine polacrilex mouth/throat (KLS Quit2) Tier 2 SP; QL (20 EA per 1 day); lozenge 2 mg AGE (Min 18 Years) gnp nicotine polacrilex mouth/throat (KLS Quit4) Tier 2 SP; QL (20 EA per 1 day); lozenge 4 mg AGE (Min 18 Years) gnp nicotine transdermal patch 24 hour (Nicoderm CQ) Tier 2 SP; QL (1 EA per 1 day); 14 mg/24hr, 7 mg/24hr AGE (Min 18 Years) goodsense nicotine mouth/throat gum 2 (KLS Quit2) Tier 2 SP; QL (24 EA per 1 day); mg AGE (Min 18 Years) goodsense nicotine mouth/throat gum 4 (KLS Quit4) Tier 2 SP; QL (24 EA per 1 day); mg AGE (Min 18 Years) goodsense nicotine mouth/throat (KLS Quit2) Tier 2 SP; QL (20 EA per 1 day); lozenge 2 mg AGE (Min 18 Years) goodsense nicotine mouth/throat (KLS Quit4) Tier 2 SP; QL (20 EA per 1 day); lozenge 4 mg AGE (Min 18 Years) hm nicotine polacrilex mouth/throat gum (KLS Quit2) Tier 2 SP; QL (24 EA per 1 day); 2 mg AGE (Min 18 Years) hm nicotine polacrilex mouth/throat gum (KLS Quit4) Tier 2 SP; QL (24 EA per 1 day); 4 mg AGE (Min 18 Years)

MedPerform Medium Formulary 01/01/2021

303 Drug Status Notes hm nicotine polacrilex mouth/throat (KLS Quit2) Tier 2 SP; QL (20 EA per 1 day); lozenge 2 mg AGE (Min 18 Years) hm nicotine polacrilex mouth/throat (KLS Quit4) Tier 2 SP; QL (20 EA per 1 day); lozenge 4 mg AGE (Min 18 Years) hm nicotine transdermal patch 24 hour (Nicoderm CQ) Tier 2 SP; QL (1 EA per 1 day); 14 mg/24hr, 21 mg/24hr, 7 mg/24hr AGE (Min 18 Years) KLS QUIT2 MOUTH/THROAT GUM 2 (RA Nicotine Gum) Tier 2 SP; QL (24 EA per 1 day); MG AGE (Min 18 Years) KLS QUIT2 MOUTH/THROAT (CVS Nicotine) Tier 2 SP; QL (20 EA per 1 day); LOZENGE 2 MG AGE (Min 18 Years) KLS QUIT4 MOUTH/THROAT GUM 4 (RA Nicotine Gum) Tier 2 SP; QL (24 EA per 1 day); MG AGE (Min 18 Years) KLS QUIT4 MOUTH/THROAT (CVS Nicotine Polacrilex) Tier 2 SP; QL (20 EA per 1 day); LOZENGE 4 MG AGE (Min 18 Years) nicotine mini mouth/throat lozenge 2 mg (KLS Quit2) Tier 2 SP; QL (20 EA per 1 day); AGE (Min 18 Years) nicotine mini mouth/throat lozenge 4 mg (KLS Quit4) Tier 2 SP; QL (20 EA per 1 day); AGE (Min 18 Years) nicotine polacrilex mouth/throat gum 2 (KLS Quit2) Tier 2 SP; QL (24 EA per 1 day); mg AGE (Min 18 Years) nicotine polacrilex mouth/throat gum 4 (KLS Quit4) Tier 2 SP; QL (24 EA per 1 day); mg AGE (Min 18 Years) nicotine polacrilex mouth/throat lozenge (KLS Quit2) Tier 2 SP; QL (20 EA per 1 day); 2 mg AGE (Min 18 Years) nicotine polacrilex mouth/throat lozenge (KLS Quit4) Tier 2 SP; QL (20 EA per 1 day); 4 mg AGE (Min 18 Years) nicotine step 1 transdermal patch 24 (Nicoderm CQ) Tier 2 SP; QL (1 EA per 1 day); hour 21 mg/24hr AGE (Min 18 Years) nicotine step 2 transdermal patch 24 (Nicoderm CQ) Tier 2 SP; QL (1 EA per 1 day); hour 14 mg/24hr AGE (Min 18 Years) nicotine step 3 transdermal patch 24 (Nicoderm CQ) Tier 2 SP; QL (1 EA per 1 day); hour 7 mg/24hr AGE (Min 18 Years) nicotine transdermal patch 24 hour 14 (Nicoderm CQ) Tier 2 SP; QL (1 EA per 1 day); mg/24hr, 21 mg/24hr, 7 mg/24hr AGE (Min 18 Years)

MedPerform Medium Formulary 01/01/2021

304 Drug Status Notes NICOTROL INHALATION INHALER 10 Tier 2 SP; ST: Requires prior MG prescription for Nicotine transdermal patch within the past 120 days; QL (1008 EA per 90 days); AGE (Min 18 Years) NICOTROL NS NASAL SOLUTION 10 Tier 2 SP; ST: Requires prior MG/ML prescription for Nicotine transdermal patch within the past 120 days; QL (160 ML per 90 days); AGE (Min 18 Years) px stop smoking aid mouth/throat gum 2 (KLS Quit2) Tier 2 SP; QL (24 EA per 1 day); mg AGE (Min 18 Years) px stop smoking aid mouth/throat gum 4 (KLS Quit4) Tier 2 SP; QL (24 EA per 1 day); mg AGE (Min 18 Years) px stop smoking aid mouth/throat (KLS Quit2) Tier 2 SP; QL (20 EA per 1 day); lozenge 2 mg AGE (Min 18 Years) px stop smoking aid mouth/throat (KLS Quit4) Tier 2 SP; QL (20 EA per 1 day); lozenge 4 mg AGE (Min 18 Years) ra mini nicotine mouth/throat lozenge 2 (KLS Quit2) Tier 2 SP; QL (20 EA per 1 day); mg AGE (Min 18 Years) ra mini nicotine mouth/throat lozenge 4 (KLS Quit4) Tier 2 SP; QL (20 EA per 1 day); mg AGE (Min 18 Years) ra nicotine gum mouth/throat gum 2 mg (KLS Quit2) Tier 2 SP; QL (24 EA per 1 day); AGE (Min 18 Years) ra nicotine gum mouth/throat gum 4 mg (KLS Quit4) Tier 2 SP; QL (24 EA per 1 day); AGE (Min 18 Years) ra nicotine mouth/throat gum 2 mg (KLS Quit2) Tier 2 SP; QL (24 EA per 1 day); AGE (Min 18 Years) ra nicotine mouth/throat gum 4 mg (KLS Quit4) Tier 2 SP; QL (24 EA per 1 day); AGE (Min 18 Years) ra nicotine polacrilex mouth/throat gum 2 (KLS Quit2) Tier 2 SP; QL (24 EA per 1 day); mg AGE (Min 18 Years) ra nicotine polacrilex mouth/throat gum 4 (KLS Quit4) Tier 2 SP; QL (24 EA per 1 day); mg AGE (Min 18 Years)

MedPerform Medium Formulary 01/01/2021

305 Drug Status Notes ra nicotine polacrilex mouth/throat (KLS Quit2) Tier 2 SP; QL (20 EA per 1 day); lozenge 2 mg AGE (Min 18 Years) ra nicotine polacrilex mouth/throat (KLS Quit4) Tier 2 SP; QL (20 EA per 1 day); lozenge 4 mg AGE (Min 18 Years) ra nicotine transdermal patch 24 hour 14 (Nicoderm CQ) Tier 2 SP; QL (1 EA per 1 day); mg/24hr, 21 mg/24hr, 7 mg/24hr AGE (Min 18 Years) sm nicotine mouth/throat gum 4 mg (KLS Quit4) Tier 2 SP; QL (24 EA per 1 day); AGE (Min 18 Years) sm nicotine mouth/throat lozenge 2 mg (KLS Quit2) Tier 2 SP; QL (20 EA per 1 day); AGE (Min 18 Years) sm nicotine polacrilex mouth/throat gum (KLS Quit2) Tier 2 SP; QL (24 EA per 1 day); 2 mg AGE (Min 18 Years) sm nicotine polacrilex mouth/throat gum (KLS Quit4) Tier 2 SP; QL (24 EA per 1 day); 4 mg AGE (Min 18 Years) sm nicotine polacrilex mouth/throat (KLS Quit4) Tier 2 SP; QL (20 EA per 1 day); lozenge 4 mg AGE (Min 18 Years) sm nicotine transdermal patch 24 hour (Nicoderm CQ) Tier 2 SP; QL (1 EA per 1 day); 14 mg/24hr, 21 mg/24hr, 7 mg/24hr AGE (Min 18 Years) sr nicotine mouth/throat gum 2 mg (KLS Quit2) Tier 2 SP; QL (24 EA per 1 day); AGE (Min 18 Years) THRIVE MOUTH/THROAT GUM 2 MG (RA Nicotine Gum) Tier 2 SP; QL (24 EA per 1 day); AGE (Min 18 Years) Transthyretin Amyloidosis Agents TEGSEDI SUBCUTANEOUS Tier 3 PA; SP SOLUTION PREFILLED SYRINGE 284 MG/1.5ML Vasomotor Symptom Agents paroxetine mesylate oral capsule 7.5 mg (Brisdelle) Tier 1 ST: Requires prior prescription for Paroxetine HCL or Venlafaxine HCL within the past 120 days; QL (1 EA per 1 day)

MedPerform Medium Formulary 01/01/2021

306 Drug Status Notes Respiratory Agents - Misc. Alpha-Proteinase Inhibitor (Human) ARALAST NP INTRAVENOUS Tier 3 SP SOLUTION RECONSTITUTED 1000 MG, 500 MG PROLASTIN-C INTRAVENOUS Tier 3 SP SOLUTION 1000 MG/20ML PROLASTIN-C INTRAVENOUS Tier 3 SP SOLUTION RECONSTITUTED 1000 MG ZEMAIRA INTRAVENOUS SOLUTION Tier 3 SP RECONSTITUTED 1000 MG Cystic Fibrosis Agents KALYDECO ORAL PACKET 25 MG, 50 Tier 2 PA; SP MG, 75 MG KALYDECO ORAL TABLET 150 MG Tier 2 PA; SP ORKAMBI ORAL PACKET 100-125 MG, Tier 2 PA; SP 150-188 MG ORKAMBI ORAL TABLET 100-125 MG, Tier 2 PA; SP 200-125 MG PULMOZYME INHALATION SOLUTION Tier 2 PA; SP 1 MG/ML SYMDEKO ORAL TABLET THERAPY Tier 2 PA; SP PACK 100-150 & 150 MG, 50-75 & 75 MG TRIKAFTA ORAL TABLET THERAPY Tier 2 PA; SP PACK 100-50-75 & 150 MG Pulmonary Fibrosis Agents ESBRIET ORAL CAPSULE 267 MG Tier 2 PA; SP ESBRIET ORAL TABLET 267 MG, 801 Tier 2 PA; SP MG OFEV ORAL CAPSULE 100 MG, 150 Tier 2 PA; SP MG Sulfonamides Sulfonamides sulfadiazine oral tablet 500 mg Tier 1

MedPerform Medium Formulary 01/01/2021

307 Drug Status Notes Tetracyclines Aminomethylcyclines NUZYRA ORAL TABLET 150 MG Tier 3 PA Tetracyclines avidoxy oral tablet 100 mg Tier 1 QL (2 EA per 1 day) demeclocycline hcl oral tablet 150 mg, Tier 1 300 mg doxycycline hyclate oral capsule 100 mg (Morgidox) Tier 1 QL (2 EA per 1 day) doxycycline hyclate oral capsule 50 mg Tier 1 QL (2 EA per 1 day) doxycycline hyclate oral tablet 100 mg Tier 1 QL (2 EA per 1 day) doxycycline hyclate oral tablet 150 mg (Acticlate) Tier 1 ST: Requires prior prescription for generic Doxycycline Monohydrate 150mg tablets within the past 120 days; QL (2 EA per 1 day) doxycycline hyclate oral tablet 20 mg Tier 1 doxycycline hyclate oral tablet 75 mg (Acticlate) Tier 1 ST: Requires prior prescription for generic Doxycycline Monohydrate 75mg tablets within the past 120 days; QL (2 EA per 1 day) doxycycline monohydrate oral capsule (Mondoxyne NL) Tier 1 QL (2 EA per 1 day) 100 mg doxycycline monohydrate oral capsule Tier 1 QL (2 EA per 1 day) 150 mg, 50 mg doxycycline monohydrate oral capsule (Mondoxyne NL) Tier 1 ST: Requires prior 75 mg prescription for generic Doxycycline Monohydrate 75mg tablets within the past 120 days; QL (2 EA per 1 day) doxycycline monohydrate oral (Vibramycin) Tier 1 suspension reconstituted 25 mg/5ml

MedPerform Medium Formulary 01/01/2021

308 Drug Status Notes doxycycline monohydrate oral tablet 100 Tier 1 QL (2 EA per 1 day) mg, 150 mg, 50 mg, 75 mg minocycline hcl oral capsule 100 mg (Minocin) Tier 1 minocycline hcl oral capsule 50 mg, 75 Tier 1 mg minocycline hcl oral tablet 100 mg, 50 Tier 1 mg, 75 mg MONDOXYNE NL ORAL CAPSULE 100 (Doxycycline Tier 1 QL (2 EA per 1 day) MG Monohydrate) MONDOXYNE NL ORAL CAPSULE 75 (Doxycycline Tier 1 ST: Requires prior MG Monohydrate) prescription for generic Doxycycline Monohydrate 75mg tablets within the past 120 days; QL (2 EA per 1 day) MORGIDOX ORAL CAPSULE 100 MG (Doxycycline Hyclate) Tier 1 QL (2 EA per 1 day) NUTRIDOX ORAL KIT 75 MG Tier 3 TARGADOX ORAL TABLET 50 MG (Doxycycline Hyclate) Tier 3 ST: Requires prior prescription for Doxycycline Hyclate 50mg/100mg immediate release capsules/tablets or Doxycycline Monohydrate 50mg/100mg immediate release capsules/tablets within the past 120 days; QL (4 EA per 1 day) tetracycline hcl oral capsule 250 mg, 500 Tier 1 mg VIBRAMYCIN ORAL SYRUP 50 Tier 2 MG/5ML Thyroid Agents Antithyroid Agents methimazole oral tablet 10 mg, 5 mg (Tapazole) Tier 1 propylthiouracil oral tablet 50 mg Tier 1

MedPerform Medium Formulary 01/01/2021

309 Drug Status Notes Thyroid Hormones ARMOUR THYROID ORAL TABLET Tier 2 180 MG, 240 MG, 300 MG CYTOMEL ORAL TABLET 25 MCG, 5 (Liothyronine Sodium) Tier 3 MCG, 50 MCG EUTHYROX ORAL TABLET 100 MCG, (Levothyroxine Sodium) Tier 1 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG LEVO-T ORAL TABLET 100 MCG, 112 (Levothyroxine Sodium) Tier 1 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG levothyroxine sodium oral tablet 100 (Euthyrox) Tier 1 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg levothyroxine sodium oral tablet 300 mcg (Levo-T) Tier 1 LEVOXYL ORAL TABLET 100 MCG, (Levothyroxine Sodium) Tier 1 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG liothyronine sodium oral tablet 25 mcg, 5 (Cytomel) Tier 1 mcg, 50 mcg NATURE-THROID ORAL TABLET Tier 3 113.75 MG, 146.25 MG, 16.25 MG, 162.5 MG, 260 MG, 32.5 MG, 325 MG, 48.75 MG, 81.25 MG, 97.5 MG NATURE-THROID ORAL TABLET 130 Tier 2 MG, 195 MG NATURE-THROID ORAL TABLET 65 (Thyroid) Tier 2 MG np thyroid oral tablet 120 mg, 15 mg, 30 (Armour Thyroid) Tier 1 mg, 60 mg, 90 mg

MedPerform Medium Formulary 01/01/2021

310 Drug Status Notes SYNTHROID ORAL TABLET 100 MCG, (Levothyroxine Sodium) Tier 3 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG UNITHROID ORAL TABLET 100 MCG, (Levothyroxine Sodium) Tier 1 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG WESTHROID ORAL TABLET 130 MG, Tier 2 195 MG WESTHROID ORAL TABLET 32.5 MG, Tier 3 97.5 MG WESTHROID ORAL TABLET 65 MG (Thyroid) Tier 2 WP THYROID ORAL TABLET 113.75 Tier 3 MG, 16.25 MG, 32.5 MG, 48.75 MG, 81.25 MG, 97.5 MG WP THYROID ORAL TABLET 130 MG Tier 2 WP THYROID ORAL TABLET 65 MG (Thyroid) Tier 2 Toxoids Toxoid Combinations ADACEL INTRAMUSCULAR $0 QL (0.5 ML per 365 days); SUSPENSION 5-2-15.5 LF-MCG/0.5 AGE (Min 18 Years) BOOSTRIX INTRAMUSCULAR $0 QL (0.5 ML per 365 days); SUSPENSION 5-2.5-18.5 LF-MCG/0.5 AGE (Min 18 Years) TDVAX INTRAMUSCULAR (Tetanus-Diphtheria $0 QL (0.5 ML per 365 days); SUSPENSION 2-2 LF/0.5ML Toxoids Td) AGE (Min 18 Years) TENIVAC INTRAMUSCULAR $0 QL (0.5 ML per 365 days); INJECTABLE 5-2 LFU AGE (Min 18 Years) Ulcer Drugs/Antispasmodics/Anticholinergic s Antispasmodics ATROPEN INTRAMUSCULAR Tier 3 SOLUTION AUTO-INJECTOR 0.25 MG/0.3ML, 0.5 MG/0.7ML, 1 MG/0.7ML, 2 MG/0.7ML

MedPerform Medium Formulary 01/01/2021

311 Drug Status Notes belladonna alkaloids-opium rectal Tier 1 suppository 16.2-30 mg, 16.2-60 mg chlordiazepoxide-clidinium oral capsule (Librax) Tier 1 5-2.5 mg CUVPOSA ORAL SOLUTION 1 Tier 3 MG/5ML dicyclomine hcl oral capsule 10 mg Tier 1 dicyclomine hcl oral solution 10 mg/5ml Tier 1 dicyclomine hcl oral tablet 20 mg Tier 1 ed-spaz oral tablet dispersible 0.125 mg (NuLev) Tier 1 glycopyrrolate oral tablet 1 mg, 2 mg Tier 1 hyoscyamine sulfate er oral tablet (Symax-SR) Tier 1 extended release 12 hour 0.375 mg hyoscyamine sulfate oral elixir 0.125 Tier 1 mg/5ml hyoscyamine sulfate oral solution 0.125 Tier 1 mg/ml hyoscyamine sulfate oral tablet 0.125 mg (Levsin) Tier 1 hyoscyamine sulfate oral tablet (NuLev) Tier 1 dispersible 0.125 mg hyoscyamine sulfate sl sublingual tablet (Symax-SL) Tier 1 sublingual 0.125 mg hyoscyamine sulfate sublingual tablet (Symax-SL) Tier 1 sublingual 0.125 mg hyosyne oral elixir 0.125 mg/5ml Tier 1 hyosyne oral solution 0.125 mg/ml Tier 1 methscopolamine bromide oral tablet 2.5 Tier 1 mg, 5 mg NULEV ORAL TABLET DISPERSIBLE (Hyoscyamine Sulfate) Tier 1 0.125 MG oscimin oral tablet 0.125 mg (Levsin) Tier 1 oscimin sr oral tablet extended release (Symax-SR) Tier 1 12 hour 0.375 mg oscimin sublingual tablet sublingual (Symax-SL) Tier 1 0.125 mg

MedPerform Medium Formulary 01/01/2021

312 Drug Status Notes propantheline bromide oral tablet 15 mg Tier 1 SYMAX DUOTAB ORAL TABLET Tier 3 EXTENDED RELEASE 0.375 MG SYMAX-SL SUBLINGUAL TABLET (Hyoscyamine Sulfate SL) Tier 1 SUBLINGUAL 0.125 MG SYMAX-SR ORAL TABLET EXTENDED (Hyoscyamine Sulfate ER) Tier 1 RELEASE 12 HOUR 0.375 MG H-2 Antagonists cimetidine hcl oral solution 300 mg/5ml Tier 1 cimetidine oral tablet 200 mg (Tagamet HB) Tier 1 cimetidine oral tablet 300 mg, 400 mg, Tier 1 800 mg famotidine oral suspension reconstituted Tier 1 40 mg/5ml famotidine oral tablet 20 mg, 40 mg (Pepcid) Tier 1 nizatidine oral capsule 150 mg, 300 mg Tier 1 nizatidine oral solution 15 mg/ml Tier 1 Misc. Anti-Ulcer sucralfate oral suspension 1 gm/10ml (Carafate) Tier 1 sucralfate oral tablet 1 gm (Carafate) Tier 1 Proton Pump Inhibitors ACIPHEX SPRINKLE ORAL CAPSULE (RABEprazole Sodium) Tier 3 ST: At least 2 prior SPRINKLE 10 MG prescriptions for Lansoprazole, Omeprazole, or Pantoprazole Sodium within the past 365 days; QL (1 EA per 1 day) ACIPHEX SPRINKLE ORAL CAPSULE Tier 3 ST: At least 2 prior SPRINKLE 5 MG prescriptions for Lansoprazole, Omeprazole, or Pantoprazole Sodium within the past 365 days; QL (1 EA per 1 day)

MedPerform Medium Formulary 01/01/2021

313 Drug Status Notes DEXILANT ORAL CAPSULE DELAYED Tier 2 ST: Requires prior RELEASE 30 MG, 60 MG prescription for Lansoprazole, Omeprazole (suspension, capsules, tablets), or Pantoprazole Sodium within the past 120 days; QL (1 EA per 1 day) esomeprazole magnesium oral capsule (GoodSense Tier 1 QL (1 EA per 1 day) delayed release 20 mg Esomeprazole) esomeprazole magnesium oral capsule (NexIUM) Tier 1 QL (2 EA per 1 day) delayed release 40 mg esomeprazole magnesium oral packet (NexIUM) Tier 1 ST: Requires prior 10 mg, 20 mg prescription for Lansoprazole, Omeprazole (suspension, capsules, tablets), or Pantoprazole Sodium within the past 120 days; QL (1 EA per 1 day) esomeprazole magnesium oral packet (NexIUM) Tier 1 ST: Requires prior 40 mg prescription for Lansoprazole, Omeprazole (suspension, capsules, tablets), or Pantoprazole Sodium within the past 120 days; QL (2 EA per 1 day) FIRST-LANSOPRAZOLE ORAL Tier 3 SUSPENSION 3 MG/ML FIRST-OMEPRAZOLE ORAL Tier 3 SUSPENSION 2 MG/ML lansoprazole oral capsule delayed (Prevacid) Tier 1 release 15 mg, 30 mg

MedPerform Medium Formulary 01/01/2021

314 Drug Status Notes lansoprazole oral tablet delayed release (Prevacid SoluTab) Tier 1 ST: Requires prior dispersible 15 mg, 30 mg prescription for Lansoprazole, Omeprazole (suspension, capsules, tablets), or Pantoprazole Sodium within the past 120 days NEXIUM ORAL PACKET 2.5 MG, 5 MG Tier 2 ST: Requires prior prescription for Lansoprazole, Omeprazole (suspension, capsules, tablets), or Pantoprazole Sodium within the past 120 days; QL (1 EA per 1 day) omeprazole oral capsule delayed Tier 1 release 10 mg, 20 mg, 40 mg OMEPRAZOLE+SYRSPEND SF ALKA Tier 3 ORAL SUSPENSION 2 MG/ML pantoprazole sodium oral packet 40 mg (Protonix) Tier 1 ST: Requires prior prescription for Lansoprazole, Omeprazole (suspension, capsules, tablets), or Pantoprazole Sodium within the past 120 days pantoprazole sodium oral tablet delayed (Protonix) Tier 1 release 20 mg, 40 mg PRILOSEC ORAL PACKET 10 MG, 2.5 Tier 3 ST: Requires prior MG prescription for Lansoprazole, Omeprazole (suspension, capsules, tablets), or Pantoprazole Sodium within the past 120 days

MedPerform Medium Formulary 01/01/2021

315 Drug Status Notes rabeprazole sodium oral capsule sprinkle (AcipHex Sprinkle) Tier 1 ST: At least 2 prior 10 mg prescriptions for Lansoprazole, Omeprazole, or Pantoprazole Sodium within the past 365 days; QL (1 EA per 1 day) rabeprazole sodium oral tablet delayed (Aciphex) Tier 1 QL (1 EA per 1 day) release 20 mg Ulcer Drugs - Prostaglandins misoprostol oral tablet 100 mcg, 200 (Cytotec) Tier 1 mcg Ulcer Therapy Combinations amoxicill-clarithro-lansopraz oral Tier 1 QL (112 EA per 10 days) OMECLAMOX-PAK ORAL 500-500-20 Tier 3 MG omeprazole-sodium bicarbonate oral (Zegerid) Tier 1 ST: Requires prior capsule 20-1100 mg, 40-1100 mg prescription for Lansoprazole, Omeprazole (suspension, capsules, tablets), or Pantoprazole Sodium within the past 120 days; QL (1 EA per 1 day) PYLERA ORAL CAPSULE 140-125-125 Tier 3 MG TALICIA ORAL CAPSULE DELAYED Tier 3 QL (168 EA per 14 days); RELEASE 250-12.5-10 MG AGE (Min 18 Years) Urinary Antispasmodics Urinary Antispasmodic - Antimuscarinics (Anticholinergic) darifenacin hydrobromide er oral tablet (Enablex) Tier 1 extended release 24 hour 15 mg, 7.5 mg GELNIQUE TRANSDERMAL GEL 10 % Tier 3 oxybutynin chloride er oral tablet (Ditropan XL) Tier 1 extended release 24 hour 10 mg, 5 mg oxybutynin chloride er oral tablet Tier 1 extended release 24 hour 15 mg

MedPerform Medium Formulary 01/01/2021

316 Drug Status Notes oxybutynin chloride oral syrup 5 mg/5ml Tier 1 oxybutynin chloride oral tablet 5 mg Tier 1 OXYTROL TRANSDERMAL PATCH Tier 3 TWICE WEEKLY 3.9 MG/24HR solifenacin succinate oral tablet 10 mg, 5 (VESIcare) Tier 1 mg tolterodine tartrate er oral capsule (Detrol LA) Tier 1 extended release 24 hour 2 mg, 4 mg tolterodine tartrate oral tablet 1 mg, 2 mg (Detrol) Tier 1 TOVIAZ ORAL TABLET EXTENDED Tier 2 RELEASE 24 HOUR 4 MG, 8 MG trospium chloride er oral capsule Tier 1 extended release 24 hour 60 mg trospium chloride oral tablet 20 mg Tier 1 Urinary Antispasmodics - Beta-3 Adrenergic Agonists MYRBETRIQ ORAL TABLET Tier 2 EXTENDED RELEASE 24 HOUR 25 MG, 50 MG Urinary Antispasmodics - Cholinergic Agonists bethanechol chloride oral tablet 10 mg, Tier 1 25 mg, 5 mg, 50 mg Urinary Antispasmodics - Direct Muscle Relaxants flavoxate hcl oral tablet 100 mg Tier 1 Vaccines Bacterial Vaccines BEXSERO INTRAMUSCULAR $0 QL (1 ML per 365 days); SUSPENSION PREFILLED SYRINGE AGE (Min 10 Years and Max 25 Years) MENACTRA INTRAMUSCULAR $0 QL (0.5 ML per 365 days); INJECTABLE AGE (Min 11 Years and Max 23 Years)

MedPerform Medium Formulary 01/01/2021

317 Drug Status Notes MENQUADFI INTRAMUSCULAR $0 QL (0.5 ML per 365 days); INJECTABLE AGE (Min 11 Years and Max 23 Years) MENVEO INTRAMUSCULAR $0 QL (1 EA per 365 days); SOLUTION RECONSTITUTED AGE (Min 11 Years and Max 23 Years) PNEUMOVAX 23 INJECTION $0 QL (0.5 ML per 365 days); INJECTABLE 25 MCG/0.5ML AGE (Min 65 Years) TRUMENBA INTRAMUSCULAR $0 QL (1.5 ML per 365 days); SUSPENSION PREFILLED SYRINGE AGE (Min 10 Years and Max 25 Years) Viral Vaccines AFLURIA QUADRIVALENT $0 QL (0.5 ML per 180 days) INTRAMUSCULAR SUSPENSION AFLURIA QUADRIVALENT $0 QL (0.25 ML per 180 days) INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.25 ML AFLURIA QUADRIVALENT $0 QL (0.5 ML per 180 days) INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML ENGERIX-B INJECTION SUSPENSION $0 QL (3 ML per 365 days); 20 MCG/ML AGE (Min 18 Years) FLUAD INTRAMUSCULAR $0 QL (0.5 ML per 180 days); SUSPENSION PREFILLED SYRINGE AGE (Min 65 Years) 0.5 ML FLUARIX QUADRIVALENT $0 QL (0.5 ML per 180 days) INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML FLUBLOK QUADRIVALENT $0 QL (0.5 ML per 180 days); INTRAMUSCULAR SOLUTION AGE (Min 18 Years) PREFILLED SYRINGE 0.5 ML FLUCELVAX QUADRIVALENT $0 QL (0.5 ML per 180 days) INTRAMUSCULAR SUSPENSION FLUCELVAX QUADRIVALENT Tier 3 INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

MedPerform Medium Formulary 01/01/2021

318 Drug Status Notes FLULAVAL QUADRIVALENT $0 QL (0.5 ML per 180 days) INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML FLUMIST QUADRIVALENT NASAL $0 QL (1 EA per 180 days) SUSPENSION FLUZONE QUADRIVALENT $0 QL (0.5 ML per 180 days) INTRAMUSCULAR SUSPENSION , 0.5 ML FLUZONE QUADRIVALENT $0 QL (0.5 ML per 180 days) INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML GARDASIL 9 INTRAMUSCULAR $0 QL (1.5 ML per 365 days); SUSPENSION AGE (Min 9 Years and Max 26 Years) GARDASIL 9 INTRAMUSCULAR $0 QL (1.5 ML per 365 days); SUSPENSION PREFILLED SYRINGE AGE (Min 9 Years and Max 26 Years) HAVRIX INTRAMUSCULAR $0 QL (2 ML per 365 days); SUSPENSION 1440 EL U/ML AGE (Min 18 Years) HEPLISAV-B INTRAMUSCULAR $0 QL (1 ML per 365 days); SOLUTION PREFILLED SYRINGE 20 AGE (Min 18 Years) MCG/0.5ML M-M-R II INJECTION SOLUTION $0 QL (2 EA per 365 days); RECONSTITUTED AGE (Min 18 Years) RECOMBIVAX HB INJECTION $0 QL (3 ML per 365 days); SUSPENSION 10 MCG/ML, 40 MCG/ML AGE (Min 18 Years) SHINGRIX INTRAMUSCULAR $0 QL (2 EA per 365 days); SUSPENSION RECONSTITUTED 50 AGE (Min 50 Years) MCG/0.5ML TWINRIX INTRAMUSCULAR $0 QL (4 ML per 365 days); SUSPENSION 720-20 AGE (Min 18 Years) TWINRIX INTRAMUSCULAR $0 QL (4 ML per 365 days); SUSPENSION PREFILLED SYRINGE AGE (Min 18 Years) 720-20 ELU-MCG/ML VAQTA INTRAMUSCULAR $0 QL (2 ML per 365 days); SUSPENSION 50 UNIT/ML AGE (Min 18 Years)

MedPerform Medium Formulary 01/01/2021

319 Drug Status Notes VARIVAX SUBCUTANEOUS $0 QL (2 EA per 365 days); INJECTABLE 1350 PFU/0.5ML AGE (Min 18 Years) Vaginal Products Miscellaneous Vaginal Products FEM PH VAGINAL GEL 0.9-0.025 % Tier 3 INTRAROSA VAGINAL INSERT 6.5 MG Tier 2 QL (1 EA per 1 day) TRIMO-SAN VAGINAL GEL 0.025-0.01 Tier 3 % Spermicides ENCARE VAGINAL SUPPOSITORY $0 100 MG OPTIONS GYNOL II CONTRACEPTIVE $0 VAGINAL GEL 3 % SHUR-SEAL CONTRACEPTIVE $0 VAGINAL GEL 2 % TODAY SPONGE VAGINAL 1000 MG $0 VCF VAGINAL CONTRACEPTIVE $0 VAGINAL FILM 28 % VCF VAGINAL CONTRACEPTIVE $0 VAGINAL FOAM 12.5 % VCF VAGINAL CONTRACEPTIVE $0 VAGINAL GEL 4 % Vaginal Anti-Infectives CLEOCIN VAGINAL SUPPOSITORY Tier 3 ST: At least 2 prior 100 MG prescriptions for Clindamycin HCL, Clindamycin Palmitate HCL, Clindamycin Phosphate vaginal, Metronidazole, or Tinidazole within the past 365 days; QL (3 EA per 30 days) clindamycin phosphate vaginal cream 2 (Cleocin) Tier 1 % CLINDESSE VAGINAL CREAM 2 % Tier 3

MedPerform Medium Formulary 01/01/2021

320 Drug Status Notes GYNAZOLE-1 VAGINAL CREAM 2 % Tier 2 metronidazole vaginal gel 0.75 % (Vandazole) Tier 1 miconazole 3 vaginal suppository 200 Tier 3 mg NUVESSA VAGINAL GEL 1.3 % Tier 3 terconazole vaginal cream 0.4 %, 0.8 % Tier 1 terconazole vaginal suppository 80 mg Tier 1 VANDAZOLE VAGINAL GEL 0.75 % (MetroNIDAZOLE) Tier 1 Vaginal Estrogens estradiol vaginal cream 0.1 mg/gm (Estrace) Tier 1 estradiol vaginal tablet 10 mcg (Yuvafem) Tier 1 ESTRING VAGINAL RING 2 MG Tier 2 QL (1 EA per 90 days) FEMRING VAGINAL RING 0.05 Tier 3 ST: Requires prior MG/24HR, 0.1 MG/24HR prescription for Estradiol Vaginal, Conjugated Vaginal Estrogens, Ospemifene, or Vaginal Prasterone within the past 120 days; QL (1 EA per 84 days) IMVEXXY MAINTENANCE PACK Tier 3 ST: Requires prior VAGINAL INSERT 10 MCG, 4 MCG prescription for Estradiol Vaginal, Conjugated Vaginal Estrogens, Ospemifene, or Vaginal Prasterone within the past 120 days; QL (18 EA per 28 days) IMVEXXY STARTER PACK VAGINAL Tier 3 ST: Requires prior INSERT 10 MCG, 4 MCG prescription for Estradiol Vaginal, Conjugated Vaginal Estrogens, Ospemifene, or Vaginal Prasterone within the past 120 days; QL (18 EA per 28 days)

MedPerform Medium Formulary 01/01/2021

321 Drug Status Notes PREMARIN VAGINAL CREAM 0.625 Tier 2 MG/GM YUVAFEM VAGINAL TABLET 10 MCG (Estradiol) Tier 1 Vaginal Progestins CRINONE VAGINAL GEL 4 % Tier 3 CRINONE VAGINAL GEL 8 % Tier 3 ST: Requires prior prescription for Progesterone (vaginal) within the past 120 days ENDOMETRIN VAGINAL INSERT 100 Tier 2 MG FIRST-PROGESTERONE VGS Tier 3 VAGINAL SUPPOSITORY 100 MG, 200 MG Vasopressors Anaphylaxis Therapy Agents epinephrine injection solution auto- (Auvi-Q) Tier 1 QL (4 EA per 1 FILL) injector 0.15 mg/0.15ml, 0.3 mg/0.3ml epinephrine injection solution auto- (EpiPen Jr 2-Pak) Tier 1 QL (4 EA per 1 FILL) injector 0.15 mg/0.3ml SYMJEPI INJECTION SOLUTION Tier 2 QL (4 EA per 1 FILL) PREFILLED SYRINGE 0.15 MG/0.3ML, 0.3 MG/0.3ML Neurogenic Orthostatic Hypotension (Noh) - Agents NORTHERA ORAL CAPSULE 100 MG, Tier 3 PA; SP 200 MG, 300 MG Vasopressors epinephrine injection solution prefilled Tier 1 syringe 1 mg/10ml midodrine hcl oral tablet 10 mg, 2.5 mg, Tier 1 5 mg Vitamins Oil Soluble Vitamins ergocal oral capsule 62.5 mcg (2500 ut) Tier 3

MedPerform Medium Formulary 01/01/2021

322 Drug Status Notes ergocalciferol oral capsule 1.25 mg (Drisdol) Tier 1 (50000 ut) phytonadione injection solution 1 Tier 1 mg/0.5ml, 10 mg/ml phytonadione oral tablet 5 mg (Mephyton) Tier 1 vitamin d (ergocalciferol) oral capsule (Drisdol) Tier 1 1.25 mg (50000 ut) vitamin k1 injection solution 1 mg/0.5ml, Tier 1 10 mg/ml Water Soluble Vitamins ASCOR INTRAVENOUS SOLUTION Tier 3 25000 MG/50ML ascorbic acid injection solution 500 Tier 1 mg/ml POTABA ORAL CAPSULE 500 MG Tier 3 pyridoxine hcl injection solution 100 Tier 1 mg/ml thiamine hcl injection solution 100 mg/ml Tier 1

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323 MedPerform Medium Formulary 01/01/2021

324 Index

1st base...... 292 active-cyclobenzaprine...... 273 AFREZZA...... 63 1ST MEDX-PATCH/ LIDOCAINE..160 active-ketoprofen...... 144 AFSTYLA...... 185 1st tier unifine pentips...... 223 active-prep kit i...... 144 AFTERA...... 127 1st tier unifine pentips plus...... 223 active-prep kit ii...... 144 AGAMATRIX ULTRA-THIN 1st tier unilet comfortouch...... 202 active-prep kit iii...... 144 LANCETS...... 203 7T LIDO...... 160 active-prep kit iv...... 140 aif #2 drug preparation kit...... 144 A.A.G.C. KIT IN TERODERM...... 140 active-prep kit v...... 141 aif #3 drug preparation kit...... 144 abacavir sulfate...... 101 active-tramadol...... 140 AIMOVIG...... 256 abacavir sulfate-lamivudine...... 101 ACUNOL...... 261 aimsco twist lancets 32g...... 203 abacavir-lamivudine-zidovudine.... 101 acyclovir...... 106, 148 AIMSCO TWIST LANCETS 33G...203 ABILIFY MYCITE...... 101 ACZONE...... 134 AKLIEF...... 135 abiraterone acetate...... 88 ADA...... 290 ak-poly-bac...... 279 ABOUTTIME PEN NEEDLE...... 223 ADACEL...... 311 AKTEN...... 282 acamprosate calcium...... 297 adapalene...... 134 AKYNZEO...... 69 acarbose...... 57 adapalene-benzoyl per-clindamy...134 ALA SCALP...... 148 ACCU-CHEK FASTCLIX adapalene-benzoyl per-niacinam...134 ala-cort...... 148 LANCETS...... 202 adapalene-benzoyl peroxide...... 135 ALA-QUIN...... 141 ACCU-CHEK MULTICLIX ADASUVE...... 99 ALBA-DERM...... 292 LANCETS...... 202 adc/f (0.5mg/ml)...... 267 albendazole...... 30 ACCU-CHEK SAFE-T PRO ADDERALL XR...... 3 albuterol sulfate...... 38 LANCETS...... 202 ADDYI...... 298 albuterol sulfate er...... 38 ACCU-CHEK SOFTCLIX adefovir dipivoxil...... 105 albuterol sulfate hfa...... 38 LANCETS...... 202 ADEMPAS...... 114 alclometasone dipropionate...... 148 acd formula a...... 42 ADVAIR DISKUS...... 38 alcoh-wipe...... 222 ACD-A NOCLOT-50...... 43 ADVAIR HFA...... 38 ALDACTAZIDE...... 169 acebutolol hcl...... 107 ADVANCED ALLERGY ALECENSA...... 89 acetaminophen-codeine...... 25 COLLECTION...... 148 alegenix...... 160 acetaminophen-codeine #2...... 25 advanced base plus...... 292 alendronate sodium...... 170 acetaminophen-codeine #3...... 25 advanced mobile lancet...... 202 ALFERON N...... 94 acetaminophen-codeine #4...... 25 ADVATE...... 185 alfuzosin hcl er...... 183 acetazolamide...... 168 ADVOCATE INSULIN PEN ALINIA...... 83 acetazolamide er...... 168 NEEDLES...... 223 aliskiren fumarate...... 81 acetic acid...... 183, 287 ADVOCATE INSULIN SYRINGE ALKINDI SPRINKLE...... 129 acetylcysteine...... 134 ...... 223, 224 ALLEVYN GENTLE...... 164 ACIPHEX SPRINKLE...... 313 ADVOCATE LANCETS...... 203 allopurinol...... 184 acitretin...... 145 ADVOCATE LANCETS 30G...... 203 almotriptan malate...... 256 ACTEMRA...... 11 ADVOCATE SAFETY LANCETS.. 203 ALOCRIL...... 285 ACTEMRA ACTPEN...... 11 ADVOCATE SAFETY LANCETS ALOMIDE...... 285 acti-lance 28g...... 202 26G...... 203 ALORA...... 177 acti-lance lite lancets 28g...... 202 adynovate...... 185 alosetron hcl...... 180 acti-lance special lancets 17g...... 202 AEMCOLO...... 82 ALPAWASH...... 292 acti-lance universal 23g...... 202 AFINITOR...... 89 ALPHAGAN P...... 279 ACTIMMUNE...... 94 AFINITOR DISPERZ...... 89 ALPHANATE/VWF active fe...... 192 AFIRMELLE...... 116 COMPLEX/HUMAN...... 185 active injection kl-3...... 129 AFLURIA QUADRIVALENT...... 318 ALPHANINE SD...... 185

I-1 alprazolam...... 32 amoxicillin...... 289 ARYMO ER...... 18 alprazolam er...... 32 amoxicillin-pot clavulanate...... 290 ARZOL SILVER NIT ALPRAZOLAM INTENSOL...... 32 amoxicillin-pot clavulanate er...... 290 APPLICATORS...... 148 alprazolam xr...... 32 amphetamine sulfate...... 3 ASCOMP-CODEINE...... 25 ALPROLIX...... 185 amphetamine-dextroamphetamine....3 ASCOR...... 323 ALREX...... 282 ampicillin...... 289 ascorbic acid...... 323 ALTABAX...... 141 ANACAINE...... 160 ASHLYNA...... 117 ALTACAINE...... 282 ANADROL-50...... 28 ASMANEX (120 METERED ALTADERM...... 292 anagrelide hcl...... 189 DOSES)...... 35 ALTAFRIN...... 278 ANA-LEX...... 29 ASMANEX (14 METERED ALTAVERA...... 116 ANALPRAM-HC...... 29 DOSES)...... 36 ALTOPREV...... 74 ANASCORP...... 288 ASMANEX (30 METERED ALTRENO...... 135 anastrozole...... 88 DOSES)...... 36 ALUNBRIG...... 89 ANDRODERM...... 28 ASMANEX (60 METERED alyacen 1/35...... 116 ANGELIQ...... 175 DOSES)...... 36 alyacen 7/7/7...... 116 ANHYDROUS BASE...... 292 ASMANEX (7 METERED DOSES)..37 ALYQ...... 114 anhydrous cream base...... 292 ASMANEX HFA...... 37 AMABELZ...... 175 ANNOVERA...... 127 aspirin...... 15, 16 amantadine hcl...... 95 anodynerx...... 160 aspirin 81...... 15 ambrisentan...... 114 ANORO ELLIPTA...... 38 aspirin adult...... 15 amcinonide...... 148, 149 anticoagulant cit dext soln a...... 43 aspirin adult low strength...... 15 AMD FOAM DRESSING...... 200 anucort-hc...... 30 aspirin childrens...... 15 AMD FOAM DRESSING ANUSOL-HC...... 30 aspirin low dose...... 15 TOPSHEET...... 200 ANZEMET...... 68 aspirin low strength...... 15 AMELUZ...... 145 APADAZ...... 25 aspirin-dipyridamole er...... 189 AMETHIA...... 116 APOKYN...... 95 assure comfort lancets 28g...... 203 AMETHIA LO...... 116 APPTRIM...... 166 ASSURE HAEMOLANCE PLUS AMETHYST...... 116 APPTRIM-D...... 166 HIGH...... 203 amiloride hcl...... 169 apraclonidine hcl...... 279 ASSURE HAEMOLANCE PLUS amiloride-hydrochlorothiazide...... 169 aprepitant...... 69 LOW...... 203 aminoacetic acid...... 183 APRI...... 116 ASSURE HAEMOLANCE PLUS AMINOAMRMS...... 276 APTIOM...... 44 MICRO...... 203 aminocaproic acid...... 195 APTIVUS...... 101 ASSURE HAEMOLANCE PLUS AMINORELIEFRMS...... 276 AQUACEL AG BURN...... 164 NORMAL...... 203 amiodarone hcl...... 33 AQUALANCE LANCETS 30G...... 203 ASSURE HAEMOLANCE PLUS AMITIZA...... 179 ARAKODA...... 85 PED...... 203 amitriptyline hcl...... 56 ARALAST NP...... 307 ASSURE ID INSULIN SAFETY AMLODIPINE BES+SYRSPEND ARANELLE...... 116 SYR...... 224 SF...... 109 ARANESP (ALBUMIN FREE)190, 191 ASSURE ID SAFETY PEN amlodipine besy-benazepril hcl...... 79 ARCALYST...... 11 NEEDLES...... 224 amlodipine besylate...... 109 ARCAPTA NEOHALER...... 39 ASSURE LANCE LANCETS...... 203 amlodipine besylate-valsartan...... 79 ARGYLE STERILE SALINE...... 183 ASSURE LANCE LANCETS 21G..203 amlodipine-atorvastatin...... 112 ARGYLE STERILE WATER...... 264 ASSURE LANCE PLUS SAFETY amlodipine-olmesartan...... 79 ARIKAYCE...... 9 25G...... 203 amlodipine-valsartan-hctz...... 80 aripiprazole...... 101 ASSURE LANCE PLUS SAFETY ammonium lactate...... 158 armodafinil...... 6 30G...... 203 AMNESTEEM...... 135 ARMOUR THYROID...... 310 ASSURE LANCE SAFETY amoxapine...... 57 ARNUITY ELLIPTA...... 35 LANCET 28G...... 204 amoxicill-clarithro-lansopraz...... 316 ARTISS...... 195 ASSURE LANCETS...... 204

I-2 ASTAGRAF XL...... 262 AZASAN...... 262 BD PEN NEEDLE MINI U/F...... 226 ASTAMED MYO...... 166 AZASITE...... 279 BD PEN NEEDLE NANO 2ND ASTRINGYN...... 195 azathioprine...... 262 GEN...... 226 ATABEX EC...... 269 azelaic acid...... 163 BD PEN NEEDLE NANO U/F...... 226 ATABEX OB...... 269 azelaic acid-niacinamide...... 135 BD PEN NEEDLE ORIGINAL U/F.226 atazanavir sulfate...... 101 azelastine hcl...... 275, 285 BD PEN NEEDLE SHORT U/F...... 226 atenolol...... 107 azelastine-fluticasone...... 275 BD SAFETYGLIDE INSULIN ATENOLOL+SYRSPEND SF...... 107 AZELEX...... 135 SYRINGE...... 226 atenolol-chlorthalidone...... 80 azeschew prenatal/postnatal...... 269 BD SAFETY-LOK INSULIN atomoxetine hcl...... 5 azithromycin...... 199 SYRINGE...... 226 atorvastatin calcium...... 74 AZOPT...... 285 BD VEO INSULIN SYR U/F atovaquone...... 83 AZURETTE...... 117 1/2UNIT...... 226 atovaquone-proguanil hcl...... 85 BACIGUENT...... 279 BD VEO INSULIN SYRINGE U/F..226 ATRAPRO CP...... 164 bacitracin...... 279 BEKYREE...... 117 ATREVIS HYDROGEL...... 292 bacitracin-polymyxin b...... 279 belladonna alkaloids-opium...... 312 ATROPEN...... 311 bacitra-neomycin-polymyxin-hc..... 282 BELSOMRA...... 197 atropine sulfate...... 278 baclofen...... 140, 274 benazepril hcl...... 77 ATROVENT HFA...... 34 bacteriostatic water(benz alc)...... 291 benazepril-hydrochlorothiazide...... 80 AUBAGIO...... 299 BALCOLTRA...... 117 BENEFIX...... 185 AUBRA...... 117 balsalazide disodium...... 179 BENLYSTA...... 265 AUBRA EQ...... 117 BALVERSA...... 89 benz per-clind-niacin-tretin...... 135 aurora lancet super thin 30g...... 204 BALZIVA...... 117 BENZEPRO...... 135 aurora lancet thin 23g...... 204 BANZEL...... 44 BENZEPRO SHORT CONTACT...135 aurora pen needles...... 224 BAQSIMI ONE PACK...... 60 benzhydrocodone-acetaminophen.. 25 aurora unifine pentips...... 224 BAQSIMI TWO PACK...... 60 benzoin compound...... 163 AUROVELA 1.5/30...... 117 BARACLUDE...... 105 benzo-lidocaine-tetracaine...... 160 AUROVELA 1/20...... 117 BAXDELA...... 178 benzonatate...... 131 AUROVELA 24 FE...... 117 BAYER ADVANCED ASPIRIN benzoyl perox-hydrocortisone...... 135 AUROVELA FE 1.5/30...... 117 REG ST...... 16 benzoyl peroxide...... 135 AUROVELA FE 1/20...... 117 BAYER ASPIRIN...... 16 benzoyl peroxide-erythromycin...... 135 AURYXIA...... 181 BAYER LOW DOSE...... 16 benzphetamine hcl...... 5 AUSTEDO...... 299 BD AUTOSHIELD...... 224 benztropine mesylate...... 95 AUTOJECT 2...... 224 BD AUTOSHIELD DUO...... 224 BERINERT...... 188 AUXIPRO VANISHING...... 292 BD INSULIN SYR ULTRAFINE II.. 224 BESER...... 149 AVAILNEX...... 166 BD INSULIN SYRINGE...... 224, 225 BESIVANCE...... 280 AVANDIA...... 65 BD INSULIN SYRINGE HALF- BETADINE OPHTHALMIC PREP. 280 AVAR CLEANSER...... 135 UNIT...... 225 BETALOAN SUIK...... 129 AVAR-E EMOLLIENT...... 135 BD INSULIN SYRINGE betamethasone dipropionate...... 149 AVAR-E GREEN...... 135 MICROFINE...... 225 betamethasone dipropionate aug.. 149 aveidaoxia...... 163 BD INSULIN SYRINGE U/F...... 225 betamethasone diprop-minoxidil....159 AVIANE...... 117 BD INSULIN SYRINGE U/F betamethasone valerate...... 149 avidoxy...... 308 1/2UNIT...... 225 BETASERON...... 299 AVITA...... 135 BD INSULIN SYRINGE U-500...... 225 betaxolol hcl...... 107, 277 AVONEX PEN...... 299 BD INSULIN SYRINGE bethanechol chloride...... 317 AVONEX PREFILLED...... 299 ULTRAFINE...... 225 BETIMOL...... 277 AXONA...... 166 BD LANCET ULTRAFINE 30G...... 204 BETOPTIC-S...... 277 AYUNA...... 117 BD LANCET ULTRAFINE 33G...... 204 bexarotene...... 94 AYVAKIT...... 89 BD MICROTAINER LANCETS...... 204 BEXSERO...... 317 azalgia...... 264 BD PEN NEEDLE MICRO U/F...... 226 bhi uri-control...... 261

I-3 bicalutamide...... 88 bumetanide...... 169 CAPRELSA...... 90 BIDIL...... 112 BUNAVAIL...... 27 capsule ezeefit #0 clear...... 290 bi-est 50:50...... 176 BUPAP...... 14 capsule ezeefit #00 clear...... 290 bi-est 80:20 progesterone...... 176 bupivacaine hcl...... 199 captopril...... 77 bi-est progest-testosterone...... 176 buprenorphine...... 27 captopril-hydrochlorothiazide...... 80 BIEST/PROGESTERONE...... 176 buprenorphine hcl...... 27 CARBAGLU...... 173 BIJUVA...... 176 buprenorphine hcl-naloxone hcl...... 27 carbamazepine...... 44 BIKTARVY...... 102 bupropion hcl...... 53 carbamazepine er...... 44 bimatoprost...... 286 bupropion hcl er (smoking det)...... 302 CARBATROL...... 44 bi-mix...... 112 bupropion hcl er (sr)...... 53 carbidopa...... 95 BIOFREQUENCY INSOLES...... 222 bupropion hcl er (xl)...... 53 carbidopa-levodopa...... 96 BIOGUARD GAUZE SPONGES... 200 buspirone hcl...... 32 carbidopa-levodopa er...... 96 BIOGUARD ISLAND DRESSINGS200 butalbital-acetaminophen...... 15 carbidopa-levodopa-entacapone..... 96 BIOGUARD NON-ADHERENT butalbital-apap-caff-cod...... 26 carbinoxamine maleate...... 70 DRESSING...... 200, 201 butalbital-apap-caffeine...... 15 CARBOGEL 940...... 292 bio-statin...... 69, 70 butalbital-asa-caff-codeine...... 26 CARBOHOL 940...... 292 bisoprolol fumarate...... 108 butalbital-aspirin-caffeine...... 15 CARDIOVID PLUS...... 276 bisoprolol-hydrochlorothiazide...... 80 butorphanol tartrate...... 27 CARDIZEM LA...... 109 BLEPHAMIDE...... 282 BYDUREON...... 62 CARDURA XL...... 183 BLEPHAMIDE S.O.P...... 282 BYDUREON BCISE...... 62 CAREFINE PEN NEEDLES.. 226, 227 BLISOVI 24 FE...... 117 BYETTA 10 MCG PEN...... 62 careone insulin syringe...... 227 BLISOVI FE 1.5/30...... 117 BYETTA 5 MCG PEN...... 62 careone lancet thin 23g...... 204 BLISOVI FE 1/20...... 118 BYSTOLIC...... 108 careone lancet ultra thin 28g...... 204 BOOSTRIX...... 311 cabergoline...... 175 careone unifine pentips...... 227 bosentan...... 114 CABLIVI...... 189 careone unifine pentips plus...... 227 BOSULIF...... 90 CABOMETYX...... 90 CARESENS LANCETS...... 204 bp 10-1...... 135 CADIRAMD...... 160 CARETOUCH INSULIN SYRINGE227 bp cleansing wash...... 135 caffeine citrate...... 5 CARETOUCH PEN NEEDLES...... 227 bp wash...... 135 CALCIFOL...... 258 CARETOUCH SAFETY LANCETS204 BPROTECTED PEDIA IRON...... 195 calcipotriene...... 145, 146 CARETOUCH SAFETY LANCETS BRAFTOVI...... 90 calcipotriene-betameth diprop...... 149 26G...... 204 bravura all-in-one...... 292 calcipotriene-clobetasol prop...... 150 CARETOUCH TWIST LANCETS BREO ELLIPTA...... 39 calcitonin (salmon)...... 170 28G...... 204 BREZTRI AEROSPHERE...... 39 CALCITRENE...... 146 CARETOUCH TWIST LANCETS briellyn...... 118 calcitriol...... 173 30G...... 204 BRILINTA...... 189 calcium acetate...... 181 CARETOUCH TWIST LANCETS brimonidine tartrate...... 279 calcium acetate (phos binder)...... 181 33G...... 204 brimonidine-dorzolamide...... 279 calcium-folic acid plus d...... 258 carisoprodol...... 274 BRIVIACT...... 44 CALQUENCE...... 90 carisoprodol-aspirin-codeine...... 274 BROMFED DM...... 131 CAMILA...... 128 carteolol hcl...... 277 bromfenac sodium (once-daily)..... 285 CAMRESE...... 118 CARTIA XT...... 109 bromocriptine mesylate...... 95, 96 CAMRESE LO...... 118 carvedilol...... 107 BROMSITE...... 285 candesartan cilexetil...... 78 carvedilol phosphate er...... 107 BROVANA...... 39 candesartan cilexetil-hctz...... 80 CAVAREST...... 265 BRUKINSA...... 90 cantharidin...... 159 CAVERJECT...... 112 budesonide...... 37, 129 capcof...... 131 CAVERJECT IMPULSE...... 112 budesonide er...... 129 capecitabine...... 86 CAYA...... 201 bullseye mini safety lancets...... 204 CAPEX...... 150 CAYSTON...... 84 BULLSEYE SAFETY LANCETS....204 CAPLYTA...... 98 CAZIANT...... 118

I-4 cbd4 freeze pump maximum str.... 160 cholestyramine light...... 72 CLEVER CHOICE COMFORT EZ cefaclor...... 115 chondroitin sulfate...... 285 ...... 161, 227 cefaclor er...... 115 chorionic gonadotropin...... 171 CLEVER CHOICE LANCETS 21G 205 cefadroxil...... 115 CHROMAGEN...... 192 CLEVER CHOICE LANCETS 23G 205 cefdinir...... 115 CHRYSADERM DAY...... 292 CLEVER CHOICE LANCETS 28G 205 cefixime...... 115, 116 CHRYSADERM NIGHT...... 292 CLICKFINE PEN NEEDLES...... 227 cefpodoxime proxetil...... 116 CICLODAN...... 141 clickfine pen needles...... 228 cefprozil...... 115 ciclopirox...... 141 CLIMARA PRO...... 176 cefuroxime axetil...... 115 ciclopirox olamine...... 142 CLINDACIN ETZ...... 136 cela base...... 292 ciclopirox treatment...... 142 CLINDACIN-P...... 136 celecoxib...... 11 ciclopirox-clobetasol...... 147 CLINDAGEL...... 136 CELONTIN...... 52 ciclopirox-clobetasol-sal acid...... 147 clindamy-benzoyl per-niacinam..... 136 CEM-UREA...... 158 ciclopirox-salicylic acid...... 147 clindamycin hcl...... 84 CENTANY...... 141 CIFEREX...... 192 clindamycin palmitate hcl...... 84 CENTANY AT...... 141 cifrazol...... 192 clindamycin phos-benzoyl perox....136 CENTRATEX...... 192 cilostazol...... 189 clindamycin phos-niacinamide...... 136 cephalexin...... 115 CILOXAN...... 280 clindamycin phosphate...... 136, 320 CERDELGA...... 189 CIMDUO...... 102 clindamycin-niacin-tretinoin...... 137 CEROVEL...... 158 cimetidine...... 313 CLINDESSE...... 320 CERVIDIL...... 288 cimetidine hcl...... 313 clind-niacin-spironolac-tretin...... 137 CETACAINE...... 160 cimetidine-lido-salicylic acid...... 159 CLINOIN...... 137 cetirizine hcl...... 71 CIMZIA...... 180 CLINPRO 5000...... 265 CETRAXAL...... 287 CIMZIA PREFILLED...... 180 clobazam...... 43 CETROTIDE...... 172 CIMZIA STARTER KIT...... 180 clobetasol prop emollient base...... 150 cevimeline hcl...... 267 cinacalcet hcl...... 173 clobetasol propionate...... 150 CHANTIX...... 302 CINRYZE...... 188 clobetasol propionate e...... 150 CHANTIX CONTINUING MONTH CIPRO...... 178 clobetasol propionate emulsion..... 150 PAK...... 302 CIPRO HC...... 287 clobetasol prop-levocetirizine...... 150 CHANTIX STARTING MONTH ciprofloxacin hcl...... 178, 280 clobetasol prop-niacinamide...... 150 PAK...... 302 ciprofloxacin-dexamethasone...... 287 clobetavix...... 151 CHARLOTTE 24 FE...... 118 citalopram hydrobromide...... 54 clocortolone pivalate...... 151 CHATEAL...... 118 CITRANATAL 90 DHA...... 269 CLODAN...... 151 CHATEAL EQ...... 118 CITRANATAL ASSURE...... 269 CLODERM...... 151 CHEMET...... 67 CITRANATAL B-CALM...... 269 clomiphene citrate...... 171 CHENODAL...... 179 CITRANATAL BLOOM...... 269 clomipramine hcl...... 57 childrens aspirin...... 16 CITRANATAL BLOOM DHA...... 269 clonazepam...... 43 childrens aspirin low strength...... 16 CITRANATAL DHA...... 269 clonidine...... 79 chlooxia...... 150 CITRANATAL HARMONY...... 269 clonidine hcl...... 79 chlordiazepoxide hcl...... 32 CITRANATAL MEDLEY...... 269 clonidine hcl er...... 5 chlordiazepoxide-amitriptyline...... 298 CITRANATAL RX...... 269 clopidogrel bisulfate...... 189 chlordiazepoxide-clidinium...... 312 CLARAVIS...... 136 clorazepate dipotassium...... 32 chlorhexidine gluconate...... 101, 265 CLARINEX-D 12 HOUR...... 132 clotrimazole...... 142, 265 chloroquine phosphate...... 85 clarithromycin...... 199 clotrimazole-betamethasone...... 142 chlorpromazine hcl...... 100 clarithromycin er...... 199 CLOVIQUE...... 261 chlorthalidone...... 169 CLEANLET LANCETS 28G...... 204 clozapine...... 99 chlorzoxazone...... 274 clemastine fumarate...... 70 c-nate dha...... 269 CHOLBAM...... 179 CLENPIQ...... 198 COAGADEX...... 185 cholecal df...... 192 CLEOCIN...... 320 COAGUCHEK LANCETS...... 205 cholestyramine...... 72, 73 CLEVER CHEK LANCETS...... 205 COARTEM...... 85

I-5 cocaine hcl...... 275 CORLANOR...... 115 cvs aspirin...... 16 codeine sulfate...... 18 CORTANE-B...... 151 cvs aspirin adult low dose...... 16 coditussin ac...... 132 CORTIC-ND...... 287 cvs folic acid...... 190 coditussin dac...... 132 CORTIFOAM...... 29 cvs lancets 21g...... 205 COLAZAL...... 180 cortisone acetate...... 129 cvs lancets micro thin 33g...... 205 colchicine...... 184 CORTISPORIN...... 141 cvs lancets original...... 205 colchicine-probenecid...... 184 CORTISPORIN-TC...... 287 cvs lancets thin 26g...... 205 COLCIGEL...... 261 CORVITA 150...... 193 cvs lancets ultra thin 30g...... 205 colesevelam hcl...... 73 CORVITE 150...... 193 cvs lancets ultra-thin 30g...... 205 colestipol hcl...... 73 corvite fe...... 193 cvs nicotine...... 302 COMBIGAN...... 277 COSENTYX...... 146 cvs nicotine polacrilex...... 302 COMBIPATCH...... 176 COSENTYX (300 MG DOSE)...... 146 cvs ultra thin lancets...... 205 COMBIVENT RESPIMAT...... 39 COSENTYX SENSOREADY (300 cyanocobalamin...... 190 COMETRIQ (100 MG DAILY MG)...... 146 CYCLAFEM 1/35...... 118 DOSE)...... 90 COSENTYX SENSOREADY PEN.146 CYCLAFEM 7/7/7...... 118 COMETRIQ (140 MG DAILY COTELLIC...... 90 cyclo/gaba 10/300...... 275 DOSE)...... 90 COVARYX...... 176 cyclobenzaprine hcl...... 274 COMETRIQ (60 MG DAILY DOSE).90 COVARYX HS...... 176 CYCLOMYDRIL...... 278 COMFORT ASSIST INSULIN CREON...... 168 cyclopentolate hcl...... 278 SYRINGE...... 228 CRESEMBA...... 70 CYCLOPHENE RAPIDPAQ...... 274 comfort assured lancets 28g...... 205 CRINONE...... 322 cyclophosphamide...... 86 comfort assured lancets 33g...... 205 CRIXIVAN...... 102 cycloserine...... 86 COMFORT EZ INSULIN SYRINGE cromolyn sodium...... 34, 179, 286 CYCLOSET...... 62 ...... 228, 229 CRYSELLE-28...... 118 cyclosporine...... 262 COMFORT EZ MICRO PEN CURITY AMD ANTIMICROBIAL CYCLOSPORINE IN KLARITY...... 281 NEEDLES...... 229 SPNGE...... 201 cyclosporine modified...... 262 COMFORT EZ PEN NEEDLES.....229 CURITY AMD ANTIMICROBIAL cyproheptadine hcl...... 72 COMFORT EZ SHORT PEN STRIP...... 201 CYRED...... 118 NEEDLES...... 229 CURITY HYPERTONIC NACL CYRED EQ...... 118 comfort lancets...... 205 STRIP...... 164 CYSTADANE...... 173 COMPLERA...... 102 CURITY IODOFORM PACKING CYSTADROPS...... 286 complete natal dha...... 269 STRIP...... 201 CYSTAGON...... 182 completenate...... 269 CURITY NACL DRESSING 6"X6- CYSTARAN...... 286 COMPRO...... 100 3/4"...... 164 CYTOMEL...... 310 CO-NATAL FA...... 269 CURITY STERILE SALINE...... 183 CYTOTINE...... 276 CONCEPT DHA...... 270 CURITY WOUND CLOSURE cytra k crystals...... 182 CONCEPT OB...... 270 1/2"X4"...... 201 dalfampridine er...... 299 CONCERTA...... 6 CURITY WOUND CLOSURE DALIRESP...... 35 CONDYLOX...... 159 1/4"X1.5"...... 201 danazol...... 28 CONJUPRI...... 109 CURITY WOUND CLOSURE dandelion...... 7 constulose...... 198 1/4"X3"...... 201 dantrolene sodium...... 274 CONTRAST ALLERGY PREMED CURITY WOUND CLOSURE dapsone...... 84, 137 PACK...... 129 1/4"X4"...... 201 dapsone-niacinamide...... 137 CONTRAVE...... 5 CURITY WOUND CLOSURE dapsone-niacinamide-spironolac...137 CONVENIENCE PAK...... 301 1/8"X3"...... 201 darifenacin hydrobromide er...... 316 COPAXONE...... 299 CUTAQUIG...... 288 DASETTA 1/35...... 118 COPIKTRA...... 90 cutis plus...... 292 DASETTA 7/7/7...... 118 CORDRAN...... 151 CUVITRU...... 288 DAURISMO...... 87 CORIFACT...... 185 CUVPOSA...... 312 DAYSEE...... 118

I-6 DAYTRANA...... 6 dexamethasone sodium phosphate DILANTIN INFATABS...... 51 DDAVP RHINAL TUBE...... 174 ...... 283 DILATRATE-SR...... 31 DEBACTEROL...... 265 DEXCOM G6 RECEIVER...... 205 diltiazem hcl...... 110 DEBLITANE...... 128 DEXILANT...... 314 diltiazem hcl er...... 110 DECADRON...... 129 dexmethylphenidate hcl...... 6 diltiazem hcl er beads...... 109 deferasirox...... 67 dexmethylphenidate hcl er...... 6 diltiazem hcl er coated beads 109, 110 deferasirox granules...... 67 DEXONTO 0.4%...... 129 dilt-xr...... 110 deferiprone...... 67 dexpanthenol...... 179 dimethyl fumarate...... 299 deferoxamine mesylate...... 67 DEXTENZA...... 283 dimethyl fumarate starter pack...... 299 DELESTROGEN...... 177 dextroamphetamine sulfate...... 3 dimoxia...... 137 DELSTRIGO...... 102 dextroamphetamine sulfate er...... 3 diphen...... 71 DELYLA...... 118 dfs/ms/menth/cap pak...... 144 di-phen...... 71 demeclocycline hcl...... 308 DIACOMIT...... 44 diphenhydramine hcl...... 71 DEMEROL...... 18 diadimaxia...... 137 diphenoxylate-atropine...... 66, 67 DENTA 5000 PLUS...... 266 diaoxia...... 137 dipyridamole...... 189 DENTAGEL...... 266 diasdimaxia...... 137 disopyramide phosphate...... 33 deoxia...... 137 diasoxia...... 137 disulfiram...... 297 DEPAKOTE...... 52 DIASTAT ACUDIAL...... 43 DIURIL...... 169 DEPAKOTE ER...... 52 DIASTAT PEDIATRIC...... 43 divalproex sodium...... 52, 53 DEPAKOTE SPRINKLES...... 52 DIATHRIVE LANCET ULTRA THIN divalproex sodium er...... 52 DEPLIN 15...... 166 30...... 205 DIVIGEL...... 177 DEPLIN 7.5...... 166 DIATHRIVE LANCETS...... 205 dofetilide...... 33 DEPO-ESTRADIOL...... 177 DIATHRIVE PEN NEEDLE...... 229 DOJOLVI...... 276 DEPO-SUBQ PROVERA 104...... 128 diazepam...... 32, 33, 43 donepezil hcl...... 297 dermacinrx analgesic combopak..... 11 DIAZEPAM INTENSOL...... 32 DOPTELET...... 191 DERMACINRX AZENASE PAK.....275 diazoxide...... 60 DORAL...... 197 DERMACINRX DUOPATCH diclofenac epolamine...... 144 dorzolamide hcl...... 286 PHARMAPAK...... 161 diclofenac potassium...... 11 dorzolamide hcl-timolol mal...... 277 DERMACINRX NEUROTRAL diclofenac sodium....12, 144, 145, 286 dorzolamide hcl-timolol mal pf...... 277 PHARMAPAK...... 161 diclofenac sodium er...... 12 DOTTI...... 177 DERMACINRX PUREFOLIX...... 193 diclofenac-misoprostol...... 12 double pm...... 283 dermacinrx surgical combopak...... 163 diclofenac-na hyaluron-niacin...... 145 DOVATO...... 102 DERMACINRX TOPICAL BASE....291 dicloxacillin sodium...... 290 doxazosin mesylate...... 79 DERMAZENE...... 142 DICOPANOL FUSEPAQ...... 70 doxepin hcl...... 57, 197 DESCOVY...... 102 DICOPANOL RAPIDPAQ...... 71 doxercalciferol...... 173 desflurane...... 182 dicyclomine hcl...... 312 doxycycline hyclate...... 308 desipramine hcl...... 57 didanosine...... 102 doxycycline monohydrate...... 308, 309 desloratadine...... 71 diethylpropion hcl...... 5 doxylamine-pyridoxine...... 69 desmopressin ace spray refrig...... 174 diethylpropion hcl er...... 5 draxace...... 137 desmopressin acetate...... 174 DIFFERIN...... 137 draxace lotion cleanser...... 137 desmopressin acetate spray...... 175 DIFICID...... 200 DRCAPS SIZE 0...... 290 desogestrel-ethinyl estradiol...... 118 DIFIL-G FORTE...... 34 DRCAPS SIZE 00...... 290 desonide...... 151 diflunisal...... 16 DRCAPS SIZE 1...... 290 desoximetasone...... 152 difmetioxrime...... 142 DRITHO-CREME HP...... 146 desvenlafaxine succinate er...... 55 DIGITEK...... 111 drixece...... 137 dexamethasone...... 129 DIGOX...... 112 DRIZALMA SPRINKLE...... 55 DEXAMETHASONE INTENSOL... 129 digoxin...... 112 dronabinol...... 69 dihydroergotamine mesylate..255, 256 DILANTIN...... 51, 52

I-7 DROPLET INSULIN SYRINGE EASY TOUCH INSULIN SAFETY ed-spaz...... 312 ...... 229, 230 SYR...... 232 EDURANT...... 102 DROPLET LANCETS ULTRA EASY TOUCH INSULIN SYRINGE EEMT...... 176 THIN 30G...... 206 ...... 232 EEMT HS...... 176 DROPLET MICRON...... 230 EASY TOUCH LANCETS 21G...... 206 efavirenz...... 102 DROPLET PEN NEEDLES....230, 231 EASY TOUCH LANCETS 23G...... 206 efavirenz-emtricitab-tenofovir...... 102 DROPLET PERSONAL LANCETS EASY TOUCH LANCETS 26G...... 206 efavirenz-lamivudine-tenofovir...... 102 30G...... 206 EASY TOUCH LANCETS 28G...... 206 EFFER-K...... 259 dropsafe safety pen needles...... 231 EASY TOUCH LANCETS EGRIFTA...... 172 drospiren-eth estrad-levomefol...... 119 28G/TWIST...... 206 EGRIFTA SV...... 172 drospirenone-ethinyl estradiol...... 119 EASY TOUCH LANCETS 30G...... 206 eha...... 161 DROXIA...... 189 EASY TOUCH LANCETS ELESTRIN...... 177 drug mart lancets thin 26g...... 206 30G/TWIST...... 206 eletriptan hydrobromide...... 257 DRUG MART ON-THE-GO EASY TOUCH LANCETS 32G...... 206 ELFOLATE...... 166 LANCET 30G...... 206 EASY TOUCH LANCETS ELIGARD...... 88 drug mart unifine pentips...... 231 32G/TWIST...... 206 ELINEST...... 119 drug mart unifine pentips plus...... 231 EASY TOUCH LANCETS ELIQUIS...... 41 DRUG MART UNILET LANCETS 33G/TWIST...... 207 ELIQUIS DVT/PE STARTER 28G...... 206 EASY TOUCH PEN NEEDLES PACK...... 41 DRUG MART UNILET LANCETS ...... 232, 233 ELITE-OB...... 270 30G...... 206 EASY TOUCH SAFETY LANCETS ELIXOPHYLLIN...... 40 DRUG MART UNILET LANCETS 21G...... 207 ELLA...... 127 33G...... 206 EASY TOUCH SAFETY LANCETS ELMIRON...... 183 DRYSOL...... 163 23G...... 207 ELOCTATE...... 186 DSUVIA...... 18 EASY TOUCH SAFETY LANCETS ELURYNG...... 127 dual complex formula 1 kit...... 144 26G...... 207 EMBRACE LANCETS ULTRA DUAVEE...... 176 EASY TOUCH SAFETY LANCETS THIN 30G...... 207 DUET DHA 400...... 270 28G...... 207 EMCYT...... 88 DUET DHA BALANCED...... 270 EASY TOUCH SAFETY PEN EMEND...... 69 duloxetine hcl...... 55 NEEDLES...... 233 EMFLAZA...... 130 DUOBRII...... 152 EASY TOUCH SHEATHLOCK EMGALITY...... 256 DUODOTE...... 67 SYRINGE...... 233 EMGALITY (300 MG DOSE)...... 256 DUOPA...... 96 EASY TWIST & CAP LANCETS....207 EMOLIVAN...... 293 DUPIXENT...... 158 EASYGEL...... 266 EMOQUETTE...... 119 DURABASE...... 293 eceoxia...... 137 EMSAM...... 53 DURABASE ADVANCED...... 293 ec-naproxen...... 12 emtricitabine...... 102 durachol...... 193 econazole nitrate...... 142 emtricitabine-tenofovir df...... 102 DUREZOL...... 283 econazole nitrate-niacinamide...... 142 EMTRIVA...... 102 dutasteride...... 183 ECONTRA EZ...... 127 EMVERM...... 30 dutasteride-tamsulosin hcl...... 183 ECONTRA ONE-STEP...... 127 enalapril maleate...... 77 DYANAVEL XR...... 3 ECOZA...... 142 enalapril-hydrochlorothiazide...... 80 easy comfort insulin syringe...... 231 EC-RX DHEA...... 8 ENBREL...... 14 easy comfort lancets...... 206 ec-rx estradiol...... 177 ENBREL MINI...... 14 easy comfort lancets twist top...... 206 ec-rx progesterone...... 296 ENBREL SURECLICK...... 14 easy comfort pen needles...... 231 ec-rx testosterone...... 28 ENCARE...... 320 easy glide pen needles...... 231 ECZEMOL...... 261 ENDARI...... 189 EASY TOUCH FLIPLOCK EDARBI...... 78 ENDEAVORRX...... 261 INSULIN SY...... 231 EDARBYCLOR...... 80 ENDOCET...... 26 EDEX...... 112 ENDOMETRIN...... 322

I-8 ENGERIX-B...... 318 equapax/atorvastatin/coq10...... 74 EVEKEO ODT...... 3, 4 ENLYTE...... 166 equapax/ibuprofen/minrex...... 9 everolimus...... 90, 263 enovarx-amitriptyline...... 116 EQUETRO...... 98 EVOTAZ...... 102 enovarx-baclofen...... 140 ergocal...... 322 EVRYSDI...... 276 enovarx-cyclobenzaprine hcl...... 274 ergocalciferol...... 323 EXCILON AMD DRAIN SPONGES enovarx-diclofenac sodium...... 144 ergoloid mesylates...... 301 ...... 201 enovarx-ibuprofen...... 144 ERGOMAR...... 256 EXEL COMFORT POINT INSULIN enovarx-lidocaine hcl...... 161 ergotamine-caffeine...... 255 SYR...... 233 enovarx-naproxen...... 144 ERIVEDGE...... 87 EXEL COMFORT POINT PEN enovarx-tramadol...... 140 ERLEADA...... 88 NEEDLE...... 233, 234 enoxaparin sodium...... 41 erlotinib hcl...... 90 EXELDERM...... 142 ENPRESSE-28...... 119 ERRIN...... 128 exemestane...... 88 ENSKYCE...... 119 ery...... 137 EXODERM...... 142 ENSPRYNG...... 262 ERY-TAB...... 199 exotic-hc...... 287 ENSTILAR...... 152 ERYTHROCIN STEARATE...... 199 E-Z JECT LANCET MICRO-THIN entacapone...... 95 erythromycin...... 137, 200, 280 33G...... 207 entecavir...... 105 erythromycin base...... 200 E-Z JECT LANCET SUPER THIN ENTERAGAM...... 166 erythromycin ethylsuccinate...... 200 30G...... 207 ENTEREG...... 181 ESBRIET...... 307 E-Z JECT LANCETS...... 207 ENTRESTO...... 112 escitalopram oxalate...... 54 E-Z JECT LANCETS 21G...... 207 enulose...... 180 ESGIC...... 15 E-Z JECT LANCETS THIN 26G.... 207 ENVARSUS XR...... 263 ESKATA...... 147 EZ SMART BLOOD GLUCOSE enzadyne...... 168 esomeprazole magnesium...... 314 LANCETS...... 207 ENZOCLEAR...... 137 ESPEROCT...... 186 EZALLOR SPRINKLE...... 74 EPANED...... 78 ESPUMIL...... 293 ezetimibe...... 76 EPCLUSA...... 105 essentra wipes 9x9"...... 163 ezetimibe-simvastatin...... 72 EPIDIOLEX...... 45 est estrogens-methyltest...... 176 EZ-LETS LANCETS 21G...... 207 EPIDUO FORTE...... 137 est estrogens-methyltest ds...... 176 EZ-LETS LANCETS 26G...... 208 EPIFOAM...... 152 est estrogens-methyltest hs...... 176 EZ-LETS LANCETS 28G...... 208 epinastine hcl...... 286 ESTARYLLA...... 119 EZ-LETS LANCETS 30G...... 208 epinephrine...... 322 estazolam...... 197 FA-8...... 190 epinephrine hcl (nasal)...... 276 estradiol...... 177, 178, 321 fagron ls plus...... 293 EPITOL...... 45 estradiol valerate...... 178 fagron natural...... 293 EPIVIR HBV...... 105 estradiol-norethindrone acet...... 176 fagron supreme...... 293 eplerenone...... 81 ESTRING...... 321 FALESSA...... 119 EPOGEN...... 191 estriol-progesterone micro...... 176 FALMINA...... 119 eq aspirin...... 16 eszopiclone...... 197 famciclovir...... 106 eq aspirin low dose...... 16 ethacrynic acid...... 169 famotidine...... 313 eq childrens aspirin...... 16 ethambutol hcl...... 86 FANAPT...... 99 eq nicotine...... 302, 303 ethosuximide...... 52 FANAPT TITRATION PACK...... 99 eq nicotine polacrilex...... 302, 303 ethoxia...... 137 FANATREX FUSEPAQ...... 45 eq nicotine step 3...... 303 ethynodiol diac-eth estradiol...... 119 FARXIGA...... 65 eql aspirin low dose...... 16 etodolac...... 12 FARYDAK...... 90 eql color lancets 21g...... 207 etodolac er...... 12 FASENRA PEN...... 34 eql color lancets micro 33g...... 207 etonogestrel-ethinyl estradiol...... 127 favipiravir...... 107 eql insulin syringe...... 233 etoposide...... 94 FAYOSIM...... 119 eql nicotine polacrilex...... 303 EUCRISA...... 163 fbl kit...... 144 eql super thin lancets 30g...... 207 EUTHYROX...... 310 FC FEMALE CONDOM...... 201 eql thin lancets 26g...... 207 EVAMIST...... 178 FC2 FEMALE CONDOM...... 201

I-9 febuxostat...... 184 FIRST-ATENOLOL...... 108 fluorouracil...... 145 FEIBA...... 186 FIRST-BACLOFEN...... 274 fluoxetine hcl...... 54 felbamate...... 49 FIRST-LANSOPRAZOLE...... 314 fluoxetine hcl (pmdd)...... 301 FELBATOL...... 49 FIRST-METRONIDAZOLE...... 82 fluphenazine hcl...... 100 felodipine er...... 110 FIRST-MOUTHWASH BLM...... 265 FLURA-DROPS...... 259 FEM PH...... 320 FIRST-OMEPRAZOLE...... 314 flurandrenolide...... 153 FEMCAP...... 201 FIRST-PROGESTERONE VGS.... 322 flurazepam hcl...... 197 FEMRING...... 321 FIRVANQ...... 83 flurbiprofen...... 12 FEMYNOR...... 119 FITALITE...... 293 flurbiprofen sodium...... 286 fenofibrate...... 73 FLAC...... 288 flutamide...... 88 fenofibrate micronized...... 73 FLAREX...... 283 fluticasone propionate...... 153, 275 fenofibric acid...... 73 FLAVOR BLEND...... 291 fluvastatin sodium...... 75 fentanyl...... 18, 19 flavor plus...... 291 fluvastatin sodium er...... 74 fentanyl citrate...... 18 flavor sweet...... 291 fluvoxamine maleate...... 54 fentanyl citrate-nacl...... 18 flavor sweet-sf...... 291 fluvoxamine maleate er...... 54 FERIVA 21/7...... 193 flavoxate hcl...... 317 FLUZONE QUADRIVALENT...... 319 FERIVAFA...... 193 flecainide acetate...... 33 FML...... 283 ferocon...... 193 flolipid...... 74 FML FORTE...... 283 ferotrinsic...... 193 FLORIVA...... 258, 269 FOAMIL...... 291 FERRALET 90...... 193 FLORIVA PLUS...... 268 folate...... 190 ferraplus 90...... 193 FLOVENT DISKUS...... 37 folic acid...... 190 FERRIPROX...... 67 FLOVENT HFA...... 37, 38 folic d3...... 193 FERRIPROX TWICE-A-DAY...... 67 FLUAD...... 318 FOLI-D...... 193 FERROCITE PLUS...... 193 FLUARIX QUADRIVALENT...... 318 folite...... 193 FERRO-PLEX HEMATINIC...... 193 FLUBLOK QUADRIVALENT...... 318 FOLIVANE-F...... 193 FERROTRIN...... 193 FLUCELVAX QUADRIVALENT.....318 FOLIVANE-OB...... 270 ferrous sulfate...... 195 fluconazole...... 70 FOLIVANE-PLUS...... 193 FETZIMA...... 56 flucon-ibuprof-itracon-terbina...... 142 FOLIXAPURE...... 193 FETZIMA TITRATION...... 56 flucytosine...... 70 FOLLISTIM AQ...... 171 FIASP...... 63 fludrocortisone acetate...... 131 FOLTREXYL...... 193 FIASP FLEXTOUCH...... 63 FLULAVAL QUADRIVALENT...... 319 foltrin...... 193 FIASP PENFILL...... 63 FLUMIST QUADRIVALENT...... 319 folvik-d...... 193 FIBRICOR...... 73 flunisolide...... 275 FOLVITE-D...... 193 FIFTY50 PEN NEEDLES...... 234 fluocinolone acet-niacinamide...... 152 FOLVITE-FE...... 193 FIFTY50 SAFETY SEAL fluocinolone acetonide...152, 153, 288 fondaparinux sodium...... 41, 42 LANCETS...... 208 fluocinolone acetonide body...... 152 FORA LANCETS...... 208 FIFTY50 SUPERIOR COMFORT fluocinolone acetonide scalp...... 153 FORTEO...... 170 SYR...... 234 fluocinonide...... 153 FOSAMAX PLUS D...... 170 FIFTY50 UNILET LANCETS 33G..208 fluocinonide emulsified base...... 153 fosamprenavir calcium...... 102 FINACEA...... 163 FLUORABON...... 258 fosfomycin tromethamine...... 84 finasteride...... 184 FLUORIDEX...... 266 fosinopril sodium...... 78 finasteride-minoxidil...... 159 FLUORIDEX DAILY RENEWAL....266 fosinopril sodium-hctz...... 80 FINE 30...... 208 FLUORIDEX ENHANCED FOSRENOL...... 181 FINGERSTIX LANCETS...... 208 WHITENING...... 266 FOSTEUM...... 166 FINTEPLA...... 45 FLUORIDEX SENSITIVITY FOSTEUM PLUS...... 166 FIRDAPSE...... 85 RELIEF...... 266 FOVEX...... 166 FIRMAGON...... 88 fluoritab...... 258, 259 FRAGMIN...... 42 FIRMAGON (240 MG DOSE)...... 88 fluorometholone...... 283 freds pharmacy unifine pentip+..... 234 FIRST - METOPROLOL...... 108 FLUOROPLEX...... 145 freds pharmacy unifine pentips...... 234

I-10 freds pharmacy unilet lanc 28g...... 208 GEL-FLOW...... 195 glycine...... 183 freds pharmacy unilet lanc 30g...... 208 GELFOAM-JMI POWDER...... 195 glycine urologic...... 183 freedom adaptaderm...... 293 GELFOAM-JMI SPONGE...... 195 glycopyrrolate...... 312 freedom derma serum...... 293 GELNIQUE...... 316 GLYDO...... 161 FREEDOM DERMA-D...... 293 gemfibrozil...... 73 GLYXAMBI...... 58 FREEDOM DERMA-N...... 293 GEMMILY...... 119 gnp adult aspirin low strength...... 16 FREESTYLE INSULINX TEST...... 166 gen7t...... 161 gnp aspirin...... 16 FREESTYLE LANCETS...... 208 gen7t plus...... 161 gnp clickfine pen needles...... 235 FREESTYLE LITE TEST...... 166 GENADUR...... 163 gnp folic acid...... 190 FREESTYLE PRECISION INS generlac...... 180 gnp insulin syringe...... 236 SYR...... 234 GENGRAF...... 263 gnp lancets...... 209 FREESTYLE PRECISION NEO GENTAK...... 280 gnp lancets 21g...... 209 TEST...... 166 gentamicin sulfate...... 141, 280 gnp lancets micro thin 33g...... 209 FREESTYLE TEST...... 166 GENTEEL BUTTERFLY TOUCH gnp lancets super thin 30g...... 209 FREESTYLE UNISTICK II LANCET...... 208 gnp lancets thin...... 209 LANCETS...... 208 GENTLE-LET GP LANCETS...... 208 gnp lancets thin 26g...... 209 frovatriptan succinate...... 257 GENTLE-LET LANCETS...... 208 gnp micro thin lancets 33g...... 209 FULPHILA...... 191 GENVOYA...... 103 gnp nicotine...... 303 fungimez...... 142 GIALAX...... 198 gnp nicotine mini...... 303 furosemide...... 169 GIANVI...... 119 gnp nicotine polacrilex...... 303 FUSION PLUS...... 194 GILENYA...... 299 gnp super thin lancets 30g...... 209 FUZEON...... 103 GILOTRIF...... 90 gnp ulticare pen needles...... 236 FYAVOLV...... 176 GILPHEX TR...... 132 gnp ultra com insulin syringe...... 236 FYCOMPA...... 43 GILTUSS TR...... 132 GOJJI STERILE LANCETS...... 209 g tussin ac...... 132 GIMOTI...... 179 GONAL-F...... 171 GABADONE...... 167 glatiramer acetate...... 299 GONAL-F RFF...... 171 gabapentin...... 45 GLATOPA...... 299 GONAL-F RFF REDIJECT...... 171 GABITRIL...... 51 GLEOSTINE...... 86 goodsense aspirin...... 16 GALAFOLD...... 173 glimepiride...... 66 goodsense aspirin adult low st...... 16 galantamine hydrobromide...... 297 glipizide...... 66 goodsense clickfine pen needle.....236 galantamine hydrobromide er...... 297 glipizide er...... 66 goodsense color lancets 33g...... 209 GALAXTRA...... 167 glipizide xl...... 66 goodsense lancets 26g univ...... 209 GALZIN...... 261 glipizide-metformin hcl...... 57 goodsense lancets 30g...... 209 GAMMAGARD...... 289 global ease inject pen needles...... 234 goodsense lancets 30g univ...... 209 GAMMAKED...... 289 global easy glide insulin syr...... 235 goodsense lancets 33g...... 209 GAMUNEX-C...... 289 global easy glide pen needles...... 235 goodsense lancets 33g univ...... 209 ganirelix acetate...... 172 global inject ease insulin syr...... 235 goodsense nicotine...... 303 GARDASIL 9...... 319 global inject ease lancets 28g...... 208 GOODSENSE PEN NEEDLE gatifloxacin...... 280 global inject ease lancets 30g...... 208 PENFINE...... 236 GATTEX...... 181 global insulin syringes...... 235 goprelto...... 275 GAVILYTE-C...... 198 GLOPERBA...... 184 GORDOFILM...... 159 GAVILYTE-G...... 198 GLUCAGEN HYPOKIT...... 61 GPL PAK...... 301 GAVILYTE-H...... 198 GLUCOCOM LANCETS 28G...... 208 grafco silver nit applicator...... 148 GAVILYTE-N WITH FLAVOR GLUCOCOM LANCETS 30G...... 209 granisetron hcl...... 68 PACK...... 198 GLUCOCOM LANCETS 33G...... 209 GRANIX...... 191 GAVRETO...... 90 GLUCOPRO INSULIN SYRINGE..235 GRASTEK...... 7 GEBAUERS SPRAY AND glyburide...... 66 griseofulvin microsize...... 70 STRETCH...... 161 glyburide micronized...... 66 griseofulvin ultramicrosize...... 70 GELFILM...... 285 glyburide-metformin...... 58 guaiatussin ac...... 132

I-11 guaifenesin ac...... 132 H-E-B INCONTROL UNIFINE HUMIRA PEN-PSOR/UVEIT guaifenesin dac...... 132 PENTIP...... 237 STARTER...... 10 guaifenesin-codeine...... 132 HEMADY...... 130 HUMULIN 70/30...... 64 guanfacine hcl...... 79 HEMANGEOL...... 108 HUMULIN 70/30 KWIKPEN...... 64 guanfacine hcl er...... 5 hematinic plus vit/minerals...... 194 HUMULIN N...... 64 GUARDIAN REAL-TIME hematinic/folic acid...... 194 HUMULIN N KWIKPEN...... 64 REPLACE PED...... 209 HEMATOGEN FA...... 194 HUMULIN R...... 64 GVOKE HYPOPEN 1-PACK...... 61 HEMLIBRA...... 186 HUMULIN R U-500 GVOKE HYPOPEN 2-PACK...... 61 HEMMOREX-HC...... 30 (CONCENTRATED)...... 64 GVOKE PFS...... 61 HEMOCYTE PLUS...... 194 HUMULIN R U-500 KWIKPEN...... 64 GYNAZOLE-1...... 321 HEMOCYTE-F...... 194 hyalucil-4...... 145 HAEGARDA...... 188 hemocyte-plus...... 194 hyaluronate-niacinam-tretinoin...... 137 HAEMOLANCE...... 210 HEMOFIL M...... 186 hyaluronate-niacin-tacrolimus...... 159 HAEMOLANCE LOW FLOW heparin (porcine) in nacl...... 42 HYCAMTIN...... 94 LANCETS...... 210 heparin lock flush...... 42 hydralazine hcl...... 82 HAEMOLANCE PLUS...... 210 heparin sodium (porcine)...... 42 hydrochlorothiazide...... 169 HAEMOLANCE PLUS HIGH heparin sodium (porcine) pf...... 42 hydrocod polst-cpm polst er...... 132 FLOW...... 210 heparin sodium lock flush...... 42 hydrocodone bitartrate er...... 19 HAEMOLANCE PLUS LOW FLOW HEPLISAV-B...... 319 hydrocodone-acetaminophen...... 26 ...... 210 hepmed...... 42 hydrocodone-homatropine...... 131 HAEMOLANCE PLUS MAX FLOW HETLIOZ...... 197 hydrocodone-ibuprofen...... 26 ...... 210 HISTEX-AC...... 132 hydrocortisone...... 29, 130, 155 HAEMOLANCE PLUS PEDIATRIC HIZENTRA...... 289 hydrocortisone (perianal)...... 30 FLOW...... 210 hm aspirin...... 16, 17 hydrocortisone ace-pramoxine 29, 154 HAILEY 1.5/30...... 120 hm folic acid...... 190 hydrocortisone acetate...... 30 HAILEY 24 FE...... 120 hm nicotine...... 304 hydrocortisone butyr lipo base...... 154 HAILEY FE 1.5/30...... 120 hm nicotine polacrilex...... 303, 304 hydrocortisone butyrate...... 154, 155 HAILEY FE 1/20...... 120 HM ULTICARE INSULIN hydrocortisone valerate...... 155 halcinonide...... 154 SYRINGE...... 237 hydrocortisone-acetic acid...... 288 halobetasol propionate...... 154 HM ULTICARE SHORT PEN hydrocortisone-iodoquinol...... 142 HALOG...... 154 NEEDLES...... 237 hydrocort-pramoxine (perianal)...... 29 haloperidol...... 99 HOMATROPAIRE...... 278 HYDROFERA BLUE FOAM haloperidol lactate...... 99 HUMALOG...... 64 DRESSING...... 164 HARVONI...... 106 HUMALOG JUNIOR KWIKPEN...... 63 HYDROFERA BLUE READY HAVRIX...... 319 HUMALOG KWIKPEN...... 63 FOAM...... 164 healthwise insulin syr/needle...... 236 HUMALOG MIX 50/50...... 63 HYDROGEL...... 293 healthwise micron pen needles..... 236 HUMALOG MIX 50/50 KWIKPEN....63 hydromet...... 131 healthwise mini pen needles...... 236 HUMALOG MIX 75/25...... 64 hydromorphone hcl...... 19 healthwise pen needles...... 236 HUMALOG MIX 75/25 KWIKPEN....64 hydromorphone hcl er...... 19 healthwise short pen needles...... 237 HUMATE-P...... 186 hydromorphone hcl-nacl...... 19, 20 healthwise unifine pentips...... 237 HUMCO BASE PAIN MGMT...... 293 hydroxocobalamin acetate...... 190 healthy accents unifine pentip...... 237 HUMIRA...... 11 hydroxychloroquine sulfate...... 85 healthy accents unilet lancets...... 210 HUMIRA PEDIATRIC CROHNS hydroxyurea...... 94 HEATHER...... 128 START...... 10 hydroxyzine hcl...... 32 h-e-b incontrol lancets 28g...... 210 HUMIRA PEN...... 10 hydroxyzine pamoate...... 32 h-e-b incontrol lancets 30g...... 210 HUMIRA PEN-CD/UC/HS HYLAFEM...... 262 h-e-b incontrol lancets 33g...... 210 STARTER...... 10 HYOPHEN...... 82 h-e-b incontrol pen needles...... 237 HUMIRA PEN-PS/UV/ADOL HS hyoscyamine sulfate...... 312 START...... 10 hyoscyamine sulfate er...... 312

I-12 hyoscyamine sulfate sl...... 312 INOVA 8/2 ACNE CONTROL JAKAFI...... 91 hyosyne...... 312 THERAPY...... 138 JANTOVEN...... 41 HYPERSAL...... 134 INQOVI...... 89 JANUMET...... 58 HYPERTENSA...... 167 INREBIC...... 91 JANUMET XR...... 58 HYQVIA...... 289 insulin syringe...... 237 JANUVIA...... 61 HYSINGLA ER...... 20 insulin syringe/needle...... 237, 238 JARDIANCE...... 65 HY-VEE LANCETS...... 210 insulin syringe-needle u-100...... 238 JASMIEL...... 120 hy-vee thin lancets...... 210 insupen pen needles...... 238 JATENZO...... 28 ibandronate sodium...... 170 INSUPEN SENSITIVE...... 238 JELMYTO...... 89 IBRANCE...... 90 INSUPEN ULTRAFIN...... 238 JENCYCLA...... 128 IBU...... 12 INTEGRA F...... 194 JENTADUETO...... 58 IBUPAK...... 12 INTEGRA PLUS...... 194 JENTADUETO XR...... 58, 59 ibuprofen...... 12 INTELENCE...... 103 JINTELI...... 176 icatibant acetate...... 188 INTRAROSA...... 320 JIVI...... 186 ICLUSIG...... 91 INTRON A...... 94 JOLESSA...... 120 IDELVION...... 186 INTROVALE...... 120 J-TIP KIT W/VIAL ADAPTERS...... 238 IDHIFA...... 91 INVELTYS...... 283 JULEBER...... 120 IFE-BIMIX 30/1...... 112 INVIRASE...... 103 JULUCA...... 103 IFEREX 150 FORTE...... 194 iodine strong...... 259 JUNEL 1.5/30...... 120 ILEVRO...... 286 iodoquimez-hc...... 142 JUNEL 1/20...... 120 imatinib mesylate...... 91 iodoquinol-hc-ketoconazole...... 142 JUNEL FE 1.5/30...... 120 IMBRUVICA...... 91 iodoquinol-hydrocortisone-aloe...... 142 JUNEL FE 1/20...... 120 imioxia...... 142 IOPIDINE...... 279 JUNEL FE 24...... 120 imipramine hcl...... 57 ipratropium bromide...... 34, 275 JUXTAPID...... 76 imipramine pamoate...... 57 ipratropium-albuterol...... 39 JYNARQUE...... 175 imiquimod...... 159 irbesartan...... 78 K.B.G.L IN TERODERM...... 144 imiquimod-levocetirizin-niacin...... 145 irbesartan-hydrochlorothiazide...... 80 KAITLIB FE...... 120 imiquimod-levocet-tretinoin...... 145 IRESSA...... 91 KALETRA...... 103 IMPAVIDO...... 82 iron supplement childrens...... 195 KALLIGA...... 120 IMVEXXY MAINTENANCE PACK.321 IROSPAN 24/6...... 194 KALYDECO...... 307 IMVEXXY STARTER PACK...... 321 ISENTRESS...... 103 KAPSPARGO SPRINKLE...... 108 IN TOUCH STERILE LANCETS ISENTRESS HD...... 103 KARBINAL ER...... 71 30G...... 210 ISIBLOOM...... 120 KARIVA...... 120 INATAL GT...... 270 isoflurane...... 182 KATERZIA...... 110 INBRIJA...... 96 isoniazid...... 86 KELNOR 1/35...... 121 INCASSIA...... 128 ISOPTO ATROPINE...... 278 KELNOR 1/50...... 121 INCRELEX...... 173 isosorbide dinitrate...... 31 KENDALL ALGINATE 12" ROPE.. 164 INCRUSE ELLIPTA...... 34 isosorbide mononitrate...... 31 KENDALL ALGINATE DRESS indapamide...... 169 isosorbide mononitrate er...... 31 2"X2"...... 164 INDOCIN...... 12 isotretinoin...... 138 KENDALL ALGINATE DRESS indomethacin...... 12 isoxsuprine hcl...... 113 4"X4"...... 164 indomethacin er...... 12 isradipine...... 110 KENDALL ALGINATE DRESS INGREZZA...... 299 ISTURISA...... 170 4"X8"...... 164 inject-ease...... 237 ithoxia...... 138 KENDALL HYDROGEL GAUZE INLYTA...... 91 itraconazole...... 70 2"X2"...... 165 INOVA...... 138 ivermectin...... 30 KENDALL HYDROGEL GAUZE INOVA 4/1 ACNE CONTROL ivermectin-metronidazol-niacin...... 163 4"X4"...... 165 THERAPY...... 138 IXINITY...... 186 KENDALL HYDROGEL GAUZE JAIMIESS...... 120 4"X8"...... 165

I-13 KENDALL HYDROGEL WOUND KORLYM...... 61 lancets super thin 28g...... 211 DRESS...... 165 KOSELUGO...... 91 lancets thin...... 211 KEPPRA...... 45 KOVALTRY...... 187 LANCETS ULTRA FINE...... 211 KEPPRA XR...... 45 kp folic acid...... 190 LANCETS ULTRA THIN...... 211 KERALYT SCALP...... 159 K-PHOS...... 259 lancets ultra thin 30g...... 211 KERLIX AMD ANTIMICROBIAL....201 K-PHOS NO 2...... 182 LANOXIN...... 112 KERLIX AMD SUPER SPONGES.201 K-PRIME...... 260 lansoprazole...... 314, 315 KESIMPTA...... 276 KRINTAFEL...... 85 lanthanum carbonate...... 181 ketamine hcl...... 182 KROGER HEALTHPRO LANCET LANTUS...... 64 ketoconazole...... 70, 142, 143 26G...... 210 LANTUS SOLOSTAR...... 64 ketoconazole-hydrocortisone...... 143 kroger insulin syringe...... 239 lapatinib ditosylate...... 91 KETODAN...... 143 kroger lancets...... 210 LARIN 1.5/30...... 121 KETOPHENE RAPIDPAQ...... 144 kroger lancets 21g...... 211 LARIN 1/20...... 121 ketoprofen...... 12 kroger lancets micro thin 33g...... 211 LARIN 24 FE...... 121 ketoprofen er...... 12 kroger lancets super thin...... 211 LARIN FE 1.5/30...... 121 ketorolac tromethamine kroger lancets thin...... 211 LARIN FE 1/20...... 121 ...... 12, 13, 144, 286 kroger lancets thin 26g...... 211 LARISSIA...... 121 KEVEYIS...... 168 kroger lancets ultrathin 30g...... 211 latanoprost...... 286 KINERET...... 11 kroger pen needles...... 239 latanoprost-timolol maleate...... 277 kinney lancets...... 210 K-TAB...... 260 LATUDA...... 98 kinney thin lancets...... 210 K-TAN PLUS...... 194 lavare wound wash...... 165 kinray insulin syringe...... 238 KURVELO...... 121 LAYOLIS FE...... 121 KIONEX...... 264 KYLEENA...... 128 LDL CARE...... 167 KISQALI (200 MG DOSE)...... 91 KYNMOBI...... 96 leader insulin syringe...... 239 KISQALI (400 MG DOSE)...... 91 L.E.T...... 161 LEADER UNIFINE PENTIPS...... 239 KISQALI (600 MG DOSE)...... 91 labetalol hcl...... 107 LEADER UNIFINE PENTIPS PLUS KISQALI FEMARA (400 MG LACRISERT...... 277 ...... 239 DOSE)...... 89 lactated ringers...... 264 LEENA...... 121 KISQALI FEMARA (600 MG lactic acid...... 158 leflunomide...... 14 DOSE)...... 89 lactic acid e...... 158 LENVIMA (10 MG DAILY DOSE).... 91 KISQALI FEMARA(200 MG DOSE) 89 lactojen...... 66 LENVIMA (12 MG DAILY DOSE).... 91 KITABIS PAK...... 9 lactulose...... 199 LENVIMA (14 MG DAILY DOSE).... 91 KLARITY-A...... 280 lactulose encephalopathy...... 180 LENVIMA (18 MG DAILY DOSE).... 91 KLARITY-L...... 283 LAMICTAL...... 45 LENVIMA (20 MG DAILY DOSE).... 91 KLONOPIN...... 43 LAMICTAL ODT...... 45 LENVIMA (24 MG DAILY DOSE).... 92 KLOR-CON...... 260 LAMICTAL STARTER...... 46 LENVIMA (4 MG DAILY DOSE)...... 92 KLOR-CON 10...... 259 LAMICTAL XR...... 46 LENVIMA (8 MG DAILY DOSE)...... 92 KLOR-CON M10...... 260 lamivudine...... 103, 106 LESSINA...... 121 KLOR-CON M15...... 260 lamivudine-zidovudine...... 103 letrozole...... 88 KLOR-CON M20...... 260 lamotrigine...... 46 lets...... 199 KLOR-CON SPRINKLE...... 260 lamotrigine er...... 46 leucovorin calcium...... 94 KLOR-CON/EF...... 260 lamotrigine starter kit-blue...... 47 LEUKERAN...... 86 KLS QUIT2...... 304 lamotrigine starter kit-green...... 47 LEUKINE...... 191 KLS QUIT4...... 304 lamotrigine starter kit-orange...... 47 leuprolide acetate...... 88 kmart valu insulin syringe 29g...... 238 LAMPIT...... 83 leuprolide acetate-bupivacaine...... 88 kmart valu insulin syringe 30g...... 238 lancets...... 211 levalbuterol hcl...... 39 KOATE...... 186 lancets 28g...... 211 levalbuterol tartrate...... 39 KOATE-DVI...... 187 lancets 30g...... 211 levatio...... 161 KOGENATE FS...... 187 lancets micro thin 33g...... 211 LEVEMIR...... 65

I-14 LEVEMIR FLEXTOUCH...... 64 LIOPEN ABSORPTION LORBRENA...... 92 levetiracetam...... 47 ENHANCING...... 293 lormate...... 167 levetiracetam er...... 47 liothyronine sodium...... 310 LORTAB...... 26 levobunolol hcl...... 277 lipo cream base...... 293 LORYNA...... 122 levocarnitine...... 173 LIPOCREAM BASE...... 293 losartan potassium...... 79 levocarnitine sf...... 173 LIPOFEN...... 73 losartan potassium-hctz...... 80 levocetirizine dihydrochloride...... 71 lipofoam rx...... 293 LOTEMAX...... 283 levofloxacin...... 178, 280 lipolayer...... 293 LOTEMAX SM...... 283 LEVONEST...... 121 lipopen ultra base...... 293 loteprednol etabonate...... 283 levonorgest-eth est & eth est...... 121 liposomal heavy...... 293 lovastatin...... 75 levonorgest-eth estrad 91-day...... 121 liposomal regular...... 293 LOW-OGESTREL...... 122 levonorgestrel...... 127 LIPOZYME...... 293 loxapine succinate...... 99 levonorgestrel-ethinyl estrad..121, 122 lisinopril...... 78 LOZIBASE S...... 291 levonorg-eth estrad triphasic...... 122 lisinopril-hydrochlorothiazide...... 80 LO-ZUMANDIMINE...... 122 LEVORA 0.15/30 (28)...... 122 LISTER-V...... 167 LUCEMYRA...... 297 levorphanol tartrate...... 20 lite touch lancets...... 212 LUMIGAN...... 286 LEVO-T...... 310 LITETOUCH INSULIN SYRINGE LUPANETA PACK...... 173 levothyroxine sodium...... 310 ...... 239, 240 LUTERA...... 122 LEVOXYL...... 310 LITETOUCH LANCETS...... 212 LUZU...... 143 LEVULAN KERASTICK...... 145 LITETOUCH PEN NEEDLES...... 240 LYDEXA...... 162 LEXIVA...... 103 lithium carbonate...... 98 LYLLANA...... 178 LIALDA...... 180 lithium carbonate er...... 98 LYNPARZA...... 92 LIBERTY MEDICAL LANCETS..... 211 LITHOBID...... 98 LYRICA...... 47 LICART...... 144 LITHOSTAT...... 184 LYSODREN...... 88 LIDO GB-300...... 301 LIVALO...... 75 LYUMJEV...... 165 lidocaine...... 161 live better lancet super thin...... 212 LYUMJEV KWIKPEN...... 165, 166 lidocaine hcl...... 161, 265 live better lancet ultra thin...... 212 LYZA...... 128 lidocaine hcl urethral/mucosal...... 161 l-methylfolate forte...... 167 MACUTEK...... 167 lidocaine viscous hcl...... 265 l-methyl-mc nac...... 167 mafenide acetate...... 148 lidocaine-hydrocort (perianal)...... 29 LO LOESTRIN FE...... 122 MAGELLAN INSULIN SAFETY lidocaine-hydrocortisone ace...... 29 LOESTRIN 1.5/30 (21)...... 122 SYR...... 240 lidocaine-prilocaine...... 161 LOESTRIN 1/20 (21)...... 122 MAGNEBIND 400...... 259 lidocaine-tetracaine...... 161 LOESTRIN FE 1.5/30...... 122 malathion...... 164 lidocanna...... 162 LOESTRIN FE 1/20...... 122 maprotiline hcl...... 53 LIDOCORT...... 29 LOJAIMIESS...... 122 MARATHON MEDICAL PENTIPS.240 lido-epinephrine-tetracaine...... 162 LOKELMA...... 264 MAR-COF BP...... 132 lidopin...... 162 LOMAIRA...... 5 marlissa...... 122 lidostream...... 162 longs insulin syringe...... 240 MARNATAL-F...... 270 LIDOTHOL...... 162 longs lancets standard...... 212 MARPLAN...... 53 LIDTOPIC MAX...... 162 longs lancets thin...... 212 MARVONA SUIK...... 199 LIFESCAN UNISTIK 2...... 211 longs lancets ultra thin...... 212 MATULANE...... 94 LIFESCAN UNISTIK II LANCETS. 211 LONHALA MAGNAIR REFILL KIT.. 34 MATZIM LA...... 110 LILLOW...... 122 LONHALA MAGNAIR STARTER MAVENCLAD (10 TABS)...... 300 LIMBREL...... 167 KIT...... 34 MAVENCLAD (4 TABS)...... 300 LIMBREL250...... 167 LONSURF...... 89 MAVENCLAD (5 TABS)...... 300 LIMBREL500...... 167 loperamide hcl...... 67 MAVENCLAD (6 TABS)...... 300 lindane...... 164 lopinavir-ritonavir...... 103 MAVENCLAD (7 TABS)...... 300 linezolid...... 84 lorazepam...... 33 MAVENCLAD (8 TABS)...... 300 LINZESS...... 180 LORAZEPAM INTENSOL...... 33 MAVENCLAD (9 TABS)...... 300

I-15 MAVYRET...... 106 mefloquine hcl...... 85 methenamine mandelate...... 84 MAXICOMFORT II PEN NEEDLE.240 megestrol acetate...... 88, 296 METHERGINE...... 288 MAXI-COMFORT INSULIN MEIJER LANCETS...... 213 methimazole...... 309 SYRINGE...... 241 MEIJER LANCETS THIN...... 213 methitest...... 28 MAXI-COMFORT SAFETY PEN MEIJER LANCETS UNIVERSAL methocarbamol...... 274 NEEDLE...... 241 21G...... 213 methotrexate...... 86 MAXICOMFORT SYR 27G X 1/2".241 MEIJER LANCETS UNIVERSAL methotrexate (anti-rheumatic)...... 10 MAXIDEX...... 283 30G...... 213 methotrexate sodium...... 87 maxi-tuss ac...... 132 MEIJER LANCETS UNIVERSAL methotrexate sodium (pf)...... 87 maxi-tuss cd...... 132 33G...... 213 methoxsalen rapid...... 146 MAYZENT...... 300 meijer pen needles...... 241 methscopolamine bromide...... 312 m-clear wc...... 132 MEIJER SUPER THIN LANCETS. 213 methyldopa...... 79 me/naphos/mb/hyo1...... 82 MEKINIST...... 92 methyldopa-hydrochlorothiazide...... 80 meclizine hcl...... 68 MEKTOVI...... 92 methylergonovine maleate...... 288 meclofenamate sodium...... 13 MELODETTA 24 FE...... 122 methylphenidate hcl...... 7 medactiv...... 167 meloxicam...... 13 methylphenidate hcl er...... 7 medic insulin syringe...... 241 melphalan...... 86 methylphenidate hcl er (cd)...... 6 medichoice safety lancet...... 212 memantine hcl...... 297 methylphenidate hcl er (la)...... 7 medichoice safety lancet extra...... 212 memantine hcl er...... 297 methylprednisolone...... 130 medichoice safety lancet norm...... 212 MEMBRANEBLUE...... 285 methyltestosterone...... 28 medicine shoppe pen needles...... 241 MENACTRA...... 317 metoclopramide hcl...... 179 MEDIDERM...... 293 M-END PE...... 132 metolazone...... 169 MEDI-DERM/L-RX...... 162 MENEST...... 178 metoprolol succinate er...... 108 MEDI-DERM-RX...... 160 MENOPUR...... 171 metoprolol tartrate...... 108 MEDIHOL BASE...... 293 MENOSTAR...... 178 metoprolol-hydrochlorothiazide..80, 81 MEDIHONEY WOUND/BURN MENQUADFI...... 318 metronidazole...... 82, 163, 321 DRESSING...... 165 MENTAX...... 143 METRONIDAZOLE medi-patch rx...... 162 MENVEO...... 318 BENZO+SYRSPEND...... 82 MEDISENSE THIN LANCETS...... 212 meperidine hcl...... 20 metyrosine...... 78 MEDLANCE EXTRA 21G...... 212 meprobamate...... 32 mexiletine hcl...... 33 MEDLANCE LITE 25G...... 212 mercaptopurine...... 86 mezparox-hc...... 155 MEDLANCE PLUS EXTRA 21G....212 mesalamine...... 180 mezparox-hc forte...... 155 MEDLANCE PLUS LANCETS...... 212 mesalamine er...... 180 MI PASTE...... 222 MEDLANCE PLUS LITE 25G...... 212 mesalamine-cleanser...... 180 MI PASTE PLUS...... 222 MEDLANCE PLUS SPECIAL MESNEX...... 94 MIACALCIN...... 170 0.8MM...... 212 METADATE ER...... 6 MIBELAS 24 FE...... 123 MEDLANCE PLUS SUPERLITE METAFOLBIC PLUS...... 167 miconazole 3...... 321 30G...... 212 METAXALL CP...... 275 miconazole-zinc oxide-petrolat...... 143 MEDLANCE PLUS UNIVERSAL metaxalone...... 274 MICROCYN SKIN AND WOUND.. 165 21G...... 213 metformin hcl...... 60 MICRODOT PEN NEEDLE...... 241 MEDLANCE UNIVERSAL 21G...... 213 metformin hcl er...... 60 MICROGESTIN 1.5/30...... 123 MEDPREDKIT...... 130 metformin hcl er (osm)...... 60 MICROGESTIN 1/20...... 123 MEDROL...... 130 methadone hcl...... 20, 21 MICROGESTIN 24 FE...... 123 MEDROLOAN II SUIK...... 130 METHADONE HCL INTENSOL...... 20 MICROGESTIN FE 1.5/30...... 123 MEDROLOAN SUIK...... 130 METHADOSE...... 21 MICROGESTIN FE 1/20...... 123 MEDROX-RX...... 160 methamphetamine hcl...... 4 MICROLET LANCETS...... 213 medroxyprogesterone acetate methaver...... 167 midazolam hcl...... 197 ...... 128, 296 methazolamide...... 168 midazolam hcl (pf)...... 197 mefenamic acid...... 13 methenamine hippurate...... 84 MIDAZOLAM+SYRSPEND SF...... 197

I-16 midodrine hcl...... 322 morphine sulfate...... 22 n-acetyl-l-cysteine...... 277 mifepristone...... 175 morphine sulfate (concentrate)...... 21 nadolol...... 108 MIGERGOT...... 255 morphine sulfate er...... 22 NAFRINSE...... 259 miglitol...... 57 morphine sulfate er beads...... 21 NAFRINSE DAILY ACIDULATED. 266 miglustat...... 189 morphine sulfate-nacl...... 22 NAFRINSE DAILY/NEUTRAL...... 266 MIGRAINE PACK...... 255 mouth wash-gp...... 291 NAFRINSE DROPS...... 259 MILI...... 123 mouthwash-af...... 291 NAFRINSE WEEKLY...... 266 MILLIPRED...... 130 mouthwash-om...... 291 naftifine hcl...... 143 MILLIPRED DP 12-DAY...... 130 MOVANTIK...... 181 NAFTIN...... 143 MIMVEY...... 176 moxifloxacin hcl...... 178, 280 nalbuphine hcl...... 27 mineral oil heavy...... 199 moxifloxacin hcl (2x day)...... 280 naloxone hcl...... 67, 68 MINITRAN...... 31 mpd safety lancet 21g...... 213 naltrexone hcl...... 68 minocycline hcl...... 309 mpd safety lancet 23g...... 213 NAMENDA XR TITRATION PACK 298 minoxidil...... 82 mpd safety lancet 28g...... 213 NAMZARIC...... 298 minoxidil-progest-tretinoin...... 159 mpd safety lancet 30g...... 213 napro...... 144 MIRCERA...... 191 ms insulin syringe...... 242 naproxen...... 13 mirtazapine...... 53 MULPLETA...... 191 naproxen dr...... 13 MIRVASO...... 163 MULTAQ...... 33 naproxen sodium...... 13 misoprostol...... 316 MULTIBASE...... 293 naratriptan hcl...... 257 MITIGARE...... 184 MULTIGEN...... 194 NARCAN...... 68 MITOSOL...... 280 MULTIGEN FOLIC...... 194 NASCOBAL...... 190 mko melt dose pack...... 196 MULTIGEN PLUS...... 194 NATACHEW...... 270 mm aspirin...... 17 multi-vit/iron/fluoride...... 267 NATACYN...... 280 mm insulin syringe/needle...... 241 multivitamin/fluoride...... 267, 268 NATALVIT...... 270 MM PEN NEEDLES...... 241 multi-vitamin/fluoride...... 268 NATAZIA...... 123 MM TWIST LANCETS...... 213 multi-vitamin/fluoride/iron...... 267 nateglinide...... 65 M-M-R II...... 319 multivitamins/fluoride...... 268 NATPARA...... 170 m-natal plus...... 270 mupirocin...... 141 NATROBA...... 164 modafinil...... 7 mupirocin calcium...... 141 NATURE-THROID...... 310 moexipril hcl...... 78 MUSE...... 112 NAYZILAM...... 43 molindone hcl...... 100 MY CHOICE...... 127 NECON 0.5/35 (28)...... 123 mometasone furoate...... 156, 275 MY WAY...... 127 nefazodone hcl...... 54 MONDOXYNE NL...... 309 MYALEPT...... 173 NEOKE ALCAR...... 277 MONOJECT FLUSH SYRINGE.....260 MYCAPSSA...... 175 neoke bhb...... 167 MONOJECT INSULIN SYRINGE.. 242 mycophenolate mofetil...... 263 NEOKE MCT70...... 276 MONOJECT SODIUM CHLORIDE mycophenolate sodium...... 263 NEOKE RA LIPOIC...... 8 FLUSH...... 261 MYDAYIS...... 4 neomycin sulfate...... 9 MONOJECT ULTRA COMFORT myferon 150 forte...... 194 neomycin-bacitracin zn-polymyx....280 SYRINGE...... 242 MYGLUCOHEALTH LANCETS neomycin-polymyxin b gu...... 183 MONOLET LANCETS...... 213 30G...... 213 neomycin-polymyxin-dexameth..... 283 MONOLET OPD LANCETS...... 213 MYLERAN...... 86 neomycin-polymyxin-gramicidin.....280 MONOLETTOR SAFETY MYNATAL...... 270 neomycin-polymyxin-hc. 283, 287, 288 LANCETS...... 213 mynatal plus...... 270 neonatal + dha...... 270 MONO-LINYAH...... 123 mynatal-z...... 270 neonatal complete...... 270 MONONINE...... 187 MYORISAN...... 138 neonatal fe...... 270 monsels ferric subsulfate...... 196 MYRBETRIQ...... 317 NEONATAL PLUS...... 270 montelukast sodium...... 35 MYSOLINE...... 47 NEO-POLYCIN...... 280 morcin...... 262 MYTESI...... 66 NEO-POLYCIN HC...... 283 MORGIDOX...... 309 nabumetone...... 13 NEORAL...... 263

I-17 NEO-SYNALAR...... 141 NINLARO...... 92 NOVOEIGHT...... 187 NEOTUSS PLUS...... 132 nisoldipine er...... 111 NOVOFINE...... 242 NEPHRON FA...... 194 nitisinone...... 173 NOVOFINE AUTOCOVER...... 243 NERLYNX...... 92 NITRO-BID...... 31 NOVOFINE PLUS...... 243 NESTABS...... 270 NITRO-DUR...... 31 NOVOSEVEN RT...... 187 NESTABS DHA...... 270 nitrofurantoin...... 84 NOVOTWIST...... 243 NEUAC...... 138 nitrofurantoin macrocrystal...... 84 NOXAFIL...... 70 NEULASTA...... 191 nitrofurantoin monohyd macro...... 84 np #2 drug preparation kit...... 145 NEULASTA ONPRO...... 191 nitroglycerin...... 31 np thyroid...... 310 NEUPOGEN...... 191 NITROMIST...... 31 NUBEQA...... 88 NEUPRO...... 96 NITRO-TIME...... 31 NUCALA...... 34 NEUREPA...... 167 NITYR...... 174 NUCORT...... 156 NEURONTIN...... 47 NIVA-PLUS...... 270 NUCYNTA...... 22 NEVANAC...... 286 NIVESTYM...... 192 NUCYNTA ER...... 22 nevirapine...... 103 nizatidine...... 313 NUDROXIPAK M-15...... 13 nevirapine er...... 103 NOCDURNA...... 175 NUEDEXTA...... 301 NEW DAY...... 128 NOLIX...... 156 NUFERA...... 194 NEXAVAR...... 92 NORA-BE...... 128 NULEV...... 312 NEXAVIR...... 264 NORDIPEN 5 INJECTION DEVICE NUMBRINO...... 275 NEXIUM...... 315 ...... 242 NUMOISYN...... 267 NEXLETOL...... 77 NORDIPEN DELIVERY SYSTEM. 242 NUPLAZID...... 98, 99 NEXLIZET...... 72 NORDITROPIN FLEXPRO...... 172 NURTEC...... 256 NEXPLANON...... 128 norethin ace-eth estrad-fe...... 123 NUTRIDOX...... 309 niacin er (antihyperlipidemic)...... 76 norethindrone...... 128 NUTRIVIT...... 267 niacinamide-spironolactone...... 138 norethindrone acetate...... 296 NUVESSA...... 321 niacinamide-sulfacetamide...... 138 norethindrone acet-ethinyl est123, 124 NUWIQ...... 187 niacinamide-tacrolimus...... 159 norethindrone-eth estradiol...... 177 NUZYRA...... 308 niacinamide-tazarotene...... 138 norethin-eth estradiol-fe...... 124 NYAMYC...... 143 niacinamide-tretinoin...... 138 norgestimate-eth estradiol...... 124 NYMALIZE...... 111 niacinamide-triamcinolone acet..... 156 norgestim-eth estrad triphasic...... 124 nystatin...... 70, 143, 265 niacin-spironolacton-tretinoin...... 138 NORLYDA...... 128 nystatin-triamcinolone...... 143 NIACOR...... 77 NORLYROC...... 128 NYSTOP...... 143 nicardipine hcl...... 110 normal saline flush...... 261 OB COMPLETE...... 270 nicotine...... 304 NORPACE CR...... 33 OB COMPLETE PREMIER...... 270 nicotine mini...... 304 NORTHERA...... 322 OB COMPLETE/DHA...... 270 nicotine polacrilex...... 304 NORTREL 0.5/35 (28)...... 124 obizur...... 187 nicotine step 1...... 304 NORTREL 1/35 (21)...... 124 OBSTETRIX DHA...... 271 nicotine step 2...... 304 NORTREL 1/35 (28)...... 124 OBSTETRIX EC...... 271 nicotine step 3...... 304 NORTREL 7/7/7...... 124 OBSTETRIX ONE...... 271 NICOTROL...... 305 nortriptyline hcl...... 57 O-CAL PRENATAL...... 271 NICOTROL NS...... 305 NORVIR...... 103, 104 OCALIVA...... 179 nifedipine...... 110 NORWICH ASPIRIN...... 17 OCCLUVAN...... 294 nifedipine er...... 110 NOURIANZ...... 95 OCELLA...... 124 nifedipine er osmotic release...... 110 NOURILITE...... 293 octreotide acetate...... 175 NIFEREX...... 194 NOURIVAN ANTIOX BASE...... 293 ODACTRA...... 7 NIKKI...... 123 NOVA SAFETY LANCETS 23G.... 214 ODEFSEY...... 104 nilutamide...... 88 NOVA SAFETY LANCETS 28G.... 214 ODOMZO...... 87 nimodipine...... 110 NOVA SUREFLEX LANCETS...... 214 OFEV...... 307 NINJACOF-XG...... 133 NOVAREL...... 172 ofloxacin...... 178, 280, 287

I-18 olanzapine...... 100 ORA-BLEND SF...... 291 OXYCONTIN...... 23 olanzapine-fluoxetine hcl...... 298 ORACIT...... 182 oxymorphone hcl...... 23 olmesartan medoxomil...... 79 ORAFATE...... 267 oxymorphone hcl er...... 23 olmesartan medoxomil-hctz...... 81 ORALAIR...... 7 OXYTROL...... 317 olmesartan-amlodipine-hctz...... 81 ORALONE...... 267 OZEMPIC (0.25 OR 0.5 olopatadine hcl...... 275, 286 ORA-PLUS...... 291 MG/DOSE)...... 62 OMECLAMOX-PAK...... 316 ORA-SWEET...... 291 OZEMPIC (1 MG/DOSE)...... 62 omega-3 rx complete...... 72 ORA-SWEET SF...... 291 OZOBAX...... 274 OMEGA-3/D-3 WELLNESS PACK..72 ORAVIG...... 265 PACERONE...... 34 omega-3-acid ethyl esters...... 72 ORENCIA...... 14 PALFORZIA (12 MG DAILY omeprazole...... 315 ORENCIA CLICKJECT...... 14 DOSE)...... 8 OMEPRAZOLE+SYRSPEND SF ORENITRAM...... 113 PALFORZIA (120 MG DAILY ALKA...... 315 ORFADIN...... 174 DOSE)...... 8 omeprazole-sodium bicarbonate... 316 ORIAHNN...... 177 PALFORZIA (160 MG DAILY OMNIBASE...... 294 ORILISSA...... 172 DOSE)...... 8 OMNIPOD 5 PACK...... 165 ORKAMBI...... 307 PALFORZIA (20 MG DAILY OMNIPOD DASH 5 PACK PODS..165 ORMECA...... 145 DOSE)...... 8 OMNIPOD DASH SYSTEM...... 165 orphenadrine citrate er...... 274 PALFORZIA (200 MG DAILY OMNIPOD STARTER...... 165 orphenadrine-asa-caffeine...... 275 DOSE)...... 8 OMNITROPE PEN 10 INJ DEVICE ORPHENGESIC FORTE...... 275 PALFORZIA (240 MG DAILY ...... 243 ORSYTHIA...... 124 DOSE)...... 8 OMNITROPE PEN 5 INJ DEVICE.243 ortho df...... 194 PALFORZIA (3 MG DAILY DOSE)....8 ondansetron...... 68 ortho-folic...... 194 PALFORZIA (300 MG ondansetron hcl...... 68 oscimin...... 312 MAINTENANCE)...... 8 one vite womens plus...... 271 oscimin sr...... 312 PALFORZIA (300 MG TITRATION)...8 ONETOUCH CLUB LANCETS oseltamivir phosphate...... 106, 107 PALFORZIA (40 MG DAILY FINE PT...... 214 OSMOPREP...... 199 DOSE)...... 8 ONETOUCH DELICA LANCETS OSPHENA...... 173 PALFORZIA (6 MG DAILY DOSE)....8 30G...... 214 OTEZLA...... 14 PALFORZIA (80 MG DAILY ONETOUCH DELICA LANCETS OTOVEL...... 288 DOSE)...... 8 33G...... 214 OTREXUP...... 10 PALFORZIA INITIAL ONETOUCH DELICA PLUS OVACE PLUS...... 147 ESCALATION...... 8 LANCET30G...... 214 OVIDREL...... 172 paliperidone er...... 99 ONETOUCH DELICA PLUS oxandrolone...... 28 PALYNZIQ...... 174 LANCET33G...... 214 oxaprozin...... 13 PANDEL...... 156 ONETOUCH FINEPOINT OXAYDO...... 22 PANRETIN...... 145 LANCETS...... 214 oxazepam...... 33 pantoprazole sodium...... 315 ONETOUCH ULTRASOFT OXBRYTA...... 189 papaverine hcl...... 113 LANCETS...... 214 oxcarbazepine...... 47 paramox-hc...... 156 ONEXTON...... 138 OXERVATE...... 282 paricalcitol...... 174 ONGENTYS...... 95 oxiconazole nitrate...... 143 PAROEX...... 265 ONUREG...... 87 OXISTAT...... 143 paromomycin sulfate...... 9 OPCICON ONE-STEP...... 128 OXTELLAR XR...... 47 paroxetine hcl...... 54 opium...... 67 oxybutynin chloride...... 317 paroxetine hcl er...... 54 OPSUMIT...... 114 oxybutynin chloride er...... 316 paroxetine mesylate...... 306 OPTION 2...... 128 oxycodone hcl...... 23 PASER...... 86 OPTIONS GYNOL II oxycodone hcl er...... 22 PAXIL...... 54 CONTRACEPTIVE...... 320 oxycodone-acetaminophen...... 26 pc lancets super thin 30g...... 214 ORA-BLEND...... 291 oxycodone-aspirin...... 26 pc pediatric iron drops...... 195

I-19 pc unifine pentips...... 243 penicillin v potassium...... 289, 290 PHOTREXA-PHOTREXA p-care k40g...... 130 pensomal...... 295 VISCOUS KIT...... 282 p-care k80g...... 130 pentamidine isethionate...... 82 physicians ez use joint/tunnel...... 130 PCCA ACACIA SYRUP BASE...... 291 pentaphene base...... 295 PHYSIOLYTE...... 264 PCCA ALADERM BASE...... 294 PENTASA...... 180 PHYSIOSOL IRRIGATION...... 264 PCCA ANHYDROUS BASE...... 294 pentazocine-naloxone hcl...... 27 PHYTOBASE...... 295 PCCA ANHYDROUS LIPODERM PENTIPS...... 243 phytonadione...... 323 BASE...... 294 pentosan polysulfate sodium...... 183 PICATO...... 145 PCCA BIOPEPTIDE BASE...... 294 pentoxifylline er...... 189 PICO WOUND THERAPY PCCA COBASE #1...... 294 PERCURA...... 167 SYSTEM...... 165 PCCA COSMETIC HRT BASE...... 294 PERFECT LANCETS 28G...... 214 PIFELTRO...... 104 PCCA CUSTOM LIPO-MAX...... 294 PERFECT LANCETS 30G...... 214 pilocarpine hcl...... 267, 279 PCCA ELLAGE VAGINAL...... 294 PERFORMAX SALT pimecrolimus...... 159 PCCA LIPODERM BASE...... 294 SUPPORTIVE BASE...... 295 pimozide...... 301 PCCA LIPOSOMIC BASE DRY.....294 PERFOROMIST...... 39 PIMTREA...... 124 PCCA LIPOSOMIC BASE perindopril erbumine...... 78 pindolol...... 108 NORMAL...... 294 PERIOGARD...... 265 pioglitazone hcl...... 65 PCCA LIPOSOMIC BASE OILY....294 permethrin...... 164 pioglitazone hcl-glimepiride...... 59 PCCA LIPOSOMIC BASE perphenazine...... 100 pioglitazone hcl-metformin hcl...... 59 SENSITIVE...... 294 perphenazine-amitriptyline...... 298 pip lancets 28g...... 214 PCCA MVC BASE...... 294 PHARMABASE COSMETIC...... 295 pip lancets 30g...... 214 PCCA NATACREAM...... 294 PHARMABASE HEAVY...... 295 PIQRAY (200 MG DAILY DOSE).... 92 PCCA POLYPEG BASE...... 294 PHARMACIST CHOICE LANCETS PIQRAY (250 MG DAILY DOSE).... 92 PCCA PRACASIL TM-PLUS BASE ...... 214 PIQRAY (300 MG DAILY DOSE).... 92 ...... 294 PHARMACIST CHOICE TSX...... 162 PIRMELLA 1/35...... 124 PCCA SWEET-SF...... 291 PHARMACY COUNTER PIRMELLA 7/7/7...... 124 PCCA SYRUP VEHICLE...... 291 LANCETS...... 214 piroxicam...... 13 PCCA VANISHING CREAM BASE294 PHENAZO...... 184 PLEGRIDY...... 300 PCCA VANISHING CREAM LIGHT phenazopyridine hcl...... 184 PLEGRIDY STARTER PACK...... 300 ...... 295 phendimetrazine tartrate...... 5 PLENVU...... 198 PCCA VANPEN BASE...... 295 phenelzine sulfate...... 53 PLEXION CLEANSING CLOTH.... 138 PCCA-PLUS...... 291 phenobarbital...... 196 PLO GEL - MEDIFLO...... 295 PCP 100...... 198 phenoxybenzamine hcl...... 78 PLO GEL - MEDIFLO PRE-MIXED295 peg 3350-kcl-na bicarb-nacl...... 198 phentermine hcl...... 5 plo transdermal...... 295 peg-3350/electrolytes...... 198 phenylephrine hcl...... 112, 278 plo20 base...... 295 peg-3350/electrolytes/ascorbat...... 198 PHENYTEK...... 52 PLO20 FLOWABLE...... 295 PEGANONE...... 52 phenytoin...... 52 PNEUMOVAX 23...... 318 PEGASYS...... 106 PHENYTOIN INFATABS...... 52 pnv tabs 29-1...... 271 PEGINTRON...... 106 phenytoin sodium extended...... 52 pnv-dha...... 271 peg-kcl-nacl-nasulf-na asc-c...... 198 pheodoyo...... 143 pnv-dha+docusate...... 271 PEG-PREP...... 198 pheyo...... 143 pnv-omega...... 271 PEMAZYRE...... 92 PHILITH...... 124 pnv-select...... 271 pen needles...... 243 PHOSLYRA...... 181 pod-care 100cg...... 130 pen needles 1/2"...... 243 PHOSPHA 250 NEUTRAL...... 259 pod-care 100kg...... 130 pen needles 3/16"...... 243 PHOSPHASAL...... 82 podocon...... 159 pen needles 5/16"...... 243 PHOSPHOLINE IODIDE...... 279 podofilox...... 159 PENCREAM...... 295 phosphorous...... 259 polidocanol...... 265 penderm...... 295 PHOSPHO-TRIN 250 NEUTRAL.. 259 POLYCIN...... 280 penicillamine...... 261 PHOTREXA VISCOUS...... 282 poly-iron 150 forte...... 194

I-20 polymyxin b-trimethoprim...... 281 prednisolone acet-moxifloxacin..... 284 PREVIDOLRX ANALGESIC...... 13 polysaccharide iron forte...... 194 prednisolone sodium phosphate PREVIFEM...... 124 poly-tussin ac...... 133 ...... 130, 131, 284 PREVYMIS...... 105 POLY-VI-FLOR...... 268 prednisolone-bromfenac...... 284 PREZCOBIX...... 104 POLY-VI-FLOR FS...... 268 prednisolone-gatifloxacin...... 284 PREZISTA...... 104 POLY-VI-FLOR/IRON...... 267 prednisolone-moxifloxacin...... 284 PRIFTIN...... 86 POMALYST...... 89 prednisolon-gatiflox-bromfenac..... 284 PRILOSEC...... 315 PORTIA-28...... 124 prednisolon-moxiflox-bromfenac....284 primaquine phosphate...... 85 posaconazole...... 70 prednisolon-moxiflox-nepafenac....284 primidone...... 48 pot & sod cit-cit ac...... 182 prednisone...... 131 PRIMLEV...... 26 POTABA...... 323 PREDNISONE INTENSOL...... 131 PRIMSOL...... 82 potassium chloride...... 260 preferred plus insulin syringe...... 244 PRO COMFORT INSULIN potassium chloride crys er...... 260 preferred plus lancets colored...... 215 SYRINGE...... 244 potassium chloride er...... 260 preferred plus lancets thin...... 215 pro comfort lancets 30g...... 215 potassium citrate er...... 182 preferred plus unifine pentips...... 244 pro comfort lancets 31g...... 215 potassium citrate-citric acid...... 182 PREFEST...... 177 pro comfort pen needles...... 244, 245 potassium hydroxide...... 116 pregabalin...... 47, 48 PROAIR RESPICLICK...... 39 povidone-iodine...... 281 PREGNYL...... 172 probenecid...... 185 PR BENZOYL PEROXIDE...... 138 PREMARIN...... 178, 322 probichew...... 66 PR CREAM...... 163 premium lidocaine...... 162 PROCENTRA...... 4 PRALUENT...... 77 premium scar...... 162 prochlorperazine...... 100 pramipexole dihydrochloride...... 97 PREMPHASE...... 177 prochlorperazine maleate...... 100 pramipexole dihydrochloride er...... 97 PREMPRO...... 177 PROCORT...... 30 PRAMOSONE...... 156, 157 prena 1 true...... 271 PROCRIT...... 192 PRAMOTIC...... 288 prena1 pearl...... 271 pro-critic...... 167 PRAMOX...... 162 prenaissance...... 271 PROCTOFOAM HC...... 30 PRASTERA...... 9 prenaissance plus...... 271 PROCTO-MED HC...... 30 prasugrel hcl...... 189 prenara...... 271 PROCTO-PAK...... 30 pravastatin sodium...... 75 PRENATABS RX...... 271 PROCTOZONE-HC...... 30 praziquantel...... 30 prenatal...... 271 PROCYSBI...... 183 prazosin hcl...... 79 prenatal 19...... 271 prodigen...... 66 PRE & POST SX POUCH...... 163 prenatal plus iron...... 271 PRODIGY INSULIN SYRINGE...... 245 PRECISION SUREDOSE PLUS prenatal vitamin plus low iron...... 271 PRODIGY LANCETS 28G...... 215 SYR...... 243, 244 PRENATAL-U...... 271 PRODIGY SAFETY LANCETS PRECISION SURE-DOSE PRENATRIX...... 271 26G...... 215 SYRINGE...... 244 prenatvite complete...... 272 PRODIGY TWIST TOP LANCETS PRECISION THINS GP LANCETS214 prenatvite plus...... 272 28G...... 215 PRECISION XTRA BLOOD prenatvite rx...... 272 PROFILNINE...... 187 GLUCOSE...... 166 PREPIDIL...... 288 progesterone...... 296 PRED FORTE...... 284 prepiv supply...... 162 progesterone compounding kit...... 296 PRED MILD...... 284 preplus...... 272 progesterone micronized...... 297 PRED-G...... 284 PRESERA...... 163 progesterone-minoxidil...... 159 PRED-G S.O.P...... 284 pressure activat safety lancet...... 215 PROGRAF...... 263 prednicarbate...... 157 pretab...... 272 PROLASTIN-C...... 307 prednisol ace-moxiflox-bromfen.....284 PREVALITE...... 73 PROLATE...... 26 prednisolone...... 130 PREVENT SAFETY PEN PROLEEVA...... 167 prednisolone acetate...... 284 NEEDLES...... 244 PROLENSA...... 286 prednisolone acetate p-f...... 284 PREVENTEZA...... 128 PROLIDA...... 162 prednisolone acetate-nepafenac... 284 PREVIDENT...... 266 PROMACTA...... 192

I-21 promella in prebiotic...... 66 pyridoxine hcl...... 323 RA E-ZJECT LANCETS ULTRA promethazine hcl...... 71, 72 pyrimethamine...... 85 THIN...... 216 promethazine-codeine...... 133 pyrimethamine-leucovorin...... 85 ra folic acid...... 190 promethazine-dm...... 133 QBRELIS...... 78 ra insulin syringe...... 245 promethazine-phenyleph-codeine. 133 QBREXZA...... 163 ra mini nicotine...... 305 promethazine-phenylephrine...... 133 qc aspirin...... 17 ra nicotine...... 305, 306 PROMETHEGAN...... 72 qc aspirin low dose...... 17 ra nicotine gum...... 305 propafenone hcl...... 33 qc childrens aspirin...... 17 ra nicotine polacrilex...... 305, 306 propafenone hcl er...... 33 qc folic acid...... 190 ra pain relief aspirin...... 17 propantheline bromide...... 313 qc lancets super thin 30g...... 215 ra pen needles...... 245 proparacaine hcl...... 282 qc lancets ultra thin...... 215 rabeprazole sodium...... 316 propranolol hcl...... 108 qc pen needles...... 245 RADIOGARDASE...... 67 propranolol hcl er...... 108 qc unifine pentips...... 245 RAGWITEK...... 8 propranolol-hctz...... 81 qc unilet lancets 28g...... 215 raloxifene hcl...... 173 propylthiouracil...... 309 qc unilet lancets micro thin...... 215 ramipril...... 78 PRO-RED AC...... 133 QDOLO...... 23 ranolazine er...... 30, 31 PROSTIN E2...... 288 QINLOCK...... 92 RAPAMUNE...... 263 protexa...... 158 QMIIZ ODT...... 13 rapid gel rx...... 262 protriptyline hcl...... 57 QNASL...... 276 RAPPORT RLS...... 222 provad...... 66 QNASL CHILDRENS...... 275 RAPPORT VTD...... 222 PROVIDA OB...... 272 quad-mix...... 112 rasagiline mesylate...... 98 pseudoeph-bromphen-dm...... 133 QUDEXY XR...... 48 RAVICTI...... 174 p-siloxan ds...... 295 quetiapine fumarate...... 100 RAYALDEE...... 174 PSORIZIDE FORTE...... 262 quetiapine fumarate er...... 100 REACT...... 128 PSORIZIDE ULTRA...... 262 QUFLORA FE...... 267 READYLANCE SAFETY PSS SELECT GP LANCETS...... 215 QUFLORA FE PEDIATRIC...... 267 LANCETS...... 216 PSS SELECT SAFETY LANCETS 215 QUFLORA GUMMIES...... 268 reality insulin syringe...... 245 PULMICORT FLEXHALER...... 38 QUFLORA PEDIATRIC...... 268 reality lancets...... 216 PULMONA...... 167 QUILLICHEW ER...... 7 reality trigger lancets...... 216 PULMOZYME...... 307 QUILLIVANT XR...... 7 REBIF...... 301 pure comfort pen needle...... 245 quinapril hcl...... 78 REBIF REBIDOSE...... 300 purevit dualfe plus...... 195 quinapril-hydrochlorothiazide...... 81 REBIF REBIDOSE TITRATION PURIXAN...... 87 quinidine gluconate er...... 33 PACK...... 300 push button safety lancets...... 215 quinidine sulfate...... 33 REBIF TITRATION PACK...... 301 push button safety lancets 28g...... 215 quinine sulfate...... 85 REBINYN...... 187 px aspirin...... 17 QUTENZA...... 162 RECLIPSEN...... 125 px extra short pen needles...... 245 QUTENZA (2 PATCH)...... 162 RECOMBINATE...... 188 px folic acid...... 190 QVAR REDIHALER...... 38 RECOMBIVAX HB...... 319 px insulin syringe...... 245 ra aspirin...... 17 RECOTHROM...... 196 px lancets ultra thin...... 215 ra aspirin adult low dose...... 17 RECOTHROM SPRAY KIT...... 196 px lancets ultra thin 28g...... 215 ra aspirin adult low strength...... 17 RECTIV...... 30 px mini pen needles...... 245 ra aspirin childrens...... 17 RECURA...... 143 px pen needle...... 245 ra childrens aspirin...... 17 REGIOCIT...... 43 px shortlength pen needles...... 245 RA E-ZJECT COLOR LANCETS REGRANEX...... 165 px stop smoking aid...... 305 33G...... 216 RELAFEN...... 13 PYLERA...... 316 RA E-ZJECT LANCETS 28G...... 216 RELENZA DISKHALER...... 107 pyrazinamide...... 86 RA E-ZJECT LANCETS THIN 26G216 RELION INSULIN SYRINGE...... 246 pyridostigmine bromide...... 85 RA E-ZJECT LANCETS THIN 28G216 RELI-ON INSULIN SYRINGE 245, 246 pyridostigmine bromide er...... 85

I-22 RELION LANCETS MICRO-THIN ribozel...... 167 salicylic acid...... 160 33G...... 216 RIDAURA...... 11 salicylic acid er...... 159 RELION LANCETS STANDARD rifabutin...... 86 salicylic acid wart remover...... 160 21G...... 216 rifampin...... 86 salicylic acid-sulfacetamide...... 139 RELION LANCETS THIN 26G...... 216 RIFAMPIN+SYRSPEND SF...... 86 salimez...... 160 RELION LANCETS ULTRA-THIN RIGHTEST GL300 LANCETS...... 216 salimez forte...... 160 30G...... 216 riluzole...... 276 saline bacteriostatic...... 291 RELION MINI PEN NEEDLES...... 246 rimantadine hcl...... 107 saline flush...... 261 RELION PEN NEEDLES...... 246 ringers irrigation...... 264 SALINE FLUSH ZR...... 261 RELION SHORT PEN NEEDLES..246 RINVOQ...... 10 salsalate...... 17 RELION ULTRA THIN LANCETS RIOMET ER...... 60 salt durable cream...... 295 30G...... 216 risedronate sodium...... 170, 171 SALT STABLE LS ADVANCED.....295 RELION ULTRA THIN PLUS risperidone...... 99 SALTSTABLE LO...... 295 LANCETS...... 216 ritonavir...... 104 SALVAX DUO PLUS...... 160 RELISTOR...... 181 rivastigmine...... 298 SANARE ADVANCED SCAR relnate dha...... 272 rivastigmine tartrate...... 298 THERAPY...... 295 REMESENSE...... 223 RIVELSA...... 125 sanare scar therapy...... 295 RENACIDIN...... 183 rixubis...... 188 SANCUSO...... 68 RENATABS WITH IRON...... 267 rizatriptan benzoate...... 257 SANDIMMUNE...... 263 repaglinide...... 65 ROCKLATAN...... 282 SANTYL...... 159 REPATHA...... 77 ropinirole hcl...... 97 SAPHRIS...... 100 REPATHA PUSHTRONEX ropinirole hcl er...... 97 sapropterin dihydrochloride...... 174 SYSTEM...... 77 ROSADAN...... 164 saps health twist top lancets...... 217 REPATHA SURECLICK...... 77 rosuvastatin calcium...... 76 saps twist top lancets...... 217 RESET FOR IOS OR ANDROID ROXYBOND...... 24 sapscare twist top lancets...... 217 APP...... 261 ROZLYTREK...... 92 SAVELLA...... 298 RESET-O FOR IOS OR ANDROID RTD WOUND CARE DRESSING..165 SAVELLA TITRATION PACK...... 298 APP...... 261 RUBRACA...... 92 SAXENDA...... 5 resorcinol-sulfur...... 138 RUCONEST...... 188 sb aspirin...... 17 RESTASIS...... 281 rufinamide...... 48 sb childrens aspirin...... 17 RESTASIS MULTIDOSE...... 281 rukobia...... 104 sb insulin syringe...... 247 RESTORA RX...... 66 RUZURGI...... 85 sb lancets thin...... 217 RETACRIT...... 192 RYBELSUS...... 62 sb lancets ultra thin...... 217 RETEVMO...... 92 RYDAPT...... 92 SCALACORT DK...... 157 RETIN-A MICRO PUMP...... 138 RYDEX...... 133 SCARZEN SKIN REPAIR...... 157 REVCOVI...... 174 RYTARY...... 97 scopolamine...... 69 revesta...... 195 sa3 derm...... 295 SECUADO...... 100 REVLIMID...... 262 SAFE-T-LANCE...... 216 SECURESAFE INSULIN REXALL LANCETS ULTRA THIN SAFE-T-LANCE PLUS...... 216 SYRINGE...... 247 30G...... 216 safety insulin syringes...... 246 SEDANARE...... 295 REXULTI...... 101 safety lancet 21g/pressure act...... 217 SELECT-OB...... 272 REYATAZ...... 104 safety lancet 23g/pressure act...... 217 SELECT-OB+DHA...... 272 REYVOW...... 257 safety lancet 28g/pressure act...... 217 selegiline hcl...... 98 RHEOSPRAY...... 291 safety lancet 30g/pressure act...... 217 selenium sulfide...... 147 RHEUMATE...... 167 SAFETY LANCETS...... 217 SELZENTRY...... 104 RHOFADE...... 164 SAFETY LANCETS 21G...... 217 SEMPREX-D...... 133 RHOPRESSA...... 281 safety lancets 28g...... 217 se-natal 19...... 272 RIAX...... 138 SAFETY LET LANCETS...... 217 SENTRA AM...... 167 ribavirin...... 106, 107 SAFETY SEAL LANCETS...... 217 SENTRA PM...... 167

I-23 SERAQUA...... 291 sm aspirin...... 18 SOVALDI...... 106 SEREVENT DISKUS...... 40 sm aspirin adult low strength...... 17 SPEEDGEL RX...... 262 SERNIVO...... 157 sm aspirin low dose...... 17 SPIRIVA HANDIHALER...... 34 SEROSTIM...... 173 sm childrens aspirin...... 18 SPIRIVA RESPIMAT...... 34 sertraline hcl...... 54 sm folic acid...... 190 spironolactone...... 169 se-tan plus...... 195 sm lancets 33g...... 218 spironolactone-hctz...... 169 SETLAKIN...... 125 sm nicotine...... 306 SPRAVATO (56 MG DOSE)...... 53 sevelamer carbonate...... 181 sm nicotine polacrilex...... 306 SPRAVATO (84 MG DOSE)...... 53 sevelamer hcl...... 181 SMART SENSE COLOR SPRINTEC 28...... 125 SEVENFACT...... 188 LANCETS 33G...... 218 SPRITAM...... 48 sevoflurane...... 182 SMART SENSE STANDARD SPRYCEL...... 93 sf...... 266 LANCETS...... 218 SPS...... 264 sf 5000 plus...... 266 SMART SENSE SUPER THIN sr nicotine...... 306 SFROWASA...... 180 LANCETS...... 218 SRONYX...... 125 SHAROBEL...... 128 SMART SENSE THIN LANCETS SSD...... 148 SHINGRIX...... 319 26G...... 218 SSKI...... 134 SHOPKO ON-THE-GO LANCETS SMARTEST LANCETS 28G...... 218 sss 10-5...... 139 30G...... 217 sod citrate-citric acid...... 182 ST JOSEPH LOW DOSE...... 18 SHOPKO UNIFINE PENTIPS...... 247 sodium chloride...... 134, 183, 261 STALEVO 100...... 97 SHOPKO UNIFINE PENTIPS sodium chloride (pf)...... 261 STALEVO 125...... 97 PLUS...... 247 sodium chloride bacteriostatic...... 291 STALEVO 150...... 97 SHOPKO UNILET LANCETS 28G 217 sodium chloride flush...... 261 STALEVO 200...... 97 SHOPKO UNILET LANCETS 30G 217 sodium citrate...... 41 STALEVO 50...... 97 SHUR-SEAL CONTRACEPTIVE...320 sodium fluoride...... 259, 266 STALEVO 75...... 97 side button safety lancet...... 217 sodium fluoride 5000 plus...... 266 stavudine...... 104 SIGNIFOR...... 175 sodium fluoride 5000 ppm...... 266 STELARA...... 146 SIKLOS...... 189, 190 sodium fluoride 5000 sensitive...... 266 STERILANCE TL...... 218 sildenafil citrate...... 113, 114 sodium hydroxide...... 116 sterile water for irrigation...... 264 SILIQ...... 146 sodium phenylbutyrate...... 174 STIMATE...... 175 silodosin...... 184 sodium polystyrene sulfonate...... 264 STIOLTO RESPIMAT...... 40 silosome transdermal...... 295 sodium sulfacetamide...... 147 STIVARGA...... 93 silprotex plus...... 295 sodium sulfacetamide wash...... 147 STRATA CTX...... 163 silver nitrate...... 148 solifenacin succinate...... 317 STRATA MARK...... 163 silver sulfadiazine...... 148 SOLIQUA...... 59 STRATA XRT...... 163 SIMBRINZA...... 279 SOLOSEC...... 9 STRENSIQ...... 174 SIMLIYA...... 125 SOLTAMOX...... 88 STRIBILD...... 104 SIMPESSE...... 125 SOLU-CORTEF...... 131 STRIVERDI RESPIMAT...... 40 SIMPONI...... 11 SOLUS V2 LANCETS 28G...... 218 SUBVENITE...... 48 simvastatin...... 76 SOLUS V2 TWIST LANCETS 30G218 SUBVENITE STARTER KIT-BLUE. 48 SINGLE-LET...... 218 SOLYDRA...... 291 SUBVENITE STARTER KIT- SINUVA...... 276 SOMAVERT...... 172 GREEN...... 48 sirolimus...... 263 SOMRYST...... 261 SUBVENITE STARTER KIT- SIRTURO...... 86 SOOLANTRA...... 164 ORANGE...... 48 SITAVIG...... 106 SOOTHEE...... 162 SUCRAID...... 168 SIVEXTRO...... 84 SORILUX...... 146 sucralfate...... 313 SKLICE...... 164 SORINE...... 108 sulfacetamide sodium...... 148, 281 SKYRIZI (150 MG DOSE)...... 146 sotalol hcl...... 109 sulfacetamide sodium (acne)...... 139 skyy derm...... 295 sotalol hcl (af)...... 109 sulfacetamide sodium-sulfur...... 139 SLYND...... 129 SOTYLIZE...... 109 sulfacetamide sod-sulfur wash...... 139

I-24 sulfacetamide-prednisolone...... 285 SYEDA...... 125 TARINA FE 1/20 EQ...... 125 sulfacetamide-sulfur in urea...... 139 SYMAX DUOTAB...... 313 taron forte...... 195 sulfadiazine...... 307 SYMAX-SL...... 313 TARON-C DHA...... 272 sulfamethoxazole-trimethoprim...... 83 SYMAX-SR...... 313 TARON-CRYSTALS...... 182 sulfamez wash...... 139 SYMBICORT...... 40 TARON-PREX...... 272 SULFAMYLON...... 148 SYMDEKO...... 307 taroxia...... 140 sulfasalazine...... 180 SYMJEPI...... 322 TASIGNA...... 93 SULFATRIM PEDIATRIC...... 83 SYMLINPEN 120...... 57 tavaborole...... 143 SULFZIX...... 167 SYMLINPEN 60...... 57 TAVALISSE...... 189 sulindac...... 13 SYMPAZAN...... 43 tazarotene...... 146 SUMADAN XLT...... 140 SYMTUZA...... 104 TAZORAC...... 146 sumatriptan...... 257 SYNALAR (CREAM)...... 157 TAZTIA XT...... 111 sumatriptan succinate...... 257 SYNALAR (OINTMENT)...... 157 TAZVERIK...... 93 sumatriptan succinate refill...... 257 SYNALAR TS...... 157 TDC MAX...... 296 SUNOSI...... 6 SYNAPRYN FUSEPAQ...... 24 tdm solution...... 292 super bi-mix...... 113 SYNAREL...... 173 TDVAX...... 311 super quad-mix...... 113 SYNDROS...... 69 TECHLITE AST LANCETS...... 219 super thin lancets...... 218 SYNERA...... 162 techlite insulin syringe...... 248 super tri-mix...... 113 SYNJARDY...... 59 TECHLITE LANCETS...... 219 SUPRAX...... 116 SYNJARDY XR...... 59 TECHLITE LANCETS 30G...... 219 SUPREP BOWEL PREP KIT...... 198 SYNRIBO...... 94 TECHLITE PEN NEEDLES... 248, 249 sure comfort insulin syringe...... 247 SYNTHROID...... 311 TEGRETOL...... 48 sure comfort lancets 18g...... 218 synvexia tc...... 162 TEGRETOL-XR...... 48 sure comfort lancets 21g...... 218 syrpalta...... 292 TEGSEDI...... 306 sure comfort lancets 23g...... 218 SYRPALTA (RED)...... 291 TEKTURNA HCT...... 81 sure comfort lancets 28g...... 218 SYRSPEND SF...... 292 TELFA AMD ISLAND DRESSING.201 sure comfort lancets 30g...... 218 SYRSPEND SF PH4...... 292 TELFA AMD NON-ADHERENT.....201 sure comfort pen needles...... 247, 248 TABLOID...... 87 telmisartan...... 79 sure result o3d3 system...... 72 TABRADOL FUSEPAQ...... 274 telmisartan-amlodipine...... 81 SURE-FINE PEN NEEDLES...... 248 TABRADOL RAPIDPAQ...... 274 telmisartan-hctz...... 81 SURE-JECT INSULIN SYRINGE.. 248 TABRECTA...... 93 temazepam...... 197 SURE-LANCE FLAT LANCETS.... 218 TACHOSIL...... 196 TEMIXYS...... 104 SURE-LANCE LANCETS 26G...... 218 tacrolimus...... 159, 263 temozolomide...... 86 SURE-LANCE THIN LANCETS tadalafil...... 113 TENCON...... 15 28G...... 219 tadalafil (pah)...... 114 TENIVAC...... 311 SURE-LANCE ULTRA THIN TAFINLAR...... 93 tenofovir disoproxil fumarate...... 104 LANCETS...... 219 TAGRISSO...... 93 terazosin hcl...... 79 SURELITE LANCETS...... 219 TAKE ACTION...... 128 terbinafine hcl...... 70 SURE-TOUCH LANCETS TAKHZYRO...... 189 terbutaline sulfate...... 40 UNIVERSAL...... 219 TALICIA...... 316 terconazole...... 321 SUSPENDRX W/BITTERBLOC TALZENNA...... 93 teroderm...... 296 SWEET...... 291 tamoxifen citrate...... 88 teroderm-plus...... 296 SUSPENDRX W/BITTERBLOC tamsulosin hcl...... 184 TERRELL...... 182 UNSWEET...... 291 tardeoxia...... 140 testosterone...... 28 SUTAB...... 198 tardimaxia...... 140 testosterone compounding kit...... 28 SUTENT...... 93 TARGADOX...... 309 testosterone cypionate...... 28 SWABFLUSH SALINE FLUSH...... 261 TARGRETIN...... 145 testosterone enanthate...... 28 SX1 MEDICATED POST- TARINA 24 FE...... 125 tetrabenazine...... 299 OPERATIVE...... 162 TARINA FE 1/20...... 125 tetracaine hcl...... 282

I-25 tetracycline hcl...... 309 tobramycin pak...... 9 travoprost (bak free)...... 286 TEXACORT...... 157 tobramycin-dexamethasone...... 285 trazodone hcl...... 54 tgt lancet micro thin 33g...... 219 TOBREX...... 281 TRECATOR...... 86 tgt lancet thin 26g...... 219 TODAY SPONGE...... 320 TRELEGY ELLIPTA...... 40 tgt lancet ultra thin 30g...... 219 todays health mini pen needles..... 249 TREMFYA...... 147 THALOMID...... 262 todays health pen needles...... 249 TREPADONE...... 168 THEO-24...... 40 todays health short pen needle...... 249 treprostinil...... 113 theophylline...... 40 todays health thin lancets 28g...... 219 TRESIBA...... 65 theophylline er...... 40 todays health thin lancets 30g...... 219 TRESIBA FLEXTOUCH...... 65 THERAHONEY...... 165 TOLAK...... 145 tretinoin...... 94, 140 THERAMINE...... 167 tolbutamide...... 66 tretinoin microsphere...... 140 THERAMINE PLUS...... 168 tolcapone...... 95 tretinoin microsphere pump...... 140 thiamine hcl...... 323 tolmetin sodium...... 13 TRETTEN...... 188 THINLETS GP LANCETS...... 219 tolsura...... 70 TREXALL...... 87 THIOLA...... 184 tolterodine tartrate...... 317 TRI FEMYNOR...... 125 THIOLA EC...... 184 tolterodine tartrate er...... 317 triamcinolone acetonide...... 157, 267 thioridazine hcl...... 101 tolvaptan...... 175 TRIAMSIL COMBIPAK...... 158 thiothixene...... 101 TOPAMAX...... 48 triamsil multipak...... 158 THRIVE...... 306 TOPAMAX SPRINKLE...... 48 triamterene...... 169 thrivite rx...... 272 topcare clickfine pen needles...... 249 triamterene-hctz...... 169 THROMBIN-JMI...... 196 topcare lancets micro-thin 33g...... 219 triazolam...... 197 THROMBIN-JMI EPISTAXIS...... 196 topcare ultra comfort ins syr...... 249 TRICARE...... 272 THROMBOGEN...... 196 TOPEX TOPICAL ANESTHETIC.. 265 TRICARE PRENATAL DHA ONE..272 TIADYLT ER...... 111 topiramate...... 49 TRI-CHLOR...... 148 tiagabine hcl...... 51 topiramate er...... 48 TRICITRASOL...... 43 TIBSOVO...... 93 toremifene citrate...... 89 tricitrates...... 182 tightening base...... 296 TORONOVA II SUIK...... 13 TRICON...... 195 TIGLUTIK...... 276 TORONOVA SUIK...... 13 TRIDERM...... 158 TILIA FE...... 125 torsemide...... 169 trientine hcl...... 261 timolol maleate...... 109, 277 TOUJEO MAX SOLOSTAR...... 65 TRI-ESTARYLLA...... 125 timolol maleate pf...... 277 TOUJEO SOLOSTAR...... 65 trifluoperazine hcl...... 101 timolol-brimon-dorzol-latanopr...... 277 TOVET...... 157 trifluridine...... 281 timolol-brimonidine-dorzolamid...... 277 TOVIAZ...... 317 trigels-f forte...... 195 timolol-dorzolamid-latanoprost...... 278 TRACLEER...... 114 trihexyphenidyl hcl...... 95 TIMOPTIC OCUDOSE...... 278 TRADJENTA...... 61 TRIKAFTA...... 307 TIMOPTIC-XE...... 278 tramadol hcl...... 24 TRI-LEGEST FE...... 125 tinidazole...... 82 tramadol hcl er...... 24 TRILEPTAL...... 49 TISSEEL...... 196 tramadol hcl er (biphasic)...... 24 TRI-LINYAH...... 125 TIS-U-SOL...... 264 tramadol-acetaminophen...... 26 TRILOAN II SUIK...... 131 TIVICAY...... 105 trandolapril...... 78 TRILOAN SUIK...... 131 TIVICAY PD...... 105 trandolapril-verapamil hcl er...... 81 TRI-LO-ESTARYLLA...... 125 tizanidine hcl...... 274 tranexamic acid...... 195 TRI-LO-MARZIA...... 125 tl-hem 150...... 195 transdermal pain base...... 296 TRI-LO-MILI...... 126 tl-icare...... 168 tranylcypromine sulfate...... 53 TRI-LO-SPRINTEC...... 126 TOBAKIENT...... 168 TRANZGEL...... 262 TRILYTE...... 198 TOBI PODHALER...... 9 TRAUMEEL...... 262 trimethobenzamide hcl...... 69 TOBRADEX...... 285 travel lancets...... 219 trimethoprim...... 82 TOBRADEX ST...... 285 TRAVEL LANCETS ADVANCED TRI-MILI...... 126 tobramycin...... 9, 281 28G...... 219 trimipramine maleate...... 57

I-26 tri-mix...... 113 TUSSICAPS...... 133 ULTRA-THIN II MINI PEN TRIMO-SAN...... 320 TUXARIN ER...... 133 NEEDLE...... 254 trinatal rx 1...... 272 TUZISTRA XR...... 134 ULTRA-THIN II PEN NEEDLE TRINATE...... 272 TWINRIX...... 319 SHORT...... 254 TRINTELLIX...... 55 TWIRLA...... 127 ULTRA-THIN II PEN NEEDLES.... 254 triple complex formula 3 kit...... 145 TYBLUME...... 126 UMECTA MOUSSE...... 158 triple pmb...... 285 TYBOST...... 105 U-MILD...... 292 triple pmk...... 285 TYDEMY...... 126 UNIFINE PENTIPS...... 254 TRI-PREVIFEM...... 126 TYMLOS...... 171 UNIFINE PENTIPS PLUS...... 254 TRI-SPRINTEC...... 126 TYVASO...... 114 UNIFINE SAFECONTROL PEN TRISTART ONE...... 272 TYVASO REFILL...... 114 NEEDLE...... 254 tri-tabs dha...... 272 TYVASO STARTER...... 114 UNILET COMFORTOUCH TRIUMEQ...... 105 UBRELVY...... 256 LANCET...... 220 TRI-VI-FLOR...... 268 UCERIS...... 29 UNILET EXCELITE...... 220 tri-vi-floro...... 268 UDENYCA...... 192 UNILET EXCELITE II...... 220 tri-vite/fluoride...... 268 ULTICARE INSULIN SAFETY SYR UNILET G.P. LANCET...... 220 TRIVORA (28)...... 126 ...... 250 UNILET G.P. SUPERLITE TRI-VYLIBRA...... 126 ULTICARE INSULIN SYRINGE LANCET...... 220 TRI-VYLIBRA LO...... 126 ...... 250, 251 UNILET GP 28 ULTRA THIN...... 220 TROKENDI XR...... 49 ULTICARE MICRO PEN UNILET LANCET...... 221 tropicamide-cyclopentolate-pe...... 278 NEEDLES...... 251 UNILET MICRO-THIN 33G...... 221 tropicamide-phenylephrine...... 278 ULTICARE MINI PEN NEEDLES.. 251 UNILET SUPERLITE LANCET...... 221 tropic-cyclopent-pe-ketorolac...... 278 ULTICARE PEN NEEDLES...... 251 UNILET SUPER-THIN 30G...... 221 tropic-cyclop-pe-keto-propar...... 279 ULTICARE SHORT PEN UNILET ULTRA-THIN 28G...... 221 tropic-proparaca-pe-ketorolac...... 279 NEEDLES...... 251 UNISPEND ANHYDROUS trospium chloride...... 317 ultiguard safepack pen needle...... 251 SWEETENED...... 292 trospium chloride er...... 317 ULTILET CLASSIC LANCETS...... 220 UNISTIK 3 GENTLE...... 221 true comfort insulin syringe...... 249 ULTILET INSULIN SYRINGE 251, 252 UNISTIK PRO SAFETY LANCET..221 true comfort pen needles...... 249 ULTILET INSULIN SYRINGE UNISTIK SAFETY LANCETS 28G 221 true comfort twist top lancets...... 219 SHORT...... 252 UNISTIK SAFETY LANCETS 30G 221 TRUEPLUS 5-BEVEL PEN ULTILET LANCETS...... 220 UNISTIK TOUCH SAFETY LANC NEEDLES...... 249, 250 ULTILET PEN NEEDLE...... 252 21G...... 221 TRUEPLUS INSULIN SYRINGE... 250 ULTILET SAFETY LANCETS...... 220 UNISTIK TOUCH SAFETY LANC TRUEPLUS LANCETS 26G...... 219 ULTILET SAFETY LANCETS 23G 220 23G...... 221 TRUEPLUS LANCETS 28G...... 220 ultra comfort insulin syringe...... 252 UNISTIK TOUCH SAFETY LANC TRUEPLUS LANCETS 30G...... 220 ULTRA FLO INSULIN PEN 28G...... 221 TRUEPLUS LANCETS 33G...... 220 NEEDLES...... 252 UNISTIK TOUCH SAFETY LANC TRUEPLUS PEN NEEDLES...... 250 ULTRA FLO INSULIN SYRINGE...252 30G...... 221 TRUEPLUS SAFETY LANCETS ultra thin lancets 31g...... 220 UNITHROID...... 311 28G...... 220 ULTRA THIN PEN NEEDLES...... 253 UNIVERSAL 1 LANCETS THIN TRULICITY...... 62 ultracare insulin syringe...... 253 26G...... 221 TRUMENBA...... 318 ultra-care lancets 30g...... 220 UNIVERSAL 1 LANCETS THIN TRUVADA...... 105 ultracare pen needles...... 253 33G...... 221 trymine cg...... 133 ultra-comfort insulin syringe...... 253 UNIVERSAL 1 LANCETS ULTRA t-support max...... 168 ULTRA-THIN II AUTO LANCET.... 220 THIN...... 221 TUKYSA...... 93 ULTRA-THIN II INS SYR SHORT. 253 universal water...... 296 TULANA...... 129 ULTRA-THIN II INSULIN UPNEEQ...... 286 TURALIO...... 93 SYRINGE...... 254 UPTRAVI...... 114 TUSNEL C...... 133 ULTRA-THIN II LANCETS...... 220 urea...... 158

I-27 urea hydrating...... 158 VARIVAX...... 320 VIOKACE...... 168 urea nail...... 158 varoxia...... 140 viorele...... 126 urea-c40...... 158 VARUBI (180 MG DOSE)...... 69 VIRACEPT...... 105 UREDEB...... 158 VASCAZEN...... 168 VIREAD...... 105 URELLE...... 83 VASCEPA...... 72 virt-c dha...... 272 uremez-40...... 158 VASHE CLEANSING...... 165 virt-fefa plus...... 195 URESOL...... 158 vb6 p5p...... 168 virt-nate dha...... 272 URETRON D/S...... 83 VCF VAGINAL CONTRACEPTIVE320 virt-phos 250 neutral...... 259 URIBEL...... 83 VECAMYL...... 81 virt-pn dha...... 272 URIMAR-T...... 83 VECTICAL...... 147 virt-pn plus...... 272 urin ds...... 83 VELIVET...... 126 virtussin a/c...... 134 uro-458...... 83 VELPHORO...... 181 virtussin ac w/alc...... 134 uro-mp...... 83 VELTASSA...... 264 virtussin dac...... 134 ursodiol...... 179 VEMLIDY...... 106 VISBIOME...... 66 URSODIOL+SYRSPEND SF...... 179 VENCLEXTA...... 87 VISIONBLUE...... 285 USTELL...... 83 VENCLEXTA STARTING PACK..... 87 VISTOGARD...... 67 uticap...... 83 VENIPUNCTURE PX1 VITAFOL FE+...... 273 UTIRA-C...... 83 PHLEBOTOMY...... 163 VITAFOL GUMMIES...... 273 UTRONA-C...... 83 venlafaxine hcl...... 56 VITAFOL ULTRA...... 273 valacyclovir hcl...... 106 venlafaxine hcl er...... 56 VITAFOL-NANO...... 273 VALCHLOR...... 145 VENTAVIS...... 114 VITAFOL-OB...... 273 valganciclovir hcl...... 105 VENTOLIN HFA...... 40 VITAFOL-OB+DHA...... 273 valproic acid...... 53 verapamil hcl...... 111 VITAFOL-ONE...... 273 valsartan...... 79 verapamil hcl er...... 111 VITAMEDMD ONE valsartan-hydrochlorothiazide...... 81 VERELAN...... 111 RX/QUATREFOLIC...... 273 VALTOCO 10 MG DOSE...... 44 VERELAN PM...... 111 vitamin d (ergocalciferol)...... 323 VALTOCO 15 MG DOSE...... 44 VERSACLOZ...... 100 vitamin k1...... 323 VALTOCO 20 MG DOSE...... 44 VERSAFREE...... 292 vitamins acd-fluoride...... 269 VALTOCO 5 MG DOSE...... 44 VERSAPLUS...... 292 VITAPEARL...... 273 value health insulin syringe...... 254 VERSAPRO...... 292, 296 VITATHELY WITH GINGER...... 273 value plus lancet standard 21g...... 221 versatile cream base...... 296 VITATRUE...... 273 value plus lancets super thin...... 221 VERSATILE RICH BASE...... 296 VITRAKVI...... 93 value plus lancets thin 26g...... 222 VERZENIO...... 93 VIVA DHA...... 273 valumark lancet super thin 30g...... 222 VIBERZI...... 180 VIVAGUARD LANCETS...... 222 valumark lancet ultra thin 28g...... 222 VIBRAMYCIN...... 309 VIZIMPRO...... 93 valumark pen needles...... 255 VICTOZA...... 62 VOGELXO...... 29 VANADOM...... 274 VIDA MIA UNIFINE PENTIPS...... 255 VOGELXO PUMP...... 29 vancomycin hcl...... 83, 84 VIDA MIA UNILET LANCETS 28G 222 VOLNEA...... 126 VANCOMYCIN+SYRSPEND SF.....84 VIDA MIA UNILET LANCETS 30G 222 vol-plus...... 273 VANDAZOLE...... 321 VIENVA...... 126 vol-tab rx...... 273 vanishing...... 296 vigabatrin...... 51 VONVENDI...... 188 vanishing cream botanical base.... 296 VIGADRONE...... 51 voriconazole...... 70 vanish-pen...... 296 VIIBRYD...... 55 VOSEVI...... 106 VANISHPOINT INSULIN VIIBRYD STARTER PACK...... 55 VOTRIENT...... 93 SYRINGE...... 255 VILAMIT MB...... 83 vp dermabase...... 296 VANOXIDE-HC...... 140 VILEVEV MB...... 83 vp fc kit...... 145 VAQTA...... 319 VIMPAT...... 49 vp gkl kit...... 145 vardenafil hcl...... 113 VINATE II...... 272 vp insulin syringe...... 255 vardimaxia...... 140 VINATE ONE...... 272 vp-heme ob + dha...... 273

I-28 vp-pnv-dha...... 273 XELJANZ XR...... 10 ZEBUTAL...... 15 VRAYLAR...... 99 XELPROS...... 287 ZEJULA...... 93 VSL#3 DS...... 66 XEMATOP BASE...... 296 zelac...... 66 VUMERITY...... 301 XEMBIFY...... 289 ZELAPAR...... 98 VUSION...... 144 XENICAL...... 5 ZELBORAF...... 93 VYFEMLA...... 126 XENLETA...... 85 ZEMAIRA...... 307 VYLEESI...... 299 XEPI...... 141 ZENATANE...... 140 VYLIBRA...... 126 XERAC AC...... 163 ZENPEP...... 168 VYNDAMAX...... 115 XERMELO...... 181 ZENZEDI...... 4 VYNDAQEL...... 115 XHANCE...... 276 ZEPOSIA...... 301 VYVANSE...... 4 XIFAXAN...... 82 ZEPOSIA 7-DAY STARTER PACK VYZULTA...... 287 XIGDUO XR...... 60 ...... 301 WAKIX...... 6 XIIDRA...... 281 ZEPOSIA STARTER KIT...... 301 walgreens adv travel lancets...... 222 XOFLUZA (40 MG DOSE)...... 107 zidovudine...... 105 WALGREENS LANCETS...... 222 XOFLUZA (80 MG DOSE)...... 107 ZIEXTENZO...... 192 walgreens lancets micro thin...... 222 XOPENEX HFA...... 40 ZIOPTAN...... 287 walgreens lancets super thin...... 222 XOSPATA...... 93 ziprasidone hcl...... 99 WALGREENS THIN LANCETS.....222 XPOVIO (100 MG ONCE ZIRGAN...... 281 WALGREENS ULTRA THIN WEEKLY)...... 94 ZITHRANOL...... 147 LANCETS...... 222 XPOVIO (40 MG ONCE WEEKLY). 94 ZITHROMAX...... 199 warfarin sodium...... 41 XPOVIO (40 MG TWICE WEEKLY) 94 ZOE SCRIPTS IDEALBASE...... 296 water for irrigation, sterile...... 264 XPOVIO (60 MG ONCE WEEKLY). 95 ZOLINZA...... 94 wegmans unifine pentips plus...... 255 XPOVIO (60 MG TWICE WEEKLY) 95 zolmitriptan...... 258 WELLMIND VERTIGO...... 262 XPOVIO (80 MG ONCE WEEKLY). 95 zolpidem tartrate...... 197 WERA...... 126 XPOVIO (80 MG TWICE WEEKLY) 95 zolpidem tartrate er...... 197 westab plus...... 273 XTAMPZA ER...... 24, 25 ZOMIG...... 258 WESTHROID...... 311 XTANDI...... 89 ZONEGRAN...... 49 WIDE-SEAL DIAPHRAGM 60...... 201 XULANE...... 127 zonisamide...... 49 WIDE-SEAL DIAPHRAGM 65...... 202 XULTOPHY...... 60 ZONTIVITY...... 189 WIDE-SEAL DIAPHRAGM 70...... 202 xurea...... 158 ZORBTIVE...... 173 WIDE-SEAL DIAPHRAGM 75...... 202 XURIDEN...... 174 ZORTRESS...... 264 WIDE-SEAL DIAPHRAGM 80...... 202 XYNTHA...... 188 ZOVIA 1/35 (28)...... 127 WIDE-SEAL DIAPHRAGM 85...... 202 XYNTHA SOLOFUSE...... 188 ZOVIA 1/35E (28)...... 127 WIDE-SEAL DIAPHRAGM 90...... 202 XYOSTED...... 29 Z-TUSS AC...... 134 WIDE-SEAL DIAPHRAGM 95...... 202 XYREM...... 297 ZUBSOLV...... 27 WILATE...... 188 XYWAV...... 297 ZUMANDIMINE...... 127 WP THYROID...... 311 xyzmune...... 264 ZYDELIG...... 94 WYMZYA FE...... 127 yl folic acid...... 190 ZYKADIA...... 94 XADAGO...... 98 YONSA...... 89 ZYLET...... 285 XALIX...... 160 YUVAFEM...... 322 ZYPITAMAG...... 76 XALKORI...... 93 ZACARE...... 140 ZYTIGA...... 89 XAQUIL XR...... 168 zaclir cleansing...... 140 XARELTO...... 41 zafirlukast...... 35 XARELTO STARTER PACK...... 41 zaleplon...... 197 XATMEP...... 87 ZARAH...... 127 XCOPRI...... 50, 51 ZARONTIN...... 52 XCOPRI (250 MG DAILY DOSE).... 50 ZARXIO...... 192 XCOPRI (350 MG DAILY DOSE).... 50 ZATEAN-PN DHA...... 273 XELJANZ...... 10 ZATEAN-PN PLUS...... 273

I-29