ACNE AGENTS, TOPICAL ‡ ANGIOTENSIN MODULATOR COMBINATIONS ANTICONVULSANTS, CONT. CONNECTICUT MEDICAID (STEP THERAPY CATEGORY) AMLODIPINE / BENAZEPRIL (ORAL) LAMOTRIGINE CHEW DISPERS TAB (not ODT) (ORAL) (DX CODE REQUIRED - DIFFERIN, EPIDUO and RETIN-A) AMLODIPINE / OLMESARTAN (ORAL) LAMOTRIGINE TABLET (IR) (not ER) (ORAL) Preferred Drug List (PDL) ACNE MEDICATION LOTION (BENZOYL PEROXIDE) (TOPICAL)AMLODIPINE / VALSARTAN (ORAL) LEVETIRACETAM SOLUTION, IR TABLET (not ER) (ORAL) • The Connecticut Medicaid Preferred Drug List (PDL) is a BENZOYL PEROXIDE CREAM, WASH (not FOAM) (TOPICAL) OXCARBAZEPINE TABLET (ORAL) listing of prescription products selected by the BENZOYL PEROXIDE 5% and 10% GEL (OTC) (TOPICAL) ANTHELMINTICS PHENOBARBITAL ELIXIR, TABLET (ORAL) Pharmaceutical and Therapeutics Committee as efficacious, BENZOYL PEROXIDE 6% CLEANSER (OTC) (TOPICAL) ALBENDAZOLE TABLET (ORAL) PHENYTOIN CHEW TABLET, SUSPENSION (ORAL) safe and cost effective choices when prescribing for HUSKY CLINDAMYCIN PH 1% PLEGET (TOPICAL) BILTRICIDE TABLET (ORAL) PHENYTOIN SOD EXT CAPSULE (ORAL) A, HUSKY C, HUSKY D, Tuberculosis (TB) and Family CLINDAMYCIN PH 1% SOLUTION (not GEL or LOTION) (TOPICAL)IVERMECTIN TABLET (ORAL) PRIMIDONE (ORAL) Planning (FAMPL) clients. CLINDAMYCIN / BENZOYL PEROXIDE 1.2%-5% (DUAC) (TOPICAL) SABRIL 500 MG POWDER PACK (ORAL) • Preferred or Non-preferred status only applies to DIFFERIN 0.1% CREAM (TOPICAL) (not OTC GEL) (DX CODE REQ.) ANTI-ALLERGENS, ORAL SABRIL TABLET (ORAL) those medications that fall within the drug classes DIFFERIN 0.1% LOTION (TOPICAL) (DX CODE REQ.) All agents require non-PDL PA TEGRETOL SUSPENSION (ORAL) listed on this PDL DIFFERIN 0.3% GEL PUMP (TOPICAL) (DX CODE REQ.) TEGRETOL XR (ORAL) • HIV medications are excluded from the PDL and do EPIDUO FORTE 0.3-2.5% GEL PUMP (TOPICAL) (DX CODE REQ.)* ANTIBIOTICS, GI TOPIRAMATE SPRINKLE CAPSULE (ORAL) not require prior authorization ERYTHROMYCIN 2% SOLUTION (not GEL) (TOPICAL) FIRVANQ SOLUTION (ORAL) TOPIRAMATE TABLET (not ER) (ORAL) • The brand-name of a generically available medication PANOXYL 10% ACNE FOAMING WASH (OTC) (TOPICAL) METRONIDAZOLE TABLET (not CAPSULE) (ORAL) TRILEPTAL SUSPENSION (ORAL) will not be covered without a PA, unless the brand is RETIN-A CREAM (TOPICAL) (DX CODE REQ.) TINIDAZOLE TABLET (ORAL)* VALPROIC ACID CAPSULE, SOLUTION (ORAL) listed on the PDL RETIN-A GEL (not MICRO)(TOPICAL) (DX CODE REQ.) VANCOMYCIN CAPSULE (ORAL)* VIMPAT SOLUTION, TABLET (not STARTER KIT) (ORAL) ANTIBIOTICS, INHALED ZONISAMIDE CAPSULE (ORAL) • Preferred brand-name medications with non- ALZHEIMER'S AGENTS BETHKIS AMPULE (INHALATION) preferred generic equivalents are listed in BOLD DONEPEZIL ODT (ORAL) KITABIS PAK 300 MG/5 ML (INHALATION) ANTIDEPRESSANTS, OTHER • DX CODE REQUIRED NOTATION will appear for DONEPEZIL 5MG & 10MG TABLET (not 23MG) (ORAL) TOBI PODHALER 28MG INHALE CAPSULE (INHALATION) BUPROPION TABLET (ORAL) preferred agents that require ICD-10 code for EXELON PATCH (TRANSDERMAL) BUPROPION SR, BUPROPION XL (NOT 450MG) (ORAL) reimbursement MEMANTINE IR TABLET (not ER CAPSULES) (ORAL) ANTIBIOTICS, TOPICAL DESVENLAFAXINE SUC ER (generic PRISTIQ) (ORAL) HUSKY Therapeutic Class ICD-10 Diagnosis List MEMANTINE 5-10MG TITRATION PACK (ORAL) GENTAMICIN 0.1% CREAM (TOPICAL) MIRTAZAPINE TABLET, ODT (ORAL) • UPDATED NOTATIONS: CHEWABLE notation will RIVASTIGMINE CAPSULES (ORAL) GENTAMICIN 0.1% OINTMENT (TOPICAL) TRAZODONE TABLET (ORAL) appear for preferred agents ANALGESICS, NARCOTICS SHORT MUPIROCIN 2% OINTMENT (not CREAM) (TOPICAL) TRINTELLIX (BRINTELLIX) (ORAL) ** New Therapeutic Class added to PDL effective 7/1/21 APAP / CODEINE 300-30 MG/12.5 ML SOLUTION (ORAL) VENLAFAXINE ER CASPULES (not TABLET) (ORAL) * New Drug added to the PDL effective 7/1/21 APAP / CODEINE 120-12 MG/5 ML SOLUTION (ORAL) ANTIBIOTICS, VAGINAL VIIBRYD TABLET (not STARTER PACK) (ORAL) Non - PDL PA Requirements APAP / CODEINE #2, #3, #4 TABLET (ORAL) CLEOCIN OVULES (VAGINAL) CONNECTICUT MEDICAID PDL PA FORM HYDROCODONE / APAP SOLUTION (ORAL) CLINDESSE 2% CREAM (VAGINAL) • Intolerance of the preferred agents HYDROCODONE / APAP TABLET (ORAL) METRONIDAZOLE VAGINAL 0.75% GEL (VAGINAL)* ANTIDEPRESSANTS, SSRIs • Adverse reaction to the preferred agents HYDROMORPHONE TABLET (IR) (ORAL) NUVESSA VAGINAL 1.3% GEL (VAGINAL) CITALOPRAM TABLET, SOLUTION (ORAL) • Inadequate response from the preferred agents MORPHINE CONC, SOLUTION, SYRUP (ORAL) ESCITALOPRAM TABLET, SOLUTION (ORAL) • Determined medically necessary appropriate MORPHINE IR TABLET (ORAL) ANTICOAGULANTS FLUOXETINE 20 MG/5 ML SOLUTION (ORAL) • Absence of appropriate formulation of the preferred OXYCODONE / APAP CAPSULE, TABLET (ORAL) ELIQUIS STARTER PACK (ORAL) FLUOXETINE CAPSULE (not 90 MG) (ORAL) agent OXYCODONE TABLET (not CAPSULE) (ORAL) ELIQUIS TABLET (ORAL) FLUOXETINE TABLET (ORAL) 10 MG only Step Therapy PA Requirements OXYCODONE 5 MG/5 ML SOLUTION (ORAL) ENOXAPARIN SYRINGE (SUBCUTANEOUS) FLUVOXAMINE TABLET (IR) (ORAL) STEP THERAPY PA FORM PROLATE TABLET (ORAL) ENOXAPARIN VIAL (SUBCUTANEOUS) PAROXETINE TABLET (IR only) (ORAL) ‡ Agents from the following FIVE categories: TRAMADOL 50 MG TABLET (not 100 MG) (ORAL) PRADAXA CAPSULE (ORAL) SERTRALINE TABLET, ORAL CONC (ORAL) ACNE AGENTS, TOPICAL, ANTIMIGRAINE TRAMADOL / APAP (ORAL) WARFARIN TABLET (ORAL) AGENTS, CYTOKINE/CAM ANTAGONISTS, XARELTO TABLET (ORAL) LIPOTROPICS, STATINS, PROTON PUMP ANDROGENIC AGENTS XARELTO STARTER PACK (ORAL) ANTIEMETIC / ANTIVERTIGO AGENTS INHIBITORS ANDROGEL 1.62% GEL PUMP (TRANSDERMAL)* APREPITANT CAPSULE (not PACK) (ORAL) Important Connecticut Medicaid Phone Numbers ANTICONVULSANTS DICLEGIS (ORAL) ANGIOTENSIN MODULATORS CARBAMAZEPINE TAB CHEW, TABLET (ORAL) DRONABINOL CAPSULE (ORAL) Gainwell Technologies Pharmacy Prior Authorization Center BENAZEPRIL TABLET (ORAL)* CARBATROL (ORAL) EMEND 80 MG CAPSULE (not TRIPACK) (ORAL)* Phone #: 1-866-409-8386 (toll-free) Fax #: 1-866-759-4110 (toll-free) DIOVAN TABLET (ORAL) CLOBAZAM TABLET (ORAL) ONDANSETRON ODT, SOLUTION, TABLET (ORAL) ENALAPRIL, ENALAPRIL / HCTZ (ORAL) CLONAZEPAM IR TABLET (not ODT or ER) (ORAL) PA forms are available on our website: ENTRESTO TABLET (ORAL) DEPAKOTE SPRINKLE (ORAL) http://www.CTDSSMAP.com IRBESARTAN, IRBESARTAN / HCTZ (ORAL) DIAZEPAM (RECTAL) (generic DIASTAT) ANTIFUNGALS, ORAL Navigate to: Pharmacy Information LISINOPRIL, LISINOPRIL / HCTZ (ORAL) DIAZEPAM DEVICE (RECTAL) (generic DIASTAT ACUDIAL) CLOTRIMAZOLE 10 MG TROCHE (MUCOUS MEM) or: information > publications > forms LOSARTAN, LOSARTAN / HCTZ (ORAL) DIVALPROEX ER (ORAL) FLUCONAZOLE SUSPENSION, TABLET (ORAL) Gainwell Technologies Provider Assistance Center OLMESARTAN, OLMESARTAN / HCTZ (ORAL)* DIVALPROEX SOD DR TABLET (ORAL) GRISEOFULVIN SUSPENSION (not TABLET) (ORAL) 1-800-842-8440 (toll-free) QUINAPRIL, QUINIPRIL / HCTZ (ORAL) EPIDIOLEX (ORAL) NOXAFIL DR 100 MG TABLET (ORAL)* Dept of Social Services Rx Consultant RAMIPRIL CAPSULE (ORAL) ETHOSUXIMIDE CAPSULE, SOLUTION (ORAL) NYSTATIN SUSPENSION (not TABLET) (ORAL) 1-860-424-5150 VALSARTAN / HCTZ (ORAL) GABITRIL TABLET (ORAL) TERBINAFINE TABLET (ORAL)

Updated September 8, 2021 ANTIFUNGALS, TOPICAL ANTIPARKINSON'S AGENTS, CONT. ANTIVIRALS, TOPICAL BRONCHODILATORS, BETA AGONIST, CONT. CLOTRIMAZOLE 1% CREAM (RX and OTC) (TOPICAL) CARBIDOPA / LEVODOPA / ENTACAPONE TABLET (ORAL) ZOVIRAX 5% CREAM (TOPICAL) PROAIR HFA (INHALATION) CLOTRIMAZOLE 1% SOLUTION (RX ONLY) (TOPICAL) PRAMIPEXOLE (IR) (ORAL) ZOVIRAX 5% OINTMENT (TOPICAL) SEREVENT DISKUS (INHALATION) CLOTRIMAZOLE-BETAMETHASONE CREAM (TOPICAL) ROPINIROLE (IR) (ORAL) KETOCONAZOLE CREAM (TOPICAL) SELEGILINE CAPSULE, TABLET (ORAL) ANXIOLYTICS CALCIUM CHANNEL BLOCKERS KETOCONAZOLE 2% SHAMPOO (TOPICAL) TRIHEXYPHENIDYL ELIXIR, TABLET (ORAL) ALPRAZOLAM IR TABLET (not ER or ODT) (ORAL) AMLODIPINE TABLET (ORAL) MICONAZOLE 2% CREAM (OTC) (TOPICAL) BUSPIRONE TABLET (ORAL) DILTIAZEM 12HR ER CAPSULE (ORAL) MICONAZOLE POWDER (not POWDER SPRAY) (OTC) (TOPICAL) CHLORDIAZEPOXIDE CAPSULE (ORAL) DILTAIZEM 24HR ER CAPSULE (not TABLET) (ORAL) NYSTATIN CREAM, OINTMENT, POWDER (TOPICAL) ANTIPSORIATICS, ORAL DIAZEPAM 5 MG/5 ML SOLUTION (not 5 MG/ML CONC) (ORAL)DILTIAZEM TABLET (ORAL) NYSTATIN-TRIAMCINOLONE CREAM, OINTMENT (TOPICAL)* ACITRETIN CAPSULE (ORAL) DIAZEPAM TABLET (ORAL) FELODIPINE ER (ORAL) ANTIHISTAMINES, MINIMALLY SEDATING LORAZEPAM TABLET, 2MG/ML INTENSOL (ORAL) NIFEDIPINE ER (ORAL) CETIRIZINE SOFTGEL (not TABLETS) (OTC) (ORAL) ANTIPSORIATICS, TOPICAL VERAPAMIL TABLET (ORAL) CETIRIZINE SOLUTION, SYRUP (RX ONLY) (ORAL) CALCIPOTRIENE 0.005% OINTMENT, SOLUTION (TOPICAL) BETA-BLOCKERS VERAPAMIL TABLET ER TABLET (not CAPSULE) (ORAL) CETIRIZINE-D TABLET (OTC) (ORAL) DOVONEX 0.005% CREAM (TOPICAL) ATENOLOL TABLET (ORAL) FEXOFENADINE 30 MG/5 ML SUSP (OTC) (ORAL) TACLONEX OINTMENT (TOPICAL) ATENOLOL / CHLORTHALIDONE (ORAL) CEPHALOSPORINS AND RELATED ANTIBIOTICS FEXOFENADINE-D TABLET (OTC) (ORAL) VECTICAL 3 MCG/G OINTMENT (TOPICAL) BISOPROLOL (ORAL) AMOXICILLIN / CLAV SUSPENSION (ORAL) LEVOCETIRIZINE TABLETS (RX & OTC) (ORAL) CARVEDILOL TABLET (not ER) (ORAL) AMOXICILLIN / CLAV TABLET (not CHEW TAB or ER) (ORAL) LORATADINE SOLUTION, SYRUP (OTC) (ORAL) ANTIPSYCHOTICS LABETALOL TABLET (ORAL) CEFACLOR CAPSULE (not SUSPENSION) (ORAL) LORATADINE OTC TABLET (not ODT) (ORAL) ABILIFY MAINTENA ER (INTRAMUSC.) METOPROLOL TARTRATE (ORAL) CEFADROXIL CAPSULE, SUSPENSION (not TABLET) (ORAL) ADASUVE (INHALATION) METOPROLOL SUCCINATE ER (ORAL) CEFDINIR CAPSULE, SUSPENSION (ORAL) ANTIHYPERTENSIVES, SYMPATHOLYTICS ARIPIPRAZOLE SOLUTION, TABLET (not ODT) (ORAL) PROPRANOLOL SOLUTION, TABLET (ORAL) CEFPROZIL SUSPENSION, TABLET (ORAL) CATAPRES-TTS PATCH (TRANSDERM) CHLORPROMAZINE TABLET (ORAL) PROPRANOLOL ER CAPSULE(ORAL) CEFUROXIME TABLET (ORAL) CLONIDINE TABLET (IR & ER) (ORAL) CLOZAPINE TABLET (not ODT) (ORAL) SOTALOL (ORAL) CEPHALEXIN CAPSULE, SUSPENSION (not TABLET) (ORAL) GUANFACINE TABLET (ORAL) FAZACLO 100 MG ODT (ORAL) METHYLDOPA TABLET (ORAL) FLUPHENAZINE DECANOATE (INJECTION) BILE SALTS FLUPHENAZINE ELIXIR/SOLN, TABLET (ORAL) URSODIOL 250MG, 500MG TABLET (ORAL) COLONY STIMULATING FACTORS ANTIHYPERURICEMICS HALOPERIDOL TABLET (ORAL) URSODIOL 300MG CAPSULE (ORAL) FULPHILA SYRINGE (SUBCUTANEOUS) ALLOPURINOL TABLET (ORAL) HALOPERIDOL DECANOATE, LACTATE (INJECTION) NEUPOGEN DISP SYRINGE, VIAL (INJECTION) MITIGARE (ORAL) HALOPERIDOL LACTATE CONC (ORAL) BLADDER RELAXANT PREPARATIONS UDENYCA SYRINGE (SUBCUTANEOUS) PROBENECID TABLET (ORAL) INVEGA SUSTENNA (INTRAMUSC) OXYBUTYNIN ER TABLET (ORAL) PROBENECID / COLCHICINE TABLET (ORAL) INVEGA TRINZA (INTRAMUSC) OXYBUTYNIN SYRUP, TABLET (ORAL) ANTIMIGRAINE AGENTS, OTHER LATUDA TABLET (ORAL) SOLIFENACIN TABLET (ORAL) CONTRACEPTIVES, ORAL AJOVY (SUBCUTANEOUS) LOXAPINE CAPSULE (ORAL) TOVIAZ ER TABLET (ORAL) *** PREFERRED EMERGENCY CONTRACEPTIVES *** EMGALITY 120 MG/ML PEN (SUBCUTANEOUS) MOLINDONE TABLET (ORAL) AFTERA 1.5 MG TABLET (ORAL) EMGALITY 120MG SYRINGE (not 100 MG) (SUBCUTANEOUS) OLANZAPINE TABLET, ODT (ORAL) BONE RESORPTION SUPPRESSION & RELATED AGENTS ELLA 30 MG TABLET (ORAL) UBRELVY TABLET (ORAL)* OLANZAPINE / FLUOXETINE (ORAL) ALENDRONATE TABLET (ORAL) OPCICON ONE-STEP 1.5 MG TABLET (ORAL) PERPHENAZINE TABLET (ORAL) CALCITONIN-SALMON 200 UNITS SPRAY (NASAL) PLAN B ONE-STEP 1.5 MG TABLET (ORAL) ANTIMIGRAINE AGENTS, TRIPTANS ‡ PERPHENAZINE / AMITRIPTYLINE (ORAL) IBANDRONATE TABLETS (ORAL) TAKE ACTION OTC (ORAL) (STEP THERAPY CATEGORY) PIMOZIDE TABLET (ORAL) TERIPARATIDE 620 MCG/2.48 ML SYR (SUBCUTANEOUS)* ALTAVERA-28 TABLET (ORAL) ELETRIPTAN TABLET (ORAL) QUETIAPINE TABLET, ER TABLET (ORAL) ALYACEN 1-35 28 TABLET (ORAL) IMITREX NASAL SPRAY (NASAL)* REXULTI TABLET(ORAL) AMETHIA 0.15-0.03-0.01 MG TAB (ORAL) RIZATRIPTAN ODT (ORAL) RISPERDAL CONSTA (INTRAMUSC.) BOTULINUM TOXINS APRI 28 DAY TABLET (ORAL) RIZATRIPTAN TABLET (ORAL) RISPERIDONE ODT, SOLUTION, TABLET (ORAL) DYSPORT VIAL (INTRAMUSC) AUBRA (ORAL) SUMATRIPTAN TABLET (ORAL) THIORIDAZINE TABLET (ORAL) AUROVELA 1 MG-20 MCG (ORAL) SUMATRIPTAN VIAL (not CARTRIDGE) (SUBCUTANEOUS) THIOTHIXENE CAPSULE (ORAL) BPH TREATMENTS AUROVELA 21 1.5-30 TABLET (ORAL) TRIFLUOPERAZINE TABLET (ORAL) ALFUZOSIN ER TABLET (ORAL) AUROVELA FE 1-20 MCG, FE 1.5-30 MCG (ORAL) ANTIPARASITICS, TOPICAL VRAYLAR CAPSULE, PACK (ORAL) DOXAZOSIN MESYLATE TABLET (ORAL) AVIANE-28 TABLET (ORAL) NATROBA 0.9% SUSPENSION (TOPICAL) ZIPRASIDONE CAPSULE (ORAL) DUTASTERIDE CAPSULE (ORAL) BLISOVI FE 1.5-30, BLISOVI FE 1-20 (ORAL) PERMETHRIN 1% CREAM RINSE, SHAMPOO (OTC) (TOPICAL) FINASTERIDE 5 MG TABLET (not 1 MG) (ORAL) CAMILA 0.35 MG TABLET (ORAL) PERMETHRIN 5% CREAM (TOPICAL) TAMSULOSIN CAPSULE (ORAL) CHARLOTTE 24 FE CHEWABLE (ORAL)* PIPERONYL BUTOXIDE / PYRETHRINS SHAMPOO (OTC) (TOPICAL) ANTIVIRALS, ORAL TERAZOSIN CAPSULE (ORAL) CHATEAL-28 TABLET (ORAL) ACYCLOVIR CAPSULE, TABLET (ORAL) CYCLAFEM 1-35-28, CYCLAFEM 7-7-7-28 (ORAL) ANTIPARKINSON'S AGENTS ACYCLOVIR SUSPENSION (ORAL) BRONCHODILATORS, BETA AGONIST DASETTA 1-35-28 TABLET (ORAL) AMANTADINE CAPSULE, SOLUTION, TABLET (ORAL) FAMCICLOVIR TABLET (ORAL) ALBUTEROL NEB SOLN 100 MG/20 ML (INHALATION) DEBLITANE 0.35 MG TABLET (ORAL) BENZTROPINE (ORAL) OSELTAMIVIR CAPSULE (ORAL) ALBUTEROL NEB SOLN 0.63, 1.25, 2.5 MG/3 ML (INHALATION)DESOGESTREL / ETHINYL ESTRADIOL (ORAL) CARBIDOPA / LEVODOPA TABLET (ORAL) OSELTAMIVIR SUSPENSION (ORAL) ALBUTEROL NEB SOLN 2.5 MG/0.5 ML (INHALATION) DROSPIRENONE-EE 3-0.02 MG TAB (ORAL) CARBIDOPA / LEVODOPA ER TABLET (ORAL) VALACYCLOVIR TABLET (ORAL) ALBUTEROL SOLUTION, SYRUP (not TABLET) (ORAL) DROSPIRENONE-EE 3-0.03 MG TAB (ORAL)

Updated September 8, 2021 CONTRACEPTIVES, ORAL, CONT. CONTRACEPTIVES, ORAL, CONT. GLUCAGON AGENTS HEPATITIS C AGENTS ELINEST-28 TABLET (ORAL) TRI-LINYAH (ORAL) BAQSIMI (NASAL) PEGASYS PROCLICK (SUBCUTANEOUS) EMOQUETTE 28 DAY TABLET (ORAL) TRI-LO-ESTARYLLA (ORAL) GLUCAGON (INJECTION) PEGASYS SYRINGE, VIAL (SUBCUTANEOUS) ENSKYCE 28 TABLET (ORAL) TRI-LO-MARZIA (ORAL) GLUCAGON EMERGENCY KIT (LILLY) (INJECTION) PEG-INTRON KIT (SUBCUTANE.) ERRIN 0.35 MG TABLET (ORAL) TRI-LO-MILI (ORAL) PROGLYCEM SUSPENSION (ORAL) RIBAVIRIN TABLET (not CAPSULE) (ORAL) ESTARYLLA 0.25-0.035 MG (ORAL) TRI-LO-SPRINTEC (ORAL) ETHYNODIOL/ETHINYL ESTRADIOL 1MG-50MCG (ORAL) TRI-PREVIFEM (ORAL) GLUCOCORTICOIDS, INHALED ***CURATIVE HEPATITIS C AGENTS REQUIRE FALMINA-28 (ORAL) TRI-SPRINTEC (ORAL) ADVAIR DISKUS (INHALATION) HEPATITIS C FORM*** GIANVI 3 MG-0.02 MG (ORAL) TRIVORA-28 (ORAL) ADVAIR HFA (INHALATION) SOFOSBUVIR / VELPATASVIR TABLET (ORAL)* HEATHER 0.35 MG TABLET (ORAL) VIENVA-28 (ORAL) ASMANEX TWISTHALER (not HFA) (INHALATION) MAVYRET TABLET (ORAL) ISIBLOOM (ORAL) WERA (ORAL) BREO ELLIPTA (INHALATION) VOSEVI TABLET (ORAL) JENCYCLA 0.35 MG (ORAL) DULERA (INHALATION) JULEBER-28 (ORAL) FLOVENT DISKUS, FLOVENT HFA (INHALATION) JUNEL 1/20 MCG, JUNEL 1.5/30 MCG (ORAL) COPD AGENTS PULMICORT RESPULES (INHALATION) HISTAMINE II RECEPTOR BLOCKER JUNEL FE 1/20, JUNEL FE 1.5/30 (not 24) (ORAL) ALBUTEROL / IPRATROPIUM NEB SOLUTION (INHALATION) PULMICORT FLEXHALER (INHALATION) CIMETIDINE OTC TABLET (not RX) (ORAL) KURVELO (ORAL) ANORO ELLIPTA (INHALATION) SYMBICORT (INHALATION) FAMOTIDINE SUSPENSION (ORAL) LARIN FE 1/20, LARIN FE 1.5/30 (ORAL) (not 24) ATROVENT 17 MCG HFA (INHALATION) TRELEGY ELLIPTA (INHALATION) FAMOTIDINE TABLET (Rx and OTC) (ORAL) LARISSIA (ORAL) COMBIVENT RESPIMAT (INHALATION) LESSINA-28 (ORAL) DALIRESP TABLET (ORAL) GLUCOCORTICOIDS, ORAL LEVONOR-ETH ESTRADIOL-28 0.1/0.02 (ORAL) (not 91) IPRATROPIUM BR 0.02% SOLUTION (INHALATION) BUDESONIDE EC (ORAL) LEVONOR-ETH ESTRADIOL-28 0.15/0.03 (ORAL) (not 91) SPIRIVA HANDIHALER (not RESPIMAT) (INHALATION) DEXAMETHASONE TABLET (ORAL) HYPOGLYCEMICS, ALPHA-GLUCOSIDASE INHIBITORS LEVORA-28 (ORAL) STIOLTO RESPIMAT (INHALATION) HYDROCORTISONE TABLET (ORAL) ACARBOSE TABLET (ORAL) LILLOW-28 TABLET (ORAL) METHYLPREDNISOLONE DOSE PACK (4 MG) (ORAL) GLYSET TABLET (ORAL) LOESTRIN 21 1/20, LOESTRIN 21 1.5/30 (ORAL) PREDNISOLONE 15 MG/5 ML SOLUTION (ORAL) LOESTRIN FE 1/20, LOESTRIN FE 1/5.30 (ORAL) CYTOKINE & CAM ANTAGONISTS ‡ PREDNISOLONE SOD PH 5 MG/5 ML SOLUTION (ORAL) HYPOGLYCEMICS, INCRETIN MIMETICS/ENHANCERS LORYNA 3 MG-0.02 MG (ORAL) (STEP THERAPY CATEGORY) PREDNISOLONE SOD PH 25MG/5 ML SOLUTION (ORAL) BYDUREON PEN INJECT (not BCISE) (SUBCUTANEOUS) LOSEASONIQUE (ORAL) ENBREL DISP SYRINGE, KIT, PEN (INJECTION) PREDNISONE TABLET (not DOSE PACK) (ORAL) BYETTA DOSE PEN (SUBCUTANEOUS) LOW-OGESTREL-28 (ORAL) ENBREL VIAL (SUBCUTANEOUS) GLYXAMBI TABLET (ORAL) LO-ZUMANDIMINE (ORAL) HUMIRA KIT, PEN INJ KIT (INJECTION) JANUMET TABLET (ORAL) MARLISSA-28 (ORAL) OTEZLA STARTER PACK, TABLET (ORAL) GROWTH FACTORS JANUMET XR TABLET (ORAL) MELODETTA 24 FE CHEWABLE (ORAL)* INCRELEX VIAL (SUBCUTANEOUS) JANUVIA TABLET (ORAL) MICROGESTIN FE 1.5-30 TABLET (ORAL) EMOLLIENTS JENTADUETO TABLET (IR) (not XR) (ORAL) MICROGESTIN FE 1-20 TABLET (ORAL) AMMONIUM LACTATE 12% CREAM (TOPICAL) ONGLYZA TABLET (ORAL) MILI (ORAL) AMMONIUM LACTATE 12% LOTION (TOPICAL) GROWTH HORMONE TRADJENTA TABLET (ORAL) MIRCETTE-28 (ORAL) GENOTROPIN CARTRIDGE (INJECTION)* TRULICITY PEN (SUBCUTANE.) MONO-LINYAH-28 (ORAL) GENOTROPIN MINIQUICK (INJECTION)* VICTOZA PEN (SUBCUTANEOUS) NATAZIA-28 (ORAL) ENZYME REPLACEMENT, GAUCHERS DISEASE NORDITROPIN FLEXPRO (INJECTION) NIKKI 3 MG-0.02 MG (ORAL) ZAVESCA 100 MG CAPSULE (ORAL) NORETHINDRONE 0.35 (ORAL) H. PYLORI TREATMENT HYPOGLYCEMICS, INSULIN & RELATED AGENTS NORETHINDRONE/ETHINYL ESTRADIOL 1-0.02 MG (ORAL) EPINEPHRINE, SELF-INJECTED PYLERA CAPSULE (ORAL) HUMALOG 100 UNIT/ML CARTRIDGE (SUBCUTANEOUS) NORETHINDRONE/ETHINYL ESTRADIOL 1.5-0.03 MG(21) (ORAL)EPINEPHRINE 0.15 MG (49502-0101-02) (INJECTION) HUMALOG MIX 50-50 KWIKPEN, VIAL NORETHINDRONE/ETHINYL ESTRADIOL FE MONOPHASIC (LOESTRINEPINEPHRINE 24 FE) 0.3 (ORAL) MG (49502-0102-02) (INJECTION) HUMALOG MIX 75-25 VIAL (SUBCUTANEOUS) NORGESTIMATE/ETHINYL ESTRADIOL MONOPHASIC 0.25-0.035 MG (ORAL) HEMOPHILIA TREATMENT HUMULIN 70/30 KWIKPEN OTC (SUBCUTANE.) NORGESTIMATE/ETHINYL ESTRADIOL TRIPHASIC (ORAL) ALPHANATE VIAL (INTRAVEN.) HUMULIN 70/30 VIAL (SUBCUTANEOUS) NORLYDA (ORAL) ERYTHROPOIESIS STIMULATING PROTEINS BENEFIX KIT (INTRAVEN.) HUMULIN N 100 UNITS/ML VIAL (SUBCUTANEOUS) PHILITH (ORAL) ARANESP DISP SYRIN, VIAL (INJECTION) COAGADEX (INTRAVEN) HUMULIN R 100 UNITS/ML VIAL (SUBCUTANEOUS) PIMTREA (ORAL) RETACRIT (INJECTION) CORIFACT KIT (INTRAVEN) HUMULIN R 500 UNITS/ML PEN, VIAL (SUBCUTANEOUS) PIRMELLA (ORAL) FEIBA NF (INTRAVEN) INSULIN ASPART 100 UNIT/ML CARTRIDGE, PEN, VIAL (SUBCUTANEOUS)* PORTIA-28 (ORAL) FLUOROQUINOLONES, ORAL HELIXATE FS (INTRAVEN.) INSULIN ASPART PROT (MIX70-30) FLEXPEN, VIAL (SUBCUTANEOUS)* PREVIFEM (ORAL) CIPRO SUSPENSION (ORAL) HEMLIBRA (SUBCUTANE.) INSULIN LISPRO 100 UNIT/ML PEN (SUBCUTANEOUS)* RECLIPSEN-28 (ORAL) CIPROFLOXACIN TABLET (IR) (ORAL) HUMATE-P KIT (INTRAVEN.) INSULIN LISPRO 100 UNIT/ML VIAL (SUBCUTANEOUS)* SEASONIQUE (ORAL) LEVOFLOXACIN TABLET (ORAL) NOVOEIGHT (INTRAVEN) INSULIN LISPRO JR 100 UNIT/ML KWIKPEN (SUBCUTANEOUS)* SHAROBEL 0.35 MG (ORAL) NUWIQ (INTRAVEN) INSULIN LISPRO MIX 75-25 KWIKPEN (SUBCUTANEOUS)* SPRINTEC-28 (ORAL) GI MOTILITY, CHRONIC SEVENFACT (INTRAVEN) LANTUS SOLOSTAR (SUBCUTANEOUS) SRONYX 0.1/0.02 (ORAL) AMITIZA CAPSULE (ORAL) WILATE VIAL (INTRAVEN) LANTUS VIAL (SUBCUTANEOUS) SYEDA-28 (ORAL) LINZESS CAPSULE (ORAL) XYNTHA KIT (INTRAVEN) LEVEMIR FLEXTOUCH, VIAL (SUBCUTANEOUS) TRI FEMYNOR (ORAL) MOVANTIK TABLET (ORAL) XYNTHA SOLOFUSE SYRINGE KIT (INTRAVEN.) TRESIBA FLEXTOUCH (SUBCUTANEOUS)

Updated September 8, 2021 HYPOGLYCEMICS, MEGLITINIDES INTRANASAL RHINITIS AGENTS MACROLIDES/KETOLIDES ONCOLOGY, ORAL - BREAST NATEGLINIDE TABLET (ORAL) AZELASTINE 0.1% SPRAY 137MCG (not 0.15%) (NASAL) AZITHROMYCIN 1 GM POWDER PACKET (ORAL) ANASTROZOLE TABLET (ORAL) REPAGLINIDE TABLET (ORAL) FLUTICASONE PROP 50 MCG SPRAY (RX & OTC) (NASAL) AZITHROMYCIN SUSPENSION, TABLET (ORAL) CYCLOPHOSPHAMIDE CAPSULE, TABLET (ORAL) IPRATROPIUM 0.03%, 0.06% SPRAY (NASAL) CLARITHROMYCIN IR TABLET (not ER) (ORAL) EXEMESTANE TABLET (ORAL) TRIAMCINOLONE 55 MCG SPRAY OTC (NASAL) E.E.S 200 SUSPENSION (GRANULES) (ORAL) IBRANCE CAPSULE (not TABLET) (ORAL) ERY-TAB DR TABLET (ORAL) LETROZOLE TABLET (ORAL) ERYTHROCIN 250 MG FILMTAB (ORAL) TAMOXIFEN CITRATE TABLET (ORAL) HYPOGLYCEMICS, METFORMINS ERYTHROMYCIN DR 250 MG CAPSULE (not FILMTAB) (ORAL) XELODA TABLET (ORAL) GLIPIZIDE-METFORMIN TABLET (ORAL) ERYTHROMYCIN DR TABLET (not ES 400MG) (ORAL) GLYBURIDE-METFORMIN TABLET (ORAL) METFORMIN IR TABLET (ORAL) METFORMIN ER TABLET (generic GLUCOPHAGE XR) (ORAL) IRON, ORAL METHOTREXATE FERATE OTC (ORAL) METHOTREXATE SODIUM PF VIAL (INJECTION) HYPOGLYCEMICS, SGLT2 FERRALET 90 DUAL-IRON (ORAL) METHOTREXATE TABLET, VIAL (ORAL) FARXIGA TABLET (ORAL) FERROUS FUMARATE TABLET OTC (ORAL) INVOKAMET TABLET (not XR) (ORAL) FERROUS FUMARATE/ASCORBIC ACID/B12-IF/FA CAPSULE (ORAL) INVOKANA TABLET (ORAL) FERROUS GLUCONATE OTC (ORAL) JARDIANCE TABLET (ORAL) FERROUS SULFATE 65 MG TABLET OTC (ORAL) MOVEMENT DISORDERS SYNJARDY TABLET (not XR) (ORAL) FERROUS SULFATE DROPS (ORAL) AUSTEDO TABLET (ORAL) XIGDUO XR (ORAL) FERROUS SULFATE OTC (ORAL) TETRABENAZINE TABLET (ORAL) ONCOLOGY, ORAL - HEMATOLOGIC FERROUS SULFATE SOLUTION OTC (ORAL) ALKERAN TABLET (ORAL) FERROUS SULFATE TABLET ER OTC (ORAL) BOSULIF TABLET (ORAL) HYPOGLYCEMICS, TZD FERROUS SULFATE, DRIED TABLET ER OTC (ORAL) MULTIPLE SCLEROSIS AGENTS BRUKINSA CAPSULE (ORAL) PIOGLITAZONE TABLET (ORAL) IFEREX 150 FORTE (ORAL) AVONEX PEN, PREFILLED SYRINGE, VIAL (INTRAMUSC.) CALQUENCE CAPSULE (ORAL) IRON 45 MG TABLET OTC (ORAL) BETASERON KIT (not VIAL) (SUBCUTANEOUS) COPIKTRA CAPSULE (ORAL) IRON POLYSACCHARIDES COMPLEX OTC (ORAL) COPAXONE 20 MG/ML SYRINGE (not 40 MG/ML) (SUBCUTANEOUS)DAURISMO TABLET (ORAL) IDIOPATHIC PULMONARY FIBROSIS IRON PS CMPLX/VIT B12/FA (ORAL) TECFIDERA CAPSULE (ORAL) FARYDAK CAPSULE (ORAL) OFEV CAPSULE (ORAL) IRON,CARBONYL/ASCORBIC ACID OTC (ORAL) TECFIDERA STARTER PACK (ORAL) HYDROXYUREA CAPSULE (ORAL) MV COMB18/FEFM-FEPOL CB1/FA (ORAL) ICLUSIG TABLET (ORAL) SLOW RELEASE IRON (ORAL) IDHIFA TABLET (ORAL) IMMUNOMODULATORS, ASTHMA IMATINIB TABLET (ORAL) FASENRA PEN, SYRINGE (SUBCUTANEOUS) LEUKOTRIENE MODIFIERS NEUROPATHIC PAIN IMBRUVICA CAPSULE, TABLET (ORAL) XOLAIR SYRINGE, VIAL (SUBCUTANEOUS) MONTELUKAST CHEW TABLET (not GRANULES) (ORAL) CAPSAICIN 0.025%, 0.075%, 0.1% CREAM (TOPICAL) INQOVI TABLET (ORAL)* MONTELUKAST TABLET (ORAL) CAPSAICIN 0.15% LIQUID (TOPICAL) INREBIC CAPSULE (ORAL) DULOXETINE 20MG, 30MG, 60MG CAPSULES (not 40MG) (ORAL)JAKAFI TABLET (ORAL) GABAPENTIN CAPSULE (ORAL) LEUKERAN TABLET (ORAL) IMMUNOMODULATORS, ATOPIC DERMATITIS LIPOTROPICS, OTHER GABAPENTIN TABLET (ORAL) MATULANE CAPSULE (ORAL) ELIDEL 1% CREAM (TOPICAL) CHOLESTYRAMINE (with SUCROSE) (not LIGHT) (ORAL) LIDODERM (TOPICAL) MERCAPTOPURINE TABLET (ORAL) EUCRISA 2% OINTMENT (TOPICAL) COLESTIPOL TABLET (not PACKET) (ORAL) LYRICA CAPSULE (IR) (not CR) (ORAL) MYLERAN TABLET (ORAL) PROTOPIC 0.03% OINTMENT (TOPICAL) EZETIMIBE TABLET (ORAL) PREGABALIN CAPSULE (ORAL) NINLARO CAPSULE (ORAL) PROTOPIC 0.1% OINTMENT (TOPICAL) FENOFIBRATE 67MG, 134MG, 200MG CAPSULE (ORAL) ZTLIDO (TOPICAL) ONUREG TABLET (ORAL)* FENOFIBRATE 48MG, 54MG, 145MG, 160MG TABLET (ORAL) POMALYST CAPSULE (ORAL) FISH OIL SOFTGEL (OTC) (ORAL) REVLIMID CAPSULE (ORAL) IMMUNOMODULATORS, TOPICAL GEMFIBROZIL TABLET (ORAL) RYDAPT CAPSULE (ORAL) IMIQUIMOD 5% CREAM PACKET (not 3.75%) (TOPICAL) NIACIN CAPLET, CAPSULE, TABLET (ORAL) NSAIDS SPRYCEL TABLET (ORAL) PODOFILOX 0.5% SOLUTION (TOPICAL) OMEGA-3 ACID ETHYL ESTERS 1GM CAPSULE (ORAL) DICLOFENAC 1% GEL (TOPICAL) TABLOID TABLET (ORAL) OMEGA-3 OTC SOFTGEL (ORAL) DICLOFENAC SODIUM DR & EC TABLET (not ER 100 MG) (ORAL)TASIGNA CAPSULE (ORAL) IBUPROFEN SUSPENSION, TABLET (ORAL) THALOMID CAPSULE (ORAL) IMMUNOSUPPRESSIVES, ORAL INDOMETHACIN CAPSULE (IR) (not ER 75 MG) (ORAL) TIBSOVO TABLET (ORAL) AZATHIOPRINE TABLET (ORAL) LIPOTROPICS, STATINS ‡ MELOXICAM TABLET (not CAPSULE) (ORAL) TRETINOIN CAPSULE (ORAL) CYCLOSPORINE MODIFIED CAPSULE (NOT 50MG) (ORAL) (STEP THERAPY CATEGORY) NABUMETONE TABLET (ORAL) UKONIQ TABLET (ORAL)* CYCLOSPORINE MODIFIED SOLUTION (ORAL) ATORVASTATIN TABLET (ORAL) NAPROXEN 250MG, 375MG, 500MG TABLET (not DR) (ORAL) VENCLEXTA TABLET, STARTING PACK (ORAL) EVEROLIMUS TABLET (ORAL)* LOVASTATIN TABLET (ORAL) NAPROXEN SUSPENSION (ORAL) XOSPATA TABLET (ORAL) MYCOPHENOLATE MOFETIL CAPSULE, TABLET (ORAL) PRAVASTATIN TABLET (ORAL) NAPROXEN 250MG, 375MG, 500MG TABLET (not ER or DR) (ORAL)XPOVIO WEEKLY DOSE (ORAL) RAPAMUNE SOLUTION (not TABLET) (ORAL) ROSUVASTATIN TABLET (ORAL) SULINDAC TABLET (ORAL) ZOLINZA CAPSULE (ORAL) TACROLIMUS CAPSULE (ORAL) SIMVASTATIN TABLET (ORAL) ZYDELIG TABLET (ORAL)

Updated September 8, 2021 ONCOLOGY, ORAL - LUNG ONCOLOGY, ORAL - RENAL CELL OPHTHALMIC, ANTI-INFLAMMATORY/IMMUNOMODULATOR PHOSPHATE BINDERS ALECENSA CAPSULE (ORAL) AFINITOR TABLET (ORAL) (not DISPERZ) RESTASIS 0.05% EYE EMULSION (OPHTHALMIC) CALCIUM ACETATE CAPSULE, GELCAP, TABLET (ORAL) ALUNBRIG TABLET, TABLET PACK (ORAL) CABOMETYX TABLET (ORAL) RESTASIS MULTIDOSE 0.05% (OPHTHALMIC) RENVELA TABLET (ORAL)* GAVRETO CAPSULE (ORAL)* FOTIVDA CAPSULE (ORAL)* XIIDRA 5% DROPS (OPHTHALMIC) GILOTRIF TABLET (ORAL) INLYTA TABLET (ORAL) PITUITARY SUPPRESSIVE AGENTS, LHRH HYCAMTIN CAPSULE (ORAL) LENVIMA CAPSULE, DAILY DOSE (ORAL) ELIGARD SYRINGE (SUBCUTANEOUS) IRESSA TABLET (ORAL) NEXAVAR TABLET (ORAL) OPHTHALMICS, GLAUCOMA AGENTS FENSOLVI SYRINGE (SUBCUTANEOUS)* LORBRENA TABLET (ORAL) SUTENT CAPSULE (ORAL) ALPHAGAN P 0.15% DROP (OPHTHALMIC) LEUPROLIDE ACETATE KIT, VIAL (SUBCUTANEOUS) RETEVMO CAPSULE (ORAL)* VOTRIENT TABLET (ORAL) BETOPTIC S 0.25% (OPHTHALMIC) LUPANETA PACK (INJECTION/ORAL) ROZLYTREK CAPSULE (ORAL) BRIMONIDINE 0.2% DROP (OPHTHALMIC) LUPRON DEPOT KIT (INJECTION) TABRECTA TABLET (ORAL) ONCOLOGY, ORAL - SKIN CARTEOLOL 1% DROP (OPHTHALMIC) LUPRON DEPOT-PED KIT (INJECTION) TAGRISSO TABLET (ORAL) BRAFTOVI CAPSULE (ORAL) COMBIGAN 0.2%-0.5% DROP (OPTHALMIC) SYNAREL NASAL SPRAY (NASAL) TARCEVA TABLET (ORAL) COTELLIC TABLET (ORAL) DORZOLAMIDE 2% DROP (OPHTHALMIC) ZOLADEX IMPLANT SYRINGE (SUB-Q) TEPMETKO TABLET (ORAL)* ERIVEDGE CAPSULE (ORAL) DORZOLAMIDE / TIMOLOL DROP (OPHTHALMIC) VIZIMPRO TABLET (ORAL) MEKINIST TABLET (ORAL) LATANOPROST 0.005% DROP (OPHTHALMIC) XALKORI CAPSULE (ORAL) MEKTOVI TABLET (ORAL) LEVOBUNOLOL 0.5% DROP (OPHTHALMIC) PLATELET AGGREGATION INHIBITORS ZYKADIA CAPSULE (ORAL) ODOMZO CAPSULE (ORAL) PILOCARPINE 1%, 2%, 4% DROPS (OPHTHALMIC) ASPIRIN-DIPYRIDAM ER 25-200 MG (ORAL) (70436-0092-05)* TAFINLAR CAPSULE (ORAL) RHOPRESSA (OPHTHALMIC) BRILINTA TABLET (ORAL) ZELBORAF TABLET (ORAL) ROCKLATAN (OPHTHALMIC) CLOPIDOGREL TABLET (ORAL) TIMOLOL 0.25% EYE DROP (OPHTHALMIC) DIPYRIDAMOLE TABLET (ORAL) OPHTHALMICS FOR ALLERGIC CONJUNCTIVITIS TIMOLOL 0.5% EYE DROP (not ONCE DAILY or PF) (OPHTHALMIC)PRASUGREL TABLET (ORAL) ALREX 0.2% (OPHTHALMIC) TIMOLOL 0.25%, 0.5% GEL-SOLUTION (OPHTHALMIC) CROMOLYN SODIUM 4% (OPHTHALMIC) TRAVATAN Z 0.004% DROP (OPHTHALMIC) PATADAY ONCE DAILY 0.7% DROPS (OTC) (OPHTHALMIC) ONCOLOGY, ORAL - OTHER PAZEO 0.7% DROPS (OPTHALMIC) POTASSIUM BINDERS AYVAKIT TABLET (ORAL)* OPIATE DEPENDENCE TREATMENTS LOKELMA POWDER PACKET (ORAL) BALVERSA TABLET (ORAL) BUPRENORPHINE SL TABLET (SUBLINGUAL) SODIUM POLYSTYRENE SULF POWDER (ORAL) CAPRELSA TABLET (ORAL) OPHTHALMIC ANTIBIOTICS BUPRENORPHINE / NALOXONE TABLETS (not FILM) (SUBLINGUAL)* COMETRIQ DAILY-DOSE PACK (ORAL) BACITRACIN-POLYMYXIN B SULFATE OINTMENT (OPHTHALMIC)NALOXONE CARPUJECT, SYRINGE, VIAL (INJECTION) KOSELUGO CAPSULE (ORAL)* CIPROFLOXACIN 0.3% SOLUTION (OPHTHALMIC) NALTREXONE TABLET (ORAL) PRENATAL VITAMINS LONSURF TABLET (ORAL) ERYTHROMYCIN 0.5% OINTMENT (OPHTHALMIC) NARCAN NASAL SPRAY (NASAL) CITRANATAL B-CALM COMBO PACK (ORAL) LYNPARZA TABLET (ORAL) GENTAK 0.3% OINTMENT (OPHTHALMIC) SUBOXONE FILM (SUBLINGUAL) COMPLETE NATAL DHA (ORAL) PEMAZYRE TABLET (ORAL)* GENTAMICIN 0.3% SOLUTION (OPHTHALMIC) VIVITROL VIAL (SUBCUTANEOUS) COMPLETENATE CHEW TABLET (ORAL) QINLOCK TABLET (ORAL)* MOXIFLOXACIN 0.5% DROPS (VIGAMOX) (OPHTHALMIC) FOLIVANE-OB CAPSULE (ORAL) RUBRACA TABLET (ORAL) OFLOXACIN 0.3% SOLUTION (OPHTHALMIC) OTIC ANTIBIOTICS M-NATAL PLUS TABLET (ORAL) STIVARGA TABLET (ORAL) POLYMYXIN B-TMP DROP (OPHTHALMIC) CIPRODEX OTIC SUSPENSION (OTIC) NIVA-PLUS TABLET (ORAL) TAZVERIK TABLET (ORAL)* TOBRAMYCIN 0.3% SOLUTON (OPHTHALMIC) NEOMYCIN / POLYMYXIN / HC SOLUTION, SUSPENSION (OTIC)PNV 29-1 TABLET (ORAL) TEMAZOLAMIDE CAPSULE (ORAL) TOBREX 0.3% OINTMENT (OPHTHALMIC) OFLOXACIN 0.3% DROP (OTIC) PNV-DHA SOFTGEL (42192-0321-30) (ORAL)* TURALIO CAPSULE (ORAL) PRENATAL VITAMIN PLUS LOW IRON (ORAL) VITRAKVI CAPSULE, SOLUTION (ORAL) PRENATAL VITAMINS TABLET (46122-0098-78) (ORAL) ZEJULA CAPSULE (ORAL) OPHTHALMIC ANTIBIOTIC-STEROID COMBINATIONS OTIC ANTI-INFECTIVES & ANESTHETICS PREPLUS CA-FE 27 MG-FA 1 MG TB (ORAL) NEOMYCIN / POLY / DEXAMETHASONE OINTMENT (OPHTHALMIC)ACETIC ACID 2% SOLUTION (OTIC) PRETAB 29 MG-1 MG TABLET (69543-0259-10) (ORAL) NEOMYCIN / POLY / DEXAMETHASONE DROP (OPHTHALMIC) SELECT-OB + DHA PACK (ORAL) SULFACETAMIDE / PREDNISOLONE 10-0.23% (OPHTHALMIC) SE-NATAL 19 TABLET (ORAL) TOBRADEX EYE DROP (OPHTHALMIC) PAH AGENTS, ORAL AND INHALED THRIVITE RX TABLET (ORAL) TOBRADEX EYE OINTMENT (OPHTHALMIC) (DX CODE REQUIRED - SILDENAFIL & TADALAFIL) TRICARE PRENATAL TABLET (ORAL) ONCOLOGY, ORAL - PROSTATE LETAIRIS TABLET (ORAL)* TRINATAL RX 1 TABLET (ORAL) ABIRATERONE TABLET (ORAL) SILDENAFIL 20 MG TABLET (ORAL) (DX CODE REQ.) TRUST NATAL DHA (ORAL) BICALUTAMIDE TABLET (ORAL) OPHTHALMIC, ANTI-INFLAMMATORIES TADALAFIL 20 MG TABLET (ADCIRCA) (ORAL) (DX CODE REQ.)VIRT-PN DHA SOFTGEL (69543-0340-30) (ORAL)* EMCYT CAPSULE (ORAL) DICLOFENAC 0.1% DROP (OPHTHALMIC) TRACLEER 62.5 MG & 125 MG TABLET (ORAL) VITAFOL GUMMIES (ORAL) ERLEADA TABLET (ORAL) FLUOROMETHOLONE 0.1% DROP (OPHTHALMIC) VENTAVIS SOLUTION (INHALATION) VITAFOL NANO TABLET (ORAL) FLUTAMIDE CAPSULE (ORAL) FML FORTE 0.25% DROP (not LIQUIFILM) (OPHTHALMIC) VITAFOL ULTRA SOFTGEL (ORAL) NILUTAMIDE TABLET (ORAL) ILEVRO 0.3% DROP (OPHTHALMIC) VITAFOL-OB CAPLET (ORAL) NUBEQA TABLET (ORAL) KETOROLAC 0.5% SOLUTION (not 0.4%) (OPHTHALMIC) VITAFOL-OB+DHA COMBO PACK (ORAL) ORGOVYX TABLET (ORAL)* LOTEMAX 0.5% DROP (not GEL) (OPHTHALMIC) PANCREATIC ENZYMES VITAFOL-ONE CAPSULE (ORAL) XTANDI CAPSULE (ORAL) PRED MILD 0.12% (not FORTE) (OPHTHALMIC) CREON CAPSULE (ORAL) WESTAB PLUS TABLET (69367-0267-01) (ORAL) YONSA TABLET (ORAL) PREDNISOLONE AC 1% DROP (OPHTHALMIC) ZENPEP CAPSULE (ORAL) ZATEAN-PN DHA CAPSULE (ORAL)*

Updated September 8, 2021 PROGESTATIONAL AGENTS STEROIDS, TOPICAL LOW POTENCY TETRACYCLINES MAKENA 275 MG/1.1 ML AUTOINJCT (SUBCUTANEOUS) CAPEX SHAMPOO (TOPICAL) DOXYCYCLINE HYCLATE CAPSULE (not DR) (ORAL) MEDROXYPROGESTERONE TABLET (ORAL) DERMA-SMOOTHE-FS BODY OIL (TOPICAL) DOXYCYCLINE HYCLATE TABLET (not DR) (ORAL) NORETHINDRONE TABLET (ORAL) DERMA-SMOOTHE-FS SCALP OIL (TOPICAL) DOXYCYCLINE MONOHYDRATE 50 MG, 100 MG CAPSULE (ORAL) PROGESTERONE VIAL (INTRAMUSC) DESONIDE 0.05% OINTMENT (not LOTION) (TOPICAL) DOXYCYCLINE MONOHYDRATE TABLET (ORAL) PROGESTERONE CAPSULE (ORAL) HYDROCORTISONE 0.5% CREAM (not ACETATE) (TOPICAL) MINOCYCLINE CAPSULE (not TABLET) (ORAL) HYDROCORTISONE 1% CREAM (not ACETATE) (TOPICAL) MORGIDOX CAPSULE (not KIT) (ORAL) HYDROCORTISONE 1% OINTMENT (TOPICAL) PROTON PUMP INHIBITORS ‡ HYDROCORTISONE 2.5% CREAM (TOPICAL) (STEP THERAPY CATEGORY) HYDROCORTISONE 2.5% LOTION (TOPICAL) ESOMEPRAZOLE 20MG CAPSULE (not PACKET) (ORAL) HYDROCORTISONE 2.5% OINTMENT (TOPICAL) THROMBOPOIESIS STIMULATING PROTEINS ESOMEPRAZOLE 40MG CAPSULE (ORAL) HYDROCORTISONE (PROCTO) RECTAL CREAM 2.5% (TOPICAL)PROMACTA TABLET (not SUSPENSION PACKET) (ORAL) NEXIUM PACKET SUSPENSION (not CAPSULE) (ORAL) OMEPRAZOLE 10MG, 20MG, 40MG CAPSULE (Rx ONLY) (ORAL) PANTOPRAZOLE TABLET (ORAL) PROTONIX SUSPENSION (ORAL) STEROIDS, TOPICAL MEDIUM POTENCY ULCERATIVE COLITIS AGENTS FLUTICASONE PROPIONATE 0.05% CREAM (TOPICAL) APRISO ER CAPSULE (ORAL) FLUTICASONE PROPIONATE 0.005% OINTMENT (TOPICAL) CANASA SUPPOSITORY (RECTAL) SEDATIVE HYPNOTICS MOMETASONE FUROATE 0.1% CREAM (TOPICAL) LIALDA DR TABLET (ORAL) ESZOPICLONE TABLET (ORAL) MOMETASONE FUROATE 0.1% OINTMENT (TOPICAL) PENTASA CAPSULE (ORAL) FLURAZEPAM CAPSULE (ORAL) MOMETASONE FUROATE 0.1% SOLUTION (TOPICAL) SULFASALAZINE TABLET (ORAL) TEMAZEPAM 15MG, 30MG CAPSULE (ORAL) SULFASALAZINE DR TABLET (ORAL) ZALEPLON CAPSULE (ORAL) ZOLPIDEM TARTRATE 5MG, 10MG TABLET (IR) (ORAL) STEROIDS, TOPICAL VERY HIGH POTENCY CLOBETASOL EMOLLIENT 0.05% CREAM (TOPICAL) UTERINE DISORDER TREATMENTS SICKLE CELL ANEMIA TREATMENTS CLOBETASOL PROPIONATE 0.05% CREAM (TOPICAL) ORIAHNN CAPSULE(ORAL)* ADAKVEO VIAL (INTRAVENOUS) CLOBETASOL PROPIONATE 0.05% GEL (TOPICAL) ORILISSA TABLET (ORAL) DROXIA CAPSULE (ORAL) CLOBETASOL PROPIONATE 0.05% OINTMENT (TOPICAL) ENDARI POWDER PACKET(ORAL) CLOBETASOL PROPIONATE 0.05% SOLUTION (TOPICAL) OXBRYTA TABLET (ORAL) CLOBEX 0.05% SHAMPOO (TOPICAL) HALOBETASOL PROPIONATE 0.05% CREAM (TOPICAL) VASODILATORS, CORONARY SKELETAL MUSCLE RELAXANTS ISOSORBIDE DINITRATE 5MG TABLETS (not 68682-0193-01) (ORAL)* BACLOFEN TABLET (ORAL) ISOSORBIDE DINITRATE 10MG, 20MG, 30MG TABLETS (ORAL)* CYCLOBENZAPRINE TABLET (not ER) (ORAL) STIMULANTS AND RELATED AGENTS (DX CODE REQ.) ISOSORBIDE DINITRATE 40 MG TAB (only 70710-1152-01) (ORAL)* METHOCARBAMOL TABLET (ORAL) (DX CODE REQUIRED - SEE SELECT AGENTS) ISOSORBIDE MONONITRATE TABLET (ORAL) TIZANIDINE TABLET (not CAPSULE ) (ORAL) ADDERALL TABLET (ORAL) (DX CODE REQ.) ISOSORBIDE MONONITRATE ER / SR TABLET (ORAL) ADDERALL XR CAPSULE (ORAL) (DX CODE REQ.) NITRO-BID 2% OINTMENT (TRANSDERM) AMPHETAMINE SALT COMBO TABLET (IR) (ORAL) (DX CODE REQ.)NITROGLYCERIN ER CAPSULE (ORAL) SMOKING CESSATION ATOMOXETINE CAPSULE (ORAL) NITROGLYCERIN PATCH (TRANSDERM) BUPROPION HCL SR 150 MG TABLET (ORAL) CLONIDINE TABLET (IR) (ORAL) NITROGLYCERIN SL TABLET (SUBLINGUAL) CHANTIX TABLET (ORAL) CLONIDINE ER (ORAL) CHANTIX STARTING MONTH BOX, CONT MONTH BOX (ORAL)CONCERTA ER TABLET (ORAL) (DX CODE REQ.) NICOTINE GUM OTC (not BRAND) (BUCCAL) DEXMETHYLPHENIDATE IR (FOCALIN)(ORAL)(DX CODE REQ.) NICOTINE LOZENGE OTC (not BRAND) (MUCOUS MEM) DEXTROAMPHETAMINE TABLET (IR) (not ER) (ORAL) (DX CODE REQ.) NICOTINE PATCH OTC (not BRAND) (TRANSDERMAL) DEXTROAMPHETAMINE / AMPHETAMINE TABLET (IR) (ORAL) (DX CODE REQ.) NICOTINE TRANSDERMAL SYSTEM (TRANSDERMAL) FOCALIN XR CAPSULE (ORAL) (DX CODE REQ.) GUANFACINE ER TABLET (ORAL) STEROIDS, TOPICAL HIGH POTENCY METHYLPHENIDATE IR TABLET (RITALIN) (ORAL) (DX CODE REQ.) BETAMETHASONE DP AUG 0.05% CREAM (TOPICAL) METHYLPHENIDATE ER TABLET (METADATE ER) (ORAL) (DX CODE REQ.) BETAMETHASONE VALERATE 0.1% CREAM (TOPICAL) METHYLPHENIDATE SOLUTION (ORAL) (DX CODE REQ.) BETAMETHASONE VALERATE 0.1% LOTION (TOPICAL) MODAFINIL TABLET (ORAL) (DX CODE REQ.) BETAMETHASONE VALERATE 0.1% OINTMENT (TOPICAL) QUILLICHEW ER CHEWABLE TABLET (ORAL) (DX CODE REQ.) TRIAMCINOLONE ACETONIDE 0.025%, 0.1%, 0.5% CREAM (TOPICAL)QUILLIVANT XR SUSPENSION (ORAL) (DX CODE REQ.) TRIAMCINOLONE ACETONIDE 0.025%, 0.1% LOTION (TOPICAL)VYVANSE CAPSULE (ORAL) (DX CODE REQ.) TRIAMCINOLONE ACETONIDE 0.1%, 0.5% OINTMENT (TOPICAL)VYVANSE CHEWABLE TABLET (ORAL) (DX CODE REQ.)

Updated September 8, 2021