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4-Tier Prescription Drug List, September 2021 Introduction

The Prescription Drug List (PDL) is the list of covered medications for PHP Marketplace Members and Members who have coverage through their employer group. The PDL applies only to prescription medications that a PHP Member picks up at a pharmacy or other outpatient location; it does not include inpatient medications or medications obtained or administered in a Physician’s office. Some over-the-counter medications are covered due to federal regulations and the Member’s specific pharmacy benefit plan.

The PDL does not define benefit coverage. Benefit coverage is determined by the Member’s specific pharmacy benefit plan. This means that there may be medications listed on the PDL that are not covered because the it is not a covered benefit under the Member’s pharmacy benefit plan.

You may also access PDL information by visiting our website at PHPMichigan.com. For general questions regarding the PDL, call toll-free PHP’s Customer Service Department at 1.800.832.9186.

Prescription Drug List Medication Overview

Medications on the PDL fall under different benefit tiers. Which medications are on a tier is based on a review of clinical, economic, and other factors. The PHP Pharmacy & Therapeutics (P&T) Committee, composed of Physicians and Pharmacists, reviews new and existing medications and provides clinical guidance for formulary development and tier placement. Guidance is based on similarities and differences compared with other medications that treat the same disease or condition. This helps ensure Members have access to a wide range of medications while controlling healthcare costs.

The tier placement of a medication on the PDL may be subject to change. When a medication changes tiers, the Member may be required to pay more or less. These changes may occur without prior notice. Members may visit the PHP website at PHPMichigan.com. Call PHP’s Customer Service Department at 1.800.832.9186 or 517.364.8500 for the most up-to-date tier status and copayment information. Tier Designations

Prescription medications are categorized within four tiers on the PDL. Each tier is assigned a copayment, which is determined by the Member’s pharmacy benefit plan. Providers may refer to the PDL as a guide to select the most appropriate medication with the lowest Member copayment for your patients.

ACA

A select list of prescription and over-the-counter medications are classified as preventive medications based up the Health Care Reform (HCR) Affordable Care Act (ACA) guidelines. These medications are available to Members at zero ($0) copayment. More information on preventive medications is included in the Member’s specific benefit plan.

Tier 1

Medications on Tier 1 will have the lowest member cost share. Most medications on this tier are generic medications.

Tier 2

Tier 2 medications are preferred branded traditional and specialty medications. A provider may consider a Tier 2 medication if no Tier 1 medication is appropriate to treat the Member’s condition. Members will have a higher cost share for Tier 2 medications.

Tier 3

Tier 3 medications are non-preferred traditional medications. Members will have the highest cost share for Tier 3 medications, unless the medication is a specialty medication and is designated as Tier 4.

Tier 4

Tier 4 medications are non-preferred specialty medications. Tier 4 medications will have the highest member cost share. For Members who have a 3-tier benefit plan structure, medications within this PDL denoted as tier 4 medications will assess the 3rd tier Member cost share.

Specific information about the member’s cost share, including copays, deductible and coinsurance amounts, can be found in the member’s Certificate of Coverage. For more information, please call PHP’s Customer Service Department at 800.832.916 or 517.364.8500. Medications listed in lowercase italics indicate the generic name of the medication. Medications listed in all UPPERCASE indicate a branded, single-source, or authorized generic medication.

Over-the-Counter Medications

For many conditions, an over-the-counter (OTC) medication may be the most appropriate treatment. OTC medications are defined as medications that do not require a prescription by federal or state law to be dispensed. Specific OTC medications are covered based on the member’s specific benefit plan and federal regulations. Therapeutic equivalent and OTC medications may not be covered under the Member’s pharmacy benefit, and they may cost less than the Member’s out-of- pocket expense for prescription medications. However, if the Patient or Physician requests a therapeutic equivalent product or an OTC product, the patient may be required to pay the entire cost of the product. This is determined by the Member’s pharmacy benefit plan.

Generic Medication Policy

Most generic medications are included on the PDL as Tier 1 medications. Members will have the lowest cost share with a Tier 1 medication, so consider prescribing a generic, Tier 1 medication when appropriate. Note that when a brand-name medication becomes available as a generic, that brand-name product may move to a higher tier. Unless the Physician specifies that the medication must be Dispensed As Written (DAW), the pharmacist may substitute the name brand for a lower cost generic equivalent. When generic substitution conflicts with state regulations or restrictions, the dispensing Pharmacist must obtain approval from the prescribing Physician or other health care professional to substitute the generic equivalent.

Self-Administered Injectables

Some Members may have coverage for self-administered injectable medications through their pharmacy benefit plan. You will find these medications included in the body of this document within the appropriate therapeutic categories.

Medications Requiring Notification and Other Pharmacy Programs

Select medications may require Prior Authorization (PA) in order to be covered. These medications are noted with a PA in this document. The list of the medications requiring PA is provided below. The list is approved by the PHP Pharmacy and Therapeutics Committee. To initiate a PA review for a certain medication, the provider or provider’s designee must complete the Prior Authorization Request Form and fax the completed form to the PHP Pharmacy Department at 517.364.8413. The Prior Authorization Request Form for medications as well as PA criteria can be found on the website at www.phpmichigan.com/providers/general-forms-and- information.

Quantity limitations are based on FDA-approved dosing recommendations and package size as well as plan benefit limitations. Such medications have a notation “QL,” for quantity limit. These quantity limitations define either the maximum supply of medication per copayment or a defined maximum amount that can be covered in a specific time period, as specified by the pharmacy benefit plan. Exceptions to the QL for certain medications are reviewed through the PA process, outlined above.

Some medications are excluded for certain uses or are only covered for specific diagnoses. In general, PHP benefit plans do not cover medications that are prescribed for conditions outside of those approved by the Federal Drug Administration (FDA).

If you have questions about the PDL or specific coverage requirements, call PHP’s Customer Service Department at 800.832.916 or 517.364.8500.

Keys To Symbols

Symbols used throughout the PDL have these definitions:

AL = Age Limitation. Prior notification may be required to be eligible for coverage depending on Patient age.

ACA = Affordable Care Act Preventative Medications. These are covered at zero copayment ($0) to the Member.

LA = Limited Access. This medication may be covered only at certain pharmacies or as a medical benefit. Coverage is based upon the Member’s benefit. For more information, please call Customer Service.

MB = Medication is covered only through the medical benefit

PA = Prior Authorization required. Approval of this medication is required prior to coverage by PHP.

QL = Quantity limit.

SP = Specialty Medication. This medication allows a maximum of a one month supply per fill.

ST = Step therapy. This medication requires trial of a preferred agent prior to coverage. Language Access Information ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1‐800‐649‐3777 (TTY: 711). Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1‐800‐649‐3777 (TTY: 711). Arabic: ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم )رقم هاتف الصم والبكم: 800-649-377 (TTY: 711)-1

Chinese: 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1‐800‐649‐3777 (TTY: 711) German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1‐800‐649‐3777 (TTY: 711). Italian: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1‐800‐649‐3777 (TTY: 711). Japanese: 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。 1‐800‐649‐3777 (TTY: 711) まで、お電話にてご連絡ください

Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1- 1‐800‐649‐3777 (TTY: 711) 번으로 전화해 주십시오. Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1‐800‐649‐3777 (TTY: 711). Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1‐800‐649‐3777 (TTY: 711). Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1‐800‐649‐3777 (TTY: 711). Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1‐800‐649‐3777 (TTY: 711). Bengali: লক্ষ্য ক쇁নঃ যদি আপদন বাাংলা, কথা বলতে পাতেন, োহতল দনঃখেচায় ভাষা সহায়ো পদেতষবা উপলব্ধ আতে। ফ ান ক쇁ন ১-1‐800‐649‐3777 (TTY: 711)। Albanian: KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 1‐800‐649‐3777 (TTY: 711). Serbo-Croatian: OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1‐800‐649‐3777 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 711). Syriac:

Exchange PHP MI eff 09/01/2021 Drug Name Drug Tier Requirements/Limits ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS AMPHETAMINES ADDERALL Tier 3 QL ADDERALL XR Tier 1 QL amphetamine sulfate Tier 1 QL amphetamine-dextroamphetamine Tier 1 QL dextroamphetamine sulfate cp24 Tier 1 QL dextroamphetamine sulfate soln 5mg/5ml Tier 1 DEXTROAMPHETAMINE SULFATE SOLN Tier 1 5mg/5ml dextroamphetamine sulfate tabs 2.5mg, Tier 3 7.5mg, 15mg, 20mg, 30mg dextroamphetamine sulfate tabs 5mg, Tier 1 10mg MYDAYIS Tier 3 QL VYVANSE Tier 2 QL ANALEPTICS caffeine citrate Tier 1 ANOREXIANTS NON-AMPHETAMINE ADIPEX-P Tier 3 QL benzphetamine hcl Tier 1 diethylpropion hcl Tier 1 PHENDIMETRAZINE TARTRATE CP24 Tier 1 QL phendimetrazine tartrate tabs Tier 1 phentermine hcl Tier 1 ANTI-OBESITY AGENTS CONTRAVE Tier 3 ST IMCIVREE Tier 4 SP, PA SAXENDA Tier 3 PA ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) AGENTS atomoxetine hcl Tier 1 QL clonidine hcl (adhd) Tier 1 guanfacine hcl (adhd) Tier 1 INTUNIV Tier 3 PA KAPVAY Tier 3 PA QELBREE Tier 2 QL DOPAMINE AND NOREPINEPHRINE REUPTAKE INHIBITORS (DNRIS) SUNOSI Tier 3 PA STIMULANTS - MISC. APTENSIO XR Tier 3 ST, QL

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 1 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits armodafinil Tier 1 ST, QL CONCERTA Tier 1 QL COTEMPLA XR-ODT Tier 3 ST, QL DAYTRANA Tier 2 ST, QL dexmethylphenidate hcl Tier 1 QL FOCALIN Tier 3 QL FOCALIN XR Tier 3 QL METHYLIN Tier 3 QL methylphenidate hcl chew Tier 1 QL methylphenidate hcl cp24 10mg, 15mg, Tier 1 ST, QL 20mg, 30mg, 40mg, 50mg, 60mg methylphenidate hcl cp24 10mg, 20mg, Tier 1 QL 30mg, 40mg, 60mg methylphenidate hcl cpcr Tier 1 QL methylphenidate hcl soln Tier 1 QL methylphenidate hcl tabs Tier 1 QL methylphenidate hcl tb24 Tier 1 QL methylphenidate hcl tbcr Tier 1 QL modafinil Tier 1 QL QUILLICHEW ER Tier 3 QUILLIVANT XR Tier 3 ST, QL RITALIN Tier 3 QL RITALIN LA Tier 3 QL AMEBICIDES AMEBICIDES SOLOSEC Tier 3 QL AMINOGLYCOSIDES AMINOGLYCOSIDES amikacin sulfate LA ARIKAYCE Tier 4 SP, PA BETHKIS Tier 4 SP, PA gentamicin in saline LA gentamicin sulfate LA KITABIS PAK Tier 4 SP, PA neomycin sulfate Tier 1 paromomycin sulfate Tier 1 streptomycin sulfate LA TOBI Tier 4 SP, PA TOBI PODHALER Tier 2 SP, PA tobramycin Tier 1 SP, PA tobramycin sulfate soln 1.2gm/30ml, LA 10mg/ml

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 2 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits tobramycin sulfate soln 40mg/ml, Tier 1 80mg/2ml tobramycin sulfate solr LA ZEMDRI LA PA ANALGESICS - ANTI-INFLAMMATORY ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES HUMIRA Tier 2 SP, PA, QL HUMIRA PEDIATRIC CROHNS D Tier 2 SP, PA, QL HUMIRA PEN Tier 2 SP, PA, QL HUMIRA PEN-CD/UC/HS START Tier 2 SP, PA, QL HUMIRA PEN-PEDIATRIC UC S Tier 2 SP, PA, QL HUMIRA PEN-PS/UV STARTER Tier 2 SP, PA, QL SIMPONI ARIA LA SP, PA, QL; MB ANTIRHEUMATIC - ENZYME INHIBITORS RINVOQ Tier 2 SP, PA, QL XELJANZ Tier 2 SP, PA, QL XELJANZ XR Tier 2 SP, PA, QL ANTIRHEUMATIC ANTIMETABOLITES OTREXUP Tier 4 SP, PA RASUVO Tier 4 SP, PA GOLD COMPOUNDS RIDAURA Tier 3 PA INTERLEUKIN-1 BLOCKERS ARCALYST LA SP, PA INTERLEUKIN-1BETA BLOCKERS ILARIS Tier 4 SP, PA INTERLEUKIN-6 RECEPTOR INHIBITORS ACTEMRA LA SP, PA, QL; MB NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS) ARTHROTEC 50 Tier 3 CALDOLOR LA PA celecoxib 50mg Tier 1 celecoxib 100mg, 200mg, 400mg Tier 1 QL DAYPRO Tier 3 diclofenac potassium Tier 1 diclofenac sodium Tier 1 diclofenac w/ misoprostol Tier 1 EC-NAPROSYN Tier 3 etodolac Tier 1 FELDENE Tier 3 FENOPROFEN CALCIUM CAPS 200mg Tier 3 PA fenoprofen calcium caps 400mg Tier 3 PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 3 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits fenoprofen calcium tabs Tier 1 FENORTHO Tier 3 PA flurbiprofen Tier 1 ibuprofen susp Tier 1 ibuprofen tabs Tier 1 INDOCIN Tier 3 indomethacin Tier 1 indomethacin sodium LA ketoprofen Tier 1 KETOROLAC TROMETHAMINE SOLN Tier 3 PA 15.75mg/spray ketorolac tromethamine soln 15mg/ml, LA 30mg/ml ketorolac tromethamine soln 30mg/ml Tier 1 ketorolac tromethamine tabs Tier 1 QL meclofenamate sodium Tier 1 mefenamic acid Tier 1 meloxicam Tier 1 MOBIC Tier 3 nabumetone Tier 1 NALFON Tier 3 PA NAPROSYN SUSP Tier 3 QL NAPROSYN TABS Tier 3 naproxen susp Tier 1 QL naproxen tabs Tier 1 naproxen tbec 375mg, 500mg Tier 1 NAPROXEN TBEC 375mg, 500mg Tier 1 naproxen sodium Tier 1 oxaprozin Tier 1 piroxicam Tier 1 SPRIX Tier 3 PA sulindac Tier 1 PHOSPHODIESTERASE 4 (PDE4) INHIBITORS OTEZLA TABS Tier 2 SP, PA, QL OTEZLA TBPK Tier 2 SP, PA, QL PYRIMIDINE SYNTHESIS INHIBITORS ARAVA Tier 3 QL leflunomide Tier 1 QL SELECTIVE COSTIMULATION MODULATORS ORENCIA LA SP, PA, QL; MB SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS ENBREL SOLN Tier 2 SP, ST, QL ENBREL SOLR; SOSY Tier 2 SP, PA, QL

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 4 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits ENBREL MINI Tier 2 SP, PA, QL ENBREL SURECLICK Tier 2 SP, PA, QL ANALGESICS - NONNARCOTIC ANALGESIC COMBINATIONS ALLZITAL Tier 3 PA butalbital-acetaminophen Tier 1 butalbital-acetaminophen Tier 1 PA butalbital-acetaminophen-caffeine Tier 1 butalbital-aspirin-caffeine Tier 1 ESGIC Tier 3 FIORICET Tier 3 SALICYLATES diflunisal Tier 1 salsalate Tier 1 ANALGESICS - OPIOID OPIOID AGONISTS ACTIQ Tier 3 PA, QL CODEINE SULFATE 30mg Tier 1 PA codeine sulfate 60mg Tier 1 PA DEMEROL LA DILAUDID LIQD; TABS Tier 3 PA DILAUDID SOLN LA fentanyl 12mcg/hr, 25mcg/hr, 50mcg/hr, Tier 1 QL 75mcg/hr, 100mcg/hr fentanyl 37.5mcg/hr, 62.5mcg/hr, Tier 3 QL 87.5mcg/hr fentanyl citrate lpop; tabs Tier 1 PA, QL fentanyl citrate soct; soln LA FENTORA 100mcg Tier 3 PA FENTORA 200mcg, 400mcg, 600mcg, Tier 3 PA, QL 800mcg hydrocodone bitartrate Tier 1 PA hydromorphone hcl liqd; tabs; tb24 Tier 1 PA hydromorphone hcl soln LA HYDROMORPHONE HCL SUPP Tier 1 PA HYDROMORPHONE HYDROCHLORI LA HYSINGLA ER Tier 3 PA INFUMORPH 200 LA INFUMORPH 500 LA LAZANDA Tier 3 PA levorphanol tartrate Tier 1 PA meperidine hcl soln 25mg/ml, 50mg/ml, LA 100mg/ml

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 5 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits meperidine hcl soln 50mg/5ml Tier 1 PA meperidine hcl tabs Tier 1 PA methadone hcl soln 5mg/5ml, 10mg/5ml Tier 1 methadone hcl soln 10mg/ml LA METHADONE HCL SOLN 10mg/ml LA methadone hcl tabs Tier 1 methadone hcl tbso Tier 1 morphine sulfate cp24 10mg, 20mg, Tier 1 QL 30mg, 50mg, 60mg, 80mg, 100mg morphine sulfate cp24 40mg Tier 1 MORPHINE SULFATE SOLN 1mg/ml, LA 2mg/ml, 4mg/ml, 5mg/ml, 8mg/ml, 10mg/ml morphine sulfate soln 10mg/5ml, Tier 1 PA 20mg/5ml, 20mg/ml, 100mg/5ml morphine sulfate soln .5mg/ml, 1mg/ml, LA 4mg/ml, 8mg/ml, 10mg/ml, 50mg/ml morphine sulfate supp 5mg, 10mg, 20mg Tier 1 PA MORPHINE SULFATE SUPP 30mg Tier 1 PA morphine sulfate tabs Tier 1 PA morphine sulfate tbcr Tier 1 QL morphine sulfate beads Tier 1 QL morphine sulfate for continuous LA microinfusion MS CONTIN Tier 3 QL NUCYNTA Tier 3 PA NUCYNTA ER Tier 3 PA OXAYDO Tier 3 PA oxycodone hcl caps Tier 1 PA oxycodone hcl conc Tier 1 PA oxycodone hcl soln Tier 1 PA oxycodone hcl t12a 10mg, 15mg, 20mg, Tier 1 QL 30mg oxycodone hcl t12a 40mg, 60mg, 80mg Tier 1 oxycodone hcl tabs Tier 1 PA OXYCONTIN 10mg, 15mg, 20mg, 30mg Tier 3 QL OXYCONTIN 40mg, 60mg, 80mg Tier 3 oxymorphone hcl tabs Tier 1 PA oxymorphone hcl tb12 5mg, 10mg, 20mg, Tier 1 30mg, 40mg oxymorphone hcl tb12 7.5mg, 15mg Tier 1 QL ROXICODONE Tier 3 PA sufentanil citrate LA PA hcl tabs 50mg Tier 1 PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 6 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits tramadol hcl tabs 100mg Tier 1 tramadol hcl tb24 Tier 1 QL ULTIVA LA PA XTAMPZA ER Tier 3 PA OPIOID COMBINATIONS acetaminophen w/ codeine soln Tier 1 PA acetaminophen w/ codeine tabs Tier 1 PA, QL acetaminophen-caff-dihydrocod Tier 1 PA, QL butalbital-acetaminophen-caffeine w/ Tier 1 QL codeine butalbital-aspirin-caffeine w/cod Tier 1 QL hydrocodone-acetaminophen soln Tier 1 PA hydrocodone-acetaminophen soln Tier 1 PA, QL hydrocodone-acetaminophen tabs Tier 1 PA, QL hydrocodone-ibuprofen Tier 1 PA, QL LORTAB Tier 2 PA oxycodone w/ acetaminophen Tier 1 PA, QL PERCOCET Tier 3 PA, QL tramadol-acetaminophen Tier 1 PA, QL ULTRACET Tier 3 PA, QL OPIOID PARTIAL AGONISTS BELBUCA Tier 3 PA BUPRENEX LA buprenorphine Tier 1 QL buprenorphine hcl soln LA buprenorphine hcl subl Tier 1 buprenorphine hcl-naloxone hcl dihydrate Tier 1 butorphanol tartrate 1mg/ml, 2mg/ml LA butorphanol tartrate 10mg/ml Tier 1 QL nalbuphine hcl LA pentazocine w/ naloxone Tier 1 PA SUBLOCADE LA PA SUBOXONE Tier 3 ZUBSOLV Tier 3 ANDROGENS-ANABOLIC ANABOLIC STEROIDS oxandrolone Tier 1 PA ANDROGENS ANDRODERM Tier 2 GENDER ANDROGEL 20.25mg/1.25gm, Tier 3 GENDER 40.5mg/2.5gm ANDROGEL 25mg/2.5gm Tier 3 QL; GENDER ANDROGEL 50mg/5gm Tier 3 ST, QL; GENDER

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 7 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits ANDROGEL PUMP Tier 3 QL; GENDER AVEED Tier 2 SP; GENDER danazol Tier 1 DEPO-TESTOSTERONE Tier 3 GENDER FORTESTA Tier 3 ST; GENDER JATENZO Tier 3 PA; GENDER NATESTO Tier 3 ST; GENDER TESTIM Tier 3 ST, QL; GENDER TESTOPEL Tier 2 GENDER testosterone gel 1% Tier 3 QL; GENDER testosterone gel 1.62%, 25mg/2.5gm, Tier 1 QL; GENDER 50mg/5gm testosterone gel 10mg/act, Tier 1 GENDER 20.25mg/1.25gm, 40.5mg/2.5gm testosterone soln Tier 1 GENDER testosterone cypionate Tier 1 GENDER testosterone enanthate Tier 1 VOGELXO Tier 3 ST, QL; GENDER VOGELXO PUMP Tier 3 ST, QL; GENDER XYOSTED Tier 3 QL ANORECTAL AND RELATED PRODUCTS INTRARECTAL STEROIDS CORTENEMA Tier 3 CORTIFOAM Tier 2 hydrocortisone (intrarectal) Tier 1 UCERIS FOAM Tier 3 PA RECTAL COMBINATIONS ANALPRAM HC Tier 3 ANALPRAM HC SINGLES Tier 3 ANALPRAM-HC CREA Tier 3 ANALPRAM-HC LOTN Tier 2 hydrocortisone acetate w/ pramoxine Tier 1 PROCTOFOAM HC Tier 2 RECTAL STEROIDS ANUSOL-HC Tier 3 hydrocortisone (rectal) Tier 1 hydrocortisone acetate (rectal) Tier 1 PROCTOCORT Tier 3 VASODILATING AGENTS RECTIV Tier 3 ANTHELMINTICS ANTHELMINTICS albendazole Tier 1 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 8 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits ALBENZA Tier 3 QL BILTRICIDE Tier 3 PA EMVERM Tier 3 PA ivermectin Tier 1 praziquantel Tier 1 PA STROMECTOL Tier 3 ANTI-INFECTIVE AGENTS - MISC. ANTI-INFECTIVE AGENTS - MISC. FLAGYL Tier 3 IMPAVIDO Tier 3 PA metronidazole caps; tabs Tier 1 METRONIDAZOLE SOLN LA metronidazole in nacl LA NEBUPENT Tier 3 pentamidine isethionate 300mg Tier 1 pentamidine isethionate 300mg LA PRIMSOL Tier 3 tinidazole Tier 1 QL trimethoprim Tier 1 XIFAXAN 200mg Tier 3 PA XIFAXAN 550mg Tier 3 PA ANTI-INFECTIVE MISC. - COMBINATIONS BACTRIM Tier 3 BACTRIM DS Tier 3 methenamine-hyosc-methylene blue- Tier 1 benzoic acid-phenyl sal methenamine-hyosc-methylene blue-sod Tier 1 phos-phenyl sal caps methenamine-hyosc-methylene blue-sod Tier 1 phos-phenyl sal tabs methenamine-hyosc-methylene blue-sod Tier 3 phos-phenyl sal tabs methenamine-hyoscamine-methylene blue- Tier 1 sodium phosphate sulfamethoxazole-trimethoprim soln LA sulfamethoxazole-trimethoprim susp; tabs Tier 1 ANTIPROTOZOAL AGENTS ALINIA SUSR Tier 3 PA, QL ALINIA TABS Tier 3 PA atovaquone Tier 1 QL LAMPIT Tier 3 PA MEPRON Tier 3 QL nitazoxanide Tier 1 PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 9 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits CARBAPENEMS ertapenem sodium LA imipenem-cilastatin LA meropenem LA PRIMAXIN IV LA PA RECARBRIO LA PA VABOMERE LA PA CHLORAMPHENICOLS chloramphenicol sodium succinate LA CYCLIC LIPOPEPTIDES daptomycin LA PA GLYCOPEPTIDES FIRVANQ Tier 2 VANCOCIN Tier 3 VANCOCIN HCL Tier 3 VANCOMYCIN LA vancomycin hcl caps Tier 1 VANCOMYCIN HCL SOLN LA vancomycin hcl solr LA VANCOMYCIN HYDROCHLORIDE SOLN LA VANCOMYCIN HYDROCHLORIDE SOLR LA 1.25gm VANCOMYCIN HYDROCHLORIDE SOLR Tier 3 750mg VANCOMYCIN HYDROCHLORIDE/ LA VIBATIV LA PA LEPROSTATICS dapsone Tier 1 LINCOSAMIDES CLEOCIN CAPS Tier 3 CLEOCIN PEDIATRIC GRANULE Tier 3 CLEOCIN PHOSPHATE LA PA clindamycin hcl Tier 1 clindamycin palmitate hydrochloride Tier 1 clindamycin phosphate LA clindamycin phosphate in d5w LA CLINDAMYCIN/SODIUM CHLORI LA LINCOCIN LA lincomycin hcl Tier 1 MONOBACTAMS AZACTAM LA PA aztreonam LA CAYSTON Tier 4 SP, PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 10 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits OXAZOLIDINONES linezolid soln LA PA linezolid susr; tabs Tier 1 QL linezolid in sodium chloride LA PA SIVEXTRO SOLR LA PA SIVEXTRO TABS Tier 3 PA ZYVOX LA PA PLEUROMUTILINS XENLETA Tier 3 PA POLYMYXINS colistimethate sodium LA COLY-MYCIN M LA PA polymyxin b sulfate LA URINARY ANTI-INFECTIVES fosfomycin tromethamine Tier 1 QL HIPREX Tier 3 MACROBID Tier 3 MACRODANTIN Tier 3 methenamine hippurate Tier 1 methenamine mandelate Tier 1 MONUROL Tier 3 QL nitrofurantoin Tier 1 nitrofurantoin macrocrystal Tier 1 nitrofurantoin monohyd macro Tier 1 ANTIANGINAL AGENTS ANTIANGINALS-OTHER ranolazine Tier 1 QL NITRATES DILATRATE SR Tier 3 GONITRO Tier 3 PA ISORDIL TITRADOSE Tier 3 isosorbide dinitrate Tier 1 isosorbide mononitrate Tier 1 NITRO-BID Tier 2 NITRO-DUR Tier 3 nitroglycerin Tier 1 nitroglycerin in d5w LA NITROLINGUAL PUMPSPRAY Tier 3 NITROMIST Tier 3 NITROSTAT Tier 3

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 11 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits ANTIANXIETY AGENTS ANTIANXIETY AGENTS - MISC. buspirone hcl Tier 1 LA hydroxyzine hcl soln LA PA hydroxyzine hcl syrp; tabs Tier 1 hydroxyzine pamoate Tier 1 meprobamate Tier 1 VISTARIL Tier 3 BENZODIAZEPINES alprazolam Tier 1 ALPRAZOLAM INTENSOL Tier 2 ATIVAN SOLN LA PA ATIVAN TABS Tier 3 chlordiazepoxide hcl Tier 1 clorazepate dipotassium Tier 1 diazepam conc Tier 1 DIAZEPAM SOAJ LA diazepam soln 5mg/5ml Tier 1 diazepam soln 5mg/ml, 50mg/10ml LA diazepam tabs Tier 1 lorazepam conc; tabs Tier 1 lorazepam soln LA oxazepam Tier 1 TRANXENE T Tier 3 VALIUM Tier 3 ANTIARRHYTHMICS ANTIARRHYTHMICS TYPE I-A disopyramide phosphate Tier 1 NORPACE Tier 3 NORPACE CR Tier 3 gluconate Tier 1 quinidine sulfate Tier 1 ANTIARRHYTHMICS TYPE I-B mexiletine hcl Tier 1 ANTIARRHYTHMICS TYPE I-C flecainide acetate Tier 1 propafenone hcl Tier 1 RYTHMOL SR Tier 3 ANTIARRHYTHMICS TYPE III amiodarone hcl Tier 1 dofetilide Tier 1 SP

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 12 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits MULTAQ Tier 2 TIKOSYN Tier 4 SP ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTI-INFLAMMATORY AGENTS cromolyn sodium Tier 1 ANTIASTHMATIC - MONOCLONAL ANTIBODIES CINQAIR LA SP, PA FASENRA LA SP, PA FASENRA PEN Tier 4 SP, PA NUCALA SOAJ; SOSY Tier 4 SP, PA NUCALA SOLR LA SP, PA XOLAIR LA SP, PA BRONCHODILATORS - ATROVENT HFA Tier 2 INCRUSE ELLIPTA Tier 2 Tier 1 LONHALA MAGNAIR STARTER K Tier 3 PA SPIRIVA HANDIHALER Tier 2 SPIRIVA RESPIMAT Tier 2 TUDORZA PRESSAIR Tier 3 LEUKOTRIENE MODULATORS ACCOLATE Tier 3 montelukast sodium Tier 1 SINGULAIR Tier 3 zafirlukast Tier 1 ZYFLO Tier 3 PA SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS DALIRESP 250mcg Tier 2 QL DALIRESP 500mcg Tier 2 STEROID INHALANTS ARNUITY ELLIPTA Tier 2 ASMANEX HFA Tier 2 ASMANEX TWISTHALER 7 METE Tier 2 ASMANEX TWISTHALER 14 MET Tier 2 ASMANEX TWISTHALER 30 MET Tier 2 ASMANEX TWISTHALER 60 MET Tier 2 ASMANEX TWISTHALER 120 ME Tier 2 budesonide (inhalation) Tier 1 QL FLOVENT DISKUS Tier 2 FLOVENT HFA Tier 2 PULMICORT Tier 3 QL PULMICORT FLEXHALER Tier 2

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 13 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits QVAR REDIHALER Tier 2 SYMPATHOMIMETICS ADVAIR DISKUS Tier 1 ADVAIR HFA Tier 2 AIRDUO RESPICLICK 55/14 Tier 3 AIRDUO RESPICLICK 113/14 Tier 3 AIRDUO RESPICLICK 232/14 Tier 3 albuterol sulfate Tier 1 ANORO ELLIPTA Tier 2 arformoterol tartrate Tier 1 PA BEVESPI AEROSPHERE Tier 2 BREO ELLIPTA Tier 2 BREZTRI AEROSPHERE Tier 2 BROVANA Tier 3 PA COMBIVENT RESPIMAT Tier 2 fluticasone-salmeterol Tier 1 formoterol fumarate Tier 1 QL ipratropium-albuterol Tier 1 levalbuterol hcl Tier 1 levalbuterol tartrate Tier 1 PERFOROMIST Tier 3 QL PROAIR HFA Tier 3 PROAIR RESPICLICK Tier 3 PROVENTIL HFA Tier 3 SEREVENT DISKUS Tier 2 STIOLTO RESPIMAT Tier 2 STRIVERDI RESPIMAT Tier 2 SYMBICORT Tier 1 terbutaline sulfate Tier 1 TRELEGY ELLIPTA Tier 2 VENTOLIN HFA Tier 3 XOPENEX Tier 3 XOPENEX CONCENTRATE Tier 3 XOPENEX HFA Tier 2 XANTHINES ELIXOPHYLLIN Tier 2 THEO-24 Tier 3 theophylline Tier 1 ANTICOAGULANTS COUMARIN ANTICOAGULANTS warfarin sodium Tier 1 DIRECT FACTOR XA INHIBITORS ELIQUIS Tier 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 14 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits ELIQUIS STARTER PACK Tier 2 XARELTO 2.5mg Tier 2 QL XARELTO 10mg, 15mg, 20mg Tier 2 XARELTO STARTER PACK Tier 2 HEPARINS AND HEPARINOID-LIKE AGENTS ARIXTRA 2.5mg/0.5ml, 5mg/0.4ml Tier 3 ARIXTRA 7.5mg/0.6ml, 10mg/0.8ml Tier 3 QL enoxaparin sodium Tier 1 QL fondaparinux sodium 2.5mg/0.5ml, Tier 1 5mg/0.4ml fondaparinux sodium 7.5mg/0.6ml, Tier 1 QL 10mg/0.8ml FRAGMIN 2500unit/0.2ml, Tier 2 5000unit/0.2ml, 7500unit/0.3ml, 12500unit/0.5ml FRAGMIN 10000unit/ml, 15000unit/0.6ml, Tier 2 QL 18000unt/0.72ml, 95000unit/3.8ml heparin (porcine) in sodium chloride LA heparin sod (porcine) in d5w LA HEPARIN SODIUM Tier 2 QL heparin sodium (porcine) Tier 1 heparin sodium (porcine) lock flush LA 1unit/ml heparin sodium (porcine) lock flush Tier 1 10unit/ml, 100unit/ml HEPARIN SODIUM/DEXTROSE LA HEPARIN SODIUM/NACL 0.45% LA LOVENOX Tier 3 QL ANTICONVULSANTS AMPA GLUTAMATE RECEPTOR ANTAGONISTS FYCOMPA Tier 3 PA ANTICONVULSANTS - BENZODIAZEPINES clobazam Tier 1 PA clonazepam Tier 1 DIASTAT ACUDIAL Tier 3 DIASTAT PEDIATRIC Tier 3 diazepam (anticonvulsant) Tier 1 KLONOPIN Tier 3 NAYZILAM Tier 3 ST, QL ONFI Tier 3 PA SYMPAZAN Tier 3 PA VALTOCO Tier 3 QL ANTICONVULSANTS - MISC. APTIOM Tier 3 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 15 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits BANZEL Tier 3 BRIVIACT SOLN 10mg/ml Tier 3 PA BRIVIACT SOLN 50mg/5ml LA PA BRIVIACT TABS Tier 3 PA carbamazepine Tier 1 CARBATROL Tier 3 DIACOMIT Tier 4 SP, PA EPIDIOLEX Tier 4 SP, PA FINTEPLA Tier 2 SP, PA gabapentin Tier 1 KEPPRA SOLN 100mg/ml Tier 3 KEPPRA SOLN 500mg/5ml LA PA KEPPRA TABS Tier 3 KEPPRA XR Tier 3 LAMICTAL Tier 3 LAMICTAL CHEWABLE DISPERS Tier 3 LAMICTAL ODT KIT Tier 3 LAMICTAL ODT TBDP Tier 3 LAMICTAL STARTER/NOT TAKI Tier 3 LAMICTAL STARTER/TAKING C Tier 3 LAMICTAL STARTER/TAKING V Tier 3 LAMICTAL XR KIT Tier 3 LAMICTAL XR TB24 Tier 3 lamotrigine chew; tabs; tb24; tbdp Tier 1 lamotrigine kit Tier 1 LEVETIRACETAM SOLN LA levetiracetam soln 100mg/ml, 500mg/5ml Tier 1 levetiracetam soln 500mg/5ml LA levetiracetam tabs Tier 1 levetiracetam tb24 Tier 1 levetiracetam in sodium chloride LA LYRICA CAPS Tier 3 QL LYRICA SOLN Tier 3 MYSOLINE Tier 3 NEURONTIN Tier 3 oxcarbazepine Tier 1 OXTELLAR XR Tier 3 pregabalin caps Tier 1 QL pregabalin soln Tier 1 primidone Tier 1 QUDEXY XR Tier 3 rufinamide Tier 1 SPRITAM Tier 3 PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 16 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits TEGRETOL Tier 3 TEGRETOL-XR Tier 3 topiramate cpsp; tabs Tier 1 topiramate cs24 Tier 3 TRILEPTAL Tier 3 TROKENDI XR Tier 3 VIMPAT SOLN 10mg/ml Tier 3 PA VIMPAT SOLN 200mg/20ml LA PA VIMPAT TABS Tier 3 PA ZONEGRAN Tier 3 zonisamide Tier 1 CARBAMATES felbamate Tier 1 FELBATOL Tier 3 XCOPRI TABS Tier 3 PA XCOPRI TBPK Tier 3 PA XCOPRI TBPK Tier 3 PA GABA MODULATORS GABITRIL Tier 3 SABRIL Tier 4 SP, PA tiagabine hcl Tier 1 HYDANTOINS CEREBYX LA PA DILANTIN Tier 3 DILANTIN INFATABS Tier 3 DILANTIN-125 Tier 3 fosphenytoin sodium LA PHENYTEK Tier 3 phenytoin Tier 1 phenytoin sodium LA phenytoin sodium extended Tier 1 SUCCINIMIDES CELONTIN Tier 3 ethosuximide Tier 1 ZARONTIN Tier 3 VALPROIC ACID DEPAKOTE Tier 3 DEPAKOTE ER Tier 3 DEPAKOTE SPRINKLES Tier 3 divalproex sodium Tier 1 valproate sodium 100mg/ml, 500mg/5ml LA valproate sodium 250mg/5ml Tier 1 valproic acid Tier 1 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 17 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits ANTIDEPRESSANTS ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS) tabs Tier 1 mirtazapine tbdp Tier 1 QL REMERON Tier 3 REMERON SOLTAB Tier 3 QL ANTIDEPRESSANTS - MISC. APLENZIN Tier 3 PA, QL bupropion hcl Tier 1 FORFIVO XL Tier 3 QL MONOAMINE OXIDASE INHIBITORS (MAOIS) EMSAM Tier 3 QL MARPLAN Tier 3 NARDIL Tier 3 PARNATE Tier 3 phenelzine sulfate Tier 1 tranylcypromine sulfate Tier 1 SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) CELEXA Tier 3 citalopram hydrobromide Tier 1 escitalopram oxalate Tier 1 fluoxetine hcl Tier 1 FLUOXETINE HYDROCHLORIDE Tier 3 fluvoxamine maleate cp24 Tier 1 fluvoxamine maleate tabs 25mg Tier 1 fluvoxamine maleate tabs 50mg, 100mg Tier 1 QL hcl tabs Tier 1 paroxetine hcl tb24 Tier 1 QL PAXIL SUSP Tier 2 PAXIL TABS Tier 3 PAXIL CR Tier 3 QL PEXEVA Tier 3 QL sertraline hcl Tier 1 ZOLOFT Tier 3 SEROTONIN MODULATORS nefazodone hcl 50mg, 100mg Tier 1 QL nefazodone hcl 150mg, 200mg, 250mg Tier 1 trazodone hcl Tier 1 TRINTELLIX Tier 2 ST VIIBRYD Tier 2 ST VIIBRYD STARTER PACK Tier 2 ST SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS) DESVENLAFAXINE ER Tier 3 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 18 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits desvenlafaxine succinate Tier 1 duloxetine hcl Tier 1 QL FETZIMA Tier 3 FETZIMA TITRATION PACK Tier 3 PRISTIQ Tier 3 venlafaxine hcl cp24 Tier 1 QL venlafaxine hcl tabs; tb24 Tier 1 TRICYCLIC AGENTS hcl Tier 1 Tier 1 ANAFRANIL Tier 3 hcl Tier 1 hcl Tier 1 hcl Tier 1 hcl Tier 1 imipramine pamoate Tier 1 NORPRAMIN Tier 3 hcl Tier 1 PAMELOR Tier 3 hcl Tier 1 maleate Tier 1 ANTIDIABETICS ALPHA-GLUCOSIDASE INHIBITORS acarbose Tier 1 miglitol Tier 1 PRECOSE Tier 3 ANTIDIABETIC - AMYLIN ANALOGS SYMLINPEN 60 Tier 2 SYMLINPEN 120 Tier 2 ANTIDIABETIC COMBINATIONS ACTOPLUS MET Tier 3 QL DUETACT Tier 3 glipizide-metformin hcl Tier 1 glyburide-metformin Tier 1 GLYXAMBI Tier 3 ST JANUMET Tier 2 ST, QL JANUMET XR Tier 2 ST, QL KOMBIGLYZE XR Tier 3 PA; MNPA pioglitazone hcl-glimepiride Tier 1 pioglitazone hcl-metformin hcl Tier 1 QL QTERN Tier 3 PA SOLIQUA 100/33 Tier 3 ST XIGDUO XR Tier 2 ST PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 19 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits XULTOPHY 100/3.6 Tier 3 ST BIGUANIDES metformin hcl soln Tier 1 PA metformin hcl tabs; tb24 (not mod or Tier 1 osm) RIOMET Tier 3 PA DIABETIC OTHER BAQSIMI ONE PACK Tier 2 QL BAQSIMI TWO PACK Tier 2 QL GLUCAGEN HYPOKIT Tier 2 QL glucagon (rdna) Tier 1 QL GLUCAGON EMERGENCY KIT Tier 3 QL GLUCAGON EMERGENCY KIT FO Tier 2 QL GVOKE HYPOPEN 1-PACK Tier 2 QL GVOKE HYPOPEN 2-PACK Tier 2 QL GVOKE PFS Tier 2 QL PROGLYCEM Tier 3 PA ZEGALOGUE Tier 2 QL DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS alogliptin benzoate Tier 3 PA; MNPA JANUVIA Tier 2 ST, QL DOPAMINE RECEPTOR AGONISTS - ANTIDIABETIC CYCLOSET Tier 3 PA INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS) ADLYXIN Tier 3 PA; MNPA ADLYXIN STARTER PACK Tier 3 PA; MNPA OZEMPIC Tier 2 ST RYBELSUS Tier 2 ST TRULICITY Tier 2 ST VICTOZA Tier 2 ST, QL INSULIN BASAGLAR KWIKPEN Tier 2 FIASP Tier 2 FIASP FLEXTOUCH Tier 2 FIASP PENFILL Tier 2 HUMULIN R U-500 (CONCENTR Tier 2 HUMULIN R U-500 KWIKPEN Tier 3 LEVEMIR Tier 2 LEVEMIR FLEXTOUCH Tier 2 NOVOLIN 70/30 Tier 1 NOVOLIN 70/30 FLEXPEN Tier 2 QL NOVOLIN N Tier 1 NOVOLIN N FLEXPEN Tier 2 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 20 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits NOVOLIN R Tier 1 NOVOLIN R FLEXPEN Tier 2 QL NOVOLOG Tier 1 NOVOLOG FLEXPEN RELION Tier 2 NOVOLOG MIX 70/30 Tier 1 NOVOLOG MIX 70/30 PREFILL Tier 2 NOVOLOG PENFILL Tier 2 TRESIBA Tier 2 TRESIBA FLEXTOUCH Tier 2 INSULIN SENSITIZING AGENTS ACTOS Tier 3 pioglitazone hcl Tier 1 MEGLITINIDE ANALOGUES nateglinide Tier 1 QL repaglinide Tier 1 QL SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS FARXIGA Tier 2 ST JARDIANCE Tier 2 ST SULFONYLUREAS AMARYL Tier 3 glimepiride Tier 1 glipizide Tier 1 GLUCOTROL XL Tier 3 glyburide Tier 1 glyburide micronized Tier 1 GLYNASE Tier 3 tolbutamide Tier 1 ANTIDIARRHEAL/PROBIOTIC AGENTS ANTIDIARRHEAL - CHLORIDE CHANNEL ANTAGONISTS MYTESI Tier 3 PA ANTIPERISTALTIC AGENTS diphenoxylate w/ Tier 1 LOMOTIL Tier 3 loperamide hcl Tier 1 MOTOFEN Tier 2 ANTIDOTES AND SPECIFIC ANTAGONISTS ANTIDOTES - CHELATING AGENTS CHEMET Tier 2 deferasirox pack Tier 4 SP, PA deferasirox tabs; tbso Tier 1 SP, PA EXJADE Tier 4 SP, PA FERRIPROX SOLN Tier 4 SP, PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 21 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits FERRIPROX TABS Tier 4 SP, PA FERRIPROX TWICE-A-DAY Tier 4 SP, PA JADENU Tier 4 SP, PA JADENU SPRINKLE Tier 4 SP, PA ANTIDOTES AND SPECIFIC ANTAGONISTS ACETADOTE LA acetylcysteine (antidote) LA deferoxamine mesylate LA SP, PA DESFERAL LA SP, PA VISTOGARD Tier 4 SP, PA BENZODIAZEPINE ANTAGONISTS flumazenil LA PA OPIOID ANTAGONISTS naloxone hcl Tier 1 naltrexone hcl Tier 1 NARCAN Tier 1 QL VIVITROL LA ANTIEMETICS 5-HT3 RECEPTOR ANTAGONISTS ALOXI LA PA granisetron hcl soln LA granisetron hcl tabs Tier 1 ondansetron Tier 1 ondansetron hcl soln 4mg/2ml LA ondansetron hcl soln 4mg/5ml Tier 1 ondansetron hcl tabs Tier 1 palonosetron hcl LA PALONOSETRON HYDROCHLORID LA SANCUSO Tier 3 PA, QL SUSTOL Tier 3 ZOFRAN Tier 3 QL ZUPLENZ Tier 3 PA, QL ANTIEMETICS - hcl Tier 1 Tier 1 TIGAN LA TRANSDERM SCOP Tier 3 TRANSDERM-SCOP Tier 3 trimethobenzamide hcl Tier 1 ANTIEMETICS - MISCELLANEOUS AKYNZEO CAPS Tier 3 PA AKYNZEO SOLN; SOLR LA PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 22 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits BONJESTA Tier 3 PA dronabinol Tier 1 MARINOL Tier 3 SYNDROS Tier 3 SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS aprepitant Tier 1 QL CINVANTI LA EMEND CAPS Tier 3 QL EMEND SUSR Tier 2 QL EMEND TRIPACK Tier 3 QL fosaprepitant dimeglumine LA VARUBI Tier 3 PA ANTIFUNGALS ANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS (ECHINOCANDINS) caspofungin acetate LA ERAXIS LA ANTIFUNGALS ABELCET LA AMBISOME LA amphotericin b LA ANCOBON Tier 3 flucytosine Tier 1 griseofulvin microsize Tier 1 griseofulvin ultramicrosize Tier 1 nystatin Tier 1 terbinafine hcl Tier 1 IMIDAZOLE-RELATED ANTIFUNGALS CRESEMBA CAPS Tier 3 CRESEMBA SOLR LA PA DIFLUCAN Tier 3 fluconazole Tier 1 fluconazole in nacl LA itraconazole Tier 1 QL ketoconazole Tier 1 NOXAFIL SOLN LA PA NOXAFIL SUSP Tier 2 SPORANOX CAPS Tier 3 QL SPORANOX SOLN Tier 2 SPORANOX PULSEPAK Tier 3 QL TOLSURA Tier 3 PA VFEND Tier 3 PA VFEND IV LA PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 23 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits voriconazole solr LA PA voriconazole susr; tabs Tier 1 PA ANTIHISTAMINES ANTIHISTAMINES - ETHANOLAMINES maleate soln Tier 1 carbinoxamine maleate tabs 4mg Tier 1 carbinoxamine maleate tabs 6mg Tier 3 fumarate Tier 1 hcl elix Tier 1 diphenhydramine hcl soln LA KARBINAL ER Tier 3 ryvent Tier 3 ANTIHISTAMINES - PHENERGAN Tier 3 hcl soln LA promethazine hcl supp; syrp; tabs Tier 1 ANTIHISTAMINES - PIPERIDINES hcl Tier 1 ANTIHYPERLIPIDEMICS ADENOSINE TRIPHOSPHATE-CITRATE LYASE (ACL) INHIBITORS NEXLETOL Tier 2 PA ANGIOPOIETIN-LIKE PROTEIN INHIBITORS EVKEEZA LA SP, PA ANTIHYPERLIPIDEMICS - COMBINATIONS ezetimibe-simvastatin Tier 1 QL NEXLIZET Tier 2 PA VYTORIN Tier 3 QL ANTIHYPERLIPIDEMICS - MISC. icosapent ethyl Tier 1 LOVAZA Tier 3 QL omega-3-acid ethyl esters Tier 1 QL VASCEPA 1gm Tier 3 VASCEPA .5gm Tier 2 BILE ACID SEQUESTRANTS cholestyramine Tier 1 cholestyramine light Tier 1 colesevelam hcl Tier 1 COLESTID Tier 3 COLESTID FLAVORED Tier 3 colestipol hcl Tier 1 QUESTRAN Tier 3 QUESTRAN LIGHT Tier 3

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 24 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits WELCHOL Tier 3 FIBRIC ACID DERIVATIVES ANTARA Tier 3 fenofibrate Tier 1 fenofibrate caps Tier 3 fenofibrate tabs Tier 1 fenofibrate micronized Tier 1 fenofibric acid Tier 1 FENOGLIDE Tier 3 FIBRICOR Tier 3 gemfibrozil Tier 1 LIPOFEN Tier 3 LOPID Tier 3 TRICOR Tier 3 TRILIPIX Tier 3 HMG COA REDUCTASE INHIBITORS ALTOPREV Tier 3 PA atorvastatin calcium 10mg, 20mg ACA AL atorvastatin calcium 40mg, 80mg Tier 1 FLOLIPID Tier 3 PA fluvastatin sodium ACA AL LESCOL XL Tier 3 LIPITOR Tier 3 lovastatin ACA AL pravastatin sodium ACA AL rosuvastatin calcium 5mg, 10mg ACA QL; AL rosuvastatin calcium 20mg, 40mg Tier 1 QL simvastatin 5mg, 10mg, 20mg, 40mg ACA AL simvastatin 80mg Tier 1 ZOCOR Tier 3 INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS ezetimibe Tier 1 QL ZETIA Tier 3 QL MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN (MTP) INHIBITORS JUXTAPID Tier 4 SP, PA NICOTINIC ACID DERIVATIVES niacin (antihyperlipidemic) tabs Tier 1 niacin (antihyperlipidemic) tbcr Tier 1 NIASPAN Tier 3 PROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS PRALUENT Tier 3 PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 25 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits REPATHA Tier 3 PA REPATHA PUSHTRONEX SYSTEM Tier 3 PA REPATHA SURECLICK Tier 3 PA ANTIHYPERTENSIVES ACE INHIBITORS ACCUPRIL Tier 3 benazepril hcl Tier 1 captopril Tier 1 enalapril maleate Tier 1 fosinopril sodium Tier 1 lisinopril Tier 1 LOTENSIN Tier 3 moexipril hcl Tier 1 perindopril erbumine Tier 1 PRINIVIL Tier 3 QBRELIS Tier 3 PA quinapril hcl Tier 1 ramipril Tier 1 trandolapril Tier 1 VASOTEC Tier 3 ZESTRIL Tier 3 AGENTS FOR PHEOCHROMOCYTOMA DEMSER Tier 2 PA DIBENZYLINE Tier 3 PA phenoxybenzamine hcl Tier 1 PA ANGIOTENSIN II RECEPTOR ANTAGONISTS ATACAND Tier 3 AVAPRO Tier 3 candesartan cilexetil Tier 1 COZAAR Tier 3 DIOVAN Tier 3 EDARBI Tier 3 irbesartan Tier 1 losartan potassium Tier 1 MICARDIS Tier 3 olmesartan medoxomil Tier 1 QL telmisartan Tier 1 valsartan Tier 1 ANTIADRENERGIC ANTIHYPERTENSIVES CARDURA Tier 3 CATAPRES-TTS-1 Tier 3 QL CATAPRES-TTS-2 Tier 3 QL CATAPRES-TTS-3 Tier 3 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 26 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits clonidine Tier 1 QL clonidine hcl Tier 1 doxazosin mesylate Tier 1 guanfacine hcl Tier 1 methyldopa Tier 1 MINIPRESS Tier 3 prazosin hcl Tier 1 terazosin hcl Tier 1 ANTIHYPERTENSIVE COMBINATIONS ACCURETIC Tier 3 amlodipine besylate-benazepril hcl Tier 1 amlodipine besylate-olmesartan medoxomil Tier 1 amlodipine besylate-valsartan Tier 1 amlodipine-valsartan-hydrochlorothiazide Tier 1 ATACAND HCT Tier 3 atenolol & chlorthalidone Tier 1 AVALIDE Tier 3 AZOR Tier 3 benazepril & hydrochlorothiazide Tier 1 bisoprolol & hydrochlorothiazide Tier 1 candesartan cilexetil-hydrochlorothiazide Tier 1 DIOVAN HCT Tier 3 DUTOPROL Tier 3 EDARBYCLOR Tier 3 enalapril maleate & hydrochlorothiazide Tier 1 EXFORGE Tier 3 EXFORGE HCT Tier 3 fosinopril sodium & hydrochlorothiazide Tier 1 HYZAAR Tier 3 irbesartan-hydrochlorothiazide Tier 1 lisinopril & hydrochlorothiazide Tier 1 losartan potassium & hydrochlorothiazide Tier 1 LOTENSIN HCT Tier 3 LOTREL Tier 3 metoprolol & hydrochlorothiazide Tier 1 MICARDIS HCT Tier 3 olmesartan medoxomil-amlodipine- Tier 1 hydrochlorothiazide olmesartan medoxomil-hydrochlorothiazide Tier 1 QL PRESTALIA Tier 3 quinapril-hydrochlorothiazide Tier 1 TARKA Tier 3 TEKTURNA HCT Tier 2

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 27 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits telmisartan-amlodipine Tier 1 telmisartan-hydrochlorothiazide Tier 1 TENORETIC 50 Tier 3 TENORETIC 100 Tier 3 trandolapril-verapamil hcl Tier 1 TRIBENZOR Tier 3 TWYNSTA Tier 3 valsartan-hydrochlorothiazide Tier 1 VASERETIC Tier 3 ZESTORETIC Tier 3 ZIAC Tier 3 ANTIHYPERTENSIVES - MISC. VECAMYL Tier 3 PA DIRECT RENIN INHIBITORS aliskiren fumarate Tier 1 TEKTURNA Tier 3 SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS) eplerenone Tier 1 INSPRA Tier 3 VASODILATORS hydralazine hcl Tier 1 minoxidil Tier 1 ANTIMALARIALS ANTIMALARIAL COMBINATIONS atovaquone-proguanil hcl Tier 1 PA COARTEM Tier 2 PA MALARONE Tier 3 PA ANTIMALARIALS chloroquine phosphate Tier 1 DARAPRIM Tier 3 PA hydroxychloroquine sulfate Tier 1 mefloquine hcl Tier 1 QL pyrimethamine Tier 1 PA QUALAQUIN Tier 3 quinine sulfate Tier 1 ANTIMYASTHENIC/ AGENTS ANTIMYASTHENIC/CHOLINERGIC AGENTS MESTINON Tier 3 MESTINON TIMESPAN Tier 3 pyridostigmine bromide Tier 1 REGONOL LA PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 28 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits ANTIMYCOBACTERIAL AGENTS ANTIMYCOBACTERIAL AGENTS CAPASTAT SULFATE LA PA cycloserine Tier 1 ethambutol hcl Tier 1 isoniazid soln LA isoniazid syrp; tabs Tier 1 MYAMBUTOL Tier 3 MYCOBUTIN Tier 3 QL PASER Tier 3 PRETOMANID Tier 3 PA PRIFTIN Tier 3 QL pyrazinamide Tier 1 rifabutin Tier 1 QL RIFADIN LA PA rifampin caps Tier 1 rifampin solr LA SIRTURO Tier 3 PA TRECATOR Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ALKYLATING AGENTS ALKERAN SOLR LA PA ALKERAN TABS Tier 3 BELRAPZO LA SP, PA BENDEKA LA SP, PA BICNU LA PA BUSULFEX LA carboplatin LA carmustine LA PA cisplatin LA CYCLOPHOSPHAMIDE CAPS Tier 1 CYCLOPHOSPHAMIDE SOLN LA cyclophosphamide solr 1gm, 500mg LA cyclophosphamide solr 2gm Tier 1 EVOMELA LA SP GLEOSTINE Tier 3 GLIADEL WAFER LA PA IFEX LA ifosfamide soln LA ifosfamide solr 1gm LA IFOSFAMIDE SOLR 3gm LA LEUKERAN Tier 2 melphalan Tier 1

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 29 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits melphalan hcl LA MYLERAN Tier 2 oxaliplatin LA PEPAXTO LA SP, PA TEMODAR CAPS Tier 4 SP TEMODAR SOLR LA SP, PA temozolomide Tier 1 SP TEPADINA LA PA thiotepa LA PA TREANDA LA SP, PA YONDELIS LA SP, PA ZEPZELCA LA SP, PA ANTIMETABOLITES ALIMTA LA ARRANON LA azacitidine Tier 1 SP capecitabine Tier 1 SP cladribine LA clofarabine LA PA cytarabine LA DACOGEN Tier 4 SP decitabine LA SP floxuridine LA fludarabine phosphate LA fluorouracil LA FOLOTYN LA SP, PA gemcitabine hcl LA GEMCITABINE HYDROCHLORIDE LA mercaptopurine Tier 1 methotrexate sodium Tier 1 ONUREG Tier 4 SP, PA, QL PURIXAN Tier 4 SP TABLOID Tier 2 TREXALL Tier 3 PA VIDAZA LA SP, PA XATMEP Tier 3 XELODA Tier 4 SP ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS CYRAMZA LA SP, PA INLYTA Tier 4 SP, PA LENVIMA 4 MG DAILY DOSE Tier 4 SP, PA LENVIMA 8 MG DAILY DOSE Tier 4 SP, PA LENVIMA 10 MG DAILY DOSE Tier 4 SP, PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 30 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits LENVIMA 12MG DAILY DOSE Tier 4 SP, PA LENVIMA 14 MG DAILY DOSE Tier 4 SP, PA LENVIMA 18 MG DAILY DOSE Tier 4 SP, PA LENVIMA 20 MG DAILY DOSE Tier 4 SP, PA LENVIMA 24 MG DAILY DOSE Tier 4 SP, PA MVASI LA SP ZALTRAP LA SP, PA ZIRABEV LA SP ANTINEOPLASTIC - ANTI-HER2 AGENTS HERZUMA LA SP, PA KANJINTI LA SP, PA ONTRUZANT LA SP, PA PERJETA LA SP, PA TRAZIMERA LA SP, PA TUKYSA Tier 4 SP, PA ANTINEOPLASTIC - ANTIBODIES ADCETRIS LA SP, PA ARZERRA LA SP, PA BAVENCIO LA SP, PA BESPONSA LA SP, PA BLINCYTO LA SP, PA DANYELZA LA SP, PA DARZALEX LA SP, PA EMPLICITI LA SP, PA ENHERTU LA SP, PA GAZYVA LA SP, PA IMFINZI LA SP, PA JEMPERLI LA SP, PA KADCYLA LA SP, PA KEYTRUDA LA SP, PA LUMOXITI LA SP, PA MONJUVI LA SP, PA MYLOTARG LA SP, PA OPDIVO LA SP, PA PADCEV LA SP, PA POLIVY LA SP, PA POTELIGEO LA SP, PA RIABNI LA SP, PA RITUXAN LA SP, PA RUXIENCE LA SP, PA SARCLISA LA SP, PA TECENTRIQ LA SP, PA TRUXIMA LA SP, PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 31 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits UNITUXIN LA SP, PA YERVOY LA SP, PA ZEVALIN Y-90 LA PA ZYNLONTA LA SP, PA ANTINEOPLASTIC - BCL-2 INHIBITORS VENCLEXTA Tier 4 SP, PA VENCLEXTA STARTING PACK Tier 4 SP, PA ANTINEOPLASTIC - CELLULAR IMMUNOTHERAPY ABECMA LA SP, PA BREYANZI LA SP, PA TECARTUS LA SP, PA ANTINEOPLASTIC - EGFR INHIBITORS ERBITUX LA SP, PA erlotinib hcl Tier 1 SP, PA GILOTRIF Tier 4 SP, PA IRESSA Tier 4 SP, PA PORTRAZZA LA SP, PA TAGRISSO Tier 4 SP, PA TARCEVA Tier 4 SP, PA VECTIBIX LA SP, PA VIZIMPRO Tier 4 SP, PA, QL ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS DAURISMO Tier 4 SP, PA ERIVEDGE Tier 4 SP, PA ODOMZO Tier 4 SP, PA ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS abiraterone acetate 250mg Tier 1 SP, PA; GENDER abiraterone acetate 500mg Tier 4 SP, PA; GENDER anastrozole Tier 1 ARIMIDEX Tier 3 AROMASIN Tier 3 bicalutamide Tier 1 CASODEX Tier 3 ELIGARD Tier 2 SP EMCYT Tier 2 ERLEADA Tier 2 SP, PA exemestane Tier 1 FARESTON Tier 3 FASLODEX LA FEMARA Tier 3 FIRMAGON Tier 4 SP flutamide Tier 1 fulvestrant LA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 32 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits hydroxyprogesterone caproate LA PA (antineoplastic) letrozole Tier 1 leuprolide acetate Tier 1 SP LUPRON DEPOT (1-MONTH) Tier 2 SP LUPRON DEPOT (3-MONTH) Tier 2 SP LUPRON DEPOT (4-MONTH) Tier 2 SP LUPRON DEPOT (6-MONTH) Tier 2 SP LYSODREN Tier 2 megestrol acetate Tier 1 NILANDRON Tier 3 PA NUBEQA Tier 2 SP, PA ORGOVYX Tier 4 SP, PA SOLTAMOX Tier 3 tamoxifen citrate Tier 1 TRELSTAR MIXJECT LA SP, PA VANTAS LA SP XTANDI Tier 2 SP, PA YONSA Tier 2 SP, PA; GENDER ZOLADEX LA SP, PA ZYTIGA Tier 4 SP, PA; GENDER ANTINEOPLASTIC - IMMUNOMODULATORS POMALYST Tier 4 SP, PA ANTINEOPLASTIC - PDGFR-ALPHA INHIBITORS AYVAKIT 25mg, 50mg Tier 4 SP AYVAKIT 100mg, 200mg, 300mg Tier 4 SP, PA ANTINEOPLASTIC - XPO1 INHIBITORS XPOVIO Tier 4 SP, PA XPOVIO 60 MG TWICE WEEKLY Tier 4 SP, PA XPOVIO 80 MG TWICE WEEKLY Tier 4 SP, PA ANTINEOPLASTIC ANTIBIOTICS bleomycin sulfate LA COSMEGEN LA PA daunorubicin hcl LA DAUNORUBICIN HYDROCHLORID LA DOXIL LA PA doxorubicin hcl LA doxorubicin hcl liposomal LA PA ELLENCE LA epirubicin hcl LA IDAMYCIN PFS 5mg/5ml, 10mg/10ml LA IDAMYCIN PFS 20mg/20ml LA PA idarubicin hcl 5mg/5ml, 10mg/10ml LA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 33 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits idarubicin hcl 20mg/20ml LA PA JELMYTO LA SP, PA mitomycin LA mitoxantrone hcl LA SP ANTINEOPLASTIC COMBINATIONS DARZALEX FASPRO LA SP, PA HERCEPTIN HYLECTA LA SP, PA INQOVI Tier 4 SP, PA KISQALI FEMARA 200 DOSE Tier 4 SP, PA KISQALI FEMARA 400 DOSE Tier 4 SP, PA KISQALI FEMARA 600 DOSE Tier 4 SP, PA LONSURF Tier 4 SP, PA PHESGO LA SP, PA RITUXAN HYCELA Tier 4 SP, PA VYXEOS LA SP, PA ANTINEOPLASTIC ENZYME INHIBITORS AFINITOR Tier 4 SP, PA AFINITOR DISPERZ Tier 4 SP, PA ALECENSA Tier 4 SP, PA ALIQOPA LA SP, PA ALUNBRIG Tier 4 SP, PA BALVERSA Tier 4 SP, PA BELEODAQ LA SP, PA BORTEZOMIB LA SP, PA BOSULIF 100mg, 500mg LA SP, PA BOSULIF 400mg Tier 4 SP, PA BRAFTOVI Tier 4 SP, PA BRUKINSA Tier 4 SP, PA CABOMETYX Tier 4 SP, PA CALQUENCE Tier 4 SP, PA CAPRELSA Tier 4 SP, PA COMETRIQ Tier 4 SP, PA COPIKTRA Tier 4 SP, PA COTELLIC Tier 4 SP, PA everolimus Tier 1 SP, PA FARYDAK Tier 4 SP FOTIVDA Tier 4 SP, PA GAVRETO Tier 4 SP, PA IBRANCE Tier 2 SP, PA ICLUSIG Tier 4 SP, PA, QL IDHIFA Tier 4 SP, PA imatinib mesylate Tier 1 SP, PA IMBRUVICA CAPS Tier 4 SP, PA, QL

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 34 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits IMBRUVICA TABS 140mg Tier 4 SP, PA, QL IMBRUVICA TABS 280mg, 420mg, 560mg Tier 4 SP, PA, QL INREBIC Tier 4 SP, PA ISTODAX (OVERFILL) LA SP, PA JAKAFI Tier 4 SP, PA KOSELUGO Tier 4 SP, PA KYPROLIS LA SP, PA lapatinib ditosylate Tier 1 SP, PA LORBRENA Tier 4 SP, PA LYNPARZA Tier 2 SP, PA MEKINIST Tier 4 SP, PA MEKTOVI Tier 4 SP, PA NERLYNX Tier 4 SP, PA NEXAVAR Tier 2 SP, QL NINLARO Tier 4 SP, PA PEMAZYRE Tier 4 SP, PA PIQRAY 200MG DAILY DOSE Tier 4 SP, PA PIQRAY 250MG DAILY DOSE Tier 4 SP, PA PIQRAY 300MG DAILY DOSE Tier 4 SP, PA QINLOCK Tier 4 SP, PA RETEVMO Tier 4 SP, PA ROMIDEPSIN LA SP, PA ROZLYTREK Tier 4 SP, PA RUBRACA Tier 2 SP, PA RYDAPT Tier 4 SP, PA SPRYCEL Tier 4 SP, PA STIVARGA Tier 4 SP, PA sunitinib malate Tier 1 SP, PA SUTENT Tier 4 SP, PA TABRECTA Tier 4 SP, PA TAFINLAR Tier 4 SP, PA TALZENNA Tier 4 SP, PA, QL TASIGNA 50mg Tier 4 SP, PA, QL TASIGNA 150mg, 200mg Tier 4 SP, PA TAZVERIK Tier 4 SP, PA temsirolimus LA SP TEPMETKO Tier 4 SP, PA TURALIO Tier 4 SP, PA TYKERB Tier 4 SP, PA UKONIQ Tier 4 SP, PA VELCADE LA SP, PA VERZENIO Tier 2 SP, PA VITRAKVI Tier 4 SP, PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 35 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits VOTRIENT Tier 4 SP, PA XALKORI Tier 4 SP, PA XOSPATA Tier 4 SP, PA ZEJULA Tier 2 SP, PA ZELBORAF Tier 4 SP, PA ZOLINZA Tier 4 SP ZYDELIG Tier 4 SP, PA ZYKADIA Tier 4 SP, PA ANTINEOPLASTIC ENZYMES ASPARLAS LA SP, PA ERWINASE LA SP, PA ONCASPAR LA SP, PA ANTINEOPLASTIC RADIOPHARMACEUTICALS LUTATHERA LA SP, PA ANTINEOPLASTICS MISC. ACTIMMUNE Tier 2 SP, PA ALFERON N LA SP, PA arsenic trioxide LA PA bexarotene Tier 1 SP dacarbazine LA ELZONRIS LA SP, PA HYDREA Tier 3 hydroxyurea Tier 1 INTRON A Tier 2 SP MATULANE Tier 2 SP NIPENT LA PA PHOTOFRIN LA PROLEUKIN LA SP SYNRIBO LA SP, PA TARGRETIN CAPS Tier 4 SP tretinoin (chemotherapy) Tier 1 TRISENOX LA PA CHEMOTHERAPY ADJUNCTS ELITEK LA PA KEPIVANCE LA CHEMOTHERAPY RESCUE/ANTIDOTE/PROTECTIVE AGENTS COSELA LA SP, PA dexrazoxane hcl LA ETHYOL LA KHAPZORY LA SP leucovorin calcium soln; tabs Tier 1 leucovorin calcium solr LA levoleucovorin calcium soln 175mg/17.5ml LA SP PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 36 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits levoleucovorin calcium soln 250mg/25ml Tier 1 SP levoleucovorin calcium solr LA SP mesna LA MESNEX SOLN LA PA MESNEX TABS Tier 3 TOTECT LA VORAXAZE LA SP, PA MITOTIC INHIBITORS ABRAXANE LA PA docetaxel conc 20mg/ml, 80mg/4ml LA DOCETAXEL CONC 20mg/ml, 80mg/4ml, LA 160mg/8ml DOCETAXEL SOLN LA ETOPOPHOS LA etoposide caps Tier 1 etoposide soln LA HALAVEN LA SP, PA IXEMPRA KIT LA SP, PA JEVTANA LA SP, PA MARQIBO LA SP, PA NAVELBINE LA PA paclitaxel LA TENIPOSIDE LA vinblastine sulfate LA vincristine sulfate LA vinorelbine tartrate LA TOPOISOMERASE I INHIBITORS CAMPTOSAR 40mg/2ml, 100mg/5ml LA PA CAMPTOSAR 300mg/15ml LA HYCAMTIN Tier 4 SP irinotecan hcl 40mg/2ml, 100mg/5ml, LA 300mg/15ml irinotecan hcl 500mg/25ml LA PA ONIVYDE LA SP, PA topotecan hcl LA TRODELVY LA SP, PA ANTIPARKINSON AND RELATED THERAPY AGENTS ANTIPARKINSON ADJUNCTIVE THERAPY carbidopa Tier 1 LODOSYN Tier 3 ANTIPARKINSON ANTICHOLINERGICS benztropine mesylate soln LA benztropine mesylate tabs Tier 1

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 37 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits COGENTIN LA PA hcl Tier 1 ANTIPARKINSON COMT INHIBITORS COMTAN Tier 3 entacapone Tier 1 TASMAR Tier 3 tolcapone Tier 1 ANTIPARKINSON DOPAMINERGICS amantadine hcl Tier 1 APOKYN Tier 2 SP bromocriptine mesylate Tier 1 carbidopa-levodopa Tier 1 carbidopa-levodopa-entacapone Tier 1 DUOPA Tier 4 SP, PA KYNMOBI Tier 4 SP, PA MIRAPEX Tier 3 MIRAPEX ER Tier 3 NEUPRO Tier 3 pramipexole dihydrochloride Tier 1 ropinirole hydrochloride Tier 1 RYTARY Tier 3 SINEMET Tier 3 STALEVO 50 Tier 3 STALEVO 75 Tier 3 STALEVO 100 Tier 3 STALEVO 125 Tier 3 STALEVO 150 Tier 3 STALEVO 200 Tier 3 ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS AZILECT Tier 3 rasagiline mesylate Tier 1 selegiline hcl Tier 1 XADAGO Tier 3 PA ZELAPAR Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS ANTIMANIC AGENTS lithium carbonate Tier 1 LITHOBID Tier 3 ANTIPSYCHOTICS - MISC. CAPLYTA Tier 3 ST EQUETRO Tier 3 GEODON CAPS Tier 3 ST GEODON SOLR LA ST PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 38 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits LATUDA Tier 3 ST NUPLAZID Tier 4 SP, PA VRAYLAR CAPS Tier 3 ST VRAYLAR CPPK Tier 3 ST ziprasidone hcl Tier 1 BENZISOXAZOLES FANAPT Tier 3 ST FANAPT TITRATION PACK Tier 3 ST INVEGA SUSTENNA LA INVEGA TRINZA LA paliperidone Tier 1 ST PERSERIS LA QL RISPERDAL Tier 3 RISPERDAL CONSTA LA risperidone Tier 1 BUTYROPHENONES HALDOL DECANOATE 50 LA HALDOL DECANOATE 100 LA haloperidol Tier 1 haloperidol decanoate LA haloperidol lactate conc Tier 1 haloperidol lactate soln LA DIBENZAPINES ADASUVE Tier 3 asenapine maleate Tier 1 ST Tier 1 CLOZARIL Tier 3 succinate Tier 1 solr LA olanzapine tabs; tbdp Tier 1 fumarate Tier 1 SAPHRIS Tier 3 ST SECUADO Tier 3 ST SEROQUEL Tier 3 ST SEROQUEL XR Tier 3 VERSACLOZ Tier 3 ZYPREXA SOLR LA PA ZYPREXA TABS Tier 3 ZYPREXA RELPREVV LA ZYPREXA ZYDIS Tier 3 DIHYDROINDOLONES molindone hcl Tier 1

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 39 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits PHENOTHIAZINES HCL SOLN Tier 1 chlorpromazine hcl tabs Tier 1 fluphenazine decanoate LA fluphenazine hcl conc; elix; tabs Tier 1 fluphenazine hcl soln LA perphenazine Tier 1 prochlorperazine Tier 1 prochlorperazine edisylate LA prochlorperazine maleate Tier 1 hcl Tier 1 trifluoperazine hcl Tier 1 QUINOLINONE DERIVATIVES ABILIFY Tier 3 ST ABILIFY MAINTENA PRSY 300mg LA ABILIFY MAINTENA PRSY 400mg Tier 3 ABILIFY MAINTENA SRER LA aripiprazole soln; tabs Tier 1 aripiprazole tbdp Tier 1 PA ARISTADA LA ARISTADA INITIO LA REXULTI Tier 3 ST THIOXANTHENES thiothixene Tier 1 ANTISEPTICS & DISINFECTANTS ANTISEPTICS & DISINFECTANTS hydrogen peroxide LA CHLORINE ANTISEPTICS CHLORHEXIDINE GLUCONATE Tier 3 ANTIVIRALS ANTIRETROVIRALS abacavir sulfate Tier 1 SP abacavir sulfate-lamivudine Tier 1 SP abacavir sulfate-lamivudine-zidovudine Tier 1 SP APTIVUS Tier 4 SP atazanavir sulfate Tier 1 SP BIKTARVY Tier 2 SP CABENUVA LA SP, PA CIMDUO Tier 2 SP COMBIVIR Tier 4 SP CRIXIVAN Tier 4 SP DELSTRIGO Tier 4 SP

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 40 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits DESCOVY Tier 2 SP DOVATO Tier 2 SP EDURANT Tier 4 SP efavirenz Tier 1 SP efavirenz-lamivudine-tenofovir disoproxil Tier 2 SP fumarate emtricitabine Tier 2 SP emtricitabine-tenofovir disoproxil fumarate Tier 1 SP EMTRIVA Tier 2 SP EPIVIR Tier 4 SP EPZICOM Tier 4 SP etravirine Tier 1 SP EVOTAZ Tier 4 SP fosamprenavir calcium Tier 1 SP FUZEON Tier 4 SP GENVOYA Tier 2 SP INTELENCE Tier 4 SP INVIRASE Tier 4 SP ISENTRESS Tier 2 SP ISENTRESS HD Tier 2 SP JULUCA Tier 4 SP KALETRA Tier 4 SP lamivudine Tier 1 SP lamivudine-zidovudine Tier 1 SP LEXIVA Tier 4 SP lopinavir-ritonavir Tier 1 SP nevirapine Tier 1 SP NORVIR Tier 4 SP ODEFSEY Tier 2 SP PIFELTRO Tier 4 SP PREZCOBIX Tier 2 SP PREZISTA Tier 2 SP RETROVIR Tier 4 SP RETROVIR IV INFUSION LA SP REYATAZ Tier 4 SP ritonavir Tier 1 SP RUKOBIA Tier 4 SP, PA SELZENTRY SOLN Tier 4 SP SELZENTRY TABS 25mg, 75mg Tier 4 SP, QL SELZENTRY TABS 150mg, 300mg Tier 4 SP SUSTIVA Tier 4 SP SYMFI Tier 2 SP SYMFI LO Tier 2 SP SYMTUZA Tier 4 SP PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 41 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits TEMIXYS Tier 2 SP tenofovir disoproxil fumarate Tier 1 SP TIVICAY Tier 4 SP TIVICAY PD Tier 4 SP TRIUMEQ Tier 2 SP TRIZIVIR Tier 4 SP TROGARZO LA SP, PA TRUVADA Tier 4 SP TYBOST Tier 4 SP VIRACEPT Tier 4 SP VIRAMUNE Tier 4 SP VIRAMUNE XR Tier 4 SP VIREAD Tier 4 SP ZIAGEN Tier 4 SP zidovudine Tier 1 SP CMV AGENTS cidofovir LA foscarnet sodium LA FOSCAVIR LA GANCICLOVIR LA ganciclovir sodium LA PREVYMIS Tier 3 PA VALCYTE SOLR Tier 3 VALCYTE TABS Tier 3 QL valganciclovir hcl Tier 1 QL HEPATITIS AGENTS adefovir dipivoxil Tier 1 SP BARACLUDE SOLN Tier 4 SP BARACLUDE TABS Tier 4 SP, QL entecavir Tier 1 SP, QL EPIVIR HBV Tier 4 SP HEPSERA Tier 4 SP lamivudine (hbv) Tier 1 SP MAVYRET Tier 2 SP, PA PEGASYS 180mcg/0.5ml Tier 4 SP, PA PEGASYS 180mcg/ml Tier 4 SP, PA, QL ribavirin (hepatitis c) Tier 1 SP, PA, QL sofosbuvir/velpatasvir Tier 2 SP, PA VEMLIDY Tier 4 SP HERPES AGENTS acyclovir Tier 1 acyclovir sodium LA famciclovir Tier 1 QL

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 42 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits SITAVIG Tier 3 PA valacyclovir hcl Tier 1 ZOVIRAX Tier 3 INFLUENZA AGENTS oseltamivir phosphate Tier 1 RELENZA DISKHALER Tier 2 rimantadine hydrochloride Tier 1 TAMIFLU Tier 3 XOFLUZA Tier 3 QL RESPIRATORY SYNCYTIAL VIRUS (RSV) AGENTS VIRAZOLE Tier 3 BETA BLOCKERS ALPHA-BETA BLOCKERS carvedilol Tier 1 carvedilol phosphate Tier 1 COREG Tier 3 COREG CR Tier 3 labetalol hcl Tier 1 BETA BLOCKERS CARDIO-SELECTIVE acebutolol hcl Tier 1 atenolol Tier 1 betaxolol hcl Tier 1 bisoprolol fumarate Tier 1 BYSTOLIC Tier 2 LOPRESSOR Tier 3 metoprolol succinate Tier 1 metoprolol tartrate Tier 1 TENORMIN Tier 3 TOPROL XL Tier 3 BETA BLOCKERS NON-SELECTIVE BETAPACE Tier 3 BETAPACE AF Tier 3 CORGARD Tier 3 HEMANGEOL Tier 3 INDERAL LA Tier 3 nadolol Tier 1 pindolol Tier 1 propranolol hcl Tier 1 sotalol hcl Tier 1 sotalol hcl (afib/afl) Tier 1 SOTYLIZE Tier 3 timolol maleate Tier 1

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 43 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKERS amlodipine besylate Tier 1 CALAN SR Tier 3 CARDIZEM Tier 3 CARDIZEM CD Tier 3 CARDIZEM LA Tier 3 diltiazem hcl Tier 1 diltiazem hcl coated beads Tier 1 diltiazem hcl extended release beads Tier 1 felodipine Tier 1 isradipine Tier 1 nicardipine hcl Tier 1 nifedipine Tier 1 nimodipine Tier 1 nisoldipine Tier 1 NORVASC Tier 3 NYMALIZE Tier 3 PA PROCARDIA XL Tier 3 SULAR Tier 3 TIAZAC Tier 3 verapamil hcl Tier 1 VERELAN Tier 3 VERELAN PM Tier 3 CARDIOTONICS CARDIAC GLYCOSIDES digoxin soln .05mg/ml Tier 1 digoxin soln .25mg/ml LA digoxin tabs Tier 1 LANOXIN SOLN LA PA LANOXIN TABS Tier 3 INOTROPES milrinone lactate LA milrinone lactate in dextrose LA CARDIOVASCULAR AGENTS - MISC. CARDIOVASCULAR AGENTS MISC. - COMBINATIONS amlodipine besylate-atorvastatin calcium Tier 1 QL BIDIL Tier 2 CADUET Tier 3 QL ENTRESTO Tier 2 IMPOTENCE AGENTS CAVERJECT IMPULSE Tier 2 QL; GENDER

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 44 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits EDEX Tier 2 QL; GENDER sildenafil citrate Tier 1 QL; GENDER tadalafil 2.5mg, 5mg Tier 1 QL; GENDER tadalafil 10mg, 20mg Tier 1 QL; GENDER PROSTAGLANDIN VASODILATORS epoprostenol sodium LA SP, PA ORENITRAM Tier 4 SP, PA REMODULIN LA SP, PA treprostinil Tier 1 SP TYVASO Tier 2 SP, PA TYVASO REFILL Tier 2 SP, PA TYVASO STARTER Tier 2 SP, PA VENTAVIS 10mcg/ml Tier 2 SP, PA, QL VENTAVIS 20mcg/ml Tier 2 SP, PA PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS ambrisentan Tier 1 SP, PA bosentan Tier 1 SP, PA, QL OPSUMIT Tier 4 SP, PA TRACLEER Tier 2 SP, PA PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS ADCIRCA Tier 4 SP, PA REVATIO SOLN LA SP, PA REVATIO SUSR Tier 4 SP, PA REVATIO TABS Tier 4 SP, PA, QL sildenafil citrate (pulmonary hypertension) LA SP, PA soln sildenafil citrate (pulmonary hypertension) Tier 1 SP, PA susr sildenafil citrate (pulmonary hypertension) Tier 1 SP, PA, QL tabs tadalafil (pulmonary hypertension) Tier 1 SP, PA PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST UPTRAVI TABS Tier 4 SP, PA UPTRAVI TBPK Tier 4 SP, PA PULMONARY HYPERTENSION - SOL GUANYLATE CYCLASE STIMULATOR ADEMPAS Tier 4 SP, PA SINUS NODE INHIBITORS CORLANOR Tier 3 TRANSTHYRETIN STABILIZERS VYNDAMAX Tier 4 SP, PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 45 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits VASOACTIVE SOLUBLE GUANYLATE CYCLASE STIMULATOR (SGC) VERQUVO Tier 2 PA CEPHALOSPORINS CEPHALOSPORIN COMBINATIONS AVYCAZ LA ZERBAXA LA CEPHALOSPORINS - 1ST GENERATION cefadroxil Tier 1 CEFAZOLIN LA CEFAZOLIN SODIUM SOLN LA cefazolin sodium solr LA CEFAZOLIN SODIUM/DEXTROSE LA cephalexin Tier 1 KEFLEX Tier 3 CEPHALOSPORINS - 2ND GENERATION cefaclor Tier 1 CEFOTAN Tier 3 cefotetan disodium LA CEFOTETAN/DEXTROSE LA CEFOXITIN SODIUM LA cefoxitin sodium 1gm, 2gm, 10gm LA cefprozil Tier 1 cefuroxime axetil Tier 1 cefuroxime sodium LA CEPHALOSPORINS - 3RD GENERATION cefdinir Tier 1 cefixime caps Tier 1 QL cefixime susr Tier 1 cefotaxime sodium LA cefpodoxime proxetil Tier 1 ceftazidime LA CEFTAZIDIME/DEXTROSE LA ceftriaxone sodium LA ceftriaxone sodium in dextrose LA CEFTRIAXONE/DEXTROSE LA FORTAZ 2gm Tier 3 FORTAZ 500mg LA SUPRAX CAPS Tier 3 QL SUPRAX CHEW; SUSR Tier 3 CEPHALOSPORINS - 4TH GENERATION CEFEPIME LA cefepime hcl LA CEFEPIME/DEXTROSE LA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 46 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits CEPHALOSPORINS - 5TH GENERATION TEFLARO LA PA CEPHALOSPORINS - SIDEROPHORES FETROJA LA PA CONTRACEPTIVES COMBINATION CONTRACEPTIVES - ORAL BEYAZ Tier 3 PA desogestrel & ethinyl estradiol Tier 1 desogestrel & ethinyl estradiol ACA desogestrel-ethinyl estradiol (biphasic) Tier 1 desogestrel-ethinyl estradiol (biphasic) ACA desogestrel-ethinyl estradiol (triphasic) Tier 1 desogestrel-ethinyl estradiol (triphasic) ACA drospirenone-ethinyl estradiol Tier 1 drospirenone-ethinyl estradiol- Tier 1 levomefolate calcium ESTROSTEP FE Tier 3 ethynodiol diacet & eth estrad Tier 1 GENERESS FE Tier 3 levonorgestrel & eth estradiol Tier 1 levonorgestrel-eth estradiol (triphasic) Tier 1 levonorgestrel-eth estradiol (triphasic) ACA levonorgestrel-ethinyl estradiol (91-day) Tier 1 levonorgestrel-ethinyl estradiol (91-day) ACA levonorgestrel-ethinyl estradiol Tier 1 (continuous) LO LOESTRIN FE ACA LOSEASONIQUE Tier 3 MINASTRIN 24 FE Tier 3 MIRCETTE Tier 3 NATAZIA ACA NEXTSTELLIS Tier 3 norethin acet & estrad-fe caps Tier 1 norethin acet & estrad-fe chew Tier 1 norethin acet & estrad-fe tabs Tier 1 NORETHIN ACET & ESTRAD-FE TABS Tier 1 norethin acet & estrad-fe tabs ACA norethindrone & eth estradiol Tier 1 norethindrone & ethinyl estradiol-fe Tier 1 norethindrone acet & eth estra Tier 1 NORETHINDRONE ACET & ETH ESTRA Tier 1 norethindrone acetate-ethinyl estradiol-fe Tier 1 norethindrone-eth estradiol (triphasic) Tier 1

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 47 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits norgestimate-ethinyl estradiol Tier 1 norgestimate-ethinyl estradiol ACA norgestimate-ethinyl estradiol (triphasic) Tier 1 norgestimate-ethinyl estradiol (triphasic) ACA norgestrel & ethinyl estradiol Tier 1 norgestrel & ethinyl estradiol ACA QUARTETTE Tier 3 SAFYRAL Tier 3 SEASONIQUE Tier 3 TAYTULLA Tier 3 YASMIN 28 Tier 3 YAZ Tier 3 COMBINATION CONTRACEPTIVES - TRANSDERMAL norelgestromin-ethinyl estradiol Tier 1 norelgestromin-ethinyl estradiol ACA TWIRLA Tier 3 COMBINATION CONTRACEPTIVES - VAGINAL ANNOVERA Tier 3 QL etonogestrel-ethinyl estradiol Tier 1 etonogestrel-ethinyl estradiol ACA NUVARING Tier 3 COPPER CONTRACEPTIVES - IUD PARAGARD INTRAUTERINE COP LA EMERGENCY CONTRACEPTIVES ELLA ACA QL levonorgestrel (emergency oc) ACA PROGESTIN CONTRACEPTIVES - IMPLANTS NEXPLANON LA PROGESTIN CONTRACEPTIVES - INJECTABLE DEPO-PROVERA CONTRACEPTIV Tier 3 DEPO-SUBQ PROVERA 104 Tier 3 medroxyprogesterone acetate ACA (contraceptive) PROGESTIN CONTRACEPTIVES - IUD KYLEENA LA LILETTA LA MIRENA LA SKYLA LA PROGESTIN CONTRACEPTIVES - ORAL norethindrone (contraceptive) .35mg Tier 1 norethindrone (contraceptive) .35mg ACA SLYND Tier 3

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 48 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits CORTICOSTEROIDS GLUCOCORTICOSTEROIDS budesonide cpep Tier 1 budesonide tb24 Tier 1 QL CORTEF Tier 3 DEPO-MEDROL LA dexamethasone elix Tier 1 dexamethasone soln Tier 1 dexamethasone tabs Tier 1 dexamethasone tbpk 1.5mg Tier 1 DEXAMETHASONE TBPK 1.5mg Tier 1 DEXAMETHASONE INTENSOL Tier 1 dexamethasone sodium phosphate Tier 1 4mg/ml, 10mg/ml, 20mg/5ml, 100mg/10ml, 120mg/30ml dexamethasone sodium phosphate LA 10mg/ml EMFLAZA Tier 4 SP, PA ENTOCORT EC Tier 3 hydrocortisone Tier 1 KENALOG-10 LA MEDROL Tier 3 MEDROL DOSEPAK Tier 3 methylprednisolone Tier 1 METHYLPREDNISOLONE ACETAT LA methylprednisolone acetate LA methylprednisolone sod succ LA MILLIPRED Tier 1 ORAPRED ODT Tier 3 ORTIKOS Tier 3 QL PEDIAPRED Tier 3 prednisolone Tier 1 prednisolone sodium phosphate Tier 1 prednisone Tier 1 PREDNISONE INTENSOL Tier 1 SOLU-CORTEF LA SOLU-MEDROL 2gm, 1000mg Tier 3 SOLU-MEDROL 40mg, 125mg LA TRIAMCINOLONE ACETONIDE LA UCERIS TB24 Tier 3 QL MINERALOCORTICOIDS fludrocortisone acetate Tier 1

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 49 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits COUGH/COLD/ALLERGY ANTITUSSIVES benzonatate Tier 1 hydrocodone w/ Tier 1 TESSALON PERLES Tier 3 COUGH/COLD/ALLERGY COMBINATIONS hydrocodone polistirex-chlorpheniramine Tier 1 polistirex promethazine & Tier 1 promethazine w/codeine Tier 1 promethazine-dm Tier 1 promethazine-phenylephrine-codeine Tier 1 pseudoephed-bromphen-dm Tier 1 TUSSICAPS Tier 3 TUXARIN ER Tier 3 QL TUZISTRA XR Tier 3 MISC. RESPIRATORY INHALANTS HYPERSAL Tier 3 sodium chloride (inhalant) Tier 1 MUCOLYTICS acetylcysteine Tier 1 DERMATOLOGICALS ACNE PRODUCTS ABSORICA Tier 3 ABSORICA LD Tier 3 ACZONE Tier 3 adapalene 0.3% Tier 1 ALTRENO Tier 3 AZELEX Tier 2 BENZACLIN Tier 3 BENZACLIN WITH PUMP Tier 3 BENZAMYCIN Tier 3 benzoyl peroxide-erythromycin Tier 1 clindamycin phosphate (topical) Tier 1 clindamycin phosphate-benzoyl peroxide Tier 1 clindamycin phosphate-benzoyl peroxide Tier 1 (refrigerate) clindamycin phosphate-tretinoin Tier 1 dapsone (topical) 5% Tier 3 dapsone (topical) 7.5% Tier 1 EPIDUO FORTE Tier 3 erythromycin (acne aid) Tier 1 EVOCLIN Tier 3 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 50 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits isotretinoin Tier 1 KLARON Tier 3 PA ONEXTON Tier 3 sulfacetamide sodium (acne) Tier 1 tretinoin Tier 1 ANTI-INFLAMMATORY AGENTS - TOPICAL diclofenac epolamine Tier 1 diclofenac sodium (topical) Tier 1 ANTIBIOTICS - TOPICAL ALTABAX Tier 3 CENTANY Tier 3 gentamicin sulfate (topical) Tier 1 mupirocin Tier 1 mupirocin calcium (topical) Tier 1 NEO-SYNALAR Tier 3 ANTIFUNGALS - TOPICAL ciclopirox gel Tier 1 QL ciclopirox sham; soln Tier 1 ciclopirox olamine Tier 1 clotrimazole (topical) Tier 1 clotrimazole w/ betamethasone Tier 1 econazole nitrate Tier 1 ECOZA Tier 3 ERTACZO Tier 3 PA JUBLIA Tier 3 PA KERYDIN Tier 3 PA ketoconazole (topical) Tier 1 LOPROX Tier 3 LOPROX SHAMPOO Tier 3 LUZU Tier 3 PA MENTAX Tier 3 QL naftifine hcl Tier 1 NAFTIN Tier 3 QL nystatin (topical) Tier 1 nystatin-triamcinolone Tier 1 oxiconazole nitrate Tier 1 QL OXISTAT CREA Tier 3 QL OXISTAT LOTN Tier 3 tavaborole Tier 3 PA XOLEGEL Tier 3 ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL AMELUZ Tier 3 CARAC Tier 3 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 51 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits diclofenac sodium (actinic keratoses) Tier 1 QL EFUDEX Tier 3 FLUOROPLEX Tier 3 fluorouracil (topical) Tier 1 KLISYRI Tier 3 PA LEVULAN KERASTICK Tier 3 PANRETIN Tier 3 PA TARGRETIN GEL Tier 4 SP, PA VALCHLOR Tier 4 SP, PA ANTIPRURITICS - TOPICAL doxepin hcl (antipruritic) Tier 1 PA, QL PRUDOXIN Tier 3 PA, QL ZONALON Tier 3 PA, QL ANTIPSORIATICS acitretin Tier 1 calcipotriene Tier 1 QL calcitriol (topical) Tier 1 COSENTYX 75mg/0.5ml, 150mg/ml Tier 2 SP, ST, QL COSENTYX 150mg/ml Tier 2 SP, PA, QL COSENTYX SENSOREADY PEN Tier 2 SP, ST, QL DOVONEX Tier 3 QL methoxsalen rapid Tier 1 SKYRIZI Tier 2 SP, PA, QL SKYRIZI PEN Tier 2 SP, PA, QL SORIATANE Tier 3 SORILUX Tier 3 QL STELARA SOLN 45mg/0.5ml Tier 2 SP, PA, QL STELARA SOSY Tier 2 SP, PA, QL tazarotene Tier 1 TAZORAC Tier 3 TREMFYA Tier 2 SP, PA, QL VECTICAL Tier 3 ANTISEBORRHEIC PRODUCTS selenium sulfide Tier 1 ANTIVIRALS - TOPICAL acyclovir topical Tier 1 QL DENAVIR Tier 3 PA XERESE Tier 3 PA, QL BURN PRODUCTS SILVADENE Tier 3 silver sulfadiazine Tier 1 SULFAMYLON Tier 3

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 52 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits CORTICOSTEROIDS - TOPICAL alclometasone dipropionate Tier 1 amcinonide Tier 1 QL APEXICON E Tier 3 PA betamethasone dipropionate (topical) Tier 1 crea; lotn betamethasone dipropionate (topical) oint Tier 1 QL betamethasone dipropionate augmented Tier 1 betamethasone valerate Tier 1 BRYHALI Tier 3 QL calcipotriene-betamethasone dipropionate Tier 1 QL CAPEX Tier 3 clobetasol propionate crea; foam; gel; Tier 1 liqd; lotn; sham; soln clobetasol propionate oint Tier 1 QL clobetasol propionate emollient base Tier 1 clobetasol propionate emulsion Tier 1 CLOBEX Tier 3 clocortolone pivalate Tier 1 CORDRAN Tier 3 PA CUTIVATE Tier 3 DERMA-SMOOTHE/FS BODY Tier 3 DERMA-SMOOTHE/FS SCALP Tier 3 desonide Tier 1 DESOWEN Tier 3 desoximetasone crea Tier 1 QL desoximetasone gel Tier 1 QL desoximetasone oint .05% Tier 1 desoximetasone oint .25% Tier 1 QL diflorasone diacetate Tier 1 DIPROLENE Tier 3 DIPROLENE AF Tier 3 DUOBRII Tier 3 QL ENSTILAR Tier 3 PA EPIFOAM Tier 3 fluocinolone acetonide Tier 1 fluocinonide crea .1% Tier 1 QL fluocinonide crea .05% Tier 1 fluocinonide gel Tier 1 fluocinonide oint Tier 1 fluocinonide soln Tier 1 fluocinonide emulsified base Tier 1 flurandrenolide Tier 1 PA fluticasone propionate Tier 1 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 53 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits halobetasol propionate Tier 1 HALOG Tier 3 QL hydrocortisone (topical) Tier 1 hydrocortisone butyrate crea Tier 1 QL hydrocortisone butyrate oint; soln Tier 1 hydrocortisone valerate Tier 1 IMPOYZ Tier 3 QL KENALOG Tier 3 LUXIQ Tier 3 mometasone furoate Tier 1 OLUX Tier 3 OLUX-E Tier 3 PANDEL Tier 3 PRAMOSONE Tier 3 prednicarbate Tier 1 PSORCON Tier 3 SYNALAR Tier 3 TACLONEX Tier 3 QL TEMOVATE CREA Tier 3 TEMOVATE OINT Tier 3 QL TOPICORT CREA Tier 3 QL TOPICORT GEL Tier 3 QL TOPICORT OINT .05% Tier 3 TOPICORT OINT .25% Tier 3 QL triamcinolone acetonide (topical) Tier 1 TRIDESILON Tier 3 VANOS Tier 3 QL ECZEMA AGENTS DUPIXENT Tier 4 SP, PA EMOLLIENTS lactic acid (ammonium lactate) Tier 1 ENZYMES - TOPICAL SANTYL Tier 3 QL IMMUNOMODULATING AGENTS - TOPICAL imiquimod 3.75% Tier 1 PA imiquimod 5% Tier 1 ZYCLARA Tier 3 PA ZYCLARA PUMP Tier 3 PA IMMUNOSUPPRESSIVE AGENTS - TOPICAL ELIDEL Tier 3 ST, QL pimecrolimus Tier 1 ST, QL PROTOPIC Tier 3 ST tacrolimus (topical) Tier 1 ST PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 54 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits KERATOLYTIC/ANTIMITOTIC AGENTS CONDYLOX Tier 3 podofilox Tier 1 QL LOCAL ANESTHETICS - TOPICAL ANACAINE Tier 3 lidocaine oint Tier 1 QL lidocaine ptch Tier 1 lidocaine hcl Tier 1 lidocaine-prilocaine Tier 1 ZTLIDO Tier 2 MISC. TOPICAL DRYSOL Tier 2 PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL EUCRISA Tier 3 ST PROTECTIVES AGAINST UV RADIATION SCENESSE LA SP, PA ROSACEA AGENTS azelaic acid Tier 1 doxycycline (rosacea) Tier 3 PA FINACEA Tier 3 ivermectin (rosacea) Tier 1 PA METROCREAM Tier 3 METROGEL Tier 3 metronidazole (topical) crea Tier 1 metronidazole (topical) gel 1% Tier 1 metronidazole (topical) gel .75% Tier 1 QL metronidazole (topical) lotn Tier 1 MIRVASO Tier 3 PA NORITATE Tier 3 PA ORACEA Tier 3 PA RHOFADE Tier 3 PA SCABICIDES & PEDICULICIDES ivermectin (pediculicide) Tier 1 lindane Tier 1 malathion Tier 1 NATROBA Tier 3 OVIDE Tier 3 permethrin Tier 1 QL spinosad Tier 1 WOUND CARE PRODUCTS ARIDA Tier 3 AZADROX Tier 3

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 55 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits BASADROX Tier 3 COLLATYL Tier 3 NORMLGEL AG Tier 3 PROTYL AG Tier 3 REGRANEX Tier 3 PA, QL SILVRSTAT WOUND DRESSING Tier 3 SOLOX Tier 3 DIAGNOSTIC PRODUCTS DIAGNOSTIC DRUGS THYROGEN LA SP, PA DIAGNOSTIC TESTS ACCU-CHEK ACTIVE STRIPS Tier 1 ACCU-CHEK ADVANTAGE STRIP Tier 1 ACCU-CHEK AVIVA STRP Tier 1 ACCU-CHEK AVIVA PLUS STRP Tier 1 ACCU-CHEK COMFORT CURVE T Tier 1 ACCU-CHEK COMPACT PLUS Tier 1 ACCU-CHEK COMPACT TEST DR Tier 1 ACCU-CHEK GUIDE STRP Tier 1 ACCU-CHEK SMARTVIEW STRIP Tier 1 NON- ACCU-CHEK/ONETOUCH TEST Tier 3 STRIPS DISK; STRP ONE TOUCH VERIO TEST STRI Tier 1 ONETOUCH ULTRA BLUE Tier 1 POGO AUTOMATIC TEST CARTR Tier 3 DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS DIETARY MANAGEMENT PRODUCTS folic acid-pyridoxine-cyanocobalamin Tier 1 DIGESTIVE AIDS DIGESTIVE ENZYMES CREON Tier 2 PANCREAZE Tier 3 ST PERTZYE Tier 3 PERTZYE Tier 3 ST SUCRAID Tier 4 SP, PA VIOKACE Tier 2 ZENPEP Tier 2 DIURETICS CARBONIC ANHYDRASE INHIBITORS acetazolamide Tier 1 KEVEYIS Tier 4 SP, PA methazolamide Tier 1

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 56 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits DIURETIC COMBINATIONS ALDACTAZIDE Tier 3 amiloride & hydrochlorothiazide Tier 1 MAXZIDE Tier 3 MAXZIDE-25 Tier 3 spironolactone & hydrochlorothiazide Tier 1 triamterene & hydrochlorothiazide Tier 1 LOOP DIURETICS bumetanide Tier 1 EDECRIN Tier 3 PA ethacrynic acid Tier 3 PA furosemide Tier 1 LASIX Tier 3 torsemide Tier 1 POTASSIUM SPARING DIURETICS ALDACTONE Tier 3 amiloride hcl Tier 1 CAROSPIR Tier 3 PA DYRENIUM Tier 3 PA spironolactone Tier 1 THIAZIDES AND THIAZIDE-LIKE DIURETICS chlorthalidone Tier 1 DIURIL Tier 3 hydrochlorothiazide Tier 1 indapamide Tier 1 metolazone Tier 1 ENDOCRINE AND METABOLIC AGENTS - MISC. ADRENAL STEROID INHIBITORS ISTURISA Tier 4 SP, PA BONE DENSITY REGULATORS ACTONEL Tier 3 QL alendronate sodium Tier 1 QL ATELVIA Tier 3 QL BINOSTO Tier 3 QL BONIVA Tier 3 QL calcitonin (salmon) 200unit/act Tier 1 QL calcitonin (salmon) 200unit/ml LA EVENITY Tier 4 SP, PA FOSAMAX Tier 3 QL FOSAMAX PLUS D Tier 3 QL ibandronate sodium soln LA ibandronate sodium tabs Tier 1 QL MIACALCIN LA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 57 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits NATPARA LA SP, PA PAMIDRONATE DISODIUM 6mg/ml LA pamidronate disodium 30mg/10ml, LA 90mg/10ml PROLIA LA SP, QL RECLAST LA SP, PA risedronate sodium tabs 5mg, 35mg, Tier 1 QL 150mg risedronate sodium tabs 30mg Tier 1 QL risedronate sodium tbec Tier 1 QL TYMLOS Tier 4 SP, PA XGEVA LA SP, PA zoledronic acid conc LA SP ZOLEDRONIC ACID SOLN 4mg/100ml LA SP, PA zoledronic acid soln 4mg/100ml, LA SP 5mg/100ml CORTICOTROPIN ACTHAR LA SP, PA GNRH/LHRH ANTAGONISTS ORILISSA Tier 3 PA GROWTH HORMONE RECEPTOR ANTAGONISTS SOMAVERT Tier 4 SP, PA; Non-Preferred GROWTH HORMONE RELEASING HORMONES (GHRH) EGRIFTA SV Tier 4 SP, PA GROWTH HORMONES GENOTROPIN Tier 2 SP, PA; GH GENOTROPIN MINIQUICK 2mg Tier 2 SP, PA GENOTROPIN MINIQUICK .2mg, .4mg, Tier 2 SP, PA; GH .6mg, .8mg, 1mg, 1.2mg, 1.4mg, 1.6mg, 1.8mg HORMONE RECEPTOR MODULATORS EVISTA Tier 3 OSPHENA Tier 3 PA raloxifene hcl Tier 1 INSULIN-LIKE GROWTH FACTOR RECEPTOR INHIBITORS TEPEZZA LA SP, PA INSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS) INCRELEX LA SP, PA; GH LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS FENSOLVI LA SP LUPANETA PACK Tier 4 SP, PA LUPRON DEPOT-PED (1-MONTH LA SP LUPRON DEPOT-PED (3-MONTH LA SP PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 58 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits SUPPRELIN LA LA SP, PA SYNAREL Tier 2 PA TRIPTODUR LA SP, PA METABOLIC MODIFIERS ALDURAZYME LA SP, PA BUPHENYL Tier 4 SP, PA calcitriol caps Tier 1 calcitriol soln 1mcg/ml Tier 1 calcitriol soln 1mcg/ml LA CARBAGLU Tier 4 SP, PA cinacalcet hcl Tier 1 SP CRYSVITA LA SP, PA doxercalciferol caps Tier 1 doxercalciferol soln LA ELAPRASE LA SP, PA FABRAZYME LA SP, PA GALAFOLD Tier 4 SP, PA HECTOROL LA PA KANUMA LA SP, PA KUVAN Tier 4 SP, PA LUMIZYME LA SP, PA MEPSEVII LA SP, PA MYALEPT Tier 4 SP, PA NAGLAZYME LA SP, PA nitisinone Tier 1 SP NITYR Tier 4 SP, PA NULIBRY LA SP, PA ORFADIN Tier 4 SP, PA paricalcitol caps 1mcg, 2mcg Tier 1 QL paricalcitol caps 4mcg Tier 1 paricalcitol soln LA PARSABIV LA SP RAVICTI Tier 4 SP, PA RAYALDEE Tier 3 PA ROCALTROL Tier 3 sapropterin dihydrochloride Tier 1 SP, PA SENSIPAR Tier 4 SP sodium phenylbutyrate Tier 1 SP, PA STRENSIQ LA SP, PA VIMIZIM LA SP, PA XURIDEN Tier 4 SP, PA ZEMPLAR CAPS Tier 3 QL ZEMPLAR SOLN LA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 59 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits POSTERIOR PITUITARY HORMONES DDAVP SOLN 4mcg/ml Tier 3 DDAVP SOLN 4mcg/ml Tier 4 DDAVP TABS Tier 3 DESMOPRESSIN ACETATE SOLN 1.5mg/ml Tier 4 SP desmopressin acetate soln 4mcg/ml Tier 1 desmopressin acetate tabs Tier 1 desmopressin acetate spray Tier 1 desmopressin acetate spray refrigerated Tier 1 STIMATE Tier 4 SP PROGESTERONE RECEPTOR ANTAGONISTS MIFEPREX Tier 3 QL PROLACTIN INHIBITORS cabergoline Tier 1 SOMATOSTATIC AGENTS MYCAPSSA Tier 4 SP, PA octreotide acetate LA SP SANDOSTATIN Tier 4 SP; Non-Preferred SANDOSTATIN LAR DEPOT LA SP, PA; Non-Preferred SIGNIFOR LA SP, PA; Non-Preferred SIGNIFOR LAR LA SP, PA; Non-Preferred SOMATULINE DEPOT LA SP, PA; Preferred VASOPRESSIN RECEPTOR ANTAGONISTS JYNARQUE Tier 4 SP, PA SAMSCA Tier 4 SP, PA tolvaptan Tier 1 SP, PA VAPRISOL LA ESTROGENS ESTROGEN COMBINATIONS ACTIVELLA Tier 3 ANGELIQ Tier 3 BIJUVA Tier 3 CLIMARA PRO Tier 3 COMBIPATCH Tier 2 DUAVEE Tier 3 estradiol & norethindrone acetate Tier 1 FEMHRT Tier 3 norethindrone acetate-ethinyl estradiol Tier 1 ORIAHNN Tier 3 PA PREFEST Tier 3 PREMPHASE Tier 2 PREMPRO Tier 2

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 60 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits ESTROGENS ALORA Tier 3 CLIMARA Tier 3 DELESTROGEN LA PA DEPO-ESTRADIOL LA DIVIGEL Tier 3 ELESTRIN Tier 3 ESTRACE TABS Tier 3 estradiol Tier 1 estradiol valerate LA ESTROGEL Tier 3 EVAMIST Tier 3 MENEST Tier 2 MENOSTAR Tier 3 MINIVELLE Tier 3 PREMARIN TABS Tier 2 QL VIVELLE-DOT Tier 3 FLUOROQUINOLONES FLUOROQUINOLONES BAXDELA SOLR LA PA BAXDELA TABS Tier 3 PA CIPRO Tier 3 ciprofloxacin hcl Tier 1 ciprofloxacin in d5w LA levofloxacin soln 25mg/ml Tier 1 levofloxacin soln 25mg/ml LA levofloxacin tabs Tier 1 levofloxacin in d5w LA moxifloxacin hcl Tier 1 moxifloxacin hcl in sodium chloride LA MOXIFLOXACIN HYDROCHLORID LA ofloxacin Tier 1 GASTROINTESTINAL AGENTS - MISC. 5-HT4 RECEPTOR AGONISTS MOTEGRITY Tier 3 PA AGENTS FOR CHRONIC IDIOPATHIC CONSTIPATION (CIC) TRULANCE Tier 3 QL BILE ACID SYNTHESIS DISORDER AGENTS CHOLBAM Tier 4 SP, PA FARNESOID X RECEPTOR (FXR) AGONISTS OCALIVA Tier 4 SP, PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 61 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits GALLSTONE SOLUBILIZING AGENTS CHENODAL Tier 4 SP, PA URSO 250 Tier 3 URSO FORTE Tier 3 ursodiol Tier 1 GASTROINTESTINAL ANTIALLERGY AGENTS cromolyn sodium (mastocytosis) Tier 1 GASTROCROM Tier 3 GASTROINTESTINAL CHLORIDE CHANNEL ACTIVATORS AMITIZA Tier 3 QL lubiprostone Tier 1 QL GASTROINTESTINAL STIMULANTS metoclopramide hcl soln 5mg/5ml, Tier 1 10mg/10ml metoclopramide hcl soln 5mg/ml LA metoclopramide hcl tabs Tier 1 metoclopramide hcl tbdp Tier 1 PA METOCLOPRAMIDE ODT Tier 1 PA REGLAN Tier 3 INFLAMMATORY BOWEL AGENTS AVSOLA LA SP, PA AZULFIDINE Tier 3 AZULFIDINE EN-TABS Tier 3 balsalazide disodium Tier 1 CANASA Tier 3 DIPENTUM Tier 3 ENTYVIO LA SP, PA INFLECTRA LA SP, PA mesalamine cp24 Tier 1 mesalamine cpdr Tier 1 QL mesalamine enem Tier 1 mesalamine supp Tier 1 mesalamine tbec 1.2gm Tier 1 mesalamine tbec 800mg Tier 1 mesalamine w/ cleanser Tier 1 RENFLEXIS LA SP, PA ROWASA Tier 3 SFROWASA Tier 3 STELARA SOLN 130mg/26ml LA SP, PA; MB sulfasalazine Tier 1 INTESTINAL ACIDIFIERS lactulose (encephalopathy) Tier 1

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 62 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits IRRITABLE BOWEL SYNDROME (IBS) AGENTS alosetron hcl Tier 1 PA, QL LINZESS Tier 2 QL LOTRONEX Tier 3 PA, QL VIBERZI Tier 3 PA PERIPHERAL OPIOID RECEPTOR ANTAGONISTS MOVANTIK Tier 3 PA PHOSPHATE BINDER AGENTS AURYXIA Tier 3 calcium acetate (phosphate binder) Tier 1 FOSRENOL Tier 3 lanthanum carbonate Tier 1 PHOSLYRA Tier 3 RENAGEL Tier 3 RENVELA Tier 3 sevelamer carbonate Tier 1 sevelamer hcl Tier 1 VELPHORO Tier 3 PA TRYPTOPHAN HYDROXYLASE INHIBITORS XERMELO Tier 4 SP, PA GENITOURINARY AGENTS - MISCELLANEOUS ALKALINIZERS ORACIT Tier 3 potassium citrate (alkalinizer) Tier 1 potassium citrate-citric acid Tier 1 sodium citrate & citric acid Tier 1 UROCIT-K 5 Tier 3 UROCIT-K 10 Tier 3 UROCIT-K 15 Tier 3 CYSTINOSIS AGENTS CYSTAGON Tier 4 SP, PA GENITOURINARY IRRIGANTS acetic acid LA neomycin/polymyxin b gu LA sodium chloride (gu irrigant) LA HYPEROXALURIA AGENTS OXLUMO LA SP, PA INTERSTITIAL CYSTITIS AGENTS ELMIRON Tier 2 QL PROSTATIC HYPERTROPHY AGENTS alfuzosin hcl Tier 1 QL AVODART Tier 3 AL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 63 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits CARDURA XL Tier 3 dutasteride Tier 1 AL dutasteride-tamsulosin hcl Tier 1 GENDER finasteride Tier 1 AL FLOMAX Tier 3 JALYN Tier 3 GENDER PROSCAR Tier 3 AL RAPAFLO Tier 3 silodosin Tier 1 tamsulosin hcl Tier 1 UROXATRAL Tier 3 QL URINARY STONE AGENTS LITHOSTAT Tier 3 THIOLA Tier 4 SP, PA THIOLA EC Tier 4 SP, PA tiopronin Tier 4 SP, PA GOUT AGENTS GOUT AGENT COMBINATIONS colchicine w/ probenecid Tier 1 GOUT AGENTS allopurinol Tier 1 colchicine Tier 1 COLCRYS Tier 2 febuxostat Tier 1 KRYSTEXXA LA SP, PA MITIGARE Tier 3 ZYLOPRIM Tier 3 URICOSURICS probenecid Tier 1 HEMATOLOGICAL AGENTS - MISC. ANTIHEMOPHILIC PRODUCTS ADVATE LA SP, PA ADYNOVATE LA SP, PA; Preferred AFSTYLA LA SP, PA ALPHANATE LA SP, PA ALPHANINE SD LA SP, PA ALPROLIX LA SP, PA BENEFIX LA SP, PA COAGADEX LA SP, PA CORIFACT LA SP, PA ELOCTATE LA SP, PA; Non-Preferred ESPEROCT LA SP, PA FEIBA LA SP, PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 64 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits FIBRYGA LA SP, PA HEMLIBRA LA SP, PA HEMOFIL M LA SP, PA HUMATE-P LA SP, PA IDELVION LA SP, PA IXINITY LA SP, PA JIVI LA SP, PA; Preferred KOATE LA SP, PA KOATE-DVI LA SP, PA KOGENATE FS LA SP, PA; Preferred KOVALTRY LA SP, PA; Preferred MONONINE LA SP, PA NOVOEIGHT LA SP, PA; Preferred NOVOSEVEN RT LA SP, PA NUWIQ LA SP, PA; Non-Preferred OBIZUR LA SP, PA PROFILNINE LA SP, PA REBINYN LA SP, PA RECOMBINATE LA SP, PA RIASTAP LA SP, PA RIXUBIS LA SP, PA TRETTEN LA SP, PA VONVENDI LA SP, PA WILATE LA SP, PA XYNTHA LA SP, PA XYNTHA SOLOFUSE LA SP, PA BRADYKININ B2 RECEPTOR ANTAGONISTS FIRAZYR Tier 2 SP, PA icatibant acetate Tier 1 SP, PA COMPLEMENT INHIBITORS BERINERT LA SP, PA CINRYZE LA SP, PA HAEGARDA LA SP, PA RUCONEST LA SP, PA SOLIRIS LA SP, PA HEMATORHEOLOGIC AGENTS pentoxifylline Tier 1 HUMAN PROTEIN C CEPROTIN LA SP, PA PLASMA KALLIKREIN INHIBITORS KALBITOR LA SP, PA ORLADEYO Tier 4 SP, PA TAKHZYRO LA SP, PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 65 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits PLATELET AGGREGATION INHIBITORS AGRYLIN Tier 3 anagrelide hcl Tier 1 aspirin-dipyridamole Tier 1 BRILINTA Tier 2 cilostazol Tier 1 clopidogrel bisulfate 75mg Tier 1 clopidogrel bisulfate 300mg Tier 1 dipyridamole Tier 1 EFFIENT Tier 3 PLAVIX Tier 3 prasugrel hcl Tier 1 ZONTIVITY Tier 3 THROMBOLYTIC ENZYMES CATHFLO ACTIVASE LA HEMATOPOIETIC AGENTS AGENTS FOR GAUCHER DISEASE CERDELGA Tier 4 SP, PA CEREZYME LA SP, PA; Preferred ELELYSO LA SP, PA; Non-Preferred VPRIV LA SP, PA; Non-Preferred ZAVESCA Tier 4 SP, PA AGENTS FOR SICKLE CELL DISEASE ADAKVEO LA SP, PA DROXIA Tier 2 OXBRYTA Tier 4 SP, PA SIKLOS 100mg Tier 3 PA, QL SIKLOS 1000mg Tier 3 PA COBALAMINS cyanocobalamin Tier 1 hydroxocobalamin acetate LA NASCOBAL Tier 3 PA FOLIC ACID/FOLATES folic acid soln LA folic acid tabs Tier 1 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE Tier 2 SP, PA DOPTELET Tier 4 SP, PA EPOGEN Tier 4 SP, PA LEUKINE LA SP, PA; Non-Preferred MIRCERA LA SP, PA MULPLETA Tier 4 SP, PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 66 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits NIVESTYM Tier 2 SP, QL; Preferred NPLATE LA SP, PA PROCRIT Tier 4 SP, PA PROMACTA Tier 4 SP, PA REBLOZYL LA SP, PA RETACRIT Tier 4 SP, PA ZIEXTENZO Tier 2 SP, QL HEMATOPOIETIC MIXTURES ferrous fumarate-folic acid Tier 1 MULTIGEN PLUS Tier 3 IRON FERAHEME Tier 3 FERRLECIT LA PA ferumoxytol Tier 1 INFED LA INJECTAFER LA PA sodium ferric gluconate complex in sucrose LA VENOFER LA STEM CELL MOBILIZERS MOZOBIL LA SP, PA HEMOSTATICS HEMOSTATICS - SYSTEMIC AMICAR Tier 3 aminocaproic acid Tier 1 LYSTEDA Tier 3 tranexamic acid soln LA PA tranexamic acid tabs Tier 1 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS BARBITURATE HYPNOTICS phenobarbital Tier 1 NON-BARBITURATE HYPNOTICS DORAL Tier 3 PA EDLUAR Tier 3 PA estazolam Tier 1 eszopiclone Tier 1 flurazepam hcl Tier 1 HALCION Tier 3 quazepam Tier 1 PA RESTORIL Tier 3 temazepam Tier 1 triazolam Tier 1 zaleplon Tier 1

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 67 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits zolpidem tartrate Tier 1 OREXIN RECEPTOR ANTAGONISTS BELSOMRA Tier 3 QL SELECTIVE MELATONIN RECEPTOR AGONISTS HETLIOZ Tier 4 SP, PA HETLIOZ LQ Tier 4 SP, PA ramelteon Tier 1 LAXATIVES LAXATIVE COMBINATIONS peg 3350-kcl-sod bicarb-sod chloride-sod ACA AL sulfate peg 3350-potassium chloride-sod ACA AL bicarbonate-sod chloride PLENVU Tier 3 SUPREP BOWEL PREP KIT Tier 2 SUTAB Tier 2 QL LAXATIVES - MISCELLANEOUS KRISTALOSE Tier 3 lactulose Tier 1 LOCAL ANESTHETICS-PARENTERAL LOCAL ANESTHETICS - AMIDES lidocaine hcl (local anesth.) jtaj Tier 1 lidocaine hcl (local anesth.) soln .5% Tier 1 lidocaine hcl (local anesth.) soln .5%, 1%, LA 1.5%, 2%, 4% LIDOCAINE HYDROCHLORIDE LA XYLOCAINE LA XYLOCAINE-MPF LA ZINGO Tier 3 MACROLIDES AZITHROMYCIN azithromycin pack; susr; tabs Tier 1 azithromycin solr LA ZITHROMAX PACK; SUSR; TABS Tier 3 ZITHROMAX SOLR LA PA ZITHROMAX TRI-PAK Tier 3 ZITHROMAX Z-PAK Tier 3 CLARITHROMYCIN clarithromycin Tier 1 ERYTHROMYCINS E.E.S. GRANULES Tier 3 ERYPED 200 Tier 3

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 68 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits ERYPED 400 Tier 3 ERYTHROCIN LACTOBIONATE LA erythromycin base Tier 1 erythromycin ethylsuccinate Tier 1 erythromycin stearate Tier 1 FIDAXOMICIN DIFICID Tier 3 PA MEDICAL DEVICES AND SUPPLIES CONTRACEPTIVES CAYA ACA FC2 FEMALE CONDOM ACA WIDE-SEAL SILICONE DIAPHR ACA DIABETIC SUPPLIES ACCU-CHEK AVIVA DEVI Tier 1 ACCU-CHEK AVIVA PLUS KIT Tier 1 ACCU-CHEK COMPACT PLUS CA Tier 1 ACCU-CHEK FASTCLIX LANCET KIT Tier 1 ACCU-CHEK FASTCLIX LANCET MISC Tier 1 QL ACCU-CHEK GUIDE KIT Tier 1 ACCU-CHEK GUIDE ME Tier 1 ACCU-CHEK MULTICLIX LANCE Tier 1 QL ACCU-CHEK NANO SMARTVIEW Tier 1 ACCU-CHEK SAFE-T-PRO LANC Tier 1 QL ACCU-CHEK SAFE-T-PRO PLUS Tier 1 QL ACCU-CHEK SOFTCLIX LANCET Tier 1 QL ADVANCE INTUITION BLOOD G Tier 3 ADVANCE MICRO-DRAW METER Tier 3 ADVANCED MOBILE LANCET 30 Tier 2 QL ADVOCATE BLOOD GLUCOSE MO Tier 3 ADVOCATE LANCETS Tier 2 QL ADVOCATE LANCETS 30G Tier 2 QL ADVOCATE REDI-CODE Tier 3 ADVOCATE REDI-CODE+ BLOOD Tier 3 ADVOCATE SAFETY LANCETS 2 Tier 2 QL AGAMATRIX AMP NO CODE ADV Tier 3 AGAMATRIX PRESTO PRO METE Tier 3 AGAMATRIX ULTRA-THIN LANC Tier 2 QL AIMSCO TWIST LANCETS 32G Tier 2 QL AIMSCO TWIST LANCETS 33G Tier 2 QL AQUALANCE LANCETS UL TRA Tier 2 QL ASSURE 3 METER Tier 3 ASSURE 4 BLOOD GLUCOSE ME Tier 3 ASSURE COMFORT LANCETS UL Tier 2 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 69 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits ASSURE HAEMOLANCE PLUS HI Tier 2 QL ASSURE HAEMOLANCE PLUS LO Tier 2 QL ASSURE HAEMOLANCE PLUS MI Tier 2 QL ASSURE HAEMOLANCE PLUS NO Tier 2 QL ASSURE HAEMOLANCE PLUS PE Tier 2 QL ASSURE LANCE LANCETS Tier 2 QL ASSURE LANCE LANCETS 21G Tier 2 QL ASSURE LANCE PLUS SAFETY Tier 2 QL ASSURE LANCE SAFETY LANCE Tier 2 QL ASSURE PLATINUM BLOOD GLU Tier 3 ASSURE PRISM MULTI BLOOD Tier 3 ASSURE PRO BLOOD GLUCOSE Tier 3 AURORA LANCET SUPER THIN Tier 2 QL AURORA LANCET THIN 23G Tier 2 QL AUTOLET PLATFORMS Tier 2 BD LANCET ULTRAFINE 30G Tier 2 QL BD LANCET ULTRAFINE 33G Tier 2 QL BD MICROTAINER LANCETS Tier 2 QL BLULINK BLOOD GLUCOSE MON Tier 3 CAREONE LANCET SUPER THIN Tier 2 QL CAREONE LANCET THIN Tier 2 QL CARESENS LANCETS Tier 2 QL CARESENS N GLUCOSE MONITO Tier 3 CARESENS N VOICE BLOOD GL Tier 3 CARETOUCH SAFETY LANCETS/ Tier 2 QL CARETOUCH TWIST LANCETS 2 Tier 2 QL CARETOUCH TWIST LANCETS 3 Tier 2 QL CLEANLET LANCETS 28G Tier 2 QL CLEVER CHEK AUTO CODE VOI Tier 3 CLEVER CHEK AUTO-CODE BLO Tier 3 CLEVER CHEK LANCETS ULTRA Tier 2 QL CLEVER CHOICE AUTO-CODE P Tier 3 CLEVER CHOICE COMFORT EZ Tier 2 QL CLEVER CHOICE MINI BLOOD Tier 3 CLEVER CHOICE TALK BLOOD Tier 3 COAGUCHEK LANCETS Tier 1 QL COMFORT ASSURED LANCETS M Tier 2 QL COMFORT ASSURED LANCETS S Tier 2 QL COMFORT LANCETS Tier 2 QL COMFORT TOUCH LANCETS ULT Tier 2 QL COMFORT TOUCH PLUS SAFETY Tier 2 QL CONTOUR BLOOD GLUCOSE MON Tier 3 CONTOUR NEXT ONE BLOOD GL Tier 3

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 70 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits COOL BLOOD GLUCOSE MONITO Tier 3 COUPON ONE TOUCH ULTRA MI Tier 1 CVS LANCETS 21G Tier 2 QL CVS LANCETS MICRO THIN 33 Tier 2 QL CVS LANCETS MICRO-THIN 33 Tier 2 QL CVS LANCETS ORIGINAL Tier 2 QL CVS LANCETS THIN 26G Tier 2 QL CVS LANCETS ULTRA THIN 30 Tier 2 QL CVS LANCETS ULTRA-THIN 30 Tier 2 QL DIATHRIVE BLOOD GLUCOSE M Tier 3 DIATHRIVE LANCETS Tier 2 QL DIATHRIVE LANCETS ULTRA T Tier 2 QL DIATHRIVE+ BLOOD GLUCOSE Tier 3 DIATRUE PLUS BLOOD GLUCOS Tier 3 DROPLET LANCETS ULTRA THI Tier 2 QL DROPLET PERSONAL LANCETS Tier 2 QL DRUG MART ON-THE-GO LANCE Tier 2 QL DRUG MART UNILET LANCETS Tier 2 QL DRUG MART UNILET MICRO TH Tier 2 QL E-Z JECT LANCETS Tier 2 QL E-Z JECT LANCETS 21G Tier 2 QL E-Z JECT LANCETS COLOR Tier 2 QL E-Z JECT LANCETS SUPER TH Tier 2 QL E-Z JECT LANCETS THIN 26G Tier 2 QL E-ZJECT LANCETS MICRO-THI Tier 2 QL EASY COMFORT LANCETS Tier 2 QL EASY COMFORT LANCETS 30G/ Tier 2 QL EASY COMFORT LANCETS TWIS Tier 2 QL EASY PLUS II BLOOD GLUCOS Tier 3 EASY STEP BLOOD GLUCOSE M Tier 3 EASY TALK BLOOD GLUCOSE M Tier 3 EASY TOUCH LANCETS 26G/PR Tier 2 QL EASY TOUCH LANCETS 28G/PR Tier 2 QL EASY TOUCH LANCETS 30G/PR Tier 2 QL EASY TOUCH LANCETS 32G/PR Tier 2 QL EASY TOUCH LANCETS 33G/TW Tier 2 QL EASY TOUCH SAFETY LANCETS Tier 2 QL EASY TRAK BLOOD GLUCOSE M Tier 3 EASY TRAK II BLOOD GLUCOS Tier 3 EASYGLUCO Tier 3 EASYMAX NG SELF-MONITORIN Tier 3 EASYMAX V BLOOD GLUCOSE S Tier 3 ELEMENT COMPACT BLOOD GLU Tier 3

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 71 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits ELEMENT PLUS BLOOD GLUCOS Tier 3 EMBRACE BLOOD GLUCOSE MON Tier 3 EMBRACE EVO COMPACT BLOOD Tier 3 EMBRACE LANCETS ULTRA THI Tier 2 QL EMBRACE PRESSURE ACTIVATE Tier 2 QL EMBRACE PRO BLOOD GLUCOSE Tier 3 EMBRACE TALK BLOOD GLUCOS Tier 3 EQL COLOR LANCETS 21G Tier 2 QL EQL COLOR LANCETS MICRO T Tier 2 QL EQL SUPER THIN LANCETS 30 Tier 2 QL EQL THIN LANCETS 26G Tier 2 QL EVOLUTION AUTOCODE Tier 3 EZ-LETS LANCETS 21G Tier 2 QL EZ-LETS LANCETS 26G SUPER Tier 2 QL EZ-LETS LANCETS 28G ULTRA Tier 2 QL EZ-LETS LANCETS 30G Tier 2 QL FIFTY50 SAFETY SEAL LANCE Tier 2 QL FIFTY50 UNILET LANCETS 33 Tier 2 QL FINE 30 Tier 2 QL FINGERSTIX LANCETS Tier 2 QL FORA G30A BLOOD GLUCOSE M Tier 3 FORA GD20 BLOOD GLUCOSE M Tier 3 FORA GD50 BLOOD GLUCOSE M Tier 3 FORA GTEL BLOOD GLUCOSE M Tier 3 FORA LANCETS Tier 2 QL FORA PREMIUM V10 BLE BLOO Tier 3 FORA TEST N' GO VOICE BLO Tier 3 FORA V10 BLOOD GLUCOSE MO Tier 3 FORA V10/V12/D10/D20 BLOO Tier 3 FORA V12 BLOOD GLUCOSE MO Tier 3 FORA V20 BLOOD GLUCOSE MO Tier 3 FORA V30A BLOOD GLUCOSE M Tier 3 FORACARE GD40 BLOOD GLUCO Tier 3 FORACARE PREMIUM V10 BLOO Tier 3 FORACARE TEST N GO BLOOD Tier 3 FORTISCARE SELF-MONITORIN Tier 3 FORTISCARE T1 SELF-MONITO Tier 3 FREESTYLE LITE BLOOD GLUC Tier 3 FREESTYLE UNISTICK II LAN Tier 2 QL GE100 BLOOD GLUCOSE MONIT Tier 3 GENTEEL BUTTERFLY TOUCH L Tier 2 QL GENTEEL CONTACT TIPS/BLUE Tier 2 GENTEEL CONTACT TIPS/CLEA Tier 2

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 72 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits GENTEEL CONTACT TIPS/GREE Tier 2 GENTEEL CONTACT TIPS/ORAN Tier 2 GENTEEL CONTACT TIPS/RAIN Tier 2 GENTEEL CONTACT TIPS/VIOL Tier 2 GENTEEL CONTACT TIPS/YELL Tier 2 GENTEEL NOZZLES Tier 2 GENTLE-LET GP LANCETS Tier 2 QL GENTLE-LET LANCETS GENERA Tier 2 QL GENTLE-LET PLATFORMS 2.4M Tier 2 GLOBAL INJECT EASE LANCET Tier 2 QL GLUCO PERFECT 3 BLOOD GLU Tier 3 GLUCOCARD 01 BLOOD GLUCOS Tier 3 GLUCOCARD SHINE Tier 3 GLUCOCARD SHINE XL Tier 3 GLUCOCOM BLOOD GLUCOSE MO Tier 3 GLUCOCOM LANCETS 28G Tier 2 QL GLUCOCOM LANCETS 30G Tier 2 QL GLUCOCOM LANCETS 33G Tier 2 QL GNP EASY TOUCH GLUCOSE MO Tier 3 GNP LANCETS 21G Tier 2 QL GNP LANCETS THIN Tier 2 QL GNP LANCETS THIN 26G Tier 2 QL GOJJI STERILE LANCETS 30G Tier 2 QL GOODSENSE LANCETS MICRO-T Tier 2 QL GOODSENSE LANCETS ULTRA-T Tier 2 QL H-E-B INCONTROL LANCETS M Tier 2 QL H-E-B INCONTROL LANCETS S Tier 2 QL H-E-B INCONTROL LANCETS U Tier 2 QL HAEMOLANCE Tier 2 QL HAEMOLANCE LOW FLOW LANCE Tier 2 QL HAEMOLANCE PLUS Tier 2 QL HAEMOLANCE PLUS HIGH FLOW Tier 2 QL HAEMOLANCE PLUS LOW FLOW Tier 2 QL HAEMOLANCE PLUS MAX FLOW Tier 2 QL HAEMOLANCE PLUS PEDIATRIC Tier 2 QL HEALTHY ACCENTS UNILET LA Tier 2 QL HW EMBRACE PRO BLOOD GLUC Tier 3 HW EMBRACE TALK BLOOD GLU Tier 3 HY-VEE LANCETS Tier 2 QL HY-VEE THIN LANCETS Tier 2 QL IN TOUCH Tier 3 IN TOUCH STERILE LANCETS Tier 2 QL KINNEY LANCETS Tier 2 QL

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 73 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits KINNEY THIN LANCETS Tier 2 QL KROGER HEALTHPRO TWIST LA Tier 2 QL KROGER LANCETS Tier 2 QL KROGER LANCETS 21G Tier 2 QL KROGER LANCETS MICRO THIN Tier 2 QL KROGER LANCETS SUPER THIN Tier 2 QL KROGER LANCETS THIN Tier 2 QL KROGER LANCETS THIN 26G Tier 2 QL LANCET TRANSPORTER CASE Tier 2 LANCETS Tier 2 QL LANCETS MICRO THIN 33G Tier 2 QL LANCETS SUPER THIN 28G Tier 2 QL LANCETS THIN Tier 2 QL LANCETS ULTRA THIN Tier 2 QL LANCETS ULTRA THIN 30G Tier 2 QL LIBERTY BLOOD GLUCOSE MET Tier 3 LIBERTY MEDICAL LANCETS 3 Tier 2 QL LIBERTY NEXT GENERATION B Tier 3 LIFESCAN UNISTIK 2 DEEP P Tier 1 QL LIFESCAN UNISTIK II LANCE Tier 1 QL LITE TOUCH LANCETS Tier 2 QL LITETOUCH LANCETS MICRO T Tier 2 QL LIVE BETTER LANCET SUPER Tier 2 QL LIVE BETTER LANCET ULTRA Tier 2 QL LONGS LANCETS STANDARD Tier 2 QL LONGS LANCETS THIN Tier 2 QL LONGS LANCETS ULTRA THIN Tier 2 QL MEDICHOICE SAFETY LANCET Tier 2 QL MEDISENSE THIN LANCETS Tier 2 QL MEDLANCE PLUS EXTRA LANCE Tier 2 QL MEDLANCE PLUS LANCETS Tier 2 QL MEDLANCE PLUS LITE LANCET Tier 2 QL MEDLANCE PLUS SPECIAL LAN Tier 2 QL MEDLANCE PLUS SUPERLITE 3 Tier 2 QL MEDLANCE PLUS UNIVERSAL L Tier 2 QL MEDLANCE/EXTRA Tier 2 QL MEDLANCE/LITE Tier 2 QL MEDLANCE/UNIVERSAL Tier 2 QL MEIJER COLOR LANCETS UNIV Tier 2 QL MEIJER LANCETS THIN Tier 2 QL MEIJER LANCETS UNIVERSAL Tier 2 QL MICROLET LANCETS Tier 2 QL MM TWIST LANCETS Tier 2 QL

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 74 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits MONOLET LANCETS Tier 2 QL MONOLET OPD LANCETS Tier 2 QL MONOLETTOR SAFETY LANCETS Tier 2 QL MPD SAFETY LANCET 21G/1.8 Tier 2 QL MPD SAFETY LANCET 28G/1.8 Tier 2 QL MPD SAFETY LANCET 30G/1.8 Tier 2 QL MPD SAFETY LANCETS 23G/1. Tier 2 QL MYGLUCOHEALTH MGH SOFTLAN Tier 2 QL NON- ACCU-CHEK/ONETOUCH TEST Tier 2 QL STRIPS MISC NOVA MAX BLOOD GLUCOSE MO Tier 3 NOVA SAFETY LANCETS 23G Tier 2 QL NOVA SAFETY LANCETS 28G Tier 2 QL NOVA SUREFLEX LANCETS Tier 2 QL ONETOUCH CLUB LANCETS FIN Tier 1 QL ONETOUCH DELICA LANCETS F Tier 1 QL ONETOUCH DELICA PLUS LANC Tier 1 QL ONETOUCH FINEPOINT LANCET Tier 1 QL ONETOUCH SURESOFT LANCING Tier 2 ONETOUCH ULTRA 2 Tier 1 ONETOUCH ULTRA MINI Tier 1 ONETOUCH ULTRALINK SYSTEM Tier 1 ONETOUCH ULTRASOFT LANCET Tier 1 QL ONETOUCH VERIO Tier 1 ONETOUCH VERIO FLEX BLOOD Tier 1 ONETOUCH VERIO IQ BLOOD G Tier 1 ONETOUCH VERIO REFLECT Tier 1 ONETOUCH VERIO SYNC BLOOD Tier 1 OPTIUM BLOOD GLUCOSE MONI Tier 3 PC LANCETS SUPER THIN 30G Tier 2 QL PENLET II REPLACEMENT CAP Tier 2 PERFECT LANCETS 30G Tier 2 QL PERFECT PRESSURE ACTIVATE Tier 2 QL PHARMACIST CHOICE MINI BL Tier 3 PHARMACIST CHOICE ULTRA T Tier 2 QL PHARMACY COUNTER LANCETS Tier 2 QL PIP LANCETS/28G Tier 2 QL PIP LANCETS/30G Tier 2 QL POGO AUTOMATIC BLOOD GLUC Tier 3 PRECISION QID MONITOR Tier 3 PRECISION SOF-TACT MONITO Tier 3 PRECISION XTRA Tier 3 PREFERRED PLUS LANCETS CO Tier 2 QL PREFERRED PLUS LANCETS SU Tier 2 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 75 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits PREFERRED PLUS LANCETS TH Tier 2 QL PRO COMFORT LANCETS 30G Tier 2 QL PRO COMFORT LANCETS 31G Tier 2 QL PRO VOICE V8 BLOOD GLUCOS Tier 3 PRO VOICE V9 BLOOD GLUCOS Tier 3 PRODIGY AUTOCODE BLOOD GL Tier 3 PRODIGY SAFETY LANCETS Tier 2 QL PRODIGY TWIST TOP LANCETS Tier 2 QL PSS SELECT GP LANCETS Tier 2 QL PSS SELECT PLATFORMS Tier 2 PSS SELECT SAFETY LANCETS Tier 2 QL PURE COMFORT LANCETS 30G Tier 2 QL PX LANCETS MICROTHIN 33G Tier 2 QL PX LANCETS ULTRA THIN Tier 2 QL PX LANCETS ULTRA THIN 28G Tier 2 QL QC LANCETS SUPER THIN Tier 2 QL QC LANCETS ULTRA THIN Tier 2 QL QC UNILET LANCETS 28G/ULT Tier 2 QL QC UNILET LANCETS 33G/MIC Tier 2 QL QUICKTEK Tier 3 QUINTET AC BLOOD GLUCOSE Tier 3 QUINTET BLOOD GLUCOSE MON Tier 3 RA E-ZJECT LANCETS 28G Tier 2 QL RA E-ZJECT LANCETS THIN 2 Tier 2 QL RA E-ZJECT LANCETS ULTRA Tier 2 QL READYLANCE SAFETY LANCETS Tier 2 QL REALITY LANCETS Tier 2 QL REALITY TRIGGER LANCETS Tier 2 QL RELION LANCETS MICRO-THIN Tier 2 QL RELION LANCETS THIN 26G Tier 2 QL RELION LANCETS ULTRA-THIN Tier 2 QL RELION PREMIER VOICE BLOO Tier 3 RELION PRIME BLOOD GLUCOS Tier 3 RELION ULTRA THIN LANCETS Tier 2 QL RELION ULTRA THIN PLUS LA Tier 2 QL RIGHTEST GD-L500 ALTERNAT Tier 2 RIGHTEST GL300 LANCETS Tier 2 QL RIGHTEST GT333 BLOOD GLUC Tier 3 SAFE-T-LANCE LOW FLOW 25G Tier 2 QL SAFE-T-LANCE NORMAL FLOW Tier 2 QL SAFE-T-LANCE PLUS SAFETY Tier 2 QL SAFETY LANCET 30G/PRESSUR Tier 2 QL SAFETY LANCETS Tier 2 QL

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 76 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits SAFETY LANCETS 21G Tier 2 QL SAFETY LANCETS 28G Tier 2 QL SAPS HEALTH CARE TWIST TO Tier 2 QL SAPS HEALTH TWIST TOP LAN Tier 2 QL SAPSCARE TWIST TOP LANCET Tier 2 QL SB LANCETS THIN Tier 2 QL SB LANCETS ULTRA THIN Tier 2 QL SINGLE-LET Tier 2 QL SM MICRO THIN LANCETS 33G Tier 2 QL SMART SENSE COLOR LANCETS Tier 2 QL SMART SENSE STANDARD LANC Tier 2 QL SMART SENSE SUPER THIN LA Tier 2 QL SMART SENSE THIN LANCETS Tier 2 QL SMARTEST EJECT BLOOD GLUC Tier 3 SMARTEST LANCETS 28G Tier 2 QL SMARTEST PROTEGE BLOOD GL Tier 3 SOLUS V2 AUDIBLE BLOOD GL Tier 3 SOLUS V2 PRESSURE ACTIVAT Tier 2 QL SOLUS V2 TWIST LANCETS 30 Tier 2 QL STERILANCE PA Tier 2 STERILANCE TL Tier 2 QL SURE COMFORT LANCETS 18G Tier 2 QL SURE COMFORT LANCETS 21G Tier 2 QL SURE COMFORT LANCETS 23G Tier 2 QL SURE COMFORT LANCETS 28G Tier 2 QL SURE COMFORT LANCETS 30G Tier 2 QL SURE-LANCE LANCETS 26G Tier 2 QL SURE-LANCE THIN LANCETS 2 Tier 2 QL SURE-TEST EASYPLUS MINI S Tier 3 SURE-TOUCH LANCETS UNIVER Tier 2 QL SURELITE LANCETS Tier 2 QL TECHLITE AST LANCETS Tier 2 QL TECHLITE LANCETS Tier 2 QL TECHLITE LANCETS 30G Tier 2 QL TGT LANCET MICRO THIN 33G Tier 2 QL TGT LANCET THIN 26G Tier 2 QL TGT LANCET ULTRA THIN 30G Tier 2 QL THINLETS GP LANCETS Tier 2 QL 1ST TIER UNILET COMFORTOU Tier 2 QL TODAYS HEALTH SUPER THIN Tier 2 QL TODAYS HEALTH ULTRA THIN Tier 2 QL TOPCARE LANCETS MICRO-THI Tier 2 QL TRAVEL LANCETS 30G Tier 2 QL

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 77 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits TRAVEL LANCETS ADVANCED 2 Tier 2 QL TRUE COMFORT TWIST TOP LA Tier 2 QL TRUE FOCUS BLOOD GLUCOSE Tier 3 TRUE METRIX Tier 3 TRUE METRIX AIR BLOOD GLU Tier 3 TRUEPLUS LANCETS 26G Tier 2 QL TRUEPLUS LANCETS 28G Tier 2 QL TRUEPLUS LANCETS 28G SUPE Tier 2 QL TRUEPLUS LANCETS 30G Tier 2 QL TRUEPLUS LANCETS 33G Tier 2 QL TRUEPLUS LANCETS 33G MICR Tier 2 QL TRUETRACK BLOOD GLUCOSE M Tier 3 ULTILET CLASSIC LANCETS Tier 2 QL ULTILET LANCETS Tier 2 QL ULTILET LANCETS 33G Tier 2 QL ULTILET SAFETY LANCETS 21 Tier 2 QL ULTILET SAFETY LANCETS 23 Tier 2 QL ULTIMA Tier 3 ULTRA THIN LANCETS 31G Tier 2 QL ULTRA-THIN II AUTO LANCET Tier 2 QL ULTRA-THIN II LANCETS 28G Tier 2 QL ULTRA-THIN II LANCETS 30G Tier 2 QL UNILET COMFORTOUCH LANCET Tier 2 QL UNILET EXCELITE Tier 2 QL UNILET EXCELITE II Tier 2 QL UNILET G.P. LANCET Tier 2 QL UNILET G.P. SUPERLITE LAN Tier 2 QL UNILET GP 28 ULTRA THIN Tier 2 QL UNILET LANCET Tier 2 QL UNILET LANCETS MICRO-THIN Tier 2 QL UNILET LANCETS SUPER-THIN Tier 2 QL UNILET SUPERLITE LANCET Tier 2 QL UNISTIK 1 Tier 2 UNISTIK 2 Tier 2 UNISTIK 2 COMFORT Tier 2 UNISTIK 2 EXTRA Tier 2 UNISTIK 2 NEONATAL Tier 2 UNISTIK 2 NORMAL Tier 2 UNISTIK 2 SUPER Tier 2 UNISTIK 3 Tier 2 UNISTIK 3 COMFORT Tier 2 UNISTIK 3 EXTRA Tier 2 UNISTIK 3 EXTRA SINGLE US Tier 2

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 78 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits UNISTIK 3 GENTLE Tier 2 QL UNISTIK 3 NEONATAL Tier 2 UNISTIK 3 NORMAL Tier 2 UNISTIK CZT COMFORT Tier 2 UNISTIK CZT NORMAL Tier 2 UNISTIK NORMAL Tier 2 UNISTIK PRO SAFETY LANCET Tier 2 QL UNISTIK SAFETY LANCETS 28 Tier 2 QL UNISTIK SAFETY LANCETS 30 Tier 2 QL UNISTIK TOUCH SAFETY LANC Tier 2 QL UNIVERSAL 1 LANCETS THIN Tier 2 QL UNIVERSAL 1 LANCETS ULTRA Tier 2 QL UNIVERSAL 1 LANCETS/33G/M Tier 2 QL VALUE PLUS LANCETS STANDA Tier 2 QL VALUMARK LANCET ULTRA THI Tier 2 QL VERASENS BLOOD GLUCOSE MO Tier 3 VIVAGUARD INO BLOOD GLUCO Tier 3 VIVAGUARD LANCETS Tier 2 QL WALGREENS ADVANCED TRAVEL Tier 2 QL WALGREENS COMFORT ASSURED Tier 2 QL WALGREENS THIN LANCETS Tier 2 QL WALGREENS ULTRA THIN LANC Tier 2 QL ZEVRX TWIST TOP LANCETS 3 Tier 2 QL PARENTERAL THERAPY SUPPLIES ABOUTTIME PEN NEEDLE 32G Tier 2 QL ABOUTTIME PEN NEEDLES 30G Tier 2 QL ABOUTTIME PEN NEEDLES 31G Tier 2 QL ALLERGY SYRINGE/1ML/27G X Tier 2 QL ALLERGY SYRINGES INTRADER Tier 2 QL ASSURE ID SAFETY PEN NEED Tier 2 QL AURORA PEN NEEDLES 29GX12 Tier 2 QL AURORA PEN NEEDLES 31G X Tier 2 QL AURORA UNIFINE PENTIPS/32 Tier 2 QL AURORA UNIFINE PENTIPS/MI Tier 2 QL BD BLUNT FILL NEEDLE/18G Tier 2 QL BD DISPOSABLE NEEDLE 23GX Tier 2 QL BD HYPODERMIC NEEDLES 18G Tier 2 QL BD INSULIN SYRINGE MICROF Tier 2 QL BD INSULIN SYRINGE/DETACH Tier 2 QL BD LUER LOCK SYRINGE/1ML/ Tier 2 QL BD LUER-LOK SYRINGE W/ECL Tier 2 QL BD NEEDLE/18G 1-1/2" Tier 2 QL BD NEEDLE/21G 1-1/2" Tier 2 QL

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 79 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits BD NEEDLE/30G X 1/2" Tier 2 QL BD PEN NEEDLE/MICRO/ULTRA Tier 2 QL BD PEN NEEDLE/MINI/ULTRA- Tier 2 QL BD PEN NEEDLE/NANO 2ND GE Tier 2 QL BD PEN NEEDLE/NANO/ULTRA Tier 2 QL BD PEN NEEDLE/ORIGINAL/UL Tier 2 QL BD PEN NEEDLE/SHORT/ULTRA Tier 2 QL BD SAFETYGLIDE SHIELDED N Tier 2 QL BD SYRINGE LUER-LOK/1ML Tier 2 QL BD VEO INSULIN SYRINGE UL Tier 2 QL CAREFINE PEN NEEDLE 32GX4 Tier 2 QL CAREFINE PEN NEEDLES 31GX Tier 2 QL CAREFINE PEN NEEDLES 32GX Tier 2 QL CAREONE UNIFINE PENTIPS 2 Tier 2 QL CAREONE UNIFINE PENTIPS 3 Tier 2 QL CAREONE UNIFINE PENTIPS P Tier 2 QL CARETOUCH PEN NEEDLES 31 Tier 2 QL CARETOUCH PEN NEEDLES 31G Tier 2 QL CARETOUCH PEN NEEDLES 32G Tier 2 QL CLEVER CHOICE COMFORT EZ Tier 2 QL CLICKFINE PEN NEEDLE 32GX Tier 2 QL CLICKFINE PEN NEEDLES 31G Tier 2 QL COMFORT EZ INSULIN SYRING Tier 2 QL COMFORT EZ MICRO/32G X 4M Tier 2 QL COMFORT EZ SHORT/31G X 8M Tier 2 QL COMFORT EZ/31G X 5MM Tier 2 QL COMFORT EZ/31G X 6MM Tier 2 QL COMFORT TOUCH PEN NEEDLES Tier 2 QL DIATHRIVE PEN NEEDLE/31 G Tier 2 QL DIATHRIVE PEN NEEDLE/31G Tier 2 QL DIATHRIVE PEN NEEDLE/32G Tier 2 QL DROPLET MICRON 34G X 9/64 Tier 2 QL DROPLET PEN NEEDLES 32G X Tier 2 QL DROPLET PEN NEEDLES 32GX5 Tier 2 QL EASY COMFORT PEN NEEDLES Tier 2 QL EASY GLIDE SYRINGE/SLIP L Tier 2 QL EASY TOUCH 32GX5MM Tier 2 QL EASY TOUCH 32GX6MM Tier 2 QL EASY TOUCH ALLERGY TRAY S Tier 2 QL EASY TOUCH FLIPLOCK NEEDL Tier 2 QL EASY TOUCH FLIPLOCK SAFET Tier 2 QL EASY TOUCH FLURINGE SYRIN Tier 2 QL EASY TOUCH HYPODERMIC NEE Tier 2 QL

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 80 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits EASY TOUCH PEN NEEDLES 29 Tier 2 QL EASY TOUCH PEN NEEDLES 31 Tier 2 QL EASY TOUCH PEN NEEDLES 32 Tier 2 QL EASY TOUCH PEN NEEDLES/31 Tier 2 QL EASY TOUCH SAFETY PEN NEE Tier 2 QL EASY TOUCH TUBERCULIN FLI Tier 2 QL EASY TOUCH TUBERCULIN SHE Tier 2 QL EASYPOINT NEEDLE 23G X 1" Tier 2 QL EASYPOINT NEEDLE/18G X 1- Tier 2 QL EASYPOINT NEEDLE/21G X 1- Tier 2 QL EXCEL COMFORT POINT INSUL Tier 2 QL EXEL COMFORT POINT INSULI Tier 2 QL FIFTY50 PEN NEEDLES 31G X Tier 2 QL FIFTY50 PEN NEEDLES 31GX5 Tier 2 QL FIFTY50 PEN NEEDLES/31GX8 Tier 2 QL FIFTY50 PEN NEEDLES/32GX4 Tier 2 QL FIFTY50 PEN NEEDLES/32GX6 Tier 2 QL GNP ULTICARE PEN NEEDLES Tier 2 QL GNP ULTICARE PEN NEEDLES/ Tier 2 QL GOODSENSE PEN NEEDLE/PENF Tier 2 QL H-E-B IN CONTROL PEN NEED Tier 2 QL H-E-B IN CONTROL UNIFINE Tier 2 QL H-E-B INCONTROL PEN NEEDL Tier 2 QL HEALTHWISE INSULIN SYRING Tier 2 QL HM ULTICARE INSULIN SYRIN Tier 2 QL HM ULTICARE SHORT PEN NEE Tier 2 QL HYPODERMIC NEEDLE 30GX1/2 Tier 2 QL INSULIN SYRINGE/0.5ML/27G Tier 2 QL INSULIN SYRINGE/U-100/1ML Tier 2 QL INSULIN SYRINGES/0.5ML/27 Tier 2 QL INSUPEN 29G X 12MM Tier 2 QL INSUPEN 31G X 5MM Tier 2 QL INSUPEN 31G X 8MM Tier 2 QL INSUPEN 33GX4MM Tier 2 QL INSUPEN PEN NEEDLES 32G X Tier 2 QL INSUPEN SENSITIVE 32GX6MM Tier 2 QL INSUPEN SENSITIVE 32GX8MM Tier 2 QL INSUPEN ULTRAFIN 30GX8MM Tier 2 QL INSUPEN ULTRAFIN 31GX6MM Tier 2 QL INSUPEN ULTRAFIN 31GX8MM Tier 2 QL KMART VALU PLUS INSULIN S Tier 2 QL KROGER PEN NEEDLES/31G X Tier 2 QL KROGER PEN NEEDLES/32G X Tier 2 QL

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 81 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits KROGER PEN NEEDLES/33G X Tier 2 QL LEADER UNIFINE PENTIPS PL Tier 2 QL LITETOUCH PEN NEEDLES 29G Tier 2 QL LITETOUCH PEN NEEDLES 31G Tier 2 QL MAXICOMFORT II PEN NEEDLE Tier 2 QL MAXICOMFORT INSULIN SYRIN Tier 2 QL MEIJER PEN NEEDLES 31G X Tier 2 QL MICRODOT PEN NEEDLE/31G X Tier 2 QL MICRODOT PEN NEEDLE/33G X Tier 2 QL MM INSULIN SYRINGE/U-100/ Tier 2 QL MONOJECT 1ML LUER LOCK TU Tier 2 QL MONOJECT HYPODERMIC NEEDL Tier 2 QL MONOJECT INSULIN SYRINGE/ Tier 2 QL MONOJECT INSULIN SYRINGE/ Tier 2 QL MONOJECT MAGELLAN SAFETY Tier 2 QL MONOJECT PHARMACY TRAY/RE Tier 2 QL MONOJECT STANDARD HYPODER Tier 2 QL MONOJECT SYRINGE PHARMACY Tier 2 QL MONOJECT TB SYRINGE-NDL 1 Tier 2 QL MONOJECT TUBERCULIN SYRIN Tier 2 QL MONOJECT TUBERCULIN SYRIN Tier 2 QL MULTI-DRAW NEEDLE 21GX1-1 Tier 2 QL NORM-JECT TUBERKULIN 1ML Tier 2 QL NOVOFINE AUTOCOVER PEN NE Tier 2 QL NOVOFINE PEN NEEDLE 32G X Tier 2 QL NOVOFINE PLUS PEN NEEDLE Tier 2 QL NOVOTWIST PEN NEEDLE 32G Tier 2 QL PC UNIFINE PENTIPS 29G X Tier 2 QL PC UNIFINE PENTIPS 31G X Tier 2 QL PEN NEEDLES 30GX8MM Tier 2 QL PEN NEEDLES 33G X 5/32" Tier 2 QL PENTIPS 29GX12MM Tier 2 QL PENTIPS 31GX5MM Tier 2 QL PENTIPS 31GX6MM Tier 2 QL PENTIPS 31GX8MM Tier 2 QL PENTIPS 32GX4MM Tier 2 QL POLY HUB NEEDLE/18G X 1-1 Tier 2 QL POLY HUB NEEDLE/21G X 1-1 Tier 2 QL POLY HUB NEEDLE/23G X 1" Tier 2 QL POLY HUB NEEDLE/30G X 1/2 Tier 2 QL PREVENT SAFETY PEN NEEDLE Tier 2 QL PRO COMFORT INSULIN SYRIN Tier 2 QL PRO COMFORT PEN NEEDLES/ Tier 2 QL

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 82 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits PRO COMFORT PEN NEEDLES/ Tier 2 QL PURE COMFORT PEN NEEDLE 3 Tier 2 QL PURE COMFORT PEN NEEDLE/3 Tier 2 QL PX MINI PEN NEEDLES 31GX5 Tier 2 QL RA PEN NEEDLES 31G X 5MM Tier 2 QL RELION PEN NEEDLES 29GX12 Tier 2 QL RELION PEN NEEDLES 31GX5/ Tier 2 QL RELION PEN NEEDLES 31GX6M Tier 2 QL RELION PEN NEEDLES 31GX8M Tier 2 QL RELION PEN NEEDLES 32G X Tier 2 QL RELION PEN NEEDLES 32GX4M Tier 2 QL RELION PEN NEEDLES/31G X Tier 2 QL SAFETY INSULIN SYRINGES 1 Tier 2 QL SECURESAFE SAFETY HYPODER Tier 2 QL SECURESAFE SAFETY INSULIN Tier 2 QL SECURESAFE SAFETY PEN NEE Tier 2 QL SURE COMFORT INSULIN SYRI Tier 2 QL SURE COMFORT PEN NEEDLES Tier 2 QL SURE-FINE PEN NEEDLES 29G Tier 2 QL SURE-FINE PEN NEEDLES 31G Tier 2 QL SYRINGE/LUER SLIP/1ML Tier 2 QL SYRINGES/LUER SLIP/WITHOU Tier 2 QL TECHLITE PEN NEEDLES 29G Tier 2 QL TECHLITE PEN NEEDLES/32G Tier 2 QL 1ST TIER UNIFINE PENTIPS Tier 2 QL TODAYS HEALTH ORIGINAL PE Tier 2 QL TODAYS HEALTH SHORT PEN N Tier 2 QL TRUE COMFORT PRO PEN NEED Tier 2 QL ULTICARE INSULIN SAFETY S Tier 2 QL ULTICARE INSULIN SYRINGE/ Tier 2 QL ULTICARE MICRO PEN NEEDLE Tier 2 QL ULTICARE MINI PEN NEEDLES Tier 2 QL ULTICARE ORIGINAL PEN NEE Tier 2 QL ULTICARE PEN NEEDLES 31G Tier 2 QL ULTICARE PEN NEEDLES/29G Tier 2 QL ULTICARE SHORT PEN NEEDLE Tier 2 QL ULTICARE SHORT SAFETY PEN Tier 2 QL ULTICARE TUBERCULIN SAFET Tier 2 QL ULTICARE U-100 INSULIN SY Tier 2 QL ULTIGUARD SAFEPACK INSULI Tier 2 QL ULTIGUARD SAFEPACK MINI P Tier 2 QL ULTIGUARD SAFEPACK PEN NE Tier 2 QL ULTIGUARD SAFEPACK/MICRO Tier 2 QL

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 83 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits ULTIGUARD SAFEPACK/MINI P Tier 2 QL ULTIGUARD SAFEPACK/SHORT Tier 2 QL ULTIGUARD SAFEPACK/SYRING Tier 2 QL ULTILET INSULIN SYRINGE/0 Tier 2 QL ULTILET INSULIN SYRINGE/1 Tier 2 QL ULTILET INSULIN SYRINGE/S Tier 2 QL ULTILET INSULIN SYRINGE/U Tier 2 QL ULTILET PEN NEEDLE 29GX12 Tier 2 QL ULTILET PEN NEEDLE 31GX5M Tier 2 QL ULTILET PEN NEEDLE 31GX8M Tier 2 QL ULTILET PEN NEEDLE 32GX4M Tier 2 QL ULTILET U-100 INSULIN SYR Tier 2 QL ULTRA FLO INSULIN PEN NEE Tier 2 QL UNIFINE PENTIPS 32GX6MM Tier 2 QL UNIFINE PENTIPS 33GX4MM Tier 2 QL UNIFINE SAFECONTROL PEN N Tier 2 QL VANISHPOINT INSULIN SYRIN Tier 2 QL WEGMANS UNIFINE PENTIPS P Tier 2 QL ZEVRX PEN NEEDLES 31G X 5 Tier 2 QL ZEVRX PEN NEEDLES 31G X 6 Tier 2 QL ZEVRX PEN NEEDLES 31G X 8 Tier 2 QL ZEVRX PEN NEEDLES 32G X 4 Tier 2 QL RESPIRATORY THERAPY SUPPLIES AEROCHAMBER MINI AEROSOL Tier 2 AEROCHAMBER MV Tier 2 AEROCHAMBER PLUS FLOW-VU Tier 2 AEROCHAMBER PLUS FLOW-VU/ Tier 2 AEROCHAMBER Z-STAT PLUS/M Tier 2 AEROCHAMBER/FLOWSIGNAL Tier 2 AEROVENT PLUS HOLDING CHA Tier 2 BREATHE EASE/LARGE MASK Tier 2 BREATHE EASE/MEDIUM MASK Tier 2 BREATHE EASE/SMALL MASK Tier 2 CLEVER CHOICE ANTI-STATIC Tier 2 COMPACT SPACE CHAMBER/ANT Tier 2 EASIVENT Tier 2 EASIVENT/MASK-LARGE Tier 2 EASIVENT/MASK-MEDIUM Tier 2 EASIVENT/MASK-SMALL Tier 2 EQ SPACE CHAMBER ANTI-STA Tier 2 FLEXICHAMBER Tier 2 INSPIRACHAMBER/ANTI-STATI Tier 2 INSPIRACHAMBER/LARGE Tier 2

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 84 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits INSPIRACHAMBER/SOOTHERMAS Tier 2 INSPIREASE DRUG DELIVERY Tier 2 MICROCHAMBER Tier 2 OPTICHAMBER DIAMOND Tier 2 OPTICHAMBER DIAMOND/LARGE Tier 2 OPTICHAMBER DIAMOND/MEDIU Tier 2 OPTICHAMBER DIAMOND/SMALL Tier 2 POCKET CHAMBER Tier 2 POCKET SPACER Tier 2 PRO COMFORT INHALER SPACE Tier 2 PROCARE SPACER CHAMBER W/ Tier 2 RITEFLO Tier 2 VORTEX VALVED HOLDING CHA Tier 2 MIGRAINE PRODUCTS CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG AIMOVIG 70mg/ml Tier 3 PA, QL AIMOVIG 140mg/ml Tier 3 PA AJOVY Tier 3 PA EMGALITY Tier 3 PA NURTEC Tier 2 PA, QL MIGRAINE COMBINATIONS CAFERGOT Tier 3 ergotamine w/ caffeine Tier 1 sumatriptan-naproxen sodium Tier 1 QL MIGRAINE PRODUCTS D.H.E. 45 LA dihydroergotamine mesylate 1mg/ml LA dihydroergotamine mesylate 4mg/ml Tier 1 PA, QL ERGOMAR Tier 2 MIGRANAL Tier 3 PA, QL SEROTONIN AGONISTS almotriptan malate Tier 1 QL AMERGE Tier 3 ST, QL eletriptan hydrobromide Tier 1 QL frovatriptan succinate Tier 1 QL IMITREX Tier 3 PA, QL IMITREX STATDOSE REFILL Tier 3 PA, QL IMITREX STATDOSE SYSTEM Tier 3 PA, QL naratriptan hcl Tier 1 QL ONZETRA XSAIL Tier 3 PA, QL rizatriptan benzoate Tier 1 QL sumatriptan Tier 1 QL sumatriptan succinate Tier 1 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 85 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits ZEMBRACE SYMTOUCH Tier 3 PA, QL zolmitriptan soln Tier 1 PA, QL zolmitriptan tabs; tbdp Tier 1 QL ZOMIG Tier 3 PA, QL MINERALS & ELECTROLYTES ELECTROLYTE MIXTURES dextrose in lactated ringers LA dextrose w/ sodium chloride LA KCL 0.3%/D5W/NACL 0.9% LA lactated ringer's LA potassium chloride in dextrose LA potassium chloride in dextrose & sodium LA chloride potassium chloride in nacl LA POTASSIUM CHLORIDE/DEXTRO LA FLUORIDE FLORIVA LIQD Tier 3 sodium fluoride chew 1mg, 2.2mg Tier 1 sodium fluoride chew .25mg, .5mg ACA AL sodium fluoride soln ACA AL sodium fluoride tabs 1mg Tier 1 sodium fluoride tabs .5mg ACA AL PHOSPHATE K-PHOS Tier 3 POTASSIUM EFFER-K Tier 2 K-TAB Tier 3 potassium chloride cpcr Tier 1 potassium chloride pack Tier 1 potassium chloride soln 2meq/ml, LA 10meq/100ml, 10meq/50ml, 20meq/100ml, 20meq/50ml, 40meq/100ml potassium chloride soln 10%, 20% Tier 1 potassium chloride soln 10meq/100ml, Tier 3 10meq/50ml, 20meq/100ml, 20meq/50ml, 40meq/100ml potassium chloride tbcr Tier 1 potassium chloride microencapsulated Tier 1 crystals er SODIUM sodium chloride LA sodium chloride flush LA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 86 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits MISCELLANEOUS THERAPEUTIC CLASSES CHELATING AGENTS CUPRIMINE Tier 4 SP DEPEN TITRATABS Tier 4 SP penicillamine Tier 1 SP SYPRINE Tier 4 SP ENZYMES HYLENEX LA PA VITRASE LA PA IMMUNOMODULATORS REVLIMID Tier 2 SP, PA THALOMID Tier 2 SP, PA IMMUNOSUPPRESSIVE AGENTS ASTAGRAF XL Tier 4 SP ATGAM LA AZASAN Tier 3 azathioprine Tier 1 CELLCEPT CAPS; TABS Tier 4 SP CELLCEPT SUSR Tier 4 SP CELLCEPT INTRAVENOUS LA SP cyclosporine caps Tier 1 SP cyclosporine soln LA SP cyclosporine modified (for microemulsion) Tier 1 SP ENSPRYNG Tier 4 SP, PA ENVARSUS XR Tier 4 SP, PA GAMIFANT LA SP, PA IMURAN Tier 3 mycophenolate mofetil Tier 1 SP mycophenolate sodium Tier 1 SP NEORAL Tier 4 SP NULOJIX LA SP, PA PROGRAF CAPS Tier 4 SP PROGRAF SOLN LA SP RAPAMUNE Tier 4 SP SANDIMMUNE CAPS Tier 4 SP SANDIMMUNE SOLN 50mg/ml LA SP, PA SANDIMMUNE SOLN 100mg/ml Tier 4 SP SIMULECT LA PA sirolimus Tier 1 SP tacrolimus Tier 1 SP THYMOGLOBULIN LA UPLIZNA LA SP, PA ZORTRESS Tier 4 SP, PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 87 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits IRRIGATION SOLUTIONS irrigation solutions, physiological LA lactated ringer's (irrigation) LA ringer's irrigation LA water for irrigation, sterile LA LYMPHATIC AGENTS SYLVANT LA SP, PA MISCELLANEOUS THERAPEUTIC CLASSES NEXAVIR LA PA POTASSIUM REMOVING AGENTS LOKELMA Tier 3 sodium polystyrene sulfonate Tier 1 VELTASSA Tier 3 PA PROGERIA TREATMENT AGENTS ZOKINVY Tier 4 SP, PA PROSTAGLANDINS alprostadil Tier 1 PROSTIN VR PEDIATRIC Tier 3 SYSTEMIC LUPUS ERYTHEMATOSUS AGENTS BENLYSTA SOAJ; SOSY Tier 4 SP, PA BENLYSTA SOLR LA SP, PA MOUTH/THROAT/DENTAL AGENTS ANESTHETICS TOPICAL ORAL lidocaine hcl (mouth-throat) Tier 1 ANTI-INFECTIVES - THROAT clotrimazole Tier 1 nystatin (mouth-throat) Tier 1 ORAVIG Tier 3 PA ANTISEPTICS - MOUTH/THROAT chlorhexidine gluconate (mouth-throat) Tier 1 DENTAL PRODUCTS PREVIDENT 5000 BOOSTER PL Tier 3 PREVIDENT 5000 DRY MOUTH Tier 3 PREVIDENT 5000 ENAMEL PRO Tier 3 PREVIDENT 5000 ORTHO DEFE Tier 3 PREVIDENT 5000 PLUS Tier 3 PREVIDENT FLUORIDE Tier 3 PREVIDENT RINSE Tier 3 sodium fluoride (dental) crea; gel; soln Tier 1 sodium fluoride (dental) pste Tier 3 sodium fluoride-potassium nitrate Tier 3

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 88 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits STEROIDS - MOUTH/THROAT/DENTAL triamcinolone acetonide (mouth) Tier 1 QL THROAT PRODUCTS - MISC. hcl Tier 1 EVOXAC Tier 3 ORAFATE Tier 3 PA hcl (oral) Tier 1 PROTHELIAL Tier 3 PA SALAGEN Tier 3 MULTIVITAMINS B-COMPLEX W/ FOLIC ACID b-complex w/ c-biotin-minerals & folic acid Tier 1 MULTIPLE VITAMINS W/ MINERALS & CALCIUM-FOLIC ACID FOLGARD OS Tier 3 PED MULTI VITAMINS W/FL & FE ped multivitamins w/fl & iron Tier 1 POLY-VI-FLOR/IRON Tier 3 PED MV W/ FLUORIDE pediatric multivitamins w/fl Tier 1 pediatric vitamins acd w/ fluoride Tier 1 POLY-VI-FLOR Tier 3 QUFLORA PEDIATRIC Tier 3 TRI-VI-FLOR Tier 3 TRI-VI-FLORO Tier 3 PEDIATRIC MULTIPLE VITAMINS & MINERALS W/ FLUORIDE FLORIVA CHEW Tier 3 PRENATAL VITAMINS ENBRACE HR Tier 3 M-NATAL PLUS Tier 3 NEONATAL COMPLETE Tier 3 NEONATAL PLUS Tier 3 NIVA-PLUS Tier 3 ONE VITE WOMENS PRENATAL Tier 3 PRENATAL Tier 3 prenatal vit w/ ferrous fumarate-folic acid Tier 1 prenatal vit w/ ferrous fumarate-l Tier 1 methylfolate-folic acid prenatal vit w/ iron carbonyl-folic acid Tier 1 PRENATAL VITAMINS PLUS LO Tier 3 prenatal without a w/ fe fumarate-l Tier 1 methylfolate-fa-dha PREPLUS Tier 3

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 89 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits TRICARE Tier 3 VITATHELY/GINGER Tier 3 WESTAB PLUS Tier 3 MUSCULOSKELETAL THERAPY AGENTS CENTRAL MUSCLE RELAXANTS baclofen soln LA baclofen tabs Tier 1 carisoprodol Tier 1 chlorzoxazone 375mg, 500mg, 750mg Tier 1 CHLORZOXAZONE 375mg, 750mg Tier 1 hcl Tier 1 GABLOFEN LA metaxalone Tier 1 methocarbamol soln LA methocarbamol tabs Tier 1 citrate soln LA orphenadrine citrate tb12 Tier 1 ROBAXIN LA PA SKELAXIN Tier 3 SOMA Tier 3 tizanidine hcl Tier 1 ZANAFLEX Tier 3 DIRECT MUSCLE RELAXANTS DANTRIUM Tier 3 dantrolene sodium Tier 1 MUSCLE RELAXANT COMBINATIONS carisoprodol w/ aspirin & codeine Tier 1 VISCOSUPPLEMENTS DUROLANE LA SP; Non-Preferred EUFLEXXA LA SP; Non-Preferred GEL-ONE LA Non-Preferred GELSYN-3 LA Non-Preferred GENVISC 850 LA HYALGAN SOLN LA Non-Preferred HYALGAN SOSY LA SP; Non-Preferred HYMOVIS LA Non-Preferred MONOVISC LA Non-Preferred ORTHOVISC LA Preferred SUPARTZ FX LA Non-Preferred SYNVISC LA Preferred SYNVISC ONE Tier 2 Preferred TRILURON LA SP TRIVISC LA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 90 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits VISCO-3 LA Non-Preferred NASAL AGENTS - SYSTEMIC AND TOPICAL NASAL AGENT COMBINATIONS azelastine hcl-fluticasone propionate Tier 1 DYMISTA Tier 3 NASAL ANTIALLERGY azelastine hcl .1% Tier 1 QL azelastine hcl .15% Tier 1 hcl (nasal) Tier 1 PATANASE Tier 3 NASAL ANTICHOLINERGICS ipratropium bromide (nasal) Tier 1 NASAL STEROIDS BECONASE AQ Tier 3 ST flunisolide (nasal) Tier 1 fluticasone propionate (nasal) Tier 1 mometasone furoate (nasal) Tier 1 NASONEX Tier 3 OMNARIS Tier 3 ST QNASL Tier 2 QNASL CHILDRENS Tier 2 ZETONNA Tier 3 ST SYMPATHOMIMETIC DECONGESTANTS ADRENALIN Tier 2 NEUROMUSCULAR AGENTS ALS AGENTS EXSERVAN Tier 3 RADICAVA LA SP, PA RILUTEK Tier 3 riluzole Tier 1 TIGLUTIK Tier 3 NEUROMUSCULAR BLOCKING AGENT - NEUROTOXINS BOTOX LA SP, PA XEOMIN LA PA SPINAL MUSCULAR ATROPHY AGENTS (SMA) EVRYSDI Tier 4 SP, PA SPINRAZA LA SP, PA ZOLGENSMA 2.6-3.0 KG LA SP, PA ZOLGENSMA 3.1-3.5 KG LA SP, PA ZOLGENSMA 3.6-4.0 KG LA SP, PA ZOLGENSMA 4.1-4.5 KG LA SP, PA ZOLGENSMA 4.6-5.0 KG LA SP, PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 91 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits ZOLGENSMA 5.1-5.5 KG LA SP, PA ZOLGENSMA 5.6-6.0 KG LA SP, PA ZOLGENSMA 6.1-6.5 KG LA SP, PA ZOLGENSMA 6.6-7.0 KG LA SP, PA ZOLGENSMA 7.1-7.5 KG LA SP, PA ZOLGENSMA 7.6-8.0 KG LA SP, PA ZOLGENSMA 8.1-8.5 KG LA SP, PA ZOLGENSMA 8.6-9.0 KG LA SP, PA ZOLGENSMA 9.1-9.5 KG LA SP, PA ZOLGENSMA 9.6-10.0 KG LA SP, PA ZOLGENSMA 10.1-10.5 KG LA SP, PA ZOLGENSMA 10.6-11.0 KG LA SP, PA ZOLGENSMA 11.1-11.5 KG LA SP, PA ZOLGENSMA 11.6-12.0 KG LA SP, PA ZOLGENSMA 12.1-12.5 KG LA SP, PA ZOLGENSMA 12.6-13.0 KG LA SP, PA ZOLGENSMA 13.1-13.5 KG LA SP, PA NUTRIENTS CARBOHYDRATES dextrose LA LIPIDS SMOFLIPID LA PA OPHTHALMIC AGENTS ARTIFICIAL TEARS AND LUBRICANTS LACRISERT Tier 2 BETA-BLOCKERS - OPHTHALMIC betaxolol hcl (ophth) Tier 1 BETIMOL Tier 2 BETOPTIC-S Tier 2 carteolol hcl (ophth) Tier 1 COMBIGAN Tier 3 COSOPT Tier 3 QL COSOPT PF Tier 3 dorzolamide hcl-timolol maleate Tier 1 dorzolamide hcl-timolol maleate Tier 1 QL ISTALOL Tier 3 levobunolol hcl Tier 1 timolol maleate (ophth) Tier 1 TIMOPTIC Tier 3 TIMOPTIC OCUDOSE Tier 3 TIMOPTIC-XE Tier 3 CYCLOPLEGIC MYDRIATICS atropine sulfate Tier 3 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 92 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits CYCLOGYL Tier 3 CYCLOMYDRIL Tier 3 cyclopentolate hcl Tier 1 homatropine hbr Tier 1 isopto atropine Tier 3 MYDRIACYL Tier 3 phenylephrine hcl (mydriatic) Tier 1 Tier 1 MIOTICS ISOPTO CARPINE Tier 3 MIOSTAT LA PA pilocarpine hcl Tier 1 OPHTHALMIC - ANGIOGENESIS INHIBITORS BEOVU LA SP, PA BEVACIZUMAB LA EYLEA LA SP, PA LUCENTIS LA SP, PA OPHTHALMIC ADRENERGIC AGENTS ALPHAGAN P Tier 3 QL apraclonidine hcl Tier 1 brimonidine tartrate .2% Tier 1 brimonidine tartrate .15% Tier 1 QL IOPIDINE Tier 3 SIMBRINZA Tier 3 OPHTHALMIC ANTI-INFECTIVES AZASITE Tier 3 bacitracin (ophthalmic) Tier 1 bacitracin-polymyxin b (ophth) Tier 1 BESIVANCE Tier 3 PA BETADINE OPHTHALMIC PREP Tier 3 BLEPH-10 Tier 3 CILOXAN OINT Tier 2 CILOXAN SOLN Tier 3 ciprofloxacin hcl (ophth) Tier 1 erythromycin (ophth) Tier 1 gatifloxacin (ophth) Tier 1 gentamicin sulfate (ophth) Tier 1 KLARITY-A Tier 3 levofloxacin (ophth) Tier 1 MOXEZA Tier 3 moxifloxacin hcl (ophth) Tier 1 NATACYN Tier 2 neomycin-bacitracin zn-polymyxin Tier 1 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 93 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits neomycin-polymyxin-gramicidin Tier 1 OCUFLOX Tier 3 ofloxacin (ophth) Tier 1 polymyxin b-trimethoprim Tier 1 POLYTRIM Tier 3 POVIDONE IODINE Tier 3 sulfacetamide sodium (ophth) Tier 1 tobramycin (ophth) Tier 1 TOBREX OINT Tier 2 TOBREX SOLN Tier 3 trifluridine Tier 1 VIGAMOX Tier 3 ZIRGAN Tier 3 ZYMAXID Tier 3 OPHTHALMIC IMMUNOMODULATORS RESTASIS Tier 2 RESTASIS MULTIDOSE Tier 2 OPHTHALMIC INTEGRIN ANTAGONISTS XIIDRA Tier 2 OPHTHALMIC KINASE INHIBITORS RHOPRESSA Tier 3 ST ROCKLATAN Tier 3 ST OPHTHALMIC LOCAL ANESTHETICS ALCAINE Tier 3 proparacaine hcl Tier 1 OPHTHALMIC NERVE GROWTH FACTORS OXERVATE Tier 4 SP, PA OPHTHALMIC STEROIDS ALREX Tier 2 bacitracin-poly-neomycin-hc Tier 1 BLEPHAMIDE Tier 3 BLEPHAMIDE S.O.P. Tier 3 dexamethasone sodium phosphate (ophth) Tier 1 DUREZOL Tier 3 EYSUVIS Tier 3 FLAREX Tier 3 fluorometholone (ophth) Tier 1 FML Tier 3 FML FORTE Tier 3 FML LIQUIFILM Tier 3 ILUVIEN LA SP, PA LOTEMAX GEL; SUSP Tier 3 LOTEMAX OINT Tier 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 94 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits LOTEMAX SM Tier 3 loteprednol etabonate Tier 1 MAXIDEX Tier 3 MAXITROL Tier 3 neomycin-polymy-dexameth Tier 1 neomycin-polymyxin-hc (ophth) Tier 1 OZURDEX LA SP, PA PRED FORTE Tier 3 PRED MILD Tier 3 PRED-G Tier 3 PRED-G S.O.P. Tier 3 prednisolone acetate (ophth) Tier 1 PREDNISOLONE ACETATE P-F Tier 3 PREDNISOLONE SODIUM PHOSP Tier 1 RETISERT LA SP, PA sulfacetamide sod-prednisolone Tier 1 TOBRADEX OINT Tier 2 TOBRADEX SUSP Tier 3 TOBRADEX ST Tier 3 tobramycin-dexamethasone Tier 1 TRIESENCE LA ZYLET Tier 2 OPHTHALMIC SURGICAL AIDS AMVISC LA AMVISC PLUS LA HEALON LA HEALON PRO LA hypromellose (intraocular) LA PA PROVISC LA OPHTHALMICS - MISC. ACULAR Tier 3 ACULAR LS Tier 3 ACUVAIL Tier 3 ALOCRIL Tier 3 ALOMIDE Tier 2 azelastine hcl (ophth) Tier 1 AZOPT Tier 3 bepotastine besilate Tier 1 BEPREVE Tier 3 brinzolamide Tier 1 bromfenac sodium (ophth) Tier 1 BROMSITE Tier 3 cromolyn sodium (ophth) Tier 1

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 95 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits CYSTADROPS Tier 4 SP, PA CYSTARAN Tier 4 SP, PA diclofenac sodium (ophth) Tier 1 dorzolamide hcl 2% Tier 1 DORZOLAMIDE HCL 2% Tier 3 epinastine hcl (ophth) Tier 1 flurbiprofen sodium Tier 1 ILEVRO Tier 3 ketorolac tromethamine (ophth) Tier 1 LASTACAFT Tier 3 NEVANAC Tier 3 olopatadine hcl Tier 1 PROLENSA Tier 3 TRUSOPT Tier 3 PROSTAGLANDINS - OPHTHALMIC bimatoprost Tier 1 QL latanoprost Tier 1 QL LUMIGAN Tier 2 TRAVATAN Z Tier 3 ST, QL travoprost Tier 1 QL VYZULTA Tier 3 PA XELPROS Tier 3 ZIOPTAN Tier 3 ST OTIC AGENTS OTIC AGENTS - MISCELLANEOUS acetic acid (otic) Tier 1 OTIC ANTI-INFECTIVES CETRAXAL Tier 3 ciprofloxacin hcl (otic) Tier 1 ofloxacin (otic) Tier 1 OTIPRIO Tier 3 OTIC COMBINATIONS CIPRO HC Tier 3 CIPRODEX Tier 3 ciprofloxacin-dexamethasone Tier 1 ciprofloxacin-fluocinolone acetonide Tier 1 CORTISPORIN-TC Tier 3 neomycin-polymyxin-hc (otic) Tier 1 OTOVEL Tier 3 pramoxine-hc-chloroxylenol Tier 1 OTIC STEROIDS DERMOTIC Tier 3 fluocinolone acetonide (otic) Tier 1 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 96 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits hydrocortisone w/acetic acid Tier 1 OXYTOCICS OXYTOCICS methylergonovine maleate Tier 1 QL PASSIVE IMMUNIZING AND TREATMENT AGENTS IMMUNE SERUMS ASCENIV LA SP, PA BIVIGAM LA SP, PA CUTAQUIG Tier 4 SP, PA CUVITRU Tier 2 SP, PA FLEBOGAMMA DIF LA SP, PA GAMASTAN LA SP, PA GAMMAGARD LIQUID LA SP, PA GAMMAGARD S/D IGA LESS TH LA SP, PA GAMMAKED LA SP, PA GAMMAPLEX LA SP, PA GAMUNEX-C LA SP, PA HEPAGAM B LA SP, PA HIZENTRA Tier 2 SP, PA HYPERRAB LA OCTAGAM LA SP, PA PANZYGA LA SP, PA PRIVIGEN LA SP, PA MONOCLONAL ANTIBODIES SYNAGIS LA SP, PA ZINPLAVA LA PA PASSIVE IMMUNIZING AGENTS - COMBINATIONS HYQVIA Tier 4 SP, PA PENICILLINS AMINOPENICILLINS amoxicillin Tier 1 ampicillin Tier 1 ampicillin sodium LA NATURAL PENICILLINS BICILLIN L-A LA penicillin g potassium LA PENICILLIN G POTASSIUM IN LA PENICILLIN G PROCAINE LA penicillin g sodium LA penicillin v potassium Tier 1 PENICILLIN COMBINATIONS amoxicillin & pot clavulanate Tier 1

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 97 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits ampicillin & sulbactam sodium LA AUGMENTIN Tier 3 BICILLIN C-R LA piperacillin sodium-tazobactam sodium LA ZOSYN LA PENICILLINASE-RESISTANT PENICILLINS dicloxacillin sodium Tier 1 NAFCILLIN LA nafcillin sodium LA OXACILLIN SODIUM SOLN LA oxacillin sodium solr LA PROGESTINS PROGESTINS AYGESTIN Tier 3 hydroxyprogesterone caproate LA SP MAKENA LA SP medroxyprogesterone acetate Tier 1 megestrol acetate (appetite) Tier 1 norethindrone acetate Tier 1 progesterone caps Tier 1 progesterone oil Tier 1 PROMETRIUM Tier 3 PROVERA Tier 3 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. AGENTS FOR CHEMICAL DEPENDENCY acamprosate calcium Tier 1 disulfiram Tier 1 ANTIDEMENTIA AGENTS ARICEPT 5mg, 10mg Tier 3 QL ARICEPT 23mg Tier 3 PA, QL donepezil hydrochloride tabs 5mg, 10mg Tier 1 QL donepezil hydrochloride tabs 23mg Tier 1 PA, QL donepezil hydrochloride tbdp Tier 1 QL EXELON Tier 3 galantamine hydrobromide cp24 Tier 1 galantamine hydrobromide soln; tabs Tier 1 QL memantine hcl cp24 Tier 1 memantine hcl soln Tier 1 memantine hcl tabs Tier 3 QL memantine hcl tabs 5mg, 10mg Tier 1 QL NAMENDA TITRATION PAK Tier 3 QL NAMENDA XR Tier 3 NAMZARIC Tier 3 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 98 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits RAZADYNE ER Tier 3 rivastigmine Tier 1 rivastigmine tartrate Tier 1 QL COMBINATION PSYCHOTHERAPEUTICS chlordiazepoxide-amitriptyline Tier 1 olanzapine-fluoxetine hcl Tier 1 perphenazine-amitriptyline Tier 1 SYMBYAX Tier 3 FIBROMYALGIA AGENTS SAVELLA Tier 3 PA SAVELLA TITRATION PACK Tier 3 PA HYPOACTIVE SEXUAL DESIRE DISORDER (HSDD) AGENTS ADDYI Tier 3 PA VYLEESI Tier 3 PA, QL MOVEMENT DISORDER DRUG THERAPY AUSTEDO Tier 4 SP, PA INGREZZA CAPS Tier 4 SP, PA INGREZZA CPPK Tier 4 SP, PA tetrabenazine Tier 1 SP, PA XENAZINE Tier 4 SP, PA MULTIPLE SCLEROSIS AGENTS AUBAGIO Tier 2 SP AVONEX Tier 4 SP, PA AVONEX PEN Tier 4 SP, PA BETASERON Tier 2 SP COPAXONE Tier 2 SP dalfampridine Tier 1 SP, PA dimethyl fumarate cpdr Tier 1 SP dimethyl fumarate misc Tier 1 SP EXTAVIA Tier 2 SP GILENYA Tier 2 SP KESIMPTA Tier 2 SP MAVENCLAD Tier 4 SP, PA MAYZENT Tier 2 SP MAYZENT STARTER PACK Tier 2 SP OCREVUS LA SP, PA REBIF Tier 2 SP REBIF REBIDOSE Tier 2 SP REBIF REBIDOSE TITRATION Tier 2 SP REBIF TITRATION PACK Tier 2 SP TECFIDERA Tier 4 SP TECFIDERA STARTER PACK Tier 4 SP TYSABRI LA SP, PA; Preferred PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 99 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits VUMERITY Tier 2 SP ZEPOSIA Tier 2 SP ZEPOSIA 7-DAY STARTER PAC Tier 2 SP ZEPOSIA STARTER KIT Tier 2 SP POSTHERPETIC NEURALGIA (PHN)/NEUROPATHIC PAIN AGENTS GRALISE Tier 3 PA LYRICA CR Tier 3 pregabalin (once-daily) Tier 1 PREMENSTRUAL DYSPHORIC DISORDER (PMDD) AGENTS fluoxetine hcl (pmdd) Tier 3 PSEUDOBULBAR AFFECT (PBA) AGENTS NUEDEXTA Tier 3 PA PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. ergoloid mesylates Tier 1 pimozide Tier 1 SMOKING DETERRENTS APO-VARENICLINE ACA AL bupropion hcl (smoking deterrent) ACA AL CHANTIX ACA AL CHANTIX CONTINUING MONTH ACA AL CHANTIX STARTING MONTH PA ACA AL nicotine ACA AL nicotine polacrilex ACA AL NICOTROL INHALER ACA AL NICOTROL NS ACA AL TRANSTHYRETIN AMYLOIDOSIS AGENTS ONPATTRO LA SP, PA VASOMOTOR SYMPTOM AGENTS BRISDELLE Tier 3 QL paroxetine mesylate (vasomotor) Tier 3 QL RESPIRATORY AGENTS - MISC. ALPHA-PROTEINASE INHIBITOR (HUMAN) ARALAST NP LA SP, PA; Non-Preferred GLASSIA LA SP, PA; Non-Preferred PROLASTIN-C LA SP, PA; Preferred ZEMAIRA LA SP, PA; Non-Preferred CYSTIC FIBROSIS AGENTS BRONCHITOL Tier 4 SP, PA BRONCHITOL TOLERANCE TEST Tier 4 SP, PA KALYDECO Tier 4 SP, PA ORKAMBI Tier 4 SP, PA PULMOZYME Tier 2 SP, PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 100 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits SYMDEKO Tier 4 SP, PA SYMDEKO Tier 4 SP, PA, QL TRIKAFTA Tier 4 SP, PA PULMONARY FIBROSIS AGENTS ESBRIET Tier 4 SP, PA OFEV Tier 4 SP, PA RESPIRATORY AGENTS - MISC. CUROSURF LA PA INFASURF LA PA SURVANTA INTRATRACHEAL LA PA SULFONAMIDES SULFONAMIDES SULFADIAZINE Tier 1 TETRACYCLINES AMINOMETHYLCYCLINES NUZYRA SOLR LA PA NUZYRA TABS Tier 4 SP, PA FLUOROCYCLINES XERAVA LA PA GLYCYLCYCLINES tigecycline LA TETRACYCLINES ACTICLATE Tier 3 demeclocycline hcl Tier 1 DORYX Tier 3 PA DORYX MPC Tier 3 PA doxycycline (monohydrate) Tier 1 doxycycline hyclate caps; tabs; tbec Tier 1 doxycycline hyclate solr LA MINOCIN LA minocycline hcl Tier 1 tetracycline hcl Tier 1 VIBRAMYCIN Tier 3 THYROID AGENTS ANTITHYROID AGENTS methimazole Tier 1 propylthiouracil Tier 1 TAPAZOLE Tier 3 THYROID HORMONES ARMOUR THYROID Tier 2 CYTOMEL Tier 3

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 101 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits levothyroxine sodium caps 13mcg, 25mcg, Tier 1 50mcg, 75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg LEVOTHYROXINE SODIUM CAPS 175mcg, Tier 1 200mcg levothyroxine sodium tabs Tier 1 liothyronine sodium soln LA PA liothyronine sodium tabs Tier 1 NATURE-THROID Tier 1 SYNTHROID Tier 2 thyroid Tier 1 TIROSINT Tier 3 TIROSINT-SOL Tier 3 QL TRIOSTAT LA PA WESTHROID 32.5mg, 65mg, 97.5mg, Tier 2 130mg WESTHROID 195mg Tier 1 WP THYROID Tier 2 ULCER DRUGS//ANTICHOLINERGICS ANTISPASMODICS BENTYL Tier 3 CUVPOSA Tier 3 dicyclomine hcl Tier 1 glycopyrrolate Tier 1 sulfate Tier 1 LEVBID Tier 3 LEVSIN Tier 3 LEVSIN/SL Tier 3 methscopolamine bromide Tier 1 SYMAX DUOTAB Tier 3 H-2 ANTAGONISTS cimetidine Tier 1 cimetidine hcl Tier 1 AL famotidine soln LA famotidine susr; tabs Tier 1 famotidine in nacl LA nizatidine caps Tier 1 ST nizatidine soln Tier 1 MISC. ANTI-ULCER CARAFATE Tier 3 sucralfate Tier 1 PROTON PUMP INHIBITORS esomeprazole sodium LA PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 102 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits FIRST-LANSOPRAZOLE Tier 1 FIRST-OMEPRAZOLE Tier 1 lansoprazole Tier 1 NEXIUM Tier 3 PA NEXIUM I.V. LA PA omeprazole Tier 1 OMEPRAZOLE + SYRSPEND SF Tier 1 pantoprazole sodium solr LA QL pantoprazole sodium tbec Tier 1 PROTONIX Tier 3 QL; AL rabeprazole sodium Tier 1 ULCER DRUGS - PROSTAGLANDINS CYTOTEC Tier 3 misoprostol Tier 1 ULCER THERAPY COMBINATIONS OMECLAMOX-PAK Tier 3 URINARY ANTISPASMODICS URINARY - ANTIMUSCARINICS (ANTICHOLINERGIC) hydrobromide Tier 1 QL DETROL Tier 3 DETROL LA Tier 3 DITROPAN XL Tier 3 GELNIQUE Tier 3 PA chloride Tier 1 succinate Tier 1 QL tartrate Tier 1 TOVIAZ Tier 2 Tier 1 QL VESICARE LS Tier 3 PA URINARY ANTISPASMODICS - BETA-3 ADRENERGIC AGONISTS MYRBETRIQ Tier 2 QL URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS chloride Tier 1 URINARY ANTISPASMODICS - DIRECT MUSCLE RELAXANTS hcl Tier 1 VACCINES BACTERIAL VACCINES ACTHIB ACA BEXSERO ACA HAEMOPHILUS B POLYSAC CONJ VAC ACA HIBERIX ACA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 103 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits MENACTRA ACA MENHIBRIX ACA MENOMUNE-A/C/Y/W-135 ACA MENVEO ACA PEDVAX HIB ACA PNEUMOVAX 23/5 DOSE ACA PREVNAR ACA PREVNAR 13 ACA TRUMENBA ACA MIXED VACCINE COMBINATIONS COMVAX ACA VIRAL VACCINES AFLURIA QUADRIVALENT 2020 ACA AL AFLURIA QUADRIVALENT 2021 ACA CERVARIX ACA ENGERIX-B ACA FLUAD 2020-2021 ACA AL FLUAD QUADRIVALENT INFLUE ACA AL FLUARIX QUADRIVALENT 2020 ACA AL FLUARIX QUADRIVALENT 2021 ACA FLUBLOK QUADRIVALENT 2020 ACA AL FLUBLOK QUADRIVALENT 2021 ACA FLUCELVAX QUADRIVALENT 20 SUSP ACA FLUCELVAX QUADRIVALENT 20 SUSP ACA AL FLUCELVAX QUADRIVALENT 20 SUSY ACA FLUCELVAX QUADRIVALENT 20 SUSY ACA AL FLULAVAL QUADRIVALENT 202 ACA FLULAVAL QUADRIVALENT 202 ACA AL FLUMIST QUADRIVALENT ACA AL FLUZONE HIGH-DOSE PF 2020 ACA AL FLUZONE QUADRIVALENT 2020 ACA AL FLUZONE QUADRIVALENT 2021 ACA GARDASIL ACA AL GARDASIL 9 ACA AL HAVRIX ACA HEPATITIS A VACCINE INJ 1 ACA HEPLISAV-B ACA IPOL INACTIVATED IPV ACA M-M-R II W/DILUENT 1 DOSE ACA PROQUAD ACA RECOMBIVA-HB INJ 2.5/.5ML ACA RECOMBIVAX HB ACA ROTARIX ACA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 104 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits ROTASHIELD SOL ACA ROTATEQ ACA SHINGRIX ACA AL TWINRIX ACA VAQTA ACA VARIVAX ACA ZOSTAVAX ACA AL VAGINAL AND RELATED PRODUCTS MISCELLANEOUS VAGINAL PRODUCTS INTRAROSA Tier 3 VAGINAL ANTI-INFECTIVES CLEOCIN CREA; SUPP Tier 3 clindamycin phosphate vaginal Tier 1 CLINDESSE Tier 2 GYNAZOLE-1 Tier 3 metronidazole vaginal Tier 1 miconazole nitrate vaginal Tier 1 QL NUVESSA Tier 3 terconazole vaginal crea Tier 1 terconazole vaginal supp Tier 1 QL VAGINAL ESTROGENS ESTRACE CREA Tier 3 estradiol vaginal Tier 1 ESTRING Tier 2 FEMRING Tier 3 IMVEXXY MAINTENANCE PACK Tier 3 IMVEXXY STARTER PACK Tier 3 PREMARIN CREA Tier 2 QL VAGIFEM Tier 3 VAGINAL PROGESTINS CRINONE Tier 2 QL ENDOMETRIN Tier 2 VASOPRESSORS ANAPHYLAXIS THERAPY AGENTS epinephrine (anaphylaxis) Tier 1 QL EPIPEN 2-PAK Tier 3 QL EPIPEN-JR 2-PAK Tier 3 QL SYMJEPI Tier 3 QL NEUROGENIC ORTHOSTATIC HYPOTENSION (NOH) - AGENTS droxidopa Tier 1 SP, PA NORTHERA Tier 4 SP, PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 105 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Drug Name Drug Tier Requirements/Limits VASOPRESSORS midodrine hcl Tier 1 VITAMINS OIL SOLUBLE VITAMINS cholecalciferol Tier 1 DRISDOL Tier 3 ergocalciferol Tier 1 MEPHYTON Tier 3 phytonadione soln LA phytonadione tabs Tier 1 WATER SOLUBLE VITAMINS POTABA Tier 2 pyridoxine hcl Tier 1 thiamine hcl Tier 1

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty 106 AL - Age Restriction MB - Medical Benefit LA- Limited Access ACA- Affordable Care Act MNPA- Medical Necessity PA GENDER- Gender Limits GH- Growth Hormone

Index 1 acetic acid ...... 63 1ST TIER UNIFINE PENTIPS ...... 83 acetic acid (otic) ...... 96 1ST TIER UNILET COMFORTOU ...... 77 acetylcysteine ...... 50 A acetylcysteine (antidote) ...... 22 abacavir sulfate...... 40 acitretin ...... 52 abacavir sulfate-lamivudine ...... 40 ACTEMRA ...... 3 abacavir sulfate-lamivudine-zidovudine ACTHAR ...... 58 ...... 40 ACTHIB ...... 103 ABECMA ...... 32 ACTICLATE ...... 101 ABELCET ...... 23 ACTIMMUNE ...... 36 ABILIFY ...... 40 ACTIQ ...... 5 ABILIFY MAINTENA ...... 40 ACTIVELLA ...... 60 abiraterone acetate ...... 32 ACTONEL ...... 57 ABOUTTIME PEN NEEDLE 32G ...... 79 ACTOPLUS MET ...... 19 ABOUTTIME PEN NEEDLES 30G ...... 79 ACTOS ...... 21 ABOUTTIME PEN NEEDLES 31G ...... 79 ACULAR ...... 95 ABRAXANE ...... 37 ACULAR LS ...... 95 ABSORICA ...... 50 ACUVAIL ...... 95 ABSORICA LD ...... 50 acyclovir ...... 42 acamprosate calcium ...... 98 acyclovir sodium ...... 42 acarbose ...... 19 acyclovir topical ...... 52 ACCOLATE ...... 13 ACZONE ...... 50 ACCU-CHEK ACTIVE STRIPS ...... 56 ADAKVEO ...... 66 ACCU-CHEK ADVANTAGE STRIP ...... 56 adapalene ...... 50 ACCU-CHEK AVIVA ...... 56, 69 ADASUVE ...... 39 ACCU-CHEK AVIVA PLUS ...... 56, 69 ADCETRIS ...... 31 ACCU-CHEK COMFORT CURVE T ...... 56 ADCIRCA ...... 45 ACCU-CHEK COMPACT PLUS ...... 56 ADDERALL ...... 1 ACCU-CHEK COMPACT PLUS CA ...... 69 ADDERALL XR ...... 1 ACCU-CHEK COMPACT TEST DR ...... 56 ADDYI ...... 99 ACCU-CHEK FASTCLIX LANCET ...... 69 adefovir dipivoxil ...... 42 ACCU-CHEK GUIDE ...... 56, 69 ADEMPAS ...... 45 ACCU-CHEK GUIDE ME...... 69 ADIPEX-P ...... 1 ACCU-CHEK MULTICLIX LANCE ...... 69 ADLYXIN ...... 20 ACCU-CHEK NANO SMARTVIEW ...... 69 ADLYXIN STARTER PACK ...... 20 ACCU-CHEK SAFE-T-PRO LANC ...... 69 ADRENALIN ...... 91 ACCU-CHEK SAFE-T-PRO PLUS ...... 69 ADVAIR DISKUS ...... 14 ACCU-CHEK SMARTVIEW STRIP ...... 56 ADVAIR HFA ...... 14 ACCU-CHEK SOFTCLIX LANCET ...... 69 ADVANCE INTUITION BLOOD G ...... 69 ACCUPRIL ...... 26 ADVANCE MICRO-DRAW METER ...... 69 ACCURETIC ...... 27 ADVANCED MOBILE LANCET 30 ...... 69 acebutolol hcl ...... 43 ADVATE ...... 64 ACETADOTE ...... 22 ADVOCATE BLOOD GLUCOSE MO ..... 69 acetaminophen w/ codeine ...... 7 ADVOCATE LANCETS ...... 69 acetaminophen-caff-dihydrocod ...... 7 ADVOCATE LANCETS 30G ...... 69 acetazolamide ...... 56 ADVOCATE REDI-CODE ...... 69 107

ADVOCATE REDI-CODE+ BLOOD ...... 69 ALLZITAL ...... 5 ADVOCATE SAFETY LANCETS 2 ...... 69 almotriptan malate ...... 85 ADYNOVATE ...... 64 ALOCRIL ...... 95 AEROCHAMBER MINI AEROSOL ...... 84 alogliptin benzoate ...... 20 AEROCHAMBER MV ...... 84 ALOMIDE ...... 95 AEROCHAMBER PLUS FLOW-VU ...... 84 ALORA ...... 61 AEROCHAMBER PLUS FLOW-VU/ ...... 84 alosetron hcl ...... 63 AEROCHAMBER Z-STAT PLUS/M ...... 84 ALOXI ...... 22 AEROCHAMBER/FLOWSIGNAL ...... 84 ALPHAGAN P ...... 93 AEROVENT PLUS HOLDING CHA ...... 84 ALPHANATE ...... 64 AFINITOR ...... 34 ALPHANINE SD ...... 64 AFINITOR DISPERZ ...... 34 alprazolam ...... 12 AFLURIA QUADRIVALENT 2020 ...... 104 ALPRAZOLAM INTENSOL ...... 12 AFLURIA QUADRIVALENT 2021 ...... 104 ALPROLIX ...... 64 AFSTYLA ...... 64 alprostadil ...... 88 AGAMATRIX AMP NO CODE ADV ...... 69 ALREX ...... 94 AGAMATRIX PRESTO PRO METE ...... 69 ALTABAX ...... 51 AGAMATRIX ULTRA-THIN LANC ...... 69 ALTOPREV ...... 25 AGRYLIN ...... 66 ALTRENO ...... 50 AIMOVIG ...... 85 ALUNBRIG ...... 34 AIMSCO TWIST LANCETS 32G...... 69 amantadine hcl ...... 38 AIMSCO TWIST LANCETS 33G...... 69 AMARYL ...... 21 AIRDUO RESPICLICK 113/14 ...... 14 AMBISOME ...... 23 AIRDUO RESPICLICK 232/14 ...... 14 ambrisentan ...... 45 AIRDUO RESPICLICK 55/14 ...... 14 amcinonide ...... 53 AJOVY ...... 85 AMELUZ ...... 51 AKYNZEO ...... 22 AMERGE ...... 85 albendazole ...... 8 AMICAR ...... 67 ALBENZA ...... 9 amikacin sulfate ...... 2 albuterol sulfate ...... 14 amiloride & hydrochlorothiazide ...... 57 ALCAINE ...... 94 amiloride hcl ...... 57 alclometasone dipropionate ...... 53 aminocaproic acid ...... 67 ALDACTAZIDE ...... 57 amiodarone hcl ...... 12 ALDACTONE ...... 57 AMITIZA ...... 62 ALDURAZYME ...... 59 amitriptyline hcl ...... 19 ALECENSA ...... 34 amlodipine besylate ...... 44 alendronate sodium ...... 57 amlodipine besylate-atorvastatin ALFERON N ...... 36 calcium ...... 44 alfuzosin hcl ...... 63 amlodipine besylate-benazepril hcl ... 27 ALIMTA ...... 30 amlodipine besylate-olmesartan ALINIA ...... 9 medoxomil ...... 27 ALIQOPA ...... 34 amlodipine besylate-valsartan ...... 27 aliskiren fumarate ...... 28 amlodipine-valsartan- ALKERAN ...... 29 hydrochlorothiazide ...... 27 ALLERGY SYRINGE/1ML/27G X ...... 79 amoxapine ...... 19 ALLERGY SYRINGES INTRADER ...... 79 amoxicillin ...... 97 allopurinol ...... 64 amoxicillin & pot clavulanate ...... 97 108 amphetamine sulfate ...... 1 armodafinil ...... 2 amphetamine-dextroamphetamine .... 1 ARMOUR THYROID ...... 101 amphotericin b ...... 23 ARNUITY ELLIPTA ...... 13 ampicillin...... 97 AROMASIN ...... 32 ampicillin & sulbactam sodium ...... 98 ARRANON...... 30 ampicillin sodium ...... 97 arsenic trioxide ...... 36 AMVISC ...... 95 ARTHROTEC 50 ...... 3 AMVISC PLUS ...... 95 ARZERRA ...... 31 ANACAINE ...... 55 ASCENIV ...... 97 ANAFRANIL ...... 19 asenapine maleate ...... 39 anagrelide hcl ...... 66 ASMANEX HFA ...... 13 ANALPRAM HC ...... 8 ASMANEX TWISTHALER 120 ME ...... 13 ANALPRAM HC SINGLES ...... 8 ASMANEX TWISTHALER 14 MET ...... 13 ANALPRAM-HC ...... 8 ASMANEX TWISTHALER 30 MET ...... 13 anastrozole ...... 32 ASMANEX TWISTHALER 60 MET ...... 13 ANCOBON ...... 23 ASMANEX TWISTHALER 7 METE ...... 13 ANDRODERM ...... 7 ASPARLAS ...... 36 ANDROGEL ...... 7 aspirin-dipyridamole ...... 66 ANDROGEL PUMP ...... 8 ASSURE 3 METER ...... 69 ANGELIQ ...... 60 ASSURE 4 BLOOD GLUCOSE ME ...... 69 ANNOVERA ...... 48 ASSURE COMFORT LANCETS UL ...... 69 ANORO ELLIPTA ...... 14 ASSURE HAEMOLANCE PLUS HI ...... 70 ANTARA ...... 25 ASSURE HAEMOLANCE PLUS LO ...... 70 ANUSOL-HC ...... 8 ASSURE HAEMOLANCE PLUS MI ...... 70 APEXICON E ...... 53 ASSURE HAEMOLANCE PLUS NO ...... 70 APLENZIN...... 18 ASSURE HAEMOLANCE PLUS PE ...... 70 APOKYN ...... 38 ASSURE ID SAFETY PEN NEED ...... 79 APO-VARENICLINE ...... 100 ASSURE LANCE LANCETS ...... 70 apraclonidine hcl ...... 93 ASSURE LANCE LANCETS 21G ...... 70 aprepitant ...... 23 ASSURE LANCE PLUS SAFETY ...... 70 APTENSIO XR ...... 1 ASSURE LANCE SAFETY LANCE ...... 70 APTIOM ...... 15 ASSURE PLATINUM BLOOD GLU ...... 70 APTIVUS ...... 40 ASSURE PRISM MULTI BLOOD ...... 70 AQUALANCE LANCETS UL TRA ...... 69 ASSURE PRO BLOOD GLUCOSE ...... 70 ARALAST NP ...... 100 ASTAGRAF XL ...... 87 ARANESP ALBUMIN FREE ...... 66 ATACAND ...... 26 ARAVA ...... 4 ATACAND HCT ...... 27 ARCALYST ...... 3 atazanavir sulfate ...... 40 arformoterol tartrate...... 14 ATELVIA ...... 57 ARICEPT ...... 98 atenolol ...... 43 ARIDA ...... 55 atenolol & chlorthalidone ...... 27 ARIKAYCE ...... 2 ATGAM...... 87 ARIMIDEX ...... 32 ATIVAN ...... 12 aripiprazole ...... 40 atomoxetine hcl ...... 1 ARISTADA ...... 40 atorvastatin calcium ...... 25 ARISTADA INITIO ...... 40 atovaquone ...... 9 ARIXTRA ...... 15 atovaquone-proguanil hcl ...... 28 109 atropine sulfate ...... 92 BACTRIM DS ...... 9 ATROVENT HFA ...... 13 balsalazide disodium ...... 62 AUBAGIO ...... 99 BALVERSA ...... 34 AUGMENTIN ...... 98 BANZEL ...... 16 AURORA LANCET SUPER THIN ...... 70 BAQSIMI ONE PACK ...... 20 AURORA LANCET THIN 23G ...... 70 BAQSIMI TWO PACK ...... 20 AURORA PEN NEEDLES 29GX12 ...... 79 BARACLUDE ...... 42 AURORA PEN NEEDLES 31G X ...... 79 BASADROX ...... 56 AURORA UNIFINE PENTIPS/32 ...... 79 BASAGLAR KWIKPEN ...... 20 AURORA UNIFINE PENTIPS/MI ...... 79 BAVENCIO ...... 31 AURYXIA ...... 63 BAXDELA ...... 61 AUSTEDO ...... 99 b-complex w/ c-biotin-minerals & folic AUTOLET PLATFORMS ...... 70 acid ...... 89 AVALIDE ...... 27 BD BLUNT FILL NEEDLE/18G ...... 79 AVAPRO ...... 26 BD DISPOSABLE NEEDLE 23GX ...... 79 AVEED ...... 8 BD HYPODERMIC NEEDLES 18G ...... 79 AVODART ...... 63 BD INSULIN SYRINGE MICROF ...... 79 AVONEX ...... 99 BD INSULIN SYRINGE/DETACH ...... 79 AVONEX PEN ...... 99 BD LANCET ULTRAFINE 30G ...... 70 AVSOLA ...... 62 BD LANCET ULTRAFINE 33G ...... 70 AVYCAZ ...... 46 BD LUER LOCK SYRINGE/1ML/ ...... 79 AYGESTIN ...... 98 BD LUER-LOK SYRINGE W/ECL ...... 79 AYVAKIT ...... 33 BD MICROTAINER LANCETS ...... 70 azacitidine ...... 30 BD NEEDLE/18G 1-1/2 ...... 79 AZACTAM ...... 10 BD NEEDLE/21G 1-1/2 ...... 79 AZADROX ...... 55 BD NEEDLE/30G X 1/2 ...... 80 AZASAN ...... 87 BD PEN NEEDLE/MICRO/ULTRA ...... 80 AZASITE ...... 93 BD PEN NEEDLE/MINI/ULTRA- ...... 80 azathioprine ...... 87 BD PEN NEEDLE/NANO 2ND GE ...... 80 azelaic acid ...... 55 BD PEN NEEDLE/NANO/ULTRA ...... 80 azelastine hcl ...... 91 BD PEN NEEDLE/ORIGINAL/UL ...... 80 azelastine hcl (ophth) ...... 95 BD PEN NEEDLE/SHORT/ULTRA...... 80 azelastine hcl-fluticasone propionate . 91 BD SAFETYGLIDE SHIELDED N ...... 80 AZELEX ...... 50 BD SYRINGE LUER-LOK/1ML ...... 80 AZILECT ...... 38 BD VEO INSULIN SYRINGE UL ...... 80 azithromycin ...... 68 BECONASE AQ ...... 91 AZOPT ...... 95 BELBUCA ...... 7 AZOR ...... 27 BELEODAQ ...... 34 aztreonam ...... 10 BELRAPZO ...... 29 AZULFIDINE ...... 62 BELSOMRA ...... 68 AZULFIDINE EN-TABS ...... 62 benazepril & hydrochlorothiazide ...... 27 B benazepril hcl ...... 26 bacitracin (ophthalmic) ...... 93 BENDEKA ...... 29 bacitracin-polymyxin b (ophth) ...... 93 BENEFIX ...... 64 bacitracin-poly-neomycin-hc ...... 94 BENLYSTA ...... 88 baclofen ...... 90 BENTYL ...... 102 BACTRIM ...... 9 BENZACLIN ...... 50 110

BENZACLIN WITH PUMP ...... 50 BLEPHAMIDE ...... 94 BENZAMYCIN ...... 50 BLEPHAMIDE S.O.P...... 94 benzonatate ...... 50 BLINCYTO ...... 31 benzoyl peroxide-erythromycin ...... 50 BLULINK BLOOD GLUCOSE MON ...... 70 benzphetamine hcl ...... 1 BONIVA ...... 57 benztropine mesylate ...... 37 BONJESTA ...... 23 BEOVU ...... 93 BORTEZOMIB...... 34 bepotastine besilate ...... 95 bosentan ...... 45 BEPREVE ...... 95 BOSULIF ...... 34 BERINERT ...... 65 BOTOX ...... 91 BESIVANCE ...... 93 BRAFTOVI ...... 34 BESPONSA ...... 31 BREATHE EASE/LARGE MASK ...... 84 BETADINE OPHTHALMIC PREP ...... 93 BREATHE EASE/MEDIUM MASK ...... 84 betamethasone dipropionate (topical) BREATHE EASE/SMALL MASK ...... 84 ...... 53 BREO ELLIPTA ...... 14 betamethasone dipropionate BREYANZI ...... 32 augmented ...... 53 BREZTRI AEROSPHERE ...... 14 betamethasone valerate ...... 53 BRILINTA ...... 66 BETAPACE ...... 43 brimonidine tartrate ...... 93 BETAPACE AF ...... 43 brinzolamide ...... 95 BETASERON...... 99 BRISDELLE ...... 100 betaxolol hcl ...... 43 BRIVIACT ...... 16 betaxolol hcl (ophth) ...... 92 bromfenac sodium (ophth) ...... 95 bethanechol chloride ...... 103 bromocriptine mesylate ...... 38 BETHKIS ...... 2 BROMSITE ...... 95 BETIMOL ...... 92 BRONCHITOL ...... 100 BETOPTIC-S ...... 92 BRONCHITOL TOLERANCE TEST ..... 100 BEVACIZUMAB ...... 93 BROVANA ...... 14 BEVESPI AEROSPHERE ...... 14 BRUKINSA ...... 34 bexarotene ...... 36 BRYHALI ...... 53 BEXSERO ...... 103 budesonide ...... 49 BEYAZ ...... 47 budesonide (inhalation) ...... 13 bicalutamide ...... 32 bumetanide ...... 57 BICILLIN C-R ...... 98 BUPHENYL ...... 59 BICILLIN L-A ...... 97 BUPRENEX ...... 7 BICNU...... 29 buprenorphine ...... 7 BIDIL ...... 44 buprenorphine hcl ...... 7 BIJUVA ...... 60 buprenorphine hcl-naloxone hcl BIKTARVY ...... 40 dihydrate...... 7 BILTRICIDE ...... 9 bupropion hcl ...... 18 bimatoprost ...... 96 bupropion hcl (smoking deterrent) . 100 BINOSTO ...... 57 buspirone hcl ...... 12 bisoprolol & hydrochlorothiazide ...... 27 BUSULFEX ...... 29 bisoprolol fumarate ...... 43 butalbital-acetaminophen ...... 5 BIVIGAM ...... 97 butalbital-acetaminophen-caffeine ..... 5 bleomycin sulfate ...... 33 butalbital-acetaminophen-caffeine w/ BLEPH-10 ...... 93 codeine ...... 7 111 butalbital-aspirin-caffeine ...... 5 CAREFINE PEN NEEDLE 32GX4 ...... 80 butalbital-aspirin-caffeine w/cod ...... 7 CAREFINE PEN NEEDLES 31GX ...... 80 butorphanol tartrate ...... 7 CAREFINE PEN NEEDLES 32GX ...... 80 BYSTOLIC ...... 43 CAREONE LANCET SUPER THIN ...... 70 C CAREONE LANCET THIN ...... 70 CABENUVA ...... 40 CAREONE UNIFINE PENTIPS 2 ...... 80 cabergoline ...... 60 CAREONE UNIFINE PENTIPS 3 ...... 80 CABOMETYX ...... 34 CAREONE UNIFINE PENTIPS P...... 80 CADUET ...... 44 CARESENS LANCETS ...... 70 CAFERGOT ...... 85 CARESENS N GLUCOSE MONITO ...... 70 caffeine citrate ...... 1 CARESENS N VOICE BLOOD GL ...... 70 CALAN SR ...... 44 CARETOUCH PEN NEEDLES 31 ...... 80 calcipotriene ...... 52 CARETOUCH PEN NEEDLES 31G ...... 80 calcipotriene-betamethasone CARETOUCH PEN NEEDLES 32G ...... 80 dipropionate ...... 53 CARETOUCH SAFETY LANCETS/ ...... 70 calcitonin (salmon) ...... 57 CARETOUCH TWIST LANCETS 2 ...... 70 calcitriol ...... 59 CARETOUCH TWIST LANCETS 3 ...... 70 calcitriol (topical) ...... 52 carisoprodol ...... 90 calcium acetate (phosphate binder) .. 63 carisoprodol w/ aspirin & codeine ..... 90 CALDOLOR ...... 3 carmustine ...... 29 CALQUENCE ...... 34 CAROSPIR ...... 57 CAMPTOSAR ...... 37 carteolol hcl (ophth) ...... 92 CANASA ...... 62 carvedilol ...... 43 candesartan cilexetil ...... 26 carvedilol phosphate ...... 43 candesartan cilexetil- CASODEX ...... 32 hydrochlorothiazide ...... 27 caspofungin acetate ...... 23 CAPASTAT SULFATE ...... 29 CATAPRES-TTS-1 ...... 26 capecitabine ...... 30 CATAPRES-TTS-2 ...... 26 CAPEX ...... 53 CATAPRES-TTS-3 ...... 26 CAPLYTA ...... 38 CATHFLO ACTIVASE ...... 66 CAPRELSA ...... 34 CAVERJECT IMPULSE ...... 44 captopril ...... 26 CAYA ...... 69 CARAC ...... 51 CAYSTON ...... 10 CARAFATE ...... 102 cefaclor ...... 46 CARBAGLU ...... 59 cefadroxil ...... 46 carbamazepine ...... 16 CEFAZOLIN ...... 46 CARBATROL ...... 16 cefazolin sodium ...... 46 carbidopa ...... 37 CEFAZOLIN SODIUM ...... 46 carbidopa-levodopa ...... 38 CEFAZOLIN SODIUM/DEXTROSE ...... 46 carbidopa-levodopa-entacapone ...... 38 cefdinir ...... 46 carbinoxamine maleate ...... 24 CEFEPIME...... 46 carboplatin ...... 29 cefepime hcl ...... 46 CARDIZEM ...... 44 CEFEPIME/DEXTROSE ...... 46 CARDIZEM CD ...... 44 cefixime ...... 46 CARDIZEM LA ...... 44 CEFOTAN ...... 46 CARDURA ...... 26 cefotaxime sodium ...... 46 CARDURA XL ...... 64 cefotetan disodium ...... 46 112

CEFOTETAN/DEXTROSE ...... 46 choline fenofibrate ...... 25 cefoxitin sodium ...... 46 ciclopirox ...... 51 CEFOXITIN SODIUM ...... 46 ciclopirox olamine ...... 51 cefpodoxime proxetil ...... 46 cidofovir ...... 42 cefprozil ...... 46 cilostazol ...... 66 ceftazidime ...... 46 CILOXAN ...... 93 CEFTAZIDIME/DEXTROSE ...... 46 CIMDUO ...... 40 ceftriaxone sodium ...... 46 cimetidine ...... 102 ceftriaxone sodium in dextrose ...... 46 cimetidine hcl ...... 102 CEFTRIAXONE/DEXTROSE ...... 46 cinacalcet hcl ...... 59 cefuroxime axetil ...... 46 CINQAIR ...... 13 cefuroxime sodium ...... 46 CINRYZE ...... 65 celecoxib ...... 3 CINVANTI ...... 23 CELEXA ...... 18 CIPRO ...... 61 CELLCEPT ...... 87 CIPRO HC ...... 96 CELLCEPT INTRAVENOUS ...... 87 CIPRODEX ...... 96 CELONTIN ...... 17 ciprofloxacin hcl ...... 61 CENTANY ...... 51 ciprofloxacin hcl (ophth) ...... 93 cephalexin ...... 46 ciprofloxacin hcl (otic) ...... 96 CEPROTIN ...... 65 ciprofloxacin in d5w ...... 61 CERDELGA...... 66 ciprofloxacin-dexamethasone ...... 96 CEREBYX ...... 17 ciprofloxacin-fluocinolone acetonide .. 96 CEREZYME ...... 66 cisplatin ...... 29 CERVARIX ...... 104 citalopram hydrobromide ...... 18 CETRAXAL ...... 96 cladribine ...... 30 cevimeline hcl ...... 89 clarithromycin ...... 68 CHANTIX ...... 100 CLEANLET LANCETS 28G ...... 70 CHANTIX CONTINUING MONTH ...... 100 clemastine fumarate ...... 24 CHANTIX STARTING MONTH PA ..... 100 CLEOCIN ...... 10, 105 CHEMET ...... 21 CLEOCIN PEDIATRIC GRANULE ...... 10 CHENODAL ...... 62 CLEOCIN PHOSPHATE ...... 10 chloramphenicol sodium succinate .... 10 CLEVER CHEK AUTO CODE VOI ...... 70 chlordiazepoxide hcl ...... 12 CLEVER CHEK AUTO-CODE BLO ...... 70 chlordiazepoxide-amitriptyline ...... 99 CLEVER CHEK LANCETS ULTRA ...... 70 CHLORHEXIDINE GLUCONATE ...... 40 CLEVER CHOICE ANTI-STATIC ...... 84 chlorhexidine gluconate (mouth-throat) CLEVER CHOICE AUTO-CODE P ...... 70 ...... 88 CLEVER CHOICE COMFORT EZ ... 70, 80 chloroquine phosphate ...... 28 CLEVER CHOICE MINI BLOOD ...... 70 chlorpromazine hcl ...... 40 CLEVER CHOICE TALK BLOOD ...... 70 CHLORPROMAZINE HCL ...... 40 CLICKFINE PEN NEEDLE 32GX ...... 80 chlorthalidone ...... 57 CLICKFINE PEN NEEDLES 31G ...... 80 chlorzoxazone ...... 90 CLIMARA ...... 61 CHLORZOXAZONE ...... 90 CLIMARA PRO ...... 60 CHOLBAM ...... 61 clindamycin hcl ...... 10 cholecalciferol ...... 106 clindamycin palmitate hydrochloride . 10 cholestyramine ...... 24 clindamycin phosphate ...... 10 cholestyramine light ...... 24 clindamycin phosphate (topical) ...... 50 113 clindamycin phosphate in d5w ...... 10 COMBIVIR ...... 40 clindamycin phosphate vaginal ...... 105 COMETRIQ ...... 34 clindamycin phosphate-benzoyl COMFORT ASSURED LANCETS M ...... 70 peroxide ...... 50 COMFORT ASSURED LANCETS S ...... 70 clindamycin phosphate-benzoyl COMFORT EZ INSULIN SYRING ...... 80 peroxide (refrigerate) ...... 50 COMFORT EZ MICRO/32G X 4M...... 80 clindamycin phosphate-tretinoin ...... 50 COMFORT EZ SHORT/31G X 8M ...... 80 CLINDAMYCIN/SODIUM CHLORI ...... 10 COMFORT EZ/31G X 5MM ...... 80 CLINDESSE ...... 105 COMFORT EZ/31G X 6MM ...... 80 clobazam ...... 15 COMFORT LANCETS ...... 70 clobetasol propionate ...... 53 COMFORT TOUCH LANCETS ULT ...... 70 clobetasol propionate emollient base 53 COMFORT TOUCH PEN NEEDLES ...... 80 clobetasol propionate emulsion ...... 53 COMFORT TOUCH PLUS SAFETY ...... 70 CLOBEX ...... 53 COMPACT SPACE CHAMBER/ANT ...... 84 clocortolone pivalate ...... 53 COMTAN ...... 38 clofarabine ...... 30 COMVAX ...... 104 clomipramine hcl ...... 19 CONCERTA ...... 2 clonazepam ...... 15 CONDYLOX ...... 55 clonidine ...... 27 CONTOUR BLOOD GLUCOSE MON .... 70 clonidine hcl ...... 27 CONTOUR NEXT ONE BLOOD GL ...... 70 clonidine hcl (adhd) ...... 1 CONTRAVE ...... 1 clopidogrel bisulfate ...... 66 COOL BLOOD GLUCOSE MONITO ...... 71 clorazepate dipotassium ...... 12 COPAXONE ...... 99 clotrimazole ...... 88 COPIKTRA ...... 34 clotrimazole (topical) ...... 51 CORDRAN ...... 53 clotrimazole w/ betamethasone ...... 51 COREG ...... 43 clozapine ...... 39 COREG CR ...... 43 CLOZARIL...... 39 CORGARD ...... 43 COAGADEX ...... 64 CORIFACT ...... 64 COAGUCHEK LANCETS ...... 70 CORLANOR ...... 45 COARTEM ...... 28 CORTEF ...... 49 codeine sulfate ...... 5 CORTENEMA ...... 8 CODEINE SULFATE ...... 5 CORTIFOAM ...... 8 COGENTIN ...... 38 CORTISPORIN-TC ...... 96 colchicine ...... 64 COSELA ...... 36 colchicine w/ probenecid ...... 64 COSENTYX ...... 52 COLCRYS ...... 64 COSENTYX SENSOREADY PEN ...... 52 colesevelam hcl ...... 24 COSMEGEN ...... 33 COLESTID ...... 24 COSOPT ...... 92 COLESTID FLAVORED ...... 24 COSOPT PF ...... 92 colestipol hcl ...... 24 COTELLIC ...... 34 colistimethate sodium ...... 11 COTEMPLA XR-ODT ...... 2 COLLATYL ...... 56 COUPON ONE TOUCH ULTRA MI ...... 71 COLY-MYCIN M ...... 11 COZAAR ...... 26 COMBIGAN ...... 92 CREON ...... 56 COMBIPATCH ...... 60 CRESEMBA ...... 23 COMBIVENT RESPIMAT ...... 14 CRINONE ...... 105 114

CRIXIVAN ...... 40 DANYELZA ...... 31 cromolyn sodium ...... 13 dapsone ...... 10 cromolyn sodium (mastocytosis) ...... 62 dapsone (topical) ...... 50 cromolyn sodium (ophth) ...... 95 daptomycin ...... 10 CRYSVITA ...... 59 DARAPRIM...... 28 CUPRIMINE ...... 87 darifenacin hydrobromide ...... 103 CUROSURF ...... 101 DARZALEX ...... 31 CUTAQUIG ...... 97 DARZALEX FASPRO ...... 34 CUTIVATE...... 53 daunorubicin hcl ...... 33 CUVITRU ...... 97 DAUNORUBICIN HYDROCHLORID ..... 33 CUVPOSA ...... 102 DAURISMO ...... 32 CVS LANCETS 21G ...... 71 DAYPRO ...... 3 CVS LANCETS MICRO THIN 33 ...... 71 DAYTRANA ...... 2 CVS LANCETS MICRO-THIN 33 ...... 71 DDAVP ...... 60 CVS LANCETS ORIGINAL ...... 71 decitabine ...... 30 CVS LANCETS THIN 26G ...... 71 deferasirox ...... 21 CVS LANCETS ULTRA THIN 30 ...... 71 deferoxamine mesylate ...... 22 CVS LANCETS ULTRA-THIN 30 ...... 71 DELESTROGEN ...... 61 cyanocobalamin ...... 66 DELSTRIGO ...... 40 cyclobenzaprine hcl ...... 90 demeclocycline hcl ...... 101 CYCLOGYL ...... 93 DEMEROL ...... 5 CYCLOMYDRIL ...... 93 DEMSER ...... 26 cyclopentolate hcl ...... 93 DENAVIR ...... 52 cyclophosphamide ...... 29 DEPAKOTE ...... 17 CYCLOPHOSPHAMIDE ...... 29 DEPAKOTE ER ...... 17 cycloserine ...... 29 DEPAKOTE SPRINKLES ...... 17 CYCLOSET ...... 20 DEPEN TITRATABS ...... 87 cyclosporine ...... 87 DEPO-ESTRADIOL ...... 61 cyclosporine modified (for DEPO-MEDROL ...... 49 microemulsion) ...... 87 DEPO-PROVERA CONTRACEPTIV ...... 48 cyproheptadine hcl ...... 24 DEPO-SUBQ PROVERA 104 ...... 48 CYRAMZA ...... 30 DEPO-TESTOSTERONE ...... 8 CYSTADROPS ...... 96 DERMA-SMOOTHE/FS BODY ...... 53 CYSTAGON ...... 63 DERMA-SMOOTHE/FS SCALP ...... 53 CYSTARAN ...... 96 DERMOTIC ...... 96 cytarabine ...... 30 DESCOVY ...... 41 CYTOMEL ...... 101 DESFERAL ...... 22 CYTOTEC ...... 103 desipramine hcl...... 19 D desmopressin acetate ...... 60 D.H.E. 45 ...... 85 DESMOPRESSIN ACETATE ...... 60 dacarbazine ...... 36 desmopressin acetate spray ...... 60 DACOGEN ...... 30 desmopressin acetate spray dalfampridine ...... 99 refrigerated ...... 60 DALIRESP ...... 13 desogestrel & ethinyl estradiol ...... 47 danazol ...... 8 desogestrel-ethinyl estradiol (biphasic) DANTRIUM ...... 90 ...... 47 dantrolene sodium ...... 90 115 desogestrel-ethinyl estradiol (triphasic) DIFICID ...... 69 ...... 47 diflorasone diacetate ...... 53 desonide ...... 53 DIFLUCAN ...... 23 DESOWEN ...... 53 diflunisal ...... 5 desoximetasone ...... 53 digoxin ...... 44 DESVENLAFAXINE ER ...... 18 dihydroergotamine mesylate...... 85 desvenlafaxine succinate ...... 19 DILANTIN ...... 17 DETROL ...... 103 DILANTIN INFATABS ...... 17 DETROL LA ...... 103 DILANTIN-125 ...... 17 dexamethasone...... 49 DILATRATE SR ...... 11 DEXAMETHASONE ...... 49 DILAUDID ...... 5 DEXAMETHASONE INTENSOL ...... 49 diltiazem hcl ...... 44 dexamethasone sodium phosphate ... 49 diltiazem hcl coated beads ...... 44 dexamethasone sodium phosphate diltiazem hcl extended release beads 44 (ophth) ...... 94 dimethyl fumarate ...... 99 dexmethylphenidate hcl ...... 2 DIOVAN ...... 26 dexrazoxane hcl ...... 36 DIOVAN HCT ...... 27 dextroamphetamine sulfate ...... 1 DIPENTUM ...... 62 DEXTROAMPHETAMINE SULFATE ...... 1 diphenhydramine hcl ...... 24 dextrose...... 92 diphenoxylate w/ atropine ...... 21 dextrose in lactated ringers ...... 86 DIPROLENE ...... 53 dextrose w/ sodium chloride ...... 86 DIPROLENE AF ...... 53 DIACOMIT ...... 16 dipyridamole ...... 66 DIASTAT ACUDIAL ...... 15 disopyramide phosphate ...... 12 DIASTAT PEDIATRIC ...... 15 disulfiram ...... 98 DIATHRIVE BLOOD GLUCOSE M ...... 71 DITROPAN XL ...... 103 DIATHRIVE LANCETS ...... 71 DIURIL...... 57 DIATHRIVE LANCETS ULTRA T ...... 71 divalproex sodium ...... 17 DIATHRIVE PEN NEEDLE/31 G ...... 80 DIVIGEL ...... 61 DIATHRIVE PEN NEEDLE/31G ...... 80 docetaxel ...... 37 DIATHRIVE PEN NEEDLE/32G ...... 80 DOCETAXEL ...... 37 DIATHRIVE+ BLOOD GLUCOSE ...... 71 dofetilide ...... 12 DIATRUE PLUS BLOOD GLUCOS ...... 71 donepezil hydrochloride ...... 98 diazepam ...... 12 DOPTELET ...... 66 DIAZEPAM ...... 12 DORAL ...... 67 diazepam (anticonvulsant) ...... 15 DORYX ...... 101 DIBENZYLINE ...... 26 DORYX MPC ...... 101 diclofenac epolamine ...... 51 dorzolamide hcl ...... 96 diclofenac potassium ...... 3 DORZOLAMIDE HCL ...... 96 diclofenac sodium ...... 3 dorzolamide hcl-timolol maleate ...... 92 diclofenac sodium (actinic keratoses) 52 DOVATO ...... 41 diclofenac sodium (ophth) ...... 96 DOVONEX ...... 52 diclofenac sodium (topical) ...... 51 doxazosin mesylate ...... 27 diclofenac w/ misoprostol ...... 3 doxepin hcl ...... 19 dicloxacillin sodium ...... 98 doxepin hcl (antipruritic) ...... 52 dicyclomine hcl ...... 102 doxercalciferol ...... 59 diethylpropion hcl ...... 1 DOXIL ...... 33 116 doxorubicin hcl ...... 33 EASY STEP BLOOD GLUCOSE M ...... 71 doxorubicin hcl liposomal ...... 33 EASY TALK BLOOD GLUCOSE M ...... 71 doxycycline (monohydrate) ...... 101 EASY TOUCH 32GX5MM ...... 80 doxycycline (rosacea) ...... 55 EASY TOUCH 32GX6MM ...... 80 doxycycline hyclate ...... 101 EASY TOUCH ALLERGY TRAY S ...... 80 DRISDOL ...... 106 EASY TOUCH FLIPLOCK NEEDL ...... 80 dronabinol ...... 23 EASY TOUCH FLIPLOCK SAFET ...... 80 droperidol...... 12 EASY TOUCH FLURINGE SYRIN ...... 80 DROPLET LANCETS ULTRA THI ...... 71 EASY TOUCH HYPODERMIC NEE ...... 80 DROPLET MICRON 34G X 9/64 ...... 80 EASY TOUCH LANCETS 26G/PR ...... 71 DROPLET PEN NEEDLES 32G X ...... 80 EASY TOUCH LANCETS 28G/PR ...... 71 DROPLET PEN NEEDLES 32GX5 ...... 80 EASY TOUCH LANCETS 30G/PR ...... 71 DROPLET PERSONAL LANCETS ...... 71 EASY TOUCH LANCETS 32G/PR ...... 71 drospirenone-ethinyl estradiol ...... 47 EASY TOUCH LANCETS 33G/TW ...... 71 drospirenone-ethinyl estradiol- EASY TOUCH PEN NEEDLES 29 ...... 81 levomefolate calcium ...... 47 EASY TOUCH PEN NEEDLES 31 ...... 81 DROXIA ...... 66 EASY TOUCH PEN NEEDLES 32 ...... 81 droxidopa ...... 105 EASY TOUCH PEN NEEDLES/31 ...... 81 DRUG MART ON-THE-GO LANCE ...... 71 EASY TOUCH SAFETY LANCETS ...... 71 DRUG MART UNILET LANCETS ...... 71 EASY TOUCH SAFETY PEN NEE ...... 81 DRUG MART UNILET MICRO TH ...... 71 EASY TOUCH TUBERCULIN FLI ...... 81 DRYSOL ...... 55 EASY TOUCH TUBERCULIN SHE...... 81 DUAVEE ...... 60 EASY TRAK BLOOD GLUCOSE M ...... 71 DUETACT ...... 19 EASY TRAK II BLOOD GLUCOS ...... 71 duloxetine hcl ...... 19 EASYGLUCO ...... 71 DUOBRII ...... 53 EASYMAX NG SELF-MONITORIN ...... 71 DUOPA ...... 38 EASYMAX V BLOOD GLUCOSE S ...... 71 DUPIXENT ...... 54 EASYPOINT NEEDLE 23G X 1 ...... 81 DUREZOL ...... 94 EASYPOINT NEEDLE/18G X 1- ...... 81 DUROLANE ...... 90 EASYPOINT NEEDLE/21G X 1- ...... 81 dutasteride ...... 64 EC-NAPROSYN ...... 3 dutasteride-tamsulosin hcl ...... 64 econazole nitrate ...... 51 DUTOPROL ...... 27 ECOZA ...... 51 DYMISTA ...... 91 EDARBI ...... 26 DYRENIUM ...... 57 EDARBYCLOR ...... 27 E EDECRIN ...... 57 E.E.S. GRANULES ...... 68 EDEX ...... 45 EASIVENT ...... 84 EDLUAR ...... 67 EASIVENT/MASK-LARGE ...... 84 EDURANT ...... 41 EASIVENT/MASK-MEDIUM ...... 84 efavirenz ...... 41 EASIVENT/MASK-SMALL ...... 84 efavirenz-lamivudine-tenofovir EASY COMFORT LANCETS ...... 71 disoproxil fumarate ...... 41 EASY COMFORT LANCETS 30G/ ...... 71 EFFER-K ...... 86 EASY COMFORT LANCETS TWIS ...... 71 EFFIENT ...... 66 EASY COMFORT PEN NEEDLES ...... 80 EFUDEX ...... 52 EASY GLIDE SYRINGE/SLIP L ...... 80 EGRIFTA SV...... 58 EASY PLUS II BLOOD GLUCOS ...... 71 ELAPRASE ...... 59 117

ELELYSO ...... 66 entacapone ...... 38 ELEMENT COMPACT BLOOD GLU ...... 71 entecavir ...... 42 ELEMENT PLUS BLOOD GLUCOS ...... 72 ENTOCORT EC ...... 49 ELESTRIN ...... 61 ENTRESTO ...... 44 eletriptan hydrobromide ...... 85 ENTYVIO ...... 62 ELIDEL ...... 54 ENVARSUS XR ...... 87 ELIGARD ...... 32 EPIDIOLEX ...... 16 ELIQUIS ...... 14 EPIDUO FORTE ...... 50 ELIQUIS STARTER PACK ...... 15 EPIFOAM ...... 53 ELITEK ...... 36 epinastine hcl (ophth) ...... 96 ELIXOPHYLLIN ...... 14 epinephrine (anaphylaxis) ...... 105 ELLA ...... 48 EPIPEN 2-PAK ...... 105 ELLENCE ...... 33 EPIPEN-JR 2-PAK ...... 105 ELMIRON ...... 63 epirubicin hcl ...... 33 ELOCTATE ...... 64 EPIVIR ...... 41 ELZONRIS ...... 36 EPIVIR HBV ...... 42 EMBRACE BLOOD GLUCOSE MON ..... 72 eplerenone ...... 28 EMBRACE EVO COMPACT BLOOD ...... 72 EPOGEN ...... 66 EMBRACE LANCETS ULTRA THI ...... 72 epoprostenol sodium ...... 45 EMBRACE PRESSURE ACTIVATE ...... 72 EPZICOM ...... 41 EMBRACE PRO BLOOD GLUCOSE ...... 72 EQ SPACE CHAMBER ANTI-STA ...... 84 EMBRACE TALK BLOOD GLUCOS ...... 72 EQL COLOR LANCETS 21G ...... 72 EMCYT ...... 32 EQL COLOR LANCETS MICRO T ...... 72 EMEND ...... 23 EQL SUPER THIN LANCETS 30 ...... 72 EMEND TRIPACK ...... 23 EQL THIN LANCETS 26G...... 72 EMFLAZA ...... 49 EQUETRO ...... 38 EMGALITY ...... 85 ERAXIS ...... 23 EMPLICITI ...... 31 ERBITUX ...... 32 EMSAM ...... 18 ergocalciferol ...... 106 emtricitabine ...... 41 ergoloid mesylates ...... 100 emtricitabine-tenofovir disoproxil ERGOMAR ...... 85 fumarate ...... 41 ergotamine w/ caffeine ...... 85 EMTRIVA ...... 41 ERIVEDGE ...... 32 EMVERM ...... 9 ERLEADA ...... 32 enalapril maleate ...... 26 erlotinib hcl ...... 32 enalapril maleate & hydrochlorothiazide ERTACZO ...... 51 ...... 27 ertapenem sodium ...... 10 ENBRACE HR ...... 89 ERWINASE ...... 36 ENBREL ...... 4 ERYPED 200 ...... 68 ENBREL MINI ...... 5 ERYPED 400 ...... 69 ENBREL SURECLICK ...... 5 ERYTHROCIN LACTOBIONATE ...... 69 ENDOMETRIN ...... 105 erythromycin (acne aid) ...... 50 ENGERIX-B ...... 104 erythromycin (ophth) ...... 93 ENHERTU ...... 31 erythromycin base...... 69 enoxaparin sodium ...... 15 erythromycin ethylsuccinate ...... 69 ENSPRYNG ...... 87 erythromycin stearate ...... 69 ENSTILAR ...... 53 ESBRIET ...... 101 118 escitalopram oxalate ...... 18 EYSUVIS ...... 94 ESGIC ...... 5 E-Z JECT LANCETS ...... 71 esomeprazole sodium ...... 102 E-Z JECT LANCETS 21G ...... 71 ESPEROCT ...... 64 E-Z JECT LANCETS COLOR ...... 71 estazolam ...... 67 E-Z JECT LANCETS SUPER TH ...... 71 ESTRACE ...... 61, 105 E-Z JECT LANCETS THIN 26G ...... 71 estradiol ...... 61 ezetimibe ...... 25 estradiol & norethindrone acetate ..... 60 ezetimibe-simvastatin ...... 24 estradiol vaginal ...... 105 E-ZJECT LANCETS MICRO-THI ...... 71 estradiol valerate ...... 61 EZ-LETS LANCETS 21G ...... 72 ESTRING ...... 105 EZ-LETS LANCETS 26G SUPER ...... 72 ESTROGEL ...... 61 EZ-LETS LANCETS 28G ULTRA ...... 72 ESTROSTEP FE ...... 47 EZ-LETS LANCETS 30G ...... 72 eszopiclone ...... 67 F ethacrynic acid ...... 57 FABRAZYME ...... 59 ethambutol hcl ...... 29 famciclovir ...... 42 ethosuximide ...... 17 famotidine ...... 102 ethynodiol diacet & eth estrad...... 47 famotidine in nacl ...... 102 ETHYOL ...... 36 FANAPT ...... 39 etodolac ...... 3 FANAPT TITRATION PACK ...... 39 etonogestrel-ethinyl estradiol ...... 48 FARESTON ...... 32 ETOPOPHOS ...... 37 FARXIGA ...... 21 etoposide ...... 37 FARYDAK ...... 34 etravirine ...... 41 FASENRA ...... 13 EUCRISA ...... 55 FASENRA PEN ...... 13 EUFLEXXA ...... 90 FASLODEX ...... 32 EVAMIST ...... 61 FC2 FEMALE CONDOM ...... 69 EVENITY ...... 57 febuxostat ...... 64 everolimus ...... 34 FEIBA ...... 64 EVISTA ...... 58 felbamate ...... 17 EVKEEZA ...... 24 FELBATOL ...... 17 EVOCLIN ...... 50 FELDENE ...... 3 EVOLUTION AUTOCODE ...... 72 felodipine ...... 44 EVOMELA ...... 29 FEMARA ...... 32 EVOTAZ ...... 41 FEMHRT ...... 60 EVOXAC ...... 89 FEMRING ...... 105 EVRYSDI ...... 91 fenofibrate ...... 25 EXCEL COMFORT POINT INSUL ...... 81 fenofibrate micronized ...... 25 EXEL COMFORT POINT INSULI ...... 81 fenofibric acid ...... 25 EXELON ...... 98 FENOGLIDE ...... 25 exemestane ...... 32 fenoprofen calcium ...... 3, 4 EXFORGE ...... 27 FENOPROFEN CALCIUM ...... 3 EXFORGE HCT ...... 27 FENORTHO ...... 4 EXJADE ...... 21 FENSOLVI ...... 58 EXSERVAN...... 91 fentanyl ...... 5 EXTAVIA ...... 99 fentanyl citrate ...... 5 EYLEA ...... 93 FENTORA ...... 5 119

FERAHEME ...... 67 FLUARIX QUADRIVALENT 2021 ...... 104 FERRIPROX ...... 21, 22 FLUBLOK QUADRIVALENT 2020...... 104 FERRIPROX TWICE-A-DAY ...... 22 FLUBLOK QUADRIVALENT 2021...... 104 FERRLECIT ...... 67 FLUCELVAX QUADRIVALENT 20 ...... 104 ferrous fumarate-folic acid ...... 67 fluconazole ...... 23 ferumoxytol ...... 67 fluconazole in nacl ...... 23 FETROJA ...... 47 flucytosine...... 23 FETZIMA ...... 19 fludarabine phosphate ...... 30 FETZIMA TITRATION PACK ...... 19 fludrocortisone acetate ...... 49 FIASP ...... 20 FLULAVAL QUADRIVALENT 202 ...... 104 FIASP FLEXTOUCH ...... 20 flumazenil ...... 22 FIASP PENFILL ...... 20 FLUMIST QUADRIVALENT ...... 104 FIBRICOR ...... 25 flunisolide (nasal) ...... 91 FIBRYGA ...... 65 fluocinolone acetonide ...... 53 FIFTY50 PEN NEEDLES 31G X ...... 81 fluocinolone acetonide (otic) ...... 96 FIFTY50 PEN NEEDLES 31GX5 ...... 81 fluocinonide ...... 53 FIFTY50 PEN NEEDLES/31GX8 ...... 81 fluocinonide emulsified base ...... 53 FIFTY50 PEN NEEDLES/32GX4 ...... 81 fluorometholone (ophth) ...... 94 FIFTY50 PEN NEEDLES/32GX6 ...... 81 FLUOROPLEX ...... 52 FIFTY50 SAFETY SEAL LANCE ...... 72 fluorouracil ...... 30 FIFTY50 UNILET LANCETS 33 ...... 72 fluorouracil (topical) ...... 52 FINACEA ...... 55 fluoxetine hcl ...... 18 finasteride ...... 64 fluoxetine hcl (pmdd) ...... 100 FINE 30...... 72 FLUOXETINE HYDROCHLORIDE ...... 18 FINGERSTIX LANCETS ...... 72 fluphenazine decanoate ...... 40 FINTEPLA ...... 16 fluphenazine hcl ...... 40 FIORICET ...... 5 flurandrenolide ...... 53 FIRAZYR ...... 65 flurazepam hcl ...... 67 FIRMAGON ...... 32 flurbiprofen ...... 4 FIRST-LANSOPRAZOLE ...... 103 flurbiprofen sodium ...... 96 FIRST-OMEPRAZOLE ...... 103 flutamide ...... 32 FIRVANQ ...... 10 fluticasone propionate ...... 53 FLAGYL ...... 9 fluticasone propionate (nasal) ...... 91 FLAREX ...... 94 fluticasone-salmeterol ...... 14 flavoxate hcl ...... 103 fluvastatin sodium ...... 25 FLEBOGAMMA DIF ...... 97 fluvoxamine maleate ...... 18 flecainide acetate ...... 12 FLUZONE HIGH-DOSE PF 2020 ...... 104 FLEXICHAMBER ...... 84 FLUZONE QUADRIVALENT 2020 ..... 104 FLOLIPID ...... 25 FLUZONE QUADRIVALENT 2021 ..... 104 FLOMAX ...... 64 FML ...... 94 FLORIVA ...... 86, 89 FML FORTE ...... 94 FLOVENT DISKUS ...... 13 FML LIQUIFILM ...... 94 FLOVENT HFA ...... 13 FOCALIN ...... 2 floxuridine ...... 30 FOCALIN XR ...... 2 FLUAD 2020-2021 ...... 104 FOLGARD OS ...... 89 FLUAD QUADRIVALENT INFLUE ...... 104 folic acid ...... 66 FLUARIX QUADRIVALENT 2020 ...... 104 folic acid-pyridoxine-cyanocobalamin 56 120

FOLOTYN ...... 30 GABLOFEN ...... 90 fondaparinux sodium ...... 15 GALAFOLD ...... 59 FORA G30A BLOOD GLUCOSE M ...... 72 galantamine hydrobromide ...... 98 FORA GD20 BLOOD GLUCOSE M ...... 72 GAMASTAN ...... 97 FORA GD50 BLOOD GLUCOSE M ...... 72 GAMIFANT ...... 87 FORA GTEL BLOOD GLUCOSE M ...... 72 GAMMAGARD LIQUID ...... 97 FORA LANCETS ...... 72 GAMMAGARD S/D IGA LESS TH ...... 97 FORA PREMIUM V10 BLE BLOO ...... 72 GAMMAKED ...... 97 FORA TEST N' GO VOICE BLO ...... 72 GAMMAPLEX ...... 97 FORA V10 BLOOD GLUCOSE MO ...... 72 GAMUNEX-C ...... 97 FORA V10/V12/D10/D20 BLOO ...... 72 GANCICLOVIR ...... 42 FORA V12 BLOOD GLUCOSE MO ...... 72 ganciclovir sodium ...... 42 FORA V20 BLOOD GLUCOSE MO ...... 72 GARDASIL ...... 104 FORA V30A BLOOD GLUCOSE M ...... 72 GARDASIL 9 ...... 104 FORACARE GD40 BLOOD GLUCO ...... 72 GASTROCROM ...... 62 FORACARE PREMIUM V10 BLOO ...... 72 gatifloxacin (ophth) ...... 93 FORACARE TEST N GO BLOOD ...... 72 GAVRETO ...... 34 FORFIVO XL ...... 18 GAZYVA ...... 31 formoterol fumarate ...... 14 GE100 BLOOD GLUCOSE MONIT ...... 72 FORTAZ ...... 46 GELNIQUE ...... 103 FORTESTA ...... 8 GEL-ONE ...... 90 FORTISCARE SELF-MONITORIN ...... 72 GELSYN-3 ...... 90 FORTISCARE T1 SELF-MONITO ...... 72 gemcitabine hcl ...... 30 FOSAMAX ...... 57 GEMCITABINE HYDROCHLORIDE ...... 30 FOSAMAX PLUS D ...... 57 gemfibrozil ...... 25 fosamprenavir calcium ...... 41 GENERESS FE ...... 47 fosaprepitant dimeglumine ...... 23 GENOTROPIN ...... 58 foscarnet sodium ...... 42 GENOTROPIN MINIQUICK ...... 58 FOSCAVIR ...... 42 gentamicin in saline ...... 2 fosfomycin tromethamine ...... 11 gentamicin sulfate ...... 2 fosinopril sodium ...... 26 gentamicin sulfate (ophth) ...... 93 fosinopril sodium & hydrochlorothiazide gentamicin sulfate (topical) ...... 51 ...... 27 GENTEEL BUTTERFLY TOUCH L ...... 72 fosphenytoin sodium ...... 17 GENTEEL CONTACT TIPS/BLUE ...... 72 FOSRENOL ...... 63 GENTEEL CONTACT TIPS/CLEA ...... 72 FOTIVDA ...... 34 GENTEEL CONTACT TIPS/GREE ...... 73 FRAGMIN ...... 15 GENTEEL CONTACT TIPS/ORAN ...... 73 FREESTYLE LITE BLOOD GLUC ...... 72 GENTEEL CONTACT TIPS/RAIN ...... 73 FREESTYLE UNISTICK II LAN ...... 72 GENTEEL CONTACT TIPS/VIOL ...... 73 frovatriptan succinate ...... 85 GENTEEL CONTACT TIPS/YELL ...... 73 fulvestrant ...... 32 GENTEEL NOZZLES...... 73 furosemide ...... 57 GENTLE-LET GP LANCETS ...... 73 FUZEON ...... 41 GENTLE-LET LANCETS GENERA ...... 73 FYCOMPA ...... 15 GENTLE-LET PLATFORMS 2.4M ...... 73 G GENVISC 850 ...... 90 gabapentin ...... 16 GENVOYA ...... 41 GABITRIL ...... 17 GEODON ...... 38 121

GILENYA ...... 99 GVOKE PFS ...... 20 GILOTRIF ...... 32 GYNAZOLE-1 ...... 105 GLASSIA ...... 100 H GLEOSTINE ...... 29 HAEGARDA ...... 65 GLIADEL WAFER...... 29 HAEMOLANCE ...... 73 glimepiride ...... 21 HAEMOLANCE LOW FLOW LANCE ..... 73 glipizide ...... 21 HAEMOLANCE PLUS ...... 73 glipizide-metformin hcl ...... 19 HAEMOLANCE PLUS HIGH FLOW ...... 73 GLOBAL INJECT EASE LANCET ...... 73 HAEMOLANCE PLUS LOW FLOW ...... 73 GLUCAGEN HYPOKIT ...... 20 HAEMOLANCE PLUS MAX FLOW ...... 73 glucagon (rdna) ...... 20 HAEMOLANCE PLUS PEDIATRIC ...... 73 GLUCAGON EMERGENCY KIT ...... 20 HAEMOPHILUS B POLYSAC CONJ VAC GLUCAGON EMERGENCY KIT FO ...... 20 ...... 103 GLUCO PERFECT 3 BLOOD GLU ...... 73 HALAVEN ...... 37 GLUCOCARD 01 BLOOD GLUCOS ...... 73 HALCION ...... 67 GLUCOCARD SHINE ...... 73 HALDOL DECANOATE 100 ...... 39 GLUCOCARD SHINE XL ...... 73 HALDOL DECANOATE 50 ...... 39 GLUCOCOM BLOOD GLUCOSE MO .... 73 halobetasol propionate ...... 54 GLUCOCOM LANCETS 28G ...... 73 HALOG ...... 54 GLUCOCOM LANCETS 30G ...... 73 haloperidol ...... 39 GLUCOCOM LANCETS 33G ...... 73 haloperidol decanoate ...... 39 GLUCOTROL XL ...... 21 haloperidol lactate ...... 39 glyburide ...... 21 HAVRIX ...... 104 glyburide micronized ...... 21 HEALON ...... 95 glyburide-metformin ...... 19 HEALON PRO ...... 95 glycopyrrolate ...... 102 HEALTHWISE INSULIN SYRING ...... 81 GLYNASE ...... 21 HEALTHY ACCENTS UNILET LA ...... 73 GLYXAMBI ...... 19 H-E-B IN CONTROL PEN NEED ...... 81 GNP EASY TOUCH GLUCOSE MO ...... 73 H-E-B IN CONTROL UNIFINE ...... 81 GNP LANCETS 21G ...... 73 H-E-B INCONTROL LANCETS M ...... 73 GNP LANCETS THIN ...... 73 H-E-B INCONTROL LANCETS S ...... 73 GNP LANCETS THIN 26G ...... 73 H-E-B INCONTROL LANCETS U ...... 73 GNP ULTICARE PEN NEEDLES ...... 81 H-E-B INCONTROL PEN NEEDL ...... 81 GNP ULTICARE PEN NEEDLES/ ...... 81 HECTOROL ...... 59 GOJJI STERILE LANCETS 30G ...... 73 HEMANGEOL ...... 43 GONITRO ...... 11 HEMLIBRA ...... 65 GOODSENSE LANCETS MICRO-T ...... 73 HEMOFIL M...... 65 GOODSENSE LANCETS ULTRA-T ...... 73 HEPAGAM B ...... 97 GOODSENSE PEN NEEDLE/PENF ...... 81 heparin (porcine) in sodium chloride . 15 GRALISE ...... 100 heparin sod (porcine) in d5w ...... 15 granisetron hcl ...... 22 HEPARIN SODIUM ...... 15 griseofulvin microsize ...... 23 heparin sodium (porcine) ...... 15 griseofulvin ultramicrosize ...... 23 heparin sodium (porcine) lock flush .. 15 guanfacine hcl...... 27 HEPARIN SODIUM/DEXTROSE ...... 15 guanfacine hcl (adhd) ...... 1 HEPARIN SODIUM/NACL 0.45% ...... 15 GVOKE HYPOPEN 1-PACK ...... 20 HEPATITIS A VACCINE INJ 1 ...... 104 GVOKE HYPOPEN 2-PACK ...... 20 HEPLISAV-B ...... 104 122

HEPSERA ...... 42 hydroxychloroquine sulfate ...... 28 HERCEPTIN HYLECTA ...... 34 hydroxyprogesterone caproate ...... 98 HERZUMA ...... 31 hydroxyprogesterone caproate HETLIOZ ...... 68 (antineoplastic) ...... 33 HETLIOZ LQ ...... 68 hydroxyurea ...... 36 HIBERIX ...... 103 hydroxyzine hcl ...... 12 HIPREX ...... 11 hydroxyzine pamoate ...... 12 HIZENTRA ...... 97 HYLENEX ...... 87 HM ULTICARE INSULIN SYRIN...... 81 HYMOVIS ...... 90 HM ULTICARE SHORT PEN NEE ...... 81 hyoscyamine sulfate ...... 102 homatropine hbr ...... 93 HYPERRAB ...... 97 HUMATE-P ...... 65 HYPERSAL ...... 50 HUMIRA ...... 3 HYPODERMIC NEEDLE 30GX1/2 ...... 81 HUMIRA PEDIATRIC CROHNS D ...... 3 hypromellose (intraocular) ...... 95 HUMIRA PEN ...... 3 HYQVIA ...... 97 HUMIRA PEN-CD/UC/HS START ...... 3 HYSINGLA ER ...... 5 HUMIRA PEN-PEDIATRIC UC S ...... 3 HY-VEE LANCETS ...... 73 HUMIRA PEN-PS/UV STARTER ...... 3 HY-VEE THIN LANCETS ...... 73 HUMULIN R U-500 (CONCENTR ...... 20 HYZAAR ...... 27 HUMULIN R U-500 KWIKPEN ...... 20 I HW EMBRACE PRO BLOOD GLUC ...... 73 ibandronate sodium ...... 57 HW EMBRACE TALK BLOOD GLU ...... 73 IBRANCE ...... 34 HYALGAN ...... 90 ibuprofen ...... 4 HYCAMTIN ...... 37 icatibant acetate ...... 65 hydralazine hcl ...... 28 ICLUSIG ...... 34 HYDREA ...... 36 icosapent ethyl ...... 24 hydrochlorothiazide ...... 57 IDAMYCIN PFS ...... 33 hydrocodone bitartrate ...... 5 idarubicin hcl ...... 33, 34 hydrocodone polistirex- IDELVION ...... 65 chlorpheniramine polistirex ...... 50 IDHIFA ...... 34 hydrocodone w/ homatropine ...... 50 IFEX ...... 29 hydrocodone-acetaminophen ...... 7 ifosfamide ...... 29 hydrocodone-ibuprofen ...... 7 IFOSFAMIDE ...... 29 hydrocortisone ...... 49 ILARIS ...... 3 hydrocortisone (intrarectal) ...... 8 ILEVRO ...... 96 hydrocortisone (rectal) ...... 8 ILUVIEN ...... 94 hydrocortisone (topical) ...... 54 imatinib mesylate ...... 34 hydrocortisone acetate (rectal) ...... 8 IMBRUVICA ...... 34, 35 hydrocortisone acetate w/ pramoxine 8 IMCIVREE ...... 1 hydrocortisone butyrate ...... 54 IMFINZI ...... 31 hydrocortisone valerate ...... 54 imipenem-cilastatin ...... 10 hydrocortisone w/acetic acid ...... 97 imipramine hcl ...... 19 hydrogen peroxide ...... 40 imipramine pamoate ...... 19 hydromorphone hcl...... 5 imiquimod ...... 54 HYDROMORPHONE HCL ...... 5 IMITREX ...... 85 HYDROMORPHONE HYDROCHLORI .... 5 IMITREX STATDOSE REFILL ...... 85 hydroxocobalamin acetate ...... 66 IMITREX STATDOSE SYSTEM ...... 85 123

IMPAVIDO ...... 9 INVEGA TRINZA ...... 39 IMPOYZ ...... 54 INVIRASE ...... 41 IMURAN ...... 87 IOPIDINE ...... 93 IMVEXXY MAINTENANCE PACK ...... 105 IPOL INACTIVATED IPV ...... 104 IMVEXXY STARTER PACK ...... 105 ipratropium bromide ...... 13 IN TOUCH ...... 73 ipratropium bromide (nasal) ...... 91 IN TOUCH STERILE LANCETS ...... 73 ipratropium-albuterol ...... 14 INCRELEX ...... 58 irbesartan ...... 26 INCRUSE ELLIPTA ...... 13 irbesartan-hydrochlorothiazide ...... 27 indapamide ...... 57 IRESSA ...... 32 INDERAL LA ...... 43 irinotecan hcl ...... 37 INDOCIN ...... 4 irrigation solutions, physiological ..... 88 indomethacin ...... 4 ISENTRESS ...... 41 indomethacin sodium ...... 4 ISENTRESS HD ...... 41 INFASURF ...... 101 isoniazid ...... 29 INFED ...... 67 isopto atropine ...... 93 INFLECTRA ...... 62 ISOPTO CARPINE ...... 93 INFUMORPH 200 ...... 5 ISORDIL TITRADOSE ...... 11 INFUMORPH 500 ...... 5 isosorbide dinitrate ...... 11 INGREZZA ...... 99 isosorbide mononitrate ...... 11 INJECTAFER...... 67 isotretinoin ...... 51 INLYTA...... 30 isradipine ...... 44 INQOVI ...... 34 ISTALOL ...... 92 INREBIC ...... 35 ISTODAX (OVERFILL) ...... 35 INSPIRACHAMBER/ANTI-STATI ...... 84 ISTURISA ...... 57 INSPIRACHAMBER/LARGE ...... 84 itraconazole ...... 23 INSPIRACHAMBER/SOOTHERMAS ..... 85 ivermectin ...... 9 INSPIREASE DRUG DELIVERY ...... 85 ivermectin (pediculicide) ...... 55 INSPRA ...... 28 ivermectin (rosacea) ...... 55 INSULIN SYRINGE/0.5ML/27G ...... 81 IXEMPRA KIT ...... 37 INSULIN SYRINGE/U-100/1ML ...... 81 IXINITY ...... 65 INSULIN SYRINGES/0.5ML/27 ...... 81 J INSUPEN 29G X 12MM ...... 81 JADENU ...... 22 INSUPEN 31G X 5MM ...... 81 JADENU SPRINKLE ...... 22 INSUPEN 31G X 8MM ...... 81 JAKAFI ...... 35 INSUPEN 33GX4MM ...... 81 JALYN ...... 64 INSUPEN PEN NEEDLES 32G X ...... 81 JANUMET ...... 19 INSUPEN SENSITIVE 32GX6MM ...... 81 JANUMET XR ...... 19 INSUPEN SENSITIVE 32GX8MM ...... 81 JANUVIA ...... 20 INSUPEN ULTRAFIN 30GX8MM ...... 81 JARDIANCE ...... 21 INSUPEN ULTRAFIN 31GX6MM ...... 81 JATENZO ...... 8 INSUPEN ULTRAFIN 31GX8MM ...... 81 JELMYTO ...... 34 INTELENCE ...... 41 JEMPERLI ...... 31 INTRAROSA ...... 105 JEVTANA ...... 37 INTRON A ...... 36 JIVI ...... 65 INTUNIV ...... 1 JUBLIA ...... 51 INVEGA SUSTENNA ...... 39 JULUCA ...... 41 124

JUXTAPID ...... 25 KRISTALOSE ...... 68 JYNARQUE ...... 60 KROGER HEALTHPRO TWIST LA ...... 74 K KROGER LANCETS ...... 74 KADCYLA ...... 31 KROGER LANCETS 21G ...... 74 KALBITOR ...... 65 KROGER LANCETS MICRO THIN ...... 74 KALETRA ...... 41 KROGER LANCETS SUPER THIN ...... 74 KALYDECO...... 100 KROGER LANCETS THIN ...... 74 KANJINTI ...... 31 KROGER LANCETS THIN 26G ...... 74 KANUMA ...... 59 KROGER PEN NEEDLES/31G X ...... 81 KAPVAY ...... 1 KROGER PEN NEEDLES/32G X ...... 81 KARBINAL ER ...... 24 KROGER PEN NEEDLES/33G X ...... 82 KCL 0.3%/D5W/NACL 0.9% ...... 86 KRYSTEXXA ...... 64 KEFLEX ...... 46 K-TAB ...... 86 KENALOG ...... 54 KUVAN ...... 59 KENALOG-10 ...... 49 KYLEENA ...... 48 KEPIVANCE...... 36 KYNMOBI ...... 38 KEPPRA ...... 16 KYPROLIS ...... 35 KEPPRA XR ...... 16 L KERYDIN ...... 51 labetalol hcl ...... 43 KESIMPTA ...... 99 LACRISERT ...... 92 ketoconazole ...... 23 lactated ringer's ...... 86 ketoconazole (topical) ...... 51 lactated ringer's (irrigation) ...... 88 ketoprofen ...... 4 lactic acid (ammonium lactate) ...... 54 ketorolac tromethamine ...... 4 lactulose ...... 68 KETOROLAC TROMETHAMINE ...... 4 lactulose (encephalopathy) ...... 62 ketorolac tromethamine (ophth) ...... 96 LAMICTAL ...... 16 KEVEYIS...... 56 LAMICTAL CHEWABLE DISPERS ...... 16 KEYTRUDA...... 31 LAMICTAL ODT ...... 16 KHAPZORY ...... 36 LAMICTAL STARTER/NOT TAKI ...... 16 KINNEY LANCETS ...... 73 LAMICTAL STARTER/TAKING C ...... 16 KINNEY THIN LANCETS ...... 74 LAMICTAL STARTER/TAKING V ...... 16 KISQALI FEMARA 200 DOSE ...... 34 LAMICTAL XR ...... 16 KISQALI FEMARA 400 DOSE ...... 34 lamivudine ...... 41 KISQALI FEMARA 600 DOSE ...... 34 lamivudine (hbv) ...... 42 KITABIS PAK ...... 2 lamivudine-zidovudine ...... 41 KLARITY-A ...... 93 lamotrigine ...... 16 KLARON ...... 51 LAMPIT ...... 9 KLISYRI ...... 52 LANCET TRANSPORTER CASE ...... 74 KLONOPIN ...... 15 LANCETS ...... 74 KMART VALU PLUS INSULIN S ...... 81 LANCETS MICRO THIN 33G ...... 74 KOATE ...... 65 LANCETS SUPER THIN 28G ...... 74 KOATE-DVI ...... 65 LANCETS THIN ...... 74 KOGENATE FS ...... 65 LANCETS ULTRA THIN ...... 74 KOMBIGLYZE XR ...... 19 LANCETS ULTRA THIN 30G ...... 74 KOSELUGO ...... 35 LANOXIN ...... 44 KOVALTRY ...... 65 lansoprazole ...... 103 K-PHOS ...... 86 lanthanum carbonate ...... 63 125 lapatinib ditosylate ...... 35 LEVSIN/SL ...... 102 LASIX ...... 57 LEVULAN KERASTICK ...... 52 LASTACAFT...... 96 LEXIVA ...... 41 latanoprost ...... 96 LIBERTY BLOOD GLUCOSE MET ...... 74 LATUDA ...... 39 LIBERTY MEDICAL LANCETS 3 ...... 74 LAZANDA ...... 5 LIBERTY NEXT GENERATION B ...... 74 LEADER UNIFINE PENTIPS PL ...... 82 lidocaine ...... 55 leflunomide ...... 4 lidocaine hcl ...... 55 LENVIMA 10 MG DAILY DOSE ...... 30 lidocaine hcl (local anesth.) ...... 68 LENVIMA 12MG DAILY DOSE...... 31 lidocaine hcl (mouth-throat) ...... 88 LENVIMA 14 MG DAILY DOSE ...... 31 LIDOCAINE HYDROCHLORIDE ...... 68 LENVIMA 18 MG DAILY DOSE ...... 31 lidocaine-prilocaine ...... 55 LENVIMA 20 MG DAILY DOSE ...... 31 LIFESCAN UNISTIK 2 DEEP P ...... 74 LENVIMA 24 MG DAILY DOSE ...... 31 LIFESCAN UNISTIK II LANCE ...... 74 LENVIMA 4 MG DAILY DOSE ...... 30 LILETTA ...... 48 LENVIMA 8 MG DAILY DOSE ...... 30 LINCOCIN ...... 10 LESCOL XL ...... 25 lincomycin hcl ...... 10 letrozole ...... 33 lindane ...... 55 leucovorin calcium ...... 36 linezolid ...... 11 LEUKERAN ...... 29 linezolid in sodium chloride ...... 11 LEUKINE ...... 66 LINZESS ...... 63 leuprolide acetate ...... 33 liothyronine sodium ...... 102 levalbuterol hcl ...... 14 LIPITOR ...... 25 levalbuterol tartrate ...... 14 LIPOFEN...... 25 LEVBID ...... 102 lisinopril ...... 26 LEVEMIR ...... 20 lisinopril & hydrochlorothiazide...... 27 LEVEMIR FLEXTOUCH ...... 20 LITE TOUCH LANCETS ...... 74 levetiracetam ...... 16 LITETOUCH LANCETS MICRO T ...... 74 LEVETIRACETAM ...... 16 LITETOUCH PEN NEEDLES 29G ...... 82 levetiracetam in sodium chloride ...... 16 LITETOUCH PEN NEEDLES 31G ...... 82 levobunolol hcl ...... 92 lithium carbonate ...... 38 levofloxacin ...... 61 LITHOBID ...... 38 levofloxacin (ophth) ...... 93 LITHOSTAT ...... 64 levofloxacin in d5w ...... 61 LIVE BETTER LANCET SUPER ...... 74 levoleucovorin calcium ...... 36, 37 LIVE BETTER LANCET ULTRA ...... 74 levonorgestrel & eth estradiol ...... 47 LO LOESTRIN FE ...... 47 levonorgestrel (emergency oc) ...... 48 LODOSYN ...... 37 levonorgestrel-eth estradiol (triphasic) LOKELMA ...... 88 ...... 47 LOMOTIL ...... 21 levonorgestrel-ethinyl estradiol (91- LONGS LANCETS STANDARD ...... 74 day) ...... 47 LONGS LANCETS THIN ...... 74 levonorgestrel-ethinyl estradiol LONGS LANCETS ULTRA THIN ...... 74 (continuous) ...... 47 LONHALA MAGNAIR STARTER K ...... 13 levorphanol tartrate ...... 5 LONSURF ...... 34 levothyroxine sodium ...... 102 loperamide hcl ...... 21 LEVOTHYROXINE SODIUM ...... 102 LOPID ...... 25 LEVSIN ...... 102 lopinavir-ritonavir ...... 41 126

LOPRESSOR ...... 43 MARINOL ...... 23 LOPROX ...... 51 MARPLAN ...... 18 LOPROX SHAMPOO ...... 51 MARQIBO ...... 37 lorazepam ...... 12 MATULANE ...... 36 LORBRENA ...... 35 MAVENCLAD ...... 99 LORTAB ...... 7 MAVYRET ...... 42 losartan potassium ...... 26 MAXICOMFORT II PEN NEEDLE...... 82 losartan potassium & MAXICOMFORT INSULIN SYRIN ...... 82 hydrochlorothiazide ...... 27 MAXIDEX ...... 95 LOSEASONIQUE ...... 47 MAXITROL ...... 95 LOTEMAX ...... 94 MAXZIDE ...... 57 LOTEMAX SM ...... 95 MAXZIDE-25 ...... 57 LOTENSIN ...... 26 MAYZENT ...... 99 LOTENSIN HCT ...... 27 MAYZENT STARTER PACK ...... 99 loteprednol etabonate ...... 95 meclizine hcl ...... 22 LOTREL ...... 27 meclofenamate sodium ...... 4 LOTRONEX ...... 63 MEDICHOICE SAFETY LANCET ...... 74 lovastatin ...... 25 MEDISENSE THIN LANCETS ...... 74 LOVAZA ...... 24 MEDLANCE PLUS EXTRA LANCE ...... 74 LOVENOX ...... 15 MEDLANCE PLUS LANCETS ...... 74 loxapine succinate ...... 39 MEDLANCE PLUS LITE LANCET ...... 74 lubiprostone ...... 62 MEDLANCE PLUS SPECIAL LAN ...... 74 LUCENTIS ...... 93 MEDLANCE PLUS SUPERLITE 3 ...... 74 LUMIGAN ...... 96 MEDLANCE PLUS UNIVERSAL L ...... 74 LUMIZYME ...... 59 MEDLANCE/EXTRA ...... 74 LUMOXITI ...... 31 MEDLANCE/LITE ...... 74 LUPANETA PACK ...... 58 MEDLANCE/UNIVERSAL ...... 74 LUPRON DEPOT (1-MONTH) ...... 33 MEDROL ...... 49 LUPRON DEPOT (3-MONTH) ...... 33 MEDROL DOSEPAK ...... 49 LUPRON DEPOT (4-MONTH) ...... 33 medroxyprogesterone acetate ...... 98 LUPRON DEPOT (6-MONTH) ...... 33 medroxyprogesterone acetate LUPRON DEPOT-PED (1-MONTH ...... 58 (contraceptive) ...... 48 LUPRON DEPOT-PED (3-MONTH ...... 58 mefenamic acid ...... 4 LUTATHERA ...... 36 mefloquine hcl ...... 28 LUXIQ ...... 54 megestrol acetate ...... 33 LUZU ...... 51 megestrol acetate (appetite) ...... 98 LYNPARZA ...... 35 MEIJER COLOR LANCETS UNIV ...... 74 LYRICA ...... 16 MEIJER LANCETS THIN ...... 74 LYRICA CR ...... 100 MEIJER LANCETS UNIVERSAL ...... 74 LYSODREN ...... 33 MEIJER PEN NEEDLES 31G X ...... 82 LYSTEDA ...... 67 MEKINIST ...... 35 M MEKTOVI...... 35 MACROBID ...... 11 meloxicam ...... 4 MACRODANTIN ...... 11 melphalan ...... 29 MAKENA ...... 98 melphalan hcl ...... 30 MALARONE ...... 28 memantine hcl ...... 98 malathion ...... 55 MENACTRA ...... 104 127

MENEST ...... 61 metolazone ...... 57 MENHIBRIX ...... 104 metoprolol & hydrochlorothiazide ..... 27 MENOMUNE-A/C/Y/W-135 ...... 104 metoprolol succinate ...... 43 MENOSTAR ...... 61 metoprolol tartrate ...... 43 MENTAX ...... 51 METROCREAM ...... 55 MENVEO ...... 104 METROGEL ...... 55 meperidine hcl ...... 5, 6 metronidazole ...... 9 MEPHYTON ...... 106 METRONIDAZOLE ...... 9 meprobamate ...... 12 metronidazole (topical) ...... 55 MEPRON ...... 9 metronidazole in nacl ...... 9 MEPSEVII ...... 59 metronidazole vaginal ...... 105 mercaptopurine ...... 30 mexiletine hcl ...... 12 meropenem ...... 10 MIACALCIN ...... 57 mesalamine ...... 62 MICARDIS ...... 26 mesalamine w/ cleanser ...... 62 MICARDIS HCT ...... 27 mesna ...... 37 miconazole nitrate vaginal ...... 105 MESNEX ...... 37 MICROCHAMBER ...... 85 MESTINON ...... 28 MICRODOT PEN NEEDLE/31G X ...... 82 MESTINON TIMESPAN ...... 28 MICRODOT PEN NEEDLE/33G X ...... 82 metaxalone ...... 90 MICROLET LANCETS ...... 74 metformin hcl ...... 20 midodrine hcl ...... 106 methadone hcl ...... 6 MIFEPREX ...... 60 METHADONE HCL ...... 6 miglitol ...... 19 methazolamide ...... 56 MIGRANAL ...... 85 methenamine hippurate ...... 11 MILLIPRED ...... 49 methenamine mandelate ...... 11 milrinone lactate ...... 44 methenamine-hyoscamine-methylene milrinone lactate in dextrose ...... 44 blue-sodium phosphate ...... 9 MINASTRIN 24 FE ...... 47 methenamine-hyosc-methylene blue- MINIPRESS ...... 27 benzoic acid-phenyl sal ...... 9 MINIVELLE ...... 61 methenamine-hyosc-methylene blue- MINOCIN ...... 101 sod phos-phenyl sal ...... 9 minocycline hcl ...... 101 methimazole ...... 101 minoxidil ...... 28 methocarbamol ...... 90 MIOSTAT ...... 93 methotrexate sodium ...... 30 MIRAPEX ...... 38 methoxsalen rapid ...... 52 MIRAPEX ER ...... 38 methscopolamine bromide ...... 102 MIRCERA ...... 66 methyldopa ...... 27 MIRCETTE ...... 47 methylergonovine maleate ...... 97 MIRENA ...... 48 METHYLIN ...... 2 mirtazapine ...... 18 methylphenidate hcl ...... 2 MIRVASO ...... 55 methylprednisolone ...... 49 misoprostol ...... 103 METHYLPREDNISOLONE ACETAT ...... 49 MITIGARE ...... 64 methylprednisolone acetate ...... 49 mitomycin ...... 34 methylprednisolone sod succ ...... 49 mitoxantrone hcl ...... 34 metoclopramide hcl ...... 62 MM INSULIN SYRINGE/U-100/ ...... 82 METOCLOPRAMIDE ODT ...... 62 MM TWIST LANCETS ...... 74 128

M-M-R II W/DILUENT 1 DOSE ...... 104 MULTIGEN PLUS ...... 67 M-NATAL PLUS ...... 89 mupirocin ...... 51 MOBIC ...... 4 mupirocin calcium (topical) ...... 51 modafinil ...... 2 MVASI ...... 31 moexipril hcl ...... 26 MYALEPT ...... 59 molindone hcl ...... 39 MYAMBUTOL ...... 29 mometasone furoate ...... 54 MYCAPSSA ...... 60 mometasone furoate (nasal) ...... 91 MYCOBUTIN ...... 29 MONJUVI ...... 31 mycophenolate mofetil ...... 87 MONOJECT 1ML LUER LOCK TU ...... 82 mycophenolate sodium ...... 87 MONOJECT HYPODERMIC NEEDL ...... 82 MYDAYIS ...... 1 MONOJECT INSULIN SYRINGE/ ...... 82 MYDRIACYL ...... 93 MONOJECT MAGELLAN SAFETY ...... 82 MYGLUCOHEALTH MGH SOFTLAN ..... 75 MONOJECT PHARMACY TRAY/RE...... 82 MYLERAN ...... 30 MONOJECT STANDARD HYPODER ..... 82 MYLOTARG ...... 31 MONOJECT SYRINGE PHARMACY ...... 82 MYRBETRIQ ...... 103 MONOJECT TB SYRINGE-NDL 1 ...... 82 MYSOLINE ...... 16 MONOJECT TUBERCULIN SYRIN ...... 82 MYTESI ...... 21 MONOLET LANCETS ...... 75 N MONOLET OPD LANCETS ...... 75 nabumetone ...... 4 MONOLETTOR SAFETY LANCETS ...... 75 nadolol ...... 43 MONONINE ...... 65 NAFCILLIN ...... 98 MONOVISC ...... 90 nafcillin sodium ...... 98 montelukast sodium ...... 13 naftifine hcl ...... 51 MONUROL ...... 11 NAFTIN ...... 51 morphine sulfate ...... 6 NAGLAZYME ...... 59 MORPHINE SULFATE ...... 6 nalbuphine hcl ...... 7 morphine sulfate beads ...... 6 NALFON ...... 4 morphine sulfate for continuous naloxone hcl ...... 22 microinfusion ...... 6 naltrexone hcl ...... 22 MOTEGRITY ...... 61 NAMENDA TITRATION PAK ...... 98 MOTOFEN ...... 21 NAMENDA XR...... 98 MOVANTIK ...... 63 NAMZARIC ...... 98 MOXEZA ...... 93 NAPROSYN ...... 4 moxifloxacin hcl ...... 61 naproxen ...... 4 moxifloxacin hcl (ophth) ...... 93 NAPROXEN ...... 4 moxifloxacin hcl in sodium chloride ... 61 naproxen sodium ...... 4 MOXIFLOXACIN HYDROCHLORID ...... 61 naratriptan hcl ...... 85 MOZOBIL ...... 67 NARCAN ...... 22 MPD SAFETY LANCET 21G/1.8 ...... 75 NARDIL ...... 18 MPD SAFETY LANCET 28G/1.8 ...... 75 NASCOBAL ...... 66 MPD SAFETY LANCET 30G/1.8 ...... 75 NASONEX ...... 91 MPD SAFETY LANCETS 23G/1...... 75 NATACYN ...... 93 MS CONTIN ...... 6 NATAZIA ...... 47 MULPLETA ...... 66 nateglinide ...... 21 MULTAQ ...... 13 NATESTO ...... 8 MULTI-DRAW NEEDLE 21GX1-1 ...... 82 NATPARA ...... 58 129

NATROBA ...... 55 nitrofurantoin ...... 11 NATURE-THROID ...... 102 nitrofurantoin macrocrystal ...... 11 NAVELBINE ...... 37 nitrofurantoin monohyd macro ...... 11 NAYZILAM ...... 15 nitroglycerin ...... 11 NEBUPENT ...... 9 nitroglycerin in d5w ...... 11 nefazodone hcl ...... 18 NITROLINGUAL PUMPSPRAY ...... 11 neomycin sulfate ...... 2 NITROMIST ...... 11 neomycin/polymyxin b gu ...... 63 NITROSTAT ...... 11 neomycin-bacitracin zn-polymyxin .... 93 NITYR ...... 59 neomycin-polymy-dexameth ...... 95 NIVA-PLUS ...... 89 neomycin-polymyxin-gramicidin ...... 94 NIVESTYM ...... 67 neomycin-polymyxin-hc (ophth) ...... 95 nizatidine ...... 102 neomycin-polymyxin-hc (otic) ...... 96 NON- ACCU-CHEK/ONETOUCH TEST NEONATAL COMPLETE ...... 89 STRIPS ...... 56, 75 NEONATAL PLUS ...... 89 norelgestromin-ethinyl estradiol ...... 48 NEORAL ...... 87 norethin acet & estrad-fe ...... 47 NEO-SYNALAR ...... 51 NORETHIN ACET & ESTRAD-FE ...... 47 NERLYNX ...... 35 norethindrone & eth estradiol ...... 47 NEUPRO ...... 38 norethindrone & ethinyl estradiol-fe .. 47 NEURONTIN ...... 16 norethindrone (contraceptive)...... 48 NEVANAC ...... 96 norethindrone acet & eth estra ...... 47 nevirapine ...... 41 NORETHINDRONE ACET & ETH ESTRA NEXAVAR ...... 35 ...... 47 NEXAVIR ...... 88 norethindrone acetate ...... 98 NEXIUM ...... 103 norethindrone acetate-ethinyl estradiol NEXIUM I.V...... 103 ...... 60 NEXLETOL ...... 24 norethindrone acetate-ethinyl NEXLIZET ...... 24 estradiol-fe ...... 47 NEXPLANON ...... 48 norethindrone-eth estradiol (triphasic) NEXTSTELLIS ...... 47 ...... 47 niacin (antihyperlipidemic) ...... 25 norgestimate-ethinyl estradiol ...... 48 NIASPAN ...... 25 norgestimate-ethinyl estradiol nicardipine hcl ...... 44 (triphasic) ...... 48 nicotine ...... 100 norgestrel & ethinyl estradiol ...... 48 nicotine polacrilex ...... 100 NORITATE ...... 55 NICOTROL INHALER ...... 100 NORM-JECT TUBERKULIN 1ML ...... 82 NICOTROL NS ...... 100 NORMLGEL AG ...... 56 nifedipine ...... 44 NORPACE ...... 12 NILANDRON...... 33 NORPACE CR ...... 12 nimodipine ...... 44 NORPRAMIN ...... 19 NINLARO ...... 35 NORTHERA ...... 106 NIPENT ...... 36 nortriptyline hcl ...... 19 nisoldipine ...... 44 NORVASC ...... 44 nitazoxanide ...... 9 NORVIR ...... 41 nitisinone ...... 59 NOVA MAX BLOOD GLUCOSE MO ..... 75 NITRO-BID ...... 11 NOVA SAFETY LANCETS 23G ...... 75 NITRO-DUR ...... 11 NOVA SAFETY LANCETS 28G ...... 75 130

NOVA SUREFLEX LANCETS ...... 75 OFEV ...... 101 NOVOEIGHT ...... 65 ofloxacin ...... 61 NOVOFINE AUTOCOVER PEN NE ...... 82 ofloxacin (ophth) ...... 94 NOVOFINE PEN NEEDLE 32G X ...... 82 ofloxacin (otic) ...... 96 NOVOFINE PLUS PEN NEEDLE ...... 82 olanzapine ...... 39 NOVOLIN 70/30 ...... 20 olanzapine-fluoxetine hcl ...... 99 NOVOLIN 70/30 FLEXPEN ...... 20 olmesartan medoxomil ...... 26 NOVOLIN N ...... 20 olmesartan medoxomil-amlodipine- NOVOLIN N FLEXPEN ...... 20 hydrochlorothiazide ...... 27 NOVOLIN R ...... 21 olmesartan medoxomil- NOVOLIN R FLEXPEN ...... 21 hydrochlorothiazide ...... 27 NOVOLOG ...... 21 olopatadine hcl ...... 96 NOVOLOG FLEXPEN RELION ...... 21 olopatadine hcl (nasal) ...... 91 NOVOLOG MIX 70/30 ...... 21 OLUX ...... 54 NOVOLOG MIX 70/30 PREFILL ...... 21 OLUX-E ...... 54 NOVOLOG PENFILL ...... 21 OMECLAMOX-PAK ...... 103 NOVOSEVEN RT ...... 65 omega-3-acid ethyl esters ...... 24 NOVOTWIST PEN NEEDLE 32G ...... 82 omeprazole ...... 103 NOXAFIL ...... 23 OMEPRAZOLE + SYRSPEND SF ...... 103 NPLATE ...... 67 OMNARIS ...... 91 NUBEQA ...... 33 ONCASPAR ...... 36 NUCALA ...... 13 ondansetron ...... 22 NUCYNTA ...... 6 ondansetron hcl ...... 22 NUCYNTA ER...... 6 ONE TOUCH VERIO TEST STRI ...... 56 NUEDEXTA ...... 100 ONE VITE WOMENS PRENATAL...... 89 NULIBRY ...... 59 ONETOUCH CLUB LANCETS FIN ...... 75 NULOJIX ...... 87 ONETOUCH DELICA LANCETS F ...... 75 NUPLAZID ...... 39 ONETOUCH DELICA PLUS LANC ...... 75 NURTEC ...... 85 ONETOUCH FINEPOINT LANCET ...... 75 NUVARING ...... 48 ONETOUCH SURESOFT LANCING ...... 75 NUVESSA ...... 105 ONETOUCH ULTRA 2 ...... 75 NUWIQ ...... 65 ONETOUCH ULTRA BLUE ...... 56 NUZYRA ...... 101 ONETOUCH ULTRA MINI ...... 75 NYMALIZE ...... 44 ONETOUCH ULTRALINK SYSTEM ...... 75 nystatin ...... 23 ONETOUCH ULTRASOFT LANCET ...... 75 nystatin (mouth-throat) ...... 88 ONETOUCH VERIO ...... 75 nystatin (topical) ...... 51 ONETOUCH VERIO FLEX BLOOD ...... 75 nystatin-triamcinolone ...... 51 ONETOUCH VERIO IQ BLOOD G ...... 75 O ONETOUCH VERIO REFLECT ...... 75 OBIZUR ...... 65 ONETOUCH VERIO SYNC BLOOD ...... 75 OCALIVA ...... 61 ONEXTON ...... 51 OCREVUS ...... 99 ONFI ...... 15 OCTAGAM ...... 97 ONIVYDE ...... 37 octreotide acetate ...... 60 ONPATTRO ...... 100 OCUFLOX ...... 94 ONTRUZANT ...... 31 ODEFSEY ...... 41 ONUREG ...... 30 ODOMZO ...... 32 ONZETRA XSAIL ...... 85 131

OPDIVO ...... 31 OXYCONTIN ...... 6 OPSUMIT ...... 45 oxymorphone hcl ...... 6 OPTICHAMBER DIAMOND ...... 85 OZEMPIC ...... 20 OPTICHAMBER DIAMOND/LARGE ...... 85 OZURDEX ...... 95 OPTICHAMBER DIAMOND/MEDIU ..... 85 P OPTICHAMBER DIAMOND/SMALL ...... 85 paclitaxel ...... 37 OPTIUM BLOOD GLUCOSE MONI ...... 75 PADCEV ...... 31 ORACEA ...... 55 paliperidone ...... 39 ORACIT ...... 63 palonosetron hcl ...... 22 ORAFATE ...... 89 PALONOSETRON HYDROCHLORID .... 22 ORAPRED ODT ...... 49 PAMELOR ...... 19 ORAVIG ...... 88 pamidronate disodium ...... 58 ORENCIA ...... 4 PAMIDRONATE DISODIUM ...... 58 ORENITRAM ...... 45 PANCREAZE ...... 56 ORFADIN ...... 59 PANDEL ...... 54 ORGOVYX ...... 33 PANRETIN ...... 52 ORIAHNN ...... 60 pantoprazole sodium ...... 103 ORILISSA ...... 58 PANZYGA ...... 97 ORKAMBI ...... 100 PARAGARD INTRAUTERINE COP ...... 48 ORLADEYO ...... 65 paricalcitol ...... 59 orphenadrine citrate ...... 90 PARNATE ...... 18 ORTHOVISC ...... 90 paromomycin sulfate ...... 2 ORTIKOS ...... 49 paroxetine hcl ...... 18 oseltamivir phosphate ...... 43 paroxetine mesylate (vasomotor) ... 100 OSPHENA ...... 58 PARSABIV ...... 59 OTEZLA ...... 4 PASER ...... 29 OTIPRIO ...... 96 PATANASE ...... 91 OTOVEL ...... 96 PAXIL ...... 18 OTREXUP ...... 3 PAXIL CR ...... 18 OVIDE ...... 55 PC LANCETS SUPER THIN 30G ...... 75 oxacillin sodium ...... 98 PC UNIFINE PENTIPS 29G X ...... 82 OXACILLIN SODIUM ...... 98 PC UNIFINE PENTIPS 31G X ...... 82 oxaliplatin ...... 30 ped multivitamins w/fl & iron ...... 89 oxandrolone ...... 7 PEDIAPRED ...... 49 oxaprozin ...... 4 pediatric multivitamins w/fl ...... 89 OXAYDO ...... 6 pediatric vitamins acd w/ fluoride ..... 89 oxazepam ...... 12 PEDVAX HIB ...... 104 OXBRYTA ...... 66 peg 3350-kcl-sod bicarb-sod chloride- oxcarbazepine ...... 16 sod sulfate ...... 68 OXERVATE ...... 94 peg 3350-potassium chloride-sod oxiconazole nitrate ...... 51 bicarbonate-sod chloride ...... 68 OXISTAT ...... 51 PEGASYS...... 42 OXLUMO ...... 63 PEMAZYRE ...... 35 OXTELLAR XR ...... 16 PEN NEEDLES 30GX8MM ...... 82 oxybutynin chloride ...... 103 PEN NEEDLES 33G X 5/32 ...... 82 oxycodone hcl ...... 6 penicillamine ...... 87 oxycodone w/ acetaminophen ...... 7 penicillin g potassium ...... 97 132

PENICILLIN G POTASSIUM IN ...... 97 pilocarpine hcl (oral) ...... 89 PENICILLIN G PROCAINE ...... 97 pimecrolimus ...... 54 penicillin g sodium ...... 97 pimozide ...... 100 penicillin v potassium ...... 97 pindolol ...... 43 PENLET II REPLACEMENT CAP ...... 75 pioglitazone hcl ...... 21 pentamidine isethionate ...... 9 pioglitazone hcl-glimepiride ...... 19 pentazocine w/ naloxone ...... 7 pioglitazone hcl-metformin hcl ...... 19 PENTIPS 29GX12MM ...... 82 PIP LANCETS/28G ...... 75 PENTIPS 31GX5MM ...... 82 PIP LANCETS/30G ...... 75 PENTIPS 31GX6MM ...... 82 piperacillin sodium-tazobactam sodium PENTIPS 31GX8MM ...... 82 ...... 98 PENTIPS 32GX4MM ...... 82 PIQRAY 200MG DAILY DOSE ...... 35 pentoxifylline ...... 65 PIQRAY 250MG DAILY DOSE ...... 35 PEPAXTO ...... 30 PIQRAY 300MG DAILY DOSE ...... 35 PERCOCET ...... 7 piroxicam ...... 4 PERFECT LANCETS 30G ...... 75 PLAVIX ...... 66 PERFECT PRESSURE ACTIVATE ...... 75 PLENVU...... 68 PERFOROMIST ...... 14 PNEUMOVAX 23/5 DOSE ...... 104 perindopril erbumine ...... 26 POCKET CHAMBER ...... 85 PERJETA ...... 31 POCKET SPACER ...... 85 permethrin ...... 55 podofilox ...... 55 perphenazine ...... 40 POGO AUTOMATIC BLOOD GLUC ...... 75 perphenazine-amitriptyline ...... 99 POGO AUTOMATIC TEST CARTR ...... 56 PERSERIS ...... 39 POLIVY ...... 31 PERTZYE ...... 56 POLY HUB NEEDLE/18G X 1-1 ...... 82 PEXEVA ...... 18 POLY HUB NEEDLE/21G X 1-1 ...... 82 PHARMACIST CHOICE MINI BL ...... 75 POLY HUB NEEDLE/23G X 1 ...... 82 PHARMACIST CHOICE ULTRA T ...... 75 POLY HUB NEEDLE/30G X 1/2 ...... 82 PHARMACY COUNTER LANCETS ...... 75 polymyxin b sulfate ...... 11 phendimetrazine tartrate ...... 1 polymyxin b-trimethoprim ...... 94 PHENDIMETRAZINE TARTRATE ...... 1 POLYTRIM ...... 94 phenelzine sulfate ...... 18 POLY-VI-FLOR ...... 89 PHENERGAN ...... 24 POLY-VI-FLOR/IRON ...... 89 phenobarbital ...... 67 POMALYST ...... 33 phenoxybenzamine hcl ...... 26 PORTRAZZA ...... 32 phentermine hcl ...... 1 POTABA ...... 106 phenylephrine hcl (mydriatic) ...... 93 potassium chloride ...... 86 PHENYTEK ...... 17 potassium chloride in dextrose ...... 86 phenytoin ...... 17 potassium chloride in dextrose & phenytoin sodium ...... 17 sodium chloride ...... 86 phenytoin sodium extended ...... 17 potassium chloride in nacl ...... 86 PHESGO ...... 34 potassium chloride microencapsulated PHOSLYRA ...... 63 crystals er ...... 86 PHOTOFRIN ...... 36 POTASSIUM CHLORIDE/DEXTRO ...... 86 phytonadione ...... 106 potassium citrate (alkalinizer) ...... 63 PIFELTRO ...... 41 potassium citrate-citric acid ...... 63 pilocarpine hcl ...... 93 POTELIGEO ...... 31 133

POVIDONE IODINE ...... 94 PREVENT SAFETY PEN NEEDLE ...... 82 PRALUENT ...... 25 PREVIDENT 5000 BOOSTER PL ...... 88 pramipexole dihydrochloride ...... 38 PREVIDENT 5000 DRY MOUTH ...... 88 PRAMOSONE ...... 54 PREVIDENT 5000 ENAMEL PRO ...... 88 pramoxine-hc-chloroxylenol ...... 96 PREVIDENT 5000 ORTHO DEFE ...... 88 prasugrel hcl ...... 66 PREVIDENT 5000 PLUS ...... 88 pravastatin sodium ...... 25 PREVIDENT FLUORIDE ...... 88 praziquantel ...... 9 PREVIDENT RINSE ...... 88 prazosin hcl ...... 27 PREVNAR ...... 104 PRECISION QID MONITOR ...... 75 PREVNAR 13 ...... 104 PRECISION SOF-TACT MONITO ...... 75 PREVYMIS ...... 42 PRECISION XTRA ...... 75 PREZCOBIX ...... 41 PRECOSE ...... 19 PREZISTA ...... 41 PRED FORTE ...... 95 PRIFTIN ...... 29 PRED MILD ...... 95 PRIMAXIN IV ...... 10 PRED-G ...... 95 primidone ...... 16 PRED-G S.O.P...... 95 PRIMSOL ...... 9 prednicarbate ...... 54 PRINIVIL ...... 26 prednisolone ...... 49 PRISTIQ ...... 19 prednisolone acetate (ophth) ...... 95 PRIVIGEN ...... 97 PREDNISOLONE ACETATE P-F ...... 95 PRO COMFORT INHALER SPACE ...... 85 PREDNISOLONE SODIUM PHOSP ...... 95 PRO COMFORT INSULIN SYRIN ...... 82 prednisolone sodium phosphate ...... 49 PRO COMFORT LANCETS 30G ...... 76 prednisone ...... 49 PRO COMFORT LANCETS 31G ...... 76 PREDNISONE INTENSOL ...... 49 PRO COMFORT PEN NEEDLES/ ... 82, 83 PREFERRED PLUS LANCETS CO ...... 75 PRO VOICE V8 BLOOD GLUCOS ...... 76 PREFERRED PLUS LANCETS SU ...... 75 PRO VOICE V9 BLOOD GLUCOS ...... 76 PREFERRED PLUS LANCETS TH ...... 76 PROAIR HFA ...... 14 PREFEST ...... 60 PROAIR RESPICLICK ...... 14 pregabalin ...... 16 probenecid ...... 64 pregabalin (once-daily) ...... 100 PROCARDIA XL ...... 44 PREMARIN ...... 61, 105 PROCARE SPACER CHAMBER W/ ...... 85 PREMPHASE ...... 60 prochlorperazine ...... 40 PREMPRO ...... 60 prochlorperazine edisylate ...... 40 PRENATAL ...... 89 prochlorperazine maleate ...... 40 prenatal vit w/ ferrous fumarate-folic PROCRIT ...... 67 acid ...... 89 PROCTOCORT ...... 8 prenatal vit w/ ferrous fumarate-l PROCTOFOAM HC ...... 8 methylfolate-folic acid ...... 89 PRODIGY AUTOCODE BLOOD GL ...... 76 prenatal vit w/ iron carbonyl-folic acid PRODIGY SAFETY LANCETS ...... 76 ...... 89 PRODIGY TWIST TOP LANCETS ...... 76 PRENATAL VITAMINS PLUS LO ...... 89 PROFILNINE ...... 65 prenatal without a w/ fe fumarate-l progesterone ...... 98 methylfolate-fa-dha ...... 89 PROGLYCEM ...... 20 PREPLUS ...... 89 PROGRAF ...... 87 PRESTALIA ...... 27 PROLASTIN-C ...... 100 PRETOMANID ...... 29 PROLENSA ...... 96 134

PROLEUKIN ...... 36 QC LANCETS SUPER THIN ...... 76 PROLIA ...... 58 QC LANCETS ULTRA THIN ...... 76 PROMACTA ...... 67 QC UNILET LANCETS 28G/ULT ...... 76 promethazine & phenylephrine ...... 50 QC UNILET LANCETS 33G/MIC ...... 76 promethazine hcl ...... 24 QELBREE ...... 1 promethazine w/codeine ...... 50 QINLOCK ...... 35 promethazine-dm ...... 50 QNASL ...... 91 promethazine-phenylephrine-codeine 50 QNASL CHILDRENS ...... 91 PROMETRIUM ...... 98 QTERN ...... 19 propafenone hcl ...... 12 QUALAQUIN ...... 28 proparacaine hcl ...... 94 QUARTETTE ...... 48 propranolol hcl ...... 43 quazepam ...... 67 propylthiouracil ...... 101 QUDEXY XR ...... 16 PROQUAD ...... 104 QUESTRAN ...... 24 PROSCAR ...... 64 QUESTRAN LIGHT ...... 24 PROSTIN VR PEDIATRIC ...... 88 quetiapine fumarate ...... 39 PROTHELIAL ...... 89 QUFLORA PEDIATRIC ...... 89 PROTONIX ...... 103 QUICKTEK ...... 76 PROTOPIC ...... 54 QUILLICHEW ER ...... 2 protriptyline hcl ...... 19 QUILLIVANT XR ...... 2 PROTYL AG ...... 56 quinapril hcl ...... 26 PROVENTIL HFA ...... 14 quinapril-hydrochlorothiazide ...... 27 PROVERA ...... 98 quinidine gluconate ...... 12 PROVISC ...... 95 quinidine sulfate ...... 12 PRUDOXIN...... 52 quinine sulfate ...... 28 pseudoephed-bromphen-dm ...... 50 QUINTET AC BLOOD GLUCOSE ...... 76 PSORCON ...... 54 QUINTET BLOOD GLUCOSE MON ...... 76 PSS SELECT GP LANCETS ...... 76 QVAR REDIHALER ...... 14 PSS SELECT PLATFORMS ...... 76 R PSS SELECT SAFETY LANCETS ...... 76 RA E-ZJECT LANCETS 28G ...... 76 PULMICORT ...... 13 RA E-ZJECT LANCETS THIN 2 ...... 76 PULMICORT FLEXHALER ...... 13 RA E-ZJECT LANCETS ULTRA ...... 76 PULMOZYME ...... 100 RA PEN NEEDLES 31G X 5MM ...... 83 PURE COMFORT LANCETS 30G ...... 76 rabeprazole sodium ...... 103 PURE COMFORT PEN NEEDLE 3 ...... 83 RADICAVA ...... 91 PURE COMFORT PEN NEEDLE/3 ...... 83 raloxifene hcl ...... 58 PURIXAN ...... 30 ramelteon ...... 68 PX LANCETS MICROTHIN 33G ...... 76 ramipril ...... 26 PX LANCETS ULTRA THIN ...... 76 ranolazine ...... 11 PX LANCETS ULTRA THIN 28G ...... 76 RAPAFLO ...... 64 PX MINI PEN NEEDLES 31GX5 ...... 83 RAPAMUNE ...... 87 pyrazinamide ...... 29 rasagiline mesylate...... 38 pyridostigmine bromide ...... 28 RASUVO ...... 3 pyridoxine hcl ...... 106 RAVICTI ...... 59 pyrimethamine ...... 28 RAYALDEE ...... 59 Q RAZADYNE ER ...... 99 QBRELIS ...... 26 READYLANCE SAFETY LANCETS...... 76 135

REALITY LANCETS ...... 76 RETISERT ...... 95 REALITY TRIGGER LANCETS ...... 76 RETROVIR ...... 41 REBIF ...... 99 RETROVIR IV INFUSION ...... 41 REBIF REBIDOSE ...... 99 REVATIO ...... 45 REBIF REBIDOSE TITRATION ...... 99 REVLIMID ...... 87 REBIF TITRATION PACK ...... 99 REXULTI ...... 40 REBINYN ...... 65 REYATAZ ...... 41 REBLOZYL ...... 67 RHOFADE ...... 55 RECARBRIO ...... 10 RHOPRESSA ...... 94 RECLAST ...... 58 RIABNI ...... 31 RECOMBINATE ...... 65 RIASTAP ...... 65 RECOMBIVA-HB INJ 2.5/.5ML ...... 104 ribavirin (hepatitis c) ...... 42 RECOMBIVAX HB ...... 105 RIDAURA...... 3 RECTIV ...... 8 rifabutin ...... 29 REGLAN ...... 62 RIFADIN ...... 29 REGONOL ...... 28 rifampin ...... 29 REGRANEX ...... 56 RIGHTEST GD-L500 ALTERNAT ...... 76 RELENZA DISKHALER ...... 43 RIGHTEST GL300 LANCETS ...... 76 RELION LANCETS MICRO-THIN ...... 76 RIGHTEST GT333 BLOOD GLUC ...... 76 RELION LANCETS THIN 26G ...... 76 RILUTEK ...... 91 RELION LANCETS ULTRA-THIN ...... 76 riluzole ...... 91 RELION PEN NEEDLES 29GX12 ...... 83 rimantadine hydrochloride ...... 43 RELION PEN NEEDLES 31GX5/ ...... 83 ringer's irrigation ...... 88 RELION PEN NEEDLES 31GX6M ...... 83 RINVOQ ...... 3 RELION PEN NEEDLES 31GX8M ...... 83 RIOMET ...... 20 RELION PEN NEEDLES 32G X ...... 83 risedronate sodium ...... 58 RELION PEN NEEDLES 32GX4M ...... 83 RISPERDAL ...... 39 RELION PEN NEEDLES/31G X ...... 83 RISPERDAL CONSTA ...... 39 RELION PREMIER VOICE BLOO ...... 76 risperidone ...... 39 RELION PRIME BLOOD GLUCOS ...... 76 RITALIN ...... 2 RELION ULTRA THIN LANCETS ...... 76 RITALIN LA ...... 2 RELION ULTRA THIN PLUS LA ...... 76 RITEFLO ...... 85 REMERON ...... 18 ritonavir ...... 41 REMERON SOLTAB...... 18 RITUXAN ...... 31 REMODULIN ...... 45 RITUXAN HYCELA ...... 34 RENAGEL...... 63 rivastigmine ...... 99 RENFLEXIS ...... 62 rivastigmine tartrate ...... 99 RENVELA ...... 63 RIXUBIS...... 65 repaglinide ...... 21 rizatriptan benzoate ...... 85 REPATHA ...... 26 ROBAXIN ...... 90 REPATHA PUSHTRONEX SYSTEM ...... 26 ROCALTROL ...... 59 REPATHA SURECLICK ...... 26 ROCKLATAN ...... 94 RESTASIS ...... 94 ROMIDEPSIN ...... 35 RESTASIS MULTIDOSE ...... 94 ropinirole hydrochloride ...... 38 RESTORIL ...... 67 rosuvastatin calcium ...... 25 RETACRIT ...... 67 ROTARIX ...... 105 RETEVMO ...... 35 ROTASHIELD SOL ...... 105 136

ROTATEQ ...... 105 SECUADO ...... 39 ROWASA ...... 62 SECURESAFE SAFETY HYPODER ...... 83 ROXICODONE ...... 6 SECURESAFE SAFETY INSULIN ...... 83 ROZLYTREK ...... 35 SECURESAFE SAFETY PEN NEE ...... 83 RUBRACA ...... 35 selegiline hcl ...... 38 RUCONEST ...... 65 selenium sulfide ...... 52 rufinamide ...... 16 SELZENTRY ...... 41 RUKOBIA ...... 41 SENSIPAR ...... 59 RUXIENCE ...... 31 SEREVENT DISKUS ...... 14 RYBELSUS ...... 20 SEROQUEL ...... 39 RYDAPT ...... 35 SEROQUEL XR ...... 39 RYTARY ...... 38 sertraline hcl ...... 18 RYTHMOL SR ...... 12 sevelamer carbonate ...... 63 ryvent ...... 24 sevelamer hcl ...... 63 S SFROWASA ...... 62 SABRIL ...... 17 SHINGRIX ...... 105 SAFE-T-LANCE LOW FLOW 25G ...... 76 SIGNIFOR ...... 60 SAFE-T-LANCE NORMAL FLOW ...... 76 SIGNIFOR LAR ...... 60 SAFE-T-LANCE PLUS SAFETY ...... 76 SIKLOS ...... 66 SAFETY INSULIN SYRINGES 1 ...... 83 sildenafil citrate ...... 45 SAFETY LANCET 30G/PRESSUR ...... 76 sildenafil citrate (pulmonary SAFETY LANCETS ...... 76 hypertension) ...... 45 SAFETY LANCETS 21G ...... 77 silodosin ...... 64 SAFETY LANCETS 28G ...... 77 SILVADENE ...... 52 SAFYRAL ...... 48 silver sulfadiazine ...... 52 SALAGEN ...... 89 SILVRSTAT WOUND DRESSING ...... 56 salsalate ...... 5 SIMBRINZA ...... 93 SAMSCA ...... 60 SIMPONI ARIA ...... 3 SANCUSO ...... 22 SIMULECT ...... 87 SANDIMMUNE ...... 87 simvastatin ...... 25 SANDOSTATIN ...... 60 SINEMET ...... 38 SANDOSTATIN LAR DEPOT ...... 60 SINGLE-LET ...... 77 SANTYL ...... 54 SINGULAIR ...... 13 SAPHRIS ...... 39 sirolimus ...... 87 sapropterin dihydrochloride ...... 59 SIRTURO ...... 29 SAPS HEALTH CARE TWIST TO ...... 77 SITAVIG ...... 43 SAPS HEALTH TWIST TOP LAN ...... 77 SIVEXTRO ...... 11 SAPSCARE TWIST TOP LANCET ...... 77 SKELAXIN ...... 90 SARCLISA ...... 31 SKYLA ...... 48 SAVELLA ...... 99 SKYRIZI ...... 52 SAVELLA TITRATION PACK ...... 99 SKYRIZI PEN ...... 52 SAXENDA ...... 1 SLYND ...... 48 SB LANCETS THIN ...... 77 SM MICRO THIN LANCETS 33G ...... 77 SB LANCETS ULTRA THIN ...... 77 SMART SENSE COLOR LANCETS ...... 77 SCENESSE ...... 55 SMART SENSE STANDARD LANC ...... 77 scopolamine ...... 22 SMART SENSE SUPER THIN LA ...... 77 SEASONIQUE ...... 48 SMART SENSE THIN LANCETS ...... 77 137

SMARTEST EJECT BLOOD GLUC ...... 77 STALEVO 100 ...... 38 SMARTEST LANCETS 28G ...... 77 STALEVO 125 ...... 38 SMARTEST PROTEGE BLOOD GL ...... 77 STALEVO 150 ...... 38 SMOFLIPID ...... 92 STALEVO 200 ...... 38 sodium chloride ...... 86 STALEVO 50 ...... 38 sodium chloride (gu irrigant) ...... 63 STALEVO 75 ...... 38 sodium chloride (inhalant) ...... 50 STELARA ...... 52, 62 sodium chloride flush ...... 86 STERILANCE PA ...... 77 sodium citrate & citric acid ...... 63 STERILANCE TL ...... 77 sodium ferric gluconate complex in STIMATE ...... 60 sucrose ...... 67 STIOLTO RESPIMAT ...... 14 sodium fluoride ...... 86 STIVARGA ...... 35 sodium fluoride (dental) ...... 88 STRENSIQ ...... 59 sodium fluoride-potassium nitrate .... 88 streptomycin sulfate ...... 2 sodium phenylbutyrate ...... 59 STRIVERDI RESPIMAT ...... 14 sodium polystyrene sulfonate...... 88 STROMECTOL ...... 9 sofosbuvir/velpatasvir ...... 42 SUBLOCADE ...... 7 solifenacin succinate ...... 103 SUBOXONE ...... 7 SOLIQUA 100/33 ...... 19 SUCRAID...... 56 SOLIRIS ...... 65 sucralfate ...... 102 SOLOSEC ...... 2 sufentanil citrate ...... 6 SOLOX ...... 56 SULAR ...... 44 SOLTAMOX ...... 33 sulfacetamide sodium (acne) ...... 51 SOLU-CORTEF ...... 49 sulfacetamide sodium (ophth) ...... 94 SOLU-MEDROL ...... 49 sulfacetamide sod-prednisolone ...... 95 SOLUS V2 AUDIBLE BLOOD GL ...... 77 SULFADIAZINE ...... 101 SOLUS V2 PRESSURE ACTIVAT ...... 77 sulfamethoxazole-trimethoprim ...... 9 SOLUS V2 TWIST LANCETS 30 ...... 77 SULFAMYLON ...... 52 SOMA ...... 90 sulfasalazine ...... 62 SOMATULINE DEPOT ...... 60 sulindac ...... 4 SOMAVERT ...... 58 sumatriptan ...... 85 SORIATANE ...... 52 sumatriptan succinate ...... 85 SORILUX ...... 52 sumatriptan-naproxen sodium ...... 85 sotalol hcl ...... 43 sunitinib malate ...... 35 sotalol hcl (afib/afl) ...... 43 SUNOSI ...... 1 SOTYLIZE ...... 43 SUPARTZ FX ...... 90 spinosad ...... 55 SUPPRELIN LA ...... 59 SPINRAZA ...... 91 SUPRAX ...... 46 SPIRIVA HANDIHALER ...... 13 SUPREP BOWEL PREP KIT ...... 68 SPIRIVA RESPIMAT ...... 13 SURE COMFORT INSULIN SYRI ...... 83 spironolactone ...... 57 SURE COMFORT LANCETS 18G ...... 77 spironolactone & hydrochlorothiazide 57 SURE COMFORT LANCETS 21G ...... 77 SPORANOX ...... 23 SURE COMFORT LANCETS 23G ...... 77 SPORANOX PULSEPAK ...... 23 SURE COMFORT LANCETS 28G ...... 77 SPRITAM ...... 16 SURE COMFORT LANCETS 30G ...... 77 SPRIX ...... 4 SURE COMFORT PEN NEEDLES ...... 83 SPRYCEL ...... 35 SURE-FINE PEN NEEDLES 29G ...... 83 138

SURE-FINE PEN NEEDLES 31G ...... 83 tamoxifen citrate ...... 33 SURE-LANCE LANCETS 26G ...... 77 tamsulosin hcl ...... 64 SURE-LANCE THIN LANCETS 2 ...... 77 TAPAZOLE ...... 101 SURELITE LANCETS ...... 77 TARCEVA ...... 32 SURE-TEST EASYPLUS MINI S ...... 77 TARGRETIN ...... 36, 52 SURE-TOUCH LANCETS UNIVER ...... 77 TARKA ...... 27 SURVANTA INTRATRACHEAL ...... 101 TASIGNA ...... 35 SUSTIVA ...... 41 TASMAR ...... 38 SUSTOL ...... 22 tavaborole ...... 51 SUTAB ...... 68 TAYTULLA ...... 48 SUTENT ...... 35 tazarotene ...... 52 SYLVANT ...... 88 TAZORAC ...... 52 SYMAX DUOTAB ...... 102 TAZVERIK ...... 35 SYMBICORT ...... 14 TECARTUS ...... 32 SYMBYAX ...... 99 TECENTRIQ ...... 31 SYMDEKO ...... 101 TECFIDERA ...... 99 SYMFI ...... 41 TECFIDERA STARTER PACK ...... 99 SYMFI LO ...... 41 TECHLITE AST LANCETS ...... 77 SYMJEPI ...... 105 TECHLITE LANCETS ...... 77 SYMLINPEN 120 ...... 19 TECHLITE LANCETS 30G ...... 77 SYMLINPEN 60 ...... 19 TECHLITE PEN NEEDLES 29G ...... 83 SYMPAZAN ...... 15 TECHLITE PEN NEEDLES/32G...... 83 SYMTUZA ...... 41 TEFLARO ...... 47 SYNAGIS ...... 97 TEGRETOL ...... 17 SYNALAR ...... 54 TEGRETOL-XR ...... 17 SYNAREL ...... 59 TEKTURNA ...... 28 SYNDROS ...... 23 TEKTURNA HCT ...... 27 SYNRIBO ...... 36 telmisartan ...... 26 SYNTHROID ...... 102 telmisartan-amlodipine ...... 28 SYNVISC ...... 90 telmisartan-hydrochlorothiazide ...... 28 SYNVISC ONE ...... 90 temazepam ...... 67 SYPRINE ...... 87 TEMIXYS ...... 42 SYRINGE/LUER SLIP/1ML ...... 83 TEMODAR ...... 30 SYRINGES/LUER SLIP/WITHOU ...... 83 TEMOVATE ...... 54 T temozolomide ...... 30 TABLOID ...... 30 temsirolimus ...... 35 TABRECTA ...... 35 TENIPOSIDE ...... 37 TACLONEX ...... 54 tenofovir disoproxil fumarate ...... 42 tacrolimus ...... 87 TENORETIC 100 ...... 28 tacrolimus (topical) ...... 54 TENORETIC 50 ...... 28 tadalafil ...... 45 TENORMIN ...... 43 tadalafil (pulmonary hypertension) ... 45 TEPADINA ...... 30 TAFINLAR ...... 35 TEPEZZA ...... 58 TAGRISSO ...... 32 TEPMETKO ...... 35 TAKHZYRO ...... 65 terazosin hcl ...... 27 TALZENNA ...... 35 terbinafine hcl ...... 23 TAMIFLU ...... 43 terbutaline sulfate ...... 14 139 terconazole vaginal ...... 105 tobramycin ...... 2 TESSALON PERLES ...... 50 tobramycin (ophth) ...... 94 TESTIM ...... 8 tobramycin sulfate ...... 2, 3 TESTOPEL ...... 8 tobramycin-dexamethasone ...... 95 testosterone ...... 8 TOBREX ...... 94 testosterone cypionate ...... 8 TODAYS HEALTH ORIGINAL PE ...... 83 testosterone enanthate ...... 8 TODAYS HEALTH SHORT PEN N ...... 83 tetrabenazine ...... 99 TODAYS HEALTH SUPER THIN ...... 77 tetracycline hcl...... 101 TODAYS HEALTH ULTRA THIN ...... 77 TGT LANCET MICRO THIN 33G ...... 77 tolbutamide ...... 21 TGT LANCET THIN 26G ...... 77 tolcapone ...... 38 TGT LANCET ULTRA THIN 30G ...... 77 TOLSURA ...... 23 THALOMID ...... 87 tolterodine tartrate ...... 103 THEO-24 ...... 14 tolvaptan ...... 60 theophylline ...... 14 TOPCARE LANCETS MICRO-THI ...... 77 thiamine hcl...... 106 TOPICORT ...... 54 THINLETS GP LANCETS ...... 77 topiramate ...... 17 THIOLA ...... 64 topotecan hcl ...... 37 THIOLA EC ...... 64 TOPROL XL ...... 43 thioridazine hcl ...... 40 torsemide ...... 57 thiotepa ...... 30 TOTECT ...... 37 thiothixene ...... 40 TOVIAZ ...... 103 THYMOGLOBULIN ...... 87 TRACLEER ...... 45 THYROGEN ...... 56 tramadol hcl ...... 6, 7 thyroid ...... 102 tramadol-acetaminophen ...... 7 tiagabine hcl ...... 17 trandolapril...... 26 TIAZAC ...... 44 trandolapril-verapamil hcl ...... 28 TIGAN ...... 22 tranexamic acid ...... 67 tigecycline ...... 101 TRANSDERM SCOP ...... 22 TIGLUTIK ...... 91 TRANSDERM-SCOP ...... 22 TIKOSYN ...... 13 TRANXENE T ...... 12 timolol maleate ...... 43 tranylcypromine sulfate...... 18 timolol maleate (ophth) ...... 92 TRAVATAN Z ...... 96 TIMOPTIC ...... 92 TRAVEL LANCETS 30G ...... 77 TIMOPTIC OCUDOSE ...... 92 TRAVEL LANCETS ADVANCED 2...... 78 TIMOPTIC-XE ...... 92 travoprost ...... 96 tinidazole ...... 9 TRAZIMERA ...... 31 tiopronin ...... 64 trazodone hcl ...... 18 TIROSINT ...... 102 TREANDA ...... 30 TIROSINT-SOL ...... 102 TRECATOR ...... 29 TIVICAY ...... 42 TRELEGY ELLIPTA ...... 14 TIVICAY PD ...... 42 TRELSTAR MIXJECT ...... 33 tizanidine hcl ...... 90 TREMFYA ...... 52 TOBI ...... 2 treprostinil ...... 45 TOBI PODHALER ...... 2 TRESIBA ...... 21 TOBRADEX ...... 95 TRESIBA FLEXTOUCH...... 21 TOBRADEX ST ...... 95 tretinoin ...... 51 140 tretinoin (chemotherapy) ...... 36 TRUEPLUS LANCETS 33G MICR ...... 78 TRETTEN ...... 65 TRUETRACK BLOOD GLUCOSE M ...... 78 TREXALL ...... 30 TRULANCE ...... 61 TRIAMCINOLONE ACETONIDE ...... 49 TRULICITY ...... 20 triamcinolone acetonide (mouth) ...... 89 TRUMENBA ...... 104 triamcinolone acetonide (topical) ...... 54 TRUSOPT ...... 96 triamterene & hydrochlorothiazide .... 57 TRUVADA ...... 42 triazolam ...... 67 TRUXIMA...... 31 TRIBENZOR ...... 28 TUDORZA PRESSAIR ...... 13 TRICARE ...... 90 TUKYSA ...... 31 TRICOR ...... 25 TURALIO ...... 35 TRIDESILON ...... 54 TUSSICAPS ...... 50 TRIESENCE ...... 95 TUXARIN ER ...... 50 trifluoperazine hcl ...... 40 TUZISTRA XR ...... 50 trifluridine ...... 94 TWINRIX ...... 105 trihexyphenidyl hcl ...... 38 TWIRLA...... 48 TRIKAFTA ...... 101 TWYNSTA ...... 28 TRILEPTAL ...... 17 TYBOST ...... 42 TRILIPIX ...... 25 TYKERB ...... 35 TRILURON ...... 90 TYMLOS ...... 58 trimethobenzamide hcl ...... 22 TYSABRI ...... 99 trimethoprim ...... 9 TYVASO ...... 45 trimipramine maleate ...... 19 TYVASO REFILL ...... 45 TRINTELLIX ...... 18 TYVASO STARTER ...... 45 TRIOSTAT ...... 102 U TRIPTODUR ...... 59 UCERIS ...... 8, 49 TRISENOX ...... 36 UKONIQ ...... 35 TRIUMEQ ...... 42 ULTICARE INSULIN SAFETY S ...... 83 TRI-VI-FLOR ...... 89 ULTICARE INSULIN SYRINGE/ ...... 83 TRI-VI-FLORO ...... 89 ULTICARE MICRO PEN NEEDLE ...... 83 TRIVISC ...... 90 ULTICARE MINI PEN NEEDLES ...... 83 TRIZIVIR ...... 42 ULTICARE ORIGINAL PEN NEE ...... 83 TRODELVY ...... 37 ULTICARE PEN NEEDLES 31G ...... 83 TROGARZO ...... 42 ULTICARE PEN NEEDLES/29G ...... 83 TROKENDI XR ...... 17 ULTICARE SHORT PEN NEEDLE ...... 83 tropicamide ...... 93 ULTICARE SHORT SAFETY PEN ...... 83 trospium chloride ...... 103 ULTICARE TUBERCULIN SAFET ...... 83 TRUE COMFORT PRO PEN NEED ...... 83 ULTICARE U-100 INSULIN SY ...... 83 TRUE COMFORT TWIST TOP LA ...... 78 ULTIGUARD SAFEPACK INSULI ...... 83 TRUE FOCUS BLOOD GLUCOSE ...... 78 ULTIGUARD SAFEPACK MINI P ...... 83 TRUE METRIX ...... 78 ULTIGUARD SAFEPACK PEN NE ...... 83 TRUE METRIX AIR BLOOD GLU ...... 78 ULTIGUARD SAFEPACK/MICRO ...... 83 TRUEPLUS LANCETS 26G ...... 78 ULTIGUARD SAFEPACK/MINI P ...... 84 TRUEPLUS LANCETS 28G ...... 78 ULTIGUARD SAFEPACK/SHORT ...... 84 TRUEPLUS LANCETS 28G SUPE ...... 78 ULTIGUARD SAFEPACK/SYRING ...... 84 TRUEPLUS LANCETS 30G ...... 78 ULTILET CLASSIC LANCETS ...... 78 TRUEPLUS LANCETS 33G ...... 78 ULTILET INSULIN SYRINGE/0 ...... 84 141

ULTILET INSULIN SYRINGE/1 ...... 84 UNISTIK CZT COMFORT ...... 79 ULTILET INSULIN SYRINGE/S ...... 84 UNISTIK CZT NORMAL ...... 79 ULTILET INSULIN SYRINGE/U ...... 84 UNISTIK NORMAL ...... 79 ULTILET LANCETS ...... 78 UNISTIK PRO SAFETY LANCET ...... 79 ULTILET LANCETS 33G ...... 78 UNISTIK SAFETY LANCETS 28 ...... 79 ULTILET PEN NEEDLE 29GX12 ...... 84 UNISTIK SAFETY LANCETS 30 ...... 79 ULTILET PEN NEEDLE 31GX5M ...... 84 UNISTIK TOUCH SAFETY LANC ...... 79 ULTILET PEN NEEDLE 31GX8M ...... 84 UNITUXIN ...... 32 ULTILET PEN NEEDLE 32GX4M ...... 84 UNIVERSAL 1 LANCETS THIN ...... 79 ULTILET SAFETY LANCETS 21 ...... 78 UNIVERSAL 1 LANCETS ULTRA ...... 79 ULTILET SAFETY LANCETS 23 ...... 78 UNIVERSAL 1 LANCETS/33G/M ...... 79 ULTILET U-100 INSULIN SYR ...... 84 UPLIZNA ...... 87 ULTIMA ...... 78 UPTRAVI ...... 45 ULTIVA ...... 7 UROCIT-K 10 ...... 63 ULTRA FLO INSULIN PEN NEE ...... 84 UROCIT-K 15 ...... 63 ULTRA THIN LANCETS 31G ...... 78 UROCIT-K 5 ...... 63 ULTRACET ...... 7 UROXATRAL ...... 64 ULTRA-THIN II AUTO LANCET ...... 78 URSO 250 ...... 62 ULTRA-THIN II LANCETS 28G ...... 78 URSO FORTE ...... 62 ULTRA-THIN II LANCETS 30G ...... 78 ursodiol ...... 62 UNIFINE PENTIPS 32GX6MM ...... 84 V UNIFINE PENTIPS 33GX4MM ...... 84 VABOMERE ...... 10 UNIFINE SAFECONTROL PEN N...... 84 VAGIFEM ...... 105 UNILET COMFORTOUCH LANCET ...... 78 valacyclovir hcl ...... 43 UNILET EXCELITE ...... 78 VALCHLOR ...... 52 UNILET EXCELITE II ...... 78 VALCYTE ...... 42 UNILET G.P. LANCET ...... 78 valganciclovir hcl ...... 42 UNILET G.P. SUPERLITE LAN ...... 78 VALIUM ...... 12 UNILET GP 28 ULTRA THIN ...... 78 valproate sodium ...... 17 UNILET LANCET ...... 78 valproic acid ...... 17 UNILET LANCETS MICRO-THIN ...... 78 valsartan ...... 26 UNILET LANCETS SUPER-THIN ...... 78 valsartan-hydrochlorothiazide ...... 28 UNILET SUPERLITE LANCET ...... 78 VALTOCO ...... 15 UNISTIK 1 ...... 78 VALUE PLUS LANCETS STANDA ...... 79 UNISTIK 2 ...... 78 VALUMARK LANCET ULTRA THI ...... 79 UNISTIK 2 COMFORT ...... 78 VANCOCIN ...... 10 UNISTIK 2 EXTRA ...... 78 VANCOCIN HCL ...... 10 UNISTIK 2 NEONATAL ...... 78 VANCOMYCIN ...... 10 UNISTIK 2 NORMAL ...... 78 vancomycin hcl ...... 10 UNISTIK 2 SUPER ...... 78 VANCOMYCIN HCL ...... 10 UNISTIK 3 ...... 78 VANCOMYCIN HYDROCHLORIDE ...... 10 UNISTIK 3 COMFORT ...... 78 VANCOMYCIN HYDROCHLORIDE/ ..... 10 UNISTIK 3 EXTRA ...... 78 VANISHPOINT INSULIN SYRIN ...... 84 UNISTIK 3 EXTRA SINGLE US ...... 78 VANOS ...... 54 UNISTIK 3 GENTLE ...... 79 VANTAS ...... 33 UNISTIK 3 NEONATAL ...... 79 VAPRISOL ...... 60 UNISTIK 3 NORMAL ...... 79 VAQTA ...... 105 142

VARIVAX ...... 105 VISCO-3 ...... 91 VARUBI ...... 23 VISTARIL ...... 12 VASCEPA ...... 24 VISTOGARD...... 22 VASERETIC ...... 28 VITATHELY/GINGER...... 90 VASOTEC ...... 26 VITRAKVI ...... 35 VECAMYL ...... 28 VITRASE ...... 87 VECTIBIX ...... 32 VIVAGUARD INO BLOOD GLUCO ...... 79 VECTICAL ...... 52 VIVAGUARD LANCETS ...... 79 VELCADE ...... 35 VIVELLE-DOT ...... 61 VELPHORO ...... 63 VIVITROL ...... 22 VELTASSA ...... 88 VIZIMPRO ...... 32 VEMLIDY ...... 42 VOGELXO ...... 8 VENCLEXTA ...... 32 VOGELXO PUMP ...... 8 VENCLEXTA STARTING PACK ...... 32 VONVENDI ...... 65 venlafaxine hcl ...... 19 VORAXAZE ...... 37 VENOFER ...... 67 voriconazole ...... 24 VENTAVIS ...... 45 VORTEX VALVED HOLDING CHA ...... 85 VENTOLIN HFA ...... 14 VOTRIENT ...... 36 verapamil hcl ...... 44 VPRIV ...... 66 VERASENS BLOOD GLUCOSE MO ...... 79 VRAYLAR ...... 39 VERELAN ...... 44 VUMERITY ...... 100 VERELAN PM ...... 44 VYLEESI ...... 99 VERQUVO ...... 46 VYNDAMAX ...... 45 VERSACLOZ ...... 39 VYTORIN ...... 24 VERZENIO ...... 35 VYVANSE ...... 1 VESICARE LS ...... 103 VYXEOS ...... 34 VFEND ...... 23 VYZULTA ...... 96 VFEND IV ...... 23 W VIBATIV ...... 10 WALGREENS ADVANCED TRAVEL ..... 79 VIBERZI ...... 63 WALGREENS COMFORT ASSURED .... 79 VIBRAMYCIN ...... 101 WALGREENS THIN LANCETS ...... 79 VICTOZA ...... 20 WALGREENS ULTRA THIN LANC ...... 79 VIDAZA ...... 30 warfarin sodium ...... 14 VIGAMOX ...... 94 water for irrigation, sterile ...... 88 VIIBRYD ...... 18 WEGMANS UNIFINE PENTIPS P ...... 84 VIIBRYD STARTER PACK ...... 18 WELCHOL ...... 25 VIMIZIM ...... 59 WESTAB PLUS ...... 90 VIMPAT ...... 17 WESTHROID ...... 102 vinblastine sulfate ...... 37 WIDE-SEAL SILICONE DIAPHR ...... 69 vincristine sulfate ...... 37 WILATE ...... 65 vinorelbine tartrate ...... 37 WP THYROID ...... 102 VIOKACE ...... 56 X VIRACEPT ...... 42 XADAGO ...... 38 VIRAMUNE...... 42 XALKORI ...... 36 VIRAMUNE XR ...... 42 XARELTO ...... 15 VIRAZOLE ...... 43 XARELTO STARTER PACK ...... 15 VIREAD ...... 42 XATMEP ...... 30 143

XCOPRI ...... 17 ZEGALOGUE ...... 20 XELJANZ ...... 3 ZEJULA ...... 36 XELJANZ XR ...... 3 ZELAPAR ...... 38 XELODA ...... 30 ZELBORAF ...... 36 XELPROS ...... 96 ZEMAIRA ...... 100 XENAZINE ...... 99 ZEMBRACE SYMTOUCH ...... 86 XENLETA ...... 11 ZEMDRI ...... 3 XEOMIN ...... 91 ZEMPLAR ...... 59 XERAVA ...... 101 ZENPEP ...... 56 XERESE ...... 52 ZEPOSIA ...... 100 XERMELO ...... 63 ZEPOSIA 7-DAY STARTER PAC ...... 100 XGEVA ...... 58 ZEPOSIA STARTER KIT ...... 100 XIFAXAN ...... 9 ZEPZELCA ...... 30 XIGDUO XR ...... 19 ZERBAXA ...... 46 XIIDRA ...... 94 ZESTORETIC ...... 28 XOFLUZA ...... 43 ZESTRIL ...... 26 XOLAIR ...... 13 ZETIA ...... 25 XOLEGEL ...... 51 ZETONNA ...... 91 XOPENEX ...... 14 ZEVALIN Y-90 ...... 32 XOPENEX CONCENTRATE ...... 14 ZEVRX PEN NEEDLES 31G X 5 ...... 84 XOPENEX HFA ...... 14 ZEVRX PEN NEEDLES 31G X 6 ...... 84 XOSPATA ...... 36 ZEVRX PEN NEEDLES 31G X 8 ...... 84 XPOVIO ...... 33 ZEVRX PEN NEEDLES 32G X 4 ...... 84 XPOVIO 60 MG TWICE WEEKLY ...... 33 ZEVRX TWIST TOP LANCETS 3 ...... 79 XPOVIO 80 MG TWICE WEEKLY ...... 33 ZIAC ...... 28 XTAMPZA ER ...... 7 ZIAGEN ...... 42 XTANDI ...... 33 zidovudine ...... 42 XULTOPHY 100/3.6 ...... 20 ZIEXTENZO ...... 67 XURIDEN ...... 59 ZINGO ...... 68 XYLOCAINE ...... 68 ZINPLAVA ...... 97 XYLOCAINE-MPF ...... 68 ZIOPTAN ...... 96 XYNTHA ...... 65 ziprasidone hcl ...... 39 XYNTHA SOLOFUSE ...... 65 ZIRABEV ...... 31 XYOSTED ...... 8 ZIRGAN ...... 94 Y ZITHROMAX ...... 68 YASMIN 28 ...... 48 ZITHROMAX TRI-PAK ...... 68 YAZ ...... 48 ZITHROMAX Z-PAK ...... 68 YERVOY ...... 32 ZOCOR ...... 25 YONDELIS ...... 30 ZOFRAN ...... 22 YONSA ...... 33 ZOKINVY ...... 88 Z ZOLADEX ...... 33 zafirlukast ...... 13 zoledronic acid ...... 58 zaleplon ...... 67 ZOLEDRONIC ACID ...... 58 ZALTRAP ...... 31 ZOLGENSMA 10.1-10.5 KG ...... 92 ZANAFLEX ...... 90 ZOLGENSMA 10.6-11.0 KG ...... 92 ZARONTIN ...... 17 ZOLGENSMA 11.1-11.5 KG ...... 92 ZAVESCA ...... 66 ZOLGENSMA 11.6-12.0 KG ...... 92 144

ZOLGENSMA 12.1-12.5 KG ...... 92 ZONEGRAN...... 17 ZOLGENSMA 12.6-13.0 KG ...... 92 zonisamide ...... 17 ZOLGENSMA 13.1-13.5 KG ...... 92 ZONTIVITY ...... 66 ZOLGENSMA 2.6-3.0 KG ...... 91 ZORTRESS ...... 87 ZOLGENSMA 3.1-3.5 KG ...... 91 ZOSTAVAX ...... 105 ZOLGENSMA 3.6-4.0 KG ...... 91 ZOSYN ...... 98 ZOLGENSMA 4.1-4.5 KG ...... 91 ZOVIRAX ...... 43 ZOLGENSMA 4.6-5.0 KG ...... 91 ZTLIDO ...... 55 ZOLGENSMA 5.1-5.5 KG ...... 92 ZUBSOLV ...... 7 ZOLGENSMA 5.6-6.0 KG ...... 92 ZUPLENZ ...... 22 ZOLGENSMA 6.1-6.5 KG ...... 92 ZYCLARA ...... 54 ZOLGENSMA 6.6-7.0 KG ...... 92 ZYCLARA PUMP ...... 54 ZOLGENSMA 7.1-7.5 KG ...... 92 ZYDELIG ...... 36 ZOLGENSMA 7.6-8.0 KG ...... 92 ZYFLO ...... 13 ZOLGENSMA 8.1-8.5 KG ...... 92 ZYKADIA ...... 36 ZOLGENSMA 8.6-9.0 KG ...... 92 ZYLET ...... 95 ZOLGENSMA 9.1-9.5 KG ...... 92 ZYLOPRIM ...... 64 ZOLGENSMA 9.6-10.0 KG ...... 92 ZYMAXID ...... 94 ZOLINZA ...... 36 ZYNLONTA ...... 32 zolmitriptan ...... 86 ZYPREXA ...... 39 ZOLOFT ...... 18 ZYPREXA RELPREVV ...... 39 zolpidem tartrate...... 68 ZYPREXA ZYDIS ...... 39 ZOMIG ...... 86 ZYTIGA ...... 33 ZONALON ...... 52 ZYVOX ...... 11

145